Fumo, riduzione del danno e rischio oncologico Francesco Grossi UOS Tumori Polmonari Ospedale Policlinico San Martino Genova
Agenda Evidence based studies against smoke (active and passive) and in favour of e-cigarette for stop smoking The tobacco war and the strategies for tobacco control
The Global Tobacco Epidemic 1.1 billion people smoke (82% live in LMICs) 20 th century: 100 million deaths 21 st century: 1 billion deaths About 7 million deaths/year Tobacco (smoking) causes 1/6 of all NCDs worldwide and is the only risk factor that causes all 4 leading NCDs WHO: tobacco is the leading preventable cause of death and disability in the world
Tremendous Economic Costs of Tobacco Use WHO/NCI Monograph: Tobacco use causes over $1 Trillion/year in economic losses Goodchild et al. (2017): $1.4 trillion/year (1.8% of global GDP) Close to 40% of economic costs in developing countries
Smoking and Cancer Mortality Skull of a Skeleton with Burning Cigarette Vincent van Gogh, 1885-1886 Newcomb, Carbone. Cigarette smoking: a clinical guide to assessment and treatment. Medical Clinics of North America Type of cancer Gender RR among smokers Mortality attributable to smoking Current Former % Lung M 22.4 9.4 90 F 11.9 4.7 79 Larynx M 10.5 5.2 81 F 17.8 11.9 87 Oral cavity M 27.5 8.8 92 F 5.6 2.9 61 Esophagus M 7.6 5.8 78 F 10.3 3.2 75 Pancreas M 2.1 1.1 29 F 2.3 1.8 34 Bladder M 2.9 1.9 47 F 2.6 1.9 37 Kidney M 3.0 2.0 48 F 1.4 1.2 12 Stomach M 1.5 MD 17 F 1.5 MD 25 Cervix F 2.1 1.9 31 Endometrial F 0.7 1.0 -
The Man Who Stopped Smoking Sir Richard Doll British Doctors Study (1954-2004)
Death Rate from Cancer of the Lung and Rate of Consumption of Tobacco Cigarettes Death rate from lung cancer Tobacco and cigarette consumption 1900-1950 Doll R and Hill B, BMJ 1950
Survival from age 35 for continuing cigarette smokers and lifelong non-smokers among UK male doctors Pt: Life is short. I will die anyway. Dr: If you continue smoking, you will lose 10 years of your life. Think what you can gain with 10 years. Doll R, BMJ 2004
Effects on survival of stopping smoking cigarettes Pt: It s too late to stop smoking at my age. Dr: At any age you stop, you will gain life years. It s never too late to stop smoking. Doll R, BMJ 2004
Smoking may be a choice but breathing is not!
The Men Who Stopped (passive) smoking Stan Glanz Takeshi Hirayama
E-cigarettes and cancer
Status quo and e-cigarette substitution, premature deaths and life years lost for all cohorts, men and women combined The 2014 US Surgeon General s Report suggested the need for a new strategy to more quickly end tobacco use, but a credible strategy has not been provided. This paper considers a strategy of switching cigarettes smokers to e-cigarette use in USA to accelerate tobacco control progress. Using a previously validated simulation model, our projections show that a strategy of replacing cigarette smoking with e-cigarette use would yield substantial life year gains, even under pessimistic assumptions regarding cessation, initiation and relative harm. Levy DT, Tob Control 2018
E-cigarettes: Comparing the Possible Risks of Increasing Smoking Initiation with the Potential Benefits of Increasing Smoking Cessation Cumulative Life-years Saved (or Lost) Under Base-case Assumptions Our analysis strongly suggests that the upside health benefit associated with e-cigarettes, in terms of their potential to increase adult smoking cessation, exceeds their downside risk to health as a result of their possibly increasing the number of youthful smoking initiators. Public messaging and policy should continue to strive to reduce young people's exposure to all nicotine and tobacco products. But they should not do so at the expense of limiting such products' potential to help adult smokers to quit. Warner KE, Nicotine Tob Res 2018
Still in Nicotine Business WHAT IS THE ROLE OF NICOTINE IN LESS HARMFUL ALTERNATIVES TO CIGARETTES? Nicotine is one of the reasons that people smoke, along with taste and ritual. In order for smokers to switch from cigarettes to less harmful alternatives, these products need to contain nicotine. https://www.pmi.com/science-andinnovation/the-role-of-nicotine But never say addiction!
Framework Convention on Tobacco Control (FCTC) Legally binding international treaty: first under the WHO Adopted May 2003; came into force in Feb 2005 Multisectoral: whole-of-government approach Includes broad range of tobacco control policies: Pictorial warnings Comprehensive smoke-free laws Higher taxes to reduce demand Bans/restrictions on marketing Support for cessation Measures to reduce illicit trade Tobacco product regulation Tobacco industry must be prevented from influencing policies Greatest disease prevention initiative in history
Protect People From Tobacco Smoke (FCTC Article 8) 2012: 1.1 billion people in 43 countries (16% of the world's population) are covered by complete smoke-free legislation. 2014: 1.3 billion people in 49 countries (18% of the world s population)
Warn About The Dangers of Tobacco (FCTC Article 11) 2012: 1.0 billion people in 30 countries (14% of the world's population) are exposed to strong graphic health warnings. 2014: 1.4 billion people in 42 countries (20% of the world s population)
1. Why has FCTC implementation been so slow? 2. Why has implementation been, in too many cases, at levels below the standards set by the FCTC Article Guidelines? Tobacco use is unlike other threats to global health. Infectious diseases do not employ multinational public relations firms. There are no front groups to promote the spread of cholera. Mosquitoes have no lobbyists. WHO Zeltner Report (2000)
Foundation for a Smoke-Free World Funded by Philip Morris for 1 Billion dollars over 12 years Funding for the Foundation for a Smoke-Free World by Philip Morris came from sales of cigarettes, a product which has killed and ruined the lives of millions of families. Effectively they are donating to a noble cause using money gained from one of the greatest public health disasters. Blood Money
The Right Path to Health Health Education through Religion Islamic Ruling on Smoking WHO Regional Office for the Eastern Mediterranean(2 nd edition, 2000) In view of the harm caused by tobacco, growing, trading in and smoking of tobacco are judged to be haram. The Prophet is reported to have said, Do not harm yourself or others. Furthermore, tobacco is unwholesome and God says in the Quran that the Prophet enjoins upon them that which is good and pure and forbids them that which is unwholesome.
Strategies for tobacco control With one billion smokers consuming 6.05 trillion cigarettes annually, successful tobacco control strategies must have the potential to reduce such numbers substantially Reactions of the tobacco industry to control strategies serve as a litmus test of potential effectiveness Tobacco products have a price elasticity of 0.5 (a 10% rise in price causes a 5% fall in demand). Taxing tobacco is a low cost strategy with great potential to reduce consumption among smokers in low socioeconomic groups and in developing countries Evidence now exists that children are the most responsive market segment to tobacco advertising Banning smoking at work can reduce daily smoking in continuing smokers by 25% - an unprecedented degree of impact. Harm reduction policies are likely to become hotly debated in nations where the decline in smoking has stalled Active monitoring and prosecution of shops that sell tobacco to children can dramatically reduce sales to children, but further research is needed on whether these actions reduce tobacco use by children Chapman S, BMJ 1996
Conclusions Tobacco is the most important and preventable cause of cancer world-wide. The growth and ageing of the world s population is going to have an enormous impact on the future cancer burden. There is a need to act now to limit the consequences of the tobacco epidemic Three main messages for the individual smoker: Risk is BIG: half of smokers are killed from a disease caused by their smoking Half of these deaths occur in MIDDLE age (35-69), losing many years of life expectancy STOPPING smoking works
Grazie per l attenzione! francesco.grossi@hsanmartino.it