ROKOK;ROKOK;TINJAUAN KESEHATANTINJAUAN KESEHATAN

MenaldiMenaldi RasminRasminFakultasFakultas KedokteranKedokteran UniversitasUniversitas IndonesiaIndonesia

DiskusiDiskusi PublikPublik FKM UIFKM UIFatwa Fatwa HaramHaram RokokRokokJakarta, 24 Jakarta, 24 PebruariPebruari 2009 2009

Tobacco epidemicTobacco epidemicWorldwide, 1.3 billion smokersWorldwide, 1.3 billion smokers47% of men and 12% of women in the world smoke47% of men and 12% of women in the world smokeRates are stable for men and rising for women inRates are stable for men and rising for women inlow & middlelow & middle--income countriesincome countriesAdditional numbers of passive smokers at riskAdditional numbers of passive smokers at risk5.5 trillion cigarettes were manufactured in 20005.5 trillion cigarettes were manufactured in 2000

:1000 cigarettes for every person:1000 cigarettes for every personWorldWorld’’s biggest preventable Killers biggest preventable Killer

5 million deaths / year5 million deaths / year10 million deaths / by 202010 million deaths / by 2020450 million in next 50 years (WHO)450 million in next 50 years (WHO)

Growing in women & youth of developing countriesGrowing in women & youth of developing countries

PrevalensiPrevalensi MerokokMerokok MenurutMenurutJenisJenis KelaminKelamin didi DuniaDunia

Mackay J, et al. The Tobacco Atlas. Second Ed. American Cancer Society Myriad Editions Limited, Atlanta, Georgia, 2006. Also available online at: http://www.myriadeditions.com/statmap/.

US24%19%

PriaWanita Australia

19%16%

Belarus53%7%

Brazil22%14%

Canada22%17%

Chile48%37%

China67%2%

Egypt45%12%

France30%21%

Iceland25%20%

Mexico13%5%

Iran22% 2%

Kenya21%1%

Sweden17%18%

Philippines41%8%

Portugal33%10%

South Africa23%8%

India47%17%

Russian Fed60%16%

Italy33%17%

Spain39%25%

Germany37%28%

FrekuensiFrekuensi MerokokMerokok didi AsiaAsia

29.4%29.4%51.6%51.6%671,017,000671,017,000IndiaIndia

39.3%39.3%48.5%48.5%46,063,00046,063,000ThailandThailand

69.0%69.0%49.9%49.9%146,860,000146,860,000IndonesiaIndonesia

53.4%53.4%51.1%51.1%958,295,000958,295,000ChinaChina

% % PriaPria yang yang merokokmerokok((SumberSumber: : WHO)WHO)

% % PriaPria((SumberSumber: : WHO)WHO)

PopulasiPopulasi((SumberSumber: : WHO)WHO)

NegaraNegara

SMOKING PROBLEMS IN SMOKING PROBLEMS IN INDONESIAINDONESIA

1.1. Tobacco consumption is increasing exceed the Tobacco consumption is increasing exceed the population growth rate population growth rate

2.2. Smoking habit begins at young age (elementary Smoking habit begins at young age (elementary school), 80% smoke school), 80% smoke ‘‘kretekkretek’’ which has 2which has 2--3 3 times tar & nicotine highertimes tar & nicotine higher

3.3. The prevalence of male smokers:The prevalence of male smokers:6060--70% in big cities and 8070% in big cities and 80--90% at rural90% at rural

BerapaBerapa batangbatang rokokrokok yang yang dihisapdihisap setiapsetiap harihari oleholehperokokperokok didi Indonesia?Indonesia?

SecaraSecara keseluruhankeseluruhan, , perokokperokok Indonesia Indonesia merokokmerokok 11 11 batangbatang atauatau lebihlebih setiapsetiap harihari. 48% . 48% merokokmerokok 1111--20 20 batangbatang perhariperhari

24% 12%12% 48% 4%Total Indonesia(n=460)

Jumlah rokok / hari

1-5 cigarettes

6-10 cigarettes

11-20 cigarettes

21-30 cigarettes

31 or more

MASALAH MASALAH

RustamadjiRustamadji & & SumediSumedi (FKUI)(FKUI)-- 25% 25% perokokperokok remajaremaja akanakan terusterus

merokokmerokokBag. Bag. PulmonologiPulmonologi FKUI (1992) FKUI (1992)

SD SD didi Jakarta Jakarta TimurTimurSiswaSiswa kelaskelas 5 5 dandan 6, 12,7% 6, 12,7% perokokperokok

11,8% 11,8% pernahpernah mencobamencobaAlasanAlasan : : cobacoba--cobacoba, , dipaksadipaksa, , iklaniklan

TV, TV, inginingin gagahgagahDepartemen Pulmonologi dan I.Kedokteran Respirasi FKUI

ROKOK DAN EKONOMIROKOK DAN EKONOMI

BiayaBiaya PembelianPembelian rokokrokok didi duniadunia : 85: 85--100 100 milyarmilyar dolardolarASASNegara Negara berkembangberkembang : : -- menghabiskanmenghabiskan 1/4 1/4 penghasilanpenghasilan parapara perokokperokok-- Malaysia :Malaysia :menghabiskanmenghabiskan 30% 30% penghasilanpenghasilan-- CinaCina : : menghabiskanmenghabiskan 60% 60% penghasilanpenghasilanMemperbesarMemperbesar jurangjurang perbedaanperbedaan kemakmurankemakmuran negaranegaraberkembangberkembang dandan negaranegara majumaju

Departemen Pulmonologi dan I.Kedokteran Respirasi FKUI

ROKOK DAN EKONOMIROKOK DAN EKONOMI

KerugianKerugian 200 200 milyarmilyar dolardolar AS/AS/tahuntahunAS (1990) : AS (1990) : biayabiaya oleholeh penyakitpenyakit akibatakibat rokokrokok52.338 52.338 jutajuta dolardolar AS / AS / tahuntahun

tddtdd : 23.653 : 23.653 jutajuta = = pengobatanpengobatan28.061 28.061 jutajuta = = produktivitasproduktivitas KerjaKerja ↓↓

((sakitsakit, , meninggalmeninggal))623 623 jutajuta = = kematiankematian tidaktidak

langsunglangsung padapadaaanaknak --anakanak

(Bank Dunia)

Estimated Annual Costs Estimated Annual Costs Attributable to TobaccoAttributable to Tobacco

Canada$12.9

Australia$14.2

France$16.4

Germany$24.4

China$4.3US

$184.5

Estimated Costs to the Economy Attributable to Tobacco (US $ Billions)

UK$2.3

Norway$1.62

1. Mackay J, et al. The Tobacco Atlas. Second Ed. American Cancer Society Myriad Editions Limited. Atlanta, Georgia, 2006. Also available online at: http://www.myriadeditions.com/statmap/.

Venezuela $.284Total Costs

Direct Healthcare Costs

O.R of being infected : ever v/s never-smokers.

Slama K et al. IJTLD i2007 11 (10):1049-1061

Kanker-kanker akibat merokok

Kanker mulut

Kanker paru

Paru perokok

So Why Do People Smoke?So Why Do People Smoke?

Since at least the 1988 Surgeon GeneralSince at least the 1988 Surgeon General’’s Reports Report11

Addiction defined as compulsive use despite damage to the indiviAddiction defined as compulsive use despite damage to the individual or dual or society and drugsociety and drug--seeking behavior can take precedence over important seeking behavior can take precedence over important prioritiesprioritiesAddiction persists despite a desire to quit or even repeated attAddiction persists despite a desire to quit or even repeated attempts to empts to quitquit

Most people smoke primarily because they are addicted to Most people smoke primarily because they are addicted to nicotinenicotine22

There is a clear link between smoking, nicotinic receptors, and There is a clear link between smoking, nicotinic receptors, and addictionaddiction22

1. Centers for Disease Control and Prevention. The Health Consequences of Smoking: Nicotine Addiction; A Report of the Surgeon General. Washington DC: US Department of Health and Human Services; 1988. 2. Jarvis MJ. BMJ. 2004;328:277-279.

AddictionAddiction –– Habitual psychological and physiological dependence Habitual psychological and physiological dependence on substance or practice which is beyond voluntary controlon substance or practice which is beyond voluntary control

–– StedmanStedman’’s Medical Dictionarys Medical Dictionary

Tobacco Dependence Mechanisms Tobacco Dependence Mechanisms

NicotineNicotine’’s actions in the central nervous systems actions in the central nervous systemNeurobiologic and physiologic effects of tobacco Neurobiologic and physiologic effects of tobacco dependence dependence Tobacco dependence and environmental Tobacco dependence and environmental reinforcementreinforcementSymptoms of withdrawalSymptoms of withdrawal

SiklusSiklus AdiktifAdiktif NikotinNikotin

Nicotine Nicotine dalamdalam RokokRokok

ReseptorReseptor didi otakotak

PelepasanPelepasan dopaminedopamine

Rasa Rasa SenangSenang dandan NyamanNyaman

Nicotine Nicotine habishabis

Dopamine Dopamine berkurangberkurang1. Jarvis MJ. BMJ. 2004; 328:277-279. 2. Picciotto MR, et al. Nicotine and Tob Res. 1999: Suppl 2:S121-S125.

DopamineDopamine

NicotineNicotine

Mechanism of Action of Nicotine Mechanism of Action of Nicotine in the Central Nervous Systemin the Central Nervous System

Nicotine binds preferentially to nicotinic Nicotine binds preferentially to nicotinic acetylcholinergicacetylcholinergic ((nAChnACh) receptors in the ) receptors in the central nervous system; the primary is the central nervous system; the primary is the αα44ββ2 nicotinic receptor in the Ventral 2 nicotinic receptor in the Ventral Tegmental Area (VTA)Tegmental Area (VTA)

After nicotine binds to the After nicotine binds to the αα44ββ2 nicotinic receptor in the VTA, it results in a release of 2 nicotinic receptor in the VTA, it results in a release of dopamine in the Nucleus Accumbens (dopamine in the Nucleus Accumbens (nAccnAcc) which is believed to be linked to reward) which is believed to be linked to reward

α4 β2β2β2α4

α4β2Nicotinic Receptor

Nicotine Stimulates Dopamine Nicotine Stimulates Dopamine Release Release

Nicotine activates Nicotine activates αα44ββ2 nicotinic 2 nicotinic receptors in the ventral receptors in the ventral tegmental area resulting in dopamine release at the nucleus tegmental area resulting in dopamine release at the nucleus accumbens. This may result in the shortaccumbens. This may result in the short--term term reward/satisfaction associated with cigarette smoking.reward/satisfaction associated with cigarette smoking.

D

Ventral Tegmental

Area

Nucleus Accumbens

Adapted from Picciotto MR, et al. Nicotine and Tob Res. 1999: Suppl 2:S121-S125.

D − α4β2 Nicotinic Receptor− Nicotine − Dopamine

RewardD

DD

Axon

The Delivery of NicotineThe Delivery of Nicotine’’s Effects Effect

There is a There is a ““kickkick”” immediately after exposure to immediately after exposure to nicotine as a result of adrenaline dischargenicotine as a result of adrenaline dischargeNicotine suppresses insulin output from the Nicotine suppresses insulin output from the pancreaspancreasNicotine indirectly causes a release of dopamine in Nicotine indirectly causes a release of dopamine in the brain regions that control pleasure and the brain regions that control pleasure and motivationmotivationNicotine can also exert a sedative effectNicotine can also exert a sedative effect

1. Schroeder SA. JAMA. 2005;294:482-487. 2. Jarvis MJ. BMJ. 2004; 328:277-279.

Nicotine May Cause UpNicotine May Cause Up--Regulation and Regulation and Desensitization of Receptors Resulting in Desensitization of Receptors Resulting in

ToleranceToleranceTolerance typically develops after longTolerance typically develops after long--term nicotine useterm nicotine use11

Tolerance is related to both the upTolerance is related to both the up--regulation (increased number) and the regulation (increased number) and the desensitization of nicotine receptors in the VTAdesensitization of nicotine receptors in the VTA11

A drop in nicotine level, in combination with the upA drop in nicotine level, in combination with the up--regulation and decreased regulation and decreased sensitivity of the nicotinic receptor, can result in withdrawal sensitivity of the nicotinic receptor, can result in withdrawal symptoms and symptoms and cravingscravings11

Smokers have the ability to self regulate nicotine intake by theSmokers have the ability to self regulate nicotine intake by the frequency of frequency of cigarette consumption and the intensity of inhalationcigarette consumption and the intensity of inhalation11

In order to maintain a steady nicotine level, smokers generally In order to maintain a steady nicotine level, smokers generally titrate their titrate their smoking to achieve maximal stimulation and avoid symptoms of witsmoking to achieve maximal stimulation and avoid symptoms of withdrawal hdrawal and cravingand craving22

Nicotine Addiction: A Chronic Nicotine Addiction: A Chronic Relapsing Medical ConditionRelapsing Medical Condition

True drug addictionTrue drug addiction11

Requires longRequires long--term clinical intervention, as do other addictive disordersterm clinical intervention, as do other addictive disordersFailure to appreciate the chronic nature of nicotine addiction mFailure to appreciate the chronic nature of nicotine addiction mayay22

Impair cliniciansImpair clinicians’’ motivation to treat tobacco dependence longmotivation to treat tobacco dependence long--termtermImpede acceptance that condition is comparable to diabetes, hypeImpede acceptance that condition is comparable to diabetes, hypertension, or rtension, or hyperlipidemia, and requires counseling, support, and appropriathyperlipidemia, and requires counseling, support, and appropriate e pharmacotherapypharmacotherapy

Relapse is Relapse is CommonCommon1,21,2

The nature of addiction, not the failure of the individualThe nature of addiction, not the failure of the individual33LongLong--term smoking abstinence in those who try to quit unaidedterm smoking abstinence in those who try to quit unaided†† = 3%= 3%––5%5%Most relapse within the first 8 daysMost relapse within the first 8 days

1. Fiore MC, Bailey WC, Cohen SJ, et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence. US Department of Health and Human Services. Public Health Service; June 2000. Available at: www.surgeongeneral.gov/tobacco/default.htm. 2. Jarvis MJ. Why people smoke. BMJ. 2004;328:277-279.

Mengapa Sulit BerhentiMerokok?

MengapaMengapa SulitSulit BerhentiBerhentiMerokokMerokok??

NikotinNikotin KomponenKomponenpenyebabpenyebab adiksiadiksiNikotinNikotin 5 5 -- 10 kali 10 kali lebihlebihkuatkuat menimbulkanmenimbulkan efekefekpsikoaktifpsikoaktif padapada manusiamanusiadaripadadaripada kokainkokain dandan morfinmorfin

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