Takaisin

Snuff use, oral cancer and mortality

Näytönastekatsaukset
Current Care Guideline group Oral cancer
22.5.2019

Snuff use increases the risk for oral cancer globally, especially among females. The use of Swedish snuff (which is the form of snuff mainly used in Finland) shows increased oral cancer risk only when combined with tobacco use «Luo J, Ye W, Zendehdel K ym. Oral use of Swedish m...»6. However, it should be noted that the Swedish snuff studies focus on males and there is no information concerning females. Also, there is a high risk of bias due to the poor definition of exposure (dose and duration) and comparison. Furthermore, there is some evidence that snuff use and even the use of Swedish snuff increases all-cause mortality and death to cardiovascular disease «Roosaar A, Johansson AL, Sandborgh-Englund G ym. C...»5, «Timberlake DS, Nikitin D, Johnson NJ ym. A longitu...»7, «Hansson J, Galanti MR, Hergens MP ym. Snus (Swedis...»8, «Sinha DN, Suliankatchi RA, Gupta PC ym. Global bur...»9 and therefore its’ use cannot be considered safe.

Description of the included studies

Table 1. Table for systematic reviews and epidemiological case/control and cohort studies (risks)
Reference Study type Population Exposure and comparison Outcomes Risk of bias «Additional comments for included studies»1
RCT=randomized controlled trial; SR=systematic review; MA=meta-analysis
«Siddiqi K, Shah S, Abbas SM ym. Global burden of d...»1 SR/MA 32 case/control and cohort studies included in the meta-analysis. Studies grouped geographically and areas analyzed separately in a meta-analysis: India, Pakistan, Sweden, Norway, North America Inclusion criteria: smoking and alcohol use adequately controlled. Exclusion criteria: cross-sectional studies, case series and case reports. Smokeless tobacco (SLT) use vs. population based risk Risk for oral, pharyngeal, oesophaegal cancers or ischaemic heart disease
Burden of the SLT use expressed as proportion of the disability-adjusted life-years (DALYs) lost and deaths reported
No risk of bias assessment of the included studies.
«Wyss AB, Hashibe M, Lee YA ym. Smokeless Tobacco U...»2 Pooled analysis of studies 11 US case-control studies (1981–2006) included in the pooled analysis (6772 cases and 8375 controls) Approx. half of the cases and controls were between 50 and 65 years of age, majority were non-Hispanic white, over two-thirds were male. Individuals excluded if: missing data on frequency of alcohol drinking or duration of cigarette, cigar, or pipe smoking SLT product use not separately described SLT use: snuff and chewing tobacco separately analyzed for never and ever cigarette smokers Head and neck cancer: oral, gum, pharynx, hypopharynx, oropharynx or larynx, all sites, also male and female separately Not reported
«Asthana S, Labani S, Kailash U ym. Association of ...»3 SR/MA 37 case-control or cohort studies (1960–2016) from Southeast Asia region (SEAR), the Eastern Mediterranean Region (EMR), Europe, and region of Americas (North and South) Exposure status in the studies included was ever versus never SLT use and should be adjusted for at least smoking status. All age groups 10-99 y included, in most studies mean age around 50 years SLT use among never versus ever users Oral cancer risk in different regions, concerning different SLT products and both sexes Not reported
«Schildt EB, Eriksson M, Hardell L ym. Oral snuff, ...»4 Case/control Sweden 1980-1989 cases 410 (354 after exclusion), alive 175 (143) controls 410 (354 after exclusion), alive 175 (143) two-thirds were males Snuff users (including also smokers) compared to never smokers ex-smokers smokers Lifetime exposure measured with a questionnaire Oral cancer risk (OR) Exposure Eligibility Study design/outcome measures
«Roosaar A, Johansson AL, Sandborgh-Englund G ym. C...»5 Cohort Sweden cohort size 9976 (1973-74, follow up 2002) all were males Snuff using smokers and never smokers compared to never snuff users Exposure recorded in the beginning with a questionnaire Oral and oropharyngeal cancer risk (hazard ratio HR) Mortality Eligibility Exposure
«Luo J, Ye W, Zendehdel K ym. Oral use of Swedish m...»6 Cohort Sweden
cohort size 279897 (1978-92, follow up 2004, or cancer, death, migration) Females excluded
Snuff users (never smoking) compared with never users of any tobacco Combined use of snuff and tobacco compared to never users of any tobacco Exposure recorded in the beginning with a questionnaire Oral cancer, lung cancer, pancreatic cancer risk (RR) Eligibility Exposure Selective reporting?
«Timberlake DS, Nikitin D, Johnson NJ ym. A longitu...»7 Cohort US
cohort size 349 282 1985-2011
SLT users; snuff, chew or both (using no other tobacco products) compared to never users of any tobacco Mortality to all causes all cancers cerebrovascular diseases coronary heart diseases (CHD) Exposure Control of confounding factors
«Hansson J, Galanti MR, Hergens MP ym. Snus (Swedis...»8 Pooled analysis of studies 8 Swedish cohort studies (1978-2004) 130 485 men who never smoked Current snuff users compared to noncurrent snuff users (adjusted to age and BMI) Incidence and survival after stroke
«Sinha DN, Suliankatchi RA, Gupta PC ym. Global bur...»9 SR/MA 16 studies worldwide SLT use compared to non-tobacco use All-cause mortality (OR) and subgroup analysis for different mortality causes and different regions Bias on the included studies mainly: Confounding Exposure and Selection also significant heterogeneity between studies

Results

Table 2. Outcome: oral cancer
Reference Number of studies and number of patients Follow-up time Absolute risk I or E Absolute risk C Relative effect (95 % CI)
I= intervention; E=exposure; C=comparison; CI=confidence interval
«Siddiqi K, Shah S, Abbas SM ym. Global burden of d...»1 32 studies - - - SLT use vs. population risk OR India 5,12 (3,27–8,02) Pakistan 8,81 (3,14–24,69) Sweden 0,92 (0,68–1,25) Norway 1,10 (0,50–2,42) North America 0,95 (0,70–1,28)
«Wyss AB, Hashibe M, Lee YA ym. Smokeless Tobacco U...»2 pooled data of 11 US case-control studies 6772 cases 8375 controls - 20/82
10/72
20/32
24/74
379/3435
52/3108
391/1735
737/2449
Never cigarette smokers: never snuff use vs. ever snuff use, cancer risk (OR) in oral cavity 3,01 (1,63–5,55) gum 12,70 (4,76–33,7) female 8,89 (3,59–22,0) male 0,86 (0,49–1,51)
«Asthana S, Labani S, Kailash U ym. Association of ...»3 37 studies globally - - - Ever snuff use vs. Never snuff use OR (adjusted for smoking status)
South East Asia 4,44 (3,51–5,61)
East mediterranean 1,28 (1,04–1,56)
European 0,86 (0,58–1,29)
American 4,72 (0,66–33,62) Significantly higher risk was found for females 5,83 (2,93–11,58) Different products: gutkha 8,67 (3,59–20,93) pan tobacco / betel liquid 7,18 (5,48–9,41) oral snuff 4,18 (2,37–7,38)
Mainpuri tobacco 3,32 (1,32–8,36) Swedish snuff 0,86 (0,58–1,29)
«Schildt EB, Eriksson M, Hardell L ym. Oral snuff, ...»4 case-control study 354 cases 354 controls Lifetime use 19/354
15/354
10/354
9/354 16/354
3/354
23/354
10/354
16/354
4/354
13/354
1/354
Reference never snuff and never tobacco OR 1,0
Snuff user’s risk for oral cancer:
never smoker 0,7 (0,4–1,2)
*ex-smoker 0,6 (0,3–1,3)
*smoker 1,2 (0,6–2,4)
Ex snuff user’s risk for oral cancer: never smoker 1,8 (0,9–3,5)
ex-smoker 1,6 (0,8–3,4)
smoker 3,1 (1,4–6,8)
«Luo J, Ye W, Zendehdel K ym. Oral use of Swedish m...»6 Cohort n 279897 26-12 years, sd 20 y 10/37755 numbers 10/698 542 person years
150/103 309 numbers 150/ 2 083 245 person years
50/87821 numbers 50/ 1751 072 person years
50/87 821 numbers 50/ 1 751 072 person years
Snuff users (non-smoking) compared to never-users of any tobacco Oral cancer RR 0,8 (0,4–1,7)
Snuff users (smokers) compared to never users of any tobacco Oral cancer RR 2,5 (1,7–3,5)
Level of evidence: moderate for the snuff used in Asia and America and among females, moderate for Swedish snuff used by male smokers.

Studies with combined risk for oral and oropharyngeal «Roosaar A, Johansson AL, Sandborgh-Englund G ym. C...»5, «Rosenquist K, Wennerberg J, Schildt EB ym. Use of ...»10or head and neck cancers «Lewin F, Norell SE, Johansson H ym. Smoking tobacc...»11 are not included in the table Outcome: oral cancer

Table 3. Outcome Mortality
Reference Number of studies and number of patients (E/C) Follow-up time Absolute risk E Absolute risk C Relative risk (95 % CI)
E=exposure; C=comparison; CI=confidence interval
«Siddiqi K, Shah S, Abbas SM ym. Global burden of d...»1 32 studies Worldwide 6,4 milj DALYs lost and 266 592 deaths /year
«Roosaar A, Johansson AL, Sandborgh-Englund G ym. C...»5 cohort 9976 28-29 years 641/867 2988/5309 All-cause mortality Daily snuff user ever smoker 1,10 (1,01–1,21) Daily snuff user never smoker 1,23 (1,09–1,40)
«Timberlake DS, Nikitin D, Johnson NJ ym. A longitu...»7 cohort 349 282 mortality median 8,8 maximum 26,3 years 355/3596
86/3596
28 387/ 340 622
5770/340 622
Current snuff user HR All-cause mortality 1,01 (0,90- 1,14)
Mortality to coronary heart diseases 1,30 (1,03–1,63)
«Hansson J, Galanti MR, Hergens MP ym. Snus (Swedis...»8 pooled analysis mean follow-up time 17 years - - Current snuff user HR for stroke 1,04 (95% CI 0,92–1,17). Mean age at stroke diagnosis was 62 and 68 years amongst current and noncurrent snuff users, respectively (P < 0,0001). HR for death during the follow-up period 1,32 (95% CI 1,08–1,61).
«Sinha DN, Suliankatchi RA, Gupta PC ym. Global bur...»9 16 studies - - - All-cause mortality (1,22; 1,11–1,34), all cancer (1,31; 1,16–1,47), UADT cancer (2,17; 1,47–3,22), stomach cancer (1,33; 1,12–1,59), cervical cancer (2,07; 1,64–2,61), IHD (1,10; 1,04–1,17) and stroke (1,37; 1,24–151).
Major regional differences in subgroup analysis
Level of evidence: moderate
IHD, ischaemic heart disease, UADT, upper aerodigestive tract.

References

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