Background
Smokeless tobacco products | Regions (WHO) | Countries (highest consumption) | Other ingredients | Preparation and use | pHa | Nicotinea (mg/g) | Total TSNAa (ng/g) |
---|---|---|---|---|---|---|---|
Snus (Swedish) | Europe (region A) | Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) | Water, sodium carbonate, sodium chloride, moisturisers, flavouring | A heat treatment process; placed between the gum and upper lip | 6.6–7.2 | 7.8–15.2 | 601–723 |
Plug, Snuff (US), Snus (US) | Americas (regions A and B) | The USA, Canada, Mexico | Sweeteners, liquorice | Plug; air cured | 4.7–7.8 | 3.9–40.1 | 313–76,500 |
Dry or moist snuff; finely ground and fire cured | |||||||
Snus; steam cured | |||||||
Snuff; kept between lip and gum, dry snuff can be inhaled too | |||||||
Chimó | Americas (region B) | Venezuela, Colombia | Sodium bicarbonate, brown sugar, Mamo’n tree ashes | Tobacco paste made from tobacco leaves; placed between the lip or cheek and gum and left there for some time | 6.9–9.4 | 5.3–30.1 | 9390 |
Nass (Naswar) | Europe (region B) and Eastern Mediterranean (region D) | Uzbekistan, Kyrgyzstan, Tajikistan, Afghanistan, Pakistan, Iran | Lime, ash, flavourings (cardamom), indigo | Sundried and powdered; placed between lip or cheek and gum | 8.4–9.1 | 8.9–14.2 | 478–1380 |
Toombak | Eastern Mediterranean (region D) and Africa (region D) | Sudan, Chad | Mixed with moist sodium bicarbonate | Fermented and grounded; placed and kept in mouth | 7.3–10.1 | 9.6–28.2 | 295,000–992,000 |
Snuff (North and West African) | Africa (region D) | Nigeria, Ghana, Algeria, Cameroon, Chad, Senegal | Dried tobacco leaves mixed with potassium nitrate and other salts | Dry snuff; finely ground and inhaled as a pinch | 9.0–9.4 | 2.5–7.4 | 1520–2420 |
Moist snuff is placed in mouth | |||||||
Snuff (South African) | Africa (region E) | South Africa | Dried tobacco leaves mixed with ash | Dry snuff; finely ground and inhaled as a pinch | 6.5–10.1 | 1.2–17.2 | 1710–20,500 |
Khaini | South East Asia (regions B and D),Western Pacific (region B), Eastern Mediterranean (region D), and Europe (region A) | India, Bangladesh, Nepal, Bhutan | Slaked lime, menthol, flavourings, areca nut | Shredded; kept in mouth between lips and gum | 9.6–9.8 | 2.5–4.8 | 21,600–23,900 |
Zarda | Bangladesh, India, Pakistan, Myanmar, Thailand, Indonesia, Nepal, Maldives, Sri Lanka, UK | Served wrapped in a betel leaf with lime, catechu, areca nuts | Shredded tobacco leaves are boiled with lime and saffron; the mixture is dried then chewed and spat | 5.2–6.5 | 9.5–30.4 | 5490–53,700 | |
Gutkha | India, Pakistan, Bangladesh, Nepal, Myanmar, Sri Lanka, UK | Betel nut, catechu, flavourings, sweeteners | Commercially manufactured; sucked, chewed, and spat | 7.4–8.9 | 0.2–4.2 | 83–23,900 | |
Afzal | Eastern Mediterranean (region B) | Oman | Dried tobacco mixed with various additives | Fermented; kept in mouth between lips and gums, users suck the juice, and spit out the rest | 10.4 | 48.7 | 3573 |
Iq’mik | Americas (region A) | The USA | Tobacco combined with fungus or plant ash | Involves a burning process to make fungus ash; chewed | 11.0 | 35.0–43.0 | 15–4910 |
Rapé | Americas (region B) | Brazil | Tobacco mixed with finely ground plant materials (tonka bean, cinnamon, clove buds, etc.) or alkaline ashes | Nasal snuff; air cured or heated, then pulverised, finely sifted, and mixed | 5.2–10.2 | 6.3–47.6 | 88–24,200 |
Pituri/Mingkulpa | Western Pacific (region B) | Australia | Tobacco mixed with wood ash | Chewed as quid, kept in mouth and/or held against skin | 5.47–11.6 | 4.8 | 15,280 |
Methods
Results
WHO sub-regions | Country | M | F | Source | Year |
---|---|---|---|---|---|
Africa (region D) | Algeria* | 10 | 0.8 | Algeria Adult Tobacco Survey [25] | 2010 |
Benin* | 9 | 3 | STEPS [26] | 2015 | |
Burkina Faso* | 5.6 | 11.6 | STEPS [26] | 2013 | |
Cameroon* | 2.2 | 3.8 | GATS [27] | 2013 | |
Cape Verde | 3.5 | 5.8 | STEPS [26] | 2007* | |
Chad | 1.9 | 0.4 | STEPS [26] | 2008 | |
Comoros | 7.72 | 2.99 | DHS [28] | 2012 | |
Gabon | 0.48 | 0.34 | DHS [28] | 2012 | |
Gambia | 0.8 | 1.4 | STEPS [26] | 2010 * | |
Ghana | 1.33 | 0.2 | DHS [28] | 2008 | |
Guinea | 1.4 | 1.5 | STEPS [26] | 2009 | |
Liberia* | 1.1 | 3.1 | STEPS [26] | 2011 | |
Madagascar | 24.66 | 19.6 | DHS [28] | 2009 | |
Mali | 5 | 1.2 | STEPS [26] | 2007 | |
Mauritania | 5.7 | 28.3 | STEPS [26] | 2006 | |
Niger | 4.55 | 2.3 | DHS [29] | 2012 | |
Nigeria* | 2.9 | 0.9 | GATS [27] | 2012 | |
Sao Tome & Principe | 3.8 | 1.9 | STEPS [26] | 2009 | |
Senegal* | 0.3 | 1 | GATS [27] | 2015 | |
Seychelles** | 0.3 | 0.4 | The Seychelles Heart Study IV [25] | 2013–14 | |
Sierra Leone | 2.9 | 12.1 | STEPS [26] | 2009 | |
Togo | 5.1 | 2.2 | STEPS [26] | 2010 | |
Africa (region E) | *Botswana* | 1.5 | 6.5 | STEPS [26] | 2014 |
*Burundi | 0.03 | 0.31 | DHS [28] | 2011 | |
Congo (Brazzaville) | 8.3 | 1.54 | DHS [28] | 2012 | |
Congo (Republic) | 8.67 | 3.22 | DHS [28] | 2013 | |
Côte d’Ivoire | 0.61 | 1.27 | DHS [28] | 2012 | |
Eritrea* | 11.6 | 0.1 | STEPS [26] | 2011 | |
Ethiopia* | 2.6 | 0.8 | GATS [27] | 2016 | |
Kenya* | 5.3 | 3.8 | GATS [27] | 2014 | |
*Lesotho | 1.3 | 9.1 | DHS [29] | 2009 | |
*Malawi | 1.9 | 5 | STEPS [26] | 2009 | |
Mozambique | 10.94 | 0.82 | DHS [28] | 2011 | |
Namibia | 1.8 | 2.3 | DHS [29] | 2006–07 | |
Rwanda* | 0.6 | 3.3 | STEPS [26] | 2012 | |
*South Africa* | 1.4 | 8.4 | South African Social Attitude Survey [25] | 2007 | |
Swaziland* | 2.7 | 1.8 | STEPS [26] | 2014 * | |
*Tanzania | 2.03 | 0.83 | DHS [28] | 2010 | |
Uganda* | 1.7 | 3 | GATS [27] | 2013 | |
Zambia* | 2.2 | 6.8 | STEPS [26] | 2017 | |
Zimbabwe | 1.6 | 0.4 | DHS [30] | 2011 | |
Americas (region A) | *Canada* | 0.8 | – | CTADS [31] | 2015* |
USA | 6.5 | 0.4 | ICS [30] | 2010 | |
Americas (region B) | Argentina | 0.1 | 0.2 | GATS [27] | 2012 |
Barbados | 0 | 0.6 | STEPS [26] | 2007* | |
*Brazil | 0.6 | 0.3 | GATS [27] | 2008 | |
Costa Rica** | 0.1 | 0 | GATS [27] | 2015 | |
Dominican Republic | 1.9 | 0.3 | DHS [29] | 2007* | |
Grenada | 2.2 | 0.3 | STEPS [26] | 2011 | |
Mexico* | 0.4 | 0 | GATS [27] | 2015 | |
Panama** | 1 | 0.5 | GATS [27] | 2013 | |
Paraguay | 3 | 1.6 | STEPS [25] | 2011 | |
St Kitts & Nevisa | 0.3 | 0.1 | STEPS [26] | 2007 | |
St Lucia** | 1.3 | 0.2 | STEPS [26] | 2012* | |
Trinidad & Tobago | 0.5 | 0.3 | STEPS [26] | 2011 | |
*Uruguay** | 0.3 | – | GATS [27] | 2009 | |
Venezuela | 6.2 | 0.9 | National Survey of Drugs in the General Population [25] | 2011 | |
Americas (region D) | Haiti | – | 2.5 | DHS [29] | 2005–06* |
Eastern Mediterranean (region B) | Kuwait** | 0.5 | 0 | STEPS [26] | 2014 |
Libya | 2.2 | 0.1 | STEPS [26] | 2009 | |
Qatar** | 1.3 | 0 | GATS [27] | 2013 | |
Saudi Arabia* | 1.5 | 0.3 | Saudi Health Information Survey [25] | 2014 | |
Tunisia | 8.6 | 2.2 | ICS [30] | 2005–06 | |
Eastern Mediterranean (region D) | Egypt* | 0.4 | 0 | STEPS [26] | 2017 |
Iraq* | 0.4 | 0.02 | STEPS [26] | 2015 | |
Morocco** | 4.4 | – | STEPS [26] | 2017 | |
Pakistan* | 11.4 | 3.7 | GATS [27] | 2014 | |
Sudan* | 14.3 | 0.2 | STEPS [26] | 2016 | |
Yemen | 13.7 | 4.8 | National Health and Demographic Survey [25] | 2013 | |
Europe (region A) | Austria* | 2.8 | 0.5 | Representative Survey on Substance Abuse [32] | 2015 |
Belgium | 1.1 | 0.6 | SEBS [33] | 2012 | |
Cyprus | 2.1 | 0.4 | SEBS [33] | 2012 | |
Czech Republic* | 2.2 | 1.2 | The use of tobacco in the Czech Republic [25] | 2015 | |
Denmark* | 2.3 | 0.9 | Monitoring Smoking Habits in the Danish Population [25] | 2015 | |
Finland* | 5.6 | 0.4 | Health Behaviour and Health among the Finnish Adult Population [25] | 2014 | |
France | 1.2 | 0.6 | SEBS [33] | 2012 | |
Germany | 3.4 | 3.4 | SEBS [33] | 2012 | |
Iceland* | 13 | 3 | May–December Household Surveys done by Gallup [25] | 2015 | |
Ireland | 2.2 | 0.9 | SEBS [33] | 2012 | |
Italy | 1.8 | 1.5 | SEBS [33] | 2012 | |
Luxembourg | 1.8 | 1 | SEBS [33] | 2012 | |
Malta | 5.5 | 1.5 | SEBS [33] | 2012 | |
Netherlands | 0.3 | 0.1 | The Dutch Continuous Survey of Smoking Habits [25] | 2011 | |
Norway* | 21 | 6 | Statistics Norway Smoking Habits Survey [25] | 2015 | |
Portugal | 4.4 | 1.1 | SEBS [33] | 2012 | |
Slovenia | 1.8 | 0.4 | SEBS [33] | 2012 | |
Spain | 0.4 | 0.2 | SEBS [33] | 2012 | |
Sweden* | 25 | 7 | National Survey of Public Health [25] | 2015 | |
Switzerland* | 4.2 | 1.2 | Addiction Monitoring survey [25] | 2013 | |
United Kingdom | 1.6 | 0.5 | SEBS [33] | 2012 | |
Europe (Region B) | Azerbaijan* | 0.2 | 0 | National study of risk factors for non-communicable diseases [25] | 2011 |
Armenia | 1.8 | 0 | DHS [29] | 2005 | |
Bulgaria | 0.3 | 0 | SEBS [33] | 2012 | |
Georgia | 1 | 0.2 | Survey of Risk Factors of Non-Communicable Diseases [25] | 2010 | |
*Kazakhstan** | 2.8 | 0 | GATS [27] | 2014 | |
Kyrgyzstan* | 10.1 | 0.1 | STEPS [26] | 2013 | |
Poland | 1 | 0.1 | GATS [27] | 2009 | |
*Romania | 0.4 | 0.2 | GATS [27] | 2011 | |
Slovakia* | 1.9 | 0.8 | Tobacco and Health Education Survey [25] | 2014 | |
Uzbekistan* | 23.2 | 0.2 | STEPS [26] | 2014 | |
Europe (region C) | Latvia* | 0.1 | 0 | Health Behaviour among Latvian Adult Population [25] | 2014 |
Lithuania | 1.2 | 0.2 | SEBS [33] | 2012 | |
Moldova* | 0.1 | 0 | DHS [29] | 2013 | |
Russia* | 0.8 | 0.1 | GATS [27] | 2016 | |
Ukraine* | 0.4 | 0 | GATS [27] | 2017 | |
South East Asia (region B) | Indonesia* | 3.9 | 4.8 | Basic Health Research [25] | 2013 |
Sri Lanka* | 26 | 5.3 | STEPS [26] | 2014 | |
Thailand | 1.1 | 5.2 | GATS [27] | 2011 | |
South East Asia (region D) | Bangladesh* | 16.2 | 24.8 | GATS [27] | 2017 |
Bhutan* | 26.5 | 11 | STEPS [26] | 2014 | |
India* | 29.6 | 12.8 | GATS [27] | 2017 | |
Maldives* | 3.9 | 1.4 | STEPS [26] | 2011 | |
Myanmar* | 62.2 | 24.1 | STEPS [26] | 2014 | |
Nepal* | 31.3 | 4.8 | STEPS [26] | 2013 | |
Timor Leste* | 16.1 | 26.8 | National survey for non-communicable disease risk factors and injuries [34] | 2014 | |
Western Pacific (region A) | Australia* | 0.6 | 0.3 | National Drug Strategy Household Survey [25] | 2013 |
Brunei Darussalam** | 1.3 | 2.7 | Knowledge, Attitudes and Practices Survey on Non-communicable Diseases [25] | 2014–15 | |
Western Pacific (region B) | Cambodia* | 0.8 | 8.6 | National Adult Tobacco Survey of Cambodia [25] | 2014 |
China | 0.7 | 0 | GATS [27] | 2010 | |
Lao People’s Democratic Republic* | 0.5 | 8.6 | National Adult Tobacco Survey [25] | 2015 | |
Malaysia* | 20.4 | 0.8 | National Health And Morbidity Survey [25] | 2015 | |
Marshall Islands** | 13.7 | 4 | STEPS [26] | 2002 | |
Micronesia | 22.4 | 3 | STEPS [26] | 2002 | |
Mongolia* | 0.8 | 0.2 | STEPS [26] | 2015 | |
Niue** | 0.3 | 0.2 | STEPS [26] | 2011 | |
Philippines* | 2.7 | 0.7 | GATS [27] | 2015 | |
Vietnam* | 0.8 | 2 | GATS [27] | 2015 |
Country | Study period | Study design | Exposure status | Inclusion of cigarette/alcohol users | Outcome | Odds ratio/relative risk (95% CIs) | Comments | Quality assessment (NOS)a | Reference |
---|---|---|---|---|---|---|---|---|---|
Cancers | |||||||||
India | 2001–2004 | Case–control | SLT with or without additives | No/no | Oral cancer | 0.49 (0.32–0.75) | Exclusive SLT users | Selection**** Comparability** Exposure* | [36] |
India | 1996–1999 | Case–control | Ever SLT users | Yes/yes | Oral cancer | 7.31 (3.79–14.1) | Never drinkers adjusted for smoking | Selection**** Comparability** Exposure* | [37] |
9.19 (4.38–19.28) | Never smokers adjusted for alcohol | ||||||||
India | 1982–1992 | Case–control | Tobacco quid chewing | Yes/no | Oral cancer | 5.80 (3.60–9.34) | Adjusted for smoking | Selection*** Comparability* Exposure* | [38] |
Pharyngeal cancer | 1.20 (0.80–1.80) | ||||||||
Lung cancer | 0.70 (0.40–1.22) | ||||||||
India | Not clear | Case–control | Chewing tobacco | No/no | Oral cancer | 10.75 (6.58–17.56) | Exclusive SLT users | Selection** Comparability* Exposure0 | [39] |
India | 1990–1997 | Cohort | Current SLT users | No/no | Oral cancer | 5.50 (3.30–9.17) | Exclusive SLT users | Selection**** Comparability* Outcome** | [40] |
Former SLT users | 9.20 (4.60–18.40) | ||||||||
India | 1990–1997 | Cohort | Current SLT user | Yes/yes | Oral cancer | 2.40 (1.70–3.39) | Adjusted for smoking and alcohol | Selection**** Comparability* Outcome*** | [41] |
Former SLT users | 2.10 (1.30–3.39) | ||||||||
India | Not clear | Case–control | Ever SLT users | No/no | Oral cancer | 4.23 (3.11–5.75) | Exclusive SLT users | Selection*** Comparability** Exposure0 | [42] |
Pharyngeal cancer | 2.42 (1.74–3.37) | ||||||||
Laryngeal cancer | 2.80 (2.07–3.79) | ||||||||
Oesophageal cancer | 1.55 (1.15–2.07) | ||||||||
India | 1968 | Case–control | Tobacco | Yes/no | Oral cancer | 4.63 (3.50–6.14) | Exclusive chewers and non-chewers data available | Selection*** Comparability** Exposure0 | [43] |
Pharyngeal cancer | 3.09 (2.31–4.13) | ||||||||
Laryngeal cancer | 2.29 (1.72–3.05) | ||||||||
Oesophageal cancer | 3.82 (2.84–5.13) | ||||||||
India | 2005–2006 | Case–control | Tobacco flakes | Yes/yes | Oral cancer | 7.60 (4.90–11.79) | Adjusted for smoking and alcohol | Selection**** Comparability** Exposure* | [44] |
Gutkha | 12.70 (7.00–23.04) | ||||||||
Mishiri | 3.00 (1.90–4.74) | ||||||||
India | Not clear | Case–control | Chewing tobacco | Yes/yes | Oral cancer | 5.00 (3.60–6.94) | Adjusted for smoking and alcohol | Selection**** Comparability* Exposure* | [45] |
India | 1982–1984 | Case–control | Chewing tobacco | Yes/no | Oral cancer | 10.20 (2.60–40.02) | Adjusted for smoking | Selection*** Comparability** Exposure* | [46] |
India | 1980–1984 | Case–control | SLT users | No/no | Oral cancer | 1.99 (1.41–2.81) | Exclusive SLT users | Selection** Comparability0 Exposure* | [47] |
India | 1952–1954 | Case–control | Chewing tobacco | No/no | Oral cancer | 4.85 (2.32–10.14) | Exclusive SLT users | Selection*** Comparability** Exposure0 | [48] |
Pharyngeal cancer | 2.02 (0.94–4.33) | ||||||||
Laryngeal cancer | 0.76 (0.37–1.56) | ||||||||
India | 1983–1984 | Case–control | Snuff (males only) | Yes/yes | Oral cancer | 2.93 (0.98–8.76) | Adjusted for smoking and alcohol; adjusted effect size is only among males | Selection*** Comparability0 Exposure* | [49] |
India | Not given | Case–control | Tobacco chewing | Yes/yes | Oropharyngeal cancer | 7.98 (4.11–13.58)b | Adjusted for smoking and alcohol | Selection*** Comparability** Exposure0 | [50] |
India | 1991–2003 | Case–control | Chewing tobacco | No/no | Oral cancer | 5.88 (3.66–7.93) | Exclusive SLT users | Selection**** Comparability** Exposure** | [51] |
India | 1950–1962 | Case–control | Tobacco with or without paan or lime | Yes/no | Oral and oropharyngeal cancer | 41.90 (34.20–51.33) | Exclusive chewer data available; data of habit was not available for the whole cohort | Selection** Comparability** Exposure0 | [52] |
Pakistan | 1996–1998 | Case–control | Naswar | Yes/yes | Oral cancer | 9.53 (1.73–52.50) | Adjusted for smoking and alcohol | Selection*** Comparability** Exposure* | [53] |
Paan with tobacco | 8.42 (2.31–30.69) | ||||||||
Sweden | 1973–2002 | Cohort | Snus | Yes/yes | Oral and pharyngeal cancer combined | 3.10 (1.50–6.41) | Adjusted for smoking and alcohol | Selection** Comparability** Outcome*** | [54] |
India | 1993–1999 | Case–control | Chewing tobacco | Yes/yes | Oral cancer | 5.05 (4.26–5.99) | Adjusted for smoking and alcohol | Selection*** Comparability** Exposure* | [55] |
Pharyngeal cancer | 1.83 (1.43–2.34) | ||||||||
Oesophageal cancer | 2.06 (1.62–2.62) | ||||||||
Norway | 1966–2001 | Cohort | Chewing tobacco plus oral snuff | No/no | Oral cancer | 1.10 (0.50–2.42) | Adjusted for smoking, might be confounded by alcohol use | Selection*** Comparability* Outcome*** | [56] |
Oesophageal cancer | 1.40 (0.61–3.21) | ||||||||
Pancreatic cancer | 1.67 (1.12–2.49) | ||||||||
Lung cancer | 0.80 (0.61–1.05) | ||||||||
Sweden | 1988–1991 | Case–control | Oral snuff | Yes/yes | Oral cancer | 1.40 (0.80–2.45) | Adjusted for smoking and alcohol | Selection** Comparability** Exposure* | [57] |
Laryngeal cancer | 0.90 (0.50–1.62) | ||||||||
Oesophageal cancer | 1.20 (0.70–2.06) | ||||||||
Pharyngeal cancer | 0.70 (0.40–1.22) | ||||||||
Sweden | 1969–1992 | Cohort | Snus | No/no | Oral cancer | 0.80 (0.40–1.60) | Exclusive SLT users | Selection*** Comparability* Outcome*** | [58] |
Lung cancer | 0.80 (0.50–1.28) | ||||||||
Pancreatic cancer | 2.00 (1.20–3.33) | ||||||||
Sweden | 2000–2004 | Case–control | Oral snuff | Yes/yes | Oral cancer | 0.70 (0.30–1.63) | Adjusted for smoking and alcohol | Selection*** Comparability** Exposure** | [59] |
Sweden | 1980–1989 | Case–control | Oral snuff | Yes/yes | Oral cancer | 0.80 (0.50–1.28) | Adjusted for smoking and alcohol | Selection** Comparability** Exposure*** | [60] |
USA | 1972–1983 | Case–control | Oral snuff | Yes/yes | Oral cancer | 0.80 (0.40–1.60) | Not clear if adjusted for smoking and alcohol | Selection** Comparability0 Exposure* | [61] |
Chewing tobacco | 1.00 (0.70–1.43) | ||||||||
USA | Not given | Case–control | SLT use | Yes/yes | Oral cancer | 0.90 (0.38–2.13) | Adjusted for smoking and alcohol | Selection*** Comparability** Exposure* | [10] |
Pharyngeal cancer | 1.59 (0.84–3.01) | ||||||||
Laryngeal cancer | 0.67 (0.19–2.36) | ||||||||
India | 2001–2004 | Case–control | Chewing tobacco | No/no | Pharyngeal cancer | 3.18 (1.92–5.27) | Exclusive SLT users | Selection*** Comparability** Exposure* | [62] |
Laryngeal cancer | 0.95 (0.52–1.74) | ||||||||
Pakistan | 1998–2002 | Case–control | Snuff dipping | No/no | Oesophageal cancer | 4.10 (1.30–12.93) | Adjusted for areca nut | Selection*** Comparability** Exposure** | [63] |
Quid with tobacco | 14.20 (6.40–31.50) | ||||||||
India | 2008–2012 | Case–control | Nass chewing | No/no | Oesophageal cancer | 2.88 (2.06–4.03) | Exclusive SLT users | Selection*** Comparability** Exposure** | [64] |
Gutkha chewing | 2.87 (0.87–9.47) | ||||||||
India | 2007–2011 | Case–control | Oral snuff | Yes/yes | Oesophageal cancer | 3.86 (2.46–6.06) | Adjusted for smoking and alcohol | Selection** Comparability** Exposure* | [65] |
India | 2011–2012 | Case–control | Chewing tobacco | Yes/yes | Oesophageal cancer | 2.63 (1.53–4.52) | Adjusted for smoking and alcohol | Selection*** Comparability** Exposure* | [66] |
Sweden | 1995–1997 | Case–control | Oral snuff | Yes/yes | Oesophageal adenocarcinoma | 1.20 (0.70–2.06) | Adjusted for smoking and alcohol | Selection*** Comparability** Exposure* | [67] |
Squamous cell carcinoma | 1.40 (0.90–2.18) | ||||||||
Sweden | 1969–1993 | Cohort | Oral snuff | Yes/no | Oesophageal adenocarcinoma | 1.30 (0.80–2.11) | Adjusted for smoking | Selection** Comparability* Outcome** | [68] |
Squamous cell carcinoma | 1.20 (0.80–1.80) | ||||||||
Sweden | 1974–1985 | Cohort | SLT users | No/NA | Lung cancer | 0.90 (0.20–4.05) | Adjusted for age, region of origin | Selection*** Comparability* Outcome** | [69] |
Morocco | 1996–1998 | Case–control | SLT users | Yes/no | Lung cancer | 1.05 (0.28–3.94) | Adjusted for smoking | Selection** Comparability** Exposure** | [70] |
USA | 1977–1984 | Case–control | SLT users | Yes/no | Oesophageal cancer | 1.20 (0.10–14.40) | Adjusted for smoking | Selection*** Comparability** Exposure** | [71] |
USA | 1986–1989 | Case–control | SLT users | Yes/no | Pancreatic cancer | 1.40 (0.50–3.92) | Adjusted for smoking | Selection*** Comparability* Exposure** | [72] |
USA | 2000–2006 | Case–control | Chewing tobacco | Yes/yes | Pancreatic cancer | 0.60 (0.30–1.20) | Adjusted for smoking and alcohol | Selection**** Comparability** Exposure* | [73] |
Oral snuff | 0.50 (0.10–2.50) | ||||||||
Pakistan | 2014–2015 | Case–control | Ever use of naswar | Yes/yes | Oral cancer | 21.20 (8.40–53.8) | Adjusted for smoking; restricted control for alcohol due to cultural sensitivity | Selection**** Comparability** Exposure*** | [74] |
India | March–July, 2013 | Case–control | Gutkha | Yes/yes | Oral cancer | 5.10 (2.00–10.30) | Adjusted for smoking and alcohol | Selection*** Comparability* Exposure** | [75] |
Chewing tobacco | 6.00 (2.30–15.70) | ||||||||
Supari with tobacco | 11.40 (3.40–38.20) | ||||||||
Quid with tobacco | 6.40 (2.60–15.50) | ||||||||
Pakistan | 1996–1998 | Case–control | Quid with tobacco | Yes/yes | Oral cancer | 15.68 (3.00–54.90) | Adjusted for smoking and alcohol | Selection** Comparability* Exposure*** | [76] |
Cardiovascular diseases (ischaemic heart disease and stroke) | |||||||||
52 countries | 1999–2003 | Case–control | Chewing tobacco | Yes/yes | Myocardial infarction | 1.57 (1.24–1.99) | Adjusted for smoking, diet, diabetes, abdominal obesity, exercise, hypertension | Selection**** Comparability** Exposure* | [35] |
Pakistan | 2005–2011 | Case–control | Dippers (Naswar) | No/NA | Myocardial infarction | 1.46 (1.21–1.78) | Adjusted for age, gender, region, ethnicity, diet, socioeconomic status | Selection**** Comparability** Exposure** | [77] |
Chewers (Paan/Supari/Gutkha) | 1.71 (1.46–2.00) | ||||||||
Bangladesh | 2006–2007 | Case–control | Ever SLT users | Yes/NA | Myocardial infarction, angina pectoris | 2.80 (1.10–7.30) | Adjusted for age, gender, smoking, hypertension | Selection** Comparability** Exposure** | [78] |
Bangladesh | 2010 | Case–control | Ever SLT users | No/NA | Myocardial infarction, angina pectoris | 0.77 (0.52–1.13) | Adjusted for age, gender, area of residence, hypertension, diabetes, stress | Selection*** Comparability** Exposure* | [79] |
India | 2013 | Case–control | Current SLT users | Yes/yes | Stroke | 1.50 (0.80–2.79) | Adjusted for age, smoking, alcohol, diabetes, hypertension | Selection** Comparability** Exposure* | [80] |
Sweden | 1989–1991 | Case–control | Current snuff users | No/NA | Myocardial infarction | 0.89 (0.62–1.29) | Adjusted for age | Selection**** Comparability** Exposure* | [81] |
Sweden | 1991–1993 | Case–control | Current snuff users | No/NA | Myocardial infarction | 0.58 (0.35–0.94) | Adjusted for heredity, education, marital status, hypertension, diabetes, cholesterol | Selection**** Comparability** Exposure** | [82] |
Sweden | 1985–2000 | Case–control | Current snuff users | No/NA | Stroke | 0.87 (0.41–1.83) | Adjusted for education, marital status, diabetes, hypertension, cholesterol | Selection**** Comparability** Exposure** | [83] |
Sweden | 1998–2005 | Case–control | Current snuff users | No/NA | Myocardial infarction | 0.73 (0.35–1.50) | Adjusted for age, hospital catchment area | Selection*** Comparability** Exposure** | [84] |
Former snuff users | 1.20 (0.46–3.10) | ||||||||
Sweden | 1988–2003 | Cohort | Current use of snuff | No/NA | Ischaemic heart disease | 0.77 (0.51–1.15) | Adjusted for age, socioeconomic status, residential area, self-reported health, longstanding illnesses, physical activity | Selection*** Comparability** Outcome*** | [85] |
Stroke | 1.07 (0.65–1.77) | ||||||||
Sweden | 1978–2004 | Cohort | Ever snuff users | No/NA | Myocardial infarction | 0.99 (0.90–1.10) | Adjusted for age, BMI, region of residence | Selection** Comparability** Outcome*** | [86] |
Sweden | 1985–1999 | Case–control | Current snuff users | No/NA | Myocardial infarction | 0.82 (0.46–1.43) | Adjusted for BMI, leisure time, physical activity, education, cholesterol | Selection**** Comparability** Exposure* | [87] |
Former snuff users | 0.66 (0.32–1.34) | ||||||||
Sweden | 1978–2003 | Cohort | Ever snuff users | No/NA | Stroke | 1.02 (0.92–1.13) | Adjusted for age, BMI, region of residence | Selection** Comparability** Outcome*** | [88] |
Sweden | 1998–2005 | Cohort | Current snuff users | No/NA | Ischaemic heart disease | 0.85 (0.51–1.42) | Adjusted for age, hypertension, diabetes, cholesterol | Selection*** Comparability** Outcome* | [89] |
Former snuff users | 1.07 (0.56–2.04) | ||||||||
Current snuff users | Stroke | 1.18 (0.67–2.08) | |||||||
Former snuff users | 1.35 (0.65–2.82) | ||||||||
Sweden | 1991–2004 | Cohort | Current snuff users | No/NA | Myocardial infarction | 0.75 (0.30–1.87) | Adjusted for age, marital status, occupation, diabetes, BMI, hypertension, physical activity | Selection*** Comparability** Outcome** | [90] |
Stroke | 0.59 (0.20–1.50) |
WHO sub-regionsa | Mouth cancer | Pharyngeal cancer | Oesophageal cancer | Ischaemic heart disease | All causes | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
M | F | All | M | F | All | M | F | All | M | F | All | M | F | All | |
Deaths | |||||||||||||||
Africa D | 184 | 83 | 267 | 120 | 37 | 157 | 294 | 124 | 418 | 3414 | 1497 | 4911 | 4012 | 1741 | 5753 |
Africa E | 305 | 149 | 454 | 95 | 41 | 136 | 449 | 276 | 725 | 2231 | 1797 | 4027 | 3079 | 2263 | 5343 |
Americas A | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 10,298 | 565 | 10,863 | 10,298 | 565 | 10,863 |
Americas B | 1189 | 112 | 1301 | 46 | 4 | 50 | 103 | 12 | 115 | 1275 | 260 | 1535 | 2613 | 389 | 3001 |
Americas D | 0 | 3 | 3 | 0 | 1 | 1 | 0 | 2 | 2 | 0 | 76 | 76 | 0 | 82 | 82 |
Eastern Mediterranean B | 27 | 3 | 31 | 21 | 1 | 22 | 13 | 1 | 14 | 818 | 122 | 940 | 879 | 128 | 1007 |
Eastern Mediterranean D | 5488 | 3756 | 9244 | 611 | 138 | 749 | 752 | 269 | 1021 | 13,062 | 1982 | 15,045 | 19,913 | 6146 | 26,059 |
Europe A | 69 | 14 | 84 | 30 | 3 | 33 | 246 | 42 | 288 | 0 | 0 | 0 | 346 | 60 | 405 |
Europe B | 286 | 5 | 291 | 85 | 1 | 86 | 189 | 2 | 192 | 6552 | 163 | 6715 | 7112 | 170 | 7283 |
Europe C | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Southeast Asia B | 663 | 467 | 1130 | 394 | 148 | 542 | 260 | 123 | 383 | 5014 | 3349 | 8363 | 6330 | 4087 | 10,418 |
Southeast Asia D | 25,966 | 9829 | 35,795 | 16,378 | 4499 | 20,876 | 9366 | 3493 | 12,859 | 147,065 | 50,509 | 197,573 | 198,774 | 68,329 | 267,103 |
Western Pacific A | 8 | 2 | 11 | 3 | 1 | 4 | 8 | 2 | 10 | 53 | 23 | 76 | 73 | 27 | 100 |
Western Pacific B | 781 | 173 | 954 | 611 | 44 | 655 | 1841 | 49 | 1890 | 7084 | 798 | 7883 | 10,317 | 1065 | 11,382 |
Worldwide | 34,966 | 14,597 | 49,563 | 18,394 | 4918 | 23,312 | 13,519 | 4397 | 17,916 | 196,867 | 61,140 | 258,006 | 263,746 | 85,052 | 348,798 |
DALYs | |||||||||||||||
Africa D | 5350 | 2499 | 7849 | 3823 | 1245 | 5068 | 7860 | 3166 | 11,027 | 78,500 | 31,152 | 109,651 | 95,533 | 38,062 | 133,595 |
Africa E | 9242 | 4105 | 13,348 | 3174 | 1323 | 4497 | 12,358 | 6590 | 18,948 | 59,082 | 32,930 | 92,012 | 83,856 | 44,948 | 128,804 |
Americas A | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 180,756 | 6870 | 187,626 | 180,756 | 6870 | 187,626 |
Americas B | 2283 | 315 | 2598 | 1321 | 104 | 1425 | 2562 | 261 | 2823 | 28,177 | 4397 | 32,575 | 34,344 | 5077 | 39,421 |
Americas D | 0 | 68 | 68 | 0 | 34 | 34 | 0 | 62 | 62 | 0 | 1745 | 1745 | 0 | 1909 | 1909 |
Eastern Mediterranean B | 758 | 90 | 848 | 593 | 42 | 634 | 301 | 23 | 324 | 16,420 | 1919 | 18,339 | 18,072 | 2073 | 20,145 |
Eastern Mediterranean D | 177,353 | 126,901 | 304,254 | 19,303 | 4655 | 23,958 | 20,904 | 7393 | 28,298 | 324,744 | 46,679 | 371,423 | 542,305 | 185,628 | 727,933 |
Europe A | 1618 | 272 | 1890 | 686 | 76 | 763 | 4959 | 682 | 5641 | 0 | 0 | 0 | 7263 | 1030 | 8293 |
Europe B | 5714 | 106 | 5820 | 2642 | 30 | 2672 | 4871 | 55 | 4926 | 141,562 | 2177 | 143,740 | 154,789 | 2369 | 157,158 |
Europe C | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Southeast Asia B | 17,730 | 10,792 | 28,523 | 11,164 | 4319 | 15,484 | 6608 | 2951 | 9558 | 122,177 | 68,896 | 191,073 | 157,679 | 86,958 | 244,637 |
Southeast Asia D | 767,549 | 258,275 | 1,025,824 | 471,141 | 131,531 | 602,672 | 252,556 | 87,759 | 340,314 | 3,697,819 | 1,114,976 | 4,812,796 | 5,189,065 | 1,592,540 | 6,781,606 |
Western Pacific A | 201 | 48 | 249 | 78 | 15 | 93 | 166 | 24 | 191 | 809 | 233 | 1042 | 1255 | 320 | 1575 |
Western Pacific B | 20,556 | 3795 | 24,351 | 18,452 | 1324 | 19,776 | 40,948 | 1055 | 42,003 | 157,624 | 15,371 | 172,995 | 237,580 | 21,545 | 259,124 |
Worldwide | 1,008,356 | 407,266 | 1,415,621 | 532,378 | 144,696 | 677,074 | 354,093 | 110,021 | 464,114 | 4,807,671 | 1,327,346 | 6,135,017 | 6,702,497 | 1,989,330 | 8,691,827 |