1. Tobacco use is causally linked to cancer through exposure to carcinogens during the curing and smoking processes. The major carcinogens include nitrosamines, benzene, polycyclic aromatic hydrocarbons, and cadmium. 2. Quitting smoking improves health outcomes for cancer patients and reduces all-cause mortality, cancer mortality, and risk of second primary cancers. Continued smoking can increase treatment toxicity and risk of recurrence. 3. India has implemented tobacco control programs like the National Tobacco Control Programme and COTPA to reduce tobacco use and exposure to carcinogens.

1. TOBACCO and CANCER
DR. KIRAN
Dr KIRAN KUMAR BR

3. WHAT IS ‘GATS’?

4. BURDEN OF THE PROBLEM

5. Its not all BAD….....

6. GOOD NEWS….....

8. What is TOBACCO?
• Tobacco is a product prepared from the leaves of the tobacco plant
by curing them.
• The plant is part of the genus Nicotiana
• While more than 70 species of tobacco are known, the chief
commercial crop is N. tabacum

9. Types of tobacco products
• Smokeless tobacco
• Loose leaf
• Pellets
• Plug
• Guṭkha is a preparation of crushed areca nut, tobacco, catechu, parafin wax,
slaked lime and sweet flavourings
• Zarda consists of tobacco, lime, spices and vegetable dyes
• Khaini is made from sun-dried or fermented coarsely cut tobacco leaves

10. Smoked Tobacco
• Cigars
• Blunts
• Cigarillos
• Little cigars
• Cigarettes
• Flavoured Cigarettes
• Filter cigarettes
• Pipe smoking
• Bidis

11. EPIDEMIOLOGY OF TOBACCO AND
CANCER
• Definitive recognition for tobacco use as a causative factor in the
seminal 1964 U.S. Surgeon General’s Report (SGR) on Smoking and
Health by Doll and Hill and Wynder and Graham
• Common index of cancer risk is pack-years-
• the number of packs of cigarettes smoked per day multiplied by the number
of years smoked in the lifetime.

13. NEUROBIOLOGY OF TOBACCO
DEPENDENCE
• The primary driver of smoking behavior is ?
• What is the ‘Estrogen of Lung Cancer’?
•
• NICOTINE—the major addictive substance and primary reinforcer of
continued smoking.
• NICOTINE IS NOT CARCINOGENIC

14. What is smoking topography?
• Smokers can affect the amount of nicotine (and accompanying
toxicants) they draw from a cigarette by altering the number of puffs
taken, puff size, frequency, duration, and velocity.

15. Is there science behind QUITTING?
• Nicotine is metabolized primarily to cotinine, which is further
metabolized to trans-3′-hydroxycotinine (3HC), catalyzed by the liver
cytochrome P450 2A6 enzyme.
• The ratio of 3HC to cotinine in plasma or saliva can be used as a
reliable noninvasive phenotypic marker for CYP2A6 activity.
• Clinical trial data clearly show that the metabolite ratio can be used to
predict success in quitting, and that the likelihood of quitting
decreases as the ratio increases, such that slower metabolizers are
more successful at achieving abstinence.

16. Evolution of Tobacco Products
• TAR- tar is not a specific substance, but simply the collected
particulate matter from cigarette smoke, without water and nicotine
• Introduction of low tar and filtered cigarettes actually increased risk
• promoting deeper inhalation and higher rates of addiction with no reductions
in cancer risk, resulting in subsequent changes in lung cancer from centrally
located squamous cell cancers to peripherally located nonsquamous cell
cancers

17. Evolution of Tobacco Products
• What is ENDS?
•

18. • Electronic nicotine delivery system or e-cigarettes or e-cigs.
• It is a handheld electronic device that simulates the feeling of tobacco
smoking. It works by heating a liquid to generate an aerosol,
commonly called a "vapor", that the user inhales.
• Using e-cigarettes is sometimes called vaping. The liquid in the e-
cigarette, called e-liquid.

19. CARCINOGENS IN TOBACCO
PRODUCTS
• The International Agency for Research on Cancer (IARC)
• Identified 72 measurable carcinogens in cigarette smoke
• Group 1 (carcinogenic to humans),
• 2A (probably carcinogenic to humans), or
• 2B (possibly carcinogenic to humans).

22. The most important carcinogens
• 1. N-nitrosamines
• 2. Benzene
• 3. PAH (polyclyclic aromatic amines),
• 4. 1,3- butadiene, and
• 5. Cadmium.
• Most of these carcinogens are formed during the ‘CURING’ process of
tobacco.
• Possible to reduce carcinogens by changing curing and storage practices.
• Smokeless tobacco products, although they are not burned, nonetheless
contain substantial levels of carcinogens, most prominently the N-
nitrosamines.

23. HOW TOBACCO USE LEADS TO
CANCER?

24. HOW TOBACCO USE LEADS TO
CANCER?
• Ciliatoxic, inflammatory, and oxidizing compounds, such as acrolein
and ethylene oxide in smoke, may also impact the likelihood of cancer
development.
• Epigenetic changes such as hypermethylation, particularly at P16,
may also play a role in lung cancer development

25. TOBACCO USE BY THE CANCER
PATIENT
• A cancer diagnosis can be used as a window of opportunity, or teachable
moment, to intervene and provide assistance in the quitting process.
• Never smoker
• having smoked less than 100 cigarettes in a person’s lifetime and no current cigarette
use.
• Former smoker
• is typically defined as no current cigarette use, usually within the past year.
• Recent smoker (or recent quit)
• is generally defined as having stopped smoking within the recent past, typically for a
period of 1 week to 1 year.
• Current smoker
• is typically defined as smoking one or more cigarettes per day every day or some
days

26. THE CLINICAL EFFECTS OF SMOKING ON THE
CANCER PATIENT
• The recently released 2014 SGR now provides substantial evidence behind the
effects of smoking by cancer patients with the following conclusions:
• 1. In cancer patients and survivors, the evidence is sufficient to infer a causal
relationship between cigarette smoking and adverse health outcomes. Quitting
smoking improves the prognosis of cancer patients.
• 2. In cancer patients and survivors, the evidence is sufficient to infer a causal
relationship between cigarette smoking and increased all-cause mortality and
cancer-specific mortality.
• 3. In cancer patients and survivors, the evidence is sufficient to infer a causal
relationship between cigarette smoking and increased risk for second primary
cancers known to be caused by cigarette smoking, such as lung cancer.
• 4. In cancer patients and survivors, the evidence is suggestive but not sufficient to
infer a causal relationship between cigarette smoking and the risk of recurrence,
poorer response to treatment, and increased treatment-related toxicity.

27. PREVENTIVE ONCOLOGY- SMOKING
CESSATION

33. What is NTCP?
• The National Tobacco Control Programme (NTCP) was launched by
the Ministry of Health and Family Welfare (MoHFW), Government of
India in 2007- 08, during the 11th five year plan

34. What is COTPA?
• COTPA stands for the “Cigarettes and Other Tobacco Products
(Prohibition of Advertisement and Regulation of Trade and
Commerce, Production, Supply and Distribution) Act, 2003”. The Act
is applicable to all products containing tobacco in any form as detailed
in the Schedule to the Act.