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Use of smokeless tobacco products is common worldwide, with increasing consumption in many countries. Although epidemiological data from the USA and Asia show a raised risk of oral cancer (overall relative risk 2·6 [95% CI 1·3–5·2]), these are not confirmed in northern European studies (1·0 [0·7–1·3]). Risks of oesophageal cancer (1·6 [1·1–2·3]) and pancreatic cancer (1·6 [1·1–2·2]) have also increased, as shown in northern European studies. Results on lung cancer have been inconsistent, with northern European studies suggesting no excess risk. In India and Sudan, more than 50% of oral cancers are attributable to smokeless tobacco products used in those countries, as are about 4% of oral cancers in US men and 20% of oesophageal and pancreatic cancers in Swedish men. Smokeless tobacco products are a major source of carcinogenic nitrosamines; biomarkers of exposure have been developed to quantify exposure as a framework for a carcinogenesis model in people. Animal carcinogenicity studies strongly support clinical results. Cancer risk of smokeless tobacco users is probably lower than that of smokers, but higher than that of non-tobacco users.

This intentionally selective global review reflects the views and frustrations of a public health physician with 45 years of frontline experience in tobacco control. In particular, it focuses on the nexus between research and policy and the long periods between relevant discoveries and application as policy. Consideration is given to the relative neglect of the possibility of reducing the carcinogenicity and toxicity of the cigarette on the grounds that it is the preferred source of nicotine for the global majority of nicotine users. Although the outcome of such change is unquantifiable, there is much in cigarette smoke that can be changed to make it less carcinogenic and less toxic. It is difficult to think of excuses for accepting the status quo.

This article considers changes in cigarette design in relation to the concept of “dose”, drawing attention to the observation that there is not one smoking related epidemic of lung cancer, but at least two. Squamous carcinoma is declining in parallel with smoking prevalence while adenocarcinoma is increasing in the face of declining smoking prevalence. It is concluded that the adenocarcinoma epidemic is unnecessary and is due substantially to cigarette design changes, including increases in tobacco specific nitrosamines, manipulation of droplet size and ventilated filters. The need for regulation of smoke constituents is emphasised.

International students pursuing higher education in the United States incur additional expenses compared to domestic students by spending on foreign credential evaluations and visa applications. These costs are usually not reflected in program fee structures, are non-refundable, and are not covered by financial aid, creating significant, and often unforeseen, financial strains on international students, particularly those from low-income backgrounds. This study compared the costs of two major foreign credential evaluators (Educational Credential Evaluators and World Education Services) and factored in the price of visa processing fees and the I-901 Student and Exchange Visitor Information System fee. It found that First-time, International, Graduate students pay up to $691 for foreign credential evaluations and visa applications. The paper suggests that higher education institutions should provide more transparent fee breakdowns and enhance financial aid packages to better support these students.

BackgroundBetween 1964 and 1996, the 10-year survival of patients having valve replacement surgery for rheumatic heart disease (RHD) in the Northern Territory, Australia, was 68%. As medical care has evolved since then, this study aimed to determine whether there has been a corresponding improvement in survival.MethodsA retrospective study of Aboriginal patients with RHD in the Northern Territory, Australia, having their first valve surgery between 1997 and 2016. Survival was examined using Kaplan-Meier and Cox regression analysis.FindingsThe cohort included 281 adults and 61 children. The median (IQR) age at first surgery was 31 (18–42) years; 173/342 (51%) had a valve replacement, 113/342 (33%) had a valve repair and 56/342 (16%) had a commissurotomy. There were 93/342 (27%) deaths during a median (IQR) follow-up of 8 (4–12) years. The overall 10-year survival was 70% (95% CI: 64% to 76%). It was 62% (95% CI: 53% to 70%) in those having valve replacement. There were 204/281 (73%) adults with at least 1 preoperative comorbidity. Preoperative comorbidity was associated with earlier death, the risk of death increasing with each comorbidity (HR: 1.3 (95% CI: 1.2 to 1.5), p<0.001). Preoperative chronic kidney disease (HR 6.5 (95% CI: 3.0 to 14.0) p≤0.001)), coronary artery disease (HR 3.3 (95% CI: 1.3 to 8.4) p=0.012) and pulmonary artery systolic pressure>50 mm Hg before surgery (HR 1.9 (95% CI: 1.2 to 3.1) p=0.007) were independently associated with death.InterpretationSurvival after valve replacement for RHD in this region of Australia has not improved. Although the patients were young, many had multiple comorbidities, which influenced long-term outcomes. The increasing prevalence of complex comorbidity in the region is a barrier to achieving optimal health outcomes.

The beginning of such a framework could lie in the process of establishing international guidelines for national regulators begun by the Tobacco Regulation Committee of WHO (TobReg),4 which has already published recommendations for upper limits for two major nitrosamines and is considering further limits.

The concept of harm reduction is controversial, as it brings to mind the failures, public misconceptions, and undermining of prevention associated with the low-tar cigarette campaign. Modern cigarettes are, however, unnecessarily carcinogenic and toxic, a situation that could be improved by sensible and serious regulation of the contents of tobacco smoke. The risks potentially associated with reducing levels of known toxicants in cigarettes are tiny in comparison with the acceptance of the status quo, which is disastrous. Failure to act in these circumstances is negligence.

Background: Incidence rates for adenocarcinoma of the lung are increasing and are higher in the United States than in many other developed countries. We examine whether these trends may be associated with changes in cigarette design. Methods: Lung cancer risk equations based on observations during 1960-1972 from the American Cancer Society Cancer Prevention Study I are applied to 5-year birth cohort-specific estimates of changes in smoking behaviors to predict birth cohort-specific rates of squamous cell carcinoma and adenocarcinoma of the lung among US White men for the period 1973-2000. These expected rates are compared to observed rates for the same birth cohorts of White men in the US Surveillance, Epidemiology and End Results (SEER) data. Results: Changes in smoking behaviors over the past several decades adequately explain the changes in squamous cell carcinoma rates observed in the SEER data. However, predicted rates for adenocarcinoma do not match the observed SEER data without inclusion of a term increasing the risk for adenocarcinoma with the duration of smoking after 1965. Conclusion: The risk of developing squamous cell carcinoma from smoking appears to have remained stable in the United States over the past several decades; however, the risk of adenocarcinoma has increased substantially in a pattern temporally associated with changes in cigarette design.

[...]the process will be slowed by corruption and other industry tactics, but once we win one country, the dominoes may fall. [...]Chapman should have welcomed the debate but also issued the clarion call for action.