“Assessment of smokeless

tobacco in relation with oral

cancers among the general
population in sohrab got of
Karachi”.

Dr. Nida Liaquat

MSPH 2009-10
Health services academy
ISLAMABAD
 Introduction
• Cancers of the oral cavity are major cancer burden in Pakistan.
• Tobacco use is a risk factor for oral cancers. Available evidence
suggests that the risk of oral diseases increases with greater use
of smokeless tobacco.
• It's been medically proven that long-time use of chewing tobacco
can lead to cancer .
• According to BBC, “4 in 10 of all cancers in India are oral cancers
and this because of extensive use of smokeless tobacco and
betel quid”. [9]
• Smokeless tobacco delivers a high dose of nicotine. An average
dose from snuff is 3.6 milligrams (mg) and from chewing tobacco
is 4.5 mg – compared to 1 to 2 mg from one cigarette
“People are dying of oral cancers because of
ignorance”[5]
Dr. Geoff Graig.
 Global Perspective
• According to the World Health Organization, of 267,000 newly diagnosed oral
cancers worldwide, close to 40% (108,843 cases) occurred in India, Pakistan,
Bangladesh, and Sri Lanka. Furthermore, oral cancer incidence and mortality rates in
South Asia are almost twice those of global rates. [2][5][7]

• Currently 27,000 new cases of oral cancer were reported in the United States every
year and 9,000 deaths from oral cancer.

• The World Health Organization predicts that tobacco deaths in India may exceed 1.5
million annually by 2020[4]

• Among women, chewing and poor oral hygiene explained 95% of oral cancer.
[6]
 Pakistan
• Time trend analysis has suggested a rise in the incidence of
oral cavity cancers in Pakistan
• The incidence of oral cavity cancers in Karachi south
district of Pakistan is the highest in the world. [1]
• Oral cancer in Karachi has already reported an up to
200% increase in cases among lower socio-economic
strata between 1998 and 2002.

• In Pakistan and south Asian subcontinent the popular

smokeless products are pan and chaalia with tobacco, Gutka,
Naswar and tumbaku.
• Use of Paan, chaalia, Gutka, Naswar, tumbaku are acceptable
in Pakistan and is considered a normal cultural practice.
 Rational
• Incidence of oral cancers in Pakistan is increasing day by day
but there is dearth of research regarding behavioral change
among Pakistanis about smokeless tobacco.

• People have wrong conceptions about smokeless tobacco. They

think they don’t smoke it; they don’t swallow it so it’s harmless.

• Oral cancers are a major cancer burden in Pakistan. They share

a common risk factor profile including regular consumption of
products of betel, areca with tobacco. People of Pakistan
considered it a normal cultural practice.

• As a dentist I used to see a lot of patients with complications

arising out of habit like Gutka eating, keeping tobacco quid in
mouth and Naswar. So I thought this awareness build up study.
 What is smokeless
tobacco
The term smokeless tobacco is used to describe tobacco that is
consumed in unburnt form. Smokeless tobacco can be used orally or
nasally. Smokeless tobacco comes in 2 basic forms:

• snuff
• Chewing tobacco.

Snuff: It is a fine grain tobacco that often comes in tea bags like
pouches that user “pinch” or “dip” between their lower lip and gums.
(Naswar)

Chewing tobacco: Comes in shredded, twisted or bricked tobacco

leaves that users put between their cheeks and gums. It is also
available in different
forms. Most popular forms in Pakistan are:

1. Paan
2. Gutka (Paan masala)
3. Naswar
4. Mainpuri
5. mishri
Carcinogens of smokeless
tobacco

Tobacco when kept in mouth leaches out carcinogens, which act

on oral mucosa causing neoplastic changes.
Tobacco contains potent carcinogens are as follows:

Formaldehyde
N-nitrosamines
Arsenic
Nicotine and metabolites of these substances
Polycyclic aromatic hydrocarbons
Hydrogen cyanide
Benzopyrene
 Aims and Objectives:
• Aim:
• To decrease morbidity and mortality associated with oral
cancers among smokeless tobacco users.
• Objectives:
• To determine the socio-demographic and cultural context
of Gutka and Paan consumption.
• To assess knowledge of the respondents about risk of oral
cancers posed by the use of smokeless tobacco.
• To identify the adverse effects of smokeless tobacco on
oral cancers among 18 to 65 years old population in
sohrab got of Karachi during three months study duration.
 Methodology
• Study Design: Cross sectional descriptive study.

• Study Population: Male and females aged 18-65 years

living in sohrab got of Karachi.
• Study area: Sohrab got of Karachi
• Study time period: 3 months
• Sampling technique:
In sohrab got mohallas will be selected by simple random
sampling and then houses will be selected by systemic
random sampling. After selecting the houses all household
having person aged 18-65 years and is regular user of
smokeless tobacco will be enrolled till the sample size is
completed. Door of the house will be knocked and if the
person of that house fulfils the criteria he/she will be
included in study.
 Methodology
Sample size:
According to study conducted by Agha khan university.
Prevalence
of smokeless tobacco among adults is 37.8%.
(Adults = above 18)
n= P (1-p)
e2
n= 0.378 (1- 0. 378)
(0.05)2

n= 94 = 95
Estimated sample size is 95.
 Study Population
Inclusion Criteria:
• Male and female aged 18-65 years who are
regular users of smokeless tobacco for more
than six months.
• Those who give verbal and written consent.
Exclusion Criteria:
• Those who don’t give verbal consent.
• Those who are below 18 or above 65.
• Those who are not regular users of smokeless
tobacco.
 Methodology
• Data collection tool:
• A structured questionnaire is developed by
the researcher to collect information on all
the variables.
•  Data Entry: Data will be entered by the
researcher using SPSS version 16.
• Plan of Analysis: Descriptive statistics
such as means, standard deviations,
frequencies, rates, and ratios will be
calculated for different variables.
 Variables
• Age
• Education of the subjects.
• Oral hygiene
• Diet
• Socio-economic group
• Gender
• Ethnicity
• Mother tongue
• occupation
• Religion
 Ethical consideration

Written/verbal consent will be taken

from the study participants. The
information obtained through the
questionnaire will be kept secure and
will not be disclosed to anyone, and
it will be used for research and
academic purpose only.
 Budget
Heads # Unit cost (Rs) Duration total cost

Data collectors 4 300/person/day 15 days 18,000

Data entry by PI 1
Training of data 4 300/person/day 2 days 2400
collectors
Stationary 2,000
Questionnaire
Printing of questionnaire 250 2 500
Rs/questionnaire
Printing of consent form 250 2 Rs/consent form 500
Transportation for data 1 1500/day 15 days 22,500
collection
Pretesting
Data collectors 2 400/person/day 2 days 800
Transportation for 2 1500/person/day 2 days 3000
pretesting
Administrative charges
Mailing/posting 2 500 1000
Food expenses 5 200/person/day 15 days 15000
Total 65,700
 Work Plan

Effects of smokeless

#
 Expected
Recommendations
• To discourage the consumption of chewing products of betel, areca
and tobacco is the first step towards the control of epidemic of oral
cancers in Pakistan and requires radical measures involving health
care professionals, media, policy makers and the community.
• Behavioral interventions are successful measures in reducing oral
use of smokeless tobacco .
• Instead of using smokeless tobacco, habit can be controlled by
eating chew gums, saunf and so on.
• Warning signs should accompany sachets and advertisements of
these items, as used for cigarettes. Chaalia sponsored music
videos showing TV stars using these products as a symbolic
offering should be countered
• Frequent consumption of fruit and vegetables, including carrots,
fresh tomatoes and green peppers, was associated with reduced
risk of oral cancer [7]
 References
1. © 2006 Samia Mazahir et al; licensee BioMed Central Ltd.
. Socio-demographic correlates of betel, areca and smokeless
tobacco use as a high risk behavior for head and neck cancers in
a squatter settlement of Karachi, Pakistan..6 pages.

2. Kavita P. Ahluwalia, D.D.S., M.P.H.

School of Dental and Oral Surgery, Columbia University, New York, New York.
cancer. 2005 December 15; 104(12 Supply): 2959–2961.
Assessing the Oral Cancer Risk of South-Asian Immigrants in New York
City

3. American Cancer Society. Cancer Facts & Figures 2008. Atlanta, GA.
2008 copyright 2009 © American Cancer Society, Inc.

4. M Rani, S Bonu, P Jha, S N Nguyen and L Jamjoum

household survey smoking and chewing in a national cross
sectional
Tobacco use in India: prevalence and predictors of smoking
and chewing in a national cross sectional household survey
Received 22 April 2003
Accepted 10 September 2003
http://tobaccocontrol.bmj.com/cgi/content/full/12/4/e4
5. D. Max Parkin, M,D Paola Pisani,PhD, J. Ferlay Global Cancer Statistics
CACancerJClin1999;49:33-64

6. Prabha BALARAM, ORAL CANCER IN SOUTHERN INDIA: THE INFLUENCE OF SMOKING,

DRINKING, PAAN-CHEWING AND ORAL HYGIENE © 2002 Wiley-Liss, Inc
7. Carlo La Vecchia, ORAL CANCER: EPIDEMIOLOGY, RISK FACTORS AND
PREVENTION. This is the html version of the file
http://mso.cinbo.org/documenti/allegati/slide/2005/24_26_Novembre/24_Novembre/Vecchia.ppt
.
8. ERNESLT. WYNDERM,. D., IRWINJ. BROSSP, H.D., AND RIVKAHkZ . FELDMANB,
A study of the etiological factors in cancer of the mouth

9. Sangeeta Darvekar Charitable Trust, a registered trust with registration no

E/3092/Thane dated 30/4/03 presents an awareness program on Oral Cancer
and named it. Oral Cancer Awareness.org

10. Monika Arora Director ,HRIDAY-SHAN, Alternate Forms of Tobacco Use

11. Educational programs of the Texas AgriLife Extension Service are open to
all people without regard to race, color, sex, disability, religion, age, or
national origin. The Texas A&M University System, U.S. Department of
Agriculture, and the County Commissioners Courts of Texas Cooperating

12. Texas Department of Health - Public Health Region 7,Office of Tobacco

Prevention & Control.

13. Scott L. Tomar, DMD, DrPH, Oral Health Effects of Smokeless Tobacco Use,
University of Florida,C
college of Dentistry.stomar@dental.ufl.edu
 Thank
you!