Precancerous lesions in oral cavity of Indian schoolchildren may hint at epidemic

Anderson et al's review of squamous cell carcinomas of the head and neck prompts me to describe an unprecedented phenomenon facing India.

Consumption of smokeless tobacco, especially Gutkha (a mixture of areca, catechu, betel nut, lime, tobacco, and mint), is rising among school children in rural India.2 It is considered to be a harmless mouth freshener, and children therefore consume in large amounts and keep it in the mouth for a long time.

A survey of school children in a coastal village in the state of Kerala showed a 29% prevalence of tobacco chewing, and another survey in Mizoram showed a rate of 56.5%. The age for initiation for Gutkha in India has been reported as 8-14 years. A survey of 986 school children in a rural part of central India showed leukoplakia in 32, erythroplakia in six, and submucous fibrosis in 18.2 Some 50-60% of patients with submucous fibrosis will develop invasive cancers. In 1991, 11 premalignant lesions were found in 200 college students who used tobacco.2

The evidence of early onset of the smokeless tobacco habit and reports of increases in oral precancers among children raise serious concerns of an impending epidemic of oral cancer in this population.3 The age at onset of oral cancer in India is falling and is significantly lower than reported in the rest of the world.

Smokeless tobacco is becoming popular among children and adolescents in Canada, the United States, Scandinavia, and the United Kingdom. 4 5 In the United States the use of smokeless tobacco has increased among adolescent boys and young men in recent years. 4 5 National data indicate that 10-12 million Americans use some form of smokeless tobacco. Tobacco in its various forms has killed more people than al-Qaeda, yet we still lack an international coalition against "tobaccoism." Let the tobacco companies not poison our future generations.

Pankaj Chaturvedi, assistant surgeon, head and neck.