Patterns of dual use of cigarettes and smokeless tobacco among US males: findings from national surveys

Scott L Tomar; Hillel R Alpert; Gregory N Connolly

doi:10.1136/tc.2009.031070

Responses

PDF

Research paper

Patterns of dual use of cigarettes and smokeless tobacco among US males: findings from national surveys

Compose a Response to This Article

Compose Response

Title *

Author Information

Contributors
First Name and Middle Initial * First or given name, e.g. 'Peter'. Last Name * Your last, or family, name, e.g. 'MacMoody'. Email Address * Your email address, e.g. higgs-boson@gmail.com Occupation * Your role and/or occupation, e.g. 'Orthopedic Surgeon'. Affiliation * Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

PLEASE NOTE:

A rapid response is a moderated but not peer reviewed online response to a published article in a BMJ journal; it will not receive a DOI and will not be indexed unless it is also republished as a Letter, Correspondence or as other content. Find out more about rapid responses.
We intend to post all responses which are approved by the Editor, within 14 days (BMJ Journals) or 24 hours (The BMJ), however timeframes cannot be guaranteed. Responses must comply with our requirements and should contribute substantially to the topic, but it is at our absolute discretion whether we publish a response, and we reserve the right to edit or remove responses before and after publication and also republish some or all in other BMJ publications, including third party local editions in other countries and languages
Our requirements are stated in our rapid response terms and conditions and must be read. These include ensuring that: i) you do not include any illustrative content including tables and graphs, ii) you do not include any information that includes specifics about any patients,iii) you do not include any original data, unless it has already been published in a peer reviewed journal and you have included a reference, iv) your response is lawful, not defamatory, original and accurate, v) you declare any competing interests, vi) you understand that your name and other personal details set out in our rapid response terms and conditions will be published with any responses we publish and vii) you understand that once a response is published, we may continue to publish your response and/or edit or remove it in the future.
By submitting this rapid response you are agreeing to our terms and conditions for rapid responses and understand that your personal data will be processed in accordance with those terms and our privacy notice.

I agree to and have read the terms and conditions for rapid responses and BMJ Privacy Notice *

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Other responses

Jump to comment:

Use of Smokeless Tobacco (SL): a cause of oral sub-mucosal fibrosis (OSMF/OSF), an alarming health situation in India and regional countries- is rising rapidly.
Chitta Ranjan CHOUDHURY
Published on: 13 May 2016
Gutkha-Ban (commercial brand of STs) in India is not implemented properly
Chitta R CHOWDHURY
Published on: 13 May 2016

Published on: 13 May 2016
Use of Smokeless Tobacco (SL): a cause of oral sub-mucosal fibrosis (OSMF/OSF), an alarming health situation in India and regional countries- is rising rapidly.
- Chitta Ranjan CHOUDHURY, Professor & Director
- Other Contributors:
  Ashoka D C, Aviduti, C and T Kirita
I refer to the recently published paper- 'Scott L Tomar, Hillel R Alpert and Georgery N Connolly. Patterns of dual use of cigarettes and smokeless tobacco among US males: findings from national surveys. Tob Control 2010;19:104-109'.
The rising trend of smokeless tobacco (ST) use, among adolescent and young adults is not only a problem in the USA, it is equally affecting the same age group population in India and...
Show More

I refer to the recently published paper- 'Scott L Tomar, Hillel R Alpert and Georgery N Connolly. Patterns of dual use of cigarettes and smokeless tobacco among US males: findings from national surveys. Tob Control 2010;19:104-109'.
The rising trend of smokeless tobacco (ST) use, among adolescent and young adults is not only a problem in the USA, it is equally affecting the same age group population in India and SE Asian Countries. In India, this age group (10-24 years old) has 315 million people (30% of total population), since India is home to just over 1.18 billion, the second largest population in the world (1). Although this cohort is healthier, and their literacy rate is higher, unfortunately, this population group is at the highest risk of chewing tobacco related fatal consequences and developing nicotine addiction. Alarmingly, a significant proportion of Indian youths is developing chewing tobacco related oral/dental diseases of high morbidity rate, and of them, oral sub-mucosal fibrosis (OSMF/OSF), a disabling oral health problem, manifested with the burning mouth sensation, restricted mouth opening, dysarthria, dysphagia and sometimes loss of hearing functions, especially in advanced cases. OSF has got high malignant transforming potential (2-10%, thus risking of full blown oral cancer (20~25% of all cancers in India, varies at locations and the regional countries).
It is a serious public health concern in India. Now-days smoking tobacco (Beedi-Indian version of smoking tobacco and conventional cigarette) is gradually being replaced with smokeless tobacco (SL). The product is marketed in various brands of chewing tobacco sachets; among them, Gutkha, Kaini, Paan-parag are common (2). These products are extremely popular, cheaper (compared with cigarettes), commonly available in every corner of the countries, and use is unrestricted in public places, unlike smoking. We studied 9,288 hospital attending cases, measuring their knowledge, attitude and practice (KAP score). The study reveled that a significant proportion of this population is unaware of the ill-effects of chewing tobacco, and a high proportion of the population both chews and smokes tobacco (2). In India SL is classified in five groups (3). Although none of the SL products in India is exactly similar to Swedish wet Snus, or up-coming Japanese ST 'Zerostyle Mint' (4), but Khaini is one which is wet. Khaini is commercially available and could be prepared at home or work-places, just by buying a sachet of tobacco flecks and a mini-tube of calcium hydroxide (slaked lime). This wet variety of SL, ie. Khaini is a very dangerous product. A study revealed that Khaini causes loss of hyterozygocity (LOH) of the chromosomes, and may delete and mutate a number of tumor suppressor genes 'TSGs'(5). ST use is now a global problem, not only confined within the SE Asian population (including SE Asian migrants in USA and Europe), but also in China, Taiwan, Indonesia, Malaysia, Sigapore, Phillipines, and Africa. In my opinion, the FCTC of WHO should come forward with a special focus and strategic plan to prevent and control ST and ST related health problems. A small interest /working group is in progress to study ST related OSF in India and regional countries. The group welcomes any advisory support and participation.
References.
(1). Ministry of Statistics & Programme implementation, East Block 10, R K Puram, New Delhi-110066 http://mospi.nic.in/ (visited 20.05.2010).
(2). Chitta Ranjan Choudhury. Effects of KAP intervention on oral mucosal lesions associated with personal habit(s). In. Publisher Nitte University, India in association with Bournemouth University, UK ; pp.59- 63, 1st ed. February 2010. BDA (British Dental Association) Lib Cat. No. Class No: D 781 CHO http://bdalib.answeb.co.uk/amlibweb/webquery.dll
(3). Chitta Ranjan Choudhury. Classification of marketed quid sachets based on composition In. Handbook of Oral Cancer Screening & Education. Publisher Nitte University, India in association with Bournemouth University , UK ; pp.11,12 & 65-67. 1st ed. February 2010. BDA (British Dental Association) Lib Cat. No. Class No: D 781 CHO http://bdalib.answeb.co.uk/amlibweb/webquery.dll
(4). Japan Tobacco Inc. (JT) (TSE: 2914). JT to Launch New Style of Smokeless Tobacco Product 'Zerostyle Mint'. http://www.jt.com/investors/media/press_releases/2010/0317_01/index.html (Visited 21.05.2010)
(5). Nobuharu Y, Tsukasu K, Akia K, Takahiko S and Chitta Choudhury. Loss of Heteozygosity (LOH) on Chromosomes 2q, 3p and 21q in Indian squamous cell carcinoma. Bull Tokyo Dent Coll (2007) 48 (3): 109-117.
Authors
1. Chitta Ranjan Choudhury*
(Correspondence) Professor & Director, International Centre for Tropical Oral Health Poole Hospital NHS and Bournemouth University, England, UK. And Dept Oral Biology & Genomic Studies, ABSM Dental Sciences, Nitte University, Mangalore, India.
Lead, OSF interventions: a multicentric study initiative.
cr_choudhury@yahoo.co.uk chittarc@bournemouth.ac.uk
2. Dr. Ashoka Dey, Registrar, Paediatrics, King's College Hospital, London.
3. Avidyti C, St Georges Mecical School, University of London.
4. Tadaaki Kirita, Professor & Chairman, Oral & Maxillofacial Surgery, Nara Medical University, Nara, Japan.
Conflict of Interest:
None declared
Show Less

Conflict of Interest:
None declared.
- Back to top
Published on: 13 May 2016
Gutkha-Ban (commercial brand of STs) in India is not implemented properly
- Chitta R CHOWDHURY, Professor, Nitte University ABSMIDS Dept of Oral Biology & Genomic Studies, Mangalore, India | C
- Other Contributors:
  Edward Lynch, Head Warwick Dentistry, UK and T. Kirita, Oral & Maxillofacial Surgery, Nara Medical University, Japan
NOT PEER REVIEWED Smokeless Tobacco(ST) such as Gutkha-ban (and the like) in India does not work!
There have been repercussions from sections of growers following the ban of Gutka (and similar products) in Karnataka, a South -Western state of India with the highest production of Areca-nut (one of the major constituents of ST, used in commercial sachet (such as Gutka etc) and home-made/vendor-made Tambula/Paan...
Show More

NOT PEER REVIEWED Smokeless Tobacco(ST) such as Gutkha-ban (and the like) in India does not work!
There have been repercussions from sections of growers following the ban of Gutka (and similar products) in Karnataka, a South -Western state of India with the highest production of Areca-nut (one of the major constituents of ST, used in commercial sachet (such as Gutka etc) and home-made/vendor-made Tambula/Paan as well.
It is essential to ban Gutkha, because tobacco containing Gutkha is highly carcinogenic, killing millions of Indian and SE- Asian people annually. Some of the areas of India have higher incidence rates of mouth cancer -- more than 30% of all cancers are oral cancer, and there is no doubt that the tobacco containing Gutkha and Tambula/Paan (usually home or vendor-made: it's a local name in Karnataka and other states of India) is strongly associated with mouth cancer-- evidenced by several studies conducted elsewhere. Hence banning of Gutkha is a step forward to help prevent mouth and head-neck cancer-- provided it has been implemented properly. But the setback of the ban is that none of the state governments and relevant agencies in India have so far come up with a strategic way of implementing the ban, including evaluation of its effectiveness. In this context, I mention that the estimated growth rate of new Gutkha and similar commercial sachets is much higher compared to the pre-ban era, and a few expensive brands are also advertised on some of the national TV channels.(Source:Department of Oral Biology & Genomic Studies, Nitte University, India)
However, as one of the member-states of UN, India has signed the Framework Convention for Tobacco Control of WHO, and the country is obliged to comply with that directive. Rightly India has got its own parliamentary verdict to ban tobacco consumption such as smoking in public places (although 'public place' is not clearly defined, and there is no definite say on Gutkha-chewing habits. On this I wrote to WHO published ( http://www.who.int/bulletin/bulletin_board/82/news06041/en/index1.html).
We understand that the police can catch and penalize a smoker violating smokefree laws, but not a chewer.
Therefore, as one of the researchers in tobacco addictions at Nitte University of India jointly with the Warwick University of the UK also being a Stakeholder of smokeless tobacco (ST) control of National Institute of Clinical Excellence (NICE) at the department of Health (DoH) in the UK, I find the demand of Areca-nut growers in Karnataka needs to be solved amicably and sensibly, because, although millions of people may depend upon Areca-farming, we cannot reconcile their living with the expense of the rising death toll from mouth cancer and disturbing disability from Oral Sub-mucus Fibrosis(OSF).
However, according to classification of Gutkha (ref. Oral Cancer Screening & Education: A Guideline Protocol: authored by Professor Chitta Chowdhury http://www.nature.com/bdj/journal/v210/n9/full/sj.bdj.2011.380.html), I need to say that "Pan-Parag" and similar products may not have tobacco in them. So probably it will be difficult to ban all the sachets not containing tobacco. But the commercial sachets containing Areca-nut without tobacco are also carcinogenic. Again the elemental copper in Areca-nut is one of the causes of oral sub-mucus fibrosis (OSF)- a disabling disease condition mentioned, and 2-7% OSF turns into full-blown mouth cancer--this is a public health concern too. If we are able to reduce the concentration of copper to a permissible limit in Areca -nut(The minimum recommended dietary allowance (RDA) for copper is 0.9 milligrams per day for most adults, 1 milligram for pregnant women, and 1.3 milligrams for women who are breast-feeding: Source-FDA, USA) or to produce totally copper-free Areca-nut, also removing carcinogenic compounds, this could be good news for the Areca-nut growers. Of course, there are many beneficial effects of Copper, but continuous consumption (by habitual chewers) of Areca-nut will exceed RDA and cause adverse effects, such as OSF and eventually cancer.
In this context, I strongly recommend that we need to ensure that none of the Gutkha and "Pan-Parag" sachet contains tobacco products or any carcinogenic compounds, including Areca-nut, and in my opinion that is absolutely impossible. Therefore, a complete ban of commercial sachets (eg. Gutkha etc) is a must. Also how to stop vendor-made and home-made Tabula/Paan products needs to be addressed urgently, because there are carcinogenic products in them as well, and these are consumed by more people compared to commercially produced Sachets. Now the question is-- how the law enforcement, health and safety regulators and policy- administrators will effectively implement the ban of Gutkha(ST) in India.
Professor Chitta Chowdhury NRT Services and Addiction Research Unit Oral & Maxillofacial Cancer Services (Prevention & Control), Department of Oral Biology & Genomic Studies, Nitte University, Deralakatte, Mangalore-675018, India & The University of Warwick Education & Development Medical Faculty PG Dentistry aliened with De Monte University of Leicester, England.
C.R.Chowdhury@warwick.ac.uk crc.ob.cod@gmail.com
Conflict of Interest:
None declared
Show Less

Conflict of Interest:
None declared.
- Back to top

Main menu

Plain text

PLEASE NOTE:

Vertical Tabs

Other responses

Jump to comment:

Conflict of Interest:

Conflict of Interest:

Log in using your username and password

Main menu

Log in using your username and password

You are here

Plain text

PLEASE NOTE:

Vertical Tabs

Other responses

Jump to comment:

Conflict of Interest:

Conflict of Interest:

Read the full text or download the PDF:

Log in using your username and password