Naswar (Smokeless Tobacco) Use and the Risk of Oral Cancer in Pakistan: A Systematic Review With Meta-Analysis

Smokeless Tobacco Cessation Support in Dental Hospitals in Pakistan: Dentists and Dental Patients' Perspectives on Current Practices, Support Needed, and Opportunities Available

INTRODUCTION

Despite evidence on the effectiveness of tobacco cessation interventions in dental settings, the implementation remains low, especially for smokeless tobacco (ST). The purpose of this study was to develop an understanding of the influences governing the implementation of ST cessation support in dental hospitals.

AIMS AND METHODS

A multicenter qualitative study was conducted at two tertiary-care dental hospitals, in Pakistan. Semi-structured interview guide, guided by the Capability-Opportunity-Motivation-Behavior (COM-B) model, were used to capture the views of dentists (n = 12) and dental patients (n = 12), regarding ST cessation support in dental hospitals. Framework approach was used to thematically analyze the data.

RESULTS

Screening of ST users in routine dental practice was seldom practiced and the cessation support offered was brief advice. Barriers identified by dentists included: Fear of offending and stereotyping patients; lack of knowledge and skills; lack of privacy; lack of belief in the effectiveness of behavioral support; lack of time and workload pressure; ST use amongst dentists; lack of referral systems and; the absence of a mandatory requirement of offering ST cessation support. Facilitators included: Delivering support through junior dentists and the length of interaction between the dentist and the patient. Naswar was the most common ST product used by dental patients. Patients reported receiving negligible cessation support from any healthcare provider.

CONCLUSIONS

A range of influences governing the implementation of ST cessation support in dental hospitals were identified. These findings can inform the implementation of behavioral interventions for ST cessation in dental and other clinical settings, in low and middle-income countries.

IMPLICATIONS

Smokeless tobacco control considerably lags, in comparison to the control of combustible tobacco. This is the first study that qualitatively explores the implementation of ST cessation support in dental settings in Pakistan. Utilizing the "Capability-Opportunity-Motivation-Behavior" model, it provides an in-depth understanding of the inability of dentists in implementing effective behavioral interventions for ST cessation support in routine dental practice. Highlighting the striking discrepancy between the patient's need for and receptivity towards cessation support and the dentists' concerns over their patients' receptivity towards cessation support, it calls for the need for effective implementation strategies to optimize dentist-led tobacco cessation interventions in low-resource settings.

Association of genetic polymorphism of glutathione S-transferases with colorectal cancer susceptibility in snuff (Naswar) addicts

Abstract The current study aimed to investigate the relationship between polymorphisms in detoxifying (GSTM1, GSTT1, and GSTP1) genes and their association with colorectal cancer (CRC) in tobacco addicts of Pashtun ethnicity. Polymorphisms in the selected genes were genotyped in a case-control study consisting of 100 histologically confirmed male CRC patients and 100 birth-year and gender-matched healthy controls using the PCR−RFLP method. The GSTM1 null, and GSTT1 null genotypes were significantly contributed to the risk of CRC in the cases (OR= 3.131, 95% CI: 1.451−6.758, P = 0.004, and OR= 3.541, 95% CI: 1.716−7.306, P = 0.001, respectively), whereas the association observed for GSTP1 Val/Val (1.139, 95% CI: 0.356−3.644, P = 0.826) did not show statistical significance. The combined GSTM1 null and GSTT1 null showed a 41-fold increased risk (95% CI: 4.945−351.950, P = 0.001), while, the combined GSTM1 null and GSTP1 Ile/Val or Val/Val variant genotypes exhibited about 3-fold (95% CI: 1.196−7.414, P = 0.019) increased risk to CRC. Similarly, the combined GSTT1 null and GSTP1 Ile/Val or Val/Val variant genotypes showed about a 3-fold (95% CI: 1.285−8.101, P = 0.013) increased risk of CRC. In the combination of three GST genotypes, the GSTM1 null, GSTT1 null, and GSTP1 Ile/Val or Val/Val variant genotypes demonstrated a more than a 22-fold (95% CI: 2.441−212.106, P = 0.006) increased risk of CRC. Our findings suggest that GSTM1 and GSTT1 polymorphism and its combination with GSTP1 may be associated with CRC susceptibility in the Naswar addicted Pashtun population of Khyber Pakhtunkhwa, Pakistan.

Cancer incidence in Khyber Pakhtunkhwa, Pakistan, 2020

BACKGROUND

To present the population-based cancer statistics for Khyber Pakhtunkhwa (KP), Pakistan, an incidence study was conducted at the Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) in Lahore, Pakistan, in 2023.

METHODS

Records from various centres on new cancers diagnosed among residents of KP between January and December 2020 were gathered. Both active and passive methods of data collection were applied, and the information was saved in a central repository at SKMCH&RC. The incidence rates were computed by age group and sex and presented per 100,000 population.

RESULTS

Among children (0-14 years), the Age-Standardised Incidence Rate (ASIR) was 4.0 in girls and 6.1 in boys, and haematologic malignancies were more prevalent; in adolescents (15-19 years), the ASIR was 7.7 in females, 9.4 in males, and bone tumours, haematologic malignancies, and neurological cancers were prominent; in adult females (> / = 20 years), the ASIR was 84.9, and cancers of the breast, digestive system, and reproductive organs were predominant; and adult males, the ASIR was 73.0, and cancers of the gastrointestinal tract, lip/oral cavity/pharynx, prostate, and Non-Hodgkin Lymphoma (NHL) were common.

CONCLUSIONS

It is crucial to investigate the aetiology of these diseases at the community level because dietary elements, infectious diseases, and tobacco use all appear to be significant contributors. Prospective studies could play a key role in highlighting the factors linked to these diseases. Therefore, cancer registration must continue in conjunction with the exploration of risk factors.

Assessing Thrombocytopenia and Chronic Liver Disease in Southeast Asia: A Multicentric Cross-Sectional Study

Background This multicentric cross-sectional study aimed to examine the prevalence of thrombocytopenia (TCP) and investigate the various causes of chronic liver disease (CLD) across 15 Southeast Asian (India, Pakistan, and Bangladesh) tertiary care centers over a three-month period. The study focused on assessing the fibrosis index (FI) and Model for End-Stage Liver Disease (MELD)-sodium (Na) score's capacity to grade and predict the progression and outcomes of patients with already diagnosed CLD. Methods The cross-sectional study enrolled 377 CLD patients. The study utilized admission registries from 15 tertiary care hospitals in Southeast Asia, spanning from April 2023 to June 2023. Various descriptive variables were collected, including gender, tobacco use (specifically, chewed tobacco), underlying etiology, presence of anemia, leukopenia, pancytopenia, infectious state, and liver cirrhosis diagnosed via traditional ultrasonography. This study examined liver failure indicators, including alanine transaminase levels, compensation status, TCP, and liver transplant (LT) listing. The MELD-Na score was the focus of frequency and percentage analysis. MELD-Na and FI medians and standard deviations were provided. Results The study of 377 patients with CLD found that TCP was present in 4% of patients and leukopenia was present in 12% of patients. The risk of TCP was significantly higher in leukopenic patients (89.5%) than in non-leukopenic patients (52.5%) (p = 0.003). The most common CLD cause was undiagnosable (31%), followed by autoimmune (26%), hepatitis C virus (21%), hepatitis B virus (14%), and schistosomiasis (8%). The majority of patients (98%) had decompensated liver disease. Of the patients, 64% had TCP, while 36% did not. The illness severity indicators MELD score and FI had mean ± SD values of 16.89 ± 6.42 and 4.1 ± 1.06, respectively. Similarly, the prevalence of LT needs among traditional ultrasonography-diagnosed cirrhotic patients was 83.1%, compared to 59.6% among non-cirrhotic patients (p = 0.001). Conclusion Leukopenia and TCP may be linked, which may affect CLD treatment and prognosis in this population. Non-invasive indicators like the FI and MELD-Na score can detect liver fibrosis and severity without invasive procedures, enhancing patient management. These findings highlight the need to improve early diagnosis methods for CLD in Southeast Asia and raise awareness among clinicians about effective diagnostic strategies for non-infectious causes of CLD.

Salivary Oxidative Stress and Antioxidant Capacity in Smokeless Tobacco (Naswar) Users

Background

Naswar, a smokeless tobacco product, commonly consumed in Pakistan, is associated with a 10-fold increase in the risk of oral cancer. However, little is known about Naswar's underlying toxicity mechanisms.

Objective

The current study aimed to investigate the effects of Naswar use on oral health and salivary parameters.

Methods

A case-control study was conducted among Naswar users (n=42) and age-matched healthy controls (n=42) in Pakistan in 2019. Participant data were collected using questionnaires. Decayed, missing, and filled teeth (DMFT) scores were computed during clinical examinations. Unstimulated whole saliva was collected to assess salivary flow rate, pH, and salivary total oxidative stress (TOS)/total antioxidant capacity (TAC) using commercially available kits. Participants' oral health parameters were compared between cases and controls using ANOVA.

Results

No significant differences were observed between the two groups in terms of age, oral health, and hygiene practices and mean DMFT score. Mean salivary pH and the salivary flow rate was significantly (p<0.001) higher in Naswar users (7.7 and 0.71 mL/minute, respectively) than in non-users (6.95 and 0.52 mL/minute, respectively). Although TOS and TAC were not significantly different between the groups, Naswar users generally had a higher TOS (51.6±42 µmol/L) and lower TAC (0.55±0.18 mmol/L) than non-users (TOS 45.5±38.2 µmol/L and TAC 0.57±0.17 mmol/L). Correlational analysis also revealed a significant positive correlation between DMFT score and Naswar use duration (r=0.796, p<0.001) and the number of dips/units consumed each day (r=0.515; p<0.001).

Conclusion

Habitual Naswar use is associated with increased salivary flow rate, pH, and TOS, and reduced TAC levels in Pakistani adults compared to non-users. The pro-oxidant changes may contribute toward deleterious effects of Naswar use including oral cancer.

Evaluation of Risk Factors in Patients with Head and Neck Cancer: A Case Control Study

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is one of the most common types of cancer worldwide. Since there are many factors that influence the development of cancer, identifying risk factors plays an important role in cancer prevention. The aim of this study was therefore to identify the risk factors for HNSCC in Mashhad, Iran.

METHODS

In this case-control study, 76 patients with HNSCC were included as the case and 91 healthy people as the control group. A checklist of risk factors was completed for each participant and the two groups were compared for the presence of risk factors. Chi-square, t test, and Mann-Whitney tests were used to compare the data. Odds ratios (ORs) for several factors have also been determined.

FINDINGS

The educational level and body mass index (BMI) of the patients in the case group were significantly lower than in the control group (P<0.001). Moreover, there were significant differences between the two groups in terms of risk factors such as tobacco smoking, the number of cigarettes smoked per day, and its duration (P=0.001, P<0.001, P=0.05), as well as the duration of hookah smoking, opium consumed per day and use of alcohol (P=0.023, P<0.001, P=0.015).

CONCLUSION

There was a direct relationship between HNSCC and risk factors such as cigarette smoking, number of cigarettes smoked per day, duration of cigarette consumption and hookah, opium consumed per day, and alcohol use. However, extensive studies with larger sample sizes are needed to better assess the impact of these factors and generalize the results.

Oral Cancer Risk Assessment for Different Types of Smokeless Tobacco Products Sold Worldwide: A Review of Reviews and Meta-analyses

Smokeless tobacco (SLT) use is a significant cause of lip and oral cavity cancers. Globally, oral cancer prevalence is strongly linked to the types of tobacco products used, their chemical composition, and their pattern of use. Except snus, all SLT products sold in different World Health Organization regions are strongly associated with oral cancer incidence. Shammah showed the highest association OR with 95% confidence intervals (CI; OR, 38.74; 95% CI, 19.50-76.96), followed by oral snuff (OR, 11.80; 95% CI, 8.45-16.49), gutkha (OR, 8.67; 95% CI, 3.59-20.93), tobacco with betel quid (OR, 7.74; 95% CI, 5.38-11.13), toombak (OR, 4.72; 95% CI, 2.88-7.73), and unspecified chewing tobacco (OR, 4.72; 95% CI, 3.13-7.11). Most SLT products containing high levels of carcinogenic tobacco-specific nitrosamines (TSNA) exhibit a high risk of oral cancer. There is an urgent need to frame and implement international policies for oral cancer prevention through legal control of the TSNA levels in all SLT product types.

PREVENTION RELEVANCE

Most smokeless tobacco products sold worldwide, mainly shammah, toombak, gutkha, betel quid with tobacco, and dry snuff, are associated with a high risk of oral cancer. A high concentration of tobacco-specific nitrosamines in smokeless tobacco products is the major causative factor for oral cancer development.

Behaviour change intervention for smokeless tobacco (ST) cessation delivered through dentists within a dental setting: a feasibility study protocol

Objectives/Aim

To adapt a structured behavioural support intervention for smokeless tobacco (ST) cessation and to assess the feasibility and acceptability of delivering the intervention via dentists within dental settings in Pakistan.

Material and methods

The study will have 3 phases: (1) Adapt a previously developed intervention to make it suitable for delivery in a clinical/dental setting through qualitative interviews with dental patients and dentists; (2) A multi-centre, pilot randomised control trial in two teaching dental hospitals in Pakistan. Participants (dental patients) will be randomly assigned to intervention or control group in a 1:1 allocation ratio to receive either a structured behavioural support intervention involving face to face counselling or self-help material plus usual care. Each participant will be in the study for approximately 6 months and the overall study is expected to run for 12 months; (3) An embedded qualitative process evaluation. All trial participants will be followed up at 3 and 6 months to assess self-reported ST use. Outcome measures will include: rates of eligibility, recruitment and retention, randomisation group cross-over rates, the provision of data on ST use behaviour, fidelity to the intervention and qualitative assessment of acceptability and feasibility.

Discussion

Despite the high use of ST in Pakistan, users are offered negligible cessation support. The findings of this multi-centre, mixed-method feasibility study will inform the scope for a larger trial on ST cessation delivered through the existing dental health system.

Implementing smokeless tobacco control policy in Pakistan: a qualitative study among Naswar supply chain actors

OBJECTIVE

To obtain insights into the perceptions of barriers and facilitators to implementation of the WHO Framework Convention on Tobacco Control (FCTC) among smokeless tobacco (SLT) supply chain actors in the Khyber Pakhtunkhwa province of Pakistan.

METHODS

We conducted a qualitative study to investigate the perceptions about SLT control policy formulation and implementation among exclusive Naswar sellers and point of sale vendors. We conducted five focus group discussions in three districts of Khyber Pakhtunkhwa using combined deductive-inductive thematic analyses.

RESULTS

We identified three central themes that potentially impact policy formulation, its implementation and application. The first theme examines the role of children in the Naswar business: as potential customers, and as potential heirs to a Naswar-selling business. A second theme targets the 'business of Naswar', which includes a specific identity of Naswar sellers, its potential to generate profits and the special case of Naswar regulation as a socially accepted and culturally rooted product. The third theme addresses the unusual ingredients of Naswar and its production process, making Naswar a health risk for consumers and producers. We also report conflicting views regarding SLT control among the supply chain actors.

CONCLUSIONS

This study provides insights into the perceptions of important SLT supply-side stakeholders regarding various SLT control policy options based on the FCTC. While there is some opposition to policy approaches like taxation and switching of business, implementing a ban on selling SLT to minors may be a viable option for policymakers in the short term.

Cancer in Lahore, Pakistan, 2010-2019: an incidence study

OBJECTIVES

To study the cancer incidence rates over 10 years (2010-2019), in Lahore, Pakistan.

DESIGN

An incidence study.

SETTING

The population-based Punjab Cancer Registry was established in 2005 in Lahore, which is the provincial metropolis of the province of Punjab (five rivers), and is located in the northeast region of Pakistan. The coordinating office of the Registry is located within Shaukat Khanum Memorial Cancer Hospital and Research Center. Both the active and passive forms of data collection are used.

PARTICIPANTS

Residents of the district of Lahore diagnosed with cancer. The average annual population of Lahore was estimated at 11.1 million.

OUTCOME MEASURES

Cancer counts and incidence rates per 100 000 population, by age-group, sex and cancer site/type, over 10 years.

RESULTS

In Lahore, from 2010 to 2019, 58 394 incident cases were reported, with the majority seen in females (57.1%). Adults accounted for 92.2%, adolescents 2.2% and children 5.6% of the total cases. Per 100 000 population, the age-standardised incidence rate was 103.4 for females and 65.6 for males. Among females, the highest incidence rates were recorded for breast cancer (76.7) in adults, bone tumour (1.2) in adolescents and lymphoid leukaemia (1.6) in children, and among males, prostate cancer (10.7) in adults, bone tumour (2.2) in young adults and lymphoid leukaemia (2.4) in children. The age-specific incidence rates peaked in the 60-70 year group, reaching a high of 420 per 100 000 in women and 330 per 1 00 000 men.

CONCLUSIONS

In Lahore, the incidence rates for cancers of the breast, prostate, lymphoid leukaemia and bone were among the highest documented. More cases were recorded in females than in males. The results reported could be used as a reference point for assessing the effectiveness of future interventions.

Novel Pathways and Mechanism of Nicotine-Induced Oral Carcinogenesis

BACKGROUND

Smokeless Tobacco (SLT) contains 9 times more nicotine than Smoked Tobacco (SMT). The carcinogenic effect of nicotine is intensified by converting nicotine-to-nicotine-derived Nitrosamines (NDNs).

METHODS

A review of the literature was conducted with a tailored search strategy to unravel the novel pathways and mechanisms of nicotine-induced oral carcinogenesis.

RESULTS

Nicotine and NDNs act on nicotinic Acetylcholine Receptors (nAChRs) as agonists. Nicotine facilitates cravings through α4β2nAChR and α7nAChR, via enhanced brain dopamine release. Nicotine binding to nAChR promotes proliferation, migration, invasion, chemoresistance, radioresistance, and metastasis of oral cancer cells. Nicotine binding to α7nAChR on keratinocytes triggers Ras/Raf-1/MEK1/ERK cascade promoting anti-apoptosis and pro-proliferative effects. Furthermore, the nicotine-enhanced metastasis is subdued on nAChR blockade through reduced nuclear localization of p-EGFR.

CONCLUSION

Protracted exposure to nicotine/NDN augments cancer-stimulatory α7nAChR and desensitizes cancer inhibitory α4β2nAChR. Since nAChRs dictate both addictive and carcinogenic effects of nicotine, it seems counterintuitive to designate nicotine just as an addictive agent devoid of any carcinogenicity.

Assessment of Unstimulated Whole Salivary Tumor Necrosis Factor Alpha (TNF-α) and Cellular Micronuclei Levels in Snuff (Naswar) Users and Non-Users for Early Diagnosis of Oral Squamous Cell Carcinoma

The aim of the study was to investigate the unstimulated whole saliva (UWS) tumor necrosis factor alpha (TNF-α) and cellular micronuclei in snuff dippers (Naswar) compared to healthy control subjects. The case control study was conducted over 9 months at a tertiary care center. Sixty patients were divided into two groups: Snuff dippers (SD) (Naswar) and non-snuff dippers (NSD) (control subjects). The included self-reported SD used Snuff twice daily for more than 12 months. UWS was collected and salivary TNF-α assessment was performed using enzyme-linked immunosorbent assay (ELISA). For cellular micronuclei, buccal mucosa was brushed to obtain cells in Naswar users, fixed with a dibutylphthalate polystyrene xylene (DPX) mounting to view micronuclei. Means and standard deviations were compared using the t-test and outcomes were related using Pearson correlation, considering p ≤ 0.05 as significant. The mean age of participants was 38.85 ± 11.56 years. The mean duration of snuff use was 20.43 ± 12.79 years and the common site for Naswar placement was the lower vestibule (n = 19, 63.3%). TNF-α levels among SD were 9.6 ± 3.3 pg/mL, which were significantly higher than levels in NSD, 5.2 ± 3 pg/mL (p < 0.05). The number of cellular micronuclei in SD was 30.7 ± 7.8, which was comparatively higher than in NSD, which was 9.2 ± 3.3 (p < 0.05). The duration of snuff use was positively correlated to TNF-α levels (p = 0.048) rather than the micronuclei number (p = 0.97). SD showed higher levels of TNF-α and cellular micronuclei compared with NSD (control subjects); a positive correlation was shown with the duration of snuff use. We conclude that TNF-α and micronuclei are potential salivary biomarkers for an oral biological effect in snuff (Naswar) users.

A Cytological Study Enlightening the Unseen Effects of Concomitant Chemoradiotherapy in Contralateral Normal Buccal Mucosa of Oral Squamous Cell Carcinoma Patients

Background/objectives In patients receiving concomitant chemoradiotherapy (CCRT) as a treatment for oral squamous cell carcinoma (OSCC), cytological changes were seen not only in neoplastic epithelial cells but the non-neoplastic epithelial cells are also affected, resulting in cytopathological atypical changes. The present study was designed to observe oral epithelial atypical cytopathologic changes induced in contralateral normal buccal mucosa in OSCC patients receiving CCRT. Methods The study included 150 patients with OSCC treated by CCRT whose details were collected from the Institute of Nuclear Medicine and Oncology Lahore (INMOL) Hospital Lahore. Cytological smears were obtained from the contralateral normal buccal mucosa of OSCC patients. The serial scrape smears were taken before, immediately after, on the 17th day (mid of treatment), and at the end of CCRT, whereas 20 patients were taken as normal healthy controls and were not exposed to CCRT. The smears were stained with hematoxylin and eosin and Papanicolaou stain. SPSS version 20 (Armonk, NY: IBM Corp.) was used for statistical analysis and p > 0.05 was considered to be significant. Results CCRT-induced oral epithelial atypical cytological changes were predominantly noted at end of therapy (19.7%) in the contralateral normal buccal mucosa. Nuclear atypia features were higher on the 17th day and end of treatment; whereas, epithelial atypia was mainly observed on the 17th day of CCRT (40%). A highly significant association was observed between epithelial atypia and radio-chemotherapy dose (p = 0.045), between CCRT-induced epithelial atypical cytological changes and days of treatment (p = 0.001), and between days of CCRT and nuclear atypia (0.000) accordingly. Atypia was not observed in any control group. Conclusion Varying degrees of oral epithelial atypical cytological changes may occur in otherwise normal contralateral mucosa of the patients receiving CCRT.

A review of tobacco abuse and its epidemiological consequences

Aim

The economic burden caused by death and disease in the world is credited mainly to tobacco use—currently linked to approximately 8,000,000 deaths per year with approximately 80% of these faralities reported in low and middle income economies. The World Health Organization (WHO) estimates that nearly 7,000,000 deaths are attributed to direct tobacco use, while approximately 1,200,000 non-smokers exposed to second hand cigarette smoke die every year. Accordingly, tobacco use is a major threat to the public health infrastructure; therefore, proper cessation interventions must be put in place to curb tobacco abuse and ease economic and social burdens caused by the tobacco epidemic.

Methods

A systematic review was conducted to investigate how scientific efforts have been advanced towards harm reduction among smokers and non-smokers. Relevant articles published during the period 2010–2020 in PubMed, Crossref, Google scholar, and Web of Science were used in this study. The articles were selected based on health impacts of cigarette smoking, tobacco cessation and emerging diseases, including Covid−19. Various cessation strategies have been identified although their efficiency is yet to match the desired results.

Results

A series of carcinogenic chemicals are generated during cigarette smoking resulting in serious health complications such as cancer and mutagenesis. The precursors for tobacco induced diseases are toxic and carcinogenic chemicals of the nitrosamine type, aldehydes, polonium-210 and benzo[a]pyrene, which bio-accumulate in the body system during cigarette smoking to cause disease. Rehabilitation facilities, use of drugs to diminish the desire to smoke, heavy taxation of tobacco products and warning labels on cigarettes are some of the cessation strategies employed towards curbing tobacco abuse.

Conclusion

The need for further research to develop better methods and research based policies for safe cigarette smoking and workable cessation strategies must be a priority in order to deal with the tobacco epidemic. Campaigns to promote tobacco cessation and abstinence are recommended in this review as a sure measure to mitigate against the deleterious impacts caused by cigarette smoking and tobacco abuse.

Addictions Causing Head-and-Neck Cancers

Head-and-neck cancers pose a serious economic burden, with most countries investing significant resources to reduce the incidence, primarily focusing on understanding addictive etiologies. The traditional literature focused on tobacco and alcohol use, with few studies on contemporary factors such as e-cigarette, waterpipe smoking, and human papillomavirus. This article attempts to collate and present an update on the globally identified etiologic factors.

The aim of this study was to identify and review the addictive etiologic factors causing head-and-neck cancers.

An electronic search was performed on Medline, Embase, and Google Scholar to identify the etiologies causing head-and-neck cancers and narrowed down on those driven by addiction. Further, we identified their constituents, mechanism of action, and the risks attributable to various forms of products.

Substances identified included smoked and chewed tobacco, alcohol, mate, marijuana, areca nut and betel quid, and viruses. An alarming majority of youth are now utilizing these substances. Furthermore, migrant movements have led to the spread of traditional practices across the regions, especially from the Asian subcontinent.

Ironically, despite modern advances and technology, we still see that a large proportion of population succumb to these cancers, emphasizing the need for more effective and targeted policies to combat this menace at the grassroots level.

Cancer care in times of conflict: cross border care in Pakistan of patients from Afghanistan

Armed conflict in Afghanistan has continued for close to 40 years and has devastated its health infrastructure. The lack of a cancer care infrastructure has meant that many Afghans seek cancer care in neighbouring countries, like Pakistan. There remains a significant lack of empirical data on the new therapeutic geographies of cancer in contemporary conflicts.

This retrospective single centre study explores the therapeutic and clinical geographies of Afghan cancer patients who were treated at the Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) in Lahore, Pakistan over a 22-year-period (1995 to 2017) covering major periods of conflict and relative peace.

Data was available for 3,489 Afghan patients who received treatment at SKMCH&RC. The mean age at presentation was 42.7 years, and 60% were men. 30.2% came from Kabul and Nangarhar districts of Afghanistan, which have relatively short travel times to Pakistan, but patients from all parts of Afghanistan migrated to SKMCH&RC for treatment. Overall, 34.1% were diagnosed with upper gastrointestinal malignancies and 55.7% presented with late stage III/IV cancer. A wide range of treatments were provided, with 25.4% of patients receiving a combination of chemotherapy and radiation treatment. 52.7% of all patients were lost to follow-up. Outcomes were more favourable for children with cancer, 42% of whom had a complete response to therapy.

Complex migration patterns, mixed political economies (refugees, forced and unforced migrants) and models of care that must be adapted to the realities of the patients rather than notional international standards all reflect the new therapeutic geographies that long-term conflict creates. This requires significant new domestic and international (e.g., United Nations High Commissioner for Refugees) policy and practises for providing cancer care in today’s contemporary conflict ecosystems that frequently cross national borders.

Association of smokeless tobacco with oral cancer: A review of systematic reviews

INTRODUCTION

Various primary studies and systematic reviews have been conducted to explain the association between smokeless tobacco and oral cancer. This study aims to consolidate and summarize the risk estimates from various systematic reviews with or without meta-analysis to provide the spectrum of estimates on the association between smokeless tobacco use and oral cancer.

METHODS

A comprehensive literature search was done on various databases (PubMed, Google Scholar, IndMED, and TOXLINE) by two of the authors independently. Both qualitative and quantitative data extraction and analysis were performed for the included systematic reviews. Range of risk estimates was obtained and analyzed as quantitative findings due to the limitation of an overview of reviews for the pooled estimates. CASP (Critical Appraisals Skills Programme) and AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews) tools were used for the quality assessment of the studies included.

RESULTS

In total, 12 systematic reviews with or without meta-analysis were included in the review. There was a positive and strong association of Smokeless Tobacco (SLT) use with oral cancer irrespective of gender, region, and type of smokeless tobacco. The risk estimate for the South–East Asia Region (SEAR) ranged 4.44–7.90, for Gutkha it was 8.67, while for Paan it ranged 6.3–7.90 and for overall SLT it ranged 1.36–7.90. Risk estimate for females ranged 5.83–14.56.

CONCLUSIONS

The study confirmed the association between SLT use and oral cancer. These findings are of high importance, especially to the South-East Asia Region.