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Break the habit How Hong Kong is winning the battle against smoking >PAGE 6


Exercise affects the brain’s response to food in different ways ...................................................... Gretchen Reynolds


Number of hard-core addicts rises ...................................................... Jeanette Wang The successful implementation of smoke-free legislation in Hong Kong has led to an overall decrease in the total number of smokers. But the remaining smokers who are finding it difficult to quit are going on to become “hard-core” smokers, according to a new study from Chinese University. The study was presented on Friday at the World Congress of Cardiology in Dubai, United Arab Emirates, organised by the World Heart Federation. It found the number of smokers in the territory who went on to become hard-core smokers grew from 23.8 per cent in 2005 to 29.4 per cent in 2008 for men and from 10.6 per cent (2005) to 16.3 per cent (2008) for women. “Hard core” is defined as daily smokers aged 26 years or older who have a smoking history of at least six years, smoke at least 11 cigarettes on average each day, have never tried to quit and don’t intend to.

Some people respond to exercise by eating more; others eat less. For many years, scientists thought that changes in hormones, spurred by exercise, dictated whether someone’s appetite would increase or drop after working out. But two recent studies suggest exercise may change your desire to eat by altering how parts of your brain respond to the sight of food. In one study by California Polytechnic State University, scientists brought 30 young, active men and women to a lab, where their heads were draped in functional MRI coils. The researchers wanted to track activity in portions of the brain known as the food-reward system, that have been shown to control whether we like and want food. In general, the more cells firing there, the more we want to eat. The volunteers vigorously rode computerised stationary bicycles or sat quietly for an hour before settling onto the MRI tables. Each swapped activities for the second session. Then they watched a series of photos flash onto computer screens. Some depicted low-fat fruits and vegetables or nourishing grains, while others showcased glistening cheeseburgers, ice cream sundaes and cookies.

“The increase in hard-core smokers is a worrying trend,” says Dr Doris Leung of Chinese University. “Smoke-free legislation has gone a long way in reducing the overall number of smokers in Hong Kong. We now need to look at how we can help those individuals with serious tobacco habits to stop.” Exercise might help. According to a study by Taiwan’s National Health Research Institute presented at the congress, active smokers (at least 30 minutes of moderate activity a day) were 55 per cent likelier to quit smoking than those who were inactive. These active smokers were 43 per cent less likely to relapse than smokers who were inactive. The study involved 434,190 people who went through a medical examination at a private, fee-paying company between 1996 and 2008. Physical activity was also shown to increase life expectancy. Smokers who participated in physical activity had an increased life expectancy of 3.7 years.


A weight-loss plan you can count on Katie McGregor


Exercise affected many different regions of the brain including those that affect the motivation to seek out food



We now need to look at how we can help those individuals with serious tobacco habits to stop

A few photos that weren’t of food were interspersed in the array. For the volunteers who had been sitting for an hour, the food-reward system lit up, especially when they viewed high-fat, sugary items. But if they had worked out for an hour first, those same people displayed much less interest and the food-reward system remained relatively quiet. “Responsiveness to food cues was significantly reduced after exercise,” says Todd Hagobian, a professor of kinesiology who oversaw the study, published last month in The Journal of Applied Physiology. “That reduction was spread across many regions of the brain, including those that affect liking and wanting food, and the motivation to seek out food.” However, a study published last year in The Journal of Obesity showed exercise having the opposite effect. Thirty-four heavy men and women began a five-days-a-week exercise regime, designed to burn about 500 calories per workout. They were allowed to eat at will. After 12 weeks, 20 of the group had lost considerable weight (about 5kg on average). But 14 had not, dropping only about a kilogram, if any. Those 14, dubbed nonresponders, also displayed the highest brain responses to food cues following exercise when the study began. After three months, they retained that undesirable lead and,

Calorie Tracker 9/10 US$2.99 As much as I think I know enough about food and calories to enjoy a free-wheeling diet, the truth is the kilograms have been increasing, and summer is approaching. The solution is to use a calorie-tracking app. A food diary is a traditional tool used by nutritionists to help people lose weight, and the Calorie Tracker app works on the same principle: when written down the calories are very real, if not they can be wafted away – to your hips. After registering an account with through the app, you set your desired weightloss goal and enter your current weight, height and age and rate your level of daily activity. The app will then give you a recommended daily calorie goal. My first goal is a terribly low 800 calories. Is this legal? As no one is watching, I drop 10 years off my age to see if that will give me more calories to burn; the answer is only a handful, shaming those who blame age for weight gain. But by changing my activity level from sedentary to lightly active I manage to get an extra 250 calories a day.

Now that is worth getting out of a chair for. To start tracking you tap the plate icon representing breakfast, lunch, snack or dinner, then select your food item from’s library, manually enter the calorie count if you already know it, or select from your recently eaten items. The app gives you a countdown as you go, telling you how many calories you have left to enjoy on that day. The fifth and sixth plate icons are to track your exercise and water consumption, and it is the exercise plate that really gets you moving. If you enjoy food as I do, it quickly becomes clear that exercise is your ticket to eating more – and still lose weight. An hour’s run gives me an extra 400 or so calories. Without the run I’m down to survival rations. Calorie tracking is not as miserable as it sounds when you have an app like this. Being well informed means that it’s easier to say no to a doughnut because you know it will sabotage a third of your daily calorie allowance. A better choice is to eat half a baked potato with salad and cheese. And one week on I can say it works: I have lost two kilograms of post-Easter bloat by eating sensibly and exercising more. I know the kilograms to come won’t fall so easily but this has been painless and I feel motivated to carry on.

in fact, showed more enthusiasm than at the start of the study. The responders’ brains, by contrast, showed a relative indifference to food pictures after exercise. Hagobian says exercise “has a definite impact on foodreward regions”. But that effect may depend on who you are and what exercise you do. Research could help most people use exercise for appetite control. But don’t take to the couch, even if exercise makes you ravenous. “Being fit can have psychological effects,” he says. It might increase your desire to eat better and shed more weight. The New York Times

ASK THE DOCTORS DR ANTHONY LUKE Q: Is exercise important for reducing breast cancer risk after menopause? A: Several studies demonstrate that exercise does protect against breast cancer. This effect may be even greater for women who are post-menopausal. For example, a case-control study from Germany published in 2008 showed that the effects of physical activity on lowering the risk of breast cancer were independent from adult weight gain, body mass index and energy intake. The researchers suggest that physical activity may reduce the risk of post-menopausal breast cancer at least in part via hormonal pathways and not solely by changing body composition. They encourage inactive post-menopausal women to become active. An earlier study in the United States showed a moderate effect for physical activity, with the greatest protection seen in women who were consistently active throughout their lifetime. A review published in the British Journal of Sports Medicine in 2008 said three-quarters of the studies showed increased activity cut the risk of breast cancer by 25 per cent to 30 per cent. Most studies show a relationship between the amount of exercise and the prevention of breast cancer. They also found greater risk decreases in specific subgroups, including post-menopausal women, and those who undertake recreational activity. Dr Anthony Luke is an associate professor of clinical orthopaedic surgery at the University of California, San Francisco. Reprinted with permission of the American College of Sports Medicine’s ACSM Fit Society Page





Jeanette Wang

Jeanette Wang

The good oil on health Researchers from Mexico, the world’s largest producer of avocados, have found that avocado oil can fight harmful free radicals tied to ageing and diseases such as cancer, hypertension and diabetes. The team from Universidad Michoacana de San Nicolas de Hidalgo found avocado oil allowed yeast cells to survive exposure to high concentrations of iron, which produces a huge amount of free

Hong Kong is not at risk from malaria, according to the latest World Malaria Risk Chart from the International Association for Medical Assistance to Travellers. In fact the disease, which is caused by the parasite Plasmodium transmitted through the bites of infected mosquitoes, has been under control in the city for more than 40 years. Statistics from the Centre of Health Protection show that cases peaked at 2,000 in 1946; in 2009 there were 23 cases. But Hongkongers shouldn’t be complacent, particularly with our globe-trotting habits. Since the 1970s, most malaria cases have been imported – meaning vigilance needs to be maintained to keep the disease at bay. Symptoms of malaria include intermittent fever, chills, sweating, headaches, tiredness, poor appetite and muscle pain. In typical cases, the fever presents itself, subsides for one to three days and then returns in a cyclical pattern. Complications include anaemia, liver and kidney failure, seizures, mental confusion, coma and death if the disease is not treated promptly. Earlier this month, The Lancet reported that the most deadly species of malaria parasite,

radicals, “even to higher levels to those found in some diseases”, says researcher Christian Cortes-Rojo. Environmental factors such as pollution can turn the oxygen molecules found in mitochondria, the power plants of cells, into free radicals. More studies are needed to confirm whether this could occur in humans too, says Cortes-Rojo.

Cadmium linked to breast cancer Prolonged exposure to a heavy metal commonly found in cosmetics, food, water and air particles has been shown to cause breast cancer to advance more aggressively. Cadmium exposure – even at a low level – can act as an endocrine disruptor and mimic oestrogen, causing abnormal growth of mammary gland cells that result in breast cancer, according to a new study by Dominican University of California researchers. The heavy metal is produced mainly as a by-product of mining, smelting and refining sulphidic ores of zinc, lead and copper. Rocks mined to produce phosphate fertilisers also contain varying amounts of cadmium. It enters the body through consuming contaminated food and water or inhaling cigarette smoke. The study was presented at the annual meeting of the American Society for Biochemistry and Molecular Biology in San Diego, California.

Make a family meal of it A family that eats together is likely to have healthier children, according to a new study by Rutgers University in New Jersey. Among the many benefits to children of frequent family meals is the increased intake of fruits, vegetables, fibre, calcium-rich foods, and vitamins. Children also eat fewer things thought to be harmful to health when a family eats together. These findings were revealed after researchers evaluated the results from 68 previously published scientific reports that looked at the link between family mealtime and children’s health. Although only a weak link between family meals and obesity risk was found, children in families with frequent family meals tended to have lower body mass index than those who had fewer.

> CONTACT US Deputy Culture Editor: Choong Tet Sieu Health Post Editor: Jeanette Wang General inquiries: Advertising: tel: 2565 2435; e-mail Printed and published by South China Morning Post Publishers Ltd, Morning Post Centre, 22 Dai Fat Street, Tai Po Industrial Estate, Tai Po, Hong Kong. Tel: 2680 8888

Plasmodium falciparum, is becoming resistant to the frontline treatment for malaria (a drug called artemisinin) on the border of Thailand and Myanmar. This has increased concern that resistance could now spread to India and Africa, as resistance to other anti-malarial drugs has done before. Eliminating malaria might then prove impossible. According to the World Malaria Report 2011, there were 266 million probable malaria cases and an estimated 153,000 deaths – mostly children and pregnant women – in 2010. Precautions, including personal anti-mosquito protective measures and drugs, need to be taken when travelling to endemic areas. Go to to plan a healthy trip, and test your knowledge of malaria here. 1. According to the World Health Organisation, how many countries and territories worldwide are considered at risk for malarial infection? a. more than 50 b. more than 80 c. more than 100

2. Once malaria parasites enter a person’s bloodstream, where do they travel to? a. liver b. kidneys c. heart 3. What is the incubation period for malarial infection? a. one week b. 10-14 days c. one month 4. The word malaria comes from two medieval Italian words meaning? a. bad air b. dirty water c. breathing problems Answers: 1. c (106 countries and territories in 2010); 2. a (they grow and multiply in the liver, then enter red blood cells); 3. b; 4. a (“mala aria”).

4 WELL-BEING THE TASTE TEST RAW GRANOLA ...................................................... Jeanette Wang When making raw granola, wholefood ingredients are sprouted and dehydrated at low temperatures, so nutrients stay intact.

Kaia Foods Buckwheat Granola Cocoa Bliss HK$118 for 340g, Just Green A friend who saw me eating raw granola asked if it tasted like cardboard. These bite-sized clusters, on the contrary, taste fantastic and have a great chocolate flavour that would satiate any sweet cravings. Verdict: nutty and slightly crunchy. I started feeling sinful, eating too much. Best washed down with a cup of coffee, milk or juice. Rob Lilwall has put his feet through a remarkable pounding, so attending to blisters is all part of his daily routine. Photo: Rob Lilwall


Tortured soles ...................................................... Rob Lilwall My cameraman, Leon McCarron, and I have now spent more than five months walking south from Mongolia towards H ong Kong. Before setting off, I wrote in this column about how I had prepared physically for the journey (through training hikes, and learning the best stretching exercises). All this preparation certainly helped. But now, more than 3,000 kilometres later, how have our bodies coped with the day-in, day-out pounding which we have been giving them? First, it should be explained what kind of strain our bodies are under. On average, we walk for 12 hours a day (covering about 35 to 40 kilometres) for five days, and then take one day off. Our packs weigh around 25kg (primarily from our camping gear, camera gear, clothes and food). Combined with my body weight, this means my feet are taking a 100kg pounding with each step, and as our total distance will eventually be 5,000 kilometres (or five million metres), this means that each foot gets five million 100kg poundings against the road. So it is testimony to the resilience of the human body (and perhaps the Ecco boots I am using) that our feet are still intact. But at the same time, they have had more problems than the rest of our bodies. About a month into the expedition, just as we reached the

end of the Gobi Desert, I developed a very sore second metatarsal. (The metatarsals are the bones in the feet.) I could barely put any weight on the centre of my foot for several weeks, and had to walk with a limp, taking as much pressure as I could on my hiking poles. After some extra days off, and inverting my ankle support so it covered my foot, I found the injury was stabilised, and I could start to walk at full speed again, and both Leon and I continued uninjured for a while. The next injury, two months into the expedition (while we were walking down the frozen Yellow River valley), was Leon’s back. This started to give him great pain, which we thought was due to his rucksack becoming unbalanced. We fell behind schedule after setting definite deadlines for our return home: my long-suffering wife is waiting for me, we have a television production schedule, and Leon needs to be back in Northern Ireland to be an Olympic torchbearer. This meant that we could not afford more time off for resting, so Leon soldiered on with the help of ibuprofen and stretching, and, thankfully, his back, like my foot, gradually stabilised. At about the same time, I started to get my first proper blisters of the expedition, and each evening before bed, I had to use my pen knife and cut open the various bubbles which were forming on my feet, and then douse everything in iodine to

My feet are taking a 100kg pounding with each step … each foot gets five million 100kg poundings against the road ROB LILWALL

prevent infection (which, you can imagine, led to a particularly intense kind of pain). My blisters recovered but in the fourth month, Leon began to get terrible blisters, some of which started to cover his whole foot, and he had to take antibiotics to stem the infections. I cannot say why it is that our feet managed for more than two months before the blisters started, as I’d have thought they would toughen up, but it seems that sometimes these things just suddenly happen, and once you have one blister, it slightly alters the way you walk, and this in turn provokes more. And now in our fifth month, Leon has suddenly developed an extremely itchy sweat rash on his back. It is getting hot now, so we need to start jumping into more streams to wash our bodies and clothes. Meanwhile, my feet often feel bruised and battered in the last

hours of the walk each day, although it is amazing how these annoyances seem to clear up by the following morning. Beneath all these niggling injuries, there is an incredible, deepseated, exhaustion seeping through us. It is not only physical exhaustion, but also mental – from having to maintain our concentration as we walk – whether to avoid twisting our ankles on tiny, mountain or forest paths, or avoid being hit by a truck on busy roads. Our days off are mostly filled with administrative and research tasks, with little time for our minds to rest. But despite the aches and pains, I think we’ve done pretty well, considering how much we’ve put our bodies through. The incredible, constantly changing landscape we pass through and the amazing, fun people we encounter are enough to make me stop wishing for the walk to end, and instead appreciate every one of those five million steps to get home to Hong Kong. There will be plenty of time for my body to rest after that. Rob Lilwall’s previous expedition, Cycling Home From Siberia, became the subject of an acclaimed motivational talk, a book, and a National Geographic TV series. Every week in Health Post, he will write about the progress of his new expedition, Walking Home From Mongolia, which is in support of the children’s charity Viva.

Two Moms in the Raw Blueberry Granola HK$128 for 227g, Just Green Shari, a mother of three with multiple sclerosis, started making her own products, including this gluten-free organic granola with no added oils or refined sugars. Verdict: moist, chewy, nutty and satisfying. Packaged as four big granola bars, it needs to be broken up to be eaten with milk.

Go Raw Organic Apple Cinnamon Granola HK$128 for 454g, Just Green Organic, gluten-free, nut-free and handmade, this is unlike the typical chunky granola. Buckwheat groats, seeds and dates are compacted together and broken up into tiny flat fragments for nibbling on or eating with a spoon. Verdict: the strong coconut and cinnamon flavour might be a turn-off, as well as its dry texture.


....................................... Eileen Aung-Thwin Lana Wong loved make-up. She took special delight in carefully creating her favourite eye make-up with eye shadow, heavy eyeliner and lashings of mascara. Enamoured with the fluttery, luscious lashes sported by female celebrities and models in glossy magazines, Wong (name changed for patient confidentiality reasons) even had fake individual lashes painstakingly glued to her real lashes to give her a permanently doe-eyed look. But while Wong’s efforts made her peepers look glamorous, she had trouble looking out of them. Her eyes were perpetually dry and uncomfortable, and were often irritated and red. Over two years, she consulted several ophthalmologists for help. The eye doctors found that her tear secretion was low and diagnosed her with dry eyes. Using special fluorescein eye drops to temporarily stain the surface of her corneas, the doctors also found that there were dry spots on the surface of her corneas. Wong was prescribed tear supplements or eye drops, and advised to take polyunsaturated fatty acids in the form of flax seed and fish oils to improve the quality of her tears. To help her eyes retain the lubricating tears longer, doctors even plugged two of the four holes (puncta) in her eyes that naturally drain away the tears. Despite these treatments, Wong continued to suffer eye dryness and irritation. Desperate for relief, she hopped from one ophthalmologist to the next. She finally found herself in the office of Dr Hui Siu-ping, a specialist in ophthalmology at Hong Kong Sanatorium and Hospital. Taking a closer look at Wong’s eyes, Hui discovered a low-grade infection of the lid margin called blepharitis. Wong’s meibomian glands – tiny pores that secrete meibum, an oily

fluid that coats and lubricates the eye – on the edge of her eyelids were coated with skin and cosmetic debris. Meibum keeps tears from evaporating too quickly, and in Wong’s case, the occlusion of the meibomian glands reduced the production of the oily substance. Taken together with her low tear production, the combination proved a double whammy for Wong’s dry eye problem. Hui tried to remove the debris, but the delicate task was hampered by the stiff artificial lashes that were firmly glued to her natural ones. “Imagine trying to clean between the teeth of a comb,” says Hui. “It became very, very difficult to clean the rim of her eyelids.” Hui advised Wong to remove the artificial lashes, but she was reluctant. Each set of artificial lashes had to be applied by a beautician and could last several weeks before they dropped off. Wong could not remove them on her own, and she would have to return to the beautician to get it done. Unable to persuade Wong, Hui sent her home with antibiotic eye drops, anti-inflammatory medication, preservative-free tear supplements and instructions on how to properly clean her eyelids. Hui explains that while preservatives in tear supplements might not hurt the casual user, they could further destabilise the tear film on the eyes for a heavy user such as Wong. This would only worsen the dry eye condition. Hui also advised Wong to stop or reduce the amount of cosmetics that she uses on or near her eye. The natural oils of her skin will dislodge the products, which will then migrate into her eyes. This, in turn, introduces more chemicals and contaminants into the sensitive organ. Adding more products and debris to her eyelids could also worsen the occlusion of the meibomian glands and make the infection worse. Still, Wong’s decades-long love affair with eye make-up could not be undone in one doctor’s visit. She

Illus trati on: A ngel a Ho

Keep your eyes peeled

tried reducing some of the eye products she used while faithfully following Hui’s regimen of cleansing and medication. After another visit or two to Hui, Wong noticed that her eyes were becoming less dry and irritated. She was finally convinced that Hui was right about the connection between her heavy use of cosmetics and her eye problems so she had her artificial lashes removed and found that her condition improved even further. But it took one final blow to convince Wong to stop using heavy eye make-up. Dolling up for a banquet, she again caked on eye make-up and, several days later, was

It was difficult to clean the rims of her eyelids, like cleaning between the teeth of a comb DOCTOR HUI SIU-PING, OPHTHALMOLOGIST

in Hui’s office with a badly infected tear duct, from which Hui had to extract pus. This time, Wong had to completely stop using cosmetic products near her eyes for a month while the infection was treated with antibiotics. Hui advised her to throw away all the products that she had applied on her eyes to avoid reintroducing the bacteria into her healthy eyes. After that harrowing experience, Wong now cherishes her health over beauty. She wears minimal eye make-up and continues to enjoy irritation-free vision.


Read the fine print: leafy green a nutritional powerhouse ...................................................... Jeanette Wang Eating spinach may not give you the same super-human strength as Popeye’s, but consuming the leafy green could do wonders for your health – particularly your eyes. Fresh spinach is a nutritional powerhouse, packed with vitamins C and E, folate (a B vitamin), and carotenoids (plant pigments) such as lutein and zeaxanthin.

Lutein – which is also found in sweet corn, kale and broccoli – and zeaxanthin together form an oily, yellow substance in the macula, a small area of the retina responsible for seeing detail and colour in our central field of vision. University of Manchester researchers have found strong evidence to suggest this yellow oil, called macular pigment, provides some protection against age-related macular degeneration. In this recipe by Kwong Fat Restaurant in Tsuen Wan, the

longan and ginger can help remove the astringency of spinach, says Ivy Ng, president of the Hong Kong Nutrition Association. “Even without the use of oil,” she says, “the dish is light but not plain.” Spinach with Chinese wolfberries and dried longans Serves 4 450g spinach, trimmed 2 tbsp Chinese wolfberries 8 dried longans

Some ginger, sliced A few fresh shiitake mushrooms, sliced 360ml chicken broth 1/3 tsp salt • Rinse spinach and slice into sections. Blanch and set aside. • Blanch Chinese wolfberries, longans, ginger and mushrooms. • Pour chicken broth into a wok. • Add Chinese wolfberries, longans, ginger and mushrooms. Bring to boil. • Add spinach.

• Season with salt and boil for 30 seconds. Serve. Recipe provided by the Health Department as part of its campaign. For more information, go to


Talking Heartened by recent successes, the government is stepping up efforts to encourage smokers to kick the habit, writes Elaine Yau


n a three-day camp last month in Sai Kung, businessman Chan Chi-kin was in no mood to enjoy the greenery and pristine beaches around him. The 44-year-old, who smoked three packs a day since he was 17, had to summon all his willpower to fend off the urge to light up. Chan, who had tried to quit on his own but failed, says the camaraderie among the quitters in the camp – organised by Tung Wah Group of Hospitals’ (TWGH) Integrated Centre on Smoking Cessation – boosted his confidence in overcoming his addiction. “My failed attempt crushed my confidence. I am afraid that I will fail again,” he says. “But the people in the camp supported and motivated me. With others also struck by cravings but unable to light up, I feel I am not alone.” The first quitting camp in Hong Kong, with seven heavy smokers, was one of several initiatives launched by the government and anti-smoking groups. Even though Hong Kong has the lowest smoking rate in the world, at 11.1 per cent, smoking still accounts for 6,000 deaths per year in the city. The annual

Chan Chi-kin, who kicked smoking recently, consults Dr Wong Chi-hong (above) and tests his breath with a Smokerlyzer (right). Photos: Dickson Lee

economic loss due to damage caused by tobacco is HK$5.3 billion. As a sign of the government’s seriousness in cracking down on tobacco addiction, investment in smoking cessation has risen from HK$3 million in 2008-09 to HK$80 million in 2012-13. The first government-sponsored cessation centre was set up by the Council on Smoking and Health in 2000 at the outpatient department of Ruttonjee Hospital. There are now 40 cessation centres under the Health Department and the Hospital Authority. The government further commissioned TWGH to provide free cessation services in 2009 – it now runs six centres. Last year, a quit-line aimed at youths was set up by the University of Hong Kong’s School of Nursing. Health Department senior medical and health officer Edmond Ma says Hong Kong must enhance cessation services if it is to further drive down the smoking rate. “Given the boost in resources, different forms of cessation are available, including counselling and nicotine replacement therapy,” he says. Ma spelled out the achievements attained by Hong Kong last month at the 15th World Conference on Tobacco or Health in Singapore, where 2,600 delegates from 124 countries shared their anti-smoking strategies. “We need to train more medical personnel in smoking cessation. Helping people to quit requires lots of skills and knowledge,” he says. The department has trained more than 100 health care workers in the field over the past two years. Novel approaches to kicking the habit are also being used. Raymond Ho Lei-ming, head of the Tobacco Control Office, says free acupuncture has been available at Pok Oi Hospital since 2010. Sessions can help relieve withdrawal symptoms such as fatigue, lack of concentration and dryness of the mouth. “It has helped around 2,400 people so far,” says Ho.

Tobacco kills one person every six seconds – or about six million people, including 600,000 nonsmokers through second-hand smoke – globally every year. The burden of tobacco-related illness and death is greatest in low- and middle-income countries. As a result of cessation efforts, the developed world accounted for 24 per cent of worldwide tobacco consumption in 2009, a drop from 38 per cent in 1990. Hong Kong got serious in combating tobacco after China ratified the World Health Organisation (WHO) Framework Convention on Tobacco Control in 2005. Financial Secretary John Tsang Chun-wah increased the tobacco tax by 50 per cent in 2009. A further 41.5 per cent rise was implemented last year. A pack of cigarettes now costs HK$50, HK$30 of which is tax. An indoor smoking ban in 2009 finally included bars and restaurants previously exempt. But Judith Mackay, senior adviser to the World Lung Foundation, says Hong Kong should increase the tax further and extend smoke-free areas to the outdoors. “Taxation and cessation are twins,” she says. Lisa Lau Man-man, chairman of the Council on Smoking and Health, agrees: “Tax should be raised to a minimum of 75 per cent of the retail price [the level recommended by the WHO].” Mackay says Hong Kong’s pictorial warnings on packaging are five years old and need to be updated. Quit-line numbers should be placed on the packs, she says. The latest government figures on smokers’ awareness of cessation services show more than 30 per cent of the 700,000 smokers in the city do not know about them. Lau says restricting the display of cigarettes at points of sale should be considered, since showing them is itself a form of promotion. Singapore is considering such a display ban, which would require shops to keep tobacco products out

6,000 Deaths caused by smoking each year in Hong Kong, where one in nine people aged 15 years or over smoke

of the sight of customers. In countries where such a ban is enforced, such as Canada and Britain, cigarette packs are kept under the counter and produced only on request. Besides anti-smoking policies, hard-hitting media campaigns portray the tobacco industry as evil money grubbers, hell-bent on killing people while raking in huge profits. During a session at the Singapore


chop conference, Norwegian Minister of Health and Care Services AnneGrete Strom-Erichsen showed an advertisement run on a regional television channel in Norway that is aimed at arousing people’s revulsion against the industry. A fat, insolent man tells the camera that they only target the black, stupid and poor. While he spouts his mantra “we don’t smoke it, we just sell it”, a pretty young girl

is shown buying cigarettes, and her money ends up lining his pockets. Strom-Erichsen says people should hold the industry in contempt. “Philip Morris took our government to court in 2010, claiming our display ban for tobacco products is in breach of European free trade rules … we will fight the intimidation to fulfil our legal duty to protect public health,” she says. Michael Eriksen, director of the

Institute of Public Health at Georgia State University in the US, says the industry makes US$35 billion in annual profits. “It’s nearly US$6,000 in profit for every death caused by tobacco,” he says. Besides media campaigns, Singapore has taken a step further by mobilising its people to become anti-smoking activists. Ang Hak Seng, chief executive of the city state’s Health Promotion Board, says government policies must be supplemented by aggressive bottom-up strategies. Former smokers have been mobilised to become activists in the board’s outreach activities. “They help us engage smokers by sharing their personal quitting journey and follow up with the smokers after events,” Ang says. An initiative called Blue Ribbon was launched recently, in which 10 markets and food centres received a Blue Ribbon award for promoting smoke-free messages to customers. Residential estates, says Ang, will adopt a voluntary smoking ban in public areas such as common corridors. Grass-roots volunteers, trained by the board as cessation counsellors, will go door to door, handing out blue ribbons and quit kits. “We provide them with specialised training on how to talk to smokers so that they don’t come across as confrontational and aggressive,” says Alice Ong, a manager with the board’s substance abuse department. “We teach them how to deal with defensive smokers, to ensure that neighbourhood harmony won’t be affected.” Singapore, whose smoking rate has fallen from 18.3 per cent in 1992 to 14.3 per cent, is leading the Asian charge in combating smoking. Its tobacco tax is 60.7 per cent; it was the first country in the world to ban duty-free cigarettes in 1991; and it has a total of 150 cessation outlets across the island. Ang aims to mobilise everyone in Singapore to create a social movement to counter smoking.

It’s important not to negate the feelings of smokers. We acknowledge that smoking brings pleasure to them. Our role is to help them find alternatives PATRICK FOK, SENIOR COUNSELLOR WITH TUNG WAH GROUP OF HOSPITALS

“International studies show that most smokers have a relapse within eight days of an attempt to quit, and only 5 per cent manage to stay smoke-free beyond 12 months,” he says. “This is why it is so important for smokers trying to quit to have a community-based supportive network made up of family, friends, ex-smokers and even Facebook acquaintances to encourage them not to give up.” A 2011 study by TWGH of 301 smokers showed that 42 per cent remained smoke-free for six months, and the figure dropped to 36 per cent after a year. Smokers were given nicotine replacement therapies (gum, patch, and inhaler), drugs such as bupropion and varenicline, and counselling to help them quit. Patrick Fok Wai-yin, senior counsellor with TWGH, says support from family and friends can make a huge difference. “It’s important not to negate the feelings of smokers,” he says. “We acknowledge that smoking brings pleasure to them. Our role is to help them find alternatives.” Dr Wong Chi-hong, a medical officer with TWGH, says many smokers have misconceptions about nicotine replacement medicines, thinking the drugs will make them resistant to cigarettes. The medicines, in fact, help relieve withdrawal symptoms such as insomnia, irritability and depressed mood. “Their psychological urges to light up may not go away completely,” Wong says. “They still have to make the effort to suppress them.” Chan Chi-kin, who takes bupropion, says he still feels the urge to light up under stress, as smoking relaxes him and helps sharpen his mind. He fends off the urge by thinking of his two girls studying at university abroad. “I must be healthy so my daughters’ studies will not be affected,” he says.


...................................................... Elaine Yau If you’re planning a visit to Kampong Glam, a shisha hot spot in Singapore’s central region, don’t be surprised if you receive an antismoking multimedia message on your phone. From last month, people who come within a kilometre of the area, which has about 40 shisha cafes, will receive an 18-second video on their mobile phone, where a hip-looking man spells out the risk of shisha smoking. Singapore’s Health Promotion Board (HPB), which launched the programme with the city state’s biggest mobile phone service provider, SingTel, is among a number of anti-tobacco groups to parlay the rise in phone connectivity and social media use into hardhitting anti-smoking campaigns. Such groups say they must counter the influence of tobacco companies, who are aggressively promoting their brands online due to the advertising restrictions and bans in developed countries. Douglas Bettcher, director of Tobacco Free Initiative of the World Health Organisation, says the bans have made the tobacco industry “more desperate”. Digital marking provides an ideal platform, as it’s tough to police, reaches out to a wide audience, and costs little or nothing to use. Facebook, for example, has 845 million users globally – and tobacco companies are quick to take advantage of this and other social media outlets. British American Tobacco has 1,400 employees on Facebook, says Becky Freeman, research officer with the University of Sydney’s School of Public Health. These employees join groups and post comments and images of hip youngsters smoking in pubs. “You may think that people have freedom of speech and we shouldn’t stop people from saying online which brands of cigarettes they enjoy smoking. But it’s another matter when employees of the tobacco companies are doing the same online,” says Freeman. “Such promoting of tobacco products online violates advertising bans.


Apps and butts People take advantage of the fact that social media is just too huge for effective monitoring.” Says Bettcher: “The monitoring and countering of the industry’s use of new media must become an essential element of tobacco control.” Twitter, with 140 million users, is another hot spot for tobacco aficionados, says Freeman. “Wordof-mouth marketing can be powerful, especially if you have a flair for writing and can write with panache online. In spite of its 140 word limit, tweets and retweets can make posts on tobacco-related stuff go viral.” According to the new edition of Tobacco Atlas, which looks at key indicators of the tobacco industry such as cigarette consumption and production, 163 tobacco brandrelated videos were found on YouTube in 2010, with one prosmoking music video being viewed more than two million times. Health advocates are fighting fire with fire. New media is ideal for not only spreading messages about health warnings, but also boosting cessation work, says Sandra Mullin, senior vice-president in policy and

In spite of its 140 word limit, tweets and retweets can make posts on tobacco-related stuff go viral BECKY FREEMAN, UNIVERSITY OF SYDNEY

communications with the World Lung Foundation. In the developing world there are 67 mobile subscriptions for every 100 people. “SMS cessation programmes can be launched in places where subscribers get quit tips through text messages,” says Mullin. Michele Ybarra, developer of SMS Turkey for smokers in the country’s capital city, Ankara, says text messages could help strengthen the resolve to quit. “Messages start two weeks before quit day. If a user has a relapse and has a cigarette in the last 24 hours,

we send them different messages concerning relapse aimed at helping them recommit to quitting.” Singapore, too, has recently launched a smoking cessation app which has a hotline embedded to help users deal with urges. “The exciting part of the app is that you are in constant communication with the people you love who will give you reply and encouragement,” says HPB chief executive Ang Hak Seng. Last year, Hong Kong’s Tobacco Control Office launched an iPhone app for quitting and has had 12,000 downloads to date, says a spokesman from the office. An Android version will be available this year. The app helps smokers understand the hazards of tobacco, introduces quitting aids and offers tips to cope with withdrawal symptoms. It also keeps track of the quitting progress and issues regular reminders according to the user’s smoking habit. It’s the latest move in a slew of initiatives that highlight the office’s recognition of the importance of new media in communicating health issues to the public. In 2009, an Online Cessation Centre was launched to help smokers measure

nicotine dependence and track daily quitting progress. That same year, a Facebook page was started by the office’s partner in tobacco control, Tung Wah Group of Hospitals’ Integrated Centre on Smoking Cessation, to facilitate information exchange among quitters. Social media campaigns, however, can be hit and miss. Stephen Hamill, associate director in communications and advocacy with the World Lung Foundation, says they’ve learned to fine-tune their campaigns after misfires that failed to attain viral growth online. For the 2009 World No Tobacco Day, the theme was the support of graphic health warnings on cigarette packs; for example, a Facebook app was developed where users could make personalised health pack warnings and post them on their personal or friends’ walls. “We wanted to spread messages on the harm of tobacco in an in-your-face way,” says Hamill. Initially, the campaign was a success with more than 200 pictures created. But it flatlined after a week, with few new users and existing users falling off. Feedback showed that people felt uncomfortable about sharing gross pictures. “You can have a conversation about tobacco harm with your spouse, but no one wants to offend their smoking friends and bosses.” Greater success was met with a Facebook smoke-free campaign in 2010 to dovetail with the Egyptian government’s move to make Alexandria the first smoke-free city in Egypt. The campaign was launched during Ramadan, when the cost of airtime on television and radio is double or triple normal rates. With a budget of only US$5,000, an online local advertising agency was hired to start a Facebook page. A moderator posted a few times each day and responded to user posts. Nonsmokers were encouraged to speak up for Alexandria’s smoking ban in public places to put pressure on the “reluctant government to provide better enforcement”, says Hamill. More than 7,000 people joined the group. “We wanted to create a perception to the media and policy makers that the smoke-free law is popular with the public.”


Cut down to size ...................................................... Dr Ben Williams When dealing with an obese patient, it’s tempting to explain the mathematics: they need to eat less and exercise more. True though this is, it’s hardly helpful. I, too, want to tell these patients to put down their venti mochas and pick up their gym clothes, but I try to remember that this advice wasn’t helpful for me and is unlikely to be helpful for my obese patients. You see, for all of my remembered life, from the time I was six until two years ago, I was really, really fat. Now I’m not.

Illustration: Bay Leung

For all of my remembered life, from when I was six until two years ago, I was really, really fat

Looking back at family photos, something big happened to my family when I was approaching school age. We grew. Well, the kids grew vertically, but the whole family grew horizontally. I more than anyone else. In elementary school I was “Ben, Ben the big fat hen”. By the time I was in high school I was approaching 140kg. After high school I studied singing, where it was not unusual to be fat. Later, I worked as a political aide during the dying days of the British Columbia New Democratic Party (NDP) government. Appearances matter in politics and though overweight males were the norm, my obesity was over the top. In 2001, the NDP was reduced to two seats in the legislature, and my smoking had increased to two packs a day. After I quit smoking, my

weight increased further still. When I started taking night classes at a community college while working during the day, I never seemed to find time for a healthy lifestyle. Eventually, I was accepted into medical school, where it was anything but normal to be fat. Even before medical school I knew a lot about diet. I had had private sessions with dietitians, had tried Weight Watchers, and knew Atkins inside out. I was great at losing weight: I lost 13kg on a low-fat diet, and gained 18kg back. I lost 22kg on a low-carb diet, and gained 24kg back. Losing weight was the easy part, keeping it off was the challenge. Oh, and I exercised a lot too; I just ate more. Back to medical school. My classmates were all very supportive of my weight-loss efforts, and no one ever said a bad word about my weight, but it still came up every day: • Cardiology: obesity correlates with hypertension and dyslipidemia (high blood pressure and high cholesterol – I already had both).

• Endocrinology: increased adipose (fat) tissue leads to insulin resistance (my fasting glucose was 6.2). • Rheumatology: as our population enlarges, so too does the burden of osteoarthritis. • Respirology, nephrology, urology, gynaecology (less of a concern for me) … The extent of my obesity was well covered: I bought expensive clothes, knew which hospitals had XXX-large scrubs, and used humour to laugh at my largeness. But I was still fat, and it sucked. During clerkship, my surgery adviser tried to convince me that surgery held more promise than medicine: to cut is to cure. He told me that he could cure diabetes. I thought he was talking about islet cell transplants, but it turned out he was a bariatric (weight-loss) surgeon, one who deals with the causes, prevention and treatment of obesity. Two months later, I called him and asked if he would see me about weight-loss surgery. There was a bit of a wait, and there were some hoops to jump through, but my time came. On May 26, 2010, I graduated from medical school. On the 27th, I had a sleeve gastrectomy, a type of restrictive weight-loss surgery. After 20 months I’ve lost 50kg and hope to shed more. I feel

healthy, people tell me that I look good, and I can still beat my children in a race. Last year, I learned to run, something my joints once disapproved of strongly. This year, I’ve taken up skiing, a sport that seemed unwise at 145kg (but is just plain fun at 95kg. Like my colleagues, I tell my patients that they need to exercise more, eat less, and lose some pounds, but I know that many will fail and will continue to need my support and encouragement. Some see fat people as lazy: I was ambitious and hard working enough to hold a fairly senior position in government at age 22 and to later be accepted into medical school. Others are more charitable and think that fat patients are ignorant: I stayed fat despite learning all about obesity in medical school. I was fat because I ate too much, and my surgeon helped me do what I had been unable to do on my own. Some patients do need a reminder that their weight is increasing because they put in more than they take out; others need us to reach a little further into the antiobesity toolbox. Dr Ben Williams is a second-year family medicine resident at the University of British Columbia in Nanaimo, BC. This column was originally published online on April 10 in CMAJ (Canadian Medical Association Journal). Reprinted with permission

20120424 health post  
20120424 health post