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Oral cancer risk factors

The key risk factors for oral cancer are discussed on this page. Oral cancer risk is also linked with age and sex

Around 91% of oral and pharyngeal cancers in the UK are linked to lifestyle: 93% in males and 85% in females.1 The majority of these cases were caused by smoking.1

Meta-analyses and systematic reviews are cited where available, as they provide the best overview of all available research and most take study quality into account. Individual case-control and cohort studies are reported where such aggregated data are lacking.

Oral cancer risk factors overview

The International Agency for Research on Cancer (IARC) evaluates evidence on the carcinogenic risk to humans of a number of exposures including tobacco, alcohol, infections, radiation (UV and ionising), occupational exposures, and medications.2 The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) evaluates evidence for other exposures including diet, overweight and obesity, and physical exercise.3 IARC and WCRF/AICR evaluations are the gold standard in cancer epidemiology. Their conclusions about oral cancer risk factors are shown in Table 4.1.1

Table 4.1: IARC and WCRF/AICR Evaluations of Oral Cancer Risk Factors

Increases risk ('sufficient' or 'convincing' evidence) May increase risk ('limited' or 'probable' evidence) Decreases risk ('sufficient' or 'convincing' evidence) May decrease risk ('limited' or 'probable' evidence)

-

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Age and sex

Oral cancer risk is strongly related to age and sex.

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Tobacco

Smoking

Tobacco smoking is classified by IARC as a cause of oral cavity, tonsil, pharynx and nasopharynx cancers (Table 4.1).2 An estimated 65% (70% in males and 55% in females) of oral and pharyngeal cancers in the UK are linked to tobacco smoking.4

Oral cavity cancer risk is 3 times higher in current smokers compared with never-smokers, a meta-analysis showed.5 Pharyngeal cancer risk is nearly 7 times higher in current smokers compared with never-smokers.5

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Oral cavity cancer risk in men is almost 3 times higher in those who have smoked the most cigarettes for the most years, compared with those who have smoked the least for the fewest years, a pooled analysis showed.6 Oral cavity cancer risk in women is more than 4 times higher in the heaviest- and longest-smokers versus the lightest- and shortest-smokers.6 Oropharynx cancer risk in men is almost twice as high in the heaviest- and longest-smokers versus the lightest- and shortest-smokers.6 Oropharynx cancer risk in women is more than 3 times higher in the heaviest- and longest-smokers versus the lightest- and shortest-smokers.6

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Oral cavity cancer risk is 35% lower in ex-smokers who quit 1-4 years previously, compared with current smokers, a pooled analysis showed.7 Oral cavity cancer risk is no higher in ex-smokers who quit 20+ years previously, compared with never-smokers.7 Oropharynx/hypopharynx cancer risk is 49% lower in ex-smokers who quit 5-9 years previously, compared with current smokers. Oropharynx/Hypopharynx cancer risk is no higher in ex-smokers who quit 20+ years previously, compared with never-smokers.7

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Head and neck cancer (comprising oral cavity, pharynx and larynx) risk is 3.5 times higher in cigar-only smokers compared with never-smokers, a pooled analysis showed.8 Head and neck cancer risk is nearly 4 times higher in pipe-only smokers compared with never-smokers. Risk increases with heavier or longer-term cigar or pipe use.8

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Oral cancer risk is around 3 times higher in bidi smokers compared with bidi never-smokers, a meta-analysis of south Asian studies showed.9

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Oropharyngeal cancer risk is not associated with marijuana smoking, a pooled analysis showed.67

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Environmental tobacco smoke

Secondhand or environmental tobacco smoke (ETS) is classified by IARC as a probable cause of pharynx cancer (Table 4.1).2

Oral and oropharyngeal cancer risk is 87% higher in never-smokers who have ever been exposed to ETS at home or work, compared with unexposed never-smokers, a case-control study showed.10 Oral and oropharyngeal cancer risk is more than twice higher in never-smokers exposed to ETS at home or work for 15+ years, compared with unexposed never-smokers.10

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Smokeless tobacco

Smokeless tobacco is classified by IARC as a cause of oral cavity cancer (Table 4.1).2 Oral cancer risk is 2-7 times higher in smokeless tobacco users versus non-users, a meta-analysis showed; the association varies by country probably due to differences in smokeless tobacco composition and format (e.g. chewing or inhaling nasally).11

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Betel quid with tobacco is classified by IARC as a cause of oral cavity, tonsil and pharynx cancers, and betel quid without tobacco as a cause of oral cavity cancer (Table 4.1).2

Oral cancer risk in non-smokers is 3.5 times higher in betel quid without tobacco users compared with non-users, meta-analyses have shown.12,13,63 Oral cancer risk in non-smokers and non-drinkers is around 15 times higher in betel quid without tobacco users compared with non-users.12,13,63

Oral cancer risk in non-smokers and non-drinkers is around 7 times higher in betel quid with tobacco users compared with non-users, a meta-analysis of studies from India (where tobacco is usually added to betel quid64) showed.63 Oral cancer risk in smokers and drinkers is over 30 times higher in betel quid with tobacco users compared with non-users.63  

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Alcohol

Alcohol is classified by IARC and WCRF/AICR as a cause of oral cavity, tonsil and pharynx cancers (Table 4.1).2,3 An estimated 30% (37% in males and 17% in females) of oral and pharyngeal cancers in the UK are linked to alcohol drinking.14

Oral and pharyngeal cancer risk in men is 35% higher per 1.5 units of alcohol consumed per day, a meta-analysis showed.15  Oral and pharyngeal cancer risk in women is 9% higher per 1.5 units of alcohol per day.15 Oral and pharyngeal cancer risk is more than 3 times higher per 6 units of alcohol per day.15 Oral and pharyngeal cancer risk is 2.5 times higher in regular drinkers compared with non- and occasional drinkers.15

Oral and pharyngeal cancer risk is almost tripled in alcohol drinkers who currently smoke tobacco, while it is 32% higher in alcohol drinkers who do not currently smoke, both compared with never-drinkers, a meta-analysis showed.16   Oral cavity, oropharyngeal and hypopharyngeal cancer risk increases with amount of alcohol consumed among ever-smokers,6 but among never-smokers the effect may be limited to oropharyngeal/hypopharyngeal cancer, pooled analyses have shown.16 Oral cancer risk is higher in alcohol drinkers who use smokeless tobacco, compared with alcohol drinkers who do not use smokeless tobacco.17,18

Oral cancer risk is not associated with use of alcohol-containing mouthwash, a meta-analysis showed.19

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Ionising radiation

X-radiation and Gamma radiation are classified by IARC as causes of salivary gland cancer; and radioiodines as probable causes, based on limited evidence (Table 4.1).2

Salivary gland cancer risk is higher in survivors of childhood cancer, Hodgkin lymphoma, and thyroid cancer, compared with the general population, cohort studies have shown; this is due to radiation treatment (radiotherapy or radioiodines) for the primary tumour.22,23,24,25.

Oral cancer risk is higher in atomic bomb survivors compared with the general population.21

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Ultraviolet (UV) radiation

Solar radiation is classified by IARC as a probable cause of lip cancer, based on limited evidence (Table 4.1).2 Confounding by tobacco use is possible.20

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Infections

Human papillomavirus (HPV)

Human papillomavirus (HPV) type 16 is classified by IARC as a cause of oral cavity, tonsil and pharynx cancers, and HPV type 18 as a probable cause of oral cancer (Table 4.1).2 An estimated 8% of oral cavity cancers and 14% of oropharyngeal cancers in the UK are linked to HPV infection.26

73% of oropharyngeal cancer cases in Europe are HPV-positive, a meta-analysis showed; this proportion has increased over time.27 12% of oral cavity, hypopharynx and larynx cancer cases in Europe are HPV-positive, with no change over time.27

Oropharyngeal, tonsil, and base of tongue cancer risk is higher in people with more past sex partners (particularly oral sex partners), and those who started having sex at a younger age, a pooled analysis showed; this reflects the sexual route of HPV transmission.28

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Epstein-Barr virus (EBV)

Epstein-Barr virus (EBV) is classified by IARC as a cause of nasopharynx cancer (Table 4.1).2 An estimated 90% of nasopharyngeal cancer cases in the UK are EBV-positive.29

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HIV/AIDS

Oral, oropharyngeal and pharyngeal cancer risk is around twice higher in people with HIV/AIDS, compared with the general population, meta-analyses have shown;30,31this may reflect higher rates of HPV infection in people with HIV.32

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Immune system

Oral cavity and pharynx cancer risk is 2-5 times higher in organ transplant recipients compared with the general population, a meta-analysis and several large cohort studies have shown.30,33,34 Lip cancer risk is particularly elevated in transplant recipients,30,33,34 perhaps associated with persistent HPV infection and increased sensitivity to UV radiation due to immunosuppressant medication.35

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Medical conditions and treatments

Oral conditions

An estimated 12% of people with oral dysplasia (including oral leukoplakia and erythroplakia) develop oral cancer, a meta-analysis showed.37

Head and neck cancer risk is 2.6 times higher in people with periodontal (gum) disease, a meta-analysis showed.61 Head and neck cancer risk is at least 60% higher in people who lose 6+ teeth, a meta-analysis showed; risk increases with number of teeth lost.62

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Hydrochlorothiazide

Hydrochlorothiazide (an antihypertensive with photosensitising effects) is classified by IARC as a probable cause of lip cancer, based on limited evidence (Table 4.1).2 Lip cancer risk among white people is 4 times higher in those using hydrochlorothiazide for 5+ years versus never-users, a cohort study showed.38

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Previous cancer

Head and neck cancer (including tongue, mouth, pharynx, and larynx) risk is 12-16 times higher in people with a previous head and neck cancer, a pooled analysis showed.39

Oral cancer (definitions vary between studies) risk is higher in survivors of oesophageal squamous cell carcinoma (SCC), lung cancer, or cervical SCC, compared with the general population, cohort studies have shown.40-42

This may reflect the effect of treatment for the primary cancer, or shared lifestyle, environmental or genetic risk factors.

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Family history and genetic conditions

Family history 

Head and neck cancer risk is 70% higher in people with a family (particularly sibling) history of head and neck cancer, versus those without such history, a pooled analysis showed.43 Head and neck cancer risk is higher in people with a family history of other tobacco-related cancers versus those without.43 Head and neck cancer risk among alcohol and tobacco users is more than 7 times higher in those with a family history of the disease versus those without.43 This indicates shared lifestyle and environmental factors contribute to the increased risk, as well as genetic risk factors.

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Occupational exposures

Formaldehyde and wood dust are classified by IARC as causes of nasopharyngeal cancer (Table 4.1).2 An estimated 11% of nasopharyngeal cancers in men in Great Britain, and around 2% in women, are linked to occupational exposure to formaldehyde or wood dust.44

Nasopharyngeal cancer death risk may not be associated with formaldehyde exposure, cohort studies have shown;47,69 however evidence is mixed.45

Nasopharyngeal cancer death risk may be 2.4 times higher in furniture and plywood workers, a pooled analysis showed;46 however evidence is mixed.47

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Asbestos and exposure to printing processes (which may entail exposure to polycyclic aromatic hydrocarbons and mineral oils) are classified by IARC as probable causes of pharynx cancer, based on limited evidence (Table 4.1).2

Oral and pharyngeal cancer risk is 25% higher in people exposed to asbestos, compared with the general population, a meta-analysis showed.48 

Oral and pharyngeal cancer risk is 14% higher in people exposed to polycyclic aromatic hydrocarbons.48

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Diet

Salted fish (Chinese-style)

Salted fish (Chinese-style) is classified by IARC as a cause of nasopharyngeal cancer (Table 4.1); nitrosamine levels are higher in Chinese-style than other types of salted fish.2 Nasopharyngeal cancer risk in adulthood is 2.5 times higher in people with the highest intakes of Chinese-style salted fish during childhood, versus those with the lowest, a case-control study showed.49 Confounding by tobacco use and vegetable intake is possible.50

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Hot maté

Consumption of hot maté (a South American drink) is classified by IARC and WCRF/AICR, as a cause of pharyngeal cancer (Table 4.1).2.3Oral and oropharyngeal cancer risk is around twice higher in maté drinkers versus non- or low-drinkers, a meta-analysis of case-control studies from Latin America showed.51 This may reflect the hot temperature of the drink, or carcinogenic substances in the drink.51

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Height

Head and neck cancer risk is 9% lower per 10cm increase in height for men, and 14% lower per 10cm height for women, a pooled analysis showed.65

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Factors shown to decrease or have no effect on oral cancer risk

Decrease

Non-starchy vegetables and fruits (not salted or pickled), and foods containing carotenoids, are classified by WCRF/AICR as probably protective against mouth, pharynx and larynx cancers (Table 4.1).3 An estimated 56% of oral cavity and pharynx cancers in the UK are linked to eating fewer than five portions of fruit and vegetables per day.52 

Oral cancer (definitions vary between studies) risk is lower in people with the highest intake of the following foods, versus those with the lowest intake, meta- and pooled analyses or systematic reviews have shown:

  • Fruit – 48% lower risk.53
  • Vegetables – 34% lower risk.53
  • Vitamin C supplements – 24% lower risk in ever- versus never-users.55
  • Calcium supplements – 36% lower risk in ever- versus never-users.55
  • Caffeinated coffee – 39% lower risk in 4 cups/day versus non-drinkers.56
  • Green tea – 20% lower risk.68

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Oral cancer risk is 26-47% lower in people who do moderate/high levels of recreational physical activity, versus those who do very little/no recreational physical activity, a pooled analysis showed.57 Pharyngeal cancer risk is 33-42% lower in people with moderate/high physical activity levels, versus very low/no physical activity.57 The association may be stronger in males, younger people, ever-smokers and ever-drinkers.57

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Oral and pharyngeal cancer risk in men is around halved in those with allergic rhinitis versus those without, a meta-analysis showed.58 Oral or pharyngeal cancer risk in women is not associated with allergy.58 Confounding by tobacco use is possible.

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No effect

WCRF/AICR make no judgment on the association between mouth, pharynx and larynx cancer risk and intake of cereals (grains) and their products; starchy roots, tubers, and plantains; dietary fibre; pulses (legumes); meat; poultry; fish; eggs; milk and dairy products; total fat; animal fats; plant oils; coffee; tea; frying; grilling (broiling) and barbecuing (charbroiling); protein; vitamin A; retinol; thiamin; riboflavin; niacin; folate; vitamin C; vitamin E; calcium; iron; selenium; body fatness; or energy intake, due to limited evidence.3

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Oral (definitions vary between studies) cancer risk is not associated with the following factors, meta- and pooled analyses or systematic reviews have shown:

  • Excess body weight60 (though some evidence of lower risk in overweight and obese people59).
  • Meat (except 91% higher risk with highest versus lowest processed meat consumption).70
  • Black tea.56,68
  • Vitamin D blood levels.71

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References for oral cancer risk factors

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Updated: 31 October 2013