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					   PREVENTION OF TOBACCO USE
               AS
        A MAJOR STRATEGY
              FOR
      PROMOTION OF HEALTH
             IN THE
        REPUBLIC OF PALAU

    Senator Caleb Otto, MBBS, MHA
Chairman, Committee on Health and Education
           7th Olbiil Era Kelulau
             Republic of Palau


International Conference on Health Promotion and
                Tobacco Control

                  Taipei, Taiwan
                March 28-31, 2005
Republic of Palau
 Population: 19,129

        Palauan and
        Mixed Palauan:
        13,364
        Other
        Micronesian:
        482
        Asian: 4882


        Caucasian: 360


        Other: 41
     Top Ten Reported Adult Chronic Illnesses
According to the Community Assessment, the following conditions were
reported as the top 10 most commonly occurring adult chronic illnesses in
Palau. These 10 conditions accounted for a total of 84.7% of chronic illnesses
reported.


                                        Overall % of             HTN
                         # of Persons       Chronic
Chronic Illness:             Affected       Illnesses             DM

#1 Hypertension                  532            24.1         Asthma
#2 Diabetics Mellitus            495            22.4
                                                                 CVD
#3 Asthma                        216              9.8
                                                                 Gout
# 4 Cardiovascular
     Disease                     153              6.9   Mental Illness
#5 Gout                          150              6.8        Arthritis
#6 Mental Illness                126              5.7
                                                              Cancer
#7 Arthritis                      73              3.3
#8 Cancer                         53              2.4   Renal Failure
                                                                             Number of Persons
#9 Renal Failure                  39              1.8           HepB             Affected
#10 Hepatitis B                   33              1.5
                                                                         0   200      400        600

                        From the Community Assessment Adult Data: Ages 15+
    Prevalence of Tobacco Use in
               Palau
   1995 Chilton/Ysaol Study:
    – 76% of those surveyed chewed betelnut.
    – 83% of those added tobacco to their chew.

1997 Substance Abuse       Needs Assessment Study:
    –18% of the sample smoked cigarettes.
    –2% used smokeless tobacco alone.
Prevalence of Tobacco Use in
        Palau (Cont.)
   2001 Youth Tobacco Survey:
    – 58% of middle school students and 71% of high
      school students are current users of ANY
      tobacco product.
          54% of middle school students and 68% of
           high school students currently chew betelnut
           with tobacco.
          18% of middle school students and 23% of
           high school students currently smoke
           cigarettes.
Prevalence of Tobacco Use in
        Palau (Cont.)
   2001 Youth Tobacco Survey (Cont.):
    –More than half (54%) of high school students
    who use tobacco with their betelnut began using
    tobacco by the age of 12.
                                Betel Nut Use
                   Do You Currently Chew Betel Nut (Ages 15 +)?

             Yes: 5264,
               47.9%




                                                                    No: 5726,
                                                                     52.1%




Do you currently chew             Total                    Yes                      No
betel nut?
                               Total      Percent      Total     Percent        Total    Percent

Total                         10,990        100.0      5,264        47.9        5,726       52.1

                        From the Community Assessment Adult Data: Ages 15+
        If you chew betel nut, do you chew daily?
                        If yes, do you chew betel nut daily?




                                                                               Yes: 4,959,
                                                                                 94.2%




                    No: 305,
                     5.8%

If yes, do you chew daily?
                                     Total                     Yes                      No
                             Total           Percent   Total         Percent    Total        Percent
Total                        5,264            100.0    4,959          94.2      305            5.8

                        From the Community Assessment Adult Data: Ages 15+
             Number of Betel Nuts Chewed per Day
                     On average, how many full betel nuts do you chew in a day?

                                                                              According to the data, 64.3% of
                                                                              respondents chew 10 or more full
                                                                              betel nuts a day. 42% chew 15 or
                         Frequency          Cumulative
                                                                              more. 26.2% chew 20 or more full
How many full                                                                 betel nuts per day.
     betel nuts do
     you chew in
     a day?           Total       %        Total       %
   Total              5,270       100.0            -       -      20 +

20 +                  1,373        26.1    1,373       26.1     15 - 19

15 to 19                840        15.9    2,213       42.0
                                                               10 to 14
10 to 14              1,175        22.3    3,388       64.3
                                                                 5 to 9
5 to 9                1,119        21.2    4,507       85.5
                                                                 1 to 4
1 to 4                  632        12.0    5,139       97.5
                                                                     0
None                    131          2.5   5,270       100                                              # Persons
                                                                          0            500       1000           1500

                              From the Community Assessment Adult Data: Ages 15+
        Do you use tobacco/cigarettes with your chew?

                                                         Yes
                                                        85.1%




                                     No
                                   14.9%


Use tobacco/cigarettes              Total                   Yes                   No
with your chew?
                                 Total      Percent     Total     Percent     Total    Percent
Total                            5,132        100.0     4,369        85.1      763        14.9



                         From the Community Assessment Adult Data: Ages 15+
If yes, how old were you when you first started to
          add tobacco with your chew?
                                                           42.3% of respondents were 14 years
                Frequency          Cumulative
                                                           old or younger when they started
                                                           adding tobacco with their betel nut.
Age at start
     tobacco   Total      %       Total       %

  Total         4,342     100.0           -       -   Less than 5
Less than 5       30        0.7      30         0.7        5 to 9
5 to 9           343        7.9     373         8.6      10 to 14
10 to 14        1,463      33.7    1,836       42.3      15 to 19
15 to 19        1,407      32.4    3,243       74.7
                                                         20 to 24
20 to 24         497       11.4    3,740       86.1
                                                         25 to 29
25 to 29         223        5.1    3,963       91.3
                                                         30 to 39                  # Persons
30 to 39         224        5.2    4,187       96.4
                                                         40 to 49
40 to 49         108        2.5    4,295       98.9
                                                      50 and over
50 and over       47        1.1    4,342      100.0
                                                                    0   500       1000         1500


                        From the Community Assessment Adult Data: Ages 15+
On average, how much tobacco do you use on a
         daily basis with your chew?
P29F-amount-tobacco      Frequency       Cumulative               43.8% (1832 persons) use 6 or more
                        Total        %   Total     %              cigarette sticks or 11 or more pinches
                                                                  of smokeless tobacco with their betel
                                                                  nut chew per day.
  Total                 4,355   100.0        -        -
Less than 1 stick        124      2.8     124     2.8
                                                               < 1 stick
1 cigarette stick        174      4.0     298     6.8
                                                                 1 stick
2 to 5 sticks           1,616    37.1    1,914   43.9      2 to 5 sticks
6 to 10 sticks          1,258    28.9    3,172   72.8     6 to 10 sticks

11 to 20 sticks          471     10.8    3,643   83.7          11 to 20

more than 20 sticks      103      2.4    3,746   86.0        < 20 sticks

                                                                1 pinch
1 pinch of smokeless      57      1.3    3,803   87.3
                                                            2-5 pinches
2-5 pinches              423      9.7    4,226   97.0
                                                          6_10 pinches
6-10 pinches              56      1.3    4,282   98.3
                                                          11-20 pinches
11-20 pinches             46      1.1    4,328   99.4
                                                          21-30 pinches
                                                                                                     # Persons
21-30 pinches             20      0.5    4,348   99.8          > 1 pack
more than 1 pack           7      0.2    4,355   100                       0   400   800   1200   1600     2000




                       From the Community Assessment Adult Data: Ages 15+
                     Do you chew tobacco/cigarettes
                     (either with Betel Nut or Alone)?
                  Yes, 4055,
                    36.9%




                                                                         No, 6935,
                                                                          63.1%




                                   Total                 Yes                         No

   Chew Tobacco                 Total      Percent   Total     Percent        Total       Percent
   Total                       10,990        100.0   4,055        36.9        6,935          63.1
NCD Steps Question

                       From the Community Assessment Adult Data: Ages 15+
    Do you currently smoke any tobacco, such as
            cigarettes, cigars, or pipes?
                                         No: 7,343,
                                           83.1%




                                        Yes: 1,492,
                                          16.9%


                                Total                     Yes                 No
Smoke Tobacco?               Total      Percent       Total     Percent   Total    Percent
Total                        8,835        100.0       1,492        16.9   7,343       83.1
NCD Steps Question

                     From the Community Assessment Adult Data: Ages 15+
  If yes (smoke), do you currently smoke tobacco
                   products daily?
                                                      Yes: 1,197,
                                                         85%




                                            No: 212, 15%




                                    Total                         Yes                     No
       Smoke Daily?         Total           Percent       Total         Percent   Total        Percent
           Total            1,409            100.0        1,197          85.0     212           15.0
NCD Steps Question

                      From the Community Assessment Adult Data: Ages 15+
      Top Perceived Community Problems
According to the data, Alcohol was the #1 perceived problem. Elder abuse was
ranked last. For example, 52% of respondents said that Alcohol was a problem,
regardless of it’s priority and ranking among the other issues, 43% said
marijuana was a problem, etc.

60%
      52%                                              #1 Alcohol
50%
            43%                                        #2 Marijuana
                  41%
40%                                                    #3 Tobacco

                                                       #4 Ice
30%
                                                       #5 Child Abuse
                        19%
20%                           14%                      #6 Violence against Women
                                    12%
                                          10% 9.6%     #7 Suicides
10%
                                                       #8 Elder Abuse
0% Alcohol
  #1



         From the Community Assessment Adult Data: Palauans Only - Ages 15+
     Tobacco Use by Teens & Children
      Is it a very important problem in your hamlet
             that needs immediate attention?
                                              P52F_              Frequency       Cumulative
   41.1% of respondents said YES in          TOBACCO_
                                              USE                Total     %     Total        %
    any order of priority
   10.9% said it was the #1 priority
                                                Total            7,938   100         -        -
   58.9% said it was no problem
                                              0 – did not list   4,676   58.9    4,676    58.9
                                              #1 priority         868    10.9    5,544    69.8
                                              #2 priority         945    11.9    6,489    81.7
                                              #3 priority         868    10.9    7,357    92.7
                                              #4 priority         328     4.1    7,685    96.8
                                              #5 priority          82     1.0    7,767    97.8
                                              #6 priority          60     0.8    7,827    98.6
                                              #7 priority          45     0.6    7,872    99.2
                                              #8 priority          66     0.8    7,938   100.0
                                              #9 priority            -       -   7,938   100.0

           From the Community Assessment Adult Data: Palauans Only - Ages 15+
           Betelnut
Nut of the areca palm (areca catechu)
 Commonly chewed with:
      • Pepper leaf
      • Lime (calcium hydroxide)
      • Tobacco
                      A Survey of Betelnut Chewing in Palau
                                Ysaol, Chilton, Callaghan, 1995

                                 Ingredients in Betelnut Chew

    Youth who chew betelnut are more likely to use tobacco. While an average of
          71% of those over 24 years old who use betelnut add tobacco,
                          87% of those under 25 years add tobacco.
The use of pepper leaf in a betelnut chew is more common among adults than children
                Nearly all those who chew betelnut add lime to their chew.

 100%




                                                                                             100%
                                                                                             100%
                       99%




                                          99%
                                 100%




                                                                   100%
                                                                   100%



                                                                                100%
              99%




                      86%




                                                       99%




                                                                                96%
                                                      96%
                                        94%
            87%




                               88%


   80%
                              84%




                                                                                                    76%
                                                72%



                                                             68%
                                                                                                          Pepper Leaf




                                                                                       65%
   60%




                                                                          58%
                                                                                                          Lime
                    51%
          48%




   40%                                                                                                    Tobacco
   20%

    0%
          5 to      15 to     25 to     35 to         45 to        55 to        65 to        >74
           14        24        34        44            54           64           74
                                        Age Group
    Challenges in Tobacco Control


   Lack of Local Data and Info on Tobacco
    Attributed Morbidity and Mortality.
     Top Ten Reported Adult Chronic Illnesses
According to the Community Assessment, the following conditions were
reported as the top 10 most commonly occurring adult chronic illnesses in
Palau. These 10 conditions accounted for a total of 84.7% of chronic illnesses
reported.


                                        Overall % of             HTN
                         # of Persons       Chronic
Chronic Illness:             Affected       Illnesses             DM

#1 Hypertension                  532            24.1         Asthma
#2 Diabetics Mellitus            495            22.4
                                                                 CVD
#3 Asthma                        216              9.8
                                                                 Gout
# 4 Cardiovascular
     Disease                     153              6.9   Mental Illness
#5 Gout                          150              6.8        Arthritis
#6 Mental Illness                126              5.7
                                                              Cancer
#7 Arthritis                      73              3.3
#8 Cancer                         53              2.4   Renal Failure
                                                                             Number of Persons
#9 Renal Failure                  39              1.8           HepB             Affected
#10 Hepatitis B                   33              1.5
                                                                         0   200      400        600

                        From the Community Assessment Adult Data: Ages 15+
•Challenges in Tobacco Control

   Public perception regarding chewing
    tobacco.
    – unhealthy to smoke, but okay to chew tobacco
    (WNTD posters contest: about 200 entries, only
      three addressed ills chewing tobacco, the rest
      only addressed ills from smoking tobacco)
    Challenges in Tobacco Control

   Influence, effect and impact on lives of
    children and young people
             Age at Beginning to Chew Betel Nut
    Question: How old were you when you first started chewing betel nut for the first
   time? 43.7% were reportedly 14 years old or younger when they started chewing.

P29B-age-         Frequency         Cumulative
    first-
    chew

               Total      %         Total   %        Less than 5
  Total         5,264         100       -        -        5 to 9
Less than 5       50      0.9%         50    0.9        10 to 14
5 to 9           529     10.0%        579   10.9        15 to 19
10 to 14        1,731    32.9%      2,310   43.8        20 to 24
15 to 19        1,499    28.5%      3,809   72.3        25 to 29
20 to 24         569     10.8%      4,378   83.1        30 to 39
25 to 29         282      5.4%      4,660   88.5        40 to 49
30 to 39         308      5.9%      4,968   94.4     50 and over                           # Persons

40 to 49         127      2.4%      5,095   96.8                   0   500   1000   1500         2000

50 and over       79      1.5%      5,174   98.3

Unknown           90      1.7%      5,264   100


                        From the Community Assessment Adult Data: Ages 15+
    How old were you when you first started smoking daily?

                     Frequency          Cumulative            According to respondents, 33% of daily
                                                              smokers started when they were age 19
  Age start
       smoke                                                  years or younger.
       daily?    Total       Percent    Total   Percent

    Total        1,492         100.0        -           -   Less than       0

  Less than 5          -           -        -           -      5 to 9       0

  5 to 9               -           -        -           -    10 to 14                         171

  10 to 14           171        11.5     171         11.5    15 to 19                                                   495

  15 to 19           495        33.2     666         44.6                                                 363
                                                             20 to 24
  20 to 24           363        24.3   1,029         69.0                                    150
                                                             25 to 29
  25 to 29           150        10.1   1,179         79.0                              100
                                                             30 to 39
  30 to 39           100         6.7   1,279         85.7    40 to 49           31

  40 to 49            31         2.1   1,310         87.8                   17
                                                              50 and
  50 and over         17         1.1   1,327         88.9                                     165           # Persons
                                                            unknown
  Unknown            165        11.1   1,492      100.0                 0        100         200    300   400     500

NCD Steps Question

                           From the Community Assessment Adult Data: Ages 15+
    Challenges in Tobacco Control

   Parents underestimating (denying?)
    children’s use (involvement)
    Does the Child Use Betel Nut Regularly?
 There are a reported 352 children who use betel nut on a regular basis.
 These are as reported by the parent or guardian, not self-reported by the
 child. As a result, this number may actually be higher than reported.

                                    No: 3,443,
                                     90.7%




                                           Yes: 352,
                                             9.3%

                            Total                        Yes                 No
Child use betel nut
regularly?               Total      Percent        Total       Percent   Total    Percent
Total                    3,795         100.0           352         9.3   3,443       90.7
        Regular Betel Nut Use By Age
Of the betel nut users, 84.9% were ages 10 – 14. 12.3% were ages 7-9 years
old. There were another 2.9%, or 10 children, reported as users who were 4-
6 years of age. There were no reported users under the age of 4 years.


                                             169
180                                        (48.1%)
                                                           1-3 Years
160                                129
                                                           4-6 Years
140
                                 (36.8%)                   7-9 Years
                                                           10-12 Years
120
                                                           13-14 Years
100
  80
                            43
  60                     (12.3%)

  40                  10
                    (2.9%)
  20           0
   0
        Does the Child Use Tobacco Regularly?
  There are a reported 286 children who use tobacco on a regular basis.
  These are as reported by the parent or guardian, not self-reported by the
  child. As a result, this number may actually be higher than reported.


                                  No: 3500,
                                   92.4%




                                               Yes: 286,
                                                 7.6%
Child use tobacco            Total                         Yes                 No
regularly?                Total      Percent        Total        Percent   Total    Percent
Total                    3,786         100.0         286             7.6   3,500       92.4
         Regular Tobacco Use By Age
Of the tobacco users, 89.2% were ages 10 – 14. 9.2% were ages 7-9 years
old. There were 1.8%, or 5 children, reported as users who were 1-6 years of
age.

160                                       152
                                                            1-3 Years
140                                     (53.4%)             4-6 Years
                                  102
                                (35.8%)
                                                            7-9 Years
120
                                                            10-12 Years
100                                                         13-14 Years
  80
  60                        26
  40                      (9.2%)
                       4
  20           1    (1.4%)
            (0.4%)
   0
    Challenges in Tobacco Control

   Tobacco use tied to cultural/traditional
    practices or values.
    – Tobacco use being tied to betelnut chewing
    Challenges in Tobacco Control

   Inability to see or unwillingness to admit
    relationship between tobacco use and
    poverty or poor quality of life
EXPENSE ON TOBACCO USE



    1 week     =   $21
    1 month    =   $90
    3 months   =   $270
    6 months   =   $540
    1 year     =   $1,095
    10 years   =   $10,950
                           Behavioral Health Questions
Events experienced in the past year by percentage
               of “yes” responses.
                                                      DEATH/Friend
35%                                                                          Death of a friend was
                                                      HOSPITALIZATION
30%
                                                                             the most experienced
                                                      ILLNESS                event with 32.5%
25%                                                   DEATH/Spouse/Child     reporting they have
20%                                                   POVERTY                experienced it.
15%                                                   WAR                    Divorce was the least
10%                                                   JOB LOSS               experience event with
                                                      OTHER STRESS           4.9% reporting “yes”
5%
                                                      JAIL                   persons.
0%
                                                      DIVORCE
                                      Total                      Yes                      No
                                  Total          %           Total           %       Total        %
DEATH/Friend                      8,695       100.0          2,826         32.5      5,869      67.5
HOSPITALIZATION                   8,697       100.0          1,524         17.5      7,173      82.5
ILLNESS                           8,686       100.0          1,465         16.9      7,221      83.1
DEATH/Spouse/Child                8,697       100.0          1,389         16.0      7,308      84.0
POVERTY                           8,696       100.0          1,115         12.8      7,581      87.2
WAR                               8,679       100.0          1,106         12.7      7,573      87.3
JOB LOSS                          8,700       100.0          1,029         11.8      7,671      88.2
OTHER STRESS                      8,663       100.0            909         10.5      7,754      89.5
JAIL                              8,695       100.0            515          5.9      8,180      94.1
DIVORCE                           8,687       100.0            425          4.9      8,262      95.1

                     From the Community Assessment Adult Data: Ages 15+
    Substance Abuse Needs Assessment, 1997
        Household Cost of Betelnut and Tobacco Chewing


   Estimated annual household
    expenditure on tobacco =
             $1,158
   Estimated annual household
expenditure on betelnut, pepper leaf,
            lime, etc. =
              $1,870
    Total estimated annual household expenditure on
              betelnut and tobacco chewing =
                         $3,028
In 1990, the mean income for households was approximately
                          $8,000
 Challenges in Tobacco Control

 Lack   of community will
Do you favor a Restriction on Advertising and
         Sponsorship for Tobacco?
                                N=6,871


 80%
                                      N=5,392
 70%
 60%
 50%
 40%                                                                     Yes
                                                                         No
 30%
 20%                N=1,479
 10%                                   78.5%
                      21.5%
  0%




    From the Community Assessment Adult Data: Palauans Only - Ages 15+
Do you favor Eliminating Smoking Indoors and
              in Public Places?
                                N=6,871


  70%
  60%               N=4,405

  50%
  40%                                                                    Yes
                                     N=2,466                             No
  30%
  20%
  10%                 64.1%            35.9%
  0%




    From the Community Assessment Adult Data: Palauans Only - Ages 15+
Do you favor No Tobacco Restrictions?
                               N=6,871


                                       N=6,558
100%

                                      95.4%
 80%

 60%
                                                                        Yes
 40%                                                                    No


 20%
                     N=313
 0%
                       4.6%




   From the Community Assessment Adult Data: Palauans Only - Ages 15+
Other Issues and Challenges
   Changing Community Standards
      •Maintaining a balance between traditionally
      valued practice regarding the use of betelnut and
      use of a ‘gateway’ habit for addiction and ill
      health. .
      •Gaining support from the community role
      models.
Tobacco Control Efforts
      in Palau
           1994
     Youth Access Law
Tobacco Control Efforts
     (continued)
            1995
    Coalition Established
History of Tobacco Control
          in Palau
             1998
     Only 2 active members
            Key Approaches
Approaches to keeping the coalition alive:
         Establishing “full time” efforts
             Key Approaches
Approaches to keeping the coalition alive (cont.):
                   •Perseverance
         Key Approaches
Approaches to addressing chewing betelnut
               with tobacco:
           Had to be resourceful
           Developed an educational campaign
        Key Approaches
Approach to addressing the lack of local
 data and info on tobacco with betelnut:




               • Initiative and persistence
       Key Approaches
Approach to dealing with a desensitized
             community:
    • Elements of the coalition’s educational
    campaign
Major challenge overall has been addressing
 the issues of tobacco use in both smoking
         and chewing with betelnut.
Our strengths have been coalition members
      that have persistence, initiative,
       resourcefulness, and passion.
    Recent Milestones in Efforts
 Participated actively and led Pacific Island
  Countries in the negotiations of the FCTC
 Signed the FCTC on the first day it was up
  for signing
 Became the 9th nation to ratify the FCTC on
  February12, 2004
            Future Efforts
 To pass legislation to implement the FCTC
 To monitor implementation efforts
                Our Vision
   To free our people from the willful attack
    on their humanity by those who only wish
    to use them to gain profits. We know they
    are targeting us because they said so…
  Here’s what an executive of
    Winston cigarette said in
response to the question whether
    or not they used tobacco.
 “We don’t smoke that s—t. We reserve
  that right for:
 The poor
 The blacks
 The young , and
 The stupid
Replace ‘black’ with the color of
           your skin
 And they are targeting you
 or Someone you love.
             Remember
 Every 8 seconds someone dies, who was:
 Poor
 of some skin color
 Young
 Stupid
Thank You Very Much

				
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