Tobacco is the only permissible substance that harms many of its consumers when used precisely as intended by its producers. It is one of the greatest causes of premature deaths in the world and can be prevented with little motivation and self-control measures by educating people to change their attitudes towards it; its situation is getting worse day by day.
Cigarette smoking is one of the most common forms of tobacco use. WHO currently estimates that around 80% of the world’s 1.2 billion tobacco users live in low- and middle-income countries.
Tobacco kills more than 7 million people each year, including more than 1.6 million non-smokers exposed to second-hand smoke. The older direct-use, second-hand-smoke and smoke-free-law figures in the original paragraph should not be presented as current estimates.
Adolescent Tobacco Use and Vulnerability
The most vulnerable group exposed to Tobacco use is adolescents, as this group accounts for the maximum share of its use. Tobacco products used by adolescents include cigarettes (the most commonly used tobacco products), cigars, shisha, hookahs, smokeless tobacco, and newer oral products such as e-cigarettes, pouches, nicotine lozenges, gums, strips, and chewing sticks. According to the CDC, almost 9 in 10 cigarette smokers start smoking by age 18, and around 99% of the smokers try it for the first time by 26 years of age. Flavoured tobacco products are more tempting to adolescents. Adolescence is defined as a transitional phase of growth and development between childhood and adulthood. The World Health Organization (WHO) defines an adolescent as any person between ages 10 and 19. This age range falls within WHO’s definition of young people, which refers to individuals between ages 10 and 24.
Tobacco use among adolescents has been a rising concern among many public health personnel and policymakers for many decades, as the global burden of this issue is rising day by day. Trends in tobacco use are increasing instead of decreasing, especially among the young population, with around 1,000 people starting smoking every single day, hence increasing the burden manyfold. Tobacco use is prevalent in approximately 33% of the world population in some form or another; as a consequence, 50% of users die prematurely due to this habit (Centers for Disease Control and Prevention, n.d.).
Three thousand two hundred young adults not more than 18 years old start smoking their first cigarette, and in addition to that, 2100 youth and young adults tend to become daily cigarette smokers, according to the CDC. There might be fewer than 3 million young smokers today if we reduce youth tobacco use to the levels maintained between 1997 and 2003.
Tobacco Use in Pakistan
Pakistan ranked 15th among countries having a high prevalence of tobacco-related illnesses. In 2013, the World Health Organization’s estimates of the smoking burden revealed that, overall, 19.1% of Pakistan’s adult population currently uses tobacco in one form or another, including 31.8 % of males and 5.8 % of females, respectively. Of these, 9.6% of the adult population are daily smokers, including 17.9% of the males and 1% of the females, respectively. Meanwhile, 2.7% of the adult population are daily water pipe smokers, including 4.4% of males and 1% of females. Furthermore, 7.1 % of adults use smokeless tobacco daily, including 10.5% of males and 3.5% of females. Considering youth, 10.7% of all the youth currently use tobacco products, of which 13.3% are boys and 6.6% are girls.
According to WHO’s latest survey results on 31 Dec 2016, the prevalence of current tobacco users among the youth of Pakistan is 10.7%; 13.3% of them are males, and 6.6% are females. Moreover, 3.3% of the youth are current smokers, 14.8% of them are males, and 0.9% are females. In addition to that, 5.3% of the youth are using smokeless tobacco, 6.4% of them are males, and 3.7% are females.
In Pakistan, nearly 1000 to 1200 students, ages 6 to 16, start smoking every day for the first time, according to the Pakistan Pediatrics Association. GYTS 2013 report on tobacco use indicated that nearly 2 in 5 ever smokers begin smoking at most ten years of age.
The Global Youth Tobacco Survey 2009 in Karachi shows that 14.1% of school children use tobacco in any form; 2.0% of them are current cigarette smokers; around 1 in 10 uses some other form of it; and 0.9% are current shisha smokers. These facts show that, besides cigarette smoking, smokeless tobacco use is more common among students (adolescents) of Karachi, but there is some public awareness, as the same report mentions that 9 out of 10 students wanted to have a ban on its use in public spaces.
One of the studies conducted among school-going children in Karachi reveals that more than 74% of the individuals used chewing tobacco products regularly.
Tobacco use results in many adverse consequences worldwide. Tobacco smoking causes about 71% of lung cancer, 42% of chronic respiratory disease and around 10% of cardiovascular disease, which is one of the ten leading causes of death.
Tobacco use leads to both non-communicable and communicable diseases. These include an increased risk of cancers such as oral, oesophageal, lung, and pancreatic cancers; precancerous conditions such as leukoplakia and oral submucosal fibrosis; atherosclerosis leading to cardiovascular illnesses; cerebrovascular accidents; diabetes; chronic obstructive pulmonary disease; immunocompromised states such as rheumatoid arthritis; and an enhanced risk of TB and several eye diseases. It may also cause erectile dysfunction in males and increase the chances of miscarriages and stillbirths in pregnant women. It can also affect mental health; one can become more addicted to it and attracted to other products that are more fatal than tobacco. Teens who smoke are threefold more certain to use alcohol as compared to nonsmokers, eightfold more certain to use marijuana, and 22-fold more certain to use cocaine, and they are more prone to risky behaviours like fighting, sexual activities, etc.
Yes, the review presents a good understanding of the local burden of the problem. The trends are showing that tobacco is the most prevalent yet preventable risk factor for deaths, and if we introduce a good surveillance system, we will be successful in decreasing the overall impact which this particular problem imposes on our health status and achieving a remarkable decline in deaths related to its consequences.
Yes, the rationale offers robust justification for setting up the surveillance system as we have seen from the trends that if we closely monitor the situation and run a good surveillance system, we can achieve tremendous success, as achieved in many different regions where prevention results in a successful downturn in the burden of the problem.
Main Objectives:
1) An accurate idea of the burden of tobacco use among the adolescents of Karachi
2) To increase insight and education among the population of Karachi about the day-by-day emerging burden of youth tobacco use all over the world and motivate them through discussing the success if they desire to quit smoking and an overall better impact on the health by refining their practices
3) By explaining to them the comparison of the hazards and benefits they think they have from tobacco use and enhancing the motivation to quit smoking amongst adolescents of Karachi
4) Exact idea about the prevalence of health-related outcomes of tobacco use, especially the more common and fatal ones like cancers, chronic obstructive pulmonary disease and Myocardial infarctions among the adolescents of Karachi
5) Role of media in the improvement of cessation of tobacco use
6) Prohibit the use of tobacco products by banning their advertisement, promotion, and sponsorship.
7) Now, as we have certain objectives, we prioritize them by keeping in view the availability of resources, competent workforce and cost-effectiveness in the achievement of those actions
8) Assessment of benefits achieved through ongoing interventions used for decreasing the burden of tobacco among adolescents in Karachi.
9) We can construct a report appropriately and precisely so that others can benefit from our work strategies.
All our objectives are related to the positive health-related outcome of the surveillance system that will be achieved by using resources in the form of a trained workforce, extracting the available resources and allocating an adequate budget to run this system by involving the stakeholders.
Case Definition:
“Tobacco use may be defined as any habitual use of the tobacco plant leaf and its products. The predominant use of tobacco is by smoke inhalation of cigarettes, pipes, and cigars. Smokeless tobacco refers to a variety of tobacco products that are either sniffed, sucked, or chewed”.
The ideal system is to do active surveillance, as we have to extract information about tobacco use on an individual basis; however, its limitation is the need for excessive funding and time during this process, so we can use sentinel surveillance to trace a more vulnerable/high-risk group that belongs to a specific region, allowing more authentic information to be collected in a limited time.
High school adolescents (9-12th standard) in private and public sectors will be our population of interest because this is the most susceptible group exposed to tobacco use, and the trends show that at this age, most of the time, the population starts using tobacco, so by using this group as our population we can gather more precise information in a short period of time and with much lower expenses in a setting of limited field staff.
Ideally, for any surveillance system, we need to collect the data continuously, but as it requires a great deal of time and resource allocation, the best period for the collection of data in the above setting is during the spring season (March through May) so that adequate information will be collected in a short period of time.
We have to gather information about age at starting to use tobacco products, gender, trends of tobacco use among adolescents, types of tobacco products used, smoking status (never, current, old, recently started), knowledge about tobacco hazards, and benefits of cessation of its use.
Certain stakeholders are required in order to run a proper surveillance system, which in our setting will be the ministries of health, regional public health staff, principals of high schools, religious scholars, cultural leaders, health counsellors, health administration, non-governmental organizations, funders, researchers, tribal or territorial government agencies, Smoke-free Coalition Coordinator, Smoke-free Coalition member and others (patients, family members etc.).
Data Sources:
Global Youth Tobacco Survey
National Youth Tobacco Survey
GP clinics
Hospital records
School health education profiles
School Health Policies and Practices Study
State tobacco tracking and evaluation system
Data collection instruments:
Surveys
A detailed questionnaire with 56 core questions designed according to GYTS guidelines, including questions like (Knowledge and attitudes of young people towards cigarette smoking, Prevalence of cigarette smoking and other tobacco use among young people, Role of the media and advertising in young people’s use of cigarettes, Access to cigarettes, Tobacco-related school curriculum, Environmental tobacco smoke (ETS), Cessation of cigarette smoking, etc.).
Interviews amongst the more intensive habitual tobacco users (U.S. Department of Health and Human Services, 2014).
Field Test Methods:
It is very difficult to dig out information about tobacco use in groups like young pregnant girls, so we can use some laboratory methods for it. Cotinine is one of the common metabolites used as a biomarker for the detection of nicotine in the body in certain fluids like blood, urine, saliva, etc., so it can be measured in order to detect whether the person is exposed to smoking or not.
The data should be disseminated at least once a year so that the population remains aware of whether the efforts made to reduce the current issue result in any improvement. Hence, more adolescents may be encouraged to quit tobacco use if the results are positive; if they are negative, greater efforts should be made to bring about a positive change.
The data should be disseminated on a local level to the Ministry of Health officials, NGOs, donor agencies, policymakers and decision-makers, health care providers, the general population, researchers, public health specialists, epidemiologists, etc. and at the international level to organizations such as WHO and CDC.
At the end of this system, we can derive figures showing which areas require more work, what benefits we obtain, how our interventions help achieve our targets, and what more is required to change adolescents’ habits regarding this preventable cause of death. We can then design further health-related programs and policies regarding the issue, authenticate the use of already available data, and establish a foundation for more fruitful research.
References
Centers for Disease Control and Prevention. (n.d.). Cigarette smoking and tobacco use among people of low socioeconomic status. https://www.cdc.gov/tobacco-health-equity/collection/low-ses.html
U.S. Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress: A report of the Surgeon General. https://www.ncbi.nlm.nih.gov/books/NBK179276/
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