SPECIAL SECTION

CHAIRMAN’S REFLECTIONS Part 13

Looking back at the first few years of working as a cardiologist at home in Qatar, is like watching an old movie. The scenes are clear, the events exciting, the struggles intense, and the heroes real. Some characters are still around; some are no longer with us.

                                                                                                                                             Hajar A. Hajar Albinali, MD*

The Evil Weed

   On November 6, 2002 the new tobaccocontrol law in Qatar was implemented. It
took several years of struggle and debate to achieve this goal. I had the honor of proposing it in my capacity as minister of health. I was proud and grateful to His Highness, the Amir of the State of Qatar for signing it as law.
   The main features of the Qatari Law number (20) for the year 2002 on tobacco and its products are the following:
Tobacco advertisement is banned in all media forms.
The import or use of automatic cigarette machine is prohibited.
Smoking is forbidden in closed public places including means of transportation, schools, hospitals, clinics, government institutions, ministries, sport clubs, theatres, lifts, shopping centers, industrial buildings and restaurants.
Shops are prohibited from selling tobacco products within 500 meters of schools or educational institutions.
The sale of cigarettes to children under the age of 18 is prohibited.
2% of tobacco taxes will be added to the budget of the ministry of health for health education and for combating smoking.
A fine no less than QR 200 (US$54) and no more than QR 500 (US$137) will be imposed on any one who smokes in prohibited places or permitted smoking in them. A jail sentence up to six months and a fine up to QR 5000 ($1370) will be imposed on other violations of the above law. The punishment will be doubled on repetition of the crime.

Fig.1 Anti-Smoking Poster

   Over the last 24 years, I made several proposals to the government to combat smoking in Qatar, first as a cardiologist, then, since 1980, as Undersecretary of Health and recently as Minister of Health. Some proposals were accepted and some were rejected over those years. In Islam, the punishment for drunkenness is flogging with eighty sticks. Once, I jokingly proposed flogging a smoker with 80 sticks as therapeutic means. It would be nice to prove the idea with a scientific study but it will be difficult to get volunteers for such a study.
   In this article I will discuss mostly my personal involvement in the fight against tobacco in Qatar. If an author narrates historical events where he played a part, he will no doubt make himself a hero and the author of this article is not an exception.
   The recently implemented Qatar law on tobacco is not as harsh as the law made by Sultan Murad IV who ruled the Ottoman Empire between 1623 and 1640. On the 7th of August 1633, while the Ottoman capital was celebrating the birth of his son, a firework probably landed on a ship at anchor in the Golden Horn and set it afire. The flames spread to the dock and then to the city. Before the fire was brought under control, it had razed 20,000 wooden buildings. Murad issued a decree, announcing that the fire had been caused by smokers, and ordered that all places where smokers were known to gather should be demolished. This decree was soon followed by another in which smoking was prohibited and violation of the law was punishable by death. Even on the battlefield, he would make a point of seeking out smokers, and punishing them by beheading, hanging, cutting them in quarters, or crushing their extremities and leaving them helpless between the lines. By the time of his death, at the age of twenty nine, Murad had put to death well over 100,000 of his subjects. Those laws were repealed in 1648 by a smoker, Mohammed IV.
   My own interest in the harmful effects of smoking started before I became a physician. My father, who was an Islamic judge, was preaching against smoking in mosques since I was a little boy. In 1971, while a second year medical student at the University of Colorado in Denver, Colorado, my father was writing a book on smoking and Islam. He elevated my ego when he asked me to write a chapter on the ill effects of smoking in that year. I spent the two-week Christmas vacation of 1971 in the medical school library researching the health hazards of smoking. The librarian gathered a huge number of books and articles for me. The title I chose for the article was Smoking: a slow suicide. It was a very useful assignment for a medical student. I learned a lot about the harmful effects of smoking before I became a physician. My father put my name as the co-author of his book. In fact I became an ardent anti-smoking person. I hated the smell of tobacco.

Fig.2 Qatar Ministry of Public Health
Anti-Smoking Poster (1982). "Slow Suicide"

   I started talking to my classmates in medical school about the dangers of smoking. Many of my classmates and the medical staff smoked cigarettes. Smoking was not prohibited in hospitals then. The following year I had to go to Fitzsimmons Army Hospital in Denver for two months on a medical rotation. I will never forget the sight of a bearded senior resident performing sigmoidscopy while smoking a cigar. The patient was probably wondering if the cigar smoke went into his rectum! The smoke irritated my eye while I was trying to look through the sigmoidscope.
   After graduation from medical school, I continued my interest on the health hazard of smoking by reading articles on smoking in medical journals. I went to Kansas City first for internship in 1973 then to the University of Oregon Health Science Center in Portland, Oregon for residency. The sight of colleagues and staff smoking was unpleasant in retrospect. I had good friends whom I liked and admired; some were cardiologists who were nicotine addicts.
   In the seventies and early eighties of the last century, smoking by doctors in hospitals was tolerated by the community. It may surprise my younger cardiology colleagues to know that in 1974 when I attended the American College of Cardiology (ACC) meeting as a resident for the first time, smoking was prevalent in the lecture halls and conference rooms. Smoking during ACC meetings was banned later.
   In the summer of 1978, when I returned to Qatar after completion of my cardiology training, I noticed that cigarette smoking was endemic in Qatar. Smokers smoked everywhere - in shops, offices, living rooms, hospital wards, in cars, etc. Many physicians and surgeons smoked while talking to patients. I saw a doctor palpating the abdomen of a patient in Rumailah hospital ward with a cigarette dangling from his mouth. Many patients smoked in the hospital and in my cardiology clinic waiting area. In 1979, curious about the prevalence of smoking in our hospitalized patients, I conducted an “on the spot survey” with the help of some friends. We visited the male wards of Rumailah hospital, asking each patient if he was a smoker or not. 46% of adult male patients were smokers. We did not go to the pediatric or the female ward because smoking is extremely rare in females in Qatar.
   Smoking was considered a normal social behavior then. I was convinced that it was the major cause of coronary artery disease in our country. I was determined to start a public education campaign against smoking in Qatar.
   In 1979 a golden opportunity came up when Qatar TV came to interview me about heart disease in Qatar. I took the TV crew with me to the male medical ward to visit a very cooperative 60 year-old smoker with lung problems due to smoking i.e. chronic obstructive pulmonary disease (COPD). He was fed up with his shortness of breath. To ease his difficulty in breathing, he needed to take oxygen cylinder wherever he went. To make it more dramatic, I took him to our stress lab and asked him to walk on the treadmill while I was supporting him. He tried but gave up a few seconds while being filmed. He complained bitterly how cigarette had crippled him. He advised people not to smoke, to avoid ending up like him. His story had a strong impact on the public when it was aired. Many people were amused and concerned when he said that he could no longer have sex with his wife as a result of smoking. Fortunately, the old man made that statement in local Gulf dialect. The TV crew being non-Gulf citizens did not understand what he said. They did not edit or cut his statement because they did not realize that he was talking about sex.
   After that interview, the newspapers found the topic interesting. Several reporters interviewed me about smoking and health. They published articles I wrote on the subject. I was asked to give lectures on the subject in the hospital, the University of Qatar and some clubs. I appeared on TV shows together with religious sheikhs. One show was with Sheikh Abdulla Al-Ansari and another with Sheikh Yousef Al Qaradawi. I remember well the show with Sheikh Al Qaradawi on Qatar TV over 22 years ago. Al Qaradawi is well-known in the Moslem world as a Islamic scholar. The topic under discussion was drugs. I used the opportunity to discuss nicotine as a drug also. On that TV appearance with the two religious sheikhs, I made a statement that created controversy. Religious sheikhs frequently repeat an old story to enforce their concept that alcohol is the worst evil. The story goes like this:

   A bad king gave a wise man a choice between death or one out of three sins. He brought before the wise man a bottle of wine, a slave and a girl. The man must either drink the wine or rape the girl or kill the slave. After careful thinking, the wise man thought the wine was the least of the three evils. He drank the wine, became drunk and lost his mind. He then killed the slave and raped the girl under the influence of alcohol.

   The moral of the story is that alcohol as a sin leads to other sins. I was inspired by that story to tell the audience that in my opinion if a person is forced, nowadays, to choose between two evils – drinking a glass of wine a day or smoking a pack of cigarettes a day – a glass of wine a day is less harmful to health than a pack of cigarettes a day. That statement created a lot of controversy. Some people misquoted me and told my father, “Your son is advising people to drink wine.” Fortunately, for me, Sheikh Al Qaradawi was sitting next to me on the show. He did not contradict my statement. My statement was made mockingly, from a health point of view. Later research on alcohol and cardiovascular disease supported my earlier statement. But I have never recommended alcohol to patients even though there may be some benefits since alcohol has other pathological effects on health.
   Thus the antismoking campaign in Qatar started. I encouraged some doctors who agreed with me to talk in public and write in newspapers. The public gets tired or bored with people who talk about the same topic repeatedly, so I purposely reduced my public speaking on smoking to give others a chance to speak. However, I wrote a few poems on smoking and published them. In 1992, the WHO recognized my efforts and awarded me a certificate and a Medal for my anti-smoking campaign in Qatar. Two years ago, I was interviewed on AlJazeera TV satellite station for 90 minutes on smoking. That program, probably, helped prepare the stage for our new tobacco law.
   In 1995, using forms filled by the patients, data collection about smoking in our hospital was repeated with the help of our staff. 25% of adult male patients admitted in Hamad Medical Corporation (HMC) were smokers. Compared to the 46% smokers in our old hospital in 1979, there was a crude drop of 21% over 16 years. Smoking among physicians and surgeons at HMC dropped from 32.2% in 1989 to 13.6% in 1995, a remarkable drop of 18.6% over a period of six years (Table 1).

Table 1: Smoking among HMC Physicians
and surgeons

   I assumed that at the present time, in the year 2002, it would be difficult to find smokers among our medical staff because of three main factors. The numbers of female doctors are increasing and most of the new Qatari medical staff are females. In 1995 female physicians comprised about 29% of HMC medical staff but they reached 39% in 2002. Public awareness about the dangers of smoking makes physicians ashamed of being seen smoking. The most important factor, which influenced our staff, was the law which we implemented in 1996, imposing a fine of Qr.200 on any person caught smoking in the premises of HMC hospitals. Several physicians and surgeons were fined.
   I made a survey of smoking in our medical staff in December 2002 by asking the department chairmen and heads of sections to identify the smokers among their medical staff list. I was surprised to see that almost 7% of our staff still smoke (table 1). The last survey revealed the highest number of smokers was in the Psychiatry Department, which was 30.7%; There were no smokers in Cardiology & Cardiovascular Surgery Department (CCS) and in the Department of Dermatology.Table 2 shows the results of the survey.

Table 2 shows the results of the survey.

   To add local flavor to our campaign against smoking, we conducted two studies. The Ministry of Health food laboratory analyzed the nicotine content of tobacco used in the water pipe. We found out that the nicotine in 10 grams of tobacco, which is the smallest amount used in water pipe, is equivalent to the amount in 52 cigarettes. My colleagues and I also conducted a pilot study on volunteers in the catheterization laboratory. We collected data from 18 patients, 16 of whom were smokers. After completion of coronary angiography, we left a pigtail catheter in the left ventricle. We recorded left ventricular and femoral artery pressures. We asked the patients to smoke two cigarettes one after the other within 12 minutes. We recorded the heart rate, blood pressure, and left ventricular end diastolic pressure at baseline and immediately after smoking each cigarette. These parameters increased after smoking. Blood samples were taken from the left ventricle and femoral artery to analyze carbon monoxide levels. Carbon monoxide increased 50% and 100% above the baseline after the first and second cigarette respectively. Table 3 shows the increased values with smoking as compared to baseline.

Table 3. Immediate effects of smoking

HR=Heart Rate, BP=Blood Pressure,
LVEDP=left ventricular end diastolic pressure,
CO=carbon monoxide.

   Two patients could not smoke the second cigarette because of dizziness after the first cigarette. Five patients had frequent PVCs during smoking but they were not aware of it. One had ventricular tachycardia at the start of the second cigarette. It resolved spontaneously. One patient had severe chest pain after smoking 1/3 of the second cigarette; the chest pain lasted 15 minutes, requiring intracoronary NTG. The cigarette-induced ventricular tachycardia and the severe chest pain convinced us to terminate the study. I wondered what percent of sudden death occurs in smokers during smoking or immediately after!
   I remember an Indian patient who was admitted to our CCU for acute myocardial infarction at the age of 25. He told me that when he was 5 years old his family took him to a homeopathic doctor in India to cure excessive tears. The doctor recommended teaching the child smoking as therapy. So he became a nicotine addict since early childhood.
   In the seventeenth century tobacco was considered a therapeutic substance. It was considered the miracle drug for every disease including asthma and tuberculosis. Now we know it has a miraculous effect in shortening life span.

Fig.3 An old cigarette advertisement

   Religious authorities in the Arabian Gulf and Saudi Arabia forbid smoking and consider it a sin. They recently proclaimed that smoking is legal ground for divorce. Therefore, a wife has a legal right to divorce her husband if he is a smoker. A Qatari cartoonist made fun of that proclamation as seen in (Fig.4).
   My father wrote a long poem, before I was born, advising on social and Islamic principles including the prohibition of smoking.

Fig.4 Wife shouting at husband: you are divorced

There was no printing or typing machine in Ras Alkhaimah, my birthplace, then. He published it in booklet form in Mecca when he was there for pilgrimage in 1950. It is of interest to me that his poem, more than half a century ago, stated that smoking causes tuberculosis (TBC) , blindness and insanity. It may be that he saw smokers coughing all the time that he thought they may have TBC. We know now that smoking does decrease immunity, which may makes the smoker susceptible to TBC. Smoking also causes macular degeneration in the eye and accelerates arteriosclerosis of the brain vessels and causes stroke.®

The advise against smoking in the poem is translated below:

Do not touch tobacco
Do not try,
Sale is forbidden
As well as buy.

Smoker who does not abstain,
will die young or become insane,
He will loose both,
health and brain

Smoker loses money and mind
He gains tuberculosis, and becomes blind

Smoker’s mouth is like a W.C.
Isn’t bad? can’t you see?