1TOBACCO BREAKS HEARTS Choose health, not tobacco 31 MAY: WORLD NO TOBACCO DAY #NoTobacco TOGETHER LET’S BEAT TOBACCO#beatNCDs 2 3TOBACCO BREAKS HEARTS Choose health, not tobacco 31 MAY: WORLD NO TOBACCO DAY #NoTobacco TOGETHER LET’S BEAT TOBACCO#beatNCDs 4WHO/NMH/PND/18.4 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. World No Tobacco Day 2018: Tobacco breaks hearts – choose health, not tobacco. Geneva: World Health Organization; 2018 (WHO/NMH/PND/18.4). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by NOVASB Printed in Switzerland This document is available electronically at http://www.who.int/tobacco. Any queries regarding this document should be addressed to tfi@who.int. 5CONTENTS Tobacco kills Magnitude of cardiovascular disease mortality Tobacco breaks hearts Second-hand smoke exposure How does tobacco break hearts? Smokeless tobacco Electronic nicotine delivery systems Heated tobacco products Do people know that tobacco can damage your heart? Benefits of quitting tobacco use Benefits to society Solutions WHO Framework Convention on Tobacco Control Global Hearts Initiative Best buys for noncommunicable disease prevention and control Opportunities References 06 06 07 07 08 09 09 10 10 12 13 14 14 15 15 16 18 6MAGNITUDE OF CARDIOVASCULAR DISEASE MORTALITY Tobacco kills over 7 million people every year (1), which means that, every day, more than 19 000 people die from tobacco use or second-hand smoke exposure. Most tobacco-related deaths occur in low- and middle-income countries: populations that are targets of intensive tobacco industry marketing. Tobacco can be deadly even for non-smokers: second-hand smoke contributes to heart disease, cancer and other diseases, causing around 890 000 premature deaths annually (1). The scale of this devastation of human health is shocking, but these deaths are preventable. The tobacco industry continues to aggressively promote the use of tobacco products and to conceal the dangers of tobacco use, but we are fighting back to help prevent this ongoing devastation. One in three deaths worldwide is caused by cardiovascular disease (CVD) (2), despite the availability of effective, inexpensive and safe treatments. In fact, CVD is the world’s leading cause of death, killing around 18 million people every year (2), with over 80% of these deaths occurring in low- and middle-income countries (2). TOBACCO KILLS 7TOBACCO BREAKS HEARTS SECOND-HAND SMOKE EXPOSURE Tobacco use and second-hand smoke exposure are major causes of CVD (1), contributing to approximately 17% of all cardiovascular deaths globally, about 3 million deaths per year (3). The cardiovascular risks attributable to tobacco smoking increase with the amount of tobacco smoked and the years of having smoked. Although there is a strong dose–response relationship between the amount of tobacco smoked per day and cardiovascular risk, the relationship is not linear (4). The risk is substantially increased by exposure even to low levels of tobacco smoke, as with exposure to second-hand smoke. In fact, smoking only about one cigarette per day incurs half the risk of developing coronary heart disease and stroke incurred by smoking 20 cigarettes per day (5). Exposure to second-hand smoke can cause coronary heart disease, increasing the risk of disease by approximately 25–30% (6). CVD is by far the greatest cause of deaths associated with second-hand smoke; around 55% of the estimated 890 000 worldwide deaths caused by second-hand smoke are attributed to ischaemic heart disease (1, 7) . The 2014 report on smoking by the United States Surgeon General concluded that a causal relationship exists between second-hand smoke and acute cardiovascular events and that the implementation of smoke-free laws and policies significantly reduced coronary events in non-smokers under 65 years of age (8). 8Tobacco smoke contains over 7000 chemicals (4) and is divided into two phases: a particulate phase and a gas phase (9). The particulate phase of smoke contains nicotine, a highly addictive substance associated with increases in heart rate, blood pressure and myocardial contractility (6), and the total aerosol residue (tar), which together contribute to heart disease through the following pathways: inflammation, impairment of the endothelium (the lining of the blood vessels), enhanced formation of clots and reduced level of high-density lipoprotein (HDL) cholesterol (4, 9, 10). The gas phase contains the poisonous gas carbon monoxide, along with other gases. Carbon monoxide replaces oxygen in the blood, thereby reducing the availability of oxygen for the heart muscle and other body tissues (4, 11). These pathophysiological effects of tobacco predispose both active tobacco users and passive smokers to the formation of atherosclerosis or narrowing of the arteries, leading to various types of CVD such as ischaemic heart disease, cerebrovascular disease, peripheral artery disease and aortic aneurysm (see Fig. 1). Tar and chemicals damage blood vessels; create an adverse lipid profile; thicken the blood increases heart rate and blood pressure replaces oxygen Nicotine CARDIOVASCULAR DISEASES Carbon monoxide HOW DOES TOBACCO BREAK HEARTS? FIG. 1. PATHOPHYSIOLOGICAL MECHANISMS OF TOBACCO USE LEADING TO CARDIOVASCULAR DISEASE Sources: (9, 10, 12); illustration provided by the Dutch Heart Foundation. 9All tobacco products are inherently harmful, including smokeless tobacco, which contains over 2000 chemical compounds, including nicotine (4, 12–15). Heavy metals such as cadmium and other substances contained in smokeless tobacco products, and additives such as liquorice or punk ash, are reported to affect the cardiovascular system adversely (13). Smokeless tobacco may also cause heart disease by acutely elevating blood pressure and contributing to chronic hypertension (16-18). Reviews of studies have found associations between smokeless tobacco use and fatal myocardial infarction and stroke (12, 14, 15, 19–21). Smokeless tobacco use is increasing in many parts of the world, and in some countries (e.g. Bangladesh, India) it is more commonly used than smoked tobacco (15, 20). Electronic nicotine delivery systems (ENDS), also known as e-cigarettes, vape pens, e-cigars or vaping devices, are battery-operated devices that heat a solution, or e-liquid, to generate an aerosolized mixture containing flavoured liquids and nicotine that is inhaled by the user (22). They also emit various potentially harmful and toxic chemicals that have known health effects resulting in a range of significant pathological changes. Further, the mixture contains nicotine, which can have adverse effects during pregnancy and may contribute to CVD. The cardiovascular system is very sensitive to nicotine and these other chemicals, and the body experiences direct effects from ENDS use (e.g. narrowing of the arteries, increased heart rate and blood pressure). Also non-users, including children and young people, are at risk of CVD through second-hand vaping (23). Evidence so far suggests that ENDS generally contain fewer toxicants than cigarette smoke. However, long-term health effects of use of ENDS are unknown; they are thought to increase the risk of chronic obstructive pulmonary disease, lung cancer and possibly CVD, as well as some other diseases associated with smoking. Further, it is presently unknown whether ENDS use translates into reduced cardiovascular risk in comparison with cigarette smoking. ELECTRONIC NICOTINE DELIVERY SYSTEMS SMOKELESS TOBACCO Heated tobacco products (HTP), also known as heat-not-burn (HNB) tobacco products, are battery-operated devices that heat tobacco to a lower temperature (up to 350°C) than when a conventional cigarette is burned, a process which occurs around 600°C. This causes an aerosol containing nicotine and other chemicals, leaving the leaf material intact but depleted of volatile substances. Currently, there is no evidence to demonstrate that HTPs are less harmful than conventional tobacco products. All forms of tobacco use are harmful, and HTPs should be subject to policy and regulatory measures like all other tobacco products. HEATED TOBACCO PRODUCTS DO PEOPLE KNOW THAT TOBACCO CAN DAMAGE YOUR HEART? While most people are aware that tobacco use increases the risk of cancer, there are gaps in knowledge of the CVD risks of tobacco use — and in many countries, these knowledge gaps are substantial (24). Findings from the Global Adult Tobacco Survey (GATS) show that the percentage of adults who do not believe that smoking causes stroke ranges from 73% in China to 11% in Egypt and Romania; for heart attacks, the figure ranges from 61% in China to 5% in Egypt (24) (see Fig. 2). 10 11 CHINA INDONESIA INDIA NIGERIA MEXICO POLAND RUSSIAN FEDERATION VIET NAM PHILIPPINES PANAMA ARGENTINA BRAZIL URUGUAY GREECE THAILAND QATAR MALAYSIA BANGLADESH TURKEY UKRAINE EGYPT ROMANIA 0 10 20 30 40 50 60 70 80 % 61% 73% 19% 55% 36% 51% 23% 49% 20% 40% 20% 38% 29% 33% 21% 27% 27% 16% 26% 9% 26% 13% 26% 8% 24% 9% 23% 24% 20% 6% 20% 6% 20% 14% 18% 6% 18% 11% 12% 5% 11% 10% 11% 30% FIG. 2. ADULTS WHO DO NOT BELIEVE, OR DO NOT KNOW, THAT SMOKING CAUSES STROKE AND HEART ATTACKS (%) Source: (24) 12 The benefits of quitting tobacco use are substantial. WHO recommends brief advice, use of counselling (toll-free quitlines) and/or mobile text messages (mCessation) as the most effective solutions to help tobacco users to quit. In addition, for those unable to quit with these recommended approaches, there also exist effective medications such as nicotine replacement therapy, bupropion or varenicline to help tobacco users to quit. BENEFITS OF QUITTING TOBACCO USE Within 20 minutes the heart rate and blood pressure drop (27) 1-4 years after quitting smokeless tobacco use the risk of death falls to nearly half that of a person who continues to use it (30) 1 year after quitting smoking the risk of coronary heart disease is about half that of a smoker (25) Within 12 hours the carbon monoxide level in the blood drops to normal (28) 5-15 years after quitting smoking the risk of stroke is reduced to that of a non-smoker (25) 6 weeks after quitting smokeless tobacco use 97% of oral leukoplakic lesions are completely resolved (29) 2-12 weeks after quitting tobacco use the circulation improves and lung function increases (25) 10 years after quitting smoking risk of lung cancer falls to about half that of a smoker, and the risk of cancer of the mouth, throat, oesophagus, bladder, cervix and pancreas decreases (25) 1-9 months after quitting smoking coughing and shortness of breath decrease (25) 15 years after quitting smoking risk of coronary heart disease is that of a person who never smoked (25) There are immediate and long-term health benefits in quitting for all tobacco users. BENEFICIAL HEALTH CHANGES THAT TAKE PLACE (25, 26) 13 PEOPLE OF ALL AGES WHO HAVE ALREADY DEVELOPED HEALTH PROBLEMS RELATED TO TOBACCO USE CAN STILL BENEFIT FROM QUITTING. Benefits in comparison with those who continue to use tobacco (26) • Aged about 30: gain almost 10 years of life expectancy • Aged about 40: gain nine years of life expectancy • Aged about 50: gain six years of life expectancy • Aged about 60: gain three years of life expectancy • After the onset of life-threatening disease: rapid benefit – people who quit tobacco after a myocardial infarction reduce their chances of death by between 36% (31) and 46% (30) The global economic cost of smoking is estimated at more than US$ 1.4 trillion per year. This includes around US$ 400 billion in direct medical care costs and nearly US$ 1 trillion in indirect costs, representing the value of lost productivity due to premature death and morbidity from exposure to second-hand smoke (32, 33). Tobacco cessation interventions are a cost-effective means of preventing CVD and save significant costs in terms of both short- and long-term medical care (34). A study that investigated the economic costs of smoking estimated that the cost of helping a smoker to quit smoking (approximately US$ 1000–1500) is offset by the short-term costs of avoided heart attacks and stroke alone (35). BENEFITS TO SOCIETY 14 The WHO Framework Convention on Tobacco Control (WHO FCTC) (36) provides a strong, concerted response to the global tobacco epidemic and its enormous health, social, environmental and economic costs. It obliges Parties to implement comprehensive, effective tobacco control measures. Through its 181 Parties, the WHO FCTC covers more than 90% of the world’s population. The WHO FCTC combines measures to reduce both demand for and supply of tobacco products, and includes other key provisions, such as a requirement that Parties act to protect public health policies from interference by commercial and other vested interests of the tobacco industry. The treaty’s scope covers the full chain of tobacco production and distribution, from farm to factory to point of sale. WHO FRAMEWORK CONVENTION ON TOBACCO CONTROL SOLUTIONSSOLUTIONS 15 GLOBAL HEARTS INITIATIVE BEST BUYS FOR NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL The World Health Assembly has endorsed a set of WHO “best buys” and other recommended interventions for governments to implement for the prevention and control of noncommunicable diseases. Tobacco and CVD control feature prominently among these “best buys”, as proven, cost-effective measures that can be scaled up in countries. The MPOWER measures feature prominently in the “best buys” (38). 1 MPOWER package: M-onitor tobacco use and prevention policies, P-rotect people from tobacco smoke, O-ffer help to quit tobacco use, W-arn about the dangers of tobacco, E-nforce bans on advertising, R-aise taxes on tobacco. This technical package is intended to assist in reducing the demand for tobacco products at country level. 2 SHAKE package: S-urveillance, H-arness industry for reformulation, A-dopt labelling, K-nowledge improvement, E-nvironment for healthy eating. This technical package has been designed to assist Member States with the development, implementation and monitoring of salt reduction strategies in the population. 3 HEARTS package: H-ealthy-lifestyle counselling, E-vidence-based treatment protocols, A-ccess to essential medicines and technology, R-isk based charts, T-eam-based care, S-ystems for monitoring. This technical package provides a strategic approach to improving cardiovascular health in countries. To support governments in strengthening the prevention and control of CVD, WHO and the United States Centers for Disease Control and Prevention launched Global Hearts, a new initiative comprising three technical packages, in September 2016 (37). On the prevention side, Global Hearts comprises the MPOWER package1 for tobacco control, aligned with the WHO FCTC, and the SHAKE package2 for salt reduction. On the management side, the HEARTS technical package3 works to strengthen management of CVD in primary health care to reduce complications such as heart attacks and stroke (37). Combined, these packages provide a set of high-impact, evidence-based interventions that, when used together, will have a major impact on improving global heart health. 16 EVERYBODY CAN FIGHT AGAINST TOBACCO NATIONAL GOVERNMENTS, LOCAL GOVERNMENT AND CITIES CAN: • advocate for comprehensive tobacco control policies as outlined in the WHO FCTC; • support the implementation and enforcement of smoke-free laws in all public places and workplaces, including offices, restaurants, bars, casinos, hospitals and clinics, to protect people from the harmful effects of second-hand smoke; • support the implementation of pictorial health warnings on all tobacco products as a cost–effective method for informing tobacco users about the health risks of tobacco; • promote the adoption of labels that warn about the CVD risks of tobacco according to the WHO FCTC guidelines for health warnings; • support the implementation of policies to provide systematic access to smoking cessation advice and pharmacotherapy; • promote the use of evidence-based mass media campaigns to raise awareness about the CVD risks of tobacco use and second-hand smoke exposure; • educate the public and correct the misconceptions about CVD and tobacco use; • implement and enforce policies to prevent tobacco industry lobbying and interference in tobacco control policy. OPPORTUNITIESOPPORTUNITIES 17 ALL HEALTH-CARE PROVIDERS, GENERAL PRACTITIONERS, DOCTORS AND CARDIOLOGISTS CAN: • ask patients about their tobacco use and provide brief advice to quit to every tobacco user; • model tobacco-free living by not smoking and by helping patients and health professionals who do smoke to quit; • ensure that clear, comprehensive smoke-free policies are established and enforced in all health facilities, organizations and training facilities (including universities) and at all events (including conferences); • advocate for tobacco-free investment of their health institute’s pension fund, savings and other financial portfolios; • implement programmes and protocols to ensure that cessation support and advice on eliminating second-hand smoke exposure are provided systematically. Non-smokers should also be advised to eliminate second-hand smoke; • support the inclusion of tobacco cessation counselling in the medical undergraduate, graduate and postdoctoral curriculum; • increase the visibility of tobacco control issues, including smoking and second-hand smoke exposure, at major clinical cardiology meetings and in continuing education programmes. COMMERCIAL ESTABLISHMENTS CAN ALSO PLAY A PART: • restaurant and bar owners should make sure that they comply with national smoke-free legislation and keep their establishments completely smoke-free; • shop owners should adhere to existing bans on tobacco advertising and promotion and should not, for instance, distribute free samples and/or display tobacco advertising in their shops; • sports clubs and sporting, recreational, music, social and cultural events should not accept any form of tobacco sponsorship, particularly for youth events; • retailers should strictly comply with restrictions on sale of tobacco products to minors, bans on tobacco advertising, promotion and sponsorship, and should not, for example, distribute free samples or display tobacco advertising where this is not consistent with their domestic law. 18 1. GBD 2016 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1345-1422. 2. Global health estimates 2016: deaths by cause, age, sex, by country and by region, 2000–2016. Geneva: World Health Organization; 2018. 3. Institute for Health Metrics and Evaluation. GBD Compare data visualization [website]. Seattle, WA: University of Washington; 2016 (http://vizhub.healthdata.org/gbd-compare, accessed 23 April 2018). 4. United States Department of Health and Human Services. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta, GA: United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 5. Hackshaw A, Morris JK, Boniface S, Tang JL, Milenković D. Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports. BMJ. 2018;360:j5855. 6. Catlin MC, Deng R, Martinez RS, Sharma R, Grossblatt N. Secondhand smoke exposure and cardiovascular effects: making sense of the evidence. Washington (DC): Institute of Medicine of the National Academies; 2009. 7. Öberg M, Woodward A, Jaakkola MS, Peruga A, Prüss-Ustün A. Global estimate of the burden of disease from second-hand smoke. Geneva: World Health Organization; 2010. 8. United States Department of Health and Human Services. The health consequences of smoking: 50 years of progress: a report of the Surgeon General. Atlanta, GA: United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. 9. Ambrose JA, Barua RS. The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol. 2004;43(10):1731-7. REFERENCESREFERENCES 19 10. Csordas A, Bernhard D. The biology behind the atherothrombotic effects of cigarette smoke. Nat Rev Cardiol. 2013;10(4):219-30. 11. United States Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, GA: United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. 12. Gupta R, Gupta S, Sharma S, Sinha DN, Mehrotra R. Risk of coronary heart disease among smokeless tobacco users: results of systematic review and meta-analysis of global data. Nicotine Tob Res. 2018 [e-pub ahead of print]. 13. Gupta R, Gurm H, Bartholomew JR. Smokeless tobacco and cardiovascular risk. Arch Intern Med. 2004;164(17):1845-9. 14. Piano MR, Benowitz NL, Fitzgerald GA, Corbridge S, Heath J, Hahn E et al. Impact of smokeless tobacco products on cardiovascular disease: implications for policy, prevention, and treatment: a policy statement from the American Heart Association. Circulation. 2010;122(15):1520-44. 15. Siddiqi K, Shah S, Abbas SM, Vidyasagaran A, Jawad M, Dogar O et al. Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries. BMC Med. 2015;13:194. 16. Hergens MP, Lambe M, Pershagen G, Ye W. Risk of hypertension amongst Swedish male snuff users: a prospective study. J Intern Med. 2008;264(2):187-94. 17. Pandey A, Patni N, Sarangi S, Singh M, Sharma K, Vellimana AK et al. Association of exclusive smokeless tobacco consumption with hypertension in an adult male rural population of India. Tob Induc Dis. 2009;5:15. 18. Anand A, Mik S. The risk of hypertension and other chronic diseases: comparing smokeless tobacco with smoking. Front Public Health. 2017;5:255. 19. Boffetta P, Straif K. Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis. BMJ. 2009;339:b3060. 20. Zhang LN, Yang YM, Xu ZR, Gui QF, Hu QQ. Chewing substances with or without tobacco and risk of cardiovascular disease in Asia: a meta-analysis. J Zhejiang Univ Sci B. 2010;11(9):681-9. 21. Vidyasagaran AL, Siddiqi K, Kanaan M. Use of smokeless tobacco and risk of cardiovascular disease: a systematic review and meta-analysis. Eur J Prev Cardiol. 2016;23(18):1970-81. 22. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. 2014;129(19):1972-86. 23. Qasim H, Karim ZA, Rivera JO, Khasawneh FT, Alshbool FZ. Impact of electronic cigarettes on the cardiovascular system. J Am Heart Assoc. 2017;6(9). 20 24. Asma S, Mackay J, Song SY, Zhao L, Morton J, Palipudi KM et al. The GATS atlas. Global Adult Tobacco Survey. Atlanta, GA: CDC Foundation; 2015. 25. United States Department of Health and Human Services. The health benefits of smoking cessation: a report of the Surgeon General. Atlanta, GA: United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1990. 26. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004;328(7455):1519. 27. Mahmud A, Feely J. Effect of smoking on arterial stiffness and pulse pressure amplification. Hypertension. 2003;41(1):183-7. 28. United States Department of Health and Human Services. The health consequences of smoking. Nicotine addiction: a report of the Surgeon General. Atlanta, GA: United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1988. 29. Martin GC, Brown JP, Eifler CW, Houston GD. Oral leukoplakia status six weeks after cessation of smokeless tobacco use. J Am Dent Assoc. 1999;130(7):945-54. 30. Arefalk G, Hambraeus K, Lind L, Michaëlsson K, Lindahl B, Sundström J. Discontinuation of smokeless tobacco and mortality risk after myocardial infarction. Circulation. 2014;130(4):325-32. 31. Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA. 2003;290(1):86-97. 32. Goodchild M, Nargis N, Tursan d’Espaignet E. Global economic cost of smoking-attributable diseases. Tob Control. 2018;27(1):58-64. 33. Hall W, Doran C. How much can the USA reduce health care costs by reducing smoking? PLoS Med. 2016;13(5):e1002021. 34. Lightwood J. The economics of smoking and cardiovascular disease. Prog Cardiovasc Dis. 2003;46(1):39-78. 35. Basu S, Glantz S, Bitton A, Millett C. The effect of tobacco control measures during a period of rising cardiovascular disease risk in India: a mathematical model of myocardial infarction and stroke. PLoS Med. 2013;10 (7):e1001480. 36. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. 37. Global Hearts Initiative [website]. Geneva: World Health Organization; 2018 (http://www. who.int/cardiovascular_diseases/global-hearts/en/, accessed 23 April 2018). 38. Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: World Health Organization; 2017. 21 22 23 24 TOGETHER LET’S BEAT TOBACCO#beatNCDs
1TOBACCO BREAKS HEARTS Choose health, not tobacco 31 MAY: WORLD NO TOBACCO DAY #NoTobacco TOGETHER LET’S BEAT TOBACCO#beatNCDs 2 3TOBACCO BREAKS HEARTS Choose health, not tobacco 31 MAY: WORLD NO TOBACCO DAY #NoTobacco TOGETHER LET’S BEAT TOBACCO#beatNCDs 4WHO/NMH/PND/18.4 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. World No Tobacco Day 2018: Tobacco breaks hearts – choose health, not tobacco. Geneva: World Health Organization; 2018 (WHO/NMH/PND/18.4). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by NOVASB Printed in Switzerland This document is available electronically at http://www.who.int/tobacco. Any queries regarding this document should be addressed to tfi@who.int. 5CONTENTS Tobacco kills Magnitude of cardiovascular disease mortality Tobacco breaks hearts Second-hand smoke exposure How does tobacco break hearts? Smokeless tobacco Electronic nicotine delivery systems Heated tobacco products Do people know that tobacco can damage your heart? Benefits of quitting tobacco use Benefits to society Solutions WHO Framework Convention on Tobacco Control Global Hearts Initiative Best buys for noncommunicable disease prevention and control Opportunities References 06 06 07 07 08 09 09 10 10 12 13 14 14 15 15 16 18 6MAGNITUDE OF CARDIOVASCULAR DISEASE MORTALITY Tobacco kills over 7 million people every year (1), which means that, every day, more than 19 000 people die from tobacco use or second-hand smoke exposure. Most tobacco-related deaths occur in low- and middle-income countries: populations that are targets of intensive tobacco industry marketing. Tobacco can be deadly even for non-smokers: second-hand smoke contributes to heart disease, cancer and other diseases, causing around 890 000 premature deaths annually (1). The scale of this devastation of human health is shocking, but these deaths are preventable. The tobacco industry continues to aggressively promote the use of tobacco products and to conceal the dangers of tobacco use, but we are fighting back to help prevent this ongoing devastation. One in three deaths worldwide is caused by cardiovascular disease (CVD) (2), despite the availability of effective, inexpensive and safe treatments. In fact, CVD is the world’s leading cause of death, killing around 18 million people every year (2), with over 80% of these deaths occurring in low- and middle-income countries (2). TOBACCO KILLS 7TOBACCO BREAKS HEARTS SECOND-HAND SMOKE EXPOSURE Tobacco use and second-hand smoke exposure are major causes of CVD (1), contributing to approximately 17% of all cardiovascular deaths globally, about 3 million deaths per year (3). The cardiovascular risks attributable to tobacco smoking increase with the amount of tobacco smoked and the years of having smoked. Although there is a strong dose–response relationship between the amount of tobacco smoked per day and cardiovascular risk, the relationship is not linear (4). The risk is substantially increased by exposure even to low levels of tobacco smoke, as with exposure to second-hand smoke. In fact, smoking only about one cigarette per day incurs half the risk of developing coronary heart disease and stroke incurred by smoking 20 cigarettes per day (5). Exposure to second-hand smoke can cause coronary heart disease, increasing the risk of disease by approximately 25–30% (6). CVD is by far the greatest cause of deaths associated with second-hand smoke; around 55% of the estimated 890 000 worldwide deaths caused by second-hand smoke are attributed to ischaemic heart disease (1, 7) . The 2014 report on smoking by the United States Surgeon General concluded that a causal relationship exists between second-hand smoke and acute cardiovascular events and that the implementation of smoke-free laws and policies significantly reduced coronary events in non-smokers under 65 years of age (8). 8Tobacco smoke contains over 7000 chemicals (4) and is divided into two phases: a particulate phase and a gas phase (9). The particulate phase of smoke contains nicotine, a highly addictive substance associated with increases in heart rate, blood pressure and myocardial contractility (6), and the total aerosol residue (tar), which together contribute to heart disease through the following pathways: inflammation, impairment of the endothelium (the lining of the blood vessels), enhanced formation of clots and reduced level of high-density lipoprotein (HDL) cholesterol (4, 9, 10). The gas phase contains the poisonous gas carbon monoxide, along with other gases. Carbon monoxide replaces oxygen in the blood, thereby reducing the availability of oxygen for the heart muscle and other body tissues (4, 11). These pathophysiological effects of tobacco predispose both active tobacco users and passive smokers to the formation of atherosclerosis or narrowing of the arteries, leading to various types of CVD such as ischaemic heart disease, cerebrovascular disease, peripheral artery disease and aortic aneurysm (see Fig. 1). Tar and chemicals damage blood vessels; create an adverse lipid profile; thicken the blood increases heart rate and blood pressure replaces oxygen Nicotine CARDIOVASCULAR DISEASES Carbon monoxide HOW DOES TOBACCO BREAK HEARTS? FIG. 1. PATHOPHYSIOLOGICAL MECHANISMS OF TOBACCO USE LEADING TO CARDIOVASCULAR DISEASE Sources: (9, 10, 12); illustration provided by the Dutch Heart Foundation. 9All tobacco products are inherently harmful, including smokeless tobacco, which contains over 2000 chemical compounds, including nicotine (4, 12–15). Heavy metals such as cadmium and other substances contained in smokeless tobacco products, and additives such as liquorice or punk ash, are reported to affect the cardiovascular system adversely (13). Smokeless tobacco may also cause heart disease by acutely elevating blood pressure and contributing to chronic hypertension (16-18). Reviews of studies have found associations between smokeless tobacco use and fatal myocardial infarction and stroke (12, 14, 15, 19–21). Smokeless tobacco use is increasing in many parts of the world, and in some countries (e.g. Bangladesh, India) it is more commonly used than smoked tobacco (15, 20). Electronic nicotine delivery systems (ENDS), also known as e-cigarettes, vape pens, e-cigars or vaping devices, are battery-operated devices that heat a solution, or e-liquid, to generate an aerosolized mixture containing flavoured liquids and nicotine that is inhaled by the user (22). They also emit various potentially harmful and toxic chemicals that have known health effects resulting in a range of significant pathological changes. Further, the mixture contains nicotine, which can have adverse effects during pregnancy and may contribute to CVD. The cardiovascular system is very sensitive to nicotine and these other chemicals, and the body experiences direct effects from ENDS use (e.g. narrowing of the arteries, increased heart rate and blood pressure). Also non-users, including children and young people, are at risk of CVD through second-hand vaping (23). Evidence so far suggests that ENDS generally contain fewer toxicants than cigarette smoke. However, long-term health effects of use of ENDS are unknown; they are thought to increase the risk of chronic obstructive pulmonary disease, lung cancer and possibly CVD, as well as some other diseases associated with smoking. Further, it is presently unknown whether ENDS use translates into reduced cardiovascular risk in comparison with cigarette smoking. ELECTRONIC NICOTINE DELIVERY SYSTEMS SMOKELESS TOBACCO Heated tobacco products (HTP), also known as heat-not-burn (HNB) tobacco products, are battery-operated devices that heat tobacco to a lower temperature (up to 350°C) than when a conventional cigarette is burned, a process which occurs around 600°C. This causes an aerosol containing nicotine and other chemicals, leaving the leaf material intact but depleted of volatile substances. Currently, there is no evidence to demonstrate that HTPs are less harmful than conventional tobacco products. All forms of tobacco use are harmful, and HTPs should be subject to policy and regulatory measures like all other tobacco products. HEATED TOBACCO PRODUCTS DO PEOPLE KNOW THAT TOBACCO CAN DAMAGE YOUR HEART? While most people are aware that tobacco use increases the risk of cancer, there are gaps in knowledge of the CVD risks of tobacco use — and in many countries, these knowledge gaps are substantial (24). Findings from the Global Adult Tobacco Survey (GATS) show that the percentage of adults who do not believe that smoking causes stroke ranges from 73% in China to 11% in Egypt and Romania; for heart attacks, the figure ranges from 61% in China to 5% in Egypt (24) (see Fig. 2). 10 11 CHINA INDONESIA INDIA NIGERIA MEXICO POLAND RUSSIAN FEDERATION VIET NAM PHILIPPINES PANAMA ARGENTINA BRAZIL URUGUAY GREECE THAILAND QATAR MALAYSIA BANGLADESH TURKEY UKRAINE EGYPT ROMANIA 0 10 20 30 40 50 60 70 80 % 61% 73% 19% 55% 36% 51% 23% 49% 20% 40% 20% 38% 29% 33% 21% 27% 27% 16% 26% 9% 26% 13% 26% 8% 24% 9% 23% 24% 20% 6% 20% 6% 20% 14% 18% 6% 18% 11% 12% 5% 11% 10% 11% 30% FIG. 2. ADULTS WHO DO NOT BELIEVE, OR DO NOT KNOW, THAT SMOKING CAUSES STROKE AND HEART ATTACKS (%) Source: (24) 12 The benefits of quitting tobacco use are substantial. WHO recommends brief advice, use of counselling (toll-free quitlines) and/or mobile text messages (mCessation) as the most effective solutions to help tobacco users to quit. In addition, for those unable to quit with these recommended approaches, there also exist effective medications such as nicotine replacement therapy, bupropion or varenicline to help tobacco users to quit. BENEFITS OF QUITTING TOBACCO USE Within 20 minutes the heart rate and blood pressure drop (27) 1-4 years after quitting smokeless tobacco use the risk of death falls to nearly half that of a person who continues to use it (30) 1 year after quitting smoking the risk of coronary heart disease is about half that of a smoker (25) Within 12 hours the carbon monoxide level in the blood drops to normal (28) 5-15 years after quitting smoking the risk of stroke is reduced to that of a non-smoker (25) 6 weeks after quitting smokeless tobacco use 97% of oral leukoplakic lesions are completely resolved (29) 2-12 weeks after quitting tobacco use the circulation improves and lung function increases (25) 10 years after quitting smoking risk of lung cancer falls to about half that of a smoker, and the risk of cancer of the mouth, throat, oesophagus, bladder, cervix and pancreas decreases (25) 1-9 months after quitting smoking coughing and shortness of breath decrease (25) 15 years after quitting smoking risk of coronary heart disease is that of a person who never smoked (25) There are immediate and long-term health benefits in quitting for all tobacco users. BENEFICIAL HEALTH CHANGES THAT TAKE PLACE (25, 26) 13 PEOPLE OF ALL AGES WHO HAVE ALREADY DEVELOPED HEALTH PROBLEMS RELATED TO TOBACCO USE CAN STILL BENEFIT FROM QUITTING. Benefits in comparison with those who continue to use tobacco (26) • Aged about 30: gain almost 10 years of life expectancy • Aged about 40: gain nine years of life expectancy • Aged about 50: gain six years of life expectancy • Aged about 60: gain three years of life expectancy • After the onset of life-threatening disease: rapid benefit – people who quit tobacco after a myocardial infarction reduce their chances of death by between 36% (31) and 46% (30) The global economic cost of smoking is estimated at more than US$ 1.4 trillion per year. This includes around US$ 400 billion in direct medical care costs and nearly US$ 1 trillion in indirect costs, representing the value of lost productivity due to premature death and morbidity from exposure to second-hand smoke (32, 33). Tobacco cessation interventions are a cost-effective means of preventing CVD and save significant costs in terms of both short- and long-term medical care (34). A study that investigated the economic costs of smoking estimated that the cost of helping a smoker to quit smoking (approximately US$ 1000–1500) is offset by the short-term costs of avoided heart attacks and stroke alone (35). BENEFITS TO SOCIETY 14 The WHO Framework Convention on Tobacco Control (WHO FCTC) (36) provides a strong, concerted response to the global tobacco epidemic and its enormous health, social, environmental and economic costs. It obliges Parties to implement comprehensive, effective tobacco control measures. Through its 181 Parties, the WHO FCTC covers more than 90% of the world’s population. The WHO FCTC combines measures to reduce both demand for and supply of tobacco products, and includes other key provisions, such as a requirement that Parties act to protect public health policies from interference by commercial and other vested interests of the tobacco industry. The treaty’s scope covers the full chain of tobacco production and distribution, from farm to factory to point of sale. WHO FRAMEWORK CONVENTION ON TOBACCO CONTROL SOLUTIONSSOLUTIONS 15 GLOBAL HEARTS INITIATIVE BEST BUYS FOR NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL The World Health Assembly has endorsed a set of WHO “best buys” and other recommended interventions for governments to implement for the prevention and control of noncommunicable diseases. Tobacco and CVD control feature prominently among these “best buys”, as proven, cost-effective measures that can be scaled up in countries. The MPOWER measures feature prominently in the “best buys” (38). 1 MPOWER package: M-onitor tobacco use and prevention policies, P-rotect people from tobacco smoke, O-ffer help to quit tobacco use, W-arn about the dangers of tobacco, E-nforce bans on advertising, R-aise taxes on tobacco. This technical package is intended to assist in reducing the demand for tobacco products at country level. 2 SHAKE package: S-urveillance, H-arness industry for reformulation, A-dopt labelling, K-nowledge improvement, E-nvironment for healthy eating. This technical package has been designed to assist Member States with the development, implementation and monitoring of salt reduction strategies in the population. 3 HEARTS package: H-ealthy-lifestyle counselling, E-vidence-based treatment protocols, A-ccess to essential medicines and technology, R-isk based charts, T-eam-based care, S-ystems for monitoring. This technical package provides a strategic approach to improving cardiovascular health in countries. To support governments in strengthening the prevention and control of CVD, WHO and the United States Centers for Disease Control and Prevention launched Global Hearts, a new initiative comprising three technical packages, in September 2016 (37). On the prevention side, Global Hearts comprises the MPOWER package1 for tobacco control, aligned with the WHO FCTC, and the SHAKE package2 for salt reduction. On the management side, the HEARTS technical package3 works to strengthen management of CVD in primary health care to reduce complications such as heart attacks and stroke (37). Combined, these packages provide a set of high-impact, evidence-based interventions that, when used together, will have a major impact on improving global heart health. 16 EVERYBODY CAN FIGHT AGAINST TOBACCO NATIONAL GOVERNMENTS, LOCAL GOVERNMENT AND CITIES CAN: • advocate for comprehensive tobacco control policies as outlined in the WHO FCTC; • support the implementation and enforcement of smoke-free laws in all public places and workplaces, including offices, restaurants, bars, casinos, hospitals and clinics, to protect people from the harmful effects of second-hand smoke; • support the implementation of pictorial health warnings on all tobacco products as a cost–effective method for informing tobacco users about the health risks of tobacco; • promote the adoption of labels that warn about the CVD risks of tobacco according to the WHO FCTC guidelines for health warnings; • support the implementation of policies to provide systematic access to smoking cessation advice and pharmacotherapy; • promote the use of evidence-based mass media campaigns to raise awareness about the CVD risks of tobacco use and second-hand smoke exposure; • educate the public and correct the misconceptions about CVD and tobacco use; • implement and enforce policies to prevent tobacco industry lobbying and interference in tobacco control policy. OPPORTUNITIESOPPORTUNITIES 17 ALL HEALTH-CARE PROVIDERS, GENERAL PRACTITIONERS, DOCTORS AND CARDIOLOGISTS CAN: • ask patients about their tobacco use and provide brief advice to quit to every tobacco user; • model tobacco-free living by not smoking and by helping patients and health professionals who do smoke to quit; • ensure that clear, comprehensive smoke-free policies are established and enforced in all health facilities, organizations and training facilities (including universities) and at all events (including conferences); • advocate for tobacco-free investment of their health institute’s pension fund, savings and other financial portfolios; • implement programmes and protocols to ensure that cessation support and advice on eliminating second-hand smoke exposure are provided systematically. Non-smokers should also be advised to eliminate second-hand smoke; • support the inclusion of tobacco cessation counselling in the medical undergraduate, graduate and postdoctoral curriculum; • increase the visibility of tobacco control issues, including smoking and second-hand smoke exposure, at major clinical cardiology meetings and in continuing education programmes. COMMERCIAL ESTABLISHMENTS CAN ALSO PLAY A PART: • restaurant and bar owners should make sure that they comply with national smoke-free legislation and keep their establishments completely smoke-free; • shop owners should adhere to existing bans on tobacco advertising and promotion and should not, for instance, distribute free samples and/or display tobacco advertising in their shops; • sports clubs and sporting, recreational, music, social and cultural events should not accept any form of tobacco sponsorship, particularly for youth events; • retailers should strictly comply with restrictions on sale of tobacco products to minors, bans on tobacco advertising, promotion and sponsorship, and should not, for example, distribute free samples or display tobacco advertising where this is not consistent with their domestic law. 18 1. GBD 2016 Risk Factors Collaborators. 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Atlanta, GA: United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 5. Hackshaw A, Morris JK, Boniface S, Tang JL, Milenković D. Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports. BMJ. 2018;360:j5855. 6. Catlin MC, Deng R, Martinez RS, Sharma R, Grossblatt N. Secondhand smoke exposure and cardiovascular effects: making sense of the evidence. Washington (DC): Institute of Medicine of the National Academies; 2009. 7. Öberg M, Woodward A, Jaakkola MS, Peruga A, Prüss-Ustün A. Global estimate of the burden of disease from second-hand smoke. Geneva: World Health Organization; 2010. 8. United States Department of Health and Human Services. The health consequences of smoking: 50 years of progress: a report of the Surgeon General. 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Risk of coronary heart disease among smokeless tobacco users: results of systematic review and meta-analysis of global data. Nicotine Tob Res. 2018 [e-pub ahead of print]. 13. Gupta R, Gurm H, Bartholomew JR. Smokeless tobacco and cardiovascular risk. Arch Intern Med. 2004;164(17):1845-9. 14. Piano MR, Benowitz NL, Fitzgerald GA, Corbridge S, Heath J, Hahn E et al. Impact of smokeless tobacco products on cardiovascular disease: implications for policy, prevention, and treatment: a policy statement from the American Heart Association. Circulation. 2010;122(15):1520-44. 15. Siddiqi K, Shah S, Abbas SM, Vidyasagaran A, Jawad M, Dogar O et al. Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries. BMC Med. 2015;13:194. 16. Hergens MP, Lambe M, Pershagen G, Ye W. Risk of hypertension amongst Swedish male snuff users: a prospective study. J Intern Med. 2008;264(2):187-94. 17. 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Qasim H, Karim ZA, Rivera JO, Khasawneh FT, Alshbool FZ. Impact of electronic cigarettes on the cardiovascular system. J Am Heart Assoc. 2017;6(9). 20 24. Asma S, Mackay J, Song SY, Zhao L, Morton J, Palipudi KM et al. The GATS atlas. Global Adult Tobacco Survey. Atlanta, GA: CDC Foundation; 2015. 25. United States Department of Health and Human Services. The health benefits of smoking cessation: a report of the Surgeon General. Atlanta, GA: United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1990. 26. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004;328(7455):1519. 27. Mahmud A, Feely J. Effect of smoking on arterial stiffness and pulse pressure amplification. Hypertension. 2003;41(1):183-7. 28. United States Department of Health and Human Services. 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How much can the USA reduce health care costs by reducing smoking? PLoS Med. 2016;13(5):e1002021. 34. Lightwood J. The economics of smoking and cardiovascular disease. Prog Cardiovasc Dis. 2003;46(1):39-78. 35. Basu S, Glantz S, Bitton A, Millett C. The effect of tobacco control measures during a period of rising cardiovascular disease risk in India: a mathematical model of myocardial infarction and stroke. PLoS Med. 2013;10 (7):e1001480. 36. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. 37. Global Hearts Initiative [website]. Geneva: World Health Organization; 2018 (http://www. who.int/cardiovascular_diseases/global-hearts/en/, accessed 23 April 2018). 38. Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: World Health Organization; 2017. 21 22 23 24 TOGETHER LET’S BEAT TOBACCO#beatNCDs
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Any queries regarding this document should be addressed to tfi@who.int. 5目录 烟草戕害生命 心血管疾病死亡率规模 烟草伤害心脏 二手烟暴露 烟草如何伤害心脏？ 无烟烟草 电子尼古丁传送系统 加热的烟草制品 人们知道烟草会损害心脏吗？ 戒断烟草使用的益处 对社会的好处 解决方案 世卫组织烟草控制框架公约 全球心脏计划 预防和控制非传染性疾病的最合算措施 机遇 参考文献 06 06 07 07 08 09 09 10 10 12 13 14 14 15 15 16 18 6 心血管疾病死 亡率规模 烟草每年造成700多万人死亡(1)，这意味着每天有超过19 000人死于烟草使用或二 手烟暴露。大多数与烟草有关的死亡发生在低收入和中等收入国家：这些国家的人 口是烟草行业密集营销的目标。 即使对于非吸烟者，烟草也可能致命：二手烟暴露导致心脏病、癌症和其它疾病， 每年造成约89万人过早死亡(1)。 这种对人类健康的损毁，其规模令人震惊，而这些死亡本是可以预防的。烟草业继 续大肆鼓吹烟草制品的使用，掩饰烟草使用的危险性，但我们正在反击，以推动防 止这种持续的损毁。 尽管存在有效、廉价和安全的救治方法，全世界仍然每三人中有一人死于心血管疾 病 (2)。事实上，心血管疾病是世界上的主要死因，每年造成约1 800万人死亡(2) ，其中80%以上的死亡发生在低收入和中等收入国家(2)。 烟草戕害生命 7 烟草伤害心脏 二手烟暴露 烟草使用和二手烟暴露是引发心血管疾病的主要原因(1)，构成全球所有心血管死亡 的约17%，每年约有300万例死亡(3)。 可归因于吸烟的心血管风险随着吸烟量和烟龄的增加而增加。不过，尽管日吸烟量 与心血管风险之间存在强烈的剂量——反应关系，但这种关系不是线性的(4)。即 使暴露于低浓度的烟草烟雾，风险也会大大增加。实际上，每天只吸一支香烟相对 于一天抽20支香烟，前者发生冠心病和脑卒中的风险为后者的一半 (5)。 二手烟暴露导致成人冠心病，使疾病风险增加约25-30%(6)。迄今为止，与二手烟 暴露有关的死亡的最主要原因是心血管疾病，由二手烟引起的全世界成年人年死亡 人数估计为89万，其中约55%可归因于缺血性心脏病 (1, 7)。 美国卫生总监2014年关于吸烟的报告认为，二手烟暴露与急性心血管事件之间存 在因果关系，无烟法和无烟政策的实施可显著减少65岁以下非吸烟者的冠状动脉事 件 (8)。 8烟草烟雾含有7000多种化学物质(4)，分为颗粒相和气相两种状态(9)。颗粒相烟雾 含有尼古丁，一种与心率加快、血压升高、心肌收缩力增加相关的高度成瘾物质(6) ，还包含气溶胶总残留物（焦油），它们通过以下途径共同引发心脏病：炎症、内 皮损伤（血管内层）、血栓形成增加和高密度脂蛋白胆固醇水平降低 (4, 9, 10)。气 相烟雾含有有毒气体一氧化碳和其它气体。一氧化碳取代血液中的氧气，减少了心 肌和其它身体组织的氧气供应 (4, 11)。 烟草的这些病理生理学效应使吸烟者和被动吸烟者都易于形成动脉粥样硬化或动脉 狭窄，导致各种心血管疾病，如缺血性心脏病、脑血管疾病、外周动脉疾病和主动 脉瘤（见图1）。 焦油和化学物质 损害血管；不利血脂； 导致血液粘稠 心率加快，血压升高 取代氧气 尼古丁 心血管疾病 一氧化碳 烟草如何伤害心脏？ 图1. 烟草使用导致心血管疾病的病理生理学机制 资料来源: (9, 10, 12); 图示由荷兰心脏基金会提供 9所有烟草制品必然有害，包括无烟烟草，无烟烟草含有2000多种化合物，包括尼 古丁(4, 12-15)。据报道，无烟烟草制品中所含的重金属如镉和其它物质以及甘草 或朋克灰等添加剂会对心血管系统产生不利影响 (13)。无烟烟草也可能通过急剧升 高血压，诱发慢性高血压而导致心脏疾病 (16-18)。对相关研究的综述发现，无烟 烟草使用与致命性心肌梗死和脑卒中之间存在关联 (12, 14, 15, 19–21)。在世界许 多地区，无烟烟草的使用正在增加，在一些国家（如孟加拉国、印度），其使用比 吸食的烟草更普遍 (15, 20)。 电子尼古丁传送系统，也称为电子烟、雾化芯、电子雪茄或雾化装置，是电池驱动 装置，用于加热溶液或电子液体，以产生含有调味液和尼古丁的雾化混合物供使用 者(22)吸入。它们还排放各种可能有害和有毒的化学物质，这些化学物质具有已知 的健康影响，会导致一系列显著的病变。此外，该混合物含有尼古丁，在怀孕期间 可能造成不良后果，并可能导致心血管疾病。心血管系统对尼古丁和其它这些化学 物质非常敏感，并且身体会受到电子尼古丁传送系统的直接影响（例如动脉变窄、 心率加快和血压升高）。非使用者包括儿童和年轻人也可能因二手蒸汽烟雾暴露 而罹患心血管疾病(23)。迄今为止的证据表明，电子尼古丁传送系统所含的毒物一 般低于卷烟烟雾。然而，长期使用电子尼古丁传送系统，预计会增加慢性阻塞性肺 病、肺癌和心血管疾病的风险，以及与吸烟相关的其它一些疾病。此外，相对于吸 烟，目前还不清楚电子尼古丁传送系统的使用是否能降低心血管风险。 电子尼古丁传送系统 无烟烟草 加热烟草制品，又称为加热但不燃烧烟草制品，是一种电池驱动装置，用于加 热烟草，但温度（最高为350℃）低于传统卷烟燃烧时的温度，后者为600℃ 左右。这会导致气雾中含有尼古丁和其它化学物质，叶片完好无损但挥发性物 质耗尽。目前，没有证据表明加热的烟草制品的害处低于传统烟草制品。所有 形式的烟草使用都是有害的，加热的烟草制品应像所有其它烟草制品一样受到 政策和监管措施的制约。 加热的烟草制品 人们知道烟草会损害心脏吗？ 大多数人尽管都意识到烟草使用会增加患癌症的风险，但对烟草使用导致心血 管疾病的风险却认识不足，而且在许多国家，这类认识上的差距还很大 (24)。 全球成人烟草调查的结果显示，不认为吸烟导致脑卒中的成年人所占的比例在 中国为73%，在埃及和罗马尼亚为11%，就心脏病发作而言，这一比例则从中 国的61%到埃及的5% (24)（见图2）。 10 11 12 戒断烟草使用的益处是巨大的。世卫组织推荐以简短建议、咨询（免费戒烟热线） 和/或手机短信（mCessation）作为帮助烟草使用者戒烟的最有效方法。此外，对 于那些用这些推荐方法仍不能成功戒烟的人，还存在有效的药物，如尼古丁替代疗 法、安非他酮或瓦伦尼克林，可帮助烟草使用者戒烟。 戒断烟草使用的益处 所有烟草使用者都可 因戒烟获得当下和 长远的健康益处 有益于健康的变化 (25, 26) 20分钟内，心率减缓，血压下降 (27) 12小时内，血液中的一氧化碳减至正常水平 (28) 2-12周后，血液循环改善，肺功能增强 (25) 戒烟6周后，97%的口腔白斑病灶完全消失 (29) 戒烟后一至九个月内，咳嗽和气短缓解 (25) 戒烟一年后，冠心病的风险比吸烟者大约降低一半 (25) 停止使用无烟烟草后一至四年内，死亡风险比继续使用者降低 将近一半 (30) 戒烟后五至十五年，脑卒中的风险与不吸烟者相当 (25) 戒烟十年后，肺癌的风险降至吸烟者的一半左右，口腔、咽 喉、食道、膀胱、子宫颈和胰腺癌的风险降低 (25) 戒烟十五年后，冠心病的风险与从不吸烟者相当 (25) 13 所有年龄段的人，如果已经发生与烟草使用有关的健康问题，仍 可以从戒烟中获益 与持续使用烟草者相比的益处 (26)： • 30岁左右：增加将近十年的预期寿命 • 40岁左右：增加九年的预期寿命 • 50岁左右：增加六年的预期寿命 • 60岁左右：增加三年的预期寿命 • 威胁生命的疾病发作后：快速获益——罹患心肌梗死后戒烟的人减少死亡的机会在36% (31)和 46% (30)之间。 吸烟导致的全球经济成本估计每年超过1.4万亿美元。这包括约4000亿美元的直接 医疗保健费用和近1万亿美元的间接费用，代表因过早死亡和二手烟暴露而损失的 生产力的价值 (32, 33)。戒烟干预是预防心血管疾病的一种具有成本效益的手段， 可以在短期和长期医疗保健方面节省巨额费用(34)。一项调查吸烟的经济成本的研 究估计，帮助吸烟者戒烟的成本（大约1000美元至1500美元），仅靠避免心脏病 发作和脑卒中一项的短期成本 (35)就可抵消。 对社会的好处 14 《世卫组织烟草控制框架公约》（《烟草控制框架公约》）(36)针对全球烟草流行 及其导致的巨大健康、社会、环境和经济代价提供了强有力的和协调一致的对策。 它要求缔约方实施全面、有效的烟草控制措施。《烟草控制框架公约》通过其181 个缔约方覆盖全球90%以上的人口。《烟草控制框架公约》将减少烟草制品的需求 与供应的措施结合在一起，并纳入其它重要规定，例如要求缔约方采取行动，保护 公共卫生政策免受烟草业的商业和其它既得利益的干扰。该条约的范围涵盖了从农 场到工厂到销售点的烟草生产和经销的整个链条。 《 世卫组织烟草控制框架公约 》 解决方案解决方案 15 《全球心脏计划》 预防和控制非传染性疾病的最合算措施 世界卫生大会批准了一套世卫组织“最合算措施”和其它建议干预措施，供各国政 府用以预防和控制非传染性疾病。烟草和心血管疾病控制是这些“最合算措施”的 典型代表，是得到证明和具有成本效益的措施，可以迅速在各国推广。MPOWER 措施在“最合算措施”中占有突出地位 (38)。 1 MPOWER包：监测烟草使用和预防政策（M-onitor），保护民众免遭烟草烟雾的危害（P-rotect），向希望停止使用烟草的人提 供帮助帮助（O-ffer），警示人们注意烟草危害（W-arn），禁止烟草广告（E-nforce），提高烟草税收（R-aise）。这一技术包旨 在帮助减少国家一级对烟草制品的需求。 2 SHAKE包：监测（S-urveillance），管控行业，促进调整（H-arness），采用标签（A-dopt），增进知识（K-nowledge），健 康饮食的环境（E-nvironment）。该技术方案旨在帮助会员国制定、实施和监测人口减盐战略。 3 HEARTS包：健康生活方式咨询（H-ealthy），循证治疗方案（E-vidence），获得基本药物和技术（A-ccess），基于风险的图表 （R-isk），基于团队的护理（T-eam），监测系统S-ystems）。这一技术包为改善各国心血管健康提供了一种战略方法。 为了支持政府加强心血管疾病的预防和控制，世卫组织和美国疾病防控中心于 2016年9月发起了《全球心脏计划》，这是一项由三个技术包组成的新计划 (37)。 在预防方面，《全球心脏计划》包含MPOWER烟草控制包1 ，与《烟草控制框架公 约》保持一致，以及用于减盐的SHAKE包2 。在管理方面，HEARTS技术包3 旨在加 强初级卫生保健中的心血管疾病管理，以减少心脏病发作和脑卒中等并发症 (37)。 这些技术包共同提供了一系列影响巨大的循证干预措施，如果配合使用，将对改善 全球心脏健康产生重大影响。 16 人人都可投入与烟草的斗争： 各国政府、地方政府和城市 • 宣传《烟草控制框架公约》所概述的全面烟草控制政策； • 支持在所有公共场合和工作场所，包括办公室、餐厅、酒吧、娱乐场所、医院 和诊所实施和执行无烟法，保护人们免受二手烟危害； • 支持所有烟草产品均应标注图形健康警语，作为向烟草使用者告知烟草健康风 险的具有成本效益的方法； • 根据《烟草控制框架公约》的健康警语准则，促进采用标识，警示烟草导致心 血管疾病的风险； • 支持实施政策，提供系统的戒烟咨询和药物治疗机会； • 推动开展循证的大众媒体运动，提高对烟草使用和二手烟暴露导致的心血管疾 病风险的认识； • 教育公众并纠正对心血管疾病和烟草使用的误解； • 执行和实施有关方针，防止烟草业游说和干预烟草控制政策。 机遇机遇 17 所有医疗保健提供者、全科医生、医生和心脏病专家： • 询问病人的烟草使用情况，并向每位烟草使用者提供简明的戒烟建议； • 通过不吸烟成为无烟草的榜样，帮助吸烟的患者和卫生专业人员戒烟； • 确保在所有卫生设施、组织和培训机构（包括大学）和所有活动（包括会议） 中制定和执行清晰、全面的无烟政策； • 通过宣传，促进你的健康机构养老基金、会计师和银行的无烟投资； • 实施有关规划和协议，确保系统地提供戒烟支持和消除二手烟接触的咨询，还 应该向非吸烟者提供消除二手烟的建议； • 支持将戒烟咨询纳入医学本科、研究生和毕业后医学教育课程；在重要临床心 脏病学会议和进修教育规划中提高烟草控制，包括吸烟和二手烟暴露问题的可 见度。 商业机构： • 餐馆和酒吧业主应确保遵守国家无烟立法并保持其设施完全无烟； • 零售商应严格遵守对向未成年人销售烟草制品的限制和禁止烟草广告、推销和 促销的规定，例如不分发免费样品和/或展示不符合国内法的烟草广告； • 体育俱乐部以及体育、娱乐、音乐、社交和文化活动，尤其是青年人的活动， 不应接受任何形式的烟草业赞助。 18 1. 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