Association of tobacco habits, including bidi smoking, with overall and site-specific cancer incidence: results from the Mumbai cohort study

Association of Tobacco Use and Cancer Incidence in India: A Systematic Review and Meta-Analysis

PURPOSE

To estimate the strength of the association between tobacco use and cancer incidence among the Indian population.

MATERIALS AND METHODS

Data from PubMed, Embase, and Virtual Health Library were searched from inception of databases till April 30, 2022. There were no restrictions except for English language and human study. Case-control and cohort studies on cancer incidence in relation to tobacco use were selected. Data were extracted independently by two investigators, and discrepancies were resolved by a third reviewer. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The quality assessment was done using the Newcastle Ottawa Scale.

RESULTS

The majority were case-control designs (60, 89.6%), covering diverse geographic regions, with Maharashtra (18, 30%) and Kerala (12, 20%) being the most studied. Pooled effect sizes were calculated using the random-effects model, and forest plots were generated. The risk of any cancer associated with smoked and smokeless tobacco was 2.71 (95% CI, 2.25 to 3.16) and 2.68 (95% CI, 2.22 to 3.14), respectively, indicating similar risks. Gender-wise, smoked tobacco had an association of 2.35 (95% CI, 2.05 to 2.65) for males, whereas for smokeless tobacco, it was 1.77 (95% CI, 1.47 to 2.07) for males and 2.34 (95% CI, 1.26 to 3.42) for females. Regardless of gender, tobacco type, and affected body parts, the risk of cancer due to tobacco use was consistent in the Indian population. Site-specific analysis showed higher risks of respiratory system cancers of 4.97 (95% CI, 3.62 to 6.32) and head and neck cancers of 3.95 (95% CI, 3.48 to 4.42).

CONCLUSION

This study underscores that both smoked and smokeless tobacco are equally harmful to human health among the Indian population, providing insights for stakeholders and policymakers to arrive at tobacco-specific interventions.

Update on numbers of tobacco-attributable deaths by country in the South-East Asia region: implications for policy

BACKGROUND

The WHO South-East Asia Region is home to around 33% of adult tobacco users. To inform tobacco control policy and practice, we conducted a study using the latest available data to update mortality attributable to overall tobacco use, including smoked tobacco, smokeless tobacco (SLT) and secondhand smoke (SHS) exposure, in the 11 countries of the Region.

METHODS

We estimated smoking, SLT use and SHS exposure using the latest available surveys for each country during 2016-2021, and then estimated all-cause and lung cancer-attributable annual deaths for each using the population-attributable fraction method. Finally, we estimated the annual total tobacco-attributable deaths including all three exposures using the multiplicative aggregation method.

RESULTS

We estimated the occurrence of 4 087 920 all-cause deaths and 105 279 lung cancer deaths annually attributable to tobacco use among the 11 countries investigated. India accounted for 63.9% of all-cause tobacco-attributable deaths.

CONCLUSIONS

The high annual number of tobacco-attributable deaths in the Region highlights the need for accelerating progress in reducing tobacco use. Implementation of the WHO Framework Convention on Tobacco Control (FCTC) and MPOWER policy package needs prioritisation at the country level. Tobacco cessation services, supply-side measures and policies to counter tobacco industry interference should be strengthened. Further work is needed to monitor progress towards FCTC implementation and analyse the impacts of policies on tobacco-related outcomes, including attributable mortality and disease burden, to inform advocacy efforts.

Non-cigarette Tobacco Use and Stroke Among West Africans: Evidence From the SIREN Study

INTRODUCTION

Non-cigarette tobacco (NCT) represents a form of tobacco use with a misperceived significance in chronic disease events. Whether NCT use is sufficient to promote stroke events, especially among Africans, is yet to be understood. This study assessed the relationship between NCT use and stroke among indigenous Africans.

METHODS

A total of 7617 respondents (NCT users: 41 vs. non-NCT: 7576) from the Stroke Investigative Research and Educational Network (SIREN) study were included in the current analysis. NCT use was defined as self-reported use of smoked (cigars or piper) or smokeless (snuff or chewed) tobacco in the past year preceding stroke events. Stroke was defined based on clinical presentation and confirmed with a cranial computed tomography/magnetic resonance imaging. Multivariable-adjusted logistic regression was applied to estimate the odds ratio (OR) and 95% confidence interval (CI) for the relationship of NCT with stroke at a two-sided p < .05.

RESULTS

Out of the 41 (0.54%) who reported NCT use, 27 (65.9%) reported using smokeless NCT. NCT users were older than non-NCT users (62.8 ± 15.7 vs. 57.7 ± 14.8 years). Overall, NCT use was associated with first-ever stroke (OR: 2.08; 95% CI: 1.02, 4.23) in the entire sample. Notably, smokeless NCT use was independently associated with higher odds of stroke (OR: 2.74; 95% CI: 1.15, 6.54), but smoked NCT use (OR: 0.16; 95% CI: 0.02, 1.63) presented a statistically insignificant association after adjusting for hypertension and other covariates.

CONCLUSIONS

NCT use was associated with higher odds of stroke, and public health interventions targeting NCT use might be promising in reducing the burden of stroke among indigenous Africans.

IMPLICATIONS

A detailed understanding of the relationship between NCT use and stroke will likely inform well-articulated policy guidance and evidence-based recommendations for public health prevention and management of stroke on the African continent.

The global burden of lung cancer: current status and future trends

Lung cancer is the leading cause of cancer-related death worldwide. However, lung cancer incidence and mortality rates differ substantially across the world, reflecting varying patterns of tobacco smoking, exposure to environmental risk factors and genetics. Tobacco smoking is the leading risk factor for lung cancer. Lung cancer incidence largely reflects trends in smoking patterns, which generally vary by sex and economic development. For this reason, tobacco control campaigns are a central part of global strategies designed to reduce lung cancer mortality. Environmental and occupational lung cancer risk factors, such as unprocessed biomass fuels, asbestos, arsenic and radon, can also contribute to lung cancer incidence in certain parts of the world. Over the past decade, large-cohort clinical studies have established that low-dose CT screening reduces lung cancer mortality, largely owing to increased diagnosis and treatment at earlier disease stages. These data have led to recommendations that individuals with a high risk of lung cancer undergo screening in several economically developed countries and increased implementation of screening worldwide. In this Review, we provide an overview of the global epidemiology of lung cancer. Lung cancer risk factors and global risk reduction efforts are also discussed. Finally, we summarize lung cancer screening policies and their implementation worldwide.

Exclusive use of different types of tobacco products, exposure to secondhand tobacco smoke and risk of subtypes of head and neck cancer among Indian males

Tobacco products are used in vary many forms in India. Although the risk of tobacco uses in developing head and neck cancer (HNC) is known, risk by exclusive use of different tobacco products on HNC and its subtypes is poorly understood. A case-control study was conducted at a tertiary cancer hospital, which receives cases from different geographical regions of India with use of different types of tobacco products. The study included 824 oral cavity (OC), 149 oropharynx (OPX) 104 hypopharyngeal (HPX) and 81 larynx (LX) cancer cases and 1206 visitor controls. Information on 11 different types of tobacco products and exposure to secondhand smoke was collected through structured questionnaires. Odds ratios (OR) and 95% confidence intervals (CI), for the association of various HNC subtypes with exclusive use of each tobacco product compared to nonusers of tobacco were estimated using logistic regression models, after adjusting for potential confounders. Exclusive use of any type of smokeless tobacco product was strongly associated with all subtypes of HNC. Gutka chewing (only) had highest risk (OR = 33.67; 95% CI = 19.8-57.0) while exclusive users of betel quid with tobacco (BQ + T), tobacco quid, Khaini, Mawa and Mishri users had a OR of 14.77, 24.20, 5.33, 2.96 and 3.32, respectively, for development of OC. Bidi smoking and secondhand smoke was independently associated with increased risk of HNC. Our study indicates that tobacco control policies should focus on product specific awareness messaging that switching between tobacco product types is not a safe alternative to complete cessation.

Influence of Oral Dipping Tombak Smokeless Tobacco on Coagulation Profile and Platelet Counts

The goal of this paper is to investigate the influence of oral dipping of Tombak Smokeless Tobacco (SLT) on prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio(INR) values, and platelet counts (PLTs), in Sudanese Tombak users. An analytical cross-sectional study was conducted at Kosti health insurance hospital, Sudan, in 2019. According to the inclusion and exclusion criteria, 100 adult users of oral Tombak for three or more years were chosen randomly as a study group. Another 100 matched healthy individuals who never used Tombak were randomly selected as a comparative group. Venous blood specimens were collected in ethylene diamine tetra-acetic acid (EDTA) containers for the PLT counts using the automated haematology analyser (Sysmex, Tokyo, Japan XK-21SYSMEX) and in trisodium citrate anti-coagulant containers for coagulation tests using a co-agulometer machine analyser. Our findings show a significant decrease in PLT count mean values in the Tombak users group (212.1 × 103/mm3 ± 74.3 × 103/mm3) compared with the non-taking Tombak group mean values (243.2 × 103/mm3 ± 83.0 × 103/mm3), (p < 0.006). Both PT and APTT were significantly prolonged in Tombak users (16.03 ± 1.22 s vs. 14.44 ± 0.557 s), p < 0.001 for PT, and (41.62 ± 7.28 s vs. 34.99 ± 4.02 s), (p < 0.001) for APTT. INR mean values were significantly longer in Tombak users (1.11 ± 0.096) vs. (1.07 ± 0.66; p < 0.001). Multiple linear regression analysis findings show a significant impact of the four investigated variables, including duration of taking Tombak, age, and frequency of taking Tombak per day (p < 0.001). In conclusion, using Tombak a Smokeless Tobacco (SLT) for a long period significantly affect Platelet counts and coagulation profile.

A Study of Head and Neck Cancer Patients with Reference to Tobacco Use, Gender, and Subsite Distribution

Context  Head and neck cancer (HNC) is very common in India, constituting 30% of all the cancers because of the widespread use of tobacco across India. The prevalence and pattern of tobacco use vary in different regions and states of the country. Although predominantly seen in males, studies have reported that the male-to-female ratio varies worldwide and also by anatomical subsite.

Aims  This study was done with an aim to determine the difference in pattern and prevalence of tobacco use in male and female patients with HNCs and compare them with different subsites' involvement in our region.

Methods and Materials  This is a retrospective analysis of 500 consecutive biopsy-proven HNC patients from a large comprehensive cancer hospital from Bihar during the period of January 2019 to June 2019. Data collected for the study included age, gender, site of the disease, and use of tobacco. The categorical data were analyzed by a chi-square test using SPSS (version 16).

Results  Our study showed a male-to-female ratio of 8.43:1 with tobacco addiction in 84.40% patients. Smokeless tobacco was used by 52.20%, combustible form by 12.80%, and both by 19.40% of the patients. Tobacco use was seen in 87.25% of male patients as compared with only 60.38% of female patients ( p -value = 0.0001). Oral cavity cancer was seen in 60.85% of male patients and 37.74% of female patients ( p -value = 0.0012), whereas oropharyngeal cancer was seen in only 11.63% of male patients as compared with 25.83% of female patients ( p -value = 0.0008). The subsite analysis showed that in patients with oral cavity cancers, no addiction was found in only 10.29% of male patients as compared with 30% of the female patients ( p -value = 0.008).

Conclusions  Our study confirms a high prevalence of tobacco use among HNC patients. So, we need to continue our efforts to create awareness against tobacco use. Besides, there is also a need for more studies to look into other etiological factors among nontobacco users.

Substance Use and Misuse among Adults with Chronic Obstructive Pulmonary Disease in the United States, 2015-2019: Prevalence, Association, and Moderation

BACKGROUND

Despite the advancements in chronic obstructive pulmonary disease (COPD) treatment, complications related to COPD exacerbation remain challenging. One associated factor is substance use/misuse among adults with COPD. Fewer studies, however, examined the prevalence and association between COPD and substance use and misuse. In addition, limited knowledge existed about the moderation effects of serious psychological distress and gender among adults with COPD and substance use/misuse. We aimed, therefore, to measure such prevalence, association, and moderation from nationally representative samples in the United States.

METHOD

Data were drawn from the 2015-2019 National Survey on Drug Use and Health. Weighted logistic regressions were used to measure the associations of last-month tobacco (cigarettes, cigars, pipe, and smokeless tobacco products), other licit and illicit substance use (alcohol, marijuana, cocaine, crack, heroin, hallucinogens, and inhalants), and substance misuse (pain relievers, tranquilizers, stimulants, and sedatives) among adults with COPD. Serious psychological distress and gender were tested as moderators in the association between COPD and substance use/misuse.

RESULTS

The findings revealed that adults with COPD [Weighted N = 53,115,718) revealed greater odds of cigarettes [adjusted odds ratio (aOR) = 2.48 (95%CI = 1.80-3.42)) and smokeless tobacco (aOR = 3.65 (95%CI = 1.75-7.65)). However, they were less likely to use alcohol (aOR = 0.61 (95%CI = 0.45-0.84)). Adults with COPD who had serious psychological distress were more likely to use pipe tobacco and alcohol; however, they were less likely to use hallucinogens and inhalants. Finally, males compared to females with COPD were less likely to use smokeless tobacco.

CONCLUSION

Adults with COPD in the United States were more likely to use tobacco products and less likely to use alcohol. In addition, serious psychological distress and gender were moderators in associations between COPD and substance use but not in substance misuse. Future studies should longitudinally assess the factors that may contribute to the initiation and progression of substance use and misuse among adults with COPD.

Association between Smokeless Tobacco and risk of malignant and premalignant conditions of oral cavity: A systematic review of Indian literature

Causative linkages of tobacco use with oral potentially malignant disorders and cancers of oral cavity have been studied. Oral squamous cell carcinoma is one of the most common cancers in India. The International Agency for Research on Cancer (IARC) monograph found a significant association between smokeless tobacco (SLT) use and oral cancer. However, only a few limited studies have been represented on the IARC monograph. Published meta-analyses have provided pooled risk estimates for oral cancers caused by tobacco, both on global and regional levels. This systematic review was aimed at summarizing all the available studies exclusively in India by collecting data from PubMed and Medline. Emphasis was laid on cohort and case–control studies, and a few cross-sectional studies for premalignant lesions were also discussed. A significant association was noticed on SLT and premalignant and malignant oral cavity lesions.

Association between smokeless tobacco use and oral cavity cancer risk in women compared with men: a systematic review and meta-analysis

BACKGROUND

The impact of smokeless tobacco (SLT) use on the risk of oral cavity cancer (OCC) has been confirmed; however, the sex-based difference in this association remains inconclusive. Therefore, this study aimed to estimate the association between SLT use and OCC risk in women and compared it to that in men.

METHODS

PubMed, Embase, and Cochrane Library databases were systematically searched for eligible studies from their inception up to August 2020. Studies reporting the effect estimates of SLT use on OCC risk in men and women, were eligible for inclusion. The relative risk ratio (RRR) was applied to calculate the sex-based difference in the relationship between SLT use and OCC risk, and pooled analysis was conducted using a random-effects model with inverse variance weighting.

RESULTS

Nineteen studies reporting a total of 6593 OCC cases were included in the final meta-analysis. The pooled relative risk (RR) suggested that SLT use was associated with an increased risk of OCC in both men (RR, 2.94; 95% confidence interval [CI], 2.05-4.20; P < 0.001) and women (RR, 6.39; 95%CI, 3.16-12.93; P < 0.001). Moreover, the SLT-use-related risk of OCC was higher in women than that in men (RRR,1.79; 95%C, 1.21-2.64; P = 0.003). The risk of OCC related to SLT use in women was still significantly higher than that in men (RRR, 1.75; 95%CI, 1.15-2.66; P = 0.008) after excluding indirect comparison results. Finally, a subgroup analysis suggested significant sex-based differences only in individuals who received chewed smokeless products, regardless of the control definition. Pooled analysis of studies with high design quality confirmed the notably higher risk of OCC in women than in men.

CONCLUSIONS

This study found that SLT use was associated with a higher risk of OCC in women than in men. Further large-scale prospective cohort studies should be conducted to verify sex-based differences in the association between use of specific smokeless products and OCC risk.

District-level epidemiology, hot spots and sociodemographic determinants of tobacco use in Indian men and women: analysis of national family health survey-4 (2015-16)

OBJECTIVES

To map district-level tobacco hot spots and understand the Sociodemographic Indices (SDI) influencing tobacco consumption in Indian men and women.

STUDY DESIGN

Cross-sectional study.

METHODS

Tobacco use data from 640 districts of India were extracted from National Family Health Survey-4, carried out from 2015 to 2016 with a sample size of 103,411 men and 699,686 women. Geographic Information System was used to map the tobacco prevalence, and hot spots were identified by spatial statistics (Getis-OrdGi∗). SDI were studied by bivariate analyses and binary logistic regression.

RESULTS

India has two major tobacco hot spots; one comprising the districts of North-Eastern states, excluding Sikkim, and the second cluster is formed by the districts of Central-Eastern states. These hot spots coincide well with demographic determinants: North-East (adjusted odds ratio [aOR] men, 5.74; aOR women, 13.54) and Central India (aOR men, 4.5; aOR women, 3.5) have higher odds of Tobacco consumption. In men, respondents with no education (aOR 2.52; 95% confidence interval [CI]: 2.26-2.81) and Muslims (aOR 3.53; 95% CI: 2.93-4.26) have higher odds of tobacco consumption. The poorest (men aOR, 2.06; 95% CI: 1.87-2.27; women aOR, 3.36: 95% CI: 2.69-4.19) and ST women (aOR 1.89; 95% CI: 1.68-2.13) have higher odds of tobacco consumption.

CONCLUSIONS

We have identified tobacco hot spots and detailed the SDI affecting tobacco use separately in men and women to guide public health policies for targeted intervention of tobacco consumption.

Association of Immigration Status and Chinese and South Asian Ethnicity With Incidence of Head and Neck Cancer

Importance

Head and neck cancer (HNC) incidence varies worldwide, although it remains one of the most common cancers among those of East Asian and South Asian ethnicity.

Objective

To determine the association of Chinese and South Asian ethnicity, independent of immigration status, with HNC incidence.

Design, Setting, and Participants

This was a retrospective population-based matched cohort study that examined data collected between 1994 and 2017 in Ontario, Canada. Data were analyzed between July 2019 and March 2020. Individuals who immigrated to Canada between 1985 and 2017 were classified as immigrants, whereas Canadian-born individuals and those who immigrated prior to 1985 were classified as long-standing residents. Two separate, matched cohorts were created: an immigration cohort, consisting of immigrants and long-standing residents hard matched on age and sex, and an ethnicity cohort, where participants were further matched on ethnicity (Chinese, South Asian, or non-Chinese/non-South Asian).

Exposures

Chinese ethnicity, South Asian ethnicity, and immigration status.

Main Outcomes and Measures

Patients newly diagnosed with primary HNC were captured in both the immigration and the ethnicity cohorts. Cause-specific hazard models were used to estimate the association of immigration status and ethnicity with HNC incidence.

Results

In the immigration cohort, 3 328 434 matched individuals (mean [SD] age, 36.73 [13.46] years; 52.8% female) were followed, across which 3173 unique HNC diagnoses were made. The hazard ratio (HR) for a new diagnosis of oropharynx cancer was lower in immigrants compared with long-standing residents (HR, 0.26 [95% CI, 0.22-0.31]). In the ethnicity cohort, after adjusting for age, sex, rurality, and deprivation, the rate of HNC diagnosis was higher for Chinese individuals (HR, 1.49 [95% CI, 1.36-1.64]) and South Asian individuals (HR, 1.29 [95% CI, 1.14-1.45]), although it was lower for immigrants (HR, 0.48 [95% CI, 0.44-0.52]) when compared with non-Chinese and non-South Asian individuals. There was no difference in the incidence of nasopharynx cancer when comparing immigrants and long-standing residents of Chinese ethnicity.

Conclusions and Relevance

Immigration status appears to offer a protective effect against a diagnosis of HNC. Chinese and South Asian ethnic groups may experience higher HNC incidence when compared with the general Ontario population.

Association of Smokeless Tobacco Use and Oral Cancer: A Systematic Global Review and Meta-Analysis

INTRODUCTION

Smokeless tobacco products have been linked to precancerous and cancers of oral cavity for long. Evidence was available on the association between smokeless tobacco (SLT) products and oral cancers at regional but not at global level. Present meta-analysis is aimed to evaluate the risk of oral cancer with the use of SLT products among "ever" versus "never" users.

METHOD

Studies published for the period (1960-2016) are retrieved using Pubmed, Indmed, EMBASE, and Google Scholar search engines for the subject "ever" versus "never" users of SLT products and estimated the risk association with oral cancer. Summary odds ratios (relative risk) are estimated and meta-analysis was performed using random-effects model.

RESULTS

Thirty-seven studies from four of six WHO regions, Southeast Asia region (SEAR), the Eastern Mediterranean Region (EMR), Europe, and region of Americas (North and South) are included in the analysis. Significant risk with SLT products with oral cancer was found for SEAR (4.44, 95% CI = 3.51 to 5.61) and for EMR (1.28, 95% CI = 1.04 to 1.56). Significantly higher risk (p < .001) was found for females (5.83, 95% CI = 2.93 to 11.58). Product wise analysis for different SLT products revealed various levels of risk viz. gutkha (8.67, 95% CI = 3.59 to 20.93), pan tobacco / betel liquid (7.18, 95% CI = 5.48 to 9.41), oral snuff (4.18, 50% CI = 2.37 to 7.38), Mainpuri tobacco (3.32, 95% CI = 1.32 to 8.36), and snus (0.86, 95% CI = 0.58 to 1.29).

CONCLUSION

A significant positive association was observed between SLT use and the risk of oral cancer, in SEAR, EMRs, and among women users.

IMPLICATIONS

The present meta-analysis demonstrates SLT product use and the risk of oral cancer at global level. Moreover, the present analysis provided data on the risk associated with individual SLT product. The results fulfil the gap in the data on independent effect of individual SLT product use on the outcome of oral cancer at global level, conclusively. Chewing SLT products was associated with higher risk of oral cancer than other types of SLT. This can serve as a useful tool for policy makers in forming strict policies in controlling SLT menace. Hence, we propose that in addition to smoking, efforts should be directed towards SLT product cessation as well in reducing oral cancer incidence.

Differential exposure to 33 toxic elements through cigarette smoking, based on the type of tobacco and rolling paper used

Environmental pollution due to various elements is increasing all across the planet owing to their use in industrial processes. The tobacco plants and the vegetables used in the manufacturing of smoking paper may accumulate these elements from the environment. Thus, tobacco and smoking paper may be relevant contributors among the content of elements in cigarettes, including some emerging pollutants such as rare earth elements (REEs). Thirty-two elements related to hi-tech industrial processes were analyzed in tobacco, rolling paper, and filters (n = 257 samples) by ICP-MS. A variety of industrial brands and "roll-your-own" cigarette papers were considered. The potential maximum daily exposure to these elements by a hypothetical heavy smoker was calculated for each type of cigarette. We found significant differences in the levels of most elements, both in the tobacco and in the paper. Black tobacco cigarettes contained the maximum levels. We found that the paper used in roll-your-own cigarettes may significantly modify their concentration of elements. Fast-burning, bleached, and flavored papers also contribute to higher levels of these pollutants. Thus, the differences in theoretical exposure depending on the type of cigarette consumed-either branded or hand-rolled-may be very striking, of up to 35-40 times. In addition to the number of cigarettes consumed per day, it is necessary to consider the type of cigarette consumed to assess the risk of exposure to toxic elements. Tobacco paper is a prominent source of exposure to toxic elements. Cigarette smoke is another source of exposure to emerging contaminants such as REE.

Pristimerin induces apoptosis of oral squamous cell carcinoma cells via G1 phase arrest and MAPK/Erk1/2 and Akt signaling inhibition

Pristimerin is an active compound isolated from the traditional Chinese herbs Celastraceae and Hippocrateaceae. It has been reported to exert antitumor effects under experimental and clinical conditions; however, the antitumor effects and underlying mechanisms of pristimerin in oral cancer cells have not yet been identified. In the present study, the anticancer potential of pristimerin was investigated in two oral squamous cell carcinoma (OSCC) cell lines, CAL-27 and SCC-25. Results demonstrated that pristimerin was toxic against the two cell lines, and exhibited inhibitory effects against proliferation. Furthermore, pristimerin exhibited a more potent anti-proliferative activity in CAL-27 and SCC-25 cells than the common chemotherapy drugs cisplatin and 5-fluorouracil. In addition, cell cycle distribution analysis revealed that G₀/G₁ phase arrest was induced following pristimerin treatment in CAL-27 and SCC-25 cells, which was strongly associated with upregulation of p21 and p27, coupled with downregulation of cyclin D1 and cyclin E. Meanwhile, pristimerin induced significant apoptosis of CAL-27 and SCC-25 cells, alongside decreased levels of caspase-3 and specific cleavage of poly (ADP-ribose) polymerase. These effects were associated with inhibition of the mitogen-activated protein kinase/extracellular signal-regulated kinase 1/2 and protein kinase B signaling pathways. With regards to these results, pristimerin may be considered a potent novel active substance for the treatment of OSCC.

Relationship between type of smokeless tobacco & risk of cancer: A systematic review

Background & objectives:

Causative linkages of smokeless tobacco (SLT) use with oral potentially malignant disorders and cancers of oral cavity, oesophagus and pancreas have been reported. Published meta-analyses have provided pooled risk estimates for major cancers caused by SLT, both on global and regional levels. This systematic review was aimed at summarizing the available studies on occurrence and mortality risk of common cancers due to various SLT products.

Methods:

PubMed and Google Scholar databases were systematically searched from 1985 till January 2018 for observational studies on SLT and cancer. The included studies were evaluated and data were extracted and reviewed.

Results:

The review included 80 studies providing 121 risk estimates for various cancers. Majority of the studies from South-East Asian Region (SEAR) and Eastern Mediterranean Region (EMR) showed a significant positive association of SLT use with oral [odds ratio (OR) ranging from 1.48 to 27.4] and oesophageal cancers (OR between 2.06 and 12.8), while studies from European Region (EUR) reported a positive association with pancreatic cancer (OR between 1.6 and 2.1). Cancer-related mortality was evaluated in a few reports with higher risk of mortality for lung (OR between 2.0 and 9.1), cervical (OR 2.0) and prostate (OR 2.1) cancers. A wide variation was noted in the association of various cancers and specific SLT products based on their nature, methods of use and inherent toxicity. The majority of chewing tobacco products displayed higher risk for oral and oesophageal cancers while the same was not observed for snus.

Interpretation & conclusions:

This review emphasizes on the significantly positive association of SLT use with oral and oesophageal cancers in SEAR and EMR and pancreatic cancer in EUR. Mortality estimates for SLT-associated cancers need further analysis. Risk analysis for cancers of other sites in SLT users also requires multicentric well-designed studies.

Longitudinal study of adolescent tobacco use and tobacco control policies in India

BACKGROUND

This project will use a multilevel longitudinal cohort study design to assess whether changes in Community Tobacco Environmental (CTE) factors, measured as community compliance with tobacco control policies and community density of tobacco vendors and tobacco advertisements, are associated with adolescent tobacco use in urban India. India's tobacco control policies regulate secondhand smoke exposure, access to tobacco products and exposure to tobacco marketing. Research data about the association between community level compliance with tobacco control policies and youth tobacco use are largely unavailable, and are needed to inform policy enforcement, implementation and development.

METHODS

The geographic scope will include Mumbai and Kolkata, India. The study protocol calls for an annual comprehensive longitudinal population-based tobacco use risk and protective factors survey in a cohort of 1820 adolescents ages 12-14 years (and their parent) from baseline (Wave 1) to 36-month follow-up (Wave 4). Geographic Information Systems data collection will be used to map tobacco vendors, tobacco advertisements, availability of e-cigarettes, COTPA defined public places, and compliance with tobacco sale, point-of-sale and smoke-free laws. Finally, we will estimate the longitudinal associations between CTE factors and adolescent tobacco use, and assess whether the associations are moderated by family level factors, and mediated by individual level factors.

DISCUSSION

India experiences a high burden of disease and mortality from tobacco use. To address this burden, significant long-term prevention and control activities need to include the joint impact of policy, community and family factors on adolescent tobacco use onset. The findings from this study can be used to guide the development and implementation of future tobacco control policy designed to minimize adolescent tobacco use.

Effects of bidi smoking on all-cause mortality and cardiorespiratory outcomes in men from south Asia: an observational community-based substudy of the Prospective Urban Rural Epidemiology Study (PURE)

BACKGROUND

Bidis are minimally regulated, inexpensive, hand-rolled tobacco products smoked in south Asia. We examined the effects of bidi smoking on baseline respiratory impairment, and prospectively collected data for all-cause mortality and cardiorespiratory events in men from this region.

METHODS

This substudy of the international, community-based Prospective Urban Rural Epidemiology (PURE) study was done in seven centres in India, Pakistan, and Bangladesh. Men aged 35-70 years completed spirometry testing and standardised questionnaires at baseline and were followed up yearly. We used multilevel regression to compare cross-sectional baseline cardiorespiratory symptoms, spirometry measurements, and follow-up events (all-cause mortality, cardiovascular events, respiratory events) adjusted for socioeconomic status and baseline risk factors between non-smokers, light smokers of bidis or cigarettes (≤10 pack-years), heavy smokers of cigarettes only (>10 pack-years), and heavy smokers of bidis (>10 pack-years).

FINDINGS

14 919 men from 158 communities were included in this substudy (8438 non-smokers, 3321 light smokers, 959 heavy cigarette smokers, and 2201 heavy bidi smokers). Mean duration of follow-up was 5·6 years (range 1-13). The adjusted prevalence of self-reported chronic wheeze, cough or sputum, dyspnoea, and chest pain at baseline increased across the categories of non-smokers, light smokers, heavy cigarette smokers, and heavy bidi smokers (p<0·0001 for association). Adjusted cross-sectional age-related changes in forced expiratory volume in 1 s (FEV₁) and FEV₁/forced vital capacity (FVC) ratio were larger for heavy bidi smokers than for the other smoking categories. Hazard ratios (relative to non-smokers) showed increasing hazards for all-cause mortality (light smokers 1·28 [95% CI 1·02-1·62], heavy cigarette smokers 1·59 [1·13-2·24], heavy bidi smokers 1·56 [1·22-1·98]), cardiovascular events (1·45 [1·13-1·84], 1·47 [1·05-2·06], 1·55 [1·17-2·06], respectively) and respiratory events (1·30 [0·91-1·85], 1·21 [0·70-2·07], 1·73 [1·23-2·45], respectively) across the smoking categories.

INTERPRETATION

Bidi smoking is associated with severe baseline respiratory impairment, all-cause mortality, and cardiorespiratory outcomes. Stricter controls and regulation of bidis are needed to reduce the tobacco-related disease burden in south Asia.

FUNDING

Population Health Research Institute, Canadian Institutes of Health Research, and Heart and Stroke Foundation of Ontario.

School workers' knowledge, attitude and behaviour related to use of Toombak: a cross sectional study from Khartoum state, Sudan

BACKGROUND

Toombak is a form of smokeless tobacco (SLT) that is locally made and consumed in Sudan and contains several carcinogenic elements. Use of Toombak has been etiologically linked to various oral diseases including oral cancer. This study aimed to obtain baseline information about the Toombak use among Sudanese school workers, as well as their knowledge about Toombak related health hazards and attitude towards their role in Toombak control. In addition, this study assessed the availability and effectiveness of control policies and preventive practices in the schools.

METHODS

A cross-sectional school-based study using one-stage stratified random sampling procedure; four schools were selected randomly from each of seven localities. A total of 239 school workers' were recruited (census) from the selected schools in Khartoum State, Sudan.

RESULTS

Of the school workers, 63% (147) were ≤40 years, half were females and 79.2% (187) were teachers. A total of 9.6% (22) school workers confirmed ever use of Toombak and the percentage of daily users amounted to 64.7% (11). Moreover, 76.2% (16) of ever Toombak users were ≥40 years and all of them were males (p < 0.001). Most of the school workers reported good knowledge, positive attitude towards their role in Toombak control and good preventive practice. Female school workers were more likely to report positive attitude towards their role in Toombak control (p < 05), and to report good knowledge. Those reporting good preventive practice in schools reported good knowledge more than two times than their counterpart (p < 0.001). Age was the strongest predictor of ever Toombak use among school workers (p < .001).

CONCLUSIONS

The use of Toombak among school workers was associated with poor knowledge, negative attitude towards their role in Toombak control and poor preventive practice, Therefore, school workers use of Toombak may reduce their motivation and use of their potential in the prevention of a major health problem caused by Toombak use and affects their role model behaviour. On the other hand, school workers engagement with preventive practices in schools' was associated with good knowledge which in turn empowers their positive attitude towards their role in Toombak control.

The Role of Chronic Mucosal Trauma in Oral Cancer: A Review of Literature

Chronic mucosal trauma resulting from sharp teeth, dentures, faulty restoration, or implants has frequently been associated with the development of oral cancer. The definitive evidence for the same is lacking. We undertook a search using the terms – dental trauma, mucosal trauma, oral cancer, squamous cell carcinoma, risk factor, potentially malignant lesion, dental factor, mechanical irritation, dental irritation, and cancer in the following electronic databases: MEDLINE, PubMed, ScienceDirect, Cochrane Database of Systematic Reviews, and Wiley InterScience. The search yielded 788 articles. Of these articles, only 22 articles described chronic mucosal trauma as risk factors for oral cancers and were considered in this review. The review shows that chronic mucosal irritation resulting from ill-fitting dentures may be considered a risk factor for the development of oral cancer, such cancers occur commonly over the lateral border of the tongue. However, no association has been proven between the duration of denture use and cancer formation. In patients without any addiction, such cancers occur more frequently in females. These cancers may present with an early nodal disease but their prognosis and outcomes have not been studied separately till now.

Estimating the carbohydrate content of various forms of tobacco by phenol-sulfuric acid method

BACKGROUND

Due to consumption of various forms of tobacco in large amounts by Indian population, it has become a cause of concern for major oral diseases. In 2008, the WHO named tobacco as the world's single greatest cause of preventable death. It is also known that certain amount of carbohydrates are incorporated in processed tobacco to make it acceptable for consumption. Thus, its role in oral diseases becomes an important question at this point of time. Through this study, it is attempted to find out the carbohydrate content of various forms of tobacco by phenol-sulfuric acid method.

MATERIALS AND METHODS

Tobacco products selected for the study were Nandi hookah tambakhu (A), photo brand budhaa Punjabi snuff (B), Miraj (C), Gai-chhap tambakhu (D), Hanuman-chhap Pandharpuri tambakhu (E), and Hathi-chhap Bidi (F). The samples were decoded and transported to laboratory and tested at various concentrations by phenol-sulfuric acid method followed by ultraviolet spectrophotometry to determine their absorbance.

RESULTS

The present study showed Hathi-chhap bidi/sample F had a maximum absorbance (1.995) at 10 μg/ml which is a smoking form of tobacco followed by rest all smokeless forms of tobacco, i.e. sample C (0.452), sample B (0.253), sample D (0.077), sample E (-0.018), and sample A (-0.127), respectively.

CONCLUSION

As the concentration of tobacco sample increases, their absorbance increases which in turn is suggestive of increase in its carbohydrate concentration. Carbohydrates in the form of sugars, either inherently present or added in it during manufacturing can serve as a risk factor for higher incidence of dental caries.

Ethnic Variation in Consumption of Traditional Tobacco Products and Lung Cancer Risk in Nepal

Lung cancer is the leading contributor to cancer deaths in the developing world. Within countries, significant variability exists in the prevalence of lung cancer risk, yet limited information is available whether some of the observed variability is associated with differences in the consumption pattern of local tobacco products with differing potency. We recruited 606 lung cancer cases and 606 controls from the B.P. Koirala Memorial Cancer Hospital in Nepal from 2009-2012. We estimated odds ratios (ORs) and 95% confidence intervals (CI) for lung cancer risk associated with different tobacco products, using unconditional logistic regression. Unfiltered cigarettes tended to be the most frequently used products across ethnic subgroup with about 53.7% of Brahmins, 60.1% of Chettris, and 52.3% of Rai/Limbu/Magar/others. In contrast, about 39.9% of Madishe/Tharu smokers reported using bidi compared with only 27.7% who smoked unfiltered cigarettes. Among those who only smoked one type of product, choor/kankat smokers had the highest lung cancer risk (OR 10.2; 95% CI 6.2-16.6), followed by bidi smokers (OR 5.6; 95% CI 3.6-8.7), unfiltered cigarettes (OR 4.9; 95% CI 3.4-7.2), and filtered cigarettes (OR 3.4; 95% CI 2.2-5.3). A clear dose-response relationship was observed between increased frequency of smoking and lung cancer risk across all ethnic subgroups. These results highlight the important role of traditional tobacco products on lung cancer risk in the low income countries.

SmokeHaz: Systematic Reviews and Meta-analyses of the Effects of Smoking on Respiratory Health

BACKGROUND

Smoking tobacco increases the risk of respiratory disease in adults and children, but communicating the magnitude of these effects in a scientific manner that is accessible and usable by the public and policymakers presents a challenge. We have therefore summarized scientific data on the impact of smoking on respiratory diseases to provide the content for a unique resource, SmokeHaz.

METHODS

We conducted systematic reviews and meta-analyses of longitudinal studies (published to 2013) identified from electronic databases, gray literature, and experts. Random effect meta-analyses were used to pool the findings.

RESULTS

We included 216 articles. Among adult smokers, we confirmed substantially increased risks of lung cancer (risk ratio (RR), 10.92; 95% CI, 8.28-14.40; 34 studies), COPD (RR, 4.01; 95% CI, 3.18-5.05; 22 studies), and asthma (RR, 1.61; 95% CI, 1.07-2.42; eight studies). Exposure to passive smoke significantly increased the risk of lung cancer in adult nonsmokers and increased the risks of asthma, wheeze, lower respiratory infections, and reduced lung function in children. Smoking significantly increased the risk of sleep apnea and asthma exacerbations in adult and pregnant populations, and active and passive smoking increased the risk of tuberculosis.

CONCLUSIONS

These findings have been translated into easily digestible content and published on the SmokeHaz website.

Gastric cancer risk in relation to tobacco use and alcohol drinking in Kerala, India - Karunagappally cohort study

AIM: To assess the risk of gastric cancer (GC) in relation to tobacco use and alcohol drinking in the Karunagappally cohort in Kerala, South India.

METHODS: This study examined the association of tobacco use and alcohol drinking with GC incidence among 65553 men aged 30-84 in the Karunagappally cohort. During the period from 1990-2009, 116 GC cases in the cohort were identified as incident cancers. These cases were identified from the population-based cancer registry. Information regarding risk factors such as socioeconomic factors and tobacco and alcohol habits of cohort members were collected from the database of the baseline survey conducted during 1990-1997. The relative risks (RRs) and the corresponding 95% confidence intervals (95%CIs) for tobacco use were obtained from Poisson regression analysis of grouped survival data, considering age, follow-up period, occupation and education.

RESULTS: Bidi smoking was associated with GC risk (P = 0.042). The RR comparing current versus never smokers was 1.6 (95%CI: 1.0-2.5). GC risk was associated with the number of bidis smoked daily (P = 0.012) and with the duration of bidi smoking (P = 0.036). Those who started bidi smoking at younger ages were at an elevated GC risk; the RRs for those starting bidi smoking under the age of 18 and ages 18-22 were 2.0 (95%CI: 1.0-3.9) and 1.8 (95%CI: 1.1-2.9), respectively, when their risks were compared with lifetime non-smokers of bidis. Bidi smoking increased the risk of GC among never cigarette smokers more evidently (RR = 2.2; 95%CI: 1.3-4.0). GC risk increased with the cumulative amount of bidi smoking, which was calculated as the number of bidis smoked per day x years of smoking (bidi-year; P = 0.017). Cigarette smoking, tobacco chewing or alcohol drinking was not significantly associated with GC risk.

CONCLUSION: Among a male cohort in South India, gastric cancer risk increased with the number and duration of bidi smoking.

Recommendations for screening and early detection of common cancers in India

Cancers of the breast, uterine cervix, and lip or oral cavity are three of the most common malignancies in India. Together, they account for about 34% of more than 1 million individuals diagnosed with cancer in India each year. At each of these cancer sites, tumours are detectable at early stages when they are most likely to be cured with standard treatment protocols. Recognising the key role that effective early detection and screening programmes could have in reducing the cancer burden, the Indian Institute for Cytology and Preventive Oncology, in collaboration with the US National Cancer Institute Center for Global Health, held a workshop to summarise feasible options and relevant evidence for screening and early detection of common cancers in India. The evidence-based recommendations provided in this Review are intended to act as a guide for policy makers, clinicians, and public health practitioners who are developing and implementing strategies in cancer control for the three most common cancers in India.

Systematic review and meta-analysis of association of smokeless tobacco and of betel quid without tobacco with incidence of oral cancer in South Asia and the Pacific

Aim

This systematic review and meta-analysis aimed to critically appraised data from comparable studies leading to quantitative assessment of any independent association between use of oral smokeless tobacco in any form, of betel quid without tobacco and of areca nut with incidence of oral cancer in South Asia and the Pacific.

Methods

Studies (case control and/or cohort) were identified by searching Pub Med, CINAHL and Cochrane databases through June 2013 using the keywords oral cancer: chewing tobacco; smokeless tobacco; betel quid; betel quid without tobacco; areca nut; Asia, the Pacific and the reference lists of retrieved articles. A random effects model was used to compute adjusted summary OR_RE for the main effect of these habits along with their corresponding 95% confidence intervals. To quantify the impact of between-study heterogeneity on adjusted main-effect summary OR_RE, Higgins' H and I₂ statistics along with their 95% uncertainty intervals were used. Funnel plots and Egger's test were used to evaluate publication bias.

Results

Meta-analysis of fifteen case–control studies (4,553 cases; 8,632 controls) and four cohort studies (15,342) which met our inclusion criteria showed that chewing tobacco is significantly and independently associated with an increased risk of squamous-cell carcinoma of the oral cavity (adjusted main-effect summary for case- control studies OR_RE = 7.46; 95% CI = 5.86–9.50, P<0.001), (adjusted main-effect summary for cohort studies RR = 5.48; 95% CI = 2.56–11.71, P<0.001). Furthermore, meta-analysis of fifteen case control studies (4,648 cases; 7,847 controls) has shown betel quid without tobacco to have an independent positive association with oral cancer, with OR = 2.82 (95% CI = 2.35–3.40, P<0.001). This is presumably due to the carcinogenicity of areca nut. There was no significant publication bias.

Conclusion

There is convincing evidence that smokeless (aka chewing) tobacco, often used as a component of betel quid, and betel quid without tobacco, are both strong and independent risk factors for oral cancer in these populations. However, studies with better separation of the types of tobacco and the ways in which it is used, and studies with sufficient power to quantify dose-response relationships are still needed.

Non-cigarette tobacco and the lung

Cigarette smoking is known to cause a wide range of damaging health outcomes; however, the effects of non-cigarette tobacco products are either unknown or perceived as less harmful than cigarettes. Smokeless tobacco, cigar smoking, and waterpipe smoking have increased in usage over the past few decades. Some experts believe that their use is reaching epidemic proportions. Factors such as a perception of harm reduction, targeted advertising, and unrecognized addiction may drive the increased consumption of non-cigarette tobacco products. In particular, the need for social acceptance, enjoyment of communal smoking activities, and exotic nature of waterpipe smoking fuels, in part, its popularity. The public is looking for "safer" alternatives to smoking cigarettes, and some groups advertise products such as smokeless tobacco and electronic cigarettes as the alternatives they seek. Though it is clear that cigar and waterpipe tobacco smoking are probably as dangerous to health as cigarette smoking, there is an opinion among users that the health risks are less compared to cigarette smoking. This is particularly true in younger age groups. In the cases of smokeless tobacco and electronic cigarettes, the risks to health are less clear and there may be evidence of a harm reduction compared to cigarettes. In this article, we discuss commonly used forms of non-cigarette tobacco products, their impacts on lung health, and relevant controversies surrounding their use.

Smokeless tobacco and oral cancer in South Asia: a systematic review with meta-analysis

Introduction. Smokeless tobacco is considered one of the major risk factors for oral cancer. It is estimated that over 90% of the global smokeless tobacco use burden is in South Asia. This paper aims to systematically review publications reporting epidemiological observational studies published in South Asia from 1984 till 2013. Methods. An electronic search in "Medline" and "ISI Web of Knowledge" yielded 734 publications out of which 21 were included in this review. All publications were assessed for quality using a standard quality assessment tool. Effect estimates (odds ratios (OR)) were abstracted or calculated from the given data. A random effects meta-analysis was performed to assess the risk of oral cancer with the use of different forms of smokeless tobacco. Results and Conclusion. The pooled OR for chewing tobacco and risk of oral cancer was 4.7 [3.1-7.1] and for paan with tobacco and risk of oral cancer was 7.1 [4.5-11.1]. The findings of this study suggest a strong causal link between oral cancer and various forms of smokeless tobacco. Public health policies in affected countries should consider SLT specific cessation programs in addition to campaigns and activities incorporated into smoking cessation programs.

A prospective study of tobacco smoking and mortality in Bangladesh

Background

Limited data are available on smoking-related mortality in low-income countries, where both chronic disease burden and prevalence of smoking are increasing.

Methods

Using data on 20, 033 individuals in the Health Effects of Arsenic Longitudinal Study (HEALS) in Bangladesh, we prospectively evaluated the association between tobacco smoking and all-cause, cancer, and cardiovascular disease mortality during ∼7.6 years of follow-up.

Cox proportional hazards models were used to estimate hazard ratios (HRs) and their 95% confidence intervals (CIs) for deaths from all-cause, cancer, CVD, ischemic heart disease (IHD), and stroke, in relation to status, duration, and intensity of cigarette/bidi and hookah smoking.

Results

Among men, cigarette/bidi smoking was positively associated with all-cause (HR 1.40, 95% CI 1.06 1.86) and cancer mortality (HR 2.91, 1.24 6.80), and there was a dose-response relationship between increasing intensity of cigarette/bidi consumption and increasing mortality. An elevated risk of death from ischemic heart disease (HR 1.87, 1.08 3.24) was associated with current cigarette/bidi smoking. Among women, the corresponding HRs were 1.65 (95% CI 1.16 2.36) for all-cause mortality and 2.69 (95% CI 1.20 6.01) for ischemic heart disease mortality. Similar associations were observed for hookah smoking. There was a trend towards reduced risk for the mortality outcomes with older age at onset of cigarette/bidi smoking and increasing years since quitting cigarette/bibi smoking among men. We estimated that cigarette/bidi smoking accounted for about 25.0% of deaths in men and 7.6% in women.

Conclusions

Tobacco smoking was responsible for substantial proportion of premature deaths in the Bangladeshi population, especially among men. Stringent measures of tobacco control and cessation are needed to reduce tobacco-related deaths in Bangladesh.

An overview of the tobacco problem in India

This is a review paper comprehensively encompassing the different aspects of tobacco control with particular reference to the Indian scenario. The information on prevalent tobacco habits in India, health hazards and environmental hazards due to tobacco use, passive smoking and its impact, economics of tobacco, legislation to control tobacco in India, the tobacco cessation services and the way ahead for effective tobacco control are discussed. Tobacco is a leading preventable cause of death, killing nearly six million people worldwide each year. Reversing this entirely preventable manmade epidemic should be our top priority. This global tobacco epidemic kills more people than tuberculosis, HIV/AIDS and malaria combined. This epidemic can be resolved by becoming aware of the devastating effects of tobacco, learning about the proven effective tobacco control measures, national programmes and legislation prevailing in the home country and then engaging completely to halt the epidemic to move toward a tobacco-free world. India is the second largest consumer of tobacco globally, and accounts for approximately one-sixth of the world's tobacco-related deaths. The tobacco problem in India is peculiar, with consumption of variety of smokeless and smoking forms. Understanding the tobacco problem in India, focusing more efforts on what works and investigating the impact of sociocultural diversity and cost-effectiveness of various modalities of tobacco control should be our priority.

Racial disparities in colorectal cancer incidence by type 2 diabetes mellitus status

PURPOSE

Type 2 diabetes mellitus (T2DM) prevalence has increased dramatically in the United States since the early 1970s. Though T2DM is known to be associated with colorectal cancer (CRC), information on racial differences in the relationship between T2DM and CRC is limited.

METHODS

Using a retrospective cohort design, we compared the association between T2DM and CRC, including subsites of the colon, in African Americans (AAs) and European Americans (EAs) in South Carolina, a region with large racial disparities in rates of both diseases. A total of 91,836 individuals who were ≥30 years old on 1 January 1990 and had ≥12 months of South Carolina Medicaid eligibility between 1 January 1990 and 31 December 1995 were included in the analyses. Cancer data from 1996 to 2007 included information on anatomic subsite.

RESULTS

Subjects who had T2DM (n = 6,006) were >50 % more likely to be diagnosed with colon cancer compared to those without T2DM (n = 85,681). The association between T2DM and colon cancer was higher in AAs [odds ratio (OR) = 1.72 (95 % confidence interval: 1.21, 2.46); n = 47,984] than among EAs (OR = 1.24; 0.73, 2.11; n = 43,703). Overall, individuals with T2DM were over twice as likely to be diagnosed with in situ or local colon cancer (OR = 2.12; 1.40, 3.22; n = 191) compared to those without T2DM, with a higher likelihood among AAs (OR = 2.49; 1.52, 4.09; n = 113).

CONCLUSIONS

Results from a Medicaid population in a high-risk region of the United States showed an increased likelihood of CRC with T2DM and suggest a racial disparity that disfavors AAs and provides further impetus for efforts aimed at diabetes prevention in this group.

Non-cigarette tobacco products: what have we learnt and where are we headed?

A wide variety of non-cigarette forms of tobacco and nicotine exist, and their use varies regionally and globally. Smoked forms of tobacco such as cigars, bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and the health hazards they present, with some clearly toxic forms (eg, in South Asia) and some forms with far fewer hazards (eg, in Sweden). Nicotine delivery systems not directly reliant on tobacco are also emerging (eg, electronic nicotine delivery systems). The presence of such products presents challenges and opportunities for public health. Future regulatory actions such as expansion of smoke-free environments, product health warnings and taxation may serve to increase or decrease the use of non-cigarette forms of tobacco. These regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by affecting attractiveness and/or toxicity.