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Burn to death


By Dr Upul Wijayawardhana

Smokers would hate me for saying this, but, it is proven beyond doubt that they not only burn themselves to death but also burn to death other innocents, so called passive smokers, who are forced to inhale the exhaled breath which contains a multitude of toxins, especially in enclosed spaces. Further, in addition to the initial discomfort of smelly hair and garments, the number of chronic illnesses passive smokers get is ever expanding, the latest addition being strokes. It has been known for a long time that passive smoking increases the likelihood of Coronary Artery disease, lung cancer, respiratory tract infections, Middle ear disease, Sudden Infant Death Syndrome and the birth of infants with low birth weight; all resulting, ultimately, in higher death rates.

I have read with great interest the obstacles placed in the path of anti-smoking measures in Sri Lanka including some correspondence alleging that this is due to the dishonesty of our politicians. Let me reassure you that Sri Lanka is not unique there being manoeuvrings by Cigarette manufacturers all over the world. There has been recent back tracking by the UK government as well, postponing legislation to compel sales of cigarettes in plain packaging.

Having seen many young patients with Coronary Artery disease, in my practice as a Cardiologist in Sri Lanka quite sometime ago, whose only identifiable risk factor was smoking, when I took a lead in the anti-smoking campaign, the obstacles I encountered were many. I have good reasons to believe that Ceylon Tobacco Company did its best to ‘catch’ me unawares and, perhaps, was behind some of the campaigns to tarnish my reputation.

I remember the Health camp that was arranged by the Sri Lanka Medical Association, co-sponsored by the Lions Club, in Beliatta, the electorate of Dr Ranjith Atapattu. I can not remember the exact year but well remember that I was the Honorary Secretary of the SLMA then and Dr Atapattu was the Minister of Health, the proper minister, before the crazy decision of the ‘old fox’ J R J to divide it to a Ministry of Teaching Hospitals and a Ministry of Health! Few days before the event, a gentleman turned up in my humble abode in Summit Flats and handed over a bundle saying "Doctor, these are the details of the Health Camp" and left quickly adding "You are the star of the show!"

That undeserved eulogy made me suspicious. This made me open the bundle which I may have left unopened had it not been for the remark. I was in for a rude shock when I noticed the layout of the programme for the Health Camp; at the two top corners, Lions logo was on one side and the logo of Ceylon Tobacco was on the other side! On enquiry, I found out that the gentleman who came to see me held a very high position in the Lions Club and was the Public Relations Director at Ceylon Tobacco. Obviously, he was trying to equate Health with Tobacco! I knew I could not be a part of this Health Camp and rang the President of SLMA, immediately, requesting cancellation of the Health Camp but he had a more sensible approach stating that it was too short a notice to do so but agreed that I could keep away, if I wished to. Fortunately, I knew Dr Atapattu well enough to ring him and let him know of my decision. I do not think, being the gentleman he is, Dr Atapattu held this against me. I am sure he was aware that I was head-strong!

Tobacco industry was then, and still is keen to attract children and ladies to increase their sales. If any school wanted a cricket score board all they had to do was to appeal to Ceylon Tobacco which would have gladly provided one with a large a cigarette on top! With every score, youngsters would be looking at that fag!

There were photographs in publications meant for ladies which attempted to make smoking fashionable. I can not forget the editorial written by a lady editor, in a weekly meant for ladies, wherein she attacked me personally stating: "this famous Cardiologist had made it his zeal to prevent us from smoking but we should be independent and tell him to role up his opinions and poke it up his ...!" Obviously, she was sponsored by the tobacco industry! She had the right to challenge me on facts but as all she did was to ridicule me, I contacted the Managing Director of the Newspaper group, who was very surprised by the remarks. No doubt she would have got the punishment she deserved but her ‘sponsors’ would have been very satisfied that they scored a ‘goal against me’

I just added two snippets to the volumes and volumes that have been written on the manipulations of the Tobacco industry which continues to date, in spite of smoking killing over 6 million smokers and passive smokers, every year, across the world, as they wield tremendous economic power over many countries of the world. It is very interesting to note that, to start with, smoking was promoted as a healthy habit and was considered ‘normal’. I remember the days when we ‘non-smokers’ had to fight for the few ‘non-smoking’ seats available on aircraft!. At a WHO meeting we discussed this and resolved to request all Airlines to designate ‘smoking’ seats, making non-smoking’ the normal. I met Capt. Rakhitha Wickramanayaka, Chairman of AirLanka, to request him to implement this to make ‘Air Lanka’ the first Airline in the world to do so but, unfortunately, a golden opportunity was missed.

Although there were a few German reports associating lung cancer with smoking in 1940s, the first definitive report was by Richard Doll, most reputed Epidemiologist of the 20th century, and Austin Bradford Hill, the pioneering Statistician who introduced Randomised Controlled Clinical Trials to Medicine, which was published in the British Medical Journal of September 30, 1950. It was a retrospective case controlled study which highlighted the possibility that increased incidence of lung cancer was due to smoking. They set up in 1951, with sponsorship from the Medical Research Council, the British Doctors Study which showed in 1956, with statistical proof, that smoking increased the risk of lung cancer. This study, which continued till 2001, while providing evidence for increased heart attacks and many other cancers due to smoking, established that smoking reduces life span by about ten years. More important was the demonstration that stopping smoking reverses the harmful effects, which was more pronounced for Coronary Artery Disease.

Taking the cue from these pioneering studies, the Surgeon General, the Chief of Public Health as designated in USA, appointed an expert committee which published the first report in January 1964. A number of reports have been published since, all of which have highlighted harmful effects of smoking as well as passive smoking. Preface by the acting Surgeon General, in the report published to commemorate 50 years since the publication of the original report, states:

"On January 11, 1964, Luther L. Terry, M.D., the 9th Surgeon General of the United States, released the first report on the health consequences of smoking: ‘Smoking and Health: Report of the Advisory Committee of the Surgeon General of the Public Health Service.’

That report marked a major step to reduce the adverse impact of tobacco use on health worldwide.

Over the past 50 years, 31 Surgeon General’s reports have utilized the best available evidence to expand our understanding of the health consequences of smoking and involuntary exposure to tobacco smoke. The conclusions from these reports have evolved from a few causal associations in 1964 to a robust body of evidence documenting the health consequences from both active smoking and exposure to secondhand smoke across a range of diseases and organ systems.

The 2004 report concluded that smoking affects nearly every organ of the body, and the evidence in this report provides even more support for that finding. A half century after the release of the first report, we continue to add to the long list of diseases caused by tobacco use and exposure to tobacco smoke. This report finds that active smoking is now causally associated with age-related macular degeneration, diabetes, colorectal cancer, liver cancer, adverse health outcomes in cancer patients and survivors, tuberculosis, erectile dysfunction, oro-facial clefts in infants, ectopic pregnancy, rheumatoid arthritis, inflammation, and impaired immune function. In addition, exposure to secondhand smoke has now been causally associated with an increased risk for stroke.

Smoking remains the leading preventable cause of premature disease and death in the United States. The science contained in this and prior Surgeon General’s reports provide all the information we need to save future generations from the burden of premature disease caused by tobacco use.

However, evidence-based interventions that encourage quitting and prevent youth smoking continue to be underutilized. This report strengthens our resolve to work together to accelerate and sustain what works—such as hard-hitting media campaigns, smoke free air policies, optimal tobacco excise taxes, barrier-free cessation treatment, and comprehensive statewide tobacco control programs funded at CDC-recommended levels. At the same time, we will explore "end game" strategies that support the goal of eliminating tobacco smoking, including greater restrictions on sales.

It is my sincere hope that 50 years from now we won’t need another Surgeon General’s report on smoking and health, because tobacco-related disease and death will be a thing of the past. Working together, we can make that vision a reality."

In spite of his optimism, more than 42 million Americans still smoke though the prevalence of smoking has come down from 42% in 1965 to 18% in 2012. I greatly doubt smoking would be eradicated in 50 years time.

In the United Kingdom, it is estimated that about 100,000 deaths a year are attributed to smoking, mostly due to lung cancer, chronic lung disease and coronary heart disease, and for every death 20 smokers are suffering from smoking related diseases. Smoking is the leading cause of preventable death in UK and kills more than obesity, alcohol, road traffic accidents, illegal drugs and HIV, collected together.

The position in Sri Lanka is summarised in the website of the National Authority on Tobacco and Alcohol as follows:

"The tobacco industry has had a strong influence on successive governments in Sri Lanka. The annual taxes from tobacco products amount to Rs. 37 billion (about 8% of total revenue). Legislation to control tobacco had been successfully stalled by the industry. However, during the presidential campaign in 2005, the control of tobacco, alcohol and dangerous drugs emerged as an issue. The first paragraph of the election manifesto of the current President of Sri Lanka, His Excellency Mahinda Rajapaksa, promised to end the dope menace by legislation. The NATA Act No. 27 of 2006 was certified in parliament on 26 August 2006 and became legally operative on 1 December 2006. The NATA committee consisting of 9 ex-officio members representing stakeholder departments and 5 nominated by the President was appointed on 9 January 2007. When the WHO/FCTC came into force in 2005, Sri Lanka was the first Asian country and the fourth in the world to ratify it. The political context in which this project will take place is therefore propitious. Given the favorable circumstances, Sri Lanka’s journey to a tobacco-smoke-free environment need not be unduly long, and it has already begun.  

Tobacco killed 100 million in the 20th century. Unless urgent action is taken to reverse it, the current global tobacco epidemic could kill 1000 million in the 21st century. Eighty percent of them would be in the third world, to which Sri Lanka belongs.

Sri Lanka is an island in the Indian Ocean in South Asia, 65,000 km2 in area, divided into 9 administrative provinces. Its population is some 20 million, with over 90% being literate. Its estimated annual mortality from tobacco related illnesses is 20,000. Sri Lanka’s recent transition from a long standing low-income country to a middle-income country has been associated with a change in its pattern of mortality and morbidity. Non Communicable Diseases (NCDs) have become the leading cause of morbidity and mortality and tobacco has appeared as the second biggest cause of all deaths and disabilities from NCDs. 

According to the latest WHO Report on the Global Tobacco Epidemic 2008, in Sri Lanka 29.9% of male and 2.5% of female adults are current smokers. According to the Global Youth Tobacco Survey conducted in 2007, 5.1% youth (13 – 15 years) ever smoked tobacco cigarettes, 39.5% of them smoked cigarettes before age 10, 8.6% are current users of other tobacco products and 69.5% are exposed to second hand smoke in public places. It is against the backdrop of these trends that the provisions of the Act No. 27 of 2006 became operative from 1 December 2006. They were especially designed to protect young people who tend to experiment with cigarettes because they underestimated the health risks and addictive power of tobacco. Social pressures calculated to seduce the young the young to indulgence in tobacco include alluring "non-ads" in the form of movies which contain episodes associating tobacco smoking with success, strength, independence and glamour. Those who emphasize the significant contribution of tobacco to the economy underestimate the negative economic costs of tobacco. The harm done to poor smokers and their families by the divergence of scarce family income to buy tobacco products is significant. In many poor families children go hungry because their fathers are tobacco addicts. Thus, the overall context in which this project will take place has necessarily to be a global one given Sri Lanka’s unique historical, cultural, economic and political environment."

It is evident that we have identified the problems and there is, again, optimism which I am not sure is justified, as tobacco companies are trying new ‘tricks’. Continuing pressure on rulers by the masses is more important than ever!

To help smokers to quit, different forms of Nicotine substitution treatments have been introduced with a degree of success. They include Nicotine patches, sprays, chewing gum etc. The latest addition are the ‘E-cigarettes’ which mimic cigarettes. These were launched by small companies but, in a sinister move, have been bought over by cigarette manufacturers probably to prevent further ‘de-normalization’ of smoking. Otherwise, why should they invest in a product that will reduce the consumption of their primary product? It is interesting that ‘E-cigarettes’ have started to appear on movies and are being advertised instead of the real thing. Obviously, though they deny, cigarette manufacturers want to promote smoking of ‘E-cigarettes’ in the hope that those who start on these (in contrast to those who use them as an aid to quitting), especially children and young adults, would graduate from ‘E-cigarettes’ to the ‘real thing’

Cigarettes is a multi billion dollar business and the manufacturers will not give up easily. The little respect I had for Maggie Thatcher, I lost when I learnt that she was paid millions to advice on how to promote smoking in developing countries, which is their target. We need to continue our fight to prevent the ‘foolish’, the gullible and the ignorant from burning themselves and others to death!

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