by Carl V Phillips
There is a popular oral dip product in India called gutka. It was recently banned, in one way or another, across much of India, though it appears that this has had relatively little impact (other than perhaps raising the price to the extremely poor people who are most of the users). Gutka is more popular in that country than is smoking, and is used by an absolutely enormous number of people.
Gutka, and the somewhat similar paan that is popular in Pakistan, appears to pose a very serious risk for oral cancer and other oral diseases, and perhaps other serious diseases. The health consequences appear comparable to those from smoking, and might even be worse — in particular because, unlike with smoking, many of the serious effects appear to occur before old age. (The “appear” caveats I keep repeating reflect the fact that most of the epidemiology about these products is so utterly lousy that precision is impossible — we had better quality information about smoking half a century ago. But there is enough information that it is difficult to doubt that there are serious and high risks.)
So, gutka and paan are, indeed, nasty. But what they are not — contrary to the typical portrayal — is tobacco. Gutka does contain tobacco, and paan sometimes does (but not always), but it is not the first ingredient and may not even be the second. The first ingredient in gutka is areca nut (also known as betel nut), and other ingredients include catechu (a derivative of the acacia tree), various flavorings, and calcium hydroxide (aka slaked lime, or just lime). The ingredients in the one packet of it that I have that lists the ingredients (most do not) are “betelnuts, tobacco, catechu, cardamom, lime, menthol, natural & artificial flavors”.
So this is tobacco only in the sense that a Big Mac, fries, and Coke is lean beef, potatoes, and water. The latter are major components of those products, of course. If they were all that was consumed it would not exactly be healthy eating, but they are not all that bad for you. But a funny thing happens when you consider everything in the foods (various unhealthy fats, high glycemic carbohydrates, carcinogenic products from cooking, etc.) — the meal becomes rather unhealthy. This is a nearly perfect analogy to the deadly implications of calling gutka “tobacco”.
Something in gutka is pretty clearly quite unhealthy. Lime is a good candidate — it is quite caustic on your skin, as you might have experienced, and is even worse for your oral mucosa. It has fairly obvious and rapid negative effects. But it might be that holding areca nut or catechu in your mouth for a long time is quite harmful too. The one thing that we can be pretty sure is not causing most of the harm is tobacco. Why? Because it is the one of the ingredients that has been extensively studied, as an oral dip exposure, and has been found to produce minimal risk.
To be precise and careful (quite unlike most of those who write about this topic), it is possible that the interaction of tobacco with the other ingredients causes more harm than the other ingredients would cause if the tobacco were absent. It is also possible that because of the way this particular tobacco is processed, it causes harms that American and Swedish style smokeless tobacco do not. (There is a plausible but unsubstantiated hypothesis that the much higher concentrations of nitrosamines in some non-Western and archaic products could make them much more hazardous, though there is no evidence that it would be anywhere close to as bad as gutka is.) Thus, we cannot conclude that the role of the tobacco is benign, but it is clearly wrong to suggest it is the main source of the problem.
Who suggests that? Pretty much everyone. The impetus for me writing this post was running across this newspaper story about how the gutka ban is failing due to the black market, with a headline that refers to it as “chewing tobacco”. But it is not just bad reporters and casual observers who make the mistake. The packets of gutka I have all display the mandated statements “tobacco kills” and “tobacco causes cancer” and what I assume are their Hindi equivalents. I do not know whether current products still have those statements (once you ban something, it is difficult to enforce labeling regulations, after all), but the point is that the government’s official statements describe the product as “tobacco”. This is probably the fault of the World Health Organization, since India’s policy is pretty much “do whatever WHO tells us to do”, but I actually do not know the story. (Anyone know? Please let me know.)
But it gets even worse than that. The anti-THR liars have made a concerted effort to trick Westerners into believing that the apparent harms from Indian “tobacco” are relevant to Western products. The classic example of this IARC Monograph 89, from the International Agency for Research on Cancer — a unit of WHO that primary is known for its science-by-committee declarations, and is mistakenly seen to be an authoritative and apolitical research organization. The authors of that document — including longtime professional anti-THR activists like Stephen Hecht (already represented in this blog), Scott Tomar (who got a passing mention but seems to have disappeared), and Deborah Winn (who will likely make an appearance) — tried to bury the fact in their 626 pages that their conclusion that smokeless “tobacco” causes cancer was basically based just on studies of gutka and paan along with a single old study of an archaic American product.
I realize that this post leaves the reader with many points of curiosity that call for more information. I will try to circle back to these sometime. But I will conclude by creating one more:
Why did I say it was deadly to refer to gutka as tobacco? THR in the West is about replacing smoking with smoke-free alternatives. But in South Asia, there is a lot of room for something else that could be called THR: The replacement of gutka and paan with smokeless tobacco (snus). Western-style smokeless tobacco could be made domestically (and thus be affordable, though perhaps more expensive than the current products — I am not sure) and it would presumably have about the same unmeasurably low risk as snus. Given that the impact of the local dip products is similar to that from smoking, this has similar potential to Western THR. But — as with Westerners who think that “tobacco” or nicotine is the problem rather than smoking — this is very unlikely to be pursued so long as everyone thinks that it is the tobacco that is the problem.
See also: WHO lying about smokeless tobacco again and The biggest victims of WHO’s anti-harm-reduction efforts are in India
Sad and frustrating Carl. Very well researched for what seems to be out there. It’s certainly something that should be looked into a lot more seriously.
I’ve heard many times of simple betel nut chewing: have you seen anything on the health consequences of that in itself? What’s the active/attractive ingredient btw?
There is some dispute about whether betel nut by itself is all that bad. You can find claims either way. Unfortunately, that lousy research that I referred to makes it difficult to sort out. Given the politics, there is no way to reach a conclusion without becoming expert in that topic itself — or finding someone who is expert and honest. I think that a educated and careful layperson could sort out the truth about snus or e-cigarettes without understanding the research itself because there is enough good information out there, but that does not seem to be the case for the Asian products. On the other hand, delving into this creates a reminder about and sympathy for those who are trying to find the signal amidst the noise about THR — it is easy to forget that.
The effects of betel nut are similar to those of other mild plant-based stimulants, though someone with more experience trying it would have to explain how it differs from tobacco or coffee.
Well Said! Gutka is not at all smokeless tobacco product but wrongly perceived so. Moreover Panmasala (which is gutka without tobacco) has no tobacco at all.. but still perceived as smokeless tobacco.
Both Gutka and Panmasala are primarily areca nut/ beetle nut (called as Supari in India and Chalia in Pakistan). Both these products have more than 80% beetle nut, 8 to 9% catechu and gutka has less than 7% tobacco while there is no tobacco in Panmasala. The harm effects of beetle nut are very well proven. The IARC regards the chewing of betel/ areca nut to be a known human carcinogen. The causitive agent for oral submucous fibrosisis is arecanut, which is chief component of gutka and Panmasala which have become popular in last 2/3 decades only. There are several studies showing increased incidences of OSF in last few decades, and OSF is caused mainly due to beetle nut and is never seen in exclusive smokeless tobacco user. This non curable non reversible disease can turn into oral cancer in as high as 20% to 25% cases.
There are already several millions of OSF patients and even after ban of gutka they have high risk of oral cancer as the OSF is not reversible even after cession of habit. 16 states of India have banned gutka but only Maharashtra state has banned Panmasala too. With availability of panmasala in other states the threat of OSF remains same! Hope these state also ban Panmasala which will be effective remedy to increased incidences of OSF and mouth cancer!
Thanks for the additional information about product composition and especially the ironic bits about panmasala. I am not sure I would trust IARC’s opinion about betel, given that they are the same ones who used research about gutka to make claims about smokeless tobacco — not a lot of credibility there. I am not saying that the evidence does not support the claim, just that I would not believe IARC’s summary of it.
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