Surgical Management of Oral Cavity Cancer: Experience at a Tertiary Care Centre in Jamshedpur

Background Cancer of the oral cavity is very common in Eastern India. This is due to the lack of awareness that chewing tobacco causes oral cancer. Because of poor economic condition and lack of access to healthcare, patients in this region often present at an advanced stage of the disease when they become symptomatic. A retrospective study was conducted at Tata Main Hospital, Jamshedpur, India, to know the epidemiology and recurrence of oral cavity cancer in this region. Materials and methods We conducted a retrospective study of oral cavity cancer patients operated at Tata Main Hospital, Jamshedpur, from January 2018 to June 2023. Data were collected from the surgical register, operation theatre notes, case sheets and hospital online data. The following parameters were observed in this study: a) age, b) gender, c) site of cancer, d) histology, e) stage of disease at presentation, f) type of neck dissection, g) margin status on the final histopathology report, h) node positivity, i) presence of perineural invasion or lymphovascular invasion and j) recurrence.  Results A total of 218 patients were operated between January 2018 and June 2023. The most common site for oral cavity cancer was the buccal mucosa with the involvement of the lower alveolus (168 patients, 77.06%), followed by the tongue (27 patients, 12.38%). Two-hundred seventeen patients were diagnosed with squamous cell carcinoma (SCC), and one patient had epithelioid sarcoma on the biopsy report. The most common stage of presentation was stage IVa (180 patients, 82.56%), followed by stage III (16 patients, 7.34%). The most frequent neck dissection performed was modified radical neck dissection (MRND) sacrificing the sternocleidomastoid muscle (SCM) and preserving the internal juglar vein (IJV) and spinal accessory nerve (SAN) (176 patients, 80%). The margin was positive for 10 patients. Node positivity on the final histopathology report grouped according to the clinical stage are as follows: stage I (33.33%), stage II (60%), stage III (75%) and stage IV (86.67%). Similarly, the presence of lymphovascular or perineural invasion on the final histopathology report grouped according to the clinical stage is as follows: stage I (0%), stage II (20%), stage III (25%) and stage IV (55.55 %). Fifteen patients lost to follow-up. Recurrence was noted in 11 patients (5.04%). Patients presenting with stages I and II had no recurrence, whereas three out of 16 patients in stage III (1.1%) and eight out of 180 patients in stage IV (4.44%) had recurrence. Conclusion SCC is the most common type of oral cavity cancer in Eastern India. It is strongly related to tobacco chewing habit. Since most of the patients in this part of the country present with an advanced stage of the disease, awareness regarding cessation of tobacco use and screening can be beneficial to the general population.

Brief intervention to enhance cessation of smokeless tobacco use in newly diagnosed patients with head and neck cancers: A randomized controlled trial in patient-relative dyads

Introduction

Tobacco use is a major causative factor for head and neck cancers (HNC). Continued use of tobacco even after cancer diagnosis is common and is associated with all-cause and cancer-specific mortality, cancer recurrence and poor treatment response. Evidence suggests that behavioral interventions, help achieve greater smoking cessation rates in HNC patients. However, intervention studies focussed on HNC patients using smokeless tobacco, which is more common than smoking in India, are sparse.

Materials and Methods

We conducted a parallel arm randomized controlled trial (RCT) on dyads of patients with recently diagnosed HNC and a close relative. The experimental arm received a brief tobacco cessation intervention (BTCI) and the control arm received treatment as usual (TAU); 27 and 25 dyads in each arm completed the trial.

Results

Overall for the dyads using SLT, the relative risk of continuing to use SLT was 3.23 times higher (odds ratio = 7.01) if BTCI was not undertaken at one-month follow-up and 4.43 times higher (odds ratio = 8.65) at 3-months follow-up. For patients only, the relative risk of continuing to use SLT at one-month and 3-months follow-ups was 4.99 and 12.04 times higher, respectively, if BTCI was not undertaken. For relatives only, the corresponding relative risk values were 2.14 and 2.2.

Conclusion

We conclude that BTCI delivered to patient-relative dyads, compared to TAU, is effective in enhancing the discontinuation rates of the use of SLT in newly diagnosed patients with HNC. This form of intervention is significantly effective for discontinuing SLT use in the relatives too.

A Study to Assess the Awareness of Adults about Precancerous and Cancerous Lesions and the Associated Risk Factors

Aim

The purpose of this study was to determine which factors contribute to the development of oral precancerous lesions and subsequent mouth cancer.

Materials and Methods

Throughout the trial, 450 patients agreed to participate in the investigation. The subjects comprised patients with squamous cell carcinoma (n = 79), oral submucous fibrosis (OSF) (n = 200), leukoplakia (n = 41), lichen planus (n = 10), and controls (n = 120). Statistical analysis of the data was carried out using the Chi-square and regression analysis.

Results

All oral precancerous lesions were shown to have a high prevalence of chewing, which was found to have a strong link with oral cancer. Oral precancerous lesions and cancer were also substantially connected with the length of time someone had the habit and how often they engaged in it.

Conclusion

Oral cancer and precancerous lesions were determined to be less of a worry when other risks such as drinking and smoking were taken into account.

Assessment of Oral Lesions With Tobacco Usage: A Cross-Sectional Clinicopathological Study in Sri Ganganagar, Rajasthan, India

Background Tobacco usage in the form of smoking or chewing has increased the risk of oral potentially malignant disorders (OPMDs) and oral cancer. These deleterious habits are also related to changes in dentition and the oral mucosa. Aim The aim of our study was to evaluate the oral changes associated with tobacco usage among residents of Sri Ganganagar. Materials and methods This study was conducted among the residents of Sri Ganganagar, Rajasthan, India, using stratified cluster random sampling, prestructured questionnaires, and detailed oral examination. A total of 100 patients with a previous history of tobacco usage were enrolled in this study after obtaining informed consent. Age- and gender-matched controls were also evaluated to correlate the findings. Clinical details were documented, including the Oral Hygiene Index-Simplified (OHI-S), Decayed-Missing-Filled Teeth (DMFT) index, Community Periodontal Index (CPI), loss of attachment, dental findings, and oral mucosal changes. Suspicious lesions were stained with toluidine blue, and a biopsy was performed for histopathological evaluation. The tabulated results were statistically analyzed using the Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM SPSS Statistics, Armonk, NY, USA) for significance. Results Attrition, abrasion, and erosion of teeth were more frequent in tobacco users than in controls. Smoker's palate, tobacco pouch keratosis, and leukoplakia were commonly noted mucosal lesions. The mean values of the parameters of the DMFT score (3.560), CPI score (2.190), and loss of attachment score (0.542) were higher among tobacco users, and it was statistically significant (P value < 0.05). Out of 100 patients, 17 had suspicious lesions. It included seven cases of oral submucous fibrosis (OSMF), two cases of tobacco pouch keratosis, and eight cases of leukoplakia. Toluidine blue staining and biopsy were performed. Histopathological examination of suspicious lesions revealed hyperkeratosis, various grades of epithelial dysplasia, and differing inflammatory responses. Out of 17 biopsied cases, there were two cases of hyperkeratosis with severe epithelial dysplasia, four cases of hyperkeratosis with moderate epithelial dysplasia, two cases of hyperkeratosis with mild dysplasia, two cases of superficially invasive squamous cell carcinoma, five cases of advanced OSMF, and two cases of moderately advanced OSMF. Conclusion Tobacco usage produces visible changes in dentition and latent alterations in the oral mucosa. Suspicious lesions should always be referred for histopathological examination to identify oral potentially malignant disorders and oral cancer so that prompt treatment could be initiated. Patient education is mandatory to avoid the usage of tobacco in any form.

Prevalence of oral potentially malignant disorders (OPMD) in adults of Western Maharashtra, India: A cross-sectional study

Background

Oral cavity cancer is estimated to be the third most common malignancy after cancer of cervix and stomach in developing countries.

Objectives

The objective of this study is to investigate the relationship between smoking, alcoholic consumption, betel quid chewing, and OPMD in a prospective manner.

Materials and Methods

A descriptive, cross-sectional study was conducted among 35-55-year-old adults of Western Maharashtra, India. Oral cavity examination as recommended by the American Dental Association specification was followed. Data recorded were transferred from precoded survey pro forma to the computer. The prevalence of OPMD was assessed by determining the percentage of the study population affected. Analysis was done to find out the risk of oral premalignant disorders. The Chi-square (x²) test and adjusted odds ratio (ORs) with 95% confidence interval (CI) were calculated. The Statistical Package for the Social Sciences (SPSS) software version 21.0 was used for the statistical analysis and significance level was set at P < 0.05.

Results

Odds of having OPMD are five times higher for those who smoke (OR = 5.78; 95% CI, [6.18, 7.82]) as compared to those who do not. The odds of suffering from OPMD are about five times higher among those who chew as compared to those who do not (OR = 4.98; 95%CI, [2.91, 7.28]). The mean frequency of tobacco chewing per day and duration in years in participants with OPMDs was significantly higher as compared with normal oral mucosa (P < 0.05 and P < 0.05), respectively, in the use of different tobacco forms.

Conclusion

These findings can be used to design case control or cohort studies to further understand the relation between habits and OPMD.

Analysis of Risk Factors Associated with Squamous Cell Carcinoma in the Indian Population

BACKGROUND

Squamous cell carcinoma (SCC) describes the carcinomatous growth in the oral cavity. Recently, various authors have described increased SCC incidence in the young population. The distribution of SCC shows varied geographic spread, with the highest distribution in Asian countries.

AIMS

The present trial was carried out to assess the associated factors that could lead to increased risk of developing oral cancer.

MATERIALS AND METHODS

Oral examination was carried out for 21 participants by a dentist and any significant oral lesion or deleterious habit if present, was recorded. The data collected were analyzed.

RESULTS

Areca nut was chewed by 47.61% participants (n = 10), smoking tobacco by 76.19% (n = 16), chewing tobacco by 38.09% (n = 8), and consuming alcohol in 9 participants (42.85%). No significant difference was seen concerning age for any factor except alcohol which showed higher intake in the older group where six participants depicted alcohol intake as compared to three participants in the younger group. In participants who chewed areca nuts, 6 participants also smoked tobacco and 1 consumed alcohol. For tobacco chewing, 5 consumed alcohol and 6 also took tobacco as smoke.

CONCLUSION

The present study showed that areca nut and tobacco chewing along with alcohol consumption and tobacco smoking increase the risk of developing SCC in the Indian population.

Estimation and comparison of serum cotinine level among individuals with smoking and tobacco chewing habit

Aims and Objectives

The present study was aimed to estimate and compare tobacco exposure in smokers and chewers. The levels of cotinine, one of the constituents of tobacco were considered as indicative of tobacco exposure. Serum Cotinine levels in individuals with the habit of smoking and tobacco chewing were estimated and compared. Base line values of cotinine levels in normal subjects were established.

Materials and Methods

The study groups comprised about 30 individuals with the habit of smoking (Group A); these 30 individuals with the habit of tobacco chewing (Group B), and 20 individuals who were never exposed to any form of tobacco as control group (Group C). Serum cotinine levels were estimated using a commercially available enzyme-linked immunosorbent assay in both test and control groups and the difference in the levels were compared.

Results

: In individuals with the habit of smoking, cotinine levels ranged between 11 ng/ml and 215 ng/ml with a mean concentration of 87.56. In tobacco chewers, the levels ranged between 11 ng/ml and 128 ng/ml with a mean concentration of 73.66. In control group, the levels ranged between 0.34 ng/ml to 2.5 ng/ml with a mean concentration of 0.93. Cotinine levels between smokers and tobacco chewers were compared and there was no statistically significant difference.

Conclusion

Difference in serum cotinine levels between smokers and tobacco chewers is not significant. The fact that cotinine level is influenced by age of the individual, frequency and duration of the habit seems to be irrelevant from the results obtained from this study. Prospective studies considering all the factors and variables, with a preferable larger sample size can probably eradicate the chaos on the reliability of cotinine as a predictive biomarker for the amount of tobacco exposure.

Expression profiling of long non-coding RNA identifies linc-RoR as a prognostic biomarker in oral cancer

Oral squamous cell carcinoma is the most aggressive cancer that is associated with high recurrence, metastasis, and poor treatment outcome. Dysregulation of long non-coding RNAs has been shown to promote tumor growth and metastasis in several cancers. In this study, we investigated the expression of 11 selected long non-coding RNAs that are associated with cell proliferation, metastasis, and tumor suppression in oral squamous cell carcinomas and normal tissues by quantitative real-time polymerase chain reaction. Out of the 11 long non-coding RNAs profiled, 9 were significantly overexpressed in tumors with tobacco chewing history. Moreover, the long non-coding RNA profile was similar to the head and neck cancer datasets of The Cancer Genome Atlas database. Linc-RoR, a regulator of reprogramming, implicated in tumorigenesis was found to be overexpressed in undifferentiated tumors and showed strong association with tumor recurrence and poor therapeutic response. In oral squamous cell carcinomas, for the first time, we observed linc-RoR overexpression, downregulation of miR-145-5p, and overexpression of c-Myc, Klf4, Oct4, and Sox2, suggesting the existence of linc-RoR-mediated competing endogenous RNA network in undifferentiated tumors. Taken together, this study demonstrated the association of linc-RoR overexpression in undifferentiated oral tumors and its prognostic value to predict the therapeutic response.

Oral verrucous hyperplasia versus oral verrucous carcinoma: A clinicopathologic dilemma revisited using p53 as immunohistochemical marker

Background:

Oral verrucous hyperplasia (OVH) and oral verrucous carcinoma (OVC) are two distinct clinicopathologic verrucous lesions. However, the distinction between the two lesions still remains enigmatic. It is almost impossible to distinguish them clinically. Thus, the final diagnosis rests on the histopathological characteristics of both lesions, being distinguished from each other by an exophytic and endophytic growth pattern, respectively.

Methods:

This institutional study was planned to review retrospectively two series of patients with histologic diagnoses of VH (n = 27) and VC (n = 27) to investigate their clinicopathological features and to analyze the role of immunohistochemical (IHC) marker p53 protein in distinguishing between the two verrucous lesions. The biopsies of the histopathologically diagnosed cases spanning last 10 years were retrieved from the archives of the Oral Pathology department of the institution. Clinical data were tabulated and analyzed for age, gender, site and tobacco habits. IHC staining was done on all the samples using p53 antibody.

Results:

Applying Chi-square test, the buccal mucosa was the most common affected site and tobacco chewing was more prevalent habit in both these lesions (P > 0.05). While the elderly males (>60 years) were the most commonly affected group in VC, a relatively younger age group of males (30–39 years) was more commonly affected in VH (P < 0.05). IHC staining with p53 antibody did not show any significant difference between these two verrucous lesions (P > 0.05).

Conclusion:

VH and VC are closely related lesions distinguished by an adequate biopsy sample.

Prevalence of oral cancer and pre-cancerous lesions and the association with numerous risk factors in North India: A hospital based study

Background:

Oral cancer is one of the most common life-threatening diseases all over the world. Developing countries face several challenges to identify and remove potential risk factors. Chewing tobacco/pan masala is considered to be the most potent risk factor for oral precancerous lesions and oral cancer.

Objectives:

To investigate the relative occurrence of different oral pre-cancerous lesions and oral cancer in North India and to identify the associated risk factors.

Materials and Methods:

A hospital-based study was conducted and 471 subjects were recruited in the study. The subjects comprised patients with squamous cell carcinoma (n = 85), oral submucous fibrosis (n = 240), leukoplakia (n = 32), lichen planus (n = 15), and controls (n = 99). Statistical analysis of the data was done using Chi-square and regression analysis.

Results:

A strong correlation was observed between the presence of the chewing habit in all the oral precancerous lesions and oral cancer. Duration of the habit and intensity of habit ware also strongly correlated with the risk of oral precancerous lesions and oral cancer. Other factors such as alcohol and smoking were found to be less important in concern with oral cancer and precancerous lesions.

Prevalence of abnormal spermatozoa in tobacco chewing sub-fertile males

AIM

The aim of the following study is to find out the prevalence of abnormal spermatozoa and associated functional parameters in clinical semen samples of sub-fertile males with the tobacco chewing habit.

SETTINGS AND DESIGN

Retrospective study was conducted at infertility unit of a tertiary health care center, in a period of 3 years.

MATERIALS AND METHOD

Semen of 642 males were analyzed; of them 194 men (30.2%) were tobacco chewers and they were grouped according to their intensity of chewing (<10 and ≥ 10 packets/day). Counts, motility, vitality, and morphology of sperms were analyzed.

RESULTS

In tobacco chewers, 66% of subjects were oligozoospermic, 85% asthenozoospermic and 28% teratozoospermic. Sperm counts (odds ratio [OR] =2.2; 95% confidence interval [CI]: 1.5-3.09), motility (OR = 3.2; 95% CI: 2.05-4.9), and normal morphology (OR = 8.4; 95% CI: 4.9-14.6) were significantly affected (P = 0.001) in tobacco chewers than the non-chewing group. Further, in comparison to the intensity of tobacco chewing, patients with the intensive practice of using ≥10 packets/day had a significant effect on sperm morphology (P = 0.003, OR = 2.7; 95% CI = 1.41-5.08) only. Structural defects in head (P = 0.001) and cytoplasmic residues (P = 0.001) were found to be positively correlated with the intensive chewing, but no significant changes were found in anomalies in mid-piece and tail.

CONCLUSION

The adverse impact of tobacco chewing on semen parameters was evident even with mild chewers, but with the intensive chewing practice, phenotypes of sperms, mainly defects in the head and cytoplasmic residue were severely affected.

An overview of the risk factors associated with multiple oral premalignant lesions with a case report of extensive field cancerization in a female patient

BACKGROUND

Field cancerization is a well-known and well-documented process of malignant transformation first coined by Slaughter et al. in 1953. Tobacco chewing was associated with the greatest increase in the risk of multiple oral premalignant lesions and may be the major source of field cancerization of the oral cavity in the Indian population. The field cancerization will probably help clinicians in complementing evaluation of pathologic biopsy specimens.

MATERIAL AND METHODS

We present a case report of field cancerization in a 63-year-old Indian female. She presented with an intra-oral generalized hyperkeratotic verruciform type white lesions involving right and left buccal mucosa, lower labial mucosa, upper and lower vestibule, dorsal, ventral and right lateral border of the tongue, hard and soft palate. Microscopic examination revealed features of verrucous carcinoma in one area, squamous cell carcinoma in another and carcinoma in situ in other areas. Based on the overall features in various areas of the oral cavity, the lesion was diagnosed as field cancerization.

CONCLUSION

Reviewing the literature revealed the presence of a field with genetically altered cells appear to be induced by tobacco (smoking/smokeless form). The large number of premalignant cells in the fields may increase cancer risk considerably. Thus screening and monitoring of the field may have serious implications for oral cancer prevention.

A study on prevalence of chewing form of tobacco and existing quitting patterns in urban population of jamnagar, gujarat

Background:

Awareness towards tobacco hazards has increased with time but its role alone towards cessation is questionable. With widespread menace of tobacco in developing countries like India, not much tobacco chewing prevalence and their quitting patterns data are available in urban Saurashtra region.

Objectives:

1. To find out prevalence of various forms of chewing tobacco and quitting attitudes in urban Jamnagar. 2. To study quitting patterns in relation with age of habit initiation, family background and habit duration.

Materials and Methods:

It was a cross-sectional study involving 2513 individuals as study population by 30-cluster sampling method. The study was carried out between June 2007 and March 2008. Pre-set, pre-tested questionnaire was used for interview purpose and the statistical analysis was done on proportion basis.

Results:

About 37.2% of study population was ever-tobacco-chewers; 32.9% of them were current-chewers and 4.3% were quitters. Approximately 28.4% of current-consumers were willing to quit. Mawa-masala (63.7%) and Gutka (57.6%) were preferred forms of chewing tobacco and 57.5% of the current-chewers chewed tobacco six to eight times a day. Tobacco initiation age between 20 and 30 years was commoner among quitters (84.2%), while a little younger in current-consumers (76.5%). About 58.3% quitters and 74.0% chewers showing willingness to quit had not consumed tobacco for more than five years, 63.8% of current-chewers had a family member consuming tobacco. With initiation of health problems, 72.2% subjects quit and 55.5% of them already knew about health hazards.

Conclusions:

Every 4 out of 10 residents was found to be exposed to chewing tobacco. With Mawa-masala and Gutka being the predominant forms, habit onset in late adolescence, years of consumption and family exposure seem to be hampering quitting. Awareness about tobacco hazards alone does not appear to be resulting in successful quitting.

Age at initiation & prevalence of tobacco use among school children in Noida, India: a cross-sectional questionnaire based survey

BACKGROUND & OBJECTIVES

Tobacco use among school children is becoming a serious problem in developing countries. The early age of initiation underscores the urgent need to intervene and protect this vulnerable group from falling prey to this addiction. The present study was thus undertaken to assess the prevalence of tobacco habits among school children, determine the age of initiation of these habits, and compare the age of initiation between students who were more than 15 and ≤ 15 yr of age.

METHODS

Data on tobacco use were collected from 4786 students of class 7 to 12 (age: 11-19 yr) studying in different private and government schools of Noida city during July- December 2005, through cluster and random sampling using a self-administered questionnaire.

RESULTS

Any kind of tobacco use was found in 537 (11.2%) students; 419 (8.8%) were 'ever smokers (including current smokers)' 219 (4.6%) were 'ever tobacco chewers (including current chewers)', 179 (3.7%) were 'exclusive smokers' and 118 (2.5%) were 'exclusive tobacco chewers'. The mean age of initiation of these habits was around 12.4 yr. More than 50 per cent of tobacco chewers reported use of khaini at least once. Nearly 70 per cent of boys and 80 per cent of girls ≤ 15 yr initiated the habit of tobacco before the age of 11 yr. A significant early uptake of tobacco chewing was reported from private school students as compared to government school students (P<0.05).

INTERPRETATION & CONCLUSIONS

Tobacco addiction is emerging as a big threat among children. Our findings indicate a recent downward shift in the age at initiation of tobacco uptake and rising prevalence among girls. Such data need to be collected from different parts of the country to develop anti-tobacco campaigns and take policy decision.

Self-reported use of tobacco products in nine rural INDEPTH Health and Demographic Surveillance Systems in Asia

Background

Tobacco use is the most preventable cause of premature death and disability. Even though tobacco use is common in many Asian countries, reliable and comparable data on the burden imposed by tobacco use in this region are sparse, and surveillance systems to track trends are in their infancy.

Objective

To assess and compare the prevalence of tobacco use and its associated factors in nine selected rural sites in five Asian countries.

Methods

Tobacco use among 9,208 men and 9,221 women aged 25–64 years in nine Health and Demographic Surveillance System (HDSS) sites in five Asian countries of the INDEPTH Network were examined in 2005 as part of a broader survey of the major chronic non-communicable disease risk factors. All sites used a standardised protocol based on the WHO STEPS approach to risk factor surveillance; expanded questions of local relevance, including chewing tobacco, were also included. Multivariable logistic regression was used to assess demographic factors associated with tobacco use.

Results

Tobacco use, whether smoked or chewed, was common across all sites with some notable variations. More than 50% of men smoked daily; this applied to almost all age groups. Few women smoked daily in any of the sites. However, women were more likely to chew tobacco than men in all sites except Vadu in India. Tobacco use in men began in late adolescence in most of the sites and the number of cigarettes smoked daily ranged from three to 15. Use of both forms of tobacco, smoked and chewed, was associated with age, gender and education. Men were more likely to smoke compared to women, smoking increased with age in the four sites in Bangladesh but not in other sites and with low level of education in all the sites.

Conclusion

The prevalence of tobacco use, regardless of the type of tobacco, was high among men in all of these rural populations with tobacco use started during adolescence in all HDSS sites. Innovative communication strategies for behaviour change targeting adolescents in schools and adult men and women at work or at home, may create a mass awareness about adverse health consequences of tobacco smoking or chewing tobacco. Such efforts, to be effective, however, need to be supported by strong legislation and leadership. Only four of the five countries involved in this multi-site study have ratified the Framework Convention on Tobacco Control, and even where it has been ratified, implementation is uneven.

Tobacco consumption in relation to causes of death in an urban population of north India

BACKGROUND

Noncommunicable diseases have become a public heath problem in India concomitant with economic development, leading to increases in tobacco consumption, obesity, and changes in diet and lifestyle. Although observation suggests that tobacco consumption is a major risk factor for deaths due to circulatory, pulmonary, and malignant diseases, such studies are not available from most populations in developing countries.

SUBJECTS AND METHODS

For the period 1999-2001, we studied the randomly selected records of death of 2222 (1385 men and 837 women) decedents, aged 25-64 years, out of 3034 death records overall from the records at Municipal Corporation, Moradabad. All the families of these deceased could be contacted individually to find out the causes of death, by scientist/doctor administered, informed consented, verbal autopsy questionnaire, completed with the help of the spouse and local treating doctor practicing in the appropriate healthcare region. Social classes and tobacco intakes were assessed by a questionnaire.

RESULTS

The prevalence of tobacco consumption, including chewing + smoking, were 45% (n = 623) among men and 15% (n = 125) among women decedents. However, smoking was observed in 20% and tobacco chewing in 30% of male decedents, while only 6% of female decedents smoked and 10% chewed tobacco. Social class had no impact on tobacco consumption in men but did influence one subgroup >55 years among women, ie, among those who had the highest tobacco consumption. Tobacco intakes were significantly more common among decedents dying due to circulatory, malignant, and pulmonary diseases, compared with other causes (men 61.1%, 76.6%, pulmonary 77.3% vs 31%, P < 0.001; women 27.5%, 75.9%, pulmonary 24.6% vs 0.42%, P < 0.001) of mortality, respectively. Pulmonary causes included chronic bronchitis and asthma. Circulatory diseases (29.1%, n = 646) including heart attacks (10.0%), stroke (7.8%), valvular heart disease (7.2%, n = 160), sudden cardiac death and inflammatory cardiac disease, each (2.0%, n = 44) were the second most common causes of deaths, after infections (41.1%, n = 915). Malignant neoplasm (5.8%, n = 131), injury (14.0%, n = 313), and miscellaneous causes of deaths, including diabetes mellitus (2.2%, n = 49) were noted in 9.1%, (n = 202) of death records. Cancers of the lung (1.6%), oral cavity (1.5%), liver (1.1%), stomach (0.9%), breast (0.31%), uterus, cervix, and ovary (0.27%) were relatively common causes for deaths due to malignancy.

CONCLUSIONS

This study shows that tobacco consumption appears to be a major contributor to deaths due to circulatory diseases and malignant diseases in India. Social class status had little impact on tobacco consumption in male decedents. Rapid changes in diet and lifestyle, increases in tobacco consumption, and possibly aging of the population, appear to be strongly associated with mortality due to cardiovascular diseases and cancer in this middle-income country.

Betel nut and tobacco chewing; potential risk factors of cancer of oesophagus in Assam, India

Cancer of the oesophagus is the most commonly diagnosed cancer in males in Assam, in north-eastern India, and ranks second for females. The chewing of betel nut, with or without tobacco and prepared in various ways, is a common practice in the region and a case-control study has been designed to study the pattern of risk associated with different ways of preparing and chewing the nuts. 358 newly diagnosed male patients and 144 female have been interviewed together with 2 control subjects for each case chosen at random from among the attendants who accompanied patients to hospital. There were significant trends in risk ratios associated with the frequency of chewing each day, with the duration of chewing in years and with the age at which the habit was started that were apparent for both males and females and which remained significant after allowance was made for other known risk factors, notably tobacco smoking and alcohol consumption. The adjusted ratios, in comparison with non-chewers, were 13.3 M and 5.7 F for chewing more than 20 times a day, 10.6 M and 7.2 F for persons who had chewed for more than 20 years and 10.3 M and 5.3 F for those who had started before the age of 20. Among the different combinations of ingredients that were chewed the adjusted odds ratios were highest for those who had been using fermented betel nut with any form of tobacco (7.1 M and 3.6 F). The risk associated with tobacco smoking and alcohol consumption, which are high in some parts of the world, were less in Assam than those associated with the chewing of betel nut.