Behavioral approaches to control noncommunicable diseases: lessons learned from global tobacco control

Transcription

1 Behavioral approaches to control noncommunicable diseases: lessons learned from global tobacco control Abu S Abdullah MBBS., MPH., PhD., FFPH(UK), FHKAM(HK) Duke Global Health Institute Duke University & Duke Kunshan University abu.abdullah@duke.edu

2 Outline Global overview of chronic NCDs Preventable behavioural risk factors to combat chronic diseases Give examples of interventions in tobacco use prevention and cessation Summarise potential strategies and barriers to target other chronic disease risk factors Discussion

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4 Chronic NCDs: a pandemic and a global problem

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6 The epidemiologic transition What changes in lifestyle and living conditions accompany the epidemiological transition? Lifestyle transition - behaviors (e.g. smoking, sedentary habits) - nutritional transition (e.g. increase fat, decrease complex carbohydrates) Drivers are: industrialization, urbanization and globalization of world markets and mass media

7 Urbanisation 100 Urban population as % of total North America Latin America & Caribbean Europe Oceania WORLD Asia Africa

8 McDonalds one of 580 outlets in China

9 The epidemiologic transition What are the results of epidemiologic transition?

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11 Changing Global Disease Burden Respiratory infectious Diarrheal Diseases Perinatal condition Major Depression Ischemic Heart Disease Ischemic Heart Disease Major Depression Traffic Accidents Cerebrovascular Disease Chronic Obstructive Pulmonary disease Source: WHO

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14 Causes of chronic diseases

15 Should we address behavioral risk factors to combat Chronic disease? Modifiable risk factors account for ~50% of premature deaths in the US Spending on preventable diseases accounts for 70% of total health care spending Effective behavioral intervention is available

16 Multiple risk factors are common For example, nearly 60% of US adults have 2 or more behavioral risk factors Am J Preventive Medicine 2004

17 Risk factor combination Among smokers - 46% overweight or obese - 61% inactive - 34% risky drinkers Among overweight or obese - 19% smoke - 62% inactive - 20% risky drinkers

18 Good news is that- Many of the risk factors are modifiable For example, 80% of cases of CHD, 90% of type 2 diabetes cases, and one-third of cancers could be avoided by changing to a healthier diet, increasing physical activity and stopping smoking

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20 Noncommunicable Diseases 4 Diseases, 4 Modifiable Shared Risk Factors Tobacco Use Unhealthy diets Physical Inactivity Harmful Use of Alcohol Cardiovascular Diabetes Cancer Chronic Respiratory Noncommunicable Diseases World Health Organization ECOSOC High-level Segment

21 How do we prioritize the interventions to pursue?

22 The case of tobacco

23 Smoking Rates in Selected US & Canada 20% 29%* Mexico 50% 59% 10% 19% Men Developed countries = 35% Developing countries = 50% Prevalence declining at extremely slow rates Countries 1.25 billion smokers worldwide 1 UK 20% 29% Spain 40% 49% 20% 29% Brazil 30% 39% 20% 29% Norway 30% 39% France & Germany 30% 39% Italy 30% 39% 10% 19% Turkey 60% & above 20% 29% China & Taiwan 60% <10% Australia 20% 29% 10% 19% Japan 50% 59% 10% 19% Men Women Both Women Developed countries = 22% Developing countries = 9% Prevalence declining in some countries (US, UK, Australia, Canada), but not in others (southern, central, eastern Europe) *23% US 2 ; 20%-30% Canada Mackay J, Eriksen M. The Tobacco Atlas. World Health Organization; Giovino G. Oncogene. 2002;21: Lemiere C, Boulet LP. Can Respir J. 2005;12:79-80.

24 Trend of Smoking Rate in adults in China ( 年 ) Male Female Urban Rural Prevalence of smoking in adults 15-69

25 ??? How many disease conditions are caused by tobacco?

26 Smoking is The Leading Preventable Cause of Disease and Death 1 Cancer Lung (#1)* Oral cavity/pharynx Laryngeal Esophageal Stomach Pancreatic Kidney Bladder Cervical Leukemia Cardiovascular Ischemic heart disease (#2)* Stroke Vascular dementia 2 Peripheral vascular disease 3 Abdominal aortic aneurysm Active Smoking Other Adverse surgical outcomes/ wound healing Hip fractures Low bone density Cataract Peptic ulcer disease Respiratory COPD (#3)* Pneumonia Poor asthma control Reproductive Low birthweight Pregnancy complications Reduced fertility SIDS *Top 3 smoking-attributable causes of death. In patients who are Helicobacter pylori positive. COPD = chronic obstructive pulmonary disease; SIDS = sudden infant death syndrome. 1. Surgeon General s Report. The Health Consequences of Smoking; Roman GC. Cerebrovasc Dis. 2005;20(Suppl 2): Willigendael EM et al. J Vasc Surg. 2004;40:

27 Risks Associated With Exposure to Secondhand Smoke Increases risk of lung cancer by 20% 30% 1,2 Worsens pre-existing lung disease, including asthma, COPD, and emphysema 2 Increases children s risk of asthma exacerbation, middle ear disease, and otitis media 2,3 Increased risk of fatal and nonfatal cardiac events 4 1. National Toxicology Program. 11th Report on Carcinogens; Available at: 2. Mackay J, Eriksen M. The Tobacco Atlas. World Health Organization; Samet JM. Tobacco Control. 2004;13(suppl 1):i57 i Glantz SA, Parmley WW. JAMA. 1995;273:

28 Also, exposure to Thirdhand smoke

29 Survival Among Male UK Physicians Born : Smokers vs Nonsmokers Percentage Survival From Age Cigarette smokers Non-smokers years Years 4 2 Doll R et al. BMJ. 2004;328:

30 Global Health Impact of Tobacco Leading preventable cause of death worldwide Tobacco kills up to ½ of its regular users Tobacco use is responsible for 1 in 10 deaths 5.4 million people die of tobacco each year If nothing changes, tobacco will kill 1 billion people in the 21 st century (vs 100 million in the 20 th century) World Health Organization Report on the Global Tobacco Epidemic, 2008

31 Developing countries will suffer the most 2000: 4 million deaths/year 2030: 8-10 million deaths/year The Tobacco Atlas, Geneva: World Health Organization, 2000.

32 ??? Why does people smoke? Why does anyone become regular smoker?

33 Why does anyone smoke cigarettes regularly? Aroma? Flavour? Taste? Enjoyment? Addiction?

34 Why does anyone become a regular adult smoker?

35 Commitment on youth smoking

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37 Additing to these, aggressive promotional campaigns of tobacco industries.

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39 What Can be Done to Reduce Tobacco Use? Effective actions to reduce tobacco use are recommended by the Framework Convention on Tobacco Control (FCTC) A set of evidence-based policies to reduce tobacco use that countries agree to adopt Ratified by 169 countries FCTC Articles are translated into action steps in the WHO s 2008 MPOWER report

40 Policies to Reduce Global Tobacco Use M onitor tobacco use and tobacco control policy P rotect people from tobacco smoke O ffer help to quit tobacco use W arn about the dangers of tobacco E nforce bans on tobacco advertising, promotion R aise taxes on tobacco MPOWER: WHO Report on the Global Tobacco Epidemic 2008

41 The tobacco harm prevention pyramid How can we promote tobacco use prevention and cessation? Pharmacotherapies Clinical Simple advice & support Assess stage of change Community Prevent public place smoking and prevent workplace smoking Prevent nicotine addiction in children Legislation Legislation Legislation

42 Examples of behavioral interventions to promote cessation

43 Smoking cessation in the clinical setting: SCHC Ruttonjee Hospital, Hong Kong SAR 3 evening sessions a week (6-9 pm) Counselling plus one week NRT: all free

44 Counseling Individualized ~30 minutes Trained counselors Problem-oriented

45 Evaluation of the clinic (First 17 months operation) Quitting 7 day point 12 months Attenders n = 841 Quit % = 39 Intention to treat n = 1203 Quit % = 27 Continuous cessation for 80% yr Attenders n = 841 Quit % = 25 Intention to treat n = 1203 Quit % = 18

46 Quitting by Adherence Adherence (N=170) Non-Adherence (N=725) p < Quitting % (95% CI) 43 (35-50) 29 (26-32)

47 Abdullah AS et al. Establishment and evaluation of a smoking cessation clinic in Hong Kong: a model for the future service provider. Journal of Public Health Medicine 2004; 26:

48 2. Reactive approach for smoking cessation: Quitline Reactive (smoker or sig other initiate the calls) Free counselling 38 hours per week Low budget

49 Objectives To provide a telephone-based counselling service to smokers who are interested to quit smoking; To give advice to non-smokers who want to avoid second hand smoking; To give advice to non-smokers to help their friends/family members to quit smoking.

50 Services Quitline service offers: Smoking cessation counseling - stage matched; Health information on smoking; Smoking cessation information packs; Follow up interview and evaluation.

51 The Smoking Cessation Quitline Quitline manned by counsellors 5554 callers over 15 months 1120 smokers 654 contact information Quit rates at 6 mths(7 day abstinence) * Available follow up 20% * Intention to treat 12%

52 Abdullah AS et al. Which smokers use the smoking cessation Quitline in Hong Kong and how effective is the Quitline? Tobacco Control 2004; 13:

53 3. Proactive approach for smoking cessation: Tel based counseling Randomized controlled trials on proactive telephone counseling targeted at smoking parents of young children

54 Objectives The purposes of this study is- To examine whether telephone counseling based on the transtheoretical model of behavior change together with educational materials could help smoking parents of young children to quit.

55 Results 952 smoker fathers and mothers Quit rate at 6 months (7 day abstinence) Intervention group: 17.6% Control group: 10.5% (P<0.005)

56 Abdullah AS, Mak YW et al. Smoking cessation intervention in parents of young children: a randomized controlled trial. Addiction 2005; 100:

57 Evidence Vs Advocacy Evidence from these initial work was used to promote territory wide and regional - Smoking cessation service - Research - Education - Policy formulation

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59 Global Tobacco Use Prevention and Cessation Initiative: Networking with China, Bangladesh, india, Vietnam, Japan, S Korea, Thailand and.

60 China Abdullah AS, Samet J et al. A review of tobacco smoking and smoking cessation practices among physicians in China: Tobacco Control 2011:1-6.

61 China Yang T, Abdullah AS, et al. Assessment of Tobacco Control Advocacy Behavioral Capacity among Students at Schools of Public Health in China. Tobacco Control, 2011 ;20(1):20-5

62 Leaders and experts in the capacity bldg workshop.

63 The project kick off ceremony in Zhejiang University.

64 China CHWs to promote SHS exposure risk reduction Abdullah AS, Hua F, et al. Second hand smoke exposure and household smoking bans in Chinese families: a qualitative study. Health & Social Care in the Community 2011: 1-9.

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67 China Healthcare system-based approach to address NCD risk factor reduction - System change in the Chinese pediatric setting and pediatrician capacity building

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69 HK Chan SC, Lam TH, Leung YD, Abdullah AS. A randomised controlled trial of a smoking reduction plus NRT intervention for smokers not willing to quit smoking. Addiction, 2011; 106(6):

70 Bangladesh Working with local partners to generate local evidence for policy change and intervention delivery Abdullah AS, Hitchman SC, et al. Socioeconomic differences in exposure to tobacco smoke pollution in Bangladeshi households with children: findings from the international tobacco control Bangladesh survey. Int J Environ Res Public Health. 2011;8:

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72 Kingdom of Saudi Arabia Memish ZA, Abdullah AS, Saeedi MY, Salloum RM, Almadani AJ, Abid O. Methods and status of a comprehensive community-based intervention focusing on non-communicable diseases and the major risk factors in the Kingdom of Saudi Arabia. The Crown Health Project Saudi Med Journal 2013; 34:

73 But, barriers exists in many countries!!

74 Possible barriers?-1 Economic factors (lack of priority in resource allocation) Lack of awareness/interests Low perception of risks Lack of policies that promote cessation Lack of training programs Abdullah and Husten, Thorax 2004

75 Possible barriers?-2 Smoking behaviour of service providers Poor healthcare systems Lack of infrastructure Industry action Abdullah and Husten, Thorax 2004

76 Lessons Learned Promotion of smoking cessation is feasible and effective; and should be tested for local replication Lessons learned in one population could be pilot tested in another Lessons learned from tobacco use cessation could be tested for physical inactivity, harmful use of alcohol and unhealthy diets prevention

77 Discussion questions What are the opportunities and challenges to applying lessons learned from tobacco use prevention and cessation to other behavioral risk factors? Is there an evaluation base supporting the application across risk factors?

78 Challenges in Addressing the Problem Limited understanding of what works Institutional (& workforce) capacity constraints Lack of coordination across sectors Lower level of investment on prevention than in addressing the disease Socio-cultural and religious issues

79 There is a need

80 Whole system approach to address chronic diseases NEED: Government commitment: policy, regulations, system change Population/community-based programs International support: capacity building, resources Framework convention for??obesity control (FCOC)??alcohol control

81 Thank You