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Impact of 'gutkha and pan masala ban' in the state of Maharashtra on users and vendors

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Background: Gutkha and pan masala contain harmful and carcinogenic chemicals. Hence, Maharashtra Government banned their manufacture, storage, distribution and sale on 19 th July 2012 for a year. Objectives: The objective of this study is to determine the impact of the ban on gutkha and pan masala on its users and vendors. Materials and methods: A cross- sectional study was conducted among gutkha and/or pan masala users and tobacco vendors in the selected area of Mumbai city, 4-6 months after the implementation of the ban. The parameters studied included knowledge regarding the ban, usage or discontinuation of use of the banned products, product availability, withdrawal symptoms among quitters, etc., Results: A total of 68 users and five tobacco vendors were enrolled in this study. Although all users were aware about the ban on gutkha, very few knew about the ban on pan masala. Only 5.9% of users knew that currently the ban had been declared for only 1 year. Electronic media was the main source of information regarding the ban as reported by 45.6% users. All users and vendors were in favor of the ban. After the ban, 23.53% gutkha users quit their habit while 55.88% reduced their gutkha consumption. Non-availability of gutkha was the most important reason stated by the gutkha users for quitting or reducing the consumption. In spite of the ban, gutkha is still available in the market, but at an increased cost or in a different form. Conclusion: Nearly 23.53% of gutkha users have quit their habit post-ban despite its availability through illegal sources.
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129
Indian Journal of Cancer | April–June 2014 | Volume 51 | Issue 2
Impact of ‘gutkha and pan masala ban’ in the state of Maharashtra
on users and vendors
Mishra GA, Gunjal SS, Pimple SA, Majmudar PV, Gupta SD, Shastri SS
Department of Preventive Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
Correspondence to: Dr. Gauravi Mishra, E‑mail: gauravi2005@yahoo.co.in
Abstract
BACKGROUND: Gutkha and pan masala contain harmful and carcinogenic chemicals. Hence, Maharashtra Government banned their manufacture,
storage, distribution and sale on 19th July 2012 for a year. OBJECTIVES: The objective of this study is to determine the impact of the ban on gutkha
and pan masala on its users and vendors. MATERIALS AND METHODS: A cross‑ sectional study was conducted among gutkha and/or pan masala
users and tobacco vendors in the selected area of Mumbai city, 4‑6 months after the implementation of the ban. The parameters studied included
knowledge regarding the ban, usage or discontinuation of use of the banned products, product availability, withdrawal symptoms among quitters,
etc., RESULTS: A total of 68 users and five tobacco vendors were enrolled in this study. Although all users were aware about the ban on gutkha,
very few knew about the ban on pan masala. Only 5.9% of users knew that currently the ban had been declared for only 1 year. Electronic media
was the main source of information regarding the ban as reported by 45.6% users. All users and vendors were in favor of the ban. After the ban,
23.53% gutkha users quit their habit while 55.88% reduced their gutkha consumption. Non‑availability of gutkha was the most important reason
stated by the gutkha users for quitting or reducing the consumption. In spite of the ban, gutkha is still available in the market, but at an increased
cost or in a different form. CONCLUSION: Nearly 23.53% of gutkha users have quit their habit post‑ban despite its availability through illegal sources.
Key Words: Ban, gutkha, pan masala, smokeless tobacco
Introduction
Gutkha and pan masala products were advertised and
marketed aggressively in South East Asia during the last
three decades, as a substitute for betel quid. Claimed to
be safer products, they are consumed by both old and
young population, specifically in India.[1] Although gutkha
is sweetened, flavored mixture of areca nut, catechu, slaked
lime, condiments and powdered tobacco, the same mixture
excluding tobacco is pan masala. Both these products
available in the market with identical brand names and
packaging and sold in small, brightly coloured packets, hold
a special appeal for children.[2] Various reports indicate the
increasing usage of these products in vulnerable sections
of the society.[1,3,4] The gutkha and pan masala industry
today is worth crores of rupees.[5] Their usage causes oral
sub mucous fibrosis, leucoplakia, erythroplakia and other
debilitating conditions named as “gutkha syndrome” by
Chaturvedi.[6,7]
Based on several reports indicating health hazards caused,
efforts are undertaken to ban the production, consumption,
sale, storage and transportation of gutkha and pan masala
by many states in India. Tamil Nadu banned gutkha in
2001 followed by Andhra Pradesh, Goa, Maharashtra
and Rajasthan in August 2002.[5] Subsequently after legal
battles, the ban in Maharashtra was lifted. However,
following example of the eight other states, Government
of Maharashtra finally banned the manufacture, storage,
distribution and sale of gutkha and pan masala, containing
either tobacco and/or nicotine or magnesium carbonate
as ingredients by whatsoever name these are available in
the market and any other products marketed separately to
constitute gutkha and pan masala as final products, effective
July 19, 2012.[8] Until May 2013, 26 states had banned
gutkha.
The ban, initiated by Food and Drug Administration (FDA)
under the Food Safety and Standards Act (FSSA), 2006 and
Prevention of Food Adulteration Act, 1954, was facilitated
by the new FSSA. As per the Government regulation,
offenders would face imprisonment for 6 months to 3 years.
The Bombay high court has upheld the ban on gutkha and
pan masala, both flavored tobacco products, in Maharashtra.
Though petitioners had argued that FDA had no power to
ban gutkha as it was not a “food” under the Act, the court
held that gutkha and pan masala fell within the definition
of “food” under the FSSA and thus commissioner of FDA
had the authority to ban them.
Considering the addictive potential of the ingredients of
gutkha and pan masala, recording the effect of their ban on
regular consumers, i.e., whether they have quit consumption
or are still getting the products by illicit trade or shifted to
other tobacco products, would be noteworthy. Similarly, the
challenges faced by quitters and experience of any withdrawal
symptoms will be of significance while devising cessation
strategies for this group. If regular consumers discontinue
consumption of gutkha and pan masala because of ban, it
would be a positive indication in support of legal ban for the
maintenance of proper public health. Thus, the response of
gutkha and pan masala users to the ban needs to be studied.
Understanding the awareness and the reactions of the
tobacco vendors about the ban is important for the further
development of public health strategy to sustain the gutkha
and pan masala ban.
Materials and Methods
This is a cross-sectional study conducted among low
socio-economic community in suburbs of Mumbai PMGP,
Mankhurd area and was one of the communities selected for
the departmental outreach cancer prevention and screening
program. A list of tobacco users in this community was
thus obtained from our previous outreach program. A list
of eligible participants was prepared by enlisting male and
female tobacco users who consumed gutkha and/or pan
masala at the time of the ban through house-to-house survey.
After identifying all important stakeholders in the community,
such as community leaders, non-governmental organizations
and health care providers, meetings were held to establish
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Table 1: Analysis of various factors responsible for
quitting the habit of gutkha consumption
Variable Gutkha
users
Quitters %
Age
<30 27 18.52
31-40 25 20.00
>40 16 37.50
Gender
Male 60 23.33
Female 08 25.00
Religion
Hindu 25 24.00
Muslim 28 27.78
Others 15 33.33
Education
Illiterate 7 28.57
Primary/secondary 51 23.53
Higher secondary and above 10 20.00
Marital status
Unmarried 16 12.50
Married 52 26.92
Age at initiation
10-20 35 17.14
21-30 16 18.75
31-40 7 57.14
>40 10 30.00
Duration of use
1-5 31 22.58
6-10 10 30.00
11-15 14 21.43
>15 13 23.08
OR=Odds ratio; CI=Confidence interval
community rapport and explain the significance of the current
study. The medical social workers (MSWs) of the study
were given the necessary training at Preventive Oncology
Department. A pre-designed proforma was pilot tested in the
community and necessary changes were made. Suitable time
of the day was identified for the interview so as to maximize
the response rate. All persons 18 years or above, using gutkha
and/or pan masala at the time of implementation of the ban
from the selected community and willing to give consent
were included in this study, whereas all tobacco vendors above
18 years in the locality were eligible to participate.
MSWs undertook house-to-house visits only of male and
female tobacco users in the community (as identified in
the previous project). The MSWs conducted a short survey
to identify the gutkha and pan masala users amongst this
population (at the time of implementation of the ban).
The eligible participants were explained the objectives and
methods of the study and were then invited for participation.
A written informed consent was obtained from those
willing to participate while the left hand thumb impression
was obtained from the illiterates. A person from the same
community invited to witness the procedure of informed
consent signed as an impartial witness. Help of a translator
was opted whenever necessary. The invited participants were
given the patient information sheet. Only after obtaining the
informed consent, the participants were enrolled in the study
and interviewed using a pre-designed and pre-tested proforma
questionnaire. The MSWs conducted personal interviews and
recorded data from the participating gutkha and pan masala
users. Tobacco vendors were also interviewed using another
set of questionnaire so as to understand their response and
implications to the ban. This trial is registered with the
clinical trial registry.
The data was compiled in the Statistical Package for the
Social Sciences (SPSS) software version 19. Data errors
were checked. The compiled data was analyzed with SPSS
version 19. The effects of the ban on change in tobacco
habit and various factors responsible for the same were
analyzed.
Results
The present study is conducted PMGP, Mankhurd area
comprising total population of around 4797, with
553 male and 548 female tobacco users. According to the
house-to-house survey conducted among the tobacco users,
there were 68 gutkha users above 18 years of age and five
tobacco vendors in the community. None of the tobacco
users consumed pan masala.
Amongst the gutkha users interviewed, 39.7% were below the
age of 30 years, the range being 19-60 years. Majority 88.2%
were males. While the number of Hindu 36.8% and Muslims
respondents 41.2% was almost equal, 20.6% were Buddhists
and 1.4% Christian. Although 10.3% users were illiterate,
majority 75% were educated either up to primary or secondary
school and 14.7% were educated above higher secondary level.
Overall, 76.5% of users were married and 23.5% unmarried.
The age at initiation of gutkha use varied from 10 years to
57 years. Nearly 38% users had started the use at 18 years
or below. Among the gutkha users, 92.6% used it daily
while 7.4% used intermittently. Nearly 60% participants used
gutkha for less than 10 years and 40% used gutkha for more
than 10 years. In univariate analysis, only age at initiation of
gutkha consumption between 31 and 40 years was found to
be statistically significant factor for quitting gutkha in post ban
period. None of the factors were significant in the multivariate
analysis [Table 1]. The maximum usage as cited by a user was
50 pouches of gutkha/day.
All users were aware that some tobacco products had been
banned in the recent past. Although all knew that gutkha
was banned, only 4.4% were aware of the ban on pan
masala. 31% participants had erroneous information that
some tobacco product, other than gutkha and pan masala
was also banned. Nearly 41% study participants could tell
the exact month of the ban, but very few 6% were aware
that it was only for the period of a year. Only 27.9% users
had the knowledge that the ban had been enforced by
Government of Maharashtra through FDA [Figure 1].
The major source of information regarding the ban
was electronic media and tobacco vendors. Many user
participants came to know about the ban directly from the
tobacco vendors while visiting to purchase gutkha while
some knew from newspapers. The other sources included
relatives and friends [Figure 2].
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131
Indian Journal of Cancer | April–June 2014 | Volume 51 | Issue 2
Overall 16 (23.53%) participants had quit consuming
gutkha after the ban was imposed while 38 (55.88%)
participants had reduced consumption. Fourteen (20.59%)
had not changed their habit of gutkha consumption even
in post ban period while none of the participants increased
use of gutkha. Amongst the 16 gutkha quitters, five
shifted to other forms of tobacco use (2-mawa, 2-paan and
one-khaini).
Non-availability of gutkha had forced 18 participants to
decrease the use, ten to quit the habit of consumption
while it did not affect the habit of 40 user participants.
Increased cost of gutkha (by illicit trade), resulted 24 to
reduce the use and one to quit the habit and failed to affect
rest 43 participants. Awareness of the ban on gutkha led to
reduction of use in 18 participants, two to quit whereas 48
remained unaffected. Awareness of health hazards of tobacco
prompted two participants to decrease the habit, two to quit
consumption and remaining 60 remained unaffected inspite
of the hazards [Figure 3].
An important highlight of this study is that all user participants
of gutkha were in favor of banning these products. The
expectation that the ban would compulsorily reduce or stop
gutkha use 30 (44.1%), prevention from cancer 37 (54.4%),
reduction in oral health problems 14 (20.6%), reduction
in unnecessary spending 9 (13.2%) were the major reasons
for the support. The participants felt that health hazards of
gutkha 62 (91.2%), easy access of children 8 (11.8%) and
large number of women initiating gutkha use were the prime
reasons for gutkha and pan masala being banned by the
Government.
While 44 (64.7%) of the user participants reported
availability of gutkha and pan masala in same quantities
as before in the post ban period, 46 (67.6%) reported the
availability of these products in black market at an increased
cost and 3 (4.4%) reported availability of gutkha and pan
masala in separate pouches.
Tobacco vendors
All (five) gutkha and pan masala vendors studied were
married men above 30 years, in this business more than
10 years. Four were educated up to primary/secondary school
while one was illiterate. With newspapers as the main source
of information about the ban, four vendors knew that gutkha
had been banned while one had incorrect information that
it was cigarette. None of them were aware of the ban on
pan masala too. Only one knew the exact time period of the
ban. Three of them were aware about the enforcing authority
for the recent ban. Only two knew about the monetary
penalty as punishment while imprisonment for the violation
of the ban was known to a single vendor. Surprisingly, all
the five vendors stated that the ban was a good initiative.
While four of them attributed the ban to gutkha and pan
masala being injurious to health, one thought that ban was
in order to prevent children from accessing gutkha and pan
masala. Before ban four vendors procured the gutkha and
pan masala pouches from wholesalers while one used to get
direct delivery at his shop. Four of them stated that their
customers included minors; though, they formed less than
a quarter of the regular buyers for three vendors, while one
Figure 1: Awareness regarding Gutkha and pan masala ban amongst users
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vendor reported up to 50% of his customers were minors.
Although all five vendors were aware of health hazards of
gutkha, cancer reported by four and oral ulceration reported
by two, were the only known hazards to them. One vendor
thought that gutkha caused tuberculosis. Three of the
vendors reported that gutkha and pan masala were not
available in the market, but two confessed that the products
were available at an increased cost. Four vendors reported
a decrease in the sale of gutkha and pan masala in post
ban period while the remaining one reported that the ban
had not affected the sale of the same. Concerning the sale
of other tobacco products, two reported it had decreased,
two said it had increased and one said that it remained
unaffected in post gutkha and pan masala ban period. Four
of the vendors reported that their shop was raided, three
times by the police and once by Brihanmumbai Municipal
Corporation officials. One shop was raided twice, but the
vendor was unaware of the identity of the officers. None of
the vendors had to shift to another (i.e., other than tobacco
sale) business because of gutkha and pan masala ban.
Discussion
The present study was conducted on the gutkha and pan
masala users and vendors from the selected slum population
of Mumbai city after about 4-6 months of gutkha and pan
masala ban by Government of Maharashtra. As the concept
of gutkha ban is new, there are very few studies assessing
its effect. Hence, the findings of this study are discussed in
Figure 2: Source of information about the ban
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Figure 3: Comparison of various factors responsible for quitting or
decreasing the habit of gutkha consumption
0
10
20
30
40
50
60
70
80
Increased
cost
Awareness of health
hazards of tobacco
Number of Gutkha Users
Factors
Not affected
Quit
Reduced
Non availability
of Gutka
Awareness
about ban
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Mishra, et al.: Impact of the ban on gutkha and pan masala
Indian Journal of Cancer | April–June 2014 | Volume 51 | Issue 2
132
comparison to other studies assessing the effects of the ban
on various types of tobacco products.[9-13]
Almost every user interviewed was aware of the ban on
gutkha, but the awareness regarding the ban on pan masala
was poor. This can be attributed to higher prevalence of
gutkha use among the user participants as compared to
pan masala. Some participants thought that some other
tobacco product, other than gutkha and pan masala was
banned. The knowledge regarding the time of the ban
of tobacco product and the authority, which enforced the
ban (Government of Maharashtra/FDA) was also inadequate,
which may be attributed to wrong source of information in
the form of hearsay information and low level of literacy.
Very few respondents were aware that the ban was only for
a year. Electronic media and newspaper were the common
sources of information quoted by the respondents. Giving
wide publicity to the gutkha ban through newspaper and
television advertisements and putting visible banners at
prominent places detailing the ban might have served the
purpose. This stream of thought was supported by a study
done by Wakefield et al.[14] According to the participants,
there was no contribution by health care providers in
imparting information regarding the ban, which is certainly
worrisome. A large number of users also came to know
about the ban only after visiting the vendors, which is
indicative of some fear of law enforcing authorities in the
mind of tobacco vendors. A number of vendors were fined
by the FDA authorities and Police for violating the ban
during the initial period following ban.
All user participants were in favor of the ban, with the
opinion that the ban would certainly reduce the use of
gutkha and pan masala. Although most of the users were
aware about carcinogenic potential of these products,
other health hazards of their use were unknown to them,
which may be attributed to less publicity regarding the
same. Singh et al.[15] stated similar findings in their study.
Anticipation of improved health and unavailability of these
products to children were expected potential benefits of
the ban by the users. These findings are suggestive of
willingness to quit the use of these products if backed by
useful scientific information, enforcement and assistance
for quitting. Similar conclusions were reported in the
studies by Wakefield et al.[14] and Li et al.[16] The services
for tobacco cessation provided in the form of tobacco
cessation clinic may play an important role in converting
this willingness of people into action.
A major cause of concern is the availability of gutkha even
after the legal ban, although at increased cost through
the black market, as reported by many users. Availability
of tobacco products in market even after ban has been
reported by other researchers also.[10] However, many users
also reported a decrease in the consumption of gutkha or
quitting the habit in post ban period due to the efforts
to be undertaken for procuring gutkha and pan masala
and increased expenditure. That increase in the cost led to
decrease use, was also supported in the studies conducted
by Townsend[17] and Gallus et al.[18] Also fear of being
caught by law enforcing authorities had also played an
important role in keeping users away from the banned
products. This decrease in use of tobacco products after
the ban along with “norm spreading” is also evident from
the literature.[19] Although some of the users had shifted to
other products, around 24% had stopped the use of gutkha
after ban indicating favor for such bans. This nature of very
useful, expected implication of the tobacco ban is reported
by various authors globally as well.[9,10,11,13] Availability of
gutkha and pan masala even after legal ban to the vendors
has been reported in a Mumbai study.[10] However, the
decrease of sale as reported by four of the participant
vendors is encouraging. The willingness of vendors to obey
the law regarding gutkha and pan masala ban, though
mainly due to fear of law enforcing authorities, can be
extended for effective implementation of the same.
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How to site this article: Mishra GA, Gunjal SS, Pimple SA,
Majmudar PV, Gupta SD, Shastri SS. Impact of 'gutkha and pan
masala ban' in the state of Maharashtra on users and vendors.
Indian J Cancer 2014;51:129‑32.
Source of Support: Nil, Conict of Interest: None declared.
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... Tamil Nadu, Maharashtra, Delhi, Andhra Pradesh and Karnataka. 17,20 However in Kerala, easy access to commercial SLT was reported by less than half of the consumers while considering availability, a quarter of them reported that the availability was not the same as before ban. The corresponding figures in West Bengal were 84.9% and 52.7% respectively. ...
... A study conducted on gutkha ban among the migrants of Karnataka revealed that more than 90% users were aware of the ban and similar finding was reported by another study conducted in Maharashtra. 17,20 In contrast, a study from Rangareddy district of Telengana reported that only 50% users were aware of the ban. 21 Similar findings were also reported from other states where the ban had been imposed. ...
... 21 Similar findings were also reported from other states where the ban had been imposed. 17,22 One study reported that ban on gutkha caused reduction of gutkha consumption, however switching over to other tobacco products for lack of availability of gutkha posed a new concern. 17 Due to easy availability of a range of tobacco products at an affordable cost, consumers could shift to other forms of tobacco products which again struck a major challenge to the policy makers. ...
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Introduction Since 2011, sale of commercially available smokeless tobacco products for chewing such as gutkha has been prohibited in many states in India. The current study attempts to understand the effectiveness and perception towards ban on gutkha sales in West Bengal and Kerala. Methods Total six districts from both the states (three districts from each state). From each district, 1 Municipality and 2 Community Development Blocks were selected randomly, representing each cluster. From each cluster, line transect survey was used to identify Point of Sale (POS) of tobacco products. Tobacco consumers and vendors were interviewed from POS. Results 865 tobacco users (West Bengal = 450, Kerala = 415) and 173 vendors (West Bengal = 90, Kerala = 83) were interviewed for the study. 16.1% of the total users from Kerala were using gutkha alone or in combination with other tobacco chewing products while in West Bengal the corresponding figure was 17.3%. Knowledge on ban was high among the consumers (95.7%) and vendors (100%) in Kerala while in West Bengal it was 64% and 62.2% respectively. Gutkha was available in 68% of the shops in West Bengal, while in Kerala no sale was reported in shops, though half of the vendors interviewed, admitted its sales in black market. Conclusion The ban had little impact in West Bengal in the open market, while it had moderate impact in Kerala. However, the black market sales in Kerala are a matter of concern. Strict legislative measures are essential to cut the supply route for effective implementation of the ban.
... Though some studies [15][16][17][18][19] have assessed vendors' perspective, but none was found comprehensive capturing information on all aspects. The objective of this study was thus to investigate vendors' knowledge on gutka ban, products covered under ban, penalties for non-compliance and action for enforcement by government agencies, their attitude in favour or against the ban and whether they had fear in case of non-compliance with the ban, and their practice whether they stopped selling banned product or not. ...
... The findings of this study complemented the findings of studies conducted among gutka users 13,15,16 , thereby providing a perspective on actual status of ban-enforcement at ground level. Furthermore, findings of this study were similar to other studies conducted among vendors 15,[17][18][19] . All vendors were aware that sale of gutka pouch was banned and of its adverse health effects as the reason for ban. ...
... However, awareness of other products covered under ban and on fines in case of non-compliance was low among vendors. Other studies among vendors had similar findings 17,18 . ...
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Background & objectives: Beginning in 2012, all States in India eventually banned the sale of gutka. This study was conducted to investigate gutka vendors' knowledge on gutka ban, products covered under ban, penalties for non-compliance and action for enforcement by government agencies. Methods: Twenty vendors were interviewed, 10 each in Mumbai (Maharashtra) and Indore (Madhya Pradesh) during May - June, 2013, one year after ban was imposed. Interviewers used a standardized questionnaire to assess vendors' knowledge of gutka ban, their attitude towards it and compliance to it in practice. Results: All 20 vendors were aware that gutka sale was banned. However, despite ban, eight of the 10 vendors in Mumbai perceived sale of pan masala as legal. In Indore, all 10 vendors perceived sale of Indori Tambakoo, a local gutka variant, as legal. No vendor was sure about the quantum of fine applicable on being caught selling the banned product. Two vendors in Mumbai and nine in Indore admitted selling gutka. Five vendors in Mumbai and four in Indore supported an existing ban on gutka. Interpretation & conclusions: All vendors were aware of the ban on gutka and reason for it. Many vendors supported the ban. However, awareness of other products covered under ban and on fines in case of non-compliance was low. Law enforcement system needs to be intensified to implement ban. Notification of ban needs to be further strengthened and made unambiguous to explicitly include all smokeless tobacco products.
... The usage of this gutkha is reported to cause potentially malignant disorder -oral submucous fibrosis manifesting debilitating features named as "Gutka syndrome or Areca Nut Chewer's syndrome" by Chaturvedi. [9] In India, gutkha has gained popularity among younger population and women, as it is easy for them to use tobacco without attracting much attention. [1] To control the tobacco menace, the Government of India implemented COTPA in the year 2003. ...
... In the present study, out of 124 respondents, 112 (90.32%) of them were aware of the ban. Similar results were reported by studies conducted by Mishra et al. [9] Many of the respondents had come to know about the ban through electronic media and newspaper, which was also appreciated by other studies. [9,10] Although 16 (12.90%) of the respondents reported to quit the habit of gutkha chewing, they had resorted to the usage of other forms of tobacco in contrast to the findings of other studies. ...
... Similar results were reported by studies conducted by Mishra et al. [9] Many of the respondents had come to know about the ban through electronic media and newspaper, which was also appreciated by other studies. [9,10] Although 16 (12.90%) of the respondents reported to quit the habit of gutkha chewing, they had resorted to the usage of other forms of tobacco in contrast to the findings of other studies. [9][10][11] Knowledge about the ban did not discourage the respondents to quit the habit of tobacco. ...
... Gutka, a commercial product which contains tobacco and areca nut, is banned in most of the states in India since 2012 under food safety regulations as it is illegal to add tobacco and nicotine to food [73]. Few studies [74][75][76][77] have assessed the effectiveness of banning and how it affects customers and sellers. Nair et al. revealed that the ban increased the awareness of smokeless tobacco (SLT) associated health effects on the public [76]. ...
... Nair et al. revealed that the ban increased the awareness of smokeless tobacco (SLT) associated health effects on the public [76]. Mishra et al. reported that SLT users appreciated the ban as it persuaded them to stop or control the habit [75]. A study done in 2014 discovered that the gutka ban has actually reduced the use of gutka but they worried that they may have found alternative products to use [78]. ...
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Areca nut is a highly addictive substance with carcinogenic properties and causes many harmful effects to the human body. Alkaloids are the major chemicals found in areca nut, and their mechanism of action has been studied for several years. About 600 million people around the world use areca nut, and its usage is higher in Asian countries. Areca nut chewers get used to the habit mainly due to social influence, stress, or lack of awareness. Some studies have reported a dependence syndrome related to areca nut chewing. Even though there are many ongoing research studies regarding tobacco addiction, less concern has been given to the areca nut addiction. There are only few studies related to areca nut cessation, and even those few cessation programs are mainly designed using tobacco cessation methodology. Sociocultural influence, behavioral factors, and accessibility are the main barriers to cessation. Behavior changing interventions proved to be more effective in areca nut cessation, but recently studies on pharmacological therapies are also emerging.
... In Sri Lanka, it was deemed successful while in other countries, the outcomes were not so successful. [1,7,[51][52][53][54] AN and ANUD habit burdens the Indian society not only due to diverse health issues but also the resulting economic and other outcomes. [1,7,55,56] Individuals may take up, owing to its use being symbolic of (1) individual freedom, (2) personal informed choice, and (3) cultural identity. ...
... Indian social environment, including the prevailing structures of social relationships (such as social inequality, accessibility, affordability, and related factors) and also sociogenic environmental conditions (e.g., sales of toxic commodities, advertisement policies, packaging pollution), contribute enormously to disease clustering and interactions. [47][48][49][50][51][52][53][54][55] Policies to regulate manufacture, advertise, and sale of AN and AN products are necessary. In India, rules have been framed to discourage public use of AN/AN products by various governmental agencies. ...
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Problem: Areca nut (AN) chewing is common among Southeast Asian population. Use of AN products (with or without tobacco) have a multifaceted effect on physical health, especially on cardiovascular, nervous, gastrointestinal, metabolic, respiratory, and reproductive systems. AN is a known group 1 carcinogen and carries addictive potential. Varying degrees of AN-related substance use disorder (SUD) have been reported among AN chewers. There is a lacuna in awareness of the health risk of AN use, prevention, and cessation programs among AN users, particularly in those who have developed SUD. Existing lacunae: The dynamic interaction of factors that promote AN use and later the risk of developing SUD at individual and community level has not been studied in depth. Understanding of the bio-psycho-socio-economic-cultural factors is necessary to identify the factors that prelude, promote, and reinforce AN usage. For managing AN-related conditions, including the several systemic disorders, there is a knowledge lacunae, among health care providers with respect to the pathophysiology of AN-related health issues, SUD, and nonavailability of structured, evidence-based cessation protocols. Solutions/recommendations: This manuscript presents a model-map to study the dynamics of AN use and the impact of AN on health and health care system at individual as well as community level. The model proposed can help the health policymakers to create evidence-based awareness and cessation protocols for AN.
... Majority of par cipants (70%) suggested ban on produc on, sale and consump on of gutkha. In the Indian study, all 17 par cipants (100%) were in favor of banning its produc on. However, implementa on of ban suffers drawback in India. ...
... It seems that mere formal educa on in college or school doesn't seem sufficient as literacy level wasn't significantly associated with the cancer knowledge. It is in agreement with a study where as high as 75% prevalence of consumers amongst educated group was 17 seen. In contrast to this, another study suggested that with schooling more than 10 years the knowledge of carcinogenic effects of smokeless tobacco was increased in an Asian 18 country. ...
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Introduction: Gutkha, a mixture of areca nut pieces, tobacco and slaked lime, is a potential carcinogen. It causes oral submucous fibrosis. Many people do not possess this knowledge and thus consume gutkha daily. The consumption is highly prevalent in Nepal because of easy availability of this material. Although ban of advertisement is implemented in Nepal in electronic media, the impact has not been significant. Objective: To find the prevalence of different beneficial effects cited, to determine awareness about cancer and attitude towards ban of advertisement, production and sale in current gutkha users from rural Terai dwellers of Nepal. Methodology: We interviewed 1217 households in a community survey in which 151 were current gutkha consumers, their responses about perceived benefits, cancer knowledge and views on ban of its sale and promotion was analyzed. The relationship with demographic variables were tested with Chi-square test with level of significance set at 0.05. Results: Among the current users, the reason of consuming gutkha was mostly 'feeling of well-being' (38.4%), about 40% thought it can cause cancer. The knowledge was not associated with gender, age group and literacy but statistically related with marital status (p<0.05). Majority were in favor of ban on advertisement (74.2%) and on production, sale and consumption (70.2%). Conclusion: The level of knowledge of cancer causation is very low and education level had not been significantly associated to knowledge. More gutkha users were in favor of its ban which is a positive finding.
... They attributed their quitting and reduction in consumption to the non-availability of the product. 6,7 However, some users shifted to using other forms of tobacco. 8,9 Though the ban has helped in constraining the use of gutkha, it was found to be still openly available in the market at an increased price. ...
... 8,9 Though the ban has helped in constraining the use of gutkha, it was found to be still openly available in the market at an increased price. 4,6,8 In the current study, similar results were seen, with the users reporting that they had reduced their use after the ban. However, the effect on quitting was not studied as the subjects included in the current study were the current users who were procuring the chewing tobacco products from the shops, the prices of which had increased, ranging from 100% to 300% depending on the product. ...
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Background: Gutkha is banned under Food Safety Act, India, effective from May, 2013 in Tamil Nadu. The current study is to find out the impact of Gutka ban on sale and consumption in Chennai city. Methods: Shop keepers (n=90) selling Gutkha and tobacco users (90) were chosen using stratified simple random sampling method from 15 zones of Chennai. Three different types of shops (platform/permanent/petty) were identified and a structured questionnaire was used. The questions included for shopkeepers were awareness about Gutkha ban, supply mode, sale and price difference and questions for users included motivation to quit, reduction in use, availability and price difference. Results: No shop had open display of Gutkha and all the shopkeepers and users were aware of the ban. Shopkeepers either bought Gutkha from the whole sale market (58.9%) or the agent (41.1%). Raid was conducted at 81% of the shops. There was a significant reduction in the sale after the ban (p<0.05). Users did not find it difficult to procure as it was easily available; however, price has increased up to 300%. Users felt guilty (18.9%) and fearful (23.3%) when using banned products. Users were motivated to quit (22.4%), made attempts to quit (58.9%) and felt the need for professional support to quit (38.9%). Significant difference was observed in the number of sachets used before and after ban (p<0.05) by the users. Conclusions: The ban did not have any impact on the availability of Gutkha, however it had a little impact on users. Stringent enforcement is crucial to achieve the purpose.
... A recent study from Mumbai showed that although all STP users were aware about the ban on gutkha, very few knew about the ban on pan masala. [9] The study also showed that almost every fourth gutkha user had quit his/her habit postban and more than half had reduced their gutkha consumption. [9] This was despite its availability through illegal sources. ...
... [9] The study also showed that almost every fourth gutkha user had quit his/her habit postban and more than half had reduced their gutkha consumption. [9] This was despite its availability through illegal sources. Nonavailability of gutkha was the most important reason for quitting/reduction of use. ...
Article
Background: India is the world's third largest consumer of tobacco. There are twice as many users of smokeless tobacco products (STPs) as cigarette smokers. The Government of Tamil Nadu has banned the sale of gutkha and pan masala in 2013. Our aim was to identify the varieties of illegal STP available in Chennai, India. Methods: In systematically chosen zones and regions of Chennai city, we randomly identified three kinds of kiosks (n = 18) and asked for "gutkha" and "pan masala," one of each product available. Details of each product were reviewed based on the information printed on the sachets. Results: Totally 65 STPs were collected; 26 distinct products and 23 brands. All products were claimed to be "tobacco" by the shop keepers. Sixty-five percent of the products informed to contain tobacco and 15.4% to contain pan masala. Five sachets did not inform about the content; 30.8% did not have a pictorial warning; a text warning was printed on 80.8%, but only two products had the messages in Tamil; 70% had promotional messages printed, and 57% had their registration numbers printed. Conclusion: The ban on STP is being systematically violated in Chennai. STP are cheap and easily available and due to promotional laudatory messages and lacking information about the content and warning of health damage, the consumers are left with the perception that they buy more or less harmless product. The Indian Government must introduce policies to control production, import, and sale of illicit STP but we also call for a coordinated international solution.
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Objective The implementation of smokeless tobacco control policies lags behind those for smoking. This scoping review summarises the studies that evaluated public policies on smokeless tobacco regulation (SLT) and provides an overview of the jurisdictional level, target groups and policy instruments. Methods Seven databases were systematically searched for studies reporting on public policies regulating SLT. All studies were independently screened by two reviewers. Data extraction was performed using a predefined extraction form. Extraction was replicated for 10% of the identified studies for quality assurance. A narrative synthesis of the included studies was used to analyse and interpret the data. The protocol was published beforehand with the OSF. Results 40 articles comprising 41 studies were included. Most of the studies reported in the articles were conducted in the USA (n=17) or India (n=14). Most studies reported outcomes for students (n=8), retailers/sellers (n=8) and users/former users (n=5). The impact of public policies on smokeless tobacco use in general was most frequently assessed (n=9), followed by the impact of taxes (n=7), product bans (n=6), sales/advertising bans near educational institutions (n=4) and health warnings (n=3) on consumer behaviour. Conclusions There are major gaps in the evaluation of smokeless tobacco regulation studies that need to be filled by further research to understand the observed outcomes. WHO reporting on FCTC implementation should be linked to studies evaluating smokeless tobacco control measures at all levels of jurisdictions and in countries that are not members of the WHO FCTC or do not provide data. Implication Large gaps in the evaluation of SLT control policies exists. For some countries, WHO FCTC evaluations are available for different levels of jurisdictions. In countries with a strong federal structure, there is a lack of data that goes beyond the national level to provide a more detailed look at compliance, indirect effects or implementation gaps. More research is needed at all levels of jurisdictions, that add to the work of the WHO to understand what works for which target group, how the different levels of jurisdiction interact, how the real-world context can be incorporated, and what indirect effects may occur.
Article
Background: Areca nut (AN) and betel quid (BQ) are classified as Group 1 carcinogens. There are approximately 600 million AN/BQ users globally; the majority of users live in the Asia-Pacific region which, correspondingly, has the highest rates of oral cancer. Despite significant disease burden associated with AN/BQ use, there have been no systematic reviews of interventions to reduce product use. Objectives: To analyze interventions that prevent use of AN/BQ, present a basis for a future systematic review on the topic, and provide decision makers with examples of strategies that have demonstrated reduced AN/BQ use. Methods: To identify publications, we searched the literature using terms for AN/BQ and related synonyms in three databases: PubMed, Embase, and Scopus. Interventions that prevent AN/BQ use, that are published in English and that provide original data analysis, were included in this review. Interventions focused primarily on disease outcomes e.g. oral cancers (secondary prevention) were excluded. Results: Our search revealed 21 interventions targeting AN/BQ use between 1990 and 2018. Strategies include product bans, media campaigns, education, cessation, and taxation at individual and population levels, with varying evidence of impact. While these studies yielded some novel and promising findings, particularly regarding the impact of product bans, mass media campaigns, and cessation interventions, research on interventions specific to AN/BQ use remains limited. Conclusions: We have assessed published interventions that reduce AN/BQ use and identified future research priorities. These findings can be used to develop evidence-based interventions and help guide policymakers in implementing evidence-based policy to regulate these products.
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Tobacco use among youth in South-East Asian countries was reviewed using available literature. Youth who are out-of-school, earning, less educated and live in rural areas are more likely to use tobacco and staft during the Preteen years. Better educated youth may know the health effects of smoking but the dangers of passive smoking are generally unknown. Youth are fairly unconcerned about the present or future effects of tobacco use on health but do favour tobacco control measures. Children and youth are more responsive than adults to tobacco education. In India, a manufactured smokeless tobacco product, gutkha, has been targeted toward youth and has become extremely popular. An evolving epidemic of oral submucous fibrosis attributed to gutka use has been documented among youth, with a resultant increase in oral cancer in lower age groups. Children in India are often illegally employed in bidi manufacturing. This review points out the need for specific actions.
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This study examined the impact of point-of-sale (POS) tobacco marketing restrictions in Australia and Canada, in relation to the United Kingdom and the United States where there were no such restrictions during the study period (2006-10). The data came from the International Tobacco Control Four Country Survey, a prospective multi-country cohort survey of adult smokers. In jurisdictions where POS display bans were implemented, smokers' reported exposure to tobacco marketing declined markedly. From 2006 to 2010, in Canada, the percentages noticing POS tobacco displays declined from 74.1 to 6.1% [adjusted odds ratio (OR) = 0.26, P < 0.001]; and reported exposure to POS tobacco advertising decreased from 40.3 to 14.1% (adjusted OR = 0.61, P < 0.001). Similarly, in Australia, noticing of POS displays decreased from 73.9 to 42.9%. In contrast, exposure to POS marketing in the United States and United Kingdom remained high during this period. In parallel, there were declines in reported exposures to other forms of advertising/promotion in Canada and Australia, but again, not in the United States or United Kingdom. Impulse purchasing of cigarettes was lower in places that enacted POS display bans. These findings indicate that implementing POS tobacco display bans does result in lower exposure to tobacco marketing and less frequent impulse purchasing of cigarettes.
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Background: The Maharashtra government has banned the production, sale, distribution and storage of gutka, and pan masala in the Maharashtra State due to the increasing burden of cancer and reproductive health problems attributable to the use of these products. In view of this, it is important to understand the way producers', sellers' and users' are adapting to the ban. Objective: During the two months following the ban (July 19 th through Sept 30, 2012), a research team studying smokeless tobacco use and promotion in a low income community of Mumbai conducted rapid surveillance to assess the impact of the ban in the study community. Materials and methods: Assessment involved documenting new points of sale, informal observations of tobacco use, and interviews with thirteen shop owners and eight gutka users'. Overall changes in accessibility, availability, patterns of use of tobacco products, perception of ban, social norms and surveillance activities were assessed. Results: Tobacco companies were marketing new products that resembled gutka, under similar brand logos. Surveillance, financial and social cost of selling gutka or using it in public have had an immediate effect on reducing local supply, demand and use and increasing stigma associated with its use. There was an increased recognition of ill-effects of gutka on cancer among sellers' but not overall. Conclusions: To reduce the overall consumption of tobacco in the community, it is critical to include programs that create awareness about effects of smokeless tobacco on health and sustain surveillance levels. This would maintain requirements of the ban, and sustain limits on accessibility, availability and use of these products in the community and other similar communities.
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