The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region - May 2018

The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region May 2018 9 789290 226550 ISBN 9789290226550 Tobacco is the leading single risk factor that causes the highest number of preventable deaths (almost 1.58 million deaths each year), cardiovascular diseases (CVDs) are the leading cause of death in the WHO SEA Region. The most common way by which tobacco kills is by causing cardiovascular diseases (CVDs), including heart disease and stroke. The good news is that quitting tobacco use at any age reduces the risk of CVDs immediately. This brief report highlights the fatal connection between tobacco and CVDs and is being launched on the occasion of ‘World No Tobacco Day’ 2018 with the campaign theme “Tobacco breaks heart”. It is intended to increase commitment to tobacco control by increasing awareness of this fatal link between tobacco use and CVDs—the leading killer in most of the countries in the Region.

The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region May 2018 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region ISBN: 978 92 9022 655 0 © 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. 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Contents Foreword by Regional Director ..........................................................v Acknowledgement ...........................................................................vi Acronyms ....................................................................................... vii Key messages ............................................................................... viii Regional context ............................................................................... 1 The leading cause of death and leading risk factor in WHO South-East Asia Region ....................................................... 1 How does tobacco kill? The relationship between leading cause of death and the leading risk factor ............................. 1 Age and tobacco as a risk factor for cardiovascular diseases ................................................................... 4 How tobacco use and secondhand exposure to tobacco is related to heart disease and stroke .................................. 5 The way forward .............................................................................. 8 References .................................................................................... 12 Country factsheets Bangladesh ............................................................................. 17 Bhutan .................................................................................... 19 India ....................................................................................... 21 Indonesia ................................................................................ 23 Maldives ................................................................................. 25 Myanmar ................................................................................ 27 Nepal ...................................................................................... 29 Sri Lanka ................................................................................ 31 Thailand .................................................................................. 33 Timor-Leste ............................................................................ 35 iii The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Regioniv Foreword by Regional Director Tobacco continues to be a major public health problem in the WHO South-East Asia Region. With more than 246 million smokers and 290 million smokeless tobacco users, it is the single largest preventable risk factor for disease in the Region. The most common way by which tobacco kills is by causing cardiovascular diseases (CVDs), including heart disease and stroke, which are the leading killers in the Region. Cardiovascular diseases account for almost 45% of all deaths related to noncommunicable diseases (NCDs), and hence their control would be central to the achievement of the Sustainable Development Goal (SDG) target that calls for a reduction in premature mortality from NCDs by one third by 2030. Given that almost half of all the 1.51 million tobacco-related deaths are from CVDs, effective tobacco control will be central to any efforts to reduce overall premature mortality from NCDs and achievement of the SDGs. The good news is that quitting tobacco use at any age reduces the risk of CVD immediately. Establishing and strengthening cessation services as an integral part of national tobacco control programmes would thus be critical to reducing CVD-related disability and death among existing users, in addition to full implementation of the WHO Framework Convention on Tobacco Control (FCTC) to prevent initiation of tobacco use. This brief report is being launched on the occasion of World No Tobacco Day 2018 with the campaign theme “Tobacco breaks heart”. It is intended to increase commitment to tobacco control by increasing awareness of the link between tobacco use and CVDs—the leading killer in most of the countries in the Region. It calls for urgent actions to accelerate national efforts and invest more resources to prevent and control tobacco use and strengthen multisectoral programmes for overall control of CVDs. Failing to do this would result in social, human and economic costs that will overwhelm our systems and economies, and challenge the Region’s ability to successfully pursue the 2030 Sustainable Development Agenda. Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia v The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Acknowledgement This report was prepared by Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Department of Noncommunicable Diseases and Environmental Health at the World Health Organization Regional Office for South-East Asia. Mr Naveen Agarwal from the NCD and Tobacco Surveillance team contributed to the report by assisting in the data collection process, preparing specific graphs and formatting the report. The editorial support provided by Mr Gautam Basu, Assistant Reports Officer, and contributions to the designing of the document made by Mr Subhankar Bhowmik, Graphic Art Associate, of the WHO Regional Office for South-East Asia, are also gratefully acknowledged. Contributions to the report were made by the following colleagues based in the WHO Regional Office for South-East Asia in the Department of Noncommunicable Diseases and Environmental Health: Dr Thaksaphon Thamarangsi, Dr Palitha Mahipala, Dr Gampo Dorji and Dr Jagdish Kaur. In addition, contributions are acknowledged from WHO country offices, in particular, Dr Tara Mona Kesaram, Dr Syed Mahfuzul Huq, and Dr Mohammd Mostafa Zaman (Bangladesh), Dr Kencho Wangdi (Bhutan), Dr Fikru Tesfaye Tullu and Mr Praveen Sinha (India), Dr Farrukh Qureshi and Dr Dina Kania (Indonesia), Ms Fathimath Huda (Maldives), Dr Chamaiparn Santikarn and Dr Myo-Paing (Myanmar), Dr Lonim Dixit (Nepal), Dr Suveendran Thirupathy and Dr Nalika Gunawardena (Sri Lanka), Dr Renu Garg (Thailand) and Mr Leonato Pinto (Timor-Leste); and from the colleagues at WHO headquarters, in particular, Dr Kirstin Schotte, Ms Leanne Riley and Ms A’isha Alison Louise Commar. The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Regionvi Acronyms CRD chronic respiratory diseases CVD cardiovascular disease ENDS electronic nicotine delivery systems GDP gross domestic product GYTS Global Youth Tobacco Survey GSHS Global Student-based School Health Survey HDL high-density lipoprotein (cholesterol) HNB heat-not-burn HTP heated tobacco products IHME Institute of Health Metrics Evaluation NCD noncommunicable disease SEA South-East Asia SDG Sustainable Development Goal STEPs STEPwise approach to surveillance WHO World Health Organization WHO FCTC World Health Organization Framework Convention on Tobacco Control UN United Nations vii The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Key messages § While cardiovascular diseases (CVDs) are the leading cause of death in the WHO South-East Asia Region, causing more than 1 in 4 deaths (3.96 million deaths or 29% of all deaths), tobacco is the leading preventable risk factor causing the largest number of deaths in the Region – more than 1 in 10 deaths (1.51 million deaths or 11.6% of all deaths). § Tobacco kills in many ways, from cancer, chronic respiratory diseases, etc. but heart disease and stroke are the commonest ways in which tobacco kills people. Overall, 48% of the 1.51 million tobacco-related deaths in the Region are from CVDs. § Tobacco use in any form and exposure to other people’s smoke (secondhand exposure to tobacco) increases an individual’s risk of death from CVDs. § Tobacco smoking causes heart disease and stroke by raising serum triglycerides and lowering “good” cholesterol, making the blood more sticky, by causing thickening and narrowing of the blood vessels, damaging their lining and increasing the build-up of plaque. § CVDs among younger population (30–44 years) and especially among men is more likely to be caused by tobacco. While overall 19% of all CVD deaths are attributed to tobacco in the WHO South-East Asia (SEA) Region, almost 40% of all CVD deaths among 30–44-year-old males are attributable to tobacco. § More than 246 million people smoke tobacco and more than 290 million use smokeless tobacco. Helping these current users to quit tobacco through well-organized tobacco cessation programmes can help to avert a substantial number of CVD deaths as the risk of heart disease begins to fall as soon as a tobacco user quits. § Half of all cardiovascular deaths in South-East Asia occur prematurely in the economically productive age group of 30–69 years of age. Cardiovascular mortality in South-East Asia, especially premature mortality, has been increasing since the 1990s. Reducing mortality from CVDs through effective control of tobacco and other risk factors will be critical to achieve the Sustainable Development Goal (SDG) of reduction by one third of premature mortality from NCDs by 2030. The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Regionviii Regional context The WHO SEA Region comprises 11 Member States with a total population of 1.9 billion accounting for about 26% of the total global population (1). There are no high- income countries in the Region. Only two countries, Maldives and Thailand comprising less than 5% of the total regional population, are classified as upper-middle-income countries. The rest of the countries are classified as lower-middle-income countries with the exception of Nepal and the Democratic People’s Republic of Korea, which are classified as low-income countries (2). Due to non-availability of recent data from Democratic People’s Republic of Korea, the regional estimates throughout the document are presented for 10 Member States excluding DPR Korea The leading cause of death and leading risk factor in WHO South- East Asia Region While tobacco is the leading single risk factor that causes the highest number of preventable deaths, cardiovascular diseases (CVDs) are the leading cause of death in the WHO SEA Region. As per estimates of the Institute of Health Metrics and Evaluation (IHME) in 2016, tobacco was estimated to be responsible for 1.51 million deaths or 11.6% of all deaths each year in the Region1 — the highest number of deaths attributed to a single risk factor (3). Tobacco is deadly even for non-smokers, exposure to secondhand smoke (SHS) is estimated to be responsible for more than 250 000 deaths in the Region each year from heart disease, cancers and other diseases (3). Overall, this translates into more than 4000 people dying every day from tobacco use (smoked and/or smokeless) and secondhand exposure to tobacco smoke. As a leading cause of death, CVDs were estimated to cause almost 3.8 million deaths (3.62–4.09 million deaths) or 27.9% all the deaths (~13.3 million) and 44% of all the NCD-related deaths (~8.6 million deaths) in the WHO SEA Region (3). Almost half of these deaths occurred in the economically productive years of 30–69 years of age. How does tobacco kill? The relationship between leading cause of death and the leading risk factor Tobacco use adversely affects almost every part of the body and kills a person prematurely from many causes (Fig. 1). 1 Excluding DPR Korea 1 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Fig. 1: Tobacco use damages every part of body Risks from Smoking Smoking can damage every part of your body Source: Centers for Disease Control and Prevention, United States Department of Health and Human Services https://www.cdc.gov/tobacco/infographics/health-effects/index.htm#smoking-risks, accessed 7 May 2018 However, CVDs, including heart attack (ischaemic heart disease) and stroke (cerebrovascular disease), are the most common ways by which tobacco kills people in the WHO SEA Region as a whole (Fig. 2) and in almost all the countries in the Region except for Thailand (Table 1). In the Region as a whole, almost half of all tobacco-related deaths (48%) are estimated to be from CVDs (Fig. 2), mainly ischaemic heart disease (29.4%) and stroke (15.3%).2 Chronic respiratory diseases (21%) and cancers (12%) are other important ways in which tobacco kills people. 2 3.3% other CVDs like cardiomyopathy, hypertensive, heart disease etc. not shown separately in Fig. 2. Almost half of all the 1.51 million tobacco-related deaths each year in the WHO South-East Asia Region are due to cardiovascular diseases. The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region2 Fig. 2: Distribution of deaths due to tobacco in the WHO South-East Asia Region* by different causes, 2016 Cardiovascular diseases 48% Cancers 12% Chronic respiratory diseases 21% Communicable, maternal, neonatal, and nutritional diseases 13% Other 6% Data source: Reanalysis of data from the Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME); 2017 (http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). *Except DPR Korea Table 1. How does tobacco kill? Percentage of deaths attributable to tobacco by different causes in the WHO SEA Region, 2016 Country Cardio- vascular diseases (%) Cancers (%) Chronic respiratory diseases (%) Communicable, maternal, neo- natal and nutri- tional diseases (%) Others (%) Total tobacco- related deaths N (%) Bangladesh 41.4 20.0 28.0 5.9 4.7 161 253 (100%) Bhutan 41.8 13.9 25.3 13.2 5.8 221 (100%) India 48.2 9.7 22.6 14.2 5.3 932 710a (100%) Indonesia 65.4 4.7 8.5 11.0 10.4 225 720 (100%) Maldives 61.5 12.2 14.2 5.1 7.0 173 (100%) Myanmar 31.6 27.7 25.3 9.1 6.3 65 651 (100%) Nepal 53.2 7.6 21.0 12.5 5.7 27 137 (100%) Sri Lanka 52.9 11.4 13.1 9.7 13.0 12 351 (100%) Thailand 23.1 38.8 19.0 14.1 5.0 81 521 (100%) Timor-Leste 53.1 11.6 14.8 14.5 6.0 739 (100%) SEA Region* 48.1 12.2 20.9 12.5 6.1 1 507 475 (100%) Data source: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME); 2017 (http://ghdx.healthdata. org/gbd-results-tool, accessed 7 May 2018). a Some other studies (Data on total tobacco deaths: Jha P et al. A nationally representative case–control study of smoking and death in India. N Engl J Med.2008;358(11):1137–1147) using different sources of data have estimated more than 1 million deaths attributable to tobacco in India from direct tobacco use and exposure to secondhand smoke. *Except DPR Korea 3 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region The cardiovascular risks attributable to tobacco smoking increase with the amount of tobacco smoked and the years of having smoked; however, the relationship is not linear (4). The risk is substantially increased by exposure to even low levels of tobacco smoke, as with exposure to SHS. In fact, smoking only about one cigarette per day incurs half the risk of developing coronary heart disease and stroke as smoking 20 cigarettes per day (5). Age and tobacco as a risk factor for cardiovascular diseases While tobacco increases the risk of CVDs in all age groups and in both men and women, it is a major risk factor for CVDs, especially among younger males (Fig. 3). This implies that cardiovascular deaths among the younger population and among men are more likely to be caused by tobacco. For example, in the Region, while overall tobacco use is responsible for 19% of all cardiovascular deaths, it is responsible for 31% of all cardiovascular deaths in the 30–44-year-old population (40% among men and 13% among women), and 21% of all cardiovascular deaths in 60–69 years age group (29% among men and 11% among women) (Fig. 3). This relationship between age and tobacco-attributable CVD mortality holds true individually in all the 10 Member States of the WHO SEA Region included in the analysis here (Table 2). Fig. 3. Percentage of all cardiovascular deaths attributable to tobacco in each of the age groups and by sex in the WHO SEA Region*, 2016 31 28 21 12 19 40 37 29 17 26 13 14 11 7 10 0 5 10 15 20 25 30 35 40 45 30–44 45–59 60–69 70+ Overall % o f C V D d ea th s ca us ed b y to ba cc o Age in years Total Male Female Data source: reanalysis of data from the Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME); 2017 (http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). *Except DPR Korea The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region4 Table 2. Percentage of cardiovascular deaths attributable to tobacco in different age groups by Member State Country 30–44 years (%) 45–59 Years (%) 60–69 Years (%) 70+ Years (%) Overall (%) Bangladesh 41.5 37.2 28.7 15.4 24.0 Bhutan 19.2 14.4 9.5 4.8 8.1 India 26.5 25.2 18.7 10.3 16.3 Indonesia 45.1 38.4 30.0 16.9 26.4 Maldives 45.3 39.3 28.6 19.0 23.9 Myanmar 33.6 32.6 27.8 18.3 23.7 Nepal 37.2 38.8 32.3 22.6 28.3 Sri Lanka 27.0 26.9 19.6 11.0 15.4 Thailand 41.6 33.9 24.2 12.0 19.1 Timor-Leste 46.1 38.7 30.0 17.1 24.3 SEA Region* 30.7 28.1 21.0 11.7 18.7 Data source: Analysis of data from IHME Global Burden of Disease study 2016; as downloaded on 7 May 2018 from http://ghdx.healthdata.org/gbd-results-tool. *Except DPR Korea How tobacco use and secondhand exposure to tobacco is related to heart disease and stroke Smoked tobacco Smoked tobacco in any form (cigarettes, bidis, hukka, cigars, etc.) increase the risk of CVDs. Tobacco smoke contains over 7000 chemicals (4) and is divided into two phases: a particulate phase and a gas phase (6). The particulate phase of smoke contains nicotine, a highly addictive substance associated with an increase in heart rate, blood pressure and myocardial contractility (7). In addition, the aerosol residue (tar) in the particulate phase of smoke together with nicotine contributes to heart disease through the following pathways: inflammation, impairment of the endothelium (the Cardiovascular diseases in younger males are more likely to be due to tobacco. 5 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region lining of the blood vessels), enhanced formation of clots and reduced level of high- density lipoprotein (HDL) cholesterol (4, 6, 8). 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, 9). 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 CVDs such as ischaemic heart disease, cerebrovascular disease, peripheral artery disease and aortic aneurysm (Fig. 4). Fig. 4: Pathophysiological mechanisms of tobacco use leading to cardiovascular disease Sources: Ambrose JA, Barua RS. J Am Coll Cardiol. 2004;43(10):1731–7 (6); Csordas A, Bernhard D. Nat Rev Cardiol. 2013;10(4):219–30 (8); United States Department of Health and Human Services. 2004 (9). Smokeless tobacco All tobacco products are inherently harmful, including smokeless tobacco. While some falsely believe that smokeless tobacco is “safer” than smoked forms of tobacco, smokeless tobacco contains over 2000 chemical compounds, including nicotine (4, 10–13). 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 (11). Smokeless tobacco may also cause heart disease The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region6 by acutely elevating the blood pressure and contributing to chronic hypertension (14–16). Reviews of studies have found associations between smokeless tobacco use and fatal myocardial infarction and stroke (10, 12, 13, 17–19). Smokeless tobacco use remains very high in most Member States of the Region, with a few exceptions (Indonesia). In many Member States (e.g. in Bangladesh, India, Myanmar and Nepal) it is more commonly used than smoked tobacco (20). Electronic nicotine delivery systems 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 (21). They also emit various potentially harmful and toxic chemicals that have known harmful health effects resulting in a range of significant pathological changes. Further, the mixture contains nicotine. The cardiovascular system is very sensitive to nicotine and these other chemicals, and the body experiences direct effects from ENDS (e.g. narrowing of the arteries, increased heart rate and blood pressure). Non-users, including children and young people, are at risk of CVD through secondhand vaping (22). Evidence so far suggests that ENDS generally contain fewer toxicants than cigarette smoke; however, it is presently unknown whether ENDS use translates into reduced cardiovascular risk in comparison with cigarette smoking. Heated tobacco products 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 that occurs at 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. The way forward Deaths from CVDs account for almost half of all NCD-related mortality, and the majority of these CVD deaths take place between 30 and 70 years of age. Preventing deaths from CVDs will be central to achieving the global NCD goal and SDG of reducing premature mortality from NCDs by one third by 2030. 7 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Tobacco use is the second largest risk factor for CVDs, and is responsible for more than 19% of all CVD deaths in the WHO SEA Region. Tobacco control is thus critical for reducing CVD mortality. Three core lines of action are suggested as a way forward. Establish and/or strengthen national tobacco cessation programmes There is a substantial body of evidence that suggests that quitting tobacco use reduces the risk of CVDs immediately. People of all ages who have already developed health problems, including CVDs related to tobacco use, can still benefit from quitting. Fig. 5: Beneficial health changes that take place on quitting tobacco with time lines Image source: https://obamacarefacts.com/obamacare-smokers/, accessed 7 May 2018 § Within 20 minutes, the heart rate and blood pressure drop (25). § Within 12 hours, the carbon monoxide level in the blood drops to normal (26). Effective tobacco control can help to avert more than 700 000 cardiovascular deaths each year in the WHO SEA Region and help to achieve SDG target 3.4 – “reduce by one third premature mortality from NCDs by 2030”. The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region8 § Between 2 and 12 weeks, the circulation improves and lung function increases (23). § One year after quitting smoking, the risk of coronary heart disease is about half that of a smoker (23). § Between 1 and 4 years after quitting smokeless tobacco use, the risk of death falls to nearly half that of a person who continues to use it (27). § Between 5 and 15 years after quitting smoking, the risk of stroke is reduced to that of a non-smoker (23). § Fifteen years after quitting smoking, the risk of coronary heart disease is that of a person who has never smoked (23). However, despite the overwhelming evidence of the benefits of quitting, tobacco quit rates are low in most of the countries of the Region (Table 3), as the extremely addictive nature of nicotine makes it difficult for most people to quit without some form of assistance. Table 3. Percentage of current smokers who have tried to stop smoking, been advised to stop smoking by the health-care provider, or are former daily users of smoked tobacco Country (year of survey) Current smokers who have tried to stop smoking in the past 12 months (%) Current smokers advised to stop smoking by a health provider in the past 12 monthsa (%) Former daily smokers (among ever daily smokers) (%) Bangladesh (2009) 47.3 52.9 17.8 Bhutan (2014) 69.0 31.8 75.7 India (2016–17) 38.5 48.8 16.8 Indonesia (2011) 30.4 34.6 9.5 Maldives* (2011) 39.0 33.6 20.3 Myanmar (2014) 43.7 33.5 21.7 Nepal (2013) 26.0 22.3 20.2 Sri Lanka (2014) 51.8 35.0 34.4 Thailand (2011) 36.7 55.8 27.2 Timor-Leste (2014) 23.0 22.5 7.4 a Among those current smokers who visited a health-care provider in the past 12 months.. Sources of data: Respective years Global Adult Tobacco Surveys in Bangladesh, India, Indonesia and Thailand and respective years STEP surveys in the other countries. na – not available; * The survey covered only the capital city of Malé, and hence the data are not representative of whole of Maldives. 9 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Organized cessation programmes greatly increase the likelihood that a quit attempt will be successful. Article 14 of the WHO Framework Convention on Tobacco Control (FCTC) is concerned with the provision of support for reducing tobacco dependence and encouraging cessation (28). The “O” in the MPOWER package developed by WHO stands for “Offer help to quit tobacco use”. At a minimum, three primary cessation interventions are recommended to be included in a comprehensive tobacco control programme. These include: cessation advice at the primary health care level; quit lines; and pharmacological therapy, including nicotine replacement therapy. However, only one Member State – India—in the Regions has achieved the highest level of implementation in this key area. Cessation programmes are either non-existent or are in need of substantial strengthening in most of the Member States. Strengthen implementation of comprehensive tobacco control policies and programmes as outlined in the WHO FCTC Nearly half of all men and two in every five women in the WHO SEA Region consume some form of tobacco, putting them at high risk of CVDs and dying from them (29). Tobacco use starts early in in the Region, in the early adolescence years. More than 10% of 13–15-year-old adolescent students in eight out of 11 Member States of the Region report using tobacco (29). More than half of all daily smokers aged 20–34 years initiated “daily” smoking before the age of 20 years (29). The youth are the target audience of the tobacco industry. Programmatic efforts must be boosted in all Member States to prevent people from initiating tobacco use. § 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 SHS (Article 8 of the WHO FCTC). § Support the implementation of large pictorial health warnings and/or plain packaging on all tobacco products as a cost-effective method of informing tobacco users about the health risks of tobacco (Article 11 of the WHO FCTC). § Promote the adoption of labels that warn about the CVD risks of tobacco according to the WHO FCTC guidelines for health warnings (Article 11 of the WHO FCTC) § Promote the use of evidence-based mass media campaigns to raise awareness about the CVD risks of tobacco use and SHS exposure (Article 12 of the WHO FCTC). § Enforce a comprehensive ban on all forms of advertising and promotion of all tobacco products (Article 13 of the WHO FCTC). The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region10 Combine effective tobacco control measures with other cost-effective interventions for CVDs The major immediate risk factors for CVDs include behavioural risk factors (tobacco smoking, harmful use of alcohol, dietary patterns such as high levels of intake of dietary salt and transfats) and physiological risk factors (raised blood pressure, raised blood glucose and cholesterol levels, and high body mass index). Harmful use of alcohol causes 4.6% of all deaths in the Region, and almost one third of these deaths (33.4%) are from CVDs (30). Of the population aged 18 years and above, 14.7% is estimated to insufficiently active (31). The population-level salt consumption remains much higher than the recommended amount in most Member States of the Region (32). Since almost 88% of all CVD deaths are attributed to preventable risk factors (3), strong tobacco control measures should be combined with other best buys for more effective control of CVDs. These include early detection and treatment of raised blood pressure and raised blood glucose and cholesterol levels, elimination of transfats in the diet, reduction in the intake of dietary salt, reduced harmful use of alcohol and creating opportunities for regular physical activity. 11 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region References 1. United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2017 revision (for the reference date as of 1 July 2017). New York: United Nations, 2017. 2. World Bank. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-catalog/world- development-indicators, accessed 7 May 2018). 3. Global Burden of Disease Collaborative Network. Global burden of disease study 2016 (GBD 2016) Results. Seattle: Institute for Health Metrics and Evaluation (IHME), 2017. http://ghdx. healthdata.org/gbd-results-tool - accessed 24 May 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. Ambrose JA, Barua RS. The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol. 2004;43(10):1731–7. 7. 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. 8. Csordas A, Bernhard D. The biology behind the atherothrombotic effects of cigarette smoke. Nat Rev Cardiol. 2013;10(4):219–30. 9. 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. 10. 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 Jan 9 [Epub ahead of print]. 11. Gupta R, Gurm H, Bartholomew JR. Smokeless tobacco and cardiovascular risk. Arch Intern Med. 2004;164(17):1845–9. 12. 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. 13. 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. The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region12 14. 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. 15. 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. 16. Anand A, MIK S. The risk of hypertension and other chronic diseases: comparing smokeless tobacco with smoking. Front Public Health. 2017;5:255. 17. Boffetta P, Straif K. Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis. BMJ. 2009;339:b3060. 18. 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. 19. 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. 20. World Health Organization, Regional Office for South-East Asia. Monitoring tobacco control among adults in selected Member States of South-East Asia Region—at a glance. New Delhi, 2005. http://www.searo.who.int/entity/tobacco/data/adult_tobacco_brochure_2015.pdf - accessed 24 May 2018. 21. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. 2014;129(19):1972– 86. 22. 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):e006353. 23. 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. 24. 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. 25. Mahmud A, Feely J. Effect of smoking on arterial stiffness and pulse pressure amplification. Hypertension. 2003;41(1):183–7. 26. 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. 27. 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. 28. World Health Organization. Guidelines for implementation of Article 14 of the WHO Framework Convention on Tobacco Control. http://www.who.int/fctc/Guidelines.pdf - accessed 24 May 2018. 13 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region 29. Rani M, Thamarangshi T, Agrawal N. Youth tobacco use in South-East Asia: implication for tobacco epidemic and options for its control in the Region. Indian J Public Health 2017; 61:S12–S17. 30. World Health Organization. Global status report on alcohol and health 2014. Geneva, 2014. http://www.who.int/substance_abuse/publications/global_alcohol_report/en/ - accessed 24 May 2018. 31. World Health Organization. Prevalence of insufficient physical activity among adults: data by WHO RegionIn: World Health Organization Global Health Observatory data repository. http:// apps.who.int/gho/data/view.main.2463 - accessed 24 May 2018. 32. Mohan S, Prabhakaran D. Review of salt and health: situation in South-East Asia Region. Technical paper. New Delhi: WHO Regional Office for South-East Asia, 2013. http://www. searo.who.int/entity/noncommunicable_diseases/events/ncd_twg_bangkok_technical_paper_ review_of_salt_and_health.pdf - accessed 24 May 2018. The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region14 15 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Country factsheets The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region16 17 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Heart disease and stroke are the commonest ways by which tobacco kills people FACTSHEET 2018 BANGLADESH 164.7 million Youth population (13–17 years) 16.3 million = 10% Economically productive population (30–69 years) 66.1 million = 40%US$ 1330 Total populationGross national income per capita (lower middle– income country) QUIT TOBACCO USE NOW - FOR A HEALTHIER HEART CVDs are the number one cause of death, causing 277 942 each year (32.8% of all deaths), as well as of premature death Ischemic heart disease Cerebrovascular diseases Chronic obstructive pulmonary disease Lower resperiratory infection Diabetes Top 5 causes of overall death 1 2 3 4 5 Tobacco control is essential for preventing and controlling deaths and disability caused by CVDs CVD deaths caused by tobacco use Ischemic heart disease Cerebrovascular diseases Lower resperiratory infection Neonatal encephalopathy Other neonatal Top 5 causes of premature death (YLL–years of life lost) 1 2 3 4 5 of all CVD deaths each year 66 749 deaths 24% Communicable, maternal, neonatal and nutritional diseases Noncommunicable diseases current tobacco users and a substantial number of people exposed to secondhand smoke are at increased risk of CVDs41.3 m Tobacco users3 Tobacco smokers4 Smokeless tobacco users5 Current tobacco use among adults (%) (15+years) GATS–2009 Current tobacco use among youth (%) (13–15 years) GYTS–2013 0 10 20 30 40 50 60 0 10 20 30 40 50 60 43.3 23.0 44.7 1.5 27.226.427.9 58.0 28.7 Tobacco users Tobacco smokers Smokeless tobacco users 6.9 2.9 4.0 1.1 5.9 2.0 9.2 2.8 0 2 4 6 8 10 4.5 Exposed to secondhand6 smoke at home (%) Adult (15+ years) GATS–2009 Youth (13–15 years) GYTS–2013 54.9 31.133.0 27.7 58.2 51.7 Total Male Female The most common way tobacco kills is from cardiovascular diseases (CVDs)2 CVDs in younger people are more likely to be caused by tobacco use Age in years 0% 10% 20% 30% 40% 50% 41% 30–44 45–59 60–69 70+ 37% 29% 15% Distribution of tobacco deaths by cause Others 5%CMNNDb 6% CRDa 28% Cancers 20% CVD 41% Tobacco1 kills 161 253 people each year 19% of all deaths % o f C VD d ea th s ca us ed b y to ba cc o The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region18 Most people start early, increasing the risk of heart disease in younger people Mean age at initiation of daily smoking:18.8 years Preventing and controlling sickness, death and disability from cardiovascular diseases Quit attempt by current 7 Smokers Smokeless tobacco users Smokers Smokeless tobacco users Former daily smokers 9 Former daily smokeless users 10 People who quit tobacco useUsers advised to quit tobacco smoking by healthcare provider 8 47.3% 28.5% 52.9% 47.9% 17.8% 5.5% Despite strong evidence that quitting both smoked and smokeless tobacco helps to immediately reduce the risk of CVDs, FEW tobacco users are quitting, requiring more programmatic effort Technical notes and key definitions: 1 Tobacco use includes use of both smoked (cigarette, bidi, hukkah) and smokeless (jarda, sada pata, gul). 2 Cardiovascular diseases include all the diseases of the heart and circulation such as coronary heart disease, angina, heart attacks and stroke (cerebrovascular disease). 3 Current tobacco user is defined as a person reporting use of any smoked or smokeless tobacco product daily or less than daily at the time of survey. 4 Current tobacco smoker is a person who reports smoking any tobacco product on a daily or less-than-daily basis at the time of survey. 5 Smokeless tobacco user is a person who reports the use of any smokeless tobacco product on a daily or less-than-daily basis at the time of survey. 6 A person passively exposed to tobacco smoke from other people using it around him/her. 7 Among current smokers and former smokers who have been abstinent for less than 12 months in the past 12 months. 8 Among those smokers who visited a healthcare provider in the past 12 months. 9 Among ever daily smokers, also known as quit ratio for daily smoking. 10 Among ever daily smokeless users, also known as quit ratio for daily smokeless users. a. CRD – chronic respiratory diseases; b. CMNND – communicable, maternal, neonatal, and nutritional diseases GATS – Global Adult Tobacco Survey; GYTS – Global Youth Tobacco Survey; STEPS – WHO STEPwise approach to noncommunicable disease risk factor surveillance Sources of data: 1. Total population, youth population and population in economically productive age group: Population – United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2017 revision (for the reference date as of 1 July 2017). New York: United Nations; 2017. 2. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-catalog/world-development-indicators, accessed 7 May 2018) 3. Data on total and proportional deaths from CVDs, tobacco use and proportion of total tobacco deaths due to CVDs: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME): 2017(http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). 4. Adult tobacco use prevalence; mean age at initiation of tobacco use, tobacco quitting, and secondhand exposure for adults data: Global Adult Tobacco Survey (GATS, 2009) (http://www.sea ro.who.int/entity/noncommunicable_diseases/data/ban_ncd_reports/en/, accessed 7 May 2018). 5. Youth tobacco use prevalence and exposure to secondhand smoke: Global Youth Tobacco Survey (GYTS, 2013): http://www.searo.who.int/tobacco/data/ban_rtc_reports , accessed 7 May 2018. Key references: 1. 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. 2. 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. 3. 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] For more information refer to Website http://www.searo.who.int/nts For technical information, please contact: Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Email: ranim@who.int; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int Prevent people from starting tobacco use: Combine tobacco control with the following strategies for effective prevention of CVDs: Quitting immediately reduces the risk of heart attack and/or stroke; Quitting helps even if a person has already had a heart attack and/or stroke, irrespective of his/her age; Train health providers to ask about tobacco use at each encounter with their patients and advise them to quit. Help people to reduce salt, sugar, tans-fat in their diet, reduce harmful use of alcohol and create opportunities for regular physical activity; Provide early screening and effective treatment for raised blood pressure and raised blood sugar levels. Help current tobacco users to quit tobacco for a healthier heart: Tobacco use starts early; Prevent them from starting tobacco use by fully implementing WHO Framework Convention on Tobacco Control: raising taxes; informing people of tobacco risk through tobacco package warnings and information campaigns; and comprehensive ban on tobacco advertising and promotion in any form. 19 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Heart disease and stroke are the commonest ways by which tobacco kills people FACTSHEET 2018 BHUTAN 808 000 Youth population (13–17 years) 73 000 = 9% Economically productive population (30–69 years) 332 000 = 41%US$ 2510 Total populationGross national income per capita (lower middle-income country) QUIT TOBACCO USE NOW - FOR A HEALTHIER HEART CVDs are the number one cause of death, causing 1 141 (29.4%) (29.4% of all deaths), as well as of premature death Ischemic heart disease Chronic Obstructive pulmonary disease Cerebrovascular disease Lower respiratory infection Diabetes Top 5 causes of overall death 1 2 3 4 5 Tobacco control is essential for preventing and controlling deaths and disability caused by CVDs CVD deaths caused by tobacco use Ischemic heart disease Lower respiratory infection Neonatal preterm birth Cerebrovascular disease Other neonatal Top 5 causes of premature death (YLL–years of life lost) 1 2 3 4 5 92 deaths Noncommunicable diseases current tobacco users and a substantial number of people exposed to secondhand smoke are at increased risk of CVDs120 000 Tobacco users3 Tobacco smokers4 Smokeless tobacco users5 Current tobacco use among adults (%) (18–69 years) STEPS–2014 Current tobacco use among youth (%) (13–15 years) GYTS–2013 0 10 15 20 25 30 35 40 Tobacco users Tobacco smokers Smokeless tobacco users 0 10 20 30 40 50 Exposed to secondhand6 smoke at home (%) Adult (18–69 years) STEPS–2014 Youth (13–15 years) GYTS–2013 0 5 10 15 20 25 20.7 20.7 20.7 15.3 16.3 14.4 Total Male Female The most common way tobacco kills is from cardiovascular diseases (CVDs)2 CVDs in younger people are more likely to be caused by tobacco use Age in years 0% 5% 10% 15% 20% 25% 19% 14% 10% 5% 30–44 45–59 60–69 70+ Distribution of tobacco deaths by cause Others 6% CMNNDb 13% CRDa 25% Cancers 14% CVD 42% 5 24.8 7.4 10.8 3.1 19.7 26.5 11.0 33.6 13.6 30.3 39.0 23.2 16.5 26.3 8.6 21.6 25.0 18.9 Communicable, maternal, neonatal, and nutritional diseases Tobacco1 kills estimated people each year 5.7% of all deaths % o f C VD d ea th s ca us ed b y to ba cc o of all CVD deaths each year8% 221 More than The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region20 Most people start early, increasing the risk of heart disease in younger people Mean age at initiation of daily smoking: 18.9 years Preventing and controlling sickness, death and disability from cardiovascular diseases Users advised to quit tobacco smoking by healthcare provider 8 Despite strong evidence that quitting both smoked and smokeless tobacco helps to immediately reduce the risk of CVDs, FEW tobacco users are quitting, requiring more programmatic effort Technical notes and key definitions: 1 Tobacco use includes use of both smoked (cigarette, bidi, cigars, cheroots, cigarillos) and smokeless (snuff, chewing tobacco, betel quid). 2 Cardiovascular diseases include all the diseases of the heart and circulation such as coronary heart disease, angina, heart attacks and stroke (cerebrovascular disease). 3 Current tobacco user is defined as a person reporting use of any smoked or smokeless tobacco product daily or less than daily at the time of survey. 4 Current tobacco smoker is a person who reports smoking any tobacco product on a daily or less-than-daily basis at the time of survey at the time of survey. 5 Smokeless tobacco user is a person who reports the use of any smokeless tobacco product on a daily or less-than-daily basis at the time of survey. 6 A person passively exposed to tobacco smoke from other people using it around him/her. 7 Among current smokers and former smokers who have been abstinent for less than 12 months in the past 12 months. 8 Among those smokers who visited a healthcare provider in the past 12 months. 9 Among ever daily smokers, also known as quit ratio for daily smoking. 10 Among ever daily smokeless users, also known as quit ratio for daily smokeless users. a. CRD – chronic respiratory diseases; b. CMNND – communicable, maternal, neonatal, and nutritional diseases GATS – Global Adult Tobacco Survey; GYTS – Global Youth Tobacco Survey; STEPS – WHO STEPwise approach to noncommunicable disease risk factor surveillance Sources of data: 1. Total population, youth population and population in economically productive age group: United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2017 revision (for the reference date as of 1 July 2017). New York: United Nations; 2017. 2. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-catalog/world-development-indicators, accessed 7 May 2018) 3. Data on total and proportional deaths from CVDs, tobacco use and proportion of total tobacco deaths due to CVDs: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME): 2017(http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). 4. Adult tobacco use prevalence; secondhand tobacco exposure; mean age at initiation of tobacco use, quitting rates: National survey for noncommunicable diseases risk factors and mental health using WHO STEPS approach in Bhutan 2014 (http://www.who.int/ncds/surveillance/steps/bhutan) accessed on 7 May 2018. 5. Youth tobacco use prevalence and secondhand exposure among 13 –15 year old population: Global Youth Tobacco Survey (GYTS–2013) http://www.searo.who.int/entity/noncommunicable_ diseases/data/bhu_ncd_reports accessed on 7 May 2018. Key references: 1. 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. 2. 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. 3. 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] For more information refer to Website http://www.searo.who.int/nts For technical information, please contact: Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Email: ranim@who.int; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int Quit attempt by current smokers 7 69.0% 31.8% People who quit tobacco use Former daily smokers 9 Former daily smokeless users 10 75.7% 38.4% Prevent people from starting tobacco use: Combine tobacco control with the following strategies for effective prevention of CVDs: Quitting immediately reduces the risk of heart attack and/or stroke; Quitting helps even if a person has already had a heart attack and/or stroke, irrespective of his/her age; Train health providers to ask about tobacco use at each encounter with their patients and advise them to quit. Help people to reduce salt, sugar, tans-fat in their diet, reduce harmful use of alcohol and create opportunities for regular physical activity; Provide early screening and effective treatment for raised blood pressure and raised blood sugar levels. Help current tobacco users to quit tobacco for a healthier heart: Tobacco use starts early; Prevent them from starting tobacco use by fully implementing WHO Framework Convention on Tobacco Control: raising taxes; informing people of tobacco risk through tobacco package warnings and information campaigns; and imposing a comprehensive ban on tobacco advertising and promotion in any form. 21 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Heart disease and stroke are the commonest ways by which tobacco kills people FACTSHEET 2018 INDIA US$ 1670 Gross national income per capita (lower middle–income country) QUIT TOBACCO USE NOW - FOR A HEALTHIER HEART CVDs are the number one cause of death, causing 2 751 972 each year (28.1% of all deaths), as well as of premature death Ischemic heart disease Chronic obstructive pulmonary disease Diarrheal diseases Cerebrovascular disease Lower respiratory infection Top 5 causes of overall death 1 2 3 4 5 Tobacco control is essential for preventing and controlling deaths and disability caused by CVDs CVD deaths caused by tobacco use Ischemic heart disease Lower respiratory infection Diarrheal disease Chronic obstructive pulmonary disease Cerebrovascular disease Top 5 causes of premature death (YLL–years of life lost) 1 2 3 4 5 of all CVD deaths each year 449 844 deaths 16% Noncommunicable diseases current tobacco users and a substantial number of people exposed to secondhand smoke are at increased risk of CVDs266.8 m Current tobacco use among adults (%) (15+ years) GATS 2016–2017 Current tobacco use among youth (%) (13–15 years) GYTS–2009 0 5 10 15 20 Tobacco users Tobacco smokers Smokeless tobacco users 14.6 8.1 11.2 3.7 11.1 6.0 19.0 6.3 9.0 Exposed to secondhand6 smoke at home (%) 0 10 20 30 40 50 Adult (15+ years) GATS 2016–2017 Youth (13–15 years) GYTS–2009 38.7 38.1 21.9 24.1 18.8 39.3 Total Male Female The most common way tobacco kills is from cardiovascular diseases (CVDs)2 CVDs in younger people are more likely to be caused by tobacco use Age in years 0% 5% 10% 15% 20% 25% 30% 26% 25% 19% 10% 30–44 45–59 60–69 70+ Distribution of tobacco deaths by cause Others 5% CMNND6 14% CRDa 23% Cancers 10% CVD 48% Tobacco users3 Tobacco smokers4 Smokeless tobacco users5 28.6 10.7 19.0 2.0 21.4 29.6 12.8 42.4 14.2 0 10 20 30 40 50 Communicable, maternal, neonatal and nutritional diseases 1339.2 million Youth population (13–17 years) 126.0 million = 9% Economically productive population (30–69 years) 560.1 million = 42% Total population Tobacco1 kills more than 1 million people each year 9.5% of all deaths % o f C VD d ea th s ca us ed b y to ba cc o The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region22 Most people start early, increasing the risk of heart disease in younger people Mean age at initiation of daily smoking: 18.7 years Prevent people from starting tobacco use: Combine tobacco control with the following strategies for effective prevention of CVDs: Quitting immediately reduces the risk of heart attack and/or stroke; Quitting helps even if a person has already had a heart attack and/or stroke, irrespective of his/her age; Train health providers to ask about tobacco use at each encounter with their patients and advise them to quit. Help people to reduce salt, sugar, tans-fat in their diet, reduce harmful use of alcohol and create opportunities for regular physical activity; Provide early screening and effective treatment for raised blood pressure and raised blood sugar levels. Help current tobacco users to quit tobacco for a healthier heart: Preventing and controlling sickness, death and disability from cardiovascular diseases Tobacco use starts early; Prevent them from starting tobacco use by fully implementing WHO Framework Convention on Tobacco Control: raising taxes; informing people of tobacco risk through tobacco package warnings and information campaigns; and imposing a comprehensive ban on tobacco advertising and promotion in any form. Technical notes and key definitions: 1 Tobacco use includes use of both smoked (cigarette, bidis, cigars, cheroots, rolled cigarettes, tobacco rolled in maize leaf and newspaper, hukkah, pipes, chillum, chutta ) and smokeless (betel quid with tobacco, khaini, tobacco lime mixture, gutka, oral tobacco, pan masala, snuff). 2 Cardiovascular diseases include all the diseases of the heart and circulation such as coronary heart disease, angina, heart attacks and stroke (cerebrovascular disease). 3 Current tobacco user is defined as a person reporting use of any smoked or smokeless tobacco product daily or less than daily at the time of survey. 4 Current tobacco smoker is a person who reports smoking any tobacco product on a daily or less-than-daily basis at the time of survey. 5 Smokeless tobacco user is a person who reports the use of any smokeless tobacco product on a daily or less-than-daily basis at the time of survey. 6 A person passively exposed to tobacco smoke from other people using it around him/her. 7 Among current smokers and former smokers who have been abstinent for less than 12 months in the past 12 months. 8 Among those smokers who visited a healthcare provider in the past 12 months. 9 Among ever daily smokers, also known as quit ratio for daily smoking. 10 Among ever daily smokeless users, also known as quit ratio for daily smokeless users. a. CRD – chronic respiratory diseases; b. CMNND – communicable, maternal, neonatal, and nutritional diseases GATS – Global Adult Tobacco Survey; GYTS – Global Youth Tobacco Survey; STEPS – WHO STEPwise approach to noncommunicable disease risk factor surveillance Sources of data: 1. Total population, youth population and population in economically productive age group: United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2017 revision (for the reference date as of 1 July 2017). New York: United Nations; 2017. 2. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-catalog/world-development-indicators, accessed 7 May 2018) 3. Data on total and proportional deaths from CVDs, tobacco use and proportion of total tobacco deaths due to CVDs: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME): 2017(http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). 4. Data on total tobacco deaths: Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra N, Kumar R, et al. A nationally representative case–control study of smoking and death in India. N Engl J Med. 2008;358(11):1137–1147. 5. Adult tobacco use prevalence secondhand tobacco exposure; mean age at initiation of tobacco use, and tobacco quitting data: Global Adult Tobacco Survey (2016–2017). 6. Youth tobacco use prevalence and exposure to secondhand smoke: Global Youth Tobacco Survey (GYTS) 2009 (http://www.searo.who.int/entity/noncommunicable_diseases/ data/india_ncd_reports , accessed 7 May 2018). Key references: 1. 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. 2. 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. 3. 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] For more information refer to Website http://www.searo.who.int/nts For technical information, please contact: Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Email: ranim@who.int; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int Quit attempt by current 7 Smokers Smokeless tobacco users Smokers Smokeless tobacco users Former daily smokers 9 Former daily smokeless users 10 People who quit tobacco useUsers advised to quit tobacco use by healthcare provider 8 38.5% 33.2% 48.8% 31.7% 16.8% 5.8% Despite strong evidence that quitting both smoked and smokeless tobacco helps to immediately reduce the risk of CVDs, FEW tobacco users are quitting, requiring more programmatic effort 23 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Heart disease and stroke are the commonest ways by which tobacco kills people FACTSHEET 2018 INDONESIA 264.0 million Youth population (13–17 years) 23.4 million = 9% Economically productive population (30–69 years) 117.3 million = 44%US$ 3400 Total populationGross national income per capita (lower middle–income country) QUIT TOBACCO USE NOW - FOR A HEALTHIER HEART CVDs are the number one cause of death, causing 558 736 each year (36.3% of all deaths), as well as of premature death Ischemic heart disease Cerebrovascular disease Tuberculosis Diabetes Chronic obstructive pulmonary disease Top 5 causes of overall death 1 2 3 4 5 Tobacco control is essential for preventing and controlling deaths and disability caused by CVDs CVD deaths caused by tobacco use Ischemic heart disease Cerebrovascular disease Tuberculosis Diabetes Neonatal preterm birth Top 5 causes of premature death (YLL–years of life lost) 1 2 3 4 5 147 510 deaths Noncommunicable diseases Communicable, maternal, neonatal, and nutritional diseases current tobacco users and a substantial number of people exposed to secondhand smoke are at increased risk of CVDs61.4 m Tobacco users3 Tobacco smokers4 Smokeless tobacco users5 Current tobacco use among adults (%) (15+ years) GATS–2011 Current tobacco use among youth (%) (13–15 years) GYTS–2014 0 20 30 40 50 60 70 Tobacco users Tobacco smokers Smokeless tobacco users 0 5 10 15 20 25 30 35 40 Exposed to secondhand6 smoke at home (%) Adult (15+ years) GATS–2011 Youth (13–15 years) GYTS–2014 0 20 40 60 80 100 78.4 57.3 81.4 75.4 61.7 52.7 Total Male Female The most common way tobacco kills is from cardiovascular diseases (CVDs)2 CVDs in younger people are more likely to be caused by tobacco use Age in years 0% 10% 20% 30% 40% 50% 45% 38% 30% 17% 30–44 45–59 60–69 70+ Distribution of tobacco deaths by cause Others 10% CMNNDb 11% CRDa 9% Cancers 5% CVD 65% 10 36.1 34.8 67.0 2.7 1.7 1.5 2.0 67.4 4.5 20.3 36.2 4.3 19.4 35.3 3.4 2.1 3.0 1.1 Tobacco1 kills 225 720 people each year 14.7% of all deaths % o f C VD d ea th s ca us ed b y to ba cc o of all CVD deaths each year26% The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region24 Most people start early, increasing the risk of heart disease in younger people Mean age at initiation of daily smoking: 17.6 years Preventing and controlling sickness, death and disability from cardiovascular diseases Users advised to quit tobacco smoking by healthcare provider 8 Despite strong evidence that quitting both smoked and smokeless tobacco helps to immediately reduce the risk of CVDs, FEW tobacco users are quitting, requiring more programmatic effort Technical notes and key definitions: 1 Tobacco use includes use of both smoked (cigarettes, kretek, cigars, pipes) and smokeless (sirih, betel quid, tobacco leaf, tobacco leaf and betel nut mixture). 2 Cardiovascular diseases include all the diseases of the heart and circulation such as coronary heart disease, angina, heart attacks and stroke (cerebrovascular disease). 3 Current tobacco user is defined as a person reporting use of any smoked or smokeless tobacco product daily or less than daily at the time of survey. 4 Current tobacco smoker is a person who reports smoking any tobacco product on a daily or less-than-daily basis at the time of survey. 5 Smokeless tobacco user is a person who reports the use of any smokeless tobacco product on a daily or less-than-daily basis at the time of survey. 6 A person passively exposed to tobacco smoke from other people using it around him/her. 7 Among current smokers and former smokers who have been abstinent for less than 12 months in the past 12 months. 8 Among those smokers who visited a healthcare provider in the past 12 months. 9 Among ever daily smokers, also known as quit ratio for daily smoking. 10 Among ever daily smokeless users, also known as quit ratio for daily smokeless users. a. CRD – chronic respiratory diseases; b. CMNND – communicable, maternal, neonatal, and nutritional diseases GATS – Global Adult Tobacco Survey; GYTS – Global Youth Tobacco Survey; STEPS – WHO STEPwise approach to noncommunicable disease risk factor surveillance Sources of data: 1. Total population, youth population and population in economically productive age group: United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2017 revision (for the reference date as of 1 July 2017). New York: United Nations; 2017. 2. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-catalog/world-development-indicators, accessed 7 May 2018) 3. Data on total and proportional deaths from CVDs, tobacco use and proportion of total tobacco deaths due to CVDs: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME): 2017(http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). 4. Adult tobacco use prevalence; mean age at initiation of tobacco use, tobacco quitting, and secondhand exposure for adults data : Global Adult Tobacco Survey (GATS, 2011) (http://www.sea ro.who.int/tobacco/data/ino_rtc_reports, accessed 7 May 2018). 5. Youth tobacco use prevalence and secondhand exposure among 13–15 year old population: Global Youth Tobacco survey (2014) (http://www.searo.who.int/tobacco/data/ino_rtc_reports, accessed 7 May 2018). Key references: 1. 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. 2. 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. 3. 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] For more information refer to Website http://www.searo.who.int/nts For technical information, please contact: Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Email: ranim@who.int; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int Quit attempt by current smokers 7 30.4% 34.6% People who quit tobacco use (former daily smokers9) 9.5% Prevent people from starting tobacco use: Combine tobacco control with the following strategies for effective prevention of CVDs: Quitting immediately reduces the risk of heart attack and/or stroke; Quitting helps even if a person has already had a heart attack and/or stroke, irrespective of his/her age; Train health providers to ask about tobacco use at each encounter with their patients and advise them to quit. Help people to reduce salt, sugar, tans-fat in their diet, reduce harmful use of alcohol and create opportunities for regular physical activity; Provide early screening and effective treatment for raised blood pressure and raised blood sugar levels. Help current tobacco users to quit tobacco for a healthier heart: Tobacco use starts early; Prevent them from starting tobacco use by fully implementing WHO Framework Convention on Tobacco Control: raising taxes; informing people of tobacco risk through tobacco package warnings and information campaigns; and imposing a comprehensive ban on tobacco advertising and promotion in any form. 25 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Heart disease and stroke are the commonest ways by which tobacco kills people FACTSHEET 2018 MALDIVES 436 000 Youth population (13–17 years) 28 000 = 6% Economically productive population (30–69 years) 193 000 = 44%US$ 10380 Total populationGross national income per capita (upper middle–income country) QUIT TOBACCO USE NOW - FOR A HEALTHIER HEART CVDs are the number one cause of death, causing 444 each year (39.4% of all deaths), as well as of premature death Ischemic heart disease Cerebrovascular disease Chronic obstructive pulmonary disease Chronic kidney disease Alzheimer disease Top 5 causes of overall death 1 2 3 4 5 Tobacco control is essential for preventing and controlling deaths and disability caused by CVDs CVD deaths caused by tobacco use Ischemic heart disease Cerebrovascular disease Chronic kidney disease Chronic obstructive pulmonary disease Congenital defects Top 5 causes of premature death (YLL–years of life lost) 1 2 3 4 5 106 deaths Noncommunicable diseases current tobacco users and a substantial number of people exposed to secondhand smoke are at increased risk of CVDs76 100 Tobacco users3 Tobacco smokers4 Smokeless tobacco users5 Current tobacco use among adults (%) (15–64 years) STEPS–2011 Current tobacco use among youth (%) (13–15 years) GYTS–2011 0 20 30 40 Tobacco users Tobacco smokers Smokeless tobacco users 0 5 10 15 20 Exposed to secondhand6 smoke at home (%) Adult (15–64 years) STEPS–2011 Youth (13–15 years) GYTS–2011 0 10 20 30 40 25.3 34.5 27.2 23.4 35.1 33.1 Total Male Female The most common way tobacco kills is from cardiovascular diseases (CVDs)2 CVDs in younger people are more likely to be caused by tobacco use Age in years 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 45% 39% 29% 19% 30–44 45–59 60–69 70+ Distribution of tobacco deaths by cause Others 7%CMNNDb 5% CRDa 14% Cancers 12% CVD 62% 10 19.9 18.8 34.7 3.4 2.6 3.9 1.4 36.0 4.4 11.2 15.2 6.7 7.9 10.4 5.0 6.2 9.2 2.9 % o f C VD d ea th s ca us ed b y to ba cc o Tobacco1 kills 173 people each year 15.3% of all deaths of all CVD deaths each year24% The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region26 Most people start early, increasing the risk of heart disease in younger people Mean age at initiation of daily smoking: 17.8 years Preventing and controlling sickness, death and disability from cardiovascular diseases Users advised to quit tobacco smoking by healthcare provider 8 Despite strong evidence that quitting both smoked and smokeless tobacco helps to immediately reduce the risk of CVDs, FEW tobacco users are quitting, requiring more programmatic effort Technical notes and key definitions: 1 Tobacco use includes use of both smoked (cigarette, pipes, cigars, cheroots, cigarillos, water pipe ) and smokeless (snuff, chewing tobacco, betel quit). 2 Cardiovascular diseases include all the diseases of the heart and circulation such as coronary heart disease, angina, heart attacks and stroke (cerebrovascular disease). 3 Current tobacco user is defined as a person reporting use of any smoked or smokeless tobacco product daily or less than daily at the time of survey. 4 Current tobacco smoker is a person who reports smoking any tobacco product on a daily or less-than-daily basis at the time of survey. 5 Smokeless tobacco user is a person who reports the use of any smokeless tobacco product on a daily or less-than-daily basis at the time of survey. 6 A person passively exposed to tobacco smoke from other people using it around him/her. 7 Among current smokers and former smokers who have been abstinent for less than 12 months in the past 12 months. 8 Among those smokers who visited a healthcare provider in the past 12 months. 9 Among ever daily smokers, also known as quit ratio for daily smoking. 10 Among ever daily smokeless users, also known as quit ratio for daily smokeless users. a. CRD – chronic respiratory diseases; b. CMNND – communicable, maternal, neonatal, and nutritional diseases GATS – Global Adult Tobacco Survey; GYTS – Global Youth Tobacco Survey; STEPS – WHO STEPwise approach to noncommunicable disease risk factor surveillance Sources of data: 1. Total population, youth population and population in economically productive age group: United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2017 revision (for the reference date as of 1 July 2017). New York: United Nations; 2017. 2. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-catalog/world-development-indicators, accessed 7 May 2018) 3. Data on total and proportional deaths from CVDs, tobacco use and proportion of total tobacco deaths due to CVDs: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME): 2017(http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). 4. Adult tobacco use prevalence; mean age at initiation of tobacco use, tobacco quitting, and secondhand exposure for adults data : WHO STEPS survey on risk factors for noncommunicable diseases Maldives, 2011 (http://www.searo.who.int/entity/ncd_tobacco_surveillance/documents/mav_reports) accessed 7 May 2018. The survey covered only the capital city of Malè, and hence the data are not representative of whole of Maldives. 5. Youth tobacco use prevalence and secondhand exposure among 13 –15 year old population: Global Youth Tobacco Survey, GYTS 2011 http://www.searo.who.int/entity/ncd_tobacco_survei llance/documents/mav_reports, accessed 7 May 2018. Key references: 1. 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. 2. 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. 3. 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] For more information refer to Website http://www.searo.who.int/nts For technical information, please contact: Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Email: ranim@who.int; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int Quit attempt by current smokers 7 39.0% 33.5% People who quit tobacco use Former daily smokers 9 Former daily smokeless users 10 20.3% 57.3% Prevent people from starting tobacco use: Combine tobacco control with the following strategies for effective prevention of CVDs: Quitting immediately reduces the risk of heart attack and/or stroke; Quitting helps even if a person has already had a heart attack and/or stroke, irrespective of his/her age; Train health providers to ask about tobacco use at each encounter with their patients and advise them to quit. Help people to reduce salt, sugar, tans-fat in their diet, and create opportunities for regular physical activity; Provide early screening and effective treatment for raised blood pressure and raised blood sugar levels. Help current tobacco users to quit tobacco for a healthier heart: Tobacco use starts early; Prevent them from starting tobacco use by fully implementing WHO Framework Convention on Tobacco Control: raising taxes; informing people of tobacco risk through tobacco package warnings and information campaigns; and imposing a comprehensive ban on tobacco advertising and promotion in any form. 27 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Heart disease and stroke are the commonest ways by which tobacco kills people FACTSHEET 2018 MYANMAR 53.4 million Youth population (13–17 years) 5.2 million = 10% Economically productive population (30– 69 years) 23.4 million = 44%US$ 1190 Total populationGross national income per capita (lower middle-income country) QUIT TOBACCO USE NOW - FOR A HEALTHIER HEART CVDs are the number one cause of death, causing 87 472 each year (23.4% of all deaths), as well as of premature death Cerebrovascular disease Ischemic heart disease Chronic obstructive pulmonary disease Alzheimer disease Lower respiratory infection Top 5 causes of overall death 1 2 3 4 5 Tobacco control is essential for preventing and controlling deaths and disability caused by CVDs CVD deaths caused by tobacco use Cerebrovascular disease Lower respiratory infection Road injuries Ischemic heart disease Tuberculosis Top 5 causes of premature death (YLL–years of life lost) 1 2 3 4 5 20 732 deaths Noncommunicable diseases Injuries Communicable, maternal, neonatal, and nutritional diseases current tobacco users and a substantial number of people exposed to secondhand smoke are at increased risk of CVDs13.3 m Tobacco users3 Tobacco smokers4 Smokeless tobacco users5 Current tobacco use among adults (%) (25–64 years) STEPS–2014 Current tobacco use among youth (%) (13–15 years) GYTS–2016 0 20 40 60 80 100 54.4 26.1 43.8 8.4 43.2 62.2 24.1 79.8 29.1 0 5 10 15 20 25 30 Tobacco users Tobacco smokers Smokeless tobacco users 13.6 26.3 3.7 10.6 21.1 2.4 5.7 11.0 1.5 Exposed to secondhand6 smoke at home (%) 0 10 20 30 40 50 Adult (25–64 years) STEPS–2014 Youth (13–15 years) GYTS–2016 39.1 32.1 46.0 33.2 37.7 29.5 Total Male Female The most common way tobacco kills is from cardiovascular diseases (CVDs)2 CVDs in younger people are more likely to be caused by tobacco use Age in years 0% 5% 10% 15% 20% 25% 30% 35% 40% 34% 33% 28% 18% 30–44 45–59 60–69 70+ Distribution of tobacco deaths by cause Others 6% CMNNDb 9% CRDa 25% Cancers 28% CVD 32% Tobacco1 kills 65 651 people each year 17.6% of all deaths % o f C VD d ea th s ca us ed b y to ba cc o of all CVD deaths each year24% The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region28 Most people start early, increasing the risk of heart disease in younger people Mean age at initiation of daily smoking: 19.8 years Preventing and controlling sickness, death and disability from cardiovascular diseases Users advised to quit tobacco smoking by healthcare provider 8 Despite strong evidence that quitting both smoked and smokeless tobacco helps to immediately reduce the risk of CVDs, FEW tobacco users are quitting, requiring more programmatic effort Technical notes and key definitions: 1 Tobacco use includes use of both smoked (cigarette, cigars, pipes) and smokeless (snuff, chewing tobacco, betel). 2 Cardiovascular diseases include all the diseases of the heart and circulation such as coronary heart disease, angina, heart attacks and stroke (cerebrovascular disease). 3 Current tobacco user is defined as a person reporting use of any smoked or smokeless tobacco product daily or less than daily at the time of survey. 4 Current tobacco smoker is a person who reports smoking any tobacco product on a daily or less-than-daily basis at the time of survey. 5 Smokeless tobacco user is a person who reports the use of any smokeless tobacco product on a daily or less-than-daily basis at the time of survey. 6 A person passively exposed to tobacco smoke from other people using it around him/her. 7 Among current smokers and former smokers who have been abstinent for less than 12 months in the past 12 months. 8 Among those smokers who visited a healthcare provider in the past 12 months. 9 Among ever daily smokers, also known as quit ratio for daily smoking. 10 Among ever daily smokeless users, also known as quit ratio for daily smokeless users. a. CRD – chronic respiratory diseases; b. CMNND – communicable, maternal, neonatal, and nutritional diseases GATS – Global Adult Tobacco Survey; GYTS – Global Youth Tobacco Survey; STEPS – WHO STEPwise approach to noncommunicable disease risk factor surveillance Sources of data: 1. Total population, youth population and population in economically productive age group: United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2017 revision (for the reference date as of 1 July 2017). New York: United Nations; 2017. 2. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-catalog/world-development-indicators, accessed 7 May 2018) 3. Data on total and proportional deaths from CVDs, tobacco use and proportion of total tobacco deaths due to CVDs: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME): 2017(http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). 4. Adult tobacco use prevalence; mean age at initiation of tobacco use, tobacco quitting, and secondhand exposure for adults data: : Report on National survey of Diabetes Mellitus and Risk Factors for noncommunicable diseases in Myanmar 2014 (http://www.who.int/ncds/surveillance/steps/myanmar, accessed 7 May 2018). 5.Youth tobacco use prevalence and secondhand exposure among 13 –15 year old population: Global Youth Tobacco Survey (GYTS – 2016). Key references: 1. 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. 2. 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. 3. 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] For more information refer to Website http://www.searo.who.int/nts For technical information, please contact: Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Email: ranim@who.int; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int Quit attempt by current smokers 7 43.7% 33.5% People who quit tobacco use Former daily smokers 9 Former daily smokeless users 10 21.7% 18.7% Prevent people from starting tobacco use: Combine tobacco control with the following strategies for effective prevention of CVDs: Quitting immediately reduces the risk of heart attack and/or stroke; Quitting helps even if a person has already had a heart attack and/or stroke, irrespective of his/her age; Train health providers to ask about tobacco use at each encounter with their patients and advise them to quit. Help people to reduce salt, sugar, tans-fat in their diet, reduce harmful use of alcohol and create opportunities for regular physical activity; Provide early screening and effective treatment for raised blood pressure and raised blood sugar levels. Help current tobacco users to quit tobacco for a healthier heart: Tobacco use starts early; Prevent them from starting tobacco use by fully implementing WHO Framework Convention on Tobacco Control: raising taxes; informing people of tobacco risk through tobacco package warnings and information campaigns; and imposing a comprehensive ban on tobacco advertising and promotion in any form. 29 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Heart disease and stroke are the commonest ways by which tobacco kills people FACTSHEET 2018 NEPAL 29.3 million Youth population (13–17 years) 3.4 million = 11% Economically productive population (30–69 years) 10.6 million = 36%US$ 730 Total populationGross national income per capita (lower-income country) QUIT TOBACCO USE NOW - FOR A HEALTHIER HEART CVDs are the number one cause of death, causing 51 028 each year (28.1% of all deaths), as well as of premature death Ischemic heart disease Chronic obstructive pulmonary disease Cerebrovascular disease Lower respiratory infection Diarrheal disease Top 5 causes of overall death 1 2 3 4 5 Tobacco control is essential for preventing and controlling deaths and disability caused by CVDs CVD deaths caused by tobacco use Ischemic heart disease Lower respiratory infection Neonatal encephalopathy Cerebrovascular disease Chronic obstructive pulmonary disease Top 5 causes of premature death (YLL–years of life lost) 1 2 3 4 5 14 432 deaths Noncommunicable diseases Communicable, maternal, neonatal, and nutritional diseases current tobacco users and a substantial number of people exposed to secondhand smoke are at increased risk of CVDs6 m Tobacco users3 Tobacco smokers4 Smokeless tobacco users5 Current tobacco use among adults (%) (15–64 years) STEPS–2013 Current tobacco use among youth (%) (13–15 years) 0 20 30 40 50 Tobacco users GSHS–2015 Cigarette smokers GSHS–2015 Smokeless tobacco users GYTS–2011 0 5 10 15 20 25 Exposed to secondhand6 smoke at home (%) Adult (15–64 years) STEPS–2013 Youth (13–15 years)* GSHS–2015 0 10 20 30 40 50 60 36.1 54.1 37.3 35.0 57.9 50.7 Total Male Female The most common way tobacco kills is from cardiovascular diseases (CVDs)2 CVDs in younger people are more likely to be caused by tobacco use Age in years 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 37% 39% 32% 23% 30–44 45–59 60–69 70+ Distribution of tobacco deaths by cause Others 6% CMNNDb 12% CRDa 21% Cancers 8% CVD 53% 10 30.8 18.5 27.0 10.3 17.8 31.3 4.8 48.1 14.1 7.2 9.5 4.8 5.0 6.8 3.0 16.2 19.7 12.9 Tobacco1 kills 27 137 people each year 14.9% of all deaths of all CVD deaths each year28% % o f C VD d ea th s ca us ed b y to ba cc o *people smoked in their presence The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region30 Most people start early, increasing the risk of heart disease in younger people Mean age at initiation of daily smoking: 18.2 years Preventing and controlling sickness, death and disability from cardiovascular diseases Users advised to quit tobacco smoking by healthcare provider 8 Despite strong evidence that quitting both smoked and smokeless tobacco helps to immediately reduce the risk of CVDs, FEW tobacco users are quitting, requiring more programmatic effort Technical notes and key definitions: 1 Tobacco use includes use of both smoked (cigarette, bidi, hukkah, cigars, pipes, cheroots, cigarillos) and smokeless (snuff, chewing tobacco, nasal snuff, khaini, surti, gutka). 2 Cardiovascular diseases include all the diseases of the heart and circulation such as coronary heart disease, angina, heart attacks and stroke (cerebrovascular disease). 3 Current tobacco user is defined as a person reporting use of any smoked or smokeless tobacco product daily or less than daily at the time of survey. 4 Current tobacco smoker is a person who reports smoking any tobacco product on a daily or less-than-daily basis at the time of survey. 5 Smokeless tobacco user is a person who reports the use of any smokeless tobacco product on a daily or less-than-daily basis at the time of survey. 6 A person passively exposed to tobacco smoke from other people using it around him/her. 7 Among current smokers and former smokers who have been abstinent for less than 12 months in the past 12 months. 8 Among those smokers who visited a healthcare provider in the past 12 months. 9 Among ever daily smokers, also known as quit ratio for daily smoking. 10 Among ever daily smokeless users, also known as quit ratio for daily smokeless users. a. CRD – chronic respiratory diseases; b. CMNND – communicable, maternal, neonatal, and nutritional diseases GATS – Global Adult Tobacco Survey; GYTS – Global Youth Tobacco Survey; STEPS – WHO STEPwise approach to noncommunicable disease risk factor surveillance Sources of data: 1. Total population, youth population and population in economically productive age group: United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2017 revision (for the reference date as of 1 July 2017). New York: United Nations; 2017. 2. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-catalog/world-development-indicators, accessed 7 May 2018) 3. Data on total and proportional deaths from CVDs, tobacco use and proportion of total tobacco deaths due to CVDs: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME): 2017(http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). 4. Adult tobacco use prevalence; mean age at initiation of tobacco use, tobacco quitting, and secondhand exposure for adults data: WHO noncommunicable diseases risk factors: STEPS Survey Nepal 2013 (http://www.searo.who.int/entity/noncommunicable_diseases/data/nep_ncd_reports) accessed 7 May 2018. 5. Youth tobacco use prevalence and secondhand exposure among 13 – 15 year old population: Global School-based Health Survey (GSHS – 2015) and Global Youth Tobacco Survey (GYTS – 2011); http://www.searo.who.int/entity/noncommunicable_diseases/data/nep_ncd_reports accessed at 7 May 2018 Key references: 1. 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. 2. 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. 3. 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] For more information refer to Website http://www.searo.who.int/nts For technical information, please contact: Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Email: ranim@who.int; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int Quit attempt by current smokers 7 26.0% 22.3% People who quit tobacco use Former daily smokers 9 Former daily smokeless users 10 20.2% 7.3% Prevent people from starting tobacco use: Combine tobacco control with the following strategies for effective prevention of CVDs: Quitting immediately reduces the risk of heart attack and/or stroke; Quitting helps even if a person has already had a heart attack and/or stroke, irrespective of his/her age; Train health providers to ask about tobacco use at each encounter with their patients and advise them to quit. Help people to reduce salt, sugar, tans-fat in their diet, reduce harmful use of alcohol and create opportunities for regular physical activity; Provide early screening and effective treatment for raised blood pressure and raised blood sugar levels. Help current tobacco users to quit tobacco for a healthier heart: Tobacco use starts early: Prevent them from starting tobacco use by fully implementing WHO Framework Convention on Tobacco Control: raising taxes; informing people of tobacco risk through tobacco package warnings and information campaigns; and imposing a comprehensive ban on tobacco advertising and promotion in any form. 31 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Heart disease and stroke are the commonest ways by which tobacco kills people FACTSHEET 2018 SRI LANKA 20.9 million Youth population (13–17 years) 1.7 million = 8% Economically productive population (30–69 years) 10.1 million = 48%US$ 3780 Total populationGross national income per capita (lower middle-income country) QUIT TOBACCO USE NOW - FOR A HEALTHIER HEART CVDs are the number one cause of death, causing 42 376 each year (34.5% of all deaths), as well as of premature death Ischemic heart disease Cerebrovascular disease Diabetes Alzheimer disease Asthma Top 5 causes of overall death 1 2 3 4 5 Tobacco control is essential for preventing and controlling deaths and disability caused by CVDs CVD deaths caused by tobacco use Ischemic heart disease Self-harm Diabetes Cerebrovascular disease Road injuries Top 5 causes of premature death (YLL–years of life lost) 1 2 3 4 5 6 530 deaths Noncommunicable diseases Injuries current tobacco users and a substantial number of people exposed to secondhand smoke are at increased risk of CVDs2.1m Current tobacco use among adults (%) (18–69 years) STEPS–2014 Current tobacco use among youth (%) (13–15 years) GYTS–2015 0 2 4 6 8 10 Tobacco users Tobacco smokers Smokeless tobacco users 3.7 1.7 3.2 0.2 4.2 0.5 6.7 0.7 2.4 Exposed to secondhand6 smoke at home (%) 0 5 10 15 20 25 30 Adult (18–69 years) STEPS–2014 Youth (13–15 years) GYTS–2015 23.5 13.4 13.913.0 25.2 21.6 Total Male Female The most common way tobacco kills is from cardiovascular diseases (CVDs)2 CVDs in younger people are more likely to be caused by tobacco use Age in years 0% 5% 10% 15% 20% 25% 30% 27% 27% 20% 11% 30–44 45–59 60–69 70+ Distribution of tobacco deaths by cause Others 13% CMNND6 10% CRDa 13% Cancers 11% CVD 53% Tobacco users3 Tobacco smokers4 Smokeless tobacco users5 25.8 15.0 29.4 15.8 26.0 5.3 45.7 5.3 0 10 20 30 40 50 of all CVD deaths each year15% % o f C VD d ea th s ca us ed b y to ba cc o Tobacco1 kills 12 351 people each year 10% of all deaths The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region32 Most people start early, increasing the risk of heart disease in younger people Mean age at initiation of daily smoking: 20.6 years Preventing and controlling sickness, death and disability from cardiovascular diseases Users advised to quit tobacco smoking by healthcare provider 8 Despite strong evidence that quitting both smoked and smokeless tobacco helps to immediately reduce the risk of CVDs, FEW tobacco users are quitting, requiring more programmatic effort Technical notes and key definitions: 1 Tobacco use includes use of both smoked (cigarette, bidi, cigars, pipes) and smokeless (chewing tobacco, betel with tobacco, babul, snuff). 2 Cardiovascular diseases include all the diseases of the heart and circulation such as coronary heart disease, angina, heart attacks and stroke (cerebrovascular disease). 3 Current tobacco user is defined as a person reporting use of any smoked or smokeless tobacco product daily or less than daily at the time of survey. 4 Current tobacco smoker is a person who reports smoking any tobacco product on a daily or less-than-daily basis at the time of survey. 5 Smokeless tobacco user is a person who reports the use of any smokeless tobacco product on a daily or less-than-daily basis at the time of survey. 6 A person passively exposed to tobacco smoke from other people using it around him/her. 7 Among current smokers and former smokers who have been abstinent for less than 12 months in the past 12 months. 8 Among those smokers who visited a healthcare provider in the past 12 months. 9 Among ever daily smokers, also known as quit ratio for daily smoking. 10 Among ever daily smokeless users, also known as quit ratio for daily smokeless users. a. CRD – chronic respiratory diseases; b. CMNND – communicable, maternal, neonatal, and nutritional diseases GATS – Global Adult Tobacco Survey; GYTS – Global Youth Tobacco Survey; STEPS – WHO STEPwise approach to noncommunicable disease risk factor surveillance Sources of data: 1. Total population, youth population and population in economically productive age group: United Nations – Department of Economic and Social Affairs, Population Division. World population prospects: the 2017 revision (for the reference date as of 1 July 2017). New York: United Nations; 2017. 2. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-catalog/world-development-indicators, accessed 7 May 2018) 3. Data on total and proportional deaths from CVDs, tobacco use and proportion of total tobacco deaths due to CVDs: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME): 2017(http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). 4. Adult tobacco use prevalence; mean age at initiation of tobacco use, tobacco quitting, and secondhand exposure for adults data: Noncommunicable disease risk factor survey Sri Lanka 2015, (http://www.who.int/ncds/surveillance/steps/STEPS-report-2015-Sri-Lanka.pdf accessed 7 May 2018). 5.Youth tobacco use prevalence and exposure to secondhand smoke: Global Youth Tobacco Survey (GYTS, 2015): http://www.searo.who.int/tobacco/data/srl_rtc_reports, accessed 7 May 2018). Key references: 1. 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. 2. 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. 3. 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] For more information refer to Website http://www.searo.who.int/nts For technical information, please contact: Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Email: ranim@who.int; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int Quit attempt by current smokers 7 51.8% 35.0% People who quit tobacco use Former daily smokers 9 Former daily smokeless users 10 34.4% 16.0% Prevent people from starting tobacco use: Combine tobacco control with the following strategies for effective prevention of CVDs: Quitting immediately reduces the risk of heart attack and/or stroke; Quitting helps even if a person has already had a heart attack and/or stroke, irrespective of his/her age; Train health providers to ask about tobacco use at each encounter with their patients and advise them to quit. Help people to reduce salt, sugar, tans-fat in their diet, reduce harmful use of alcohol and create opportunities for regular physical activity; Provide early screening and effective treatment for raised blood pressure and raised blood sugar levels. Help current tobacco users to quit tobacco for a healthier heart: Tobacco use starts early; Prevent them from starting tobacco use by fully implementing WHO Framework Convention on Tobacco Control: raising taxes; informing people of tobacco risk through tobacco package warnings and information campaigns; and imposing a comprehensive ban on tobacco advertising and promotion in any form. 33 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Heart disease and stroke are one of the commonest ways by which tobacco kills people FACTSHEET 2018 THAILAND 69.0 million Youth population (13–17 years) 4.5 million = 6% Economically productive population (30–69 years) 37.9 million = 55%US$ 5640 Total populationGross national income per capita (upper middle-income country) QUIT TOBACCO USE NOW - FOR A HEALTHIER HEART CVDs are the number one cause of death, causing 98 895 each year (21.9% of all deaths), as well as of premature death Ischemic heart disease Cerebrovascular disease Lower respiratory infection Alzheimer disease Liver cancer Top 5 causes of overall death 1 2 3 4 5 Tobacco control is essential for preventing and controlling deaths and disability caused by CVDs CVD deaths caused by tobacco use Ischemic heart disease Road injuries Cerebrovascular disease Lower respiratory infection Liver cancer Top 5 causes of premature death (YLL–years of life lost) 1 2 3 4 5 of all CVD deaths each year 18 869 deaths 19% Noncommunicable diseases current tobacco users and a substantial number of people exposed to secondhand smoke are at increased risk of CVDs14.6 m Current tobacco use among adults (%) (15+ years) GATS–2011 Current tobacco use among youth (%) (13–15 years) GYTS–2015 0 5 10 15 20 25 Tobacco users Tobacco smokers Smokeless tobacco users 15.0 14.0 20.7 7.1 4.1 1.3 21.8 8.1 2.7 Exposed to secondhand6 smoke at home (%) 0 10 20 30 40 50 Adult (15+ years) GATS–2011 Youth (13–15 years) GYTS–2015 36.0 33.8 31.3 36.639.9 32.3 Total Male Female Almost one-fourth of all tobacco-related deaths are from cardiovascular diseases (CVDs)2 CVDs in younger people are more likely to be caused by tobacco use81 521 Distribution of tobacco deaths by cause people each year 18% of all deaths Others 5% CMNND6 14% CRDa 19% Cancers 39% CVD 23% Tobacco users3 Tobacco smokers4 Smokeless tobacco users5 26.9 24.0 46.6 2.6 3.2 1.1 5.2 47.2 7.6 0 10 20 30 40 50 Communicable, maternal, neonatal and nutritional diseases % o f C VD D ea th s ca us ed b y to ba cc o Age in years 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 42% 34% 24% 12% 30–44 45–59 60–69 70+ Injuries Tobacco1 kills The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region34 Most people start early, increasing the risk of heart disease in younger people Mean age at initiation of daily smoking: 17.4 years Preventing and controlling sickness, death and disability from cardiovascular diseases Technical notes and key definitions: 1 Tobacco use includes use of both smoked (cigarettes, hand-rolled cigarettes, cigars, pipes and water pipes) and smokeless (snuff by mouth, snuff which had a component of tobacco by nose, chewing tobacco, and betel quid with tobacco). 2 Cardiovascular diseases include all the diseases of the heart and circulation such as coronary heart disease, angina, heart attacks and stroke (cerebrovascular disease). 3 Current tobacco user is defined as a person reporting use of any smoked or smokeless tobacco product daily or less than daily at the time of survey. 4 Current tobacco smoker is a person who reports smoking any tobacco product on a daily or less-than-daily basis at the time of survey. 5 Smokeless tobacco user is a person who reports the use of any smokeless tobacco product on a daily or less-than-daily basis at the time of survey. 6 A person passively exposed to tobacco smoke from other people using it around him/her. 7 Among current smokers and former smokers who have been abstinent for less than 12 months in the past 12 months. 8 Among those smokers who visited a healthcare provider in the past 12 months. 9 Among ever daily smokers, also known as quit ratio for daily smoking. 10 Among ever daily smokeless users, also known as quit ratio for daily smokeless users. a. CRD – chronic respiratory diseases; b. CMNND – communicable, maternal, neonatal, and nutritional diseases GATS – Global Adult Tobacco Survey; GYTS – Global Youth Tobacco Survey; STEPS – WHO STEPwise approach to noncommunicable disease risk factor surveillance Sources of data: 1. Total population, youth population and population in economically productive age group: United Nation, Population division, World population prospects: The 2017 Revision for the reference date as of 1 July 2017 2. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-ca talog/world-development-indicators, accessed 7 May 2018) 3. Data on total and proportional deaths from CVDs, tobacco use and proportion of total tobacco deaths due to CVDs: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME): 2017(http://ghdx.healthdata.org/gbd-results-tool, accessed 7 May 2018). 4. Adult tobacco use prevalence; mean age at initiation of tobacco use, and tobacco quitting data: Global Adult tobacco survey (2011) http://www.searo.who.int/tobacco/data/tha_rtc_reports , accessed on 7 May 2018. 5. Youth tobacco use prevalence and exposure to second hand smoke: Global Youth Tobacco Survey (GYTS–2015) (http://www.searo.who.int/tobacco/data/tha_rtc_reports, accessed 7 May 2018). Key references: 1. 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. 2. 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. 3. 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] For more information refer to Website http://www.searo.who.int/nts For technical information, please contact: Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Email: ranim@who.int; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int Quit attempt by current 7 Smokers Smokeless tobacco users Smokers Smokeless tobacco users Former daily smokers 9 Former daily smokeless users 10 People who quit tobacco useUsers advised to quit tobacco use by healthcare provider 8 36.7% 16.4% 55.8% 16.3% 27.2% 16.3% Despite strong evidence that quitting both smoked and smokeless tobacco helps to immediately reduce the risk of CVDs, FEW tobacco users are quitting, requiring more programmatic effort Prevent people from starting tobacco use: Combine tobacco control with the following strategies for effective prevention of CVDs: Quitting immediately reduces the risk of heart attack and/or stroke; Quitting helps even if a person has already had a heart attack and/or stroke, irrespective of his/her age; Train health providers to ask about tobacco use at each encounter with their patients and advise them to quit. Help people to reduce salt, sugar, tans-fat in their diet, reduce harmful use of alcohol and create opportunities for regular physical activity; Provide early screening and effective treatment for raised blood pressure and raised blood sugar levels. Help current tobacco users to quit tobacco for a healthier heart: Tobacco use starts early; Prevent them from starting tobacco use by fully implementing WHO Framework Convention on Tobacco Control: raising taxes; informing people of tobacco risk through tobacco package warnings and information campaigns; and imposing a comprehensive ban on tobacco advertising and promotion in any form. 35 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region Heart disease and stroke are the commonest ways by which tobacco kills people FACTSHEET 2018 TIMOR-LESTE 1.3 million Youth population (13–17 years) 0.2 million = 12% Economically productive population (30–69 years) 0.3 million = 26%US$ 2060 Total populationGross national income per capita (lower middle-income country) QUIT TOBACCO USE NOW - FOR A HEALTHIER HEART CVDs are the number one cause of death, causing 1 615 each year (29.2% of all deaths), as well as of premature death Ischemic heart disease Cerebrovascular disease Lower respiratory infection Diarrheal disease Neonatal preterm birth Top 5 causes of overall death 1 2 3 4 5 Tobacco control is essential for preventing and controlling deaths and disability caused by CVDs CVD deaths caused by tobacco use Lower respiratory infection Diarrheal disease Neonatal preterm birth Ischemic heart disease Congenital defects Top 5 causes of premature death (YLL–years of life lost) 1 2 3 4 5 of all CVD deaths each year 393 deaths 24% Noncommunicable diseases Communicable, maternal, neonatal, and nutritional diseases current tobacco users and a substantial number of people exposed to secondhand smoke are at increased risk of CVDs400 000 Tobacco users3 Tobacco smokers4 Smokeless tobacco users5 Current tobacco use among adults (%) (18–69 years) STEPS–2014 Current tobacco use among youth (%) (13–15 years) GYTS–2013 0 20 30 40 50 60 70 80 Tobacco users Tobacco smokers Smokeless tobacco users 0 10 20 30 40 50 60 70 Exposed to secondhand6 smoke at home (%) Adult (18–69 years) STEPS–2014 Youth (13–15 years) GYTS–2013 0 20 40 60 80 100 92.1 66.0 94.6 87.4 69.6 62.1 Total Male Female Tobacco1 kills The most common way tobacco kills is from cardiovascular diseases (CVDs)2 CVDs in younger people are more likely to be caused by tobacco use739 % o f C VD d ea th s ca us ed b y to ba cc o Age in years 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 46% 39% 30% 17% 30–44 45–59 60–69 70+ Distribution of tobacco deaths by cause people each year 13.4% of all deaths Others 6% CMNNDb 14% CRDa 15% Cancers 12% CVD 53% 10 56.1 48.6 69.5 19.8 9.6 16.1 26.8 70.6 28.9 42.4 65.5 23.9 35 61.4 15.4 8.4 7.7 9.3 The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region36 Most people start early, increasing the risk of heart disease in younger people Mean age at initiation of daily smoking: 16.4 years Preventing and controlling sickness, death and disability from cardiovascular diseases Users advised to quit tobacco smoking by healthcare provider 8 Despite strong evidence that quitting both smoked and smokeless tobacco helps to immediately reduce the risk of CVDs, FEW tobacco users are quitting, requiring more programmatic effort Technical notes and key definitions: 1 Tobacco use includes use of both smoked (cigarette, kreteks, tobacco lulun, cigars or pipes) and smokeless (songe/chewing tobacco, mama malus, betel with songe/chewing tobacco). 2 Cardiovascular diseases include all the diseases of the heart and circulation such as coronary heart disease, angina, heart attacks and stroke (cerebrovascular disease). 3 Current tobacco user is defined as a person reporting use of any smoked or smokeless tobacco product daily or less than daily at the time of survey. 4 Current tobacco smoker is a person who reports smoking any tobacco product on a daily or less-than-daily basis at the time of survey. 5 Smokeless tobacco user is a person who reports the use of any smokeless tobacco product on a daily or less-than-daily basis at the time of survey. 6 A person passively exposed to tobacco smoke from other people using it around him/her. 7 Among current smokers and former smokers who have been abstinent for less than 12 months in the past 12 months. 8 Among those smokers who visited a healthcare provider in the past 12 months. 9 Among ever daily smokers, also known as quit ratio for daily smoking. 10 Among ever daily smokeless users, also known as quit ratio for daily smokeless users. a. CRD – chronic respiratory diseases; b. CMNND – communicable, maternal, neonatal, and nutritional diseases GATS – Global Adult Tobacco Survey; GYTS – Global Youth Tobacco Survey; STEPS – WHO STEPwise approach to noncommunicable disease risk factor surveillance Sources of data: 1. Total population, youth population and population in economically productive age group: United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2017 revision (for the reference date as of 1 July 2017). New York: United Nations; 2017. 2. Gross national income per capita 2016 (by Atlas method) and current country economic classification: World Bank, 2017. (http://data.worldbank.org/data-catalog/world-development-indicators, accessed 7 May 2018) 3. Data on total and proportional deaths from CVD, tobacco use and proportion of total tobacco deaths due to tobacco: WHO noncommunicable diseases risk factors: STEPS Survey Timor-Leste 2013 (https://nada.searo.who.int/index.php/catalog/68/related_materials) accessed 7 May 2018. ccessed 7 May 2018). 4. Adult tobacco use prevalence; secondhand tobacco exposure; mean age at initiation of tobacco use, quitting rates: WHO noncommunicable diseases risk factors: STEPS Survey Timor-Leste 2013 (https://nada.searo.who.int/index.php/catalog/68/related_materials) accessed 7 May 2018. 5. Youth tobacco use prevalence and secondhand exposure among 13–15 year old population: Global Youth Tobacco Survey (GYTS-2013); http://www.searo.who.int/entity/noncommunicable_ diseases/data/tls_ncd_reports accessed at 7 May 2018 Key references: 1. 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. 2. 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. 3. 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] For more information refer to Website http://www.searo.who.int/nts For technical information, please contact: Dr Manju Rani, Regional Adviser, NCD and Tobacco Surveillance, Email: ranim@who.int; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int Quit attempt by current smokers 7 23.0% 22.5% People who quit tobacco use Former daily smokers 9 Former daily smokeless users 10 7.4% 29.7% Prevent people from starting tobacco use: Combine tobacco control with the following strategies for effective prevention of CVDs: Quitting immediately reduces the risk of heart attack and/or stroke: Quitting helps even if a person has already had a heart attack and/or stroke, irrespective of his/her age; Train health providers to ask about tobacco use at each encounter with their patients and advise them to quit. Help people to reduce salt in their diet, reduce harmful use of alcohol, and create opportunities for regular physical activity; Provide early screening and effective treatment for raised blood pressure and raised blood sugar levels. Help current tobacco users to quit tobacco for a healthier heart: Tobacco use starts early; Prevent them from starting tobacco use by fully implementing WHO Framework Convention on Tobacco Control: raising taxes; informing people of tobacco risk through tobacco package warnings and information campaigns; and imposing a comprehensive ban on tobacco advertising and promotion in any form.

The fatal link between tobacco and cardiovascular diseases in the WHO South-East Asia Region May 2018 9 789290 226550 ISBN 9789290226550 Tobacco is the leading single risk factor that causes the highest number of preventable deaths (almost 1.58 million deaths each year), cardiovascular diseases (CVDs) are the leading cause of death in the WHO SEA Region. The most common way by which tobacco kills is by causing cardiovascular diseases (CVDs), including heart disease and stroke. The good news is that quitting tobacco use at any age reduces the risk of CVDs immediately. This brief report highlights the fatal connection between tobacco and CVDs and is being launched on the occasion of ‘World No Tobacco Day’ 2018 with the campaign theme “Tobacco breaks heart”. It is intended to increase commitment to tobacco control by increasing awareness of this fatal link between tobacco use and CVDs—the leading killer in most of the countries in the Region.