title: Smokeless tobacco and oral potentially malignant disorders in South Asia: a protocol for a systematic review.
abstract: Oral potentially malignant disorders (OPMDs) are chronic lesions or conditions characterized by a potential for malignant transformation. Apart from being possible pre-cursors to oral cancer, OPMDs themselves are usually painful and debilitating conditions having an influence on the quality of life, both in terms of pain and social disability. Smokeless tobacco (SLT) use is considered a major risk factor for OPMDs. SLT use is a culturally and socially acceptable habit in South Asia. According to a recent report, 90 % of the SLT burden of the whole world lies in the South Asian countries of Pakistan, India, Sri Lanka, Bangladesh, Bhutan, Nepal, Afghanistan, and Maldives. This review aims to assess the association between the use of various SLT products in South Asia and risk of OPMDs.
  
  
  
  This review will focus on epidemiological studies on the use of SLT and risk modification for OPMDs, which have been carried out in the human population of South Asian countries. Articles reporting estimates of relative risk, e.g., odds ratio (OR) or relative risk (RR) with their 95 % confidence intervals (CI) for SLT users versus non-users. Articles reporting data from which these effect estimates can be computed will be included in the review. We will search MEDLINE, the Science Citation Index (SCI), Scopus, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases for relevant literature using a combination of keywords and MeSH terms, where applicable. Appropriate sources of gray literature will also be included in the search. The electronic searches will be supplemented by a hand search of the bibliographies of the included articles. The included studies will be assessed for their quality using an established quality assessment tool. All relevant data from the included articles will be recorded in an MS Excel spread sheet and then transferred to Rev Man 5.3 to carry out a meta-analysis. Heterogeneity among the estimates will be assessed through the I (2) statistic. Sensitivity and subgroup analysis will be carried out to see the effects of individual or group of studies on the pooled effect estimate. Results of the review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
  
  
  
  This review may have a potential limitation with regard to the designs of the studies included as we expect that most of the included studies will be of the observational types. We will however try to address this issue by conducting sensitivity and subgroup analysis of similar quality studies.
  
  
  
  PROSPERO CRD42015029705 .
authors: Leibniz Institute for Prevention Research and Epidemiology-(BIPS), Achterstrasse 30, 28359, Bremen, Germany. khan@bips.uni-bremen.de.|Khyber Medical University, Peshawar, Pakistan. khan@bips.uni-bremen.de.
authors: Zohaib
authors: 0000-0002-1885-8254
authors: Z
authors: Khan
authors: Pakistan Cancer Support Group, Khyber Pakhtunkhwa, Pakistan.|Department of Social Welfare and Special Education, Khyber Pakhtunkhwa, Pakistan.|Pakistan Paraplegic Centre, Peshawar, Pakistan.
authors: Sheraz
authors: S
authors: Khan
authors: Leibniz Institute for Prevention Research and Epidemiology-(BIPS), Achterstrasse 30, 28359, Bremen, Germany.
authors: Lara
authors: L
authors: Christianson
authors: Khyber Medical University, Peshawar, Pakistan.
authors: Sara
authors: S
authors: Rehman
authors: Leibniz Institute for Prevention Research and Epidemiology-(BIPS), Achterstrasse 30, 28359, Bremen, Germany.|Department of Anthropology and Cultural Research, Bremen University, Bremen, Germany.|Department of Clinical Pharmacy and Pharmacy Management, Nnamdi Azikiwe University, Awka, Nigeria.
authors: Obinna
authors: O
authors: Ekwunife
authors: Leibniz Institute for Prevention Research and Epidemiology-(BIPS), Achterstrasse 30, 28359, Bremen, Germany.|Department of Anthropology and Cultural Research, Bremen University, Bremen, Germany.
authors: Florence
authors: F
authors: Samkange-Zeeb
mesh_terms: D001208:Asia / Q000453:epidemiology; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D009062:Mouth Neoplasms / Q000453:epidemiology* / Q000517:prevention & control; D011230:Precancerous Conditions / Q000453:epidemiology* / Q000517:prevention & control; D011788:Quality of Life; D012307:Risk Factors; D000078202:Systematic Reviews as Topic; D064424:Tobacco Use / Q000009:adverse effects*; D014030:Tobacco, Smokeless / Q000009:adverse effects*
keywords: Betel quid; Erythroplakia; Gutkha; Leukoplakia; Oral potentially malignant disorders; Paan; Smokeless tobacco; South Asia; Submucous fibrosis