Association of Tobacco Use with Severity of Oral Submucous Fibrosis and Risk of Malignant Transformation: A Cross-Sectional Study

Abstract

Objective: To determine the association of tobacco and areca nut consumption patterns with the clinical severity of oral submucous fibrosis (OSMF) and histopathological indicators of malignant potential.

Study Design: Analytical cross-sectional study.

Place and Duration of Study: Tertiary care hospital, Lahore, Pakistan, from 1 January 2026 to 30 June 2026.

Methodology: A total of 120 patients with clinically diagnosed OSMF were enrolled through consecutive sampling. Tobacco and areca nut consumption patterns, habit duration, daily frequency, cumulative quid-years, clinical stage, interincisal distance, and histopathological findings were assessed. Malignant potential was defined as moderate or severe epithelial dysplasia or oral squamous cell carcinoma (OSCC). Associations were evaluated using Spearman correlation, ordinal logistic regression, and Firth penalized logistic regression.

Results: The mean age was 33.8 ± 8.7 years, and 79 (65.8%) patients were male. Smokeless tobacco was the most common exposure (42.5%), while 44 (36.7%) patients had stage IV disease. Among 116 habit users, cumulative quid-years showed a strong positive correlation with OSMF stage (ρ = 0.80, p < 0.001), whereas interincisal distance was inversely correlated (ρ = −0.94, p < 0.001). Habit duration (adjusted OR 1.48, 95% CI 1.30–1.69) and daily frequency (adjusted OR 2.08, 95% CI 1.65–2.63) were significantly associated with advanced disease (both p < 0.001). Histopathological malignant potential was identified in 14 (11.7%) patients, including three with OSCC. Greater cumulative exposure was associated with malignant potential (OR 1.20 per 10 quid-years, 95% CI 1.04–1.39; p = 0.011).

Conclusion: Greater cumulative tobacco and areca nut exposure was significantly associated with advanced OSMF and histopathological malignant potential. Detailed habit assessment, clinical staging, and appropriate histopathological evaluation may support early identification of high-risk patients.