Tobacco-related cancer prevention

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]

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

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

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

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]

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]

Screening, cessation, and chemoprevention pathways for adults at risk of oral, lung, and oesophageal cancer from tobacco and areca-nut use.

1.ICMR Consensus Document on Tobacco-Related Cancer Prevention (2021); USPSTF Lung Cancer Screening; FCTC implementation guidance (2021)