Knowledge and Perceptions of Smokeless Tobacco.
Aim: To determine pattern of use as well as
knowledge and perceptions of smokeless tobacco.
Objective: To study about discrepancies in belief,
behavior, and knowledge towards tobacco consumption and its control.
Historical
overview:
The tobacco plant is thought to have originated on the mainland between North and South America. Its cultivation probably dates back at least 5000 years; tobacco seeds were discovered during archaeological excavations in both Mexico and Peru around 3500 BC, which shows that tobacco was an article of value to the inhabitants. Globally, smokeless tobacco use is disproportionately concentrated in low-income and middle-income countries like India and Bangladesh.
Manufacturing:
Smokeless tobacco is consumed without burning the product, and can be used orally or nasally. Oral smokeless tobacco products are placed in the mouth, cheek or lip and sucked (dipped) or chewed. Tobacco pastes or powders are used in a similar manner and applied to the gums or teeth. Fine tobacco mixtures are usually inhaled and absorbed in the nasal passages.
There are many different botanical classifications for tobacco plants. The genus Nicotiana is classified into three main subgenera, N. rustica, N. tabacum and N. petuniodes. Smokeless tobacco products use N. tabacum, and sometimes N. rustica. In the USA, tobacco is also classified by the curing method (e.g. flue-cured, air-cured, dry air-cured tobacco) and by production areas (Virginia, North Carolina, Tennessee, Wisconsin)
Oral use:
Oral use of smokeless tobacco is practiced in Africa, North America, South-East Asia, Europe and the Middle East, and consists of placing a piece of tobacco or tobacco product in the mandibular groove and either chewing or sucking it for a certain period of time: a ‘chaw‘, which refers to a portion of tobacco the size of a golf ball, is generally chewed, whereas a ‘quid’ is usually a much smaller portion and is held in the mouth rather than chewed.
Smokeless tobacco (SLT) consumption:
Non-communicable diseases (NCDs) contributes to more than 50 per cent
disability adjusted life years (DALYs) in India; and tobacco contributes to 7·4
per cent of DALYs which is next to diet and high blood pressure. According to
Global Burden of Disease (GBD) 2015, tobacco use contributed to 5.9 per cent
out of total DALYs in India. Smokeless tobacco (SLT) consumption is a
multifactorial process influenced by varied range of contextual factors i.e., social,
environmental, psychological and the genetic factors which are linked to the
tobacco use. The determinants associated with the SLT use are gender,
educational level, wealth index (inverse association), urban-rural residence,
socio-economic status and low tax. Taking the view from tobacco control
programmes, there is a need to address determinants of SLT use with State level
monitoring and socio-economic inequalities, progress and review of the taxation
of the SLT use in India.
This NHFS
and GATS survey in India shows the study of data of smokeless tobacco use :
Name
of survey
|
Data
collection
|
Sample
design
|
Marital
status
|
Age
group
|
Sampled
men
|
Sampled
women
|
Coverage
rate
|
Response
rare
|
NHFS-2
|
1998-99
|
Multi
stage stratified
|
All
men and women
|
15+
|
2,63,273
|
254,106
|
>99%
|
95.50%
|
NHFS-3
|
2005-06
|
Multi
stage stratified
|
All
men and women
|
15-54
(M)
|
74,369
|
124,385
|
99%
|
87.1%
(M)
|
15-54
(F)
|
94.5%
(W)
|
|||||||
GATS
|
2009-10
|
Multi
stage stratified
|
All
men and women
|
15+
|
33,767
|
35,529
|
99.90%
|
94.80%
|
Types of smokeless tobacco:
1. Betel
quid with tobacco:
Betel quid with tobacco, commonly known as paan or pan, consists of four main ingredients: (i) betel leaf (Piper betle), (ii) areca nut (Areca catechu), (iii) slaked lime and (iv) tobacco. Of these, tobacco is the most important ingredient for regular users. Betel quid can be prepared by the vendor or at home. Various tobacco preparations are used in unprocessed, processed or manufactured forms. Tobacco may be used in raw, sun-dried or roasted form, then finely chopped or powdered and scented. Alternatively, tobacco may be boiled, made into a paste and scented with rosewater or perfume. The final product is placed in the mouth and chewed. Betel quid with tobacco is used in Central, East, South and South-East Asia, in the western Pacific and in migrant communities arising therefrom. Exposure to and the health effects of betel quid with or without tobacco are described in detail in a previous monography.
2. Creamy
snuff:
Creamy snuff consists of finely ground tobacco mixed with aromatic substances, such as clove oil, glycerin, spearmint, menthol and camphor, salts, water and other hydrating agents. It is often used to clean teeth. The manufacturer recommends letting the paste linger in the mouth before rinsing. Creamy snuff is manufactured commercially and marketed as a dentifrice, and is commonly used as such by women in South Asia.
3. Dry
snuff:
In Europe and the USA, tobacco (primarily Kentucky and Tennessee tobacco) is fire-cured, then fermented and processed into a dry, powdered form. The moisture content of the finished product is less than 10%. Dry snuff is packaged and sold in small metal or glass containers. Typically, in the USA, a pinch (called a ‘dip’) is held between the lip or cheek and gum. In Europe, it is commonly inhaled into the nostrils.
In India, dry snuff was once commonly used nasally, but is now used mainly orally. It is frequently prepared at home by roasting coarsely cut tobacco on a griddle and then powdering it. This pyrolysed snuff-like preparation, mainly used in Goa, Maharashtra, Gujarat and eastern parts of India, is widely used by the poorer classes as a dentifrice (applied to the teeth and gums), especially by women, but tends to be used many times a day, due to its addictive properties. It is known as bajjar or tapkir/ tapkeer. In many regions of the world, dry snuff is used both orally and nasally. In northern Africa, dry snuff is known as naffa, tenfeha or nufha.
4.
Gudhaku:
Gudhaku is a paste made of powdered tobacco and molasses. It is available commercially and is stored in a metal container. Gudhaku is applied to the teeth and gums with the finger, predominantly by women in India in the States of Bihar, Orissa, Uttar Pradesh and Uttaranchal.
5.
Gul:
Gul contains tobacco powder, molasses and other ingredients and is manufactured commercially. It is applied to the teeth for the purpose of cleaning and then to the gums many times during the day. Gul is used in South Asia, including the Indian Subcontinent.
6.
Gutka:
Gutka is manufactured commercially and consists of sun-dried, roasted, finely chopped tobacco, areca nut, slaked lime and catechu mixed together with several other ingredients such as flavorings and sweeteners. The product is sold in small packets or sachets. It is held in the mouth, sucked and chewed. Saliva is generally spat out, but is sometimes swallowed. Gutka is used in South Asia, including the Indian Subcontinent, and by Asian expatriates in several parts of the world, especially Canada, the United Kingdom and the USA (IARC, 2004a).
7.
Khaini:
Khaini is made from sun-dried or fermented coarsely cut tobacco leaves. The tobacco used for khaini is from N. rustica and/or N. tabacum. The tobacco leaves are crushed into smaller pieces. A pinch of tobacco is taken in the palm of the hand, to which a small amount of slaked lime paste is added. The mixture is then rubbed thoroughly with the thumb. Khaini is usually prepared by the user at the time of use, but is also available commercially. It is held in the mouth and sucked or chewed. Areca nut may sometimes be added to khaini by the user. Khaini is used in South Asia, including the Indian Sub-continent.
8.
Mawa:
Mawa is a mixture of small pieces of sun-cured areca nut with crushed tobacco leaves and slaked lime. The resulting mixture is about 95% areca nut by weight. It is placed in the mouth and chewed for 10–20 min. Mawa is used in South Asia, including the Indian Subcontinent.
9.
Mishri:
Mishri is made from tobacco that is baked on a hot metal plate until toasted or partially burnt, and then powdered. It is applied to the teeth and gums as a dentifrice, usually twice a day and more frequently in some cases. Users then tend to hold it in their mouths. Mishri is used in South Asia, including the Indian Subcontinent.
10. Moist
snuff:
The tobacco is either air- or fire-cured, then processed into fine particles (‘fine-cut’) or strips (‘long-cut’). Tobacco stems and seeds are not removed. The final product may contain up to 50% moisture. Moist snuff is sold either loose or packaged in small, ready-to-use pouches called packets or sachets. A pinch (called a dip) or a pouch is placed and held between the lip or cheek and gum. Saliva may be swallowed or, more commonly, spat out. Moist snuff is used in Europe and North America, and is the most common form of smokeless tobacco in the USA.
Tobacco controlling policies and regulations:
Tobacco
use is a major public health challenge in India with 275 million adults
consuming different tobacco products. Government of India has taken various
initiatives for tobacco control in the country. Besides enacting comprehensive
tobacco control legislation (COTPA, 2003), India was among the first few
countries to ratify WHO the Framework Convention on Tobacco Control (WHO FCTC)
in 2004. The National Tobacco Control Programme was piloted during the 11 th Five
Year Plan which is under implementation in 42 districts of 21 states in the
country. The advocacy for tobacco control by the civil society and community
led initiatives has acted in synergy with tobacco control policies of the
Government.
Under the
Prevention of Food Adulteration Act (PFA) (Amendment) 1990, statutory warnings
regarding harmful health effects were made mandatory for paan masala and
chewing tobacco.
In 1992,
under the Drugs and Cosmetics Act 1940 (Amendment), use of tobacco in all
dental products was banned.The Cable Television Networks (Amendment) Act 2000
prohibited tobacco advertising in state controlled electronic media and
publications including cable television. Under the Chairmanship of Shri Amal
Datta, the 22 nd Committee on Subordinate Legislation in
November 1995 recommended to the Ministry of Health to enact legislation to
protect non-smokers from second hand smoke. In addition, the committee
recommended stronger warnings for tobacco users, stricter regulation of the
electronic media and creating mass awareness programmes to warn people about
the harms of tobacco..
In 2004,
the Government ratified the WHO Framework Convention on Tobacco Control (WHO
FCTC), which enlists key strategies for reduction in demand and reduction in
supply of tobacco. Some of the demand reduction strategies include price and
tax measures and non-price measures (statutory warnings, comprehensive ban on
advertisements, promotion and sponsorship, tobacco product regulation etc).
References:
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