Smokeless tobacco: a ticking time bomb for Pakistan

Abstract

Oral cancers are one of the most prevalent cancers worldwide with almost 300,000 cases reported annually1. In Pakistan, it is the leading type of cancer in men and women after breast cancer. Each year around 16,000 new cases of oral cancers are documented with 5500 cases resulting in death2. There are multiple etiological factors for oral cancers among which the use of smokeless tobacco (SLT) is at the top of the list. SLT is available in different consumable forms such as chewable tobacco, betel leaf, snuff (naswar), Betelnut, etc., which contain a number of carcinogenic substances3. Studies have revealed that naswar is the most common etiological factor of oral cancers among the Pakistani population as compared to the other forms of SLT3. The basic constituents of naswar are slaked lime, powdered tobacco, and indigo which contain more potent carcinogens such as unionized nicotine and tobacco-specific N-nitrosamines, that are specifically harmful to the oral cavity4. It can be used through different routes either inhaled nasally or by placing inside the mouth under the tongue. The nicotine is absorbed into the oral mucosa which is further aided by the increased pH of the mouth by slaked lime5. It has been observed historically that the use of SLT products is very commonly acceptable in Pakistani culture3. The sale and production of naswar are not well regulated and it is being sold by different vendors at cheaper prices and in different package sizes with no such instructions and health warnings written on it1,2. Moreover, some scientific data implicates it as replacement therapy for tobacco smoke cessation as it is a cheaper nicotine substitute1. In 2005, Pakistan formalized the WHO “Framework Convention on Tobacco Control (FCTC),” which addresses the details of the regulation and control of tobacco and SLT products by regulating its price, taxation, packaging, labeling, advertisement, promotion, and sponsorship5. In the last few years, Pakistan has made significant progress in smoking cessation policies but regulation of STL production and taxing is still lagging5,6. A case-control study, conducted in Khyber Pakhtunkhwa, Pakistan, revealed that 68% (men) and 38% (women) of oral cancer patients in Pakistan are due to naswar use. It was also shown that those who used naswar ever in their lifetime have 20 times more risk to develop oral cancers compared with the nonusers of naswar1. Thus, the increasing incidence of oral cancers with the relative use of naswar sets a ground basis for the implementation of strict policies regarding the manufacture and sales of SLT. Studies have provided shreds of evidence that there is a marked decrease in tobacco product use among young people by applying a ban on their promotion and advertisement. Health warnings and relevant constituents written on packages can also be an important tool for minimizing SLT use6. Sticking firmly to the FCTC protocols of smokeless tobacco use is the dire need of time. Furthermore, awareness regarding the harmful effects of STL use should prevail on urban and rural levels as there is a great lack of knowledge among the local population. Ethical approval None. Sources of funding None. Author contribution S.F., O.A.S., G.S., and A.K.: wrote the manuscript. O.A.S. and S.A.: review editing, formatting, and referencing. Conflict of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) N/A. Guarantor Omer Ahmed Shaikh. Financial Disclosure The author(s) received no financial support for the research, authorship, and/or publication of this article.