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, known in India as gutka, was a harmless stimulant and at first he ignored the milky lump growing inside his mouth. Now Shaikh is one of about 200,000 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 2 cents on street corners from Bangalore to New Delhi. Sales of chewing tobacco, worth 210.3 billion rupees ($4.6 billion) in 2004, are on track to double by 2014, according to Datamonitor, a branch of the international research firm based in Hyderabad, India.
“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 center, 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.”
India had almost 70,000 diagnosed cases of cancers of the mouth in 2008, the highest in the world ahead of the U.S. at 23,000 cases, according to statistics compiled by the World Health Organization’s International Agency for Research on Cancer.
Selling Near Schools
“I have seen many children who started chewing gutka when they were 8 or 10 years old and got cancer in their teens,” Chaturvedi said as patients with tubes protruding from their throats and swollen jaws awaited their turn outside his office.
Gutka is sold at street stalls across India in bright rectangular pouches. Once opened, the powder emits a spicy smell. Inside the mouth, it has the consistency of gravel and creates a tingling sensation on the tongue. It’s the abrasion of the mouth’s lining that can accelerate the effect of nicotine and cancer-causing chemicals, according to Dhirendra Sinha, a technical officer for tobacco control at the WHO’s New Delhi office.
Street vendors crowd around schools, breaking Indian law, which prohibits the sale of tobacco products within 100 yards of educational institutions, says Devika Chadha, a program director at the Salaam Bombay Foundation, a nonprofit organization that works with schools to educate children about tobacco’s dangers.
In Khetwadi, a low-income neighborhood in Mumbai, on a recent morning, three street vendors had set up their 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 as he sat on a motorcycle chatting with friends. The habit is easy to sustain with “all these shops,” he said, pointing at the street stalls. He isn’t related to Safiq Shaikh.
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 the Geneva-based WHO.
Manufacturers like to keep gutka’s other ingredients a mystery. Rajendra Malu, who owns the brand called “Jhee,” says a pouch contains three-fourths areca nut, 12 percent tobacco flakes and proprietary fragrances he won’t disclose.
A chemical analysis of gutka highlighted in a 2008 report from the WHO found that it contains chromium, nickel, arsenic and lead as well as tobacco-related nitrosamines, all of which are known carcinogens.
Malu estimates he sold 250 million packets last year from his manufacturing plant in the western state of Gujarat. He 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 from the living room of his apartment in Mumbai’s Prabha Devi neighbourhood.
While gutka is mostly used in India, Pakistan, Bangladesh and Sri Lanka, its reach is worldwide because of migration, according to the International Agency for Research on Cancer.
“The practice of areca nut chewing and the presence of oral precancerous lesions are spreading from South Asia to the Western countries, with the potential of becoming a major public health issue,” researchers at the University of British Columbia in Vancouver wrote in a commentary published 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 U.S. teenage boys using smokeless tobacco went up to 4.4 percent from 3.4 percent between 2002 and 2007, according to a nationwide survey published by the Department of Health and Human Services.
Tobacco companies such as Philip Morris International Inc. and British American Tobacco Plc 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.
Altria Group Inc., which sells Marlboro cigarettes in the U.S., last month said profit had exceeded analysts’ estimates, helped by rising shipments of smokeless tobacco.
“There’s movement of consumption,” Chief Executive Officer Michael Szymanczyk in an Oct. 20 conference call. “Some of that movement is people smoking fewer cigarettes and using smokeless tobacco as an alternative.”
Smokeless, Not Harmless
A spokesman for Altria, Bill Phelps, declined to comment and deferred to a statement found on Philip Morris USA’s website that says public health authorities found smokeless tobacco products are addictive and can cause cancer, heart problems and diseases of the mouth, gums and teeth.
A British American Tobacco spokeswoman, Kate Matrunola, said some smokeless tobacco products like Swedish snus are less damaging than cigarettes, though “smokeless does not mean harmless.”
Earlier this month, delegates from governments of 171 countries, including India, agreed at the latest session of the WHO Framework Convention on Tobacco Control to regulate flavouring ingredients that are used to lure youngsters and focus more on control and prevention of smokeless tobacco.
In India, billboards, television commercials and even public transport buses around Mumbai advertise a fragrant chewable product close to gutka in texture and taste called pan masala. The difference: it contains no tobacco and it’s promoted as a breath freshener. The price, packets and street sellers are almost identical, though, increasing the confusion about which product is which, says Prakash Gupta, who heads the non-profit research firm Healis.
Godfrey Philips India Ltd., which is 25.1 percent-owned by Philip Morris International, began selling its own version of pan masala this year.
Gutka, whose name is derived from a Punjabi word meaning “a miniature version of Sikhism’s holy book of scriptures,” has a health warning on the packet and the image of a scorpion to indicate its use has been linked to cancer.
That’s not effective enough, says Jagdish Kaur, chief medical officer at the tobacco control unit of India’s Ministry of Health and Family Welfare, and a new set of tobacco warning labels with graphic images of mouth cancer has been approved.
People “need to be very clearly told” about the risks, Kaur said in a telephone interview. “It cannot be just a scorpion or butterfly or whatever.”
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. It’s also easy to store and transport.
“Selling it in packets has revolutionized the sale of smokeless tobacco in India,” says Babu Mathew, a dental surgeon who headed the Trivandrum Oral Cancer Screening project, which followed 200,000 residents of the southern Indian state of Kerala for 15 years.
Mathew says he has seen multiple cases of patients developing cancers five or 10 years after starting on gutka.
A panel convened by the WHO’s International Agency for Research on Cancer found in 2004 that areca nut caused cancer in animal studies, and that in humans it triggers the development of precancerous lesions. Tobacco, meantime, brings on genetic mutations that can lead to cancer.
Doctors point to three reasons why gutka bring on cancer much faster than cigarettes or 400-year-old paan. Both tobacco and areca nut play a role, say Mathew and Tata Memorial’s Chaturvedi.
The tobacco in gutka releases cancer-causing chemicals called nitrosamines in the mouth. In paan, they are neutralized 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, says Warnakulasuriya of King’s College London. 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, according to Chaturvedi.
“This injury and healing process is going on for 24 hours,” and over time it makes the inner lining of the mouth very stiff, Chaturvedi says.
The muscles in the mouth eventually lose their ability to stretch, resulting in a pre-cancerous condition called oral submucous fibrosis.
“From an uncommon disease found mainly among old persons in India, oral submucous fibrosis is emerging as a new epidemic mainly among the youth,” according to a 2004 report by India’s Ministry for Health and Family Affairs and the World Health Organization.
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.
“Before I could put four fingers inside, now I can only put two,” said Aqeel Shaikh, 32, Safiq’s older brother. Shaikh says he chewed six packets of gutka a day for six years before he gave up the habit.
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