Chewing tobacco: choice or addiction?

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PUBLISHED July 10, 2022

CARACHI:

Zulekha Latif, a housewife, doesn’t remember exactly when she started chewing gutka. But she recalls that for the past three decades she has been using one or another form of chewing tobacco. She can barely open her mouth, her gums hurt, there is occasional bleeding, but she won’t stop. “It’s a habit and support throughout life,” she smiles without telling me what type of support it is. She spends around 50 rupees a day on gutka which is not readily available in her town of Badin. “I used to chew betel nuts when I was barely seven years old. It was replaced by paan then gutka.

Kiran, a home-based worker, spends 100 rupees a day on mawa, a popular form of gutka in Karachi. Like the other women in her family, Kiran doesn’t remember exactly when she started chewing gutka. “I can’t function without taking mawa. It stimulates my body and helps me complete my tasks easily and quickly. Showing the mawa packet in his hand, Kiran shares that his total income in one day is only 350 rupees for six to eight hours of work. “Everyone chews mawa. It’s a habit and no one considers it a bad thing, at least in our region,” she adds.

According to medical professionals, factory workers, electricians, mechanics, transit drivers, rickshaw drivers, maids, security guards and restaurant workers, for the most part chew some form of chewing tobacco.

Common gutka is made up of different ingredients, some of which are harmful: ground betel nut, tobacco, catechu, lime, and sweet or savory flavorings. Although they know that it is illegal to carry gutka, majority of addicts carry stocks of gutka or mainpuri when traveling from one place to another because they cannot live without it.

Doctors say that constant use of mainpuri or gutka is one of the root causes of mouth cancer. They also warn that a patient develops a non-healing ulcer in mouth cancer, which is initially painless, but over time results in severe pain, occasional bleeding and perforation. Its treatment becomes very difficult at an advanced stage. “Users know it is very harmful but they don’t give up on it,” said Dr. SM Qaisar Sajjad, Secretary General of the Pakistan Medical Association (PMA). “In all its forms, it causes oral cancer,” he added. He said the PMA was leading campaigns to ban [chewable] tobacco and chhalia in all their forms to save people’s lives as these are dangerous to health.

According to data shared by the PMA, in Pakistan, 166,000 people die every year due to the use of tobacco in different forms. “Good quality chhalia juice is also clinically proven to be carcinogenic, and when mixed with tobacco, other dangerous products and chemicals, it becomes more dangerous to human health,” explained the Dr Sajjad. Carcinogen is defined as a substance that causes cancer. PMA data shows that around 200,000 new cases of cancer are reported each year, including 40,000 cases of cancer of the oral cavity, which includes the lips, gums, tongue, oral cavity and pharynx.

Research from Pakistan shows that smokeless tobacco is the second leading cause of cancer-related death in both men and women.

“Not only men, but even teenage boys and girls are using gutka without taking care of their health,” Dr. Sajjad said. He said that in some areas of Badin, Thatta and Sujawal, children under the age of ten, imitating their parents, were chewing gutka.

“It’s very common and nobody considers it dangerous,” said Abdul Sattar, a resident of Gharo. He said most of the people he knows in his area use gutka. “It’s the favorite thing of the poor,” he smiles. “We don’t feel bad if it causes illness or if people don’t like our smiles. It doesn’t matter,” he said.

Interestingly, different forms of chewing tobacco are popular in different regions. Gukta is common everywhere. In some areas, such as Tando Ghulam Ali, Gulab Laghari, Nao Dubalo and Tando Allahyar, choro is common, a form of tobacco mixed with betel nuts and cloves. In Badin, Safina – an Indian product – is famous, and is even used by educated people who do not consider it a bad habit or harmful to their health.

“Gutka users cannot even easily open their mouths,” said Abdul Aziz, a trader in Seerani, a town in Badin district. “I know people who really want to give it up but can’t. It’s a bad habit.”

Understanding the seriousness of the problem and on the recommendations of the health department and health experts, the government of Sindh, after consultation with various stakeholders, passed a bill on December 18, 2019. Sindh Assembly, “Prohibition of Preparation, Manufacture, Storage, Sale and Use of Gutka and Manpuri Bill, 2019”, prohibits the import, export, manufacture, sale and purchase of gutka, of mainpuri and their derivatives in the province. The bill states, “Tobacco use is one of the greatest challenges people face today. Of 90% of tobacco-related oral cancer cases, 82% involve the mouth and throat. The survival rate for cancer patients, who live five years, is fifty-one percent, while forty-eight percent live ten years after being diagnosed.

Legally, no one may produce, prepare or manufacture a mixture or substance which, with the exception of gutka and mainpuri, includes pan parag or other similar mixtures which are prepared or obtained by a series of operations at from these ingredients: any of the forms of chhalia (betel nut), catechu, tobacco, lime and other materials, which are “harmful to health and unfit for human consumption within the meaning of the article of the ordinance on Pure Foods of Sindh, 1960 and also contravenes the provisions of Rule 11 of the Pure Foods Rules of Sindh, 1965.”

The new law prohibits anyone from possessing, offering for sale, distributing or delivering any prohibited substance. The bill also prohibits owning, operating or controlling premises or machinery for the manufacture of mainpuri, gutka and their derivatives. Penalties are also provided for in the bill in the event of contravention of the aforementioned provisions: “Anyone who contravenes these provisions…. shall be punished with imprisonment for up to three years but not less than one year and liable to a fine not less than two hundred thousand rupees.

On the directives of the Sindh High Court, senior police officials have issued orders to launch a crackdown on the sellers and makers of gutka, mainpur and mawa. The media confirms that the police have launched several raids and arrested some people involved in the crime, but the number of users continues to increase steadily. “I don’t see the number of users going down,” Dr Sajjad said.

“Yes, the number is not going down,” said a senior police official on condition of anonymity. He said even some politicians frequent this business. “It’s a good business, people make a lot of money in a few months,” he explained.

Although betel nut users are found throughout Pakistan, gutka and mainpuri users are mainly concentrated in the three lower Sindh divisions: Karachi, Hyderabad and Mirpurkhas. The situation is relatively pathetic in the lower parts of Sindh, the coastal belt. Officials and health professionals say the majority of Thatta residents use chewing tobacco.

A PMA health professional has stated that betel nut is the leading cause of oral cancer and submucosal fibrosis. About 122 brands of chhalia (sweet Supari) are readily available everywhere; chhalia is prepared by artificial coloring and artificial sugar. Artificial color is also proven to be carcinogenic. Gutka is a more dangerous item, freely available and prepared by chhalia and other dangerous chemicals. He added, “Due to overuse of chhalia, submucosal fibrosis is very common in adolescents, especially school and college students. It is an untreatable disease, in which the mucous membrane of the oral cavity is fibrotic, leading to limitation of the opening of the mouth and severe burning in the mouth.

It is important to note that chhalia does not grow in Pakistan and fungus infected chhalia is imported. According to doctors, any food infected with fungi eaten for a long time can cause liver cancer. Speaking to Express Tribune, Dr Sajjad said: “It is very unfortunate that even in the presence of the law, gutka, mawa, manipuri, chhalia and their derivatives are freely available in the markets and people consume them openly. And as a result, the cases of mouth cancer and submucosal gibrosis are increasing in the country, especially in Sindh.

“Half the population uses either gutka or mainpuri or safina,” said Badin District Police Chief Superintendent Shah Nawaz Chachar. According to Badin police statements, more than 300 people have been arrested for selling or supplying gutkas in the past six months. The police also claim that there is not a single factory in the district that produces chewing tobacco. “It is supplied to my district from different routes,” Chachar said. He told an interesting story about the gutka supply mechanism in his district. “Providers use family as shelter and carry Safina when traveling with family members; it is difficult to get every vehicle checked,” he added.

Senior police officials have issued an order that a police officer will be fired or punished if found using chewing tobacco. More than twenty police officers were fired and forty were transferred from Badin to other districts for violating orders.

Chachar believes this is a social problem. “I faced at least twenty-five protests for taking action against vendors and shoppers in the neighborhood,” he said. “There is a need for mass awareness in lower Sindh,” he insisted.

Another senior police officer told The Express Tribune that the makers and sellers are like mafias. “It is not easy to take action against them, and they will stop their activity forever,” he explained. “It’s not just gutka, it’s an economy that the people involved in it don’t want to leave.”

Noman Khatri, an electrician and gutka user in Karachi, opines that he has seen different forms of chewing tobacco since childhood. “I’m thirty-five now and I’ve heard it causes dangerous health issues, but I don’t see people taking the warnings seriously,” he said. He also mentions some of his acquaintances who died of oral cancer. “I saw their condition and how they went off gutka for a few days.” But, he added, it is difficult to disconnect from this addiction for long.

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