Oral tobacco use behind surge in oral cancers in India

Oral tobacco use is driving a growing epidemic of oral cancers in South Asia, particularly in India, which has nearly 200 million users.[1]India, Pakistan, Bangladesh are among the countries with the highest incidence of oral cancer in 2018, according to the World Cancer Research Fund.

Oral tobacco is considered a major risk factor for oral cancer. It is estimated that over 90% of users are in South Asia. The popularity of oral tobacco exploded in the 1980s when manufacturers began grinding the various ingredients into powder form and selling them in small packets, called gutka, paan masala, zarda, or khaini. The powder is held under the user's lip or cheek and when saliva mixes with it, it creates a paste that releases nicotine over about 15 to 20 minutes.

Social factors in the success of oral tobacco in South Asia

Overall, smokeless tobacco use among adults aged 15 years and older was 21.4 % in India, 20.6 % in Bangladesh and 7.7 % in Pakistan, resulting in a total of over 230 million users.[2]. Several factors explain the popularity of this product in these countries. Firstly, its financial affordability and availability: they are on sale on every street corner and are up to three times cheaper than a manufactured cigarette. They are therefore popular with low-income people and young people. Oral tobacco is also very socially accepted and is consumed in all places, especially in the workplace. While smoking is socially unacceptable for women in a large part of the middle and underprivileged classes, oral tobacco is considered a traditional product. Its increasing consumption by women is socially accepted with nearly 13% female consumers in India.

Many Indian Bollywood stars have been paid large sums to promote such products, including 'gutkas', which are marketed as breath fresheners. These products are also sold in colourful and attractive packaging, which do not carry any health warnings.[3].

Incidence of oral cancers in South Asia: the case of India

Oral cancer mortality rates in South Asia are more than double the global average and strongly correlated with oral tobacco product use and nearly 90% of oral cancers are attributable to oral tobacco use.[4]-[5].

Globally, oral cancer is the sixth most common type of cancer.[6], with India contributing nearly one-third of the total burden. The country ranks second in the number of reported cases of oral cancer after China. About 77,000 new cases and 52,000 deaths are reported annually and about 70% of cases are diagnosed at an advanced stage of the disease compared to 40% in developed countries.

In 2021, in India, the share of tobacco-associated cancers is increasing and it represents 48.7% of all cancers in men and 16.5% of cancers in women. On average, it is estimated that nearly one-third (32.6%) of cancers are attributable to tobacco in the country. Among these cancers, the most common in men is oral cancer (24.4 %), followed by lung cancer (22.4 %) and tongue cancer (16.6 %). The most common cancer in women was oral cancer (26.4 %), followed by lung cancer (22.9 %) and esophageal cancer (20.8 %). Doctors are also noting that oral cancer patients are increasingly younger, with the prevalence among Indians under 40 skyrocketing.

Keywords: India, South Asia, oral tobacco, oral cancer, mouth cancer

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[1] Joe Wallen, Experts warn smokeless tobacco is fueling an epidemic of oral cancer across Asia, The Telegraph, November 16, 2021, accessed November 22, 2021

[2] Zhao, L., Mbulo, L., Twentyman, E., Palipudi, K., & King, BA (2021). Disparities in smokeless tobacco use in Bangladesh, India, and Pakistan: Findings from the Global Adult Tobacco Survey, 2014-2017. PloS one, 16(4), e0250144. https://doi.org/10.1371/journal.pone.0250144

[3] Tobacco Free Generation, Food laws a boost to counter tobacco industry in India, September 2, 2021, accessed November 22, 2021

[4] Borse, V., Konwar, AN, & Buragohain, P. (2020). Oral cancer diagnosis and perspectives in India. Sensors international, 1, 100046. https://doi.org/10.1016/j.sintl.2020.100046

[5] Siddiqi K et al. Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries. BMC Medicine. 2015;13(194).

[6] Eskiizmir, Görkem & Ermertcan, Aylin & Yapici, Kerim. (2017). Nanomaterials: Promising structures for the management of oral cancer. 10.1016/B978-0-323-47720-8.00018-3.