Giving up the tobacco habit - a cancer survivor's tale

Dr Umanath Nayak tells us the impact of tobacco on our lives and how it affects the country.

Playing with fire became a dangerous habit with Agarwal!

Mr Agarwal is a businessman dealing with the manufacture and sales of 'fire bricks' used for lining furnaces in industries to provide insulation against the tremendous heat generated. Fire bricks, his passion, were what brought him to Hyderabad from his native state of Uttar Pradesh. As business improved, work pressures increased; and to ease his mind, Agarwal started playing with another kind of fire a chewable mixture of areca nut, lime paste and panmasala with aromatic spices. Though technically the mixture he used did not contain tobacco, the effects of its long-term use could be as devastating and debilitating as tobacco-chewing.

In India, tobacco-chewing is not just a habit; it is a religion! It is no surprise that the country has one of the highest incidences of oral cancer and has the dubious distinction of being referred to as 'the oral cancer capital' of the world. Tobacco is generally consumed as a constituent of the betel nut, locally known as pan. Pan has traditionally been in use since generations by both men and women, young and old. It is even served during marriage functions and festivals. In recent times, tobacco has become commercially available in convenient, ready-to-use, attractive packs in forms such as khaini, mishri (a powdered mixture of tobacco and areca nut), snuff (which is inhaled through the nose) and pan masala (a mixture of areca nut and lime paste which may or may not contain additional tobacco).

Areca nut has been shown by many scientific studies to be the cause of oral submucous fibrosis, a condition characterized by stiffening of the inner mucosal lining of the cheek and other parts of the oral cavity due to the deposition of fibrous tissue. This restricts the extent to which the mouth can open. In severe cases, it can result in a total inability to open the mouth. Though not cancer, this is an extremely debilitating condition by itself and very difficult to treat. (Read: Oral cancer: Symptoms, diagnosis and treatment)

Oral submucous fibrosis is also pre-cancerous and a significant proportion of people with this condition ultimately succumb to oral cancer.This condition is increasingly being seen among students and young adults who, attracted by the stylish, using them at an early age and get addicted. The absence of tobacco engenders the erroneous belief that these products are safe to consume, leading to disastrous consequences. It is estimated that there are over 20 million adolescents in India in the age group of 15 20 years who. are addicted to some form of tobacco or panmasala. The Indian government has only recently woken up to the reality of the health hazards of these chewable tobacco products. While restrictions on smoking in public places and a ban on the advertisement of all tobacco products have been in existence since 2003, they have done very little to curb the evil of tobacco-chewing. After the tobacco control legislation of 2003, a modest reduction in the sale of cigarettes and other smoking products was negated by a significant increase in the sale and consumption of chewed tobacco. A pictorial warning depicting oral cancer on all tobacco products (including chewed) was to replace the existing warnings from June 2010 onwards, However, pressure from the strong tobacco lobby has kept this on hold. The present warnings, enforced from 31 May 2009, show an X- ray picture of a cancer stricken lung which is considered too soft to have any real impact. Pictorial warnings have significantly reduced the consumption of tobacco products in countries such as Brazil and Mauritius and thus brought down the incidence of oral and lung cancers there.

Many countries of the European Union, Canada, Singapore and others have also adopted pictorial warnings with encouraging results. Hopefully, the Indian government will be able to resist pressures from vested interests to enact this legislation and curb the menace of tobacco -chewing, which has reached epidemic proportions in India. It is unclear whether this restriction, once enforced, will also apply to products that do not contain tobacco. These pan products masala are equally dangerous and are consumed by a segment of the population that is largely clueless about their catastrophic effects. Perhaps only public interest litigation, on the lines of what happened in the USA during the 1980s in connection with smoking, can result in any significant impact on the evil of tobacco-chewing in India. (Read: Living (and dying) with cancer)

Agarwal was not entirely clueless about the effects that his habit was having on him. But it was too late as he was already addicted and had difficulty concentrating without consuming . Even his wife's admonishments fell on deaf ears pan and masalaheultimately landed up paying a heavy price for his addiction. He noticed stiffening of his cheeks, a gradual restriction in the degree to which his mouth would open and frequent mouth sores, but chose to ignore these warning signs. One day, when he felt a fleshy growth in the region of his lower jaw, he panicked.

An appointment with his dentist and a biopsy confirmed his worst fears. He had oral cancer.

Surgery being the preferred treatment option, he was advised to see me. My examination told me that the cancerous growth was already in an advanced stage (stage III), and had involved most of the inner lining of the cheek as well as the lower gum.

This type of oral cancer is referred to as gingivo-buccal cancer (or 'Indian oral cancer') in view of its typical location in the furrow between the cheek and the lower gum the location where the tobacco or is usually kept.

The location of the cancer dictated panmasala that a portion of Agarwal's lower jaw, in addition to most of the cheek mucosa, would have to be removed during surgery. In the earlier days, this kind of operation was referred to as a 'commando operation', a term coined during the Second World War to indicate the risky nature of the operation, which was akin to a commando military operation. In those days, the risk of dying from this operation was so high that the name stuck. However, in recent times, with advances in surgical and anaesthesia techniques, this operation is considered totally safe and the word 'commando' is used for this procedure only in a historical sense. To replace the cheek lining after excision, a flap of skin is usually taken from another part of the body.

I discussed with Agarwal the choices of reconstructive surgery. The skin could either be taken from the chest wall a quick and simple option with a relatively faster recovery time, or from the forearm, using the technique of microvascular surgery. In microvascular surgery, the blood vessels supplying the transposed forearm skin are sutured to the blood vessels in the neck to maintain the blood supply of the flap. This option, though cosmetically superior, involves a longer operating time and recovery period. Being anxious to get back to his business quickly, Agarwal preferred the first one. His family members, meanwhile, explored other centres in India and abroad for his surgery, but Agarwal was firm that he wanted it done in Hyderabad under my care. His trust and faith in us was vindicated and his surgery went off successfully and uneventfully. Four weeks later, he was started on post-operative radiotherapy.

Now, three years later, Agarwal is back in the business of selling 'fire bricks' and believes that he is cured of the cancer. This, to some extent, obviates the guilt he felt during treatment the guilt of indulging in what was dangerous to him and putting himself and his family through all the suffering.

When I recently asked him how he felt now, he likened himself to a 'broken toy' which has been put back together, but will never ever be the same again.

Three cancers and M.A. Reddy still could not give up smoking! First diagnosed with cancer of the tonsil in 1999 and treated successfully with radiation, he developed a second cancer in his mouth in 2002, requiring surgery, and finally a third one on his soft palate in 2006. While one would have been enough for most, Mr Reddy, an Air Force man, defied all odds and survived three! Not only did he survive them, he staunchly refused to give up smoking, which is what was probably responsible for his cancers in the first place.

The development of multiple cancers in the mouth, throat, food pipe or lungs, together or separately, is a well-known feature of tobacco-related cancers. In smokers and tobacco chewers, genetic mutations in the cells predisposing the individual to the development of cancer occur in all areas of the upper air and food passages and the lungs. The severity of these changes, though, may vary. Areas of severe changes (medically termed severe dysplasia) progress to clinically evident cancer. Successful treatment of the cancer, however, does not reverse the process in other areas and fresh cancers can still develop in the areas at risk, sometimes many years later. These fresh cancers (called second or third primary, as the case may be) are a different entity from recurrent cancers. Recurrent cancers are cancers that have relapsed following treatment, either in or around the same site as the previous cancer or at sites distant from the original cancer. Both fresh primaries and recurrent cancers are more common among those who continue to smoke and drink after their initial cancer is treated. It is extremely important for the person to discontinue these habits once he/she has been diagnosed with a tobacco-related cancer of the head and neck region or the lungs.

It was not very early in life that M.A. Reddy picked up the habit of smoking. Cricket was his passion. At the very young age of 17, he represented the state of Andhra Pradesh in the Ranji trophy. He had the distinction of playing with the likes of the legendary C.K. Nayudu, India's first test cricket captain, and Vijay Manjrekar. On completing his studies, he joined the Air Force. One day, his senior officer commanded him, in true military tradition, to start drinking and smoking. M.A. Reddy obliged and was soon addicted to both alcohol and cigarettes. He continued with these habits even after taking voluntary retirement from the Air Force after serving for 20 years. A few failed business ventures did not help matters. Just when his last gamble of manufacturing pump sets was finally paying off, the tragedy struck. He was diagnosed with cancer.

I was in Europe on a month's fellowship when M.A. Reddy was diagnosed with cancer of the tonsil. My colleague at Apollo treated him with radiotherapy. On my return, I started seeing him regularly for follow - up. I strongly advised him to change his habits. I explained that continuing to smoke and drink would put him at grave risk for the development of future cancers, but he persisted. My words proved prophetic. Within three years, he developed a second cancer on the floor of his mouth. It was completely excised surgically without much difficulty as it was in an early stage.

The second cancer scared him and his family, and serious attempts were made to make M.A. Reddy kick his habit. But the willpower was lacking.

Many commercial preparations (nicotine skin patches, nicotine -impregnated chewing gum, etc.) are available in the market to help smokers kick the habit. Nicotine skin patches are adhesive patches containing the active ingredient of tobacco, nicotine, which gets absorbed through the skin and reduces the urge to smoke.

'Smo - quit' is an oral drug which, when taken regularly, makes cigarettes taste unpleasant and thus takes away the pleasure of smoking, making it less difficult to abstain. But unless there is a genuine interest in giving up and a strong willpower, all these remedies are bound to fail. Other addictions, such as alcohol and drugs, are physical addictions and abrupt cessation of the habit produces physical symptoms of withdrawal, requiring medical supervision or institutionalization. Smoking, on the other hand, is a psychological dependence and no serious untoward side -effects result from abrupt cessation, except for a temporary loss of concentration and sleeplessness. It is important after quitting to avoid parties and friends who smoke, till such time that the urge to start again goes away. Some distraction to take the mind off the thought can also be a great help. To succeed, it is vital that one must genuinely want to give up the habit. This is something that I do know from my personal experience.

I was a regular smoker during my medical college days. As an oncologist in Bangalore, the habit continued. I tried to kick the habit on numerous occasions but never succeeded. I was always confident that when it really mattered I would be able to give it up. When I was selected for a fellowship in the USA, I realized that continuing to smoke would amount to professional suicide, considering the strong anti - smoking sentiment prevalent in the USA at that time. My professors and colleagues there would not take kindly to my habit. Considering that I had specialized in head and neck cancer, I obviously had no other option. How could I advise my patients to give up smoking when I myself could not? I was just not sure how and when. (Read: War on Tobacco)

At the Mumbai airport, about to check in for my New York flight, I was asked the mandatory question, 'Smoking or non-smoking?'

I hesitated for a fraction of a moment, then on an impulse answered, 'Non-smoking, please.'

Then and there, I took out the packet of cigarettes from my pocket and dropped it into the trash bin. I managed the 22 -hour flight to New York without any incident, started a new life and have not smoked since (save for that occasional cigar)!

On my advice, M.A. Reddy tried 'Smo-quit' for a while, but found that he could no longer enjoy his smoking sessions. He also developed constipation while on it and soon discontinued the medicine. He did try to cut down on his smoking and drinking, but was unable to give up completely.

In the year 2006, during a routine follow-up, I noticed some mottled patches on his soft palate that looked suspicious. A biopsy confirmed that he had indeed developed a third cancer.

One more cancer, one more surgery, and back to his old habits.

In spite of being fully aware that smoking was killing him, M.A. Reddy was not able to give up. To understand why and also to do some counselling, I met him one evening at his favourite haunt, the Secunderabad Club. Over a couple of drinks, I was finally able to get to the truth .M.A. Reddy lost his father at a very young age, when he was hardly twelve. Getting over this loss is not easy for anyone. When he was in his early fifties, his only son, barely out of his teens, was killed in a high -speed car crash. His son's death created a profound sense of guilt in him. The thought that his son might not have gone out of control so early in his life if he had guided the boy properly during his growing years and spent more time with him kept disturbing him. The final straw was the cancer. Just when his business was peaking and the huge investments he had made in manufacturing pump sets were showing returns, he was diagnosed with cancer. Unfortunately, no one counselled him at that time that the cancer was curable and that very soon he would be able to get back to whatever he was doing. His family members panicked and he felt pressurized into disposing of all his investments at short notice. When I started seeing him a few months after his radiation treatment, it was already too late and he had resigned himself to a semi- retired life. There was no motivation left in him to fight against his habits, which, by now, had a vice-like grip. The three major tragedies in his life had broken him completely. The subsequent diagnosis of the second and third cancers merely compounded his feelings of hopelessness.

Read more about causes, symptoms, diagnosis and treatment of oral cancer.

From our session at the Secunderabad Club, I learnt the importance of counselling a cancer patient early on regarding the long-term implications of the disease and its treatment. The focus often is so much on the treatment and control of the cancer that the important issue of the psychological impact of the cancer on the patient is forgotten. That evening, I obtained an assurance from M.A. Reddy that he would give up smoking, if for nothing else then to prove that he still had the mental strength to do it. (Read: Natural remedies to quit smoking)

Excerpt from Dr Umanath Nayak's book 'Enduring Cancer Stories of Hope'. Dr Nayak is a Head and Neck Cancer surgeon, Apollo Cancer Hospitals, Hyderabad. His book may be purchased online through Flipkartand can also be downloaded on Amazon Kindle.

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