การลดปัจจัยเสี่ยงต่อความดันโลหิตสูงและเบาหวาน ของประชากร ศ.นพ.ประกิต วาทีสาธกกิจ วันที่ 25 มีนาคม 2555 “สังคมไทยไร้โรคเบาหวานและความดันโลหิตสูง ด้วยพระบารมีปกเกล้าฯ” Action on Smoking and heath Foundation/มูลนิธิรณรงค์เพื่อการไม่สูบบุหรี่

4 modifiable shared risk factors cause 4 major NCDs which account for 4 — 4 — 80 4 modifiable shared risk factors cause 4 major NCDs which account for 80% of all NCD deaths Shared Risk Factors Tobacco use Unhealthy diets Physical inactivity Harmful use of alcohol Non-communicable diseases Cardiovascular diseases  Diabetes (Type II) Cancer Chronic respiratory disease

Thailand NCDs Death (2009) Ischemic heart disease = 34,384 Stroke = 50,829 Cancer = 80,711 COPD = 18,660 DM = 26,380 Total major NCDs = 210,963 Total death (all causes) = 415,900 Death from NCDs = 50.7% Death from NCDs before 60 yrs old = 27% The Thai Working Group on Burden Attributable to Risk Factors IHPP.MOH 2009

2 million DALY loss in 2004 for male or 34 % of all DALY loss in males DALY Loss Thailand 2 million DALY loss in 2004 for male or 34 % of all DALY loss in males from NCD risk factors

0.9 million DALY loss in 2004 for female DALY Loss Thailand 0.9 million DALY loss in 2004 for female or 23 % of all DALY loss in females from NCD risk factors

Total number of major NCDs cases Hypertension = 10,000,000 Diabetes = 3,200,000 Cardiovascular disease = 690,000 Stroke = 730,000 COPD = 270,000 Thailand’s 4th National Health Examination Survey 2009.

การสำรวจสุขภาพประชาชนโดยการตรวจร่างกาย (4) จำนวนผู้ป่วย (ล้านคน) สูบบุหรี่ (ล้านคน) อัตราการสูบบุหรี่ (%) ความดันสูง (♂) 5.1 1.6 31.37 เบาหวาน (♂) 1.4 0.54 38.5 อัตราการสูบบุหรี่ ความดันสูง (♀) = 2.4% เบาหวาน (♀) = 1.28% วิชัย เอกพลากร 2554

เรื่องอื่นข้าไม่เกี่ยว คนไข้เป็นเบาหวาน แพทย์ก็ดูแต่ FBS / Hba1c คนไข้เป็นความดัน เราก็ดูแต่ BP เรื่องอื่นข้าไม่เกี่ยว

Tobacco control Milestone Thailand Establish NGO focal point for tobacco control (1986) National Committee for Tobacco Control 1989 Tobacco Control Office MOH 1991 Tobacco Product Control Act 1992 Nonsmoker’s Health Protection Act 1992 Increasing Tax for Health Policy 1993 Health Promotion Foundation Act 2001 Graphic Health Warning 2005 / 2007 / 2010 Ban point of sale display of cigarette pack (2005) Ban Tobacco Company CSR activity in electronic medias (2005) 100% Smoke free public & work places

การควบคุมยาสูบในประเทศไทย ใช้แต่เครื่องบินทิ้งระเบิด และยิงปืนใหญ่เป็นหลัก เมื่อไรทหารราบจะมา?

Global Adult Tobacco Survey : Thailand Country Report Tobacco Use : Key findings 23.7 % (12.5 million adults) smoke tobacco 35.7 % of smoker have the first cigarette between 6-30 minutes of waking up 24.4 % of smoker have the first cigarette ≤ 5 minutes of waking up GATS Thailand 2009

Key findings 6 in 10 smokers plan to or are thinking of quitting 6 in 10 smokers were asked if they smoke by health care provider 5 in 10 smokers received advice to quit by health care provider “Quitting on your own” was the most common cessation method GATS Thailand 2009

Use of cessation method Quit on your own 88.9 % Pharmacotherapy 10.6 % Counseling 5.8 % Other 2.9 % GATS Thailand 2009

Nation Capacity Assessment on the Implementation of Effective Tobacco Control Policies in Thailand November 2008 By WHO

Key Findings Government capacity for coordinating tobacco control is not strong The government infrastructure for tobacco control is weak

The infrastructure of NGOs is insufficient Law enforcement is suboptimal Implementation of NGOs activities at grassroots level has been limited Funding for tobacco control is in-sufficient especially for government activities

National Capacity Assessment offer help to quit tobacco use (WHO 2008) Key findings 1. A national systematize, multi-level treatment and management system, integrated into the primary health care system, does not exist

2. The MOPH gives to tobacco dependence management a low priority than to other tobacco control strategies 3. Tobacco dependence management is not funded

4. Utilization of current services is low 5. The tobacco dependence management approach utilizes a predominantly medical model

6. First – line drug for treatment of tobacco dependence are not included in essential drug list 7. Quitline exist but they need to be coordinated within on , single national quitline

Recommendations 1. Advocate for a systems approach for tobacco dependence management 2. Give priority for the development of brief treatment interventions 3. Fund tobacco dependence management

4. Consolidate national treatment guidelines 5. Establish national quitline 6. Promote quit attempts 7. Monitor services

Thai smoker who seek cessation assistance Do you have medication to help me? No medication?? Current medication being used by smoking cessation clinics Vitamin / Nortriptyline Herb tea Silver Nitrate mouthwash Bupropion / Varernicline / Nicotine gum / patch

Medication Available in Thailand Nicotine chewing gum OTC Nicotine patch Nortriptyline Prescription/ on national drug list Bupropion Prescription/ not on national drug list Varenicline Prescription/not on national drug list

Puthchinaraj Hospital Smoking Cessation Clinic Patient who smoke Want to quit % OPD 1,039 437 42.86 IPD 632 395 62.50 Dr. Ratapum Champunot

Total cost per quitting case = 2008 baht Abstinence rate (%) 6 months 12 months Pseudoephedrine (60 my x 2) N=275 34.6 33.1 Nortryptyline (10 my x 2) N=252 34.9 35.7 B.Com (1x2) N=260 39.6 40.0 Total cost per quitting case = 2008 baht Dr. Ratapum Champunot

Non pharmacological role of smoking cessation medication in Thai patient Satisfy patient’s believe (That I need medication to help) (50% of smoker make quit attempt but failed) Retention of patient Placebo effect

เงื่อนไขที่จะเป็นคลินิกอดบุหรี่ที่ประกันสุขภาพจะออกค่าใช้จ่ายการรักษาให้ (ญี่ปุ่น) คลินิก/รพ. จะต้องปลอดบุหรี่ 100% ต้องมีเครื่องวัด Carbonmonoxide ต้องมีแพทย์อย่างน้อยหนึ่งคนที่มีประสบการณ์ในการรักษาการอดบุหรี่

คลินิก/รพ. ที่เข้าร่วมโครงการมีจำนวน 10,254 แห่ง ต้องมีพยาบาลประจำอย่างน้อยหนึ่งคนทำหน้าที่ประจำคลินิกอดบุหรี่ ผู้ป่วยจะต้องมีระดับการติดบุหรี่ (Tobacco depence screen)ตามเกณฑ์ที่กำหนด ต้องยินดีที่จะมารับการรักษาติดต่อกัน 5 ครั้ง คลินิก/รพ. ที่เข้าร่วมโครงการมีจำนวน 10,254 แห่ง (มิถุนายน 2010)

Rec : Give priority for the development of brief treatment interventions (2008) Smoke-free Hospital Project Integrating 5A approach into daily practice Training of brief treatment interventions for staffs at “Sub-district Hospital”

Key findings 2009 2011 - Asked if they smoke by health care provider 60% 65% - Received advice to quit 50% 55%

On going advocacy To provide free cessation treatment for patients who attend diabetes and hypertension clinics Smoking prevalence - Diabetic ♂ = 37% (N = 540,000 smokers) - Hypertension ♂ = 30% (N = 1.6 million smokers) รวมจำนวนผู้ป่วยเบาหวาน-ความดันสูงที่สูบบุหรี่ = 2,140,000 คน

On going effort : To recruit medical professional organizations to sign petition to submit to Minister of Health, to support inclusion of first line smoking cessation medication into national drug-list and include in UHI benefit

Initiation of NCD network in Thailand With the initiative of the WHO and the RTG, a forum of NCD control (NCD network) has been formulated since 30 June 2010 with several health experts and specialists in areas of prevention and control of NCDs in Thailand.

Diseases and risk factors being chosen by Thai NCD network Diseases/risk factors Tobacco use Unhealthy diets Physical inactivity Harmful use of alcohol Overweight & obesity Cardiovascular diseases + Hypertension Diabetes Cancer Chronic Respiratory disease +* *as a result of obesity including obstructive sleep apnea

Goals 1. To support movements to raise the problems of NCDs as a priority on the national agenda on social and human development. 2. To control 5 main NCDs, including cardiovascular diseases, hypertension, diabetes, cancers, and chronic respiratory diseases.

Goals (cont.) 3. To control unhealthy lifestyles, including tobacco use, unhealthy diets, physical inactivity, obesity, and harmful use of alcohol.

Stakeholders Ministry of Public Health, Thailand (MOPH) World Health Organization (WHO) National Health Security Office (NHSO) Thai Health Promotion Foundation (ThaiHealth) Mahidol University Chulalongkorn University Diabetes Association of Thailand the Royal College of Physicians of Thailand the Thoracic Society of Thailand the National Cancer Institute of Thailand the Action on Smoking and Health Foundation, Thailand Center for alcohol study, Thailand (CAS) Health System Research Institute, Thailand (HSRI) International Health Policy Program, Thailand (IHPP) Ministry of Interior Ministry of Education Ministry of Finance Ministry of Commerce Ministry of Social Development and Human Security Ministry of Agriculture and Cooperatives Ministry of Transportation and Telecommunication Local governments’ representatives Private enterprises’ representatives Non-governmental organizations (NGO) Foundation for consumers Reporters and Media representatives