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Introduction: Oral squamous cell carcinoma (OSCC) is a significant global health concern, primarily associated with tobacco use, including naswar—a smokeless tobacco mixture widely used in South Asia. Naswar is composed of ground tobacco leaves, slaked lime, and occasionally flavoring agents. When mixed with saliva, it releases carcinogenic nitrosamines, nicotine, and other harmful toxins. Despite the well-documented risks, including oral cancer, naswar continues to be used by many. Its harmful effects extend beyond oral health, contributing to heart disease, gastrointestinal issues, and reproductive health problems. It is also associated with mouth lesions, gum disease, and an elevated risk of oral cancers. This study emphasizes the urgent need for targeted global strategies to address naswar-related oral cancers. Case Presentation: This article details the case of a 62-year-old woman with a 40-year history of naswar consumption, who was diagnosed with advanced oral squamous cell carcinoma (SCC) affecting the right side of her face. She was referred to the Maxillofacial Surgery Department of Zahedan University of Medical Sciences. Despite recommendations for surgical intervention, the patient declined treatment following comprehensive consultations with medical professionals. This case highlights the complexities of managing advanced oral SCC in chronic naswar users and underscores the role of patient autonomy in treatment decisions. Conclusions: This case illustrates the challenges in treating advanced oral SCC in long-term naswar users and emphasizes the critical importance of respecting patient autonomy in treatment decision-making.

Background and Objectives: Smokeless tobacco products pose a complex and widespread public health challenge. Among various types of smokeless tobacco products, Nass (Naswar) is considered the most important type of this product in Iran. In this study, we investigated the level of toxic metal of cadmium in samples of Nass used in Rafsanjan City. Materials and Methods: In this cross-sectional study, a total of 26 samples of Nass were randomly collected from the urban area of Rafsanjan in the summer 2022. After the initial preparation, atomic absorption spectroscopy was used for the analysis of cadmium levels in the samples.  Independent t-test was applied to evaluate the difference in the mean level of metals in the samples. Results: The results of the present study indicate the presence of cadmium in all samples under investigation. The average level of cadmium in all samples under study was 2. 98±0. 58 µg/g and the range of variation of cadmium levels was between 1. 25 and 3. 70 µg/g. Although the difference in cadmium levels in light brown samples compared to green samples was not significant, its level in bulk samples (3. 3±0. 30 µg/g) was significantly higher than packaged samples (2. 8±0. 58 µg/g) (p=0. 01). Conclusion: The present study is the first study on the level of cadmium contamination in Nass samples available in the Iranian market. The results of the current study indicate a potential risk of exposure to cadmium through the consumption of Nass among Iranian consumers. Therefore, increasing public awareness is recommended to reduce the use of Nass.

Introduction: Drug addiction has been one of the most important health and social crises in recent decades. One of the types of addiction that is prevalent among adolescents today is the addiction to Naswā r, with the increasing youth tendency towards Naswā r, the purpose of the present study was to investigate the lived experiences Naswā r abuser adolescents. Methods: This study was carried out in a qualitative way and the phenomenological method was used. Participants were selected among the youth of Kerman. Twenty participants were selected through purposeful sampling. Data collection method was a semi-structured interview that was rewritten with the consent of the participants and analyzed by Colaizzi method. Results: During the process of reviewing the lived experiences of Naswā r abuser adolescents, two main themes with three contexts each were extracted; the main theme of personal factors with three contexts "sensual seduction, misassumption, risk taking and looking for excitement" and the main theme of social factors, with three contexts "family problems, availability of drug, and influenceability by peers". Conclusions: By describing the determinants of Naswā r consumption, in addition to individual factors; this study found social factors as an important factor to such behaviors. Therefore, it is suggested to the national authorities to address this problem as an urgent and health priority; by using effective methods to educate and inform adolescents and their families about the side effects of Naswā r; by facilitating suitable and accessible pastime; and by using life skill classes to teach them how to say no to drugs.

Background: Smokeless tobacco (ST) use is one of the most important public health problems in Southeast Asia. The use of these substances increases the incidence of some cancers and other diseases. The purpose of this review study was to investigate on ST use in Iran. Methods: A literature search was conducted on PubMed, Google Scholar, and three national databases [Scientific Information Database (SID), IranMedex, and IranDoc] based on the standard search strategy. Findings: Most consumer people lived in Sistan and Baluchestan Province (Zahedan and Chabahar Cities) and Golestan Province, Iran. ST use rates ranged from 11. 0% to 45. 7% among college students in Sistan and Baluchestan (Zahedan and Chabahar) and Golestan. There are various types of ST consumed in Iran that have been mentioned in various articles, including Pan, Gutka, Nass, Naswar, Biti, and Supari. Conclusion: Most studies on ST have been conducted in Sistan and Baluchestan and Golestan Provinces and we need more research for other provinces. Consumption by women is a warning and a threat to women's health in the future. Further studies will be needed to find out more precisely the prevalence of consumption in Iran.

Background: Head and neck cancer is the most common malignancy in Sindh, Pakistan. The type of cancer can be observed in the oral cavity, lips, buccal mucosa, oropharynx, hypopharynx, nasopharynx, the floor of the mouth and hard palate in Sindh. Objectives: The present study was conducted at the Nuclear Medicine Oncology and Radiotherapy Institute Nawabshah (NORIN), Sindh, with the objective of reviewing descriptive epidemiological characteristics and incidence of head and neck cancer in this rural area. Methods: In this study, we divided head and neck cancer patients according to their gender, age, districts, tumor location, probable causative agents, and stage of cancer when they had been admitted to the Radiotherapy Department of NORIN. Results: In total, 1, 030 patients were registered during the study period from January 2012 to December 2016, comprising 56% males and 44% females. The most common site of the head and neck tumors was the oral cavity (58%), followed by the tongue, tonsil, floor of the mouth, gum, hard palate, soft palate, and lips. Other sites of head and neck cancer were hypo-pharynx, nasopharynx, salivary gland, parotid gland, oral-pharynx, and lyrnx. Most patients came in NORIN at stage III and stage IV of their disease and most of them were at the age of 40-85 years. Most patients were the residents of Nawabshah and neighboring districts. Conclusions: Head and neck malignancy was the mostcommontype of cancer registered in NORIN in the last five years. Because of the lack of awareness, education, and diagnostic facilities, most patients start cancer treatment at later stages of the disease, which makes it very difficult to cure. Smoking and the use of alcohol, Gutka, Supari, Naswar, Man-Pori, etc., are the main causes of head and neck cancer.

Background: Opioid abuse prior to hospitalization in patients undergoing surgical procedures is associated with challenges in pain management, determining anesthetic dose, and providing nursing care. This study aimed to evaluate opioid abuse/dependence in hospitalized patients undergoing major elective surgery. Materials and Methods: A total of 1000 patients who were candidates for major elective surgery were assessed for demographic characteristics, perioperative and postoperative pain management, type and route of opioid abuse, and the current use of other abused substances. Results: Substance abuse was observed in 34% of surgical inpatients. The mean duration of substance abuse was 4. 3 ±,1. 9 , years. Opioids were the most frequently abused substances (67. 9%), followed by naswar (16. 4%) and marijuana (8. 5%). The inhalation route (60%) was the most common route for opioid use, followed by injection (29. 4%) and oral route (10. 6%). The prevalence of opioid abuse in females (54. 6%) was significantly higher than males (45. 4%), (P , = , 0. 032, odd ratio =1. 18, 95% CI , = , 1. 03-1. 42). Low education level was associated with a higher rate of substance abuse (P , = , 0. 042, Odd ratio=1. 39, 95% CI , = , 1. 14-1. 64), but there was no significant correlation between sex, education level, and substance abuse type. Overall, opioid abuse and dependence were associated with at least a 30% increase in the need for opioid analgesics to relieve postoperative pain. No opioid withdrawal signs were recorded in opioid-abusing patients. Conclusion: The results showed substance/drug abuse in more than one-third of surgical inpatients (34%) and a higher rate of drug abuse in women, which was an unexpected finding. Opioid abuse was significantly associated with education level. Opioid-dependent patients received higher doses of opioids during postoperative periods. Since opioid abuse can affect both preoperative and postoperative surgical and nursing health professionals, especially nurses, need continued medical education and professional support in caring for these individuals.

INTRODUCTION Guild merchants have always been known as a section of society that in the context of economic and social developments have had a wide and effective position and function in various fields. In the Iranian economy, guilds, as the last economic link, have a special importance in the growth and dynamism of the country's economy and act as the economic heart of society due to their breadth and direct relationship with individuals (1). One of the high-risk behaviors among this group is the consumption of different types of smokeless tobacco (SLT) products (2). The term smokeless tobacco refers to the consumption of unburned tobacco in the form of chewing, spitting, dipping and snuff (2). There are usually a variety of SLT products (at least 40 types) in the world, including: Pan, Pan-Prague, Gutkha, Naswar (Nass), Mava and BT, Chaini Khaini, Zarda Pako, Supari and Manipuri (2). Smokeless tobacco (SLT) consumption annually causes the death of more than 250, 000 people worldwide, with the majority of these deaths (85%) occurring in Southeast Asia (1). SLT products are highly addictive due to their high concentration of nicotine and contain more than 3, 000 chemicals (2). At least 28 carcinogenic chemicals have been identified in SLT products, of which tobacco-specific nitrosamines and N-nitrosonornicotine are the primary carcinogens (3). SLT products increase the risk of tooth decay, esophageal cancer and pancreas. In addition, consumption of SLT products causes respiratory cancer, infertility, gastrointestinal cancer, acute hypertension, increased risk of cardiovascular disease, diabetes, preterm birth, Low Birth Weight (LBW), anemia Iron deficiency and nicotine dependence (4-7). In order to understand and determine the factors affecting the consumption behavior of tobacco products, various models and theories of behavioral sciences have been used. Different models of behavior change and psychology are very helpful in understanding the factors affecting behavior or non-compliance with health care instructions (11). One of these theories is the Trans Theoretical Model. This model is a complete and coherent model that predicts how behavior changes and when (12). This model helps to understand when people are ready for change (the stages of preparation for change) and how to weigh the advantages and disadvantages of smoking (decision balance) based on their beliefs about individual abilities. Environmental capacities and existing real and mental barriers overcome the tempting situations of smoking (perceived self-efficacy). The model consists of 4 structures: stages of change preparation, balance in decision making, self-efficacy and change processes. The structure of the stages of change includes 5 stages, which are: pre-contemplation, contemplation, preparation, action and maintenance. The above five stages for tobacco consumption behavior are defined as follows: The pre-contemplation stage of the person consuming tobacco products does not think about quitting at all. In the contemplation phase, the person smokes, but considers quitting within the next 6 months. In the preparation phase, the person continues to use tobacco, but plans to quit smoking within the next month. The stage of action in which people have practically quit smoking but have been doing so for less than 6 months and the maintenance phase at which the person has quit smoking for more than 6 months (12). Despite the great potentials of this model and proving its effectiveness, in various searches, a study that used this model in designing educational interventions aimed at temptation / self-efficacy of SLT products was not found. Therefore, due to the lack of a study on the subject of research in Iran, this study was conducted to determine the effect of education based on transtheoretical model on the temptation / self-efficacy of SLT products among guild traders. METHODOLOGY The present quasi‑experimental study was conducted among Chabahar merchants’ guilds using one intervention group. Inclusion criteria include: being 20 to 50 years old, consuming at least one form of SLT products (pan, pan parague, gutkha, mava, naswar, BT or khaini, pan masala), having the consent to participate in the study and having the business license and those who were seasonal guilds were excluded from the study. According to the results of a similar study (14) the participants’ mean score of SLT consumption was 3. 59 before the intervention, which reached to 3. 86 after the intervention. Considering a 95% confidence interval and 80% probability of sample size, a total of 310 individuals were selected. Ultimately, to increase the study accuracy and reduce the effects of sample loss, this study was conducted on 320 individuals. The data collection tool was a researcher-made questionnaire that consisted of two parts: the first part included demographic characteristics (age, gender and type of business) and the second part was related to the temptation/ self-efficacy questionnaire. The questionnaire consisted of 9 questions, each of which contained the infrastructure of positive social situations, negative situations and habitual situations. Each of the 3 scales was designed with a 5-point Likert scale. In this study, participants were asked to rate their temptation to consume their SLT products based on a 5-point Likert scale in any of the proposed conditions,not much,relatively,very,too much. In this study, CVR and CVI were calculated to be 0. 85 and 0. 9, respectively, and Cronbach's alpha and ICC were estimated to be 0. 76 and 0. 84, respectively. The educational methods used in the mentioned classes were based on short lectures, questions and answers, group discussions with videos and photos related to the destructive effects of tobacco products on general health and oral health, and using data projectors and PowerPoint. The topics discussed in the two sessions were: Session 1) Types of smokeless tobacco products and their ingredients, the effect of tobacco on the circulatory system, cardiovascular system, respiratory system, gastrointestinal tract, mouth, gums and teeth, diseases caused by consumption of tobacco products, especially cancers, Session 2) Negative attitudes about consuming smokeless tobacco products (role of tobacco products in calming the nerves, relieving fatigue, etc. ), temptation and addiction to tobacco products, negative social effects of consuming these products, negative views of society and real friends, Obstacles in the path of quitting tobacco and proposed solutions, scientific and correct methods of quitting tobacco products and the benefits of quitting these products. After 6 months from the intervention, the information of the questionnaire was collected again after prior coordination and by visiting the facilitators in person at the workplace of the subjects. Descriptive and inferential statistical methods were used to describe and analyze the data. Data were presented as mean (standard deviation) for quantitative data and frequency (percentage) for qualitative data. Tests (ANOVA, Tukey and paired t-test) were used in data analysis. Values of P <0. 05 were considered significant and SPSS 20 software was used for analysis. RESULTS According to the results of the study, most of the merchants were Textile and clothing class (19. 4%) and most of them were between 20-30 years old (Table 1). Table 1: Determining the demographic variables of guilds Variables Groups Ferquency Percentage Age 20-30 years 221 69. 1 30-40 years 77 24. 1 40-50 years 22 6. 8 Gender Male 198 62. 0 Female 122 38. 0 Guilds Bakers and confectioners 13 1. 4 Textile and clothing 62 19. 4 Grocers and perfumers 46 14. 4 Car and motorcycle repairmen 37 11. 6 Hairdressers and cosmetics 61 19. 1 Tailors and embroiderers 25 7. 8 Hoteliers and restaurants 7 2. 2 Door and window makers and lathes 9 2. 8 wholesalers of food 33 10. 3 Others 27 8. 3 The mean scores of the whole structure of temptation / self-efficacy before and after the intervention were 16. 53±1. 64 and 9. 22±2. 71, respectively. The results of paired t-test show that the mean score of this structure after the intervention was significantly lower than the mean score before the intervention and this difference was statistically significant (P-Value <0. 001). The mean score of positive, negative and habitual situations of temptation / self-efficacy components after the intervention was lower than before the intervention, which was statistically significant (P-Value <0. 001) (Table 2). Table 2: Determining and comparing the mean score of temptation / self-efficacy and its components before and after the intervention Temptation/self-efficacy Before the intervention After the intervention Minimum Maximum Mean difference P-Value (Paired T Test) Mean SD Mean SD Positive situations 7. 91 1. 04 4. 28 1. 5 2 10 -3. 63 <0. 001 Negative situations 4. 72 0. 45 2. 46 1. 08 1 5 -2. 26 <0. 001 Habitual situations 3. 9 0. 7 2. 5 1. 3 1 5 -1. 4 <0. 001 Total 16. 53 1. 64 9. 22 2. 71 4 20 -7. 31 <0. 001Before the intervention, the mean scores of temptation/self-efficacy of smokeless tobacco products in positive situations among pre-contemplation and contemplation individuals were 7. 98±1. 01 and 7. 82±1. 00, respectively. Also, the mean scores of guild traders in negative situations in individuals in the pre-contemplation and contemplation stage were 4. 73±0. 44 and 4. 75±0. 43, respectively and according to the ANOVA statistical test, there was a significant relationship between the stages of change and the structure of temptation/ Self-efficacy was present in positive, negative and habitual situations (P-Value <0. 05) (Table 3). Table 3: Determining and comparing the mean score of temptation/ self-efficacy according to the stages of change before the intervention Temptation-self-efficacy Stages of change P-Value (ANOVA) Pre-contemplation contemplation Preparation Positive situations 7. 98±1. 01 7. 82±1. 00 6. 00±0. 00 <0. 001 Negative situations 4. 73±0. 44 4. 75±0. 43 4. 14±0. 69 0. 003 Habitual situations 3. 93±0. 7 3. 88±0. 68 3. 14±0. 37 0. 014 Temptation/self-efficacy 16. 63±1. 59 16. 45±1. 51 13. 28±0. 48 <0. 001 According to the results of Table 5, the mean score of temptation/ self-efficacy in terms of stages of change in the post-intervention stage in habitual situations in individuals in the pre-contemplation and contemplation stage was 2. 67±1. 26 and 2. 83. ±1. 32, respectively. The mean score of temptation/ self-efficacy of smokeless tobacco products in guild trades in negative situations in people in the pre-contemplation and contemplation stage in the post-intervention was 2. 54±1. 15 and 2. 5±1. 05, respectively. Table 5: Determining and comparing the mean score of temptation/ self-efficacy according to the stages of change after the intervention Temptation-self-efficacy Stages of change P-Value (ANOVA) Pre-contemplation contemplation Preparation Action Maintenance Positive situations 4. 76±1. 17 4. 61±1. 37 4. 94±1. 38 3. 4±1. 6 3. 12±1. 33 <0. 001 Negative situations 2. 54±1. 15 2. 5±1. 05 2. 63±1. 06 2. 34±0. 99 2. 2±1. 11 0. 238 Habitual situations 2. 67±1. 26 2. 83±1. 32 3. 04±1. 22 1. 95±1. 25 1. 76±0. 94 <0. 001 Temptation/self-efficacy 9. 97±2. 09 9. 94±2. 26 10. 61±2. 18 7. 70±2. 83 7. 08±2. 58 <0. 001 DISCUSSION The aim of this study was to determine the effect of education based on Trans-theoretical model on the temptation/ self-efficacy of SLT products among guild traders. In general, the results showed that the intervention was effective in reducing the consumption of SLT products. The results of the present study in the pre-intervention stage showed that the mean scores of negative situations and the temptation to consume SLT products had the highest value, followed by positive situations and the lowest were related to negative situations. This finding suggests that negative situations such as anxiety, anger, and frustration cause the person to slip and be tempted to use SLT products, reducing people's self-efficacy in overcoming and adapting to these situations. On the other hand, positive situations such as parties, celebrations and being in the company of friends can also increase the temptation to consume SLT products, because in these situations the pressure of others, friends and peers can also tempt the consumption of these products. The findings of the present study are the same as those of Farkich et al. (15) and Minilk et al. (16). The results of the study by Wagner et al. (17) showed that the negative situations of smoking temptation, both in healthy people and in patients with chronic disease, had the highest value, which was followed by positive and habitual situations. They assigned the amount to themselves, which did not agree with the findings of the present study. Also, the results of the present study in the pre-intervention stage showed that the mean scores of temptation in all situations (positive situations, negative situations and habitual situations) among people in the preparation stage were significantly lower than the people in the pre-contemplation stage. Was. This finding is similar to the expected Trans-theoretical model. According to this model, it is expected that with the movement of people from the pre-contemplation stage to the preparation stage, the average scores of the temptation to use tobacco will decrease. The results of Kim's (20) study on Korean adolescents showed that the temptation to smoke was greater in pre-contemplation individuals than in preparation individuals. After the intervention, the mean scores of the subjects' temptation to consume SLT products in all situations (positive situations, negative situations and habitual situations) decreased and their self-efficacy to overcome tempting situations increased. In the study of Hekmat Po et al. (23), Adelman et al. (24) and Hong et al. (25), following the educational intervention, the temptation of the treatment group decreased and their self-efficacy increased significantly. The findings of the study conducted by Mehrabizadeh Honarmand et al. (26) are consistent with the findings of our study in this section. In the study of Kim et al. (27), although the mean scores of temptation in positive, negative and habitual situations had decreased, but the difference in mean scores before and after the intervention was not significant, which is not fully consistent with the results of the present study. One of the possible reasons is the difference in demographic characteristics of the subjects in the study with the findings of the present study. CONLUSION By designing and implementing interventions based on the transtheoretical model, it is possible to reduce the temptation of people consuming these products in different stages of change and increase their self-efficacy to overcome tempting situations. Due to insufficient cost allocation and large volume of research samples, it was not possible to provide Nicotine Replacement Therapy (NRT). Considering the effectiveness of the intervention on reducing the consumption of smokeless tobacco products in the present study, it is suggested that this intervention model be used in other cities, especially the cities of Sistan and Baluchestan province. CONFLICT OF INTEREST The authors declare that there are no conflicts of interest regarding the publication of this manuscript. Code of Ethics: IR. SSU. SPH. REC. 1396. 105