Smoking Ourselves to Oblivion: What to do about it.

Smoking and Lung Cancer

1.3 billion people smoke tobacco in the world. Over 80% tobacco users live in low- and middle-income countries. Tobacco kills up to half of its users (WHO).

In 2020 2.2 million new cases of lung cancer was reported and estimated 1.8 million deaths resulted in the same year, making lung cancer a leading cause in cancer related deaths (Sung H et al., 2021).

Lung cancer in Tanzania is as lethal as it can get. A recent 2021 report by International Agency for Research on Cancer showed that lung cancer ranks at 9th in top ten cancers in the country. On the other note there are 762 deaths for 862 new cases. The high mortality of lung cancer is because most of the times it is diagnosed late where the disease has already spread to other organs.

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The major risk factors for lung cancer are smoking, smoking and smoking. Smoking tobacco increases the risk factor for lung cancer by 25% compared to non-smokers. Other risk factors include exposure to radon, asbestos, arsenic, radioactive ores and inhaled chemicals. It should also be added that tobacco use is a risk factor for all four main Non-Communicable Diseases (NCDs) categories – cancer, cardiovascular disease, chronic respiratory disease, and diabetes.

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In 2019, smoking accounted for 7.7 million deaths Without intervention, deaths attributable to smoking will increase over the coming decades (Reitsma et al., 2021). With population growth, the absolute number of smokers has risen in many parts of the world, Tanzania has not been spared. It is estimated that tobacco smokers in Tanzania has increased by over 25% in the period between 1990-2019 (Reitsma et al., 2021).

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The 2018 Tanzania GATS (Global Adult Tobacco Survey) found that: 8.7% overall (2.6 million adults), 14.6% of men, and 3.2% of women currently used tobacco (smoking and/or smokeless tobacco). Overall, 31.1% of ever daily current smokers initiated daily smoking at age 17-19, 48.6% initiated at age 20 and above, 11.5% initiated at age 15-16, and 8.8% initiated when they were less than 15 years of age. These statistics shows that smoking is not an adult problem only but cuts across to include children.

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Tobacco smoke contain many substances, over 4000 substances, that are detrimental to our health.

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These substances affect almost all systems and organ in the body.

Now that I have made my case on smoking and its effects one can ask ‘So, what next?’ and the answer could be like this. There are many things we can individually and collectively to stop this trend. We can start by preventing all this from happening i.e. primary prevention. Primary prevention is the number one goal to achieve the strategic objectives stated in the National Cancer Control Strategy (NCCS) of Tanzania that was to last for 10 years (2013-2022).

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In preventing new cases of cancer different efforts can be made at different levels in the society. One of the places to start is in the primary health care. We have all heard about the saying ‘prevention is better than cure’ and it can be applied in this case also.

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Of course, just telling a patient that smoking is bad for their health won’t help much. In fact in the patient mind she might be thinking my grandfather smoked all his life and died peacefully at a good old age, why should I stop smoking!?. Many people who smoke can have these sentiments and deny the truth reflected in the damning statistics. On the other hand, nicotine which is one of the many components of a cigarette smoke has potent addictive properties. Once an individual is hooked with the smoke it can be very difficult to stop smoking tobacco even if she wants to. Not getting the dopamine high may lead to uncomfortable symptoms which can only be soothed by a puff of smoke according to the mind of the victim!

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This is why we are as primary care physicians have to be equipped and ready to advice and assist wherever possible our patients in the matter of smoking. A one on one session at the consultation room between a patient and their doctor is a great opportunity to initiate and effectively assist tobacco smoking cessation. But how can we do it?

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As Sun Tzu wrote ‘If you know your enemy and know yourself, you need not fear the result of a hundred battles’. We can adapt that advice in first knowing the barriers to tobacco (our enemy) treatment delivery in primary care. Different studies have shown the following to be such barriers (Pipe AL et al., 2022):

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The 2018 Tanzania GATS found that:

• ??48.4% of tobacco smokers attempted to quit smoking in the past 12 months.
• 36.5% of tobacco smokers who visited a health care provider in the past 12 months were advised to quit.
• 76.8% of current smokers planned to or were thinking of quitting.

We can assist more patients to quit smoking by application of the 5A’s model. According to the Toolkit for delivering the 5A’s and 5R’s brief tobacco interventions in primary care published by WHO 5A stands for Ask, Advise, Assess, Assist, Arrange. These are activities which takes 3-5 minutes where a health care provider can help patients quit smoking in a primary care setting. The following is a table explaining the 5A’s model for helping patients ready to quit:

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If the patient is not ready to quit then you can use the 5R’s model to motivate them to quit. 5R’s stands for relevance, risks, rewards, roadblocks, and repetition.

If the patient doesn’t want to be a non-tobacco user (doesn’t think that quitting is important), focus more time on “Risks” and “Rewards”.

If the patient wants to be a non- tobacco user but doesn’t think he or she can quit successfully (doesn’t feel confident in their ability to quit), focus more time on the “Roadblocks”.

If patients remain not ready to quit, end positively with an invitation to them to come back to you if they change their minds.

If your patient is a non-smoker you can offer a brief advice to inform them about the dangers of secondhand smoke (SHS) and help them avoid exposure to SHS. You can do this by appyliung the 5A's model as follows:

This is a simple tool that when applied well can help patient to quit smoking and thus reduce their risk of developing smoking associated diseases including the lethal lung cancer.

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NUGGETS

• ???????If you stop smoking before a cancer develops, your damaged lung tissue gradually starts to return to normal. Ten years after stopping smoking, your risk is reduced to 1/3 of what it would have been if you continued to smoke.
• ???There is no evidence that smoking low tar or "light" cigarettes reduces the risk of lung cancer.
• ??????If you don't smoke, but breathe in the smoke of others (called secondhand smoke or environmental tobacco smoke), you are also at increased risk for lung cancer. A nonsmoker who is married to a smoker has a 30% greater risk of developing lung cancer than the spouse of a nonsmoker.
• ??????Shisha smoking has become popular among young people. Studies have shown that hookah smoke contains the same cancer-causing substances as cigarettes. It is addictive and may lead to cigarette smoking in the future.
• ??????In a study done by Reitsma et al in 2021 in 204 countries they found 83% of all smokers began smoking between the ages of 14 and 25. Thus the age range of 14–25 years: a critical window for intervention.

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CONCLUSION

As we have seen the pleasurable high attained by smoking tobacco can lead to numerous health devastating outcomes. It needs a multi-sectoral effort to help people realize the effects and take informed decision to quit smoking. As primary health care practitioners, we play an important role in saving people lives from the adverse effects of smoking. Knowledge is power and by having the 5A’s and 5R’s we can work together with other professionals to help patients to cease from tobacco use.

We should also remember that in this modern era of digital information and the internet we can also use these platforms to make the society aware of tobacco effects and assist them to get help to quit from smoking. Our country has a large population of young people where most are vulnerable to engage in risky behaviors such as smoking tobacco. Digital technology used by many adolescents and youths could be utilized effectively by spreading educative articles, facts, videos and posts to prevent the future generation from succumbing to the detrimental effects of smoking tobacco.

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REFERENCES

https://acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.21660#:~:text=Lung%20cancer%20remained%20the%20leading,female%20breast%20(6.9%25)%20cancers.

https://www.who.int/news-room/fact-sheets/detail/tobacco. Acessed on 04/08/2022

Quick facts lung cancer: what you need to know—now. From the Experts at the American Cancer Society. 2007. Pg 10-12

Pipe AL, Evans W, Papadakis S. Tob Control 2022;31:340–347.

Reitsma MB, Flor LS, Mullany EC, Gupta V, Hay SI, Gakidou E. Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990–2019. Lancet Public Health 2021;

Tanzania's 2018 Global Adult Tobacco Survey (GATS)

The Global Cancer Observatory – International Agency for Research on Cancer

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