Presentation by Feras Hawari, M.D., a pulmonologist and the Global Bridges regional director for the Eastern Mediterranean region, at the Global Bridges Preconference at the 15th World Conference on Tobacco OR Health in Singapore.

1. Challenges faced in
implementing tobacco
dependence treatment in Jordan
and the EMR
Feras I. Hawari, M.D
Regional Director, Global Bridges EMR
Director, Cancer Control Of fice
Chief Section, Pulmonar y and Critical Care
Director, Respirator y Therapy Ser vice
King Hussein Cancer Center

2. Scenarios: Impact of
Treatment
520
500 500
Trend
Cumulative deaths from tobacco (millions)
If smoking
400
uptake halves
by 2020
300 340
halves by 2020
220 If adult smoking
200 halves by 2020
190
100 70
0
1950 1975 2000 2025 2050
Year
Source: Peto et al

3. WORLD, DEATHS, BY BROAD CAUSE GROUP, 2001
Total deaths: 56,554,000
Noncommunicable
conditions
(33.1 million)
Communicable
diseases, maternal
and perinatal
conditions and
nutritional Injuries
deficiencies (5.1 million)
(18.4 million)
Source: WHR 2002
Vilius GRABAUSKAS

4. DEATHS, BY BROAD CAUSE GROUP AND WHO
REGION, 2001
Noncommunicable Communicable diseases,
Injuries
conditions maternal and perinatal
conditions and nutritional
deficiencies
75%
50%
25%
AFR AMR EMR EUR SEAR WPR
Source: WHR 2002
Vilius GRABAUSKAS

5. Noncommunicable Diseases ( 2006 - 2015 )
2005 2006-2015 (cumulative)
Geographical Total NCD NCD Trend: Death
Trend: Death
regions (WHO deaths deaths deaths from infectious
from NCD
classification) (millions) (millions) (millions) disease
Africa 10.8 2.5 28 +6% +27%
Americas 6.2 4.8 53 -8% +17%
Eastern
4.3 2.2 25 -10% +25%
Mediterranean
Europe 9.8 8.5 88 +7% +4%
South-East Asia 14.7 8.0 89 -16% +21%
Western Pacific 12.4 9.7 105 +1 +20%
Total 58.2 35.7 388 -3% +17%
(WHO, Chronic Disease Report, 2005)

6. Prevalence (%) of tobacco smoking and
overweight/obesity in EMR
6

7. MPOWER
 Monitor tobacco use and prevention policies
 Protect people from tobacco smoke
 Offer help to quit tobacco use
 Warn about the dangers of tobacco
 Enforce bans on tobacco advertising,
promotion and sponsorship
 Raise taxes on tobacco

9. Challenges in TDT
 Poor implementation of the FCTC agreements: pictorial
warnings, SHS exposure that would drive the intention to
quit
 Spread of other forms of tobacco (waterpipe)
 Health care system as a barrier for TDT: classification of TD,
HCP as barriers , TDT ser vices, access, cost and availability
 Lack of TDT training and absence of TDT from medical
curricula

10. International quit rates
1

11. 1

12.  High level of interest in quitting with the
majority of the sample having had a
quitting attempt (60%),
 More than half of the population
considering quitting in the next year (57%)
 Smoking < 10 cigarettes/ day were more
likely to want to quit than those who
smoked >10 cigarettes or more per day.
- High addiction: may support the need
for good
treatment programs
Abughosh, Wu, Hawari et al. Epidemiol open access 2011, 1:2
1

13. MPOWER
 Monitor tobacco use and prevention policies
 Protect people from tobacco smoke
 Of fer help to quit tobacco use
 Warn about the dangers of tobacco
 Enforce bans on tobacco adver tising, promotion
and sponsorship
 Raise taxes on tobacco
1

14. Poor implementation of the FCTC
agreements: pictorial warnings, SHS
exposure that would drive the intention to
quit
1

15. Prevalence of Lifestyle Health Problems in
Jordan
Prevalence
Health Morbidity Study (1996) Jordan behavioural risk factor
Problems survey (2007)
Overall Male Female Overall Male Female
Smoking (Adult) 27% 48% 10% 29% 50% 6%
25 years and older ( 18 years and above )
Smoking GYTS 2000 25% 15%
(Adolescent) GYTS 2009 17% 7%
Excessive Body 66% 63% 70%
Weight ( 18 years and above )
(BMI: > 25)
Diabetes 7% 16%
( 18 years and above )
Inadequate 32%
Exercise
( 18 years and above )
Smoke Water
Pipe 9%
Adolescents and Adults

16. 1

17. Abughosh, Wu, Hawari et al. Epidemiol 2011, 1:2
1

18. ‫‪ ‬الشكل ٢ - الصورة‬ ‫‪ ‬الشكل ١ - العبارة‬
‫التحذيرية‬ ‫التحذيرية الصحية‬
‫:تحذير‬
‫احــــــترس، التـــدخيـــن يدمـــــر الصحة‬
‫ويسبب الوفاة‬
‫وزارة الصحة‬
‫1‬

19. New Jordanian pictorial warnings
Hawari , Bader, Beano et
al. BMC Public Health 2011
May 31;11:414.
Hawari , Bader, Beano et al. BMC Public Health 2011 May 31;11:414.
1

20. Hawari , Bader, Beano et al. BMC Public Health 2011 May 31;11:414.
Hawari, Bader, Beano et al. BMC Public Health 2011 May 31;11:414.
2

21. HawariHawari, Bader, Beano et BMC Public Health 2011 May 31;11:414.
, Bader, Beano et al. al. BMC Public Health 2011 May 31;11:414.
2

22. Spread of other forms of tobacco
2

23.  Invented in India by a
physician as a less
harmful way of
smoking (1556-1605)
 Hakim Abul Fath
suggested that passing
of smoke through the
ball of water will make
it harmless
2

24. Dangers of waterpipes
 Smoke from WP can
cause cancer and
CAD
 Contains addictive
nicotine
 Expose smoker to
more smoke over
time (0.15-1 .0
liter/session)
2

25.  Social activity
 People share the WP
 Of ten mix cigarettes
and WP
 EMR and SEA have the
highest rates but is
spreading over the
world
2

26. Action needed against WP
 Research: trends, harms, cessation etc…
 Subjected to same anti-tobacco regulations
 Health warnings
 Fight false adver tisement about WP safety
 Cessation inter ventions
 HCP education about risks to vulnerable
groups
2

27. Smoking is not considered a disease
or a substance abuse and high cost
of TDT when compared to cigarettes
price
2

28. Evaluating factors that influence the
ser vice
 Goal: comprehensive analysis of factors in order
to develop a smoking cessation ser vice that is:
Accessible
Integrates within existing healthcare systems
Takes into account unique social, physical and
economic environment of target community
Operates ef ficiently
Measurable and ef fective (positive patient
outcomes)
Sustainable
2

29. Health care system as a barrier for
TDT
 Smoking is not considered a disease or a
substance abuse:
-No health insurance coverage
-No clear accessible ser vices
-When ser vices exist (like in Jordan) they are not
integrated, of ten fragmented with no consistent
implementation of clear practice guidelines
2

30. Cost considerations
 Hypothetical scenarios produce drug
estimates of $280 to $770 for 12 weeks
treatment (not inclusive of clinic fees)
NRT using gum alone ($275)
Varenicline ($336)
NRT patches and gum ($492)
 Countering costs:
A pack-a-day smoker spends $42 to $84
per month
Savings due to avoiding harmful ef fects of
tobacco
3

31. HCP as a barrier to TDT
 HCP are victims of tobacco
dependence
 Lack of TDT training and absence of
TDT from medical curricula
 Barriers to the use of medications:
training, availability, time to counsel
 Scarcity of data regarding the
tobacco burden
 Lack of awareness of existing
treatment guidelines 3

32. HCP as a barrier to TDT
Health professionals
 39% of health professionals are current smokers
Male physicians 94.6%
Female physicians 5.4%
Male nurses 83.8%
Female nurses 16.2%
Shishani et. al Eur J card vasc nur 2010 Sep 6
3

33. Barriers to medication use
 Patient misperceptions (skepticism
about NRT, over-optimism about not
using aids, misperceptions of the role
of nicotine in causing the
dependence or physical harm from
smoking)
 When medication is used, it is under-
used (too little for too shor t a time )
Reduced ef fectiveness
 Availability of drugs
3

34. THANK YOU!
3