India tops list of oral cancer cases caused by smokeless tobacco and areca nut in South Asia, says Lancet

Why is India among countries with the highest disease burden?

“Free accessibility with intense surrogate marketing of smokeless tobacco and areca nut have meant that India has one of the highest burdens of oral cancer in the world. While the revenue to the government is minimal, the health impact and associated healthcare losses are huge. The ban on gutkha was a courageous step that has been circumvented by the tobacco industry,” says Dr Pankaj Chaturvedi, Head and Neck Cancer surgeon and Director, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Kharghar, Navi Mumbai.

One of the co-authors of the study, Dr Chaturvedi raised a red flag about the areca nut industry that has engaged Bollywood celebrities for advertising paan masala as a mouth freshener. “Areca nuts cause a painful disease called submucous fibrosis apart from mouth cancer that is incurable. Unfortunately that is affecting our younger population and destroying families emotionally and financially. We need to implement the existing laws and regulations effectively for control of smokeless tobacco and areca nuts,” he argues.

Why is this study significant?

An estimated 300 million people use smokeless tobacco and 600 million people use areca nut globally, with the highest rates of use in south-central Asia, southeast Asia and Melanesia.

What constitutes smokeless tobacco products?

Smokeless tobacco products are consumed without burning and can be chewed, sucked, inhaled, applied locally, or ingested. The most popular is gutkha, a mixture of tobacco, crushed areca nut, flavourings and spices. It is placed in the mouth, usually between the gum and cheek, and chewed. Khaini is made from sun-dried or fermented coarsely cut tobacco leaves. Paan masala is a mixture of areca nut, tobacco, lime, catechu and spices.

“Smokeless tobacco and areca nut products are available to consumers in many different forms across the world,” wrote Dr Harriet Rumgay, a scientist at the Cancer Surveillance Branch at IARC and the first author of the study.

The gender burden: Men or women?

Globally, an estimated 77 per cent of oral cancer cases attributable to smokeless tobacco and areca nut use were among men (92,600 cases) and 23 per cent were among women (27,600 cases). Generally, the proportions of oral cancer cases attributable to smokeless tobacco and areca nut use were higher among men than among women, except in southern Africa and South-East Asia. Although men are the main consumers of smokeless tobacco or areca nut in most regions of the world, in these regions, the prevalence of smokeless tobacco or areca nut use among women is higher than that among men.

In India, consumption of areca nut (30 per cent) and betel quid with tobacco (28 per cent) were responsible for the most oral cancer cases among women, followed by gutka (21 per cent) and khaini (21 per cent). Among men, the products that caused the largest proportions of oral cancer cases were khaini (47 per cent), gutka (43 per cent), betel quid with tobacco (33 per cent), and areca nut (32 per cent).