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Posted: 01 Jun 2013 05:46 PM PDT

Various measures have been taken to discourage people from taking up, or continuing, this harmful habit.

IN university, I took a public health unit under a doctor who was a heavy smoker, regularly finishing off a pack or two of cigarettes a day.

Ironically, he was in charge of the case study we had to analyse on the correlation between smoking and lung cancer.

With all the medical evidence available, we naturally came to the conclusion that smoking and lung cancer are indeed strongly linked to one another.

Although we had a healthy respect (read: a little fear) of him – he was a retired colonel from the Royal Malaysian Armed Forces and still had that brusque, no-nonsense air about him – some of the braver ones in our group did try to persuade him to cut down on his smoking in light of our results.

His answer: Prove to me that smoking directly causes lung cancer, and I will quit.

Unfortunately, he did have a point. A vast majority of lung cancer patients are smokers, but not all smokers develop lung cancer.

According to the British charity Cancer Research UK, smoking causes 90% of lung cancer cases, with a further 3% caused by passive or secondhand smoking.

Meanwhile, the US Centers for Disease Control and Prevention states that smokers are 15 to 30 times more likely to get, or die from, lung cancer than non-smokers.

The more and the longer one smokes, the higher the risk. And even smoking a few cigarettes a day, or only occasionally, can increase one's risk of developing lung cancer.

In fact, quitting smoking at any age can lower the risk of lung cancer – a risk that will continue to decrease the longer one stays clear of the habit.

In addition, smoking is a risk factor for a number of other serious diseases.

Among these are cardiovascular conditions like heart attacks, stroke and peripheral arterial disease, chronic obstructive pulmonary disease, impotence, decreased fertility, high blood pressure, and cancers of other parts of the body.

Pregnant women who smoke are also more likely to experience miscarriages, stillbirths, premature delivery and a baby with low birth weight.

Craving a smoke

However, quitting this addictive practice is easier said than done.

The chemical nicotine in tobacco is the reason why people continue to feel the need to smoke.

Nicotine is a drug that acts as both a stimulant and depressant, producing feelings of euphoria, as well as relaxation, in its users.

It also creates dependence in its users, resulting in withdrawal symptoms when the smoker doesn't get his or her usual fix. This is why smokers often find it so hard to kick the habit.

Despite the scientific evidence that nicotine, and even tobacco, are harmful substances, they are legal substances.

This is probably due to societal traditions and norms, beginning from the time when tobacco was actually thought to have medicinal properties, as well as the not-inconsiderable influence wielded by the tobacco industry.

So, the focus of public health advocates has always been on preventing non-smokers from picking up the habit, as well as getting current smokers to quit it.

The general strategies employed towards these objectives usually include mass media awareness campaigns, graphic health warnings on cigarette packs, increasing the price of tobacco via sin taxes, creating smoke-free environments, providing easy access to quit-smoking programmes, and banning advertisements by tobacco companies.

'Tak Nak Merokok'

Most Malaysians would be familiar with the Tak Nak media campaigns initiated by the Health Ministry in 2004-2010.

With a RM100mil allocation, the ministry went on an all-out media blitz to encourage Malaysian citizens to "say no" to smoking.

Campaign posters were posted up on billboards, government premises, newspapers and magazines, while television and radio advertisements were bought and played on air.

But was this campaign actually effective?

According to the International Tobacco Control (ITC) Malaysia National Report, an average of 93% of the 1,867 adult and 112 youth smokers surveyed from across the country said that they had seen the campaign.

Around 43% of all smokers and those who had already quit smoking said that anti-smoking advertising made them more likely to want to quit smoking, or more likely to stay off the habit, respectively.

However, the report, which surveyed its respondents four times over a period of four years, did not state whether any smokers had quit as a direct result of the campaign.

The report, produced as part of the multi-country ITC Policy Evaluation Project, was published in March 2012.

In addition to increasing awareness of the negative consequences of smoking, tobacco companies are also banned from advertising their products.

Since 2004, under the Control of Tobacco Product Regulations, most avenues for direct and indirect advertising of tobacco products in Malaysia have been legally closed off.

This includes obvious advertising arenas like the mass media, shops and entertainment outlets, as well as less obvious ones like product placements in shows or movies.

However, when queried five years after the legislation was passed, over one-fifth of adult smokers "often" or "very often" noticed advertisements or photos of smoking that encouraged or made them think about smoking in the past six months.

These advertisements or photos were seen in places like coffee shops, stores that sell cigarettes, street vendors, discos, karaoke centres and other entertainment outlets.

And although event sponsorship by tobacco companies is banned in Malaysia, around 19% of adult smokers and 6% of youth smokers saw or heard about tobacco companies or cigarette brands in conjunction with a sporting, arts or cultural event.

The ban on giving out free samples of tobacco products and promoting tobacco products on non-tobacco merchandise was more effective, with 13% or less of smokers noticing these tactics.

But the law still allows for the display of cigarette packs at the point of sale, meaning that those cigarette cupboard displays behind the cashier in stores that sell them are legal, and there is currently no prohibition against advertising tobacco products on the Internet.

Graphic warning

Scare tactics are often employed in the war against smoking. And nowhere is this more evident than on the packaging of cigarettes.

For 32 years, beginning in 1976, the warning on cigarette packs were one-line sentences in Malay and English stating respectively: "Amaran Kerajaan Malaysia: Merokok Membahayakan Kesihatan" and "Warning by the Malaysian Government: Smoking is Hazardous to Health".

It was after the 2009 amendments to the Control of Tobacco Product Regulations, that the rotating group of gruesome photos seen on cigarette packs nowadays were made compulsory.

The photos demonstrate some of the consequences of smoking: cancers of the neck, lung and mouth, gangrene, premature birth and miscarriage, and must cover at least 40% of the front of the pack, and 60% of the back,

In addition, packs must carry the Quit Smoking infoline number and the following text: "Produk ini mengandungi lebih 4,000 bahan kimia termasuk tar, nikotina dan karbon monoksida yang membahayakan kesihatan" (This product contains over 4,000 chemicals including tar, nicotine and carbon monoxide that endanger health) and "Dilarang Jual Kepada Orang Bawah Umur 18 Tahun" (Sales prohibited to persons under 18 years of age).

The pictorial health warnings seem to have had their intended effect, with over two-thirds of smokers noticing the pictures "often" and "very often" about one month after the ruling came into force.

Although only 14% of smokers reported that the graphic warnings were more likely to make them quit smoking, around 45% reported that they gave up smoking a cigarette because of the photos – an indicator that the smoker would attempt to quit in the future.

Sin taxes

Some governments have also gone the route of hitting smokers where it hurts – their wallets.

Imposing high taxes to drive up the price of tobacco products is deemed as one of the best ways to discourage people from picking up, or continuing the habit.

In Malaysia, locally-produced cigarettes are charged an excise tax of eight sen per stick, while imported cigarettes from the Association of South-East Asian Nations (Asean) are subjected to an import tax of 10 sen per stick, and those imported from other countries are charged two sen per stick.

Cigarettes sold here also have a minimum price of RM6.40, and price promotion methods, like discounts, are banned.

The problem is, despite these measures, cigarette affordability – the amount of resources or income required to purchase a pack of cigarettes – is quite high in Malaysia. This means that people can afford cigarettes quite easily in this country with their level of income.

This is reflected in the fact that only 36% of smokers thought "often" or "very often" about the money they spend on their habit.

And price is an important factor for smokers, as 81% of those who smoke factory-made cigarettes say that one of the reasons they chose their brand was price.

In addition, illegal cigarettes, which are generally cheaper, can be easily obtained in local convenience stores, according to the Malaysian Pack Study.

Done in conjunction with the fourth survey of the ITC Malaysia National Report, the study found that just under one-fifth of smokers were puffing on illicit cigarettes.

Over a quarter of these smokers indicated that price was a factor in their selection of cigarette brands, and 72% obtained these cigarettes from convenience stores.

Smoke-free zones

Other efforts to discourage smoking and decrease cases of secondhand smoking include banning the practice in public areas like healthcare, educational and government institutions, public transport, air-conditioned eating places, shopping centres and workplaces, airports, stadiums, places of worship, petrol stations, fitness centres, and public places like toilets, lifts, theatres and libraries.

However, over a quarter of smokers reported that they noticed other people smoking in air-conditioned restaurants despite the ban.

The Government has also made available facilities to enable smokers to get the help they need to quit smoking.

These include the nationwide Quit Smoking Infoline, Quit Smoking Clinics in every state, and the availability of drugs that help smokers decrease their dependence on nicotine like nicotine replacement therapy, varenicline and bupropion in community pharmacies.

Going back to the lecturer I mentioned at the beginning of the article, I heard that he died a few years ago.

The cause? Lung cancer.

He never did quit his smoking habit.

Exercise for the brain

Posted: 01 Jun 2013 05:49 PM PDT

The therapeutic properties of exercise is well supported by a substantial amount of research.

THE benefits of exercise are well publicised. Exercise is associated with a reduction in physical illnesses such as cardiovascular disease, colon and breast cancer, obesity and mental illness (including depression and anxiety disorders) across the adult lifespan.

The National Health and Morbidity Survey 2011 revealed that about 64.3% of Malaysians were physically active. The level of physical activity gradually decreased with increasing age, and this was particularly apparent in senior citizens.

Despite evidence of the importance of exercise, the prevalence of overweight and obese Malaysians was 29.4% and 15.1% respectively based on the World Health Organization (1998) classification.

Although some are aware of the benefits of exercise, there are many who are unaware that exercise has considerable benefits for the brain. This is put aptly by John Ratey, author of A User's Guide to the Brain. "Exercise is really for the brain, not the body. It affects mood, vitality, alertness and feelings of well-being."

There is increasing evidence that exercise can improve learning and memory, delay age-related cognitive decline, reduce risk of neurodegeneration and alleviate depression.

Exercise and brain function

Exercise improves brain function in different ways. It enhances learning and plasticity, is neuroprotective, and is therapeutic and protective against depression

Exercise enhances learning and plasticity, which is the capacity of the brain and nervous system to continuously alter neural pathways and synapses in response to experience or injury.

The effects of exercise have been demonstrated in ageing human populations in which sustained exercise has augmented learning and memory, improved executive functions, impeded age-related and disease-related mental decline, and protected against age-related atrophy in parts of the brain areas that are vital for higher cognitive processes.

Physical activity has a positive effect on cognition, which includes every mental process that may be described as an experience of knowing (including perceiving, recognising, conceiving, and reasoning).

There is a significant relationship between physical activity and improved cognition in normal adults as well as those with early signs of Alzheimer's disease (AD), in which there is mild impairment of memory or cognition.

There is a dose-response relationship between exercise and health-related quality of life, with moderate exercise associated with the best outcomes.

The literature on the effects of exercise on cognition during children's development is less substantial. However, a meta-analysis by Sibley & Etnier reported a positive correlation between physical activity and cognitive performance in children aged between four and 18 years in eight categories, i.e. perceptual skills, intelligence quotient, achievement, verbal tests, mathematic tests, memory, developmental level/academic readiness and others.

A beneficial relationship was found for all categories, with the exception of memory, which was unrelated to physical activity behaviour, and for all age groups, although it was stronger for children in the ages of four to seven and 11 to 13 years, compared with the ages of eight to 10 and 14 to 18 years.

Recent studies have reported that an increase in the time dedicated to physical health-based activities is not associated with a decline in academic performance.

The literature on the impact of exercise on cognition in young adults is limited, probably because cognition peaks during young adulthood and there is little room for exercise-related improvement at this stage of the lifespan.

Although there is considerable evidence that exercise can facilitate learning in humans and other animals, there are gaps in knowledge regarding the types of learning that are improved with exercise.

Exercise protects the brain (neuroprotective). It reduces the impact of brain injury and delays the onset and decline in several neurodegenerative diseases. For example, therapeutic exercise programmes after a stroke accelerates functional rehabilitation.

Furthermore, physical activity delays the onset and reduces the risk for AD, Huntington's disease and Parkinson's disease, and can even slow functional decline after neurodegeneration has begun.

There is evidence that exercise is therapeutic and protective in depression, which is associated with a decline in cognition.

Depression is considered to be a health burden that is greater than that of ischaemic heart disease, cerebrovascular disease or tuberculosis.

Clinical trials have reported the efficacy of aerobic or resistance training exercise in the treatment of depression in young and older patients, with benefits similar to that of antidepressant medicines. More exercise leads to greater improvements.

Trials have also reported improvement in depressive symptoms in AD compared to those non-exercising individuals whose depressive symptoms worsened.

Bipolar disorders do not appear to respond as well to exercise, but those with anxiety respond even faster.

There is a convergence of the concept that brain health and cognition are influenced by the interplay of various central and peripheral factors. Brain function is believed to be impaired by peripheral risk factors that lead to cognitive decline, including hypertension, hyperglycemia, insulin insensitivity and dyslipidemia, features that are commonly known as the "metabolic syndrome".

Of these factors, hypertension and glucose intolerance play crucial roles. Exercise not only reduces all these peripheral risk factors but also improves cardiovascular health, lipid–cholesterol balance, energy metabolism, glucose use, insulin sensitivity and inflammation.

As such, exercise improves brain health and function by directly enhancing brain health and cognitive function, and indirectly, by reducing the peripheral risk factors for cognitive decline.

It is believed that exercise initiates an interactive cascade of growth factor signals which lead to the stimulation of plasticity, improvement of cognitive function, reduction of the mechanisms that drive depression, stimulation of neurogenesis and improvement of cerebrovascular perfusion.

Although much is known about the effects of exercise and physical activity on brain and cognition, there are many important questions that are unanswered.

They include questions like the design of exercise interventions which optimise the effects on cognition and brain health; when it is best to begin; what are the best varieties, intensities, frequencies and duration of exercise; is it ever too late to start an exercise programme; and can exercise be used to reduce the effects of neurodegenerative diseases.

Knowing the how

Exercise affects many sites in the nervous system and stimulates the secretion of chemicals like serotonin and dopamine, which make humans feel calm, happy, and euphoric. You do not have to wait for these feelings to occur – you can initiate them by exercising.

There is no shortage of advice on the various physical exercises that enhances cardiovascular health. Prior to embarking on exercise, a consultation with the doctor would be helpful, especially for senior citizens. This will help in choosing the appropriate exercise for one's individual situation.

In general, what is good for the heart is also good for the brain.

The usual recommended minimum is half an hour of moderate exercise thrice a week. This can be walking, jogging, swimming, playing games, dancing etc.

The public is often reminded about a healthy lifestyle, which is focused on physical health. However, it is also important to exercise mentally and keep the brain healthy.

There are publications and activities available that can help you make a start and continue to improve cognition, memory, creativity and other brain functions.

Anyone at any age can do so, even senior citizens. It is moot to remember the adage: if you don't use it, you lose it.

Malaysia Festival of the Mind 2013

The ninth Malaysia Festival of the Mind will be held from June 15-16, 2013, at Universiti Tunku Abdul Rahman (UTAR) Perak Campus in Kampar, and June 22-23 at Tunku Abdul Rahman University College (TARC) Main Campus in Setapak, Kuala Lumpur.

It is open to the public from 9.30am - 4.30pm. Talks, workshops, exhibitions and competitions will be held to create awareness about the human mind and its unlimited potential; as well as ways of tapping into and developing one's brainpower to the fullest.

For further information, visit www.utar.edu.my/mmlm or email mmlm@utar.edu.my or call (03) 7625 0328 (Justin/Sin Yee) or (05) 468 8888 (Wei See/Jamaliah).

> Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

Boosting pertussis immunity

Posted: 01 Jun 2013 05:49 PM PDT

The immunity granted by the pertussis vaccine wanes over time, so it is important to get your booster shots.

PERTUSSIS, or better known as whooping cough, is a disease that causes severe, almost uncontrollable coughing.

Waning immunity in adults caused a resurgence of the disease in the US where up to 2,520 cases (37.5 cases per 100,000 residents) were reported in the first half of 2012.

This represented an increase of 1,300% compared with the same period in 2011, and it is officially recognised as the worst outbreak in the US in over a half century.

We in Malaysia have not been spared the same fate.

The only difference is that most cases of prolonged cough go undiagnosed here because many doctors do not think of pertussis any more.

Booster shots are vital

One of the main reasons for the pertussis outbreak in the US is due to waning immunity.

Most children in the US are immunised with a five-dose series of the Diptheria-Tetanus-acellular Pertussis (DTaP) vaccine starting at two months of age.

The protective effects of the DTaP vaccine will typically last between four and 12 years (average of six years). This means that in the worst case scenario, children aged five years old are already at risk of pertussis if their immunity wears off.

Findings from three different studies in the US on pertussis outbreaks (e.g. pertussis epidemic, 2010, The Journal of Pediatrics 2012) have all pointed to the same conclusion – regardless of the initial effectiveness of the vaccine, there are periods (ages 7-12 and 11-14) during which there appears to be a gap in the immunity provided.

This "gap" in protection can be covered by giving the Tdap (tetanus with lower doses of diphtheria and pertussis antigens) vaccine to teens and adults.

The current practice in Malaysia is to give dT (double antigen consisting of diphtheria and tetanus antigens) at school age.

A change to Tdap will help boost immunity against the pertussis bacteria, Bordetella pertussis, in addition to providing boosters for tetanus and diphtheria.

The dangers of complacency

You might not think that pertussis is a dangerous disease. However, it can cause severe coughing fits that may lead to cracked or broken ribs.

This type of complication has been known to occur in 5-6% of pertussis cases.

Another highly common complication that may result from pertussis is secondary bacterial pneumonia, where the lung(s) of the pertussis victim becomes infected.

It is this pneumonia which causes the majority of deaths that have been linked to pertussis.

It is always the young who are at risk, and young children or babies, especially those below two years of age, face the greatest threat of suffering from complications.

There are numerous other complications which have been linked to pertussis, namely:

·The effects of pressure due to severe coughing can also cause blood vessels (especially in the facial region) to burst, thus causing nosebleeds. This may also result in blood being coughed up, or bruises forming on one's skin.

·Another possible problem that may result from the increase in pressure during coughing bouts includes the formation of a hernia.

·Weight loss and dehydration due to excessive vomiting.

·Lack of oxygen to the brain, which may cause fits, or in some rare cases, brain damage.

What to do if you have it

Pertussis is a highly infectious disease, particularly in its early stages.

By the time you learn that you have it, you might very well have passed on the infection to people that you have been in close contact with and who are not immunised (or who have not previously had whooping cough).

This happens because symptoms usually only develop between seven and 14 days after you have been infected.

So what should you do?

Other than seeing a doctor, you should also stay away from others as much as possible for around 21 days, or until you have finished a five-day course of antibiotics.

It is important to note that even if antibiotics are started at a later stage, they are still important as their use can help stop the spread of infection to others.

Stay alert

If your child is infected with pertussis, make sure that you do not delay getting him medical attention. He may need to be treated in a hospital.

Young children or infants are more likely to need hospitalisation as they are at greater risk for complications such as pneumonia (about one in five children under one year of age are affected).

Pertussis can even be life-threatening to infants below six months of age.

While it is true that most pertussis victims can make a full recovery, the misery caused by the persistent bouts of coughing is a great torment.

The best way to protect against whooping cough is to make sure your child gets vaccinated with the DTaP combination vaccine in the National Immunisation Programme.

To prevent circulation of the bacteria, adults and older children should get the Tdap vaccine.

As the Tdap vaccine is not mandatory, there is a need for parents and caregivers of children to be constantly reminded of the importance of this booster shot.

These are crucial for protecting children during the immunity-gap period.

At the present moment, a Tdap vaccine for teenagers and adults who are in contact with babies too young to be vaccinated will help to control the cycle of transmission.

Besides children, it is important that parents and all adults or adolescents in close contact with children be vaccinated against pertussis. This helps prevent the spread of pertussis to others who have not yet been immunised against it.

Even if you have been fully vaccinated during your childhood and schooldays, you will still need a booster shot to strengthen your body's immunity against the disease.

The Tdap booster shot is recommended for anyone aged 11 to 64 years.

We need to be vigilant in Malaysia as there have been cases of pertussis detected among children and adults with prolonged paroxysmal cough.

Doctors should confirm the cause of severe prolonged paroxysmal cough in their patients.

> Datuk Dr Zulkifli ismail is a consultant paediatrician and paediatric cardiologist. This article is a courtesy of Positive Parenting Programme by the Malaysian Paediatric Association, supported by an educational grant from Sanofi Pasteur. The opinions expressed in the article are the views of the author. For further information, please visit mypositiveparenting.org.

Kredit: www.thestar.com.my

Ahad, 2 Jun 2013

The Star Online: Lifestyle: Health

The Star Online: Lifestyle: Health

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