An
Authored Article by Nilesh Jain, Managing
director, Harm Reduction Research & Innovation Centre (HRRIC) on “the Consumption of
smokeless tobacco products and the spurge in the rate of oral cancer across
India.”
“We
have to make sure that we empower people to assist them Quit or Switch”
With
a large disease and economic burden due to tobacco harm, India is among
the top countries with a high rate of oral cancer. India sees around one lakh
new cases of oral cancer each year with more than 90 percent of these
attributed to tobacco use Smokeless tobacco products (SLTs) account for over
one‐third of all tobacco consumed in India. It wouldn’t be
surprising to know that oral cancer incidence rates are at an all time high of
20 per 100000 population. Oral cancer now accounts for about 30% of all
types of cancers in India. Chewing betel
quid containing tobacco is a well‐established cause of oral cancer in India.
Apart from this traditional form of smokeless tobacco, tobacco with lime,
tobacco tooth powder and other new branded products have gained popularity
recently, especially in the backdrop of the gutka ban in several states across
India. XYZ, in conversation with Nilesh, unveils the enormous harm caused
by SLTs and the importance of harm reduction intervention for better public
health.
What
do you feel about the addiction of SLT among people in India?
According
to the available literature25.9% of adults use smokeless tobacco in India.
People often perceive “smokeless as harmless” and these products are often
promoted and marketed as a less harmful alternative to smoking. The most
consumed SLT in India is the chewing form of smokeless tobacco which contains
nicotine, the factor responsible for tobacco addiction. Some chewing tobacco
products contain microscopic abrasives which increase the rate of absorption of
nicotine and carcinogens into cell membranes. Another factor is the
disparities found in the tobacco market due to socio-demographic neighborhood.
Lower-income societies often become victims of tobacco marketing. The adults
are often induced to start using harmful substances through innovative
marketing strategies or through cultural influence. Apparently, women are most
commonly found using SLT products. They use their children to purchase tobacco
for them, thus exposing children at a very young age resulting in early initiation
and addiction. Due to less knowledge and awareness in such communities the
usage of smokeless tobacco products is higher. In addition to this, low
socio-economic groups also lack the resources required to combat the ill
effects or morbidities associated with tobacco consumption making it a clear
case of an “addiction crisis”.
How
does the consumption of SLT impact oral health?
For
smokeless tobacco users, the risk of cancer to the cheek and gum is nearly 50
times greater than non-users. 60-78% of smokeless tobacco users have been found
to have oral lesions. Smokeless tobacco products are known to contain more than
28 constituents that are carcinogenic in nature. The most harmful compounds in
smokeless tobacco are tobacco-specific nitrosamines (TSNAs) and their levels
are directly related to the risk of cancer. The commonly consumed SLT products
like Khaini, Mishri, etc. have a high concentration of TSNAs and have been
detected in the saliva of tobacco chewers. Studies state that based on the
behavioral differences in the usage of SLT products, the risk of oral
cancer is higher among females than in males. Carcinogens present in SLT
products are ingested and processed, leading to metabolic activation of
carcinogens. Chewing tobacco consists of areca nut, slaked lime, and tobacco
which elevates generation of reactive oxygen species (ROS), cellular turnover,
collagen synthesis, causes damage to DNA, fibroblast and even chromosomal which
overall contributes to oral mucosa fibrosis and ultimately oral cancer. In addition to oral cancer,
women also experience increased risk of infertility, pregnancy complications,
premature births, low birth weight infants, and stillbirths
Most
of the oral cancer cases are diagnosed in the advanced stages and the
disfigurement as well as dysfunctionality caused by the treatment further
affects the quality of life apart from imposing a financial burden.
What
do you think is the remedy?
I
believe we need further evidence-based published literature on SLT
cessation at par with smoking cessation. Vast amounts of data convincingly
demonstrate their presence in various forms of smokeless tobacco, but products
available in India have been examined in only scattered studies. Studies
assessing the efficacy of SLT cessation interventions must be carried out.
Another way to address this will be public education for awareness building on
behavioral change on Tobacco consumption and the introduction of harm reduction
concepts. Also, there should be an integrated health-care delivery mechanism
under the National Health Mission framework working at the district / rural
level that is focused on curbing TB, oral cancers andCOPD..
How
can harm reduction interventions reduce the lethal impact of SLT?
The
ability of the person to succeed in quitting substances completely depends on
the balance between the individual's motivation to quit substance use and his
level of dependence on the substances. We have to make sure that we empower
people to assist them to quit or switch to a healthier alternative. For any
harm reduction intervention to be effective, the motivation of the substance
user is indispensable. Also, the method of intervention is directly related to
the assessment of nicotine dependence. Public health professionals can use the
Fagerstrom Test for Nicotine Dependence to assess nicotine dependence for
referrals and appropriate interventions in the outreach programs. Training
related to the well being of the health after substance use through social
workers, NGOs and health professionals through
cessation techniques and tools can help users understand Reduced Risk
Products like proven Swedish Snus. Setting-up and strengthening of cessation
facilities including the provision of pharmacological & other RRP treatment
facilities at the district level can help us address the issue at the grassroot
level. SLT cessation intervention-based research needs to be encouraged,
especially in the low-income group countries which have weak tobacco cessation
support. Organizations like Harm Reduction Research & Innovation center are
actually working towards tobacco cessation and adopt an evidence-based approach
to support the policymakers, social planners and product developers to deliver
innovative harm reduction techniques and further reduce individual drug-related
harm.
(Anand et
al., 2014)
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