The triple burden of qat, shammah, and smoking in oral cancer patients from Hodeidah, Yemen, 2025

Oral cancer poses a significant public health challenge in Yemen, further exacerbated by common cultural practices (qat chewing, shammah use, and tobacco smoking). This study aimed to (1) establish age-adjusted incidence rate (AAIR) of oral cancer, (2)characterize multi-carcinogen exposure patterns (“triple burden”) and (3)identify structural management shortcomings in Hodeidah Governorate, Yemen. A retrospective cross-sectional analysis was conducted on consecutive cases of oral cancases registered at the National Cancer Center, Al-Thawara General Hospital in Hodeidah during 2025. To calculate AAIR per 100,000 person-years, we utilized the weights from the WHO World Standard Population. Significance was set at p<0.05. The cohort included 46 females (63.9%) and 26 males (36.1%)(mean age 60.6±14.6 years). Notably, 90.3% were residing in rural areas. Crude incidence rate was 2.04 per 100,000 (95% CI: 1.60-2.57); AAIR) was 5.65 (95% CI: 4.42-7.12), with female predominance (6.71 vs. 4.58 per 100,000). Common subsites were oral cavity Not Otherwise Specified (54.2%) and tongue (31.9%). Exposures were notably prevalent: qat (81.9%), shammah (76.4%), and smoking at (50.0%).Qat chewing was significantly more frequent among males (96.2% vs. 73.9%; p=0.033). The “triple burden” was observed in (44.4%) of cases. Median symptom-to-diagnosis delay was 45 days; with a shorter presentation-to-diagnosis delay of just 6.5 days; however, rural cases of gingival or jaw lesions showed the longest delay (21 days). All patients underwent chemotherapy exclusively; none received surgery or radiotherapy during their treatment course. A multivariable analysis did not identify any significant predictors for either triple burden or diagnostic delay, suggesting community-level cultural factors drive these trends. Age-adjusted burden of oral cancer is almost three times higher than crude estimates. The significant prevalence of  the“triple burden”, combined with patient-level diagnostic delays in rural areas, highlights the urgent need for integrated cessation programs and enhanced early detection efforts. Additionally, the lack of surgical and radiotherapeutic options reflectscritical infrastructure gaps that call for immediate humanitarian iintervention.