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  Table of Contents  
Year : 2014  |  Volume : 51  |  Issue : 5  |  Page : 1-2

Smokeless tobacco use and public health in countries of South-East Asia region

Regional Director, World Health Organization, Regional Office for South East Asia, New Delhi, India

Date of Web Publication19-Dec-2014

Correspondence Address:
P K Singh
Regional Director, World Health Organization, Regional Office for South East Asia, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.147415

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How to cite this article:
Singh P K. Smokeless tobacco use and public health in countries of South-East Asia region. Indian J Cancer 2014;51, Suppl S1:1-2

How to cite this URL:
Singh P K. Smokeless tobacco use and public health in countries of South-East Asia region. Indian J Cancer [serial online] 2014 [cited 2022 Dec 7];51, Suppl S1:1-2. Available from:

World Health Organization (WHO) South-East Asia region (SEAR) is home to nearly 90% of global smokeless tobacco (SLT) users that is over 250 million from among 300 million SLT users in the world. SLT is chewed, sucked, snuffed orally and nasally, sipped or gargled and applied on teeth and gums as dentifrice. Myriad varieties of SLT products for each of these are available in countries of the WHO SEAR. Among all SLT products, traditionally betel quid has been the most commonly used product in most countries, including Bangladesh, Maldives, Myanmar, Sri Lanka, and Thailand. However, Khainee, a mixture of tobacco with slaked lime, is used most commonly in India and Nepal. Nearly, 5% of the adult population use tobacco as dentifrice in Bangladesh and India. Most of the SLT products used in countries of SEAR are found to be mutagenic, carcinogenic, cardiotoxic and contain heavy metals.

WHO SEAR is the biggest producer and user of SLT products, but with a wide variation across countries. The prevalence of SLT among adults varies from 1.1% in Thailand to 51.4% in Myanmar among men, while it ranges from 1.9% in Timor-Leste to 27.9% in Bangladesh among women. In Bhutan, India, Myanmar, Nepal, and Sri Lanka, SLT use was found to be higher among males as compared to females; however, in Bangladesh, Indonesia, and Thailand, SLT use was higher among females as compared to males. Within countries also, the prevalence of SLT use varies widely in different parts. For instance, the prevalence of current use of SLT in India ranges from 48.7% in Bihar to 4.5% in Himachal Pradesh. In Thailand, prevalence of current use of SLT varies from 0.8% in Bangkok to over 4% in the northern and north-eastern region; in Nepal prevalence varies from 10.1% in midwestern to 19.7% in the eastern region.

[TAG:2]Increasing Trend of Smokeless Tobacco Use Among Youth in Countries of South-East Asia Region [/TAG:2]

Global Youth Tobacco (GYTS) Survey has been periodically implemented in countries of the WHO SEAR. The findings from GYTS 2013 indicate that the prevalence of current use of SLT among school going youth aged 13-15 years varies from 5.0% in Thailand to 23.2% in Bhutan; among boys from 7.1% in Bangladesh to 27.2% in Bhutan; and among girls from 3.7% in Bangladesh to 19.8% in Bhutan.

The findings from GYTS conducted at different time periods indicate that the prevalence of SLT is significantly higher among boys than girls in Bhutan (2013), India (2009), Maldives (2011), Myanmar (2011), and Sri Lanka (2011). The prevalence of current SLT use remains almost the same in Bangladesh (2007-2011), India (2006-2009), Myanmar (2007-2011) and Sri Lanka. However, in Bhutan, the prevalence of current SLT use has increased from 9.4% in 2009 to 23.2% in 2013 and from 6.1% in 2007 to 16.2% in 2011 in Nepal.

  Dual Use Top

Health risks associated with exclusive use of one form of tobacco alone has a different health risk profile when compared to dual use (smoking + SLT). Dual users may have a harder time quitting tobacco than those who only smoke or use SLT. Dual users are at additional risk of cancers and heart diseases compared to users of single form of tobacco.

Based on the findings from the Global Adult Tobacco Survey (GATS) in Bangladesh, India, Indonesia and Thailand and STEPwise approach to surveillance of Non Communicable Diseases risk factors (NCD STEPS) Surveys in Bangladesh and Myanmar, dual use was more prevalent among males. Dual use is nearly 20% in Bangladesh and India and over 30% in Myanmar. It is less prevalent in Indonesia (2.2%) and Thailand (1.0%). Dual use is higher among males and increases with age, and decreases with higher education and possession of wealth. In addition, dual users of tobacco in Bangladesh had lower body mass index indicating more undernourishment compared to non-users.

  Smokeless Tobacco Use Attributable Deaths Marked Among Women Top

SLT users are at higher risk of all-cause mortality and mortality from specific diseases. Relative risks are generally higher for women compared with men being 1.34 (1.27-1.42) for women and 1.17 (1.05-1.42) for men. The number of deaths attributable to SLT use in India is estimated to be 368,127 with a higher number of deaths among women (217,076) compared with men (151,051).

A major disease consequence of SLT use is oral cancer, myocardial infarction and other cardiovascular diseases are also demonstrated as potential disease consequences of SLT use. Betel quid chewing, with added tobacco, increases the risk of oral/oropharyngeal cancer in an exposure-dependent manner, independently of tobacco and alcohol use. The relative risk for oral/oropharyngeal cancer is 7.74 for chewing betel quid with tobacco; being much higher in women (14.56) than in men.

Although, there is no report on all-cause mortality and cause-specific mortality for individual SLT products, one study from Bangladesh reported high relative risk with Gul (tobacco product used as dentifrice) for cardiac ailments.

  Rising Incidence of Mouth Cancer in SEAR Top

The incidence of mouth cancer is increasing in SEAR especially among the younger generation. The findings from a recent study conducted in Ahmedabad, India show that the age-specific incidence rates of mouth cancer have increased over the time. This increase was found to be very rapid in the younger age groups. The increase in mouth cancer could be clearly related to increasing in gutka consumption. Gutka has now been banned all over India, but a more vigorous implementation is necessary.

  Smokeless Tobacco Control Policies in Countries of SEAR Top

Many countries in SEAR have initiated steps to regulate SLT. Bhutan and Thailand have banned import of SLT products. Bhutan introduced a policy to ban the manufacture and sale of tobacco products, including SLT products, in 2004 and introduced comprehensive legislation to implement the 2004 policy in 2010. Bangladesh, India, and Nepal have policies to implement graphic health warnings on SLT products. Individual states in India invoked food safety laws in 2011 to ban gutka and pan masala containing tobacco, the most common forms of SLT products used by youth. A few states in India have banned production and sale of flavored and packaged SLT products. India has also strengthened pictorial health warnings and used intensive mass media campaigns to inform people about the harms of SLT. The country has also introduced SLT cessation in the tobacco dependence treatment guidelines and in the National Tobacco Control Program. In the area of taxation, India has introduced presumptive taxes on SLT, based on number and production capacity of machine. Consequently, revenue collection on SLT products has increased more than fourfold in the last five years. Nepal has banned the use of SLT products in public places. Bangladesh, India, and Nepal have legally mandated pictorial health warnings covering 50%, 85%, and 75% respectively of the principal display areas on SLT packaging. In 2013, a comprehensive tobacco control legislation of Bangladesh included SLT. Myanmar has banned use of betel quid chewing in government premises. However, the countries of the SEAR lack adequate laboratory testing capacity to test for constituents of SLT products.

  Community-Based Tobacco Cessation Program Top

There is a lack of tobacco cessation programs in countries of the SEAR. WHO had supported several initiatives for training health professionals and established clinical and community cessation programs but it has not been integrated into national programs or and in primary health care. There is a scarcity of literature especially on SLT cessation. One recent study has indicated that tobacco use among family members and in the community was the primary reason for initiation and addiction to tobacco. Health education and counseling did encourage quitting with quit rate up to 33.5%. Changing cultural norms associated with SLT, strict implementation of antitobacco laws in the community and work places and providing cessation support are important measures in preventing initiation and continuation of tobacco use.

  Effect of Tobacco Industry Interference on Smokeless Tobacco Use Among Adults Top

Tobacco industry employs specific marketing tactics which include advertising at the point of sale, sales at discounted prices, free coupons, free samples, surrogate advertisements, and other modalities. Like everywhere else, in SEAR also, advertisement influences youth for initiation of tobacco use. Adults are also more likely to use SLT with even a low level of exposure to SLT marketing.

  Economics of Smokeless Tobacco Use in India and Bangladesh Top

Most of the economics research on tobacco focuses only on cigarettes, however increasing taxes even for the SLT products can have significant negative impact on the prevalence.

Even though, there is some price rise in SLT products, it is less than the income growth indicating increasing affordability. Thus, the tax increase on SLT products needs to take care of inflation as well as affordability. Also, taxes on SLT products should not be less than taxes on smoked tobacco products to avoid a wide price differential between the two types of products that may encourage substitution discouraging quitting behavior.

There is substantial movement in the direction of SLT control in the SEAR but much is needed to be done, especially on strengthening policies and its implementation, people's education on the harm of SLT use, health professionals training on SLT cessation and sensitization of policy makers. As recommended by the expert groups, I urge member states in the SEAR to improve surveillance of SLT products, to increase taxes on SLT products (in line with other smoking tobacco products such as cigarettes), to bring about a rise in price; to estimate price elasticity for SLT products to quantify the effect of price change on consumption; to introduce a comprehensive ban on the manufacture, import, sale, and promotion of any new SLT product and strictly regulate those that are already in the market; to have a license requirement for all SLT vendors with strict application of relevant legislation and trading standards - for example sale to minors; and to offer appropriate cessation support to people who use SLT and assess the effectiveness of cessation interventions.


The author alone is responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.


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