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The use of pan masala / gutkha is considered a benign and socially acceptable habit by most Indians. There is even an element of prestige associated with the habit. However, such use has, in recent decades, become a major public health problem and an important cause of oral cancer. The addictive nature of tobacco compounds the problem, as quitting becomes difficult even for concerned users. This “socially accepted addiction” is, in fact, proving more dangerous than other addictions.

According to WHO estimates, there are nearly 2.5 crore tobacco users in India, including both smoked and chewed forms. In India, tobacco consumption is responsible for half of all cancers in men and a quarter of all cancers in women, in addition to being a risk factor for heart- and lung-related problems. India also has one of the highest rates of oral cancer in the world.

Smokeless tobacco

In India, smokeless tobacco takes many forms. Piper betel leaf filled with sliced areca nut, slaked lime, catechu and other spices, with or without tobacco, is referred to as pan masala; gutkha is a chewable tobacco containing areca nut. They come in attractive foil packs and sachets. A third form, mishri, is powdered tobacco rubbed on the gums as toothpaste. Zarda, khaini and mava are other popular forms. There is wide regional and local variation in ingredients and nomenclature.

The habit of chewing tobacco is increasing because of its legality, free availability, relatively cheap cost and increasing education about the well established hazards of smoking. However, studies have confirmed that smokeless tobacco is as harmful as smoked tobacco. In fact, chewing tobacco could result in significantly greater deleterious cardiovascular effects due to a larger overall exposure owing to prolonged absorption.

Oral submucous fibrosis (OSMF)

Oral submucous fibrosis (OSMF) is a pre-cancerous condition linked with use of smokeless tobacco products; it starts with a balding tongue, white patches and soreness in the mouth and an inability to eat hot / spicy foods. If the patient persists with chewing tobacco, it will lead to stiffening of the mouth and an inability to open it fully; this stage is referred to as OSMF. Difficulty in eating properly and consequent nutritional deficiencies are common. Once the user has reached this stage, the only treatment option is painful surgical correction.

Over the last couple of decades, dentists, ENT surgeons and cancer specialists have reported an alarming increase in patients presenting with OSMF, especially young people addicted to pan masala and gutkha. Though exact figures are hard to come by, it is estimated that one percent of Indians in the 15 – 50 yrs age group suffers from OSMF. Between 5 and 10 percent of OSMF patients go on to develop oral cancer, principally cheek cancer.

Treating the addiction

Medication can help with both the craving and the withdrawal symptoms that follow quitting. Nicotine gums specific for gutkha users will also help. Additionally, some patients will need to involve themselves in psychotherapy.

A spurious distinction

While cigarette smoking has been the chief whipping boy of the vocal anti-tobacco lobby, the skyrocketing number of pan masala and gutkha addicts has gone almost unnoticed. The govt. of India, various state govts and the higher judiciary have clamped down hard on cigarette smoking: banning smoking in public places, banning the sale of cigarettes to minors and mandating pictorial warnings on cigarette packets are some recent examples. However, chewing tobacco, in its various avatars, seems to have attracted much less censure. In fact, pan masala is one of the most highly advertised products across all Indian media. Alarmingly, ads and the sponsorship of high-profile sporting events by the chewing tobacco industry is increasingly targeted at the youth audience. It is time we stopped making this artificial distinction between smoking and chewing tobacco.

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