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
thcentury: 100 million deaths
21
stcentury: 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
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
Tremendous Economic Costs of
Tobacco Use
Smoking and Cancer Mortality
Skull of a Skeleton with Burning Cigarette
Vincent van Gogh, 1885-1886
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 -
Newcomb, Carbone.
Cigarette smoking: a clinical guide to assessment and treatment. Medical Clinics of North America
The Man Who Stopped Smoking
“British Doctors’ Study” (1954-2004)
Sir Richard Doll
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
Doll R, BMJ 2004
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.”
Effects on survival of stopping smoking cigarettes
Doll R, BMJ 2004
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.”
Smoking may be a choice…
…but breathing is
not !
The Men Who Stopped (passive) smoking
Takeshi Hirayama
Stan Glanz
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
Warner KE, Nicotine Tob Res 2018
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.
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-and- innovation/the-role-of-nicotine
But never say “addiction”!
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
Framework Convention on Tobacco Control
(FCTC)
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)
Protect People From Tobacco Smoke
(FCTC Article 8)
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)
Warn About The Dangers of Tobacco
(FCTC Article 11)
“ 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)
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?
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
ndedition, 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
