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The current study aimed to investigate the relationship between polymorphisms in detoxifying (GSTM1, GSTT1, and GSTP1) genes and their association with colorectal cancer (CRC) in tobacco addicts of Pashtun ethnicity. Polymorphisms in the selected genes were genotyped in a case-control study consisting of 100 histologically confirmed male CRC patients and 100 birth-year and gender-matched healthy controls using the PCR−RFLP method. The GSTM1 null, and GSTT1 null genotypes were significantly contributed to the risk of CRC in the cases (OR= 3.131, 95% CI: 1.451−6.758, P = 0.004, and OR= 3.541, 95% CI: 1.716−7.306, P = 0.001, respectively), whereas the association observed for GSTP1 Val/Val (1.139, 95% CI: 0.356−3.644, P = 0.826) did not show statistical significance. The combined GSTM1 null and GSTT1 null showed a 41-fold increased risk (95% CI: 4.945−351.950, P = 0.001), while, the combined GSTM1 null and GSTP1 Ile/Val or Val/Val variant genotypes exhibited about 3-fold (95% CI: 1.196−7.414, P = 0.019) increased risk to CRC. Similarly, the combined GSTT1 null and GSTP1 Ile/Val or Val/Val variant genotypes showed about a 3-fold (95% CI: 1.285−8.101, P = 0.013) increased risk of CRC. In the combination of three GST genotypes, the GSTM1 null, GSTT1 null, and GSTP1 Ile/Val or Val/Val variant genotypes demonstrated a more than a 22-fold (95% CI: 2.441−212.106, P = 0.006) increased risk of CRC. Our findings suggest that GSTM1 and GSTT1 polymorphism and its combination with GSTP1 may be associated with CRC susceptibility in the Naswar addicted Pashtun population of Khyber Pakhtunkhwa, Pakistan. Resumo O presente estudo teve como objetivo investigar a relação entre polimorfismos em genes desintoxicantes (GSTM1, GSTT1 e GSTP1) e sua associação com câncer colorretal (CCR) em tabagistas da etnia pashtun. Os polimorfismos nos genes selecionados foram genotipados em um estudo de caso-controle composto por 100 pacientes do sexo masculino com CCR, confirmados histologicamente, e 100 controles saudáveis, pareados por ano de nascimento e sexo usando o método PCR-RFLP. Os genótipos GSTM1 nulo e GSTT1 nulo contribuíram significativamente para o risco de CCR nos casos (OR = 3,131, IC 95%: 1,451-6,758, P = 0,004; OR = 3,541, IC 95%: 1,716-7,306, P = 0,001, respectivamente), enquanto a associação observada para GSTP1 Val/Val (1,139, IC 95%: 0,356-3,644, P = 0,826) não apresentou significância estatística. O GSTM1 nulo e o GSTT1 nulo combinados mostraram um risco 41 vezes maior (IC 95%: 4,945-351,950, P = 0,001) para CCR, enquanto os genótipos GSTM1 nulo e GSTP1 Ile/Val ou Val/Val combinados apresentaram risco cerca de 3 vezes maior (IC 95%: 1,196-7,414, P = 0,019) para CCR. Da mesma forma, os genótipos combinados GSTT1 nulo e GSTP1 Ile/Val ou Val/Val tiveram um risco para CRC cerca de 3 vezes maior (95% CI: 1,285-8,101, P = 0,013). Na combinação de três genótipos GST, os genótipos GSTM1 nulo, GSTT1 nulo e GSTP1 Ile/Val ou Val/Val apresentaram um risco 22 vezes maior (IC 95%: 2,441-212,106, P = 0,006) para CRC. Nossos achados sugerem que o polimorfismo GSTM1 e GSTT1 e sua combinação com GSTP1 podem estar associados à suscetibilidade ao CRC da população pashtun de Khyber Pakhtunkhwa, Paquistão, viciada em Naswar.

Objective To investigate the single nucleotide polymorphic variations of N-acetyltransferase 2, phase-II metabolising enzyme, and associated risk factors for oral cancer. Methods The case-control study was conducted from November 2017 to April 2018 after approval from the Institute of Molecular Biology and Biotechnology, Bahauddin Zakariya University, Multan, Pakistan, and comprised oral cancer patients and healthy controls. Single nucleotide polymorphism of the N-acetyltransferase 2 gene associated with oral cancer was analysed. Factors assessed using tetra-primer amplification refractory mutation system polymerase chain reaction included age, smoking, naswar, betel leaves and nuts. Results Of the 201 subjects, 94(47%) were patients and 107(53%) were controls, while 108(54%) were aged 10-30 years. Single nucleotide polymorphism rs1208 of N-acetyltransferase 2 gene was primarily A803G and Lys268Arg, with allelic frequency of G/A. Age range 51-70 was significantly (p=0.00001) associated with the prevalence of oral cancer in terms of genotypic relationship with A803G. Substantial allelic association was found between the gene and oral cancer (p=0.006895). Smoking increased the cacner risk 7-fold (odds ratio: 7.0). Conclusions The genetic variant of N-acetyltransferase 2 rs1208 was found to be significantly associated with oral cancer progression and development of associated risk factors.

The aim of the study was to assess the situation related to tobacco consumption among adolescents aged 13 – 15 in the Kyrgyz Republic.Materials and Methods. The study used a two-stage selection of schoolchildren in grades 7 – 9 (teenagers 13 – 15 years old) to conduct the survey. At the 1st stage, information was collected about all schools of the republic, where children of the target group study. the schools in which the survey was subsequently conducted were selected by the statistical sampling method according to the number of students in grades 7 – 9. The grades whose students participated in the questionnaire were set at stage 2 by random sampling in each school The survey includes 43 questions from the Standard main Questionnaire of the Global Youth Tobacco Survey (GYTS) and 30 supplementary questions (73 in total) with multiple choice of answers. The statistical processing was performed using the SUDAAN software package (US Centers for Disease Control and Prevention); a 95% confidence interval was calculated to calculate weighted prevalence estimates and standard errors (SE).Results. The survey found that 6.0% of schoolchildren (9.5% of boys and 2.4% of girls) currently use various types of tobacco; 4.4% of schoolchildren currently use tobacco (6.8% of boys and 2.0% of girls); 2.4% of schoolchildren smoke cigarettes; 2.4% use smokeless tobacco, 2.8% use other tobacco products (hookah); 2.8% of schoolchildren smoke electronic cigarettes (3.9% of boys and 1.7% of girls). Tobacco use most often begins before age 7 or after age 12. 16.8% of schoolchildren are exposed to tobacco smoke at home, of which 14.2% are in closed places and 14.8% in open public places. 87.2% of schoolchildren purchase cigarettes in a shop, kiosk, from a street vendor, and in the market. During the visit to the point of sale 26.7% noticed tobacco advertising and promotions; 49.7% saw anti-tobacco messages in the mass media. Definitely think that smoking tobacco by other people is bad for them, 71.2% of schoolchildren.Conclusion. A high percentage of teenagers consuming e-cigarettes, hookah, and smokeless tobacco products has been noted, although > 50% of them are aware of the dangers of tobacco use. Every 6th student is a passive smoker. The vast majority of schoolchildren aged 13 – 15 who try to quit smoking do not receive professional help in quitting tobacco use, and are exposed to protobacco media marketing campaigns.

Background According to the World Refugee Survey by US Committee for Refugees and Immigrants, migrants from Afghanistan constitute the 4th largest group of migrants to India. No previous study has been conducted to assess the tobacco consumption status and pattern among this marginalised migrant population. Aim To get an insight of the tobacco usage pattern, accessibility and attitude towards tobacco cessation among the migrant population from Afghanistan. Methodology A cross-sectional study was conducted among a convenience sample of Afghan tobacco users residing in Delhi, India in the month of June 2017. A close-ended self-administered validated questionnaire in Persian language was distributed at local cafes and restaurants. Statistical analysis Data was entered in MS Excel Spreadsheet and descriptive statistics using SPSS version 21 were carried out. Results A total of 127 male Afghan tobacco users with mean age of 33.49± 11.97 years completed the questionnaire. Better work opportunities were the most common reason for migration. Most of them (69%) smoked tobacco and 15.5% used only Naswar. Half (52%) of the respondents continue to use tobacco products manufactured in Afghanistan with 62% procuring the product through social means (friends/family). On assessing barriers to tobacco use, majority (85%) found higher cost of tobacco products to be a deterrent while19% agreed lack of availability to be a barrier. 50% felt that law enforcement and tobacco use regulation in India curbed their tobacco use. Tobacco usage was a stress buster for 64% of the respondents. Although 72% were interested in quitting tobacco, 58% feared losing friends if they quit. Strikingly, 93% were unaware about the availability of cessation services. Conclusion Even as Afghans migrate from their homeland, they carry their cultural and social practices with them, including tobacco products, patterns and practices.

BackgroundIn England, many people of South Asian origin consume smokeless tobacco (ST). ST use can lead to oral cancer, which is disproportionately high in South Asians. Our aims were to assess the compliance of ST product retailers with statutory regulations and to explore the supply chain of ST.MethodsWe undertook a multimethods study between August 2017 and July 2019 in five English boroughs with a high proportion of ethnic South Asians. We purchased ST products and conducted field surveys with ST retailers at point of sale. Qualitative interviews were conducted with ST retailers and suppliers. ST packs were assessed for regulatory compliance, while quantitative and qualitative data triangulated information on retailers’ practices and the ST supply chain.ResultsWe collected 41 unique ST products, which included dry snuff, naswar, gutka, chewing tobacco and zarda. ST products were not registered, and demonstrated low compliance with health warning (14.6%) and packaging (56.1%) requirements. ST availability in surveyed boroughs was high (38.2%–69.7%); dry snuff, naswar and zarda were most commonly available. ST retailers demonstrated limited knowledge of regulations, and one-third were found to advertise ST at point of sale. Qualitative insights revealed illicit supply and distribution networks, as well as ST production in discreet locations.ConclusionST products are widely available in England, yet non-compliant with statutory regulations. In order to safeguard consumers, in particular ethnic South Asians, stronger efforts are needed to regulate the supply chain of ST at both national and international levels.

The aim of the study was to investigate the unstimulated whole saliva (UWS) tumor necrosis factor alpha (TNF-α) and cellular micronuclei in snuff dippers (Naswar) compared to healthy control subjects. The case control study was conducted over 9 months at a tertiary care center. Sixty patients were divided into two groups: Snuff dippers (SD) (Naswar) and non-snuff dippers (NSD) (control subjects). The included self-reported SD used Snuff twice daily for more than 12 months. UWS was collected and salivary TNF-α assessment was performed using enzyme-linked immunosorbent assay (ELISA). For cellular micronuclei, buccal mucosa was brushed to obtain cells in Naswar users, fixed with a dibutylphthalate polystyrene xylene (DPX) mounting to view micronuclei. Means and standard deviations were compared using the t-test and outcomes were related using Pearson correlation, considering p ≤ 0.05 as significant. The mean age of participants was 38.85 ± 11.56 years. The mean duration of snuff use was 20.43 ± 12.79 years and the common site for Naswar placement was the lower vestibule (n = 19, 63.3%). TNF-α levels among SD were 9.6 ± 3.3 pg/mL, which were significantly higher than levels in NSD, 5.2 ± 3 pg/mL (p &lt, 0.05). The number of cellular micronuclei in SD was 30.7 ± 7.8, which was comparatively higher than in NSD, which was 9.2 ± 3.3 (p &lt, 0.05). The duration of snuff use was positively correlated to TNF-α levels (p = 0.048) rather than the micronuclei number (p = 0.97). SD showed higher levels of TNF-α and cellular micronuclei compared with NSD (control subjects), a positive correlation was shown with the duration of snuff use. We conclude that TNF-α and micronuclei are potential salivary biomarkers for an oral biological effect in snuff (Naswar) users.

Salivary biomarkers can be used as diagnostic and predictive aids in early detection of oral cancer or potentially malignant disorders. A cross-sectional comparative study was conducted over a period of one year from August 2016 to August 2017 in a multicentre setting in Islamabad. A total of 60 patients were recruited and divided into two equal groups of naswar users and non-users. Un-stimulated saliva samples were collected and analysed by using an enzyme-linked immunosorbent assay (ELISA) technique. Data was entered in SPSS version 22.0. The results were then analysed by using independent t-test. Statistically significant difference was found regarding the levels of salivary IL-8 between the naswar users and non-users (p

Background: Although glue sniffing has been linked with significant morbidity and mortality, it is still under-researched and poorly recognized issue globally. Objective: A scoping review was performed to identify the factors and outcomes related to glue sniffing in India, Pakistan, Nepal and Bangladesh. Methods: Ten databases; Medline via Ovid, Google scholar, EBSCOhost (CINAHL Plus), ProQuest Central, PsycInfo, IndMED, Ovid Embase, Scopus, PubMed, and Science Direct were searched from their inception to January 2019 for both qualitative and quantitative studies examining any aspect of glue-sniffing. Studies published only in English language were included. Prevalence of glue-sniffing in SAARC region was the primary outcome measure. Findings: Of 8951studies screened, 344 were assessed for eligibility and 31 studies were included. The majority of the studies were conducted in India (15) and Pakistan (11). Meta-analysis of proportion, using random effects model, for both primary and secondary outcomes found that the highest incidence of glue sniffing was 57% (0.57, CI 95% 0.49-0.66) in India. The overall incidence of tobacco and naswar (snuff) as was 83% (0.83, 95% CI 0.80-0.86). Conclusions: The prevalence of glue sniffing, especially among street children, is alarmingly high and presents a challenge for health and social services for countries in SAARC region. More research work is required to examine long term impact of glue sniffing on physical and mental health.

There are many reasons why people use addictive substances including the euphoric and stimulating effects they have. This article introduces the addictive substances Paan, Naswar, nicotine, and other related products. It also deals with their use by people who are not aware of their addictive properties and use them for their side effects as mouth freshener and tasty and fragrant snacks. Furthermore, they are marketed in beautiful and attractive packages for various age groups, even children and adolescents (who inadvertently use them, without being aware of their effects and over time become addicted to them). Therefore, providing information to, and constant education of, target groups can be effective in improving the public health.

Objectives: Aim of our study was to assess the expression of salivary Interleukin 1-beta (IL-1β) and clinical periodontal parameters in naswar users and non-users (controls). Methods: Eighty four individuals (forty-two naswar users and forty-two controls) were included in the study which was conducted between August 2017 and May 2018. Salivary IL-1β levels, plaque index (PI), bleeding on probing (BOP), probing depth (PD) and clinical attachment loss (CAL) was assessed in all the participants. Results: PD of 4mm (p0.05). Conclusion: Periodontal inflammatory conditions were worse and salivary IL-1β levels were elevated in naswar users as compared to controls.

Introduction Provision of alternate livelihoods to smokeless tobacco (SLT) supply chain (SC) actors can help in curtailing SLT business and its consumption. We explored the reasons for SC actors’ engagement in Naswar (SLT used in South Asia) business and their willingness to switch to other alternatives. Aims and Methods We conducted an equal-status concurrent mixed-methods study in four districts of Khyber Pakhtunkhwa province of Pakistan. We surveyed 286 general points of sale (GPOS) and exclusive Naswar (EN) vendors through multistage cluster sampling. Additionally, we interviewed 15 tobacco farmers interpretively, being distinct from other SC actors. We assessed the association between vendors’ willingness to switch and their awareness about tobacco-harms, profit margin, Naswar as a family business, length of business, education level, and shop type using logistic regression. Qualitative data assessed the farmer’s viable alternatives to switch and were analyzed using deductive–inductive thematic analysis. Results Product demand—77% and profit margins—75% were the main drivers for selling SLT by EN vendors. Half of the GPOS and 25% EN vendors expressed willingness to stop Naswar’s sale. Vendors aware of tobacco-harms were more willing to switch, but less likely to switch if Naswar was perceived to bring “good profit.” Farmers were mainly cultivating tobacco because of profitability, family-run farm, and perceived land-suitability for tobacco. Lack of government support was main constraint for farmers looking to switch. Conclusions A considerable portion of Naswar SC actors in Pakistan are willing to switch to viable alternatives, with profitability of alternatives, support from authorities, and social obligations as key considerations in doing so. Implications This study highlights that good profit margins in the Naswar business, lack of awareness of tobacco-related health harms, and absence of the government’s support are key detriments to switching to alternative businesses among Naswar SC actors in Pakistan. These findings are the first to come out in the context of both Pakistan and Naswar product, making a case for policy interventions focusing on tax increases, awareness campaigns about tobacco-harms, and a proactive role by the government to provide support for the security of livelihoods to those tobacco SC actors who want to switch to other alternatives.

Background Smokeless tobacco (SLT) use is associated with multiple adverse health effects. It is prominent in Bangladesh, India, and Pakistan, but disparities in use within and across these countries are not well documented or understood. This study assessed the prevalence, patterns, and correlates of SLT use in these three countries. Method Data came from the Global Adult Tobacco Survey, a household survey of adults aged ≥15 years. Data were collected in 2014 (Pakistan), 2017 (Bangladesh), and India (2016–2017). Current SLT use (nasal or oral use) was defined as reported SLT use daily or less than daily at the time of the survey. Prevalence of both overall and specific SLT types were assessed. Multivariate logistic regression was used to assess correlates of SLT use. Results Overall, SLT use among adults ≥15 years of age was 20.6% in Bangladesh, 21.4% in India, and 7.7% in Pakistan, corresponding to 22.0 million SLT users in Bangladesh, 199.4 million in India, and 9.6 million in Pakistan. Among current tobacco users overall, the percentage of those who used SLT was 58.4% (CI: 56.0–60.7) in Bangladesh, 74.7% (CI: 73.4–76.0) in India, and 40.3% (CI: 36.2–44.5) in Pakistan. The most commonly used oral SLT product was Zarda (14.5%) in Bangladesh, Khaini (11.2%) in India, and Naswar (5.1%) in Pakistan. Females had greater odds of SLT use than males in Bangladesh, but lower odds of SLT use than males in India and Pakistan. In all three countries, the odds of SLT use was higher among those 25 years and older, lower education, lower wealth index, and greater exposure to SLT marketing. Conclusion An estimated 231 million adults aged 15 years or older currently use SLT in Bangladesh, India, and Pakistan, comprising 40.3%-74.7% of overall tobacco product use in these countries. Moreover, marked variations in SLT use exist by population groups. Furthermore, exposure to pro-SLT marketing was found to be associated with higher SLT use compared to non-exposed. It is important that tobacco control strategies address all forms of tobacco product use, including SLT.

ObjectiveTo obtain insights into the perceptions of barriers and facilitators to implementation of the WHO Framework Convention on Tobacco Control (FCTC) among smokeless tobacco (SLT) supply chain actors in the Khyber Pakhtunkhwa province of Pakistan.MethodsWe conducted a qualitative study to investigate the perceptions about SLT control policy formulation and implementation among exclusive Naswar sellers and point of sale vendors. We conducted five focus group discussions in three districts of Khyber Pakhtunkhwa using combined deductive-inductive thematic analyses.ResultsWe identified three central themes that potentially impact policy formulation, its implementation and application. The first theme examines the role of children in the Naswar business: as potential customers, and as potential heirs to a Naswar-selling business. A second theme targets the ‘business of Naswar’, which includes a specific identity of Naswar sellers, its potential to generate profits and the special case of Naswar regulation as a socially accepted and culturally rooted product. The third theme addresses the unusual ingredients of Naswar and its production process, making Naswar a health risk for consumers and producers. We also report conflicting views regarding SLT control among the supply chain actors.ConclusionsThis study provides insights into the perceptions of important SLT supply-side stakeholders regarding various SLT control policy options based on the FCTC. While there is some opposition to policy approaches like taxation and switching of business, implementing a ban on selling SLT to minors may be a viable option for policymakers in the short term.

Introduction Smokeless tobacco (SLT) is a significant contributor to tobacco-related harm in Pakistan but its control has lags behind that of combustible tobacco. We assessed the compliance of Naswar’s (a widely used SLT product in the Southeast Asia) packaging and sales practices with the national legislations and relevant articles of the WHO framework convention on tobacco control (FCTC). Aims and Methods A cross-sectional observational audit was conducted in three districts of Pakistan. We recruited 286 general point of sale (GPOS) and exclusive Naswar sellers (ENS) through a multistage cluster sampling strategy. Data were gathered on packaging and labeling practices of Naswar and advertisement and promotion practices inside and outside the shops. Statistical tests for association between the dependent variable-advertisement practices, and independent variables-area and vendor types were conducted. Results We analyzed 133 and 49 unique Naswar products sold in 229 GPOS and by 57 ENS, respectively. None of the local products had any written or pictorial health warning. More than half of retailers used one or two methods of advertising Naswar inside the shops while only 9% advertised outside the shops. ENS were more likely to be noncompliant with tobacco advertisement and promotion compared with GPOS. Conclusions The study presents first insights on the compliance of Naswar packaging and sale practices with local regulations and WHO FCTC provisions in Pakistan. Almost all products were on display in the shops and none of the local products had any health warning or contents disclosure on the packages. Implications Naswar is a form of SLT used extensively in Pakistan, Central Asia, and Pashtun populations across the globe. This study provides an important insight into the Naswar retail environment in a geographical setting where the use of Naswar is endemic. The study brings to fore previously unreported issues like an urban–rural disparity, and differences between exclusive and nonENS, with regards to Naswar advertisement and promotion. These findings have potential implication on the implementation of tobacco control retail policies. The lack of health warnings and free display of Naswar brands call for alignment of tobacco control efforts with the FCTC.

Genetic variations develop inherited tendency to progress cancer. The incidence rate of head and neck cancer (HNC) is 15–40% of all cancer types worldwide but this ratio is worse in South Asian region of Pakistan. We collected 185 samples and observed variations in IFNG, GTF2H4, OAS3 and SULF1 genes of HNC samples associated with tobacco, betel leaf and nuts, naswar and gutka. We performed the tetra-arm PCR and found significant allelic associations of IFNG rs11177074 (P = 0.001135), GTF2H4 rs2894054 (P = 0.0001), OAS3 rs12302655 (P = 0.000001) and SULF1 rs4737999 (P = 0.00001) with HNC. The cancer and control samples were in Hardy–Weinberg equilibrium and the pooled odds ratios was 95% of confidence. Tobacco and naswar was progressive factor of HNC compare to betel leaves and nuts. The irrational habits of population of the Southern Punjab is bringing a substantial change in SNPs and therefore these variants could be used as genetic biomarkers to diagnose HNC.

In Pakistan, extensive use of several precarious chewable tobacco formulations has made oral cancer the second leading malignancy. Selection of literature was done by a survey of studies published from 1990 to 2017 mainly, from PUBMED and few from other search engines, on naswar, gutka, areca nut and betel quid, which included published reviews, original articles and other data sources on chewable tobacco, its epidemiology, pathological implications, and psychological effects. These studies have revealed that the chemicals in these formulations bind and mutate DNA of oral mucosa through down regulating cellular repair pathways and upregulating genetic networks associated with pathogenesis. Areca nut, having aercoline (the major alkaloid) causes carcinogenicity, mutagenicity, and genotoxicity of oral mucosa through increased production of growth factors and corticotrophin-releasing hormone, and genetic alteration in expression of CASP8, APAF-1, BAX, BAD, and upregulation of caspas-3. Gutka addiction leads to precancerous lesions resulting in characteristic facial abnormalities, following trismus. Naswar, in addition to oral cancer, causes adverse cardiovascular events by reducing glutathione per oxidase (GPx) and super-oxide dismutase (SOD), serum levels of HDL, whereas, increasing the ratio of cholesterol, LDL, triglycerides and LDL-C/HDL-C. Betel quid (Paan), causes psychoactivity affecting central and autonomic nervous systems leading to dependence with decreased cognition, euphoria, sweating, salivation, palpitation, heightened alertness and zest to work. Metabolically, cardio-acceleration, cortical desynchronisation of EEG, elevated plasma noradrenaline and adrenaline were found. This review highlights the corrosive effects of various most popular chewable tobacco formulations; and damage done by their cocktail of carcinogenic substances and added ingredients, leading to oropharangeal cancer.

Tobacco use remains a major cause of preventable morbidity and mortality worldwide. The World Health Organization states that 19.1% of the Pakistani population consumes smoked or smokeless tobacco (SLT). Although many population focused studies have focused on the use of SLT in Pakistan, but they have failed to address the use of SLT among laborers, especially the niche population of public and heavy load drivers (that is, transporters). This study aimed to estimate the prevalence of SLT consumption among this population and the relationship of this parameter with knowledge, attitudes, and practices regarding SLT use. From a sample size of 714 participants, 615 responses were obtained, generating an overall response rate of 86%. The prevalence of SLT consumption in the study population was 93.7%; here, gutka was the most frequently consumed preparation (60.2%), followed by naswar (35.8%), paan (32.4%), and Mawa (16.7%). A masticatory habit was the most commonly cited factor leading to dependence (87.8%), followed by the influence of friends and family (83.9%), peer pressure (80.7%), and increased alertness (52.8%). However, 61.3% of participants reported experiencing strong withdrawals upon ceasing SLT use and believed themselves to be addicted and unable to quit usage. These findings suggest that for transporters, a high-risk occupational group dependent on SLT consumption, specific, tailored tobacco-cessation programs and medical assistance are needed to reduce the burden of tobacco-related morbidity and mortality. Key words: Smokeless tobacco (SLT), tobacco use, gutka, heavy load and public drivers, transporters, Karachi.

Background and Objective The aim of the present study was to compare clinical periodontal parameters and to assess the release of C-telopeptides pyridinoline cross-links (ICTP) and C-terminal crosslinked telopeptide (CTX) from gingival collagen of naswar (NW) and non-naswar (control) dippers. Material and Methods Eighty-seven individuals (42 individuals consuming NW and 45 controls) were included. Clinical (plaque index, bleeding on probing, probing depth and clinical attachment loss) and radiographic (marginal bone loss) periodontal parameters were compared among NW and control groups. Gingival specimens were taken from subjects in NW and control groups, assessed for ICTP and CTX levels (using ELISA) and analyzed using micro-Raman spectroscopy. The significance of differences in periodontal parameters between the groups was determined using Kruskal-Wallis and Mann-Whitney U tests. The percent loss of dry mass over exposure time and the rate of release of ICTP and CTX from all groups were compared using the paired t-test to examine the effects of exposure time. Results Clinical and radiographic periodontal parameters were significantly higher in the NW group than the control group (P

Nicotine is the principal addictive agent present in Naswar, a smokeless dipping tobacco product. 5-Hydroxytryptamine (5-HT) has been implicated in the reinforcement properties of nicotine. Also, the hypothalamic-pituitary-adrenal (HPA) axis is of vital importance in evaluating the response to stress and nicotine addiction. The study aimed to evaluate serum tryptophan and cortisol levels in Naswar users in relation to addiction. Additionally, serum cotinine levels were also determined to assess daily nicotine exposure. The study comprised 90 healthy Naswar users and 68 non-tobacco users. Estimation of serum cortisol, tryptophan and albumin was carried out. From the Naswar user group, 20 were selected for the estimation of serum cotinine for which blood was drawn twice first in the morning and then in the evening. Serum tryptophan and cortisol levels in Naswar users were significantly raised compared to the control group. However, no difference in the levels of albumin between Naswar users and the control group were found. The mean cotinine values rose from the morning value of 366.0 ± 40.69 ng/ml (mean ± SEM) to an evening value of 503.1 ± 42.96 ng/ml that in turn is equivalent to consumption of 40 cigarettes. Elevated cortisol levels might constitute an important aspect of Naswar addiction. Additionally, raised levels of serum tryptophan in Naswar users could lead to raised concentration of 5-HT which also might be a significant factor contributing to Naswar addiction. Also, serum cotinine concentrations equivalent to an intake of about 40 cigarettes per day is quite alarming.

Objectives: To explore what naswar (smokeless tobacco) users know aboutthe effects of naswar on their oral and general health. Methods: This cross sectional surveywas undertaken in the city of Peshawar, Pakistan. Sample size of 96 participants based on 95%C.I with interval width of 10% was used for this study. Only male naswar users were included.Keeping in mind the resources and time constraints the participants were purposely sampled.All the participants were consented before being included in the sample. Survey tool whichincluded open, closed and semi structured questions was self-administered. Findings: 42.7%(95% CI: 32.8-52.6%) of the respondents considered naswar, either harmless or resultingin minor side effects. There was lack of awareness of the existence of oral and lung canceramong a significant proportion (41% with 95% CI: 31.8-58.5%) of participants. In response toa question about harmful effects of naswar use, vast majority of the respondents mentionedone or the other form of oral (non serious) or tooth problems. Only 10.41% (95%CI: 4.3-16.5%)mentioned its association with cancer and none mentioned about the risk of cardiovasculardisease. Conclusion: Our survey appears to indicate that level of awareness of naswar usersin Peshawar is poor. We recommend to the government of NWFP to make an effort to educatethe people about the harmful effects of naswar use.

Background: Head and neck cancer is the most common malignancy in Sindh, Pakistan. The type of cancer can be observed in the oral cavity, lips, buccal mucosa, oropharynx, hypopharynx, nasopharynx, the floor of the mouth and hard palate in Sindh. Objectives: The present study was conducted at the Nuclear Medicine Oncology and Radiotherapy Institute Nawabshah (NORIN), Sindh, with the objective of reviewing descriptive epidemiological characteristics and incidence of head and neck cancer in this rural area. Methods: In this study, we divided head and neck cancer patients according to their gender, age, districts, tumor location, probable causative agents, and stage of cancer when they had been admitted to the Radiotherapy Department of NORIN. Results: In total, 1,030 patients were registered during the study period from January 2012 to December 2016, comprising 56% males and 44% females. The most common site of the head and neck tumors was the oral cavity (58%), followed by the tongue, tonsil, floor of the mouth, gum, hard palate, soft palate, and lips. Other sites of head and neck cancer were hypo-pharynx, nasopharynx, salivary gland, parotid gland, oral-pharynx, and lyrnx. Most patients came in NORIN at stage III and stage IV of their disease and most of them were at the age of 40 - 85 years. Most patients were the residents of Nawabshah and neighboring districts. Conclusions: Head and neck malignancy was the most common type of cancer registered in NORIN in the last five years. Because of the lack of awareness, education, and diagnostic facilities, most patients start cancer treatment at later stages of the disease, which makes it very difficult to cure. Smoking and the use of alcohol, Gutka, Supari, Naswar, Man-Pori, etc., are the main causes of head and neck cancer.

Objectives: Aim of our study was to assess the expression of salivary Interleukin 1-beta (IL-1β) and clinical periodontal parameters in naswar users and non-users (controls). Methods: Eighty four individuals (forty-two naswar users and forty-two controls) were included in the study which was conducted between August 2017 and May 2018. Salivary IL-1β levels, plaque index (PI), bleeding on probing (BOP), probing depth (PD) and clinical attachment loss (CAL) was assessed in all the participants. Results: PD of 4mm (p0.05). Conclusion: Periodontal inflammatory conditions were worse and salivary IL-1β levels were elevated in naswar users as compared to controls. doi: https://doi.org/10.12669/pjms.35.3.10 How to cite this:Abbasi ZA, Hadi NI, Zubairi AM, Hosein M. Salivary Interleukin 1-beta levels and clinical periodontal parameters in habitual naswar users and non-users. Pak J Med Sci. 2019;35(3):674-679. doi: https://doi.org/10.12669/pjms.35.3.10 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Esophageal squamous cell carcinoma (ESCC) is one of the aggressive malignancies and mechanisms underlying its pathogenesis remain unclear. Cyclooxygenase-2 (COX-2) enzyme system plays a crucial role in many gastrointestinal malignancies and is an important regulator of cell growth, proliferation, apoptosis, differentiation and transformation. More precise outcome of COX-2 in ESCC is less investigated. In this study we investigated the risk factors of ESCC and expression of COX-2 in Carcinoma in situ (CIS) and ESCC compared to normal esophageal mucosa. ESCC relationship to clinico-pathological parameters using immunohistochemistry was also part of this investigation. Current study was conducted in the Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan. A total of 69 diagnosed patients of ESCC, both Pakistanis and Afghans were enrolled. Various risk factors associated with ESCC were recorded. Mean age at the time of diagnosis was 55 years. Out of 69 patients of ESCC 46 (67%) were users of dipping tobacco (Naswar). Expression of COX-2 was determined in normal esophageal mucosa, CIS and invasive ESCC using Immunohistochemistry (IHC). Differences of mean were computed using ANOVA followed by applying Post Hoc test. Patients were categorized as positive with high expression or negative with low to nil expression. ANOVA showed large differences in expression of COX-2 in normal healthy mucosa compared with CIS and ESCC with the mean difference of -9.529 and -7.370 respectively, p-value being .05 at 95% CI. Our complete cohort (23-85 years) showed statistically significant difference in the expression of COX-2 gene in ESCC and CIS tissue samples compared with normal healthy mucosa. Results of this study indicate that over-expression of COX-2 is positively associated with ESCC.

Objectives To compare self-perceived oral symptoms and clinical (plaque index [PI], bleeding on probing [BOP], clinical attachment loss [CAL]) and radiographic (marginal bone loss [MBL]) periodontal parameters among naswar (NW) and non-naswar dippers (NNW). Methods One hundred and forty-two individuals (72 patients consuming naswar and 70 controls) were included. All participants completed a baseline questionnaire that included information regarding demographic characteristics and self-perceived oral symptoms. Clinical periodontal parameters (PI, BOP, PD and CAL) were recorded. MBL was measured on digital panoramic radiographs. Results Pain in teeth, pain on chewing, bleeding gums and burning sensation in the mouth was significantly worse among NW than NNW (p 6 mm) and MBL among NW group. Conclusions Self-perceived oral symptoms and periodontal parameters were worse among naswar dippers. It is highly recommended that naswar dipping should be considered a potential threat that could have major effects on periodontal tissues.

The incidence and prevalence of oral precancerous conditions and lesions is very high in various parts of India, especially Central India. Most commonly seen oral pre cancerous conditions here include oral submucous fibrosis (OSMF), leukoplakia, oral lichen planus (OLP) and erythroleukoplakia. Facts and figures about these conditions such as aetiology, clinical features, signs and symptoms, staging, rate of transformation from precancer to cancer and high number of affected population are well documented in literature. The health care fraternity, chiefly the dentists, oncologists, ENT specialists and even physicians also have in depth knowledge of these conditions. However general population remains largely unaware about the concept of oral precancer. Often individuals with precancer even notice the alterations, such as reduced mouth opening in OSMF, but they are not aware about the causes and consequences of these changes. Awareness about oral precancers causes and features can be very helpful in prevention, control and early diagnosis of oral cancer. India has been proactive in initiating many campaigns for public awareness, habit cessation along with legislations against availability of causative agents of oral cancer. These campaigns mainly advise against the use of alcohol, tobacco and tobacco preparations such as cigarettes, bidi, gutkha etc.; by drawing attention to the fact that a frequent consequence of such addictive habits is oral cancer. The warnings issued by means of televised infomercials, hoardings and on commercial packaging’s of tobacco products mostly depict graphic images of advanced stages of cancerous lesions, however not much of an emphasis is laid on the possibility of occurrence of oral precancer and its appearances. Similarly somewhat inadequate warnings are issued regarding usage of many other potentially harmful products and preparations, which are widely available and consumed by the population. An important example of such prospectively harmful preparation is –Kharra -a local product commonly consumed in Central India which is a smokeless, chewable combination of tobacco, beetle nut and lime. Kharra consumption is a remarkably frequent and regular addictive habit amongst precancer patients in central India. Other such products include beetle nut, arecanut, lime, catechu, preparations such as pan quid (beetle leaf), pan masala, jarda, khaini, hookah, snuff, naswar etc. The general population is largely unaware about the plausible association of kharra, beetle nut and many such products with oral precancer and cancer. There are also many self-perceived notions and misconceptions the populace has about the use of these substances. Some of the common mistaken beliefs are: (a) Tobacco, beetle nut etc.; consumed regularly but in self perceived, small quantities are not harmful; rather they may be helpful in improving digestion, increasing concentration and even in pain relief (b) Only smoking is harmful and chewable forms do not posses any threat (c) these products may be harmful only in the old age and not the young (d) quantity of tobacco in kharra and pan quids is very less to cause any potential harm (e) beetle nut/arecanut and beetle leaf (pan) are used in many Hindu religious customs, so a great part of the population does not envision any probable disadvantages from consumption of these products. Other challenges in habit cessation include psychological dependence, withdrawal symptoms and unavailability of guidance for structured de addiction. If the population is made aware of the precancerous conditions and lesions and it may be very helpful in prevention, control and early diagnosis of oral cancer. Early detection and management of oral pre cancer and cancer results in a better prognosis. There is an alarming lack of awareness about oral precancer, due to this gap in knowledge the affected individuals do not seek treatment in the early stages of the disease [1]. Deducing from already established facts in the literature and from ongoing doctoral project, I would like to put forth certain suggestion which may be further helpful in enhancing the effectiveness of existing programs and implementation of newer policies to increase the awareness about oral pre cancer and thus prevent any eventual development of oral cancer; The conditions under the umbrella of oral precancer should also have easy to use names in local vernacular languages instead of the currently used long and difficult to remember medical terminologies and nomenclature which are difficult for general population to follow. Information about potentially harmful causative agents, products, preparations / mixtures, signs, symptoms, clinical features, self-examination methods and possible transformation of these precancerous conditions in to cancerous conditions should be highlighted for the population. Examples of such initiatives is the information being provided for conditions like diabetes, dengue, swine flu etc. which makes it easier for the patients to notice developments in the initial stages and seek help for the same. Infomercials should not only highlight advanced stages of cancer as they mostly do at present but also draw attention towards precancerous conditions and their appearances. Specially designed programs should be initiated for school going population, adolescents and young adults, as it is observed that, these age groups are vulnerable to addiction of aforementioned high risk products and they gradually progress from one product to another. e.g. Fennel chewer gradually starts consuming beetle nut then kharra, gutka and progresses to more concentrated preparations of smokeless or smoking forms of tobacco. Professional establishments; where it is now a known fact that the employees tend to consume addictive products as a result of work stress should adopt policies such as no tobacco in the premises/on duty and should provide facilities for regular oral health checkup, cessation counseling and NRTs. Common examples of such vocations in India include factory workers, workers of night shifts, drivers of transport corporations etc. Number of centers providing habit cessation, de addiction counseling facilities should be increased. Similarly number of telephonic hotlines providing information about the conditions and cessation should also be increased. Such avenues must be able to help users from all age groups and socio economic back grounds. It is commonly observed that the dentists, physicians many times refrain from counseling or informing the individuals with oral precancer, users of tobacco, beetle nut etc. about impending dangers. Such counseling is a known to promote habit stoppage and thus further hazardous consequences. Health care workers must be trained in conducting such cessation sessions. Attention must also be given to eradicate the misconceptions about usage of such products. Awareness and knowledge about oral precancer and potentially malignant disorders and their risk factors is crucial for prevention and early detection of oral cancer [2]. There is lack of published data available on this aspect in the context of Indian population thus highlighting the need of further studies to be carried out in this direction.

The aim of the present split-mouth retrospective study was to compare the clinical periodontal parameters among gutka-chewers and naswar-dippers.A structured questionnaire was used to record demographic information. Jaw quadrant in which, gutka or naswar were placed were defined as "test-sites". The remaining jaw quadrants were designated as "control-sites". Clinical [plaque index (PI), bleeding on probing (BOP), probing pocket depth (PPD) and clinical attachment loss (CAL)] and radiographic [alveolar bone loss (ABL)] parameters were compared among gutka-chewers and naswar-dippers in the test- and control sites. Data were analysed using non-parametric Wilcoxon signed rank test followed by post hoc analyses with the Bonferroni correction. p .05 were considered statistically significant.Seventy-five gutka-chewers and 72 naswar-dippers with mean ages of 45.2 ± 0.8 years and 47.3 ± 2.8 years, respectively were included. Gutka-chewers and naswar-dippers were consuming their respective smokeless tobacco product 10.2 times and 8.5 times daily for 15.1 ± 2.7 and 12.3 ± 3.4 years, respectively. Among gutka-chewers and naswar-dippers, scores of PI, BOP, PPD ≥4 mm, CAL and ABL were significantly higher in the test-sites compared with their respective control-sites (p .01).Periodontal inflammatory parameters were poorer in the test-sites among gutka-chewers and naswar-dippers compared with the control-sites.

Introduction With an annual increase of 16000 new cases each year, oral cancer is the second most common cancer in Pakistan. There is conflicting evidence regarding the carcinogenicity of different forms of smokeless tobacco (SLT) from different countries. This difference in evidence may be attributed to the varied composition of SLT products used around the world, necessitating the establishment of individual risks related to each SLT product. Methods An electronic search in relevant databases yielded 119 publications, out of which six were included in this review. Effect estimates (odds ratios (ORs)) were abstracted or calculated from the given data. A fixed effects meta-analysis was performed to assess the risk of oral cancer with the use of Naswar. Population attributable fractions (PAF) were also calculated. Results The Meta Odds Ratio (mOR) for oral cancer associated with the "ever use" of Naswar compared to "never use" was 11.8 (95% CI = 8.4-16.4), I2 = 67%. The pooled estimate for oral cancer in "Ever-users" of Naswar compared to "Never-users," in the Khyber Pakhtunkhwa province was 18.3 (95% CI = 8.7-38.5), I2 = 0%. The PAF for oral cancer associated with the use of Naswar in Pakistan was 44% (95% CI = 35-53). Discussion This review highlights a strong relationship between oral cancer incidence and the use of Naswar in Pakistan and adds to the evidence base on the carcinogenicity of SLT products in humans. Although the synthesized evidence may not be of a high quality, it represents the "best available evidence" which can be used to inform policy. Implications The carcinogenicity of Naswar, a form of smokeless tobacco used extensively in Pakistan, Afghanistan, and Central Asia, has yet to be recognized by the International Agency for Research on Cancer (IARC), partly due to the lack of evidence on the association of Naswar use and cancer. Additionally, Naswar is yet un-regulated in Pakistan and evades the tax net, resulting in it being freely available to both adults and children at very cheap prices compared to cigarettes, which has been the main focus of tobacco control in Pakistan. This review provides ample evidence for the IARC to declare Naswar as carcinogenic, as well as the Government of Pakistan to regulate the production and sale of Naswar.

Oral cancer (OC) is highly prevalent worldwide with significant mortality and morbidity. An individual inflicted by this disease may experience devastating consequences such as disfiguring of the face after surgery and possibly an inability to take food through the oral cavity and disruption of normal speech. Smoking, alternate chewing habits, and alcohol are major risk factors. Other factors include high-risk HPV, diet, oral hygiene, and socioeconomic status. In the West, cigarette smoking and alcohol are the key risk factors. Betel quid (areca nut; major component) and its related products are chewed commonly in many parts of the world, being most prevalent in the Asian continent. More than 600 million people are known to chew betel quid worldwide. Unlike tobacco smoking, betel quid is culturally well accepted and openly consumed by all strata of society. Other commercially distributed products include gutka and naswar which almost always contain a significant component of chewable tobacco and are easily available and consumed widely by both adults and children. On the face of such high burden of OC, there is an urgent need to implement control on these products. Screening methods may also be implemented for high-risk populations, keeping in mind the cost and resources involved.

Tobacco products which are used in a way other than smoking are known as smokeless tobacco. The most common smokeless tobaccos are chewing tobacco, naswar, snuff, snus, gutka, and topical tobacco paste. Any product which contains tobacco is not safe for human health. There are more than twenty-five compounds in smokeless tobacco which have cancer causing activity. Use of smokeless tobacco has been linked with risk of oral cancer. Smokeless tobacco contains tobacco-specific nitrosamines (TSNAs), polonium, formaldehyde, cadmium, lead, and benzo[a]pyrene, which are carcinogenic agents. Although there is presence of some compounds, carotenoids and phenolic compounds, that have cancer inhibiting properties, they are in low concentrations. Dry snuff use is linked with higher relative risks, while the use of other smokeless tobacco is of intermediate risk. Moist snuff and chewing tobacco have a very low risk for oral cancer. Therefore, from this review article, it was concluded that smokeless tobacco has risk for oral cancer - either low, medium or high depending on the balance between cancer causing agents and cancer inhibiting agents.

Various forms of tobacco available are Beedi, Cigars, Cigarettes, Creamy snuffs, Dipping tobaccos, Gutkha, Hookah, Kreteks, Roll-Your-Own Pipe, smoking, Snuff, Snus. The most common smokeless tobacco products are chewing tobacco, naswar, snuff, snus, gutkha and topical tobacco paste.A pre-packaged mixture of areca nut, tobacco, slaked lime, catechu, and flavoring agents is popularly known as Gutkha.Gutka, a dry preparation commercialized since 1975, containing areca nut, slaked lime, catechu, condiments and powdered tobacco, was originally available custom‐mixed from pan vendors. For the last couple of decades, gutka has been available in several brands. A similarly packaged mixture without tobacco, often with an identical brand name, is called pan masala. Oral cancer is one of the most common non-communicable diseases worldwide with an estimated increase of 275,000 new cases each year (Warnakulasuriya, S.: 2009). Oral cancer is the term used for cancers that form in tissues of the oral cavity (the mouth) or the oropharynx (the part of the throat at the back of the mouth). These along with other head and neck cancers are the sixth most prevalent type of cancer in the world and one of the leading causes of death in developing countries. (A Jemal,. et al.: 2011)This sociological study aims at to explore the causative factors associated with gutkha addiction and to know whether the addicts know the composition of gutkha and whether aware of health problems arising out of gutkha addiction.

Background Naswar is a type of finely ground, moistened smokeless dipping tobacco product being commonly used in Pakistan. Although, nicotine is the most important psychoactive agent present in Naswar, it also exerts immunosuppressive effects and could alter the levels of cytokines. Additionally, the effects of Naswar consumption on thyroid hormones are not known. Methods Eighty healthy males aged 16–43 years were selected for the study and were divided into a control group comprising 31 healthy subjects with no history of tobacco use in any form, with age matched test group comprising 49 exclusive Naswar users who were consuming Naswar for at least 1 year. Estimation of serum interleukin (IL)-1β, IL-6, free thyroxine (FT4), free triiodothyronine (FT3) and thyroid stimulating hormone (TSH) was carried out. The data was analyzed by statistical programme (SPSS) using student's independent samples t-test. One way Anova followed by post hoc Tukey test was applied to assess parameters in Naswar users grouped according to duration of Naswar usage. Pearson’s correlation coefficient was applied to assess correlations between parameters. Results IL-1β was found to be significantly lowered in Naswar users compared to the control group whereas serum FT3 and FT4 levels in Naswar users were significantly raised compared to the control group. However, no differences in the levels of serum IL-6 and TSH between Naswar users and the control group were found. Also, serum FT3 and FT4 were consistently raised whereas IL-1β was lowered in Naswar users irrespective of duration of Naswar consumption. IL-1β was negatively correlated with FT3 in Naswar users. Conclusion The findings suggest that Naswar users might be in an immune suppressive state as evident by the lowered levels of interleukin 1β. Additionally, alterations in the levels of thyroid hormones signify the impact of Naswar consumption on thyroid function.

Aim: To determine the subjective quality of sleep among temporarily employed individuals at high altitude and analyze the factors associated with poor sleep quality. Study design: Descriptive cross sectional study Subjects and Methods: The sample population comprised of men living at a height of 4500 meter or more above sea level at Karakorum ranges in periphery of district Skardu for more than one month and less than three months and having normal BMI and good sleep quality at sea level. Quality of sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI). Relationship of Age, altitude, smoking, use of naswar, Frequent awakenings during the night, temperature-related discomfort, multiple calls for toilet, environment related issues (too many people in one room, snoring of companion, untidy room), uncontrollable worry, and breathing difficulties was assessed with the sleep disturbances. Results: A total of 103 men with good sleep quality at sea level when screened through the PSQI were included in the final analysis. Out of them, 39.8% persisted with good sleep quality, while 60.2% had poor sleep quality at HA. After applying the logistic regression we found that smoking, frequent awakenings, uncontrollable worry and breathing difficulties had significant association with poor sleep quality at HA. Conclusion: This study showed a high prevalence of poor sleep quality among individuals at high altitude. Special attention should be paid to smokers and those who suffer from breathing difficulties or remain worried or anxious most of the times.

Tobacco is being used in various forms including cigarette, shisha, cigar and bidi smoking and smokeless tobacco. Smokeless tobacco constitutes various forms of tobacco i-e paan/ betel quid, tobacco with lime, naswar, gutka, qiwam, tobacco tooth powder, minpuri, areca nut (supari) [1,2]. Qiwam consists of thick paste of boiled tobacco mixed with powdered spices such as saffron, cardamom, aniseed and aroma, while paan/ betel quid is a mixture of the leaf of the Piper betle vine, aqueous calcium hydroxide paste [slaked lime] [1,2]. Smokeless tobacco is commonly used in South Asia, where it has become part of South Asian culture. Furthermore, South Asia is a major producer and exporter of tobacco and over one-third of tobacco consumed in South Asia is smokeless [2]. Traditional forms like, tobacco with lime; betel quid and tobacco tooth powder are commonly used among South Asian population [2]. With the passage of time, tobacco usage is increasing not only among men but also among women of reproductive age, children, teenagers, medical and dental students [2].

Oral cancer is one of the most common cancers in Uzbekistan and is appeared to be most common cancers worldwide. All forms of tobacco have been implicated as causative agents including cigarette, cigar and pipe tobacco, as well as chewing tobacco. It is important to differentiate between conventional loose leaf (traditional) forms of smokeless tobaccos and the newer types such as snus, there is a significant difference in risk. Gingival inflammation, periodontal inflammation, and alveolar bone damage, dental caries, tooth abrasion, and dysplasia and oral squamous cell carcinoma (SCC) are all associated with smokeless tobacco use. Tobacco can damage cells in the lining of the oral cavity and oropharynx, causing cells to grow more rapidly to repair the damage. Researchers believe that DNA-damaging chemicals in tobacco are linked to the increased risk of oral cancer. However, the minimal risk for oral cancer is associated with SLT use.

Background Naswar is a niche smokeless tobacco product from Pakistan. There is little information about its availability and user characteristics. Methods This cross-sectional survey identified outlets selling Naswar in two wards of one London borough and interviewed a purposively recruited sample of 73 Naswar purchasers. Data were analysed using descriptive and chi-square tests (significance, P 0.05). Results Of 65 outlets identified 15 sold Naswar. The purchasers’ mean (SD) age was 32 (+10) years and 63% had completed only secondary education. Naswar consumption was significantly associated with tobacco dependency, whilst starting Naswar use at a younger age, having lower education levels, using Naswar more frequently and being of Pakhtunkhwa origin was associated with high monthly consumption (P 0.05). Conclusions Naswar was widely available. Naswar purchasers of Pakistani origin were employed and young, but with limited education and little knowledge of Naswar’s health impacts. Naswar dependency and consumption was linked to behavioural and socio-demographic factors. Further evidence is needed to support policy development.

A Working Group of the Monographs programme of the International Agency for Research on Cancer has classified smokeless tobacco as carcinogenic to humans (Group 1). This review article summarizes the data that support the evaluations of sufficient evidence in humans and in experimental animals for the carcinogenicity of smokeless tobacco whether used alone or with betel quid. It also identifies compounds of smokeless tobacco relevant to carcinogenicity (prominently tobacco-specific nitrosamines) and addiction (nicotine). The epidemiological evidence is summarized for oral cancer, other cancers associated with smokeless tobacco and oral potentially malignant lesions with a focus on analytical studies from the SEARO Region. Studies on cancer in experimental animals are summarized with a focus on studies applying smokeless tobacco products typical for the regions, such as mishri and naswar.