Tobacco control: an issue twinned with oral cancer control

Abstract

Oral cancer is a silent crisis in India. Thirty per cent of all cancers are oral cancer, and approximately 17% of all cancers in men and 10.5% of all cancers in women are oral cancer. Approximately 70,000 new cases are reported annually and 46,000 oral cancer-related deaths occur each year in India; furthermore, the number of cases is rapidly increasing. With this crescendo there may be an estimated 100,000 new cases by 2020, which is insurmountable, especially in emerging economies like India. This astronomical increase is a direct result of tobacco usage. The Global Adult Tobacco Survey performed in 2010 (GATS-2010) reported that approximately 274.5 million people in India use tobacco in various forms. Increasing use of smokeless tobacco, especially by women and children, is of major concern. The World Health Organisation has identified tobacco control and oral cancer control measures as a health priority. However, prevention of tobacco use in India is a great challenge owing to low overall literacy rates and to greater prevalence among people in lower socio-economic strata. Addressing this problem requires a multidisciplinary approach. This paper presents a situational analysis of oral cancer in India and the role of tobacco in making it the epicentre of the disease, and focuses on the role of dental care-givers in influencing and promoting tobacco-control programmes and early detection of oral cancer.

INTRODUCTION

Oral cancer is a major public health problem and medical care challenge globally, but remains a silent crisis in India where it is one of the three most common cancers. Although easily detectable and largely preventable, it is primarily diagnosed in advanced stages, resulting in increased morbidity and mortality. Oral cancer includes a heterogeneous group of cancers of the oral cavity, involving the lips, tongue, labial mucosa, buccal mucosa, palate, floor of the mouth, gingiva and other anatomical sites. There is lack of specificity and definition in the description of sites when referring to oral cancer in the literature¹, and also in cancer registries. For example, in the International Classification of Diseases (ICD)-10, malignant neoplasms of the lip, oral cavity and oropharynx are given the code: C00-C14².

Approximately 30% of all cancers in India are oral cancer. The age-adjusted rate is 20 per 100,000 population³. Oral cancer accounts for approximately 17% of all cancers in male subjects and 10.5% of all cancers in female subjects⁴. The increased occurrence of oral cancer in younger age groups is of major concern. India continues to report the highest prevalence of oral cancer globally, with approximately 70,000 new cases annually and 46,000 oral cancer-related deaths annually⁵. According to crude incidence projections by Globocan, oral cancer will continue to be a major problem and the rate will increase by 2020 and 2030 in both sexes¹.

NATIONAL CANCER REGISTRIES

Population-based cancer registries (PBCR) provide data to Globocan. However, the data may be an under-representation, as cancer registration is voluntary in India and most patients are lost to follow up. In addition, there are no cancer registries in the most populous and poorer states. Furthermore, Indian cancer registries do not have a provision for recording potentially premalignant oral disorders⁶. Most of the population is in rural India, and there are only three cancer registries in rural areas. The registries reporting the incidence of oral cancer are Barshi PBCR, Chennai PBCR, Delhi PBCR, Dindigul Ambilikkai PBCR, Ernakulam PBCR, Karunagapally PBCR, Mumbai PBCR and Manipuri PBCR¹. Therefore, even with complete registration in those areas, the data are incomplete.

ROLE OF TOBACCO

The aetiology of oral cancer is multifactorial, with tobacco being the single greatest risk factor in making India the centre of oral cancer. Approximately 34.6% of adults (47.9% of men and 20.3% of women) use tobacco in various forms⁷. Fourteen per cent of adults (24.3% of men and 2.9% of women) smoke⁷. Tobacco use in children and adolescents is reaching pandemic levels; 20 million children between 10 and 14 years of age are addicted to tobacco⁸. Tobacco use among school and college students ranges from 6.9% to 22.5%, and the prevalence of tobacco use is higher among corporation school students than among private school students⁹. Studies on tobacco use among medical students showed cigarette smoking to be common (17–33.2%). Initiation of tobacco use peaks at 10th standard to 12th standard school/college students (15–17 years of age). Tobacco use in street children is initiated at very early ages (between 5 and 10 years of age) by chewing tobacco, available as sachets, followed by beedis and cigarettes, to suppress the hunger, helplessness and depression of street life⁸. With a problem of this magnitude among children, addressing tobacco as a paediatric concern can help in controlling the condition¹⁰.

FORMS OF TOBACCO USE

Tobacco use varies widely according to geographical region and to gender (from 33% to 80% in male subjects and from 7% to 67% in female subjects). Factors contributing to tobacco use include lack of awareness as a result of poor literacy rates, ready exposure to tobacco use and deeply ingrained cultural habits11., 12.. Various forms of tobacco use, including the use of smoke and smokeless products, are specific to geographical area. Beedi and cigarettes are the most common forms of smoking in all regions, chutta and dhumti are reverse smoking forms and hookli, Chilum and hookah are other smoking forms. Use of smokeless forms of tobacco include chewing with beetel quid, placing tobacco lime mixtures in the labial and/or buccal vestibule, chewing or sucking tobacco-arecanut preparations and using Manipuri tobacco, pan Masada. mishri, gudhaku and creamy snuff as dentifrices, all of which lead to addiction¹³.

Consumption of smoke and smokeless forms of tobacco causes oral cancer¹⁴. The direct relationship between tobacco and oral cancer led to the aphorism ‘cancer is where tobacco is’¹⁵. Beedi smoking is the most common form of indigenous smoking in India and case–control studies demonstrate a direct relationship between the number of beedi smoked and the time since first starting beedi smoking, and oral cancer. The incidence of oral cancer is 42% higher among beedi smokers than among cigarette smokers¹⁶. Chutta smoking is associated with cancer of the palatal region, and the risk of oral precancerous lesions is five to 19 times higher with chutta smoking than with the use of chewing tobacco¹⁷.

Smokeless forms of tobacco are widely used in all sections of society. Currently, 25.9% of adults use smokeless tobacco with an increase in use, possibly as a result of increased awareness of the hazards of smoking, together with the marketing efforts of manufacturers of smokeless tobacco products. In fact, 50% of the oral cancer burden in India is attributed to smokeless tobacco use¹⁸. Smokeless tobacco does not carry the trouble of lighting or of second-hand smoke and it is therefore convenient and does not draw much public attention. Consequently, it is popular with users, especially women and young adults for whom smoking is often considered taboo in Indian society.

The tobacco addiction of a large number of adults begins during adolescence. Initiation often occurs early in life by imitating family members or peers, and is influenced by advertisements on television and hoardings and in newspapers, social gatherings and also by ease of access and affordability. Another key influence is that of Bollywood movies, especially on adolescents¹⁹.

ORAL CANCER AND TOBACCO CONTROL IN INDIA

In India, cancer control is synonymous with tobacco control. Studies have shown risk reduction in oral cancer after cessation of tobacco use20., 21.. Effects of tobacco-use cessation have been demonstrated in the regression rate of leukoplakia, a premalignant lesion. Regression of leukoplakia was significantly greater among those who stopped or reduced tobacco consumption²⁰. However, this chronic habit is so ingrained in all sections of society that tobacco control in India poses a special challenge that is exacerbated as a result of reckless behaviour and the overall low literacy rate. Tolerance in society is greater than in most high-income countries; 29% of adults are exposed to second-hand smoke in public places⁷. Legislation banning smoking in public places has tended to be ineffective. Additional legislation mandates that pictorial messages and statutory warnings should be displayed on 40% of principal display areas to educate the public. However, at the point of sale, brand names are displayed and, importantly, people mostly purchase individual sticks and thus have less opportunity to view the warnings²². There is also a lack of tobacco-cessation advice and support²³. Even so, five in 10 current tobacco users report an intention to quit⁷. However, chronic dependency on tobacco is associated with relapse over the years, even for those who do attempt to quit. Oral cancer and tobacco control will therefore require a multidisciplinary approach (Figure 1), including a thorough understanding of the underpinning social, economic and cultural factors. Consideration of all possible modalities is beyond the scope of this paper. The current focus is on dental caregivers and the role of the dental health education system in equipping practitioners to intervene successfully with tobacco users.

Figure 1.

Multidisciplinary approach to oral cancer control and tobacco control.

ROLE OF DENTAL HEALTH PROFESSIONALS

Dental health professionals have considerable opportunity to participate in the promotion of tobacco-control programmes. Studies have shown that incorporation of behavioural interventions as part of oral examinations increases tobacco-cessation rates²⁴. The role of dentists is highly valuable in strengthening tobacco-cessation programmes; dental professionals have greater opportunities to integrate education and intervention with their patients.

Owing to the practical and theoretical knowledge of dentists pertaining to the adverse effects of tobacco on oro-pharyngeal areas, and the opportunity to meet all age groups, their role is especially valuable, both in tobacco-cessation programmes and in early detection of oral cancer. They can also serve as role models by abstaining from tobacco use and encouraging their patients to also do so, as a positive example. They can promote modification of behaviour by integrating education and intervention and thereby can be very influential in the following aspects:

• •Encouraging avoidance of tobacco use and/or postponing initiation in children and young adults
• •Promoting quitting, in those who have recently started to use tobacco, before they become heavily addicted
• •Counselling women, especially those of childbearing age, on the adverse effects and potential harm to babies
• •Early detection of premalignant and malignant lesions
• •Training all patients in self-examination of the oral cavity.

Moreover, several clinics across the country participate in providing ‘free dental check ups’ sponsored by multinational companies, such as Colgate. These services could be expanded to include tobacco-cessation counselling and screening for oral cancer and precancers for the larger population examined by dental professionals. This could facilitate early detection of premalignant and malignant lesions, as well as providing the opportunity to counsel patients to abstain from tobacco.

To increase active participation, however, the dental health-education system needs to equip dental students appropriately by revising the dental curriculum based on need and in view of the changing pattern of diseases. This should include providing training to dental students and dental hygienists on tobacco-cessation counselling programmes, together with continuing dental education to increase and strengthen knowledge and familiarity with tobacco-cessation programs, including pharmacotherapy. With 289 dental colleges in the country, oral health education, awareness of oral cancer, training on self-examination of the oral cavity and tobacco-cessation programmes can be extended to all rural areas that currently are underserved with health-care facilities. Dental colleges can also conduct oral cancer diagnostic and treatment-related services.

CONCLUSION

Oral cancer is a substantial public health threat; with the crescendo of cases, it may pose an endemic threat to the country as it is most often diagnosed at advanced stages, leading to increased morbidity and mortality. Out-of-pocket expenditure for treatment facilities are unaffordable for patients, and cancer diagnosis and treatment-related services are limited in rural India. Prevention of tobacco use and early detection of treatable cancer are of great value in decreasing the burden of this disease. Utilisation of dental colleges as centres for tobacco-cessation counselling and treatment, their intervention for early detection of oral cancer and treatment, and their integration with primary health centres, can make services available to wider regions of the country, especially those areas underserved with cancer diagnosis and treatment facilities.

Acknowledgements

The authors have no acknowledgements.

Competing interests

The authors have no competing interests.