dna Conversations: Listen to your Lung

Smoking has not been looked at very kindly in recent years.  Ever since the 1980s the movement against smoking has been gaining momentum.  But in India, smoking is only part of the entire problem.  The bigger problem is tobacco – which is often chewed.  Worse, tobacco users prefer to smoke bidis, whose prices have never been touched by the government.

How serious is the problem?  And what are the steps the government should take to reduce the risk that tobacco holds out.

dna put together a panel of eminent specialists in the field, comprising (in alphabetical order) Dr. Sachin Almel, Senior Consultant, Medical Oncology, P.D. Hinduja Hospital; Dr. Kumar Prabhash, Prof. Medical Oncology, Tata Memorial Hospital; Dr. Anjana Sainani, Senior Consultant, Medical Oncology, Jaslok Hospital; and Dr. Tejinder Singh, Senior Consultant, Medical Oncology, Fortis Hospital; 

The discussion, moderated by RN Bhaskar – with editorial support from Maitri Porecha – highlighted issues that are often overlooked. Given below are edited excerpts:

dna: Everyone knows that tobacco causes cancer.  The government is trying to highlight that message by putting up huge signs on every packet here and there. =What are your views on this subject? 

Prabhash: The tobacco problem is similar to any bad habit we may have in life.  And, especially, if you have a bad habit in a society, well, like corruption, it doesn’t go away because there are many stakeholders.  And if you have many stakeholders, they do have their own selfish interests.  Otherwise, the solution is simple. If you don’t have tobacco, we don’t have a problem. The problem is that we cultivate tobacco without having anything really positive out of it.  And this is not only in India.  This is across the world. The change that they are seeing now – and that is a comparative change – it has happened because, for decades, the people have struggled and people have raised their voice so that people get aware.  And then, once people are aware, the government has to listen.

Singh: I think there are many stakeholders. Somewhere down the line, we require our own consciousness also. Something similar as is going to happen with the 'Swachh Bharat campaign.'  Its main goal is to create greater consciousness so that we try to stop dirtying a place. 
Tobacco has been part of our life for many years.  We have to start to consciously think that it is creating more trouble now and we should start stopping it.

Almel: It is more like a disease. It’s not just a habit.  We should target the younger population, the school children and – because those are the impressionable minds where, if we can put a right impression, maybe we could prevent the habit formation. I mean, nip it in the bud.  It is not just cancer but a lot of other diseases.  

Sainani:  There are 5 million juvenile smokers in India itself.  So it starts right from childhood.  It has therefore to be caught at that stage. In western countries, fair-skinned people do not allow their child to step out without a cap, without sun glasses, without sunscreen, as there is a risk of acquiring Melanoma, or skin cancer.  So the same should be done for curtailing tobacco, which is obviously a bigger killer…
Children are the ones who have now tell their own fathers not to smoke.  Children are the easiest targets to teach, to begin with. Also, our country is highly affected by celebrities, and there are many celebrities who make a difference in everybody’s life. I think they can make lot of difference.  

dna: Singapore does it very effectively with school children.
I have a friend whose child one day comes home and asks his father, “Do you want me to be an orphan?”  His teachers told him what to tell the parents.  And the child came and gave a lecture to the father.  The father was feeling miserable after that. Children are great persuaders, great negotiators.

Prabhash:   In India, the cigarette smoking rate is around 13%.  But the problem for us is tobacco used in other forms.

Sainani:  Until ten years ago it was thought it was a disease of the men, but now because of the smoking habits spilling over to women, we are seeing almost equal numbers of cancer related to tobacco in both.

Singh: The chewing of tobacco habit is an India habit. Almost like 80-90% of global oral cancer burden is sitting in India. 80% of the global cancer burden is purely related to chewing tobacco.  In India, especially among males, 60% of the cancer will be related to tobacco in some form, either smoking or the chewing of gutka (a tobacco based product).  
Putting a pictorial warning is helpful; trying to increase the amount of pictorial warnings is also helpful.  Celebrities should be roped in to spread the message of anti-smoking. I recently saw a toothpaste in which there is tobacco. People have begun using it because they are addicted to it; it has become a habit. Even in the morning they want something with tobacco to be there inside them.

Almel:  They became dependent for their daily routine. 

Sainani:  It starts as a 'fun' thing. Then from fun you move to dependence. It is equally addictive as it has nicotine. Ultimately it goes to the level of dependency which is a disease, where the person also doesn’t know what he’s doing.  So, it spirals out of control, even if they want to, they cannot give up.

Prabhash:  In Western countries, the administration has done one simple thing – it has increased the cost. It is beyond reach of a lot of common people, and therefore that has also brought down the incidence to a great extent. Gutka and other forms of tobacco, are available at dirt-cheap prices in India.  That’s why school kids and even labourers have easy access to it.

Singh:  We have to somehow ban the advertisements also.  There are ‘premium’ gutkas coming into the market, big, big celebrities giving interviews about this ‘premium’ product. I don’t know, what is ‘premium,’ and what is ‘non-premium,’ because both will cause cancer.

dna: You’ve got two aspects of cancer with tobacco, one is the oral cancer – around the mouth – and the second is lungs – affecting the respiratory system.

Sainani: In fact, it covers other organs as well like stomach, kidneys and bladder.  You have cancers affecting these organs too. And it has an association even with colon cancer. Because there is one passage.

Singh:  Oral cancer is more common in India. But if you want to know more about deadly types of cancer –  if you see the number of cancers coming and how many are getting treated – many more are dying because of lung cancers which are far more deadly.

dna:  Lung cancer is more deadly?

Sainani:  Lung cancer is the topmost cause for cancer death.

Almel:  But physically if you go to see the most visible form of cancer is oral cancer.  
dna:  So, visibility-wise, its oral cancer that catches eye, but when it comes to death, it’s lung cancer.

Sainani:  But then oral cancer is associated with so many problems of chewing, swallowing, they can’t eat; they can’t swallow their own saliva. It can be very painful.

Singh:  Yeah. And any kind of disfigurement is more painful to people around. 

Sainani:  In tongue cancer surgeries, half the tongue has to be discarded.  For the young man who has a communication job, his life is over.  He has got children to look after;  things like that.  That is why, I think that any type of cancer is bad.

Almel:  And we promote just a simple line – any kind of tobacco is bad; any cancer is is also bad.  So there is nothing like good tobacco and bad tobacco. So there is no premium and non-premium.  Every gutka is one and the same. There is no such thing as 'premium'.

dna:  Okay. Again, when it comes to cancer, you got some alarming numbers – they are coming up.  When it comes to death, you say lung cancer is more corrosive, is more deadly and would we have some numbers on that kind of cancer in India?

Prabhash:  Each year we have around a million new cancer patients in India.  That is around 10 lakh new cancer patients annually.  Out of those, almost 70,000 or 80,000 are new patients of lung cancer in India every year.  But it was very rightly discussed that head and neck cancer is the commonest cancer.  So if you take total head and neck cancer, they constitute around 2 to 2.5 lakh new cancer patients every year in India, out of 10 lakh new cases. That make it 25%. That’s huge number.  And out of those, half of them are oral cavity cancer cases.  Of the 10 lakh new cancer patients every year, almost half of them are tobacco-related.  So if the tobacco is dispensed with, you will not have half of the cancer cases in the country.

dna:  Where do the rest comes from?
Sainani:  Basically cancer is multi-factorial. Some of the factors we don’t even understand, many are environment-related and some others genetic. 

Singh:  If everyone stops tobacco in any form, you will imagine how many transferal deaths we’ll prevent.

Sainani:  An example is Africa. Where the smoking rate is only hardly some 10% in men and some 5% in females, roughly.  So we don’t see so much of smoking related deaths or tobacco related deaths. 

Singh:  If suppose a person is smoking, one part is cancer, but the biggest part is lung disease or COPD [Chronic Obstructive Pulmonary Disease] It’s like a longstanding respiratory disease where you literally crave for oxygen.  You hear of young people dying of heart attacks – most of them are related to smoking.  Most of the young deaths we are seeing, youngsters aged 30-34 years, having heart attacks, are invariably related to smoking, even chain smoking.  So heart diseases are prominent.  Kidney diseases are prominent.  Sexual diseases are prominent.  There are infertility problems. There are also psychological problems.  Many psychiatric diseases are related to smoking apart from cancer. 

Prabhash:  So it is expected that in 21st century around a billion death related to tobacco will occur. But I think India is the capital of smoking related diseases.

Sainani:  Like if you see lung cancer patients, 80% of them will have a smoking history or a history of tobacco use.  

dna:  But how much of this lung problem would be passive smoking?

Singh:  Passive smoking is part of it and then there is something called, ‘third hand smoking,’ means a person who has smoked in a room and after he has gone, a second, or third person comes in and touches the chair, and gets smoke particles on his hand.  He will get also exposed because he breathes in the air. 
Even pregnant ladies are getting exposed to smoke, and they have a high likelihood of having low birth-weight babies. 

dna: What do you think India should be doing?

Singh: We should focus on school children. Illicit trading of tobacco products should be stopped.  A lot of trading and selling continues in spite of the ban.  

Almel:  The legislation has to be there and we see that legislation does have an impact. = In the medical college – at the time when I was getting educated – smoking was fashionable.  But I don’t see my younger colleagues or students considering it fashionable any more.  So it does make a difference.  Wherever possible – on TV, in newspapers, in schools, through textbooks, politicians, actors, whoever,  just keep spreading this message. You know, it it works. But there is a key element missing. Obviously, there is a customer.  We have a supply source, which continues because we have not been able to give the farmer an alternative crop which grows in that soil and which can be remunerative.  We need an alternative, a viable commercial cash crop. 

Sainani:  And they should equate tobacco to, say, cocaine or heroin.  They must equate it to it being as severe as other narcotic drugs.  Tobacco – its sale or its use – should invite similar punishment.  Unfortunately, tobacco does not come in the category of narcotics but it is equally addictive.  

Singh:  We ourselves need to introspect as well. Spitting is a very common habit with Indians. It is a part of our culture where tobacco chewers are known to keep spitting. The spit passes infections. In auto rickshaws, nowadays a small campaign is going on behind every auto rickshaw- 'Stop spitting. Stop TB.'

Sainani:  So we tell the younger generations that tobacco is a killer thing, which is both  disease and death related, I think it has to start with our own consciousness plus teaching people at our home and other levels as well. 

dna:  Singapore, apart from other countries, has been very strict about open-air smoking.

Almel:  Public smoking has been banned in some countries, and I think the Indian government too was contemplating following suit. It wanted to make smoking illegal in all public places, not just the restaurants or cinema halls, but even on the streets. But I don’t think that worked out. I don’t know.

Singh:  The government has banned it in public transport like buses or trains.  The penalty however is Rs 500 rupees. The government increases the cost of cigarette every year in the budget, but all other tobacco products are spared. The cigarettes have kept becoming more expensive, but the bidi is still there, tobacco is still there, which is very, very cheap.

Singh:  Bidi removal will be very difficult task because it’s part of many people’s income.

dna: In terms of treatment costs, is lung cancer more expensive or oral cancer more expensive to treat or it’s not a right question to ask because the costs vary?

Prabhash:  We can have a corporate hospital, in which maybe a surgeon removing a small lesion can charge a great deal. 

dna: But on an average?

Almel:  Most of the cancers come to us at advanced stages.  And there you use a lot of drugs and lot of other things, which are expensive.

Sainani:  And lung surgery is definitely more expensive. Because even if you are operating a Stage I disease, it’s a major surgery.

dna: So not only is it deadly, it’s a very expensive disease.

Singh:  Whether it is oral or lung, it doesn’t really matter which is more costly.  If you have it, then you have it. It is bad either way.  It hurts you emotionally, financially, psychologically. In all such cases you will always say that a cancer patient is a cancer patient.  You seldom have a person saying I have oral cancer, but you have lung cancer, hence I am better off. You can't compare between the two. 

Sainani:  And both these malignancies are multi-modality, which means, that one will might have to use surgery, radiotherapy, chemotherapy, all three modalities, sometimes. What happens is that in lung cancer, we treat. But the relapse factor is high – it is so aggressive by nature, biologically, that it comes back.  
So the point is, it’s a frustrating malignancy that we have to treat and retreat at least couple of times – and failures are known. That’s why more and more drugs are being tried.  But basically, it’s the biology of the disease that it keeps coming back; it doesn’t come under control or respond to the best of medicines at times. 

Prabhash:  So before treatment, the question is can we pick them early? Dr. Shankar Narayan from Kerala enrolled two groups of people in his study.  In one group of people the screening was done by graduates. He trained the graduate to find out, if the disease can be picked up early.  To open the mouth and see it.  That’s all.  And oh, and they were able to identify it early and they found that if you do this, or that, instead of doing nothing, the results in the former category are better. And when the patient goes to the doctor early enough, then you decrease the mortality because of this disease.

Sainani:  Oral cancer thus is easy to detect, but in lung cancer, getting early detection is difficult.

Prabhash:  Somehow – and the sad part is that – we always scream that we don’t have research in our country in many healthcare settings.  But even if we have the facilities, we we don’t implement it.

dna:  Okay.  So just to sum up a few things: One is talk to children.  Second is, try to stop the production of tobacco just once.  Third, early detection wherever possible.  
Are there any other things that the government should be doing? Or is there a policy that needs to be modified?

Prabhash:  Screening for patients should be started at an affordable rate and at the place with where it is feasible for patient to take it.  I work in Tata Hospital; we get patients coming from thousands of kilometers.

Sainani:  In the healthcare budget we’ll have to focus on cancer treatment.

Almel: It’s easier said than done, having treatment at affordable rates and bringing it to where it is needed. Dispersing the knowledge to various nooks and corner of the country, it’s not going to happen overnight.  But having said that you need to start somewhere. 

dna:  Is there no way to detect lung infection or lung cancer at an early stage?

Almel:  You can only suspect. The thing is that, there have been studies where people have said that the high risk population – meaning those who are heavy smokers or exposed to heavy smoking – should be made to undergo say, X-ray test or maybe a CT scan test on a regular basis.  But that has not really worked out, as the screening programmes have not been cost effective.

Singh:  You require a CT scan, at regular intervals, to be undertaken by this high risk population. 

dna:  But isn't a simple x-ray screening adequate? 

Prabhash:  It will be too late by then.  Upto 14 states or more – I don’t remember the exact number – have banned this Gutka.  Earlier it used to be packaged and marketed as a food product. Now you don’t get it in these states.  It has been defined as a tobacco product.

In many states today, they do recognize that there is public-private partnership to ensure the healthcare is available to majority of people. Like in Maharashtra, we have Rajiv Gandhi Jeevandayee Yojana.  So if you have cancer, you have multiple hospitals where you can go and get treatment, which was possible sometime back.  This is free for the patients below the poverty line. In fact it was started in Andhra Pradesh and Karnataka, now we have many more states like Tamil Nadu, Goa, Jharkhand, Bihar, Punjab, Delhi among others.  Most of the states have some or the other scheme which state that if you have cancer, but can’t pay for yourself, the state will take care of it.

In some places, the law enforcement authorities have also begun supporting this cause.  For instance, in Thane, I about an incident where a couple of guys on the street were smoking and a passerby lady saw a cop there and told him that this is a public place and that the guys should not be smoking there. And the cop actually reprimanded the guys.

Almel:  For beedi you need not have any kind of registration, anybody can make it.

Sainani:  And the root is always at the childhood stage.  You ask any patient 50-year old, 80-year-old or a just newly diagnosed, 35-year-old – young person. They may have started smoking, around 10 years, 15 years ago – or may be 40 years ago.  So basically the awareness building must start at 10-12 years of age. Because in lung cancer what is happening is that it afflicts those who start smoking early in childhood.

Almel:  Lung cancer is one disease which will not happen immediately, if you start smoking it is not going to happen in one year.  You see it 20 years later. 

Now is the time when we are seeing large numbers of people and population getting lung cancer.  Because the economic boom started in the 1990s, and the emergence of call-centres contributed to it. 

One of the most common places where people picked up this smoking was call centers because of the hectic pressure, night jobs and other things. So they started having this smoking habits. You are beginning to see lung cancer cases today 10, 15, 20 years later.  And so the past is catching up with us now.

Sainani:  And now, we were not talking about that, but I think even smoking often goes hand in hand with alcohol.  So as we know now to take cancer as a causative factor, alcohol is also a factor. It’s a lifestyle disease.  But that’s among the affluent.  The lower levels it’s not always lifestyle, but it could be the addictive nature of the substance.  Or it could be both. 

Prabhash:  I think newspapers should do its bit for Generation Next – advocating that the teenage population should avoid smoking in any form. You should not get hold of a cigarette, you should not get hold of a bidi, should not get hold of gutka. 

“Smoking kills” -- salient points

1. 110 million smokers in India
2. Smoking can affect the heart, blood vessels, bones, reproductive organs, eyes, mouth and other organ
3. Tobacco has 70 chemicals are considered to be “carcinogenic” i.e. cancer-causing agents
4. Smoking causes cancers of the Lung, Head & Neck, Urinary Bladder, Kidneys, Pancreas and Colon
5. Being exposed to smoke at the workplace puts you at a higher risk for lung cancer
6. Approximately 63,000 new lung cancer cases are reported each year
7. There is a direct dose response relationship between the number of cigarettes smoked and the risk of lung cancer
8. Most lung cancers do not cause any symptoms until they have spread too far to be cured
9. Quitting smoking can also add years to your life