Oral microbiome dysbiosis among cigarette smokers and smokeless tobacco users compared to non-users.

Tobacco use significantly influences the oral microbiome. However, less is known about how different tobacco products specifically impact the oral microbiome over time. To address this knowledge gap, we characterized the oral microbiome of cigarette users, smokeless tobacco users, and non-users over 4 months (four time points). Buccal swab and saliva samples (n = 611) were collected from 85 participants. DNA was extracted from all samples and sequencing was carried out on an Illumina MiSeq, targeting the V3-V4 region of the 16S rRNA gene. Cigarette and smokeless tobacco users had more diverse oral bacterial communities, including a higher relative abundance of Firmicutes and a lower relative abundance of Proteobacteria, when compared to non-users. Non-users had a higher relative abundance of Actinomyces, Granulicatella, Haemophilus, Neisseria, Oribacterium, Prevotella, Pseudomonas, Rothia, and Veillonella in buccal swab samples, compared to tobacco users. While the most abundant bacterial genera were relatively constant over time, some species demonstrated significant shifts in relative abundance between the first and last time points. In addition, some opportunistic pathogens were detected among tobacco users including Neisseria subflava, Bulleidia moorei and Porphyromonas endodontalis. Overall, our results provide a more holistic understanding of the structure of oral bacterial communities in tobacco users compared to non-users.

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.

Determinants of Quit Attempts and Short-Term Abstinence among Smokeless Tobacco Users in India: Global Adult Tobacco Survey, 2016-17.

OBJECTIVE: Smokeless tobacco is the preponderant form of tobacco in India. The cessation indicators are weaker for smokeless tobacco users than smokers. There is a dearth of literature on the effectiveness of the interventions that motivate and assist smokeless tobacco users in quitting in program settings. METHODS: Data from Global Adult Tobacco Surveys (GATS), 2016-17, was analysed. Quit attempts in the previous 12 months among SLT users and duration of abstinence were the two outcome variables. The chief exposure variables were the receipts of various interventions that warned about the dangers of smokeless tobacco or encouraged quitting. Logistic regression analyses were employed to identify determinants of quit attempts. For the hazard of relapse to tobacco use, survival analysis was used. RESULTS: The odds of quit attempts among SLT users in the previous 12 months were more among those who received advice from healthcare providers (OR 2.09; 1.87-2.34), noticed messages from media that made them think about quitting (OR 1.67; 1.50-1.86) and noticed a warning label that made them think about quitting (OR 1.39; 1.25-1.55). Those who used counselling (HR 0.81; 0.70-0.93) or medication (HR 0.79; 0.66-0.95) sustained abstinence from smokeless tobacco for a longer duration compared to those who did not use any cessation method. CONCLUSION: Quit advice by healthcare providers is an influential determinant of a quit attempt, and this intervention needs to be scaled up. The media messages and warning labels were effective among those who considered quitting after noticing them. Cessation methods can help prolong the abstinence from smokeless tobacco, but the reach of cessation methods is limited.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.