Feature Tobacco Control

Gutkha wars: India toughens up on oral tobacco use

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8238 (Published 04 December 2012) Cite this as: BMJ 2012;345:e8238
  1. Meera Kay, journalist, Bangalore
  1. meerakay{at}ymail.com

This ubiquitous form of smokeless tobacco has been outlawed in much of India, but greater efforts are needed to implement these bans to reduce oral cancer, reports Meera Kay

In early November 1.31 lakh (131 000) pouches of the chewing tobacco product gutkha were seized from a godown (warehouse) in Bhopal, and two people were arrested.1 Gutkha is a concoction of tobacco, areca nut, slaked lime, catechu, and flavourings to be used orally. Bhopal is the capital of Madhya Pradesh, and this was the first state to declare war on gutkha, in April 2012.1

Paan masala is a stimulating oral preparation of betel leaf and areca, which can also contain tobacco. To date, 15 states—Madhya Pradesh, Kerala, Bihar, Maharashtra, Himachal Pradesh, Rajasthan, Haryana, Jharkhand, Chhattisgarh, Gujarat, Punjab, Uttarkhand, Mizoram, Delhi, and Sikkim—and one union territory, Chandigarh, have banned the sale, manufacture, and distribution of gutkha and paan masala that contain tobacco, confirmed Bhavna Mukhopadhyay, executive director of the Voluntary Health Association of India, a non-profit umbrella organisation that links more than 4500 health and development institutions.

Now the directors of 12 regional cancer centres, the Indian Dental Association, and Tata Memorial Hospital, Mumbai, have called on the prime minister for a federal ban on the manufacture and sale of all smokeless tobacco products.2

Gutkha is the second most common form of smokeless tobacco product after khaini, a tobacco-lime mixture.3 Smokeless tobacco contains at least 29 carcinogens. “India has the most oral cancer cases of anywhere in the world, the reason being the rampant use of smoking and smokeless tobacco products,” said Gauravi Mishra, consultant at the department of preventive oncology at the Tata Memorial Hospital. “Every year we add 74 000 new cases, and 50 500 patients die of oral cancer,” she added.

Habitual gutkha use is associated with several oral mucosal disorders, including oral submucous fibrosis (OSF), oral cancer, and periodontal disease, with consequences that might extend beyond the oral cavity. “Gutka use mainly leads to OSF, an irreversible condition that results in restricted mouth opening primarily because of the presence of dense fibrous bands in the oral mucosa. The most serious aspect of OSF is its very high potential for cancer development: the relative risk is almost 400 times that of a non-user,” said Mishra.

Vigorous attempt

This is not the first time that Indian states have tried to ban gutkha, but it is the most vigorous attempt. In 2004 Maharashtra had banned gutkha and paan masala; however, the ban was challenged in the Supreme Court by the gutkha manufacturer Ghodawat Paan Masala. “Since paan masala, gutkha and supari are eaten for taste and nourishment, they all come under the category of food,” the court ruled, repealing the ban.4 It said that only central government had the power to ban a foodstuff. At the time the federal government did not try to ban gutkha, but the ruling paved the way for a ban under food legislation.

At present, the gutkha lobby is aggressively opposing the ban, calling it discriminatory because it has outlawed gutkha under food rather than tobacco regulations. The Smokeless Tobacco Association, All Indian Kattha Factories Association, and Central Arecanut and Cocoa Marketing and Processing Co-operation Ltd, have issued an advertisement that says that gutka is less harmful than cigarettes.5

After a conference on smokeless tobacco in April 2011 organised by the federal health ministry, the World Health Organization, and the Public Health Foundation of India, the Food Safety and Standards Authority of India (FSSAI), part of the health ministry, issued a notice that prohibited tobacco’s use as an ingredient in any food product. Because the Supreme Court had already classified gutkha as a food, there was no doubt that it would be banned.

Clarifying the ban on gutkha and not other tobacco products, such as cigarettes, Mukhopadhyay said, “Unfortunately, cigarettes are not a food item. Besides, there is no provision of a ban under the Control of Tobacco Products Act, commonly known as COTPA.” “Cigarettes can only be regulated,” she said.

COTPA came into effect in 2004 and prohibits smoking in public places, tobacco advertising, sponsorship of sports and cultural events by tobacco companies, and sale of tobacco to under 18 year olds. The legislation also requires that cigarette packets show pictorial health warnings and an indication of nicotine and tar content.

Pro-tobacco agencies

Some pro-tobacco agencies have suggested that it is illegal to ban chewing tobacco because COPTA does not provide for a ban. But the “FSSAI notification came after COTPA and overrides the latter,” said Rijo John, health economist and the coauthor of the report The Economics of Tobacco and Tobacco Taxation in India.6

Consumption of smokeless tobacco is high in India, with occasional or daily use by 26% of the population aged over 15. As many as 32.9% of men and 18.4% of women in India use smokeless tobacco.3 The Global Youth Tobacco Survey India, 2009, found that 12.5% (16.2% of boys and 7.2% of girls) use tobacco products other than cigarettes.3

John has estimated the economic cost of smokeless tobacco in India for 2004 at $390m. This includes direct medical costs attributable to four groups of diseases related to tobacco use: tuberculosis, respiratory diseases, cardiovascular diseases, and neoplasms. “However, the cost of premature mortality due to tobacco use is not included, and it can be very large, sometimes up to 70-80% of the total cost,” he adds.

In Bihar and Maharashtra use of smokeless tobacco such as gutkha is much more common than smoking.7 Use of smokeless tobacco tends to be inversely related to education and income, excepting regional differences in sociocultural norms.7 In India, smoking among women and young people is less socially acceptable, but use of oral tobacco has no such taboo so most women who use tobacco use it in smokeless forms. Tobacco use, in whatever form, generally begins during adolescence.7

Awareness of the hazards of smokeless tobacco use is low in rural populations. On the other hand, many believe tobacco, smoked or smokeless, has medicinal value for curing or palliating common discomforts such as toothache, headache, and stomach ache. This might lead adults to advise non-users, including children, to start using tobacco.8

Spreading awareness

The ban on gutkha has been welcomed. “Even if challenged in the Supreme Court, it has already gone a long way in spreading awareness about the harms of gutkha and pan masala. Hopefully the message has percolated to the grass-roots. We hope to see fewer new gutkha addicts and more users quitting rather than substituting to other tobacco products,” Mishra added.

Although the ban on gutkha is hailed as the first step towards reducing tobacco consumption in India, stringent action will be needed from the government and health advocacy groups to eradicate tobacco consumption. Bans alone may not be effective. “Continuous monitoring and raiding, including of small roadside gutkha and paan vendors, is warranted and is going to be costly. The fine for selling gutkha should be substantial,” John says. He also said that the public needs educating about the ill effects of smokeless tobacco. “Massive counter advertising campaigns on television and radio and in newspapers need to be carried out on a regular basis. Such demand-side measures will eventually yield results,” he added.

Currently, the ban is not universal and is for a period of one year in some states. Experts say that when bans are reconsidered they should be made permanent. Stakeholders such as the police, Municipal Commission, Collectors, and Vigilance departments will need to be involved in implementation. Enforcement is needed at entry points, such as state borders and railway stations, because users might try to smuggle gutkha from neighbouring states.

Finally, gutkha manufacturers’ licences need to be cancelled for a ban on these products to work or they may revert to making other tobacco products. “Stronger public opinion would develop as people start realising the harms of all forms of tobacco not only to oneself but also to the society. This is expected to lead to stronger measures in future to ban all forms of tobacco products, including cigarettes,” concluded Mishra.

Provenance and peer review: Commissioned; not externally peer reviewed.

Competing interests: None declared.


Cite this as: BMJ 2012;345:e8238