IJPH 48-3

Indian Journal of Public Health

68

Vol.XXXXX No.2 April-June, 2006

SMOKELESS TOBACCO USE AND ITS IMPLICATIONS IN WHO SOUTH EAST ASIA REGION *Dhirendra N Sinha1. Madhumita Dobe2, Khalilur Rahman3 The term ‘smokeless tobacco’ is used to describe tobacco that is consumed in un-burnt form. Smokeless tobacco can be used orally or nasally. In the nasal use, a small quantity of very fine tobacco powder mixed with aromatic substances called dry snuff is inhaled. Oral use of smokeless tobacco is widely prevalent in the South East Asia Region; the different forms include chewing, sucking and applying tobacco preparations to the teeth and gums.

Prevalence among adults Prevalence of smokeless tobacco use in South East Asia varies from country to country in the WHO South East Asia Region; from 1% in Thailand and Indonesia to 25% in Bangladesh (Table1). Prevalence of smokeless tobacco use also varies within different regions of one country; for example in India it varies from 7.2% in Jammu and Kashmir to 80.3% in Mizoram.

Smokeless tobacco use in South Asia raises various concerns. Smokeless tobacco contains several carcinogenic compounds. About 35–40% of tobacco consumption in India is in smokeless forms, mostly of the species Nicotiana rustica, while most smoking tobacco is Nicotina tabacum. Samples of N. rustica have been found to contain higher concentrations of tobacco-specific nitrosamines than N. tabacum.

Projected Prevalence of smokeless tobacco use in South East Asia was calculated on the basis of WHO reports and other relevant studies conducted in different member countries. Among 1.5 billion Southeast Asians, over 250 million people use smokeless tobacco products; about 17% of total population in Southeast Asia uses oral tobacco; of which 95% belong to India (82%) and Bangladesh (13%)(Table1).

Table-1: Smokeless tobacco use prevalence among adults in South East Asia Country

Prevalence reference used for projection

Present smokeless tobacco use

Bangladesh

Rahman et al1 2004

25

1374390000

34359750

NFHS2

28.3 M 12.4 F

531277078 495738169

150351413 61471533

Indonesia

WHO, 20013

1

212092000

2120920

Myanmar

WHO,

20014

15

47749000

4774900

Nepal

WHO, 20015

10

23043000

2304300

Srilanka

WHO, 20016

10

18924000

1892400

Thailand

WHO, 2001

1

62806000

6280600

SEA Region

Projection7

16.9

1529068247

257903276

India

1School

Population 2001

Projected number of smokeless tobacco users

of Preventive Oncology, Patna, Bihar, India, 2Professor &Head of Health Education, Department of Health Education, All India Institute of Hygiene and Public Health, Kolkata, 3Regional Advisor/Tobacco Free Initiative WHO South-East Asia Regional Office, New Delhi. *Corresponding author : E-mail: [email protected]

69

Prevalence among youth In countries of South Asia, traditional values do not favor smoking by the young , but there is no such taboo against using smokeless tobacco. According to the Global Youth Tobacco Survey, prevalence of smokeless tobacco use among young on students (13-15 year) in Southeast Asia ranged from 4% in Bangladesh to 20.4% in Myanmar 8-11(Table2). There was no statistical difference in smokeless tobacco use among boys and girls in Bangladesh and Myanmar (Table2) indicating changing social norms in SEA. Prevalence of smokeless tobacco use varies within different regions of one country; for example in India it varies from 2% in Himachal Pradesh to 55.6% in Bihar. The use of tobacco products as dentrifice among school going children is a special problem in India. GYTS data indicates that prevalence of use of tobacco products as dentrifice among school going children varies between 6% (Goa) to 68% (Bihar) 12. Among disadvantaged youth group high (45%71%) prevalence of tobacco use was reported in Southeast Asia7

Table-2: Current use of smokeless tobacco among students (13-15 years) in SEA;GYTS, 2000-03 India

Nepal

Myanmar

Bangladesh

Total

14.6 (±1.5)

9.3 (±2.5)

20.4 (±2.7)

4.0 (±0.7)

Male

18.5 (±2.1)

11.8 (±2.8)

35.4 (±4.2)

3.9 (±0.8)

8.4 (±1.9)

5.6 (±3.5)

6.6 (±1.8)

3.5 (±1.1)

Tradition among women While more and more young girls are taking up smoking in urban areas, women in rural areas still prefer smokeless form of tobacco and most women who initiate tobacco, use it in smokeless forms

Smokeless tobacco use in India by sex and age,India NFHS 1998 50

45

Pe 40 rc en 30 t 20 us 10

38

25

19 14

2 4

4

45

38

Female Male 8

23

25

12

0 15-19

20-24

25-29

30-39

40-49

50-59

60+

Age group

Increasing Trend Increasing use has been reported not only among men, but also among such vulnerable groups as children, teenagers, women of reproductive age and by immigrants of South Asian origin wherever they have settled. In India, per capita smokeless tobacco consumption has increased among the poor between 1961 and 2000 in both rural and urban areas 13. Though there is no statistical report of increasing use of Smokeless tobacco products through years in Nepal; report of Customs Department of the Ministry of Finance, Nepal, suggesting 87 times increase in import of smokeless tobacco products within three years6, is an indication of increasing trend in Nepal. In Bhutan, tobacco consumption trend has changed from that of smoking to other forms like oral use. Sacks of ‘Baba’ are on sale in the vegetable market at Thimphu. Many people, including young boys and monks chew ‘Baba’ and scented khaini. Evidence for a trend toward increasing use of tobacco and areca nut products like gutka, pan masala and tobacco toothpaste by youth has been gathered in several recent studies7 The WHO and other Studies throughout region,1-7 revealed that use of smokeless tobacco products was mainly a rural phenomenon seen more among males with decreasing trend of current use with higher education and socioeconomic level.


70

Smokeless (Oral & Nasal) tobacco products A. Chewing 1.

Betel quid with tobacco: Tobacco is the most important ingredient of betel for regular users in Bangladesh, India, Myanmar and Nepal. In Indonesia tobacco is used as part of the mixture chewed with sirih (betel);practiced for the most part in rural areas.Various tobacco preparations used in betel quid are:Tobacco Leaf – Kaddipudi(South India), Hogesoppu, Gundi(Orissa, India),Zarda(various brands in Bangladesh, India, Myanmar and Nepal), Qiwam Various brands in Bangladesh and India); Hnatsay (Honey Soaked Tobacco) one of the special products used in Myanmar; Betel quid masala (betel quid) Pan masala:

2.

Tobacco and slaked lime (khaini) ,

3.

Tobacco, areca nut and slaked lime preparations; Examples are Gutka(India, Nepal, Bangladesh) Mainpuri tobacco(India) Mawa(India) Dohra(Uttar Pradesh,India).Recently, varieties of Gutka is being produced industrially on a large scale commercially marketed and are available even in small plastic and aluminum foil. New forms of smokeless tobacco have been emerging over the last few decades, enticing new consumers.

B. Applying Tobacco: Several oral tobacco preparations such as mishri, gudhaku, bajjar Red Tooth Powder - Lal Dantmanjan and creamy snuff, are intended primarily for cleaning teeth. Such use, however, soon becomes an addiction. C. Sipping/Sucking Tobacco Products: Tobacco water (Known as Tuibur in Mizoram and Hidakphu in Manipur) is sipped and retained in mouth for 5-10 minutes and then spat out. In general, in one sip usually 5 -10 ml tobacco water is kept within mouth It is either sipped directly from bottle or through cotton soaked with Tobacco water B. Inhaling Tobacco Products: Include products used nasally, common practice in WB and Bangladesh


Awareness of the hazards of smokeless tobacco use is very low in rural populations and many believe tobacco has curative or palliative effect for common discomforts such as toothache, headache, and stomachache. This often leads to advice for initiating tobacco use from adults to other non-users, even children14.

Hazards of Smokeless Tobacco Products use in SEA Many of the risks to health and life caused by tobacco consumption develop over a long period, and take decades to become fully evident but tobacco use also inflicts immediate harm on users and their families. Scarce family resources are spent on tobacco products instead of on food, or other essential needs. Each tobacco user represents one or more people whether the user or his or her spouse or child who is needlessly going hungry. The national household expenditure survey in India in 1986-87 found that between 2.54% of all household expenditures were for tobacco, pan, and intoxicants; the percentage was highest for the lowest income urban households15. Path Canada, India project study, found that disadvantaged adolescents use tobacco at the cost of their meals spending on gutka purchase the money which they could have spent for buying eggs. 16

Average monthly expenditures on tobacco and other Gutkha items,India Bidi 200

Cigarette

150

Milk

rupees 100 50

Eggs

0

Meat

Fruit Clothing

Source 17 Smokeless tobacco use in South East Asia may be considered as a potent contributor to mortality. The evidence from three cohort studies in India indicates

71

that the age-adjusted relative risk of mortality for users of smokeless tobacco is elevated compared to that of non-tobacco users18. The major health consequences associated with smokeless tobacco use in Southeast Asia include cancers of several sites (e.g. the upper respiratory and digestive tracts), and poor reproductive outcomes. The significance of the interaction between alcohol and tobacco in causing head and neck cancers and genotoxicity is well documented19 In India, the number of newly diagnosed tobacco-related cancers has been estimated at approximately 250 000 out of a total of 700 000–900 000 new cancers diagnosed each year20. Tobacco-related cancers account for about one-third of all cancers in Bangladesh, India and Sri Lanka. Significant dose–response trends were observed for frequency of chewing per day in many studies, and for duration of habit in some of them21. Retention of the quid overnight, showed a 36-fold increased risk. In case series studies22 from Bangladesh and Myanmar, the site of origin of the majority of the lesions corresponded with the site maximally exposed to betel quid, usually in the buccal mucosa. There are some research results on the impact of smokeless tobacco on blood pressure and cardiac disease23-25. Adverse reproductive outcomes from smokeless tobacco use during pregnancy have been well documented. Many studies, including WHO SEA Region study clearly pointed out significantly higher percentage of lower gestation period, lower birth weight and increased male fetus wastage among smokeless tobacco users26-28.

Recommendations for Control of Smokeless Tobacco Products Smokeless tobacco is promoted intensively in India; In Bangladesh, Myanmar and Sri Lanka promotion is not very visible however in Nepal it is visible to some extent. Betel chewing promotion is mainly through culture but its tobacco ingredients especially zarda are heavily promoted in India. Gutka is the most advertised smokeless tobacco product. They are promoted through all media and influence the youth and people at large The WHO FCTC covers the whole gamut of tobacco products – both smoking and smokeless. Some

of the Member Countries in the Region have for mulated comprehensive tobacco control legislation29 covering all types of tobacco products. For a stronger global and regional tobacco control it needs to be enforced vigorously In Southeast Asia, especially there is evidence of demonstrable feasibility and efficacy of anti-tobacco education for the community through controlled intervention studies in areas with high prevalence of tobacco chewing. WHO initiatives for Community Cessation Intervention have shown that it is feasible, cost effective and sustainable30. The government and non-governmental agencies to help over 250 million smokeless tobacco users to quit should establish more community based cessation intervention. There is need for bringing about a change through appropriate IEC interventions in the widespread belief that smokeless tobacco use is less harmful than smoking Due to lack of information many thousands pregnant women continue with smokeless tobacco use during pregnancy. Actually smoking is supposed to be dangerous for pregnancy so both females and male smokers switch over to smokeless tobacco during the pregnancy. There is a paucity of communication material on the effects of smokeless tobacco. Keeping in mind the high quality of tobacco advertising that commands the attention of the public, skilled media professionals should work with health professionals and health authorities in preparing attractive communication material, in simple language with unequivocal meaning, incorporating messages about all forms of smokeless tobacco and smoking. Anti-tobacco education must be imparted through schools, hospital outreach programs, existing government health programs such as maternal and child health programs and routine home visits, using suitable materials. Suitable programmes and activities should be developed targeting rural people, in particular the women who use the smokeless tobacco products most. The tobacco control measures, including national tobacco control legislation in some countries in the Region do not address the problem posed by smokeless tobacco products. These measures and legislation need to be revised or amended in order to control the smokeless tobacco products under the law and in line with the provisions of the WHO FCTC.


72

‘Smokeless tobacco use’ need to be given a priority during planning and management of comprehensive tobacco control; Smokeless tobacco control should move parallel to control on smoking tobacco products in all respect such as product information, proper warning; price increase etc. .

References 1.

Rahman M, Rahman M, Flora MS, Aktar SFU, Hossain S, Mascie-Taylor C G N, Community Based Health Behaviour Surveillance in Urban and Rural Areas of Bangladesh-A Baseline Study;National Institute of Preventive and Social medicine (NIPSOM),January 2004

2.

International Institute for Population Sciences (IIPS) and ORC Macro. National Family Health Survey (NFHS-2) 1998-99: India. Mumbai: IIPS. 2000.

3.

World Health Organization. , Sentinel Tobacco Use Prevalence Survey In Indonesia, 2001, WHO, SEARO, New Delhi

4.

World Health Organization. , Sentinel Tobacco Use Prevalence Survey In Myanmar, 2001, WHO, SEARO, New Delhi

5.

World Health Organization. , Economics of tobacco in Nepal, 2001, WHO, SEARO, New Delhi

6.

World Health Organization. , Sentinel Tobacco Use Prevalence Survey In Sri Lanka, 2001, WHO, SEARO, New Delhi

7.

8.

9.

World Health Organization. Oral Tobacco use and its implications in South East Asia, World Health Organization, Regional Office for South East Asia, New Delhi Reddy KS and Gupta PC. Report on Tobacco Control in India. Ministry of Health and Family Welfare, New Delhi, India. November 2005. World Health Organization. , Report on Global Youth Tobacco Survey in Nepal, 2001, WHO, SEARO, New Delhi

10. World Health Organization. , Report on Global Youth Tobacco Survey in Bangladesh, 2001, WHO, SEARO, New Delhi


11. World Health Organization. , Report on Global Youth Tobacco Survey in Myanmar, 2001, WHO, SEARO, New Delhi 12. Sinha DN, Gupta PC, Pednekar M, Use of tobacco products as dentifrice among adolescents in India: questionnaire study, BMJ 2004; 328:323-324 (7 February) 13. National Sample Survey Organization, India. NSS Report Nos. 184 & 461 (55/1.0/4). Reports covering 1961–62 and 1999–2000 14. Gupta, PC and Ray, C., Tobacco and youth in the South East Asian region Ind J Cancer, 39 (1), 2002, 5-355. 15. Chari MS, Rao BVK. Role of tobacco in the national economy: past and present. In: Gupta PC, Hamner JE III, Murti PR (eds). Control of Tobacco-Related Cancers and Other Diseases. Proceedings of an International Symposium, TIFR. Bombay, January 15–19, 1990. Oxford University Press, Bombay, 1992; 57–64. 16. PATH Canada, India Project study, Through personal communication from Ms Shoba John, [email protected] 17. Indian Council for Medical Research. Report of the Expert Committee on the Economics of Tobacco Use. Department of Health, Ministry of Health and Family Welfare, Government of India, New Delhi, 2001. 18. Gupta PC, Mehta HC. Cohort study of all-cause mortality among tobacco users in Mumbai, India. Bull. World Health Organ. 2000; 78: 877–83. 19. Health consequences of using smokeless tobacco: a report of the Advisory Committee to the Surgeon General (1986). Bethesda, MD: US Department of Health and Human Services. 20. National Cancer Registry Programme (NCRP). 2001 Population Based Cancer Registries, Consolidated Report. http://icmr.nic.in/ncrp/ bcifuture.pdf. accessed on March 10, 2003 21. Gupta PC. Oral cancer and tobacco use in India: A new epidemic. Tobacco the growing epidemic. Proceedings of the 10th World Conference on Tobacco or Health, 24–28 August 1997, Beijing, China. 2000.

73

22. Ahmed F, Islam KM. Site predilection of oral cancer and its correlation with chewing and smoking habit—a study of 103 cases. Bangladesh Med. Res. Counc. Bull. 1990; 16: 17–25 23. Hazarika NC, Biswas D, Narain K, Kalita HC, Mahanta J. Hypertension and its risk factors in tea garden workers of Assam. Natl Med. J. India 2002; 15: 63–8. 24. Khurana M, Sharma D, Khandelwal PD. Lipid profile in smokers and tobacco chewers—a comparative study. J. Assoc Physicians India 2000; 48: 895–7. 25. Nanda PK, Sharma MM. Immediate effect of tobacco chewing in the form of ‘paan’ on certain cardio-respiratory parameters. Indian J. Physiol. Pharmacol. 1988; 32:105–13.

26. World Health Organization. , India, Effects of smokeless tobacco use in Pregnancy, WHO, SEARO, New Delhi 27. World Health Organization. , Bangladesh, Effects of smokeless tobacco use in Pregnancy, WHO, SEARO, New Delhi 28.

Verma RC, Chansoriya M, Kaul KK. Effect of tobacco chewing by mothers on fetal outcome. Indian Pediatr. 1983; 20: 105–11

29. The gazette of India, The Cigarettes and other tobacco products(Prohibition of advertisement and regulation of trade and commerce, production, supply and distribution) Act , 2003, No 34 of 2003 30. World Health Organization., India Community cessation Pilot testing, WHO, SEARO, New Delhi.