1. Lifestyle and
2. Tobacco and 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
|Dr Ashish Goel
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.
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.
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
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.
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.
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.
Activity and Cancer
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
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.
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)
3. Physical activity (a brisk walk for at least
20 minutes a day) is desirable. Yoga asanas can
compliment physical activity/exercise. Keep weight
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.
Dr Ashish Goel, MBBS, MS,DNB
Dr AK Dewan, MS, MCh
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
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.
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,
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 NGOs
is very important in this regard by distribution
of IEC material to individuals in various establishments.
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.
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
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
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
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.
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.
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,
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.
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 Worlds 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.
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
- Anti-tobacco campaigns
- Educational programmes
- Encourage bans on surrogate
- 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
India needs an Anti Tobacco campaign
- Over 120 million Indians
smoke. 10% of world tobacco smokers live in
- 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
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
- New warnings made 58%
smokers think more about smoking health effects.
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
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%
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.
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.