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ORIGINAL ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 2  |  Page : 129-132
 

Impact of 'gutkha and pan masala ban' in the state of Maharashtra on users and vendors


Department of Preventive Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication7-Aug-2014

Correspondence Address:
G A Mishra
Department of Preventive Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.138182

Clinical trial registration NCT01896375

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 » Abstract 

Background: Gutkha and pan masala contain harmful and carcinogenic chemicals. Hence, Maharashtra Government banned their manufacture, storage, distribution and sale on 19 th July 2012 for a year. Objectives: The objective of this study is to determine the impact of the ban on gutkha and pan masala on its users and vendors. Materials and Methods: A cross- sectional study was conducted among gutkha and/or pan masala users and tobacco vendors in the selected area of Mumbai city, 4-6 months after the implementation of the ban. The parameters studied included knowledge regarding the ban, usage or discontinuation of use of the banned products, product availability, withdrawal symptoms among quitters, etc., Results: A total of 68 users and five tobacco vendors were enrolled in this study. Although all users were aware about the ban on gutkha, very few knew about the ban on pan masala. Only 5.9% of users knew that currently the ban had been declared for only 1 year. Electronic media was the main source of information regarding the ban as reported by 45.6% users. All users and vendors were in favor of the ban. After the ban, 23.53% gutkha users quit their habit while 55.88% reduced their gutkha consumption. Non-availability of gutkha was the most important reason stated by the gutkha users for quitting or reducing the consumption. In spite of the ban, gutkha is still available in the market, but at an increased cost or in a different form. Conclusion: Nearly 23.53% of gutkha users have quit their habit post-ban despite its availability through illegal sources.


Keywords: Ban, gutkha, pan masala, smokeless tobacco


How to cite this article:
Mishra G A, Gunjal S S, Pimple S A, Majmudar P V, Gupta S D, Shastri S S. Impact of 'gutkha and pan masala ban' in the state of Maharashtra on users and vendors. Indian J Cancer 2014;51:129-32

How to cite this URL:
Mishra G A, Gunjal S S, Pimple S A, Majmudar P V, Gupta S D, Shastri S S. Impact of 'gutkha and pan masala ban' in the state of Maharashtra on users and vendors. Indian J Cancer [serial online] 2014 [cited 2020 Jan 23];51:129-32. Available from: http://www.indianjcancer.com/text.asp?2014/51/2/129/138182



 » Introduction Top


Gutkha and pan masala products were advertised and marketed aggressively in South East Asia during the last three decades, as a substitute for betel quid. Claimed to be safer products, they are consumed by both old and young population, specifically in India. [1] Although gutkha is sweetened, flavored mixture of areca nut, catechu, slaked lime, condiments and powdered tobacco, the same mixture excluding tobacco is pan masala. Both these products available in the market with identical brand names and packaging and sold in small, brightly coloured packets, hold a special appeal for children. [2] Various reports indicate the increasing usage of these products in vulnerable sections of the society. [1],[3],[4] The gutkha and pan masala industry today is worth crores of rupees. [5] Their usage causes oral sub mucous fibrosis, leucoplakia, erythroplakia and other debilitating conditions named as "gutkha syndrome" by Chaturvedi. [6],[7]

Based on several reports indicating health hazards caused, efforts are undertaken to ban the production, consumption, sale, storage and transportation of gutkha and pan masala by many states in India. Tamil Nadu banned gutkha in 2001 followed by Andhra Pradesh, Goa, Maharashtra and Rajasthan in August 2002. [5] Subsequently after legal battles, the ban in Maharashtra was lifted. However, following example of the eight other states, Government of Maharashtra finally banned the manufacture, storage, distribution and sale of gutkha and pan masala, containing either tobacco and/or nicotine or magnesium carbonate as ingredients by whatsoever name these are available in the market and any other products marketed separately to constitute gutkha and pan masala as final products, effective July 19, 2012. [8] Until May 2013, 26 states had banned gutkha.

The ban, initiated by Food and Drug Administration (FDA) under the Food Safety and Standards Act (FSSA), 2006 and Prevention of Food Adulteration Act, 1954, was facilitated by the new FSSA. As per the Government regulation, offenders would face imprisonment for 6 months to 3 years. The Bombay high court has upheld the ban on gutkha and pan masala, both flavored tobacco products, in Maharashtra. Though petitioners had argued that FDA had no power to ban gutkha as it was not a "food" under the Act, the court held that gutkha and pan masala fell within the definition of "food" under the FSSA and thus commissioner of FDA had the authority to ban them.

Considering the addictive potential of the ingredients of gutkha and pan masala, recording the effect of their ban on regular consumers, i.e., whether they have quit consumption or are still getting the products by illicit trade or shifted to other tobacco products, would be noteworthy. Similarly, the challenges faced by quitters and experience of any withdrawal symptoms will be of significance while devising cessation strategies for this group. If regular consumers discontinue consumption of gutkha and pan masala because of ban, it would be a positive indication in support of legal ban for the maintenance of proper public health. Thus, the response of gutkha and pan masala users to the ban needs to be studied.

Understanding the awareness and the reactions of the tobacco vendors about the ban is important for the further development of public health strategy to sustain the gutkha and pan masala ban.


 » Materials and Methods Top


This is a cross-sectional study conducted among low socio-economic community in suburbs of Mumbai PMGP, Mankhurd area and was one of the communities selected for the departmental outreach cancer prevention and screening program. A list of tobacco users in this community was thus obtained from our previous outreach program. A list of eligible participants was prepared by enlisting male and female tobacco users who consumed gutkha and/or pan masala at the time of the ban through house-to-house survey. After identifying all important stakeholders in the community, such as community leaders, non-governmental organizations and health care providers, meetings were held to establish community rapport and explain the significance of the current study. The medical social workers (MSWs) of the study were given the necessary training at Preventive Oncology Department. A pre-designed proforma was pilot tested in the community and necessary changes were made. Suitable time of the day was identified for the interview so as to maximize the response rate. All persons 18 years or above, using gutkha and/or pan masala at the time of implementation of the ban from the selected community and willing to give consent were included in this study, whereas all tobacco vendors above 18 years in the locality were eligible to participate.

MSWs undertook house-to-house visits only of male and female tobacco users in the community (as identified in the previous project). The MSWs conducted a short survey to identify the gutkha and pan masala users amongst this population (at the time of implementation of the ban). The eligible participants were explained the objectives and methods of the study and were then invited for participation. A written informed consent was obtained from those willing to participate while the left hand thumb impression was obtained from the illiterates. A person from the same community invited to witness the procedure of informed consent signed as an impartial witness. Help of a translator was opted whenever necessary. The invited participants were given the patient information sheet. Only after obtaining the informed consent, the participants were enrolled in the study and interviewed using a pre-designed and pre-tested proforma questionnaire. The MSWs conducted personal interviews and recorded data from the participating gutkha and pan masala users. Tobacco vendors were also interviewed using another set of questionnaire so as to understand their response and implications to the ban. This trial is registered with the clinical trial registry.

The data was compiled in the Statistical Package for the Social Sciences (SPSS) software version 19. Data errors were checked. The compiled data was analyzed with SPSS version 19. The effects of the ban on change in tobacco habit and various factors responsible for the same were analyzed.


 » Results Top


The present study is conducted PMGP, Mankhurd area comprising total population of around 4797, with 553 male and 548 female tobacco users. According to the house-to-house survey conducted among the tobacco users, there were 68 gutkha users above 18 years of age and five tobacco vendors in the community. None of the tobacco users consumed pan masala.

Amongst the gutkha users interviewed, 39.7% were below the age of 30 years, the range being 19-60 years. Majority 88.2% were males. While the number of Hindu 36.8% and Muslims respondents 41.2% was almost equal, 20.6% were Buddhists and 1.4% Christian. Although 10.3% users were illiterate, majority 75% were educated either up to primary or secondary school and 14.7% were educated above higher secondary level. Overall, 76.5% of users were married and 23.5% unmarried. The age at initiation of gutkha use varied from 10 years to 57 years. Nearly 38% users had started the use at 18 years or below. Among the gutkha users, 92.6% used it daily while 7.4% used intermittently. Nearly 60% participants used gutkha for less than 10 years and 40% used gutkha for more than 10 years. In univariate analysis, only age at initiation of gutkha consumption between 31 and 40 years was found to be statistically significant factor for quitting gutkha in post ban period. None of the factors were significant in the multivariate analysis [Table 1]. The maximum usage as cited by a user was 50 pouches of gutkha/day.
Table 1: Analysis of various factors responsible for quitting the habit of gutkha consumption

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All users were aware that some tobacco products had been banned in the recent past. Although all knew that gutkha was banned, only 4.4% were aware of the ban on pan masala. 31% participants had erroneous information that some tobacco product, other than gutkha and pan masala was also banned. Nearly 41% study participants could tell the exact month of the ban, but very few 6% were aware that it was only for the period of a year. Only 27.9% users had the knowledge that the ban had been enforced by Government of Maharashtra through FDA [Figure 1].
Figure 1: Awareness regarding Gutkha and pan masala ban amongst users

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The major source of information regarding the ban was electronic media and tobacco vendors. Many user participants came to know about the ban directly from the tobacco vendors while visiting to purchase gutkha while some knew from newspapers. The other sources included relatives and friends [Figure 2].

Overall 16 (23.53%) participants had quit consuming gutkha after the ban was imposed while 38 (55.88%) participants had reduced consumption. Fourteen (20.59%) had not changed their habit of gutkha consumption even in post ban period while none of the participants increased use of gutkha. Amongst the 16 gutkha quitters, five shifted to other forms of tobacco use (2-mawa, 2-paan and one-khaini).
Figure 2: Source of information about the ban

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Non-availability of gutkha had forced 18 participants to decrease the use, ten to quit the habit of consumption while it did not affect the habit of 40 user participants. Increased cost of gutkha (by illicit trade), resulted 24 to reduce the use and one to quit the habit and failed to affect rest 43 participants. Awareness of the ban on gutkha led to reduction of use in 18 participants, two to quit whereas 48 remained unaffected. Awareness of health hazards of tobacco prompted two participants to decrease the habit, two to quit consumption and remaining 60 remained unaffected inspite of the hazards [Figure 3].

An important highlight of this study is that all user participants of gutkha were in favor of banning these products. The expectation that the ban would compulsorily reduce or stop gutkha use 30 (44.1%), prevention from cancer 37 (54.4%), reduction in oral health problems 14 (20.6%), reduction in unnecessary spending 9 (13.2%) were the major reasons for the support. The participants felt that health hazards of gutkha 62 (91.2%), easy access of children 8 (11.8%) and large number of women initiating gutkha use were the prime reasons for gutkha and pan masala being banned by the Government.

While 44 (64.7%) of the user participants reported availability of gutkha and pan masala in same quantities as before in the post ban period, 46 (67.6%) reported the availability of these products in black market at an increased cost and 3 (4.4%) reported availability of gutkha and pan masala in separate pouches.
Figure 3: Comparison of various factors responsible for quitting or decreasing the habit of gutkha consumption

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Tobacco vendors

All (five) gutkha and pan masala vendors studied were married men above 30 years, in this business more than 10 years. Four were educated up to primary/secondary school while one was illiterate. With newspapers as the main source of information about the ban, four vendors knew that gutkha had been banned while one had incorrect information that it was cigarette. None of them were aware of the ban on pan masala too. Only one knew the exact time period of the ban. Three of them were aware about the enforcing authority for the recent ban. Only two knew about the monetary penalty as punishment while imprisonment for the violation of the ban was known to a single vendor. Surprisingly, all the five vendors stated that the ban was a good initiative. While four of them attributed the ban to gutkha and pan masala being injurious to health, one thought that ban was in order to prevent children from accessing gutkha and pan masala. Before ban four vendors procured the gutkha and pan masala pouches from wholesalers while one used to get direct delivery at his shop. Four of them stated that their customers included minors; though, they formed less than a quarter of the regular buyers for three vendors, while one vendor reported up to 50% of his customers were minors. Although all five vendors were aware of health hazards of gutkha, cancer reported by four and oral ulceration reported by two, were the only known hazards to them. One vendor thought that gutkha caused tuberculosis. Three of the vendors reported that gutkha and pan masala were not available in the market, but two confessed that the products were available at an increased cost. Four vendors reported a decrease in the sale of gutkha and pan masala in post ban period while the remaining one reported that the ban had not affected the sale of the same. Concerning the sale of other tobacco products, two reported it had decreased, two said it had increased and one said that it remained unaffected in post gutkha and pan masala ban period. Four of the vendors reported that their shop was raided, three times by the police and once by Brihanmumbai Municipal Corporation officials. One shop was raided twice, but the vendor was unaware of the identity of the officers. None of the vendors had to shift to another (i.e., other than tobacco sale) business because of gutkha and pan masala ban.


 » Discussion Top


The present study was conducted on the gutkha and pan masala users and vendors from the selected slum population of Mumbai city after about 4-6 months of gutkha and pan masala ban by Government of Maharashtra. As the concept of gutkha ban is new, there are very few studies assessing its effect. Hence, the findings of this study are discussed in comparison to other studies assessing the effects of the ban on various types of tobacco products. [9],[10],[11],[12],[13]

Almost every user interviewed was aware of the ban on gutkha, but the awareness regarding the ban on pan masala was poor. This can be attributed to higher prevalence of gutkha use among the user participants as compared to pan masala. Some participants thought that some other tobacco product, other than gutkha and pan masala was banned. The knowledge regarding the time of the ban of tobacco product and the authority, which enforced the ban (Government of Maharashtra/FDA) was also inadequate, which may be attributed to wrong source of information in the form of hearsay information and low level of literacy. Very few respondents were aware that the ban was only for a year. Electronic media and newspaper were the common sources of information quoted by the respondents. Giving wide publicity to the gutkha ban through newspaper and television advertisements and putting visible banners at prominent places detailing the ban might have served the purpose. This stream of thought was supported by a study done by Wakefield et al. [14] According to the participants, there was no contribution by health care providers in imparting information regarding the ban, which is certainly worrisome. A large number of users also came to know about the ban only after visiting the vendors, which is indicative of some fear of law enforcing authorities in the mind of tobacco vendors. A number of vendors were fined by the FDA authorities and Police for violating the ban during the initial period following ban.

All user participants were in favor of the ban, with the opinion that the ban would certainly reduce the use of gutkha and pan masala. Although most of the users were aware about carcinogenic potential of these products, other health hazards of their use were unknown to them, which may be attributed to less publicity regarding the same. Singh et al. [15] stated similar findings in their study. Anticipation of improved health and unavailability of these products to children were expected potential benefits of the ban by the users. These findings are suggestive of willingness to quit the use of these products if backed by useful scientific information, enforcement and assistance for quitting. Similar conclusions were reported in the studies by Wakefield et al. [14] and Li et al. [16] The services for tobacco cessation provided in the form of tobacco cessation clinic may play an important role in converting this willingness of people into action.

A major cause of concern is the availability of gutkha even after the legal ban, although at increased cost through the black market, as reported by many users. Availability of tobacco products in market even after ban has been reported by other researchers also. [10] However, many users also reported a decrease in the consumption of gutkha or quitting the habit in post ban period due to the efforts to be undertaken for procuring gutkha and pan masala and increased expenditure. That increase in the cost led to decrease use, was also supported in the studies conducted by Townsend [17] and Gallus et al. [18] Also fear of being caught by law enforcing authorities had also played an important role in keeping users away from the banned products. This decrease in use of tobacco products after the ban along with "norm spreading" is also evident from the literature. [19] Although some of the users had shifted to other products, around 24% had stopped the use of gutkha after ban indicating favor for such bans. This nature of very useful, expected implication of the tobacco ban is reported by various authors globally as well. [9],[10],[11],[13] Availability of gutkha and pan masala even after legal ban to the vendors has been reported in a Mumbai study. [10] However, the decrease of sale as reported by four of the participant vendors is encouraging. The willingness of vendors to obey the law regarding gutkha and pan masala ban, though mainly due to fear of law enforcing authorities, can be extended for effective implementation of the same.

 
 » References Top

1.Nair U, Bartsch H, Nair J. Alert for an epidemic of oral cancer due to use of the betel quid substitutes gutkha and pan masala: A review of agents and causative mechanisms. Mutagenesis 2004;19:251-62.  Back to cited text no. 1
    
2.World Health Organization. Tobacco Cessation: A Manual for Nurses, Health Workers and Other Health Professionals. New Delhi: World Health Organization, Regional Office for South East Asia; 2010.  Back to cited text no. 2
    
3.Global Adult Tobacco Survey: India Report 2009-10. Geneva (CH): World Health Organization, Centre for Disease Control and Prevention; 2010.  Back to cited text no. 3
    
4.Gupta PC, Ray CS. Tobacco and youth in the South East Asia region. Indian J Cancer 2002;39:5-35.  Back to cited text no. 4
    
5.Gupta PC, Ray CS. Epidemiology of betel quid usage. Ann Acad Med Singapore 2004;33:31-6.  Back to cited text no. 5
    
6.Gupta PC. Gutka: A major new tobacco hazard in India. Tob Control 1999;8:134.  Back to cited text no. 6
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7.Chaturvedi P. Gutka or areca nut Chewer′s syndrome. Indian J Cancer 2009;46:170-2.  Back to cited text no. 7
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8.Commissioner of Food Safety, Food and Drug Administration, Government of Maharashtra. Gazette of Government of Maharashtra; 2012. p.4-5.  Back to cited text no. 8
    
9.Buonanno P, Ranzani M. Thank you for not smoking: Evidence from the Italian smoking ban. Health Policy 2013;109:192-9.  Back to cited text no. 9
    
10.Nair S, Schensul JJ, Bilgi S, Kadam V, D′Mello S, Donta B. Local responses to the Maharashtra gutka and pan masala ban: A report from Mumbai. Indian J Cancer 2012;49:443-7.  Back to cited text no. 10
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11.Guzmán A, Walsh MC, Smith SS, Malecki KC, Nieto FJ. Evaluating effects of statewide smoking regulations on smoking behaviors among participants in the survey of the health of Wisconsin. WMJ 2012;111:166-71.  Back to cited text no. 11
    
12.Martin SA, Celli BR, DiFranza JR, Krinzman SJ, Clarke JG, Beam H, et al. Health effects of the federal bureau of prisons tobacco ban. BMC Pulm Med 2012;12:64.  Back to cited text no. 12
    
13.Lunze K, Migliorini L. Tobacco control in the Russian federation - A policy analysis. BMC Public Health 2013;13:64.  Back to cited text no. 13
    
14.Wakefield MA, Spittal MJ, Yong HH, Durkin SJ, Borland R. Effects of mass media campaign exposure intensity and durability on quit attempts in a population-based cohort study. Health Educ Res 2011;26:988-97.  Back to cited text no. 14
    
15.Singh V, Pal HR, Mehta M, Kapil U. Tobacco consumption and awareness of their health hazards amongst lower income group school children in national capital territory of Delhi. Indian Pediatr 2007;44:293-5.  Back to cited text no. 15
    
16.Li L, Borland R, Fong GT, Thrasher JF, Hammond D, Cummings KM. Impact of point-of-sale tobacco display bans: Findings from the International Tobacco Control Four Country Survey. Health Educ Res 2013;28:898-910.  Back to cited text no. 16
    
17.Townsend J. Price and consumption of tobacco. Br Med Bull 1996;52:132-42.  Back to cited text no. 17
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18.Gallus S, Schiaffino A, La Vecchia C, Townsend J, Fernandez E. Price and cigarette consumption in Europe. Tob Control 2006;15:114-9.  Back to cited text no. 18
    
19.Bhaumik S. Ban on smoking in workplaces in India has led to more smoke free homes. BMJ 2013;346:f2186.  Back to cited text no. 19
[PUBMED]    


    Figures

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