A Research Agenda for Betel Quid and Areca Nut and Oral Cancer Recommendations from the International Conference on Betel Quid and Areca Nut
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1 A Research Agenda for Betel Quid and Areca Nut and Oral Cancer Recommendations from the International Conference on Betel Quid and Areca Nut Presented by: Mark Parascandola Epidemiologist National Cancer Institute
2 Interna'onal Conference on Betel Quid and Areca Nut Kuala Lumpur, Malaysia, April 27-28, 2016
3 International Conference on Betel Quid (BQ) and Areca Nut (AN) When and where: Kuala Lumpur, Malaysia, April Goal: Convene regional experts in BQ/AN and gain a greater understanding of the impact of use of BQ/AN, both with and without tobacco. Objectives of the conference: Identify research priorities Build research networks Identify evidence- based prevention and control strategies Four Plenary Sessions and Concurrent Breakout Sessions: Biology, Disease and Epidemiology Prevention, Addiction and Dependence Screening and Early Diagnosis of Oral Cancers Policy Interventions and Economic Aspects of Betel-Leaf and Areca Nut Use 3
4 Defining a global research and policy agenda for betel quid and areca nut H Mehrtash, K Duncan, M Parascandola, et. al. Forthcoming in Lancet Oncology More than 600 million users, ~10% of the global population, with prevalence especially high in Asia-Pacific Region Betel quid and areca nut are known risk factors for oral and oesophageal cancers, along with effects on the cardiovascular, nervous, gastrointestinal, metabolic, respiratory, and reproductive systems. Unlike tobacco, for which the WHO Framework Convention on Tobacco Control provides evidence-based policies for reducing tobacco use, no global policy exists for the control of betel quid and areca nut use. Research is needed to advance understanding of the basic biology, mechanisms, and epidemiology of betel quid and areca nut use, to advance prevention and cessation programs and policies for betel quid and areca nut users, and to design evidence-based screening and early diagnosis programs for oral cancer. 4
5 Betel Quid and Cancer 2004 IARC report BQ and AN classified as carcinogenic to humans (Group 1) by IARC, with or without tobacco Sufficient evidence that BQ without tobacco causes oral cancer and BQ with tobacco causes oral cancer and cancer of the pharynx and esophagus BQ/AN use may account for up to 50% of oral cancers in some countries Oral cancers are the sixth most common cancer in the world with a clear geographical varia'on in incidence, and the prevalence of oral cancers is especially high in countries in South and South East Asia where BQ/AN use is common
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7 CP Wen 2010 Oral Cancer Risk Factors: Taiwan
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10 Cancer: Biological mechanisms and biomarkers associated with specific constituents
11 Variations in ph Level Determine Free Nicotine Levels
12 Total NNAL concentrations in urine of ST users varies across products
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16 Relative Risks associated with ST use vary between countries
17 Annual Burden of Disease Attributable to Smokeless Tobacco Use in Two Countries: Sweden and India Country/disease Sex Relative risk Prevalence of smokeless tobacco use Attributable fraction Attributable burden of disease Sweden Oral cancer men women % 7% 0% 0% 0 0 Esophageal cancer men women % 7% 13.5% 4.0% 39 4 India Oral cancer men women % 18% 57.5% 42.5% 26,131 10,359 Esophageal cancer men women % 18% 47.1% 32.7% 13,569 6,308
18 Annual Burden of Disease Attributable to Smokeless Tobacco Use in Two Countries: Sweden and India Country/disease Sex Relative risk Prevalence of smokeless tobacco use Attributable fraction Attributable burden of disease Sweden Oral cancer men women % 7% 0% 0% 0 0 Esophageal cancer men women % 7% 13.5% 4.0% 39 4 India Oral cancer men women % 18% 57.5% 42.5% 26,131 10,359 Esophageal cancer men women % 18% 47.1% 32.7% 13,569 6,308
19 Global Products Conclusion ST products should not be viewed as a single homogenous product category for assessing composition or health effects Because of these widely varying characteristics, along with different patterns of use, ST products are likely to differ across regions in their abuse liability, toxicity, carcinogenicity, and impact on health
20 The Economics of Tobacco and Tobacco Control Tobacco use imposes an enormous health and economic burden on the global workforce Tobacco use remains one of the world s leading causes of preventable premature death, including death from cancer. Globally, there are 1.1 billion tobacco smokers age 15 or older, and tobacco use burdens economies with more than US$ 1 trillion in health care costs and lost produc'vity annually. Monograph available online at 20
21 Raising Tobacco Taxes: A Critical Strategy Though highly cost-effective in reducing tobacco use, increased tobacco taxation is the least implemented intervention Only 10% of the world s population is covered by taxation policies that are judged to be at the highest level of enforcement, compared to other tobacco control policies There is big room for improvement many LMICs, as well as China and Russia, have excise tax shares <50%. Price per Pack in International Dollar Purchasing Power Parity (PPP) of Most Popular Brand and the Share of Excise and Total Tax in Price, by Country Income Group, 2014 Share of the World Population Covered by Selected Tobacco Control Policies, 2014 Source: NCI-WHO Monograph on the Economics of Tobacco and Tobacco Control (Figure) 21
22 The Global Tobacco Control Laboratory Ongoing introduc'on of many new tobacco control policies driven by the Framework Conven'on on Tobacco Control (FCTC), but policies and 'melines differ widely across countries. Diverse and changing condi'ons in pacerns of tobacco use, cultural and social adtudes, economic forces, and healthcare environments. A series of natural experiments are currently under way. Opportunity for studying the impact of different policies in different environments and understanding what works. Expanding tobacco control research and research-capacity in the developing world is crucial to reducing the disproportionate burden of tobacco use and cancer.
23 Defining a global research and policy agenda for betel quid and areca nut H Mehrtash, K Duncan, M Parascandola, et. al. Forthcoming in Lancet Oncology More than 600 million users, ~10% of the global popula'on, with prevalence especially high in Asia-Pacific Region Betel quid and areca nut are known risk factors for oral and oesophageal cancers, along with effects on the cardiovascular, nervous, gastrointes'nal, metabolic, respiratory, and reproduc've systems. Unlike tobacco, for which the WHO Framework Conven'on on Tobacco Control provides evidence-based policies for reducing tobacco use, no global policy exists for the control of betel quid and areca nut use. Research is needed to advance understanding of the basic biology, mechanisms, and epidemiology of betel quid and areca nut use, to advance preven'on and cessa'on programs and policies for betel quid and areca nut users, and to design evidence-based screening and early diagnosis programs for oral cancer. 23
24 Defining a global research and policy agenda for betel quid and areca nut Recommenda?ons for future research direc?ons (1) Characterisa'on of the types of betel quid and areca nut products and their use across popula'ons in the Asia Pacific region Strengthen the understanding of the biological and behavioral basis of areca nut dependence to aid in the development of effec've preven'on and cessa'on interven'ons Development and evalua'on of targeted betel quid and areca nut use preven'on and cessa'on methods that include the evalua'on of exis'ng preven'on campaigns and messages, and defining the role of health-care providers in preven'on and cessa'on interven'ons 24
25 Defining a global research and policy agenda for betel quid and areca nut Recommenda?ons for future research direc?ons (2) Study of the cultural and social conven'ons that mo'vate the use of betel quid and areca nut products Quan'fica'on of the dose-response rela'onships between various betel quid and areca nut products, with and without tobacco, and the risk of oral and oesophageal cancers Development, evalua'on, and implementa'on of effec've screening and early diagnosis programs for oral cancers Comple'on and implementa'on of transla'onal research to best apply effec've policy interven'ons in tobacco control to this diverse field to mi'gate the poten'al risk of disease 25
26 cancer.gov cancer.gov/espanol
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Cigarettes. Ada Ellisman, Bryan Gibson, & Evie White
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