Manab, from Kalahandi district in Odisha, had a habit of chewing tobacco that he had picked up when he was young and was addicted to it. Its effects caught up to him when was 38-years-old, when a seemingly minor mouth ulcer turned into a daunting health ordeal. Little did he imagine that the burning sensation and persistent sore in the left buccal mucosa (inside lining of the cheek) would escalate into a serious life-threatening disease that would require a complex surgery.
The ulcer refused to heal despite medications for three months, gradually spreading to the jawbone. Manab began experiencing trismus (lockjaw), a condition where he could no longer open his mouth properly. Alarmed by the condition, he approached Manipal Hospitals in Bhubaneswar, where a detailed clinical examination, including CT scan and biopsy, revealed an advanced case of oral cavity cancer with significant jawbone involvement.
Given the severity and spread of the cancer, doctors recommended a composite surgical intervention that would both remove the tumour and reconstruct the damaged jaw. A multidisciplinary team led by surgical oncologist Dr Nitish Ranjan Acharya and plastic surgeon Dr Biswajit Mishra performed a composite resection of the cancerous lesion and followed it up with a microvascular reconstruction using a free fibula bone graft harvested from the patient’s leg, along with a large skin paddle for facial contour and mucosal lining.
Emphasising the challenges of treating advanced head and neck cancers, Dr Acharya said this was a highly complex case requiring precision and coordination between surgical oncology and plastic surgery teams. “The surgery aimed at not just to remove the cancer and make the patient survive, but at functional and aesthetic restoration, enabling Manab to speak, eat, and maintain a good quality of life again,” he said. Dr Mishra corroborated the intricacies in reconstructing the jaw afresh and reposed hope in the advancements in treatment. “Rebuilding the jaw using the patient’s fibula is an intricate procedure, requiring microsurgical anastomosis of blood vessels. There have been several advancements in maxillofacial surgery. This case was a perfect example of how advanced reconstructive surgery can offer a new lease of life to cancer patients,” he said.
Tobacco dependence continues to pose a major public health challenge in India, causing cancers of the mouth, throat, lungs, oesophagus, bladder, kidney, pancreas, cervix, and colon, with consequences that go beyond cancer, leading to a slew of severe debilitating diseases involving the heart and other organs. Tobacco use is responsible for approximately 33% of cancer-related deaths worldwide, and tobacco-related cancers contribute to around 28% of India's cancer burden.
According to the Global Adult Tobacco Survey (GATS-2) and the National Family Health Survey (NFHS-5), around 28.6% of Indian adults consume tobacco in some form, including smoking products like cigarettes and beedis, as well as smokeless forms such as gutkha, khaini, and betel quid with tobacco. The consumption pattern varies significantly between the states with northeastern states leading the chart. Smokeless tobacco dominates consumption in the eastern and central regions, with women also accounting for a significant proportion. However, southern states fare better with states like Kerala (17%), Goa (18%), Tamil Nadu (20%), Telangana (22%) and Andhra Pradesh (22%) reporting comparatively lower usage rates, thanks to better health awareness, literacy, and tobacco control measures. Tobacco use is higher in rural areas (32.4%) than urban (21.3%), and significantly more prevalent among men (42.4%) than women (14.2%). “Around 80% of the 1.2 billion smokers worldwide live in low-and middle-income nations, which bear the brunt of the disease and death caused by tobacco use.
“The cost of treating the sickness as well as lost human capital due to mortality and morbidity caused by cigarette use are all included in the comprehensive economic cost of tobacco. The World Bank claims that 82,000-99,000 kids and teenagers all over the world begin smoking every day,” said a study led by Dr Suranjana Jonak Hazarika of Government Dental College, Assam.
The National Cancer Registry Programme (NCRP) of the Indian Council of Medical Research (ICMR) reported over 1.46 million new cancer cases in 2022, with oral, lung, and oesophageal cancers leading the list in tobacco-prevalent regions. The cancer burden is predicted to rise to 2.98 million by 2025 from 2.67 million in 2021. The cancer spectrum differs from region to region due to diverse lifestyles.
Not surprisingly, states with high tobacco consumption also report high cancer incidence. Mizoram has the highest rate of cancer in India, particularly lung cancer. Kerala and Goa, with lower tobacco usage, have relatively better cancer control statistics.
“While Gujarat has a high prevalence of gutka, Karnataka has the highest rates of cigarette and beedi consumption. Oral cavity cancers, mostly preventable, account for over 30% of all cancers in men in several high-burden states. Oral cancer is among the top three most reported cancers in men in Odisha and it is a direct outcome of rampant khaini and gutka usage. Lung cancer, strongly associated with smoking, is also on the rise, particularly in urban male populations,” said Dr Basavaraj S Kumbar, consultant, internal medicine, Aster Whitefield Hospital, Bengaluru.
The National Cancer Registry Programme has linked oral and lung cancers as top contributors to cancer mortality in regions with high tobacco use. The Northeast, in particular, sees an unusually high burden of nasopharyngeal and oesophageal cancers, directly associated with tobacco chewing and smoking.
Diseases caused by tobacco consumption - like oral cancers, lung cancer, chronic obstructive pulmonary disease (COPD) and cardiovascular conditions - remain among the leading preventable causes of death globally.
Treatment for these diseases involves a dual approach - helping individuals quit tobacco and managing the resulting health conditions.
“The first step in combating tobacco-related diseases is cessation. Effective smoking cessation therapies include behavioural counselling and nicotine replacement therapy, apart from the routine medications. Combining pharmacological and behavioural treatments provides the best chance of success. These treatments not only help reduce dependency but also improve the prognosis of diseases linked to tobacco use,” said Dr Debasis Behera, associate professor of Pulmonary medicine at KIMS, Bhubaneswar.
India has made significant strides in cancer detection and treatment infrastructure. Advanced oncological surgeries, including microvascular reconstruction of jaws in oral cancer cases, are now increasingly available in tertiary centres. Cancer treatments for the lungs, oral cavity, or throat involve surgery, chemotherapy, radiation, or targeted drug therapies depending on the stage and type.
Surgery is the standard protocol for respiratory issues like COPD, bronchodilators, corticosteroids, pulmonary rehabilitation, and in severe cases. However, lifestyle changes, medications to control blood pressure and cholesterol, and in some cases, surgical interventions like bypass or angioplasty are used for cardiovascular diseases.
But challenges remain due to late diagnosis. Over 60% of oral cancers are detected in stages III and IV, especially in rural belts where access to cancer screening is limited. Many high-burden states lack adequate radiotherapy units and trained oncologists, leading to treatment delays. Sometimes, cancer treatment remains expensive, and many patients abandon treatment midway due to cost and logistics.
India has implemented several tobacco control measures under the Cigarettes and Other Tobacco Products Act (COTPA), 2003, and aligned with the WHO Framework Convention on Tobacco Control (FCTC).
There is also a ban on tobacco advertisements and smoking in public places, requirement to display large pictorial warnings on cigarette packs, apart from prohibition on sale of tobacco near educational institutions. But enforcement remains patchy and inconsistent. Gutkha is still widely available in sachets, often under disguised branding. Street vendors sell tobacco freely near schools, making these products accessible to underage users.
India has also launched the National Tobacco Quitline (1800-112-356) and mobile apps for counselling. However, tobacco cessation clinics are absent in many districts. Health experts stress a multi-pronged approach to combat the tobacco epidemic with strengthening tobacco cessation services. Stronger enforcement, punitive fines, and community surveillance are essential to build a tobacco-free society, they add.
“The only effective way to curb the cancer burden from tobacco is by bringing down its use. De-addiction remains a significant challenge due to the addictive nature of nicotine. There should be strategies to widely adopt nicotine replacement therapies. Behavioural counselling apart, focus must be on community outreach, health education in schools, workplaces, and rural areas,” said Dr Kumbar. As the country gears up to meet its public health targets, Dr Behera said there is an urgent need to formulate a strong policy and move from awareness to action.
Quitting tobacco will not only save lives, it reduces the nation’s cancer burden, lowers healthcare costs, and improves the overall quality of life, he added.