# Presentation: 526195

## Tobacco Burden in Egypt and Efforts for Control and Prevention : Global Support Needs in Developing Countries

**Mostafa K. Mohamed**
**Ain Shams University Cairo Egypt**
**Egyptian Smoking Prevention Research Institute**** ****(ESPRI)**
**Funded by U.S. NIH (Fogarty International Center) **

**Interagency Committee on Smoking and health (ICSH) **
**Meeting on The Global tobacco Epidemic. **
** ****Omni Shoreham Hotel Washington DC April 13 2005**

## Global tobacco control is a major challenge for the public health community. Why ?
In Developing Countries communities are increasingly subjected to intense direct and indirect marketing of tobacco products, 
Also local resources, infrastructure, and overall capacity are insufficient to meet  these  challenges. 
Solution:  Global Network International Centers for tobacco control  research and Prevention

- In Developing Countries communities are increasingly subjected to intense direct and indirect marketing of tobacco products,
- Also local resources, infrastructure, and overall capacity are insufficient to meet  these  challenges.
- Solution:  Global Network International Centers for tobacco control  research and Prevention

## One such center is located in Egypt “Egypt Smoking Prevention Research Institute [ESPRI], 2002-2007  
   at the National Hepatology & Tropical Medicine Research Institute (NHTMRI) in Cairo, which is affiliated with the MOHP
This was made possible by the leadership of 
Dr. Ebenezer Israel (founding Principal Investigator [PI]) at the University of Maryland, 
Dr. Christopher Loffredo (new PI as of July 1, 2005) at Georgetown University
Dr. Mostafa K. Mohamed (major foreign investigator) at Ain Shams University in Cairo. 
NIH    R01TW05944-03

-    **at the National Hepatology & Tropical Medicine Research Institute (NHTMRI) in Cairo, which is affiliated with the MOHP**
- This was made possible by the leadership of
- Dr. Ebenezer Israel (founding Principal Investigator [PI]) at the University of Maryland,
- Dr. Christopher Loffredo (new PI as of July 1, 2005) at Georgetown University
- Dr. Mostafa K. Mohamed (major foreign investigator) at Ain Shams University in Cairo.
- NIH    R01TW05944-03

## Tobacco Prevention Success Requires Cross-Sector Platforms and Long-Term Cooperative Partnerships

**Government**

- Strong Political Commitment
- Presidential, Ministerial leadership
- Multinational agreements FCTC

**Academics**

- Ongoing research
- Evolving Tobacco preventive and Control strategies
- Tobacco Burden and Outcome measurement

**Non-Governmental Organizations (NGOs)**

- Continuous Strong Advocacy
- Real-time surveillance
- Internet organization tools
- Steering Wheel concept

- Support and human resources
- Political reach/ change Norms
- Multinational collaboration
**TV Ads   Australia**

**Media**

**Notes:**
(Title appears) So perhaps, that is a good place to conclude this series on the Global Burden of Disease, with the notion that poor health is a downward spiral, a negative continuum that requires aggressive coordinate action to assure course reversal.  
It is clear that a challenge of this magnitude requires cross-sector health platforms and cooperative partnerships. What might each sector contribute? (Government text and box appears) Government can provide consistent high health objectives, presidential leadership and multi-national agreements.  
(Academics text and box appears) Academics can provide ongoing research, evolving diagnostic and treatment strategies and outcome measurements. (Non-government text and box appears) Non-governmental organizations or NGO’s can provide health services on the ground, real-time surveillance, and expertise in internet organization.  
And (industry text and box appears) industry can provide financial and human resources, political contacts, and multi-national infrastructure.

## Actions to Alter the Tobacco Burden of Disease In Developing countries 

**Actions to Alter the ****Tobacco Burden of Disease In **Developing countries

**Resources are required to create infrastructure and provide support for :**
**Steering Wheel Action Group**
**Tobacco Research Capacity Building**
**Internet Access to International Sites **
**Organization of Network of Tobacco Control officers at the MOH**
**Media Production and collaboration **

**Notes:**
(Title appears) To turn words into action, however requires knowledge of what works and how much it costs.  Both are required to substantially alter the burden of disease. (1st bullet appears) In developing countries, resources are required to create infrastructure for (1st sub-bullet appears) clean water, (2nd sub-bullet appears) sanitation, (3rd  sub-bullet appears) adequate nutrition and (4th  sub-bullet appears) medical supplies. 
As necessary are strategies that successfully accomplish vaccination, maternal education, and safe sex. (2nd  Bullet appears) In developed countries, the resources to educate, diagnose, and treat long term a population currently overwhelmed by (1st sub-bullet appears) diabetes, (2nd  sub-bullet appears) heart disease, (3rd  sub-bullet appears) cancer and (4th  sub-bullet appears) depression, and more importantly to develop educational and motivational tools that successfully promote healthy diets, exercise, early screening, and treatment compliance are all required.

## ESPRI researchers : 
 > 10 University  Professors
 > 15 trainees  University staff and MOHP trainees
ESPRI collaborators : 
WHO EMRO
Ministry of Health and Population, 
with major universities in Egypt,
Non-governmental organizations Medical Syndicate ...etc ..
Act as a steering wheel to perform a wide array of tobacco-related research, prevention, and capacity building activities. 

-  > 10 University  Professors
-  > 15 trainees  University staff and MOHP trainees
**ESPRI collaborators : **
- WHO EMRO
- Ministry of Health and Population,
- with major universities in Egypt,
- Non-governmental organizations Medical Syndicate ...etc ..
- Act as a steering wheel to perform a wide array of tobacco-related research, prevention, and capacity building activities.

## Tobacco Burden in Egypt and Efforts for Control and Prevention

- Burden of tobacco use in Egypt and EMRO region
- Activities of ESPRI and importance of seeding an active steering group for  the Tobacco prevention activities in the targeted countries
- Importance of selecting appropriate collaborators from different  perspectives (academics, ministry officials etc..) to tackle the whole issue
- Water-pipe smoking, Religious Influence
- 		 A unique perspective in the whole region
**5. **Consortium Collaboration Proposal future vision

## Prevalence of Smoking among  Adult Males in Egypt

**Smoking is less than 1% among females**

**National Household Survey in All 27 Governorates  in Egypt  sample over 5000 individuals.  **

## Slide 9

## Slide 10

##  There was evidence of large smoking effects on TB mortality  

**A study was done to estimate the burden of tobacco use in the country on mortality and morbidity: 23,000 deaths annually (8% of total adult deaths/year) were due to cigarette smoking . **
** ****There was evidence of large smoking effects on TB ****mortality **** **

**1-  **** The role of ESPRI in research for implementation of the FCTC?**

## The DALY: A Comparative Tool to Measure Health

**One**

***“******One year lost to poor health.”***

**Disability**

**Adjusted**

**Life**

**Year**

- Murray and Lopez, Science, 1996

**The DALY: A Comparative ****Tool to Measure Health**

**Notes:**
(Title Appears) The creation of a unit of measure – (Daly graphic appears) The DALY or disability adjusted life year, the equivalent of (quote appears) one year of active living lost to poor heath - provided a method of comparing and prioritizing the many competing health needs of the world’s population.
In the first three segments of this four part series we’ve considered definitions and findings, environmental contributors and individual risk factors.  In today’s final segment, we’ll consider now best to use those findings to influence action.

## Distribution of Burden of Diseases in Egypt 1999 

**Distribution of Burden of Diseases in Egypt 1999 **

**The Burden of Diseases among males and females is increasingly represented by Chronic Non Communicable Disease   (> 60 %) similar to the developed countries**

## Burden of diseases related to smoking in Egypt Mostafa K. Mohamed, Mostafa El Husseini, Tayseer Elsawy 

- The overall aim :  is to provide estimates of deaths and years of life lost due to smoking in Egypt.
- These estimates were based on Attributable Fraction Methodology that applies current information on smoking prevalence and relative risk of death from smoking related diseases.

## Slide 15

## Smoking Related Mortality ( 8%) of all deaths > 35 years  (13% among males and 1% among females). 
 Disability adjusted Years of life lost (DALYS) due to smoking related diseases were estimated at 288325 years 
This figure was about 10% of DALYS lost due to all diseases among males and 0.6% among females.

-  Disability adjusted Years of life lost (DALYS) due to smoking related diseases were estimated at 288325 years
- This figure was about 10% of DALYS lost due to all diseases among males and 0.6% among females.

## “Business as usual” projections of burden due to 5 leading selected risks, 2010 and 2020

**2010**

**2020**

## Slide 18

## Leading 10 selected risk factors and diseases or injuries

***Developing high mortality (AfrD, AfrE, AmrD, EmrD, SearD)***
**Risk factor****	****% DALYs****	****  Disease or injury****	****% DALYs**
**Underweight ****	****14.9%****	**** HIV/AIDS****	****9.0%**
**Unsafe sex ****	****10.2%****	**** Lower respiratory infections****	****8.2%**
**Unsafe water, S&H****	****5.5%****	**** Diarrhoeal diseases****	****6.3%**
**Indoor smoke****	****3.7%****	**** Childhood cluster diseases****	****5.5%**
**Zinc deficiency****	****3.2%****	**** Low birth weight****	****5.0%**
**Iron deficiency****	****3.1%****	**** Malaria****	****4.9%**
**Vitamin A deficiency ****	****              3.0%         Unipolar depr. disorders****	****3.1% Blood pressure ****	****2.5%****	**** Ischaemic heart disease****	****3.0%**
**Tobacco****	****2.0%****	**** Tuberculosis****	****2.9%**
**Cholesterol ****	****1.9%****	**** Road traffic injury                   2.0%****	**

## Leading 10 selected risk factors and diseases or injuries

***Developing lower mortality (Amr B, EmrB, SearB, WprB)***
**Risk factor****	****% DALYs****	****  Disease or injury****	****% DALYs**
**Alcohol ****	****6.2%****	****   Unipolar depr. disorders****	****5.9%**
**Blood pressure ****	****5.0%****	****   Cerebrovascular disease****	****4.7%**
**Tobacco****	****4.0%****	****   Lower respiratory infections****	****4.1%**
**Underweight ****	****3.1%****	****   Road traffic injury****	****4.1%**
**Overweight/obesity****	****2.7%****	****   COPD****	****3.8%**
**Cholesterol ****	****2.1%****	****   Ischaemic heart disease****	****3.2%**
**Low fruit & vegetables ****	****1.9%****	****   Birth asphyxia/trauma****	****2.6%**
**Indoor smoke from solid fuels ****	****1.9%****	****   Tuberculosis****	****2.4%**
**Iron deficiency ****	****1.8%****	****   Alcohol use disorders ****	****2.3%**
**Unsafe water, S&H****	****1.7%****	****   Deafness****	****2.2%**

## Leading 10 selected risk factors and diseases or injuries

***Developed (Amr A, Eur A, Eur B, Eur C, WprA)***
**Risk factor****	****% DALYs****	****  Disease or injury****	****% DALYs**
**Tobacco****	****12.2%****	****   Ischaemic heart disease****	****9.4%**
**Blood pressure ****	****10.9%****	****   Unipolar depr.  disorders****	****7.2%**
**Alcohol ****	****9.2%****	****   Cerebrovascular disease****	****6.0%**
**Cholesterol ****	****7.6%****	****   Alcohol use disorders****	****3.5%**
**Overweight/obesity****	****7.4%****	****   Dementia & other CNS ****	****3.0%**
**Low fruit & vegetables ****	****3.9%****	****   Deafness****	****2.8%**
**Physical inactivity ****	****3.3%****	****   COPD****	****2.6%**
**Illicit drugs ****	****1.8%****	****   Road traffic injury****	****2.5%**
**Unsafe sex****	****0.8%****	****   Osteoarthritis****	****2.5%**
**Iron deficiency****	****0.7%****	****   Trachea & lung cancers ****	****2.4%**

## To help MOHP officials recognize the magnitude of the problems (exposure level and impact on health), ESPRI has been providing baseline information: 

**National survey and developing methodology for follow up surveys**
**School surveys  (urban and rural areas)**
**Water-pipe profile surveys in villages and in Cairo**
**Cigarette and water-pipe smoking among women**

**1. What role does ESPRI have to carry out and evaluate research for ratification and implementation of the FCTC?**

## Egypt has enacted many of the FCTC required laws. However, enforcing is lacking and ESPRI has provided baseline data to track improvement in compliance.
  Compliance Research studies:
Sales to minors:
Research study: more than 1000 shop owners were interviewed, and 94 % were selling tobacco to minors. 
Access of minors to water pipe in Shisha Cafes:   25 shisha cafes were visited and all of them provided shisha to minors.

-   Compliance Research studies:
- Sales to minors:
- Research study: more than 1000 shop owners were interviewed, and 94 % were selling tobacco to minors.
- Access of minors to water pipe in Shisha Cafes:   25 shisha cafes were visited and all of them provided shisha to minors.

**1-  **** The role of ESPRI in research for implementation of the FCTC?**

## Compliance Research studies:
Hospital Smoking:  A base line study was completed and follow up is being done to assess the success of our intervention.
100 hospitals were visited.  We observed staff and visitors smoking. There was evidence of cigarette butts on the floor of the wards and waiting areas.   95% of hospitals had such evidence.
Three focal persons were assigned for each governorate to start intervention to make hospitals smoke-free. 

**Hospital Smoking:  A base line study was completed and follow up is being done to assess the success of our intervention.**
- 100 hospitals were visited.  We observed staff and visitors smoking. There was evidence of cigarette butts on the floor of the wards and waiting areas.   95% of hospitals had such evidence.
- Three focal persons were assigned for each governorate to start intervention to make hospitals smoke-free.

**1-  **** The role of ESPRI in research for implementation of the FCTC?**

## More Compliance Research Studies:
School Surveys:  We helped MOHP for secondary analysis of GYTS  Studies in rural areas on children smoking. 
Testing cotinine levels for validation of the survey.
Transportation surveys:  we surveyed 500 Taxis , 100 minibuses and 25 large buses. 
METRO underground was the only place that has achieved full compliance with the smoking ban.
Government buildings surveys, including Ministry of Health

**School Surveys:  We helped MOHP for secondary analysis of GYTS  Studies in rural areas on children smoking. **
**Testing cotinine levels for validation of the survey.**
**Transportation surveys:  we surveyed 500 Taxis , 100 minibuses and 25 large buses. **
**METRO underground was the only place that has achieved full compliance with the smoking ban.**
**Government buildings surveys, including Ministry of Health**

**1-  **** The role of ESPRI in research for implementation of the FCTC?**

##     Testing for specific tobacco products that are common in the region:
ESPRI initiated testing of water-pipe tobacco products (Shisha, Nargilah etc..) to measure the levels of toxic chemicals,  mutagenicity, and carcinogenicity, in comparison to cigarettes. In conjunction with  information on inhalation, puffing and other topographical characteristics, this will lead to the extrapolation of levels of exposure among water-pipe smokers compared to cigarettes.

- ESPRI initiated testing of water-pipe tobacco products (Shisha, Nargilah etc..) to measure the levels of toxic chemicals,  mutagenicity, and carcinogenicity, in comparison to cigarettes. In conjunction with  information on inhalation, puffing and other topographical characteristics, this will lead to the extrapolation of levels of exposure among water-pipe smokers compared to cigarettes.

**1-  **** The role of ESPRI in research for implementation of the FCTC?**

## RELIGION IS A PUBLIC HEALTH TOOL

**Tobacco use is a social problem.**
**It requires real change in social beliefs and social norms.**
**Religion has worked successfully in this regard across EMR not only in tobacco but in other areas of health such as HIV/AIDS.**
**Religious message therefore must be activated whenever possible and used as needed.**

## EMRO LEADSESPRI works to promote and evaluate the role of such activity

- EMRO has been working with the leaders of Christian churches and Islamic institutions to endorse and support tobacco control through religious messages since the 80’s of the last century.

## Slide 29

## COLLABORATION WITH Community Religious Leaders Coptics and Muslims

**ESPRI is currently working with the Religious Leaders  to:**
**Train them on tobacco control related Health issues for Helping disseminate the messages within the communities at the civil society level.**

## ESPRI:    STUDYING THE IMPACT OF THE FATWA DISTRIBUTION

- 2 years after the Fatwa distribution; the Department of Community Medicine, Ain Shams University, studied the impact of the Fatwa distribution.
- The study focused on Mosques’ attendants in Five major cities in Egypt:
- Cairo,
- Giza,
- Alexandria, and
- Ismailia.
- Beni Sweif

## Results Among all Individuals

- Among 3635 surveyed, 2836 believed in the Fatwa, 39% of them were smokers.
- Among smokers who believed in the Fatwa, following the Fatwa distribution they reported:
- 68% intended to stop smoking.
- 61% tried to stop smoking.
- 60% actually reducing the number of cigarettes they smoked.
- 69% would try to convince a friend to quit.

## 
Regarding the decision on whether to stop selling tobacco products:

Among 1523 shop-owners surveyed:
 1210 owners (79.4%) believed in the Fatwa,
27 owners (1.8%  ) did not, and
286 owners (18.8%) were not sure.

- Regarding the decision on whether to stop selling tobacco products:
- Among 1523 shop-owners surveyed:
-  1210 owners (79.4%) believed in the Fatwa,
- 27 owners (1.8%  ) did not, and
- 286 owners (18.8%) were not sure.

## Three village intervention studies are helping to identify the most effective ways of implementation of FCTC in Egypt by  providing evidence-based methods for: 

**Prevention of initiation among youth. **
**Decreasing tobacco use among smokers **
**Decreasing passive smoking exposure among women and kids**
**Successful smoking cessation  tools**

**1-  **** The role of ESPRI in research for implementation of the FCTC?**

## Networking with universities for 
Curriculum development at  medical schools
Maintaining a smoke free campus   
ID of students are confiscated if they smoke on campus
Employees will forfeit their monthly bonus if they smoke

**Curriculum development at  medical schools**
**Maintaining a smoke free campus   **
**ID of students are confiscated if they smoke on campus**
**Employees will forfeit their monthly bonus if they smoke**

**2- ****What is  ESPRI doing, in terms of advocacy, to increase tobacco control  capacity?**

## Media Advocacy for Tobacco laws and implementation
Emphasis : Non-smokers rights to a smoke-free environment In addition to Awareness issues
Radio talks by experts, with youth contests for prizes based on their knowledge of the right answers
 Development of songs, drama, and TV spots for use by national media and NGO’s
 A satellite TV show was arranged with a famous youth religious leader (Amr Khaled), who spoke on passive smoking

**Emphasis : Non-smokers rights to a smoke-free environment In addition to Awareness issues**
**Radio talks by experts, with youth contests for prizes based on their knowledge of the right answers**
** ****Development of songs, drama, and TV spots for use by national media and NGO’s**
** ****A satellite TV show was arranged with a famous youth religious leader (Amr Khaled), who spoke on passive smoking**

**2- What is ESPRI doing, in terms of advocacy, for  effective implementation of the FCTC requirements?**

## FUTURE DITRECTION

- Continue the efforts in this line.
- Involve other partners.
- Develop a more appealing messages to specific population groups (Youth-Women).
- Enhancing partnership with other regions.

## During the first two  years ESPRI focused on local research and developing research tools and resources. We are starting to  initiate regional (Middle East) collaborations:
Starting a Middle East and Africa Journal of Tobacco Research 
Initiation of a web site with information in Arabic for the region.
Starting collaboration with Iraq
Ongoing collaboration with WHO EMRO 
on  Water-Pipe Monograph
Burden of Disease for other countries in the EMRO region

**Starting a Middle East and Africa Journal of Tobacco Research **
**Initiation of a web site with information in Arabic for the region.**
**Starting collaboration with Iraq**
**Ongoing collaboration with WHO EMRO **
**on  Water-Pipe Monograph**
**Burden of Disease for other countries in the EMRO region**

**Future Directions : there a significant benefit to sharing  research and research capacity across countries and regions **