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The use of Tobacco

Tobacco is the only permissible substance that harms many of its consumers when used precisely as deliberated by its producers. It is one of the greatest causes of the prematurely deaths in the world and can be prevented by little motivation and self-control measures by educating the people to change their attitudes towards it, besides that its situation is getting worse day by day.

Cigarette smoking is one of the commonest forms of the tobacco use. According to recent facts and figures of WHO, there are more than 1.1 billion smokers in the world and overall 80% of this amount is shared by low and middle income countries, but the trends are little different, if we divide them amongst men and women, where men smokers are more prevalent in low to middle income countries and women smokers are more prevalent in upper to middle income countries and high income countries and much lower in the low and low-middle income countries.

Each year Tobacco use end up with deaths of greater than 7 million people, At least 6 million of those deaths are related to direct use of tobacco whereas around 890000 people are estimated to die from second hand smoke. Smoking is responsible for 6% of the deaths of females and 12% deaths of males respectively. But the good thing is that Prevention plays a much vital role in it as WHO reveals that higher than 1.4 billion people, or one fifth of the world’s population, are secured by comprehensive national smoke-free laws.

The most vulnerable group exposed to Tobacco use is adolescence as this shares maximum weight of its use. Tobacco products used by adolescents include cigarettes (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 CDC, almost 9 per 10 cigarette smokers start smoking in their 18’s and around 99% of the smokers tried it first time by not more than 26 year of age, and the fashion of flavored tobacco products is more tempting towards the adolescents. Adolescence is defined as 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 adolescence is the most rising concern among many public health personnel and policy makers for many decades as the global burden of this issue is rising day by day, trends of tobacco use are increasing instead of any decrease especially among the young population in which around 1000 of them starts smoking each single day hence increasing the burden many folds, Use of tobacco is prevalent in approximately 33% world population in some form or the other, as a consequence of that 50% of the people die due to this habit early in their ages.

3200 of the young adults having age not more than 18 years old start smoking their first cigarette and in addition to that 2100 youth and young adults tends to become daily cigarrete smokers according to CDC. There might be lesser than 3 million young smokers today if we achieve youth tobacco use as it was maintained during year 1997 and 2003.

Pakistan ranked at 15th number amongst countries having high prevalence of tobacco-related illnesses. In 2013, World Health Organization’s estimates of smoking burden reveals that overall there are 19.1% of Pakistan’s adult population currently use tobacco in one form or another including 31.8 % of males, 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. While 2.7% of the adult population are daily water pipe smokers including 4.4 % males and 1 % females. Furthermore, 7.1 % of adults use smokeless tobacco daily including 10.5% males and 3.5% of females. Considering youth, 10.7% of the all the youth currently use tobacco products in which 13.3% are boys and 6.6% are girls.

According to WHO latest survey results at 31 Dec 2016, prevalence of current tobacco users among youth of Pakistan is 10.7%, 13.3% of them are males and 6.6% are females. Moreover there are 3.3% of the youth which are current smokers, 14.8% of them are males and 0.9% are females. In addition to that 5.3% of the youth is using smokeless tobacco, 6.4% of them are males and 3.7% are females.

In Pakistan, Nearly 1000 to 1200 students having 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 begins smoking at most 10 years of age.

According to Global youth tobacco survey 2009 in Karachi shows that 14.1% of the school going children’s use tobacco in any form, 2.0% of them are current cigarette smokers and around 1 in 10 uses some other form of it, 0.9% are current shisha smokers, these facts are showing that besides cigarette smoking smokeless tobacco use is more common among students ( adolescents) of Karachi but there is some awareness present among the public as in the same report it is mentioned that 9 out of 10 students wanted to have a ban on its use in public spaces.

One of the study conducted among school going children’s in Karachi reveals that more than 74% of the individuals used chewing tobacco products regularly

Tobacco use results in many vulnerable 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 10 leading causes of deaths

Tobacco use leads to both non-communicable including increased risk of cancers like oral, esophagus, lung and pancreatic cancers, some precancerous conditions like leukoplakia and oral submucosal fibrosis etc., atherosclerosis leading to cardiovascular illnesses cerebrovascular accidents, diabetes, chronic obstructive pulmonary disease, immunocompromised states like rheumatoid arthritis and communicable diseases like enhance risk of TB, several eye diseases ,may be erectile dysfunctions in the males and chances of miscarriages and stillbirth in pregnant ladies. It can also affect the mental health like one gets more addicted to it, attracted towards other products which are more fatal than tobacco. Teens who smoke are three folds more certain to use alcohol as compared to nonsmokers, eight folds more certain to use marijuana, and 22 folds more certain to use cocaine, and they are more habitual towards risky behaviors like fighting, sexual activities etc.

Yes , the review present a good understanding of the local burden of the problem. The trends are showing that the tobacco is the most prevalent yet preventable risk factor for the deaths and if we introduce a good surveillance system, we will be successful in declining the overall impact which this particular problem imposing on our health status and a remarkable decline in deaths related to its consequences

Yes the rationale offer 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 successful downturn in the burden of the problem

Main Objectives:

1) An accurate idea of 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 them the comparison of the hazards and benefits they think they have from the tobacco use and enhancing the motivation of quit smoking amongst adolescents of karachi

4) Exact idea about 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 improvement of cessation of tobacco use

6) Prohibit the use of tobacco products by banning its advertisement, promotion and sponsorship.

7) Now as we got certain objectives we prioritize them by keeping in view the availability of resources, competent workforce and cost effectiveness in 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 in an appropriate manner in a precise manner so that others can benefit through our work strategies.

All our objectives are related to the positive health related outcome of the surveillance system that will achieved by using a resources in the form of trained work force, 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 be done is active surveillance as we have to extract the information about the tobacco use on individual basis but the limitation of it is the need of excessive funding and time consumption during this process so we can use the sentinel surveillance in order to trace more vulnerable/high risk group that belongs to the specific region so more authentic information is collected in limited time duration.

High school adolescents (9-12th standard) in private and public sectors will be our population of interest because this is most susceptible group exposed to tobacco use and the trends shows that at this age maximum of the time the population starts using tobacco, so by using this group as our population we can gather much precise information in short period of time and with much lesser 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 , so the best period for the collection of data in above setting is during the spring season(March through may) so that adequate information will be collected in short period of time

We have to gather information about Age at starting the 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, 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, Principal of high schools, religious scholars, Cultural leaders, health counselors, 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:


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.

Field test methods: it is very difficult to dig out the information about the tobacco use in groups like young pregnant girls so we can use some laboratory methods to it, Cotinine is one of the common metabolite use as a biomarker for detection in 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 in an year so that the population remain aware of the efforts they made in declining the current issue results in some improvement or not and hence more of the adolescents encouraged on quitting the tobacco use if results are positive and if those are negative, one should struggle more to bring about a positive change

The data should be disseminated on local level to the ministry of health officials, NGO’s, donor agencies, policymakers and decision-makers, health care providers, general population, researches, public health specialists, epidemiologists etc. and on international levels like WHO, cdc etc.

Now at the end of this system we can drive some figures that in which area we to work hard and what benefits we get at the end , how is our interventions playing rule in achieving our targets and what more is required to changing the habits of our adolescence regarding this preventable cause of death , we can design further health related programs and policies regarding the issue, authenticate use of already available data, we can establish a foundation by facilitating for the more fruitful research works.




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