Cheap chewing tobacco makes India the oral cancer capital of the world……Adi Narayan
Safiq Shaikh was 13 when he began chewing a blend of tobacco and spices that jolted him awake when his job at a textile loom got too dreary. Five years later, doctors in Mumbai lopped off his tongue to halt the cancer that was spreading through his mouth.
Shaikh believed the fragrant, granular mixture he chewed gutka was a harmless stimulant and at first he ignored the milky lump growing inside his mouth. Now Shaikh is one of about 2 lakh Indians diagnosed with a tobacco-related malignancy this year, says his surgeon, Pankaj Chaturvedi.
India has the highest number of oral cancers in the world after a group of entrepreneurs known locally as “gutka barons” turned a 400-year-old tobacco product hand-rolled in betel leaves into a spicy blend sold for prices ranging from `1 to `7 on street corners from Bangalore to New Delhi. Sales of chewing tobacco, worth `21,030 crore in 2004, are on track to double by 2014, according to research firm Datamonitor.
“Now you have an industrial version of a traditional thing” spurring demand, said Chaturvedi, who works at Tata Memorial Hospital in Mumbai, Asia’s largest cancer treatment centre, and draws cartoons to warn of tobacco’s dangers in his spare time. “By the time you are experimenting with this product, you become the slave of the industry.”
70,000 cases
India had almost 70,000 diagnosed cases of cancers of the mouth in 2008, the highest in the world, ahead of the US at 23,000 cases, according to statistics compiled by the World Health Organisation’s International Agency for Research on Cancer (IARC).
Street vendors crowd around schools, breaking the law, which prohibits the sale of tobacco products within 100 yards of educational institutions, says Devika Chadha, a programme director at the Salaam Bombay Foundation, a non-profit that works with schools to educate children about tobacco’s dangers.
In Khetwadi in Mumbai, on a recent morning, three vendors had set up stalls about 55 yards from Sant Gadge Maharaj College as students gathered near the school gates. Javeed Shaikh, 21, says he began chewing gutka three years ago and now consumes two or three packets a day.
“I’m trying to quit and it’s hard,” he said. The habit is easy to sustain with “all these shops,” he said, pointing at the street stalls.
The combination of tobacco and areca nut makes gutka and its hand-made ancestor, known as paan, addictive, scientists say. Areca nut is the fourth-most commonly used psychoactive substance in the world after tobacco, alcohol and caffeine, according to WHO.
Manufacturers like to keep gutka’s other ingredients a mystery. Rajendra Malu, who owns the brand “Jhee,” says a pouch contains three-fourths areca nut, 12% tobacco flakes and proprietary fragrances he won’t disclose.
A chemical analysis of gutka in 2008 found that it contains chromium, nickel, arsenic and lead as well as tobacco-related nitrosamines, all of which are known carcinogens.
Malu shrugs at the mention of a link between gutka and cancer. “I have been chewing tobacco for the last 37 years and I am not suffering from anything,” he said.
Gutka first appeared in the 1970s, when a New Delhi paan seller began giving clients a ready-made version of paan, according to Malu. Unlike paan, gutka doesn’t stain the mouth pink or leave the hands sticky.
“Selling it in packets has revolutionised the sale of smokeless tobacco in India,” says Babu Mathew, a dental surgeon who headed the Trivandrum Oral Cancer Screening project, which followed 2 lakh residents of Kerala for 15 years.
Foreign takers
While gutka is mostly used in the Indian sub-continent, its reach is worldwide because of migration, according to the IARC. “The practice of areca nut chewing and the presence of oral precancerous lesions are spreading from South Asia to the Western countries,” researchers at the University of British Columbia wrote in a commentary last year.
More youngsters are picking up the habit. A survey of 1,500 teenagers in Mumbai aged 13 to 15 found that double the students identified themselves as tobacco chewers compared with a decade ago, according to Healis, a public health research institute.
That’s not just true in India. The number of US teenage boys using smokeless tobacco went up to 4.4% from 3.4% between 2002 and 2007, according to a survey published by the US department of health and human services.
Tobacco firms like Philip Morris International and British American Tobacco are selling more nicotine products that are sucked, not burned, in response to smoking bans. The situation in India could be a harbinger of the global risks posed by smokeless products, says Saman Warnakulasuriya, a professor of oral medicine at King’s College London.
Doctors point to three reasons why gutka bring on cancer much faster than cigarettes or 400-year-old paan.
The tobacco in gutka releases cancer-causing chemicals called nitrosamines in the mouth. In paan, they are neutralised in part by the fresh betel leaf, a benefit that gutka lacks, according to Mathew.
The chemicals in areca nut, meantime, stimulate the production of collagen, a protein that causes the mouth’s muscles to thicken. At the same time, the coarse chunks of areca nut rub against the gums and cause tiny injuries that expose the blood vessels in the mouth, a trauma that can take several hours to heal.
The muscles in the mouth eventually lose their ability to stretch, resulting in a pre-cancerous condition called oral submucous fibrosis.
Patients who previously could grab a sizable chunk of an apple in a single bite are able to open their mouth to just about the size of a grape. Bloomberg