{"id":906,"date":"2011-07-02T14:56:44","date_gmt":"2011-07-02T14:56:44","guid":{"rendered":"http:\/\/touchoncology.com\/the-challenge-of-eliminating-tobacco-induced-cancers-in-the-developing-world-2\/"},"modified":"2011-07-02T14:56:44","modified_gmt":"2011-07-02T14:56:44","slug":"the-challenge-of-eliminating-tobacco-induced-cancers-in-the-developing-world-2","status":"publish","type":"post","link":"https:\/\/touchoncology.com\/lung-cancer\/journal-articles\/the-challenge-of-eliminating-tobacco-induced-cancers-in-the-developing-world-2\/","title":{"rendered":"The Challenge of Eliminating Tobacco-induced Cancers in the Developing World"},"content":{"rendered":"

This forms part of a larger epidemiological transition in which the burden of chronic, non-communicable disease is now increasing in less developed countries. Tobacco use is the single largest preventable cause of cancer in the world today. In addition to the accumulating risks associated with diet, alcohol and industrial exposure, the increase in tobacco use in developing countries will result in large increases in tobacco-induced cancers and death. This article summarises the current status of the tobacco epidemic and tobacco-induced cancer burden and the challenges in curbing the tobacco epidemic in the developing world. It also explores potential policy responses to the growing tobacco epidemic in developing countries. Such responses may include mobilising the political will of governments to implement the WHO Framework Convention on Tobacco Control (WHO FCTC) to fulfil their commitment to fight the tobacco epidemic and protect their population from tobacco-related death. Another response is the integration of tobacco control interventions into the overall framework of chronic disease prevention and control, together with encouraging more engagement in tobacco control from oncologists as part of their routine practice. <\/p>\n

A Growing Tobacco Epidemic in Developing Countries<\/strong>
Tobacco use is the single largest preventable cause of cancer in the world today. Tobacco kills one person every six seconds.3 <\/Sup>It kills up to one in every two users of those who use it as intended.3,4 <\/Sup>In the 20th century, it is estimated that the tobacco epidemic has killed 100 million people worldwide. Unless urgent action is taken there could be up to one billion deaths during the 21st century.5 <\/Sup>Tobacco use is growing fastest in low-income countries as a result of low prices and steady population growth coupled with tobacco industry targeting, ensuring that millions of people become fatally addicted each year. More than 80% of the world’s tobacco-related deaths by 2030 will be in low- and middle-income countries.6 <\/Sup><\/p>\n

More than 40% of the world’s smokers live in two major developing countries: China and India. As many as 100 million Chinese men currently under 30 years of age will die from tobacco use.7 <\/Sup>In India, about one-quarter of deaths among middle-aged men are caused by smoking.8 <\/Sup>As the number of smokers in this group increases with population growth, so will the number of deaths. The shift of the tobacco epidemic to the developing world will lead to unprecedented levels of disease and early death in countries where population growth and the potential for increased tobacco use are highest and where healthcare services are least available.

Association Between Tobacco and Cancer<\/strong>
No part of the human body escapes damage from tobacco use. Tobacco use is the single most important risk factor for cancer and causes a large variety of cancer types, such as lung, larynx, oesophagus, stomach, bladder, oral cavity and others (see Table 1<\/I>). The parts of the body with direct contact with smoke (lungs, oral cavity and oesophagus) are at the greatest risk of developing cancer. Environmental tobacco smoke (passive smoking) causes lung cancer. The proportion of lung cancers in ex-smokers and those who have never smoked that are attributable to environmental tobacco smoke was estimated as between 16 and 24%, mainly the result of the contribution of work-related exposure.
\nLung cancer is recognised to be the most important cause of death from cancer in the world (1.3 million deaths\/year).2 <\/Sup>The major cause of the disease is tobacco smoking, primarily of cigarettes. Tobacco’s role in increasing the chance of lung cancer is one of the most widely known of tobacco’s harmful effects on human health. Sir Richard Doll’s 1950 paper demonstrating the association between smoking and lung cancer has become a public health classic. After half a century, the report of the Surgeon General in 2004 stated that cancer “was among the first diseases causally linked to smoking”.10 <\/Sup><\/p>\n

For smoking-attributable cancers, the risk generally increases with the number of cigarettes smoked and the number of years of smoking, and generally decreases after quitting completely. Risk of lung cancer is particularly dependent on duration of smoking; therefore, the earlier the age at initiation of smoking, the greater the individual risk. Furthermore, the longer the time period during which a major proportion of adults in a population have smoked, the greater the incidence and mortality from the disease in that population. Risk of lung cancer is also proportional to the number of cigarettes smoked, increasing with increasing cigarette usage. In populations with a long duration and heavy intensity of cigarette usage, the proportion of lung cancer attributable to smoking is of the order of 90%.11 <\/Sup>This attributable proportion applies to men in most Western populations. In populations in which women are increasingly using cigarettes, the attributable proportion in women is also approaching this level. In the US, the risk of dying from lung cancer is more than 22 times higher women who smoke cigarettes compared with those who have never smoked.12 <\/Sup>Recently, the spread of tobacco use to developing countries has led to papers describing similar patterns there. In a study of one million deaths in China, lung cancer risk was two to four times higher among men who smoked compared with men who did not smoke. This association was generally consistent over both rural and urban areas.7 <\/Sup>A newly published study in South Africa showed that the odds ratio for lung cancer among current smokers was 16.3 (95% confidence interval [CI] 9.6–27.6) for men and 6.4 (95% CI 4.0–10.4) for women compared with those who have never smoked.
\n All forms of tobacco are lethal. Bidis are small hand-rolled cigarettes typically smoked in India and other South-East Asian countries. Bidi smokers have a three-fold higher risk of oral cancer compared with non-smokers and are also at increased risk of lung, stomach and oesophageal cancer.14 <\/Sup>Kreteks, clove and tobacco cigarettes, most commonly smoked in Indonesia, place smokers at increased risk of acute lung injury and lung cancer as well.15 <\/Sup>Shisha, tobacco cured with flavourings and smoked from hookahs primarily in the eastern Mediterranean region, is linked to lung disease, cardiovascular disease and cancer.15 <\/Sup>

Tobacco-related Cancer Burden in Developing Countries <\/strong>
Tobacco use is responsible for up to 1.5 million cancer deaths per year, 60% of these deaths occurring in low- and middle-income countries.1 <\/Sup>A shifting tobacco epidemic in developing countries, together with the rapid ageing of populations and other factors, is likely to lead to a new epidemic of tobacco-induced cancers in developing countries. In low-and middle-income countries, tobacco-attributable deaths have been projected to double between 2002 and 2030.1 <\/Sup>Lung cancer is the most frequent type of cancer in developing countries (see Figure 1<\/I>).16 <\/Sup>It is projected that the number of lung cancer deaths will nearly double by 2030 (from 1.3 million in 2005 to 2.2 million in 2030). The burden of this increase will be felt most dramatically in low- and middle-income countries in Africa and Asia. The first estimates of the health impacts of smoking in China and India have also shown substantially increased risk of mortality from, among others, lung cancer and oral cancer.17 <\/Sup>
\nA first analysis of time trends in cancer mortality in China at the national level, based on data from a national mortality routine reporting system in China, demonstrated that between 1987 and 1999 the age-standardised mortality rate for lung cancer showed significant increasing trends in both urban and rural areas and for both sexes.18 <\/Sup>As the Chinese population ages, and smoking prevalence remains high, the number of new lung cancer cases will continue to increase and the overall burden of lung cancer will remain high.A systematic review of the published studies on epidemiology, diagnosis and treatment of lung cancer in India showed that with the increasing prevalence of smoking lung cancer has reached epidemic proportions in India. It has surpassed the earlier most common form of cancer, that of the oropharynx, and is now the most common malignancy in males in many hospitals.19 <\/Sup>In view of the large population in India, the burden of lung cancer will be enormous in the future.
\nEliminating Tobacco-induced Cancers by Reducing Tobacco Use in Developing Countries
Although some other factors (e.g. population ageing and urbanisation) are associated with the increased cancer burden in developing countries, addressing tobacco is also addressing cancer, as tobacco use is becoming the greatest threat to cancer control in developing countries. The decrease in the overall lung cancer burden that is currently occurring in the US has been proved to be mainly attributed to tobacco control efforts over the past 40 years.20,21 <\/Sup>Therefore, reducing tobacco use should be a critical priority to eliminate tobacco-induced cancers in developing countries. Currently, there are a number of common policy deficiencies or challenges to both tobacco control and cancer prevention in developing countries. These include the lack of effective surveillance and control, lack of capacity in healthcare systems, lack of funding and coverage at the national level and lack of political will, but, more fundamentally, the aggressive tobacco industry marketing efforts.

World Health Organization Tobacco Control Tools for Cancer Prevention <\/strong>
WHO and its Member States recognised the global burden of noncommunicable diseases as one of the major challenges for development in the 21st century (demonstrated in World Health Assembly [WHA] resolution 58.22 at the 58th WHA). Moreover, the Member States of the WHO have expressed strong commitment to developing and reinforcing comprehensive cancer control programmes in which prevention is considered a key element. In this regard, public policy targeting behavioural changes including tobacco control is a key component of the overall strategy for the prevention of noncommunicable diseases.
Extending far beyond the health sector, cancer prevention actively involves a broad spectrum of occupational, social and political sectors. The major aim is to create environments where health choices are the easier ones, and to increase individual skills in making healthier lifestyle choices.22 <\/Sup>The draft action plan for the global strategy for the prevention and control of non-communicable diseases, which was discussed at the 61st WHA in May 2008, provides a clear road-map for scaling up the WHO’s technical assistance at global, regional and country levels to address the growing burden of non-communicable diseases. As outlined in the following sections, the WHO FCTC and WHO’s complementary technical package for tobacco control (MPOWER) are key components of the WHO’s global strategy for preventing non-communicable diseases.World Health Organization Framework Convention on Tobacco Control <\/I><\/strong>
The WHO FCTC is the first global health treaty negotiated under the auspices of the WHO. This convention is an evidence-based treaty that reaffirms the right of all people to the highest standard of health. It represents a paradigm shift in developing a regulatory strategy to address addictive substances. In contrast to previous drug control treaties, the WHO FCTC asserts the importance of demand reduction strategies, as well as supply reduction issues. <\/p>\n

In contrast to previous drug control treaties, the WHO Framework Convention on Tobacco Control asserts the importance of demand reduction strategies, as well as supply reduction issues. <\/H4 >The WHO FCTC was developed in response to the globalisation of the tobacco epidemic. The spread of the tobacco epidemic is exacerbated by a variety of complex factors with cross-border effects, including trade liberalisation, direct foreign investment, global marketing, transnational tobacco advertising, promotion and sponsorship, and the international movement of contraband and counterfeit cigarettes. Therefore, the convention addresses both public health and economic dimensions of the tobacco epidemic with evidence-based measures that set a global minimum standard. <\/p>\n

Less apparent than the economic and health impact of the WHO FCTC’s methods is its political and multisectoral impact. Co-operation and political resolve have become essential as more sectors become involved with the battle against the tobacco epidemic. There is a growing awareness of the effectiveness of the multisectoral approach’s synergistic core. As Dr Margaret Chan, Director General of WHO, stated: “Multiple sectors influence health and should pay attention to the health impact of their policies”.23 <\/Sup>Each of the WHO FCTC’s measures enhances the efficacy of the others. Thus, the whole of the WHO FCTC is greater than the sum of its parts. <\/p>\n

The WHO FCTC provides the context for a substantial scale-up of the WHO’s efforts at a country level to reduce the burden of noncommunicable disease by implementing a core package of cost-effective demand reduction measures. The treaty itself has catalysed organisational and national programmatic movement to address the effects of non-communicable disease and its determinants.23 <\/Sup><\/p>\n

The WHO FCTC came into force on 27 February 2005 and quickly became one of the most rapidly embraced treaties in the UN’s history. The convention has re-invigorated tobacco control efforts and has established tobacco control as a priority on the public health and development agenda.Understanding the importance of the political momentum developed during the negotiations and the tremendous global support for the WHO FCTC, whose parties cover more than 80% of the world’s population, the WHO has established MPOWER, a package of six proven tobacco control policies designed to help countries implement and build on the core elements of the WHO FCTC convention. The MPOWER policies, and the corresponding demand reduction articles of the WHO, offer a cost-effective road-map for saving millions of lives in the future. The MPOWER package includes the most effective policies that are proved to reduce the prevalence of tobacco use:5 <\/Sup>