Tobacco Use and Cancer: A Stealthy Pandemic

The toll of tobacco use on global morbidity and mortality is so staggering that it becomes difficult to comprehend outside the context of a pandemic.

Tobacco use, in the course of less than one century and without significant public fanfare or outcry, has become the world’s leading cause of preventable death. Consider the following:

• Tobacco use killed 100 million people worldwide during the 20th century;

• Tobacco use will kill 1 billion people during this century, unless strong, decisive action is taken soon

to prevent this;

• Tobacco use will kill 5 million people worldwide during 2006;

• Tobacco use will kill about 650 million people who are alive today, about 10% of the world’s

population;

• Tobacco use accounts for 12 percent of global adult mortality (Mackay, Eriksen, & Shafey, 2006)1.

The toll of tobacco use on global morbidity and mortality is so staggering that it becomes difficult to comprehend outside the context of a pandemic. Estimates of the 1918 Spanish flu pandemic, for example, vary widely, but there is increasing agreement that approximately 50 million people died during the time in which that illness circled the globe (World Health Organization [WHO], 2005)2. If current estimates of the death toll from the avian flu, should that become pandemic, are correct, we would expect anywhere from 2 to 7 million deaths to occur from that disease. Viewed in this context, the expected global death toll from tobacco use in just this century – 1 billion people, as noted above – dwarfs other pandemics, which nevertheless receive considerably more attention and, importantly, resources with which to deal with them (WHO, 2005) 2.

Tobacco and Health

Tobacco use causes or is implicated in at least 13 cancers, most notably lung cancer; heart and atherosclerotic diseases; chronic obstructive lung diseases such as emphysema, asthma, and chronic bronchitis; numerous prenatal and postnatal complications; and many other diseases and health issues such as diabetes, cataracts, periodontitis, and bone mass loss. The United States Surgeon General concluded, in 2004, that “Smoking harms nearly every organ of the body…”

It is also important to note that the health effects from tobacco smoke derive not only from the smoke directly inhaled by the smoker but also from secondhand smoke, smoke that is inhaled by others. Inhalation of secondhand smoke is estimated to kill nearly 50,000 nonsmokers in the U.S. each year, 3,000 of which are due to lung cancer. Worldwide, the death toll among nonsmokers from inhalation of secondhand smoke approaches approximately 1 million per year. Nonsmokers exposed to secondhand smoke, have an increased lung cancer risk of about 25% and a similar increased risk of heart disease (Mackay et al., 2006) 1.

Children are especially vulnerable to the effects of secondhand smoke, which causes increases in middle ear infections, sudden infant death syndrome, croup, asthma attacks, and coughs and colds. Unfortunately, nearly half the world’s children are exposed to tobacco smoke on a daily, ongoing basis, the majority of them in their homes.

Tobacco Use in Asia

Tobacco use in Asia, as in the rest of the world, has received scant attention, in comparison to its importance as a cause of death and disability, as well as its severe economic impact on individuals, families, and nations.

Tobacco use prevalence in Asia is as diverse as the many countries which comprise the region. In general terms, however, the region has very high prevalence of use among men – e.g. Cambodia: 70% of men smoke, Japan: 59%, Bangladesh: 60% - and considerably lower use among women – e.g. Thailand: 4% of women smoke, India: 3%, Vietnam: 4%.

This diversity of prevalence presents both challenges and opportunities. With prevalence exceptionally high among men (by comparison, smoking rates among men in North America and Western Europe generally range between 20 and 25%) (World Bank, 1998)3, it is difficult to shield children from adult male nonsmoking role models and to portray smoking as a non-normative behavior, a tobacco control tactic that has worked well in the West. Alternatively, with smoking among women at very low rates (by comparison, smoking rates among women in North America and Western Europe generally range between 18 and 25%) (Shafey, Dolwick, & Guindon, 2003)4, there is an exceptional opportunity to prevent the spread of this pandemic to the billion-plus nonsmoking women in Asia. But the challenge on that issue will be to confront the multinational tobacco industry, which views Asian women as an enormous, untapped tobacco market.

Complicating any analysis of tobacco use in Asia is the widespread use of smokeless forms of tobacco, as well as alternate forms of smoking tobacco. There are hundreds of variations across Asia, including use of such smokeless products as paan masala, betel quid, gutkha, and areca nut and slaked lime preparations and such smoked products as bidis, kreteks, chuttas, and dhumti (Mackay et al., 2006) 1. Common to all of these variations, however, is their inclusion of tobacco and its many carcinogens – more than 60 in smoked tobacco – and increased risk of heart and lung diseases and, with the smokeless varieties, the sharply increased risk of oral cancers. In India, for example, where the use of many varieties of smokeless tobacco is common, the most common cancer diagnosis is that of the oral cavity (Mackay et al., 2006) 1.

Healthcare Implications for Asia

There are more than 1.3 billion smokers in the world, with more than half of them living in Asia (Shafey et al., 2003)4. Additionally, as the multinational tobacco industry shifts its marketing attention away from the high-income nations to those in the low- and middle-income range, the number of smokers, and the subsequent disease burden, will also shift to the low- and middle-income nations (Table 1).

Healthcare Implications for Asia

Industrialized Countries

Developing Countries

While tobacco related deaths will only increase slightly in the industrialized world during the next 30years, they will more than triple in the developing world.

This has enormous implications for healthcare providers and the healthcare industry in Asia. Since smoking and tobacco use kills about half of its users and causes significant illness in nearly all of them at some point, or points, in their lifetime, there is every expectation that significant numbers of smokers will require increased care as the tobacco pandemic reaches and spreads across Asia.

In a recent analysis of the future healthcare challenges in Asia due to tobacco use, longtime Asian tobacco control scientist Dr. Judith Mackay warned that “…Healthcare facilities in Asia will be unable to cope with the enormity of this epidemic. Although there will be spectacular advances in the diagnosis, investigation, and treatment of tobacco-related diseases…most of this technology and will be expensive…and have no impact on mortality.” Mackay further noted that “In Hong Kong, the Hospital Authority estimates that the hospital costs of just three tobacco-related diseases in 1996 were HK$635” and the total annual medical and social costs of smoking are “…one quarter of the total healthcare budget” (Mackay, 1998)5. In 2006, 10 years after the Hong Kong analysis, the challenges – and costs – are even greater.

Potential Solutions

Despite the enormity of the problem – with the burden of tobacco use and its attendant disease shifting to the low- and middle-income nations and, especially, Asia – there are nevertheless strong, positive steps that can be taken to blunt the effects of the tobacco pandemic. These steps include:

• Educating a largely unsuspecting public about the health and economic dangers of tobacco use;
• Involving healthcare providers in delivering nonsmoking messages and treatment to all of their patients and, particularly, reducing the number of physicians who smoke;

• Making all healthcare facilities entirely smoke-free;

• Protecting all nonsmokers, including children and workers, from secondhand smoke by enacting strong, enforced regulations restricting smoking in public places;

• Placing tobacco under the identical governmental regulatory schemes in which other dangerous products are placed;

• Raising cigarette excise taxes as high as possible, since most smokers are price-sensitive;

• Supporting, implementing, and enforcing the World Health Organization’s global tobacco treaty, the Framework Convention on Tobacco Control.

Implementing these action steps will not be easy, nor will they be inexpensive. Additionally, the multinational tobacco industry will intervene in every way possible to thwart their implementation. The alternative however, is a healthcare system overwhelmed with millions upon millions of additional lung cancer cases, economies ravaged by the loss of productive workers and taxpayers who die in middle age from tobacco use, and nonsmoking women and children suffering needlessly from the smoke of others.

Summary

The global toll of death and disease from tobacco use has reached pandemic levels. This has occurred largely unnoticed by the public and even much of the healthcare community. The effects of this pandemic will be especially severe in Asia, to where the burden of tobacco use is shifting from the West. Specific actions can be taken to blunt the effects of this pandemic, although their implementation will be challenging.