Cancer Research, Statistics, and Treatment

: 2021  |  Volume : 4  |  Issue : 4  |  Page : 765--767

Cigarettes are killers that travel in “packs”: A physician's perspective

Pratik Biswas 
 Consultant Pulmonologist, Department of Pulmonary Medicine ILS Hospitals, Howrah, West Bengal, India

Correspondence Address:
Pratik Biswas
Flat No. 5, Mukti Residence, 47A Ghosh Para, Haltu, Kolkata - 700 078, West Bengal

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Biswas P. Cigarettes are killers that travel in “packs”: A physician's perspective.Cancer Res Stat Treat 2021;4:765-767

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Biswas P. Cigarettes are killers that travel in “packs”: A physician's perspective. Cancer Res Stat Treat [serial online] 2021 [cited 2022 Jul 1 ];4:765-767
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I read the review article titled, “Patterns of smoking among oncologists of Eastern India: A questionnaire-based survey,” by Chatterjee et al. and the accompanying editorial published in Cancer Research, Statistics, and Treatment.[1],[2] I want to congratulate the authors for publishing this article and would like to make some contributions to it.

Tobacco is responsible for killing almost half its users. This makes it one of the biggest public health threats, other than the ongoing coronavirus disease-2019 pandemic. Data have shown that almost 8 million people die in a year globally due to tobacco use. About 7 million of these deaths are a result of direct tobacco use and approximately 1.2 million are caused by second-hand smoke among non-smokers.[3] It has been firmly established that there is no safe level of exposure to tobacco beyond which it will cause disease, and all forms of tobacco are harmful. One of the active psychopharmaceutical drugs in tobacco is nicotine, which is a potent euphoriant responsible for causing addiction. About 69 out of 4800 chemicals in cigarette smoke are carcinogenic. Other than malignancy, tobacco smoking is responsible for many other diseases such as coronary heart disease, chronic bronchitis, stroke, peptic ulcer disease, and infertility.[4]

Although there has been a decrease in tobacco consumption in the last 7 years, as per the Global Adult Tobacco Survey (GATS-2) 2016–2017 report,[5] India still has a large number of people (about 275 million adults) who use tobacco in various forms, making it the second-largest tobacco consumer all over the world.[6] In the age group of 15–24 years, the prevalence of tobacco consumption has decreased by 33% as per GATS-2 and various review articles,[7] and the overall prevalence of tobacco consumption has decreased by 6%. The GATS-2 report also revealed increased awareness about the ill effects of tobacco intake among adults; for example, almost 61.9% of people thought of quitting tobacco smoking because of the warnings displayed on the products package.[5] In spite of these silver linings, India is yet to reach the target of “relative reduction in the prevalence of current tobacco use by 30% by 2025,” as per the National Health Policy, 2017.[5]

The aftermath of tobacco consumption, especially smoking on cancer, is significant at many levels. About 80% of lung cancer deaths are due to smoking, and in fact, 30% of all cancer deaths are the result of smoking.[8] Smoking increases the risk of lung cancer and other types of cancers such as leukemia, head and neck, esophageal, stomach, colorectal, cervical, bladder, pancreatic, kidney, liver, uterine, and ovarian cancers.[8]

Smoking is also known to worsen the outcome of patients with cancer.[9] People with cancer who smoked previously or continue to smoke, have worse survival.[10] As pointed out by Warren et al., the chances of recurrence of malignancy, decrease in treatment response, increased complications during treatment, and development of a second malignancy are higher among smokers.[11] However, there are some reports which suggest that some of the effects of smoking might be reversible; data have shown survival benefit among patients with head-and-neck and lung cancers who quit smoking in the past 1 year. Therefore, health-care professionals, including oncologists, have a definite role in tobacco control, especially with regard to patients who have been newly diagnosed with malignancies and can help indirectly by setting examples.

Pipe et al. found that doctors who were actively smoking were less likely to advocate smoking cessation to their patients, as they were less likely to think of smoking as harmful compared to their non-smoking colleagues. It was found that smoking physicians had other priorities than to help patients quit smoking, whereas doctors who were non-smokers believed in implementing and advising smoking cessation (52% vs. 44%; P < 0.001).[12]

The questionnaire-based survey by Chatterjee et al.[1] was performed among oncologists to assess the patterns of smoking at IPGMER, Kolkata, India, from April to May 2017. In order to assess smoking patterns, a predesigned questionnaire was sent to the oncologists in West Bengal via e-mail. The questionnaire was e-mailed to 262 oncologists, out of which a total of 132 (50.4%) participants provided appropriate responses. Out of the 132 participants, 130 (98.4%) were men and only 2 (1.6%) were women. Among them, 50 were ever-smokers and 82 were never-smokers. The median age for starting smoking was 19 years. The most common reasons for smoking initiation were peer pressure (55%) and adventure (33%). Among a total of 76 smokers in the ever- and never-smoker groups, 43 (56.5%) had attempted to quit for a median of two times. There were 69.7% successful quitters in the group, which is quite a good number. The most common reason to quit was worry about one's health, whereas the most common reason for relapse was mental stress.

The response to the questionnaire was poor, as only 50.4% of the participants responded; moreover, only 1.6% of the participants were women. The results obtained from this questionnaire-based study cannot be generalized to the entire Indian population of oncologists because of the high age-standardized prevalence of smoking in West Bengal compared to other states as per GATS-2.[13]

A study carried out in Kerala, one of the largest in India, reported that nearly 51% of the medical students had not attempted to quit smoking in the preceding 1 year and 42% of the physicians and medical school faculty were current smokers.[14] About one-third of the faculty and physicians and approximately one-sixth of the medical students had attempted to quit smoking nearly four times. In Kashmir, a study among young doctors showed that 70% smokers initiated smoking between the ages of 11 and 20 years, and the most common reason for smoking initiation was peer pressure.[15]

Smoking among health-care workers, especially oncologists, is a major problem from a public health point of view, as health-care workers are role models for the entire society. Advising patients about the health risks of smoking is the standard of care. The combination of counseling and medication is more effective than either alone for smoking cessation. Delivering a diagnosis of cancer is said to be a “teachable moment” for patients, as they may be more open to advise and counseling. In one of the studies, it was observed that oncologists, despite being excellent at documenting smoking behavior in their prescriptions, advise smoking cessation to only about 25% of their patients.[16]

In 2007, the World Health Organization (WHO) introduced “MPOWER” for cessation of smoking in a cost-effective and practical way. The 6 MPOWER measures are:

Monitor tobacco use and prevention policiesProtect people from tobacco useOffer help to quit tobacco useWarn about the dangers of tobaccoEnforce bans on tobacco advertising, promotion, and sponsorshipRaise taxes on tobacco.

Therefore, for the sake of one's own health and also for the sake of patients, the implementation of smoking cessation (as advocated by MPOWER measures of the WHO) should be encouraged in society, including among physicians. Further, studies involving a larger number of physicians should be conducted to get an accurate picture of the scenario.

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Conflicts of interest

There are no conflicts of interest.


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