Smokeless tobacco keratosis in oral mucosa with epithelial dysplasia: A case report

RATIONALE

Smokeless tobacco use is a risk factor for the development of various oral lesions, among which is smokeless tobacco keratosis (STK). This condition is caused by constant frictional irritation of smokeless tobacco products against the oral mucosa and appears as a White-to-gray plaque with wrinkling.

PATIENT CONCERNS

A 50-year-old man who had been using smokeless tobacco for 24 years visited our clinic complaining of changes in the lower right sulcus of the oral cavity for 10 days. Clinical examination revealed a unilateral, nonhomogeneous White lesion in the area of the complaint. Histopathological examination showed hyperkeratosis, areas of keratin plugging, and mild dysplastic epithelial changes.

DIAGNOSIS

The clinico-histopathological correlation suggested a diagnosis of STK with focal mild epithelial dysplasia.

INTERVENTION AND OUTCOME

A comprehensive management plan included maintaining oral hygiene, education on the detrimental effects of smokeless tobacco, advice to cease smoking, and regular follow-up to monitor the potential for malignant transformation. The patient was referred to a tobacco cessation society for tailored advice and counseling. On follow-up visits, there was an improvement in the lesion after habitual cessation.

LESSONS

The diagnosis of tobacco-related oral lesions is often delayed, which may result in malignant transformation. This illustrates the need to train healthcare professionals to identify tobacco-related conditions at an early stage and to educate patients regarding the harmful effects of tobacco use.

Evaluation of possible role of fluoride in pathogenesis of oral submucous fibrosis: A pilot study

BACKGROUND

Oral submucous fibrosis (OSMF) is a potentially malignant disorder. Although areca nut chewing is an established risk factor, its low prevalence among nut chewers indicates additional factors likely facilitates pathogenesis. We recently demonstrated high fluoride levels in smokeless tobacco products and hypothesized a potential pathological role of fluoride in OSMF. Further exploring this novel role, this study compared fluoride levels in tissue, serum, and saliva samples from OSMF patients and healthy controls.

METHODS

The ethically approved study included 25 clinically confirmed OSMF patients and 25 healthy matched controls. OSMF cases underwent buccal mucosal incisional biopsy, while controls had buccal mucosa tissue sampling during third molar removal. Fasting venous blood and unstimulated saliva were collected. Fluoride levels were analysed using ion chromatography and expressed as median (IQR).

RESULTS

OSMF cases showed significantly higher fluoride concentrations compared with controls in tissue biopsies (30.1 vs. 0 mg/kg, p < 0.0001), serum (0.4 vs. 0 mg/L, p = 0.005) and saliva (1.3 vs. 0 mg/L, p < 0.0001). Majority (68%) of controls had undetectable fluoride levels across all samples. Tissue fluoride weakly correlated with OSMF severity (r = -0.158, p = 0.334).

CONCLUSION

The preliminary findings demonstrated increased tissue fluoride levels in OSMF patients compared with healthy controls. Along with a previous study showing high fluoride content in smokeless tobacco products, these findings provided early evidence suggesting fluoride could play a contributory role in OSMF pathogenesis. Further large-scale investigation is warranted to definitively establish whether the association between fluoride exposure and OSMF is indicative of causation.

Health effects associated with chewing tobacco: a Burden of Proof study

Chewing tobacco use poses serious health risks; yet it has not received as much attention as other tobacco-related products. This study synthesizes existing evidence regarding the health impacts of chewing tobacco while accounting for various sources of uncertainty. We conducted a systematic review and meta-analysis of chewing tobacco and seven health outcomes, drawing on 103 studies published from 1970 to 2023. We use a Burden of Proof meta-analysis to generate conservative risk estimates and find weak-to-moderate evidence that tobacco chewers have an increased risk of stroke, lip and oral cavity cancer, esophageal cancer, nasopharynx cancer, other pharynx cancer, and laryngeal cancer. We additionally find insufficient evidence of an association between chewing tobacco and ischemic heart disease. Our findings highlight a need for policy makers, researchers, and communities at risk to devote greater attention to chewing tobacco by both advancing tobacco control efforts and investing in strengthening the existing evidence base.

Smokeless Tobacco Use is Associated With Worse Medical and Surgical Outcomes Following Total Hip Arthroplasty

BACKGROUND

Studies have demonstrated increased complication risk after total hip arthroplasty (THA) in patients who smoke cigarettes. It is unclear if smokeless tobacco use confers a similar impact. The purpose of this study was to (1) evaluate rates of postoperative complications after THA in smokeless tobacco users and people who smoke compared to matched controls, and (2) compare rates of postoperative complications in smokeless tobacco users versus patients who smoke.

METHODS

A retrospective cohort study was conducted using a large national database. For patients who underwent primary THA, smokeless tobacco users (n = 950) and people who smoke (n = 21,585) were matched 1:4 with controls (n = 3,800 and 86,340, respectively), and smokeless tobacco users (n = 922) were matched 1:4 with people who smoke (n = 3,688). Joint complication rates within 2 years and medical complications within 90 days postoperatively were compared using multivariable logistic regressions.

RESULTS

Within 90 days of primary THA, smokeless tobacco users demonstrated significantly higher rates of wound disruption, pneumonia, deep vein thrombosis, acute kidney injury (AKI), cardiac arrest, transfusion, readmission and longer length of stay compared to tobacco naïve controls. Within 2 years, smokeless tobacco users demonstrated significantly higher rates of prosthetic joint dislocations and overall joint-related complications compared to tobacco naïve controls.

CONCLUSION

Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. Smokeless tobacco use may be under-diagnosed in patients undergoing elective THA. Surgeons may consider delineating between smoking and smokeless tobacco use during preoperative counseling.

Arterial Stiffness and Carotid Intima-Media Thickness in Children Exposed to Smokeless Tobacco in Fetal Life

BACKGROUND

Arterial stiffening and increased intima-media thickness can be seen as early as childhood and are associated with increased risk of cardiovascular events in adult life. The authors hypothesized that exposure to prenatal smokeless tobacco (Swedish snus) without additional nicotine exposure after the breastfeeding period would be associated with increased arterial stiffness and intima-media thickening in preschool children.

METHODS AND RESULTS

This was a longitudinal follow-up cohort study of children aged 5 to 6 years exposed to high doses of nicotine in utero. Women exclusively using snus and unexposed controls were enrolled in early pregnancy (gestational age range, 6-12 weeks). Exposure data were collected during and after pregnancy with questionnaires from both groups. For this study, only children of women using >48 mg nicotine per day during their entire pregnancy were included in the exposure group. Outcomes were determined in 40 healthy children (21 exposed to snus in utero). Ultrasonography of the common carotid artery was used to determine carotid intima-media thickness and calculate arterial stiffness index from the relationship between pulsatile changes in arterial diameter and arterial pressure. Children exposed to snus in fetal life had higher carotid stiffness (median 4.1 [interquartile range (IQR), 2.4-5] versus 2.9 [IQR, 2.1-3.5]; P=0.014) than tobacco-free controls. Carotid strain (relative diameter change) was lower in children exposed to snus (mean 16% [SD, 5.7%] versus 21% [SD, 6.6%]) than in controls (P=0.015). Carotid intima-media thickness did not differ significantly between children exposed to snus and controls.

CONCLUSIONS

Exposure to snus during fetal life was associated with a stiffer carotid artery in preschool children.

Oral lichenoid lesions in two snuff users with contact allergy to carvone

BACKGROUND

Contact allergy to the mint-tasting flavour carvone has been observed in patients with oral lichenoid lesions (OLL). Mint-flavoured products such as toothpaste frequently contain carvone. Snuff is a smokeless tobacco product that is chewed or placed in the mouth rather than smoked. In Sweden, the use of snuff and its flavoured versions is extremely common.

OBJECTIVES

To investigate whether the consumption of mint-flavoured snuff is associated with contact allergy to carvone and subsequently plays a role in the aetiology of OLL.

METHODS

Regarding the two patients, patch testing with snuff pouches was performed. High-performance liquid chromatography and gas chromatography-mass spectrometry analysis were used for identification of carvone in different snuff samples.

RESULTS

Two patients with OLL were contacted allergic to carvone when patch tested. Both were using mint-flavoured snuffs several hours a day for many years. One patient was contacted allergic to the snuff pouch tested as is. Carvone was detected in the snuff samples of both patients.

CONCLUSIONS

The patients were recommended to avoid the use of mint-flavoured snuffs, toothpaste and foodstuffs. At follow-up 3 months later, the patients had a dramatic clinical improvement of the OLL and oral symptoms. Exposure to mint-flavoured snuffs can be overlooked as a possible aggravating/provoking factor in OLL.

A systematic review of cancer risk among users of smokeless tobacco (Swedish snus) exclusively, compared with no use of tobacco

The main objective of this systematic review was to assess cancer risk, and mortality after cancer diagnosis, for exclusive users of Swedish snus, compared with non-users of tobacco. We followed international standards for systematic reviews and graded our confidence in the risk estimates using the GRADE approach. Our search gave 2450 articles, of which 67 were assessed in full text against our inclusion criteria. Of these, 14 cohort-studies and one case-control study were included in the review. The studies investigated risk of cancer in the oral cavity or oropharynx (3 studies), esophagus (1 study), stomach (1 study), pancreas (2 studies), colorectum (2 studies), anus (1 study) and lung (1 study), as well as malignant lymphoma (1 study), leukemia and multiple myeloma (1 study), melanoma (1 study), any cancer (1 study) and mortality after cancer diagnosis (4 studies). Cancer risk could only be evaluated in men as there was a general lack of data for women. All included studies were evaluated to have a moderate risk of bias, mostly related to validity of exposure information. An increased risk of cancer of the esophagus, pancreas, stomach and rectum as well as an association between use of snus and increased mortality after a cancer diagnosis was reported. Our confidence in the various risk estimates varied from moderate through low to very low.

Smokeless Tobacco Use and Its Association with Type 2 Diabetes: A Case Control Study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a prevalent metabolic disorder characterized by hyperglycemia and insulin resistance. Its incidence is increasing globally, with a significant impact on public health. Smokeless tobacco (SLT) is a form of tobacco consumption that has been associated with various health risks, including potential effects on glucose homeostasis. This case-control study aimed to investigate the association between SLT use and T2DM. Additionally, the study aimed to assess the relationship of age, gender, socioeconomic status (SES), body mass index (BMI), family history of diabetes, physical activity, and periodontal status with T2DM participants.

METHODS

The study was conducted over 24 months and included 82 T2DM cases and 164 non-diabetic controls. Demographic data, tobacco use, medical history, oral hygiene habits, BMI, and periodontal status were collected through a self-administered questionnaire and interviews. Statistical analyses were performed using Statistical Package for Social Sciences (SPSS) for Windows 26.0 (SPSS, Inc. Chicago, Illinois).

RESULTS

The majority of T2DM cases were in the age group of 31-50 years, and there was a significant association between gender and T2DM, with more males being diabetic. There was no significant association between SES and diabetes. Obesity was found to be a significant risk factor for T2DM. Among SLT users, gutkha was the most commonly used product. SLT use was significantly associated with T2DM. Family history of diabetes and physical inactivity were also significantly associated with diabetes.

CONCLUSION

The study suggests that SLT use is a risk factor for T2DM and may be associated with increased diabetes risk. Further research is warranted to understand the underlying mechanisms and potential interventions to reduce the impact of SLT on diabetes risk.

Qualitative Analysis of Opinions and Beliefs Associated with the Use of Tobacco Dentifrice among Individuals Attending a Tobacco Counselling Session

BACKGROUND

Smokeless tobacco (SLT) use is positively associated with oral, oesophageal, and pancreatic cancers. The tobacco dentifrice is a type of SLT which is applied to the teeth and gums. It is available in different forms which include mishri, gul/gulmanjan, gudhaku, snuff, red tooth powder, and creamy snuff. This qualitative study aims to explore the opinions and beliefs associated with the harmful effects of tobacco dentifrice use.

METHODOLOGY

Thirty in-depth interviews were conducted among tobacco dentifrice users visiting a dental hospital. The data were coded and analysed using thematic analysis in ATLAS.ti software 8.

RESULTS

A total of 11 codes and six categories were generated which comprised of the reason for the initiation, awareness of health effects, perception of oral tobacco application, perception of quitting, the reason for continued use, and use in society. Family, peers, access to the product, curiosity were important factors to initiate the tobacco dentifrice use. Participants believed in the myth that tobacco dentifrice was beneficial for the teeth, gums, and bowel movements. The participants considered tobacco dentifrice to be less harmful than other forms of tobacco. However, some participants were aware of its adverse effects on health and have tried to quit in the past. None of the participants had taken any professional help for quitting.

CONCLUSION

There were strong beliefs and myths among the participants that tobacco dentifrice was beneficial for oral and general health. There is a need to create awareness and improve the standard of the health warning of such products.

The Association Between Tobacco Use and Risk of COVID-19 Infection and Clinical Outcomes in Sweden: A Population-Based Study

Background: The association between tobacco use and COVID-19 is controversial. During the early course of the pandemic, limited testing prevented studying a wide spectrum of clinical manifestations. Objective: To examine the potential causal association between tobacco use and COVID-19 during the second wave (1 October 2020-30 June 2021) of the pandemic in Stockholm, Sweden. Methods: A population-based cohort study was conducted in the Stockholm region of Sweden, with information on tobacco use collected prior to the pandemic. Adjusted relative risks (RR) of COVID-19 and 95% confidence intervals (CI) were calculated, contrasting current smokers and snus users to non-users of tobacco. Results: Compared with non-users of tobacco, current smokers had a lower risk of COVID-19 (RR 0.78, 95% CI = 0.75-0.81) and of hospitalisation for the disease. Current snus users had a higher risk of COVID-19. Heavy smokers and snus users had longer hospital stays than non-users of tobacco. Conclusion: Tobacco use may have a different impact on the risk of being infected with SARS-CoV-2 and the risk of developing severe clinical manifestations. Further research is needed to determine the underlying mechanisms.

Effects of chewing tobacco on corneal endothelium in patients with diabetes mellitus

OBJECTIVE

To determine the impact of tobacco chewing on corneal endothelial structure in patients with diabetes mellitus (DM).

METHODS

Corneal endothelial parameters (endothelial cell count, ECD; coefficient of variation, CV; hexagonality, Hex, and central corneal thickness, CCT) were analysed in 1234 eyes of 1234 patients using non-contact specular microscopy (EM 4000 Tomey Nishi-Ku, Nagoya, Aichi, Japan). The study group (with a present history of tobacco chewing) comprising of 948 subjects, with 473 having DM was compared with age and gender-matched control group comprising of 286 subjects (139 having DM) with no history of tobacco use in any form.

RESULTS

Tobacco chewers had a significantly reduced ECD (P = 0.024) and Hex (P = 0.009) as compared with non-chewers. Similar results were noted in ECD (P = 0.004) and Hex (P = 0.005) in patients with DM. Tobacco chewers had a significantly decreased ECD values among males, HbA1C ≤ 7.5% and duration of DM ≤ 20 years, and significantly decreased Hex among those with >50 years of age, females, and duration of DM > 20 years. The CV and CCT values were comparable between the study and the control groups. Tobacco chewers showed a significant association of ECD with age, HbA1C, and duration of DM; CV with HbA1C; Hex with age and duration of DM; and CCT with gender, age, HbA1C and duration of DM.

CONCLUSIONS

Tobacco chewing may negatively impact corneal health, especially confounded by additional factors like age and DM. These factors must be accounted for in the pre-operative evaluation of such patients prior to any intra-ocular surgery.

Trend over time on knowledge of the health effects of cigarette smoking and smokeless tobacco use in Bangladesh: Findings from the International Tobacco Control Policy Evaluation Bangladesh Surveys

INTRODUCTION

Cigarette smoking and smokeless tobacco (ST) use are prevalent in Bangladesh. This longitudinal study examined how knowledge of the health effects of smoking and ST use in Bangladesh has changed overtime with the country's acceleration of tobacco control efforts.

METHODS

Data were analysed from the International Tobacco Control Survey, a nationally representative longitudinal study of users and non-users of tobacco (aged 15 and older) in Bangladesh, across four waves conducted in 2009 (n = 4378), 2010 (n = 4359), 2012 (n = 4223) and 2015 (n = 4242). Generalised estimating equations assessed the level of knowledge about harms of tobacco use across four waves. Multivariable logistic regressions assessed whether knowledge of health effects from cigarette smoking and ST use in 2015 differed by user group.

RESULTS

In 2015 survey, most tobacco users were aware that cigarette smoking causes stroke (92%), lung cancer (97%), pulmonary tuberculosis (97%) and ST use causes mouth cancer (97%) and difficulty in opening mouth (80%). There were significant increases in the total knowledge score of smoking related health harm from 2010 to 2012 (mean difference = 0.640; 95% confidence interval [CI] 0.537, 0.742) and 2012 to 2015 (mean difference = 0.555; 95% CI 0.465, 0.645). Participants had greater odds of awareness for ST health effects from 2010 to 2015.

DISCUSSION AND CONCLUSIONS

The results suggest that increasing efforts of awareness policy interventions is having a positive effect on tobacco-related knowledge in Bangladesh. These policy initiatives should be continued to identify optimal methods to facilitate behaviour change and improve cessation of smoking and ST use.

Social Determinants and the Prevalence of Paan Masala Use among Adults in India: Results from Global Adult Tobacco Survey, 2016-17

BACKGROUND

Gutkha or Paan masala with tobacco is commonly used smokeless tobacco product in India. Given the restrictions on advertisement and promotion of Gutkha and the necessity of warning labels on tobacco products, the tobacco industry has popularised paan masala without tobacco as a surrogate product. Paan masala itself is harmful for health but remains beyond scope of current tobacco control policies. It was important to understand prevalence and determinants of its use (with or without tobacco).

METHODS

Data from the Global Adult Tobacco Survey (GATS)-2, India was used to estimate prevalence of paan masala use (with or without tobacco) in India. Multi-nominal regression and logistic regression were used to calculate risk ratios and odds ratios.

RESULTS

The prevalence of any form of paan masala was 12.1% among adults in India. Prevalence was higher among males (17.8%) than females (6.0%), aged 25-44 years (14.5%) than those aged 65 years or above (9.0%). Relative risk ratio (RRR) for Paan masala with tobacco was significantly high among those with no formal schooling (RRR:2.00) and among those in poorest wealth quintiles (RRR:1.26). While, RRR were lower for Paan masala use without tobacco among those with no formal schooling (RRR:0.95) and among poorest wealth quintiles (RRR:0.78). Region-wise AOR were highest for North-East (AOR:4.80) and Central regions (AOR:4.76) compared to South India.

CONCLUSION

The prevalence of paan masala use is high in India. Persons belonging to lower socioeconomic status or having no formal schooling have higher risk of consuming paan masala with tobacco. However, persons from higher wealth quintiles or having formal schooling had higher risk of use of paan masala without tobacco. These findings need careful attention of policy makers and law enforcers as it indicates different marketing strategies might have adopted by industry to target these two mutually exclusive population groups.

Determinants of initiation, continuation and cessation of smokeless tobacco use among pregnant and lactating women: a qualitative study from low-income communities in urban India

Smokeless tobacco (SLT) consumption increases the risk of cardiovascular diseases and cancer and leads to adverse reproductive health outcomes among women and newborns. This study examines the factors associated with initiation, continuation and cessation of SLT use among women in the reproductive age so as to formulate and include prevention and cessation interventions from its inception. The study was conducted in urban low-income communities in India. Using snowball and purposive sampling techniques, in-depth interviews were conducted with 20 pregnant and 22 lactating women who currently used SLT products. Data were analysed using thematic analysis with the help of QSR NVivo software. Findings revealed that factors such as people influencing usage change with different life stages including pre-marital and post-marital periods. Perceived health benefits, altered taste preferences during pregnancy and social influences were also studied. Women were found to be more aware of the harmful effects of tobacco during pregnancy than during breastfeeding. Social stigma around women consuming tobacco acted as a major driving factor for cessation. Most of the participants were willing to quit but were not aware of any technique or programme for cessation. The findings of the study highlight the need to develop behavioural change intervention tools, which are culturally and locally appropriate and have a gender-sensitive approach. Different socio-cultural factors associated with initiation/cessation at different life stages should also be taken into consideration while developing these tools.

Pan-American prevalence of smokeless tobacco use and association with oral potentially malignant disorders and head and neck cancer: a systematic review and meta-analysis

OBJECTIVES

To determine the prevalence of smokeless tobacco (SLT) use and its association with oral potentially malignant disorders (OPMDs) and head and neck cancer (HNC) in the Pan-American Health Organization (PAHO) region.

STUDY DESIGN

A literature search was conducted across 9 databases and other sources. The eligibility criteria were pediatric (0-18 years old) and adult (19 years and older) populations consuming any type of SLT. Meta-analysis was performed to determine the prevalence of SLT and the association between its use and OPMDs/HNC in the PAHO region; the Grading of Recommendations Assessment, Development, and Evaluation tool was used to verify the certainty of evidence.

RESULTS

Fifty-nine studies from 6 PAHO countries were included, of which 51 were also subjected to quantitative analysis. The pooled SLT prevalence of use was 15% (95%CI: 11.93-18.69) overall, 17% (95%CI: 13.25-22.65) in adults, and 11% (95%CI: 8.54-14.78) in the pediatric population. The highest reported SLT prevalence of use was 33.4% (95%CI: 27.17-39.93) in Venezuela. HNC was positively associated with SLT use (OR = 1.98, 95%CI: 1.54-2.55), with a moderate certainty of evidence. Among OPMDs, only leukoplakia reported a positive association with SLT use (OR = 8.38; 95%CI: 1.05-67.25). However, the quality of the evidence was very low.

CONCLUSION

A high consumption of SLT use, chewing tobacco and snuff, is reported among the adult population residing in the PAHO region with a positive association with the development of oral leukoplakia and HNC.

Quick nic: novel smokeless nicotine products and pediatric trends

PURPOSE OF REVIEW

The development and marketing of smokeless nicotine products in recent years have become increasingly popular among adolescents. In addition to well known conventional inhaled nicotine products, noninhaled products, such as nicotine toothpicks, orbs, lozenges, strips, and more, have dangerously captivated a new youth audience. Although smokeless nicotine products may seem to be less threatening than conventional inhaled nicotine products, there are significant risks associated with the use of these products, including addiction and severe health issues. The purpose of this review is to provide up-to-date information about alternative nicotine products currently on the market that may appeal to youth, and the dangers of nicotine use for pediatric populations.

RECENT FINDINGS

Smokeless nicotine products appeal to minors with their varying flavors and discrete packaging. These products may lead to nicotine toxicity as well as severe health problems, such as cancer, issues with reproduction, and heart attacks. Nicotine is extremely dangerous for young children; in fact, using nicotine products before the age of 18 years can lead to addiction and is linked to an increased likelihood of experimenting with stronger nicotine products or illicit drugs. The development of inconspicuous nicotine packaging has led to increasing concerns for accidental nicotine exposure and overdose in youth.

SUMMARY

Greater knowledge regarding current nicotine products on the market, specifically smokeless nicotine products, will help clinicians be more aware of the dangers associated with these products. Clinicians will be better able to provide their patients and families with proper guidance to avoid nicotine addiction, further drug use, and detrimental health issues. Caregivers and medical professionals must recognize novel and inconspicuous nicotine products commonly used among youth, understand the signs of nicotine abuse and dependence, and take measures to address possible nicotine-related health risks.

Salivary superoxide dismutase activity in smokeless tobacco consumers and non-consumers: A biochemical study

Aim and Objective

Tobacco can alter the antioxidative capacity of saliva, and it is the first fluid that is exposed to tobacco. Superoxide dismutase (SOD) is the first line defense antioxidant that plays an important protective role against peroxidation of lipids, converts superoxide radicals into hydrogen peroxide, and decreases the toxic effects of free radicals. The aim of this study was to estimate and compare the levels and activity of SOD in the saliva of smokeless tobacco (SLT) consumers and non-consumers.

Method and Methodology

Total of 64 individuals were divided into two groups (study and control) with 32 patients each. The patients were divided into two groups-Group I: 32 healthy individuals who do not consume SLT (control group) and Group II: 32 individuals who consume SLT for a period more than 1 year (study group). Saliva samples were collected for analysis from both the groups.

Results

The results of this study showed that antioxidant salivary SOD enzyme activity in tobacco chewers is higher in comparison to non-chewers.

Conclusion

The present study enlightens us to the possible relationship between SOD enzyme levels, oxidative stress, and tobacco habit. In initial or early stages, antioxidant levels increase, thereby showing an evidence of endogenous activity. But as the duration of the habit increases, there is decrease in the body's defense mechanism, and the level of SOD starts to fall resulting in oral lesions. This will help in establishing the reliability of SOD in saliva as a potential biomarker of oxidative stress in tobacco chewers. Further, it may also help in establishing the role of oxidative stress in the pathogenesis of premalignant lesions and oral cancer.

Compliance with COTPA (Packaging and Labeling) Rules, 2008 and its amendments in smokeless tobacco products sold across Mangaluru taluk, Karnataka, India

Introduction

India introduced the Cigarettes and Other Tobacco Products Act (COTPA) (Packaging and Labeling [P and L]) Rules in 2008. These rules utilize the tobacco package to communicate tobacco-caused harms; it also seeks to restrict the delivery of misleading information about the product on the pack. The enormous burden of tobacco-related oral cancers in India necessitates the compliance with the law regarding presentation of information in powerful and salient ways, intentionally designed to increase the awareness in target individuals.

Objectives

The objectives of the study are to assess the compliance to implementation and enforcement of the COTPA (P and L) Rules, 2008 and its amendments in 2014 and 2018.

Materials and Methods

Chewing tobacco products were retrieved and evaluated for compliance with the law. The specified pictorial and textual health warnings, area, clarity, rotation, and language were assessed as per the recommendations.

Results and Conclusion

Even though chewing tobacco products in India have introduced pictorial and textual health warnings, majority of them do not comply with the law. The products displayed the specified health warnings on a total of 70.6% on average, failing to abide by the government-specified average of 85%. 50% of the products did not follow the rotation of pictorial and textual health warning even after completion of the interregnum period of 12 months (September 2019). To ensure consumers' right to be informed about the health risks from a product, all the details regarding the contents, health warnings and messages, and product care instructions must be mentioned as specified under the law.

Smokeless tobacco keratosis

Smokeless tobacco keratosis is a benign lesion characterized by the formation of white, gray, or pale macules or papules with wrinkling or rugae. It forms in the oral mucosa in response to the use of smokeless tobacco products. We present a 50-year-old man with an extensive history of smokeless tobacco use and development of the characteristic lesion. Shave biopsy showed typical changes of this benign condition and tobacco cessation was recommended.

The contribution of smoking and smokeless tobacco to oesophageal squamous cell carcinoma risk in the African oesophageal cancer corridor: Results from the ESCCAPE multicentre case-control studies

Tobacco use is a well-established risk factor for oesophageal squamous cell carcinoma (ESCC) but the extent of its contribution to the disease burden in the African oesophageal cancer corridor has not been comprehensively elucidated, including by type of tobacco use. We investigated the contribution of tobacco use (smoking and smokeless) to ESCC in Tanzania, Malawi and Kenya. Hospital-based ESCC case-control studies were conducted in the three countries. Incident cases and controls were interviewed using a comprehensive questionnaire which included questions on tobacco smoking and smokeless tobacco use. Logistic regression models were used to estimate odds ratios (OR) and their 95% confidence intervals (CI) of ESCC associated with tobacco, adjusted for age, sex, alcohol use, religion, education and area of residence. One thousand two hundred seventy-nine cases and 1345 controls were recruited between August 5, 2013, and May 24, 2020. Ever-tobacco use was associated with increased ESCC risk in all countries: Tanzania (OR 3.09, 95%CI 1.83-5.23), and in Malawi (OR 2.45, 95%CI 1.80-3.33) and lesser in Kenya (OR 1.37, 95%CI 0.94-2.00). Exclusive smokeless tobacco use was positively associated with ESCC risk, in Tanzania, Malawi and Kenya combined (OR 1.92, 95%CI 1.26-2.92). ESCC risk increased with tobacco smoking intensity and duration of smoking. Tobacco use is an important risk factor of ESCC in Tanzania, Malawi and Kenya. Our study provides evidence that smoking and smokeless tobacco cessation are imperative in reducing ESCC risk.

An Insight into Survivin in Relevance to Hematological, Biochemical and Genetic Characteristics in Tobacco Chewers with Oral Squamous Cell Carcinoma

BACKGROUND

Survivin is an inhibitor of apoptosis protein (IAP), encoded by the Baculoviral IAP Repeat Containing 5 (BIRC5) gene located on q arm (25.3) on chromosome 17. It is expressed in various human cancers and involved in tumor resistance to radiation and chemotherapy. The genetic analysis of the BIRC5 gene and its protein survivin levels in buccal tissue related to oral squamous cell carcinoma (OSCC) in South Indian tobacco chewers has not been studied. Hence, the study was designed to quantify survivin in buccal tissue and its association with pretreatment hematological parameters and to analyze the BIRC5 gene sequence.

METHOD

In a single centric case control study, buccal tissue survivin levels were measured by ELISA. A total of 189 study subjects were categorized into Group 1 (n = 63) habitual tobacco chewers with OSCC, Group 2 (n = 63) habitual tobacco chewers without OSCC, and Group 3 (n = 63) healthy subjects as control. Retrospective hematological data were collected from Group 1 subjects and statistically analyzed. The BIRC5 gene was sequenced and data were analyzed using a bioinformatics tool.

RESULTS

Survivin protein mean ± SD in Group 1 was (1670.9 ± 796.21 pg/mL), in Group 2 it was (1096.02 ± 346.17 pg/mL), and in Group 3 it was (397.5 ± 96.1 pg/mL) with significance (p < 0.001). Survivin levels showed significance with cut-off levels of absolute monocyte count (AMC), neutrophil/lymphocyte ratio (NLR), and lymphocyte/monocyte ratio (LMR) at (p = 0.001). The unique variants found only in OSCC patients were T → G in the promoter region, G → C in exon 3, C → A, A → G, G → T, T → G, A → C, G → A in exon 4, C → A, G → T, G → C in the exon 5 region.

CONCLUSIONS

The tissue survivin level increased in OSCC patients compared to controls; pretreatment AMC, LMR, and NLR may serve as add-on markers along with survivin to measure the progression of OSCC. Unique mutations in the promoter and exons 3-5 were observed in sequence analysis and were associated with survivin concentrations.

Sudanese Toombak smokeless tobacco users harbour significantly altered long-term cortisol body production

The Sudanese, in particular its male population, are known to utilise a smokeless tobacco product (Toombak) which is placed in the oral cavity and can be replaced several times a day. Toombak has been shown to harm human health and is highly addictive. The effect on body cortisol response over a retrospective period in users of this product has not been previously explored. In addition, psycho-dependency scores of Toombak users have not been analysed. In this study, 37 male subjects, age 18-45 years were recruited, of which 18 were non-users of Toombak and 19 were Toombak users. One hair sample was collected from each user and non-user of Toombak. Each hair sample (n=37) was placed in a pre-prepared long piece of foil with two labels on either side marked: 'scalp-side' and 'distant-side'. Cortisol was extracted by mincing 10 mg of 'scalp-side' hair, not exceeding 3 cm, with methanol addition, incubation, and sonication. Cortisol was measured using the enzyme-linked immunosorbent assay kit (Enzo Life Sciences, UK). The amount of hair cortisol in the samples was determined using spectrophotometry at wavelength 405 nm measured in pg/ml and visualised with a four parametric logistic curve. Toombak users were further asked to complete the Fagerstrom Test for Nicotine Dependence-Smokeless Tobacco questionnaire (FTND-ST) comprising of six questions. Scores of > 5 indicated a significant dependence, while a score of < 4 marked low to moderate dependence. The mean concentration of hair cortisol in Toombak users (9.7 pg/ml) was significantly lower (p=0.023) compared to non-users (19.4 pg/ml), with total concentrations ranging from 2.1 to 55.6 pg/ml. FTND-ST scores ranged from 4 to 9, with high levels of psycho-dependency (score > 5) and nicotine tolerance found in 85 % of Toombak users. Cortisol body release in Sudanese smokeless tobacco users was found to be significantly altered. While low cortisol levels do lead to anxiolytic effects, in the long-term, this can allow for increased susceptibility to low cortisol-associated diseases.

Prevalence and determinants of oral potentially malignant disorders in rural areas of South India

Purpose

Oral potentially malignant disorders are associated with a risk of undergoing malignant transformation and a concomitant increase in morbidity and mortality. Moreover, epidemiological studies, especially from rural areas, are important in assessing their prevalence and the identification of determinants of these disorders so that preventive strategies can be employed in tackling them.

Methods

Cross-sectional descriptive study was conducted based on guidelines of the World Health Organization's Guide Epidemiology and Diagnosis of Oral Mucosal Disease and Conditions 1995 in rural areas of south India.

Results

Prevalence of oral potentially malignant disorders (OPMDs) in the studied population was 13.28%, with oral submucous fibrosis (OSMF) accounting to 6.21% and erythroplakia at 1.3%. Regression analysis revealed, age 40-54 years (odds ratio [OR] = 3.8, confidence interval [CI] at 95%-1.5-4.0, P < 0.05), lower socioeconomic groups (OR = 2.1, CI at 95%-1.4-3.1, P < 0.05), habits (OR = 3.2, CI at 95%-1.9-3.8, P < 0.05), smoke form of tobacco-beedi (OR = 2.5, CI at 95%-1.6-2.8, P < 0.05), smokeless form of tobacco-areca nut lime and leaf and tobacco (OR = 3.1, CI at 95%-1.9-3.4, P < 0.05) to be the possible determinants for OPMDs.

Conclusions

The overall prevalence of OPMDs in the studied population was 13.28%. The most common OPMDs were OSMF. Identified determinants were age, socioeconomic group, ethnicity, diet, body mass index, and associated harmful habits.

Current tobacco use and COVID-19 diagnoses in a cohort of adult clients of public dental clinics in Sweden

Smoking has been linked with both increased and decreased risk of COVID-19, prompting the hypothesis of a protective role of nicotine in the pathogenesis of the disease. Studies of the association between use of smokeless tobacco and COVID-19 would help refining this hypothesis. We analysed data from 424,386 residents in the Stockholm Region, Sweden, with information on smoking and smokeless tobacco (snus) use prior to the pandemic obtained from dental records. Diagnoses of COVID-19 between February and October 2020 were obtained from health-care registers. We estimated the risk of receiving a diagnosis of COVID-19 for current smokers and for current snus users relative to non-users of tobacco, adjusting for potential confounders (aRR). The aRR of COVID -19 was elevated for current snus users (1.09 ;95%CI = 0.99-1.21 among men and 1.15; 95%CI = 1.00-1.33 among women). The risk for women consuming more than 1 can/day was twice as high as among non-users of tobacco. Current smoking was negatively associated with risk of COVID-19 (aRR = 0.68; 95% CI = 0.61-0.75); including hospital admission (aRR = 0.60; 95% CI = 0.47-0.76) and intensive care (aRR = 0.43; 95% CI = 0.21-0.89). The hypothesis of a protective effect of tobacco nicotine on COVID-19 was not supported by the findings. The negative association between smoking and COVID-19 remains unexplained.

Smoking, use of smokeless tobacco, HLA genotypes and incidence of latent autoimmune diabetes in adults

AIMS/HYPOTHESES

Smoking and use of smokeless tobacco (snus) are associated with an increased risk of type 2 diabetes. We investigated whether smoking and snus use increase the risk of latent autoimmune diabetes in adults (LADA) and elucidated potential interaction with HLA high-risk genotypes.

METHODS

Analyses were based on Swedish case-control data (collected 2010-2019) with incident cases of LADA (n=593) and type 2 diabetes (n=2038), and 3036 controls, and Norwegian prospective data (collected 1984-2019) with incident cases of LADA (n=245) and type 2 diabetes (n=3726) during 1,696,503 person-years of follow-up. Pooled RRs with 95% CIs were estimated for smoking, and ORs for snus use (case-control data only). The interaction was assessed by attributable proportion (AP) due to interaction. A two-sample Mendelian randomisation (MR) study on smoking and LADA/type 2 diabetes was conducted based on summary statistics from genome-wide association studies.

RESULTS

Smoking (RR_pooled 1.30 [95% CI 1.06, 1.59] for current vs never) and snus use (OR 1.97 [95% CI 1.20, 3.24] for ≥15 box-years vs never use) were associated with an increased risk of LADA. Corresponding estimates for type 2 diabetes were 1.38 (95% CI 1.28, 1.49) and 1.92 (95% CI 1.27, 2.90), respectively. There was interaction between smoking and HLA high-risk genotypes (AP 0.27 [95% CI 0.01, 0.53]) in relation to LADA. The positive association between smoking and LADA/type 2 diabetes was confirmed by the MR study.

CONCLUSIONS/INTERPRETATION

Our findings suggest that tobacco use increases the risk of LADA and that smoking acts synergistically with genetic susceptibility in the promotion of LADA.

DATA AVAILABILITY

Analysis codes are shared through GitHub ( https://github.com/jeseds/Smoking-use-of-smokeless-tobacco-HLA-genotypes-and-incidence-of-LADA ).

Awareness, susceptibility, and use of oral nicotine pouches and comparative risk perceptions with smokeless tobacco among young adults in the United States

BACKGROUND

Oral nicotine pouches (NPs) that contain nicotine but no tobacco leaves are rapidly gaining popularity. However, there is limited research on NPs, including within priority populations. In the current study, we examined awareness of, susceptibility to, and use of NPs in young adults as well as comparative risk perceptions with smokeless tobacco.

METHODS

In 2021, 609 young adults (18-25 years) completed an online survey. Participants reported on NP awareness, susceptibility, and use as well as on comparative product perceptions for NPs versus smokeless tobacco. We ran unadjusted between-groups comparisons and an adjusted multinomial logistic regression to identify relationships between product perceptions and NP susceptibility and use.

RESULTS

41.5% of participants had heard of NPs before. Participants were non-susceptible (66.2%), susceptible (23.5%), or had used NPs (10.3%). Comparative product perceptions between NPs and smokeless tobacco suggested that young adults, as a whole, expressed uncertainty about the relative risk/benefit of using NPs versus smokeless tobacco. However, as expected, unadjusted and adjusted findings indicated that favorable perceptions of NPs versus smokeless tobacco were disproportionately observed among susceptible participants and NP users compared to non-susceptible individuals. Demographic differences were also observed (e.g., NP users were more likely than non-susceptible and susceptible individuals to have used smokeless tobacco).

CONCLUSIONS

Young adults reported awareness of, susceptibility to, and use of NPs, with findings indicating that favorable perceptions of NPs versus smokeless tobacco may contribute to NP susceptibility and use beyond known correlates like smokeless tobacco use. However, further research is needed to understand the full range of factors that are associated with NP susceptibility and use. It will be important to disentangle factors that are associated with potential positive public health impacts (e.g., switching from smokeless tobacco to exclusive NP use) from those associated with negative public health impacts (e.g., initiation among nicotine naïve individuals).

Does Maras powder affect the nasal mucociliary clearence?

PURPOSE

Many studies have been conducted about the effect of cigarettes and other tobacco products on mucociliary clearance. However, there has been no study of the relationship between mucociliary clearance and Maras powder, which is a smokeless tobacco product. The aim of this study was to evaluate the effect of Maras powder use on mucociliary clearance through comparisons with cigarette smokers and those who used no tobacco products.

METHODS

The study included 75 male volunteers, aged 23-54 years. Group 1 (n: 25) comprised subjects who do not use any tobacco products, Group 2 (n: 25) those who smoked cigarettes, and Group 3 (n: 25) those who used Maraş powder. The saccharin test was used to evaluate mucociliary clearance and the time was recorded in seconds. The groups were statistically compared in respect of mean age and mucociliary clearance time (MCCT).

RESULTS

The mean MCCT was determined to be 645.8 ± 200 secs for the whole study sample, 497 ± 108 secs for Group 1, 796 ± 200 secs for Group 2, and 644 ± 161 secs for Group 3. The difference between the groups in respect of MCCT was statistically significant (p < 0.001). No statistically significant difference was determined between the groups in respect of mean age (p = 0.730).

CONCLUSION

The study results demonstrated that the nasal mucociliary clearance time was prolonged both by cigarettes and by the use of Maras powder, and that this time was prolonged more by cigarette smoking than the use of Maras powder.

Awareness of health risks associated with smokeless tobacco use among users in Pretoria

BACKGROUND

Smokeless tobacco (ST) refers to all tobacco-containing products that are not smoked but rather consumed through other means. Contrary to the popular belief that ST products are safe, the use of such products exposes users to health risks. To assess the awareness of health risks associated with ST use among users in a Pretoria community, the study was conducted in Ramotse community, located in Tshwane region 2, Gauteng, South Africa.

METHODS

This was a cross-sectional design, using a piloted, structured and self-administered questionnaire.

RESULTS

Of 479 participants with a mean age of 43 years (ranging from 18 to 89 years), most were in the age group 30-39 years (148; 31.6%), followed by ≥ 50 years (138; 29.4%). There were more females (371; 77.5%), more unemployed (263; 54.9%), married (236; 49.7%), had reached the secondary level of education (270; 56.4%), did not have any chronic illness (274; 57.2%), used snuff by nose (338; 70.6%), and were unaware of health risks associated with ST use (452; 94.4%).

CONCLUSION

This study has demonstrated a poor awareness of health risks associated with ST use among the users in a Pretoria community. As a result, health education at various levels of the community (clinic, schools, ward-based outreach team or WBOT, etc.) could be one strategy for resolving the problem.

Update on new forms of tobacco use

Smoking remains the leading cause of morbidity and mortality worldwide. Because of its clear influence on cardiovascular and respiratory diseases, it is an important factor in internal medicine consultations. Although the rate of smoking cessation has been increasing in recent years, there is a percentage of patients who continue to smoke because they are unable or unwilling to quit, despite having tried existing pharmacological and non-pharmacological therapies. For this group of patients there are strategies based on interventions aimed at reducing the negative effects of smoking without the need for complete cessation. In this review it is shown that due to the absence of combustion of organic matter in conventional cigarettes, snus, e-cigarettes and heated tobacco products generate significantly lower levels of toxic substances.

'95% less harmful'? Exploring reactions to quantitative modified risk claims for snus and e-cigarettes

OBJECTIVES

Studies examining perceptions of 'modified risk tobacco product' (MRTP) messages for e-cigarettes and smokeless tobacco have indicated consumers want statistics and quantification of harm reduction. However, limited research exists on reactions to quantitative MRTP messages.

DESIGN

We conducted 12 focus groups in the USA in 2019-6 focused on e-cigarette messages and 6 on snus messages. Eight groups were with current smokers (ages 21-66) and four with young adult (ages 18-25) non-smokers (n=57). Participants discussed messages stating that use of snus and vaping products have been estimated by scientists to be about 90% and 95% less harmful than smoking cigarettes, respectively.

RESULTS

Several participants agreed the messages strongly communicated that the products are less harmful than cigarettes, were attention getting and could be 'convincing'. However, participants expressed scepticism about the source and accuracy of the stated figures, and some noted the claims could be misleading and attractive to young people. Comments also reflected some claim misunderstandings (eg, that e-cigarettes only pose a 5% chance of harm). Participants also agreed that stating e-cigarette risks 'are unlikely to exceed 5% of cigarette smoking harms' was confusing and less impactful than the '95% less harmful' wording.

CONCLUSIONS

Quantitative claims suggesting high levels of reduced risk when comparing e-cigarettes or smokeless tobacco/snus relative to cigarettes may be successful in gaining attention and being persuasive for some audiences, particularly, if from more credible sources. However, message developers, users and evaluators should be mindful of message limitations and aim to mitigate unintended consequences.

Comparison of severity of periodontal clinical parameters among naswar/snuff users: Cross sectional study

Background

Naswar is a moist, non-chewable, and smokeless tobacco product ensconced in the buccal vestibule or floor of the mouth. Consumption of naswar is very popular in South Asia, especially Pakistan. This cross-sectional study compared the periodontal clinical parameters amongst mild, moderate, and severe naswar users.

Methods

318 naswar users, categorized into three equal groups (n = 106) severe naswar users, moderate naswar users, and mild naswar users were drawn for this study. Bleeding on probing, pocking depth, gingival recession, and attachment loss were assessed using the UNC-15 probe and compared among the three groups of naswar users. Data analysis was done with the help of SPSS. Statistical significance was deliberated at p value ≤0.05.

Results

28.9 ± 7.6 years was the mean age presentation. The mean % of bleeding on probing score was 61.95% in severe naswar users, 56.62% in moderate naswar users, and 51.23% in mild naswar users with a p-value of 0.001*. In severe, moderate, and mild naswar users the probing pocket depth (4-6mm) were 35.14%, 30.95%, and 23.21% respectively. 26.78% severe naswar users were having mean percentage for probing pocket depth (>6m) followed by moderate naswar users (17.26%) and mild naswar users (17.26%) with a significant p-value (0.001*). Clinical attachment loss (CAL) was 2.50 percent in light naswar users, 3.0 percent in moderate naswar users, and 4.25 percent in severe naswar users. Clinical attachment loss (CAL) was 2.50 percent in light naswar users, 3.0 percent in moderate naswar users, and 4.25 percent in severe naswar users. Severe naswar users had a high mean percentage of gingival recession (23.21%), whereas light 13.67 percent and moderate 14.88 percent naswar users had a smaller difference.

Conclusions

Clinical periodontal parameters were more worsen in heavy naswar users compared to moderate and light naswar users.

Quantitative measurement of harmful and potentially harmful constituents, pH, and moisture content in 16 commercial smokeless tobacco products

Smokeless tobacco products expose adult and youth tobacco users to various addictive and carcinogenic constituents that can cause long-term nicotine dependence and oral cancers. In this study, nicotine, benzo[a]pyrene (B[a]P), N'-nitrosonornicotine (NNN), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), acetaldehyde, crotonaldehyde, formaldehyde, moisture, and pH levels in 16 smokeless tobacco products were measured on a wet-weight basis (wwb). In addition, change in analytical variability with increasing replicate measurements was assessed. Total nicotine in the products varied from 6.2 to 35.5 mg/g. The percentage of total nicotine in the unprotonated form ranged from 0.1 to 62%; whereas, product moisture varied from 7.4 to 57%. The quantities of harmful and potentially harmful constituents (HPHCs) range from 0.46 to 179.9 ng/g for B [a]P, 270-12206 and 81-20716 ng/g for NNN and NNK, respectively, and 0.33-6.85 and 0.13-5.67 μg/g for acetaldehyde and formaldehyde, respectively. This study shows wide variation in smokeless tobacco product HPHC quantities. The results also show that analytical variability stabilizes after seven replicate measurements.

Smokeless tobacco use and oral potentially malignant disorders among people living with HIV (PLHIV) in Pune, India: Implications for oral cancer screening in PLHIV

INTRODUCTION

In India, smokeless tobacco (SLT) is a predominant form of tobacco used among people living with HIV (PLHIV). Despite SLT being a risk factor for oral potentially malignant disorders (OPMDs), no prior studies have quantified the association of OPMDs with SLT use among PLHIV. This limits the planning of preventive and control strategies for oral cancer among PLHIV, who are at higher risk for the disease.

METHODS

We enrolled 601 PLHIV and 633 HIV-uninfected individuals in an oral cancer screening study at BJ Government Medical College, Pune, India. Oral cavity images were collected using an m-Health application and reviewed by three clinicians. Participants with two clinician positive diagnoses were deemed to have suspected OPMDs. Prevalence ratios (PRs) were used to quantify the association between suspected OPMDs and SLT use among PLHIV. PRs for current SLT users, across HIV status and use duration were also estimated. Corrected PRs were obtained by modifying the maximum likelihood estimation. Models were adjusted for age, smoking, alcohol use and CD4 counts.

RESULTS

Of those enrolled, 61% were men, median age was 36 years (IQR: 28-44), and 33% currently use SLT. Proportion of current SLT users was similar across PLHIV and HIV-uninfected groups but use duration for current SLT use was higher among PLHIV(p<0.05). Among PLHIV, current SLT users had a 5-times (95% CI:3.1-7.0) higher prevalence of suspected OPMDs, compared to non-users. Relative to HIV uninfected individuals with the same SLT use duration, significant associations with suspected OPMDs were seen for PLHIV with<10 use years (PR: 3.5, 95% CI: 1.5-8.1) but not for PLHIV with≥10 use years (PR: 1.3, 95% CI: 0.9-1.8).

CONCLUSION

PLHIV that are current SLT users are at high risk of OPMDs and potentially oral cancer. The development of strategies for screening, early detection, and management of OPMDs must be considered for this group.

Associations of Smokeless Tobacco Use With Cardiovascular Disease Risk: Insights From the Population Assessment of Tobacco and Health Study

INTRODUCTION

Cigarette smoking is strongly associated with the development of cardiovascular disease (CVD). However, evidence is limited as to whether smokeless tobacco (ST) use is associated with CVD.

AIMS AND METHODS

Using data from 4347 adults in the Population Assessment of Tobacco and Health Study (2013-2014), we compared geometric mean concentrations of CVD-related harm biomarkers and biomarkers of exposure among exclusive ST users and exclusive cigarette smokers-in relation to recent nicotine exposure-and never tobacco users, adjusting for age, sex, race/ethnicity, income, body mass index, and CVD. Biomarker levels among exclusive ST users who were former established cigarette smokers were compared with exclusive cigarette smokers.

RESULTS

Compared with cigarette smokers, ST users had significantly higher concentrations of total nicotine equivalents (TNE) but lower concentrations of inflammatory (high-sensitivity C-reactive protein, interleukin-6, intercellular adhesion molecule, fibrinogen) and oxidative stress (8-isoprostane) biomarkers (all p < .05). Biomarker levels among ST users were similar to never smokers. ST users who were former cigarette smokers had lower levels of inflammatory and oxidative stress biomarkers and biomarkers of exposure (cadmium, lead, 1-hydroxypyrene, acrylonitrile, and acrolein), compared with cigarettes smokers (p < .05), despite having higher TNE levels (p < .05). Among cigarette smokers, but not among ST users, inflammatory biomarkers and TNE were highly correlated.

CONCLUSIONS

ST use is not associated with increases in biomarkers of CVD-related harm and exposure, compared with never smokers, despite exposure to nicotine at levels higher than those observed among cigarette smokers. These findings support the concept that increases in CVD risk among cigarette smokers is caused primarily by constituents of tobacco smoke other than nicotine.

IMPLICATIONS

Despite having higher levels of nicotine and compared with exclusive cigarette smokers, exclusive ST users (including those who were former cigarette smokers) had significantly lower concentrations of inflammatory and oxidative stress biomarkers, comparable to levels observed among never tobacco users. These findings suggest that increases in CVD risk among cigarette smokers is caused primarily by tobacco constituents other than nicotine and that switching to ST is likely associated with lower CVD risk.

Associations between microbial communities and key chemical constituents in U.S. domestic moist snuff

BACKGROUND

Smokeless tobacco (ST) products are widely used throughout the world and contribute to morbidity and mortality in users through an increased risk of cancers and oral diseases. Bacterial populations in ST contribute to taste, but their presence can also create carcinogenic, Tobacco-Specific N-nitrosamines (TSNAs). Previous studies of microbial communities in tobacco products lacked chemistry data (e.g. nicotine, TSNAs) to characterize the products and identify associations between carcinogen levels and taxonomic groups. This study uses statistical analysis to identify potential associations between microbial and chemical constituents in moist snuff products.

METHODS

We quantitatively analyzed 38 smokeless tobacco products for TSNAs using liquid chromatography with tandem mass spectrometry (LC-MS/MS), and nicotine using gas chromatography with mass spectrometry (GC-MS). Moisture content determinations (by weight loss on drying), and pH measurements were also performed. We used 16S rRNA gene sequencing to characterize the microbial composition, and additionally measured total 16S bacterial counts using a quantitative PCR assay.

RESULTS

Our findings link chemical constituents to their associated bacterial populations. We found core taxonomic groups often varied between manufacturers. When manufacturer and flavor were controlled for as confounding variables, the genus Lactobacillus was found to be positively associated with TSNAs. while the genera Enteractinococcus and Brevibacterium were negatively associated. Three genera (Corynebacterium, Brachybacterium, and Xanthomonas) were found to be negatively associated with nicotine concentrations. Associations were also investigated separately for products from each manufacturer. Products from one manufacturer had a positive association between TSNAs and bacteria in the genus Marinilactibacillus. Additionally, we found that TSNA levels in many products were lower compared with previously published chemical surveys. Finally, we observed consistent results when either relative or absolute abundance data were analyzed, while results from analyses of log-ratio-transformed abundances were divergent.

Clinicopathological Evaluation of Tobacco-related Oral Mucosal Lesions

AIM

To clinically evaluate the nature of precancerous and cancerous lesions associated with tobacco consumption habit and to correlate clinical profile with the histopathological findings of clinically suspected precancerous and cancerous lesions.

MATERIALS AND METHODS

These included the examination of patients who visited the outpatient department (OPD) of the institute that includes 1,500 patients who had tobacco chewing habits were classified into the following two groups according to their characteristics. The study group comprised 270 patients, of which 170 gave consent for biopsy and 100 patients who not gave consent were counseled for tobacco cessation.

RESULTS

Among 270 patients, the highest number of patients, 146 (54.07%) patients, were found to be smokeless tobacco consumers followed by 65 (24.07%) patients who were smoked tobacco consumers while 59 (21.85%) patients were found to have both the habits. Wide variation was noted in duration and frequency of habit. Most prevalent site was the buccal mucosa affected in 138 (51.11%) patients who consumed both smoked as well as smokeless tobacco. And on clinical examination, 138 (51%) patients had leukoplakia followed by 54 (20%) patients with oral squamous cell carcinoma and 40 (15%) patients with oral submucous fibrosis (OSMF). Other patients were tobacco pouch keratosis 17 (6%), smoker's melanosis 8 (3%), smoker's palate 7 (3%), and erythroplakia 6 (2%). The patients who gave consent (170 patients) were evaluated histopathologically to correlate with clinical findings.

CONCLUSION

Tobacco-related oral lesions are also high, which brings an alarming signal toward the development of cancer. Our contribution as healthcare providers can be made by conducting more oral health education programs and educating the general population about the adverse effects of tobacco. The appropriate clinical assessment and categorization of all these lesions aided us in motivating patients to undergo necessary treatments and also to discontinue their habits in order to prevent deterioration of their conditions.

CLINICAL SIGNIFICANCE

Set up de-addiction centers in dental colleges and help tobacco users in discontinuing their habits. Interestingly, this study also served as a mirror for those patients who were unaware of the lesions they were giving abode to in their oral cavities.

Smokeless tobacco and cigarette smoking: chemical mechanisms and cancer prevention

Tobacco products present a deadly combination of nicotine addiction and carcinogen exposure resulting in millions of cancer deaths per year worldwide. A plethora of smokeless tobacco products lead to unacceptable exposure to multiple carcinogens, including the tobacco-specific nitrosamine N'-nitrosonornicotine, a likely cause of the commonly occurring oral cavity cancers observed particularly in South-East Asian countries. Cigarettes continue to deliver a large number of carcinogens, including tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons and volatile organic compounds. The multiple carcinogens in cigarette smoke are responsible for the complex mutations observed in critical cancer genes. The exposure of smokeless tobacco users and smokers to carcinogens and toxicants can now be monitored by urinary and DNA adduct biomarkers that may be able to identify those individuals at highest risk of cancer so that effective cancer prevention interventions can be initiated. Regulation of the levels of carcinogens, toxicants and nicotine in tobacco products and evidence-based tobacco control efforts are now recognized as established pathways to preventing tobacco related cancer.

Tobacco and its Relationship with Oral Health

Tobacco and its various forms cause major oral health problems. Tobacco either in smoked or smokeless forms is prevalent in Nepal and counts as a risk factor for the causation of various red and white lesions, premalignant lesions, oral cancers, gingival and periodontal diseases. Tobacco in conjunction with other risk factors adds a potential threat to oral diseases and its timely control is a cure to those threats. This article focuses on tobacco and its forms affecting oral health and also focuses on its prevention and control from the ground to the National level.

Tobacco Users among the Patients who Visited Dental Outpatient Department of a Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction: Smoked and smokeless forms of tobacco is a preventable cause of morbidity and mortality with inevitable effects on the oral cavity as well. The aim of the study was to find out the prevalence of tobacco users among the patients who visited dental outpatient departments of a tertiary care hospital. Methods: A descriptive cross-sectional study was carried out among 255 patients visiting the dental outpatient department of a tertiary care hospital over the duration of six months. Data collection was done through personal interviews and clinical examinations. History of tobacco use was taken and patients were divided into current users, never users and ever users. Clinical examination was done using Decayed Missing Filled Teeth index, community periodontal index modified and loss of attachment. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data. Results: Among 255 patients, 91 (35.69%) (95% Confidence Interval = 29.81-41.57) patients used tobacco. Among them, 72 (28.2%) were current users, who had taken tobacco at least once during the past 30 days and 19 (7.5%) were ever users who had taken tobacco but not during the past 30 days. Conclusions: The prevalence of tobacco use among our study participants is similar in comparison to that of the general population. Our study shows greater prevalence of the use of a smokeless form of tobacco than the smoked form of tobacco.

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.

Use of Smokeless Tobacco Before Conception and Its Relationship With Maternal and Fetal Outcomes of Pregnancy in Thatta, Pakistan: Findings From Women First Study

INTRODUCTION

Smokeless tobacco (SLT) consumption during pregnancy has adverse consequences for the mother and fetus. We aimed to investigate the effects of maternal pre-pregnancy SLT consumption on maternal and fetal outcomes in the district of Thatta, Pakistan.

AIMS AND METHODS

We conducted a secondary data analysis of an individual randomized controlled trial of preconception maternal nutrition. Study participants were women of reproductive age (WRA) residing in the district of Thatta, Pakistan. Participants were asked questions regarding the usage of commonly consumed SLT known as gutka (exposure variable). Study outcomes included maternal anemia, miscarriage, preterm births, stillbirths, and low birth weight. We performed a cox-regression analysis by controlling for confounders such as maternal age, education, parity, working status, body mass index, and geographic clusters.

RESULTS

The study revealed that 71.5% of the women reported using gutka, with a higher proportion residing in rural areas as compared with urban areas in the district of Thatta, Pakistan. In the multivariable analysis, we did not find a statistically significant association between gutka usage and anemia [(relative risk, RR: 1.04, 95% confidence interval, CI (0.92 to 1.16)], miscarriage [(RR: 1.08, 95% CI (0.75 to 1.54)], preterm birth [(RR: 1.37, 95% CI (0.64 to 2.93)], stillbirth [(RR: 1.02, 95% CI (0.39 to 2.61)], and low birth weight [(RR: 0.96, 95% CI (0.72 to 1.28)].

CONCLUSIONS

The study did not find an association between gutka usage before pregnancy and adverse maternal and fetal outcomes. In the future, robust epidemiological studies are required to detect true differences with a dose-response relationship between gutka usage both before and during pregnancy and adverse fetomaternal outcomes.

IMPLICATIONS

While most epidemiological studies conducted in Pakistan have focused on smoking and its adverse outcomes among males, none of the studies have measured the burden of SLT among WRA and its associated adverse outcomes. In addition, previously conducted studies have primarily assessed the effect of SLT usage during pregnancy rather than before pregnancy on adverse fetal and maternal outcomes. The current study is unique because it provides an insight into the usage of SLT among WRA before pregnancy and investigates the association between pre-pregnancy SLT usage and its adverse fetomaternal outcomes in rural Pakistan.

Spatial, temporal, and demographic patterns in prevalence of chewing tobacco use in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Chewing tobacco and other types of smokeless tobacco use have had less attention from the global health community than smoked tobacco use. However, the practice is popular in many parts of the world and has been linked to several adverse health outcomes. Understanding trends in prevalence with age, over time, and by location and sex is important for policy setting and in relation to monitoring and assessing commitment to the WHO Framework Convention on Tobacco Control.

METHODS

We estimated prevalence of chewing tobacco use as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 using a modelling strategy that used information on multiple types of smokeless tobacco products. We generated a time series of prevalence of chewing tobacco use among individuals aged 15 years and older from 1990 to 2019 in 204 countries and territories, including age-sex specific estimates. We also compared these trends to those of smoked tobacco over the same time period.

FINDINGS

In 2019, 273·9 million (95% uncertainty interval 258·5 to 290·9) people aged 15 years and older used chewing tobacco, and the global age-standardised prevalence of chewing tobacco use was 4·72% (4·46 to 5·01). 228·2 million (213·6 to 244·7; 83·29% [82·15 to 84·42]) chewing tobacco users lived in the south Asia region. Prevalence among young people aged 15-19 years was over 10% in seven locations in 2019. Although global age-standardised prevalence of smoking tobacco use decreased significantly between 1990 and 2019 (annualised rate of change: -1·21% [-1·26 to -1·16]), similar progress was not observed for chewing tobacco (0·46% [0·13 to 0·79]). Among the 12 highest prevalence countries (Bangladesh, Bhutan, Cambodia, India, Madagascar, Marshall Islands, Myanmar, Nepal, Pakistan, Palau, Sri Lanka, and Yemen), only Yemen had a significant decrease in the prevalence of chewing tobacco use, which was among males between 1990 and 2019 (-0·94% [-1·72 to -0·14]), compared with nine of 12 countries that had significant decreases in the prevalence of smoking tobacco. Among females, none of these 12 countries had significant decreases in prevalence of chewing tobacco use, whereas seven of 12 countries had a significant decrease in the prevalence of tobacco smoking use for the period.

INTERPRETATION

Chewing tobacco remains a substantial public health problem in several regions of the world, and predominantly in south Asia. We found little change in the prevalence of chewing tobacco use between 1990 and 2019, and that control efforts have had much larger effects on the prevalence of smoking tobacco use than on chewing tobacco use in some countries. Mitigating the health effects of chewing tobacco requires stronger regulations and policies that specifically target use of chewing tobacco, especially in countries with high prevalence.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Impact of smokeless tobacco-associated bacteriome in oral carcinogenesis

Smokeless tobacco products possess a complex community of microorganisms. The microbial community ferment compounds present in the smokeless tobacco products and convert them into carcinogens like tobacco-associated nitrosamines. However, the potential of smokeless tobacco products associated bacteriome to manipulate systemic inflammation and other signaling pathways involved in the etiology of oral cancer will be a risk factor for oral cancer. Further, damage to oral epithelial cells causes a leaky oral layer that leads to increased infiltration of bacterial components like lipopolysaccharide, flagellin, and toxins, etc. The consumption of smokeless tobacco products can cause damage to the oral layer and dysbiosis of oral microbiota. Hence, the enrichment of harmful microbes due to dysbiosis in the oral cavity can produce high levels of bacterial metabolites and provoke inflammation as well as carcinogenesis. Understanding the complex and dynamic interrelation between the smokeless tobacco-linked bacteriome and host oral microbiome may help to unravel the mechanism of oral carcinogenesis stimulated by smokeless tobacco products. This review provides an insight into smokeless tobacco product-associated bacteriome and their potential in the progression of oral cancer. In the future, this will guide in the evolution of prevention and treatment strategies against smokeless tobacco products-induced oral cancer. Besides, it will assist the government organizations for better management and cessation policy building for the worldwide problem of smokeless tobacco addiction.

Central Australian Aboriginal women's pregnancy, labour and birth outcomes following maternal smokeless tobacco (pituri) use, cigarette use or no-tobacco use: a prospective cohort study

BACKGROUND

Outcomes related to maternal smoked tobacco (cigarette) use have been substantially examined over the past 50 years with resultant public health education targeted towards the reduction of use during pregnancy. However, worldwide the effects of maternal smokeless tobacco use have been less well explored and in Australia, there has been no examination of maternal outcomes in relation to the use of Australian Nicotiana spp. (tobacco plant) as a smokeless tobacco, colloquially known as pituri. The aim of this study is to describe the maternal outcomes of a group of central Australian Aboriginal women in relation to their self-reported tobacco use.

METHODS

Eligible participants were > 18 years of age, with a singleton pregnancy, > 28 weeks gestation, and who planned to birth at the Alice Springs Hospital (the major regional hospital for central Australia, in the Northern Territory, Australia). The sample consisted of 73 conveniently recruited women categorized by tobacco-use status as no-tobacco users (n = 31), pituri chewers (n = 19), and smokers (n = 23).

RESULTS

There were differences in the groups in relation to teenage pregnancies; 35% of no-tobacco users, compared with 5% of pituri users, and 13% of smokers were <  20 years of age. The chewers had a higher rate (48%) of combined pre-existing and pregnancy-related elevated glucose concentrations compared with smokers (22%) and no-tobacco users (16%).The pituri chewers had the lowest rate (14%) of clinically significant post-partum hemorrhage (> 1000 ml) compared with 22% of smokers and 36% of the no-tobacco users.

CONCLUSIONS

This is the first research to examine pituri use in pregnancy and the findings indicate possible associations with a range of adverse maternal outcomes. The use of smokeless tobacco needs to be considered in maternal healthcare assessment to inform antenatal, intrapartum and postpartum care planning.

IMPLICATIONS FOR PUBLIC HEALTH

Female smokeless tobacco use is a global phenomenon and is particularly prevalent in low and middle income countries and in Indigenous populations. The findings contribute to the developing knowledge around maternal smokeless tobacco use and maternal outcomes. Maternal screening for a broader range of tobacco and nicotine products is required.

NOTE TO READERS

In this research, the central Australian Aboriginal women chose the term 'Aboriginal' to refer to themselves, and 'Indigenous' to refer to the broader First Peoples. That choice has been maintained in the reporting of the research findings.

Evaluation of Nicotine Dependence in Adult Population of Eastern Nepal

Background Tobacco consumption is a leading cause of premature death in the world. Tobaccorelated deaths are associated with cardiovascular diseases, pulmonary diseases, oral potentially malignant disorders, cancer, others. Moreover there is also associated nicotine dependence which might result to numerous tobacco-associated diseases. Objective This study was conducted to analyze the degree of nicotine dependence considering its potential health risk, in the Eastern region of Nepal. Method A descriptive questionnaire based study was conducted among current tobacco users of six districts of Eastern Nepal. Fagerstrom Test for Nicotine Dependence (FTND) and Fagerstrom Test for Nicotine Dependency for Smokeless Tobacco (FTNDST) questionnaire were used for tobacco smokers and chewers, respectively. Result Of the total participants, 836 were males and 359 females, among whom 736 were active tobacco smokers and 432 chewers, 34.8% had tried to stop consuming tobacco and 306 (25.6%) had oral lesions in white or red forms. Very low nicotine dependence was found among 244 (31.47%) tobacco smokers and 37 (8.56%) chewers whereas 36 (4.71%) smokers and 103 (23.84%) chewers had very high nicotine dependence. The mean score for FTND was 3.73±2.37 and 5.74±2.12 for FTND-ST. A significant difference in duration and age group with FTND score was observed, however not with FTND-ST. Conclusion The information regarding degree of nicotine dependence can be used as baseline information for planning of preventive strategies and implementation of tobacco cessation and control programs.