|Ahead of print
Prevalence, patterns and sociocultural factors associated with use of tobacco-based dentifrices (Gul) in India
Rashmi Mehra, Vikrant Mohanty, YB Aswini, Shivam Kapoor, Vaibhav Gupta
Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, Maulana Azad Medical College Campus (Govt. of NCT Delhi), B.S. Zafar Marg, New Delhi, India
|Date of Submission||01-Nov-2018|
|Date of Decision||04-Oct-2019|
|Date of Acceptance||04-Oct-2019|
|Date of Web Publication||08-Jul-2020|
Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, Maulana Azad Medical College Campus (Govt. of NCT Delhi), B.S. Zafar Marg, New Delhi
Source of Support: None, Conflict of Interest: None
Background: India poses a novel tobacco problem with majority of the tobacco users consuming smokeless form of tobacco (21.4%). Gul is one such Smokeless Tobacco (ST) product that is manufactured commercially as a dentifrice to be applied to the teeth and then to gums many times during the day, making it a cheap and easy tobacco source. Hence, the aim of the present study was to estimate the usage of Gul and its social determinants among adults in the capital city of India, Delhi.
Methods: The cross-sectional study was conducted among 1300 adults across 27 Delhi government dispensaries across 3 districts of Delhi through multistage stratified random sampling. A structured, close-ended, validated questionnaire inquiring about the tobacco practices was used for all the participants and a specially constructed, structured, close-ended, validated proforma was used for Gul users to assess practice and pattern of use.
Results: The overall prevalence of Gul users was found to be 4.9% with a mean usage duration of 6.28 ± 6.75 years. The usage was found to be more among males (67.7%) and unskilled workers (45.2%). 74.9% started using Gul to treat dental pain with 93.47% of them reporting pain relief.
Conclusion: Gul usage is an emerging menace in Delhi. Awareness programs and initiatives are the need of the hour to bring this tobacco product under the tobacco control policy radar and at the same time educate people about the actual contents and ill effects of Gul usage.
Keywords: Illegal tobacco products, non-cigarette tobacco products, packaging and labelling, socioeconomic status, tobacco industry
|How to cite this URL:|
Mehra R, Mohanty V, Aswini Y B, Kapoor S, Gupta V. Prevalence, patterns and sociocultural factors associated with use of tobacco-based dentifrices (Gul) in India. Indian J Cancer [Epub ahead of print] [cited 2020 Aug 9]. Available from: http://www.indianjcancer.com/preprintarticle.asp?id=289213
| » Introduction|| |
The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing more than 7 million people a year, with over 6 million of these deaths caused due to direct use of tobacco. Tragically, the epidemic is now shifting towards the developing world, where more than 80% of the world's tobacco consumers reside.
Tobacco in India is used in diverse forms: smoked tobacco including cigarettes or bidis (dried tobacco rolled in paper or leaf), Smokeless Tobacco (ST) such as chewing Khaini, Surti, or Paan Masala, sucking Gutkha, applying Gul or Gudaku as dentifrice.
On the world tobacco map, India occupies a distinct place as the second-largest producer and consumer of tobacco, its share of the global burden of tobacco-induced disease and death is substantial with an estimated 12 million cases of preventable tobacco related illnesses each year., The World Health Organization (WHO) also predicts that India will have the fastest rate of rise in deaths attributable to tobacco with deaths exceeding 1.5 million annually by 2020. Thus, with its 250 million tobacco consumers, India is sitting on the edge of an unparalleled health crisis.
ST in its various forms has been implicated in many life threatening and debilitating diseases including cancer of the mouth, esophagus, and pancreas.[5-7] ST use is a strong risk factor for both oral leukoplakia and snuff-induced lesions. Its use has been associated with increased gingival recession, cervical abrasion, and root caries.,
According to the Global Adult Tobacco Survey-2 (GATS-2, 2016-2017), 28.6% (267 million) of adults in India use some form of tobacco with majority of the tobacco users consuming smokeless form of tobacco (21.4%). Every fifth adult in India uses smokeless tobacco out of which Khaini is the most commonly used ST product (12.5%) followed by Gutkha used by 8% of adults. Six percent of adults use betel quid with tobacco and 5% (3% male and 6% females) use tobacco products like Mishri, Gul, and Gudakhu by oral application. Delhi, being the capital city of the country, experiences an influx of migrant population from states, both near and far experiencing a continuous social transition. This migration of citizens from all walks of life, from both urban and rural areas makes it a zone of cultural conglomeration. Of the total 3 million migrants living in Delhi, 40% belong to the state of Uttar Pradesh, followed by 20% hailing from Bihar. It has been seen that tobacco practices of individuals are at large governed by their culture which they carry with them from their place of origin. In the North Eastern state of Assam, prevalence of smokeless tobacco among school going students of ages 13 to 15 years was found to be 25.3% out of which a whopping 18.8% was the orally applied form. Among users of orally applied form of ST, 58.5% applied tobacco containing toothpaste, 25% red toothpowder, and 16.3% used Gul. In Delhi, 24.3% of the adult population were current tobacco users with 6.9% of them using only smokeless form of tobacco. When comparing Delhi with various states and union territories, it had smokeless tobacco usage prevalence of 10.5%, with orally applied form of tobacco (as Mishri, Gul, and Gudakhu) as 0.3%.
Gul (tobacco containing dentifrice) is a pyrolyzed tobacco product mixed with sugar or molasses, alkaline modifiers, and other unknown ingredients which is marketed under different brand names in small tin cans and used as a dentifrice in the eastern part of India across the states of Assam, Arunachal Pradesh, Uttar Pradesh (UP), and Bihar. Studies conducted to determine the nicotine content in commonly used dental cleaning aids in India, found that Gul contained 216.10 mg/g of nicotine along with total Tobacco Specific Nitrosamines (TSNAs) ranging in 13,400-17,100 ng/g.,
Unfortunately, in a developing country like India which is still fighting the battle of poverty, Gul seems to offer a one stop solution for both dental needs and tobacco cravings. There is limited published literature on the use of this uncontrolled tobacco threat since its use has increased multifold from data obtained from 0.3% (GATS 1) to 1.6% (GATS 2). It continues to be sold at grocery stores without the stipulated health warnings. Hence, we conducted a study to assess the patterns, practices and prevalence of Gul usage in the capital city of India, Delhi.
| » Materials and Methods|| |
The present cross-sectional study was conducted among adults visiting Allopathic Delhi Government Dispensaries (DGD) under the Directorate of Health Services (DHS), Government of National Capital Territory of Delhi, India from July 2017 to December 2017. The sample size calculated by using prevalence of Gul users of 0.3% for 15 year and above adults with 95% confidence interval and a precision of 0.003 was calculated to be 1277 using EPI-INFO Version 3 which was rounded off to 1300 adults. The dispensaries were selected through multistage stratified random sampling. A total of 254 Allopathic dispensaries function across 8 districts of Delhi with a cumulative annual OPD of 97, 35,186. In our study, 3 districts were selected randomly using lottery method. The 3 districts which were included in the study were North, North-East, and Central. Adults who were unwilling or uncooperative to participate in the study were not included in the study. The study was conducted after the ethical approval given by the Institutional Ethical Review Board of Maulana Azad Institute of Dental Sciences, New Delhi. Necessary permissions and clearance from the DHS, Government of National Capital Territory of Delhi and an informed written consent in local language was obtained from each of the adult participant after explaining the aims and objectives of the study.
The instrument used in the study was a structured, validated, close-ended, interview-based questionnaire in English which was administered by face to face interview by a single interviewer. The questionnaire was developed in English and then translated to Hindi which included details of socio-demographic factors including Kuppuswamy classification of socioeconomic status—2017 was used to assess the socioeconomic status to which the subject belonged. The oral hygiene measures used by the subject were inquired.
The proforma for Gul users included a close-ended, structured questionnaire comprising of 17 questions which was developed in English with the help of public health experts in the field of tobacco control to assess the pattern and practice of Gul usage. This questionnaire inquired about the duration, frequency, method of use, and brand of Gul used. It further assessed the reasons for initiation of Gul usage and whether the user knew that Gul contains tobacco. It also inquires about any other family members using Gul and self-perceived changes in weight, hunger, taste, working capacity felt by the user of Gul. A thorough literature search was done and questions were selected from previous studies [GATS I and GATS II]. Apart from that, with the help of two public health experts, new items were added. A consultative committee consisting of three specialists in public health dentistry carried out face and content validation of the 20-item questionnaire using Lawshe approach. The questions considered essential were further rated on a scale of 1–10 and analyzed using Aiken V index. An item with a value of V > 0.7 indicated a high degree of agreement among experts and hence was considered for inclusion in this study. The resultant 17-item questionnaire was pilot tested for reliability by Test-Retest Method among 8 Gul users before the implementation of this study (α = 0.82). No further changes were made to the questionnaire.
A single examiner was trained (2 days) and calibrated (3 days) by the guide in the Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences. An interval of 2 days was given to allow the examiner to assimilate their knowledge of recording the WHO Oral Health Assessment Proforma 2013 and practice the procedure. In order to test the intra-examiner variability, age matched samples of 30 adults were examined under identical conditions on two occasions, at least a week apart in the department. The results so obtained were subjected to Kappa Statistics. The intra examiner agreement for the entire interview and clinical examination was satisfactory (κ-value 0.75-0.82). These values reflected high degree of conformity in the observations during clinical examination.
Data collection was done on each day at different centers. An approximate duration of 7 minutes was spent per participant to record a written consent, socio-demographic factors and oral hygiene practices. An additional 5 minutes were spent to record tobacco exposure of tobacco users. In case of Gul users, an additional 10 minutes were spent to record the Gul specific proforma and to perform the clinical examination. Thirty adults were screened each day and the assessment forms were reviewed by the examiner on the same day, for completeness and accuracy of recordings. Number of participants included from each center were equally distributed by dividing number of participants to be included from a certain district by number of dispensaries to be included.
The data from the questionnaire was converted into a digital spreadsheet MS Excel©. Data was analyzed using SPSS version 21©. Descriptive tables and graphs were drawn and presented. Chi-square test was applied to compare socio-demographic characteristics among Gul users. Multivariate logistic regression models were estimated to assess the unadjusted association respectively of different socioeconomic and demographic characteristics with Gul usage.
| » Results|| |
The present study assessed the usage of Gul and its determinants among patients visiting DGD. A total of 1300 subjects were included in the study following the study flow chart as shown in [Figure 1]. Numbers of DGDs included from Central, North East and North districts were 3, 19, and 6, respectively with total sample from each district being 226, 741, and 333, respectively.
The study included 1300 adult subjects with a mean age of 37.08 ± 14.24 years. A total of 62 (4.9%) current exclusive Gul users were found. Their mean age was found to be 40.11 ± 13.81 years. The mean duration of use since initiation of habit was found to be 6.28 ± 6.75 years. The socio-demographic characteristics of the Gul users were also compiled and are presented in [Table 1].
|Table 1: Socio-demographic characteristics of Gul users among the study subjects|
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The association of Gul use among the study population with socioeconomic and demographic factors was assessed using multinomial logistic regression analysis and is represented in [Table 2]. It was also seen that those hailing from certain states (UP) were more likely to use Gul (P = 0.00). It was also seen that the lower class had 1.77 times greater association with Gul usage (P = 0.00). Similarly, those living in a nuclear family set up were almost 5 times more likely to be using Gul.
|Table 2: Multinomial Logistic Regression Analysis used to assess association of Gul use among the study population with socioeconomic and demographic factors|
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The practices and pattern of Gul usage including the age of initiation, reason for initiation, method of application, frequency of use and duration since they have been using Gul have been represented in [Graph 1].
Gul users reported that most of them purchased Gul from grocery store (82%, n = 51) followed by tobacco selling shop (8%, n = 5). The average cost of Gul was found to be Rs. 12 for a package of 25 grams with reported monthly expense of Rs. 43 by Gul users.
[Graph 2] shows the oral hygiene practices of Gul users. 50% (31/62) of the Gul users brushed their teeth once a day with toothbrush. Majority (68%) of Gul users did not use a toothpaste to clean their teeth and most of them (45.16%, n = 28) had never received dental care.
It was observed that 97.8% (n = 46) of Gul users who initiated the habit to alleviate dental pain reported that they experienced pain relief on using it. All individuals (n = 13) who initiated habit to improve oral hygiene reported a self-perceived improvement in oral hygiene.
Most of the Gul users (70.5%) reported that none of their other family members used Gul. About 60.7% users denied knowing that Gul contained tobacco and 91.8% said they had never endorsed it to any other person. Only 39.3% (n = 24) used toothpaste and toothbrush apart from using Gul as an oral hygiene aid.
| » Discussion|| |
ST is more prevalent than smoked form of tobacco in India as assessed by various studies.,, In India legislation like the Drugs and Cosmetics Act 1940 and the Food Safety and Standards Authority of India Regulations (FSSAI) 2011 (Notified in August 2011) prohibits the use of nicotine and tobacco in any food product (Regulation 2.3.4). The use of tobacco as an ingredient in dental care products is prohibited by law in India. Such products, in the form of powder or paste, are applied most commonly with the index finger to teeth and gums. Various tobacco products are used as dentifrice in different parts of India including Gul, Gudakhu, Bajjar, etc., Several judicial rulings have implied that Gul is not included as a dentifrice but as tobacco product under the regulation of Cigarette and Other Tobacco Products Act (COTPA, 2003).
India is more rural than urban, but modernization has resulted in drifting of population to urban areas. Delhi is no different and further being the capital city of India has seen a great transition and diversification in its demography. Delhi accounts for 58.4% of migration from rural parts of India with major chunk of the migration occurring from states of UP and Bihar. Migration operates within the framework of social, cultural, economic context, and it plays an important role to alter the conditions of the entire space within which these processes operate. Migration is primarily associated with search for better work opportunities, facilities and infrastructure. India's tobacco consumption pattern and practice is vastly based on cultural norms and regional variability. The consumption of tobacco has a symbolic aspect that can be explored in terms of the individual lifestyle, self-image and social relationships. According to the GATS-2 2016-2017 India, the prevalence of orally used tobacco (as snuff, mishri, Gul, gudakhu) was 1.6% among adults in Delhi.
In our study, around 4.9% of the sample population used Gul. This is higher than the national data of 3.8% and 1.6% of Delhi population using orally applied tobacco (including Gul, Gudakhu, and Mishri). Sarkar et al. showed contrasting results with only 0.1% of respondents using Gul. This increase in the usage of Gul could possibly be attributed to the influx of population from other states like UP and Bihar which have a much higher prevalence of Gul usage of 18.9%.,
It was seen in our study that lower proportion of males (4.6% of male participants, n = 42/906) used Gul than females (5.07% of female participants, n = 20/394). This is in contrast with previous data obtained from Delhi which showed higher consumption among males than females., Our results are in line with study conducted by Sinha et al. which found that female Gul users (41.3%) were more than males (8.8%). As seen in our study, other studies have shown that tobacco-based dentifrices were more frequently used by females (6.3%) in contrast to males (3.3%) and also among children, thus posing a unique puzzle to tobacco control advocates., This could be due to the greater social power men exercise in comparison to women, which can also be seen in greater restrictions on women's behavior and lifestyle, including social embargo on tobacco use. The taboo has been less stringent for smokeless tobacco in comparison to smoked form, perhaps because it is relatively odorless and less perceptible, less stigmatized for women and easier to conceal.
It was also observed in our study that majority of the Gul users were illiterate (46.8%) which was similar to the results obtained by Gupta et al., This could possibly be because of the poor tobacco-related literacy and existing myths and customs pertaining to tobacco use in the community. Majority of the Gul users belonged to the upper lower class which was in line with study conducted by Rani et al. It is also likely that poor and less educated people are less aware of the health hazards of tobacco consumption; more likely to find themselves in conditions predisposing them to initiation of smoking and chewing of tobacco; and more likely to have higher degree of fatalism or higher overall risk taking behavior. The ease of availability at the nearest grocery store, as reported by our study subjects is alarming, since it violates COTPA, providing easy access to the product to children and adolescents.
The money spent on Gul probably serves many functions including oral hygiene aid, pain relief, and alternative tobacco source. It was seen in our study that majority of the Gul users had never visited a dentist and 74.19% reported that they started using Gul for pain relief for dental pain. Hence, the upper lower class, with its limited paying capacity resorts to such measures for pain relief instead of visiting a dentist. The belief that smokeless tobacco has a protective effect on teeth and is a pain killer is widely prevalent in many parts of rural India. Use of tobacco products as a dentifrice among adolescents in India has recently been reported, highlighting the continuation of the misconception till date. According to a study, a family with a monthly income of Rs. 5000 spends Rs. 200 on personal hygiene products including soap and toothpaste. A drastic difference exists in the cost of Gul and toothpaste, leaving the poor with limited buying power to the clutches of this tobacco containing dentifrice. Inclusion of oral hygiene aids to the essential drug list or further reducing taxes could alleviate the plight of the underprivileged and make oral hygiene more affordable to the common man.
Our study does present few limitations, such as the limited number of districts and dispensaries covered. Future studies must be more comprehensive community-based door-to-door surveys with self-administered questionnaire to avoid response bias. Since tobacco practices vary across populations, our study has limited external validity in terms of Gul usage. However, it has been seen that the socioeconomic determinants of ST use gravitate to similar patterns. Mixed methodology studies could be of much utility in terms of assessing the use and spread of use of Gul. Awareness programs and initiatives are the need of the hour to educate people about the actual contents and ill effects of Gul usage. There is also a need to foster the implementation of COTPA with respect to Gul to regulate the sale of such products as dental hygiene aids in local grocery shops and further testing of various brands of Gul is imperative. Community-based awareness programs to educate the population about the ill effects of tobacco, specifically Gul, could be initiated by bringing on board local community leaders for increased impact of this measure. There should be incorporation of awareness about Gul and tobacco cessation services into the existing programs for the reproductive, maternal, and child health. This could be further fostered by training of Accredited Social Health Activist (ASHA), so as to make maximum effect at the grass root level.
In conclusion, our present study has managed to bring forth the prevalence of Gul users (4.9%) who mostly belonged to the lower socioeconomic background, majority being illiterate. It was also found that almost all users used Gul as a dental pain reliever. Our study has emphasized that the growing menace of Gul usage must now be given the required heed, so as to contain the damage that is being done by it.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]