Cancer Prevention
1. Lifestyle and Cancer
2. Tobacco and Cancer

Lifestyle & Cancer Dr A Goel, MBBS, MS, DNB Dr AK Dewan, MS, MCh   (Dr. Dewan is medical Director of Ganga Prem Hospice and Dr. Goel is one of the Hospice's visiting oncologists.)

Dr Ashish Goel

According to a world cancer report, cancer rates are set to increase at an alarming rate globally. Cancer rates could increase by 50% to 15 million new cases world wide by 2020. This steady increase is mainly due to an increase in the aging population and current trends in smoking and unhealthy life style habits across the globe in both developing and developed countries. Cancer is now emerging as a major public health problem in developing countries, matching its effect in industrialized countries. In developing countries, including India, oral cancer is the most common cancer in males and breast cancer in females. However cervical cancer remains the most common cancer in rural women. Lung cancer remains the second most common cancer in both males and females.

Epidemiological studies have shown that 70-90% of all cancers are environmental. Lifestyle related factors are the most important and the most preventable among the environmental exposures. Tobacco consumption either as chewing tobacco or smoking tobacco accounts for 50% of all cancers in men. Unhealthy dietary practices and reproductive and sexual practices account for 20-30% of all cancers. Appropriate changes in lifestyle can, therefore, reduce the mortality and morbidity from a good proportion of cancer and heart diseases.

Diet and Cancer
Most of the cancers have some relationships with diet, predominant among them being cancer of the upper aero digestive tract (mouth, throat etc), esophagus (food pipe), lungs, stomach, large intestine, and breast cancer in women.
The role of diet takes special importance in countries like India which are fast moving towards industrialization and westernization. This coupled with other habits like smoking and alcohol abuse will lead to increase in the chronic disease burden especially in cancer and cardiovascular diseases. Prompt action has to be taken to spread the message of a healthy life style and good dietary practices.

Several studies have identified high fat diet and meat consumption as risk factors and a diet rich in fruits and green and yellow vegetables as protective against many cancers. The biologically active ingredients of fruits and vegetables (carotenoids) have substantial anti-cancer properties.

The main risk factor for cancer of the mouth and throat is tobacco and alcohol. A diet rich in green and yellow vegetables has been shown to offer protection against oral cancer. Avoidance of tobacco and alcohol is however the most important preventive action against mouth, throat and lung cancers. Consumption of large amounts of red chillies, food at very high temperatures and alcohol consumption are the main risk factors for stomach cancer. Heavy consumption of red meat can lead to risk of colon cancer. White meat such as that of poultry does not have this risk.

Lifestyle and Cancer
A large number of factors have been identified as risk factors for breast cancer. Menarche at an early age, first pregnancy at a late age, that is more than 30 years, having a single child, nulliparity, and menopause late age increase the risk of developing breast cancer. In postmenopausal women, obesity and postmenopausal hormone replacement therapy are associated with increased breast cancer risk. A high fat diet is also identified as a risk factor. Physical activity is found to be protective for breast cancer. There may be a moderate protective effect from high vegetable consumption, but results for fruit, fiber, and meat consumption are inconclusive. In contrast, there appears to be a definite association between alcohol and breast cancer risk, with the risk increasing with the amount of alcohol consumed. Decreased intake of nutrients such as vitamin C, folic acid, and beta carotene may enhance the risk related to alcohol consumption. Obesity is associated with both an increased risk of breast cancer development in postmenopausal women and increased breast cancer mortality.

Long-term use of hormone replacement therapy for post menopausal symptoms (estrogen-progestin combinations) increases the risk of breast cancer in women. There is no evidence of any link between birth control pill use and breast cancer risk. The analysis of older oral contraceptives however showed that women who took the pill for four or more years before their first full-term pregnancy had a increase in premenopausal breast cancer risk.

Having a first intercourse at an early age, having multiple sexual partners, keeping poor sexual hygiene, having repeated child birth etc are some of the reproductive risk factors for cervical cancer. Improvements in the living standards of women have resulted in a reduction in the incidence of cervical cancer. Regular cervical cytology examination (pap smear) by all women who have initiated sexual activity can prevent the occurrence of cervical cancer.

Hygiene and Cancer
There is definite evidence of association between poor personal hygiene and cervical cancer in women and penile cancer in men. Most of the evidence supports a high incidence of HPV infection in penile cancer patients. HPV is a virus which is transmitted from skin to skin contact during sexual intimacy. Persistent HPV infection may lead to several premalignant changes further increasing the risk of cancer if left untreated.

Other risk factors for penile cancer include smoking, having an age of more than sixty years, and AIDS. Personal hygiene in the genital area is very important. Oily secretions, dead skin and bacteria which can build up under the foreskin (known as smegma) can lead to persistent infection and irritation leading to premalignant changes and development of carcinoma penis. Some of these risk factors can be avoided.

HPV has the strongest link with cervical cancer development. It is an extremely common virus that is transmitted through sexual contact. Studies have shown that smoking can accelerate the cervical damage caused by HPV. Having many sex partners or having sex with someone who has had many sex partners may increase the risk further. Having sex at an early age also increases the risk for cervical cancer.

Physical Activity and Cancer

Researchers have established that regular physical activity can improve health by helping to control weight, maintaining healthy bones, muscles and joints, reducing the risk of developing high blood pressure and diabetes, promoting psychological well-being, reducing the risk of death from heart disease, and reducing the risk of premature death.

In addition to these health benefits, physical activity can also affect the risk of cancer. There is convincing evidence that physical activity is associated with a reduced risk of cancers of the colon and breast. Several studies have also reported links between physical activity and a reduced risk of cancers of the prostate and lung, and of endometrial cancer.

Colorectal cancer has been the most extensively studied cancer in relation to physical activity. Several studies have shown a consistent association between increase in physical activity either in intensity, duration, or frequency leading to a reduced risk of developing colon cancer by 30-40 percent, relative to those who are sedentary, regardless of their body mass index (BMI). The protective effect appears greatest with high-intensity activity, although the optimal exercise levels and duration are still difficult to determine. The association of physical activity with breast cancer incidence has been extensively studied and over 60 studies have indicated that physically active women are at lower risk of developing breast cancer than inactive women; however the amount of risk reduction achieved through physical activity varies widely between 20-80%. There is also an inverse association between physical activity and endometrial cancer incidence, however the evidence is not as strong as the positive effect found for breast cancer.

Summary
1. Promote the use of a vegetarian diet. Use fresh fruits and green vegetables. Wash fruits and vegetables thoroughly before consumption.
2. Stop the use of tobacco (smoking and chewing) and alcohol.
3. Physical activity (a brisk walk for at least 20 minutes a day) is desirable. Yoga asanas can compliment physical activity/exercise. Keep weight in check.
4. Keep small family norms and breast feeding of babies. Have timely marriage and childbirth. Avoid HRT after menopause.
5. Practice monogamy and maintain sexual hygiene.

Tobacco and Cancer
Dr Ashish Goel, MBBS, MS,DNB
Dr AK Dewan, MS, MCh

Tobacco cultivation has a history of about 8000 years. It was introduced in India by Portuguese traders in the 16th century, and later on gained acceptance into the social and cultural practices of India.

Tobacco is a major cause of preventable mortality and morbidity around the world. It is responsible for more deaths than those resulting from road traffic accidents, suicides, homicides, maternity mortality and other causes combined. In India nearly half of all cancers in men are associated with tobacco use including mouth (oral cavity), lip and tongue, throat (oropharynx, larynx & hypopharynx), oesophagus, lung and urinary bladder. In women, less than one fifth of cancers at these sites, including oesophagus and oral cavity are tobacco related. Tobacco related cancers constitute a lower proportion of all cancers among women due to lower prevalence of tobacco consumption compared to men.

Prevalence of Tobacco Use in India

Around the world China is the largest consumer of tobacco where as much as 60 % of the population indulges in smoking followed by USA, UK and Australia. According to epidemiological studies by the Indian Council of Medical Research there are 184 million tobacco consumers in India. Fifty-five thousand children take up this habit every year. Nearly eight lakh deaths in India are tobacco related.

Prevalence of tobacco use among men above 15 years of age varies from 46 - 63% in urban areas and 32 - 74% in rural areas. Among women it varies from 2 - 16% in urban areas and 20 - 50% in rural areas. Use of smokeless tobacco is however similar in both men and women. Several studies conducted in India on cancer at various sites have shown that both smoking and smokeless tobacco use (including tobacco with lime and paan with tobacco) lead to elevated risks for intra-oral, oropharyngeal, oesophageal and cervical and penile cancers. Smoking also causes increase in risk for lung, hypopharynx, larynx and stomach cancers as well.

Besides cancer; tobacco is also responsible for high blood pressure, heart disease, peripheral vascular disease, bronchitis and emphysema ultimately leading to COPD, stroke, impotence and male infertility. Consumption of tobacco during pregnancy may lead to placental complications, perinatal death, low birth weight, miscarriage and fetal malformations.

Tobacco Habits in India
In India tobacco is consumes in a variety of forms across various parts of the country; and for each form a wide variety of products are available. All these tobacco forms are equally harmful.

1. Smoked Tobacco- cigarette, cigar, bidi, dhumti, chutta, hookah, chillum etc.
2. Chewed Tobacco- pan, gutkha, khaini, mawa, pan masala etc.
3. Applied forms- snuff, tobacco based toothpaste, creamy snuff.

Anti-tobacco Interventions
Several large community intervention studies have been conducted in India to assess the effectiveness of various communications strategies in persuading individuals to reduce or give up their habits. Some of these studies were also evaluated in terms of the regression of oral precancerous lesions in those who stopped using tobacco, as an indicator of reduction in oral cancer risk. Several primary prevention approaches may include health education and making the public aware of the health hazards of tobacco. Educational institutional and mass media campaigns including the role of NGO’s is very important in this regard by distribution of IEC material to individuals in various establishments.

Tobacco Cessation Clinics
Informal tobacco cessation clinics using counselling have been in operation for a long time in India. With the recent availability of nicotine replacement therapy, such as nicotine patches and Buproprion, several health facilities have set up tobacco cessation clinics for people who want to quit, but are unable to do so on their own. These clinics employ pharmacological support in addition to behavioral therapy, which may include individual, group or telephone counselling, rational emotive therapy and yoga with pranayam.

Oral Cancer Screening
The aim of screening is to identify precancerous lesions and early malignant lesions in order to treat them early and achieve high cure rates. Because the mouth is a region which can be easily seen by an individual; it may allow early detection of lesions by the individual himself and by the health worker.

Legislation
In order to curb the use of tobacco in India, health researchers, health care providers, lawyers and others have jointly proposed comprehensive legislation on advertisement, sale and use of tobacco. The Tobacco Products Bill, 2001 prohibits advertising and sports sponsorship by tobacco companies.

There is prohibition on smoking in public places such as hospitals, dispensaries, educational institutions, conference rooms, domestic air flights, A/C sleeper coaches in trains, sub-urban trains, A/C buses, etc. It disallows the sale of tobacco to persons below 18 years and within 100 meters of educational institutions, government and semi-government offices.

Clear health warnings are mandatory on all packages in local languages and in English, along with tar and nicotine content, to inform the public about the risks of using the products.

Warning on Cigarette Packages/Advertisements
The Cigarette (Regulation of Production, Supply and Distribution) Act 1975 requires that all packages and advertisements of cigarettes carry a statutory warning, “Cigarette smoking is injurious to health”. The Act provides specific instructions related to minimum font size, colour contrast, etc for the warning.

Warning on Smokeless Tobacco Products
Realizing the need for a warning on smokeless tobacco products (classified as food material), the provisions under the Prevention of Food Adulteration Rules, necessitates that every package and advertisement of smokeless tobacco product should have a warning stating that “chewing of tobacco is injurious to health”. Packages of areca nut should also state that “chewing of supari may be injurious to health”.

Community Education on Tobacco
Anti-tobacco education needs to be targeted at decision-makers, professionals and the general public, especially the youth. Efficacy of educational activities in tobacco cessation had amply been demonstrated by various organizations. No Tobacco Day (31st May) activities have been a regular feature since 1988, which generally comprise of educational advertisements in newspapers along with a programmes and workshops on the theme. Tobacco has been included as a topic in books brought about by NCERT. National Cancer Control Programme also stresses on anti-tobacco education, in view of the fact that half of the cancers among men and about one fifth of the cancers among women in India pertain to tobacco related sites. The anti-tobacco community education activities have been initiated in about 60 districts through district level projects for control of cancers. Coverage of the entire country for anti-tobacco education is a formidable job and can not be achieved without active support from Non-Governmental Organizations and mass media. They, however, need support from the health departments for availability of reliable and impartial information on the subject. Support would be needed not only from health related non-governmental organization but also from other related sectors like education, economics, agriculture, welfare, etc.

Prevalence of Tobacco Use among Young People
Recently there has been an increase in tobacco consumption in young people including school children. A recent ICMR study reports that one-fourth of college students smoke. The prevalence of smoking in youth varies in different states 4.0% in Himachal Pradesh to 75.3% in Mizoram. Currently smokeless tobacco use has been found to be more common among students aged 13 to 15 years.

The determinants of tobacco use among the youth are many. Socio-demographic factors such as gender, state and region, and rural versus urban residence are the most important factors. Others include factors affecting social norms, family influence and tobacco use by friends, exposure to advertisements in media and community; access and availability of tobacco products in area of residence; concurrent alcohol and tobacco smoking, levels of awareness about harmful effects of tobacco and attitude towards government tobacco control policies on access and availability of tobacco products to minors; school policies; tobacco control strategies and tobacco industry tactics to attract the youth.

Tobacco is used by the youth all over India with a wide range of variation among states. Two in every ten boys and one in every ten girls use a tobacco product. There is no statistical difference in rural and urban populations. Many young people have the misconception that tobacco is good for teeth or health. Initiation to tobacco products before the age of 10 years is increasing. States having higher levels of curricular teaching have a low prevalence of tobacco use by students.

World No Tobacco Day, 31st May 2010
The theme Of World No Tobacco Day 2010 has been Gender and Tobacco with an emphasis on marketing to women.

Women compromise 20% of World’s smokers that is to say there are 1 billion women who smoke.
Who - Director General (Margaret Chan) says:
“Protect and promote the health of women which is crucial to health and development - not only for the citizens of today but also for those of future generations.”

Tobacco advertising increasingly targets girls. At present 7% adolescent girls and 12 % adolescent boys smoke.

How Can We Help Revesrs the Trend?

• World Tobacco Day is for reminding the public, NGOs, governments, etc.
• Media coverage is needed to make people aware of health problems caused by tobacco.
• Anti-tobacco campaigns
• Educational programmes
• Encourage bans on surrogate advertisements
• Publish Images that symbolize World No Tobacco Day
• Support a total ban on advertisements (Print, screen, internet)
• Abstinence of tobacco at least for 24 hours
• Make everyday World No Tobacco day

Why India needs an Anti Tobacco campaign

• Over 120 million Indians smoke. 10% of world tobacco smokers live in India.
• One third of Indians (57% men & 11% women) consume some form of tobacco.
• India cannot afford the health costs of tobacco-related diseases. Approx. Rs 300 billion were spent from public and private funds on tobacco related diseases in 2002-3.
• Smoking kills 10 lakh Indians annually.

Pictorial Health Warnings Work !

• An individual who smokes 1 pack of cigarettes a day is confronted with a health warning over 7000 times a year.
• A 2002 WHO survey of 9,058 smokers in 4 countries revealed that 44% smokers said new warnings increased their motivation to quit.
• New warnings made 58% smokers think more about smoking health effects.

Lack of Pictorial Tobacco Warnings in India

• June 1 2009: Pictorial warnings regulation came into force; warnings looked ordinary with illustrations of crabs.
• June 1 2010: More graphic pictorial warnings scheduled to come into force.
• May 17, 2010: Govt. of India defers enforcement date to December 1, 2010, apparently under pressure from tobacco lobby

An excerpt from Finance Minister's speech on April 29, 2010 in Lok Sabha:
“I had proposed an increase in excise duty on almost all tobacco products including cigars and cheroots. I have received a large number of representations on behalf of the manufactures of hand-rolled cheroots' – an industry located primarily in the cottage and household sector. Considering the nature of this labour intensive industry, I now propose to reduce the excise duty on hand-rolled cheroots priced up to Rs.3 per stick to 10% ad valorem. Similarly, the additional excise duty on this product shall now be 1.6% ad valorem.“

Violations of and Problems with Tobacco Laws In India

• Direct or indirect advertising of tobacco products still go on despite it being banned under the Cigarettes and other Tobacco Products Act enacted in 2003
• Tobacco Taxes In India are very low
• Bidis are very cheap in India. Taxes on bidis only 9% of retail price.
• Cigarette taxes account for approximately 38% of retail price although taxes recommended by the World bank are from 65% to 80% of retail price.
• Taxes in India are complex. Cigarettes are taxed based on their length; and differential taxes on hand-versus machine rolled bidis.
  

Summary

India needs to upgrade its efforts to control tobacco abuse through a sustained campaign which includes both lobbying the government for appropriate tax and advertisng legislation and education programmes to increase public awareness of the dangers od tobacco consumption.

TOBACCO KILLS!