Dohra- a mixture of potent carcinogens

Dohra is a mixture of areca nut (Supari), catechu (Katha), edible lime, peppermint, cardamom (Illayachi) and some flavoring agents12. It is being used with and without tobacco in a few areas of Uttar Predesh (UP), India and sold in the market without any brand name. There are evidence that chronic use of this product is a major risk factor of oral submucous fibrosis (OSF) in the younger age group3 which might later progress to oral cancer (OC). Till date, major aspects related to Dohra i.e. varieties, its constituents, processing of the products, marketing, price, storage and its use have not been studied. Since it is associated with potentially malignant disorders (PMD) and OC, this study was aimed to give details on dohra through (i) gathering information through study tour to different areas of Uttar Pradesh (UP), where group discussions with Dohra vendors and with community members of different age group were done, and (ii) collecting information through literature search.

Material & Methods

The information on Dohra was collected through study tour to three different areas of UP, i.e., Jaunpur, Allahabad and Pratapgarh by group discussions with Dohra vendors, and with community members of different age groups.

Lliterature search: The screening of studies was performed on PubMed databases (since inception) and Google on November 13, 2017. A total of 53 studies were obtained from PubMed using the phrase ‘dohra’ of which only two studies were found relevant34. These studies had minimal information on the association of this product with OSF. In addition, all the 19 available pages of Google were screened using the word ‘dohra tobacco’, which gave additional three studies156 (Figure).

Close

Figure

Flowchart describing the included/excluded literature.

Export to PPT

Inclusion & exclusion criteria: Studies on dohra or studies which found any parameter related to dohra were included in the study. The studies not having any description/mention of dohra, and those published in languages other than English were excluded.

Results & Discussion

During the survey in UP it was found that dohra was consumed and available in different areas of Eastern UP and prepared by the user for their personal use or prepared by small-scale industry for sale. The product was wrapped and sold in the recycled plastics and may be used as such or with tobacco. It was available mostly in betel shops or any other store/kiosks and was also available in special dohra shops. It was available in both dry and wet forms. The shelf life of wet dohra was only a few days while the dry dohra could be consumed for months.

Of the five studies found on dohra, only two were on the association of dohra with OSF34. The consumption of dohra was very frequent in areas of UP. The study by Ansari et al5 in Eastern UP population, found that 4.73 per cent (14/296) individuals consumed dohra among whom majority were in an age group of 20-29 years.

Dohra was found to be produced and sold in three major districts of Eastern UP, India, i.e., Jaunpur, Allahabad and Pratapgarh167. The major localities in Jaunpur and nearby regions where dohra was produced and/or sold included Jaunpur city, Shahganj, Mariahu, Machhali Shahar, Kerakat, Badlapur, Mungra Badshahpur, Kheta Sarai, Muftiganj, Rampur, Nauperwa, Singramau and Shambhuganj. In Allahabad, dohra was produced and/or sold in almost all the localities; however, the major localities comprised Daraganj, Kydganj, Mutthiganj, Ahiyapur, Meerapur, Mausamganj, Gaughat and Kalyanidevi. It was also available in the locations nearby Allahabad such as Naini, Mirzapur, Fatehpur, Khaga and Kaushambi. Dohra in Pratapgarh was found to be sold in a locality named Chowk. The nearby locations where it was available were Kunda, Babuganj Bazar and Patti.

Varieties of dohra:The dohra of Jaunpur and Pratapgarh was of one variety, i.e., wet dohra whereas dohra of Allahabad was of two major varieties i.e. ‘sukha sada dohra’, which was not sweet in taste, and ‘sukha meetha mulethi dohra’ which was slightly sweet in taste. There were other less common varieties such as ‘Chandan ka dohra’, ‘Santare ka dohra’, ‘Tal makhana ka dohra’, ‘Zaifer aur javitri ka dohra’ (sold in winter), etc.

Processing of dohra: The dohra from Jaunpur, Allahabad and Pratapgarh varied in their processing; however, the processing done in either ‘homemade dohra’ or in ‘dohra from small-scale industries’ within these districts was similar.

Jaunpur: The main constituent of dohra was areca nut. For the preparation, areca nut was first peeled off and soaked in a utensil for three days8. After that, it was soaked in edible lime water, followed by cutting it into thick slices. The reason behind soaking areca nut in water was to reduce the time and cost of cutting. Once the areca nut was cut down into thick slices clove powder, cardamom powder, peppermint and some other flavouring agents were added and mixed properly with hand. In the past, people were also using mountainous catechu (Pahari Katha) in dohra; however, these days, it was hardly used by the dohra vendors. Since different traders used variable quantities of ingredients for dohra preparation, therefore, there was no standard composition of dohra. Dohra from Jaunpur was sold without any tobacco, however, consumers add different types and quantity of tobacco according to their wish and taste.

Allahabad: The dohra of Allahabad was different from that of Jaunpur and Pratapgarh, as it was a dry product. For making dohra different varieties of areca nut were used. The areca nut was peeled and cut into thin slices. In the next step, edible wet lime and dry catechu was added to areca nut and the components were once again properly mixed with hands until it attained dark red or brownish colour. Once that stage was reached clove powder and cardamom powder were added and the resultant mixture was again thoroughly mixed. Finally, peppermint was added to the resultant mixture and final mixing was performed to complete the dohra preparation. Some people also used some flavouring agents to give different taste to dohra. Most of the people consumed dohra with either processed branded tobacco or locally processed unbranded tobacco leaves.

Pratapgarh: The areca nut was peeled and soaked in water for around a day followed by cutting into small thin slices. The edible wet lime and catechu were mixed with hand until it reached a dark reddish or brownish colour. Later on, peppermint, clove powder and cardamom powder were added to make the dohra. Unlike Allahabad, people here consumed dohra mostly with unprocessed raw, finely ground tobacco.

Availability & marketing of dohra: Dohra was mostly available in betel shops or any other store/kiosks and was also available in special dohra shops. It was being sold in small plastic packets. Usually, the vendor prepared different sizes of packets and sold them according to weight which usually costed ₹ 5, 10, 20 or 50. It was also sold with a rate of around ₹ 500/kg in Jaunpur, ₹ 1200/kg in Allahabad for both varieties of ‘dry dohra’ and ₹ 800/kg in Pratapgarh.

Health warnings on dohra: The dohra does not contain any statutory warning label in the form of sign(s) or picture(s) or written warnings, and hence, the consumers are unaware of the harmful health hazards of the product, leading to higher consumption of the product by the consumers. People prefer to consume dohra than gutka (a form of smokeless tobacco product) considering it to be harmless since there are no warnings.

Addiction due to dohra: The dohra is a product which contains a potent carcinogen in the form of areca nut910. Dohra is mostly consumed with tobacco, which is also a well-known carcinogen11. Around 80-90 per cent of the people consume dohra with tobacco and the rest use without tobacco. Continuous consumption of this product tends to make people addicted to it and difficult to quit.

Impact of dohra on human health:Consumption of dohra leads to oral submucous fibrosis which is a commonly known condition in tobacco chewers as well512. It decreases the salivary secretion (xerostomia), causes dental problems (stained teeth, periodontitis), digestive system problems and intestinal cancer13.

In conclusion, the dohra was found to be produced, consumed and sold in the Eastern UP. Different varieties of dohra existed such as dry dohra (sukha dohra), dry mulethi dohra (sukha mulethi dohra) and wet dohra (geela dohra). Different processing methods were being used for producing dohra. More studies on this product need to be undertaken. As this product increases the risk of cancer, it needs to be completely banned. If not, at least, the product should be sold in a packet with statutory warning sign and proper details of constituents it contains, so that the consumers are aware of its adverse impact on their health.