The harmful nature of many ST products, and the fact that million people around the world use ST [ 8 ], make ST consumption a global public health issue. Many ST products lead to different types of head and neck cancers [ 9 , 10 ].
An increased risk of cardiovascular deaths has been reported [ 11 ], and its use in pregnancy is associated with stillbirths and low birth weight [ 12 , 13 ]. Because of the diversity described above, ST should not be considered as a single product, but rather as groups of products with differences in their toxicity and addictiveness, depending on their composition.
As a consequence, it is difficult to estimate the global risks of ST to human health and to agree on international policies for ST prevention and control. Several country-specific studies [ 14 , 15 ] have been carried out, and in , we published an estimate of the global burden of disease associated with ST use [ 16 ]. We used a novel approach, whereby we classified ST products according to their availability in different geographical regions of the world.
For example, ST products in South Asia pose a much greater risk to health than those available in Nordic countries, where the manufacturing process removes many of the toxins from the finished product [ 6 , 17 ].
Using this approach, we estimated the worldwide burden of disease attributable to ST consumption, measured in terms of disability adjusted life years DALYs lost and the numbers of deaths in [ 16 ]. Here, we update this estimate to include data up to , providing an indication of how the global ST arena has changed in the intervening years. Our methods for updating the estimates of ST disease burden were broadly the same as those used in our earlier publication; these are well described elsewhere [ 16 ].
Here, we will summarise these methods and explain any modification made, particularly in relation to the revised timelines. These individual estimates were then summarised for 14 World Health Organization WHO sub-regions Additional file 1 : Appendix 1 as well as for the world. We searched for the latest estimates for x countries included in our previous study as well as those additional y countries where estimates have been made available since for the first time.
We derived single estimates for each country preferring nationally representative surveys using internationally comparable methods over non-standardised national or sub-national surveys. We also updated risk estimates for individual diseases caused by ST; however, we kept to the original list of conditions, i. We only searched for papers published since our last literature search; our updated search strategies can be found in Additional file 1 : Appendix 3.
As before, all searches and data extraction were independently scrutinised by a second researcher and any discrepancies were arbitrated by a third researcher. All case definitions for diseases and exposure ST use used in the retrieved articles were checked for accuracy and consistency and all analyses undertaken in these studies were assessed to see if they controlled for key confounders mainly smoking and alcohol. We assessed study quality using the Newcastle-Ottawa Scale for assessing non-randomised studies in meta-analysis [ 24 ].
Where possible, we pooled effect sizes to obtain country-specific risk estimates. For all outcomes in the meta-analyses, we conducted a GRADE assessment to assess the quality of evidence. We also pooled these effect sizes to obtain non-specific global risk estimates. Given that the risk varies from country to country, depending upon which products are locally popular, we used country-specific risk estimates where possible.
In countries with no estimates, we used estimates of those countries where similar ST products were consumed. For other countries without estimates that consumed ST products known to contain high levels of TSNAs, we applied non-specific global estimates. Where no information was available on the composition of ST, we did not apply any estimates. Details on how these statistically significant estimates were applied to each WHO sub-region can be found in web Additional file 1 : Appendix 4.
A sensitivity analysis was also carried out by estimating risk estimates separating out cohort from case-control studies. For each country, we used their point prevalence of ST use and the allocated risk estimate for each condition to estimate its population attributable fraction PAF as below:. The attributable burden AB due to ST was then estimated in deaths and DALYs lost for these conditions for both men and women using the following equation.
ST consumption was reported in countries Fig. A variety of age ranges as young as 15 or as old as 89, including no upper age limit were used to define adults. ST consumption was more common among males than females in 95 countries Table 2.
Among males, Myanmar Among females, Mauritania Within Europe, Sweden Our post systematic literature search identified an additional four studies demonstrating a causal association between ST and oral cancer; these included two Pakistan-based and one India-based case-control studies and one US-based cohort study Table 3. No new studies were found for pharyngeal and oesophageal cancers.
PRISMA flow diagrams describing the selection process of the studies identified in the literature searches are provided in Additional file 1 : Appendix 5b,c. By adding the new studies to the list of studies selected in our first estimates and revising the meta-analyses, we found that the pooled estimates were statistically significant for cancers of the mouth Fig. The non-specific pooled estimate for oral cancers, based on 36 studies, were 3.
The country-specific relative risk for oral cancers for India was higher RR 5. Since no new studies were added for pharyngeal and oesophageal cancers, their non-specific risk estimates of 2. For cardiovascular diseases, we identified another three Swedish studies for ischaemic heart disease and another two one in Asia and one in Sweden for stroke Table 3.
In the absence of any new non-Swedish studies on ischaemic heart disease Fig. However, the country-specific Sweden relative risk for ischaemic heart disease RR 0. Separate risk estimates for cohort and case-control studies are included in the Additional file 1 : sensitivity analysis 2. The above risk estimates were included in the mathematical model to estimate the population attributable fraction PAF , as follows also see Additional file 1 , Appendix 4 for detailed justification : For oral, pharyngeal and oesophageal cancers, Sweden- and US-based country-specific risk estimates were applied to Europe A and America A regions, respectively.
No risk estimates were applied to Europe C due to the non-existence of any risk estimates or information about the toxicity of ST products. For all other regions, non-specific country estimates were applied. A few exceptions were made to the above assumptions: a Pakistan-based country-specific estimate was applied for oral cancers for Pakistan and an India-based estimate for the other two cancers; for the UK, India-based country specific estimates were applied due to the predominant use of South Asian products in the country.
Europe A due to the availability of Sweden-based country specific estimates and Europe C due to the non-availability of relevant information. According to our estimates, 2,, DALYs lost and 90, deaths due to oral, pharyngeal and oesophageal cancers can be attributed to ST use across the globe Table 4. Among these figures, three quarters of the total disease burden was among men.
ST consumption is now reported in at least two thirds of all countries; however, health risks and the overall disease burden attributable to ST use vary widely depending on the composition, preparation and consumption of these products. Southeast Asian countries share the highest disease burden not only due to the popularity of ST but also due to the carcinogenic properties of ST products.
In countries e. Sweden where ST products are heavily regulated for their composition and the levels of TSNAs, the risk to the population is minimal. We found ST prevalence figures in 12 countries that did not previously report ST use; new figures were also obtained for 55 countries included in the previous estimates [ 16 ].
Among these 55 countries: 19 reported a reduction in ST use among both men and women e. Bangladesh, India, Nepal , 14 only among men e. Laos, Pakistan and eight only among women e. Bhutan, Sri Lanka Fig. On the other hand, 13 countries showed an incline in ST use among both men and women e.
We are now reporting ST use in 12 more countries; however, the main reason for the increased burden of disease was a global rise in the total mortality and DALYs lost—oral, pharyngeal and oesophageal cancers, in particular. The disease burden due to these cancers lags several decades behind the risk exposure. Therefore, a significant reduction in ST-related disease burden as a result of a reduced prevalence will not become apparent for some time to come. Among other studies estimating ST-related global disease burden, our mortality estimates were far more conservative than those reported by Sinha et al.
Moreover, Sinha et al. None of these risks were substantiated in our systematic reviews and meta-analyses. A reason for the slight difference between these two estimates might be that ours included pharyngeal cancers in the estimates while GBD Study only included oral and oesophageal cancers. Our methods have several limitations. These have been described in detail elsewhere [ 16 ] but are summarised here.
Our estimates were limited by the availability of reliable data and caveated by several assumptions. The ST use prevalence data were not available for a third of countries despite reports of ST use there. Where prevalence data were available, there were very few studies providing country-specific disease risks—a particular limitation in Africa and South America.
In the absence of country-specific risk estimates, the model relied on assuming that countries that share similar ST products also share similar disease risks. For other countries, the extrapolated risks were based on similarities between ST products sold there and in the above five countries. As previously noted, the total disease burden observed in is a consequence of risk exposure over several decades. Therefore, the attributable risk based on the prevalence figures gathered in the last few years may not be accurate.
If ST prevalence has been declining in a country over the last few decades, the disease burden obtained by applying more recent prevalence figures may underestimate attributable disease burden.
On the other hand, if ST use is on the rise e. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. A single copy of these materials may be reprinted for noncommercial personal use only. This site complies with the HONcode standard for trustworthy health information: verify here. This content does not have an English version. This content does not have an Arabic version.
See more conditions. Healthy Lifestyle Quit smoking. Products and services. Smokeless tobacco products Chewing tobacco and other forms of smokeless tobacco are more harmful and addictive than you might think.
By Mayo Clinic Staff. Thank you for Subscribing Our Housecall e-newsletter will keep you up-to-date on the latest health information. Please try again. Something went wrong on our side, please try again. Show references Smokeless tobacco fact sheets. Centers for Disease Control and Prevention.
Accessed Jan. Health risks of smokeless tobacco. American Cancer Society. Seidenberg AB, et al. Kleigman RM, et al. Substance abuse. In: Nelson Textbook of Pediatrics. Elsevier; Rostron BL, et al. This sucking and chewing allows nicotine to get into the bloodstream through the gums, without the need to swallow the tobacco juices.
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