Presentation by Gustavo Zabert, M.D., a pulmonologist and the Global Bridges regional director for the Latin American region, at the Global Bridges Preconference at the 15th World Conference on Tobacco OR Health in Singapore.

1. Workshop
Role of healthcare systems and
providers in changing tobacco
dependence treatment and
tobacco policy
Latin America 2011
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2. 15th World Conference on Tobacco or Health
Singapore March 19th 2012
Company Type of relationship Content Area
Pfizer Principal investigator for Investigator iniciated research in
MOTIVARE001 research protocol motivation to quit
Astra National Coordinator (independent COPD research project in Argentina
Zeneca contractor) for PUMA research
project
Novartis Principal investigator for a COPD Cross sectional study to explored
prevalence´s protocol in Argentina COPD in Argentina
I never had any relationship with tobacco industries
Gustavo Zabert
Disclosure of COI
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3. Latin America
• South of Rio Bravo
•Area 21,069,500 km²
(7,880,000 sq mi),
•2010 pop 590 million
•Languages : Spanish,
Portuguese, Quechua, Maya,
Guaraní, Aymara, Nahuatl, and
others.
•Combined GDP at 5.16
trillion (US 6.27 trillion)
•33 countries (CA-Ca-SA)
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4. Smoking in Latin America
• 1/3 of population smoke
• Highest prevalence
•Males: Cuba and Chile
•Females: Argentina and Chile
•Teens: Argentina and Chile
•Physicians Cuba, Argentina and Chile
•Tobacco related mortality 265.000 death per
year (underestimated)
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5. Smoking in Latin America
FCTC (except Argentina, Cuba, Dominican Republic, El
Salvador, Haiti, and St. Vincent and Grenadines)
• Art 6 Panama and Venezuela
• Art 8 Smoke free envitoment
•Nat'l smoke free law: Uruguay (2006), Panamá (2008),
Guatemala (2009), Colombia (2009), Perú (2010), Trinidad y
Tobago (2010), Honduras (2010), Barbados (2010),
Venezuela (2011)
•State smoke free law: 7 in Brazil and 9 in Argentina
•After IAHF report Paraguay (2011), Argentina (2011) y
Ecuador (2011) had launched Nat'l smoke free law.
Allemani, L., et al., Convenio Marco para el Control del Tabaco: desafíos para
América Latina y el Caribe. Reporte de la Sociedad Civil. 2010, IAHF
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6. Smoking in Latin America
•Art 11 Warning and images at least 30% of surface
(Bolivia, Brasil, Chile, Colombia, Honduras, México,
Nicaragua Panamá, Paraguay, Perú, Uruguay y
Venezuela)
•Art 14 7 Guidelines, CTS less than 10 points (top
Brazil)
•Art 15 Smuggling CARICOM 50%, Bolivia 46%, Brazil
35%., (Paraguay export 90% of production but only 5%
legally)
Allemani, L., et al., Convenio Marco para el Control del Tabaco: desafíos para
América Latina y el Caribe. Reporte de la Sociedad Civil. 2010, IAHF
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7. Informal Survey among TDT
(early in 2011)
Brasil Chile México Argentina Uruguay Perú Paraguay
Si Si Si Si Si Si Si
Nat´l Guidelines
2008 2003 2008 2005† 2009 2010 2010
Person Si Si Si Si Si
No Si
responsible Parcial Parcial Parcial Parcial Parcial
Score de tratamiento (máximo 10 puntos)
Treatment score 9 6 6 7 8 5 3
Nat´l Quitline 2 1 1 2 1 1 0
Nat´l treatment
6 4 4 4 5 4 3
System
Reimbursement
1 1 1 1 2 0 0
of treatment.
† Update process in 2011
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8. Treatment affordability in Latin
America Mac
Drug/Marlboro and Drug/Big
Full treatment in U$ - OTC prices
Marlboro Big Mac
NRT Mexico 21 Mexico 28
NRT Argentina 157 Paraguay 183
Bupropion Uruguay 10 Brazil 6
Nortriptiline Brazil 11 Brazil 6,6
Varenicline Argentina 175 Paraguay 200
Varenicline Uruguay 50 Chile 48
Drug/ Marlboro higher index favors smoking (not quitting)
Drug/ Big Mac lower index Tt is more affordable (quitting)
Informal Survey among TDT (early in 2011)
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9. Smoking Prevalence among Doctors
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10. Doctors and tobacco in LA
 < 30% had ever been trainned
 <10% recalled 5A strategy
 <15% recognize NRT as effective
 Smoking behavior bias their attitude
 Medical students showed similar figures
 Subset population showed
Worst scenario (psychologists, Surgeons,
GO)
Better scenario (pulmonologists, GP)
Zabert G Los Medicos y el Tabaco en MEDEF II: Tiempo de Intervenir
Ed Polemos
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11. Intervention Works!
* Minervini MC y col .RAMR 2006(3):100-105
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12. LA Global Bridges: aims for 2011
• Aim 1: to develop a large network of health care providers
and organizations to promote tobacco dependence
treatment and fully implementation of the Article 14th of
FCTC.
• Aim 2: to survey the smoking cessation training programs in
Latin America as well as the organization that provide
support and/or endorse the curricula.
• Aim3: To develop a training strategy for HCP and train at
least
• 150 HCP in a basic level
• 20 HCP in an advance level to act as faculty for the
basic level for the following years
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13. LA Global Bridges: Metrics 2011
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14. GLOBAL BRIDGES LA: Metrics
Date Course Attendees Hours
April 28, 2011 Puebla (Mexico) 70 8
May 7, 2011 Neuquén (Argentina) 15 8
March 31, 2011 Neuquén (Argentina) 42 12
Julio 1, 2011 Asuncion (Paraguay) 86 8
August 4, 2011 Cordoba (Argentina) 62 4
August 8, 2011 Parana (Argentina) 39 8
September 7, 2011 San José (Costa Rica) 43 8
October 15, 2011 Lima (Peru) 17 4
October 25, 2011 Quito (Ecuador) 36 12
Total 406
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15. GLOBAL BRIDGES Latin America
Evaluation scores
 Maximum 20 point
 Maximum score achieved 20
point
 Mean score for post training
14, 9 points (range 11- 20)
 Mean score for pre training
11, 3 points (range 4-18)
 Difference 3, 6 points (Δ 32%
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16. GLOBAL BRIDGES Latin America
Evaluation scores
Percentage of questions scored correctly
Concept Pre Post Change OR
P1 Epidemiology 29,41% 63,95% 117,44% 2,17 (1,73-2,73)
P2 FCTC 26,92% 46,28% 71,92% 1,71 (1,33-2,106)
P3 Epidemiology 41,58% 60,34% 45,12% 1,45 (1,20-1,75)
P4 CO Biomarker 58,91% 92,88% 57,66% 1,57 (1,39-1,77)
P5 Smoking behav 88,94% 94,28% 6,00% 1,06 (1,01-1,12=
P6 Initiation during teen 81,07% 87,84% 8,35% 1,08 (1,00-1,17)
P7 Neurobiology reward 50,49% 83,45% 65,28% 1,65 (1,42-1,91)
P8 Why brief intervention 43,63% 53,72% 23,13% 1,23 (1,02-1,34)
P9 Prochaska 62,75% 84,46% 34,60% 1,34 (1,19-1,51)
P10 FNDT 48,73% 71,86% 47,47% 1,47 (1,25-1,73)
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17. GLOBAL BRIDGES Latin America
Evaluation scores
Percentage of questions scored correctly
Concept Pre Post Change OR
P11 Cognitive and drugs treat 94,03% 94,94% 0,97% 0,99 (0,95-1,04)
P12 NRT 52,00% 49,65% -4,52% 0,98 (0,88-1,20)
P13 Craving 57,29% 80,20% 39,99% 1,22(1,59-1,65)
P14 Non nicotine Drugs 27,08% 44,78% 65,36% 1,65 (1,26-2,15)
P15 Physician Role 77,39% 88,59% 14,47% 1,14(1,05-1,24)
P16 Relaps and success 83,17% 87,59% 5,31% 1,05(0,99-1,13)
P17 Antidepressant drugs 67,88% 75,27% 10,89% 1,19(0,98-1,24)
P18 Adverse effects Varenicline 22,87% 86,17% 276,78% 3,74(2,88-4,01)
P19 Laser for smk cessation 81,05% 91,17% 12,49% 1,12(1,04-1,21)
P20 NRT in CV pts 60,82% 77,66% 27,69% 1,27(1,12-1,45)
Average 57,80% 75,75% 46,32%
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18. LA Global Bridges team
 LA Regional Director
Gustavo Zabert- gzabert@gmail.com
 LA Regional secretary
Vicki Baldi victoriabaldi@gmail.com
 LA Host Organization
Interamerican Heart Foundation (IAHF)
Beatriz Champagne beatriz.champagne@interamericanheart.org
Javier Valenzuela Javier.valenzuela@interamericanheart.org
 Faculty team
Carlos Jimenez Ruiz (Spain) Raul Sansores Martinez (Mexico)
Erika Urdapilleta (Mexico) Eduardo Bianco (Uruguay)
Daniel Buljuvacich (Argentina) Rogelio Pendino (Argentina)
Edgardo Sandoya (Uruguay) Victor San Martin (Paraguay)
Roberto Castro Cordoba (Costa Rica) Fernando Müller (Argentina)
Justino Regalado Pineda (Mexico) Andres Mainini (Argentina)
Luis D Larrateguy (Argentina)
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19. Faculty Puebla 2011
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20. “Every breath we draw (without
tobacco smoke), every step we
take, every meal we eat, is an
attempt to fight off death”
Arthur Schopenhauer
(free version)
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