19.1% percent of adults (age 15+) currently use tobacco in any form (men 31.8%; women 5.8%).1 12.4% of adults smoke tobacco 7.7% use smokeless tobacco 3% use waterpipes (hookah or shisha)

1. TOBACCO AND HEALTH
DR SINDHU ALMAS
MBBS, MPH (MHPE), (PHD)
DEPARTMENT OF COMMUNITY MEDICINE & PUBLIC HEALTH
SCIENCES
LUMHS

2. CLASSROOM RULES
• NO CROSS TALK
• RAISE HAND IF YOU HAVE QUESTION
• CELLPHONE: SWITCH OFF OR PUT ON SILENT MODE

4. PERCENTAGE OF DEATHS ARE
RELATED TO SMOKING?
• THE AVERAGE PERSON WHO SMOKES WILL DIE
ABOUT EIGHT YEARS EARLIER THAN A SIMILAR
NON-SMOKER
• THIS MEANS THAT ABOUT 15% OF GLOBAL DEATHS
ARE ATTRIBUTED TO SMOKING. IN SOME
COUNTRIES IT'S MORE THAN 1-IN-5 DEATHS.
SMOKING DEATHS TYPICALLY AFFECT OLDER
POPULATIONS: MORE THAN HALF OF DEATHS
OCCURRED IN PEOPLE OVER 70 YEARS OLD; 93%
WERE OVER 50 YEARS.

5. WHICH COUNTRY HAS THE MOST
SMOKERS 2021?
• NAURU HAS THE HIGHEST SMOKING RATES IN
THE WORLD AT 52.1%. ODDLY, WOMEN SMOKE
SLIGHTLY MORE THAN MEN IN NAURU (52.6%
TO 51.7%), WHICH IS SOMEWHAT OF AN
OUTLIER. THE SECOND-HIGHEST RATE
BELONGS TO KIRIBATI, WHOSE (52.0%) TOTAL
CONSISTS OF 68.6% OF MALES AND 35.5% OF
FEMALES, WHICH IS A MORE TYPICAL
DISTRIBUTION.
• SMOKING RATES BY COUNTRY 2022 - WORLD POPULATION REVIEW
• HTTPS://WORLDPOPULATIONREVIEW.COM › COUNTRY-RANKINGS › S...

6. TOBACCO-RELATED CANCERS
• SMOKING CAUSES CANCER OF THE:
• LUNG (80-85 % OF CASES), ORAL CAVITY, PANCREAS, LARYNX,
KIDNEY, ESOPHAGUS, BLADDER (30-40 % OF CASES)
• SMOKING LINKED TO CANCER OF THE LARGE
INTESTINE & SOME FORMS OF LEUKEMIA
• SMOKELESS TOBACCO (CHEW TOBACCO, SNUFF
ETC.) IS A MAJOR CAUSE OF CANCER OF THE MOUTH
• BPG REFERENCE (APPENDIX C.2): PG. 57

7. RISK OF DEVELOPING CANCER
• RISK OF DEVELOPING CANCER INCREASES WITH:
• DURATION OF SMOKING
• NUMBER OF CIGARETTES PER DAY
• DEGREE OF INHALATION
• RISK OF LUNG CANCER IS SIGNIFICANTLY REDUCED
WITH SMOKING CESSATION
• BPG REFERENCE (APPENDIX C.2): PG. 57

8. THE TOLL OF TOBACCO IN
PAKISTAN
• 19.1% PERCENT OF ADULTS (AGE 15+)
CURRENTLY USE TOBACCO IN ANY
FORM (MEN 31.8%; WOMEN 5.8%).1
• 12.4% OF ADULTS SMOKE TOBACCO
• 7.7% USE SMOKELESS TOBACCO
• 3% USE WATERPIPES (HOOKAH OR
SHISHA)
• 1PAKISTAN GLOBAL ADULT TOBACCO SURVEY (GATS): FACT
SHEET. WORLD HEALTH ORGANIZATION; 2014. AVAILABLE
FROM: WWW.EMRO.WHO.INT/TOBACCO/TFI-NEWS/GATS-PAK-
RESULTS.HTML.

9. • AMONG YOUTH (AGES 13-15):2
• 10.7% USE ANY TOBACCO PRODUCT (BOYS
13.3%; GIRLS 6.6%)
• 7.2% SMOKE TOBACCO, AND 5.3% USE
SMOKELESS TOBACCO
• AMONG YOUTH WHO HAVE EVER SMOKED,
NEARLY 40% FIRST TRIED A CIGARETTE
BEFORE AGE 10
• 2 PAKISTAN GLOBAL YOUTH TOBACCO SURVEY (GYTS). WORLD HEALTH
ORGANIZATION; 2013. AVAILABLE
FROM: WWW.EMRO.WHO.INT/IMAGES/STORIES/TFI/DOCUMENTS/GYTS_FS_PAK_
2013.PDF?UA=1.

10. SECOND-HAND SMOKE EXPOSURE
• THERE IS NO SAFE LEVEL OF SECOND-HAND SMOKE.3
• 72.5% OF ADULTS (16.8 MILLION PEOPLE) WHO WORK INDOORS
ARE EXPOSED TO TOBACCO SMOKE AT THE WORKPLACE.1
• 86% OF ADULTS WHO VISITED RESTAURANTS IN 2014 (49.2
MILLION PEOPLE) WERE EXPOSED TO SECOND-HAND SMOKE, AND
76.2% OF ADULTS WHO USED PUBLIC TRANSPORT WERE EXPOSED
TO SECOND-HAND SMOKE.1

11. • 37.8% OF YOUTH (AGES 13-15) ARE
EXPOSED TO SECOND-HAND SMOKE
IN PUBLIC PLACES, WHILE 21% OF
YOUTH ARE EXPOSED TO SECOND-
HAND SMOKE IN THEIR HOMES.2
• 3 WORLD HEALTH ORGANIZATION. WHO REPORT ON THE GLOBAL TOBACCO
EPIDEMIC 2009.

12. HEALTH RISKS OF
SECOND-HAND SMOKE
 EXPOSURE TO SECOND-HAND SMOKE CAUSES THE FOLLOWING
DISEASES AND CONDITIONS:
◦ IN ADULTS:
 HEART DISEASE
 LUNG CANCER
 NASAL SINUS CANCER
◦ IN CHILDREN:
 SUDDEN INFANT DEATH SYNDROME (SIDS)
 FETAL GROWTH IMPAIRMENT
 BRONCHITIS, PNEUMONIA & OTHER LOWER RESPIRATORY TRACT INFECTIONS
 ASTHMA EXACERBATION
 MIDDLE EAR DISEASE
 RESPIRATORY SYMPTOMS

13. HEALTH RISKS OF SECOND-HAND
SMOKE
 ALSO LINKED TO:
◦ IN ADULTS:
 STROKE
 CERVICAL CANCER
 BREAST CANCER
 MISCARRIAGES
◦ IN CHILDREN:
• ADVERSE IMPACT ON COGNITION AND BEHAVIOR
• DECREASED LUNG FUNCTION
• ASTHMA INDUCTION
• EXACERBATION OF CYSTIC FIBROSIS

14. ASSIGNMENT
• SEARCH RESEARCH ARTICLE TO PROVE ABOVE MENTIONED
DISEASES RELATED TO SECOND-HAND SMOKING

16. HEALTH CONSEQUENCES
• TOBACCO USE IS DEADLY. SMOKING KILLS
UP TO HALF OF ALL LIFETIME USERS.4
• TOBACCO KILLS OVER 163,600 PEOPLE
EACH YEAR IN PAKISTAN. ALMOST 31,000
OF THESE DEATHS ARE DUE TO EXPOSURE
TO SECOND-HAND SMOKE.5
• TOBACCO CAUSES ABOUT 16.0% OF ALL
MALE DEATHS AND 4.9% OF FEMALE
DEATHS. OVERALL, 10.9% OF ALL DEATHS
ARE CAUSED BY TOBACCO.5
• 4 WORLD HEALTH ORGANIZATION. TOBACCO: KEY FACTS. UPDATED MAY 27, 2020.

17. • TOBACCO CAUSES 66.5% OF ALL
DEATHS FROM TRACHEAL, BRONCHUS,
AND LUNG CANCER, 53.2% OF DEATHS
FROM CHRONIC OBSTRUCTIVE
PULMONARY DISEASE, 21.9% OF
DEATHS FROM ISCHEMIC HEART
DISEASE, 15.2% OF DEATHS FROM
DIABETES MELLITUS, AND 16.8% OF
DEATHS FROM STROKE.5
• 5 GLOBAL BURDEN OF DISEASE (GBD) 2019. SEATTLE, WA: INSTITUTE FOR HEALTH METRICS
AND EVALUATION (IHME), UNIVERSITY OF WASHINGTON; 2021. AVAILABLE
FROM: VIZHUB.HEALTHDATA.ORG/GBD-COMPARE/.

18. TOBACCO INDUSTRY
• INTERNATIONAL COMPANIES HOLD ALMOST
ALL OF THE CIGARETTE MARKET IN PAKISTAN.
IN 2017, BRITISH AMERICAN TOBACCO LED
WITH 65.6% OF THE RETAIL VOLUME MARKET
SHARE, AND PHILIP MORRIS INTERNATIONAL
FOLLOWED WITH 30%. IN PAKISTAN, 52 BILLION
CIGARETTES WERE SOLD IN 2017.8
• 8 EUROMONITOR INTERNATIONAL 2018.

19. EFFECTS OF SMOKING ON THE
CARDIOVASCULAR SYSTEM
• SMOKING:
• IS A DOMINANT CAUSE OF HEART DISEASE, STROKE & DISEASES
OF THE BLOOD VESSELS
• CAUSES ABOUT 30% OF ALL HEART DISEASE DEATHS
• ACCOUNTS FOR ABOUT ¾ OF ALL CASES OF PERIPHERAL
VASCULAR DISEASE
• AS A RESULT OF SMOKING, EACH YEAR IN CANADA:
• MORE THAN 17,600 CARDIOVASCULAR DEATHS
• MORE THAN 2,000 DEATHS FROM STROKE
• MANY OF THESE DEATHS OCCUR PREMATURELY
(BEFORE AGE 70)

20. EFFECTS OF SMOKING ON THE
CARDIOVASCULAR SYSTEM
• INCIDENCE OF CORONARY HEART DISEASE
(CHD) IS 2 TO 4 TIMES GREATER IN SMOKERS
• SMOKING IS A MAJOR RISK FACTOR FOR HEART ATTACKS AND
SUDDEN CARDIAC DEATH
• SMOKING ACTS SYNERGISTICALLY WITH OTHER RISK FACTORS
(HIGH CHOLESTEROL & BLOOD PRESSURE) TO INCREASE THE RISK
OF CHD
• QUITTING SMOKING SUBSTANTIALLY REDUCES THE RISK OF CHD
AND STROKE

22. PULMONARY DISEASES
RELATED TO TOBACCO USE
• SMOKING IS RESPONSIBLE FOR MORE THAN 8,000 DEATHS
FROM RESPIRATORY DISEASES PER YEAR IN CANADA
• SMOKING DEPRESSES THE BODY’S IMMUNE SYSTEM & OTHER
DEFENSE MECHANISMS
• SMOKERS ARE AT INCREASED RISK FOR RESPIRATORY
INFECTIONS COMPARED TO NON-SMOKERS
• SMOKING MAY INCREASE SUSCEPTIBILITY TO THE COMMON
COLD

23. COPD
• CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
• CHRONIC BRONCHITIS
• CHRONIC AIRWAY OBSTRUCTION
• EMPHYSEMA & RELATED DISORDERS
• SMOKING ACCOUNTS FOR 80% – 90% OF ALL COPD DEATHS

24. EFFECTS OF SMOKING ON PREGNANCY,
NEWBORNS AND BREASTFEEDING
• BLEEDING DURING PREGNANCY
• ECTOPIC PREGNANCY
• FERTILIZED EGG IMPLANTS OUTSIDE OF UTERUS
• MISCARRIAGE
• PREMATURE DELIVERY
• STILLBIRTH
• ABNORMALITIES OF THE PLACENTA

25. EFFECTS OF SMOKING ON PREGNANCY,
NEWBORNS AND BREASTFEEDING
• BABIES BORN WITH LOW BIRTH WEIGHT (LESS THAN 2500 G)
• BABIES RECEIVE NICOTINE & CARBON MONOXIDE FROM
MOTHER’S BLOOD
• MAY CONTRIBUTE TO SUDDEN INFANT DEATH SYNDROME
(SIDS)
• NICOTINE & OTHER CHEMICALS GET INTO BREAST MILK
• DECREASED QUANTITY OF BREAST MILK

26. EFFECTS OF SMOKING ON
EARLY CHILDHOOD
• INCREASED RISK OF ALLERGIES
• HIGHER BLOOD PRESSURE IN CHILDHOOD
• INCREASED LIKELIHOOD OF OBESITY
• STUNTED GROWTH
• POORER LUNG FUNCTION
• INCREASED LIKELIHOOD OF ASTHMA

27. EFFECTS OF SMOKING ON
CLIENT/PATIENT RECOVERY
• SMOKING CAN AFFECT RECOVERY FROM ILLNESS & SURGERY
• EXP. INCREASED RECOVERY TIME FOR PATIENTS WHO SMOKE
• EXAMPLES:
• SMOKING INCREASES THE RISK OF RECURRENCE IN PERSONS WHO
HAVE SURVIVED A HEART ATTACK
• ULCERS HEAL LESS READILY AND ARE MORE LIKELY TO RECUR

28. OTHER HEALTH RISKS
• Gastrointestinal problems
- Ulcers
- Chronic Bowel Disease
- Crohn’s Disease
• Type 2 diabetes
- 50 % increased likelihood
of getting Type 2 diabetes
• Rheumatologic conditions
- Rheumatoid arthritis
• Cataracts
• Orthopedic conditions
- Osteoporosis
• Skin conditions
- Contact allergies
•Kidney damage
- Worsens kidney
problems for
patients/clients with
diabetes, high blood
pressure etc.
• Tooth and gum problems
- Oral cancer
- Tooth loss, decay
- Periodontal (gum)
disease

29. ADDITIONAL HAZARDS
• FOR MEN:
• ERECTILE DYSFUNCTION
• FERTILITY MAY BE IMPAIRED
• FOR WOMEN:
• RISK FOR CERVICAL CANCER
• EARLY MENOPAUSE
• INCREASED MENSTRUAL DISORDERS
• FERTILITY MAY BE IMPAIRED
• SMOKING AND THE USE OF ORAL CONTRACEPTIVES GREATLY
INCREASES THE RISK OF STROKE, HEART ATTACK AND OTHER
VASCULAR COMPLICATIONS

30. COSTS TO SOCIETY
• TOBACCO EXACTS A HIGH COST ON SOCIETY.
• THE ECONOMIC COST OF SMOKING IN
PAKISTAN IS RS 615.07 BILLION (US$3.85
BILLION), EQUAL TO 1.6% OF PAKISTAN'S GDP.6
• IN 2019, THE ECONOMIC COST OF SMOKING
WAS ABOUT FIVE TIMES GREATER THAN THE
REVENUE FROM THE TOBACCO INDUSTRY.
• 6 NAYAB D, NASIR M, MEMON JA, ET AL. THE ECONOMIC COST OF TOBACCO-
INDUCED DISEASES IN PAKISTAN. PAKISTAN INSTITUTE OF DEVELOPMENT
ECONOMICS, ISLAMABAD. 2021. AVAILABLE
AT: HTTPS://TOBACCONOMICS.ORG/RESEARCH/THE-ECONOMIC-COST-OF-
TOBACCO-INDUCED-DISEASES-IN-PAKISTAN/

32. • MONEY SPENT ON TOBACCO REDUCES
HOUSEHOLDS' SPENDING ON FOOD, HEALTH,
EDUCATION, HOUSING, AND HOUSEHOLD
DURABLES.
• IN PAKISTAN, TOBACCO-CONSUMING
HOUSEHOLDS SPEND ON AVERAGE 2.7% OF
THEIR MONTHLY BUDGET ON TOBACCO.7
• POOR HOUSEHOLDS SPEND 3.0% OF THEIR
BUDGET ON TOBACCO. THIS IS MORE THAN
THEY SPEND ON EDUCATION (1.8%).7
• 7 SALEEM W, IQBAL MA. THE CROWDING OUT EFFECT OF TOBACCO SPENDING IN
PAKISTAN. SOCIAL POLICY AND DEVELOPMENT CENTRE. MARCH 2021.
AVAILABLE AT: HTTPS://SPDC.ORG.PK/PUBLICATIONS/THE-CROWDING-OUT-
EFFECT-OF-TOBACCO-SPENDING-IN-PAKISTAN

33. STRATEGIES TO INCLUDE TOBACCO USE
IN HEALTH ASSESSMENT
• Expand the area where vital signs are recorded to
include tobacco use or use an alternative universal
identification system.
Example:
• Simply ask all patients, "Do you smoke, or have you ever
smoked?, Are you exposed to secondhand smoke at home?"
and note their response in the chart.

34. STRATEGIES TO INCLUDE TOBACCO USE
IN HEALTH ASSESSMENT
• EXPAND THE AREA WHERE VITAL SIGNS ARE RECORDED TO
INCLUDE TOBACCO USE OR USE AN ALTERNATIVE UNIVERSAL
IDENTIFICATION SYSTEM.
• SIMPLY ASK ALL PATIENTS, "DO YOU SMOKE, OR HAVE YOU EVER SMOKED?,
ARE YOU EXPOSED TO SECONDHAND SMOKE AT HOME?" AND NOTE THEIR
RESPONSE IN THE CHART.
Example:

35. PAKISTAN
TOBACCO CONTROL POLICIES
• PAKISTAN BECAME A PARTY TO THE WHO
FRAMEWORK CONVENTION ON TOBACCO CONTROL
ON FEBRUARY 27, 2005.
• SMOKE FREE PLACES: SMOKING IS PROHIBITED IN
ALL PLACES OF PUBLIC WORK OR USE, AND ON ALL
PUBLIC TRANSPORT. SMOKING IS PERMITTED IN
HOTEL GUEST ROOMS. WITH RESPECT TO OUTDOOR
AREAS, SMOKING IS PROHIBITED IN OUTDOOR
WAITING AREAS FOR BUSES AND TRAINS. SUB-
NATIONAL JURISDICTIONS MAY ENACT SMOKE FREE
LAWS THAT ARE MORE STRINGENT THAN THE
NATIONAL LAW.

36. • TOBACCO ADVERTISING, PROMOTION AND
SPONSORSHIP: MANY FORMS OF TOBACCO
ADVERTISING AND PROMOTION ARE PROHIBITED,
INCLUDING ADVERTISING ON DOMESTIC TV, RADIO,
PRINT MEDIA, BILLBOARDS, POINT OF SALE
ADVERTISING AND PRODUCT DISPLAY, DIRECT
TARGETING OF INDIVIDUALS, AND RETAILER
INCENTIVE PROGRAMS. MOST OTHER FORMS OF
ADVERTISING AND PROMOTION ARE ALLOWED.
THERE ARE SOME RESTRICTIONS ON TOBACCO
SPONSORSHIP AND THE PUBLICITY OF SUCH
SPONSORSHIP.

37. • TOBACCO PACKAGING AND LABELLING: THE MINISTRY OF
HEALTH HAS ISSUED ONE WARNING CONTAINING BOTH A
PICTURE AND TEXT THAT MUST BE PLACED ON ALL CIGARETTE
PACKS. THE WARNING MUST OCCUPY 60 PERCENT OF THE
PACK AND BE PLACED ON THE FRONT TOP OF THE PACK IN
URDU AND ON THE BACK TOP OF THE PACK IN ENGLISH. (THE
INCREASES IN SIZE ANNOUNCED IN SRO 127(E)/2017 (TO 50
PERCENT AND, SUBSEQUENTLY, 60 PERCENT) REPLACE THE
2015 NOTIFICATION (SRO 22(KE)/2015) THAT WOULD HAVE
INCREASED THE SIZE TO 85 PERCENT OF PACKAGING. THIS
NOTIFICATION, HOWEVER, WAS DELAYED SEVERAL TIMES AND,
ULTIMATELY, NEVER IMPLEMENTED.) HEALTH WARNINGS ARE
NOT REQUIRED ON SMOKELESS TOBACCO PRODUCTS.

38. • TOBACCO TAXATION AND PRICES: THE
WORLD HEALTH ORGANIZATION
RECOMMENDS RAISING TOBACCO
EXCISE TAXES SO THAT THEY
ACCOUNT FOR AT LEAST 70 PERCENT
OF RETAIL PRICES. TOBACCO EXCISE
TAXES IN PAKISTAN ARE WELL BELOW
THESE RECOMMENDATIONS.
• HTTPS://WWW.TOBACCOCONTROLLAWS.ORG/LEGISLATION/FACTSHEET/POLICY_ST
ATUS/PAKISTAN