Public Health

In India, an Epidemic of Oral Cancer


Safiq Shaikh was 13 when he began chewing a blend of tobacco and spices that jolted him awake whenever his job at a textile loom got too dreary. Five years later, doctors in Mumbai lopped off his tongue to halt the cancer spreading through his mouth.

Shaikh believed the fragrant, granular mixture he chewed, known in India as gutka, was harmless, so at first he ignored the milky lump growing inside his mouth. Now he is one of about 200,000 Indians diagnosed with a tobacco-related malignancy this year, says his surgeon, Dr. Pankaj Chaturvedi, who works at Tata Memorial Hospital in Mumbai.

Chaturvedi says a group of entrepreneurs known as "gutka barons" bear much of the blame for this epidemic by mass marketing a mix of tobacco and areca nut for 1 rupee (2 cents) a pack on street corners across India. Sales of chewing tobacco in India, worth 210.3 billion rupees ($4.6 billion) in 2004, are on track to double by 2014, according to Datamonitor, the international research firm. Before, a traditional chewing mixture, known as paan, came with or without tobacco. It had to be handmade, was messy to carry around, and lacked modern packaging. "Now you have an industrial version of a traditional thing" spurring demand, says Chaturvedi.

On Dec. 7, India's Supreme Court banned the sale of tobacco products in plastic wrappers as of Mar. 1, citing harm to public health and environmental damage from improper disposal of the packets. The ban on the cheap, colorful packaging was aimed directly at the gutka merchants. Yet the sale of gutka remains legal, and marketers may switch to other packaging.

Gutka creates a tingling sensation on the tongue. It's the abrasion of the mouth's lining—caused by coarse chunks of areca nut—that can accelerate the effect of nicotine and cancer-causing chemicals, according to Dhirendra Sinha, a technical officer for tobacco control at the New Delhi office of the World Health Organization (WHO).

Street vendors of gutka 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 that works with schools to educate children about tobacco's dangers. "I have seen many children who started chewing gutka when they were 8 or 10 years old and got cancer in their teens," Chaturvedi says as patients with tubes protruding from their throats wait their turn outside his office.

While Indian law bans the consumption of tobacco products before the age of 18, enforcement of the law is spotty, says Chadha. The federal government says it's up to the states to enforce these laws, and often the states lack the resources. According to the Press Trust of India, the Indian news service, a minister in the Maharashtra state government, which includes Mumbai, said on Dec. 24 that school principals will be given authority to fine gutka vendors who set up stalls within 100 meters of their school.

In Khetwadi, a poor Mumbai neighborhood, three street vendors on a recent morning set up stalls about 55 yards from Sant Gadge Maharaj College as students gathered near the school gates. Javeed Shaikh, 21,(no relation to Safiq Shaikh) 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 says.

Rajendra Malu, who owns the company that makes the Jhee brand of gutka, says a pouch contains three-fourths areca nut and 12 percent tobacco flakes, as well as proprietary fragrances he won't disclose. A chemical analysis of gutka in a 2008 report from the WHO found that a typical mix contains chromium, nickel, arsenic, lead, and tobacco-related nitrosamines, all known carcinogens.

Malu estimates he sold 250 million packets last year made at his plant in Gujarat state. 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 says. On being asked about children's consumption of gutka, he replies, "This is not a fact."

A survey of 1,500 Mumbai residents aged 13 to 15 found that double the students identified themselves as tobacco chewers vs. a decade ago, according to Healis, a public health research institute. In accordance with the law, packages of gutka bear a health warning and the image of a scorpion to indicate its use has been linked to cancer. That's not effective, says Jagdish Kaur, chief medical officer at the tobacco control unit of the Ministry of Health & Family Welfare. While the government has just mandated a new set of warning labels on tobacco products to show graphic images of mouth cancer, the industry has gotten a one-year delay in publishing them.

Gutka brings on cancer much faster than its traditional handmade counterpart, says Saman Warnakulasuriya, a professor of oral medicine at King's College London. The tobacco releases nitrosamines while the chemicals in areca nut stimulate the production of collagen, a protein that thickens the mouth's muscles. Abrasions from the areca 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," he says: Over time it stiffens the inner lining of the mouth, resulting in a pre-cancerous condition called oral submucous fibrosis. Once a a disease of the elderly, it is now spreading to young Indians, according to a government report.

Patients who previously could grab a sizable chunk of an apple in a single bite are eventually 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," says 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.

The bottom line: A mass-produced chewing tobacco in India that is popular among teenagers is triggering a surge in mouth cancers.

Narayan is a reporter for Bloomberg News in Mumbai.

Later, Baby
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