Last Updated on March 11, 2024 by Neelam Singh
In a paper published in the International Journal of Science and Healthcare Research in 2021, authors Hindol Das and Shilpa Motghare wrote that India has the greatest number of oral cancer cases than any other nation worldwide and recently got the epithet “The Oral Cancer Capital of the World”.
India and Oral Cancer
So, it didn’t really come as a surprise when Lancet, in a recent study, revealed, “The widespread consumption of smokeless tobacco products, such as khaini and paan masala, has become a major contributor to the escalating burden of oral cancer in India. Cultural practices deeply ingrain these habits and often perceive them as socially acceptable, leading to a high prevalence of usage across diverse demographics.”
The study has drawn attention to smokeless tobacco’s potential contribution to the nation’s rising mouth cancer incidence. Dr Vishal Rao, the chief of head and neck surgical oncology and robotic surgery at HCG Cancer Centre, Bangalore, says, “Smokeless tobacco products contain a variety of potentially harmful chemicals, including high levels of tobacco-specific nitrosamines (TSNAs). There are also other cancer-causing agents in smokeless tobacco, such as polonium–210 (a radioactive element found in tobacco fertiliser) and polynuclear aromatic hydrocarbons (also known as polycyclic aromatic hydrocarbons).” Karnataka has banned gutka and other chewing tobacco products as a result of Dr Rao’s numerous anti-tobacco efforts. Gutka is a combination of slaked lime, areca nut, chewing tobacco, spices, and catechu and banned in several states.
Rising Cases
The Lancet study states that the burden of tracheal, bronchus, and lung cancer (TBL) is notably high in Asia, with smoking found to be as the primary risk factor.
“Tobacco control, therefore, must be identified as a major policy target in Asia, as it is the single biggest risk factor of several neoplasias prevalent in Asia.”
The study titled “Temporal patterns of cancer burden in Asia, 1990–2019: a systematic examination for the Global Burden of Disease” stated that India alone accounted for 32.9% of global deaths and 28.1% of new cases of lip and oral cavity cancer in 2019. Citing the global adult tobacco survey (GATS) report, it highlighted those 199.4 million adults in India consumed smokeless tobacco. The report observed “Notably, more than 50% of the oral cancer burden has been attributed to smokeless tobacco (SMT), whose prevalence has grown in recent times in South Asia, including India.”
Tobacco Ban remains Invalid
It’s a sad reality to note that, despite the ban on gutka, it continues to be up for selling and consumption.
Yet another study published in Lancet authored by Gururaj Arakeri, Dr Vishal Rao, Shekhar Patil and Peter A. Brennan, highlighted that the ban on gutkha in India has not succeeded in reducing the use of smokeless tobacco, as evidenced by the continued prevalence of its use in two-packet form. “India is the world’s third-largest producer and exporter (in tonnage) of tobacco products. However, unlike most other countries, the use of smokeless tobacco exceeds smoked tobacco use in India. Around 21·4% (199·4 million) of adults in India use smokeless tobacco, whereas 10·7% (99·5 million) use smoked tobacco products.”
Dr Avinash Chaitanya S, Consultant Head and Neck Surgical Oncology, CARE Hospitals, HITEC City, Hyderabad, says, “Chewing tobacco in its various forms is known to be one of the major causes of oral cancer. Despite some Indian states banning it since 2012, a variety of factors contribute to the widespread use and availability of gutkha. These include lax enforcement of the bans, inadequate awareness campaigns, cultural acceptance of smokeless tobacco, economic factors driving production and distribution, and challenges in regulating informal markets. Additionally, the addictive nature of the ingredients in gutka makes it challenging for individuals to quit, contributing to continued use despite the bans.”
Smokeless Tobacco: Equally Dangerous
Smokeless tobacco is contributing majorly to oral cancer, esophageal cancer and pancreatic cancer according to Dr Sandeep Nayak, Director, Department of Surgical Oncology, Fortis Hospital, Bannerghatta Road, Bengaluru.
“Oral cancers and head and neck cancers are the most common cancers among men and 70% of these cancers can be attributed to tobacco usage. Over the years, the usage of tobacco has remained consistent. Initially, the enforcement agencies put strict bans but soon became lax in that. The enforcement agency doesn’t have consistency. The demand is high in UP, Bihar, WB and North-Eastern states for Khaini and Gutka and manufacturers want to tap into these markets as that’s a huge market”, stresses Dr Nayak.
Surrogate advertising featuring top-notch actors from the film industry has also contributed to its continued consumption.
Legal Hurdles
Dr Rao reveals that there are legal hurdles in the way with Indian manufacturers challenging state bans in courts. He states that recent judgments by the Delhi and Madras High Courts lifted the states’ ban on the sale of chewing tobacco, calling the prohibitions unjustified and illegal.
“The ban on gutka came after the FSSAI Food safety act, section 2.3.4 suggested that no food product should contain nicotine or tobacco. Considering that areca nut came under the food schedule, the act considered adding tobacco or nicotine to them a violation, thus resulting in the ban of gutka. However, today, to circumvent the same, the industry has created a new approach that adds tobacco into food (pan masala) and not food into tobacco, and using this contention, they have approached the Supreme Court with a stay order that is currently sub judice and waiting for the next subsequent judgement. There are loopholes in regulation. Most of the respondents are purchasing tobacco and mixing it with a packet of pan masala with Zarda. This has adversely affected the very purpose and consequent impact of the ban”.
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