The tobacco splatter marring the walls of our community
Shail Bhatt discusses India’s detrimental obsession with smokeless tobacco and presents an argument for why it must be solved.
As I was walking through the streets of my hometown of Ahmedabad, India, I came across a freshly painted white wall. It was bright and spotless. Less than an hour later, as I was walking back towards home, the same wall was now marred by a disgusting splatter of dark red. The wall had become a new target for people to spit on.
This was smokeless tobacco, a type which is usually chewed, sucked, and spat out afterwards. Nicotine and other chemicals, many of which are carcinogenic, are absorbed into the body through the lining of the mouth. Paan (betel leaf with areca nut), gutka (a crushed combination of tobacco, areca nut, slaked lime and other flavourings), and other smokeless tobacco (SLT) products are common throughout the South Asian world.
The impacts of smokeless tobacco products are detrimental in nearly every way, be they towards health, hygiene, or infrastructure. According to the Global Adult Tobacco Survey, there are over 232 million smokeless tobacco users in India and Bangladesh. The prevalence of these users in India, nearly 33% among men and 18% among women, is alarming, and the highest of any country in the world. Such a terrifying prevalence is accompanied with the fact that oral cancer accounts for 30-40% of all cancer cases reported in India, and that a third of all mouth cancer cases worldwide are found in the Indian subcontinent.
There are 3 major types of carcinogenic compounds found in smokeless tobacco products: tobacco-specific nitrosamines (TSNAs), N-nitrosamino-acids, and N-nitrosamines. Within these, N-nitrosonornicotine (NNN) and nicotine-derived nitrosamine ketone (NNK) are most deadly. These two chemicals are responsible for mutations in tumour-suppressing genes and cell-cycle regulators, initiating the growth of a cancerous tumour. Furthermore, they bind to nicotinic acetylcholine receptors (which control communication between cells) and increase cell proliferation and migration. So, while nicotine itself causes dependence to the product by activating the body’s reward system, it also aids in creating an environment for cancer to grow in. This way, the user becomes hooked and continues consuming SLTs, which in turn, fuel the creation of a tumour in a vicious feedback loop.
On top of the direct health implications, there are many other ways by which smokeless tobacco products are damaging society. The red splatter on the white wall is just for starters; spitting on the road, out of moving vehicles, into urinals (clogging the toilets and making them foul and virtually unusable). This is not only grossly displeasing, but also harmful for others. Spitting can spread communicable diseases like flu, Epstein-Barr virus (mono), and occasionally even herpes. In India itself, the total medical costs of treating smokeless tobacco reaches an astounding $389 million each year. While smoking causes 6 million deaths a year worldwide, smokeless tobacco causes 250,000 deaths each year, with nearly three-quarters of them occurring in India. Sadly, however, things are not improving. In the bustling and rapidly urbanizing city of Mumbai, 40% of school students and 70% of college students consume some form of smokeless tobacco.
While the efforts of the Indian government’s “Clean India” initiative are commendably addressing some big issues like the usage of plastic, access to toilets, and clean-up of neighbourhoods, the issue of spitting and tobacco consumption has haunted India for quite some time. It’s a constant battle between good and evil: on one hand, on all of the tobacco-filled products, 85% of the packet content has graphic deterrents; on the other hand, adverts for tobacco remain ubiquitous on the radio and television, with the health and safety guidelines being skimmed over at high speed.
Similarly, several laws exist to control tobacco consumption, and there are several state-wide bans on tobacco as well; despite 24 states having banned smokeless tobacco, however, tobacco still continues to be consumed and sold at an alarming rate. A quick visit to a cancer hospital showed me that nearly half of the cases every day were carcinomas of the base of the tongue and of the buccal mucosa (the lining of the cheeks). Upon asking the consulting doctor as to the cause of the frequency of oral cancer cases, the doctor replied with only one word: tobacco.
With an inelastic product like smokeless tobacco, raising prices doesn’t help. A lack of awareness of the perils of gutka, the seemingly ubiquitous consumption, and lack of access to (and acknowledgement of) cessation therapies are keeping the number of users high. I had the opportunity to sit in on a therapy session for tobacco addicts quickly saw that once users were pointed to the right people, the results show and the numbers decrease. There are 5 D’s that help tobacco users get over their urges: Distraction, Drinking liquids, Deep breathing, Discussing the issue, and Delaying the urge. Substituting SLTs for chewing gum or Nicotex can also be used to phase out the need for tobacco. Yet, the fact remains that a more concrete system needs to be in check against SLT products: the government needs to have stricter laws and regulations against tobacco. A greater focus needs to be made on educating adolescents, as most users unknowingly begin in their youth.
Why don’t we drink poison? Because we know it will injure us, harm us, or even kill us. Then why not the same for tobacco? Maybe then the red splatter on the wall would fade away and leave behind a cleaner and healthier society.