Killer tobacco
THREE years ago, in 2020, GLOBOCAN, the global platform for cancer statistics, cited 10,538 new cases of lung cancer in Pakistan, making it the third most common cancer in the country after breast and oral cavity cancer. While two regional cancer registries, including the Karachi Cancer Registry (KCR) and Punjab Cancer Registry, are a substantial source of data related to lung cancer, the figures don’t give a precise picture since there is no central population-based cancer registry.
Each year, World Lung Cancer Day is observed on Aug 1. Interestingly, a decline has been noted in the incidence of lung cancer worldwide by 2.2 to 2.3 per cent a year — in men since the mid-1980s though only since the mid-2000s in women. The explanation for this difference lies in the difference in historical patterns of smoking uptake and cessation between men and women.
A similar trend is noted in the Pakistani population as well. The biggest driving force behind the worldwide decline in the use of tobacco products is the constant nudging by medical experts and others. Pakistan’s Ministry of National Health Services and Regulations has implemented the WHO guidelines of pictorial health warnings on cigarette packaging to be “50pc or more of the principal display areas”. There has also been a surge of anti-smoking and anti-tobacco campaigns. The recent heavy taxation on cigarettes has also proved a deterrent.
While smoking is the greatest risk factor for lung cancer and responsible for 80pc of lung cancer deaths, the disease can also occur in non-smokers. People who have never smoked account for 20pc of lung cancer deaths. Radon exposure is the second major reason. Other risk factors include the use of multiple forms of combustible tobacco such as cigars, pipes, water pipes (hookahs or shishas). Many water pipe users assume this to be less toxic than cigarette, though this may deliver the same or even higher level of toxins.
Anti-smoking policies must factor in new trends.
Despite the efforts to discourage them, 19.1pc of adults aged 15-plus use tobacco in Pakistan, while a significant percentage of non-smokers are affected by second-hand smoke in public transport and offices. People are not only becoming immune to the government’s repeated health warnings in digital and print media, they are also enraged at the recent price increase in tobacco products. Smoking to relieve stress is a common excuse, especially in lower-income groups. Strong lobbying by the tobacco industry that calls the efforts of anti-tobacco organisations ‘hooliganism’ and the ‘spread of misinformation’ also encourages tobacco users.
Meanwhile, lung cancer in Pakistan has caused an enormous financial burden. While the health sector tries to cope, waiting lists of patients are long, especially in government-funded radiotherapy units. What is perturbing is these facilities are reserved for the urban areas and patients in the rural areas are sometimes never even diagnosed, let alone treated for their condition.
Another recent challenge is the fast-growing trend of vaping in Pakistan. The culture was initially limited to a specific socioeconomic class. But with growing demand and competition among vape shops, these fruity-flavoured brightly coloured vials are now available in most places. These devices aerosolise the e-liquid that typically contains nicotine salts. Though the connection between vaping and lung cancer is still unexplored and a lot of research is needed on the subject, the hazards of vaping lie in its being a gateway to the use of combustible tobacco among those who would otherwise have been non-smokers.
Many research articles show that adolescents and young adults using e-cigarettes and vape are more likely than non-users to consume combustible tobacco. Unfortunately, many misinformed smokers switch to vaping while trying to discontinue smoking, assuming this to be a ‘healthier’ alternative. To date, no e-cigarette or vape is FDA-approved as a cessation aid, and should not be used to quit smoking. Users should not go on to smoke cigarettes and stop using these aids too; former smokers using e-cigarettes should not revert to smoking.
Health is precious. In times, where people are increasingly being afflicted by idiopathic health conditions, practices should be adopted for a healthier and safer lifestyle, with the government stepping up policymaking to regulate the mushroom growth of cessation aids, too. Traditional policies that are in place to discourage smoking need to be revisited, preferably backed by research, to factor in newer trends so that the population can be discouraged from practices that lead to potentially serious and sometimes fatal diseases such as lung cancer.
The writer is an academic medical researcher and doctor working for a tertiary care hospital in Karachi.
Published in Dawn, August 1st, 2023