ROKOK; TINJAUAN KESEHATAN

Menaldi Rasmin
Fakultas Kedokteran Universitas Indonesia

Diskusi Publik FKM UI Fatwa Haram Rokok Jakarta, 24 Pebruari 2009

Tobacco epidemic

Worldwide, 1.3 billion smokers 47% of men and 12% of women in the world smoke Rates are stable for men and rising for women in low & middle-income countries Additional numbers of passive smokers at risk 5.5 trillion cigarettes were manufactured in 2000 :1000 cigarettes for every person Worlds biggest preventable Killer
5 million deaths / year 10 million deaths / by 2020 450 million in next 50 years (WHO)

Growing in women & youth of developing countries

Prevalensi Merokok Menurut Jenis Kelamin di Dunia

Canada 22% 17%

US 24% 19% Mexico 13% 5% Brazil 22% 14%

Pria Wanita

Chile 48% 37%

Russian Fed Sweden Iceland 60% 17% 25% 16% 18% 20% Germany France Portugal 30% 37% Belarus 33% 21% 28% 53% 10% Italy China 7% Spain 33% Iran 67% 39% 17% 22% 2% 25% 2% Egypt Kenya India 45% Philippines 21% 47% 12% 41% 1% 17% 8% South Africa Australia 23% 19% 8% 16%

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

Frekuensi Merokok di Asia

Negara
Populasi (Sumber: WHO)
958,295,000 671,017,000 146,860,000 46,063,000

% Pria (Sumber: WHO)

51.1% 51.6% 49.9% 48.5%

% Pria yang merokok (Sumber: WHO)

53.4% 29.4%

China India Indonesia Thailand

69.0%
39.3%

SMOKING PROBLEMS IN INDONESIA

1.

2.

3.

Tobacco consumption is increasing exceed the population growth rate Smoking habit begins at young age (elementary school), 80% smoke kretek which has 2-3 times tar & nicotine higher The prevalence of male smokers: 60-70% in big cities and 80-90% at rural

Berapa batang rokok yang dihisap setiap hari oleh perokok di Indonesia?

Secara keseluruhan, perokok Indonesia merokok 11 batang atau lebih setiap hari. 48% merokok 11-20 batang perhari
Jumlah rokok / hari

Total Indonesia (n=460)

1-5 cigarettes 6-10 cigarettes 11-20 cigarettes 21-30 cigarettes 31 or more

12%

24%

48%

12%

4%

MASALAH

Rustamadji & Sumedi (FKUI) - 25% perokok remaja akan terus merokok Bag. Pulmonologi FKUI (1992)

SD di Jakarta Timur
Siswa kelas 5 dan 6, 12,7% perokok 11,8% pernah mencoba Alasan : coba-coba, dipaksa, iklan TV, ingin gagah
Departemen Pulmonologi dan I.Kedokteran Respirasi FKUI

ROKOK DAN EKONOMI

Biaya Pembelian rokok di dunia : 85-100 milyar dolar AS Negara berkembang : - menghabiskan 1/4 penghasilan para perokok - Malaysia :menghabiskan 30% penghasilan - Cina : menghabiskan 60% penghasilan Memperbesar jurang perbedaan kemakmuran negara berkembang dan negara maju

Departemen Pulmonologi dan I.Kedokteran Respirasi FKUI

ROKOK DAN EKONOMI

Kerugian 200 milyar dolar AS/tahun AS (1990) : biaya oleh penyakit akibat rokok 52.338 juta dolar AS / tahun tdd : 23.653 juta = pengobatan 28.061 juta = produktivitas Kerja (sakit, meninggal) 623 juta = kematian tidak langsung pada anak -anak

(Bank Dunia)

Estimated Annual Costs Attributable to Tobacco Estimated Costs to the Economy Attributable to Tobacco (US $ Billions)
Norway $1.62 Germany $24.4 China $4.3

Canada $12.9 US $184.5

UK $2.3 France $16.4

Total Costs Direct Healthcare Costs

Venezuela $.284 Australia $14.2

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

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

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

Kanker-kanker akibat merokok

Kanker mulut

Kanker paru

Paru perokok

So Why Do People Smoke?

Addiction Habitual psychological and physiological dependence on substance or practice which is beyond voluntary control Stedmans Medical Dictionary

Since at least the 1988 Surgeon Generals Report1

Addiction defined as compulsive use despite damage to the individual or society and drug-seeking behavior can take precedence over important priorities Addiction persists despite a desire to quit or even repeated attempts to quit

Most people smoke primarily because they are addicted to nicotine2 There is a clear link between smoking, nicotinic receptors, and addiction2
1. Centers for Disease Control and Prevention. The Health Consequences of Smoking: Nicotine Addiction; A Report of the Surgeon General. Washington DC: US Department of Health and Human Services; 1988. 2. Jarvis MJ. BMJ. 2004;328:277-279.

Tobacco Dependence Mechanisms

Nicotines actions in the central nervous system Neurobiologic and physiologic effects of tobacco dependence Tobacco dependence and environmental reinforcement Symptoms of withdrawal

Siklus Adiktif Nikotin

Dopamine
Nicotine dalam Rokok Reseptor di otak Pelepasan dopamine Rasa Senang dan Nyaman Nicotine habis Dopamine berkurang
1. Jarvis MJ. BMJ. 2004; 328:277-279. 2. Picciotto MR, et al. Nicotine and Tob Res. 1999: Suppl 2:S121-S125.

Nicotine

Mechanism of Action of Nicotine in the Central Nervous System

2 2 4 2 4

4 2 Nicotinic Receptor

Nicotine binds preferentially to nicotinic acetylcholinergic (nACh) receptors in the central nervous system; the primary is the 42 nicotinic receptor in the Ventral Tegmental Area (VTA) After nicotine binds to the 42 nicotinic receptor in the VTA, it results in a release of dopamine in the Nucleus Accumbens (nAcc) which is believed to be linked to reward

Nicotine Stimulates Dopamine Release

Nicotine activates 42 nicotinic receptors in the ventral tegmental area resulting in dopamine release at the nucleus accumbens. This may result in the short-term reward/satisfaction associated with cigarette smoking.
D

Axon Ventral Tegmental Area Nicotine

D D

Reward

Nucleus Accumbens

D Dopamine

42 Nicotinic Receptor

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

The Delivery of Nicotines Effect

There is a kick immediately after exposure to nicotine as a result of adrenaline discharge Nicotine suppresses insulin output from the pancreas Nicotine indirectly causes a release of dopamine in the brain regions that control pleasure and motivation Nicotine can also exert a sedative effect

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

Tolerance typically develops after long-term nicotine use1 Tolerance is related to both the up-regulation (increased number) and the desensitization of nicotine receptors in the VTA1 A drop in nicotine level, in combination with the up-regulation and decreased sensitivity of the nicotinic receptor, can result in withdrawal symptoms and cravings1 Smokers have the ability to self regulate nicotine intake by the frequency of cigarette consumption and the intensity of inhalation1 In order to maintain a steady nicotine level, smokers generally titrate their smoking to achieve maximal stimulation and avoid symptoms of withdrawal and craving2

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

Nicotine Addiction: A Chronic Relapsing Medical Condition

True drug addiction1 Requires long-term clinical intervention, as do other addictive disorders Failure to appreciate the chronic nature of nicotine addiction may2

Impair clinicians motivation to treat tobacco dependence long-term Impede acceptance that condition is comparable to diabetes, hypertension, or hyperlipidemia, and requires counseling, support, and appropriate pharmacotherapy

Relapse is Common1,2 The nature of addiction, not the failure of the individual3

Long-term smoking abstinence in those who try to quit unaided = 3%5% Most relapse within the first 8 days

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

Mengapa Sulit Berhenti Merokok ? Merokok?

Nikotin Komponen penyebab adiksi Nikotin 5 - 10 kali lebih kuat menimbulkan efek psikoaktif pada manusia daripada kokain dan morfin

35