Cultural Aspects of Smokeless Tobacco Use and the Impact of Chewing Pan Masala in the Oral Cancer Scenario

Figure 1. Thamboola with tobacco (current practice). Figure 2. Indian Pan Masala brands.

The dentist was astonished to find that a 21-year-old engineer, groomed well in a middle-class family and about to join a famous IT firm in the city of Bangalore, could not open her mouth even to permit an impression tray with alginate. She had come to him to improve her facial appearance with orthodontic treatment. She had been using pan masala for the last eight years, even as a school girl; three-four packets a day!

In India, tobacco is chewed in several forms. The predominant varieties are Mainpuri tobacco, Mawa, Khaini, Mishri, Gattipodi, scented tobacco, and Jafna tobacco, although there are many more. Any type of tobacco chewing habit is an accepted social norm in Indian society. Let us consider why pan chewing, unlike smoking and drinking, is an accepted social behavior among all classes. The habit of Thamboola Charavana (chewing of betal leaf with areca nut, also known as betel nut, both derived from the Betel Pine, Semen arecae, and spices) has been prevalent in India for more than 3000 years. Ashtanga Hridaya, a basic book on Ayurveda, the ancient system of medicine in India, lists the ingredients for Thamboola Charavana as betal leaf, areca nut, camphor, copra, cardamom, cloves, nutmeg and slaked lime1. This book also states that Thamboola Charavana will reduce bad breath and increase the secretion of gastric juices. Manusmrithi, the Magna Carta of ancient India, states that it is the duty of the wife to give Thamboola to her husband after every meal.

Chewing of betal leaf with areca nut and other spices (e.g., masala) used to be a harmless habit. The Portuguese introduced tobacco into India and it became a commercial commodity by the middle of the 17^th century. Narahari, an Ayurvedic physician who lived during the time of the Mogul Emperer, Akbar, used tobacco broth for the first time for gargling, to treat bad breath and gum diseases². Gradually, tobacco became more frequently used as an ingredient of Thamboola Charavana. Today tobacco is a home remedy for tooth ache. As time passed, the more expensive spices in Thamboola were replaced by tobacco by the poor man, who used it to dull the pangs of hunger. (Figure 1)

		Source / Brand				SOSIP(a)			Relative Activity (units)(b)
		Raja Chap Khaini				66			0.73
		Moolchand Superb Gutukha				114			1.25
		Rahat				270			2.97
		Vimal				397			4.36
		Badshah				321			3.53
		Superfit				9			0.09
		Tara				159			1.75
		Pan Parag #1				763			8.38
		Panking				210			2.31
		Manikchand				1249			13.73
		Mahak				888			9.76
		Yamu				343			3.77
		Jubilee				189			2.08
		Talab				113			1.24
		Rajdarbar				371			4.08
		Crane				383			4.21
		Kuber				367			4.03
		Kamla Pasand				133			1.46
		Kanchan				137			1.51
		Tulsi				277			3.04
		Zatpat				41			0.45
		Pan Parag #2				100			1.09
		4-Nitroquinoline Oxide (Reference Mutagen)				91			1.00
	(A) Expressed as the SOS inducing potency (SOSIP)   (B)  Expressed as the relative activity in units. One unit is expressed as the SOSIP of 1µg of 4-Nitroquinoline Oxide, the standard reference directacting mutagen.
		Table 1. Relative Mutagenic Activities of Pan Masala Assessed by the Superoxide Scavenging (SOS) Microplate Assay (SOSMA).

Until recently, pan was disbursed by pan wallas (delivery boys) fresh from pan shops, which were found all over the country even in the remotest corner. In this form of pan, tobacco, betel nut and slaked lime were packed in one or two fresh, tender betel leaves and consumed immediately. Such pan was wet, difficult to distribute on a large scale and inconvenient to carry. The solution was to use a dry mixture of lime, betel nut, tobacco other spices and flavoring agents without betal leaf, which could be easily packed in separate sachets and tins in varying quantities, depending on the requirements of the consumer. This form of pan is known as pan masala. Other psychotrophic substances like gambir, bhang and ganja may also be found in particular brands of pan, but the composition is generally kept as closely guarded secret. All of these ingredients are hazardous to health. Pan masala was shown to be mutagenic by Bagwe et al (1990)3, Polasa K. et al (1993)⁴ and Patel R.K. et al (1994)⁵. Studies conducted by the Regional Cancer Centre (RCC), Trivandrum, in collaboration with the John Hopkins University, Baltimore, USA, by Babu Mathew and P.P. Nair in 1996 on 22 brands of pan masala has shown that 19 brands were highly mutagenic. The results are shown in the table below.

Analysis of various samples of pan masala at the National Institute for Occupational Health (NIOH) showed the presence of heavy metals such as nickel, cadmium, lead and pesticides in many samples⁶. Polycylic hydrocarbons and traces of habit-forming substances were also found in some samples.

The massive advertising campaigns aimed at youth in higher income brackets have increased the sale of pan masala. There are more than 12 brands of pan masala with annual turnover of more than 2 000 million Indian rupees. (Figure 2)

Bar graph showing the crude annual incidence rate of oral cancer in males of all ages in selected countries. Average incidence rates for more and less developed countries are also shown. Graph created with Globocan 2002.

To create a taste for pan masala in later life, children are encouraged to use certain substances as mouth fresheners, e.g. Pan Pas, from Pasand Vardhan, which may not contain tobacco but are surrogates for pan masala. As they reach adolescence, children start chewing pan masala and are thus exposed to the risks of chewing tobacco, which they continue throughout their lives. Hence parents and teachers should dissuade children from using such substances.

From the epidemiological evidence, it is clear that oral precancerous changes occur in pan masala chewers much earlier than in conventional betel chewers. This is because of the absence of betal leaf in pan masala. In conventional pan, the carotenoids present in the betel leaf act as free radical quenchers (anti oxidants), thereby reducing the toxicity of tobacco and areca nut⁷. High pan masala consumers among men include bus, taxi and auto-rickshaw drivers, watchmen, painters and carpenters. Women consumers are mostly office workers.

During the last decade, researchers and clinicians have become increasingly aware of a new disease called localized oral submucous fibrosis (OSF) in adolescent pan masala users⁸. In older betel chewers more generalized OSF due to betel chewing occurs. The classical OSF seen in conventional betel nut chewers is a disease characterized by blanching of the oral mucosa, inability to tolerate spicy food, difficulty in opening the mouth and difficulty in protruding the tongue. The elastic nature of the oral mucosa is gradually lost. This is due to stimulation of collagen growth in the submucosa and prevention of collagen breakdown as a consequence of exposure to an alkaloid, arecoline, as well as tannins and flavenoids, all present in areca nuts. The other pan masala-related oral lesions are leukoplakia, erthroplakia and pigmentary changes. (Figure 3)

Figure 3. Pan-chewing teenager with OSF and Leukoplakia.

Conventional betel nut chewers with OSF, leukoplakia and erythoplakia develop squamous cell carcinoma within 10 to 15 years. In our experience, precancerous localized OSF seen in pan masala users more rapidly undergoes malignant transformation.

The reported prevalence of OSF in Gujarat in 1967 was 0.16%. A resurvey in the same area by the same team in 1998 showed that the prevalence had increased to 3.36% - almost 20 fold⁹. A prevalence survey of three colleges in Trivandrum city, Kerala, by Babu Mathew et al in 1996 showed that 7.6% of the boys and 5.2% of the girls were pan masala users¹⁰. The recent reports from Bhopal showed a prevalence of 1.98% OSF among teenage school children in Bhopal city¹¹.

Figure 4. Pan-chewing teenager with cancer of tongue.

In the precancer registry of RCC, there are 23 teenagers with OSF due only to pan masala use. Hazare and Goyal from Nagpur have calculated the relative risk of developing OSF in pan masala users, demonstrating a direct proportional increase in the disease with the increased frequency of pan masala consumption.

Other reported health hazards of pan masala are anxiety, irrational fear, depression, desperation, introvert behaviour, forgetfulness, loss of temper, mental derangement, suicidal tendencies and impotence. Anybody who consumes this product with gutka for the first time may have a momentary loss of consciousness. There was a report of sudden death in a teenager from Kasargode District in Kerala, who tasted pan masala. The cause of death was confirmed on autopsy as anaphylactic shock.

There are very few reports of successfully overcoming addiction to pan masala which may be more difficult than alcoholic detoxification or giving up smoking.

The use of pan masala can be controlled by a three-pronged strategy. There should be proper health education and awareness-raising of the economic, social and health hazards of pan masala. There should be proper legislation to control the production, storage, distribution and sale. Advocacy activities to make this habit an unacceptable social practice may also be effective in controlling its use. Voluntary organizations in the colleges, such as the National Service Scheme (NSS) and National Cadet Core (NCC) and scouts and guides in schools, may work to reduce pan masala use. Religious organizations are often active campaigners against pan masala.

No meaningful federal legislation has been introduced relating to the control of pan masala in India, although some states (Tamil Nadu, Andhra Pradesh, Gova, etc.) have banned the sale of pan masala and the Allahabad High Court has banned it in Uttar Pradesh. Students should boycott sports and cultural activities sponsored by pan masala companies. The federal government is now thinking of introducing a bill to control this menace.

We wish to narrate a tragic drama that was staged in our clinics two years ago. Noushad from Malappuram, Kerala, a 12^th-year standard student, was referred to RCC for an ulcer on the tongue. He was 16 years of age. OSF was diagnosed in association with an ulcer on the left margin of the tongue (Figure 4). On questioning he confessed that he had been consuming ten packets of pan masala a day for the last six years. First given free to him by his neighbour, a shop-keeper, Noushad later bought or stole it. A biopsy of the ulcer was reported as squamous cell carcinoma and the patient underwent treatment at RCC, Trivandrum. Even during treatment he could not resist pan masala and in spite of all possible measures, we could not save this young man.

M. Krishnan Nair and Babu Mathew, Amrita Institute of Medical Sciences, Kerala, India

References

1. Babu Mathew, Cultural Aspects of Tobacco Chewing Abstract Book XI World Conference on Tobacco or Health Vol, 2, Page 288. 2000

2. Babu Mathew. Pan Masala, a prelude to oral cancer epidemic in South East Asia. International Journal of Cancer Supplement 13, Page 80. 2002.

3. Bagwe A.N., Ganu U.K., Gokhale S.V. and Bhisey R.A. Evaluation of Mutagenisity of Pan Masala, a chewing substitute widely used in India. Mutation Research 1990; 241: 349-54.

4. Polasa K., Babu S and Shenolikan I.S. Dose dependent genotoxic effect of Pan Masala and areca nut in the salmonella typhimuricam assay. Food chem. Toxicol 1993:31: 439-42.

5. Patel R.K., Trivedi AM, Jaju R.J., Adhvaryu S.G. and Balan DB. Ethnol Potentialities the Clastogenicity of Pan Masala and in vitro experience. Carcinogensis 1994; 19:2017-21.

6. National Institute of Occupational Health. Toxicological evaluation of Pan Masala. Annual Report of National Institute of Occupational Health (ICMR), Ahamedabad 1989-90. Page 60-66.

7. Lahiri M. and Bhide S.V. studies on Possible Protective effect of plant derived phenols and the vitamins precursors –ß carotene and α tocopherol on 7,12, dimethylbenz (a) anthracine induced tumour initiation events. Phytotherapy Research 1994: 8: 237-40.

8. Babu S., Sesikiran B. and Bhat R.V. Oral fibrosis among teenagers chewing tobacco areca nut and pan masala letter. The Lancet - 1996 348: 692.

9. Gupta.P.C., Sinor P.A., Bhosle R.B. Oral Submucous fibrosis in India: A New Epidemic National Medical Journal of India: 1998:11: 113-116.

10. Sannyal (Personal Communication Dr. Babu Mathew) 2004. Prevalence of Oral submucous fibrosis in school children of Bhopal city.

11. Hazare and Goyal OSMF. Areca nut and Pan masala use. A case control study National Medical Journal of India, 1998:11: Page 299.