3rd March 2017, Volume 130 Number 1451

Muhammed Yakin, Ratu Osea Gavidi, Brian Cox, Alison Rich

Head and neck cancers are the fifth most common malignancy worldwide, accounting for an estimated 984,430 cases in 2012.1 Head and neck cancers are cancers arising in the lips, oral…

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Oral cancer is a significant health issue with high morbidity and mortality rates. With late diagnosis, approximately half of the affected patients die of the disease within five years. Certain factors, particularly alcohol and tobacco consumption, place individuals at a higher risk of getting oral cancer. In New Zealand, four out of five individuals consume alcohol and approximately two out of five use tobacco, which places them at higher risk of developing oral cancer. We have provided an overview of these and other oral cancer risk factors and their prevalence in New Zealand. We hope that this will further encourage doctors and dentists to provide regular advice regarding tobacco cessation and judicious alcohol use.


Oral cancer constitutes the majority of head and neck cancers, which are the fifth most common malignancy worldwide, accounting for an estimated 984,430 cases in 2012. Between 2000 and 2010, there were 1,916 cases of OSCC in New Zealand with a male to female ratio of 1.85:1, and an age-standardised incidence rate of 42 persons per 1,000,000 population. This article presents an overview of the main risk factors for oral and oropharyngeal cancers and their prevalence in New Zealand. Alcohol consumption is the most prevalent risk factor in New Zealand, followed by tobacco. Given the high prevalence of these two risk factors and their synergistic effect, it is important for doctors and dentists to encourage smoking cessation in smokers and to recommend judicious alcohol intake. Research is needed to determine the prevalence of use of oral preparations of tobacco and water-pipe smoking in New Zealand, especially due to changing demography and increases in migrant populations. UV radiation is also an important risk factor. Further investigations are also needed to determine the prevalence of oral and oropharyngeal cancers attributable to oncogenic HPV infection.

Author Information

Muhammed Yakin, Previously at Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin; Ratu Osea Gavidi, Department of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Fiji; Brian Cox, Hugh Adam Cancer Epidemiology Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Alison Rich, Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin.


Muhammed Yakin, Previously at Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054.

Correspondence Email


Competing Interests



  1. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. CA Cancer J Clin. 2015 Mar; 65(2):87–108.
  2. Tapia JL, Goldberg LJ. The Challenges of Defining Oral Cancer: Analysis of an Ontological Approach. Head Neck Pathol. 2011 Dec; 5(4):376–84.
  3. Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol. 2009 Apr–May; 45(4–5):309–16. Review.
  4. Warnakulasuriya S. Living with oral cancer: Epidemiology with particular reference to prevalence and life-style changes that influence survival.Oral Oncol. 2010 Jun; 46(6):407–10. Review.
  5. Speight P, Warnakulasuriya S, Odgen G. Early Detection and Prevention of Oral Cancer: a management Strategy for Dental Practice. British Dental Association; 2010. Available from: http://www.bda.org/dentists/policy-campaigns/public-health-science/public-health/Documents/early_detection_of_oral_cancer.pdf [Accessed 25 May 2016].
  6. Gavidi RO, Rich AM, Cox B, King T. Comparing the occurrence of oral squamous cell carcinoma in New Zealand and the Fiji Islands from 2000-2010. Int J Cancer Res. 2014 Mar; 48(1):1212–25.
  7. Blot WJ, McLaughlin JK, Winn DM, Austin DF, Greenberg RS, Preston-Martin S. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res. 1988 Jun 1; 48(11):3282–7.
  8. Petti S. Lifestyle risk factors for oral cancer. Oral Oncol. 2009 Apr-May; 45(4-5):340–50. Review.
  9. Sarode SC, Sarode GS, Tupkari JV. Oral potentially malignant disorders: Precising the definition. Oral Oncol. 2012 Sep; 48(9):759–60.
  10. Rodriguez T, Altieri A, Chatenoud L, Gallus S, Bosetti C, Negri E, Franceschi S, Levi F, Talamini R, La Vecchia C. Risk factors for oral and pharyngeal cancer in young adults. Oral Oncol. 2004 Feb; 40(2):207–13.
  11. Cogliano VJ, Baan R, Straif K, Grosse Y, Lauby-Secretan B, El Ghissassi F, Bouvard V, Benbrahim-Tallaa L, Guha N, Freeman C, Galichet L, Wild CP. Preventable exposures associated with human cancers. J Natl Cancer Inst. 2011 Dec 21; 103(24):1827–39.
  12. Guha N, Warnakulasuriya S, Vlaanderen J, Straif K. Betel quid chewing and the risk of oral and oropharyngeal cancers: A meta-analysis with implications for cancer control. Int J Cancer. 2014 Sep 15; 135(6):1433–43.
  13. International Agency for Research on Cancer. List of Classifications by cancer sites with sufficient or limited evidence in humans, Volumes 1 to. 2015. Available from: http://monographs.iarc.fr/ENG/Classification/Table4.pdf [Accessed 7 May 2016].
  14. Lopes V, Murray P, Williams H, Woodman C, Watkinson J, Robinson M. Squamous cell carcinoma of the oral cavity rarely harbours oncogenic human papillomavirus. Oral Oncol. 2011 Aug; 47(8):698–701.
  15. Lingen MW, Xiao W, Schmitt A, Jiang B, Pickard R, Kreinbrink P, Perez-Ordonez B, Jordan RC, Gillison ML. Low etiologic fraction for high-risk human papillomavirus in oral cavity squamous cell carcinomas. Oral Oncol. 2013 Jan; 49(1):1–8.
  16. World Health Organisation. Tobacco : deadly in any form or disguise. Report of the Tobacco Free Initiative, WHO/Non-communicable Diseases and Mental Health. Geneva: 2006. Available from: http://www.who.int/tobacco/communications/events/wntd/2006/Report_v8_4May06.pdf [Accessed 23 Feb 2016].
  17. Ministry of Health. New Zealand Health Survey. 2015. Available from: http://www.health.govt.nz/publication/annual-update-key-results-2014-15-new-zealand-health-survey [Accessed 15 Feb 2016].
  18. Ministry of Health. The New Zealand Guidelines for Helping People to Stop Smoking. 2014. Available from: http://www.health.govt.nz/publication/new-zealand-guidelines-helping-people-stop-smoking [Accessed 15 Feb 2016].
  19. Yu V, Rahimy M, Korrapati A, Xuan Y, Zou AE, Krishnan AR, Tsui T, Aguilera JA, Advani S, Crotty Alexander LE, Brumund KT, Wang-Rodriguez J, Ongkeko WM. Electronic cigarettes induce DNA strand breaks and cell death independently of nicotine in cell lines. Oral Oncol. 2016 Jan; 52:58–65.
  20. Cervellati F, Muresan XM, Sticozzi C, Gambari R, Montagner G, Forman HJ, Torricelli C, Maioli E, Valacchi G. Comparative effects between electronic and cigarette smoke in human keratinocytes and epithelial lung cells. Toxicol In Vitro. 2014 Aug; 28(5):999–1005.
  21. White J, Li J, Newcombe R, Walton D. Tripling use of electronic cigarettes among New Zealand adolescents between 2012 and 2014. J Adolesc Health. 2015 May; 56(5):522–8.
  22. Znaor A, Brennan P, Gajalakshmi V, Mathew A, Shanta V, Varghese C, Boffetta P. Independent and combined effects of tobacco smoking, chewing and alcohol drinking on the risk of oral, pharyngeal and esophageal cancers in Indian men. Int J Cancer. 2003 Jul 10; 105(5):681–6.
  23. Lokhande S, Glover M, Selket K. Chewing tobacco use among South-East Asian men in Auckland. Int J Migr Heal Soc Care. 2013 Jan; 9(1):46–52.
  24. Yoganathan P. Betel chewing creeps into the New World. N Z Dent J. 2002 Jun; 98(432):40–5. 
  25. Perusco A, Rikard-Bell G, Mohsin M, Millen E, Sabry M, Poder N, Williams M, Farag L, Hua M, Guirguis S. Tobacco control priorities for Arabic speakers: key findings from a baseline telephone survey of Arabic speakers residing in Sydney’s south-west. Health Promot J Austr. 2007 Aug; 18(2):121–6.
  26. Kheirallah KA, Alsulaiman JW, Mohammad H A-S, Alzyoud S, Veeranki SP, Ward KD. Waterpipe Tobacco Smoking among Arab Youth; a Cross-Country Study. Ethn Dis. 2016 Jan 21; 26(1):107–12.
  27. Daher N, Saleh R, Jaroudi E, Sheheitli H, Badr T, Sepetdjian E, Al Rashidi M, Saliba N, Shihadeh A. Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors. Atmos Environ (1994). 2010 Jan 1; 44(1):8–14.
  28. Dangi J, Kinnunen TH, Zavras AI. Challenges in global improvement of oral cancer outcomes: Findings from rural Northern India. Tob Induc Dis. 2012 Apr 12; 10:5.
  29. Schmidt-Westhausen AM, Al Sanabani J, Al-Sharabi AK. Prevalence of oral white lesions due to qat chewing among women in Yemen. Oral Dis. 2014 Oct; 20(7):675–81.
  30. Ahrens W, Pohlabeln H, Foraita R, Nelis M, Lagiou P, Lagiou A, Bouchardy C, Slamova A, Schejbalova M, Merletti F, Richiardi L, Kjaerheim K, Agudo A, Castellsague X, Macfarlane TV, Macfarlane GJ, Lee YC, Talamini R, Barzan L, Canova C, Simonato L, Thomson P, McKinney PA, McMahon AD, Znaor A, Healy CM, McCartan BE, Metspalu A, Marron M, Hashibe M, Conway DI, Brennan P. Oral health, dental care and mouthwash associated with upper aerodigestive tract cancer risk in Europe: The ARCAGE study. Oral Oncol. 2014 Jun; 50(6):616–25.
  31. Wilson G, Conway DI. Mouthwash use and associated head and neck cancer risk. Evid Based Dent. 2016 Mar; 17(1):8–9.
  32. Sneyd MJ, Cox B. A comparison of trends in melanoma mortality in New Zealand and Australia: the two countries with the highest melanoma incidence and mortality in the world. BMC Cancer. 2013 Aug 6; 13:372.
  33. Major ethnic groups in New Zealand – 2013 Census. 2013. Available from: http://www.stats.govt.nz/Census/2013-census/profile-and-summary-reports/infographic-culture-identity.aspx [Accessed 7 Sep 2016].
  34. Salmon PJM, Chan WC, Griffin J, McKenzie R, Rademaker M. Extremely high levels of melanoma in Tauranga, New Zealand: possible causes and comparisons with Australia and the northern hemisphere. Australas J Dermatol. 2007 Nov; 48(4):208–16.
  35. Colantonio S, Bracken MB, Beecker J. The association of indoor tanning and melanoma in adults: Systematic review and meta-analysis. J Am Acad Dermatol. 2014 May; 70(5):847–57.e1-18.
  36. Münger K, Phelps WC, Bubb V, Howley PM, Schlegel R. The E6 and E7 genes of the human papillomavirus type 16 together are necessary and sufficient for transformation of primary human keratinocytes. J Virol. 1989 Oct; 63(10):4417–21.
  37. Münger K, Baldwin A, Edwards KM, Hayakawa H, Nguyen CL, Owens M, Grace M, Huh K. Mechanisms of Human Papillomavirus-Induced Oncogenesis. J Virol. 2004 Nov; 78(21):11451–60.
  38. Combes JD, Franceschi S. Role of human papillomavirus in non-oropharyngeal head and neck cancers. Oral Oncol. 2014 May; 50(5):370–9.
  39. El-Naggar AK, Westra WH. p16 expression as a surrogate marker for HPV-related oropharyngeal carcinoma: a guide for interpretative relevance and consistency. Head Neck. 2012 Apr; 34(4):459–61. 
  40. Zafereo ME, Xu L, Dahlstrom KR, Viamonte CA, El-Naggar AK, Wei Q, Li G, Sturgis EM. Squamous cell carcinoma of the oral cavity often overexpresses p16 but is rarely driven by human papillomavirus. Oral Oncol. 2016 May; 56:47–53.
  41. Robinson M, Sloan P, Shaw R. Refining the diagnosis of oropharyngeal squamous cell carcinoma using human papillomavirus testing. Oral Oncol. 2010 Jul; 46(7):492–6. 
  42. Ang KK, Harris J, Wheeler R, Weber R, Rosenthal DI, Nguyen-Tân PF, Westra WH, Chung CH, Jordan RC, Lu C, Kim H, Axelrod R, Silverman CC, Redmond KP, Gillison ML. Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med. 2010 Jul 1; 363(1):24–35.
  43. Benson E, Li R, Eisele D, Fakhry C. The clinical impact of HPV tumor status upon head and neck squamous cell carcinomas. Oral Oncol. 2014 Jun; 50(6):565–74.
  44. Elwood JM, Youlden DR, Chelimo C, Ioannides SJ, Baade PD. Comparison of oropharyngeal and oral cavity squamous cell cancer incidence and trends in New Zealand and Queensland, Australia. Cancer Epidemiol. 2014 Feb; 38(1):16–21.
  45. Ministry of Health - New Zealand. HPV Immunisation Programme Implementation Evaluation. 2012. Available from: http://www.health.govt.nz/system/files/documents/publications/hpv-immunisation-programme-evaluation-v2.doc [Accessed 7 Sep 2016].
  46. Lucas-Roxburgh R, Benschop J, Dunowska M, Perrott M. Prevalence of human papillomaviruses in the mouths of New Zealand women. N Z Med J. 2015 Sep 25; 128(1422):45–52.
  47. Ou P, Gear K, Rahnama F, Thomas S, Nagappan R, Kee D, Waldvogel-Thurlow S, Jain R, McIvor N, Izzard M, Douglas R. Human papillomavirus and oropharyngeal squamous cell carcinoma: a New Zealand cohort study. ANZ J Surg. 2016 Sep 20.


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