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Health Promotion

MRes
Nov 2015

Learning Outcomes
•
•
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Health Promotion
Risk factors for Oral cancer
What are the causes?
How can we prevent or minimise risk?

How do we avoid this?

What causes Oral Cancer?
General Discussion
What do you think?

Risk factor awareness among GP’s
& GDP’s

Other causes?
• Mouth wash use?
• Genetic susceptibility
• Effects of cancer treatment eg radiotherapy and
continued smoking (exposure to carcinogens)
• Deprivation (David Conway)

What are the risk factors for oral
cancer?
•

What are the risk factors for oral
cancer?
• HPV
&
Oral
Sex
?

How does HPV cause cancer?

How does HPV cause cancer?
• P53 degradation (through ubiquitin-mediated
proteolysis)
• Rb TSG pathway inactivation
• P16 upregulation

P53 degradation
• The usual function of P53 is to arrest cells in
G1 or induce apoptosis to allow host DNA to
be repaired
...

• Both p16 & pRb are tumour suppressors
• CyclinD1 promotes cell cycle to S phase
• P16 slows this down and blocks G1 to S phase

• Cyclin D1 and CDK4 interact, block role of pRb by
phosphorylation
• This releases transcription factors egE2Fs so cell
goes into S phase and hence cell division
• HPV E7 interferes with pRb grt  p16 expression
• Why does  p16 grt cancer risk?

HPV 16 & 18
• HPV attacks the p53 gene
...
or pushes cell into
apoptosis
• If p53 inactivated, virus can take over the cell
• OR

• Other agents can cause DNA damage
(after HPV attack on p53)
• HPV also activates telomerase
• Encourages cell division ,
• Abnormal DNA may grt cancer

Can we screen for HPV?

Can we screen for HPV?
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•
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Cytology?
Serology?
Tissue sections: PCR? In situ hibridisation?
Surrogate markers?

Best method for HPV detection is
not established
• Techniques used :
• real-time PCR assays to quantify viral load,
type-specific DNA in-situ hybridisation,
detection of serum antibodies directed against
HPV epitopes,
• IHC detection of surrogate biomarkers (eg,
P16 protein)
...
5%
women (prevalence 7%)
• Prevalence ↑ age, no
...
Cost?
...
Effect of the ban?
• Tobacco Manufact
...


% who chew tobacco UK

Cigarette consumption
• USA:@20% smoke (16% W,21% M)
• Produces 400,000 tons tobacco/year

•

Cigarette consumption:USA
• 2000
...
4 % W
• Why have tobacco control legislation failed?
• In 1999 Over 600,000 tonnes grown
•
•
•
•

Tobacco smoke
• Contains over 4,000 chemical compounds,
present as either gases or as tiny particles
...


Why does smoking cause cancer?
• Cancer causing chemicals:
Tar,arsenic, polycyclic aromatic hydrocarbons eg
Benzopyrene (PAH),
Nitrosamines,acrolein(mutagen,carcinogen)
• Other poisons:
Hydrogen cyanide,CO,Ammonia
Carcinogens …
...

precursors of mutations grt cancer

Other forms of TOBACCO
• Reverse Smoking
Caribbean
• Bidi smoking
India
• Tobacco chewing
Asia
• Qat Somalia
• Water pipe
• http://www
...
com
• eCigarettes

Hookahs
• water moisture makes the smoke less irritating
giving a false sense of security
• A 40 min session consists of 50 to 200
inhalations (each of 0
...
50 liters of
smoke)

Hookahs
• 25g tobacco with no nicotine
• Typically x1/day using -molasses mixture each
• an hour- session consumes 100 to 200 times
the smoke of a single cigarette

Areca nut

Effects of Chewing the Nut
• Alters mood – psychotropic
• (Expels parasitic worms from the body –
anthelmintic??)
• (Parasympathetic properties produce euphoria
and counteract fatigue ??)
• Suppresses appetite

Constituents of the Betel Quid
•
•
•
•
•

Areca nut
Betel leaf
Lime – Calcium hydroxide
Spices
Tobacco

Pathogenesis
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•
•
•

Areca nut: Alkaloids,Flavonoids,Copper
Arecoline (an alkaloid)↑ collagen synthesis (170%)
Flavonoids (eg tannins in nut) inhibit collagenase
Cu stimulates lysyl oxidase grt mature collagen
Inflam→T cells→cytokines→↑ collagen
DNA damage:
Lime can release reactive oxygen species from
extracts of areca nut
Areca is a Group 1 carcinogen (ie don’t need
tobacco)

Signs and Symptoms
•
•
•
•
•

Mucosal petechiae
Burning sensation when eating
Restriction in mouth opening
Difficulty in mastication, speech and swallowing
Reduced mobility of the tongue and atrophy of
filiform papillae
• Staining and wear of teeth
• Fibrous bands in the buccal mucosa

• Malignant rate 7-30%

eCigarettes

Electronic cigarettes
• Vaporise nicotine or
flavoured
vapor(‘vaping’):
LED
Battery
Atomiser (heat)
Cartridge (mouthpiece)
Propylene glycol

• sales↑ x2every year
• 7million users in
Europe
• $1
...

Now cheaper
attractive to youth,
Addictive
...
on ingredients

eCigarettes
• UK to ban the sale to
those under 18

• 1
...

Glasgow)
• Healthcare costs £20 billion,$33 billion/year
• UK £9 billion in tax (2% of all taxation !)
• Ban terms ‘mild’ , ‘low tar’
• ecigarettes as a medicine by 2016 (currently
no regulation:whats in it ?is it safe?)
• Encourage youth to smoke?

Summary tobacco
•
•
•
•
•

What are the worldwide trends in its use?
What methods have been used to prevent it?
Why is smoking bad for you?
Why does smoking cause cancer?
What forms can tobacco be used?

Why does ALCOHOL cause oral cancer?

Alcohol & Tobacco

ALCOHOL: Oral and Pharyngeal cancer
Source: Tramacere et al (2010), meta-analysis, 17045 cases from 29 studies

CATEGORICAL ANALYSIS: compared to non- or occasional drinkers (<1 d/d) ≤1 drink* per day, RR 1
...
10–1
...
24 (95% CI 4
...
30)

(*1 drink = 12
...
RR function and 95% CI, describing the best fitting dose–response relationship between alcohol consumption
and the risk of oral and pharyngeal cancer

Dose response:
per 10grams /day
RR 1
...
25–1
...
5 mg/kg
Lemon flavour 26 mg/kg
Earl Grey tea leaves 10mg/kg
Coffee roasted @30mg/kg
Av total daily intake from food 48-96 mg/kg

Are alcohol mouthwashes safe?

Are alcohol mouthwashes safe?
• YES
• Boyle et al 2012
Meta analysis 18 studies
• No sig
...
trend for more risk
with more MW used

Oral Acetaldehyde levels after MW use
Moazzez et al (W Wade) Eur J Oral Sci 2011
• Measured Acetaldehyde (AA) in saliva after
MW with 21% Ethanol, Listerine Cool
Mint(21%Ethanol), store brand Alc MW +
CPC,8
...
)
A known mutagen and carcinogen
• Alcohol is metabolised in salivary
glands,mucosa,oral bacteria hence
exposure to Acet
...
Yearly toll
• Scots drink 25% more than E&W (12 v 10 litres
pure alcohol)
• Av Scot drinks 540 pints (46 bottles of Vodka/year)

• 50 million litres pure alcohol sold in Scotland
• Av weekly intake 26
...
8)

Qu:what is UK alcohol safe limit?
Men

Women

Qu:what is UK alcohol safe limit?
Women

Men
• Daily Limit
• 4 units max
...
7
2 Scotland Inverclyde 77
...
2
4 Scotland Renfrewshire 55
...
0

Qu: methods to reduce harmful
drinking?

Qu: methods to reduce harmful
drinking?
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•
•

CBT
ABI
Disulfiram (inhibits ALDH)
Read Allen Carr ‘easy way to control drinking’

UK female alcohol death rates
1998-2004

1998–2004 Rank order

1 Scotland Glasgow City 30
...
2
3 Scotland North Lanarkshire 18
...
3
5 Northern Ireland Belfast West 18
...

2
...

4
...
g
...
5% Beer X 568 ml / 1000= 2
...
com
(7calories/gram alcohol
1 pint @ 1 doughnut !)

Benefits of beer
• Rich in Vitamin B:
Riboflavin B2
Niacin B3
Pyroxidine B6
Folate B9
Cobalamin B12
1 pint = 10% daily
intake

Benefits of beer cont
...
6 to 32
mg /pint (people >
30mg/day dense
bone)

• 1 pt beer 10% daily
fibre !
• Beer can prevent H
...
units : Do they know
what they are ?

How many Units of alcohol in a beer?

Alcohol limits exceeded/month

SUMMARY: MCAW Dundee
• Student awareness of alcohol as an OC risk
factor improved (2000:10%, 2008 :50%)
• However only @25% know UK safe limits
• Huge underestimation in no
...
5 units/wk/adult
Implications of 40% under reporting
Result?
1/3 adults > weekly limits (21/14 units)
75% adults > daily limit (4/3 units) in last week

‘New’ guidelines
• Men daily max 4 units but 60% = 2
...
8

What do the surveys capture?
• General Lifestyle Survey (GLF)
Weekly drinking
• Health Survey in England (HSE)
Above daily limits, binge drinking on heaviest
day in last week

How much alcohol is consumed
but not recorded in surveys
• Sold but not captured in surveys

How much alcohol is consumed
but not recorded in surveys
• Sold but not captured in surveys
Under 16 years old
Homeless
Institutions eg Armed forces
Drinking non responders to surveys
Bought but not consumed eg cooking, expires
Consumed by visitors to UK
• ESTIMATED:2 L alcohol/capita

How much alcohol is consumed
but not recorded in surveys
• Alcohol not in sales statistics

How much alcohol is consumed
but not recorded in surveys
• Alcohol not in sales statistics
Legal & illegal imports, homebrew
Counterfeit production
Consumption whilst abroad
• ESTIMATED:2
...
9 L alcohol/capita

Survey v B&S Stats report
• Drinking > weekly guideline:
We claim its 29% M,20% F
Stats
...
survey :F < M
After stats F= M
• Stats revision: Women affected > Men

Implications of the B&S study
• @40% under reporting their alcohol in take ,
• Hence many of us drinking > rec
...
As we were with tobacco, we're in
deep denial about the dangers of alcohol
•
Discuss
• Is she right or is this a nanny state?and what
about equality of the sexes?

http://www
...
co

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