1. THE BURDEN OF SMOKING IN SOUTH AFRICAN GOLD MINE WORKERS Presented by Dr Vanessa Govender Occupational Medical Practitioner To Parliamentary Health Portfolio Committee 23 January 2007

2. Contents Introduction South Africa Health effects Employer Gold mines – Occupational lung diseases - HIV/AIDS - Smoking policy Role of HCWs Conclusion

3. Cigarette smoking is the most prevalent modifiable risk factor for increased morbidity and mortality in the world (WHO) Introduction WHO “global public health emergency”

4. Progressive legislation Tobacco Products Control Act, Act 83 of 1993 (32.6%) Tobacco Products Control Amendment Act, Act 12 of 1999 (28.5%) (van Walbeek 2002) SMOKING IN SOUTH AFRICA Prevalence = 22%

5. Tobacco Products Control Amendment Bill 2006 Increased penalties for employers failing to protect employees from tobacco smoke New offences such as prohibiting health institutions from sale of tobacco To prevent young people from starting Help smokers quit SMOKING IN SOUTH AFRICA

6. NORMAL LUNG SMOKER’S LUNG

7. SMOKER’SBODY

10. Smokers: have more hospital admissions take longer to recover from illness have higher out patient health care costs (Osinubi 2002)) BURDEN OF SMOKING ON EMPLOYERS Absenteeism is 50% higher amongst smokers (US dept of health,education, welfare 1979) Absenteeism is 50% higher amongst smokers (US dept of health,education, welfare 1979)

11. BURDEN OF SMOKING ON EMPLOYERS Current smokers miss more days at work, more unproductive time at work than former smokers or non- smokers (Bunn et al. 2006)

12. BURDEN OF SMOKING ON EMPLOYERS 18 LOST DAYS PER YEAR! ($1.7 billion pa) Average 3 smoking breaks Borrow, buy, beg,light up,puff Lasting 13 minutes each = 39 minutes lost productivity per day (Wendland-Boyer 2000)

13. Smoking is higher among people employed in labour intensive industries than among those in professional and people orientated industries (van Walbeek 2002) SMOKING IN SOUTH AFRICAN MINES

14. MHSC project: Overall decrease in smoking trends 1998 – 2002 White mine workers of all ages tend to smoke more heavily than black mine workers 4% whites, 5% blacks took up smoking after employment Overall prevalence 44% (Cheyip 2004) SMOKING IN SOUTH AFRICAN MINES Unpublished prevalence = 60%

15. OCCUPATIONAL LUNG DISEASES Silicosis, COAD, TB, lung cancer are compensable diseases Attributable to high levels of free crystalline silica dust (ODMWA 1973) Employer take measures to assess the risk and control it (MHSA 1996) Medical surveillance examinations – on employment, during employment and on termination

16. OCCUPATIONAL LUNG DISEASES Gold mines are committed to dust control Global elimination of silicosis programme (WHO) National elimination of silicosis programme MHSC - milestones Dust control alone may be inadequate to control OLD

17. OCCUPATIONAL LUNG DISEASES TB COAD Silicosis Lung cancer SILICA DUST SMOKING

18. OCCUPATIONAL LUNG DISEASES In SA: Smoking significantly increases the risk for deaths from tuberculosis, chronic obstructive airways disease and lung cancer (Sitas et al. 2004)

19. TB SILICA DUST HIV SMOKING

20. 1. TUBERCULOSIS Silica dust lifelong risk for development of TB, even in absence of silicosis Risk increases with increasing severity of radiological silicosis And with cumulative dust exposure Persists long after exposure has stopped (Hnizdo, Murray 1998) Established silicosis, risk for TB increases up to three-fold (Churchyard 2001) Established silicosis, risk for TB increases up to three-fold (Churchyard 2001)

21. 1. TUBERCULOSIS Incidence rate 41 new cases / 1 000 employees per annum TB accounts for large majority of occupational diseases

22. 1.TUBERCULOSIS (TB) In addition to silica dust, smoking, is an independent, added risk factor for TB (Hnizdo, Murray 1998)

23. 1. TUBERCULOSIS Smoking increases risk of Acquiring TB Severity of TB (Altet-Gomez et al. 2005) Progression from latent to active TB Progression to disability Progression to death (Doll, Hill 1954) In SA: 20% of TB deaths due to smoking (Sitas et al. 1998) In SA: 20% of TB deaths due to smoking (Sitas et al. 1998)

24. 1. TUBERCULOSIS WHERE THERE’S SMOKE (and silica dust and HIV) THERE’S TB (NCAS Press release World TB day 24/3/06) Smoking is BAD for TB!

25. 2. CHRONIC OBSTRUCTIVE AIRWAYS DISEASE COAD Emphysema Chronic bronchitis SILICA DUST SMOKING TB

26. 2. COAD Smoking is a greater risk factor for serious disability from COAD than silica dust alone (Hnizdo 1992)

27. 2. COAD Figure 1: Attributable fractions for severe airflow limitation ( Hnizdo 1992) Combination dust and smoking, 40% Smoking, 42% Dust, 8% Other, 10%

28. 2. COAD Elimination of silica dust 48% Elimination of smoking 82% Estimated preventable fraction (Hnizdo 1992)

29. Suggestive association between silicosis and smoking (Hessel 2003) 3. SILICOSIS

30. Silica dust, radon and diesel particulate matter can cause lung cancer Smoking increases this risk (Hnizdo,Murray1998) 4. LUNG CANCER

31. Control of silica dust related diseases requires control of BOTH dust AND smoking

32. SMOKING AND HIV/AIDS 70 – 80% of HIV infected people smoke (Patel et al. 2005) Smoking may be associated with increased risk for acquiring HIV infection (Furber 2006) Smoking was not associated with increased risk of progression to AIDS (probably due to HAART -more research required)

33. SMOKING AND HIV/AIDS Patients on HAART Tobacco smoking independent risk factor for non-AIDS related mortality (true for non-HAART as well) Protease inhibitors side-effect dyslipidaemia (high cholesterol ) Risk for cardiovascular disease (Patel et al. 2005)

34. SMOKING AND HIV/AIDS Added health risks in HIV positive smoking patients HIV associated respiratory infections Accelerated lung damage HIV associated oropharyngeal lesions AIDS-defining and non AIDS-defining malignancies Cardiovascular disease (on HAART) (Patel et al. 2005)

35. SMOKING AND HIV/AIDS Tuberculosis is a leading cause worldwide of morbidity and mortality among HIV-infected people

36. Do you know your ABCs? D = don’t smoke! (NCAS press release, World Aids Day 2006) A = abstain B = be faithful C = condomise

37. PUBLIC HEALTH BURDEN HIV TB SILICA DUST SMOKING

38. SMOKING IN SOUTH AFRICAN MINES SMOKING IS PROHIBITED UNDERGROUND

39. SMOKING IN SOUTH AFRICAN MINES “Smoking in the workplace policy” – strategic focus on employee well-being and health promotion Objectives: To provide a healthy working environment To minimise harm due to secondary smoke To educate smokers about the harmful effects of smoking To provide advice, guidance and support to employees who wish to stop Identify high risk groups

40. Critical success factors for workplace policy Enabling environment- partnerships, stakeholder involvement, support NCAS, MHSC,WHO Evidence base Political will Tougher legislation SMOKING INTERVENTION PROGRAM

41. National Council Against Smoking (NCAS) Professional and expert advice Information pamphlets, self-help material Posters health information National quit line 011 – 720 3145

42. Mine Health and Safety Council Elimination of silicosis programme Milestones Holistic approach to occupational diseases Identified research on smoking in the mines

43. Research Question What are health care workers’ knowledge, attitudes and practices regarding prevention of smoking amongst gold mine workers … are there opportunities for implementing smoking interventions??? ROLE OF HEALTH CARE WORKERS

44. WHO initiatives: 2005 - World No Tobacco Day “Health Professionals against Tobacco” 2004 - Code of Practice on Tobacco Control for Health Professional Organisations – smoking history, brief advice and documentation as part of routine care ROLE OF HEALTH CARE WORKERS

45. Russell 1979: simple but firm advice from a general practitioner (GP) can result in 5% of smokers stopping Raw, McNeil, West 1999: 50% of smokers will stop after GPs advice, using established protocols and medication, savings of $700,00 per life year gained ROLE OF HEALTH CARE WORKERS

46. HCWs have a moral, ethical and professional obligation to assist people to stop smoking and prevent people from starting Popularly revered in the workplace and community Occupational and primary health care services on-site, accessible, high utilisation rate ROLE OF HEALTH CARE WORKERS

47. Conclusion WHO Tobacco Free Initiative 1999: There are only two causes of death that are large and growing worldwide TOBACCO HIV

48. Conclusion PREVENTION…….. is better than CURE…….

49. Conclusion “… the mining industry will do well to remember that mining is not just about rocks and rubble, but about people.” Minister of Minerals and Energy, Phumzile Mlambo-Ngcuka, Sheq Conference 2004

50. Conclusion At Gold Fields, we pride ourselves in enhancing workers’ health, and with the support of tougher legislation like the proposed Tobacco Bill, we can achieve leaps of excellence in occupational health and safety, not only at our operations but industry- wide in South Africa

51. Acknowledgements Gold Fields International Mining South Africa Pty (Ltd) School of Public Health, University of Witwatersrand, Johannesburg, South Africa National Institute for Occupational Health,National Health Laboratory Services,Johannesburg, South Africa National Council Against Smoking Mine Health and Safety Council (MHSC) for funding this project National Quit Line 011 – 720 3145

52. THANK YOU National Quit Line 011 – 720 3145

53. For Value Buy Gold Buy Growth Buy Gold Fields www.goldfields.co.za