Journal of Preventive Medicine

Introduction
Gastrointestinal (GI) cancers are common cancers in Iran. In previous studies, non-preventable risk factors such as demographic characteristics, family history and genetics as well as preventable risk factors related to lifestyle such as diet, consumption of hot tea, salty foods, the presence of nitrates and other trace elements in water or food, smoking, alcohol consumption, body mass index and Helicobacter infection have been reported for GI cancers [5, 6, 7, 8, 9]. The International Agency for Research on Cancer (IARC) declared the use of opium to be carcinogenic to humans; therefore, opium use has harms similar to cigarette smoking and alcohol use [10].
Tobacco and opium use have become important public health concerns in Iran. Due to wrong beliefs, tobacco consumption, especially hookah smoking, has increased in the last few years in Iran, especially in the south of the country [14]. There are limited studies on the effect of the simultaneous use of tobacco and opium on the development of cancers, especially GI cancers. Therefore, in this study, we aim to assess the relationship between smoking tobacco and opium and the effects of their simultaneous use on GI cancers in Hormozgan Province.

Methods
This case-control study was conducted on 180 people: 60 with GI cancers whose medical files were in the cancer registration center of East of Hormozgan, registered in 2019, and 120 healthy people (with no cancer) in Minab City. The patients were selected based on the results of pathology tests and history of using opium and its derivatives in people who started using opium less than a year before diagnosis [18]. Exclusion criteria were having other cancers or malignancies in other organs, and lack of cooperation. The data was collected by a questionnaire surveying demographic information, information about the type of cancer and family history of the disease, and information about the history of opium use and tobacco consumption in the last ten years. Chi-square and Fisher’s exact test were used to evaluate the difference between the two case and control groups. Also, the relationship of tobacco and opium consumption with GI cancers was investigated using logistic regression models.

Results
The mean age of participants was 55.58±12.80 (ranged 30-81) in the control group and 56.22±13.88 (ranged 30-90) in the case group. The GI cancer types included stomach cancer (n=37, 61.67%), small intestine cancer (n=14, 23.33%), colon cancer (n=2,3.33%), liver cancer (n=6, 10.0%) and esophagus cancer (n=1, 1.67%). The rate of GI cancers in men was 1.5 times higher than in women.
The prevalence of opium, cigarette, and hookah use in the case group was 65%, 40%, and 55%, respectively. In the control group, it was 9.2%, 10%, and 4.2%, respectively. This difference between the two groups was significant (P<0.001). Tobacco and opium use greatly increased the risk of GI cancers. The risk increased significantly in people using only cigarettes (OR=5.08), only hookah (OR=17.71), only opium (OR=31.05), both opium and hookah (OR=65.81), both opium and cigarettes (OR=77.08) and all three substances of cigarettes, hookah and opium (OR=110.74) (P<0.05) (Figure 1). The odds ratios obtained in all groups (P<0.05) were significant, except for people with only cigarette consumption (P=0.07).

Conclusion
This study identified a positive and significant relationship between opium and tobacco use and GI cancers. The risk of these cancers was significantly high in people who used both tobacco and opium. It is recommended to conduct further studies considering the pattern of substance consumption and by controlling confounders (such as consumption of hot foods, alcohol, nitrates and toxins, Helicobacter pylori, etc.) to understand the role of each substance and their effects.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Hormozgan University of Medical Sciences, Bandar Abbas, Iran (Code: IR.HUMS.REC.1400.105).

Funding
This study was financially supported by Hormozgan University of Medical Sciences, Bandar Abbas, Iran.

Authors' contributions
All authors equally contribute to preparing all parts of the research.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors thank Hormozgan University of Medical Sciences for their financial and technical support during the experimental work.


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