‘The true face of tobacco is disease,death and horror

by Dr Anula Wijesundere  
Chairperson, Sri Lanka Medical Association Expert Committee on Alcohol, Tobacco & Illicit Drugs.
Vice President, Sri Lanka Temperance Association
President, Success, Colombo

Annually, the 31st day of May has been declared by the World Health Organization as the “World No Smoking Day”. The objective of this declaration was to encourage all persons smoking or chewing tobacco to quit for at least 24 hours and also create awareness amongst the people about the dangers and health risks of smoking. The theme this year is “Protecting children from tobacco industry’s interference” The theme is focused in advocating for an end to targeting of children to harmful tobacco products.

The tobacco epidemic is one of the biggest medical, public health, social, environmental and economic threats the world has faced, killing over 8 million people from tobacco use annually. This includes an estimated 1.3 million non-smokers who are exposed to the toxins in tobacco smoke.

Smoking: the global disease burden

 The WHO estimates 1.3 billion smokers worldwide of which   800 million are from the developing world.

 Globally 8.7 million deaths occur annually out of which   1.3 million deaths occur from second hand smoking.

 Globally 11,000 deaths occur daily.

 Smoking kills one person every 8 seconds somewhere in the world.

In 2020, 23.3, % of the world population used tobacco: 36.7 % of men and 7.8 % of women.

A loss of 20 years in life expectancy is observed amongst smokers.

The annual healthcare expenditure on diseases related to smoking is US $1.4 trillion

 Smoking is the largest, single and preventable cause of death in the developing world.

From World Health Organization (WHO)

https://www.who.int campaign.

WHO Global Report on trends in prevalence of tobacco use 2000 -2025

Tobacco use: The Sri Lankan Scenario 

 19.4% overall (3.2 million adults), 36.2% of men, and 4.9 % of women currently use tobacco. (1)

  9.1% overall (1.5 million adults), 19.7% of men, and < 0.1% of women currently smoked tobacco. (1)

13.4 overall (2.2 million adults), 23.4% of men, and4.9% of women currently used smokeless tobacco. ,(1)

Currently over 1.5 million Sri Lankans smoke 7.74 million cigarettes daily. (2)

Sri Lankans spend Rs 520 million daily or Rs 189.8 billion yearly on tobacco use (2)

 20,000 Sri Lankans die annually from tobacco related diseases. (3)

57 people die a day due to tobacco use (3)

 Annual health care expenditure related to diseases associated with smoking alone is Rs 89.37 billion. (3)

The above statistics clearly showcase the heavy burden on the state resulting from tobacco use.

From: (1). GATS Global Adult Tobacco Survey. Fact Sheet Sri Lanka 2020.

(2)  Sri Lanka Customs and CTC Price Notice Data. Cigarette Sales and Expenditure in 2022 – Compiled by ADIC

(Alcohol & Drug Information Centre)

(3)  National Authority on Tobacco & Alcohol. Fact Sheet 2018. Be Free from Tobacco

The Nature and Composition of Cigarettes:

No level of tobacco inhalation is safe for your health.  Considering that tobacco kills more than half its regular uses, tobacco is indeed rotten, inside out and outside in… Thus, smoking can be justifiably called suicidal to the smoker. As passive smoking is equally harmful to family members, tobacco can be considered homicidal as well.  Furthermore, smoking is extremely teratogenic to the unborn baby and tobacco can therefore referred to as an infanticide too.

Tobacco smoke contains more than 3000 toxic chemicals.  Of this number about 300 chemicals are associated with a variety of diseases, while 50 have been proven to be carcinogenic. Among other chemicals, tobacco smoke contains nicotine, toluene, butane, ammonia,cadmium, hydrogen cyanide and carbon monoxide.

The hazards of tobacco inhalation are clearly evident when we realise that its constituents are utilised to produce many toxic compounds. Nicotine is used commercially to make insecticides.  Toluene is an industrial solvent while ammonia is found in toilet disinfectants.

 Cigarette lighter fluid contains butane while carbon monoxide is the gas that emanates from car exhaust fumes.  Cyanide capsules were utilised by the   LTTE terrorist suicide carders.

Tobacco and Nicotine –

Nicotine is the single most active ingredient in tobacco with numerous toxic effects. Without nicotine addiction there will be no tobacco industry. This certainly destroys the legal status that smoking is a matter of choice. Nicotine is addictive, psycho active, and induces tolerance.  Most importantly, nicotine apart from its toxicity, is carcinogenic, atherogenic, mutagenic and teratogenic.

Smokeless Tobacco / e cigarettes/ vaping devices / electronic nicotine devices.

Sri Lanka faces a mounting crisis as vaping gains popularity among women and schoolchildren. Although the incidence of smoking tobacco among women is very low at < 0.1%, 4.9% of women currently used smokeless tobacco. (1).  E cigarettes are banned in Sri Lanka but are smuggled in through air ports and sea ports. And found in several schools

 E cigarettes are currently sold and distributed on line as electronic devices which contain liquid nicotine. Their identification is difficult as they are manufactured in various forms as perfume bottles, wrist watches, pen drives and power banks, etc.

Vaping affects students as nicotine exposure can impact learning, memory and attention, and lead to increased risk of addiction to other illicit drugs. Every effort must be made to eradicate this menace and safeguard the future of the nation’s youth.

Smoking and Heart Disease.

Cardio vascular diseases (Heart attacks) are the leading cause of death globally and smoking is indeed   a major risk factor for heart attacks.

Smoking promotes formation of cholesterol containing unstable atherosclerotic plaques within the coronary arteries which rupture causing heart attacks.

Smoking increases the level of total cholesterol and the bad cholesterol – LDL

Smoking decreases the good cholesterol – HDL

Carbon Monoxide in smoke reduces myocardial blood supply.

Smoking increases the blood pressure.

The very act of smoking induces angina.

Smoking is an important contributory factor leading to strokes or brain attacks.??

Rupture of atherosclerotic plaques in the aorta can cause sudden death. (repeat)?

Smoking and diseases of the Respiratory System

The toxins within tobacco smoke cause diseases of the respiratory tract by the following detrimental effects.

1.Changing the nature of the mucosal cells lining the respiratory tract and making it pre-cancerous (squamous metaplasia)

2. Destroying the action of the cilia which wafts off pathogens entering the respiratory tract thus promoting disease.

3. Changing the nature of respiratory tract secretions making the secretions thick and viscid.?

The diseases of the respiratory tract associated directly with smoking are-

 chronic bronchitis, emphysema and carcinoma of pharynx, larynx and bronchus. Smoking also aggravates bronchial asthma and pneumonia and leads to pulmonary heart disease (Cor pulmonale).

 In 1955, Prof Richard Doll & Dr Bradford Hill clearly proved the direct association of smoking with bronchial cancer.  The incidence of bronchial carcinoma is twenty times higher among smokers than non-smokers.

Smoking & Cancer.: 

Smoking is also directly associated with carcinoma of the tongue, cheek, lips, nose esophagus, stomach, bladder, cervix pancreas, kidney and colon.

Other harmful effects of smoking,

These include gum infection, gastric and duodenal ulceration, peripheral vascular disease with gangrene of toes and osteoporosis, leading to fractures.

Smoking also leads to deterioration of vision from toxic amblyopia and macular degeneration.

Maternal smoking during pregnancy

Maternal smoking can increase pregnancy loss via ectopic pregnancies and miscarriages. It is also very harmful to the unborn baby, resulting in the following detrimental effects in the baby.

Low birth weight babies – small for dates or pre term births with increased risk of illness disability and death.

Congenital abnormalities in the foetus

Poor cognitive function

Development of small tests with less sperms.

Smoking during pregnancy   also leads to delay in establishment of breast feeding and poorer quantity and quality of milk produced.

Smoking and male infertility

Smoking can make men impotent by reducing the blood flow to the penis and preventing an erection. Furthermore, smoking produces malformed sperms and reduces sperm counts. Cessation of smoking improves the sperm count and the quality.?

Environmental harm due to tobacco

Tobacco cultivation and consumption results in the pollution of air, water and soil. The cultivation of tobacco requires large amounts of pesticides and fertilisers which can be toxic and pollutes water supplies.  Each year tobacco cultivation uses millions of hectares of land leading to soil erosion and global deforestation. Tobacco manufacturing also produces    millions of tons of solid waste. Each year, trillions of cigarette butts are littered worldwide, with a significant portion finding their way to the oceans. Clearly tobacco is a global scourge that affects water, air and soil in a most deleterious manner, effecting sustainability and development globally.

 Cessation of Smoking

Smoking is the single most preventable cause of death worldwide.

Cessation of smoking is the most cost-effective healthcare intervention.

Prolongs life by at least 20 years.

Doctors and all health care personnel have a major role to play in helping smokers to quit smoking. Simply by telling a smoker to quit smoking is effective in 1 out of 10 addicts quitting the habit.

The advantages of overcoming smoking must be impressed briefly-

To have better health.

Be a role model for the children.

Protect the family from passive smoking.

Save the money wasted on tobacco for the betterment of the family.

Assist the smoker to stop smoking by providing counselling, non-tobacco pastels and treatment with nicotine replacement therapy if available.

The free help line introduced by NATA – “Call 1948 for free from tobacco ” has proved to be helpful and successful in overcoming tobacco addiction. This facility must be certainly be popularised and utilised to its fullest potential in the future.

Ending the tobacco menace

 In Sri Lanka the incidence of smoking has decreased as successive governments have prioritised the control of tobacco in the country. Special appreciation must be made of President Maithripala Sirisena who as the Minister of Health gave superb leadership to the campaign against tobacco consumption, earning the wrath of multinational tobacco companies.

  Sri Lanka was the first country in Asia and the fourth country in the world to ratify the WHO Framework Convention on Tobacco Control on 11th November 2003. The control of tobacco was further strengthened by the passage of the National Authority on Tobacco and Alcohol Control unanimously in the Parliament of Sri Lanka in 2006.

 The way forward to end the tobacco menace.

 1 Strengthen the NATA Act-

Strengthen current policies while addressing policy gaps.

Ban smoking in all public places – e.g.  parks, beaches, shopping malls, markets etc.  All public places to be included in the “No smoking zones. “

Ban on menthol flavoured cigarettes, e cigarettes, vaping machines, electronic nicotine devices must be implemented fully. Vigilance by custom officers at airports and sea ports is essential to confiscate these products to prevent circulation of these devices among school children.

 2. Amendments to the NATA Act.    Prohibition of the sale of single sticks of cigarettes completely. This is very important as single stick cigarettes circumvent the health warnings on packs and are much more affordable.

 3 Establishment of “smoke free zones “in each MOH area in the country, where no sales of tobacco products occur. Currently, the target of one zone in each MOH area has been achieved. Target for 2 zones in each area in the future.

4 Introduction of “Smoke Free Generation” for children born from 2010 onwards. This was successfully passed in the parliament of the United Kingdom recently.

The Sri Lanka Medical Association, NATA, ADIC and the Temperance Association of Sri Lanka hope to give leadership to promote

“Smoke Free Generations” from 2010 in the parliament of Sri Lanka in the near future

5 Correct Taxation from the Tobacco Industry is mandatory

Over the last decade incorrect, inadequate and irrational taxation of tobacco has led to a loss of Rs 200 billion for the Sri Lankan government. (ADIC Press release 2021) If the government was able to collect this money as tax revenue, these funds could have been utilized for development projects – hospitals, schools, irrigation projects and highways, for the health, education and the economic well-being of its citizens.  It is therefore imperative that treasury officials work independently and tax the tobacco industry correctly and rationally to prevent the country losing billions of tax money in the next budget.

I will conclude with the time-honored saying of David Byrne “The true face of tobacco is disease, death and horror “