A case–control study in North Carolina involving 255 women with oral and pharyngeal cancer and 502 controls revealed that the exceptionally high mortality from this cancer among white women in the South is primarily related to chronic use of snuff. The relative risk associated with snuff dipping among white nonsmokers was 4.2 (95 per cent confidence limits, 2.6 to 6.7), and among chronic users the risk approached 50-fold for cancers of the gum and buccal mucosa — tissues that come in direct contact with the tobacco powder. In the absence of snuff dipping, oral and pharyngeal cancer resulted mainly from the combined effects of cigarette smoking and alcohol consumption. The carcinogenic hazard of oral snuff is of special concern in view of the recent upswing in consumption of smokeless tobacco in the United States. (N Engl J Med. 1981,; 304: 745–9.) IN the United States the geographic patterns of mortality from cancer of the oral cavity and pharynx show a remarkable sex difference.1 , 2 Among men the tumors occur excessively in the urban Northeast, which is consistent with geographic patterns of tobacco smoking and alcohol consumption — the major risk factors for oral and pharyngeal cancer. In contrast, among women the mortality rates in the Southeast exceed those in the North by 30 per cent in urban areas and by 90 per cent in rural areas. The differences are most pronounced for cancer of the oral cavity, and the use of snuff. . .
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