Tobacco Exposure and Risk of Renal Cell Carcinoma: A Case-control Study

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M. Sharf-Ul-Alam, Md. Ziaul Islam This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9337138/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background and Objective: Tobacco is a significant modifiable risk factor for renal cell carcinoma (RCC). However, this association remains underexplored in Bangladesh due to variations in tobacco types and usage patterns. Given that nearly half of the Bangladeshi population consumes tobacco and is exposed to widespread secondhand smoke, this study examined the link to RCC. Methods A matched case–control study was conducted from January to December 2023 at two tertiary hospitals in Dhaka, including 71 histologically confirmed RCC cases and 71 age-, sex-, and residence-matched controls. Information on tobacco use, diet, comorbidities, and sociodemographic features was obtained through structured interviews. Multivariable logistic regression was applied to estimate adjusted odds ratios (AORs), controlling for key confounders. Results Direct ever tobacco consumption increased the risk of RCC by more than fivefold (AOR = 5.54; 95% CI: 2.23–13.24). Early initiation of tobacco use, especially between ages 15–19, further heightened the risk (AOR = 9.85; 95% CI: 1.72–56.34). Both smoking (AOR = 3.47; 95% CI: 1.39–8.68) and heavy use exceeding 20 pack-years (AOR = 7.72; 95% CI: 1.79–33.20) were strong predictors. Each additional pack-year raised RCC risk by 6% (AOR = 1.06, 95% CI: 1.01–1.10), and short-term quitters (2–14 years) showed elevated risk compared to non-smokers. Smokeless tobacco (SLT) use also independently increased risk (AOR = 3.98; 95% CI: 1.73–9.11), while combined smoking and SLT consumption further amplified it (AOR = 6.70; 95% CI: 1.58–28.45). Exposure to indoor secondhand tobacco smoke (SHS) significantly increased RCC risk (AOR = 4.07; 95% CI: 1.78–9.30). Men were more affected by indoor SHS, whereas women showed greater vulnerability to SLT. Conclusions All forms of tobacco, including smoked, smokeless, and secondhand, are strongly associated with RCC, with early and combined exposures posing a higher risk. Comprehensive tobacco control policies, smoke-free environments, and targeted awareness programs are needed to curb RCC risk in Bangladesh. Renal Cell Carcinoma (RCC) Tobacco exposure Smoking Smokeless tobacco Secondhand tobacco smoke Case control study Bangladesh Introduction Renal cell carcinoma (RCC) accounts for nearly 90% of all kidney cancers [ 1 ] and is most common in the sixth and seventh decades of life, showing a clear male predominance [ 2 ]. With an annual increase of 1.1% [ 3 ] and nearly doubled case detection rates over recent decades [ 4 ], RCC has emerged as a major global health concern. In 2020, approximately half a million new RCC cases and 179,000 related deaths were reported worldwide [ 5 ]. A growing trend is evident in the Indian subcontinent, with earlier onset and increased mortality. [ 6 , 7 ]. In Bangladesh, around 1,500 new cases and 1,000 related deaths were documented in 2020 [ 5 ]. Similar to other developing countries, improved diagnostic facilities [ 8 ] and widespread risk factors, including westernized lifestyles and tobacco consumption, may underlie the growing RCC burden in Bangladesh [ 9 ]. Tobacco is one of the most widespread risk factors for RCC, with over 1.3 billion users worldwide. Derived from Nicotiana species plants , tobacco products are broadly classified as smoked or smokeless (SLT) forms [ 10 – 12 ], with global use shaped by availability, accessibility, and socio-cultural factors [ 12 ]. Bangladesh, a major producer and consumer of tobacco, exhibits extensive use of both forms, deeply embedded in traditional practices. Common smoked products include cigarettes, bidis (unprocessed, low-grade tobacco), cigars, pipes, and hookahs (water pipes), while SLT varieties include zarda (processed tobacco leaf consumed with betel leaf or quid), gul (powdered tobacco ash), sadapata (raw tobacco leaf), khaini (crushed dried tobacco leaf), and pan mashala (a mixture of tobacco, lime, and areca nut) [ 13 ]. According to the National STEPS Survey for NCD Risk Factors (2018), 43.7% of Bangladeshi adults (59.6% men and 28.3% women) used tobacco. Among them, 23.5% were smokers (46.6% men, 1% women), 27.5% used smokeless tobacco (26.9% men, 28.1% women), and 7.2% used both forms [ 14 ]. Unlike smoking, smokeless tobacco (SLT) is not culturally stigmatized in this region, explaining its higher prevalence among women [ 15 ]. Over 83% of the world’s chewing tobacco users live in South Asia, highlighting the region’s unique consumption patterns [ 16 ]. In addition, exposure to secondhand smoke is pervasive across Bangladesh, with 39% of individuals affected at home, 42.7% at workplaces, and nearly half in public settings [ 17 ]. Non-smoking women and children are especially vulnerable to its harmful effects [ 18 ], as tobacco smoke contains high levels of particulate matter (PM), a known carcinogen. Globally, smokers generate about 209 million kg of PM annually, with nearly 80% released indoors [ 19 ]. Tobacco contains a well-established human carcinogen, responsible for 20–25% of RCC cases [ 20 ]. The risk rises with longer and heavier use but declines after cessation [ 21 ]. Eliminating smoking could prevent up to 28% of RCC cases [ 22 ]. Although tobacco is a recognized RCC risk factor [ 23 ], evidence from South Asia remains limited, particularly regarding local products (zarda, gul, sadapata), combined exposures, and population-based studies. This study examines associations between smoking, smokeless tobacco (SLT), and secondhand tobacco smoke (SHS) with RCC among Bangladeshi adults, aiming to fill this regional gap and support stronger tobacco control and cancer prevention efforts. Materials and Methods Study design and settings This matched case–control study was conducted between January and December 2023 at the National Institute of Cancer Research and Hospital (NICRH) and Bangabandhu Sheikh Mujib Medical University (BSMMU), two premier tertiary cancer hospitals in Bangladesh treating RCC patients nationwide. Study participants and sampling The study included 71 RCC patients and 71 matched controls, with 40 men and 31 women in each group. Cases were adult RCC patients (≥ 18 years) diagnosed histologically within the past 12 months, excluding critically ill ones. Controls were healthy attendants of other patients, matched with the cases by age (± 5 years), sex, and district of residence. Hospital-based convenience sampling was used for feasibility and inclusion of recent confirmed cases. Data measurement This study examined RCC as the outcome and tobacco exposure as the primary independent variable encompassing both direct consumption and secondhand tobacco smoke (SHS) inhalation. Participants who consumed ≥ 100 smoked in their lifetime were classified as ever tobacco users, current users consumed tobacco daily, or most days in a week, and past users had quit for ≥ 1 year of interview [ 24 ]. Occasional smokers were those who smoked ≥ 100 cigarettes but no more than twice weekly [ 25 ]. Smoking intensity was assessed in pack-years (PPY = packs/day × years) [ 26 ], with the average daily cigarette consumption calculated for each decade of smoking. A nicotine-based equivalence was applied for bidi smoking, where 1 pack-year of cigarette ≈ 43 bidis/day/year was considered [ 27 ]. Individuals who had consumed any form of smokeless tobacco on a daily or weekly basis for at least one year were considered as smokeless tobacco consumers. Secondhand smoke (SHS) refers to the inhalation of tobacco smoke by non-smokers, originating from either mainstream (exhaled) or side stream (from the tip) smoke [ 28 ]. SHS exposure was assessed in indoor (home, confined workplace) and outdoor (public places, including transport, restaurants, markets, and healthcare facilities) settings. Indoor exposure was defined as living with a smoker for ≥ 1 year who smoked in the bedroom or living room. Workplace exposure was defined as someone smoking within 10 feet of the participant at least once a week for ≥ 1 year, and public exposure as at least one hour per week in public areas [ 26 ]. Among the associated factors, information on socio-demographic characteristics, family history of RCC, occupational exposure, and dietary habits was obtained through self-reported responses, whereas drug history (including NSAIDs and statins) and comorbidities such as hypertension, diabetes, and urinary tract infections (UTI) were extracted from medical record reviews. Dietary assessment focused on foods commonly consumed in Bangladesh and linked to RCC risk, with regular intake defined as ≥ 1 serving/day in the two years prior to diagnosis or interview [ 29 ]. Commonly consumed animal-based foods rich in high-quality protein, such as fish, meat, eggs, and milk, were classified as protein foods [ 30 ]. Chronic analgesic use was defined as taking NSAIDs at least twice a week for one month or more within the past two years [ 31 ]. Data collection Data were collected through face-to-face interviews and medical record reviews using a pretested semi-structured questionnaire covering socio-demographics, tobacco use, SHS exposure, and RCC-related factors, including diet, habits, family, and occupational history. Adapted from the Global Adult Tobacco Survey (2020) and expert input, the questionnaire was translated into Bangla and back-translated for accuracy. Interviews were conducted in Bangla, lasting 20–30 minutes in a private setting. Data analysis Data were cleaned, coded, and analyzed using SPSS v26. Categorical variables were presented as frequency and percentage, while continuous variables were reported as mean (± SD) or median (IQR), depending on the distribution. Bivariate analyses included chi-square, t-test, and Mann–Whitney U test. And significant factors emerged from these were employed as covariates into multivariable logistic regression model using a backward stepwise approach. Tobacco consumption-related factors were adjusted for age, sex, district of residence, and key confounders, including education, income, regular fruits & protein intake, and hypertension. Multicollinearity was low (VIF 1.16–2.29) among the covariates. Pack-years were analyzed both continuously and categorically (non-smoker, ≤ 20, >20) with consistent trends. Statistical significance was set at p < 0.05 with 95% CI. A Chi-square test with Cohen’s h was performed on 142 participants to assess the effect of tobacco use on RCC risk. Tobacco use was 80.3% and 39.4% among the cases and controls, respectively, yielding a large effect size (h = 0.68). Power analysis (α = 0.05) indicated 99.9% power, confirming the study’s ability to detect significant associations. Ethical consideration Ethical approval was obtained from the IRB of NIPSOM (Memo No. NIPSOM/IRB/2023/06), with data collection permission from NICRH and BSMMU authorities. All participants gave written informed consent to participate in the study after being clearly informed about the study’s purpose, procedures, and confidentiality. Participation was voluntary, and withdrawal was allowed at any time. Data were securely stored in a password-protected folder with restricted access. Results The level of education differed significantly (p < 0.01), with more cases lacking formal education (32.4% vs. 11.3%) and fewer having higher secondary education (25.4% vs. 54.9%) compared to controls. Additionally, cases had significantly (p = 0.01) lower mean monthly family income (37,042.2 BDT vs. 43,704.2 BDT) compared to controls [Table 1 ]. Table 1 Comparison of socio-demographic characteristics between cases and controls Attributes Categories Cases (n = 71) f (%) Controls (n = 71) f (%) P-value Age (In years) Mean (± SD) 53.8 (± 12.1) 53.5(± 12.5) 0.87 1 Level of education No formal education 23 (32.4) 8 (11.3) < 0.01 Up to secondary level 30 (2.3) 24 (33.8) Higher secondary and above 18 (25.4) 39 (54.9) Occupation Service 19 (26.8) 27 (38.0) 0.29 Business 8 (11.3) 11 (15.5) Homemaker 24 (33.8) 20 (28.2) Day laborer 20 (28.2) 13 (18.3) Place of residence Urban 32 (45.1) 41 (57.7) 0.13 Rural 39 (54.9) 30 (42.3) Family type Nuclear 44 (62.0) 43 (60.6) 0.86 Joint 27 (38.0) 28 (39.4) Monthly family income (BDT) Mean (± SD) 37042.2 (± 1444) 43704.2 (± 1821) 0.01 1 BDT = Bangladeshi Taka; IQR = Inter-quartile Range. p-values were obtained by chi-square test. 1 p-value obtained by independent samples t-test A significantly (p < 0.01) higher proportion of cases had ever consumed tobacco (80.3% vs. 39.4%), and started consumption earlier (median age 20 years vs. 25 years, p = 0.04) compared to controls. More cases were smokers (45.1% vs. 21.1%, p < 0.01), and they smoked for a longer duration (mean 28.6 years vs. 20.2 years, p = 0.05), although the difference was not significant. Cases smoked significantly more tobacco (pack-years) annually (median 22.3 packs vs. 8.5 packs; p = 0.03) than controls. SLT use was more common among cases (57.7% vs. 22.5%, p < 0.01), but there were no significant differences in duration or frequency of SLT consumption. Significantly (p < 0.01) higher proportion of cases also used both smoking and SLT (22.5% vs. 4.2%) than controls [Table 2 ]. Table 2 Comparison of tobacco exposure and related factors between cases and controls Attributes Categories Cases (n = 71) f (%) Controls (n = 71) f (%) p-value Direct tobacco consumption (n = 142) Never 14 (19.7) 43 (60.6) < 0.01 Ever 57 (80.3) 28 (39.4) Onset of tobacco consumption (n = 85) ≥ 20 years 37 (64.9) 26 (92.9) < 0.01 15–19 years 20 (35.1) 2 (7.1) Median (IQR) 20 (15–30) 25 (22–30) 0.04 2 Type of tobacco consumption (n = 85) Smoked 16 (28.1) 12 (42.9) 0.15 Smokeless 25 (43.9) 13 (46.4) Both 16 (28.1) 3 (10.7) Smoking (n = 142) No 39 (54.9) 56 (78.9) < 0.01 Yes 32 (45.1) 15 (21.1) Duration of smoking in years (n = 47) 4–19 9 (28.1) 9 (60.0) 0.07 20–39 14 (43.8) 5 (33.3) ≥ 40 9 (28.1) 1 (6.7) Mean (± SD) 28.6 (± 13.7) 20.2 (± 13.1) 0.05 1 Nature of smoking (n = 47) Current 18 (56.3) 7 (46.7) 0.54 Past 14 (43.7) 8 (53.3) Number of sticks smoked per day (n = 47) 3–20 22 (68.8) 11 (73.3) 0.99 3 21–35 10 (31.2) 4 (26.7) Mean (± SD) 16.5 (± 10.0) 13.1 (± 8.1) 0.2 1 Pack per year (n = 47) Up to 20 15 (46.9) 12 (80.0) 0.03 More than 20 17 (53.1) 3 (20.0) Median (IQR) 22.3 (7.1–46.4) 8.5 (3.7–20.0) 0.03 2 Cigarette smoking (n = 47) No 7 (21.9) 1 (6.7) 0.38 3 Yes 25 (78.1) 14 (93.3) Bidi smoking (n = 47) No 20 (62.5) 13 (86.7) 0.17 3 Yes 12 (37.5) 2 (13.3) Duration of smoking cessation in years (n = 22) 15–35 5 (35.7) 7 (87.5) 0.01 2–14 9 (64.3) 1 (12.5) Mean (± SD) 11.9 (± 7.8) 22.7 (± 9.7) 0.01 1 SLT consumption (n = 142) No 30 (42.3) 55 (77.5) < 0.01 Yes 41 (57.7) 16 (22.5) Duration of SLT consumption in years (n = 57) 5–25 26 (63.4) 7 (43.8) 0.17 26–50 15 (36.6) 9 (56.3) Mean (± SD) 22.6 (± 11.2) 26.8 (± 13.3) 0.23 1 Frequency of SLT consumption per day (n = 48) 1–5 32 (78.0) 10 (62.5) 0.38 3 6–10 9 (22.0) 6 (37.5) Mean (± SD) 4.4 (± 2.6) 4.3 (± 2.2) 0.9 1 Nature of SLT consumption (n = 57) Current 33 (80.5) 15 (93.8) 0.40 3 Past 8 (19.5) 1 (6.2) Betel quid consumption (n = 57) No 0 0 Yes 41 (100.0) 16 (100.0) Zarda consumption (n = 57) No 14 (34.1) 6 (37.5) 0.81 Yes 27 (6.9) 10 (62.5) Sadapata and Gul consumption (n = 57) No 34 (82.9) 12 (75.0) 0.75 3 Yes 7 (17.1) 4 (25.0) Duration of SLT consumption cessation in years (n = 9) 11–25 3 (37.5) 0 1.00 2–10 5 (62.5) 1 (100.0) Mean (± SD) 10.0 (± 9.1) 3.0 0.49 1 Combined smoking and SLT consumption (n = 142) No 55 (77.5) 68 (95.8) < 0.01 Yes 16 (22.5) 3 (4.2) IQR = Inter-quartile Range; SLT = Smokeless Tobacco. 1 p-value obtained by independent samples t-test. 2 p-value obtained by Mann–Whitney U test as the data were skewed 3 p-value obtained by continuity correction. All other p-values were obtained by chi-square test. Exposure to secondhand tobacco smoke (SHS) was more common among cases than controls (64.8% vs. 53.5%), but the difference was not significant (p = 0.17). Indoor SHS exposure was significantly higher in cases (62.0% vs. 25.4%, p < 0.01), with most cases exposed daily compared to controls. However, the duration of indoor SHS exposure was indistinguishable between cases and controls. Exposure to outdoor SHS was similar between cases and controls (p = 0.86), suggesting no association with RCC risk in this study [Table 3 ]. Table 3 Comparison of secondhand smoking (SHS) between cases and controls Attributes Categories Cases (n = 71) f (%) Controls (n = 71) f (%) P-value Secondhand tobacco smoke exposure (n = 142) No 25 (35.2) 33 (46.5) 0.17 Yes 46 (64.8) 38 (53.5) Indoor SHS exposure (n = 142) No 27 (38.0) 53 (74.6) < 0.01 Yes 44 (62.0) 18 (25.4) Frequency of Indoor SHS exposure (n = 62) Less than daily 5 (11.4) 4 (22.2) 0.48 4 Daily 39 (88.6) 14 (77.8) Duration of indoor SHS exposure in Years (n = 62) 2–9 9 (20.5) 5 (27.8) 0.68 3 10–19 27 (61.4) 9 (50.0) 20–29 8 (18.1) 4 (22.2) Mean (± SD) 13.39 (± 5.74) 13.78 (± 6.68) 0.87 1 Outdoor SHS exposure ((n = 142) No 42 (59.2) 41 (57.7) 0.86 Yes 29 (40.8) 30 (42.3) Frequency of outdoor SHS exposure (n = 59) Less than daily 10 (34.5) 17 (56.7) 0.11 Daily 19 (65.5) 13 (43.3) Duration of outdoor SHS exposure in years (n = 59) 2–9 9 (31.0) 11 (36.7) 0.70 10–19 14 (48.3) 11 (36.7) 20–29 6 (20.7) 8 (26.7) Median (IQR) 14.0 (8.0–19.0) 11.5 (6.0–20.0) 0.70 2 SHS = Secondhand Tobacco Smoke; IQR = Inter-quartile Range. p-values were obtained by chi-square test 1 p-value obtained by independent samples t-test. 2 p-value obtained by Mann–Whitney U test. 3 p-value obtained by Fisher’s Exact Test. 4 p-value obtained by continuity correction. Table 4 shows other factors in terms of dietary habits and health conditions that were compared between cases and controls. Significantly (p < 0.01) lower proportion of cases consumed fruits (7.0% vs. 50.7%) and proteins (43.7% vs. 74.6%, p < 0.01) regularly. No significant differences were observed in vegetable, tea, or coffee consumption. Regarding health conditions, cases had a higher prevalence of hypertension (45.1% vs. 28.2%, p = 0.03), but no significant differences were found for diabetes, urinary tract infections, or analgesic and statin use. No participants from both groups had a family history of RCC, alcohol consumption, or any occupational history with exposure associated with elevated risk of RCC [Table 4 ]. Table 4 Comparison of other factors associated with RCC between cases and controls Attributes Categories Cases (n = 71) f (%) Controls (n = 71) f (%) P-value Fruits No 66 (93.0) 36 (49.3) < 0.01 Yes 5 (7.0) 36 (50.7) Vegetables No 5 (7.0) 3 (4.2) 0.46 Yes 66 (93.0) 68 (95.8) Protein No 40 (56.3) 18 (25.4) < 0.01 Yes 31 (43.7) 53 (74.6) Tea No 22 (31.0) 15 (21.1) 0.18 Yes 49 (69.0) 56 (78.9) Coffee No 67 (94.4) 61 (85.9) 0.09 Yes 4 (5.6) 10 (14.1) HTN No 39 (54.9) 51 (71.8) 0.03 Yes 32 (45.1) 20 (28.2) DM No 54 (76.1) 45 (63.4) 0.11 Yes 17 (23.9) 26 (36.6) UTI No 57 (80.3) 63 (88.7) 0.16 Yes 14 (19.7) 8 (11.3) Analgesics (NSAIDs) No 56 (78.9) 50 (70.4) 0.24 Yes 15 (21.1) 21 (29.6) Statin No 55 (77.5) 46 (64.8) 0.09 Yes 16 (22.5) 25 (35.2) HTN = Hypertension; DM = Diabetes Mellitus; UTI = Urinary Tract Infection; NSAID = Non-steroidal Anti-inflammatory Drugs. All p-values were obtained by chi-square Ever tobacco consumers had a 5.5-fold higher risk of RCC (AOR = 5.54, 95% CI: 2.32–13.24, p < 0.01). Early onset of tobacco use (15–19 years) increased the odds nearly tenfold (AOR = 9.85, 95% CI: 1.72–56.34, p = 0.01). Smokers were 3.5 times more likely to develop RCC (AOR = 3.47, 95% CI: 1.39–8.68, p 20 packs/year) had even higher odds (AOR = 7.72, 95% CI: 1.79–33.20, p < 0.01). Each additional pack-year raised RCC risk by 6% (AOR = 1.06, 95% CI: 1.01–1.10, p < 0.01). Short-term quitters (2–14 years) showed elevated risk (AOR = 18.03, 95% CI: 1.05–309.30, p = 0.04) compared to non-smokers. SLT users (AOR = 3.98, 95% CI: 1.73–9.11, p < 0.01), combined users (AOR = 6.70, 95% CI: 1.58–28.45, p = 0.01), and those exposed to indoor SHS (AOR = 4.07, 95% CI: 1.78–9.30, p < 0.01) had significantly greater RCC risk [Table 5 ]. Table 5 Estimation of tobacco related risk of RCC by multivariable logistic regression Attributes related to tobacco consumption Categories Univariable LR Multivariable LR COR (95% CI) P-value AOR (95% CI) P-value Ever tobacco consumption (n = 142) No Reference Reference Yes 6.25 (2.94–13.28) < 0.01 5.54 (2.32–13.24) < 0.01 Age at onset (years) (n = 142) ≥ 20 Reference Reference 15–19 7.02 (1.51–32.70) 0.01 9.85 (1.72–56.34) 0.01 Smoking a (n = 142) No Reference Reference Yes 3.06 (1.46–6.40) 0.03 3.47 (1.39–8.68) 20 8.13 (2.23–29.66) < 0.01 7.72 (1.79–33.20) < 0.01 Pack per year (PPY) d Year 1.06 (1.02–1.10) < 0.01 1.06 (1.01–1.10) < 0.01 Duration of smoking cessation (n = 117) Non-smoker Reference Reference 2–14 12.92 (1.5-106.1) 0.01 18.03 (1.05–309.30) 0.04 15–35 1.02 (0.3–3.4) 0.48 0.61 (0.15–2.42) 0.48 SLT consumption b (n = 142) No Reference Reference Yes 4.70 (2.26–9.74) < 0.01 3.98 (1.73–9.11) < 0.01 Combined smoking & SLT consumption (n = 142) No Reference Reference Yes 6.59 (1.82–23.79) < 0.01 6.70 (1.58–28.45) 0.01 Indoor SHS exposure c (n = 142) No Reference Reference Yes 4.80 (2.34–9.83) < 0.01 4.07 (1.78–9.30) < 0.01 COR= Crude Odds ratio, AOR= Adjusted Odds ratio, CI= Confidence interval, SLT= Smokeless tobacco, SHS= Secondhand Tobacco Smoke, LR= Logistic Regression. The variables are adjusted for level of education, monthly family income, daily fruits intake, daily protein intake and hypertension The risk of RCC was 7.1 (AOR = 7.06, 95% CI: 1.86–26.82, p < 0.01) and 5.6 (AOR = 5.61, 95% CI: 1.45–21.60, p = 0.01) times higher for male and female ever tobacco consumers, respectively. The risk of RCC for male smokers was 4.7 times (AOR = 4.74, 95% CI: 1.57–14.31, p < 0.01). SLT consumption was strongly linked to RCC for both sexes (AOR = 3.79, 95% CI: 1.26–11.41, p = 0.01 for males; AOR = 4.90, 95% CI: 1.28–18.70, p = 0.02 for females). Indoor SHS exposure significantly increased RCC risk by 4.8-fold among males (AOR = 4.81, 95% CI: 1.72–13.44, p < 0.01), while the association was non-significant for females (AOR = 2.81, 95% CI: 0.72–10.90, p = 0.13) [Table 6 ]. Table 6 Sex variation of tobacco consumption related risk factors of RCC (n = 142) Tobacco consumption related attributes Categories Male Female AOR (95% CI) P-value AOR (95% CI) P-value Ever tobacco consumption No Reference Reference Yes 7.06 (1.86–26.82) < 0.01 5.61 (1.45–21.60) 0.01 Smoking a No Reference Reference Yes 4.74 (1.57–14.31) < 0.01 - - SLT consumption b No Reference Reference Yes 3.79 (1.26–11.41) 0.01 4.90 (1.28–18.70) 0.02 Indoor SHS No Reference Reference Yes 4.81 (1.72–13.44) < 0.01 2.81 (0.72–10.90) 0.13 AOR= Adjusted Odds ratio, CI= Confidence interval, SLT= Smokeless tobacco, SHS= Secondhand tobacco smoke, The variables are adjusted for level of education, monthly family income, daily fruits intake, daily protein intake and hypertension Discussion The current hospital-based case–control study in Bangladesh identified ever direct tobacco use, smoking, smokeless tobacco (SLT) consumption, and indoor exposure to secondhand smoke (SHS) as independent and significant risk factors for renal cell carcinoma (RCC). Sex-based variations in risk were observed, with males exhibiting a higher risk for indoor secondhand smoke (SHS) exposure, while females faced a higher risk for ever having consumed tobacco and smokeless tobacco (SLT). Since the proportion of female smokers in this study was very low, consistent with a recent Bangladeshi study [ 32 ], the gender difference in smoking risk could not be determined. The gender difference may be attributable to complex interactions among hormonal, metabolic, and tobacco consumption pattern-related differences between males and females [ 33 ]. According to the United States Food and Drug Administration (FDA), tobacco products contain 79 identified carcinogens, while the International Agency for Research on Cancer (IARC) reports that tobacco products and smoke contain 533 probable, possible, and confirmed human carcinogens [ 34 ]. Carcinogenic compounds such as polycyclic aromatic hydrocarbons, nitrosamines, and heavy metals like cadmium and arsenic can enter the bloodstream through absorption from the respiratory or digestive tract, are filtered by the kidneys, and damage renal tubular cells via DNA adduct formation, oxidative stress, and mutagenesis [ 35 – 37 ]. Prolonged tobacco exposure can also reprogram tumor metabolism by altering oxidative phosphorylation, amino acid utilization, and metal homeostasis, thereby promoting tumor progression [ 38 ]. This aligns with our finding of a higher lifetime RCC risk among individuals who initiated tobacco use during adolescence, consistent with prior research [ 39 ]. Adolescence is a critical period of kidney development when the kidneys are more vulnerable to DNA damage and tobacco-related carcinogens [ 40 ]. Environmental tobacco smoke (ETS) also contains similar toxins, and prolonged exposure increases RCC risk in a dose-dependent manner [ 26 , 41 ]. Tobacco-induced inflammation, angiogenesis, and impaired DNA repair further enhance these carcinogenic effects, raising RCC risk in both active and passive smokers [ 36 , 37 ]. Our study reinforces the evidence that smoking is a major risk factor for RCC, aligning with previous research from Western countries showing a 1.2–2.4 times higher risk among smokers depending on smoking status, intensity, and duration [ 2 , 21 , 23 , 42 – 46 ]. A 2024 Mendelian randomization study also supports a causal link, finding that genetically predicted smoking initiation increases RCC risk (OR 1.55, 95% CI 1.04–2.33) [ 3 ]. These studies reported a lower RCC risk among smokers than ours, likely due to differences in sample size and unaddressed genetic or environmental factors. A higher prevalence of carcinogen-detoxifying gene variants, such as CYP1A1 (Ile462Val, MspI) and deletions in GSTM1 and GSTT1 [ 47 , 48 ], may increase RCC susceptibility among Asian smokers. Additionally, elevated levels of PM10 and NO₂, common in Southeast Asia and worsened by indoor and public smoking, have been linked to greater RCC risk [ 49 , 50 ]. The study found a consistent but non-linear association between smoking and RCC risk, with heavy smokers (> 20 pack-years) showing a markedly higher likelihood of developing RCC, aligning with previous studies [ 22 ]. Short-term quitters remained at elevated risk due to residual biological damage from past smoking [ 21 ], while long-term cessation (15–35 years) significantly lowered the risk, underscoring the benefits of quitting and maintaining a smoke-free lifestyle. These findings are consistent with prior research [ 21 , 22 , 51 ], suggesting that the reduced risk after prolonged cessation may result from the recovery of biological repair mechanisms [ 52 ]. Our study found that SLT consumption is associated with a higher risk of RCC, with females appearing more vulnerable than males. Elevated estrogen levels in females may accelerate nicotine metabolism, increasing exposure to nicotine-derived carcinogens and thereby raising RCC risk [ 53 ]. Besides, differences in the metabolism process of tobacco-induced carcinogens may make females more vulnerable to RCC at lower doses [ 54 ]. In contrast, Goodman et al. (1986) reported a fourfold higher RCC risk among men, while the association in women was not statistically significant [ 55 ]. Similarly, a population-based case–control study in California found no link between smokeless tobacco use and RCC [ 56 ]. A Norwegian cohort of 10,136 men also showed no increased kidney cancer risk among snus (a local SLT product) users, with adjusted relative risks of 0.72 (95% CI: 0.44–1.18) for ever users, 1.17 (95% CI: 0.63–2.16) for former users, and 0.47 (95% CI: 0.23–0.94) for current users [ 57 ]. Overall, the evidence linking SLT use to RCC risk is limited and inconsistent, likely reflecting regional differences in SLT products and usage practices [ 58 – 60 ]. Common smokeless tobacco products in Southeast Asia, such as Zarda and Gul, are classified as Group 1 carcinogens by the International Agency for Research on Cancer (IARC) because of their high content of tobacco-specific nitrosamines (TSNAs), which may contribute to RCC development [ 61 ]. Consistent with our findings, Goodman et al. (1986) also reported that cumulative smoking and SLT consumption increased RCC risk by 26-fold, reflecting the synergistic effects of both forms of tobacco use [ 55 ]. Evidence suggests that secondhand tobacco smoke exposure is significantly associated with increased risk of RCC [ 20 , 26 , 41 , 62 ], which conflicts with our findings showing no significant effect of overall SHS exposure on RCC development. Bias from self-reporting and the misclassification of mild exposure as non-exposure may have influenced our results, highlighting the need for more objective evaluation. However, according to our findings, indoor SHS exposure was significantly associated with RCC. Both mainstream and side-stream secondhand smoke are carcinogenic; however, side-stream smoke, emitted from the burning tip due to incomplete combustion, is more hazardous. It contains higher concentrations of carcinogens like arsenic and cadmium, making it particularly dangerous in confined indoor settings such as the home and office [ 19 ]. Trapped smoke in indoor settings for extended periods increases the risk of higher carcinogen exposure, even if a non-smoker is not in direct contact with a smoker [ 20 ]. Individuals living with a smoker partner is 1.6 times more likely to develop cancer compared to those living with non-smokers [ 63 ], indicating the importance of of indoor smoking restriction. Males exposed to indoor secondhand smoke (SHS) are at a higher risk of developing renal cell carcinoma (RCC), which can be attributed to the cumulative effects of both passive and active smoking. This study provides crucial new evidence on the role of smokeless tobacco and secondhand smoke in RCC risk, exposures that are common but remain understudied in Bangladesh. Inclusion of both smoked and smokeless tobacco along with secondhand tobacco smoke exposure, the study provides more comprehensive assessment of tobacco related risk to RCC in this setting. These findings can inform the development of context specific tobacco control interventions to reduce RCC burden. The findings emphasize the need for stronger tobacco control in Bangladesh, addressing local tobacco products and secondhand smoke exposure through stricter smoke-free laws, higher taxes, and promotion of smoke-free homes and workplaces. Islami et al 2025, showed that reducing smoking prevalence through sustained strict tobacco control policy can significantly avert millions of tobacco attributable cancer mortality [ 64 ]. Public awareness campaigns on the link between tobacco use and RCC, along with integrating tobacco cessation support into primary healthcare and NCD programs, are vital preventive measures. Gender-specific strategies, such as increasing SLT awareness among women and enforcing indoor smoking bans for men, are also recommended. Furthermore, stricter regulation of tobacco products, promotion of smoke-free environments, and stronger national surveillance are essential to reduce RCC risk in Bangladesh. However, this study has limitations that should be considered when interpreting its findings. Self reported data on tobacco use and other factors, including diet may have introduced recall bias, although structured interviews likely minimized this. Hospital-based convenience sampling may introduce selection bias and limit the generalizability of the findings. Residual confounding factors like BMI, physical activity, environmental exposures and genetic susceptibility could not be excluded. Future studies with larger, population-based samples and objective measures are recommended. Conclusion Tobacco consumption, including smoking, smokeless tobacco (SLT), and indoor secondhand smoke (SHS) exposure, were independent risk factor of RCC in Bangladesh. Early initiation, prolonged use, and combined exposures further heightened this risk. Men were more affected by indoor SHS, while women showed greater susceptibility to SLT. The study findings recommend stronger and comprehensive tobacco control measures targeting local products, including cessation support, public education, and indoor smoking restrictions to curb RCC burden in Bangladesh. Abbreviations AOR Adjusted Odds Ratio CI Confidence Interval DM Diabetes Mellitus HTN Hypertension IQR Inter-quartile Range NSAID Non-steroidal Anti-inflammatory Drugs RCC Renal Cell Carcinoma SHS Secondhand Tobacco Smoke SLT Smokeless Tobacco UTI Urinary Tract Infection VIF Variance Inflation Factor WHO World Health Organization Declarations Ethics statement Ethical approval was obtained from the IRB of NIPSOM (Memo No. NIPSOM/IRB/2023/06). All participants signed informed written consent. Acknowledgement The authors express their heartiest gratitude to all participants of the study. Conflict of interest The authors have no conflicts of interest, real, potential, or perceived, to declare. Funding This work was supported by Bangladesh Medical Research Council (BMRC) in student’s grant category. Data availability Anonymized data is available upon request from the corresponding author. Authors’ contributions SMS was involved in concept generation, data collection, statistical analysis and manuscript preparation, while MZI was engaged in concept generation, supervision and critical review of the manuscript. Declaration regarding the use of Artificial Intelligence (AI) The AI software Claude 3.5 Sonnet was used to improve the English language and grammar. The authors thoroughly checked the AI-edited version and carried full responsibility for the content. References Hsieh JJ, Purdue MP, Signoretti S, Swanton C, Albiges L, Schmidinger M, Heng DY, Larkin J, Ficarra V. Renal cell carcinoma. Nat reviews Disease primers. 2017;3(1):1–9. https://doi.org/10.1038/nrdp.2017.9 . Capitanio U, Bensalah K, Bex A, Boorjian SA, Bray F, Coleman J, Gore JL, Sun M, Wood C, Russo P. Epidemiology of renal cell carcinoma. Eur Urol. 2019;75(1):74–84. https://doi.org/10.1016/j.eururo.2018.08.036 . Cui H, Du J, Xue H, Zhao Y, Li C. The causal relationship between smoking, alcohol consumption, and renal clear cell carcinoma: A Mendelian randomization study. Front Genet. 2024;15:1391542. https://doi.org/10.3389/fgene.2024.1391542 . Rose TL, Kim WY. Renal cell carcinoma: a review. JAMA. 2024;332(12):1001–10. 10.1001/jama.2024.12848 . World Health Organization. International Agency for Research on Cancer, World Health Organization. Global cancer observatory; 2021. Pallagani L, Choudhary GR, Himanshu P, Madduri VK, Singh M, Gupta P, Shrivastava N, Baid G, Meenakshi R, Aasma N, Pareek P. Epidemiology and clinicopathological profile of renal cell carcinoma: a review from tertiary care referral centre. J Kidney Cancer VHL. 2021;8(1):1. 10.15586/jkcvhl.2021.1 . Sidharth M, Luitel BR, Gupta DK, Maskey P, Chalise PR, Sharma UK, Gyawali PR, Shrestha GK, Sayami G, Joshi BR. Pattern of Renal Cell Carcinoma-A Single Center Experience in Nepal. Kathmandu Univ Med J. 2011;9(3):185–8. 10.3126/kumj.v9i3.6302 . Hassan MR, Sultana R, Khan MR, Arefin MS, Chowdhury AM. Renal cell carcinoma: epidemiology, risk factors and clinicopathological profile. BIRDEM Med J. 2025;15(1):16–21. 10.3329/birdem.v15i1.79308 . Makino T, Kadomoto S, Izumi K, Mizokami A. Epidemiology and prevention of renal cell carcinoma. Cancers. 2022;14(16):4059. 10.3390/cancers14164059 . World Health Organization. Tobacco. [Internet]. Geneva, World Health Organization. : 2025 Jun 25 [cited 2025 Oct 8]. Available from: https://www.who.int/news-room/fact-sheets/detail/tobacco Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco Product Use Among Adults—United States, 2020. MMWR Morb Mortal Wkly Rep. 2022;71(11):397–405. 10.15585/mmwr.mm7111a1 . Huque R, Zaman MM, Huq SM, Sinha DN. Smokeless tobacco and public health in Bangladesh. Indian J Public Health. 2017;61(5):18–24. 10.4103/ijph.IJPH_233_17 . Sultana P. Tobacco Use in Bangladesh. InHealth Promotion 2022 Jun 21. IntechOpen. 10.5772/intechopen.105012 World Health Organization. National STEPS survey for non-communicable diseases risk factors in Bangladesh 2018. InNational STEPS survey for non-communicable diseases risk factors in Bangladesh 2018 2018. Available from: https://www.who.int/bangladesh/about-us/publications/m/item/2018-national-steps-survey-for-non-communicable-diseases-risk-factors-in-bangladesh Flora MS, Mascie-Taylor CG, Rahman M. Gender and locality differences in tobacco prevalence among adult Bangladeshis. Tob Control. 2009;18(6):445–50. 10.1136/tc.2008.028142 . Gakidou E, Afshin A, Abajobir AA, et al. Health effects associated with chewing tobacco: a Burden of Proof study. Nat Commun. 2024;15(1):1082. 10.1038/s41467-024-45074-9 . Global Adult Tobacco Survey Collaborative Group. Global adult tobacco survey (GATS): core questionnaire with optional questions. Atlanta, GA: Centers for Disease Control and Prevention. 2020:11 – 6. 10.15585/mmwr.mm7111a1 Fischer F, Minnwegen M, Kaneider U, Kraemer A, Khan MM. Prevalence and determinants of secondhand smoke exposure among women in Bangladesh, 2011. Nicotine Tob Res. 2015;17(1):58–65. 10.1093/ntr/ntu129 . Zhou Y, Huang H, Zou C, Deng M, Tu X, Deng W, Yu C, Li J. Chemical Dissection of PM2. 5 in Cigarette Smoke: Main and Sidestream Emission Factors and Compositions. Toxics. 2025;13(9):711. 10.3390/toxics13090711 . Cumberbatch MG, Rota M, Catto JW, La Vecchia C. The role of tobacco smoke in bladder and kidney carcinogenesis: a comparison of exposures and meta-analysis of incidence and mortality risks. Eur Urol. 2016;70(3):458–66. 10.1016/j.eururo.2015.06.042 . Liu X, Peveri G, Bosetti C, Bagnardi V, Specchia C, Gallus S, Lugo A. Dose-response relationships between cigarette smoking and kidney cancer: a systematic review and meta-analysis. Crit Rev Oncol/Hematol. 2019;142:86–93. 10.1016/j.critrevonc.2019.06.003 . Dhôte R, Pellicer-Coeuret M, Thiounn N, Debré B, Vidal-Trecan G. Risk factors for adult renal cell carcinoma: a systematic review and implications for prevention. BJU Int. 2000;86(1):20–7. 10.1046/j.1464-4096.2000.086001020.x . Gansler T, Fedewa SA, Flanders WD, Pollack LA, Siegel DA, Jemal A. Prevalence of cigarette smoking among patients with different histologic types of kidney cancer. Cancer Epidemiol Biomarkers Prev. 2020;29(7):1406–12. 10.1158/1055-9965.EPI-20-0192 . Wang TW, Asman K, Gentzke AS, Cullen KA, Holder-Hayes E, Reyes-Guzman C, Jamal A, Neff L, King BA. Tobacco product use among adults—United States, 2017. Morb Mortal Wkly Rep. 2018;67(44):1225. 10.15585/mmwr.mm6744a2 . Oksuz E, Mutlu ET, Malhan S. Characteristics of daily and occasional smoking among youths. Public Health. 2007;121(5):349–56. 10.1016/j.puhe.2006.12.007 . Theis RP, Dolwick Grieb SM, Burr D, Siddiqui T, Asal NR. Smoking, environmental tobacco smoke, and risk of renal cell cancer: a population-based case–control study. BMC Cancer. 2008;8:387. 10.1186/1471-2407-8-387 . Datta R, Singh S, Joshi A, Marwah V. Concept of BIDI years: Relevance to the perioperative period. Lung India. 2022;39(4):337–42. 10.4103/lungindia.lungindia_595_21 . Shafey O, Eriksen M, Ross H, Mackay J. The Tobacco Atlas. 3rd ed. Atlanta, GA: American Cancer Society; 2009. Available from: https://www.afro.who.int/sites/default/files/2017-09/Front%20Matter.pdf Bravi F, Bosetti C, Scotti L, Talamini R, Montella M, Ramazzotti V, Negri E, Franceschi S, La Vecchia C. Food groups and renal cell carcinoma: a case–control study from Italy. Int J Cancer. 2007;120(3):681–5. 10.1002/ijc.22225 . Kabir Y, Islam MS, Hossain MA, Chowdhury SD, Rahman MA, Sarker AR, Mondal K, Barua B. Nutrient composition in selected key foods of animal origin in Bangladesh. Eur J Pharm Med Res. 2020;7(5):42–51. 10.5281/zenodo.3940156 . Gago-Dominguez M, Yuan JM, Castelao JE, Ross RK, Yu MC. Regular use of analgesics is a risk factor for renal cell carcinoma. Br J Cancer. 1999;81(3):542–8. 10.1038/sj.bjc.6690728 . Shimul SN, Hussain AG, Nargis N. Estimating own-price and cross-price elasticity of cigarette consumption by price tiers in Bangladesh. Tob Control. 2024;33(Suppl 2):s44–50. 10.1136/tc-2022-057679 . Mancini M, Righetto ML, Baggio G. Gender-related approach to kidney cancer management: moving forward. Int J Mol Sci. 2020;21(9):3378. 10.3390/ijms21093378 . Li Y, Hecht SS. Carcinogenic components of tobacco and tobacco smoke: A 2022 update. Food Chem Toxicol. 2022;165:113179. https://doi.org/10.1016/j.fct.2022.113179 . Muscat JE, Hoffmann D, Wynder EL. The epidemiology of renal cell carcinoma: a second look. Cancer. 1995;75(10):2552–7. 10.1002/1097-0142(19950515)75:10%3C2552::AID-CNCR2820751015%3E3.0.CO;2-L . IARC Working Group. Tobacco Smoke and Involuntary Smoking. IARC Monographs, Vol. 83. Lyon: IARC. 2004. Available from: https://publications.iarc.fr/83 Lee CH, Ko AM, Warnakulasuriya S, Ling TY, Sun KT, Ko YC. Intercountry prevalences and practices of betel-quid use in South, Southeast and Eastern Asia regions and associated oral preneoplastic disorders: an IARC multicenter study. Int J Cancer. 2011;129(7):1741–51. 10.1002/ijc.25809 . Hakimi AA, Reznik E, Lee CH, Creighton CJ, Brannon AR, Luna A, et al. An integrated metabolic atlas of clear cell renal cell carcinoma. Cancer Cell. 2016;29(1):104–16. 10.1016/j.ccell.2015.12.004 . McLaughlin JK, Lindblad P, Mellemgaard A, McCredie M, Mandel JS, Schlehofer B, Pommer W, Niwa S, Adami HO. International renal-cell cancer study I. Tobacco use. Int J Cancer. 1995;60:194–8. 10.1002/ijc.2910600211 . Reigle J, Secic D, Biesiada J, Wetzel C, Shamsaei B, Chu J, et al. Tobacco smoking induces metabolic reprogramming of renal cell carcinoma. J Clin Invest. 2021;131(1):e140522. https://doi.org/10.1172/JCI140522 . Hu J, Ugnat AM, Canadian Cancer Registries Epidemiology Research Group. Active and passive smoking and risk of renal cell carcinoma in Canada. Eur J Cancer. 2005;41(5):770–8. 10.1016/j.ejca.2004.12.022 . McLaughlin JK, Mandel JS, Blot WJ, Schuman LM, Mehl ES, Fraumeni JF Jr.. A population-based case-control study of renal cell carcinoma. J Natl Cancer Inst. 1984;72(2):275–84. 10.1093/jnci/72.2.275 . Kreiger N, Marrett LD, Dodds L, Hilditch S, Darlington GA. Risk factors for renal cell carcinoma: results of a population-based case-control study. Cancer Causes Control. 1993;4(2):101–10. 10.1007/BF00053150 . Hunt JD, Van der Hel OL, McMillan GP, Boffetta P, Brennan P. Renal cell carcinoma in relation to cigarette smoking: meta-analysis of 24 studies. Int J Cancer. 2005;114(1):101–8. 10.1002/ijc.20618 . Pascual D, Borque A. Epidemiology of kidney cancer. Adv Urol. 2008;2008(1):782381. 10.1155/2008/782381 . Bukavina L, Bensalah K, Bray F, Carlo M, Challacombe B, Karam JA, Kassouf W, Mitchell T, Montironi R, O'Brien T, Panebianco V. Epidemiology of renal cell carcinoma: 2022 update. Eur Urol. 2022;82(5):529–42. 10.1016/j.eururo.2022.08.019 . Zhang H, Zhang Z, Huang J, Chen M, Pan Q, Pan Y, et al. GSTM1 and GSTT1 polymorphisms contribute to renal cell carcinoma risk: evidence from meta-analysis. Sci Rep. 2015;5:17971. 10.1038/srep17971 . Zhong Z, Li H, Zhong H, Zhou T, Xie W, Lin Z. Glutathione S-transferase gene polymorphisms and renal cell carcinoma susceptibility: systematic review and meta-analyses. BMC Med Genet. 2018;19:98. 10.1186/s12881-018-0620-y . Dahman L, Gauthier V, Camier A, Bigna JJJ, Glowacki F, Amouyel P, et al. Air pollution and kidney cancer risk: a systematic review and meta-analysis. J Nephrol. 2024;37(6):1779–90. 10.1007/s40620-024-01984-x . Velasco E, Retama A, Stratoulias D. Air Pollution in Southeast Asia. InAir Quality Management and Research in Southeast Asia 2024 Dec 1 (pp. 23–35). Cham: Springer Nature Switzerland. 10.1007/978-3-031-69088-4_3 Sheikh M, Mukeriya A, Zahed H, Feng X, Robbins HA, Shangina O, et al. Smoking cessation after diagnosis of kidney cancer is associated with reduced risk of mortality and cancer progression: a prospective cohort study. J Clin Oncol. 2023 Mar;29. 10.1200/JCO.22.02472 . Zhang M, Liu S, Yang L, Jiang Y, Huang Z, Zhao Z, Deng Q, Li Y, Zhou M, Wang L, Chen Z. Prevalence of smoking and knowledge about the hazards of smoking among 170 000 Chinese adults, 2013–2014. Nicotine Tob Res. 2019;21(12):1644–51. 10.1093/ntr/ntz117 . Lynch WJ, Roth ME, Carroll ME. Biological basis of sex differences in drug abuse: preclinical and clinical studies. Psychopharmacology. 2009;230(1):1–19. 10.1007/s00213-009-1588-2 . Gakidou E, Afshin A, Abajobir AA, et al. Health effects associated with chewing tobacco: A Burden of Proof study. Nat Commun. 2021;15(1):1082. https://doi.org/10.1038/s41467-024-45074-9 . Goodman MT, Morgenstern HA, Wynder EL. A case-control study of factors affecting the development of renal cell cancer. Am J Epidemiol. 1986;124(6):926–41. 10.1093/oxfordjournals.aje.a114482 . Yuan JN, Castelao JE, Gago-Dominguez M, Yu CM, Ross RK. Tobacco use in relation to renal cell carcinoma. Cancer Epidemiol Biomarkers Prev. 1998;7(5):429–33. Boffetta P, Aagnes B, Weiderpass E, Andersen A. Smokeless tobacco use and risk of cancer of the pancreas and other organs. Int J Cancer. 2005;114(6):992–5. 10.1002/ijc.20710 . Kendrick PJ, Reitsma MB, Abbasi-Kangevari M, Abdoli A, Abdollahi M, Abedi A, Abhilash ES, Aboyans V, Adebayo OM, Advani SM, Ahinkorah BO. Spatial, temporal, and demographic patterns in prevalence of chewing tobacco use in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet Public Health. 2021;6(7):e482–99. 10.1016/S2468-2667(21)00065-7 . WHO Global Report on Trends in Prevalence of Tobacco Use 2000–2030. World Health Organization. 2021. Available from: https://www.who.int/publications/i/item/9789240088283 Yang H, Ma C, Zhao M, Magnussen CG, Xi B. Prevalence and trend of smokeless tobacco use and its associated factors among adolescents aged 12–16 years in 138 countries/territories, 1999–2019. BMC Med. 2022;20(1):460. 10.1186/s12916-022-02662-0 . Htay ZW, Bhandari AKC, Parvin R, Abe SK. Effects of smokeless tobacco on cancer incidence and mortality: a global systematic review and meta-analysis. Cancer Causes Control. 2025;36(4):321–52. 10.1007/s10552-024-01933-w . Kabaria R, Klaassen Z, Terris MK. Renal cell carcinoma: links and risks. Int J Nephrol Renovasc Dis. 2016;9:45–52. 10.2147/IJNRD.S75916 . Sandler DP, Everson RB, Wilcox AJ. Passive smoking in adulthood and cancer risk. Am J Epidemiol. 1985;121(1):37–48. 10.1093/oxfordjournals.aje.a114268 . Islami F, Nargis N, Liu Q, Bandi P, Siegel RL, Choudhury PP, Freedman ND, Warner KE, Jemal A. Averted lung cancer deaths due to reductions in cigarette smoking in the United States, 1970–2022. CA: A Cancer Journal for Clinicians. 2025;75(3):216–25. 10.3322/caac.70005 Additional Declarations No competing interests reported. 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With an annual increase of 1.1% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and nearly doubled case detection rates over recent decades [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], RCC has emerged as a major global health concern. In 2020, approximately half a million new RCC cases and 179,000 related deaths were reported worldwide [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A growing trend is evident in the Indian subcontinent, with earlier onset and increased mortality. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In Bangladesh, around 1,500 new cases and 1,000 related deaths were documented in 2020 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Similar to other developing countries, improved diagnostic facilities [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and widespread risk factors, including westernized lifestyles and tobacco consumption, may underlie the growing RCC burden in Bangladesh [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTobacco is one of the most widespread risk factors for RCC, with over 1.3\u0026nbsp;billion users worldwide. Derived from \u003cem\u003eNicotiana species plants\u003c/em\u003e, tobacco products are broadly classified as smoked or smokeless (SLT) forms [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], with global use shaped by availability, accessibility, and socio-cultural factors [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Bangladesh, a major producer and consumer of tobacco, exhibits extensive use of both forms, deeply embedded in traditional practices. Common smoked products include cigarettes, bidis (unprocessed, low-grade tobacco), cigars, pipes, and hookahs (water pipes), while SLT varieties include \u003cem\u003ezarda\u003c/em\u003e (processed tobacco leaf consumed with betel leaf or quid), \u003cem\u003egul\u003c/em\u003e (powdered tobacco ash), \u003cem\u003esadapata\u003c/em\u003e (raw tobacco leaf), \u003cem\u003ekhaini\u003c/em\u003e (crushed dried tobacco leaf), and \u003cem\u003epan mashala\u003c/em\u003e (a mixture of tobacco, lime, and areca nut) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the National STEPS Survey for NCD Risk Factors (2018), 43.7% of Bangladeshi adults (59.6% men and 28.3% women) used tobacco. Among them, 23.5% were smokers (46.6% men, 1% women), 27.5% used smokeless tobacco (26.9% men, 28.1% women), and 7.2% used both forms [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Unlike smoking, smokeless tobacco (SLT) is not culturally stigmatized in this region, explaining its higher prevalence among women [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Over 83% of the world\u0026rsquo;s chewing tobacco users live in South Asia, highlighting the region\u0026rsquo;s unique consumption patterns [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition, exposure to secondhand smoke is pervasive across Bangladesh, with 39% of individuals affected at home, 42.7% at workplaces, and nearly half in public settings [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Non-smoking women and children are especially vulnerable to its harmful effects [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], as tobacco smoke contains high levels of particulate matter (PM), a known carcinogen. Globally, smokers generate about 209\u0026nbsp;million kg of PM annually, with nearly 80% released indoors [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTobacco contains a well-established human carcinogen, responsible for 20\u0026ndash;25% of RCC cases [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The risk rises with longer and heavier use but declines after cessation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Eliminating smoking could prevent up to 28% of RCC cases [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Although tobacco is a recognized RCC risk factor [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], evidence from South Asia remains limited, particularly regarding local products (zarda, gul, sadapata), combined exposures, and population-based studies. This study examines associations between smoking, smokeless tobacco (SLT), and secondhand tobacco smoke (SHS) with RCC among Bangladeshi adults, aiming to fill this regional gap and support stronger tobacco control and cancer prevention efforts.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e \u003cstrong\u003eStudy design and settings\u003c/strong\u003e \u003cp\u003eThis matched case\u0026ndash;control study was conducted between January and December 2023 at the National Institute of Cancer Research and Hospital (NICRH) and Bangabandhu Sheikh Mujib Medical University (BSMMU), two premier tertiary cancer hospitals in Bangladesh treating RCC patients nationwide.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy participants and sampling\u003c/strong\u003e \u003cp\u003eThe study included 71 RCC patients and 71 matched controls, with 40 men and 31 women in each group. Cases were adult RCC patients (\u0026ge;\u0026thinsp;18 years) diagnosed histologically within the past 12 months, excluding critically ill ones. Controls were healthy attendants of other patients, matched with the cases by age (\u0026plusmn;\u0026thinsp;5 years), sex, and district of residence. Hospital-based convenience sampling was used for feasibility and inclusion of recent confirmed cases.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData measurement\u003c/strong\u003e \u003cp\u003eThis study examined RCC as the outcome and tobacco exposure as the primary independent variable encompassing both direct consumption and secondhand tobacco smoke (SHS) inhalation. Participants who consumed\u0026thinsp;\u0026ge;\u0026thinsp;100 smoked in their lifetime were classified as ever tobacco users, current users consumed tobacco daily, or most days in a week, and past users had quit for \u0026ge;\u0026thinsp;1 year of interview [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Occasional smokers were those who smoked\u0026thinsp;\u0026ge;\u0026thinsp;100 cigarettes but no more than twice weekly [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Smoking intensity was assessed in pack-years (PPY\u0026thinsp;=\u0026thinsp;packs/day \u0026times; years) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], with the average daily cigarette consumption calculated for each decade of smoking. A nicotine-based equivalence was applied for bidi smoking, where 1 pack-year of cigarette\u0026thinsp;\u0026asymp;\u0026thinsp;43 bidis/day/year was considered [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Individuals who had consumed any form of smokeless tobacco on a daily or weekly basis for at least one year were considered as smokeless tobacco consumers.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eSecondhand smoke (SHS) refers to the inhalation of tobacco smoke by non-smokers, originating from either mainstream (exhaled) or side stream (from the tip) smoke [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. SHS exposure was assessed in indoor (home, confined workplace) and outdoor (public places, including transport, restaurants, markets, and healthcare facilities) settings. Indoor exposure was defined as living with a smoker for \u0026ge;\u0026thinsp;1 year who smoked in the bedroom or living room. Workplace exposure was defined as someone smoking within 10 feet of the participant at least once a week for \u0026ge;\u0026thinsp;1 year, and public exposure as at least one hour per week in public areas [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the associated factors, information on socio-demographic characteristics, family history of RCC, occupational exposure, and dietary habits was obtained through self-reported responses, whereas drug history (including NSAIDs and statins) and comorbidities such as hypertension, diabetes, and urinary tract infections (UTI) were extracted from medical record reviews. Dietary assessment focused on foods commonly consumed in Bangladesh and linked to RCC risk, with regular intake defined as \u0026ge;\u0026thinsp;1 serving/day in the two years prior to diagnosis or interview [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Commonly consumed animal-based foods rich in high-quality protein, such as fish, meat, eggs, and milk, were classified as protein foods [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Chronic analgesic use was defined as taking NSAIDs at least twice a week for one month or more within the past two years [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData collection\u003c/strong\u003e \u003cp\u003eData were collected through face-to-face interviews and medical record reviews using a pretested semi-structured questionnaire covering socio-demographics, tobacco use, SHS exposure, and RCC-related factors, including diet, habits, family, and occupational history. Adapted from the Global Adult Tobacco Survey (2020) and expert input, the questionnaire was translated into Bangla and back-translated for accuracy. Interviews were conducted in Bangla, lasting 20\u0026ndash;30 minutes in a private setting.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData analysis\u003c/strong\u003e \u003cp\u003eData were cleaned, coded, and analyzed using SPSS v26. Categorical variables were presented as frequency and percentage, while continuous variables were reported as mean (\u0026plusmn;\u0026thinsp;SD) or median (IQR), depending on the distribution. Bivariate analyses included chi-square, t-test, and Mann\u0026ndash;Whitney U test. And significant factors emerged from these were employed as covariates into multivariable logistic regression model using a backward stepwise approach. Tobacco consumption-related factors were adjusted for age, sex, district of residence, and key confounders, including education, income, regular fruits \u0026amp; protein intake, and hypertension. Multicollinearity was low (VIF 1.16\u0026ndash;2.29) among the covariates. Pack-years were analyzed both continuously and categorically (non-smoker, \u0026le;\u0026thinsp;20, \u0026gt;20) with consistent trends. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 with 95% CI. A Chi-square test with Cohen\u0026rsquo;s h was performed on 142 participants to assess the effect of tobacco use on RCC risk. Tobacco use was 80.3% and 39.4% among the cases and controls, respectively, yielding a large effect size (h\u0026thinsp;=\u0026thinsp;0.68). Power analysis (α\u0026thinsp;=\u0026thinsp;0.05) indicated 99.9% power, confirming the study\u0026rsquo;s ability to detect significant associations.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical consideration\u003c/strong\u003e \u003cp\u003eEthical approval was obtained from the IRB of NIPSOM (Memo No. NIPSOM/IRB/2023/06), with data collection permission from NICRH and BSMMU authorities. All participants gave written informed consent to participate in the study after being clearly informed about the study\u0026rsquo;s purpose, procedures, and confidentiality. Participation was voluntary, and withdrawal was allowed at any time. Data were securely stored in a password-protected folder with restricted access.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe level of education differed significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with more cases lacking formal education (32.4% vs. 11.3%) and fewer having higher secondary education (25.4% vs. 54.9%) compared to controls. Additionally, cases had significantly (p\u0026thinsp;=\u0026thinsp;0.01) lower mean monthly family income (37,042.2 BDT vs. 43,704.2 BDT) compared to controls [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of socio-demographic characteristics between cases and controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttributes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCases (n\u0026thinsp;=\u0026thinsp;71)\u003c/p\u003e \u003cp\u003ef (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControls (n\u0026thinsp;=\u0026thinsp;71)\u003c/p\u003e \u003cp\u003ef (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (In years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.8 (\u0026plusmn;\u0026thinsp;12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.5(\u0026plusmn;\u0026thinsp;12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.87\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUp to secondary level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (33.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigher secondary and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (54.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eService\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (38.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBusiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (15.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHomemaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (33.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (28.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDay laborer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (28.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (18.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (54.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (42.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFamily type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (62.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43 (60.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJoint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (38.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (39.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly family income (BDT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37042.2 (\u0026plusmn;\u0026thinsp;1444)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43704.2 (\u0026plusmn;\u0026thinsp;1821)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e \u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBDT\u0026thinsp;=\u0026thinsp;Bangladeshi Taka; IQR\u0026thinsp;=\u0026thinsp;Inter-quartile Range.\u003c/p\u003e \u003cp\u003ep-values were obtained by chi-square test.\u003c/p\u003e \u003cp\u003e \u003csup\u003e1\u003c/sup\u003ep-value obtained by independent samples t-test\u003c/p\u003e \u003cp\u003eA significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) higher proportion of cases had ever consumed tobacco (80.3% vs. 39.4%), and started consumption earlier (median age 20 years vs. 25 years, p\u0026thinsp;=\u0026thinsp;0.04) compared to controls. More cases were smokers (45.1% vs. 21.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and they smoked for a longer duration (mean 28.6 years vs. 20.2 years, p\u0026thinsp;=\u0026thinsp;0.05), although the difference was not significant. Cases smoked significantly more tobacco (pack-years) annually (median 22.3 packs vs. 8.5 packs; p\u0026thinsp;=\u0026thinsp;0.03) than controls. SLT use was more common among cases (57.7% vs. 22.5%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), but there were no significant differences in duration or frequency of SLT consumption. Significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) higher proportion of cases also used both smoking and SLT (22.5% vs. 4.2%) than controls [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of tobacco exposure and related factors between cases and controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttributes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCases (n\u0026thinsp;=\u0026thinsp;71)\u003c/p\u003e \u003cp\u003ef (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControls (n\u0026thinsp;=\u0026thinsp;71)\u003c/p\u003e \u003cp\u003ef (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDirect tobacco consumption (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (19.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43 (60.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (80.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (39.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOnset of tobacco consumption (n\u0026thinsp;=\u0026thinsp;85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (92.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (35.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (15\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (22\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eType of tobacco consumption (n\u0026thinsp;=\u0026thinsp;85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmoked\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmokeless\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (43.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (46.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (10.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSmoking (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (54.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (78.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (21.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eDuration of smoking in years (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.6 (\u0026plusmn;\u0026thinsp;13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.2 (\u0026plusmn;\u0026thinsp;13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.05 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNature of smoking (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (53.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of sticks smoked per day (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (68.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.99\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (31.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (26.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.5 (\u0026plusmn;\u0026thinsp;10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.1 (\u0026plusmn;\u0026thinsp;8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.2 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePack per year (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUp to 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (46.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (53.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.3 (7.1\u0026ndash;46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.5 (3.7\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCigarette smoking (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.38\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (78.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (93.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBidi smoking (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.17\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDuration of smoking cessation in years (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.9 (\u0026plusmn;\u0026thinsp;7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.7 (\u0026plusmn;\u0026thinsp;9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e \u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSLT consumption (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (77.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (22.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDuration of SLT consumption in years (n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (63.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (56.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.6 (\u0026plusmn;\u0026thinsp;11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.8 (\u0026plusmn;\u0026thinsp;13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.23 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFrequency of SLT consumption per day (n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (78.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.38\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (37.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4 (\u0026plusmn;\u0026thinsp;2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.3 (\u0026plusmn;\u0026thinsp;2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.9 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNature of SLT consumption (n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (80.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (93.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.40\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBetel quid consumption (n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eZarda consumption (n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (62.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSadapata and Gul consumption (n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (82.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.75\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDuration of SLT consumption cessation in years (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0 (\u0026plusmn;\u0026thinsp;9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.49 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCombined smoking and SLT consumption (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (77.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68 (95.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (4.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIQR\u0026thinsp;=\u0026thinsp;Inter-quartile Range; SLT\u0026thinsp;=\u0026thinsp;Smokeless Tobacco.\u003c/p\u003e \u003cp\u003e \u003csup\u003e1\u003c/sup\u003ep-value obtained by independent samples t-test.\u003c/p\u003e \u003cp\u003e \u003csup\u003e2\u003c/sup\u003ep-value obtained by Mann\u0026ndash;Whitney U test as the data were skewed\u003c/p\u003e \u003cp\u003e \u003csup\u003e3\u003c/sup\u003ep-value obtained by continuity correction.\u003c/p\u003e \u003cp\u003eAll other p-values were obtained by chi-square test.\u003c/p\u003e \u003cp\u003eExposure to secondhand tobacco smoke (SHS) was more common among cases than controls (64.8% vs. 53.5%), but the difference was not significant (p\u0026thinsp;=\u0026thinsp;0.17). Indoor SHS exposure was significantly higher in cases (62.0% vs. 25.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with most cases exposed daily compared to controls. However, the duration of indoor SHS exposure was indistinguishable between cases and controls. Exposure to outdoor SHS was similar between cases and controls (p\u0026thinsp;=\u0026thinsp;0.86), suggesting no association with RCC risk in this study [Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of secondhand smoking (SHS) between cases and controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttributes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCases (n\u0026thinsp;=\u0026thinsp;71)\u003c/p\u003e \u003cp\u003ef (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControls (n\u0026thinsp;=\u0026thinsp;71)\u003c/p\u003e \u003cp\u003ef (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSecondhand tobacco smoke exposure (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33 (46.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (64.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38 (53.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIndoor SHS exposure (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (38.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53 (74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (62.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (25.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFrequency of Indoor SHS exposure (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than daily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.48\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDaily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (88.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (77.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eDuration of indoor SHS exposure in Years (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.68\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (61.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (22.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.39 (\u0026plusmn;\u0026thinsp;5.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.78 (\u0026plusmn;\u0026thinsp;6.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.87\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOutdoor SHS exposure ((n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42 (59.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (40.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30 (42.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFrequency of outdoor SHS exposure (n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than daily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17 (56.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDaily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (65.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13 (43.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eDuration of outdoor SHS exposure in years (n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (36.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (48.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (36.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (20.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (26.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.0 (8.0\u0026ndash;19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.5 (6.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.70\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSHS\u0026thinsp;=\u0026thinsp;Secondhand Tobacco Smoke; IQR\u0026thinsp;=\u0026thinsp;Inter-quartile Range.\u003c/p\u003e\n\u003ch3\u003ep-values were obtained by chi-square test\u003c/h3\u003e\n\u003cp\u003e \u003csup\u003e1\u003c/sup\u003ep-value obtained by independent samples t-test.\u003c/p\u003e \u003cp\u003e \u003csup\u003e2\u003c/sup\u003ep-value obtained by Mann\u0026ndash;Whitney U test.\u003c/p\u003e \u003cp\u003e \u003csup\u003e3\u003c/sup\u003ep-value obtained by Fisher\u0026rsquo;s Exact Test.\u003c/p\u003e \u003cp\u003e \u003csup\u003e4\u003c/sup\u003ep-value obtained by continuity correction.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows other factors in terms of dietary habits and health conditions that were compared between cases and controls. Significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) lower proportion of cases consumed fruits (7.0% vs. 50.7%) and proteins (43.7% vs. 74.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) regularly. No significant differences were observed in vegetable, tea, or coffee consumption. Regarding health conditions, cases had a higher prevalence of hypertension (45.1% vs. 28.2%, p\u0026thinsp;=\u0026thinsp;0.03), but no significant differences were found for diabetes, urinary tract infections, or analgesic and statin use. No participants from both groups had a family history of RCC, alcohol consumption, or any occupational history with exposure associated with elevated risk of RCC [Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of other factors associated with RCC between cases and controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttributes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCases (n\u0026thinsp;=\u0026thinsp;71)\u003c/p\u003e \u003cp\u003ef (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControls (n\u0026thinsp;=\u0026thinsp;71)\u003c/p\u003e \u003cp\u003ef (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFruits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66 (93.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36 (49.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36 (50.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVegetables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66 (93.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68 (95.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProtein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53 (74.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49 (69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56 (78.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCoffee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67 (94.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61 (85.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (14.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (54.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 (71.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (28.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54 (76.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45 (63.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26 (36.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (80.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63 (88.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (19.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (11.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnalgesics (NSAIDs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (78.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50 (70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21 (29.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55 (77.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46 (64.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (35.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHTN\u0026thinsp;=\u0026thinsp;Hypertension; DM\u0026thinsp;=\u0026thinsp;Diabetes Mellitus; UTI\u0026thinsp;=\u0026thinsp;Urinary Tract Infection; NSAID\u0026thinsp;=\u0026thinsp;Non-steroidal Anti-inflammatory Drugs.\u003c/p\u003e\n\u003ch3\u003eAll p-values were obtained by chi-square\u003c/h3\u003e\n\u003cp\u003eEver tobacco consumers had a 5.5-fold higher risk of RCC (AOR\u0026thinsp;=\u0026thinsp;5.54, 95% CI: 2.32\u0026ndash;13.24, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Early onset of tobacco use (15\u0026ndash;19 years) increased the odds nearly tenfold (AOR\u0026thinsp;=\u0026thinsp;9.85, 95% CI: 1.72\u0026ndash;56.34, p\u0026thinsp;=\u0026thinsp;0.01). Smokers were 3.5 times more likely to develop RCC (AOR\u0026thinsp;=\u0026thinsp;3.47, 95% CI: 1.39\u0026ndash;8.68, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and heavy smokers (\u0026gt;\u0026thinsp;20 packs/year) had even higher odds (AOR\u0026thinsp;=\u0026thinsp;7.72, 95% CI: 1.79\u0026ndash;33.20, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Each additional pack-year raised RCC risk by 6% (AOR\u0026thinsp;=\u0026thinsp;1.06, 95% CI: 1.01\u0026ndash;1.10, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Short-term quitters (2\u0026ndash;14 years) showed elevated risk (AOR\u0026thinsp;=\u0026thinsp;18.03, 95% CI: 1.05\u0026ndash;309.30, p\u0026thinsp;=\u0026thinsp;0.04) compared to non-smokers. SLT users (AOR\u0026thinsp;=\u0026thinsp;3.98, 95% CI: 1.73\u0026ndash;9.11, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), combined users (AOR\u0026thinsp;=\u0026thinsp;6.70, 95% CI: 1.58\u0026ndash;28.45, p\u0026thinsp;=\u0026thinsp;0.01), and those exposed to indoor SHS (AOR\u0026thinsp;=\u0026thinsp;4.07, 95% CI: 1.78\u0026ndash;9.30, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) had significantly greater RCC risk [Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEstimation of tobacco related risk of RCC by multivariable logistic regression\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAttributes related to tobacco consumption\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eUnivariable LR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMultivariable LR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEver tobacco consumption (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.25 (2.94\u0026ndash;13.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.54 (2.32\u0026ndash;13.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge at onset (years)\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.02 (1.51\u0026ndash;32.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.85 (1.72\u0026ndash;56.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSmoking\u003csup\u003ea\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.06 (1.46\u0026ndash;6.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.47 (1.39\u0026ndash;8.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePack per year\u003csup\u003ea\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUp to 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.79 (0.75\u0026ndash;4.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.89 (0.69\u0026ndash;5.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.13 (2.23\u0026ndash;29.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.72 (1.79\u0026ndash;33.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePack per year (PPY)\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.06 (1.02\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.06 (1.01\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDuration of smoking cessation (n\u0026thinsp;=\u0026thinsp;117)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.92 (1.5-106.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.03 (1.05\u0026ndash;309.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.02 (0.3\u0026ndash;3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.61 (0.15\u0026ndash;2.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSLT consumption\u003csup\u003eb\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.70 (2.26\u0026ndash;9.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.98 (1.73\u0026ndash;9.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCombined smoking \u0026amp; SLT consumption (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.59 (1.82\u0026ndash;23.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.70 (1.58\u0026ndash;28.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIndoor SHS exposure\u003csup\u003ec\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.80 (2.34\u0026ndash;9.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.07 (1.78\u0026ndash;9.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eCOR= Crude Odds ratio, AOR= Adjusted Odds ratio, CI= Confidence interval, SLT= Smokeless tobacco, SHS= Secondhand Tobacco Smoke, LR= Logistic Regression. The variables are adjusted for level of education, monthly family income, daily fruits intake, daily protein intake and hypertension\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe risk of RCC was 7.1 (AOR\u0026thinsp;=\u0026thinsp;7.06, 95% CI: 1.86\u0026ndash;26.82, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and \u003cb\u003e5.6\u003c/b\u003e (AOR\u0026thinsp;=\u0026thinsp;5.61, 95% CI: 1.45\u0026ndash;21.60, p\u0026thinsp;=\u0026thinsp;0.01) times higher for male and female ever tobacco consumers, respectively. The risk of RCC for male smokers was 4.7 times (AOR\u0026thinsp;=\u0026thinsp;4.74, 95% CI: 1.57\u0026ndash;14.31, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). SLT consumption was strongly linked to RCC for both sexes (AOR\u0026thinsp;=\u0026thinsp;3.79, 95% CI: 1.26\u0026ndash;11.41, p\u0026thinsp;=\u0026thinsp;0.01 for males; AOR\u0026thinsp;=\u0026thinsp;4.90, 95% CI: 1.28\u0026ndash;18.70, p\u0026thinsp;=\u0026thinsp;0.02 for females). Indoor SHS exposure significantly increased RCC risk by 4.8-fold among males (AOR\u0026thinsp;=\u0026thinsp;4.81, 95% CI: 1.72\u0026ndash;13.44, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), while the association was non-significant for females (AOR\u0026thinsp;=\u0026thinsp;2.81, 95% CI: 0.72\u0026ndash;10.90, p\u0026thinsp;=\u0026thinsp;0.13) [Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSex variation of tobacco consumption related risk factors of RCC (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTobacco consumption related attributes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEver tobacco consumption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.06 (1.86\u0026ndash;26.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.61 (1.45\u0026ndash;21.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSmoking\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.74 (1.57\u0026ndash;14.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSLT consumption\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.79 (1.26\u0026ndash;11.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.90 (1.28\u0026ndash;18.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIndoor SHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.81 (1.72\u0026ndash;13.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.81 (0.72\u0026ndash;10.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAOR= Adjusted Odds ratio, CI= Confidence interval, SLT= Smokeless tobacco, SHS= Secondhand tobacco smoke, The variables are adjusted for level of education, monthly family income, daily fruits intake, daily protein intake and hypertension\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current hospital-based case\u0026ndash;control study in Bangladesh identified ever direct tobacco use, smoking, smokeless tobacco (SLT) consumption, and indoor exposure to secondhand smoke (SHS) as independent and significant risk factors for renal cell carcinoma (RCC). Sex-based variations in risk were observed, with males exhibiting a higher risk for indoor secondhand smoke (SHS) exposure, while females faced a higher risk for ever having consumed tobacco and smokeless tobacco (SLT). Since the proportion of female smokers in this study was very low, consistent with a recent Bangladeshi study [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], the gender difference in smoking risk could not be determined. The gender difference may be attributable to complex interactions among hormonal, metabolic, and tobacco consumption pattern-related differences between males and females [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the United States Food and Drug Administration (FDA), tobacco products contain 79 identified carcinogens, while the International Agency for Research on Cancer (IARC) reports that tobacco products and smoke contain 533 probable, possible, and confirmed human carcinogens [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Carcinogenic compounds such as polycyclic aromatic hydrocarbons, nitrosamines, and heavy metals like cadmium and arsenic can enter the bloodstream through absorption from the respiratory or digestive tract, are filtered by the kidneys, and damage renal tubular cells via DNA adduct formation, oxidative stress, and mutagenesis [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProlonged tobacco exposure can also reprogram tumor metabolism by altering oxidative phosphorylation, amino acid utilization, and metal homeostasis, thereby promoting tumor progression [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This aligns with our finding of a higher lifetime RCC risk among individuals who initiated tobacco use during adolescence, consistent with prior research [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Adolescence is a critical period of kidney development when the kidneys are more vulnerable to DNA damage and tobacco-related carcinogens [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Environmental tobacco smoke (ETS) also contains similar toxins, and prolonged exposure increases RCC risk in a dose-dependent manner [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Tobacco-induced inflammation, angiogenesis, and impaired DNA repair further enhance these carcinogenic effects, raising RCC risk in both active and passive smokers [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study reinforces the evidence that smoking is a major risk factor for RCC, aligning with previous research from Western countries showing a 1.2\u0026ndash;2.4 times higher risk among smokers depending on smoking status, intensity, and duration [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR43 CR44 CR45\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. A 2024 Mendelian randomization study also supports a causal link, finding that genetically predicted smoking initiation increases RCC risk (OR 1.55, 95% CI 1.04\u0026ndash;2.33) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These studies reported a lower RCC risk among smokers than ours, likely due to differences in sample size and unaddressed genetic or environmental factors. A higher prevalence of carcinogen-detoxifying gene variants, such as CYP1A1 (Ile462Val, MspI) and deletions in GSTM1 and GSTT1 [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], may increase RCC susceptibility among Asian smokers. Additionally, elevated levels of PM10 and NO₂, common in Southeast Asia and worsened by indoor and public smoking, have been linked to greater RCC risk [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study found a consistent but non-linear association between smoking and RCC risk, with heavy smokers (\u0026gt;\u0026thinsp;20 pack-years) showing a markedly higher likelihood of developing RCC, aligning with previous studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Short-term quitters remained at elevated risk due to residual biological damage from past smoking [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], while long-term cessation (15\u0026ndash;35 years) significantly lowered the risk, underscoring the benefits of quitting and maintaining a smoke-free lifestyle. These findings are consistent with prior research [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], suggesting that the reduced risk after prolonged cessation may result from the recovery of biological repair mechanisms [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study found that SLT consumption is associated with a higher risk of RCC, with females appearing more vulnerable than males. Elevated estrogen levels in females may accelerate nicotine metabolism, increasing exposure to nicotine-derived carcinogens and thereby raising RCC risk [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Besides, differences in the metabolism process of tobacco-induced carcinogens may make females more vulnerable to RCC at lower doses [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. In contrast, Goodman et al. (1986) reported a fourfold higher RCC risk among men, while the association in women was not statistically significant [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Similarly, a population-based case\u0026ndash;control study in California found no link between smokeless tobacco use and RCC [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. A Norwegian cohort of 10,136 men also showed no increased kidney cancer risk among snus (a local SLT product) users, with adjusted relative risks of 0.72 (95% CI: 0.44\u0026ndash;1.18) for ever users, 1.17 (95% CI: 0.63\u0026ndash;2.16) for former users, and 0.47 (95% CI: 0.23\u0026ndash;0.94) for current users [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the evidence linking SLT use to RCC risk is limited and inconsistent, likely reflecting regional differences in SLT products and usage practices [\u003cspan additionalcitationids=\"CR59\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Common smokeless tobacco products in Southeast Asia, such as Zarda and Gul, are classified as Group 1 carcinogens by the International Agency for Research on Cancer (IARC) because of their high content of tobacco-specific nitrosamines (TSNAs), which may contribute to RCC development [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Consistent with our findings, Goodman et al. (1986) also reported that cumulative smoking and SLT consumption increased RCC risk by 26-fold, reflecting the synergistic effects of both forms of tobacco use [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence suggests that secondhand tobacco smoke exposure is significantly associated with increased risk of RCC [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e], which conflicts with our findings showing no significant effect of overall SHS exposure on RCC development. Bias from self-reporting and the misclassification of mild exposure as non-exposure may have influenced our results, highlighting the need for more objective evaluation. However, according to our findings, indoor SHS exposure was significantly associated with RCC. Both mainstream and side-stream secondhand smoke are carcinogenic; however, side-stream smoke, emitted from the burning tip due to incomplete combustion, is more hazardous. It contains higher concentrations of carcinogens like arsenic and cadmium, making it particularly dangerous in confined indoor settings such as the home and office [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Trapped smoke in indoor settings for extended periods increases the risk of higher carcinogen exposure, even if a non-smoker is not in direct contact with a smoker [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Individuals living with a smoker partner is 1.6 times more likely to develop cancer compared to those living with non-smokers [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e], indicating the importance of of indoor smoking restriction. Males exposed to indoor secondhand smoke (SHS) are at a higher risk of developing renal cell carcinoma (RCC), which can be attributed to the cumulative effects of both passive and active smoking.\u003c/p\u003e \u003cp\u003eThis study provides crucial new evidence on the role of smokeless tobacco and secondhand smoke in RCC risk, exposures that are common but remain understudied in Bangladesh. Inclusion of both smoked and smokeless tobacco along with secondhand tobacco smoke exposure, the study provides more comprehensive assessment of tobacco related risk to RCC in this setting. These findings can inform the development of context specific tobacco control interventions to reduce RCC burden. The findings emphasize the need for stronger tobacco control in Bangladesh, addressing local tobacco products and secondhand smoke exposure through stricter smoke-free laws, higher taxes, and promotion of smoke-free homes and workplaces. Islami et al 2025, showed that reducing smoking prevalence through sustained strict tobacco control policy can significantly avert millions of tobacco attributable cancer mortality [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Public awareness campaigns on the link between tobacco use and RCC, along with integrating tobacco cessation support into primary healthcare and NCD programs, are vital preventive measures. Gender-specific strategies, such as increasing SLT awareness among women and enforcing indoor smoking bans for men, are also recommended. Furthermore, stricter regulation of tobacco products, promotion of smoke-free environments, and stronger national surveillance are essential to reduce RCC risk in Bangladesh.\u003c/p\u003e \u003cp\u003eHowever, this study has limitations that should be considered when interpreting its findings. Self reported data on tobacco use and other factors, including diet may have introduced recall bias, although structured interviews likely minimized this. Hospital-based convenience sampling may introduce selection bias and limit the generalizability of the findings. Residual confounding factors like BMI, physical activity, environmental exposures and genetic susceptibility could not be excluded. Future studies with larger, population-based samples and objective measures are recommended.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTobacco consumption, including smoking, smokeless tobacco (SLT), and indoor secondhand smoke (SHS) exposure, were independent risk factor of RCC in Bangladesh. Early initiation, prolonged use, and combined exposures further heightened this risk. Men were more affected by indoor SHS, while women showed greater susceptibility to SLT. The study findings recommend stronger and comprehensive tobacco control measures targeting local products, including cessation support, public education, and indoor smoking restrictions to curb RCC burden in Bangladesh.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHTN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInter-quartile Range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNSAID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-steroidal Anti-inflammatory Drugs\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRenal Cell Carcinoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSecondhand Tobacco Smoke\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSLT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSmokeless Tobacco\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUTI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUrinary Tract Infection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVIF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVariance Inflation Factor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the IRB of NIPSOM (Memo No. NIPSOM/IRB/2023/06). All participants signed informed written consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their heartiest gratitude to all participants of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest, real, potential, or perceived, to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Bangladesh Medical Research Council (BMRC) in student\u0026rsquo;s grant category.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnonymized data is available upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSMS was involved in concept generation, data collection, statistical analysis and manuscript preparation, while MZI was engaged in concept generation, supervision and critical review of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration regarding the use of Artificial Intelligence (AI)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe AI software Claude 3.5 Sonnet was used to improve the English language and grammar. The authors thoroughly checked the AI-edited version and carried full responsibility for the content.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHsieh JJ, Purdue MP, Signoretti S, Swanton C, Albiges L, Schmidinger M, Heng DY, Larkin J, Ficarra V. Renal cell carcinoma. Nat reviews Disease primers. 2017;3(1):1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/nrdp.2017.9\u003c/span\u003e\u003cspan address=\"10.1038/nrdp.2017.9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCapitanio U, Bensalah K, Bex A, Boorjian SA, Bray F, Coleman J, Gore JL, Sun M, Wood C, Russo P. Epidemiology of renal cell carcinoma. Eur Urol. 2019;75(1):74\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.eururo.2018.08.036\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2018.08.036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCui H, Du J, Xue H, Zhao Y, Li C. The causal relationship between smoking, alcohol consumption, and renal clear cell carcinoma: A Mendelian randomization study. Front Genet. 2024;15:1391542. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fgene.2024.1391542\u003c/span\u003e\u003cspan address=\"10.3389/fgene.2024.1391542\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRose TL, Kim WY. Renal cell carcinoma: a review. JAMA. 2024;332(12):1001\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2024.12848\u003c/span\u003e\u003cspan address=\"10.1001/jama.2024.12848\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. International Agency for Research on Cancer, World Health Organization. Global cancer observatory; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePallagani L, Choudhary GR, Himanshu P, Madduri VK, Singh M, Gupta P, Shrivastava N, Baid G, Meenakshi R, Aasma N, Pareek P. Epidemiology and clinicopathological profile of renal cell carcinoma: a review from tertiary care referral centre. J Kidney Cancer VHL. 2021;8(1):1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15586/jkcvhl.2021.1\u003c/span\u003e\u003cspan address=\"10.15586/jkcvhl.2021.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSidharth M, Luitel BR, Gupta DK, Maskey P, Chalise PR, Sharma UK, Gyawali PR, Shrestha GK, Sayami G, Joshi BR. Pattern of Renal Cell Carcinoma-A Single Center Experience in Nepal. Kathmandu Univ Med J. 2011;9(3):185\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3126/kumj.v9i3.6302\u003c/span\u003e\u003cspan address=\"10.3126/kumj.v9i3.6302\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHassan MR, Sultana R, Khan MR, Arefin MS, Chowdhury AM. Renal cell carcinoma: epidemiology, risk factors and clinicopathological profile. BIRDEM Med J. 2025;15(1):16\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3329/birdem.v15i1.79308\u003c/span\u003e\u003cspan address=\"10.3329/birdem.v15i1.79308\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakino T, Kadomoto S, Izumi K, Mizokami A. Epidemiology and prevention of renal cell carcinoma. Cancers. 2022;14(16):4059. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/cancers14164059\u003c/span\u003e\u003cspan address=\"10.3390/cancers14164059\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Tobacco. [Internet]. Geneva, World Health Organization. : 2025 Jun 25 [cited 2025 Oct 8]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/tobacco\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/tobacco\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco Product Use Among Adults\u0026mdash;United States, 2020. MMWR Morb Mortal Wkly Rep. 2022;71(11):397\u0026ndash;405. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15585/mmwr.mm7111a1\u003c/span\u003e\u003cspan address=\"10.15585/mmwr.mm7111a1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuque R, Zaman MM, Huq SM, Sinha DN. Smokeless tobacco and public health in Bangladesh. Indian J Public Health. 2017;61(5):18\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ijph.IJPH_233_17\u003c/span\u003e\u003cspan address=\"10.4103/ijph.IJPH_233_17\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSultana P. Tobacco Use in Bangladesh. InHealth Promotion 2022 Jun 21. IntechOpen. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5772/intechopen.105012\u003c/span\u003e\u003cspan address=\"10.5772/intechopen.105012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. National STEPS survey for non-communicable diseases risk factors in Bangladesh 2018. InNational STEPS survey for non-communicable diseases risk factors in Bangladesh 2018 2018. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/bangladesh/about-us/publications/m/item/2018-national-steps-survey-for-non-communicable-diseases-risk-factors-in-bangladesh\u003c/span\u003e\u003cspan address=\"https://www.who.int/bangladesh/about-us/publications/m/item/2018-national-steps-survey-for-non-communicable-diseases-risk-factors-in-bangladesh\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlora MS, Mascie-Taylor CG, Rahman M. Gender and locality differences in tobacco prevalence among adult Bangladeshis. Tob Control. 2009;18(6):445\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/tc.2008.028142\u003c/span\u003e\u003cspan address=\"10.1136/tc.2008.028142\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGakidou E, Afshin A, Abajobir AA, et al. Health effects associated with chewing tobacco: a Burden of Proof study. Nat Commun. 2024;15(1):1082. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41467-024-45074-9\u003c/span\u003e\u003cspan address=\"10.1038/s41467-024-45074-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlobal Adult Tobacco Survey Collaborative Group. Global adult tobacco survey (GATS): core questionnaire with optional questions. Atlanta, GA: Centers for Disease Control and Prevention. 2020:11\u0026thinsp;\u0026ndash;\u0026thinsp;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15585/mmwr.mm7111a1\u003c/span\u003e\u003cspan address=\"10.15585/mmwr.mm7111a1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFischer F, Minnwegen M, Kaneider U, Kraemer A, Khan MM. Prevalence and determinants of secondhand smoke exposure among women in Bangladesh, 2011. Nicotine Tob Res. 2015;17(1):58\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ntr/ntu129\u003c/span\u003e\u003cspan address=\"10.1093/ntr/ntu129\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Y, Huang H, Zou C, Deng M, Tu X, Deng W, Yu C, Li J. Chemical Dissection of PM2. 5 in Cigarette Smoke: Main and Sidestream Emission Factors and Compositions. Toxics. 2025;13(9):711. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/toxics13090711\u003c/span\u003e\u003cspan address=\"10.3390/toxics13090711\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCumberbatch MG, Rota M, Catto JW, La Vecchia C. The role of tobacco smoke in bladder and kidney carcinogenesis: a comparison of exposures and meta-analysis of incidence and mortality risks. Eur Urol. 2016;70(3):458\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eururo.2015.06.042\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2015.06.042\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu X, Peveri G, Bosetti C, Bagnardi V, Specchia C, Gallus S, Lugo A. Dose-response relationships between cigarette smoking and kidney cancer: a systematic review and meta-analysis. Crit Rev Oncol/Hematol. 2019;142:86\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.critrevonc.2019.06.003\u003c/span\u003e\u003cspan address=\"10.1016/j.critrevonc.2019.06.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDh\u0026ocirc;te R, Pellicer-Coeuret M, Thiounn N, Debr\u0026eacute; B, Vidal-Trecan G. Risk factors for adult renal cell carcinoma: a systematic review and implications for prevention. BJU Int. 2000;86(1):20\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1046/j.1464-4096.2000.086001020.x\u003c/span\u003e\u003cspan address=\"10.1046/j.1464-4096.2000.086001020.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGansler T, Fedewa SA, Flanders WD, Pollack LA, Siegel DA, Jemal A. Prevalence of cigarette smoking among patients with different histologic types of kidney cancer. Cancer Epidemiol Biomarkers Prev. 2020;29(7):1406\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1158/1055-9965.EPI-20-0192\u003c/span\u003e\u003cspan address=\"10.1158/1055-9965.EPI-20-0192\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang TW, Asman K, Gentzke AS, Cullen KA, Holder-Hayes E, Reyes-Guzman C, Jamal A, Neff L, King BA. Tobacco product use among adults\u0026mdash;United States, 2017. Morb Mortal Wkly Rep. 2018;67(44):1225. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15585/mmwr.mm6744a2\u003c/span\u003e\u003cspan address=\"10.15585/mmwr.mm6744a2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOksuz E, Mutlu ET, Malhan S. Characteristics of daily and occasional smoking among youths. Public Health. 2007;121(5):349\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.puhe.2006.12.007\u003c/span\u003e\u003cspan address=\"10.1016/j.puhe.2006.12.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTheis RP, Dolwick Grieb SM, Burr D, Siddiqui T, Asal NR. Smoking, environmental tobacco smoke, and risk of renal cell cancer: a population-based case\u0026ndash;control study. BMC Cancer. 2008;8:387. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2407-8-387\u003c/span\u003e\u003cspan address=\"10.1186/1471-2407-8-387\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDatta R, Singh S, Joshi A, Marwah V. Concept of BIDI years: Relevance to the perioperative period. Lung India. 2022;39(4):337\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/lungindia.lungindia_595_21\u003c/span\u003e\u003cspan address=\"10.4103/lungindia.lungindia_595_21\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShafey O, Eriksen M, Ross H, Mackay J. The Tobacco Atlas. 3rd ed. Atlanta, GA: American Cancer Society; 2009. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.afro.who.int/sites/default/files/2017-09/Front%20Matter.pdf\u003c/span\u003e\u003cspan address=\"https://www.afro.who.int/sites/default/files/2017-09/Front%20Matter.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBravi F, Bosetti C, Scotti L, Talamini R, Montella M, Ramazzotti V, Negri E, Franceschi S, La Vecchia C. Food groups and renal cell carcinoma: a case\u0026ndash;control study from Italy. Int J Cancer. 2007;120(3):681\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijc.22225\u003c/span\u003e\u003cspan address=\"10.1002/ijc.22225\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKabir Y, Islam MS, Hossain MA, Chowdhury SD, Rahman MA, Sarker AR, Mondal K, Barua B. Nutrient composition in selected key foods of animal origin in Bangladesh. Eur J Pharm Med Res. 2020;7(5):42\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5281/zenodo.3940156\u003c/span\u003e\u003cspan address=\"10.5281/zenodo.3940156\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGago-Dominguez M, Yuan JM, Castelao JE, Ross RK, Yu MC. Regular use of analgesics is a risk factor for renal cell carcinoma. Br J Cancer. 1999;81(3):542\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/sj.bjc.6690728\u003c/span\u003e\u003cspan address=\"10.1038/sj.bjc.6690728\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShimul SN, Hussain AG, Nargis N. Estimating own-price and cross-price elasticity of cigarette consumption by price tiers in Bangladesh. Tob Control. 2024;33(Suppl 2):s44\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/tc-2022-057679\u003c/span\u003e\u003cspan address=\"10.1136/tc-2022-057679\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMancini M, Righetto ML, Baggio G. Gender-related approach to kidney cancer management: moving forward. Int J Mol Sci. 2020;21(9):3378. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijms21093378\u003c/span\u003e\u003cspan address=\"10.3390/ijms21093378\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, Hecht SS. Carcinogenic components of tobacco and tobacco smoke: A 2022 update. Food Chem Toxicol. 2022;165:113179. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.fct.2022.113179\u003c/span\u003e\u003cspan address=\"10.1016/j.fct.2022.113179\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuscat JE, Hoffmann D, Wynder EL. The epidemiology of renal cell carcinoma: a second look. Cancer. 1995;75(10):2552\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/1097-0142(19950515)75:10%3C2552::AID-CNCR2820751015%3E3.0.CO;2-L\u003c/span\u003e\u003cspan address=\"10.1002/1097-0142(19950515)75:10%3C2552::AID-CNCR2820751015%3E3.0.CO;2-L\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIARC Working Group. Tobacco Smoke and Involuntary Smoking. IARC Monographs, Vol. 83. Lyon: IARC. 2004. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://publications.iarc.fr/83\u003c/span\u003e\u003cspan address=\"https://publications.iarc.fr/83\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee CH, Ko AM, Warnakulasuriya S, Ling TY, Sun KT, Ko YC. Intercountry prevalences and practices of betel-quid use in South, Southeast and Eastern Asia regions and associated oral preneoplastic disorders: an IARC multicenter study. Int J Cancer. 2011;129(7):1741\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijc.25809\u003c/span\u003e\u003cspan address=\"10.1002/ijc.25809\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHakimi AA, Reznik E, Lee CH, Creighton CJ, Brannon AR, Luna A, et al. An integrated metabolic atlas of clear cell renal cell carcinoma. Cancer Cell. 2016;29(1):104\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ccell.2015.12.004\u003c/span\u003e\u003cspan address=\"10.1016/j.ccell.2015.12.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcLaughlin JK, Lindblad P, Mellemgaard A, McCredie M, Mandel JS, Schlehofer B, Pommer W, Niwa S, Adami HO. International renal-cell cancer study I. Tobacco use. Int J Cancer. 1995;60:194\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijc.2910600211\u003c/span\u003e\u003cspan address=\"10.1002/ijc.2910600211\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReigle J, Secic D, Biesiada J, Wetzel C, Shamsaei B, Chu J, et al. Tobacco smoking induces metabolic reprogramming of renal cell carcinoma. J Clin Invest. 2021;131(1):e140522. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1172/JCI140522\u003c/span\u003e\u003cspan address=\"10.1172/JCI140522\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu J, Ugnat AM, Canadian Cancer Registries Epidemiology Research Group. Active and passive smoking and risk of renal cell carcinoma in Canada. Eur J Cancer. 2005;41(5):770\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejca.2004.12.022\u003c/span\u003e\u003cspan address=\"10.1016/j.ejca.2004.12.022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcLaughlin JK, Mandel JS, Blot WJ, Schuman LM, Mehl ES, Fraumeni JF Jr.. A population-based case-control study of renal cell carcinoma. J Natl Cancer Inst. 1984;72(2):275\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jnci/72.2.275\u003c/span\u003e\u003cspan address=\"10.1093/jnci/72.2.275\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKreiger N, Marrett LD, Dodds L, Hilditch S, Darlington GA. Risk factors for renal cell carcinoma: results of a population-based case-control study. Cancer Causes Control. 1993;4(2):101\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/BF00053150\u003c/span\u003e\u003cspan address=\"10.1007/BF00053150\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunt JD, Van der Hel OL, McMillan GP, Boffetta P, Brennan P. Renal cell carcinoma in relation to cigarette smoking: meta-analysis of 24 studies. Int J Cancer. 2005;114(1):101\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijc.20618\u003c/span\u003e\u003cspan address=\"10.1002/ijc.20618\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePascual D, Borque A. Epidemiology of kidney cancer. Adv Urol. 2008;2008(1):782381. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1155/2008/782381\u003c/span\u003e\u003cspan address=\"10.1155/2008/782381\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBukavina L, Bensalah K, Bray F, Carlo M, Challacombe B, Karam JA, Kassouf W, Mitchell T, Montironi R, O'Brien T, Panebianco V. Epidemiology of renal cell carcinoma: 2022 update. Eur Urol. 2022;82(5):529\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eururo.2022.08.019\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2022.08.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang H, Zhang Z, Huang J, Chen M, Pan Q, Pan Y, et al. GSTM1 and GSTT1 polymorphisms contribute to renal cell carcinoma risk: evidence from meta-analysis. Sci Rep. 2015;5:17971. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/srep17971\u003c/span\u003e\u003cspan address=\"10.1038/srep17971\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhong Z, Li H, Zhong H, Zhou T, Xie W, Lin Z. Glutathione S-transferase gene polymorphisms and renal cell carcinoma susceptibility: systematic review and meta-analyses. BMC Med Genet. 2018;19:98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12881-018-0620-y\u003c/span\u003e\u003cspan address=\"10.1186/s12881-018-0620-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahman L, Gauthier V, Camier A, Bigna JJJ, Glowacki F, Amouyel P, et al. Air pollution and kidney cancer risk: a systematic review and meta-analysis. J Nephrol. 2024;37(6):1779\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40620-024-01984-x\u003c/span\u003e\u003cspan address=\"10.1007/s40620-024-01984-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVelasco E, Retama A, Stratoulias D. Air Pollution in Southeast Asia. InAir Quality Management and Research in Southeast Asia 2024 Dec 1 (pp. 23\u0026ndash;35). Cham: Springer Nature Switzerland. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/978-3-031-69088-4_3\u003c/span\u003e\u003cspan address=\"10.1007/978-3-031-69088-4_3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheikh M, Mukeriya A, Zahed H, Feng X, Robbins HA, Shangina O, et al. Smoking cessation after diagnosis of kidney cancer is associated with reduced risk of mortality and cancer progression: a prospective cohort study. J Clin Oncol. 2023 Mar;29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/JCO.22.02472\u003c/span\u003e\u003cspan address=\"10.1200/JCO.22.02472\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang M, Liu S, Yang L, Jiang Y, Huang Z, Zhao Z, Deng Q, Li Y, Zhou M, Wang L, Chen Z. Prevalence of smoking and knowledge about the hazards of smoking among 170 000 Chinese adults, 2013\u0026ndash;2014. Nicotine Tob Res. 2019;21(12):1644\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ntr/ntz117\u003c/span\u003e\u003cspan address=\"10.1093/ntr/ntz117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLynch WJ, Roth ME, Carroll ME. Biological basis of sex differences in drug abuse: preclinical and clinical studies. Psychopharmacology. 2009;230(1):1\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00213-009-1588-2\u003c/span\u003e\u003cspan address=\"10.1007/s00213-009-1588-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGakidou E, Afshin A, Abajobir AA, et al. Health effects associated with chewing tobacco: A Burden of Proof study. Nat Commun. 2021;15(1):1082. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41467-024-45074-9\u003c/span\u003e\u003cspan address=\"10.1038/s41467-024-45074-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoodman MT, Morgenstern HA, Wynder EL. A case-control study of factors affecting the development of renal cell cancer. Am J Epidemiol. 1986;124(6):926\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/oxfordjournals.aje.a114482\u003c/span\u003e\u003cspan address=\"10.1093/oxfordjournals.aje.a114482\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan JN, Castelao JE, Gago-Dominguez M, Yu CM, Ross RK. Tobacco use in relation to renal cell carcinoma. Cancer Epidemiol Biomarkers Prev. 1998;7(5):429\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoffetta P, Aagnes B, Weiderpass E, Andersen A. Smokeless tobacco use and risk of cancer of the pancreas and other organs. Int J Cancer. 2005;114(6):992\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijc.20710\u003c/span\u003e\u003cspan address=\"10.1002/ijc.20710\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKendrick PJ, Reitsma MB, Abbasi-Kangevari M, Abdoli A, Abdollahi M, Abedi A, Abhilash ES, Aboyans V, Adebayo OM, Advani SM, Ahinkorah BO. Spatial, temporal, and demographic patterns in prevalence of chewing tobacco use in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet Public Health. 2021;6(7):e482\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2468-2667(21)00065-7\u003c/span\u003e\u003cspan address=\"10.1016/S2468-2667(21)00065-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO Global Report on Trends in Prevalence of Tobacco Use 2000\u0026ndash;2030. World Health Organization. 2021. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240088283\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240088283\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang H, Ma C, Zhao M, Magnussen CG, Xi B. Prevalence and trend of smokeless tobacco use and its associated factors among adolescents aged 12\u0026ndash;16 years in 138 countries/territories, 1999\u0026ndash;2019. BMC Med. 2022;20(1):460. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12916-022-02662-0\u003c/span\u003e\u003cspan address=\"10.1186/s12916-022-02662-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHtay ZW, Bhandari AKC, Parvin R, Abe SK. Effects of smokeless tobacco on cancer incidence and mortality: a global systematic review and meta-analysis. Cancer Causes Control. 2025;36(4):321\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10552-024-01933-w\u003c/span\u003e\u003cspan address=\"10.1007/s10552-024-01933-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKabaria R, Klaassen Z, Terris MK. Renal cell carcinoma: links and risks. Int J Nephrol Renovasc Dis. 2016;9:45\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/IJNRD.S75916\u003c/span\u003e\u003cspan address=\"10.2147/IJNRD.S75916\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandler DP, Everson RB, Wilcox AJ. Passive smoking in adulthood and cancer risk. Am J Epidemiol. 1985;121(1):37\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/oxfordjournals.aje.a114268\u003c/span\u003e\u003cspan address=\"10.1093/oxfordjournals.aje.a114268\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIslami F, Nargis N, Liu Q, Bandi P, Siegel RL, Choudhury PP, Freedman ND, Warner KE, Jemal A. Averted lung cancer deaths due to reductions in cigarette smoking in the United States, 1970\u0026ndash;2022. CA: A Cancer Journal for Clinicians. 2025;75(3):216\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3322/caac.70005\u003c/span\u003e\u003cspan address=\"10.3322/caac.70005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Renal Cell Carcinoma (RCC), Tobacco exposure, Smoking, Smokeless tobacco, Secondhand tobacco smoke, Case control study, Bangladesh","lastPublishedDoi":"10.21203/rs.3.rs-9337138/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9337138/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and Objective:\u003c/h2\u003e \u003cp\u003eTobacco is a significant modifiable risk factor for renal cell carcinoma (RCC). However, this association remains underexplored in Bangladesh due to variations in tobacco types and usage patterns. Given that nearly half of the Bangladeshi population consumes tobacco and is exposed to widespread secondhand smoke, this study examined the link to RCC.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA matched case\u0026ndash;control study was conducted from January to December 2023 at two tertiary hospitals in Dhaka, including 71 histologically confirmed RCC cases and 71 age-, sex-, and residence-matched controls. Information on tobacco use, diet, comorbidities, and sociodemographic features was obtained through structured interviews. Multivariable logistic regression was applied to estimate adjusted odds ratios (AORs), controlling for key confounders.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDirect ever tobacco consumption increased the risk of RCC by more than fivefold (AOR\u0026thinsp;=\u0026thinsp;5.54; 95% CI: 2.23\u0026ndash;13.24). Early initiation of tobacco use, especially between ages 15\u0026ndash;19, further heightened the risk (AOR\u0026thinsp;=\u0026thinsp;9.85; 95% CI: 1.72\u0026ndash;56.34). Both smoking (AOR\u0026thinsp;=\u0026thinsp;3.47; 95% CI: 1.39\u0026ndash;8.68) and heavy use exceeding 20 pack-years (AOR\u0026thinsp;=\u0026thinsp;7.72; 95% CI: 1.79\u0026ndash;33.20) were strong predictors. Each additional pack-year raised RCC risk by 6% (AOR\u0026thinsp;=\u0026thinsp;1.06, 95% CI: 1.01\u0026ndash;1.10), and short-term quitters (2\u0026ndash;14 years) showed elevated risk compared to non-smokers. Smokeless tobacco (SLT) use also independently increased risk (AOR\u0026thinsp;=\u0026thinsp;3.98; 95% CI: 1.73\u0026ndash;9.11), while combined smoking and SLT consumption further amplified it (AOR\u0026thinsp;=\u0026thinsp;6.70; 95% CI: 1.58\u0026ndash;28.45). Exposure to indoor secondhand tobacco smoke (SHS) significantly increased RCC risk (AOR\u0026thinsp;=\u0026thinsp;4.07; 95% CI: 1.78\u0026ndash;9.30). Men were more affected by indoor SHS, whereas women showed greater vulnerability to SLT.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAll forms of tobacco, including smoked, smokeless, and secondhand, are strongly associated with RCC, with early and combined exposures posing a higher risk. Comprehensive tobacco control policies, smoke-free environments, and targeted awareness programs are needed to curb RCC risk in Bangladesh.\u003c/p\u003e","manuscriptTitle":"Tobacco Exposure and Risk of Renal Cell Carcinoma: A Case-control Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 14:18:01","doi":"10.21203/rs.3.rs-9337138/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-11T18:24:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T21:17:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T13:47:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296192023841012059825047645405955848231","date":"2026-04-30T10:18:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"299756851495976191839801779226981979746","date":"2026-04-29T13:15:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118607457374276531592711749817100118013","date":"2026-04-29T12:28:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-29T12:10:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-08T18:33:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-08T03:10:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-08T03:09:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2026-04-06T20:33:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"82cfcab2-001b-4099-a71d-e6e351d1e4d9","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-11T18:24:49+00:00","index":52,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T21:17:01+00:00","index":49,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T13:47:17+00:00","index":47,"fulltext":""},{"type":"reviewerAgreed","content":"296192023841012059825047645405955848231","date":"2026-04-30T10:18:10+00:00","index":45,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T14:18:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 14:18:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9337138","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9337138","identity":"rs-9337138","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}