HEALTH TRIBUNE Wednesday, May 31, 2000, Chandigarh, India
 


May 31 is World No-Tobacco Day


Crafty boost to a killer
By Dr S.K. Jindal
Every year the world celebrates May 31 as No-Tobacco Day. The campaign against tobacco largely owes its origin to the first official report of the US Surgeon-General in 1964 who described smoking as a health hazard of sufficient importance and identified many causal relationships and smoking-disease associations. Several US Surgeons-General's reports have been published since then and more than one-third of a century later, smoking remains the leading cause of preventable premature death.

4 million go up in smoke every year
T
he international drive against cigarette smoking will turn a new corner in October when the World Health Organisation (WHO) opens its first-ever public hearing on global tobacco control.

When you are put to sleep
By Dr Jyotsna Wig
G
eneral anaesthesia is a reversible, drug-induced state of unconsciousness whereby the body's response to a noxious stimulus is suppressed. Arousal does not occur in response to the stimulus. Anaesthesia has a profound effect on normal patient physiology. We should talk about it on No-Smoking Day because smoking creates problems for anaesthetists.

 
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May 31 is World No-Tobacco Day
Crafty boost to a killer
By Dr S.K. Jindal

Every year the world celebrates May 31 as No-Tobacco Day. The campaign against tobacco largely owes its origin to the first official report of the US Surgeon-General in 1964 who described smoking as a health hazard of sufficient importance and identified many causal relationships and smoking-disease associations. Several US Surgeons-General's reports have been published since then and more than one-third of a century later, smoking remains the leading cause of preventable premature death.

It has now been estimated that from the 1990 level of 2.6 per cent of all disease-burden worldwide, tobacco is expected to increase its share to just under 9 per cent of the total burden in 2020, killing more people than any single disease.

The scenario for the developing countries is much worse. The World Bank assessment of the tobacco issue in 1993 clearly states that "unless smoking behaviour changes, three decades from now, premature deaths caused by tobacco in the developing world will exceed the expected deaths from AIDS, tuberculosis and complications of child-birth combined".

The awareness of tobacco hazards spread rather fast in the USA and Europe. It is the Third World which is going to sustain the trauma for long. An analyst has correctly stated that the tobacco industry has got a good buffer. No matter how badly things go in the USA, international sales will carry them along.

Although one has talked about it repeatedly, it is always useful to recall the enormous health problems with which tobacco is either related causally or associated promotionally. It is an important cause of cancers not only of the respiratory tract such as the mouth, the pharynx, the larynx, the trachea and the lungs, but also of the oesophagus, the stomach and even of distant organs like the urinary bladder.

It can promote cancers of blood and of almost any organ of the body. It causes chronic bronchitis and emphysema, subsequently resulting in chronic respiratory debility, failure and death.

It contributes to about a quarter of cases of coronary heart disease, cerebral stroke and peripheral vascular diseases. It increases the incidence of respiratory infections especially among the children. It can cause abortion and low birth weight of a new-born baby in case a pregnant woman smokes. The prolonged exposure of a non-smoker to smoking from others can also cause problems such as cough and precipitation of an acute attack in an asthmatic individual, the worsening of angina in a patient with heart disease or pneumonia even in a young healthy child.

It is because of these associations that tobacco has been identified as almost a disease in itself. According to Dr G.H. Brundtland, the WHO Director-General, tobacco is a communicated disease — communicated through advertising!

It is rather unfortunate that advertising has caught the fancy of many young minds. There is no better exposition of this strategy than that by Allan Landers, who for years was the macho man for "Winston" — the tobacco company: "They make you believe that if you smoke, you are going to be sexy, attractive, successful, accepted by your peers, rocking and macho, cool and sassy. They project this image in every section of the media— from day-time movies to night-time movies, magazines and even cartoon characters". Landers had realised his follies in advertising after he had suffered from the consequences of smoking. He is now a dedicated tobacco control activist.

The stories of tobacco enthusiasts turning into no-tobacco activists after becoming victims of this poison are endless. The list includes the celebrated Dr Jeffrey Wigand, a former executive of Brown & Williamson, whose true story, "The Insider", depicted in the CBS television "60 Minutes programme" had shaken entire America.

What is most depressing about the tobacco story is not necessarily its disease potential, but an enormous amount of misery it brings to the families of its victims in particular and the societies of the poor developing countries in general. It poses a huge economic burden, not only by way of expenditure on tobacco products, but more because of the costs of management and huge losses due to disability and early deaths from the smoking-related diseases.

In modern times when information is easily disseminated, there is no reason to accept what has proved to be dangerous the world over. We must benefit from the results of global research.

Dr Jindal, Professor and Head of the Department of Pulmonary Medicine at the PGI, Chandigarh, has changed and improved the lives of thousands of smokers all over the country.


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4 million go up in smoke every year

The international drive against cigarette smoking will turn a new corner in October when the World Health Organisation (WHO) opens its first-ever public hearing on global tobacco control.

Those invited to appear before this hearing at the WHO's Geneva headquarters include medical experts, non-governmental organisations (NGOs), tobacco farmers and the tobacco industry.

"This is a historic opportunity for everyone, including those in the tobacco industry to present their views on a major public issue that is of great concern to us", said Dr Gro Harlem Brundtland, the WHO's Director-General.

According to a WHO press release, the hearings on October 12 and 13 are part of the international body's effort to seek a wider spectrum of opinion as it tries to secure support for the Framework Convention on Tobacco Control (FCTC) — the world's first public health convention that attempts to address such concerns as tobacco advertising and promotion, agriculture diversification of tobacco plantations, cigarette smuggling, taxes and subsidies.

The FCTC, which was unveiled last May at the World Health Assembly, has been welcomed by health experts and the anti-smoking lobby as a necessary legal instrument to curb smoking and take on the powerful tobacco industry.

"It is clear that there is enormous support for participation in the process", admitted an adviser at the Pan American Health Organisation's Department on Prevention and Control of Tobacco use.

But while they wait for the FCTC to make a further dent in the global cigarette habit, the anti-smoking lobby has a reason to feel happy about its achievements so far. This month, the Washington-based Worldwatch Institute (WWI) revealed in a report that the world was turning away from smoking.

"After a century-long build-up in cigarette smoking, the world is turning away from cigarettes following the US lead. In 1999 cigarettes smoked per person in the USA fell by a staggering 8 per cent and for the world as a whole by more than three per cent", declared the report, titled "World Kicking the Cigarette Habit".

The drop in the USA has been significant over the last two decades, it added, where the number of cigarettes smoked per person annually fell from a high of 2,810 in 1980 to a 1,633 in 1999 — a decline of 42 per cent.

Worldwide, on the other hand, there has been an 11 per cent fall over the last 10 years, from a high of 1,027 cigarettes smoked per person annually in 1990 to 915 in 1999. What impressed the WWI were the declines in nearly all the major cigarette consuming countries, "including such bastions of smoking as France, China and Japan". Quoting the US Department of Agriculture's world tobacco database, the report noted that the number of cigarettes smoked per person in France annually had dropped by 19 per cent since Peaking in 1985, 8 per cent in China since 1990, and 4 per cent in Japan since 1992.

In the USA, the drop in smoking has been attributed to a number of reasons — a growing awareness about the health-damaging effects of smoking, rising cigarette prices, rising cigarette taxes, aggressive anti-smoking campaigns and a decline in the social acceptability of smoking.

Health experts like Selin do not consider the current drop in smoking as a blow to the tobacco industry. "The world's biggest markets, including China, India and other parts of Asia, remain largely untapped", And she expects the tobacco industry to target these markets with aggressive promotion campaigns. "In most of these markets, tobacco remains unregulated, meaning that tobacco companies can engage in promotional activities that would never be allowed in many developed countries.

Narendra Wagle, of the Association for Consumer Action on Safety and Health in India, agrees. "Multinational corporations with their huge resources and promotional skills could cause aggravation of health problems in India", he observes.

For Wagle, the opening up of the Indian economy would help spread this "killer tobacco disease". Currently, according to the WHO, tobacco kills four million people annually, and that toll is due to rise to 10 million deaths per year by 2030. "We have to act fast and we have to move ahead in a responsible manner if we want to save lives", says Dr Derek Yach, the head of the WHO's Tobacco Control Programme. (IPS)
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When you are put to sleep
By Dr Jyotsna Wig

General anaesthesia is a reversible, drug-induced state of unconsciousness whereby the body's response to a noxious stimulus is suppressed. Arousal does not occur in response to the stimulus. Anaesthesia has a profound effect on normal patient physiology. We should talk about it on No-Smoking Day because smoking creates problems for anaesthetists.

milestone: Valerius Cordus synthesised diethyl ether in 1540. Faraday described the analgesic properties of ether in 1818. Priestly synthesised nitrous oxide in 1722. Jean Baptist Dumas described chloroform in 1834. The stage was set for general anaesthesia by 1840.

General anaesthesia started with the use of ether. The administration of anaesthesia required no more than a rag to hold over the patient's mouth and nose, and a dropper bottle to saturate the rage with an anaesthetic agent.

It hit the headlines on October 16, 1846, when a patient — a journalist — was anaesthetised at the Massachusetts General Hospital. Ether anaesthesia was used in London on December 19 for a dental extraction and on December 21 for the above-knee amputation of a leg

Anaesthesia had the Royal approval in 1853 when Queen Victoria received chloroform analgesia for the birth of Prince Leopold.

The improvement of patient safety has remained a powerful stimulus for research and professional training of anaesthetists.

Modern anaesthesia uses a combination of drugs, each with a specific action, to produce the triad:

i) Lack of awareness (hypnosis)

ii) Analgesia (suppression of physiological response to stimuli)

iii) Skeletal muscle relaxation (suppression of muscle tone and contraction)

There are three phases of a successful anaesthetic:

(i) Induction: Today intravenous induction is most commonly used, as it is not unpleasant to the patient and the excitation phase passes quickly. Inhalational — induction agents are also used. Newer induction agents are free from the drawbacks of ether. It is common knowledge that ether is pungent. It causes excessive salivation. It increases the risk of coughing and laryngospasm and postoperative nausea and vomiting.

(ii) Muscle relaxants: Having rendered the patient unconscious, a muscle relaxant is used to facilitate endotracheal intubation (passing a tube in the windpipe). This is necessary to produce adequate operating conditions for the surgeon.

Analgesics are used to reduce pain. Why should these be necessary if the patient is unconscious? The autonomic nervous system responds to painful stimuli by raising one's heart rate and blood pressure. These effects may be dangerous for patients with heart disease. Good analgesia produces a smoother anaesthetic and reduces the dose of the anaesthetic used. Effective analgesia, if started before surgery, may reduce the postoperative pain. Opioids are commonly used for this purpose. The main unwanted effect of opioids is respiratory depression-reduction in the respiratory rate. Non-steroidal groups of drugs are also popular these days for this purpose.

Maintenance: The patient is maintained in an anaesthetised state so that the operation can proceed. The patient's airway, breathing, circulation, level of consciousness and pain are monitored throughout the course of anaesthesia.

Recovery: The anaesthetist's responsibility does not end with the surgeon's final stitch. Unconscious patients die unless their airways are maintained. Patients who have received muscle relaxants will need assisted ventilation until the relaxants used have been reversed or metabolised. Recovery occurs as a result of redistribution or expiration of the agent used.

Before returning to the ward, the patient should be awake and well oxygenated, with good airway control and muscle function. The patient must be comfortable before leaving the recovery room.

In sum, anaesthesia has made rapid strides since ether was first used more than 150 years ago. New and safe drugs have been developed for the comfort of the patient. The essential factor is a well-trained anaesthetist. A seemingly trivial error of judgement can easily produce an irreversible disaster. Modern drugs and equipment are effective, controllable and predictable, but it is the anaesthetist who makes the anaesthetic safe.

Dr Jyotsna Wig is Professor of Anaesthesiology and Resuscitation at the PGI.

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