Wrapped inside betel leaves and placed in the corner of the mouth, chewing tobacco has been a practice in India for centuries.
While there is certainly an increased awareness in terms of the harmful effects this could have on health, the medical fraternity is very much concerned about the growing number of cancerous lesions in the mouth.
The prestigious scientific journal Lancet has placed India at the second position -next to China - in terms of those consuming smokeless tobacco.
Various forms of loose-leaf chewed tobacco are commonly consumed in the Indian subcontinent. Smokeless tobacco use is particularly prevalent in India, Bangladesh and among women in Thailand.
What is less known to most people in India is that more than 4,000 different chemicals have been found in tobacco and over 60 of these chemicals are known carcinogens.
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Almost 30 percent of the Indian population older than age 15 use some form of tobacco. Men use more smoked tobacco while women are more likely to use the chewed variety.
In case of paan with tobacco, the main ingredients of paan are the betel leaf, areca nut (supari), slaked lime (chuna), and catechu (katha).
Sweets and other condiments are also added for flavour. The varieties of paan are named for the different strengths of tobacco in it. It is a myth that chewing tobacco with betel leaf is not harmful.
The International Agency for Research on Cancer (IARC) has rightly established that people who chew both the betel leaf and the areca nut along with tobacco have a higher risk of damaging their gums and having cancers of the mouth, pharynx, esophagus and stomach.
Khaini is yet another common chewing tobacco seen mostly among the women folk. Dried tobacco leaves are crushed and mixed with slaked lime and chewed as a quid. The practice of keeping the quid in the mouth between the cheeks and gums causes most cancers of the gums - the most common form of mouth cancer in India.
Let us pause and take a look at a case study here.
Raghav Sharma (name changed) was diagnosed with stage IV mouth cancer. A road-side vendor in Delhi, he earned his living out of selling vegetables.
Sharma underwent surgery and had to get the central portion of his lower jaw removed. For this, he gave away all that he had to save himself.
Now, the same man has knocked the door of the hospital again with two marble-sized yellowish lumps in his gums.
The ugly dreadful cancer is back again with a vengeance and the doctors have no other option but to go for a second surgery.
There is an urgent need for increasing awareness on the ill effects of chewing tobacco. Interestingly, there are misconceptions that tobacco has germicidal compositions that could cleanse the teeth.
Mishri is one of the kind which is applied on the teeth like a tooth powder. In due course, the individual gets addicted to the usage and becomes totally dependent on the product. The user also ends up damaging his teeth and gums.
Gudakhu, again used commonly by women, is a paste of tobacco and sugar molasses and involves direct application of tobacco to the gums, thus increasing the risk of cancer of the gums.
A campaign that empowers cancer survivors to tell their stories to influence policymakers and raise awareness among other tobacco users about the damaging effects of tobacco on health is the need of the hour.
Besides cancer of mouth, use of tobacco, in the smoke or smokeless form, may lead to other serious diseases including heart, lung, circulatory diseases and stroke.
Once diagnosed with cancer, the genetic damage is irreversible.
(Dr Rajat Arora is MD, MRCP (UK), DM, Interventional Cardiologist and Medical Director at Yashoda Hospitals in Delhi. He can be contacted at drrajat@yashodahospital.org)