THE BURDEN OF SMOKING THE BURDEN OF SMOKING IN SOUTH AFRICAN GOLD IN SOUTH AFRICAN GOLD

MINE WORKERSMINE WORKERSPresented by Dr Vanessa Govender

Occupational Medical Practitioner

To Parliamentary Health Portfolio Committee

23 January 2007

Contents

• Introduction• South Africa• Health effects• Employer• Gold mines

– Occupational lung diseases- HIV/AIDS- Smoking policy

• Role of HCWs• Conclusion

Cigarette smoking is the most prevalent modifiable risk factor

for increased morbidity and mortality in the world

(WHO)

IntroductionIntroduction

WHO “global public health emergency”

WHO “global public health emergency”

• Progressive legislation

• Tobacco Products Control Act, Act 83 of 1993 (32.6%)

• Tobacco Products Control Amendment Act, Act 12 of 1999 (28.5%) (van Walbeek 2002)

SMOKING IN SOUTH AFRICASMOKING IN SOUTH AFRICA

Prevalence = 22%Prevalence = 22%

Tobacco Products Control Amendment Bill 2006

• Increased penalties for employers failing to protect employees from tobacco smoke

• New offences such as prohibiting health institutions from sale of tobacco

• To prevent young people from starting• Help smokers quit

SMOKING IN SOUTH AFRICASMOKING IN SOUTH AFRICA

NORMAL LUNG SMOKER’S LUNG

SMOKER’S BODY

Smokers:

• have more hospital admissions

• take longer to recover from illness

• have higher out patient health care costs

(Osinubi 2002))

BURDEN OF SMOKING ON EMPLOYERSBURDEN OF SMOKING ON EMPLOYERS

Absenteeism is 50% higher amongst smokers

(US dept of health,education, welfare 1979)

Absenteeism is 50% higher amongst smokers

(US dept of health,education, welfare 1979)

BURDEN OF SMOKING ON EMPLOYERSBURDEN OF SMOKING ON EMPLOYERS

Current smokers miss more days at work, more unproductive time at work than former smokers or non-smokers

(Bunn et al. 2006)

BURDEN OF SMOKING ON EMPLOYERSBURDEN OF SMOKING ON EMPLOYERS

18 LOST DAYS PER YEAR! ($1.7 billion pa)18 LOST DAYS PER YEAR! ($1.7 billion pa)

• Average 3 smoking breaks

• Borrow, buy, beg,light up,puff

• Lasting 13 minutes each

= 39 minutes lost productivity per day

(Wendland-Boyer 2000)

Smoking is higher among people

employed in labour intensive industries than among those in

professional and people orientated industries

(van Walbeek 2002)

SMOKING IN SOUTH AFRICAN MINESSMOKING IN SOUTH AFRICAN MINES

MHSC project:

•Overall decrease in smoking trends 1998 – 2002•White mine workers of all ages tend to smoke more heavily than black mine workers•4% whites, 5% blacks took up smoking after employment•Overall prevalence 44%

(Cheyip 2004)

SMOKING IN SOUTH AFRICAN MINESSMOKING IN SOUTH AFRICAN MINES

Unpublished prevalence = 60%Unpublished prevalence = 60%

OCCUPATIONAL LUNG DISEASES

• Silicosis, COAD, TB, lung cancer are compensable diseases

• Attributable to high levels of free crystalline silica dust (ODMWA 1973)

• Employer take measures to assess the risk and control it (MHSA 1996)• Medical surveillance examinations – on employment,

during employment and on termination

OCCUPATIONAL LUNG DISEASES

• Gold mines are committed to dust control• Global elimination of silicosis programme (WHO)• National elimination of silicosis programme• MHSC - milestones

• Dust control alone may be inadequate to control OLD

OCCUPATIONAL LUNG DISEASES

TBCOAD

SilicosisLung cancer

SILICA DUST

SMOKING

OCCUPATIONAL LUNG DISEASES

In SA: Smoking significantly increases the risk for deaths from tuberculosis, chronic

obstructive airways disease and lung cancer

(Sitas et al. 2004)

TBSILICA DUST

HIV

SMOKING

1. TUBERCULOSIS 1. TUBERCULOSIS

• Silica dust lifelong risk for development of TB, even in absence of silicosis

• Risk increases with increasing severity of radiological silicosis

• And with cumulative dust exposure• Persists long after exposure has stopped

(Hnizdo, Murray 1998)

Established silicosis, risk for TB increases up to three-fold (Churchyard 2001)

Established silicosis, risk for TB increases up to three-fold (Churchyard 2001)

1. TUBERCULOSIS 1. TUBERCULOSIS

•Incidence rate 41 new cases / 1 000 employees per annum

• TB accounts for large majority of occupational diseases

1.TUBERCULOSIS (TB)1.TUBERCULOSIS (TB)

In addition to silica dust, smoking, is an independent,

added risk factor for TB (Hnizdo, Murray 1998)

1. TUBERCULOSIS1. TUBERCULOSIS

Smoking increases risk of

•Acquiring TB•Severity of TB (Altet-Gomez et al. 2005)

•Progression from latent to active TB•Progression to disability •Progression to death (Doll, Hill 1954)

In SA: 20% of TB deaths due to smoking (Sitas et al. 1998)

In SA: 20% of TB deaths due to smoking (Sitas et al. 1998)

1. TUBERCULOSIS1. TUBERCULOSIS

WHERE THERE’S SMOKE

(and silica dust and HIV)

THERE’S TB(NCAS Press release World TB day

24/3/06)

Smoking is BAD for TB!Smoking is BAD for TB!

2. CHRONIC OBSTRUCTIVE AIRWAYS DISEASE

2. CHRONIC OBSTRUCTIVE AIRWAYS DISEASE

COADEmphysema

Chronic bronchitis

SILICA DUST

SMOKING

TB

2. COAD2. COAD

• Smoking is a greater risk factor for serious disability from COAD than silica dust alone

(Hnizdo 1992)

2. COAD2. COAD

Figure 1: Attributable fractions for severe airflow limitation (Hnizdo 1992)

Combination dust

and smoking, 40%

Smoking, 42%

Dust, 8%

Other, 10%

2. COAD2. COAD

Elimination of silica dustElimination of silica dust

48%48%

Elimination of smokingElimination of smoking

82%82%

Estimated preventable fraction (Hnizdo 1992)

Estimated preventable fraction (Hnizdo 1992)

• Suggestive association between silicosis and smoking

(Hessel 2003)

3. SILICOSIS3. SILICOSIS

• Silica dust, radon and diesel particulate matter can cause lung cancer

• Smoking increases this risk

(Hnizdo,Murray1998)

4. LUNG CANCER4. LUNG CANCER

Control of silica dust related diseases requires control of BOTH dust AND smoking

SMOKING AND HIV/AIDSSMOKING AND HIV/AIDS

• 70 – 80% of HIV infected people smoke (Patel et al. 2005)

• Smoking may be associated with increased risk for acquiring HIV infection (Furber 2006)

• Smoking was not associated with increased risk of progression to AIDS (probably due to HAART -more research required)

SMOKING AND HIV/AIDSSMOKING AND HIV/AIDS

Patients on HAART

•Tobacco smoking independent risk factor for non-AIDS related mortality (true for non-HAART as well)

•Protease inhibitors side-effect dyslipidaemia (high cholesterol)

•Risk for cardiovascular disease(Patel et al. 2005)

SMOKING AND HIV/AIDSSMOKING AND HIV/AIDS

Added health risks in HIV positive smoking patients

• HIV associated respiratory infections• Accelerated lung damage• HIV associated oropharyngeal lesions• AIDS-defining and non AIDS-defining

malignancies• Cardiovascular disease (on HAART)

(Patel et al. 2005)

SMOKING AND HIV/AIDSSMOKING AND HIV/AIDS

Tuberculosis is a leading cause worldwide of morbidity and

mortality among HIV-infected people

Do you know your ABCs?Do you know your ABCs?

D = don’t smoke! (NCAS press release, World Aids Day 2006)

A = abstain

B = be faithful

C = condomise

PUBLIC HEALTH BURDENPUBLIC HEALTH BURDEN

HIVTB

SILICA DUST

SMOKING

SMOKING IN SOUTH AFRICAN MINESSMOKING IN SOUTH AFRICAN MINES

SMOKING IS PROHIBITED UNDERGROUND

SMOKING IN SOUTH AFRICAN MINESSMOKING IN SOUTH AFRICAN MINES

“Smoking in the workplace policy” – strategic focus on employee well-being and health promotion

Objectives:• To provide a healthy working environment• To minimise harm due to secondary smoke• To educate smokers about the harmful effects of smoking• To provide advice, guidance and support to employees who wish to stop•Identify high risk groups

Critical success factors for workplace

policy

• Enabling environment- partnerships, stakeholder involvement, support NCAS, MHSC,WHO

• Evidence base

• Political will

• Tougher legislation

SMOKING INTERVENTION PROGRAMSMOKING INTERVENTION PROGRAM

National Council Against Smoking (NCAS)

• Professional and expert advice• Information pamphlets, self-help material• Posters health information• National quit line 011 – 720 3145

Mine Health and Safety Council

• Elimination of silicosis programme • Milestones• Holistic approach to occupational diseases• Identified research on smoking in the mines

Research Question

What are health care workers’ knowledge, attitudes and practices regarding prevention of smoking amongst gold mine workers

… are there opportunities for implementing smoking interventions???

ROLE OF HEALTH CARE WORKERSROLE OF HEALTH CARE WORKERS

WHO initiatives:

• 2005 - World No Tobacco Day “Health Professionals against Tobacco”

• 2004 - Code of Practice on Tobacco Control for Health Professional Organisations – smoking history, brief advice and documentation as part of routine care

ROLE OF HEALTH CARE WORKERSROLE OF HEALTH CARE WORKERS

• Russell 1979: simple but firm advice from a general practitioner (GP) can result in 5% of smokers stopping

• Raw, McNeil, West 1999: 50% of smokers will stop after GPs advice, using established protocols and medication, savings of $700,00 per life year gained

ROLE OF HEALTH CARE WORKERSROLE OF HEALTH CARE WORKERS

• HCWs have a moral, ethical and professional obligation to assist people to stop smoking and prevent people from starting

• Popularly revered in the workplace and community

• Occupational and primary health care services on-site, accessible, high utilisation rate

ROLE OF HEALTH CARE WORKERSROLE OF HEALTH CARE WORKERS

Conclusion

WHO Tobacco Free Initiative 1999:There are only two causes of death that are large and growing worldwide

TOBACCOHIV

Conclusion

PREVENTION…….. is better than CURE…….

Conclusion

“… the mining industry will do well to remember that mining is not just about rocks and rubble, but about people.”

Minister of Minerals and Energy,

Phumzile Mlambo-Ngcuka, Sheq Conference 2004

Conclusion

At Gold Fields, we pride ourselves in enhancing workers’ health, and

with the support of tougher legislation like the proposed

Tobacco Bill, we can achieve leaps of excellence in occupational

health and safety, not only at our operations but industry-wide in

South Africa

AcknowledgementsAcknowledgements

• Gold Fields International Mining South Africa Pty (Ltd)• School of Public Health, University of Witwatersrand,

Johannesburg, South Africa• National Institute for Occupational Health,National

Health Laboratory Services,Johannesburg, South Africa• National Council Against Smoking• Mine Health and Safety Council (MHSC) for funding this

project

National Quit Line 011 – 720 3145

THANK YOU

National Quit Line 011 – 720 3145

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