
Public health campaigns have led to reduction of health risks of tobacco in several countries. However in South Asian region several studies indicate increasing health risks in the context of at least some aspects of tobacco consumption, particularly use of smokeless tobacco. Increased incidence of oral cancer has emerged as the biggest and fast increasing risk in this context.
On July 27 2024 Cancer Mukt Bharat Foundation, a Delhi-based non-profit organization, released the findings of a study conducted on 1869 cancer patients. This revealed that around 26 per cent of cancer patients in India have tumors in the neck and head, and there is an upward trend of such cases in the country. Dr. Ashish Gupta, a senior oncologist who is leading the Cancer Mukt Bharat campaign said that India is seeing surge in head and neck cancer cases due to increasing tobacco consumption and HPV infection. According to him, around 80 to 90 per cent of oral cancer patients have been found to use tobacco in some form.
In particular a very high rise in the consumption of smokeless tobacco (SLT) has been noticed in recent years in India and several neighboring countries. Although advertising of tobacco products is banned, manufacturers use surrogate or substitute advertising to promote SLT. Earlier various flavoring, fragrance and mouth-freshner (fff) substances used to be mixed by them with tobacco and areca nut, two products of known high health risk. The mixture came to be known popularly as gutka. This led to spread of tobacco chewing among a much larger number of people as fff substances (often called pan masala) made chewing tobacco and areca nut more attractive. There have been allegations of some manufactures also adding other harmful agents for a bigger kick, without proper disclosure.
Once a big increase in oral cancer was reported and regulations were tightened, several manufacturers started selling fff products in one pouch and SLT in another pouch. All that their increasingly addicted consumers had to do was to mix the two pouches available conveniently from the same shops. Simultaneously, the manufacturers increasingly promoted their fff products as attractive lifestyle products or even as success in life products, using highly successful film stars for this purpose.
Thus the format of packing and consumption changed slightly but the health risk essentially remained the same—the use of fff to increase the consumption of highly harmful SLT and areca nut among a much larger number of people, including women and children.
This trend has spread in most other parts of South Asia as well plus some other neighboring countries. South Asia and nearby areas constitute the biggest hub of SLT consumption in the entire world. According to the Global Adult Tobacco Survey Second Round 2016-17 (GATS 2), 21.4% of adults in India consume SLT. 85% of SLT users here use it on daily basis. Bangladesh, Pakistan, Nepal and Sri Lanka also report high use, ranging from 15 to 30 per cent for men, somewhat lesser for women. SLT use is spreading fast among the young and adolescents.
SLT is the leading cause of oral cancer and an important cause of several other serious health problems. India carries one-third of the global burden of oral cancer, which is the leading cancer among males in India, Bangladesh and Pakistan. It is also the second most important cancer for women in India and Bangladesh. According to GLOBOCAN data, oral cancer accounts for over 16 per cent of all cancers among males in India.
A study by the Tata Memorial Centre found that as much as INR 23 billion was spent on the treatment of oral cancer in India in year 2020. Most affected are in age-group 30-50, often the sole earning members of their households. As cure is so expensive and in fact unaffordable for most affected poorer people, prevention is the best option and for prevention a big reduction of SLT consumption is the most obvious way.
SLT is also a leading cause of oral mucous fibrosis, a condition in which it progressively becomes more and more difficult and painful to open the mouth. In addition SLT use has been linked to some other cancers, cardiovascular disease and stroke.
Although awareness level of serious health impacts of SLT is high, the trend of giving up SLT is low. One reason is the addictive nature of the product, but surrogate advertising linking it to success and attractive lifestyle is also an important factor, particularly among the young. In fact the increasing consumption among adolescents is perhaps the most worrying.
Even when visiting very remote villages this writer has seen small shops displaying SLT and fff pouches very prominently as though this is the most essential need of people. Even those men who are finding it difficult to make both ends meet pick up several pouches from these shops quite regularly. While travelling also a lot of SLT is consumed. The social stigma that fortunately still exists to some extent regarding smoking in public places does not apply to SLT consumption.
A relatively new trend is that many women have also taken up the consumption of SLT. Women are expected to be the most helpful in such campaigns against substance abuse but if they themselves become users of SLT at a significant scale, then it will be difficult to campaign against SLT.
Unless these trends are checked now, the problem can go out of hand with all household members—men, women, adolescents– consuming SLT to a lesser or greater extent.
Public health campaigns in South Asia should place much higher emphasis on reducing the consumption on tobacco products with special emphasis on reducing SLT.
Bharat Dogra is Honorary Convener, Campaign to Save Earth Now. His recent books include Man over Machine, A Day in 2071, Planet in Peril and Earth without Borders.