All in the name of flavour, fragrance & freshness: Commonly used smokeless tobacco preparations in & around a tertiary hospital in India

Eleven countries in WHO South-East Asia Region (SEAR) are inhabited by 1.536 billion people comprising about 25.35 per cent of the world population. Tobacco consuming habits of people of this Region are unique in the sense that they are used to smoke tobacco as well as consume smokeless tobacco (SLT), whereas in other parts of the world smoking is the most popular form of tobacco use1. As per Global Adult Tobacco Survey conducted in India2, 21 per cent adults use only smokeless tobacco among tobacco users and 5 per cent smoke as well as use smokeless tobacco. There is a general misconception among lay public that smokeless tobacco particularly sweetened and flavoured paan masalas (commercial preparation of areca nut and/or tobacco and spices) and gutka (mixture of tobacco, areca nut and molasses) are relatively safe to use. However, it is now well established that chronic use of tobacco, betel nut and saccharin based products are responsible for the increasing prevalence of early onset submucous fibrosis, leukoplakia, oral cancers and tendency to develop diabetes, hypertension and coronary artery disease (CAD) at young age in Indian people3–7.

Variour brands of paan masalas and gutkas are being advertised and sold in Indian markets without impunity in the name of flavour, fragrance and freshness. With increasing ban on smoking at public places, the use of smokeless tobacco preparations as a replacement has risen. Therefore, the present study was undertaken with the objective of highlighting the deceptive and aggressive marketing techniques adopted by the manufacturers of smokeless tobacco preparations exploiting cultural, social and religious values. The study was also aimed to highlight the lack of transparency in terms of content, weight, quality control and warning.

Material & Methods

The empty pouches of the used paan masalas, gutka, khaini (chewing tobacco mixed with other ingredients like lime, spices and added flavours) or surti (dried tobacco leaves for chewing)8 were collected from the entry and exit gate of a tertiary care hospital in Delhi, India and nearly parking areas; places where people usually throw their pouches before entering or leaving the hospital premises. The pouches were then segregated according to their trade names and their constituents as per written declaration by the manufacturer on each packet were noted. Information on net weight, cost, presence and type of warning, and quality assurance on each brand provided on side of the sachets was noted. These details were tabulated and the ill effects of these constituents on long term usage were noted from literature. As the hospital where this study was carried out, is a tertiary care hospital catering to the health needs of entire East Delhi and neighbouring States, this exercise also provided an idea about the type of usage and preferences regarding paan masalas and gutkas (smokeless tobacco) in local area.

Results & Discussion

A total of 1136 pouches representing 33 samples/brands were collected over a period of 30 days. Warning regarding the harmful effect of tobacco was written in 90.9 per cent of brands with 81.8 per cent in English language only (Table I), in a font size less than mandatory 3 mm. The contents of the products were mentioned in 84.8 per cent of brands and only 27.3 per cent of these mentioned the net weight of the ingredients. The plausible biomolecules based upon the declared contents and their pharmacological and toxicological profile was worked out on the basis of available literature (Table II). As evident, most of the gutka preparations contained tobacco (Nicotiana tabacum), betel nut (Areca catechu), unknown flavouring agents and undeclared spices.

Table I Details of different brands of smokeless tobacco/gutka/paan masala/ mouth fresheners

Table II Putative constituents of paan masalas, gutkas, mouth freshners and their known pharmacological and toxicological profile

There are several public health issues related with free sale, purchase and consumption of paan masalas and gutkas over the counters. Full contents were not given in most of these preparations. Even in those where contents were written, the actual quantity (weight per gram) was not mentioned. There was no quality control of the ingredients mentioned. This is despite the fact that smokeless tobacco products are classified as food material under the provisions of Prevention of Food Adulteration (PFA) Rules (1955)9. In such a situation there is a possibility that the spurious or substandard variety of material might have been used. There is also a possibility of an adulterant being mixed in these products because of lack of quality control. Products having high sugar contents like sugar coated fennel, sugar coated betel nuts, dates, mishri (crystallized sugar balls), and saccharine used in certain oral freshners may not be healthy. Prevention of Food Adulteration Rules (1955)9 clearly state that every package of food (including smokeless tobacco) which is permitted to contain artificial sweetener shall carry the following label, namely name of artificial sweetener and a warning that it is not recommended for children and should also mention quantity of sugar added per 100 g of product. It is also pertinent to mention that in many products aromatic substances like fennel (Foeniculum vulgaris), cardamom (Elettaria cardamomum), clove (Syzygium aromaticum), mint (Mentha arvensis) and rose petal (Rosa centifolia) are mixed with cardiotoxic substances like tobacco (Nicotiana tabacum) and betel nut (Areca catechu). Nicotiana tobacum and Areca catechu may have an adverse effect on the sperm count as has been proved in animal studies10 and might be carcinogenic1112. Use of heavy metals like silver in some preparations could pose serious renal or hepatic problems. It has also been recorded that many paan masala products contained unknown spices and flavouring substances which could be harmful. Individuals consuming paan masala is high quantities may be susceptible to toxic effects of saccharin including bladder distension and bladder cancer as average and maximum amounts of saccharin in pan masala samples were found to be 1.6 and 3 fold higher than the maximum permitted levels allowed under PFA act of India13.

The manufacturers of these preparations adopt deceptive and aggressive marketing techniques. Many of these paan masalas or gutka create a false impression as if the product is related to betel (Piper betel) in some form or other by giving it a name associated with paan like ‘paan masala’. Alternatively, they put a picture of betel over the sachet. Another technique is to give it a catchy name, slogan or phrase to attract young mind. The very fact that none of these products have betel in any form amounts to total deception. This is a deliberate marketing technique to impress people because use of betel leaves in the Indian society is culturally, socially and religiously acceptable. The bioactive molecule hydroxychavicol of betal plant (Piper betel) inhibits platelet aggregation, thromboxane B2 and prostaglandin G214–16.

One of the drawbacks of this study was lack of any detailed chemical analysis of the constituents of the preparations. Secondly, the data shown here were representative of a local catchment area of a hospital which perhaps can not be extrapolated to a larger community.

In conclusion, smokeless tobacco consumption is a common habit in South East Asia Region. Many people are unknowingly getting caught in the trap set by the tobacco selling companies. These companies market their products as mouth fresheners and flavouring agents. Chronic consumption of these potentially toxic substances may lead to submucous fibrosis, leukoplakia, oral cancers other disorders. Lack of transparency in terms of content, weight, quality control and warning is silently playing havoc with the lives of unsuspecting consumers. There is an urgent need to reign in these products under a mandatory quality control.34