Red Flags
- Suspected oral cancer (non-healing ulcer ≥3 weeks, leucoplakia/erythroplakia, lump, restricted mouth opening, neck lymph node) — same-day ENT/oral oncology, biopsy[1]
- Haemoptysis, persistent cough ≥3 weeks, weight loss, hoarseness — chest imaging and rapid lung cancer pathway[1]
- Dysphagia, persistent retrosternal pain, weight loss in tobacco/alcohol user — upper GI endoscopy for oesophageal carcinoma[1]
- Submucous fibrosis with progressive trismus or burning — biopsy at high-risk site; areca-nut and tobacco cessation; dysplasia surveillance[1]
First-line treatment
Interventions
- Brief intervention at every visit — Ask, Advise, Assess, Assist, Arrange[1]Document tobacco status; firm clear unambiguous advice to quit; assess motivation; offer pharmacotherapy + behavioural support; schedule follow-up; integrated into NCD clinics
- Behavioural support[1]Quitline, group, individual counselling; mobile health interventions; combine with pharmacotherapy for highest quit rates; address triggers, withdrawal, social context
- Lung cancer screening with low-dose CT[1]Eligible adults 50–80 with ≥20 pack-years current or quit <15 years; annual LDCT with structured reporting (Lung-RADS); link to multidisciplinary nodule pathway and cessation support
- Oral potentially malignant disorder surveillance[1]Leucoplakia, erythroplakia, oral submucous fibrosis, oral lichen planus; biopsy of suspicious lesions; regular follow-up every 3–6 months; tobacco and areca-nut cessation primary intervention
- Population-level interventions[1]Pictorial warnings, taxation, smoke-free public spaces, advertising ban, plain packaging — most effective at population level; clinician advocacy for policy adherence
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Varenicline[1] | α4β2 nicotinic partial agonist | 0.5 mg PO daily × 3 days, 0.5 mg BD × 4 days, then 1 mg BD × 11 weeks (extend to 24 weeks for relapse prevention) | — | Most effective single agent for smoking cessation; nausea; rare neuropsychiatric symptoms; recently revalidated as safe |
| Nicotine replacement therapy (combination)[1] | Nicotine substitution | Patch 21 mg/24 h × 4 weeks, 14 mg × 2 weeks, 7 mg × 2 weeks; gum/lozenge 2–4 mg PRN for cravings | — | First-line, widely available; combine patch (basal) + gum (acute cravings) for higher quit rates than monotherapy |
| Bupropion[1] | NDRI antidepressant | 150 mg PO daily × 3 days then 150 mg BD × 7–12 weeks | — | Alternative cessation agent; contraindicated in seizure disorder, eating disorder, MAOI co-use; start 1–2 weeks before quit date |
| Cytisine (where available)[1] | Plant-derived nicotinic partial agonist | 1.5 mg PO 6× daily × 3 days then taper over 25 days per RACE protocol | — | Cost-effective alternative to varenicline; comparable efficacy in some trials; widely used in Eastern Europe and increasingly elsewhere |
Varenicline[1]
α4β2 nicotinic partial agonist
- Adult
- 0.5 mg PO daily × 3 days, 0.5 mg BD × 4 days, then 1 mg BD × 11 weeks (extend to 24 weeks for relapse prevention)
- Paediatric
- —
Most effective single agent for smoking cessation; nausea; rare neuropsychiatric symptoms; recently revalidated as safe
Nicotine replacement therapy (combination)[1]
Nicotine substitution
- Adult
- Patch 21 mg/24 h × 4 weeks, 14 mg × 2 weeks, 7 mg × 2 weeks; gum/lozenge 2–4 mg PRN for cravings
- Paediatric
- —
First-line, widely available; combine patch (basal) + gum (acute cravings) for higher quit rates than monotherapy
Bupropion[1]
NDRI antidepressant
- Adult
- 150 mg PO daily × 3 days then 150 mg BD × 7–12 weeks
- Paediatric
- —
Alternative cessation agent; contraindicated in seizure disorder, eating disorder, MAOI co-use; start 1–2 weeks before quit date
Cytisine (where available)[1]
Plant-derived nicotinic partial agonist
- Adult
- 1.5 mg PO 6× daily × 3 days then taper over 25 days per RACE protocol
- Paediatric
- —
Cost-effective alternative to varenicline; comparable efficacy in some trials; widely used in Eastern Europe and increasingly elsewhere
Safety-net
- Quitting tobacco at any age reduces cancer, cardiovascular, and respiratory disease risk; relapse is part of recovery — multiple attempts are normal[1]
- Self-examine the mouth monthly under good light; report any non-healing ulcer, white or red patch, lump, or change in chewing/speaking[1]
- Smokeless tobacco (gutka, khaini, paan masala) is not safer than smoking — it causes oral and oesophageal cancer and submucous fibrosis[1]
Referral criteria
- Suspected oral, oropharyngeal, lung, or oesophageal cancerENT, thoracic, or GI oncology rapid-access pathway[1]
- Oral potentially malignant disorder requiring biopsy or specialist surveillanceOral and maxillofacial surgery / oral oncology[1]
- Eligible for lung cancer screening but no screening pathway available locallyPulmonology or NCD clinic with imaging access[1]
- Treatment-resistant tobacco dependence after multiple cessation attemptsTobacco cessation clinic or addiction specialist[1]
Clinical summary
Screening, cessation, and chemoprevention pathways for adults at risk of oral, lung, and oesophageal cancer from tobacco and areca-nut use.