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BRIEF COMMUNICATION
Year : 2018  |  Volume : 14  |  Issue : 2  |  Page : 437-440

Patterns of tobacco use in patients with upper aero digestive tract cancers: A hospital-based study


1 Department of Gynecologic Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
2 Department of Pathology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
3 Department of Cancer Epidemiology and Biostatistics, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India

Date of Web Publication8-Mar-2018

Correspondence Address:
Dr. Manigreeva Krishnatreya
Department of Cancer Epidemiology and Biostatistics, Dr. B. Borooah Cancer Institute, Guwahati, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.199459

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 > Abstract 


Background: Tobacco use is a major risk factor for increasing the burden of upper aero digestive tract (UADT) cancer in the population of Northeast India.
Objective: The objective of this study was to investigate the pattern of tobacco use in different UADT cancer.
Materials and Methods: This was a retrospective study of electronically recorded data of the Hospital Cancer Registry for the period of May 2014 to December 2014. The UADT cancers were evaluated for gender and age-group distribution, their relative proportion, and association with tobacco use and tobacco-associated risk in males to develop UADT cancers. The type of tobacco usage was clustered as chewable, smoking, and both. Relative risk (RR) of UADT with tobacco usage was identified for males.
Results: A total of 1965 (n) UADT cancer patients were identified, male:female was 2.9, tobacco habits was in 1608 (81.8%) patients, both forms of tobacco use in 705 (43.8%), chewable tobacco use in 588 (36.6%) and smoking in 315 (19.6%) patients, tobacco habits in males ranges from 67.3% to 94.3% and in females range from 5.7% to 32.7%, RR of UADT cancer in males for tongue cancer was 1.5 (confidence interval [CI] =1.2–1.9), oropharynx was 1.4 (CI = 1.0–1.8), hypopharynx 1.4 (CI = 1.1–1.7), esophageal cancer was 1.4 (CI = 1.3–1.7), and for laryngeal cancer RR was 1.7 (CI = 1.0–3.0).
Conclusion: Consumption of chewable tobacco is the major form of tobacco use alone or in combination in UADT cancer patients of our population.

Keywords: Northeast India, pattern, tobacco use, upper aero digestive tract cancers


How to cite this article:
Kataki AC, Sharma JD, Krishnatreya M, Baishya N, Kalita M. Patterns of tobacco use in patients with upper aero digestive tract cancers: A hospital-based study. J Can Res Ther 2018;14:437-40

How to cite this URL:
Kataki AC, Sharma JD, Krishnatreya M, Baishya N, Kalita M. Patterns of tobacco use in patients with upper aero digestive tract cancers: A hospital-based study. J Can Res Ther [serial online] 2018 [cited 2021 Dec 1];14:437-40. Available from: https://www.cancerjournal.net/text.asp?2018/14/2/437/199459




 > Introduction Top


In India, upper aero digestive tract (UADT) cancers account for a significant proportion of all cancers. The cancers of the lip, tongue, mouth, pharynx, larynx, and esophagus are UADT cancers and constitute a major part of tobacco-related cancers.[1] The habit of tobacco consumption can be in chewable form and nonchewable forms such as smoking. Data from epidemiological research have shown that tobacco smoking including chewable tobacco use is the major risk factor for the development of UADT cancer.[2] Tobacco and alcohol play a role in the development of UADT cancers by interfering in DNA repair resulting in genetic polymorphism of genes.[3],[4] The habit of chewing tobacco and betel nut or areca nut is very common in the population of Northeast (NE) India. NE India is geographically a distinct region of India with distinct food habits and lifestyle behaviors. Moreover, chewable tobacco consumption is a customary habit among the different ethnic and sociocultural groups of this part of the country. Smokeless tobacco is used as betel/areca nut, gutkha, oral snuff (snuff dipping), and/or administered through the nose (nasal snuff).[5] Areca nut in various forms acts synergistically in the development of cancer in the UADT when consumed with tobacco. An earlier study from the region has shown that chewing of betel nut results in a similar or higher risk of cancer as that of smoking and alcohol use.[6] Significant interaction between detoxification systems such as the glutathione S-transferase (GSTT1) gene and moderate smoking has been observed in the development of UADT.[7] The main objective of this study was to investigate the pattern of tobacco use in patients with UADT cancers in our population.


 > Materials and Methods Top


It was a retrospective study of electronically recorded data obtained from a Hospital Cancer Registry (HCR). The HCR of the study center is a major source of registration for NE Population-based Cancer Registries. The data obtained was from the period May 2014 to December 2014. The UADT cancers were identified in the database by the International Statistical Classification for Diseases, 10th revision coding (ICD-10). The ICD-10 codes for UADT cancers related to tobacco are C00-06, C09-15, and C32. The cases included in the study were histological confirmed cases of UADT cancer. The cases were evaluated for gender and age-group distribution, their relative proportion, and association with tobacco use and tobacco-associated risk in males. The information on tobacco consumption history was obtained by direct interview at the time of patient registration by trained medical social workers (MSWs). MSW asked patients about their use of betel/areca nut and smoking, but no history of alcohol consumption or dietary habits was obtained. The information asked for tobacco use was categorical; past/present tobacco user (PTU) and no tobacco user. In case of PTU, further history on the types of tobacco use was obtained. The type of tobacco usage is clustered as chewable, smoking, and both. The data were exported onto a spreadsheet program. The variables were matched by unique identification numbers allotted during the time of registration. Strict confidentiality was maintained while handling the data set, and no patient identifying information was shared or divulged.

Statistical analysis

Descriptive statistics was used to present the results. Relative risk (RR) of UADT with tobacco usage was identified for males. As tobacco use is more in males, therefore, females were considered as the reference group in the estimation of the risk ratios. Chi-square was used to test for differences in the variables. P <0.05 was set as the level of significance. Statistical Package for Social Sciences (SPSS 17.0, IBM Inc., Chicago, IL, USA) was used for carrying out the present analysis.


 > Results Top


Data from a total of 1965 (n) patients identified in the registry database and were included for the present analysis. There were 1464 (74.5%) males and 501 (25.5%) females. Of all UADT sites, in patients with lip and oral cavity cancer, 20% and 22%, respectively, were seen below 44 years of age [Figure 1]. The majority of patients of UADT in the present study were from the esophagus (30.8%), followed by hypopharynx (23.4%), and the distribution of other UADT cancer sites are shown in [Table 1]. Tobacco habits were seen in 1608 (81.8%) patients. Consumption of both forms of tobacco was seen in 705 (43.8%) patients, and only chewable tobacco use was seen in 588 (36.6%) patients with UADT cancers [Table 1].
Figure 1: The picture shows the age at diagnosis and percentage distribution for the study group of patients

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Table 1: The baseline characteristics of patients with upper aero digestive tract related to tobacco use

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Of UADT cancer patients with history of tobacco use, 1291 (88.1%) males were tobacco users, and 317 (63.2%) females were tobacco users. Among the types of tobacco consumption, chewable tobacco consumption was seen in 262 (82.6%) females and consumption of both forms of tobacco was seen in 676 (52.4%) males [Table 2].
Table 2: Gender-wise distribution and site-wise distribution of tobacco habits

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In the present study cohort, majority of patients were taking both forms of tobacco (chewable and smoking form) except in patients with cancers of lip and oral cavity, where 45% and 60.4% patients, respectively were consuming only chewable tobacco [Table 2]. Patients with esophageal cancers, 40.1% and 39.2% of patients were consuming both forms and chewable tobacco, respectively as shown in [Table 2]. Smoking patients in our study cohort were in the range of 9.7–25.8% of all UADT cancer patients.

Tobacco habits were more prevalent in males (67.3–94.3%) compared to females (5.7–32.7%) [Table 3]. Hence, the RR was measured for males and the RRs measuring the association of the UADT cancers with tobacco use were as follows: The RR of UADT cancer in males for lip cancer was 1.2 (confidence interval [CI] =0.6–2.2); for tongue cancer, RR was 1.5 (CI = 1.2–1.9); RR in oral cavity was 1.0 (CI = 0.9–1.2); RR for oropharynx was 1.4 (CI = 1.0–1.8); in hypopharynx, the RR was 1.4 (CI = 1.1–1.7); in esophageal cancer, the RR in males was 1.4 (CI = 1.3–1.7), and for laryngeal cancers in males, the use of tobacco is associated with an RR of 1.7 (CI = 1.0–3.0) as shown in [Table 3].
Table 3: Relative risk for males in relation to females for tobacco usage

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 > Discussion Top


This study has shed light on the pattern of tobacco usage in UADT cancer patients in our population. The prevalence of tobacco habits is highest in the eastern and NE part of India, and highest numbers of current tobacco users are seen in the NE part of the country.[8] An earlier report from India had estimated the cost of the tobacco-attributable burden of just three groups of diseases such as cancer, heart disease, and lung disease at Rs. 277.611 billion (US$ 6.5 billion).[9] From this study, it was seen that majority of UADT cancers related to tobacco use were males (more than 74.5%). Studies have shown that mortality due to UADT cancers in males can be prevented if smoking habits were absent.[10],[11] However, in our population, the habit of smoking was not so pronounced in males with UADT (22.4%). In our study, the majority of male patients used combined form tobacco (52.4%), and in females, chewable tobacco consumption was seen in the vast majority (82.6%) of patients with UADT cancers.

In India, oral cancer is significant public health importance. One of the significant findings from the present study shows the higher prevalence of oral cancer in relatively young patients. A study by Rani et al. had showed that the majority of tobacco users in the country are in the age group of 40–50 years.[12] The rampant use of chewable forms of tobacco such as gutkha, zarda, etc., by the younger generation, nowadays is a worrisome sign and hence may contribute to increasing numbers of oral cancer patients in the relatively younger population. The lifetime risk of UADT cancer in betel nut chewer was 9.42% and it was 1.65% for nonchewers.[13] Hence, a reduction in the consumption of chewable tobacco can significantly lower the burden of oral cancers, in our population. It has been observed that the challenges for oral cancer prevention in India are the significant gaps in the public's knowledge, attitudes, and behaviors.[14]

In our present retrospective analysis, there was a higher risk in males in most of UADT cancers associated with tobacco use (P< 0.05), which is consistent with the high prevalence of tobacco use among males of the study cohort, except for cancers of the lip and oral cavity (P > 0.05), where the higher risk in males was not statistically significant in the backdrop of higher proportion of chewable tobacco use in females (82.6%) of the study cohort. In addition, in cancers of the lip and oral cavity, significantly higher proportions (45% and 60.4%, respectively) of tobacco users were consuming chewable tobacco. This can be an indirect evidence to suggest chewable tobacco usage is the major risk factor for the development of cancers of the lip and oral cavity. In addition, as majority of males with UADT were combined tobacco users, so there is a cumulative risk for males in the occurrence cancers of oropharynx, hypopharynx, larynx, and esophagus. Furthermore, the net effect of field cancerization in combined tobacco users would be greater.[15] If the frequency or duration of tobacco use had been recorded in the data at our disposal, we could have looked for a dose-response relationship between cancer risk and tobacco use, especially in smokers which have been established.[16] In India, “bidi” a local form of smoking is very common among the rural masses and population with low socioeconomic status. Esophagus is the most common site of synchronous primary in the head and neck cancers.[17] In the present study, patients with esophageal cancers were consuming combined form, chewable tobacco, and smoking form in almost similar proportions, with a minor incremental numbers for combined form of tobacco use. Jhavar et al. have shown that tobacco use in any form increases the risk of multiple primary neoplasms in UADT.[18] Hence, with the pattern of tobacco usage seen from the present study, the increased risk of the second primary cancers in our population will remain higher. However, the proportion of smoking patients in the study for UADT sites was less in comparison with chewable tobacco use with the exception of laryngeal cancers. In this study, smoking was the predominant tobacco habit in patients with laryngeal cancers.

There are some limitations of the study, the foremost being the absence of dose-response relationship of UADT cancers with tobacco usage as the present study used categorical data of tobacco usage. Another limitation was the lack of information on alcohol use or diet in the records of the database. The findings of this type of study cannot be applicable to populations where the pattern of tobacco usage is different.


 > Conclusion Top


This study has demonstrated that consumption of chewable tobacco is the major form of tobacco use alone or in combination among the UADT cancer patients in our population. This is significant considering higher consumption of chewable tobacco use in the NE India, especially in the children and teenagers, that will pose a major health concern in the future as far as UADT cancer burden is concerned. This type of study provides indirect evidence of an association between different types of tobacco usage with UADT cancers. We also recommend that at the time of patient registration, additional information such as alcohol and dietary habits should be obtained to adjust for these confounders in conducting a hospital registry-based study. This type of a retrospective study can be readily carried out from electronically recorded data of cancer registry.

Acknowledgment

The authors would like to thank the National Centre for Disease Informatics and Research under Indian Council of Medical Research for providing the necessary technical support to our hospital cancer registry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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2.
Vineis P, Alavanja M, Buffler P, Fontham E, Franceschi S, Gao YT, et al. Tobacco and cancer: Recent epidemiological evidence. J Natl Cancer Inst 2004;96:99-106.  Back to cited text no. 2
    
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Danoy P, Michiels S, Dessen P, Pignat C, Boulet T, Monet M, et al. Variants in DNA double-strand break repair and DNA damage-response genes and susceptibility to lung and head and neck cancers. Int J Cancer 2008;123:457-63.  Back to cited text no. 3
    
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McKay JD, Truong T, Gaborieau V, Chabrier A, Chuang SC, Byrnes G, et al. A genome-wide association study of upper aerodigestive tract cancers conducted within the INHANCE consortium. PLoS Genet 2011;7:e1001333.  Back to cited text no. 4
    
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West R, McNeill A, Raw M; Health Development Agency for England. Smokeless tobacco cessation guidelines for health professionals in England. Br Dent J 2004;196:611-8.  Back to cited text no. 5
    
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Phukan RK, Ali MS, Chetia CK, Mahanta J. Betel nut and tobacco chewing; potential risk factors of cancer of oesophagus in Assam, India. Br J Cancer 2001;85:661-7.  Back to cited text no. 6
    
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Silva TM, Marques CR, Marques Filho MF, Marques AB, Di Pietro G, Rios-Santos F. Association of the GSTT1 polymorphism in upper aerodigestive tract cancer with tobacco smoking. Genet Mol Res 2014;13:528-37.  Back to cited text no. 7
    
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Global Adult Tobacco Survey India 2009-2010. Ministry of Health and Family Welfare, Government of India and World Health Organization; 2009-2010.  Back to cited text no. 8
    
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Reddy KS, Gupta PC. Report on Tobacco Control in India. New Delhi: Ministry of Health and Family Welfare, Government of India; 2004.  Back to cited text no. 9
    
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Singhal S, Quiñonez CR, Jha P. An observational study to assess changes in social inequality in smoking-attributable upper aero digestive tract cancer mortality among Canadian males between 1986 and 2001. BMC Public Health 2013;13:328.  Back to cited text no. 10
    
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Everatt R, Kuzmickiene I, Virviciute D, Tamošiunas A. Cigarette smoking, educational level and total and site-specific cancer: A cohort study in men in Lithuania. Eur J Cancer Prev 2014;23:579-86.  Back to cited text no. 11
    
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Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: Prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control 2003;12:e4.  Back to cited text no. 12
    
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Hsu WL, Chien YC, Chiang CJ, Yang HI, Lou PJ, Wang CP, et al. Lifetime risk of distinct upper aerodigestive tract cancers and consumption of alcohol, betel and cigarette. Int J Cancer 2014;135:1480-6.  Back to cited text no. 13
    
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Coelho KR. Challenges of the oral cancer burden in India. J Cancer Epidemiol 2012;2012:701932.  Back to cited text no. 14
    
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Waridel F, Estreicher A, Bron L, Flaman JM, Fontolliet C, Monnier P, et al. Field cancerisation and polyclonal p53 mutation in the upper aero-digestive tract. Oncogene 1997;14:163-9.  Back to cited text no. 15
    
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Polesel J, Talamini R, La Vecchia C, Levi F, Barzan L, Serraino D, et al. Tobacco smoking and the risk of upper aero-digestive tract cancers: A reanalysis of case-control studies using spline models. Int J Cancer 2008;122:2398-402.  Back to cited text no. 16
    
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Krishnatreya M, Rahman T, Kataki AC, Das A, Das AK, Lahkar K. Synchronous primary cancers of the head and neck region and upper aero digestive tract: Defining high-risk patients. Indian J Cancer 2013;50:322-6.  Back to cited text no. 17
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18.
Jhavar S, Sarin R, Mulherkar R, Benner A, Agarwal JP, Dinshaw K. Glutathione S-transferase M1 or T1 null genotype as a risk factor for developing multiple primary neoplasms in the upper aero-digestive tract, in Indian males using tobacco. Oral Oncol 2004;40:84-91.  Back to cited text no. 18
    


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