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  Table of Contents  
REVIEW ARTICLE
Year : 2012  |  Volume : 49  |  Issue : 4  |  Page : 347-351
 

Smokeless tobacco use in Myanmar


1 WHO Regional Office for South-East Asia, New Delhi, India
2 Ministry of Health, Union of the Republic of Myanmar,

Date of Web Publication26-Feb-2013

Correspondence Address:
N N Kyaing
WHO Regional Office for South-East Asia, New Delhi
India
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DOI: 10.4103/0019-509X.107727

PMID: 23442397

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 » Abstract 

Smokeless tobacco (SLT) use in various forms is highly prevalent in Myanmar. The aim of this paper is to study the socio-cultural background of SLT use and products of SLT in Myanmar and the prevalence of SLT based on surveys and from other published data bases. Information was obtained from the literature review and through search on PubMed and Google. The use of SLT is deep rooted in Myanmar culture, and there is also wide-spread belief that it is not as dangerous as smoking. SLT use is growing in Myanmar. About 9.8% of the 13-15-year-old school children and 20.8% adults use SLT; it is many-fold higher among men. The use of SLT is prevalent using many different types of tobacco and forms of its use in Myanmar. The socio-cultural acceptance and the myths were compounded by the lack of specific SLT control component in the National Tobacco Control Legislation adopted needs to be addressed as a priority through intensified community awareness programs, public education programs, and advocacy campaigns. Effective enforcement of the law and amendment to include specific components of SLT in the provisions of the law is highly recommended. The prevalence of SLT is high among school children and adults (especially in men) in Myanmar. Betel quid and tobacco is a common form of SLT use. Although control of smoking and consumption of tobacco product law exists, its implementation is weak.


Keywords: Betel quid with tobacco, prevalence of Smokeless tobacco use, smokeless tobacco


How to cite this article:
Kyaing N N, Sein T, Sein A A, Than Htike M M, Tun A, Shein N. Smokeless tobacco use in Myanmar. Indian J Cancer 2012;49:347-51

How to cite this URL:
Kyaing N N, Sein T, Sein A A, Than Htike M M, Tun A, Shein N. Smokeless tobacco use in Myanmar. Indian J Cancer [serial online] 2012 [cited 2014 Dec 19];49:347-51. Available from: http://www.indianjcancer.com/text.asp?2012/49/4/347/107727



 » Introduction Top


The use of SLT products in diverse forms is highly prevalent in Myanmar as compared to other countries. [1] The misconception that smokeless tobacco (SLT) use is less dangerous than tobacco smoking is a big challenge to the tobacco control measures. This is compounded by the ease of purchase and low prices of SLT products. In the current status of increasing SLT use in Myanmar, it is necessary to carry out a systematic review for the extent and patterns of its use among the Myanmar people. The aim of this paper is (i) to describe the tradition and cultural factors for the initiation and continuation SLT use among the Myanmar people, (ii) to identify the various forms of its use of products, and (iii) to examine the prevalence trend of SLT use in Myanmar.


 » Materials and Methods Top


Data sources for this review was obtained from published reports and documents, research findings, series of studies, and surveys conducted in Myanmar such as the Sentinel Prevalence Survey on Tobacco Use in 2001, 2004, and 2007; Global Youth Tobacco Surveys (GYTS) in 2001, 2007, and 2011; Effectiveness of School Tobacco Control Study in 2011; NCD Risk Factor Survey in Myanmar, 2009; and WHO Report on the Global Tobacco Epidemic, 2011.


 » Results Top


Tradition and culture of smokeless tobacco use

Kun-ywet is the Myanmar term for betel leaf, areca nut is called Kun-thee, and the preparation is called Kun-yar. Offering and chewing Kun-yar or betel quids is ceremonial and deeply rooted in the traditional culture of Myanmar, similar to that of all countries in South Asia like India, Sri Lanka, Pakistan, Bangladesh, Indonesia, Philippines, Malaysia, Cambodia, Laos, and Vietnam. Traditionally, for a visitor to a house in Myanmar in olden days, the first three items offered to the guests as hospitality were (i) cheroots/cigarettes for smoking, (ii) a container (special lacquer box called kun-it) consisting fresh betel leaves, cut pieces of areca nuts (betel nuts), silver betel nut cutter, silver boxes containing slake-lime, and catechu (shar-si), cured tobacco, and other condiments (clove, sweet root, cardamom, aniseed, etc.) in a tray, to be prepared as Kun-yar for mouth-freshening, and (iii) a plate with the fermented tea-leaves (lahpet) combined with variety of fried beans. These are accompanied by the hot Myanmar green tea to drink. [2],[3],[4]

Myanmar people believe that Kun or Kun-yar (be tel leave, betel nut, and condiments), hsey (cigarettes/cheroots with tobacco), and lahpet (fermented tea-leaves) are the essential delicacies to be served to guests coming to their homes, weddings, and any other ceremonious occasion. Thus, no ceremony or occasion is considered complete without kun, hsey, and lahpet. It is considered impolite to refuse the above three offerings as a token of friendship and hospitality, particularly in the rural areas. People who attend marriage receptions or ordination ceremonies are usually offered cigarettes or cheroots as a gesture of appreciation. Tobacco companies and their sales agents usually exploit this culture by free distribution as gifts or selling in subsidized prices. Similar practices are also present in many Asian countries. [2],[4]

Agricultural aspects

Although the National Tobacco Control Program of the Ministry of Health, Myanmar has conducted several educational campaigns on the hazards of chewing betel quids with areca nut tobacco, both men and women between 10-30 years of age are increasingly chewing betel quids or pan. [3] While the land used for betel nuts (areca nuts) remain the same around 12,000 acres, the land used for betel leaves had been almost doubled from 9,000 acres in 2000 to 19,000 in 2005. Many small-scale betel leaf growers termed this growth as "Green Gold era." While a proportion of locally produced betel leaves have been exported, majority of leaves are consumed locally. This can be noted with an increasing number of people chewing betel quids and mushrooming of small and big kiosks selling betel quids in every corner of the streets both in rural and urban areas in Myanmar. These kiosks also promote sales of tobacco products. [4]

Methods of use

Usually people start chewing betel preparation without tobacco, but the majority adds tobacco in the preparation in later stages and become addicted to tobacco. Adding different forms of tobacco, flavors, and contents in the betel preparation has become fashionable and is being practiced widely among both sexes and all ages. [2],[3],[4]

Common SLT products consumed in Myanmar is called Kun-Yar, which may be simply betel quid with Myanmar tobacco or betel quid with various other forms of tobacco. Raw tobacco is also chewed among some tribal groups. Kun-yar, Myanmar version of pan, is chewed for breath-freshening and mouth-cleansing by majority of adult males and females both in rural and urban areas. [2],[3],[4]

The preparation of Kun-yarla normally involves applying slaked lime and catechu (sharsay) to a betel vine leaf to which small pieces of areca nut are added. The betel quid leaf is then folded into a square or triangle shape. Tobacco is the most important ingredient of Kun-yar for regular users. A variety of tobaccos are added into the betel quid preparation such as Myanmar tobacco (Myanmar Hsay), tobacco leaves, and stem treated with alcohol and honey (HsayPaung or HnutHsay) as well as SLT imported from India and Bangladesh, which is usually referred to as HsayHmwe. The tobacco water (HsayPaung Yay) is a liquid form of tobacco and it is also used to spray on the ingredients of a betel preparation. [2],[3],[4]

Catechu is an astringent, reddish-brown substance that is often smeared on the betel leaf before it is used to wrap the ingredients of a betel quid. Catechu is prepared by decoction and extraction from the hard wood of Acacia catechu, a tree indigenous to India and Myanmar. It is sometimes referred to as black catechu or cutch. Since the tree is scarce now, use of catechu for betel quid has reduced. Betel leaf is also used for medicinal purposes in many traditional medicine recipes. [2],[3],[4]

Other ingredients are also added according to the customer preference and the betel quid leaf is folded into a square or triangle shape. Other sweetening and flavoring agents such as liquorices/sweet root (Nwe-cho), aniseed (Samone-sapar), cardamom (Phalar), clove (Lay Hnyin), pineapple flower (Narnut- pwint), black cumin (Samone-net), aniseed oil (Samone-hsee), cress (Samone-ni), sesamon seed (Hnan), coconut shreds or pickled coconut shreds, gone-khar, Gamone (some form of orchid or lily), lemon and, artificial areca nut (Thit-khauk) as perchoice.[2]

Current popular brands of treated tobacco imported from India are Signal,45, 92, 100, 162, 350 (zarda), Saga, Parijet, Powe, and Queen. Popular domestic brands of treated tobacco are Bayinma, Top, Shwe Let Wah, ShweBamar, and Natsae. Other different brands are also available in the market and the popularity varies by region. Various brands were mostly found in the Rakhine State located in the western part of Myanmar bordered by Bangladesh. [2],[3] In rural areas and, particularly, in the hilly tribes, chewing raw tobacco is a tradition that were initially for treatment of dental problems and later becomes habitual. In some hilly areas, tobacco leaves were soaked in water for some time, and the tobacco water is sipped slowly; the tobacco water is regarded as a relaxant and is usually taken in the evenings after hard work. [3] In hilly tribes of Chin Sates, working men and women used to carry tobacco-soaked water to work and sip it throughout the day as they believed that the "tobacco water" refreshes them. [2]

Prevalence of SLT use

Trends in SLT use had been explored based on findings of previously conducted surveys and studies. According to the Myanmar GYTS, 2011, a school-based survey of students aged 13-15 years of 7 th to 10 th grades, about one in five (18.6%) students reported current use of any tobacco products, where 6.8% were current cigarettes smoker, 8.2% were current cheroot smokers, 9.8% were current user of any SLT products, and 7.5% were current user of tobacco with betel quid. The GYTS of 2007 and 2011 show an increase in prevalence (from 6.5% to 9.8% of 13-15 years old students). The prevalence of SLT use among boys was about four times higher than that in girls [Figure 1]. [5],[6]
Figure 1: Prevalence of SLT use among students aged 13-15 years[6-8] Source: GYTS, 2007 and 2011

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A study on effectiveness of School Tobacco Control Program was conducted in the capital city Nay Pyi Taw in 2011. An early age of initiation has been identified by this study that 5.2% of 5 th , 6 th , and 7 th graders were current users of SLT products mainly in the form of betel quid with tobacco (6.3% among boys and 4.1% among girls). [7]

Sentinel Prevalence Studies of Tobacco Use in Myanmar were conducted in the years 2001, 2004, and 2007 with the objective of building a database on prevalence of tobacco use for planning and evaluation of tobacco control interventions in Myanmar. Study results showed that although prevalence of smoking is gradually declining, prevalence of SLT use such as chewing of betel quid with tobacco is rising steadily among both sexes in both rural and urban areas [Table 1]. [8],[9]
Table 1: Prevalence of smokeless tobacco use among adults in Myanmar

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According to results of the WHO Non-communicable Disease Risk Factor survey conducted in 2009, an alarmingly high percentage (51.4%) of male respondents aged 15-64 years used SLT and its use was extremely high even among the age group of 15-24 years men (45%). The consumption was highest in 25-34 years old men (63%) and 45-54 years old women (32.1%). More than one-third of men (37.7%) and about one in ten women (12.2%) consumed SLT daily. Concurrent use of smoking and SLT was observed in 22.7% of men and 2.8% of women [Figure 2]. The highest rate of concurrent use was observed in the age group of 25-34 years among men (30%), while the rate was higher in the older age group of women (4.9% in 45-54 years among women). [10]
Figure 2: Smokeless tobacco use status among adults. WHOSEARO, Non-communicable Disease Risk Factor survey, Myanmar 2009

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Social and legal aspects of SLT use

Studies show that there is wide-spread belief in Myanmar misleading to the concept that SLT use is not as dangerous as smoking. Perhaps due to this reason, SLT use is not seriously taken as a dangerous act for the youth; hence, parents do not prohibit SLT use as strictly as smoking. The long-standing cultural use of SLT for social and religious occasions hinders efforts to control SLT use. [2],[3],[4]

The "Control of Smoking and Consumption of Tobacco Products" law adopted in 2006 actually covers SLT in broad definition, but its enforcement has been weak. Although government has issued circulations prohibiting sale of SLT in government compounds in 2011 and has prohibited spitting chewed tobacco in public places, there is weak public compliance. [11]

Effects of SLT use

Like smoked forms of tobacco, SLT also contains carcinogens and other toxic chemicals. Chewing of betel quid containing tobacco was significantly associated with the occurrence of oral and oropharyngeal cancer where the risk was > 10 times higher in chewers as compared with non-chewers. Low birth weight and stillbirths are two major adverse reproductive outcomes found in association with SLT use in pregnancy. Hospital data of the 20 th century showed that oral cancer rank among the top ten cancers including India and other South-East Asian countries. In Myanmar, during the year 1974 to 2001, oral and oro-pharyngeal cancers have consistently been the fifth most common cancers for both genders. [1],[7]


 » Discussion Top


Myanmar has the highest prevalence of SLT use in the South-East Asia Region especially among men. [11] The current prevalence of SLT use revealed the urgent need to focus on the SLT problem in Myanmar. The GYTS results [5] also showed that SLT use among students of age 13-15 years has increased in both sexes. As there was a wide spread myth that SLT is not as harmful as cigarettes, parents and teachers tend to show less concern on their children chewing betel with tobacco. The law also does not specifically prohibit sale of SLT to minors nor prohibits sale of SLT within 100 yards of schools. This is one area that needs to be emphasized by the national tobacco control program and get incorporated into existing rules and regulations. [11],[12]

Dissemination of fact sheet containing GYTS, GSPS findings, [5] and suggestions to all educational schools and institutions are also required to carry out. Currently in Myanmar, there is "The Control of Smoking and Consumption of Tobacco Products Law" in place. The law includes the provisions for limiting environmental tobacco smoke, i.e., designation of no-smoking areas, prohibiting sale of tobacco to or by minors under 18 years of age, sale of cigarettes in loose forms, and selling of tobacco products within the compound or 100 feet from the compound of the schools, the provision regarding packaging and labeling of tobacco products and preventing all forms of tobacco advertising, promotion, and sponsorship among others. Law enforcement is weak; further regulations and notifications are urgently required to put the law into effective enforcement. [11],[12]

Further data from the NCD risk factor survey in Myanmar, 2009 and findings from Poverty Alleviation and Tobacco Control study in Myanmar, 2005 revealed that use of SLT products is most commonly reported among the low income group and low education group. [3],[13] Tobacco users spend a considerable amount of hard-earned income on tobacco. The lowest income users of SLT were spending 20% of their income on tobacco, potentially leading to deprivations. [14]

Other evidence for increased SLT use comes from trade information on increasing trade. There is considerable trade of Indian SLT products flowing legally as well as illegally into Myanmar, Nepal, Sri Lanka, Bangladesh, and Bhutan. [13] Efforts should be prioritized on law enforcement as well as amendment of existing national law to include the control of SLT products and illicit trade of tobacco in Myanmar.

Myanmar tobacco control program was established in the year 2000 and has been focusing mainly on smoking tobacco products. The Ministry of Health in collaboration with relevant sectors and NGOs should endorse a more comprehensive tobacco control strategy that includes use of all forms of tobacco products. Documentation of various aspects of SLT and its use is an important step towards formulating and implementing SLT control policies in Myanmar as well as for the region. Community awareness campaigns should be implemented with the involvement of NGOs and relevant ministries. Public education on the dangers of SLT is the most important step that needs to be followed by advocacy and effective law enforcement.


 » Conclusion Top


SLT use is highly prevalent in Myanmar. Betel quid chewing with tobacco is a common form entertained socio-culturally in Myanmar. About 9.8% of the 1315-year-old school children used SLT and 20.8% adults indulged in this habit. Males outnumber females many-fold in the use of SLT. Control of smoking and consumption of tobacco product law exists, but its implementation is weak.


 » Acknowledgments Top


Authors wish to thank the Tobacco Control Programme, Ministry of Health, Myanmar for permission to use their studies to be referred and analyzed and to the TFI unit of the WHO Regional Office for South-East Asia for their support.

 
 » References Top

1.World Health Organization, Regional Office for South-East Asia. Meeting report of Expert group consultation on smokeless tobacco control and cessation, New Delhi, India, 16-17 Aug 2011.  Back to cited text no. 1
    
2.Kyaing NN. Study on types and constituents of tobacco used in Myanmar. National Tobacco Control Project, Department of Health, Ministry of Health, Myanmar; 2004.  Back to cited text no. 2
    
3.Tun A. Update on types and constituents of tobacco used in Myanmar. Report to WHOSEARO, 2011.  Back to cited text no. 3
    
4.Sein T, Maung NS. Tobacco legislation and ways of tobacco industry in Myanmar, Draft report to WHOSEARO, 2012.  Back to cited text no. 4
    
5.World Health Organization, Regional Office for South-East Asia. Factsheet on Global Youth Tobacco Survey: Myanmar. New Delhi: WHO SEARO; 2011.  Back to cited text no. 5
    
6.Tun A. Project report: A study on effectiveness of school tobacco control program in Nay Pyi Taw, Myanmar, 2011.  Back to cited text no. 6
    
7.Ministry of Health, Myanmar. Brief profile on tobacco control in Myanmar. Nay Pyi Taw, Ministry of Health, Myanmar; 2009.  Back to cited text no. 7
    
8.Kyaing NN, Latt NN, Aung TT, Lwin KS. The sentinel prevalence study of tobacco use: Myanmar Country Report. New Delhi: WHO SEARO; 2004.  Back to cited text no. 8
    
9.National Tobacco Control Programme, MoH, Myanmar, Official report to WHOSEARO for Global Tobacco Control Report 2012.  Back to cited text no. 9
    
10.World Health Organization, Regional Office for South-East Asia. Non-communicable disease risk factor survey, Myanmar 2009. New Delhi: WHO-SEARO; 2011.  Back to cited text no. 10
    
11.WHO Report on the Global Tobacco Epidemic, 2011.  Back to cited text no. 11
    
12.Reichart PA, Way TH. Oral cancer and pre-cancer in Myanmar: A short review. J Oral Pathol Med 2006;35:193-6.  Back to cited text no. 12
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13.Gupta PC, Ray CS, Sinha DN, Singh PK. Smokeless tobacco: A major public health problem in the SEA Region: A review. Indian J Public Health 2011;55:199-207.  Back to cited text no. 13
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14.Kyaing NN, Rahman K, Percucic AM. Study on poverty alleviation and tobacco control in Myanmar, HNP Discussion Paper. Economics of Tobacco Control Paper No. 31. Washington DC. World Bank; 2005.  Back to cited text no. 14
    


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