Document Type: Research Articles
Public Health Foundation of India, Gurugram, National Capital Region, India.
Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA.
Background: We analyzed in detail the studies utilized in most recent global systematic review of risk of cancer
mortality with smokeless tobacco (SLT) use to report challenges in the available data that limit the understanding of
association between SLT use and cancer mortality. Methods: For each study, we documented study design, reporting of
mortality risk by type of SLT variant, SLT use frequency, and sex of SLT user for oral, oesophageal, pharyngeal, laryngeal
and orolaryngeal cancers. These findings are discussed within the context of prevalence of SLT use by geographic regions
and sex. Results: Majority of studies reported mortality risk for oral (70.6%) followed by oesophageal cancer (38.2%).
The availability of population-based evidence was low (35.3%). The geographic distribution of studies did not reflect
the geographic distribution of countries with high SLT consumption; 61.8% of the studies were from India followed by
Sweden (20.6%). Hospital-based (84.2%) studies reported risk with chewing tobacco and the population-based studies
(61.5%) with non-chewing tobacco. Hardly any study reported on a particular type of SLT. Definition of SLT use as
current, ever or former was limited without consideration of the wide variations in frequency and duration of use within
these patterns. Mortality risk reporting for males dominated all cancers other than oral (50% males). Conclusions:
Unless the methodological and generalizability challenges identified in this review are addressed in future research
to develop a stronger scientific basis of the association of SLT use and cancer mortality, we would continue to face
significant challenges in monitoring the health effects of SLT.