Oral mucosal lesions are caused by local factors, systemic diseases (metabolic or immunologic), drug related reactions, or lifestyle factors such as consumption of tobacco, areca nut, betel quid or alcohol.

Risk factors differ from country to country as well as from state to state, for example, chewing of tobacco, areca-nut, betel quid is popular in developing countries whereas cigarette smoking and high consumption of alcohol is popular in developed countries. With an increase in the use of various oral habitual products in India over the past few decades, the incidence and prevalence of oral potentially premalignant conditions such as leukoplakia, oral submucous fibrosis and squamous cell carcinoma(SCC) have also increased[1,2].

Motor vehicle drivers are more prone for the habit of using various forms of tobacco and areca nut to beat the stress and peer pressure. Tobacco use in different forms and Areca nut are  the prime factors responsible for potentially malignant disorders and cancerous lesions[3].

Oral mucosal lesions were more prevalent in 51-60 years age group with 34%, subjects with secondary level of school education 39%, subjects with labourers by occupation 27.5%, subjects with no or less than 5000 income 56%. According to the Global Adult Tobacco Survey-2 (GATS-2) reports in the year 2016-17, 28.6% of the Indian population consumes tobacco in some form; 10.7% uses smoke, and 21.4% uses SLT. Khaini (11%) and beedis (8%) are the dominant tobacco products consumed in India and the prevalence of overall use of tobacco is 20% in Tamil Nadu. According to the World Health Organization (WHO ) estimates, globally, there were 100 million premature deaths due to tobacco in the 20th century, and if the current trends of tobacco use continue, this number is expected to rise to 1 billion in the 21st century[4]. Very few hospital based studies have been conducted to assess the prevalence of the tobacco use and their epidemiological and behavioural patterns.

Therefore, the present study was conducted to evaluate the prevalence of oral mucosal lesions associated with tobacco and areca nut use among the motor vehicle drivers in NTR district, which helps to develop and implement locally relevant tobacco intervention strategies.  

Aim

The aim of this study is to estimate the prevalence of oral mucosal lesions associated with tobacco and areca nut use among the motor vehicle drivers in NTR district.

Objectives 

Primary objective: The main primary objective of this study is to estimate the prevalence of oral mucosal lesions associated with habit of using tobacco and areca nut in motor vehicle drivers in NTR district.

Secondary objectives:

• To evaluate the habit of consumption of tobacco and arecanut among the motor vehicle drivers
• To correlate the habits associated with occupational stress which  triggers the oral mucosal lesions

Methodology

Source of data

The study sample will comprise of 100 subjects of motor vehicle drivers attending to the tertiary institution who consume Tobacco in any form or Areca nut will be selected after obtaining a written informed consent.   

Inclusion criteria 

All the motor vehicle drivers with habit of consumption of Areca nut or Tobacco in any form attending to the tertiary institution will be included in this study. 

Exclusion criteria  

• Subjects without consumption of Areca nut or Tobacco in any form will be excluded from this study.
• Subjects with systemic diseases which influences the oral mucosa will be excluded.
• Subjects who diagnosed with HIV / AIDS will be excluded.
• Subjects under medication which alters the integrity of oral mucosa.

Method of collection of data

The study protocol was analyzed and approved by the institutional ethical review committee. The present cross sectional study was conducted among 100 subjects with habit of consumption of Areca nut or Tobacco. The subjects were selected based on the inclusion and exclusion criteria and those who were willing to participate in the study. The need and outcome of the study will be explained to the subjects and an informed consent will be obtained. 

Study design

 A total of 100 subjects with consumption of Areca nut or Tobacco in any form will be enrolled in the study. A self structured, pre-tested questionnaire was used for data collection and it was followed by clinical examination for any tobacco and areca nut associated oral mucosal lesions.  

The clinical diadnosis of oral mucosal lesions and conditions such as oral carcinoma, leukoplakia, erythroplakia, lichen planus, smoker’s palate, leukoedema, and other lesions were based on the pertinent WHO criteria and International seminar on oral leukoplakia and associated lesions related to tobacco habits. 456 Lesions such as frictional white lesion, oral candidiasis, smoker’s melanosis, median rhomboid glossitis, and recurrent aphthous ulcer were grouped under other lesions. The clinical diagnosis of chewer’s mucosa, oral submucous fibrosis (OSMF), and quid-induced lichenoid lwsion were based on the criteria provided by Zain et al.,[5]

Questionnaire

 The questionnaire consisted of 15 questions. Patients were interviewed through a pre-tested structured questionnaire to collect data like age, sex, education, occupation, and socio-economic status, form of tobacco, age of onset, frequency, duration, and reason for initiation, triggers for tobacco use, any previous attempt to quit the habit use.

The data were analyzed using Fisher’s exact test to estimate risk of developing an oral lesion in relation to the risk factors in question. The mean age of the study population was 44.01±11.91. Among the type of consumption of tobacco, cigarette smoking stood highest 65% among the subjects which was represented in Table 1 and Figure 1

Table: 1

Among the subjects the duration of consumption of tobacco was seen 1-10 years in 57% individuals and 11-20 years frequency in 25% of the individuals. More than 30 years frequency was seen in 9% individuals as shown in Table 2 and Figure 2.

Table 2: duration of consumption

Table: 3

When the subjects are evaluated for the reason of initiating for the habit 65% of the subjects started smoking because of peer pressure as shown in table 4.

Table: 4 Reason for initiation of habit

66% of the subjects attempted to quit tobacco consuming habit but failed. Only 34% of the subjects never attempted to quit tobacco consuming habit as shown in Table 5.

Table: 5 Attempt to quit tobacco

Among the subjects 60% of the individuals were both smokers and alcoholics and only 40% of the subjects consume only tobacco as shown in as Table 6

Table: 6 Alcohol habit

The prevalence of oral and mucosal lesions were seen in 44% of the subjects as shown in Table 7.

Table: 7 prevalence of lesion

Homogenous Leukoplakia is the highest prevalent oral and mucosal lesion in 11% of the subjects and Oral Sub Mucous Fibrosis is the next most prevalent lesion in 10% of the subjects as shown in Table 8

Table: 8 Type of lesion present (for 44 patients with lesions)

The study showed increased prevalence of oral and mucosal lesions in the  subjects who consume tobacco in smoking form (36.1%), smokeless tobacco (60.9%) and 80% in subjects who consume both smoking and smokeless forms of tobacco as shown in Table 9 and Figure 3. This was found to be statistically significant (p<0.05)

Table: 9 Type of tobacco consumption and presence of lesion

In the present study, the most frequent habit reported was the consuming both smoking and smokeless tobacco (80%), followed by smokeless tobacco(60.9%) and smoking tobacco (36.1%) This was found to be statistically significant (p<0.05). Bhowate et al., [6] in their study reported that 66.3% of the population chewed tobacco in the form of smokeless tobacco. This is in accordance with our present study. Maher et al [7] also reported a similar finding in their study.

The prevalence (44%) of oral mucosal changes in subjects with habits in the present study is higher in comparison to previous studies[8,9,10].

The overall prevalence of leukoplakia (25%) in the presence study was more than that reported in many epidemiological studies [6,11,12,13,14]. This difference can be explained by the difference in the study population and the tobacco habits of Indian population and western population.

The prevalence of Oral Sub Mucous Fibrosis (OSMF) in the present study is very high (22.7%) in compare with previous other studies [6, 9, 10,15]. The results of our study further confirms the strong relation reported by various other studies between smokeless tobacco and OSMF [7,16]

The most frequently occurring oral mucosal lesion associated with tobacco use among current tobacco users was smoker’s palate (59.4%), followed by tobacco pouch keratosis (18.5%), oral submucous fibrosis (18.5%) and leukoplakia (15.9%) [17]. This is in contrary to our present study results.

As a single habit chewing was more popular compared to smoking followed by alcohol. This may be due to acceptability in the society. Amongst the chewers gutka was more popular followed by khaini. Similarly, amongst smokers cigarette was more common. Although they have developed reasoning capability of their mind for quitting smoking and alcohol or may be due to the work/ peer group/ family pressure, but diverging themselves to tobacco chewing habits due to the acceptability in the society and surroundings. Persons who are having knowledge about the tobacco related cancers have more prevalence equally for tobacco smoking chewing and drinking alcohol, which clearly indicates that only having knowledge about ill effect of tobacco is not sufficient to change their attitudes, behaviour and practices. Peer group pressure was the most important single cause of initiation of tobacco habits. To the utter surprise the family traditions and customs has no role for initiation [18]. This is in accordance with our presence study.

More than half (66%) tobacco users want to quit the habit due to social pressure (commonest reason) followed by the knowledge that it is a dirty habits. Most common symptoms which tobacco users have were burning sensation in stomach or acidity, followed by breathlessness and muscular pain in hands and feet and even 10% reported the problem in swallowing food with burning sensation. Even after having a strong desire for quitting the habits, none of the subjects had quit after several attempts due to strong urge/ craving (commonest reasons) followed by social peer pressure and day drowsiness, dizziness.

Implications

The main implication of this study is to estimate the prevalence of oral mucosal lesions associated with habit use which lead to potentially malignant disorders and cancerous lesions and to augment the efforts of counseling the subjects for tobacco cessation and to implement locally relevant tobacco intervention strategies.

Areca nut and Tobacco use in different forms is one of the prime factors responsible for potentially malignant disorders and cancerous lesions. Lack of awareness regarding harmful effects is a major reason. There was strong association of these habits with respect to frequency and duration and occurrence of the oral lesions. Occupational stress, lack of awareness and knowledge, influencing and trigerring factors play a major role in addiction of the tobacco and areca nut habit usage which leads to potentially malignant disorders and oral cancer

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