Cultural carcinogens in oral squamous cell carcinoma risk across global populations
Nicole C. Nowak1, Alyssa Forsyth2, Brooke Blan3, Shivani S. Ambardekar4, Kelly Frasier5, Nicole Werpachowski6 and Adrian P. Mansini7
1 Rush Medical College, Chicago, IL 60612, USA
2 Texas College of Osteopathic Medicine, Fort Worth, TX 76107, USA
3 Midwestern University, Arizona College of Osteopathic Medicine, Glendale, AZ 85308, USA
4 Department of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
5 Northwell Health, New Hyde Park, NY 11040, USA
6 Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
7 Department of Dermatology, Rush University Medical Center, Chicago, IL 60612, USA
Correspondence to:
Nicole C. Nowak, email: [email protected]
Keywords: oral squamous cell carcinoma; cultural carcinogens; dermatology; prevention; global disparities
Received: November 10, 2025 Accepted: May 21, 2026 Published: June 04, 2026
ABSTRACT
Oral squamous cell carcinoma (OSCC) is one of the most prevalent cancers worldwide, leading to significant illness and death, particularly in low- and middle-income countries. In addition to tobacco, alcohol, and human papillomavirus (HPV), several culturally ingrained practices, such as areca nut chewing, toombak, khat, reverse smoking, and hot mate drinking, remain underrecognized but important cultural factors contributing to OSCC globally.
These exposures operate through the formation of nitrosamine-induced DNA adducts, oxidative stress, chronic inflammation, and thermal injury. Areca nut and toombak are associated with oral submucous fibrosis and carcinoma, while reverse smoking and mate are linked to thermal and polycyclic aromatic hydrocarbon–related effects. Khat is connected to oxidative and cytogenetic damage.
This narrative review combines epidemiological, mechanistic, and public health evidence on cultural carcinogens in OSCC, emphasizing prevention strategies that honor cultural identity through education, harm reduction, and community involvement. Dermatologists specializing in mucocutaneous oncology can detect early lesions like leukoplakia, erythroplakia, and oral submucous fibrosis. Including oral mucosal screening in routine care provides an effective, affordable way to prevent diseases in high-risk populations.
Culturally sensitive, dermatology-focused prevention can help reduce OSCC incidence and disparities while respecting community identity.
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