Reverse smoking and its effects among indian reverse smokers: A scoping review

Divya Vinnakota; Saira Hakkim; Maneesha Varghese Pellissery; Madhini Sivasubramanian; Mohammad Tariqul Islam Khan; Afroza Hoque; Abu Rushd Mohammad Mashrur; Ali Davod Parsa; Russell Kabir

doi:10.4103/jpcdoh.jpcdoh_4_22

REVIEW ARTICLE

Year : 2022 | Volume : 3 | Issue : 3 | Page : 67-74

Reverse smoking and its effects among indian reverse smokers: A scoping review

Divya Vinnakota¹, Saira Hakkim², Maneesha Varghese Pellissery², Madhini Sivasubramanian¹, Mohammad Tariqul Islam Khan³, Afroza Hoque⁴, Abu Rushd Mohammad Mashrur⁵, Ali Davod Parsa², Russell Kabir²
¹ Department of Nursing and Public Health, University of Sunderland, London, UK
² School of Allied Health, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford, UK
³ Department of Dental Anatomy, Bangladesh Dental College, Dhaka, Bangladesh
⁴ Department of Medical Education, Chattagram International Medical College, Chattogram, Bangladesh
⁵ Department of Conservative Dentistry, Chittagong Medical College, Chittagong, Bangladesh

Date of Submission	01-Feb-2022
Date of Decision	28-Mar-2022
Date of Acceptance	29-Mar-2022
Date of Web Publication	20-Jun-2022

Correspondence Address:
Russell Kabir
School of Allied Health, Anglia Ruskin University, Chelmsford
UK

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcdoh.jpcdoh_4_22

Abstract

Reverse smoking is a unique style of tobacco use in which the smoker places the lit end of a chutta into his or her mouth while smoking and then inhales the smoke from the lit end. The purpose of this scoping review is to explore reverse smoking and identify its effects among Indian reverse smokers. Literature search was conducted using PubMed, PubMed Central, Embase, and CINAHL Plus. Boolean operators AND/OR was used with the search terms. Search was limited to the original research articles, English language articles, and full-text articles. Finally seven original articles were selected for the scoping review. The studies were conducted between 1971 and 2016, where more studies were identified in the 21^st century (2002–2016). Four themes emerged from the data analysis. The first themes explore the palatal mucosal changes in reverse smokers; the second theme presents carcinoma and reverse smoking; third theme focuses on effects of keratinization on detection of epithelial atypia, and lastly, the fourth theme focuses on reverse smoking and psychosocial factors. Reverse smokers are more likely to develop precancerous palatal alterations and squamous cell carcinoma of the palate. To make healthy choices, a strong focus on health promotion is required, which includes initiatives that emphasize the need of educating individuals about disease risks.

Keywords: India, reverse smoking, scoping review, smoking

How to cite this article:
Vinnakota D, Hakkim S, Pellissery MV, Sivasubramanian M, Khan MT, Hoque A, Mohammad Mashrur AR, Parsa AD, Kabir R. Reverse smoking and its effects among indian reverse smokers: A scoping review. J Prim Care Dent Oral Health 2022;3:67-74

How to cite this URL:
Vinnakota D, Hakkim S, Pellissery MV, Sivasubramanian M, Khan MT, Hoque A, Mohammad Mashrur AR, Parsa AD, Kabir R. Reverse smoking and its effects among indian reverse smokers: A scoping review. J Prim Care Dent Oral Health [serial online] 2022 [cited 2023 Mar 23];3:67-74. Available from: http://www.jpcdoh.org/text.asp?2022/3/3/67/347801

Introduction

Tobacco smoking is by far the most widespread form of smoking today and it is one of the leading causes of death and disease in India, with about 1.35 million people dying each year.^[1] India is also the world's second-largest tobacco consumer and manufacturer. In the country, a wide range of tobacco products are offered at extremely affordable prices. Tobacco is smoked and chewed in a variety of ways in India. According to the Global Adult Tobacco Survey India, 2016–17, about 267 million adults (15 years and older) in India (29% of all adults) use tobacco.^[1] In India, smokeless tobacco is the most popular type of tobacco. Tobacco usage is one of the most serious public health hazards worldwide. It not only results in the loss of lives but it also has significant social and economic consequences.^[2] In India, the total economic losses linked to tobacco smoking from all diseases for people aged 35 years and up totalled INR 177 341 crores in 2017–18.(USD 27.5 billion).^[1] The WHO indicates that by 2020, tobacco deaths in India can surpass 1.5 million annually.^[3]

Reverse smoking is a unique style of tobacco use in which the smoker places the lit end of a chutta into his or her mouth while smoking and then inhales the smoke from the lit end. Chuttas are cheroots that have been coarsely processed and range in length from 5 to 9 cm. In Andhra Pradesh's coastal districts, particularly Visakhapatnam and Srikakulam, reverse chutta smoking is common.^[4] Unlike males, who smoke chuttas in either the traditional or reverse manner, women almost exclusively smoke chuttas in the reverse manner, which they regard to be a more feminine form of smoking. As a chutta lasts longer when smoked in this manner, the reverse smoker typically smokes up to two chuttas every day. The most common argument for reverse smoking is that the chutta is less likely to be extinguished by water sprayed on it during domestic chores, as well as the threat of hot ashes falling on nursing infants.^[4] In various parts of the world, reverse smoking has been documented with similar explanations.^[5] Reverse smoking has been linked to a variety of oral mucosal changes, ranging from minor changes such as leukoedema, melanosis, and smoker's palate to more serious potentially malignant illnesses or lesions like leukoplakia and erythroplakia, which can eventually lead to oral cancer.

A research study states that the relationship between a reverse smoker and their family members was statistically significant. Family members played a big role in influencing the participants to take up reverse smoking, whether intentionally or unknowingly, where classmates and friends impacted them after their parents at home.^[6] Few studies focused on the relationship between the type of smokeless tobacco and the risk of cancer;^[7] tobacco products and their health issues;^[8] mortality among reverse chutta smokers in South India;^[9] smokeless tobacco and oral potentially malignant disorders in South-east Asia,^[10] but there is no previous review on reverse smoking and its effects among Indian reverse smokers. The aim of this scoping review is to explore reverse smoking and identify its effects among Indian reverse smokers. We also examine the need for additional study in this area as well as the feasibility of implementing interventions.

Methodology

Study design

This scoping review has included both quantitative and qualitative primary research studies.

Search strategy

The databases used for the initial review of literature were PubMed, PubMed Central, Embase, and CINAHL Plus.

A wide range of literature search was conducted on published literature to identify different types of publications. The literature search was limited to the country India only as smokeless tobacco is most common in India^[1] and there is no search limit of publication period. The text words and relevant indexing was used in the search strategy to capture the concept of reverse smoking and its effects on the reverse smokers in India.

The search terms were employed using Boolean operators (AND/OR) and for indexing articles the medical subject headings browser was used.

The literature search in the databases used the following keywords:

Reverse smoking, reverse chutta smoking, reverse chutta smokers, Indian reverse smokers, tobacco, conventional smoking, and smokeless tobacco
Oral neoplasms, precancerous conditions, dietary nutrients, premalignant lesions, epidemiology, carcinoma, hyperparakeratosis, hyperorthokeratosis, and dyskeratosis
India.

Search was limited to the original research articles, English language articles, and full-text articles.

In addition, reference lists of the included studies were searched to identify relevant studies known as reference harvesting.

To avoid duplication bias, duplicate articles were removed before the implementation of inclusion and exclusion criteria.

Implementation of inclusion and exclusion criteria

Initially, articles were screened for the study design that resulted after applying limitations as shown in [Table 1]. Further for the relevant articles, titles and abstracts against inclusion criteria were scanned and then followed by screening of full articles which are identified in the initial screening as relevant potential articles. The articles that are not with sufficient information on reverse smoking and its effects were excluded. Editorials, letters to the editors, review articles, and commentaries were excluded. After the implementation of inclusion and exclusion criteria, seven papers were chosen for the thematic analysis.

Table 1: Inclusion and exclusion criteria

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Results

Distribution of studies

The search revealed only seven articles discussing reverse smoking and its effects on oral cavity among reverse smokers in India. The studies were conducted between 1971 and 2016, where more studies were identified in the 21^st century (2002–2016). The characteristics of the studies are shown in [Table 2].

Table 2: Characteristics of Included Studies

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The following four themes emerged from the data analysis. The first themes explores the palatal mucosal changes in reverse smokers, the second theme presents carcinoma and reverse smoking, third theme focuses on effects of keratinization on the detection of epithelial atypia, and finally, the fourth theme focuses on reverse smoking and psychosocial factors.

Palatal mucosal changes in reverse smokers

The clinical manifestations of reverse smoking-related mucosal alterations are diverse. When compared to traditional smokers, the clinical appearance of oral mucosa changes.^[6] Tobacco's effects on the oral mucosa range from mild mucosal changes to full-blown oral cancer, and the consequences vary depending on the kind of tobacco used.^[11] Because of the proximity of heat and tobacco materials during smoking, the most noticeable abnormalities linked with reverse smoking recorded in the literature were detected on the palate and tongue.^[6] When the tobacco habits are compared to the site of the lesion, the leukoplakia and preleukoplakia lesions were found exclusively on the palate.^[12] Reverse smokers are more likely to develop precancerous palatal changes and squamous cell carcinoma of the palate.^[13] Hyperpigmentation, depigmentation, stomatitis nicotina, preleukoplakia, leukoplakia, erythroplakia, and palatal cancer are the most common oral mucosal lesions linked with reverse smoking.^[6]

Hyperpigmentation of the palatal mucosa is described as well-defined diffuse or localized grayish black pigmentation caused by increased melanin synthesis by melanocytes. Elevated melanin deposition as a protective reaction to heat and its antioxidant qualities against harmful chemicals created during tobacco combustion within the oral cavity causes this pigmentation, which was restricted to the hard palate and had regular edges.^[14]

Melanin is a natural antioxidant generated by melanocytes that helps to scavenge the harmful chemicals released during tobacco combustion. Oral pigment alterations and depigmented regions are the signs of parts of the palatal mucosa that are clinically devoid of melanin pigmentation in heavy smokers. The severe toxic content over a period exceeds the levels of melanocytes to make melanin, robbing the depigmented regions of their melanin defence barrier, or the toxic impacts may induce melanocyte function loss.^[14]

The toxins of tobacco smoke enter through the hypertrophied ductal openings of minor salivary glands, and the pseudostratified columnar epithelial linings of ducts undergo squamous metaplasia in response to chronic irritation caused by heat and chemicals released during reverse smoking, and this metaplastic squamous epithelium has a high malignant potential.^[14]

Ulcerations, defined as a red region with a crater or excavation of varied degrees that was persistent, symptomatic, and seen in depigmented areas surrounded by hyperpigmentation, are malignant.^[14]

Carcinoma and reverse smoking

Oral cancer is linked to reversible smoking and other types of tobacco use.^[4] The tongue, buccal mucosa, gingiva, lips, and floor of the mouth are the most frequent sites for cancer in the oral cavity, although the palate is less prevalent, except among reverse smokers, where it is the most common site.^[15]

Reverse smoking has been linked to a variety of oral mucosal alterations, ranging from minor changes such as leukoedema, melanosis, and smoker's palate to more serious potentially malignant illnesses or lesions like leukoplakia and erythroplakia, which can eventually lead to oral cancer.^[6]

The smoke generated by the chutta comes into close touch with the mouth mucosa in reverse smokers. This produced smoke has a high alkaline pH, which makes it easier for chemicals like nicotine alkaloid, reducing sugars, and nitrogen to be absorbed. Aside from that, it raises internal temperature by roughly 760°C and intraoral air temperature by up to 120°C. Temperature changes operate as co-carcinogens as well. When compared to traditional smokers, these modifications are responsible for an increased risk of oral cancer.^[11]

Effect of keratinization on detection of epithelial atypia

In the mouth, the palate is a highly keratinized region. Reverse smoking causes widespread hyperorthokeratosis of the palatal mucosa, which is frequently coupled with epithelial atypia.^[16]

When comparing reverse smokers to traditional chutta smokers and nonsmokers, cytological research revealed a higher percentage of parakeratinization, hyper parakeratinization, and dyskeratosis. The palatal mucosa of reverse chutta smokers has a parakeratosis and dyskeratosis pattern of keratinisation, indicating an enhanced proliferative potential of the epithelium, and thus cytological assessment of keratinization pattern can be employed in the early diagnosis of high-risk lesions.^[13] At the same time, lesions in highly keratinized parts of the mouth obstruct the exfoliation of probable atypical cells that emerge from the epithelium's deeper layers. The degree of keratinization has an inverse relationship with the accuracy of cytological diagnosis. The highly keratinized surface of the hard palate, similar to atypias, may obstruct the free migration of cancer cells toward the outer surfaces, contributing to the high rate of false negative diagnosis. If there is a breach in the epithelium, such as an area of ulceration, the cytological smears are likely to identify cancer cells much more readily.^[16]

Reverse smoking and psychosocial factors

Human behavior is influenced and determined by a wide range of circumstances. Reverse smokers learned to smoke mostly from their mother and the people around them, primarily family and friends. Second, they are continuing the habit despite no physical advantages, and they have tried but failed to stop, implying that reverse smoking has a powerful psychological influence. Reverse smokers' lack of understanding of the harmful consequences of nicotine and tobacco-related products may explain why, when asked if they had seen any changes in their mouths as a result of reverse smoking, the most prevalent response was “no.”^[6]

The early age at which the habit is initiated, which causes the changes to look chronic and gradual; hence, the people may perceive them as normal. Furthermore, restricted access to health facilities and a lack of knowledge about dental health care might be linked to the social component that influences reverse smoking.^[6]

Discussion

Sri Lanka, Venezuela, Sardinia, and Panama are among the countries where reverse smoking is common.^[17] Reverse smoking is particularly popular in the districts of Vizianagaram, Srikakulam, and Visakhapatnam in the Indian state of Andhra Pradesh. There are no recent studies on its exact prevalence because, as a result of urbanization and higher literacy rates, such practises appear to be on the downslide. The clinical manifestations of mucosal alterations caused by reverse smoking are diverse. In comparison to traditional smokers, the clinical appearance of oral mucosa varies.

Because of the close proximity of heat and tobacco products during smoking, the most apparent alterations linked with reverse smoking recorded in the literature were detected on the palate and tongue. Hyperpigmentation, depigmentation, stomatitis nicotina, preleukoplakia, leukoplakia, erythroplakia, and palatal cancer are the most common oral mucosal lesions linked with reverse smoking.^[12],[17]

There are various theories as to why females in the coastal region of Andhra Pradesh prefer reverse smoking.^[12] Initially, ladies began reverse smoking to conceal their smoking habits from their husbands and parents. Second, if they smoke in the traditional technique, the burnt end of the chutta becomes extinguished owing to strong winds and splashing of water during housework and fishing. Fisherwomen wanted to keep the hot ashes from falling on the fishing net and damaging it while weaving. There are a few taboos associated with this behaviour, such as smoking chutta in reverse to relieve tooth pain and hide halitosis, and forcing youngsters to smoke chutta in reverse to cure various diseases.

In a pilot study conducted in Andhra Pradesh, reverse chutta smokers had 36.6% parakeratinized cells and 11.3% hyperparakeratotic cells, compared to 23.8% and 2.2% of parakeratinized cells and hyperparakeratotic cells in conventional chutta smokers and 31.3% and 2.5% of parakeratinized cells and hyperparakeratotic cells in nonsmokers.^[13]

When comparing reverse smokers to traditional chutta smokers and nonsmokers, cytological research revealed that reverse smokers had a higher percentage of parakeratinization, hyper parakeratinization, and dyskeratosis. Hence, this result could indicate high-risk lesions in the hard palate of reverse smokers. However, while cytology is not a substitute for biopsy, it may be useful to the clinician in identifying the hyperparakeratotic character of the lesion, which may signal potentially high-risk lesions in oral cancer control programs involving mass screening of the community.

However, previous studies have found that reverse smoking (i.e., with the lighter end inside the mouth), which is common among women in Andhra Pradesh's coastal region in east-central India, is strongly linked to oral, particularly palatal, precancerous lesions that can progress to carcinoma and exhibit epithelial atypia of the palate.^[12],[16] Whereas another study states that relative risk of developing oral cancer among those with precancerous lesions has been found to be extremely high, indicating that these lesions are part of the cancer causative pathway.^[18]

The tongue, buccal mucosa, gingiva, lips, and floor of the mouth are the most common sites for cancer in the oral cavity, but the palate is less prevalent, except in reverse smokers, where it is the most common site.^[15]

All of the participants in one study^[6] who acquired habit of reverse smoking were from lower socioeconomic backgrounds, suggesting that there may be a link between their economic level and their smoking behaviours. These findings matched those of a study conducted by^[19] which found that people with inadequate financial resources and little understanding of the detrimental consequences of tobacco are more likely to start smoking.

Conclusion

Reverse smokers are more likely to develop precancerous palatal alterations and squamous cell carcinoma of the palate. To make healthy choices, a strong focus on health promotion is required, which includes initiatives that emphasise the need of educating individuals about disease risks. It is necessary to run information campaigns aimed at high-risk groups in order to influence personal routines and behaviours. Individuals and communities must be empowered to define priorities, make decisions, and plan and implement solutions in order to improve their health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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