European Journal of Cardiovascular Medicine

Oral cancer remains a major public health challenge worldwide, particularly in low- and middle-income countries, where late diagnosis and high-risk habits contribute to poor outcomes [1,2]. Globally, more than 377,700 new cases of oral cavity and lip cancers were reported in 2020, marking it among the more common cancers, especially in men [3]. In India, oral cancer constitutes a substantial burden, with high incidence rates linked to widespread use of tobacco, areca nut chewing, alcohol consumption, betel quid practices, and poor oral hygiene [4,5]. Despite the relative accessibility of the oral cavity for examination, many individuals present at an advanced stage, with the 5-year survival rate still hovering around 50 % in many settings [6,7].

One of the key determinants of delayed diagnosis is the level of public awareness about oral cancer, including knowledge of its risk factors, early signs and symptoms, and attitudes toward screening [8]. Several regional studies in India and other countries have demonstrated considerable gaps in awareness: many adults are unfamiliar with premalignant lesions, misattribute early symptoms (such as non-healing ulcers or patches), or do not perceive their tobacco or alcohol habits as risk factors [9,10]. For example, a semi-urban population in Kerala showed that although 86 % of participants had heard of oral cancer, only 62 % correctly identified causes such as tobacco, alcohol or betel chewing, and many believed that oral cancer is incurable [11]. Similarly, in northern India, general public awareness in a semi-urban district was low, and was strongly correlated with literacy level and age [12].

Given that semi-urban populations often lie at the interface between rural and urban health systems, and may have limited access to health education programs, targeting these populations for assessment of awareness is particularly relevant. Identifying demographic determinants and knowledge gaps can help health authorities design targeted educational interventions and early screening campaigns. To the best of our knowledge, few community-based questionnaire studies have been conducted recently in semi-urban settings to quantify awareness levels and associated risk factor knowledge among adult populations in India.

Therefore, the aim of the present study is to assess the level of awareness about oral cancer and knowledge of its risk factors among adults in a selected semi-urban area, and to examine associations between awareness and sociodemographic variables (e.g., age, sex, education, tobacco/alcohol use). We hypothesize that awareness will be suboptimal, and that higher education, younger age, and non-use of tobacco/alcohol will be associated with better awareness.

Study Design and Setting

This study was a community-based cross-sectional survey conducted in a semi-urban area. The selected area represented a semi-urban locality characterized by mixed occupational and socioeconomic profiles. The study was designed to assess awareness of oral cancer and its risk factors among adults residing in this community.

Study Population and Sampling Technique

The study population consisted of adults aged 18 years and above who had been residents of the selected semi-urban area for at least six months. Individuals who had a prior diagnosis of oral cancer or potentially malignant disorders, or who were unable to comprehend the questionnaire due to cognitive impairment or severe illness, were excluded.

The sample size was calculated using the formula for a single population proportion:

Assuming an expected awareness proportion of 50 %, a 95 % confidence level (Z = 1.96), and a 5 % margin of error, the minimum sample size required was 384. After adding 10 % to compensate for possible non-responses, the final sample size was set at 420 participants.

A multistage sampling technique was employed. In the first stage, wards within the semi-urban area were selected by simple random sampling. In the second stage, households were selected using systematic random sampling, taking every kth house from the starting point. In households with more than one eligible adult, one participant was selected randomly using the lottery method.

Questionnaire and Data Collection

Data were collected using a structured, interviewer-administered questionnaire developed after an extensive review of previous literature and validated oral cancer awareness surveys. The questionnaire was initially drafted in English, translated into the local language ([insert language]), and then back-translated to ensure linguistic accuracy.

The instrument consisted of four sections:

1. Socio-demographic details: age, gender, education, occupation, income, and marital status.
2. Habit history: tobacco use (smoked and smokeless forms), alcohol consumption, and duration/frequency of habits.
3. Awareness of oral cancer: knowledge regarding causative factors, signs and symptoms, curability, and screening awareness.
4. Attitude and preventive behavior: willingness to undergo screening and perceived susceptibility.

A pilot study was carried out on 5 % of the total sample (n = 20) in a neighboring area to pretest the questionnaire for clarity, reliability, and internal consistency. Necessary modifications were made based on feedback from the pilot phase. Cronbach’s alpha for internal reliability was 0.81, indicating good consistency.

Trained field investigators (dental interns and public health workers) conducted face-to-face interviews at participants’ residences. Each interview lasted approximately 15–20 minutes. The investigators explained the study purpose, ensured confidentiality, and obtained written informed consent before participation. Participants were encouraged to answer truthfully, and non-responders were revisited once before being replaced.

Scoring and Variable Definition

Each correct response to awareness questions was awarded one point, while incorrect or “don’t know” responses were scored as zero. The total knowledge score was calculated by summing correct responses, with a maximum possible score of 10. The median score (4) was used as the cutoff to categorize participants as having adequate or inadequate awareness.

Independent variables included age group, gender, education level, tobacco and alcohol use, and income category. Dependent variables included awareness level (adequate/inadequate).

Data Processing and Statistical Analysis

The collected data were coded and entered into Microsoft Excel, then imported into SPSS version 26.0 for analysis. Descriptive statistics such as frequencies, percentages, means, and standard deviations were used to summarize the data.

Associations between categorical variables were analyzed using the Chi-square test (or Fisher’s exact test where appropriate). The independent-samples t-test was used for comparing continuous variables. Variables that showed significance (p < 0.10) in bivariate analysis were entered into a multivariate logistic regression model to identify independent predictors of adequate awareness. The strength of association was expressed as adjusted odds ratios (AOR) with 95 % confidence intervals (CI). A p-value of less than 0.05 was considered statistically significant.

Socio-demographic profile of participants

A total of 420 adults participated in the study, with a response rate of 95.4 %.
The mean ± SD age was 38.6 ± 13.2 years, ranging from 18–72 years. Males comprised 52.1 % (n = 219) and females 47.9 % (n = 201). Nearly half (48.6 %) had completed secondary education, while 18.8 % were graduates.

Around 43.3 % reported tobacco use (smoked or smokeless), 32.9 % reported alcohol consumption, and 27.1 % used both.

Table 1 presents the detailed socio-demographic distribution.

Table 1. Socio-demographic characteristics of study participants (N = 420)

Awareness of oral cancer

Overall, 78.8 % of respondents had heard of oral cancer, but only 54.3 % could identify at least one correct risk factor. Less than half (45.5 %) recognized tobacco chewing as a major cause, while only 22.6 % identified alcohol as a risk factor. Approximately 31 % were aware that non-healing ulcers could be an early sign, and 18.3 % mentioned white/red patches as warning lesions.

Table 2 shows the distribution of awareness items.

Table 2. Awareness and knowledge about oral cancer among participants

The mean total knowledge score (maximum = 10) was 4.2 ± 2.1.
Using the median (4) as cutoff, 52.6 % were categorized as having adequate awareness.

Association between socio-demographic factors and awareness

Bivariate analysis showed that awareness level was significantly associated with education (p < 0.001), tobacco habit (p = 0.021), and gender (p = 0.037).
Age and alcohol use were not statistically significant.

Table 3 summarizes these relationships.

Table 3. Association between awareness level and socio-demographic variables

*p < 0.05, **p < 0.001 (Chi-square test)

Multivariate logistic regression analysis

After adjusting for confounders (age, gender, education, tobacco and alcohol use), the regression model showed that higher education and non-tobacco use were independent predictors of adequate awareness. Graduate participants were 3.45 times more likely to have adequate awareness than illiterates (AOR = 3.45, 95 % CI 1.72–6.91, p < 0.001).
Non-tobacco users had 1.72 times higher odds of adequate awareness (AOR = 1.72, 95 % CI 1.08–2.73, p = 0.023).

Table 4. Multivariate logistic regression for predictors of adequate awareness (N = 420)

*p < 0.05, **p < 0.001; reference categories: female, illiterate, non-tobacco, non-alcohol.

The study revealed moderate awareness levels of oral cancer among semi-urban adults.
While three-fourths of respondents had heard of oral cancer, only half recognized major risk factors.
Educational attainment emerged as the strongest determinant: awareness increased significantly from 22 % in illiterates to 80 % in graduates. Tobacco users demonstrated poorer awareness (45 %) than non-users (58 %), suggesting behavioral complacency among those at highest risk. Gender also showed marginal association, with men having slightly higher awareness—possibly reflecting greater exposure to media and health messages.
Regression analysis confirmed that education and non-tobacco use remained significant independent predictors even after adjustment. Despite moderate knowledge about preventability, only 19.8 % knew about screening facilities, highlighting the urgent need for community-based health education and oral screening programs targeting lower-educated and high-risk groups

In this semi-urban adult population, the present study revealed moderate levels of awareness about oral cancer but marked deficiencies in specific knowledge domains, particularly regarding risk factors and early warning signs. Although nearly 79 % of participants had heard of oral cancer, only about half could name at least one established risk factor (e.g. tobacco, alcohol), and fewer recognized premalignant lesions such as non-healing ulcers or red/white patches. These findings align with other community and hospital-based surveys which frequently document this “heard-of but don’t know specifics” pattern [11–13].

The discrepancy between general awareness and detailed knowledge is important: hearing the name “oral cancer” may not translate into meaningful preventive behavior or early help seeking. Inadequate recognition of risk factors such as alcohol and areca nut habits suggests that many individuals underestimate their own vulnerability. This gap is consistent with prior reports in India and other low- and middle-income countries, where misconceptions and limited dissemination of health education restrict deep understanding [14,15]. A review of oral cancer prevention in India stresses that despite policy efforts and public campaigns, community-level penetration of knowledge, particularly into rural and semi-urban strata, remains inadequate [14].

Our finding that educational attainment strongly correlated with higher awareness is unsurprising but still instructive. The steep gradient — from about one in four illiterate participants to nearly four in five among graduates achieving “adequate awareness” — underscores how formal schooling acts as both a conduit for health information and a proxy for cognitive skills that allow assimilating risk communication. Similar associations have been documented elsewhere, with education emerging as a consistent predictor of cancer awareness in both oral and non-oral cancers [13,16]. In contrast, age and alcohol use did not maintain statistically significant associations in our adjusted model, although univariate trends suggested lower awareness among older and alcohol-consuming participants. This may reflect overlapping correlations between age, education, and exposure to media/information sources.

Tobacco use was inversely associated with adequate awareness in our study. Tobacco users were less likely to exhibit correct knowledge relative to non-users, even though they are among the highest-risk individuals. This counterintuitive pattern—where those most in need of awareness are least informed—has also been seen in other surveys. Some users rationalize their habit, disengage from health messaging, or avoid thinking about risks, creating a knowledge–behavior disjunction. Encouragingly, in our multivariable model, non-tobacco users had approximately 1.7 times the odds of adequate awareness compared to users, after adjustment.

Gender showed a modest association in univariate analysis (males slightly more aware), but it lost significance after controlling for education and habits. This implies that the apparent gender difference may largely be mediated through educational and behavioral correlates rather than gender per se. Some studies in India report similar findings, though others report persistent gender gaps favoring males in cancer awareness campaigns [12,17].

The relative paucity of awareness concerning oral cancer screening and the belief in the benefit of early detection are notable. Less than one in five participants knew about screening, and only about 57 % believed early detection improves cure chances. This indicates an urgent need to integrate screening messaging into community outreach. The utility of opportunistic screening and visual oral examination in high-risk populations is well accepted, but its uptake depends on awareness, acceptability, and trust [14,18].

From a public health view, our results reinforce that mass awareness campaigns should go beyond superficial brand recognition and invest in depth: teaching symptoms, high-risk behaviors, and pathways to screening and care. Tailoring messages to low-education strata, using mass media plus interpersonal communication (e.g. community health workers), is essential. Studies evaluating oral cancer prevention programs in India emphasize that combining school-based education, tobacco control, and community screening produces better outcomes than isolated interventions [14].

There are limitations to note. First, the cross-sectional design precludes causal inference. Second, self-reported responses may carry recall or social desirability bias. Third, we used a cut-off based on median or percentage correct responses, which may differ across samples; this limits comparability. Fourth, sampling in one semi-urban area limits generalizability to other regions. Nonetheless, strength lies in a reasonably large sample size, face-to-face interviews, and multivariate modeling.

Future research could explore longitudinal educational interventions to track knowledge uptake, behavior change, and ultimately reduced incidence or stage at diagnosis. Also, qualitative work may uncover deeper beliefs, myths, and barriers in semi-urban groups. Integrating oral health screening into primary healthcare and training frontline providers to opportunistically assess the oral cavity may help bridge the gap between awareness and action. Ultimately, reducing the burden of oral cancer in India and similar settings will demand synchronized efforts in risk reduction, early detection, and public education [19,20].

In conclusion, our study demonstrates that among semi-urban adults, although general awareness of oral cancer is moderately high, detailed knowledge about risk factors, early signs, and screening is significantly lacking. Education level and tobacco non-use emerged as key independent predictors of better awareness. Efforts to reduce the burden of oral cancer should emphasize depth of knowledge over mere name recognition, targeting less-educated and high-risk users via culturally appropriate communication. Integrating community-based oral screening, strengthening tobacco cessation outreach, and embedding oral health modules into primary care may convert awareness into timely detection and improved outcomes.

1. Anirudh PB, Ty S, A S, S R. Assessment of Knowledge of and Attitude Toward Oral Cancer Among the Outpatient Population in a Tertiary Care Rural Hospital. 2023;15(3):e36637. doi:10.7759/cureus.36637. PMID: 37155442.
2. Muthanandam S, Babu BV, Muthu J, Suganya R, Vezhavendhan N, Kishore M. Assessment of Knowledge, Awareness and Attitude towards Oral Precancer and Cancer among Narikuravar Population in Pondicherry State. South Asian J Cancer. 2021;10(4):225-229. doi:10.1055/s-0041-1733316.
3. Zhou XH, Huang Y, Yuan C, Zheng SG, Zhang JG, Lv XM, et al. A survey of the awareness and knowledge of oral cancer among residents in Beijing. BMC Oral Health. 2022;22(1):367. doi:10.1186/s12903-022-02398-6.
4. Varela-Centelles P, Seoane J, Ulloa-Morales Y, Estany-Gestal A, Blanco-Hortas A, García-Pola MJ, et al. Oral cancer awareness in North-Western Spain: a population-based study. Med Oral Patol Oral Cir Bucal. 2021;26(4):e518-e525. doi:10.4317/medoral.24401.
5. Yadav K, Hariprasad R, Gupta R, Upadhayay S, Sharma V, Kumari M, et al. Cancer awareness and its association with demographic variables and mobile phone usage among the rural population of a district in North India. Indian J Med Res. 2022;156(1):94-103. doi:10.4103/ijmr.IJMR_3145_20.
6. Sabi EM, Mujamammi AHA, Abdulghani M, Almesfer YM, Alsuwaida AA, Balobaid AS, et al. Awareness level of cancer risk factors and warning signs among Saudi adults in a tertiary hospital in Riyadh. Asian Pac J Cancer Prev. 2021;22(8):2421-2428. doi:10.31557/APJCP.2021.22.8.2421.
7. Chugh A, Kaur A, Bhardwaj P, Vishnoi JR, Joshi N, Kumar S, et al. Gap areas in mitigation of oral cancer: a cross-sectional study evaluating awareness and knowledge of risk factors in oral cancer in a tertiary hospital. Natl J Maxillofac Surg. 2023;14(1):27-34. doi:10.4103/njms.njms_427_21.
8. Deshpande M, Meshram M, Paul P, Reche A, Bhowate RR, Deshpande A, et al. Assessment of cancer patients’ relatives’ knowledge, perception, and attitude toward cancer. 2023;15(8):e43457. doi:10.7759/cureus.43457.
9. Schroeder K, Panny A, Shimpi N. Community awareness and oral cancer screening in rural Wisconsin. J Dent Hyg. 2021;95(4):51-58.
10. Nagaraj V, Priya S, Muthanandam S, Devi M, Giri U, Babu MA. Self-negligence and awareness among oral precancerous and cancer patients – a cross-sectional questionnaire study. J Oral Maxillofac Pathol. 2023;27(2):282-286. doi:10.4103/jomfp.jomfp_420_21.
11. Nazar HS, Ariga J, Shyama M. Oral cancer knowledge, attitudes, and practices among newly graduated dentists in Kuwait. Asian Pac J Cancer Prev. 2022;23(2):459-465. doi:10.31557/APJCP.2022.23.2.459.
12. Gone H, Abdul NS, Pisarla M, Kumar KP, Kulkarni G, Audurthi RK. A cross-sectional study to assess factors that determine tobacco habit initialization and cessation and oral cancer awareness among the general population of Vikarabad District, Telangana. J Pharm Bioallied Sci. 2021;13(Suppl 2):S1613-S1619. doi:10.4103/jpbs.jpbs_312_21.
13. Uguru CC, Chukwubuzor O, Otakhoigbogie U, Ogu UU, Uguru NP. Awareness and knowledge of risk factors associated with oral cancer among military personnel in Nigeria. Niger J Clin Pract. 2023;26(1):73-80. doi:10.4103/njcp.njcp_322_22.
14. Sinha S, Pisulkar SG, Nimonkar S, Dahihandekar C, Purohit H, Belkhode V. Effect of structured education training program on oral health awareness among school-going children of Central India: a cross-sectional study. 2022;14(7):e27161. doi:10.7759/cureus.27161.
15. Pai Khot AJ, Ankola AV, Sankeshwari RM, Choudhury AR, Kumar KRS, Shah MA. Knowledge, attitude, and practices toward tobacco control among rural community health care workers of Belagavi district, Karnataka. J Family Med Prim Care. 2022;11(6):3257-3269. doi:10.4103/jfmpc.jfmpc_2216_21.
16. More AB, Rodrigues A, Sadhu BJ. Effects of smoking on oral health: awareness among dental patients and their attitude towards its cessation. Indian J Dent Res. 2021;32(1):23-26. doi:10.4103/ijdr.IJDR_711_18.
17. Alqarawi SA, Aljarbooa EF, Almuqaytib AY, Alomar IA, Altwaijri MH, Aldakhil AY, et al. Assessment of Saudi females’ knowledge regarding HPV infection, screening, and prevention: a cross-sectional study. 2023;15(1):e33311. doi:10.7759/cureus.33311.
18. Muhihi AJ, Anaeli A, Mpembeni RNM, Sunguya BF, Leyna G, Kakoko D, et al. Public knowledge of risk factors and warning signs for cardiovascular disease among adults in rural Tanzania. BMC Public Health. 2020;20(1):1832. doi:10.1186/s12889-020-09956-z.
19. Tafere Y, Jemere T, Desalegn T, Melak A. Women’s knowledge and attitude towards cervical cancer preventive measures and associated factors in North Central Ethiopia. Arch Public Health. 2021;79(1):136. doi:10.1186/s13690-021-00659-4.
20. Shamaun S, Jaleel R, Gull Y, Shahid A, Iqbal M, Qazi TN. Knowledge and attitude of cervical cancer screening and vaccination in patients attending gynecology outpatient clinic at a tertiary hospital in Pakistan. South Asian J Cancer. 2022;12(1):17-22. doi:10.1055/s-0042-1751093.