The magnitude of tobacco smoking-betel quid chewing-alcohol drinking interaction effect on oral cancer in South-East Asia. A meta-analysis of observational studies

Abstract

Tobacco smoking, betel quid chewing and alcohol drinking are oral cancer risk factors. Observational studies unanimously report that oral cancer risk in smoking-drinking-chewing exposed subjects is exceptionally high. However, none of them assessed the fractions of this risk attributable to the three individual risk factors and to the smoking-drinking-chewing interaction. The present study sought to assess the magnitude of the smoking-drinking-chewing interaction effect on oral cancer. A meta-analysis of observational South-East Asian studies which reported oral cancer odds ratios (ORs) stratified for smoking-drinking-chewing exposures was performed. The pooled ORs were estimated and controlled for quality, heterogeneity, publication bias and inclusion criteria. The smoking-drinking-chewing interaction effect was estimated through the pooled Relative Excess Risk due to Interaction (RERI, excess risk in smoking-drinking-chewing exposed individuals with respect to the risk expected from the addition of the three individual risks of smoking, drinking and chewing). Fourteen studies were included with low between-study heterogeneity. The pooled ORs for smoking, drinking, chewing, smoking-drinking-chewing, respectively were 3.6 (95% confidence interval -95% CI, 1.9-7.0), 2.2 (95% CI, 1.6-3.0), 7.9 (95% CI, 6.7-9.3), 40.1 (95% CI, 35.1-45.8). The pooled RERI was 28.4 (95% CI, 22.9-33.7). Among smoking-drinking-chewing subjects, the individual effects accounted for 6.7% (smoking), 3.1% (drinking), 17.7% (chewing) of the risk, while the interaction effect accounted for the remaining 72.6%. These data suggest that 44,200 oral cancer cases in South-East Asia annually occur among smoking-drinking-chewing exposed subjects and 40,400 of these are exclusively associated with the interaction effect. Effective oral cancer control policies must consider concurrent tobacco smoking, alcohol drinking, betel quid chewing usages as a unique unhealthy lifestyle.

Figure 1. Components of the Relative Excess Risk (RER) in the category of SM/DR/BQ.

In unexposed subjects there was no RER (RER_unexposed = 0), as these subjects were the reference group. RER_SM (in black) accounted for 6.7% of RER_SM/DR/BQ. RER_DR (in light grey) accounted for 3.1% of RER_SM/DR/BQ. RER_BQ (in white) accounted for 17.7% of RER_SM/DR/BQ. The SM/DR/BQ interaction effect, that is, the Relative Excess Risk due to Interaction (RERI) between SM, DR and BQ (RERI_SM/DR/BQ, in dark grey) accounted for 72.6% of RER_SM/DR/BQ.