Tobacco control is most cost-effective way to prevent cancer
- Special on World Cancer Day: 4 February 2010 -

Professor (Dr) Rama Kant *

Most public health programmes of the Government of India are directed towards communicable diseases such as malaria, filaria, polio, tuberculosis and leprosy etc. The occurrence of certain diseases due to lifestyle changes like diabetes, respiratory/cardiac diseases, tobacco related disease and cancer, has now been recognized, and public health programmes are also being initiated against them.

But these are few and far between. Life style diseases have a peculiar “follow others” ingredient which becomes still more complicated due to ignorance, especially in families where the elders have addictions and wrong eating habits, and the youngsters are exposed to the “role model” phenomenon. In many situations elders tell children that tobacco is bad for children and the latter are confused as to how it is bad for them and good for others. This ambiguity, coupled with peer pressure proves to be disastrous for the youth.

Most important part of all this is that the diseases and death caused by these life style aberrations are preventable.

Smoking And Tobacco Related Cancers

Lung Cancer
Lung cancer is one fatal but preventable life-style disease. Smoking causes 90% of lung cancer. Non-smokers who breathe in other peoples’ tobacco smoke, known as second-hand smoke, are also at an increased risk of lung cancer. Children and teenagers exposed to second hand smoke may be particularly at risk of lung cancer later in life as well as an increased risk of asthma and other respiratory problems.

Mouth and Throat cancer
Oral cancer is the most common cancer in India. Smoking is a major cause of cancers of the oral cavity (tongue, lips, gums) oesophagus and larynx.

Majority of oral cancers occur because of chewing Tobacco, gutka etc.
According to Dr Geoff Craig "People are dying of oral cancer because of ignorance". There are about 7,00,000 new cases of cancers every year in India out of which tobacco related cancers are about 3,00,000. Cost of treatment of one oral cancer patient is about Rs 3.5 lacs. This can be completely prevented by simple changes in lifestyle and regular screening. About 2000 deaths a day in India are tobacco related.

Cancer of the pancreas, stomach and kidney
Smoking is also, at least a contributory and, may be, a causal factor in the development of cancer of the pancreas and of the kidney. When you inhale cigarette smoke, you will always swallow some of it , Consequently, the risk of developing stomach cancer is higher among smokers.

Cancer of uterus, cervix, colon and bladder
Apart from these, smoking has been found to increase the risk of uterine cancer, cancer of the cervix, cancer of the colon and bladder.

Other health hazards attributed to tobacco use
Smokers and tobacco chewers are also at an increased risk of developing myeloid leukaemia., especially oral sub mucous fibrosis.

This condition is characterized by limited opening of mouth and burning sensation on eating of spicy food. This is a progressive lesion in which the opening of the mouth becomes progressively limited, and later on even normal eating becomes difficult. It occurs almost exclusively in India and Indian communities living abroad.

Tobacco when kept in mouth leaches out potent carcinogens. Habit of smoking is also equally dangerous. Treatment is surgery, and in advanced cases surgery followed by radiation therapy. 70% of the cases after treatment comeback with relapse and the ultimate result is death. The cost of the treatment is Rs.3.5 lacs on an average and in spite of this high cost there is no guarantee of total cure.

Therefore the most important aspect is PREVENTION. Use of tobacco in smoking or chewing or any other form must be stopped immediately.

The Government of the State of Maharashtra, India, had initiated a campaign against smok ing in 1986. The first reaction of smokers, mostly from urban upper-middle classes, was "We smoke because we like it. It is none of your concern. After all, it is we who would suffer, not you".

Indian Society against smoking in UP and also state of Maharashtra initiated anti tobacco programs in public gatherings etc. WHO came forward to help people by introducing aggressive anti tobacco campaigns through establishment of Tobacco cessation clinics in several states.

Tobacco-related deaths outnumber those caused by AIDS, car accidents, alcohol, homicides, illegal drugs, suicides, and fires, combined.. Fortunately, the past decade has been one in which data concerning predictors of tobacco use initiation and approaches to tobacco use prevention have been accumulating.

Factors that influence the onset of smoking are complex and numerous, and a better understanding of these factors is needed to reduce the rate of smoking. Younger individuals with less fortunate socio economic backgrounds and from single-parent homes are at higher risk of initiating smoking and experimenting with cigarettes and smokeless tobacco. On the other hand, adolescents who have friends and parents who smoke are significantly more likely to initiate smoking themselves.

Moreover, several psychological factors, including higher rates of depression and sociability, have been linked with a higher probability that an adolescent will start smoking. Lastly, the impact of the tobacco industry’s targeting of adolescents with aggressive advertising, marketing, promotional campaigns, and sponsorships on youth smoking initiation rates should not be overlooked.

Women, minorities, blue-collar workers, adolescents, and even children are bombarded by clever and often insidious marketing and advertising gimmicks. In fact, a strong correlation between smoking rates among adolescents and sales promotion expenditures by tobacco companies has been documented.

Prevention initiatives need to have two thrusts: (1) school-based programs, and (2) community-wide approaches.

School-based programs encourage students who have yet to experiment with tobacco to abstain from use through
(1) enforcement of anti tobacco policies (e.g., prohibitions against tobacco use and tobacco advertising on campus);
(2) education about the adverse health and social consequences of tobacco use (e.g., cancer risk, exacerbation of asthma, stained teeth and foul-smelling breath and clothing, and ostracism by non smoking peers);
(3) education regarding the reasons that adolescents smoke (e.g., peer acceptance, stress management) and about alternative methods for attaining such goals;
(4) education concerning the social influences on smoking, such as media, adults, and peers, and strategies for resisting such influences (e.g., refusal skills, assertiveness);
(5) the use of teachers and peer leaders as health counselors; and
(6) support for students who abstain from smoking as well as for those students who have quit. A meta-analysis of school-based prevention studies showed that programs involving peer and social elements can reduce adolescent smoking rates by as much as 30%.

Community-wide smoking prevention programs involve approaches that include counter advertising (e.g., antismoking billboard ads) and anti tobacco policies (i.e., restricting access, raising taxes, instituting bans). Evaluations of the benefits of counter advertising media campaigns suggest that this approach can effectively reduce smoking initiation rates.

The past few years have witnessed a burgeoning of anti tobacco legislation. Initiatives to restrict access to tobacco among children and adolescents are being strengthened. Evaluations of the effects of work-site and hospital smoking bans indicate that cigarette consumption is significantly reduced by such policies, with the rate of second-hand smoke exposure completely eliminated. Although studies have yet to evaluate the impact on cessation rates of restaurant and bar smoking bans, such policies undoubtedly eliminate exposure to second-hand smoke for others sitting there.

Over the past decade, the growing national commitment to reducing the prevalence of tobacco use has resulted in a substantial growth in the scientific literature and availability of clinical interventions concerning the promotion of smoking cessation and prevention. Never before has there been a more hospitable climate for conducting empirical research into the determinants and treatment of tobacco addiction and for the implementation of cessation and prevention programs. Today, the commitment to support tobacco control research and initiatives from federal and state government agencies and from private granting institutes has never been stronger

Yet, despite many advances in treating tobacco addiction and preventing initiation of tobacco use, the rate of decline in smoking among adults has slowed down, and the prevalence of tobacco use has actually increased, especially chewing tobacco. More research and wider availability of cessation and prevention initiatives are necessary if there is any hope of eradicating tobacco use among our population.

Specifically, the psychosocial and socio demographic determinants of smoking initiation must be systematically identified. Further, additional research concerning genetic and gene-environment interaction determinants of tobacco addiction is essential.

Finally, since current data indicate that optimal cessation programs can produce modest 20 to 40% cessation rates at best, a greater emphasis on evaluating more comprehensive, multi-component cessation interventions could greatly improve upon current efficacy.

Counselling by clinical psychologists, of those addicted to tobacco along with pharmacotherapy can assist in this difficult task.