Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 28-32

Tobacco Related Oral Lesions in South Indian Industrial Workers

1 Kalyani Speciality Dental Clinic, Guntur Andhra Pradesh, India
2 School of Dentistry, Faculty of Medical Sciences, The University of West Indies, Jamaica, West Indies
3 Department of Oral and Maxillofacial Pathology, SIBAR Institute of Dental Sciences, Guntur Andhra Pradesh, India

Date of Submission24-Jan-2021
Date of Acceptance07-Apr-2021
Date of Web Publication06-Aug-2021

Correspondence Address:
Kiran Kumar Kattappagari
Professor, Department of Oral and Maxillofacial Pathology, SIBAR Institute of Dental Sciences, Guntur,Andhra Pradesh, 522509
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jofs.jofs_24_21

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Introduction: Tobacco is the leading causative factor for both oral potentially malignant disorders and oral cancer. Tobacco use is higher among lower income population. Low-income population of India are majorly employed as industrial workers. The aim of this study is to estimate the prevalence of oral lesions associated with tobacco related habits among industrial workers. Materials and Methods: Cross-sectional epidemiological investigation was conducted among 1000 industrial workers using simple random sampling technique. Information on patient demographics, tobacco related (smoke and smokeless) and other deleterious habits, and clinical examination details were recorded in a structured format. The data were analyzed using Statistical Package for Social Sciences version 20.0. Results were tabulated using frequency distribution and mean with a standard deviation. Multiple logistical regression was used to analyze oral lesions by different variables. Results: Among the 1000 industrial workers screened, smoking habit was observed in 13.20%, while 86.8% were using smokeless tobacco. The prevalence of tobacco related oral lesions among individuals with smoke/smokeless tobacco habit was 13.8%. The study documented tobacco related oral lesions such as leukoplakia (6.5%), oral submucous fibrosis (2%), smoker’s palate (2.7%), tobacco related pigmentation (1.9%), erythroplakia (0.3%), and oral squamous cell carcinoma (0.2%). Conclusion: The study documented potentially malignant disorders and oral cancer among users with tobacco related habits. The results also revealed that higher prevalence of potentially malignant disorders over oral cancer. Thus, preventive programs for early detection of oral precancer and oral cancer such as tobacco cessation, tobacco counselling programs are emphasized for industrial workers.

Keywords: Epidemiology, occupation, oral lesions, tobacco, smoke, smokeless

How to cite this article:
Kommalapati RK, Rajendra AS, Kattappagari KK, Kantheti LP, Poosarla C, Baddam VR. Tobacco Related Oral Lesions in South Indian Industrial Workers. J Orofac Sci 2021;13:28-32

How to cite this URL:
Kommalapati RK, Rajendra AS, Kattappagari KK, Kantheti LP, Poosarla C, Baddam VR. Tobacco Related Oral Lesions in South Indian Industrial Workers. J Orofac Sci [serial online] 2021 [cited 2022 Oct 6];13:28-32. Available from:

  Introduction Top

Tobacco is considered a common risk factor for major noncommunicable diseases (NCDs). WHO stated that tobacco use is a major risk factor for NCDs, such as cardiovascular disease, cancer, chronic respiratory disease, and diabetes. Majority of tobacco consumers (particularly smokers) begin their habits during their early teen age. WHO predicted that tobacco users among younger individuals may lead to deaths of 250 million children and young people alive today. Majority of such populations are identified from the developing countries.[1] WHO estimated in 2004 that 194 million males and 45 million females from India are consuming tobacco products to chew or smoke.[2] In addition, WHO mentioned that India will observe the fastest death rate due to tobacco related conditions; however, this notation to death reflects to NCDs and not necessarily to cancer related death. India has the highest number of oral cancer cases in the world due to the use of smokeless tobacco. Smokeless tobacco increases the risk of oral cancer development by sixfold.[3] Oral cancer contributes to 30% of all cancer cases in India. Evidence-based reports mentioned that India has the highest prevalence of tobacco chewing (40%) and smoking (20%) population. Beedi smoking is a common type of smoking practice in India. Higher prevalence of smokeless tobacco users may be due to low cost, and often it is harder to recognize the habit of an individual by a member of their family, thus the habit of smokeless tobacco consumption remains unknown to family members.[4]

Another justification for higher tobacco consumption in India may be attributed to Indian tradition which permits an individual to consume tobacco and areca nuts in different forms.[5] A National Sample Survey from India stated that the prevalence of alcohol use is 4.5%, smoking tobacco is 16.2%, and chewing tobacco (smokeless tobacco) is 14%. The report also stated that tobacco related practices are common among males than females and rural than urban population.[6]

Tobacco consumption is a harmful habit with the increased risk of oral potentially malignant disorders (OPMDs) and oral cancer. The changes in the oral mucosa may just begin as change in surface color or texture. Thus, lesions receive lesser attention by the tobacco consumer due to innocent appearing clinical presentation and are often neglected for early detection and care. Tobacco smoking is also a risk factor for periodontal disease and due to lack of awareness of routine dental examination among Indians, the cases with periodontal diseases are undiagnosed at an early stage. Various types of tobacco related products popular across Indian states are listed in [Table 1]. Although anti-smoking campaigns and mass media communication on patient education in newspapers, television, and radios are available, awareness on tobacco related practices remains an ongoing challenge in making an effective change. The challenges may be due to economic status, illiteracy, religious practices, psycho-social, peer and celebrity member influence, emotional, and family burden.[5],[7] Peer and celebrity member influence begins as a fashion smoking practice that may eventually turn into serious habit.
Table 1 Various types of tobacco related products identified across India[7]

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OPMD is a recent term used for referring to precancer, precursor, or premalignant lesion of oral cavity.[8] The term OPMDs was coined with the notation that all lesions and conditions listed under this category are associated with increased potential for malignant transformation.[9]

Existing literature on the frequency of tobacco related habits and oral lesions associated with tobacco related habits majorly focuses on youth/students, medical/dental students, loom workers, and tobacco workers. As mentioned earlier, two top reasons for the communication gap in attaining effective change from the anti-smoking campaigns are economic status and illiteracy.[10] The authors of this study believe that the target population on low economic status and illiteracy may be identified in industrial workers. In addition, the number of industrial sectors in India is continuously rising in the recent decade.[11] Hence, the data on tobacco related habits and oral lesions associated with tobacco habits will be useful for policy making decisions. Considering the importance of morbidity, quality of life, and influence on mortality, the study preferred to investigate the oral lesions related to tobacco habits linked to higher morbidity, negative impact on quality of life, and mortality [Table 2].[12] Thus, the present study attempted to identify the prevalence of tobacco related habits and oral lesions associated with tobacco related habits among industrial workers in Andhra Pradesh, South India.
Table 2 Tobacco related oral lesions categorized based on the level of morbidity impacting quality of life and mortality

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  Materials and Methods Top

The current study is a cross-sectional epidemiological investigation conducted in industrial workers in Andhra Pradesh, South India from March 2018 to August 2018. The study was approved (protocol no. 128/IEC/ SIBAR/2018) by Institutional Ethics committee SIBAR Institute of Dental Sciences, Guntur on 6th Jan. 2018. Based on the industrial workers population in the study region, the sample size was estimated as 900 individuals with a 95% accuracy rate, a 95% confidence interval, and marginal error of 2%. Ten percentage oversampling with an additional approximation of 10 individuals was planned; hence, a total of 1000 individuals were recruited for the study.

The main aim of the study was to focus on tobacco related OPMDs; however, nontobacco related OPMDs may be encountered during data collection. Hence, for the convenience of the study, OPMDs were classified into the following sections:
  1. Tobacco related OPMDs − Oral leukoplakia, erythroplakia, palatal changes with reverse smoking, oral submucous fibrosis
  2. Nontobacco related OPMDs − Oral lichen planus, oral lichenoid lesions, graft versus host disease, discoid lupus erythematosus, epidermolysis bullosa, dyskeratosis congenita, actinic Cheilitis.

Study criteria

Sectional criteria of the study:

Inclusion criteria

Individuals of 28 years and above

Have signed informed consent form

Individuals available on the day of screening

Exclusion criteria

Individuals who had acute and painful dental problems

Questionnaire focused on demographic details, tobacco related habit, and alcohol history was collected. The clinical examination was performed by a calibrated examiner with oral disease background. The lymph nodes were examined for all the participating individuals during extraoral examination. Basic dental examination instruments were used to conduct oral cavity examination. The individuals with clinically evident oral mucosal changes were subjected for toluidine blue and acetic acid staining for detection of OPMDs. The clinical information was computerized using Microsoft Excel documents and later subjected for statistical analysis using Statistical Package for Social Sciences version 20.0, Armonk, NY, IBM Corp.

Statistical analysis

The continuous variables in the data were mentioned as number, standard deviation, mean values, and proportions as percentages. The chi-square test was employed to assess the difference between the groups. Student t test was used to identify the mean exposure of tobacco habits. Multiple logistic regressions were used to analyze the oral lesions by different variables.

  Results Top

The present study was conducted using a cross-sectional design with a WHO proforma for recording oral mucosal lesions and tobacco related habits among industrial workers in Guntur city. A total of 1000 workers from various industries who satisfied the exclusion and inclusion criteria of the study were individuals of 28 years and above and individuals available on the day of screening. The study consisted of 53.9% of males and 46.1% of females. Majority of study participants were identified from 28 to 38 years of age intervals. The minimum number of participants was in the age group from 59 to 68 years. The mean age of the study population was 34.95 ± 11.97 years. In this study, 86.8% of individuals were chewing various forms of tobacco, whereas 13.2% were tobacco smokers. Gender distribution of tobacco smokers and smokeless tobacco users is given in [Table 3]. Age distribution of study participants of various forms of tobacco use showed statistical significance with P ≤ 0.001. Age distribution of study participants based on various forms of smokeless tobacco practice showed higher levels of consumption of khaini than other forms of smokeless tobacco habits. Comparison of age distribution of study participants based on smokeless tobacco users and tobacco smoker showed both habits were prevalent from 28 to 38 years age group. Age- and gender-based distribution of study participants with and without tobacco related oral lesions is presented in [Table 4]. Both smokeless tobacco and tobacco users are highly prevalent in the age group from 28 to 38 years. Distribution of tobacco related oral lesions in various anatomic locations of oral cavity on both genders showed prevalence in the following order: buccal mucosa, labial mucosa, vestibule, corner of mouth, and palate. Buccal mucosa is the most frequently involved site for tobacco related oral mucosal lesions in both males and females. Distribution of tobacco related oral lesions (OPMDs) based on the age is presented in [Figure 1](a). Oral leukoplakia, erythroplakia, and oral submucus fibrosis are more frequently seen in the age group from 28 to 38 years. Gender distribution of tobacco related oral lesions showed predilection for males [Figure 1]b.
Table 3 The frequency of smoke and smokeless tobacco users by gender

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Table 4 Age and gender distribution of tobacco related oral lesions among study participants

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Figure 1 (a) Distribution of tobacco related oral lesions in relation to age

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  Discussion Top

The study observed 53.90% males and 46.10% females. Our interpretation was similar to findings of Gupta and Ray,[12] who found the maximum number of cases to be males (61.20%) than females (39.80%). The mean age of the present study was 27.95 ± 11.97 years, which ranges from 15 to 69 years. Most of the study population were from 20 to 29 years. Similarly, an Indian study reported in 2008 observed higher predilection in the age group from 20 to 30 years.[13]

The current study documented 868 (86.80%) individuals with smokeless tobacco habits and tobacco smoking habit in 132 (13.21%) individuals. The study observed a similar prevalence rate of tobacco habit with a report from Goa, India.[14] The current study reported tobacco smoking as 13.21%, and Goa study stated 15%. Another study from Andhra Pradesh reported smoking prevalence as 67%.[15] The variation in the prevalence within the same geographic area should be attributed to industrial workers who probably may prefer the type of tobacco habit based on affordability. The cost range for smokeless tobacco may be way cheaper than smoking form of tobacco.[15] Interestingly, consumption of smokeless tobacco was predominantly observed in females (99.78%) than males (75.70%). Similar findings were reported by Sankaranarayan et al. [16] in 1989. Higher prevalence of smokeless tobacco among females may be related to social barriers for smoking form of tobacco among the women. Our qualitative interpretation on this item is that smokeless tobacco allows an individual to be pouched or snuffed in the oral vestibule and may go unnoticed by fellow work partners or family members. A study stated that the prevalence of OPMDs was higher among individuals with higher lifetime consumption of smokeless tobacco such as Pan Parag, Gutka, and Mawa.[17] Our study reported that cigarettes are the most common form of smoking tobacco product, followed by cigarettes without filter. Similar observation was made in the study conducted by Chandra and Govindraju[18] in 2012.

The study observed oral leukoplakia, oral submucous fibrosis, and oral cancer to be more prevalent among the age group from 20 to 29 years (36.22%), which can be attributed as early consequences of tobacco related habits. Similar observation was observed in the study conducted by Mehrotra et al.[19] in 2010.This study reinforces the concepts on association of tobacco products with OPMDs through the available data. A literature mentioned that any form of tobacco products may be associated with the occurrence of potentially malignant lesions.[20] Leukoplakia is more commonly seen among males followed by oral submucous fibrosis. A less number of oral mucosal lesions were observed in females. This could be due to the fact that tobacco smoking is more commonly associated with oral mucosal lesions than smokeless tobacco. Smokeless tobacco is usually associated with oral submucous fibrosis and no other forms of oral mucosal lesions. In addition, traditionally males are more known to be affected by workplace related stress, financial burden, and psychological trauma due to lack of life partner or family issues. This study also supports the view that smokeless tobacco (Pan Parag, Mawa, and pan masala) is the risk factor for causing potentially malignant disorders and cancer.[21],[22]

Recommendations on social accountability from the findings of the study

Based on the interpretation of results, the authors of the study recommend the following for the policy making individuals: (1) Educational videos on self-screening for oral precancer and cancer, (2) workplace restriction on tobacco related products, (3) facilitation of outreach services of oral diseases by the management of industries, (4) collaboration of dental schools with industries for periodic oral cancer screening, (5) tobacco cessation and counselling programs among industry workers, (6) educating family members on the impact of tobacco related habits and oral health, overall health, and quality of life, (7) knowledge on the hospital costs involved in the late or terminal stages of oral cancer, (8) oral precancer or cancer month programs in industries, and (9) targeting the schools where children of industrial workers usually obtain their education for early education on tobacco related health and social hazards.

  Conclusion Top

Leukoplakia, oral submucous fibrosis, and oral cancer are early consequences of tobacco related habits, whereas pigmentation and smoker’s melanosis are late consequences. The study documented higher prevalence of oral lesions related to tobacco habits among industrial workers. The study emphasizes the importance of special preventive programs targeting industrial workers including self-screening for oral precancer and cancer, tobacco cessation, counselling programs, and early detection of oral cancer. Workplace restriction for smoking or smokeless tobacco, educating family members on tobacco related oral lesions and its impact on health, and overall health and lifestyle may also play a role in bringing forward a societal change.


We thank Professor L Krishna Prasad, President, SIBAR Health Research Foundation, Guntur, Andhra Pradesh for providing funding support in conducting the research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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