Medical Bytes with Dr. K
Sera walked down the street with a cigarette in one hand, wisps of smoke floating from her mouth, and carrying a very expectant abdomen. Her doctor had advised and encouraged her to quit smoking. But she just couldn’t give up the smokes. Despite being 32 weeks pregnant, she continued to smoke up to 20 cigarettes a day. Then one morning Sera woke up at 5am with abdominal cramps and vaginal bleeding. She was rushed to the hospital. On arrival there was no fetal heart sound and unfortunately, a stillbirth. Tears rolled down her cheeks. This was her second stillborn child. Meanwhile, 45-year-old Ramu started smoking when he was only 12 years old. Now he smokes up to 30 cigarettes a day. He’s had numerous attempts at quitting – all unsuccessful. For the past three months he’s been coughing profusely, feeling tired, and losing weight. Finally he paid a visit to his General Practitioner who organised a chest x-ray. Unfortunately Ramu was diagnosed with advanced lung cancer and survived for only two months after the diagnosis. On the other side of town, 70-year-old Jim was diagnosed with chronic lung disease 10 years ago. He had to cough every morning with copious white phlegm and constant wheezing. His doctor had prescribed regular inhalers to improve his condition. Despite this, he continued to smoke up to 40 cigarettes a day. Jim’s specialist had advised him that his oxygen levels were low and that he needed home oxygen to improve his situation. But because Jim was a smoker, he could not be prescribed oxygen as he could set fire to himself while smoking. So Jim ended up house bound as he could barely walk without feeling short of breath. All three of these people have one thing in common - the addiction to a thin cylinder of finely cut tobacco rolled in paper - the dreaded cigarette! There are more than 7,000 chemicals in cigarette smoke and more than 70 of these are linked to cancer (US Food and Drug administration). These chemicals include nicotine, tar, carbon monoxide, ammonia, formaldehyde, hydrogen cyanide and arsenic to name a few – some of the same ingredients used to make rat poison, lighter fuel, batteries, and rocket fuel. The cigarette’s addictive nature comes from nicotine’s stimulant effect. With every puff it causes a person to crave for more and more. Globally about 15 billion cigarettes are sold daily or about 10 million every minute. There are 1.1 billion tobacco users in the world – equivalent to the entire population of India and more. This number is expected to increase to 1.6 billion over the next 2 decades. What’s alarming is 80% of the 1 billion smokers live in low-and middle-income countries. This includes Fiji. According to the latest STEPwise approach to chronic disease risk factor surveillance (2011), 16.6% of Fijians smoke every day, and the average age for taking up smoking has gone down from 22.2 to 20.7 years. In 2016 the World Health Organization (WHO) reported the prevalence of smoking in persons 15 years and older. Fiji ranked number 38 with 25.7% prevalence. Iran ranked 84 with 11.1% prevalence, which was the lowest. The prevalence in New Zealand was 16.3% and in Australia was 14.9%. We can see that Fiji has a fairly high prevalence of smoking amongst people over the age of 15. It is four times more common in males at 23.6% of the total smoker population in Fiji, compared to women at 5.1%. May 31st marks World No Tobacco Day. This year the theme is “Tobacco - a threat to development.” About six million people die from tobacco use every year. This is expected to grow to more than eight million a year by 2030 without intensified action. Tobacco use is a threat to any person regardless of age, gender, race and cultural or educational background. It brings suffering, disease and death. It drains families and national economies. Tobacco use decreases productivity and increases health-care related costs. Tobacco use worsens health inequalities and exacerbates poverty as poor people prioritize cigarettes and spend less on basic necessities -- food, healthcare and education for their children. Other than the effects on human beings, tobacco use also affects the environment. Growing tobacco requires a large amount of pesticides and fertilizers. These can be toxic and pollute water supplies. Tobacco growing uses about 4.3 million hectares of land resulting in global deforestation between 2%-4% (WHO). With all the information that is available about the harmful effects of tobacco, why are we still continuing with this practice? What can we do to eliminate tobacco from society and the world? If you are a smoker and have decided you want to quit, making a pact with yourself is not enough – otherwise you’d likely have quit already. It is, however, an essential first step. Then there are a few methods that you can try, if you want the best chance of success. Most people successfully quit smoking when they use some sort of nicotine therapy. This could involve applying a nicotine patch, nicotine lozenges or gums. For most people who smoke, there are certain triggers that cause them to crave cigarettes. This includes smoking when stressed, at lunch breaks or when out with friends. Trigger avoidance is important so that you actively avoid the situations that make you feel like you need a cigarette. For example if you normally smoke at lunch time, then do something else to keep yourself distracted and engaged. Going cold turkey is a very successful method. This is when you decide that you will never take another cigarette again. Of course this requires a lot of planning, support from people around you and intense willpower. The other option would be
to slowly cut down on cigarette use until you no longer need another cigarette. Quitting is something personal and each individual has to find the method that works for him or her. On the global scene the WHO framework Convention on Tobacco Control (WHO FCTC) guides the global fight against the tobacco epidemic. It is an international treaty with 180 parties (179 countries and the EU) and Fiji is a member. Today at least half the world’s countries, representing nearly 40% of the world’s population, have implemented at least one of WHO FCTC’s most cost-effective measures to the highest levels. Fiji has adopted some of these measures. In 2010, the government of Fiji Tobacco Control Decree came into effect. This decree includes prohibiting advertising and promotion of tobacco products. It also looks at labeling of tobacco product containers so that there are obligatory health warnings and tar and nicotine content labeling. There are also restrictions on sale and smoking of tobacco products and prohibition on supplying tobacco to persons under 18 years old. Smoking is also prohibited in certain public areas and buildings. There is a spot fine of $200 for smoking in public places that needs to be strongly enforced, as there are many people who continue to smoke in public places without consequences. At the moment, 44% of the cost of cigarettes is tax. Increasing this tax may further discourage cigarette sales. Nicotine replacement therapy is quite expensive in Fiji and if the cost of this were subsided by the government, it would encourage more people to try this method to quit smoking. A quit-line would also help support those who are attempting to quit. This is essentially a free telephone service that supports people through the effort to stop smoking. Banning all forms of direct and indirect advertising can also create a more positive attitude to avoiding tobacco. So on 31 May, let’s vow to make every day a “no tobacco day”. Wise words from Ian Fleming: “Smoking I find the most ridiculous of all the varieties of human behavior and practically the only one that is entirely against nature. Can you imagine a cow or any other animal taking a mouthful of smoldering straw then breathing in the smoke and blowing it out through its nostrils?” Till we meet next month, live, love, laugh and have a smokefree time!
“If you are a smoker and have decided you want to quit, making a pact with yourself is not enough – otherwise you’d likely have quit already.”
DR. KRUPALI RATHOD TAPPOO is an Australian qualified General Practitioner, a Fellow of the Royal Australian College of General Practitioners and the Medical Coordinator for Fiji-based NGO Sai Prema Foundation. Dr. Krupali is based at Mitchells Clinic in Tappoocity Suva and has a special interest in women and children’s health.