Background
Methods
Inclusion and exclusion criteria
Data sources and search strategy
Article selection and screening
Quality assessment
Data extraction and synthesis
S.No. | Author Year of publication | Country | Methodology Data collection method | Sample characteristics | Response (rate %) | ||||
---|---|---|---|---|---|---|---|---|---|
Sample size | Ethnic group | Gender (%) | Socio-economic status (as reported in study) | Age range (years) | |||||
1 | Summers et al. 1994 [37] | UK | Quantitative home-based structured interviews | 296 | Bangladeshi | F = 100 M = 0 | Low | 25–68 | 98.6 |
2 | Pearson et al. 1999 [38] | UK | Quantitative Questionnaire | 158 | Bangladeshi | F = 42 M = 58 | NRª | 40–83 | 85 |
3 | Shetty et al. 1999 [27] | UK | Quantitative Questionnaire | 367 | South Asians (Indian, Pakistani, Bangladeshi etc.)- percentage not reported clearly | M = 56.1 | Low-middle | 16–65 | NR |
4 | Khan et al. 2000 [39] | UK | Quantitative Questionnaire | 390 | Indian (21.5%), Pakistani (4.3%), Bangladeshi (9.2%) | F = 83.8 M = 16.2 | Low-middle | > 16 (Median age = 44) | NR |
5 | Vora et al. 2000 [28] | UK | Quantitative Questionnaire | 524 | South Asians (Indian, Pakistani, Bangladeshi, Sri Lankan)- percentage not reported | M = 100 F = 0 | Low | 16–87 | NR |
6 | Prabhu et al. 2001 [26] | UK | Quantitative Questionnaire | 204 | Bangladeshi | M = 51.5 | Low | 12–18 | 70.0 |
7 | Changrani et al. 2006 [21] | USA | Pilot study (quantitative) Questionnaire | 138 | Indian (30.4%) Bangladeshi (69.5%) | M = 55.79 | Low-middle | > 18 | 96 |
8 | Croucher et al.2011 [40] | UK | Quantitative Structured interviews | 369 | Bangladeshi | M = F | NR | > 30 | 77 |
9 | Siddique et al. 2013 [41] | UK | Quantitative Questionnaire | 96 | Indian-Gujarati | M = 53.1 | NR | 16–81 | 100 |
10 | Lokhande et al. 2013 [22] | New Zealand | Qualitative Semi-structured interview | 10 | South Asians (Indian = 90%, Pakistani = 10%) | M = 100 F = 0 | NR | 18–67 | NR |
11 | Banerjee et al. 2014 [23] | USA | Qualitative 6 Focus groups | 39 | Indian(38.5%), Pakistani(28.2%), Bangladeshi(33.3%) | M = 87.2 F = 12.8 | NR | 25–71 | NR |
12 | Hrywna et al. 2016 [42] | USA | Qualitative 8 Focus groups | 78 | South Asians (Indian = 83.3%), | M = 60.3 | NR | 18–67 | NR |
13 | Merchant et al. 2016 [24] | UK | Quantitative Questionnaire | 201 | South Asians (Indian = 77%, Pakistani = 16%, Bangladeshi, Sri Lankan, Malaysian-Indian) | M = 61 | NR | 18–44 | NR |
14 | Shi et al. 2017 [43] | USA | Quantitative Questionnaire | 73 | South Asian (12.3%) Rest (Other countries) | M = 50.7 F = 49.3 | NR | 37.67 | 54.8 |
15 | Mukherjea et al. 2018 [44] | USA | Quantitative (2004 CAITUS survey data) | 1618 | Asian Indians In California | NR | Middle | > 18 | NR |
16 | Petti et al. 2018 [25] | Italy | Quantitative Interviews using questionnaire | 211 | South Asians (Indian = 17.5%, Pakistani = 40.3%, Bangladeshi = 26.1%, Sri Lankan = 16.1%) | M = 100 F = 0 | NR | 18–73 | 72 |
S.N. | Author Year of Publication Study design | Findings | Quality Rating (scores in %) | ||
---|---|---|---|---|---|
Knowledge | Attitudes | Practices | |||
1 | Summers et al. 1994 [37] Cross sectional study | • 62% perceived pan chewing practice as good, 20% as bad, 13% ‘neither good nor bad’ and 5% ‘did not know” • Participants frequently unaware of their oral condition as well as the harmful effects of Pan | • 4% stated that pan chewing was just a habit and 22% claimed that it was pleasant and refreshing. • 12% claimed that it was good for teeth and gums. 11% thought it “aided digestion” and 6% considered that it relieved pain and had an anti-inflammatory effect. • Believed that it made lips attractive (red) • Pan used in Social gatherings, auspicious occasions and etiquette. | • > 16 quid daily use among heavy pan chewers • Tobacco was employed in smoking, pan chewing and for oral hygiene purposes • 59% women claimed that they spat pan out after finishing chewing pan, 24% swallowed it, 17% stored it in buccal sulcus and 3% were in habit of sleeping with quid in their mouth. • The mean age of onset 17 years, but 51% were started at age of 10 years. • 58% never had dental visits. | B (62.5) |
2 | Pearson et al. 1999 [38] Cross sectional study | • 43% of participants did not know that pan chewing habit could be bad for health. • More females (49%) than males (38%) were unaware of the harmful effects of pan chewing. | • 23% believed pan chewing habit was good for the health- relieves pain, aids in digestion, freshens mouth and keeps teeth strong. • Females were less likely than males to feel that regular check-ups are important. • Barriers to use of dental services included language, cost and fear (21%) • 64% indicated preference for GP over dentist regarding check-up of mouth ulcer. 39% expressed the wish to learn more about oral healthcare. | • 78% reported habit of pan chewing and half of them developed it by the age of 17. • 14% reported addiction to pan chewing habit. • 33% were tobacco smokers and 64% of them started this habit before the age of 21. • 71% of smokers also chewed pan. • 25% never visited a dentist. | B (75) |
3 | Shetty et al. 1999 [27] Cross sectional study | • 42% of respondents could not identify early sign of Oral Cancer. • > 50% were not aware of sites of mouth prone for Oral Cancer. • 80% indicated smoking as a possible risk factor for oral cancer. • Misconceptions about the causes of oral cancer such as use of oral contraceptives, removal of teeth and eating sugary food. | • Significant difference seen in Betel quid chewing habit among age groups (42.2% of adults in 50–80-year age group practicing this habit as compared to only 5.3%in 16–29-year age group. • Traditional method of betel quid chewing is being replaced with readily processed areca nut and tobacco products. | B (62.5) | |
4 | Khan et al. 2000 [39] Cross sectional study | • Tobacco chewing habit was found common amongst Bangladeshis (approx. 50%), Indians (> 40%), and Pakistanis (> 20%). • Only 3% of Bangladeshis and Pakistanis reported habit of drinking alcohol while > 20% of Indians were engaged in this habit. • Indians educated beyond the age of 16 years were more likely to chew products containing tobacco. • Less educated Bangladeshis were more engaged in practice of chewing tobacco. • Smoking habits were found less common in Indians (< 10%) and Pakistanis (< 10%) as compared to Bangladeshis (approx.20%). | B (50) | ||
5 | Vora et al. 2000 [28] Cross sectional study | • 78% of Sikh males did not know about oral cancer • 10% recognized alcohol as a risk factor for oral cancer • Major sources of knowledge included school/college education, the press and media, and health education leaflets | • The chewing of pan is prevalent among 2nd generation Hindus, Muslims and Jains but low usage was observed among Sikhs. • Sikh males tend to drink alcohol more, whereas Muslim males use tobacco and chew pan | B (62.5) | |
6 | Prabhu et al. 2001 [26] Cross sectional study | • Only few knew about association of pan chewing and oral cancer. • Majority of teenagers have not identified with this cultural norm even if their parents were regular betel quid chewers. | • Many from lower socio-economic status and less inclined to think that it could cause cancer. • More likely to agree that pan tasted good. • Tended to think it made their teeth and gums stronger | • Median age of first chewing - 9 years • Similar proportions of adolescent males and females chewed pan • 28% chewed Pan & 51% of whom chewed on most days | B (62.5) |
7 | Changrani et al. 2006 [21] Piot study | • Bangladeshis more likely to identify pan as a cause of oral cancer than Indians (66% vs 48%) • Indians identified gutka as a cause of oral cancer more correctly than Bangladeshi (93% vs 60%) | • Health benefits of pan were cited as “relieves constipation,” “improves stamina,” “fights cold,” relieving tension, and for mood improvement. • Pan also believed to cause harms like cancer, dental problems, ulcers, addiction, and hypertension | • The communities migrated with pan and gutka use habits • Pan was popular in Bangladeshis while gutkha use considerably limited. | B (50) |
8 | Croucher et al. 2011 [40] Cross sectional study | • Superior oral cancer knowledge following campaign awareness. • Younger male respondents with some completed education more likely to be aware of oral cancer | • Limited dental attendance as compared to medical visits | B (75) | |
9 | Siddique et al. 2013 [41] Pre and Post intervention study | Gutka was the most correctly identified risk factor among first generation females (50%) and second-generation males and females (63 and 69% respectively). | • First generation Gujarati Muslim males had the highest proportion of regular supari users (33%), greater than their female counterparts (12%) • Complete absence of regular gutka use in Gujarati Muslims except among first generation males (42%) | B (62.5) | |
10 | Lokhande et al. 2013 [22] Grounded theory case study | • Mixed understanding about harmful effects of chewing tobacco. • More knowledge about ill effects of smoking. | • Flavoured gutka for “fresh breath” • Find chewing mentally stimulating, gives pleasure, improved their mood and helped them relax • Get the supply from friends of India or Fiji due to ban in New Zealand • Cultural norms as barrier to cease tobacco chewing | • Gutka was preferred choice for chewing tobacco. • Use ranged from twice a day to 12 times a day • Daily use ranged from twice a day to 12 times a day | A (88.8) |
11 | Banerjee et al. 2014 [23] Focus group study | • Acknowledgment of addiction • Scepticism about the pan-cancer link | • Compensatory beliefs • SATP believed to relieve boredom, aid in digestion after meals, reduce stress, and to increase alertness • Encouraged by pleasant sensations of smell, taste and cosmetic benefits | • Early age initiation • Easy availability • Habit inherited from generations • Changed patterns of gutka/tambaku pan use behaviour after immigration | A (88.8) |
12 | Merchant et al. 2016 [24] Cross sectional study | • Pakistani and Bangladeshi more likely to have low knowledge as compared to Indians. • Followers of Islam were found low knowledge than Hindus. • Males, and the better educated, more likely to report risk factors for oral cancer | • 42% of total subjects used tobacco, Gutka or Pan in combination with alcohol; while 41% people stated habit of Smoking and 5% reported tobacco chewing habit. • Participants of Indian or Sri Lankan ethnic origin were more likely to consume alcohol than those of Pakistani, Bangladeshi or Malaysian-Indian origin. • Rare dental visits reported | B (50) | |
13 | Hrywna et al. 2016 [42] Focus group study | • Variety of opinions about the classification of SATP • Awareness about health risks regarding use of tobacco products | • Use of SATP common at social gatherings or after meals. • Perceived benefits with use of SATP like stress relief, relaxation, relieving boredom, mouth cleanse and as an aid for digestion. | • > 70% reported having tried at least one SATP and more than half (51.5%) currently use a SATP. • Native born older males described gutkha as the most common SATP while native born older females described pan/pan masala as the most popular products | B (77.7) |
14 | Shi et al. 2017 [43] Pre and Post intervention study | • 52.3% believed AN alone could cause cancer • Overall low understanding of AN’s carcinogenic properties | • Perceived harms like addiction, kidney stones and thinning of blood | • 64.6% used AN • 8.2% reported social use • 28.6% reported usage during celebrations only, and 28.6% reported daily use. | C (37.5) |
15 | Mukherjea et al. 2018 [44] Based on old CAITUS cross sectional study | • Integral religious practices with CST use • The prevalence of current CST use was 13.0% (14.0% for men and 11.8% for women). • More CST use was reported by AIs who had a college degree or higher level of education, were born in India, and were practicing Hinduism. | C (37.5) | ||
16 | Petti et al. 2018 [25] Cross sectional study | • knowledge about oral carcinogenicity of BQ was lower among chewers (41.2% vs 46.6%). • Lack of awareness toward oral cancer and other BQ chewing-related diseases. | • Significantly associated attitudes were being a routine smoker, being born to parents who were also chewers, the perception that chewing is good for health (43.6%) and that it helps to relieve stress. • two- thirds believed that pan chewing helps to relieve stress, while 17% stated that it led to stress relief | • The high BQ chewing prevalence rate (40%) in immigrants from the Asia / Indian subcontinent reported • BQ usage, along with smoking and tobacco chewing, as an integral part of the lifestyle of these people before and after migration | B (75) |
Definition of terms
Results
Study selection summary
Study characteristics
Quality of the included studies
Study findings
Theme 1: Oral cancer knowledge
“There is a mixture of happiness and sadness, but I sometimes feel sad and very low.. . I think there is “100% health risk” to chew tobacco which can cause mouth disease.”(page 48) [22].
“I think supari is the most popular, that’s not on the [survey] …. When I was younger I never even knew it was tobacco … I might have even put one in my mouth because I didn’t know. It didn’t even taste that bad from my memory. I would say supari and gutkha.” (page 5) [42].
Theme 2: Oral cancer attitudes
“It has benefit; it can be therapeutic too sometimes,” (page 7) [42].
“And there are people who feel good; they think it releases tension/worries. So sometimes I think that having a little can cool your mood if you are feeling angry or annoyed.” (page 535) [20].
“I find the smell of it very pleasant when I chew it. When someone else eats, I am attracted to the smell. That’s why I eat it.” (page 535) [20].
“To feel good or get a buzz. I’m sure that’s why people use it.” (page 7) [42].
“My friends chew it and I cannot say no to them when they offer – it is rude to say no in our culture.. . Every third person in Pakistan chews tobacco.” (page 48) [22].
“I think paan is always a tradition at parties and weddings. A lot of these chewing things like supari and gutkha, I’ve seen when I was in India … the older men, after they eat their food or if they’re going on a walk they just pack a lip ….” (page 6) [42].
“...If you go to Jersey City or Iselin [cities in New Jersey with large South Asian populations], you’ll see it’s something that’s so deeply rooted in their culture that it’s ok for us to do it. It justifies everything”. (page 7) [42].
Theme 3: Oral cancer practices
“From observing. Mother would have it. Grandmother would have it. Aunts use it. When everyone would have it, I would have it too. To see what it’s like.” (page 535) [20].
“I must have influenced my son to get addicted to chew tobacco.” (page 48) [22].
“One of my brothers here said that it can be found in Pakistani...I mean Indian and Bangladeshi stores. Other stores don’t sell it, it’s true. Meaning...it is used by Bangladeshi and Indians as well...If some- one says it is restricted, I won’t agree. Not so much.” (page 534) [20].
“Now that we go to the doctor, doctor asks do you smoke, do you drink. That’s all, not more than that. But they don’t say that you should not touch this at all. They don’t say that.” (page 537) [20].