Risk Factors for Smoking in the EMR Region Kawkab Shishani, BSN, PhD The Hashemite University Risk Factors for Smoking in the EMR Region Kawkab Shishani, BSN, PhD The Hashemite University Epidemiology of Diabetes & Other Non- Communicable Diseases Alexandria, Egypt 6-13 th January 2009

Petra: Jordan’s Wonder of the World

Objectives 1.Describe the scope of the problem 2.Examine smoking among selected populations 3.Differentiate between forms of tobacco use 4.Discuss why smoking is harmful 5.Value WHO position on tobacco control 6.Summarize how health care professionals can provide the leadership in tobacco control

Question Why it is important to study smoking ? 1. Smoking is the chief avoidable risk factor for NCDs 2. Smoking Affects the progression of NCDs (> complications) 3. Unlike the other risk factors such as physical activity and nutrition that affects only those who do not comply to them, smoking affects smoker as well as those around

Why Do Farmers Grow Tobacco? The wealth generated by leaf tobacco production helps to improve quality of life and attracts educational, health and social facilities in, otherwise, relatively impoverished, rural areas. International tobacco growers association

Scope of the Problem  1,3 billion smokers:  80% in developing countries  20% in developed countries  The number is expected to increase by 1.7 per cent annually  By 2030, 80% of deaths due to tobacco will occur in developing countries

Scope of the Problem  Most cigarettes consumed worldwide are international brands  As smoking rates in the US and Europe is declining, new markets are needed  Globalization made it easy for companies to access new markets internationally (Asia, Africa, Middle East)

Smoking: Men and Women  Global smoking (M: 4> F)  ↑ in smoking rates in F > M  Ratio of smoking M: F  Developed countries 3:1  Developing countries 7:1

Smoking: Men and Women EMR country profilehttp://

Smoking: Men and Women  50%-66% of women use “light”  Addiction in M>F  Biological responses to nicotine differ between M & F  Smoking in women is reinforced by less nicotine than in men (Perkins et al., 1991)

Female Smoking & Low Birth Weight

Smoking: Youth WHO (2007). Sifting the evidence: Gender and tobacco control

Youth Smoking in EMR EMR country profilehttp://

I can't stop smoking. I am addicted to cigarettes. Smoking: Youth  Parent (father smokes)  Access to cigarettes  Peer pressure  Experimentation  Imitating adults

Smoking: Health Professionals

GHPS: Jordan CharacteristicWomen % (n) Men % (n) Total % (n) Once started clinical work smoking Decreased Stayed the same Increased Do you want to quit smoking Yes No Have you ever tried to quit Yes No How many times you tried to quit 1-3 times 34.4 (32) 35.5 (33) 30.1 (93) 62.0 (54) 37.9 (33) 54.9 (50) 45.1 (41) 77.8 (28) 24.2 (104) 34.7 (149) 41.0 (176) 52.0 (216) 48.0 (199) 61.9 (255) 38.1 (157) 37.9 (161) 26.1(136) 34.9 (182) 39.1 (204) 53.8 (270) 46.2(232) 60.6(305) 39.4 (198) 74.4 (189)

Learning Need Assessment Nurses % Physicians % Total % Cigarettes and argileh are both addicting Taught in classes about dangers of smoking Discuss in any of your classes why people smoke Ever received any formal training in smoking cessation Provide materials to support smoking cessation to patients (Shishani, Nawafleh, & Sivarajan Froelicher, 2008) GHPS: Jordan

Forms Of Tobacco Use Waterpipe  Waterpipe  Cigarettes  Chewing

Second Hand Smoking  At home:  Smoking around children  Children prepare waterpipe for parents  Cultural issues  Public places (hospitals, buses, taxis,..)

Waterpipe: The Emerging Epidemic Myths: Myths:  It is safe alternative for cigarettes (WHO study group, 2005)  Chemicals filtered by the water (bubbling)  Not addictive; can quit anytime (Asfar et al. BMC Public Health 2005) Highest rates are in MENA (Shihadeh., 2004) Highest rates are in MENA (Shihadeh., 2004) Social practice (Café employees) Social practice (Café employees) Children smoke with their parents (Maziak et al., 2004) Children smoke with their parents (Maziak et al., 2004)

Waterpipe: The Emerging Epidemic  Nicotine in 1 head of unflavored tobacco = 70 regular cigarettes;  Flavored tobacco = 20cigarettes  A single smoking session: 2.25 mg nicotine, high levels of arsenic, cobalt, chromium, and lead (Shihadeh, 2003)  Cotinine levels are almost the same among waterpipe and cigarette smokers (Bacha, Salameh, Waked, 2007)

Chemicals Produced From Smoking  Nicotine  Tar  Carbon monoxide  Benzopyrene  Cyanide hydrogen

How Does Nicotine Work? From Benowitz N. Nicotine Addiction. Primary Care 1999; 26(3):611-31

Why Nicotine Matters Short term effectLong term effect

Tobacco Dependence: A Chronic Disease  The long delay between the onset of smoking and associated morbidities  70% of the smokers want to quit Unsuccessful  44% tried to quit  Only 7% succeed

Tobacco Dependence: A Chronic Disease  A Chronic disease model:  Long term nature  Minimum number achieve permanent abstinence  Periods of relapse and remissions  No ideal intervention  Emphasis on education and counseling (same like in DM, HTN) (US Department of Health and Human Services, 2008)

WHO Efforts to Control Tobacco Use (FCTC)  Price and tax measures  Protection from exposure to tobacco smoke  Educational and public awareness programmes  Promoting the cessation of tobacco use  Sales to and by minors  Research, surveillance and exchange

Where Do We Go From Here?  Monitoring tobacco use to provide accurate tracking of epidemiological data about the extent of tobacco exposure (GTSS)  Report morbidities associated with smoking  Public Education (media, curricula)  Health Insurance companies (reimburse tobacco dependence treatments)

Why Do We Need A Plan in EMR  Lack of human resources (experienced in tobacco control  Lack of adequate studies on hazards of smoking  Research encouragement (Funding)

2008 Update

5 As A1. Ask—Systematically identify all tobacco users at every visit A2. Advise—Strongly urge all tobacco users to quit A3. Assess—Determine willingness to make a quit attempt A4. Assist—Aid the patient in quitting (provide counseling and medication) A5. Arrange—Ensure follow-up contact Treating Tobacco Use and Dependence: 2008 Update” Clinical Guideline

Elements of Counseling Problem solving/ skills training Recognize danger situations – Develop coping skills- Identify and practice coping Provide basic information Supportive treatment Encourage the patient in the quit Attempt Communicate caring and concern. Encourage the patient to talk about the quitting process. Treating Tobacco Use and Dependence: 2008 Update” Clinical Guideline

Format of Counseling   Assessment   Program clinician   Program intensity   Format   Type of counseling   Medication   Population Treating Tobacco Use and Dependence: 2008 Update” Clinical Guideline