Fabricio Vela - Master Thesis by Fabricio Vela

QUIT IT! Fabricio Vela DIA 2016/17 1st. supervisor Joris Fach 2nd. supervisor Roger Bundschuh

CONTENT PAGE

RECOVERY by Joris Fach

QUIT IT!

11 TOBACCO 35

LUNG CANCER

49 CESSATION 71 THERAPIES 91 CONCEPT 95 PROGRAM 103 NETWORK 107 LOCATION 115 DESIGN 120

DRAWINGS & MODELS

157 BIBLIOGRAPHY

RECOVERY by Joris Fach

In a health obsessed society, in which fitness clubs and organic food stores spring up at every street corner, the loss of agility and productivity is not an option. Hence, whenever bad luck does strike, it causes daily routines to collapse. Recovery always takes too long and lasting dysfunctions are ruinous. As such, our health has become part of a social equation, differentiating often underfunded public care from exclusive private rehabilitation centers. Additionally, the ownership of health-related data has become highly sensitive, as it is utterly valuable to both pharmaceutical companies, as well as future employers. Overall, however, the health care industry is one of the most reliably growing ones of recent years. Hospitals have expanded into imposing conglomerates of impenetrable bigness that often fail to connect to their context on almost every level. Pharmaceutical enterprises treat themselves to lush campuses, marking their newly acquired power and influence. Keeping all of the above in mind, we will commence the semester by looking at the human body itself, understanding its organic functions and amazing resilience, but also study sports injuries, chronic diseases, psychological instabilities, drug addictions and their respective treatments. As the radius of mobility become restrained, the design of immediate surroundings becomes crucial. We will thus speculate on productive environments for recovery, imagining paradisiacal states of urban arcadia in which physical rehabilitation overlaps with exciting cultural programs, making every step of a recovery an exciting one for both body and mind.

Recovery

QUIT IT! One in eight deaths are tobacco-related worldwide. In this day and age, no one can plea ignorance towards the dangers of smoking. It has been over 18 years since Phillip Morris first acknowledeged that smoking causes lung cancer and other deadly diseases and even though the percentage of the population who smoke has declined since 1980, it was in the last decade when that decrease was most notorious. Worldwide advertisement restrictions, plain and warning packaging policies, public smoking bans and increased cigarette prices related with high-tax policies have contributed with said results. Nevertheless, it makes it more striking to find people who continue to smoke and, in some places, to see it in even higher proportion. The average adult in Germany smoked 13 times more cigarettes per day than a Peruvian in 2013. Since smoking has been pushed out from enclosed places into public ones, itâ&#x20AC;&#x2DC;s not hard to agree with those numbers. Lung cancer accounts for 1 in 5 cancer related deaths and has one of the lowest survival rates (11%). Considering that between and 80% and 90% of the cases are caused by smoking, focusing on prevention ought to have a high impact on the long term. Therefore, the objective of this thesis is to create a space which, while treating tobacco consumption, contributes to the reduction of lung cancer from a healthy lifestyle positive reinforcement perspective; eliminating the negative image and stigma linked to traditional addiction rehabilitation treatments.

Quit it!

TOBACCO Reports from the WHO estimate that tobacco kills around 6.5 million people every year, where an estimate 10% are due to second-hand smoke. Out of the top 10 leading causes of death, tobacco is cause for 8, including ischemic heart disease, chronic obstructive pulmonary disease, lung cancer, upper aerodigestive cancer and tuberculosis. Consequently, tobacco is the 2nd deadliest risk factor and 1st preventable, since its responsible, specially when combining direct smokers and second-hand smoke victimâ&#x20AC;&#x2122;s statistics. Additionally, tobacco is linked with mental illness, where between 45 and 60% of people diagnosed with different psychological conditions are reported to be former or current smokers.

Tobacco

What is Tobacco? Tobacco is both the specie of Nicotiana plant and the product resulting from curing its leaves, which dried leaves are used as main ingredient in different tobacco products, such as cigarettes, cigars and pipes, to mention a few. One of the main properties of tobacco is it addictivness, caused by nicotine, an stimulant alkaloid. Nicotine levels in tobacco depend on the tobacco type and curation process, which is determined by the final intended product. Air and Fire curing produce high-nicotine tobacco, used for cigar, pipes, chewing and snuff; while Sun-cured tobacco is low on nicotine, being mainly used in the production of oriental tobacco. The most common method is the Flue-cured process, consisting of hanging the tobacco in heated barns, protected from smoke. The nicotine levels resulting from this method are medium to high.

What is Tobacco?

Tobacco History Tobacco finds its origins in the Americas with traces of cultivation going as back as 6000 BC and traces of smoking as early as 1 BC. With the arrival of Columbus, tobacco was introduced to all continents and quickly became a priced commodity. In 1761 and 1795 were made public the first reports connecting tobacco with cancer, but it wasn’t until 1987 that the first tobaccorelated health regulations were enabled Africa

2002

Provides global leadership in drafting the WHO FCTC

USA

1994

CEOs of cigarette companies testify before Congress that it is their opinion that nicotine is not addictive First place to use tobacco tax to counter tobacco

Australia

1987

USA

1964

SG’s Report determines smoking causes lung cancer

USA

1913

Birth of the “modern” cigarette: the Camel brand

1833

Phosphorus friction matches make smoking easier

Germany

1795

S.T. von Soemmering reports lip cancers in pipe smokers

New Zealand

1768

Pipe smoker Cap. James Cook seen as a demon

England

1761

John Hill's studies warn snuff users of nasal cancer risk

Russia

1710's

Peter the Great encourages his courtiers to smoke tobacco, seen as fashionable and pro-European

USA

1700's

African slaves initially used to work in tobacco fields

Turkey

1633

Death penalty for smoking

England

1614

7000 tobacco shops open on Virginia's tobacco first sale

Americas

1612

Tobacco first grown commercially

1600's

Philosopher Fang Yizhi: smoking "scorches one’s lung”

Africa

1560

Portuguese and Spaniards ship tobacco to East Africa

China

1530-60

China

Middle East

Early 1500

Tobacco introduced via Japan or the Philippines Tobacco first introduced when the Turks took it to Egypt

America

1492

Columbus discovers tobacco and takes it to Europe

America

1 BC

Begin of tobacco smoking by indigenous communities

America

6000 BC

First cultivation of the tobacco plant

Tobacco Hisotry

Delivery Systems Despite the fact that tobacco is the main product, nicotine delivery is the key element that is put out for consumers to use. Increased blood pressure and heart rate, nausea and diarrhea are some of the effects of nicotine consumption and the level of absorption depends on the way it is taken, being combustion the most efficient and the most harmful, since doubling the damage by toxic smoke inhalation and exposure.

Clinically Approved

Uncertain Safety

NRT Nicotine replacement therapy from nasal spray, patches, inhaler and gum

E-cigarettes Consists of inhaled vapor from heated liquid nicotine

SNUS Forbidden in Europe (except Sweden), is a moist tobacco powder

Dissolvable Products Wafers, lozenges, sticks, strips and orbs which are still in research stage

Heat-non-Burn Products New products which vaporize nicotine from tobacco

Established Harms

Smokeless Tobacco Dipping and chewing tobacco, snuff and toombak are some examples, with proven increase in oral, head and neck cancer. Water Pipes One puff is almost the same as inhaling the smoke of one cigarette, it has been misleadingly presented as "healthy", despite having the same risk as cigarettes Combusted Tobacco Thousands of toxic chemicals, 69 carcinogens; cigarettes, cigars, little cigars and cigarillos have long been proven as a health hazard

Delivery Systems

Nicotine Used at some point as a pesticide, nicotine harm is well documented but a side effect of anti-tobacco campaigns has been the development of nicotine related products, carrying problems of their own. Nicotine posinong was uncommon until recent years with the introduction of e-cigarettes, which vaporize liquid nicotine. Promoted as a healthier option, its real harm is still to be determined.

1 pack=12 units 1 patch 1 unit

Orbs NRT Patch E-cigarette

1 pack=20 units Cigarette 9 pieces

NRT Gum Deadly Dose

12 pouches

SNUS

1/2 34g can

Snuff

0mg

25mg

Nicotine

50mg

Market Share Regardless of there being more or less harmful methods of consuming tobacco, the reality shows that cigarettes are by far the most common delivery system in the world and, despite being a decrease in recent years, it still has a larger market share than all the other products combined.

E-cigarettes Smokless tobacco Other smoking tobacco Cigars

Cigarettes

25'000'000'000

Market Share

50'000'000'000

Cigarette Carcinogens Cigarettes have been proven a health risk and out upon burning, its 600+ ingredients combine to create over 7000 chemicals, 69 of them known to be carcinogens.

Acetone

found in nail polish remover

Acetic Acid

an ingredient in hair dye

Ammonia

a common household cleaner

Arsenic

used in rat poison

Benzene

found in rubber cement

Butane

used in lighter fluid

Cadmium

active component in battery acid

Carbon Monoxide

released in car exhaust fumes

Formaldehyde

embalming fluid

Hexamine

found in barbecue lighter fluid

Lead

used in batteries

Naphthalene

an ingredient in mothballs

Methanol

a main component in rocket fuel

Nicotine

used as insecticide

Tar

material for paving roads

Toluene

used to manufacture paint

Cigarette Carcinogens

Current Smokers One billion people smoke. Responsible for 1 out of every 4 smokers in the world, not only Chinaâ&#x20AC;&#x2122;s consumer population has doubled in the last 25 years but so has the intensity. Nevertheless, Germany is the highest ranked country with under 100 million inhabitants with over 20 million regular smokers.

25'000'000

China

Indonesia

India United States of America Russian Federation Japan Brazil Germany Bangladesh Pakistan Philippines Ukraine Turkey Viet Nam France Italy 18

Mexico Republic of Korea

Current Smokers

50'000'000

Average Daily Cigarettes per Smoker Being 13 cigarettes per day the worldâ&#x20AC;&#x2122;s average consumption rate, Germanyâ&#x20AC;&#x2122;s 14 daily cigarettes is considered average, but still is a high amount compared to other European references as France and the United Kingdom (11 cigarettes per day).

China

Indonesia

India United States of America Russian Federation Japan Brazil Germany Bangladesh Pakistan Philippines Ukraine Turkey Viet Nam France Italy Mexico Republic of Korea

Average Daily Cigarettes per Smoker

% of Smokers per Country in the World Although tobacco consumption is a global issue, there are regions where the percentage of smokers are significantly higher, as seen in Central and Eastern Europe as well as South East Asia. While in countries such as Indonesia and the Philippines, smoking comes family tradition to a point where parents pressure their sons to smoke. Nevertheless, Europe, lead by Greece and Russia, has the cumulative highest percentage of adult smoker population.

% of Smokers per Country in the World

+ 35% 30% - 35% 25% - 30% 20% - 25% 15% - 20% 10% - 15% 5% - 10% No Data

% of Smokers per Country in the World

% of Smokers per Country in Europe Considering Greece and Russia’s + 36% of adult population regularly smoking, Germany’s 28.3% -7th in Europe- could seem marginal, but it is still very high compared to the world’s 19% average. Looking at the map, its noticeable how Scandinavian and Western Europe show lower smoking prevalence while Eastern countries have some of the highest numbers in the world. + 35% 30% - 35% 25% - 30% 20% - 25% 15% - 20% 10% - 15% 5% - 10% No Data

% of Smokers per Country in the Europe

% of Smokers per Region in Germany In a scattered map, Berlinâ&#x20AC;&#x2122;s 36% of smoking adults highly contrasts with Brandenburgâ&#x20AC;&#x2122;s country minimum of 16%. To put it in perspective, if Berlin was a country, it would have the same smoking prevalence as Greece and Russia, competing for 4th place in the world. In a highly dense, urban environment, the risk of second-hand smoke is even more latent, making it the most appropriate place to face the situation and find solutions. + 35% 30% - 35% 25% - 30% 20% - 25% 15% - 20% 10% - 15% 5% - 10% No Data

% of Smokers per Region in the Germany

Physical Illness Eyes Cataracts Blindness (macular degeneration Stinging, excessive tearing and blinking Ear Hearing loss Ear infection Mouth and Throat Cancer of lips, mouth, throat, larynx and pharynx Sore throat Impaired sense of taste Bad breath Circulatory System Buerger's disease (inflammation of arteries, veins and nerves in the legs) Acute myeloid leukimia Liver Liver cancer Urinary System Bladder, kidney and ureter cancer Hands Peripheral vascular disease, poor circulation (cold fingers)

Skin Psoriasis Loss of skin tone, wrinkling, premature aging Wounds and Surgery Impaired wound healing Poor postsurgical recovery Burns from cigarettes and from fires caused by cigarettes Legs and Feet Peripheral vascular disease, cold feet, leg pain and gangrene Deep vein thrombosis

Physical Illness

Brain and Psyche Stroke (cerebrovascular accident) Addiction/withdrawal Altered brain chemistry Anxiety about tobacco's health effects

Hair Odor and decoloration

Nose Cancer of nasal cavities and paranasal sinuses Chronic rhinosinusitis Impaired sense of smell

Teeth Periodontal disease (gum disease, gingivitis, periodontitis9 Loose teeth, tooth loss Root-surface caries, plaque Discoloration and staining

Heart Coronary thrombosis (heart attack) Atherosclerosis (damage and occlusion of coronary vasculature)

Chest and Abdomen Esophageal cancer Gastric, colon and pancreatic cancer Abdominal aortic aneurysm Peptic ulcer (esophagus, stomach, upper portion of small intestine) Possible increased risk of breast cancer Female Reproduction Cervical and ovarian cancer Premature ovarian failure, early menopause Reduced fertility Painful menstruation Male Reproduction Infertility (sperm deformity, loss of motility, reduced number) Impotence Prostate cancer death Skeletal System Osteoporosis Hip fracture Susceptibility to back problems Bone marrow cancer Rheumatoid arthritis Immune System Impaired resistance to infection Possible increased risk of allergic diseases

Lungs Lung, brochus and tracheal cancer Chronic obstructive pulmonary disease (COPD) and emphysema Chronic bronchitis Respiratory infection (influenza, pneumonia, tuberculosis) Shortness of breath, asthma Chronic cough, excessive sputum production Others Diabetes Sudden death Secondhand Smoke Thickening of arterial walls Pregnant Women Placental abruption Placenta previa Premature rupture of membranes Premature birth Spontaneous abortion / miscarriage Ectopic pregnancy Fetuses, Infants, Children Stunted gestational development Stillbirth Sudden infant death syndrome (SIDS) Reduced lung function and impaired lung development Asthma and bronchitis exacerbation Acute lower respiratory infection (bronchitis and pneumonia) Respiratory irritation (cough, phlegm, wheeze) Childhood cancers Orofacil cleft Possible increased risk of allergic diseases Possible increased risk of learning disability and attention-deficit / hyperactivity disorder

Physical Illness

Mental Illness Although it is unclear if smoking increases the risk of mental illness or mental illness encourages smoking, a US study revealed is that people diagnosed with mental illness are twice as prone to smoking. the feeling of anxiety relief, relaxation or happiness are confused as helpful results from smoking but are actually withdrawal relief and dopamine release caused by nicotine

No mental illness Social phobia Agoraphobia Panic disorder Major depression Dysthymia Panic attacks Simple phobia Non-affective psychosis Alcohol abuse or dependence Antisocial personality, antisocial behavior or conduct disorder Posttraumatic stress disorder Generalized anxiety disorder Drug abuse or dependence Bipolar disorder 0%

50%

Mental Illness

100%

Death Toll â&#x20AC;&#x153;Globally, tobacco use killed 100 million people in the 20th century, much more than all deaths in World Wars I and II combined. Tobaccorelated deaths will number around 1 billion in the 21st century if current smoking patterns continue.â&#x20AC;? (Eriksen 2015) The legal status and social acceptance of tobacco, and even more so cigarette smoking, might be misleading, but tobacco was 6.5 times deadlier than alcohol and illegal drugs combined during the 20th century and projections for the 21st century show that tobacco related deaths will increase by 10 times; meaning that action has to be done now.

HIV WWI WWII 20th Century

21st Century (WHO estimate)

50'000'000

Death Toll

100'000'000

Deaths per Risk Factor - Global Tobacco and secondhand smoke caused 7.3 million deaths in 2015 alone, a 20% increase since 1990. Smoking is also regarded as the number one preventable cause of death and is responsible for 15 times as many deaths as drug abuse and 3 times more than alcohol abuse.

6'000'000

High blood pressure Smoking High plasma glucose High total cholesterol Ambient pollution Diet high in sodium High body-mass index Diet low in whole grains Diet low in fruits Household fuel pollution Impaired kidney function Alcohol use Diet low in nuts and seeds Diet low in vegetables Low physical activity Diet low in omega-3 Unsafe sex Unsafe water source Childhood wasting No handwashing Secondhand smoke Unsafe sanitation High processed meat diet Lead exposure Drug use Diet high in trans acid Low polyunsaturated fatty Diet low in fiber Childhood underweight Non breastfeeding Low bone mineral density Occupational pollution Childhood stunting

Death per Risk Factor - World

12'000'000

Deaths per Risk Factor - Germany Because of Germany being a developed, high-income country it is relatively safer from problems as pollution or malnutrition, but smoking accounts for 14% of deaths, 18 and 5 times more compared to drugs and alcohol abuse respectively.

125'000

250'000

Death per Risk Factor - Germany

Tobacco Deaths per Cause - Global Ischemic heart disease, chronic obstructive pulmonary disease, lung cancer and cerebrovascular disease add up to 75% of total smoking related deaths worldwide with lung cancer being the only one to have increased in rate in the last 25 years.

1'000'000

Ischemic heart disease COPD Lung cancers Cerebrovascular disease Low respiratory infections Esophageal cancer Liver cancer Hypertense heart disease Tuberculosis Stomach cancer Pancreatic cancer Diabetes mellitus Larynx cancer Other CV & circ. diseases Lip and oral cavity cancer Bladder cancer Colon and rectum cancer Asthma Peptic ulcer disease Leukemia Kidney cancer Aortic aneurysm Nasopharynx cancer Interstitial lung disease Atrial fibrillation and flutter Falls Cervical cancer Road injuries Peripheral artery disease Pneumoconiosis Other chronic respiratory Rheumatoid arthritis Other transport injuries

Tobacco Deaths per Cause - World

2'000'000

Tobacco Deaths per Cause - Germany Unlike global trends, lung cancer is the leading tobacco-related death cause with 1 out 3 cases alone. Consequently lung cancer, as well as the rest of diseases mentioned, is a serious problem in Germany that could be prevented by antismoking action.

25'000

50'000

Tobacco Deaths per Cause - Germany

Social Consequences of Tobacco Carrying such a large burden of diseases and death attributable to tobacco, thereâ&#x20AC;&#x2122;s a social cost in life expectancy and health costs that affects society as a whole. Yearly, Germany loses an estimate 2.2 million Years of Life (YLL) due to tobacco-related diseases, meaning that every year, each smoker reduces its life expectancy by 11 months. Studies insist that persistent smoking can cut life expectancy by 10 years on average. This issues have not only a human cost but a financial one. In 2015, Germany spent almost 80 billion euros in factors related to tobacco. The biggest piece of the pie was allocated in direct health costs from both smoking and secondhand smoke, with nearly 24 billion euros, , 35% more than the entire budget for education and research. An important sum could be diverted to other affairs with more prevention programs, considering that currently the government only spends about 1 million euros in tobacco education.

Women

100% 80%

11y

60% 40% 20%

Men

100% 80% 12y 60% 40% 20%

Life Expectancy Smokers v Non-smokers

30y

40y

50y

Social Consequences of Tobacco

60y

70y

80y

100'000'000 €

TOTAL COST 79'101.52 Mio €

Direct Costs 25'471.86 Mio € Health cost from smoking Health cost from secondhand smoke Care costs Rehabilitation measures Accidents Health cost from secondhand smoke in children Occupational rehabilitation

Indirect Costs 53'683.66 Mio € Resource loss Long-term unemployment Work disability Short-term unemployment Reduced unemployment Care requirements Rehabilitation time

Social Consequences of Tobacco

LUNG CANCER Tobacco and lung cancer is the easiest health-related association that one can make. Lung cancer may not be the deadliest disease caused by smoking, but it is the most â&#x20AC;&#x153;effectiveâ&#x20AC;?. Between 80 and 90% of lung cancer cases are caused by smoking and/or seconhand smoke exposure. Furthermore, lung cancer is the deadliest type of cancer, with only 9 out of 10 cases resulting in death. This means that 1.3 of the 1.6 million deaths from lung cance can -and should- be prevented. Nevertheless, efforts so far have been discouragingly fruitless with lung cancer deaths been increasing each year at a faster rate than ischemic heart disease and chronic obstructive pulmonary disease, which in turn are decreasing. Seeing that in Germany, lung cancer is a considerably higher problem compared to the rest of the world and its the most linkable disease to tobacco, taking it as a case study for the harms of smoking could contribute with awareness on the subject.

Lung Cancer

Cancer â&#x20AC;&#x153;Cancerâ&#x20AC;? refers to the general overgrowth of abnormal cells in any part of the body, which crowd out normal cells. These cells can grow and extend to other parts of the body and continue growing from there on. Whether it is lung, prostate, colon or any other type of cancer depends on where the cancer cells started. Among the medical practice, there is general consensus that cancer is the disease of our time. An illness responsible for 15% of deaths worldwide and with an estimate 15 million new cases each year, itâ&#x20AC;&#x2122;s almost certainly affected someone close to us regardless of our age, gender, birthplace, or socio-economic status.

Low

Medium

Female

High

Male

Very High

Human Development Index

Gender

Cancer

Incidence Mortality

0 - 14

15 - 39

40 - 44

45 - 49 East Mediterranean

50 - 54

Africa

55 - 59

South East Asia

60 - 64

America

65 - 69

Europe

70 - 74

Western Pacific

75 +

WHO Region

Age

Cancer Incidence & Mortality by Age, Gender, Region and Income

Lung Cancer Lung cancer accounts for 1 in 5 cancer related deaths and has one of the lowest survival rates (11%) with a death toll of 1.6 million people yearly it takes more than twice as many lives as liver cancer, the 2nd deadliest type of cancer. It is also the 5th leading death cause in the world but in Germany, a country with significantly lower pneumonia and lung disease problems, lung cancer is the 3rd leading cause of death. Considering that in the year 2000, lung cancer was ranked 10th in most common death causes globally and, according to projections by the World Health Organization (WHO) by 2030 it will have the 2nd highest increase in death rate among the top 10 leading causes of death. This means that lung cancer is not only a problem now, but it will be an even bigger problem in years to come.

Lung Cancer

Cancer Incidence & Deaths per Type - Global 0

1'000'000

2'000'000

Lung

Breast

Colorectum

Prostate

Stomach

Liver

Cervix uteri

Oesophagus

Bladder

Non-Hodgkin lymphoma

Leukemia

Pancreas

Incidence Mortality

Cancer Incidence & Deaths per Type - Global

Causes & Risk Factors Smoking is by far the leading cause of lung cancer, being responsible between 80 and 90% of all cases, including secondhand smoke. Carcinogens and Radon are among other main causes, which are mainly due to unsafe working environment. Since such problems, along air pollution, are not a big problem in Germany, most of lung cancer cases presented are tobacco-related. Among other risk factors, poor diet, family history and previous therapy are factors that increase the chances for the illness 0%

100%

50%

Smoking Exposure to Carcinogens Radon Air Pollution

Smoking

Air pollution

Secondhand smoke

131.29 337

-61.7

Rn Radon 222.018

known

Diesel exhaust

118 unknown Radon

Asbetos

Poor diet

Chest radiation therapy

Family history

Causes & Risk Factors

Symptoms One of the main reasons for lung cancerâ&#x20AC;&#x2122;s high mortality rate is misdiagnosis and the mild symptoms presented in early stages, such as coughing and shortness of breath. Even in late stages, symptoms are not as revealing as they could be for such a disease.

Coughing

Shortness of breath

Pneumonia

Bronchitis

Coughing blood

Chest pains

zzz

zz zz zz zzz zz

Upper body pain

Wheezing

Dysphagia

Hoarseness

Weight loss

Fatigue

Symptoms

Survival Rate & Stages Survival rates vary depending on the extent of the disease, which is measured by the stage it is in. Early stages have a considerably benign survival rate, but since most of those cases are farily asymptomatic, nearly 75% of all lung cancer patients are diagnosed during late stages, where survival rates drop; resulting in a meager 11% total survival rate. Lung cancer staging is done using the TNM system, which measures the size of the Tumor, whether it has spread to the lymph Nodes and if it has Metastasized to other organs. For example, a T2N1M0 cancer would mean the tumor is between 3cm and 7cm, spread to lymph nodes within one lung and hasnâ&#x20AC;&#x2122;t metastasized to other organs. Other factors considered are its proximity to the chest wall and its relation to the heart membrane.

II A

II B

III A

III B

Incidence Mortality

50%

Survival Rate & Stages

100%

SZ <3cm SD One SP CW HM -

IIA

SZ 3-5cm SD One SP Nodes CW HM -

IIIA

SZ Any SD Both SP CW Break HM Break

IIIB

SZ Any SD Both SP Organs CW Break HM -

SZ 3-5cm SD One SP CW HM -

IIB

SZ >7cm SD One SP CW Break HM Reach

IIIA

SZ Any SD Both SP CW HM Break

IIIB

SZ Any SD Both SP Nodes CW Break HM Break

Survival Rate & Stages

IIA

SZ 5-7cm SD One SP CW HM -

IIB

SZ 5-7cm SD One SP Nodes CW HM -

IIIA

SZ Any SD One SP Nodes CW Break HM -

SZ Any SD Both SP Rest CW Break HM Break

Deaths per Cause - Global 0

4'000'000

Coronary Heart Disease Stroke Lung Disease Influenza and Pneumonia Lung Cancers HIV / AIDS Diarrhoeal Diseases Diabetes Mellitus Road Traffic Accidents Hypertension Low Birth Weight Liver Disease Tuberculosis Other injuries Kidney Disease Suicide Birth Trauma Liver Cancer Stomach Cancer Colon - Rectum Cancers Alzheimers / Dementia Falls Malaria Congenital Anomalies Breast Cancer Violence Inflammatory / Heart Malnutrition Endocrine Disorders Oesophagus Cancer Meningitis Asthma Drownings Rheumatic Heart Disease Pancreas Cancer Prostate Cancer Lymphomas Oral Cancer Maternal Conditions Leukemia Fires Cervical Cancer

Deaths per Cause - Global

8'000'000

Deaths per Cause - Germany 0

75'000

150'000

Deaths per Cause - Germany

Death Rate Variation - Global

2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 Lung Cancer

Total Deaths

Death Rate Variation - Global

Population

Death Rate Variation - Germany

2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 Lung Cancer

Total Deaths

Population

Death Rate Variation - Germany

CESSATION In 2003 the WHO Framework Convention on Tobacco Control treaty established a set of requirements that every country must implement in order to reduce tobacco supply and demand. Thanks to this actions global cigarette consumption per capita (excluding China) has decreased in the past 20 years, but on account to population growth, total cigarette sales have grown, making tobacco a powerful industry. Hence, action is required to attend the problem by both preventing and quitting tobacco consumption. Personal benefits from quitting tobacco are immediate, ranging from decreasing lung cancer risk in half after 10 years from quitting smoking to gaining 3 year in life expectancy after quitting as late as when being 60 years old. In 2012, the direct health cost for Germany due to smoking was 25.4 Bn EUR, out of which only 0.14 Bn EUR were allocated for cessation measures – around 0.5%. This reflects the current situation of cessation policies, placing Germany 33rd among 34 countries in the 2013 Tobacco Control Scale in Europe, with a scoring of 32/100 and 2/10 in the “Cessation” section.

Cessation

Initiation Most of all smokers start the habit before they turn 18 years old, being highly influeciable to external elements. A 2015 survey conducted in Germany showed that 23.3% of the youth population between 12 and 17 years old had smoked at least once; skyrocketing to 71.8% in the 18 to 25 year old age group. Furthermore, as many as 38% of 17-year-old boys are reported to be smokers, compared to 31% of girls in the same age group in a country where it is illegal to sell tobacco products to anyone under 18 years of age. As it has previously mentioned, the dangers of tobacco are well documented and well-known amongst the general population; then what motivates people to take up such a dangerous habit.

11 - 13

Male Female

50%

Inititation

100%

Motives According to the WHO, there are Socioenvironmental and Personal factors that drive people to smoking. Parental influence, use by peers and advertising influence are among the first ones, mainly due to people being unavoidably exposed to them. The ladder refers to sociodemographics and socioeconomic factors, as well as knowledge, attitude and belief towards the dangers of tobacco, combined with self-esteem and self-image issues. Clearly, external factors as advertising and ingnorance can be directly addressed, other social or economic factors can be improved by means of specific targeted policies. Nevertheless, parental influence, self-esteem and self-image are factors developed at early age and resulting in smoking during adolescence and even early 20â&#x20AC;&#x2122;s. Consequently, facing tobacco issues among young -or about-to-beparents could be fruitful not only for the current generation but for future ones, growing up in a tobacco-free, conscious and healthy environments.

Personal

Socioenvironmental

Parental influence

Sociodemographic factors

Self-image

Peer tobacco use

Socioeconomic factors

Self-esteem

Marketing and advertising

Knowledge, attitudes, beliefs

Motives

Addiction Different studies compare tobacco -specifically, nicotine- addiction to be at similar levels of heroin and cocaine, surpassing those of amphetamines, cannabis and ecstacy. Moreover, a 1994 epidemiology study from the US determined that the highest dependence rate among its users, where 1 out of every 3 tobacco users claiming to have become addicted to smoking at some point. 0

1.5

50%

100%

Heroin Cocaine Tobacco Alcohol Cannabis Drug Dependence

Capture Rates Cannabis Alcohol Cocaine Heroin Tobacco

Addiction

"(...) as a former smoker, I constantly struggle with it. ... Have I fallen off the wagon? Yes."

Barack Obama

"Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times." Mark Twain

"I will go so far as to say probably smoking had something to do with my pancreatic cancer." Patrick Swayze

"My rule of life prescribed as an absolutely sacred rite smoking cigars and also the drinking of alcohol before, after and if need be during all meals and in the intervals between them." Winston Churchill

"Smoking kills. If you're killed, you've lost a very important part of your life."

Brooke Shields

Addiction

Perception of Smoking In 2014, an online survey in Germany showed that cigarette harm awareness is most spread amongst smokers, with 3 of every 4 smokers knowing of the dangers their habit caused. Among other findings, unsurprisingly 45% of smokers revealed that it is easier to continue smoking rather than quitting, showing the addictive power of cigarettes; and as twice as many people acknowledged they required help to quit smoking compared to people who thinks 0%

50%

I am aware that the consumption of cigarettes is harmful to health

Cigarettes are too expensive

I advocate the smoking ban in restaurants

It is easier to smoke farther than to stop

I do not find dissuasive health notes & pictures of effects of the cigarette consumption on cigarette packs

I advocate the smoking ban in bars and pubs

I roll cigarettes myself to save money

Perception of Smoking

100%

they can do it on their own. Furthermore, there has ben an important change in perception towards smoking. During the golden era of tobacco, advertisement pointed smoking as feature that made men look more appealing and women more independent. Now, that image may well be gone, with only 3% of people regarding smoking as â&#x20AC;&#x153;coolâ&#x20AC;?.

50%

100%

If I am honest, I am missing the money I spend on smoking regularly at a different place I would like to stop smoking, but need external support (for example from friends, family members, doctors, therapies, etc.) I buy cigarettes regularly abroad / duty-free area or let me bring cigarettes from abroad / duty-free area to save money

Electronic cigarettes are a good alternative to conventional cigarettes

I could stop smoking at any time

I find smoking cool

Total Population Smokers Former Smokers Non-Smokers

Perception of Smoking

Reasons to Quit In the same 2014 study, germans agree that the main reasons for quitting are health and saving money. In general, the search of an improvement in wellbeing, whether health, stamina or the sake of others, is a key factor that drives people to quitting.

50%

Health

Saving money

Better condition

Cigarette smell bothers me / others

Will-power to prove it

Improve stamina

Reasons to Quite

100%

50%

100%

Model for others (e.g., children, friends)

For family's sake

For partner's sake

Better concentration

Smoking is uncool

Total Population Smokers Former Smokers Non-Smokers

Reasons to Quite

Personal Benefits Better health, better economy and better social interactions are the main benfits from quitting and one can start reaping them from the moment of putting out the last cigarette. Normal blood pressure and pulse rate within the first 20 minutes to life expectancy levels returning to those of someone who never smoked after 30 years of quitting are among the health benefits. Also, smoking can become an expensive habit. On average, any German who decides to quit smoking can save 1,300 € per year only on cigarette costs, not counting savings in health matters. Moreover, upon quitting, people become freely interact without having to leave for a smoke, with “free of smoke” policies increasing. Additionally, there’s no more concerns about secondhand smoke and how one’s behaviout affect others.

Quitting at 30y

100% 80% 10y

60% 40% 20%

Quitting at 60y

100% 80% 4y

60% 40% 20% Life Expectancy Smokers v Non-smokers

30y

40y

50y

Personal Benefits

60y

70y

80y

20 minutes Blood pressure and pulse rate drops to normal Temperature in hands and feet increase to normal 8 hours Carbon monoxide level in blood drops to normal Oxygen level in blood increases to normal 24 hours Chance of heart attack decreases 48 hours Nerve ending start regrowing Ability to smell and taste enhanced 2 weeks to 3 months Circulation improves Walking becomes easier Lung function increases up to 30%

24 hours

4€

1 week

30€

1 month

110€

6 months

650€

1 year

1,300€

5 years

6,600€

10 years

13,200€

15 years

19,750€

30 years

39,500€

1 to 9 months Coughing, sinus, fatigue, shortness of breath and congestion decrease 1 year Excess risk of coronary heart disease down 50% 5 years Lung cancer death rate for former smoker decreases by half Stroke risk is reduced to that of a non-smoker 5-15 years after quitting 10 years Lung cancer death rate similar to non-smokers Precancerous cells are replaced Risk of cancer of the mouth, throat, bladder, esophagus, kidney and pancreas decrease 15 years Risk of coronary heart disease reduce to non-smoker's level

Personal Benefits

FCTC In 2003 the WHO Framework Convention on Tobacco Control treaty established a set of requirements that every country must implement in order to reduce tobacco supply and demand. Regarding supply, countries must eliminate all forms of illicit trade in tobacco products, prohibit sales to and by minors, provide support for economically viable alternative activities; while the measures relating to the reduction of demand are implementing price and tax measures that help reduce tobacco consumption, protection from exposure to tobacco smoke, regulating and disclosing of the contents of tobacco products, ensuring that packaging and labelling of tobacco products carry health warnings, assuring education, communication, training and public awareness of hazards caused by tobacco, banning tobacco advertising, promotion and sponsorship, demanding reduction measures concerning tobacco dependence and cessation according to each countries specific circumstances. Thanks to this actions global cigarette consumption per capita (excluding China) has decreased in the past 20 years, but on account to population growth, total cigarette sales have grown, making tobacco a powerful industry. Hence, action is required to attend the problem by both preventing and quitting tobacco consumption. Women

50% 40% 30% 20% 10%

Men

50% 40%

FCTC establishment

30% 20% 10%

Smoking prevalence World v Germany

2000

2005

FCTC

2010

2012

MPOWER The MPOWER package comprises six measures which contribute in the implementation of the FTCT. ° Monitor tobacco use and prevention policies ° Protect people from tobacco smoke ° Offer help to quit tobacco use ° Warn about the dangers of tobacco ° Enforce bans on tobacco advertising, promotion and sponsorship ° Raise taxes on tobacco

Complete policies

Recent, representative and periodic data for both adults and youth

Moderate policies

Recent and representative data for both adults and youth Recent and representative data for either adults or youth No known data, or no recent data, or data that are not both recent and representative

Minimal policies No policy or weak policy Un-reported/categorized

Monitoring

Smoke-free environments Cessation programs Warning labels Mass media Advertising bans Taxationr 0%

50%

MPOWER

100%

Implementation in Germany In 2012, the direct health cost for Germany due to smoking was 25.4 Bn EUR, out of which only 0.14 Bn EUR were allocated for cessation measures – around 0.5%. This reflects the current situation of cessation policies, placing Germany 33rd among 34 countries in the 2013 Tobacco Control Scale in Europe, with a scoring of 32/100 and 2/10 in the “Cessation” section. To mention some examples, Germany and Bulgaria are the only countries in Europe that allow tobacco advertisement. Also, Germany has the most cigarette vending machines per capita in the world. Recent, representative and periodic data for both adults and youth

National quit line, and both NRT and some cessation services cost-covered

All public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation)

National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio

Medium size warnings with all appropriate characteristics OR large warnings missing some appropriate characteristics

82% tax on retail price

Ban on all forms of direct and indirect advertising Compliance 9/10

United Kingdom Smoke-free Monitoring policies

Cessation Programs

Wanings Health

Warnings Advertising bans Mass Media

Taxation

Germany

Three to five public places completely smoke-free

Ban on national Medium size warnings television, radio and missing some appropriate print media as well as on characteristics OR large some but not all other warnings missing many forms of direct and/or appropriate indirect advertising characteristics Compliance 7/10

National campaign conducted with 5–6 NRT and/or some appropriate cessation services (at least characteristics, or with 7 one of which is characteristics excluding cost-covered) airing on television and/or radio

Implementation in Germany

73% tax on retail price

30 pts

Price

22 pts

Public place bans

15 pts

Public info

13 pts

Advertising bans

10 pts

Health warnings

10 pts

Treatment

UK Ireland Iceland Norway Turkey France Spain Malta Finland Ukraine Sweden Hungary Netherlands Belgium Italy Denmark Bulgaria Switzerland Romania Slovenia Estonia Poland Serbia Latvia Portugal Croatia Slovakia Luxembourg Lithuania Greece Czech Republic Cyprus Germany Austria 50

Implementation in Germany

100

Cessation programs The first step to quit smoking is having the will to quit. From there on, different approaches can be taken with highly effective rates when recomended by a specialist. In Germany, most people try to quit by their own means, which without an appropriate plan, has a very low success rate. This is probably due to unawareness of the addictive levels of nicotine resulting in unpreparedness to face the symptoms of withdrawal. The most succesful cessation programs consist on Nicotine Replacement Therapy (NRT), by means of gum, patches and inhalers. Results improve when combining different types of therapy; for example NRT with medical assistance or prescription drugs (varenicilin, bupropion) with therapy While not being medically proved but praised by its users as the reason for quitting success acupuncture, hypnosis, meditation or sports are some methods which contribute to consumption reduction. On the other hand, e-cigarettes are being used as a cessation method and, even if it contains less nicotine than cigarettes, still has some level of harm yet to be fully determined.

Cessation programs

Former smokers Smokers who tried to quit Maximum success rate

50%

100%

Unassisted

Nicotine Replacement Therapy (NRT)

Medical assistance

Acupuncture, Acupressure

Cessation therapy

E-cigarette

Prescription drugs

Other

No information

Cessation programs

Quitting Disposition With so many benefits from quitting and diseases caused by continuing smoking, it comes as no surprise that smokers want to quit, more so since the turn of the century, with an average 78% willing to quit and 66% actually tried at some point. Nevertheless, the addictive component of cigarettes is responsible for the slow decrease in tobacco consumers and the high relapse percentages shown worldwide.

Never and not planning to

Multiple times

Never, but planning to

Quitting Disposition

Once

Attempting to Quit Results from a 2013 Gallup survey revealed that former smokers required, on average, six attempts to finally be able to overcome their habits; while current smokers have tried to quit four times. In Germany, over 80% of the people think that the reason for people relapsing is the lack of will, and only 2% are aware that the main reason is that cigarettes are addictives and smokers are their victims. Another important insight is the awareness of poor cessation programs by nearly a third of the population, recognizing to some extent the need of specialized help to quit smoking and reducing the risk of relapsing.

Don't know Others Habit, smoking is easy in certain situations Smoking is an addiction Lack of information about negative consequences Tobacco taxes are too low Few offers for cessation programs Tobacco advertisement and easy accessibility Smokers lack will-power 0%

50%

Attempting to Quit

100%

Deterrents The first step to quit smoking is having the will to quit. From there on, different approaches can be taken with highly effective rates when recomended by a specialist. In Germany, most people try to quit by their own means, which without an appropriate plan, has a very low success rate. This is probably due to unawareness of the addictive levels of nicotine resulting in unpreparedness to face the symptoms of withdrawal. The most succesful cessation programs consist on Nicotine Replacement Therapy (NRT), by means of gum, patches and inhalers. Results improve when combining different types of therapy; for example NRT with medical assistance or prescription drugs (varenicilin, bupropion) with therapy While not being medically proved but praised by its users as the reason for quitting success acupuncture, hypnosis, meditation or sports are some methods which contribute to consumption reduction. On the other hand, e-cigarettes are being used as a cessation method and, even if it contains less nicotine than cigarettes, still has some level of harm yet to be fully determined. 0%

50%

Have never played with the idea of quitting Fear of weight gain Need for cigarettes would be too great Fear of anxiety / irritability Craving while being with friends Would miss the "rolling" procedure Would miss the taste of cigarettes Would miss work hours "cigarette breaks" Craving while drinking alcohol Others

Deterrents

100%

Perception of “Rehab” Though its mostly associated with drugs and alcohol rehabilitation, the idea of needing the help of a institutionalised rehabilitation program has an inhibiting effect on patients, who fear stigmatization. Perhaps the most common reason for the negative image of rehabilitation is the view of addicts as morally weak, instead of victims of a disease; but media depiction of addicts as poor, homeless and prone to crime favors the existing bias. This perception discourages addicts to seek help for fear of discrimination and low regard from their peers.

Perception of „Rehab“

THERAPIES Unlike drug, alcohol or even gambling addiction, smoking is not considered as a disease by social or medical standards, despite having higher levels of addictiveness and harm than many of the former. For this reason, and after years of hearing by all means existing, people want to quit smoking. Unassisted cessation is by far the most common method used, as it is general belief that quitting smoking is mostly about will-power, alas being the least efficient method to quit, with a vast majority relapsing during the first year. Nevertheless, there is a vast array of options whether one prefers medical, psychological, spiritual or alternative methods, with any of them showing better results than unassisted and combining different treatments proven to be the best way to quit. Different permutations can be achieved, according to individual needs and beliefs, thus offering a high opportunity for personalized treatments.

Therapies

Unassisted It is both the “most common” and the “most successful for failing” method to quit smoking, with 90% of smokers using it but only 3 to 5% succeeding long term. Because of smoking being regarded as a choice and not as an addiction, the notion of quitting is seen as a matter of willpower. Furthermore, a comprehensive 2008 study mentioned misconceptions on the safety and efficacy of NRT’s, as well as misunderstandings regarding behavioural therapies. Nevertheless, as the definition of “unassisted” has shades of grey, where personal research, discontinued counselling or phone assistance are sometimes also included in this method, the use of general guidelines are found to be helpful, especially in combination with other methods. “Cold turkey”, cigarette reduction or even contingency contracts are some of the methods used. In any case, there are several guidelines available for people who intend to quit on their own to help face withdrawal symptoms, including one that says “prepare for relapse”, which comes to show how low expectations should one have of such a method.

Unassisted

Nicotine Replacement Therapy (NRT) Deriving from the notion of â&#x20AC;&#x153;cigarette reductionâ&#x20AC;?, NRT consists in replacing combusting or chewing tobacco consumption with medically approved products that contain nicotine but which intake dosage is easier to control. Although E-cigarettes, snus and other similar products used to quit smoking also contain nicotine, NRT refers exclusively to patches, chewing gum, lozenges, nose sprays and inhalers. This products focus only on the physical aspect of the addiction and as they are over-thecounter products, can be self-medicated. To improve effectiveness, itâ&#x20AC;&#x2122;s suggested to combine this treatment with behavioural therapy, in order to attend to the psychological issues that increase relapse probabilities. Having a 15% success rate, Nicotine Replacement Therapy is considerably more effective than unassisted methods, but it still has a low prevalence among Germans, with only 6% using this method, less than half as many compared to the US, UK and Australia.

Nicotine Replacement Therapy (NRT)

Medical assistance Knowing the hazards of tobacco, most doctors encourage smokers to quit during check-ups, mostly in ear-mouth-and-throat, lungs and heart specialities, while even an eye doctor knows as well the dangers of smoking, would probably not get involved in such cases. Since this method doesnâ&#x20AC;&#x2122;t require specifically attending cessation therapy but a general consultation which ends in general medical advice, it has a higher attendance rate than other active means. Also included in this category are assisted self-help methods such as telephone quit-lines, internet and phone-app based counselling and pamphlets; all of which either inform, follow up or both on individual progress made by smokers on their own.

Medical Assistance

Acupuncture & Acupressure Unlike NRTâ&#x20AC;&#x2122;s or medical counselling, acupuncture has not been scientifically proven to contribute in quitting, but studies have shown it contributes in mitigating withdrawal symptoms as well as encourage a change of negative habits that could cause relapse. Considered as an alternative method to quit smoking, it is more efficient when combined with herbs and hypnotherapy, regarding the patient has a sensibility towards such methods. Nevertheless, as a unique treatment, studies have shown that acupuncture helps smoking reduction by affecting negatively taste of tobacco for regular consumers. Operating on the basis of needle insertion at specific point, in this case mostly in the ears and wrists, acupuncture works in a similar way as acupressure, which uses manual pressure instead of needles applied on the same locations.

Acupuncture & Acupressure

Cessation Therapy Cessation courses vary in duration, approach and provider. From a one-day intensive session to a 90-minutes-a-week 6 weeks course – or even in-patient treatments- in group or individual treatment, the therapy begins from a behavioural stand, knowing that the first step to successfully quit is modify the habits that trigger the need for a cigarette and care about inquiries about withdrawal effects, such as anxiety or weight gain. Afterwards, a “quit-day” is planned and a “last cigarette” is taken by participants in a way that encourages mutual support for challenges ahead. Next, a maintenance stage ensues where relapse is avoided by offering alternatives and support. As a program closure, many courses offer alternative therapy as a complement, with hypnosis and acupuncture being the most common. Since this therapy is only partially covered by German insurance companies, many are offered by private practices in some cases even lacking medical aid, potentially reducing its real effectivity percentage. However, most courses include a one-year follow up including a contingency clause, where in case of relapse, there’s a partial refund.

Cessation Therapy

E-Cigarette A highly debated alternative, e-cigarettes (also known as “vapers”) have a very divisive position in the medical community for many reasons. As a product of vaporized liquid which may or may not contain nicotine, it has been proven not to have short-term hazardous effects on people, with its long-term effect still unknown; yet, it has proven to be a successful replacement for cigarette consumption whereas its protestors claim it is dangerously normalising smoking again. Ties with “Big Tobacco” reinforce this position. The Bundeszentrale für gesundheitliche Aufklärung (BZgA) includes E-cigarettes as a cessation method, although they don’t recommend its use. Also, statistics show that after 12-months, a high percentage of e-cigarette consumers relapse and end using both cigarettes and vapers simultaneously. Nevertheless, the initial efficacy combined with behavioural therapy could prove to be in the right direction, provided the users use nicotine-free liquids, without losing the social elements that reinforce smoking.

E-Cigarette

Prescription Drugs Proven to be the best individual method to successfully quit smoking, prescribed medications Varenicline and Bupropion SR are the most common. Working as partial stimulants for nicotine receptors, they decrease both the need for smoking and withdrawal symptoms. Having an intended period of use of 3 to 6 months, they also work as antidepressants, with side-effects as cardiovascular disease (Varenicline) and epileptic seizures (Bupropion SR) amongst others, ideally should be used accompanied by counselling.

Prescription Drugs

Other Therapies and Aids As far as alternative methods go, hypnosis yields the highest abstinence levels (in combination with cessation courses). Nevertheless, both placebo and actual hypnosis groups got better results, as shown by 2000 meta study, compared to unassisted methods, thus being regarded as â&#x20AC;&#x153;possibly efficaciousâ&#x20AC;? (Green, 2000). Animal-assisted-therapy studies show that almost 30% of smokers would be highly motivated to quit smoking knowing second-hand smoke to be harmful to pets. Also, pet ownership reduces anxiety and increases self-esteem, important elements during the early abstinence stage of quitting. Not necessarily being a treatment method itself, an appropriate diet is a key part of the quitting process, as there are physical and psychological downsides when one stops smoking that could disrupt a personâ&#x20AC;&#x2122;s diet and cause a weight increase. During the first weeks after quitting, the lack of nicotine will develop anxiety effects and alter the metabolism increasing appetite; additionally, the handto-mouth habit can be replaced with compulsive eating, generally unhealthy and easy to get food. To avoid these, a healthy dietary replacement must be prepared in advance, with fruits, vegetables, water and milk substituting sweets, meat, alcohol and coffee. In a similar note, studies have shown that exercise is a helpful aid for reducing tobacco withdrawal and cravings, as exercise releases endorphins, neutralizing the anxiety created by nicotine; as well as contributing in avoiding potential weight gain. Since studies are not conclusive as if exercise alone is enough to quit, combined treatments are proven to be twice as successful in long-time abstinence, so NRT and/or cessation courses are recommended along a continuous workout programme. The same effect apply to yoga as a complementary activity to help minimize withdrawal symptoms, with a 2012 study showing higher 7-day prevalence rates for yoga participants compared to people not engaged in physical activity. More at-hand aid techniques to help battle relapse are listening to relaxing music, play with a rubber ball, take sugar-free candy (e.g. pepper-mints) and similar activities that physically and mentally distract one from such cravings.

Other Therapies and Aids

Combined Therapies Medical, non-medical and alternative therapies have individual varying results and none guarantee success, since a high level of personal disposition is required. Therefore, the most recommended way to achieve smoke freedom is to combine two or more cessation methods, according to each patientâ&#x20AC;&#x2122;s best suit. Although it is proven to have an increased effectiveness, therapy combination has to be watched with care, avoiding, for example, adding prescription drugs to a NRT treatment or with E-cigarette, which would represent an increase in nicotine intake and defeat the purpose. Thus, medical consultation is always recommended.

Combined Therapies

Medical Cessation course NRTCourse + Assistance Meds 2 NRT's + NRT Medication

Hypnosis

Course + Hypnosis

Course + Acupuncture Course + Acupuncture Animal assisted + Hypnosis Course + Music Course + E-cig Course Acupuncture Assistance Course + Yoga Medical assistance + Meds + Meds Course + Meds + Acupuncture Course + Exercise Acupuncture + Animal-assisted

50% Quit lines 40%

Unassisted

Quit line + E-cig

Animal-assisted Music + Animal-assisted

30%

ste ssi

a Un

20% E-cigarette

E-cig + Exercise

Yoga + Music Music

Alt

ern

ati

Exercise + Yoga Yoga

10% Exercise

Method efficacy

Efficacy according to studies

Combined Therapies

Estimated efficacy

CONCEPT The harms of tobacco is well documented, there an important awareness environment, solution policies are proposed and there is a political will to make a difference; but existing programs are not reaching the majority of people who need -and want- to take part in them. As a starting point, the project will focus on patients who are in their late 20’s and early 30’s for two main reasons. Research shows that 30 years old is the “last chance” to quit smoking without it having irreparable tolls on one’s health. Although quitting at any age will bring benefits in different measure, 30 years becomes a hinge age. The second reason is that, being at the edge of parenthood, it will also reduce influence on children and decrease secondhand smoke hazard. The objective of the project is to analyse what smokers willing to quit need, what are the main obstacles they find and what pushes them to relapse in their attempts to stop smoking and integrate medical, behavioural and alternative treatments to minimize relapse by encouraging and re-learning how to carry a healthy lifestyle, which in return will reduce anxiety and withdrawal symptoms at home, work and social interactions. By opening the project to patients (treatment) and public (awareness), different cessation programs can be seen in a safe environment, modifying the media-constructed image of addict=deplorable and by normalising therapies, increase attendance and participation in highly effective treatment, unlike the wide-spread-low-success “cold turkey”.

Concept

Open House For different reasons, Berlin homes are enclosed compartments, where individual lifestyle is kept private - opposite with the capitals liberal attitude. Not only creating a healthy environment is needed for one to quit smoking, but by creating a place where community life can happen while allowing for individual development to occur, people will be atracted to participate and invested in returning by their own choice. A home-like place where life is expected to happen and taught free from tobacco addiction. To achieve this, the project will be open and integrated, with gradients of flow and use instead of partitions, managing the levels of privacy required in a medical treatment with the public inclusion aspirations by enhancing the sensorial qualities of different activities like cooking, walking, listening to music, socializing, etc. and reconnecting patients with them in an environment free of smoke and freeing them of the need of smoking. Material, visuals, sound and smell will be key elements in a project that will attend to the different ways people can react to tobacco abstinence and become part of the treatment itself.

Open House

Soothing Freedom Working. Working-out. Studying. Taking a break. Cooking. Eating Talking on the phone. Having a beer with friends. Having a beer by yourself. These are some of the situations which regular and nonregular smokers automatically turn into â&#x20AC;&#x153;cigarette timeâ&#x20AC;?. Anxiety over a restriction in any of this situations shows how smokers have become slaves over their addiction and teaching to carry on with a regular non-smoking life can not only reduce relapse incidence but free people of a burden. Therefore, the project must be inclusive on different levels, beginning with fellow patients, family members, friends and extending to general society. The success of the project will rely on the environment created, as it not only has to be, but be perceived as healthy; as well as an environment people escape to and can look as replicable in their homes and workplaces. Furthermore, the diversitiy of treatments present the opportunity of a varied program which can be taken as a chance of diverse integration and operate like a small city

Soothing Freedom

PROGRAM The project seeks to combine medical, alternative and unassisted treatment methods in a complementary practice set in its main goal to help people quit smoking in a permanent manner and contribute in modifying unhealthy habits. Traditional consultation for private and group therapies interconect with spaces dedicated to common lifestyle where patients can enjoy their everyday activities or take on new interests in an environment where they can be assisted of any sort of tobacco-related anxiety.

Program

Program Schedule

Group Therapy

Private Therapy

Acupuncture

Hypnosis

Smoking

Information Center

Kitchen

Garden

Front Desk

Workspace

Meeting Room

Toilets

Storage

Technical

Cafe

Bar

Restaurant

Program Schedule

COLOR STRENGH

MATERIAL STRENGH

227

Lobby Front Desk Waiting Room

15 2 15

15 3 15

60 12 60

1 1 1

60 12 60

*** * *** * ** **

Information center General Counseling

2 1

4 2

6 3

18 12

1 2

18 24

** ** ** * *** **

Course Course, Meds, Hypnosis, Music

1 1

15 2

16 3

48 12

1 3

48 36

** ** *** *** *** *** *** * *** ** ** *** * ***

Acupuncture Common kitchen

Acupuncture Diet Therapy

1 1

1 15

2 16

15 48

1 1

15 48

* *** *** *** *** *** *** ** * *** *** * * **

Smokers yard Patients court Staff court

Course Animal-assisted, All Therapies

1 1 17

15 15

16 16 17

1 1 1

48 96 51

** *** ** ** ** *** * ***

Group Therapy Private Therapy

48 96 51

Storage

NOISE ISOLATION

727

VIEW

PRIVACY

ACCESSIBILITY

CENTRE STANDARD

QTY

259

OCCUPIED AREA

865

COVERED AREA

MAX PEOPLE

COMMENTS

NATURAL LIGHT

** ** **

MAX VISITORS

* * *

MAX EMPLOYEES

* *** * ** *** ** ** *** **

TOTAL

ROOM

* *** ** ** * ***

*** *** * *** * *

Staff room Drugstore

8 2

8 4

24 20

1 1

24 20

* *** *** *** *** ** *** * * **

* *

Manager's Office Manag. Workspace

1 3

2 1

3 4

9 12

1 1

9 12

* *

*** ** *** **

** **

Restrooms Restrooms Staff Storage Technical

2 1 2 2

12 4.5 10 10

2 2 1 1

24 9 10 10

** * * *

*** *** *** ***

* * * *

*** *** *** ***

* * * *

* *** *** * * *

*** * ** *** ** ** ** * * ** ** *** *** *** * ** * *** *** *** * ** *** * ** *** * * *** ** *** * * *** * * ** *** * * *** * * **

* * * *

35% 222 3

2 24 16 2 2 1

138 2 24 16 2 2 1

10 48 32 15 8 5

Walls & Circulation 20.3 13.5

TOTAL COVERED AREA TOTAL OCCUPIED AREA

Qualities and Relationships

1 1 1 1 2 1

10 48

35%

32 15 16 5

Acupuncture

Private Therapy

Group Therapy

General Counseling

** **

* *

*** ***

* *

** *

* *

48 36

** ** *** *** *** *** *** * *** ** ** *** * ***

* *

** **

* *

** **

* *

*** *** *** ** *** ** ** ** *** ** ** * *** *** *** *

** *

* *

15 48

* *** *** *** *** *** *** ** * *** *** * * **

* *

** **

* *

** **

* *

** ***

* **

* *** ** ** * ***

* * *

* * **

* * *

* * * * *** ***

* * *

** * ***

* *

1 3 1 1 1 1 1

48 96 51

*** *** * *** * *

* *

Lobby

Common Kitchen

* *

Front Desk

Smokers Yard

* *

Waiting Room

Patients court

* *

Information Center

Staff court

** **

Drugstore

* *

Manager's Office

* *

** ** ** * *** **

Manag. Workspace

* *

18 24

Restrooms

** *** ** ** ** *** * ***

1 2

Restrooms Staff

* * *

Counter

* ** **

CafÃ©

* * *

Terrace

* * *

Kitchen

** ** *

*** * *** * ** **

Restrooms

* * *

60 12 60

Storage

Staff room

MATERIAL STRENGH

** *** **

1 1 1

NATURAL LIGHT

* * *

227

VIEW

** *** * ** ** ** * * *

727

PRIVACY

* *** * ** *** ** * *** *

259

ACCESSIBILITY

Storage

COLOR STRENGH

** ** **

Technical

NOISE ISOLATION

* * *

TOTAL COVERED AREA TOTAL OCCUPIED AREA

QTY

* *** * ** *** ** ** *** **

* * *

865

** *** *** *** *** *** ** *** ***

*** ** *** ** *** ** *** ** *** * * *

* ** ** ***

* *

* **

* *

* * ** *** * * * * * *** ** *** *** *** *** ** *** ** * * * * * * * * *

1 1

24 20

* *** *** *** *** ** *** * * **

* *

** ** *** ** *** ***

* *

*** *** *** *** *** ** *** *

* *

** *

* *

** * ** ***

1 1

9 12

* *

*** ** *** **

** **

** *** ** ***

* *

***

** *** ** *** *** *** ***

* *

** **

2 2 1 1

24 9 10 10

** * * *

*** *** *** ***

* * * *

*** *** *** ***

* * * *

* * * ** ** *** ** *** **

* * *

* * * * * *** *** *** *** ** ** ** *** ** * ** ** ** ** *

* * * *

** * * *

** *** *** *** * * ** * * * * * * * * *

* *** *** * * *

*** * ** *** ** ** ** * *** ** *** * ** ** *** *** *** * ** * *** *** * *** *** *** * ** * *** ** *** * ** *** * * *** ** * * *** *** * * *** * * ** ** ** ** * *** * * *** * * ** *** * * **

* * * *

** *

35% 222 138 1 1 1 1 2 1

10 48

35%

32 15 16 5

3 5

Qualities and Relationships

100

Page Title

101

102

NETWORK With an existing network of over 25 centres which vary between medical and alternative, one of the main factors that improve attendance to cessation therapies is the availability of facilities. Taking as references a 1km - a 10 minute walk - as well as all existing providers in Berlin central area, 13 new centres are proposed as part of an extended complementary network. The area of analysis is determined, for practical purposes, by the S-Bahn ring. From the proposed locations, the project focused is the one located at Ida-Wolff-Platz in Kreuzberg, very close to Mitteâ&#x20AC;&#x2122;s fi nancial district

Network

103

Availability

104

Therapy course

Acupuncture / Acupressure

Hypnosis

Other

Availability

0km

Availability

1km

2km

105

106

LOCATION Adjacent to a square and a school, the site’s location between Kreuzberg’s residential areas and Mitte’s fast paced worklife has the potential to atract a high variety of people seeking to quit smoking. Although not directly connected, the visual connection between Ida-Wolff-Platz and the park at the Tempodrom create a strong link with green areas that are to be preserved by the project, while facing the specific situation given by the school on one side and projected housing developments on the other

Location

107

108

Location

109

Ida-Wolff-Platz

110

Site

111

Analysis

The site has a strong connection with the adjacent building, a pre-war school, but is isolated from its following neighbour, a new housing development open towards the site. Furthermore, the main facade faces a square but also has a park as backdrop, existing a visual connection of green areas which are to be preserved. Additionally, given the projectâ&#x20AC;&#x2122;s requirement of functioning as an attractor, the design compensates the recess from the main avenue by adopting a bold but meaningful formal approach

112

Analysis

113

114

DESIGN Starting from an iconic formal approach intended to draw people and expose the buildingâ&#x20AC;&#x2122;s program, the design looks to respect the immediate context as well as preserve the visual connection between the green open areas. From the inside, a bidirectional a strong link to a public non-treatment space grounds the project, mostly intending to attract potential new patient and arouse curiosity, reaching its peak in a public staircase which offers continous views and sitting spaces ending on a public smoking area where commited smokers can enjoy without disturbing non-smokers. Finally, all treatments are given with equal value, whether medical or alternative, by combining spaces provided withing the building and facilitating visual connections when possible.

Design

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Volumetric Process

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Volumetric Process

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Functional Distribution

The program is divided in three: treatment facilities, awareness and attraction of smokers. Then, the building is divided in the same manner, with the first triangle devoted to the therapies, the second serving as a cafe for patients and non-patients and finally, a public smokers terrace on the rooftop accesible by a roof staircase providing views and a more protected environment for nonsmokers.

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Functional Distribution

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Level -1

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Level -1

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Level 0

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Level 0

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Level 1

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Level 1

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Level 2

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Level 2

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Level 3

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Level 3

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Level 4

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Level 4

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Roof

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Roof

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Section 1

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Section 1

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Section 2

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Section 2

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Section 3

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Section 3

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Section 4

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Section 4

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Section 5

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Section 5

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Elevation

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Elevation

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Axonometric View

Level -1

146

Axonometric View

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148

Site Model

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Site Model

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Model

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Model

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Eldrige, Lynne. Verywell. n.d. https://www.verywell.com/lung-cancer-4014694 (accessed December 30, 2016). Eriksen, Michael P. „The tobacco atlas.“ Atlanta, Ga, 2015. Eriksen, Michael P., and Judith Mackay. „The Tobacco Atlas.“ Geneva, 2002. FAO. November 2016. http://www.fao.org/faostat/en/#data/QC (accessed January 16th, 2017).

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Fiore, Michael C. Treating tobacco use and dependence : 2008 update. Rockville: U.S. Dept. of Health and Human Services, Public Health Service, 2008. Fujimoto, Sou. „Primitive Future.“ El Croquis 151. Sou Fujimoto 2003-2010. Theory and intuition, framework and experience, 2010: 130-143. GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012. n.d. http://globocan.iarc.fr/ (accessed December 21, 2016). Institute for Health Metrics and Evaluation (IHME). „Global Burden of Disease Study 2015.“ 2016. http://ghdx.healthdata.org/gbd-results-tool (accessed 01 11, 2017). Jha, Prabhat, et al. „21st-Century Hazards of Smoking and Benefits of Cessation in the United States.“ The New England Journal of Medicine, 2013: 341-350. Jones, Jeffrey M. Smoking Habits Stable; Most Would Like to Quit. July 18, 2006. http://www.gallup.com/poll/23791/smoking-habits-stable-most-wouldlike-quit.aspx (accessed December 21, 2016). Joosens, Luk, and Martin Raw. „The Tobacco Control Scale 2013.“ Brussels, 2014. Kraft, Benedikt. „The future of architecture is primitive.“ Deutsche BauZeitschnit, 2013: 94-101. Mental Health Foundation. n.d. https://www.mentalhealth.org.uk/a-to-z/s/ smoking-and-mental-health (accessed January 18th, 2017). Nicoderm CQ. n.d. https://www.nicodermcq.com/ (accessed January 16th, 2017). Nicorette. n.d. https://www.nicorette.com/ (accessed January 16th, 2017).

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Nutt, David, Leslie A. King, William Saulsbury, and Colin Blakemore. „Development of a rational scale to assess the harm of drugs.“ Lancet, 2007: 1047-1053. O’Leary, Dane. Do Public Perceptions of Addiction Discourage Addicts from Recovery? n.d. http://rehab-international.org/blog/public-perceptionsaddiction-discourage-addicts-recovery (accessed January 21st, 2017). The Tobacco Atlas. n.d. http://www.tobaccoatlas.org (accessed December 16, 2016). United Nations. „World Population Prospects: The 2015 Revision, key findings and advance tables.“ New York, 2015. WHO. „A guide for tobacco users.“ Geneva, 2014. WHO Framework Convention on Tobacco Control. „Guidelines for implementation : article 5.3, article 8, article 9 and 10, article 11, article 12, article 13, article 14.“ Geneva, 2013. WHO Framework Convention on Tobacco Control. „WHO Framework Convention on Tobacco Control.“ Geneva, 2005. WHO Tobacco. n.d. http://www.who.int/mediacentre/factsheets/fs339/en/ (accessed December 19, 2016). Wikipedia. Tobacco. January 9th, 2017. https://en.wikipedia.org/wiki/Tobacco (accessed January 16th, 2017). World Life Expectancy. n.d. http://www.worldlifeexpectancy.com/worldrankings-total-deaths (accessed November 14, 2016). YouGov. „Smoking is definitely not cool, heavy drinking is less clear.“ n.d. https://today.yougov.com/news/2016/11/09/smoking-definitely-not-coolheavy-drinking-less-cl/ (accessed December 21, 2016).

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I Dessau International Architecture School Anhalt University Department 3 ÂŠ 2016/17