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ly/ftadkk

Fundamentals of
Tobacco Addiction
Hafid Algristian, dr., SpKJ
Psychiatrist, Lecturer
Univ. NU Surabaya – RSI Jemursari
Topik Bahasan:

• Tren penggunaan tembakau di dunia;

• Dampak tembakau terhadap kesehatan;

• Penolakan terhadap tembakau di seluruh dunia.

 Bahan Bacaan:
U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of
Progress. A Report of the Surgeon General. Atlanta, GA: U.S. 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. Printed with corrections,
January 2014. https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-
report.pdf

U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report
of the Surgeon General. Atlanta, GA: U.S. 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, 2016.
https://www.cdc.gov/tobacco/data_statistics/sgr/e-
cigarettes/pdfs/2016_sgr_entire_report_508.pdf

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice
Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May
2008.
Tren Penggunaan Tembakau
• Sekitar 1,1 milyar orang, atau satu dari lima orang di seluruh
dunia merokok tembakau, menyebabkan sekitar 7,2 juta kematian
per tahun.
• Merokok membunuh setidaknya 214.000 orang tiap tahunnya di
Indonesia, dan 100.000 orang di Turki.
Ten Years In Public Health 2007-2017, Report By Dr Margaret
Chan, Director-general, World Health Organization

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Tren Penggunaan Tembakau
• Siapa bilang tembakau memperkaya devisa negara?
Justru penggunaan tembakau di seluruh dunia ini memangkas
pendapatan ekonomi global secara signifikan.
• Pada 2017, US National Cancer Institute dan WHO bersama-sama
menyebutkan bahwa, “Penggunaan tembakau menjadi beban
pengeluaran kesehatan global lebih dari 1,4 trilyun dolar dan
produktivitas sumber daya manusia di suatu negara menurun tiap
tahunnya.
Ten Years In Public Health 2007-2017, Report By Dr Margaret
Chan, Director-general, World Health Organization

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Tren Penggunaan Tembakau: Indonesia

1. Smoking prevalence rates in Indonesia have

increased since 1995
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Tren Penggunaan Tembakau: Indonesia

2. Female Smokers: a 5-fold increase

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Tren Penggunaan Tembakau: Indonesia
3. Perokok Muda:
 Global Youth Tobbaco Survey 2014 (GYTS 2014):
 20.3% anak usia sekolah (36% of men, 4.3% of women),
 57.3% of 13-15 tahun anak usia sekolah menjadi perokok pasif
 60% are exposed in the home and in public places.
 GATS 2011 data also shows the prevalence of smokers in Indonesia
by 34.8%, and as many as 67% of men in Indonesia are smokers (the
largest number in the world)

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Tren Penggunaan Tembakau: Indonesia
4. Passive smokers also get the danger:
 51.3% Adults exposed to cigarette smoke at work
 85.4% Adults exposed to cigarette smoke in restaurants
 78.5% Adults are exposed to secondhand smoke at home
 68.8% Adults exposed to tobacco smoke outside the home

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Tren Penggunaan Tembakau: Indonesia
Tantangan: Indonesia has not signed the FCTC
(Framework Convention of Tobacco Control):
1. Ads everywhere (balloon effect).
2. Promoting lifestyle for youth, even scholarship.
3. Indonesia is The Largest Island Country (more than 13.000
island, but only 6.000 are named), many cultures and sub-
cultures (merokok bagian dari budaya).

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Tren Penggunaan Tembakau: Indonesia
Balloon Effect
o Partial Banned is Ineffective:
o if one form of advertising is NOT PROHIBITED or LIMITED
the cigarette industry will switch to other forms of
advertising that are not banned (balloon effect)
 more creative, more persuasive.
o Supervision is difficult:
o cigarette advertisements are banned on television before
21.30 - in fact there are still many covert advertisements
(acknowledged by KPI and Badan POM).
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Tren Penggunaan Tembakau: Indonesia
Youth Lifestyle
• Sports: "(Sponsorship) Sports are the best way of attracting
attention, setting an example and influencing our target
market" (Phillips Morris International document in Asia)
• Music: "Music is the language, source, ideas and trends of
young people ..." (Young Life style study, Phillip Morris in Hong
Kong, 1989)
• Film: "Movies are better than other forms of promotion
because the audience is completely unaware of our sponsor ..."
(RJ Reynolds Tobacco, 1972)
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Tren Penggunaan Tembakau: Indonesia
Smoking Design
Current American Blended Cigarettes

“…today’s cigarette smokers – both men and women –

have a much higher risk for lung cancer and chronic
obstructive pulmonary disease (COPD) than smokers
in 1964, despite smoking fewer cigarettes.
…changes in the design and composition of cigarettes
since the 1950s are responsible for smokers’
increased risk of developing lung cancer.”
Surgeon General, Tobacco Report 2014
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Dampak terhadap Kesehatan
Health Risk
Stroke, Blindness, cataract, Age-related macular degeneration, Periodontitis,
Coronary heart disease, Aortic aneurysm, Atherosclerotic peripheral vascular
disease, Chronic obstructive pulmunary disease, Tuberculosis, Asthma,
Pneumonia, Other respiratory effects, Male sexual function-erectile
dysfunction, Hip fractures, Impaired immune function

The condition in red is a new disease that has been causally linked to smoking.
Surgeon General, Tobacco Report 2014

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Dampak terhadap Kesehatan
Health Risk
Type 2 Diabetes mellitus.
“The evidence is sufficient to infer that cigarette smoking is a cause of
diabetes. The risk of developing diabetes is 30–40% higher for active smokers
than nonsmokers. There is a positive dose-response relationship between the
number of cigarettes smoked and the risk of developing diabetes.”

Berhenti merokok pada pasien jantung koroner, dapat menurunkan resiko

kematian hingga 36% pada dua tahun pertama.
Critchley JA et al. Mortality risk reduction in patients with coronary heart disease: A systematic review.
JAMA, 2003;290:86-97

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Dampak terhadap Kesehatan
Health Risk
Buerger disease (thromboangiitis obliterans):
A disease in which the characteristic pathologic findings
— acute inflammation and thrombosis (clotting) of
arteries and veins — affected the hands and feet. The
classic Buerger’s Disease patient is a young male (e.g.,
20–40 years old) who is a heavy cigarette smoker,
but some cases occur in patients who smoke
“moderately”; others have been reported in users of
smokeless tobacco. Buerger’s Disease is postulated to
be an “autoimmune” reaction triggered by some
constituent of tobacco.

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Dampak terhadap Kesehatan
Health Risk
Kesuburan Pria dan Wanita:
There is consistent evidence that links smoking in men to chromosome changes or DNA
damage in sperm (germ cells), affecting male fertility, pregnancy viability, and anomalies
in offspring.
Reproductice effects in women: Reduced fertility, Conditions causally associated with
maternal smoking during pregnancy: Preterm delivery and fetal growth
restriction, Placenta previa, Placental abruption, Ectopic pregnancy , Sudden
infant death syndrome (SIDS), Orofacial clefts.

How Tobacco Smoke Causes Disease: The Biology and

Behavioral Basis for Smoking-Attributable Disease. A Report
of the Surgeon General, 2010.

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Dampak terhadap Kesehatan
Health Risk
Penuaan Dini:
Several other measures of health and well-being have also been evaluated in relation to
smoking, including ability to walk a short distance, frailty, overall quality of life, and
successful aging.

In studies of middle-aged (Ostbye et al. 2002) and older people (Ostbye et al. 2002; Hardy et
al. 2010), current smokers reported greater difficulty than never smokers in walking a
short distance.

The Health Consequences of Smoking: A Report of Surgeon

General Report. 2014

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Dampak terhadap Kesehatan
Drug Abuse Risk
Resiko menyalahgunakan zat lain:
Among adolescents, early initiation of tobacco use is associated with the use of other
substances (Kandel and Yamaguchi 1993).
In a cohort study of adolescents, reports of “ever” and “daily” smoking were associated with
increased risks in the future of using marijuana and other illicit drugs as well as
disorders involving the use of multiple drugs (Lewinsohn et al. 1999).
In addition, early-onset smokers were found to be more likely to have substance use
disorders than late-onset smokers or nonsmokers (Hanna and Grant 1999).

Surgeon General, Report on Tobacco 2012

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Dampak terhadap Kesehatan
Cancer Risk
Radikal Bebas Penyebab Kanker:
When smokers inhale smoke, each cigarette puff delivers a mixture of carcinogens
and toxicants. Tobacco smoke contains more than 7,000 chemicals, and at least
69 of these can cause cancer. These include polycyclic aromatic hydrocarbons;
tobacco-specific nitrosamines; aromatic amines; and volatile carcinogens such
as formaldehyde, acetaldehyde, 1,3-butadiene, and benzene (as well as various
metals). Cigarette smoke is often separated into two phases (tar and gas),
which both contain free radicals. The gas phase is less stable and contains
approximately 1015 radicals per puff; and the more stable tar phase has been
estimated to contain more than 10 17 free radicals per gram.
Surgeon General, Tobacco Report 2014
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Dampak terhadap Kesehatan
Cancer Risk
Oropharynx, Larynx, Esophagus, Trachea, bronchus, lung, Acute myeloid leukemia,
Stomach, Liver, Pancreas, Kidney and ureter, Cervix, Bladder, Colorectal.
The condition in red is a new disease that has been causally linked to smoking.
Surgeon General Tobacco Report 2014

Di Indonesia (2014), jumlah kanker paru yang terkait rokok  30901 kasus.
http://www.worldlifeexpectancy.com/indonesia-lung-cancers

Pasien yang berhenti merokok di usia 50-60 tahun dapat terhindar dari resiko
kanker peru, dan yang berhenti di usia 30 tahun berpeluang 90% terhindar.
Peto R et al. Smoking, smoking cessation, and lung cancer in the UK since 1950: combination of national
statistics with two casecontrol studies. BMJ 2000;321:323–9.

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Dampak terhadap Kesehatan
Death Risk
Adult male and female smokers lost an average of 13.2 and 14.5 years of
life, respectively, because they smoked.
Fellows JL et al. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Economic Costs --- United
States, 1995—1999. MMWR, April 12, 2002 / 51(14);300-3

A systematic review was recently published and showed that tobacco smoking is related to a
significantly increased risk for Alzheimer’s disease.

Smoking and increased Alzheimer’s disease risk: A review of potential mechanisms. Timothy C. Et al.
Alzheimer’s & Dementia 10 (2014) S122-S145.

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Dampak terhadap Kesehatan
Sebuah studi tentang persentase kematian dokter dibandingkan
penggunaan tembakau di United Kingdom.
• Tujuan: Membandingkan bahaya rokok tembakau pada pria yang rutin
menggunakan tembakau dalam jangka waktu tertentu, dan penurunan resiko
kematian jika kebiasaan merokok dihentikan pada usia tertentu.
• Desain penelitian: Penelitian prospektif dari tahun 1951 hingga 2001.
• Tempat: United Kingdom.
• Subyek: Partisipan adalah 34.339 dokter laki-laki berkebangsaan Inggris.
Informasi tentang kebiasaan merokoknya didapatkan semenjak 1951, dan
setelahnya secara periodik, menyebabkan kematian yang diamati selama 50 tahun
ke depan.

Doll R, Peto R, Boreham J, Sutherland I . Mortality in relation

to smoking: 50 years’ observations on male British Doctors.
23 BMJ. 2004 Jun 26;328(7455):1519. Epub 2004 Jun 22.
Persentase Dokter yang meninggal
pada usia 35-70 tahun per dekade kelahiran
Merokok
45
40
35 “Penurunan resiko kematian pada
Tidak Pernah non-smokers ini dapat disebabkan
30
Merokok karena tercegahnya kemunculan
25 penyakit akibat merokok, dan
20 kalaupun sakit, mudah mengalami
perbaikan kondisi tubuh.”
15
10 Doll R, Peto R, Boreham J,
5 Sutherland I . Mortality in
relation to smoking: 50 years’
0 observations on male British
Doctors. BMJ. 2004 Jun
1900-1909 1910-1919 1920-1929 26;328(7455):1519. Epub
2004 Jun 22.
Persentase Dokter yang meninggal
pada usia 35-70 tahun per dekade kelahiran

• Mereka yang berhenti merokok pada usia 25-34 tahun, mendapat “tambahan
usia harapan hidup” (life expectancy) sekitar 10 tahun, dan mendapat
kekebalan yang hampir sama pada laki-laki yang tidak pernah merokok.
• Mereka yang berhenti merokok pada usia 40 tahun mendapat 9 tahun.
• Mereka yang berhenti merokok pada usia 50 tahun mendapat 6 tahun.
• Mereka yang berhenti merokok pada usia 60 tahun mendapat 3 tahun.

Doll R, Peto R, Boreham J, Sutherland I . Mortality in relation

to smoking: 50 years’ observations on male British Doctors.
BMJ. 2004 Jun 26;328(7455):1519. Epub 2004 Jun 22.
Penolakan terhadap Tembakau
After carefully examining the available evidence, the
Report of the Surgeon General declared that:
• Cigarettes and other forms of tobacco are addicting.
• Nicotine is the drug in tobacco that causes addiction.
• The pharmacologic and behavioral processes that determine
tobacco addiction are similar to those that determine addiction
to drugs such as heroin and cocaine.

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Penolakan terhadap Tembakau
Kasus Membandel:
• The compulsive nature of cigarette smoking is most apparent in
extreme cases: for example, the laryngectomized patient who,
having already suffered severe consequences of smoking,
continues to smoke through a tracheostomy hole.

• Similarly, 50 percent or more of patients recovering from surgery

for a smoking-related disease (e.g., cancer, cardiovascular disease)
resume smoking while in the hospital or shortly after discharge

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Penolakan terhadap Tembakau
Diagnosis Kecanduan Tembakau:
• International Statistical Classification of Diseases and Related
Health Problems 10th Revision (ICD-10) Version for 2010,
Chapter V: Mental and behavioural disorders (F00-F99),
Mental and behavioral disorders due to psychoactive substance use
(F10-F19):
• F17: Mental and behavioral disorders due to use of tobacco /
F17.2: Tobacco (Nicotine) Dependence Syndrome,
• F17.4: Nicotine withdrawal
• American Psychiatric Association’s
• DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition):
• Tobacco use disorder
• Under the heading of substance use disorders.
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Penolakan terhadap Tembakau
Dunia Sudah bersuara.
Bagaimana Indonesia?
Bagaimana kita?

29
Terimakasih.

Fundamentals of
Tobacco Addiction
Hafid Algristian, dr., SpKJ
Psychiatrist, Lecturer
Univ. NU Surabaya – RSI Jemursari

http://bit.ly/ftadkk