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ORIGINAL ARTICLE
Year : 2015  |  Volume : 11  |  Issue : 1  |  Page : 199-203

Risk of oral cancer associated with gutka and other tobacco products: A hospital-based case-control study


1 Indian Institute of Public Health, Bhubaneswar, Odisha, India
2 Department of Public Health, Manipal University, Manipal, Karnataka, India
3 Department of Statistics, Manipal University, Manipal, Karnataka, India

Date of Web Publication16-Apr-2015

Correspondence Address:
Sandeep Mahapatra
Indian Institute of Public Health, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.143332

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 > Abstract 

Background: Although tobacco deaths rarely make headlines, tobacco kills one person every six seconds. Tobacco kills a third to half of all people who use it, on average 15 years prematurely.
Aim of the Study: To study the risk of oral cancer associated with gutka consumption and other tobacco products.
Objective: (1) To find the association between gutka consumption and oral cancer. (2) To study the association between oral cancer and other tobacco products.
Methodology: A case-control study of 134 cases and 268 controls, over a period of 5 months, from March 2013 to July 2013, was carried out at the Kasturba medical hospital in Manipal, India. The participants were personally interviewed by the investigator using a structured questionnaire on consumption of tobacco, poly-ingredient dip products, alcohol, dietary practices, oral hygiene practices and demographic status.
Results: Univariate logistic regression followed by multivariate logistic regression was done for identifying the risk factors and adjusted for the confounding variables. Analysis showed that gutka (<0.001, OR = 5.1 95% CI = 2.0-10.3), chewing tobacco (P < 0.001, OR = 6.0 95% CI = 2.3-15.7), supari (P < 0.001, OR = 11.4 95% CI = 3.4,38.2), betel quid (P < 0.001, OR = 6.4 95% CI = 2.6-15.5), bidi (P < 0.05, OR = 2.3 95% CI = 1.1-4.8) and alcohol (P < 0.001, OR = 3.7 95%CI = 1.8-7.5) had strong association with oral cancer upon adjustment.
Conclusion: The study provided strong evidence that gutka, supari, chewing tobacco, betel quid, bidi and alcohol are independent risk factors for oral cancer.

Keywords: Case-control, tobacco, oral dip products, oral cancer, smoking, gutka


How to cite this article:
Mahapatra S, Kamath R, Shetty BK, Binu V S. Risk of oral cancer associated with gutka and other tobacco products: A hospital-based case-control study. J Can Res Ther 2015;11:199-203

How to cite this URL:
Mahapatra S, Kamath R, Shetty BK, Binu V S. Risk of oral cancer associated with gutka and other tobacco products: A hospital-based case-control study. J Can Res Ther [serial online] 2015 [cited 2022 May 26];11:199-203. Available from: https://www.cancerjournal.net/text.asp?2015/11/1/199/143332


 > Introduction Top


Cancer is a disease with high-incidence and mortality rate. It is a global problem and not just a problem of industrialized nations. As a country, India entered into the era of the population explosion in the 1920's. The mortality rate of cancer started declining after 1940. The cohort era in the 1940's entered the "cancer prone" age in the 1980's. [1]

Among all the cancers worldwide oral cancer ranks sixth. The occurrence shows marked geographical variation. An estimated 9 million new cases of cancer are diagnosed every year. [2] Tobacco-related deaths rarely make it to the headlines. It is estimated that every 6 s, one person dies due to tobacco. [3] About a third to half of people who use tobacco die, [3] which is about 15 years prematurely. [4],[5],[6] Globally, 1 in 10 deaths occurs due to tobacco-related causes, which amounts to more than 5 million deaths a year. [3] Unless urgent action is taken to tackle the situation, tobacco deaths will rise to more than 8 million annually by 2030. [3],[7] If the current trends are not checked, an estimated 500 million people alive today will be killed by reasons associated with tobacco. [7]

The emergence of newer, chewable flavored forms of tobacco along with several other ingredients, called gutka has changed the trends in the tobacco market. [8] Gutka contains areca nut, slaked lime, catechu, condiments, and powered tobacco. It was originally available custom-mixed from paan vendors gutka has been commercially available since 1975. [9] Gutka has been available in several brands for the last few decades gutka is exported to 22 countries worldwide, this shows its spreading usage. The usage is common among migrant workers. [10] Studies show that gutka is sold to even minors in the South-East Asia, and it has a growing demand in the region. [11],[12] Gutka use in India is mainly by youth and adults <40 years of age, mostly males. [12],[13] Gutka can be highly addictive, than ordinary chewing tobacco. Previous studies have found gutka to be a gateway to smoking. [9] Five million children in India are estimated to be addicted to gutka, who are under the age of 15 years. [9] As there are many different forms of products used in the recent times, it becomes important to find out there harmful effects to one's health.

Furthermore, there is a scarcity of studies related to new tobacco products in the market, especially related to gutka. There is no much documented evidences on risk of oral cancer related to tobacco products, especially gutka in Udupi district. Thus, this study would like to investigate how gutka, tobacco and oral dip products consumption are associated with oral cancer.

Aim and objectives

The aim was to study the risk of oral cancer associated with gutka consumption and other tobacco products. The primary objective was to find the association between gutka consumption and oral cancer. Secondary objective was to study the association between oral cancer other tobacco products.


 > Methodology Top


This study was an unmatched case-control study conducted at Kasturba Medical Hospital, Manipal, Udupi District, Karnataka between March 2013 and July 2013. Patients diagnosed with oral cancer receiving treatment at Shirdi Sai Baba Cancer Hospital were included in the study as cases and the patients in the Department of Ophthalmology and General medicine at Kasturba medical hospital during the study period were included in the study as controls.

A case was defined as a person aged 18 years and above with laboratory-confirmed primary diagnosis of oral cancer according to ICD10. All cases that were histopathologically diagnosed as oral cancer on or after January 1, 2012 and visited the hospital during the study period were included. Cases diagnosed before January 1, 2012 metastatic lesions in the oral cavity from other sites and soft palate, uvula/tumors of major salivary glands were excluded as malignancies, which occur at that site, differ in etiology, histology and natural history from those arising in the covering epithelium of the upper aero digestive tract.

A control was defined as a person aged 18 years and above who visited the Department of Ophthalmology and General Medicine during the study period. People who did not have the history of oral cancer and visited the hospital during the study period were included as controls. People with any other malignancy and/or people suffering from any disease associated with the study exposures were excluded.

Sample size was calculated with the help expert opinion. The sample size was calculated as 134 cases and 268 controls. Allocation ratio was kept as 1:2, hence for every case, there were two controls were selected.

The cases and controls were personally interviewed by the investigator using a structured questionnaire. The questionnaire was validated using expert opinion. The questionnaire included demographic information such as age, gender, religion, literacy, occupation, District/Taluk, medical history, date of diagnosis, and site. The second part of the questionnaire included questions on oral hygiene practices and the last part of the questionnaire aimed at questions on the anticipated risk factors, which comprised of questions on type, frequency, and duration of the habits. Few data have not been cited because they were beyond the scope of this paper.

The data analysis was used using the SPSS version 16 (licensed to: team EQX 6 th birthday 1337). Univariate logistic regression was done followed by multivariate logistic regression for identifying the risk factors and adjusting for the confounding variables.


 > Results Top


The mean age of the respondents was 46.9 years with a standard deviation of 13.10 years. The minimum age of the respondents was 18 years, whereas the maximum age was 83 years. Majority of study participants were in the age group in between 46 and 55 years. Most of the cases were between the age group of 56-65 years. The mean age of the cases were 52.1 years with a standard deviation of 1.1 (30, 83) [Table 1]. Among the 134 oral cancer cases carcinoma of a tongue was seen in 56% of the cases, considering the lateral surface of tongue and base of the tongue under carcinoma of the tongue followed by 39.6% of buccal (cheek) mucosa carcinomas [Figure 1], [Table 2]. Majority of participants were males. Of the 134 cases, 82.8% were males and 17.2% were females. Of the 268 controls, the males and females were 88.8% and 11.2%, respectively. Among 134 studied cases, 95.5% were Hindus and only 4.5% were Muslims. Whereas among 268 controls 94.4% were Hindus, 2.6% were Muslims and 3% were Christians. Only 6.7% of the total 134 cases were found to be illiterates. The maximum number of cases, that is, 59% had education until primary level. Only 2.2% of cases had education until degree or above. Among the 268 controls, 2.1% had education until degree and above. Of the total 268 controls 76.5% had mixed diet [Table 3].
Figure 1: The frequency distribution of cases by their cancer site

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Table 1: Distribution of cases and controls by their age groups


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Table 2: Frequency distribution of cases by their cancer site


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Table 3: Distribution of cases and controls by their sociodemographic characteristics


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Among the 114 cases who reported to be of the mixed diet group, 12.3% consumed mixed diet regularly compared to 14.2% of the 205 the controls having mixed diet. Majority of the cases consumed gutka. Of 134 cases 35.8% had the habit of gutka consumption compared to 10.4% of the controls out of 268. Of the total of 134 cases, 14.9% consumed supari compared to 2.6% out of the total of 268 controls. Of 134 cases 20.1% had the habit of chewing tobacco compared to 3.4% among the 268 controls in the study. Among the 134 cases, 17.9% had the habit of consuming betel quid compared to 6.3% among 268 controls. Among the 134 cases, 9.7% had the habit of using snuff compared to 4.9% among the 268 controls. Of the 134 cases, 2.2% had both habits, that is, of chewing smokeless tobacco and also inhaling of snuff. Of the 134 cases, 17.9% smoked cigarettes compared to 16% among the 268 controls who smoked cigarettes. Majority of the cases smoked bidi as compared to the controls. Of the 134 cases, 35.5% smoked bidi compared to only 7.5% among the 268 controls. Among the 50 cases who consumed alcohol 70% consumed it daily compared to only 5% of the 60 controls who consumed alcohol daily [Table 4]. It was interesting to find that 08 (6%) out of the total 134 cases had no history of any anticipated risk factors.
Table 4: Distribution of cases and controls by selected habits toward tobacco, alcohol, and diet


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Uni-and multi-variate analyses were done after adjusting for age, gender, social class, education level, diet, tobacco products, oral dip products, and alcohol. Univariate analysis revealed that the odds of oral cancer in the respondents who consumed gutka was 4.8 (95% confidence interval [CI]: 2.8, 8.1; P < 0.001) times higher as compared to respondents who did not consume gutka. Respondents who consumed supari were 6.5 (95% CI: 2.7, 15.9; P < 0.001) times more likely to get oral cancer as compared to respondents who did not consume supari. Chewing tobacco users had 7.3 (95% CI: 3.3, 16.0; P < 0.001) times higher odds of getting oral cancer when compared to respondents who did not chew tobacco. The odds of oral cancer was 3.2 (95% CI: 1.7, 6.2; P < 0.001) times higher in respondents who consumed betel quid compared to respondents who did not consume betel quid. Respondents who smoked bidi had 6.9 (95% CI: 3.9, 12.3; P < 0.001) times higher chance of getting oral cancer as compared to people who did not smoke bidi. The respondents who consumed alcohol were 2.1 (95% CI: 1.3, 3.2; P < 0.05) times more likely to get oral cancer as compared to people who did not consume alcohol [Table 5].
Table 5: Univariate analysis


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Conversely, this study did not show any association between consumption of mishri, betel quid and smoking cigarettes with the risk of oral cancer.

Multivariate analysis approved the risk of studied tobacco and oral dip products after adjusting for gender, education, age, social class, diet, alcohol, other tobacco types, and dip products. The respondents who consumed gutka were 5.1 (95% CI: 2.0, 10.3; P < 0.001) times more likely to get oral cancer compared to people who did not consume gutka. The respondents who consumed supari were 11.4 (95% CI: 3.4, 38.2; P < 0.001) times more likely to get oral cancer compared to people who did not consume supari. However, a wide CI was found which may be as a result of less number of participants who consumed supari among the study population. The respondents who consumed chewing tobacco were 6.0 (95% CI: 2.6, 15.5; P < 0.01) times more likely to get oral cancer as compared to people who did not consume chewing tobacco. The odds of getting oral cancer in respondents was 6.4 (95% CI: 2.6, 15.5; P < 0.001) times higher in respondents who consumed betel quid when compared to respondents who did not consume betel quid. Bidi smokers were 2.3 (95% CI: 1.1, 4.8; P < 0.05) times more likely to get oral cancer when compared to people who did not smoke bidi [Table 6].
Table 6: Multivariate analysis


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 > Discussion Top


The respondents who consumed gutka were 5.1 (95% CI: 2.0, 10.3; P < 0.001) times more likely to get oral cancer compared to people who did not consume gutka. The findings were similar to a study by Madani et al. [14] which showed gutka to be a risk factor with an odds of 12.0 (6.6, 21.7).

The respondents who consumed supari were 11.4 (95% CI: 3.4, 38.2; P < 0.001) times more likely to get oral cancer compared with people who did not consume supari. However, a wide CI was found which may be as a result of less number of participants who consumed supari among the study population. Similar findings were seen in a study by Madani et al. [15] which showed supari to be a risk factor with an odds of 6.3 (2.9, 14.0).

The respondents who consumed chewing tobacco were 6.0 (95% CI: 2.6, 15.5; P < 0.01) times more likely to get oral cancer when compared to people who did not consume chewing tobacco. The findings were similar to a study by Sharma et al. [16] which showed chewing tobacco to be associated with oral cancer with an odds of 8.18 (3.61, 19.3).

The odds of getting oral cancer in respondents was 6.4 (95% CI: 2.6, 15.5; P < 0.001) times higher in respondents who consumed betel quid when compared to respondents who did not consume betel quid. Similar findings were reported in a study conducted by Dikshit and Kanhere [17] which showed betel quid consumption to be a risk for oral cancer with an odds of 5.5 (3.4, 8.9).

Bidi smokers were 2.3 (95% CI: 1.1, 4.8; P < 0.05) times more likely to get oral cancer when compared to people who did not smoke bidi. Similar results were seen in a study conducted by Znaor et al. [18] which showed smoking to be a risk of oral cancer with an odds of 2.4 (1.2, 5.9). The findings were also similar to a study conducted by Rahman et al.[19] which showed an increased risk of oral cancer for bidi smokers compared to never smokers with an odds of 3.1 (2.0-5.0).


 > Conclusion Top


It was interesting to know that 48 out of 134 cases consumed gutka, whereas only 38 out of 268 controls consumed gutka. This result confirms the prior findings that have shown gutka as the strong risk for oral sub-mucous fibrosis. In this study, a higher chance of oral cancer was found in consumers chewing tobacco. This study confirmed previous findings that showed chewing tobacco as a strong risk for oral cancer. In this study, smoking in general, appears to increase the risk of oral cancer, but similar to other studies in India no association was found between cigarette smoking and the risk of oral cancer. An increased chance of oral cancer was found among bidi smokers as compared to respondents who did not smoke bidi, which collaborated with earlier studies. [15],[19],[20] Consumption of alcohol had a higher risk of oral cancer in this study, which collaborated with previous studies. [15],[19]

This study provided strong evidence for gutka, supari, chewing tobacco, betel quid, and bidi to be independent risk factors for oral cancer.


 > Limitations Top


Similar to other case-control studies one of the main limitation of the study was recall bias and selection bias to some extent. To minimize recall bias the cases diagnosed on and after January 1, 2012 were selected. The proportion of females in the control group is less. The probable reason could be lack of privacy in a hospital setting. Unlike the interview of cases the controls could not be interviewed privately due to controlled settings. Another limitation which should be mentioned is that the subjects were derived from a hospital and therefore, may not approximate the relative risk for the general population. As the sample size was less the dose-response relationship between oral cancer and tobacco products could not be established.

 
 > References Top

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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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