Smokeless tobacco use in Sri Lanka

Review Article Smokeless tobacco use in Sri Lanka Somatunga LC, Sinha DN 1, Sumanasekera P 2, Galapatti K 2, Rinchen S 1, Kahandaliyanage A 1, Mehta FR 3, Jayasuriya-Dissanayake NL 3 Ministry of Healthcare and Nutrition, Sri Lanka, 1 World Health Organization, Regional Office for South East Asia, New Delhi, India, 2 Alcohol and Drug Information Centre, Colombo, 3 World Health Organization, Sri Lanka, Colombo Correspondence to: Dr. Dhirendra N. Sinha, E mail: sinhad@who.int Abstract To comprehensively review the issues of smokeless tobacco use in Sri Lanka. This review paper is based on a variety of sources including Medline, WHO documents, Ministry of Health and Nutrition, Colombo and from other sources. RESULTS: The prevalence of smokeless tobacco (SLT) use in Sri Lanka has been reported high, especially among rural and disadvantaged groups. Different smokeless tobacco products were not only widely available but also very affordable. An increasing popularity of SLT use among the youth and adolescents is a cause for concern in Sri Lanka. There were evidences of diverse benign, premalignant, and malignant oral diseases due to smokeless tobacco use in the country. The level of awareness about health risks related to the consumption of smokeless tobacco products was low, particularly among the people with low socio economic status. In Sri Lanka various forms of smokeless tobacco products, some of them imported, are used. At the national level, 15.8% used smokeless tobacco products and its use is three fold higher among men compared to women. Betel quid is by far the traditional form in which tobacco is a general component. Other manufactured tobacco products include pan parag/pan masala, Mawa, Red tooth powder, Khaini, tobacco powder, and Zarda. Some 8.6% of the youth are current users of smokeless tobacco. There are studies demonstrating the harmful effects of smokeless tobacco use, especially on the oral mucosa, however, the level of awareness of this aspect is low. The highest mean expenditure on betel quid alone in rural areas for those earning Rs. 5,000/month was Rs. 952. The core issue is the easy availability of these products. To combat the smokeless tobacco problem, public health programs need to be intensified and targeted to vulnerable younger age groups. Another vital approach should be to levy higher taxation. Key words: Impact of smokeless tobacco use, policy intervention, prevalence of smokeless tobacco use, smokeless tobacco products Introduction Smokeless Tobacco (SLT) use is widely prevalent in many forms in Sri Lanka. Chewing betel quid with tobacco has been a part of cultural practice among Sri Lankans for centuries. The smokeless tobacco use, especially in rural areas, has been reported to be high. The trends of availability of manufactured smokeless tobacco products in different parts of the country and its increasing popularity among youth and Quick Response Code: Access this article online Website: www.indianjcancer.com DOI: 10.4103/0019-509X.107729 PMID: 23442399 adolescents add new dimension to the tobacco epidemic in the country. The morbidity and mortality are also increasingly becoming apparent due to smokeless tobacco use. Hence, in this context, smokeless tobacco use in Sri Lanka was reviewed. Materials and Methods This review paper is based on information from following sources: Literature search including PECOS: Mentioned in Tables 1 and Table 2 One local study commissioned paper by WHO SEARO Data on smokeless tobacco from the Ministry of Health and Nutrition, Colombo and WHO Personal communication with experts in Sri Lanka. The present review mainly concentrates on the 357

Table 1: Percentage of current users of tobacco products among adults aged 15 64 years, 2011 Current users Total (%) Male (%) Female (%) Smokeless tobacco 15.8 24.9 6.9 Any smoked tobacco 15.0 29.9 0.4 Source: Wolrd Health Organi sation (2011) [7], The global tobacco epidemic report (2011), Sri Lanka. [6] Table 2: Prevalence of betel quid use with tobacco among males aged 18 years and above in Colombo and Polonnaruwa district, 2007 Age group Urban (%) Rural (%) 18 24 0 2.7 (0.56 4.9) 25 34 0.4 ( 0.35-1.0) 10.4 (7.3 13.6) 35 44 2.5 (0.8 4.2) 21.2 (16.3 26.1) 45 54 1.7 (0.04 3.4) 20.2 (15.1 25.3) 55 64 2.9 (0.37 5.5) 31.4 (23.9 38.8) >65 3.9 ( 0.4 6.6) 36.0 (27.4 44.7) Total (18 >65) 1.7 (0.92 2.27) 17.6 (15.6 19.7) Source: VA de Silva et al., Sri Lanka [7] availability and affordability of smokeless tobacco products, awareness about the consequences of smokeless tobacco use among population, morbidity and mortality issues, and health policies to combat smokeless tobacco epidemic in Sri Lanka. Results Use of betel quid Betel quid is called bulath hapaya in Sinhala and its use has been culturally encouraged in Sri Lankan homes since the ancient times. Offering of betel quid to any visitor to a home and also after any meal or tea has been widely practiced in ancient Sri Lanka. It is still considered an important social and cultural custom in the rural household. When greeting or worshiping elders and dignitaries at family and social functions like weddings and also at auspicious occasions like the Dawn of the Sinhala or Tamil New Year in April, which is considered the biggest cultural event in Sri Lanka, it is customary to offer a sheaf of betel leaves with a dried leaf of tobacco. Even the children are taught to practice this age old tradition when meeting their teachers on the first day of their schooling. [1] Basically, betel quid contains betel leaf (Piper betle), locally called bulath kola, pieces of arecanut (Areca catechu), slaked lime (calcium hydroxide), and may contain a few flakes of tobacco. Other substances, such as cardamom, saffron, cloves, aniseed, turmeric, etc., are often added to the betel quid. Betel quid can be prepared at home for personal consumption, or by vendors for sale. One preparation of quid (bulath vita) may cost about Rs.10. 358 Betel quid is sold in small kiosks or on the streets by vendors. Betel quid, with its ingredients wrapped in a small piece of newspaper, is known as bulath vita and is sold for around Rs. 15. Betel quid presented as a cone, which is prepared by neatly wrapping grated colored coconut kernels, arecanut scrapings, and some other spices in a betel leaf, is called sara bulath vita. This form is offered by street vendors at times of public functions. In recent years, another form called beeda [Figure 1] has been introduced, which is made up of the quid wrapped in a betel leaf accompanied with a small sachet of a mixture of unknown products imported from neighbouring countries. These are put together in cellophane packets and sold at prices ranging from Rs 15 to 50 per packet depending on their sizes. These unknown products are reported to cause giddiness or a high feeling when chewed. [2-3] Ingredients Betel quid and tobacco are available in most parts of the country. The most common form of smokeless tobacco use in Sri Lanka is as an ingredient of betel quid, more often in the rural and estate areas. There is a wide customer choice for tobacco components. Chewing along with newer manufactured tobacco products is a new fashion. [2,3] In Sri Lanka, tobacco (species of Nicotiania) is called dumkola and is grown in two seasons: The Maha (November to May) and the Yala (May to November). Tobacco farmers are categorized depending on the types of tobacco plants grown, the main markets for their produce, and methods used for the curing of the tobacco leaf. Majority of the farmers grow tobacco for Ceylon Tobacco Company (CTC) that manufactures cigarettes. A very small amount of tobacco is grown for chewing. The raw tobacco that comes from the Jaffna peninsula in the north of Sri Lanka is popular for chewing. [2,3] Betel vine is grown mainly in the western part of Sri Lanka. Gampaha district is the major supplier of betel quid in the country. This non seasonal crop yields good income to farmers. The commercial production of betel vine, with bigger leaves with dark green color combined with thickness, is known as kalu bulath. The demand for betel leaves is constant and high throughout the year. A sheaf of betel contains 25 leaves, and is priced at Rs. 25 per sheaf. Sri Lanka also exports betel leaves to other countries such as Bangladesh, India, Maldives, and Pakistan. Arecanut in Sinhala is called puwak and is cultivated in most parts of the country, especially in the wet and intermediate zone. The price of betel quid mostly

[Downloaded free from http://www.indianjcancer.com on Thursday, March 28, 2013, IP: 125.16.60.178] Click here to download free Android application for this jou Figure 1: Beeda preparation (Photo credit: Alcohol and Drug Figure 2: Packet of Pan masala, (Photo credit: Alcohol and Drug Figure 3: Flakes of Mawa, (Photo credit: Alcohol and Drug Information Centre (ADIC), Colombo, Sri Lanka) Figure 4: Red tooth powder, (Photo credit: Alcohol and Drug depends on the availability of arecanut in the market. The cost of one arecanut ranges from 50 cents to Rs. 5 during the year. There are different forms of arecanut according to the way they are produced unripe arecanut, ripe arecanut, and fermented arecanut known as madapuwak. though the data on prevalence is not available. It is very cheap costing just about Rs 2 per packet.[1] Other manufactured smokeless tobacco products in Sri Lanka A study commissioned by the WHO among the population in Colombo, Monaragala, and Nuwara Eliya districts representing the urban, rural, and estate sectors, respectively, found that the following smokeless tobacco products are used.[1] Pan parag/pan masala is a product consisting of areca nut, slaked lime, catechu (Acacia catechu), some condiments, and tobacco may be added [Figure 2]. They come in many brands, often imported from India and Pakistan. Its use is widespread among adolescents in Sri Lanka even Mawa is a blend of pieces or thin shavings of dried arecanut with tobacco flakes and slaked lime, and comes in an attractive packet. It is chewed. It costs around Rs. 50 per packet, and is popular among adolescents [Figure 3]. This is also imported from other countries.[1] Red tooth powder is imported mainly from India. It is a powdery preparation containing tobacco, and is used by placing it between the teeth and gums. This power is believed to help maintain oral health. It is popular among school children. It costs about Rs 150 per bottle [Figure 4].[1] Khaini (also known under the brand name Hans) consists of tobacco mixed with lime and honey/alcohol packed in plastic sachets. Hans is one of the most popular brands found only in Colombo. Khaini is kept 359

[Downloaded free from http://www.indianjcancer.com on Thursday, March 28, 2013, IP: 125.16.60.178] Click here to download free Android application for this jou between lips and gums and the quid is sucked or spat out. Common users of Khaini are people in the lower income groups, particularly the labor community. It costs about Rs.150 [Figure 5]. Tobacco powder is widely available, affordable, and popular among young students. This product is placed in the mouth and sucked or used nasally. Elderly used it in the past thinking that it had some medicinal value that could prevent influenza [Figure 6]. Babul and Babul like products are a mixture of tobacco leaf, arecanut, lime, and some other substances. It is basically imported from India and available in urban areas. It comes always with tobacco while pan parag may be without tobacco in it. Babul Beeda, imported from Pakistan, is another popular brand in Sri Lanka, which is primarily used in bulath vita, and is a favorite among people of all ages[2,3] [Figure 7]. Figure 5: Packets of Khaini, (Photo credit: Alcohol and Drug Smokeless tobacco use among adults Studies in eighties and nineties show that the prevalence of betel chewing was very high in rural Sri Lanka. In one study among villagers in 1982, 54% of males and 42% of females used betel quid regularly.[4] According to the National Oral Health Survey of 1994/1995, the prevalence of betel quid use was 33.78% among 35 44 year olds and 47.7% among 45 74 year olds with an overall prevalence of 40.5% among 35 75 year olds.[5] Figure 6: Tobacco powder, (Photo credit: Alcohol and Drug Information Centre (ADIC), Colombo, Sri Lanka) At the national level, in 2007, 15.8% of adult population aged 15 64 years in Sri Lanka used smokeless tobacco. Smokeless tobacco use among men (24.9%) was over three fold more than that of women (6.9%). Overall, there was no significant difference between the smokeless tobacco use (15.6%) and any tobacco smoked (15%) among the current tobacco users. However, smokeless tobacco use (6.9%) was higher than smoking (0.4%) among females [Table 1].[6,7] In rural (Polonaruwa) and urban (Colombo) district, one study among 2,684 males aged 18 years and above showed that the prevalence of betel quid use with tobacco in the rural area (17.6%) was significantly higher than in the urban area (1.6%). The prevalence was lowest among males between 18 24 years of age (2.7%) and highest among over 65 years (36%). In rural areas, the prevalence of betel chewing was 18.2% among Sinhalese and 6.6% among moors. In the rural areas, prevalence of betel chewing was significantly associated with age, and the odds of being a betel quid chewer increased with age; with the odds for those aged >65 years being 19.85 compared to the reference group 18 24 years [Table 2].[8] 360 Figure 7: Babul beeda packets[3] Asian betel quid consortium of South and East Asia carried out the prevalence study on betel quid chewing across six Asian countries. In Sri Lanka, the study among 1,072 subjects from three provinces of Gangawata Korale, Udunuwara, and Yatinuwara with the response rate of 99%, showed the prevalence of betel quid with tobacco was 6.4% among men and 3.2% among women.[9]

Smokeless tobacco use among youth Sri Lanka conducted Youth Tobacco Survey (GYTS) in 2011. A total of 4,031 students aged 13 15 years participated in the survey. The overall response rate was 84.2%. The prevalence of current users of smokeless tobacco among students was 8.6%. The prevalence was higher among males (13%) than females (4.1%). The overall prevalence of betel quid with tobacco was 7.1%; it was higher among boys (11.3%) than girls (2.9%). However, other than betel quid with tobacco, both boys and girls used equally other forms [Table 3]. [10] When the difference in SLT use among boys and girls was compared between 2007 and 2011, the change was not statistically significant. However, a gradual rise in the total SLT use was noticed during this period [Figure 8]. [10,11] Awareness Many studies also revealed that the overall understanding and the level of awareness about health risks attributable to consumption of smokeless tobacco products is low among Sri Lankans. [12-14] The population with low socio economic status was found to have a low level of awareness about oral cancer and OPMD (oral potentially malignant disorders). [12] Estate workers were significantly less aware than villagers even through the SLT use is high as compared with others. Most estate people only knew that tobacco can cause health Table 3: Percentage of current users of smokeless tobacco among students aged 13 15 years old Smokeless tobacco use Tobacco with betel Any form of smokeless tobacco other than betel quid Total 8.5 (7.1 10.1) 7.1 (5.8 8.7) 2.5 (1.9 3.2) Male 13.0 (10.7 15.7) 11.3 (11.3 14.0) 3.0 (2.2 4.0) Female 4.1 (3.2 5.1) 2.9 (2.2 3.8) 1.8 (1.2 2.6) Source: Sri Lanka GYTS 2011 [9] Figure 8: Percentage of current users of smokeless tobacco among youth aged 13 15 years Source: Sri Lanka GTYS Reports of 2007 and 2011 [3,4] problems, but they were not aware that the major risk of consuming smokeless tobacco products was oral cancer. Most of the rural and estate sector users did not know the symptoms of oral cancer. Many users believed that the use of smokeless tobacco products makes them feel manly, energetic, and excited. Spitting by betel quid users is also a common problem in Sri Lanka. Most of the users are unaware that this could cause tuberculosis and other diseases. [1] Some women in the tea plantation use betel quid to keep themselves warm in cold season, avoid bad breath, and hunger. Also, some workers in the estate use it to keep away the leeches while they are working. It seems as if chewing betel quid among estate workers has become a necessity as they believe that they can survive without food but not without betel quid. [13] Health impact of smokeless tobacco use in Sri Lanka Oral cancer is the most common cancer among men in Sri Lanka accounting up to 12% of total malignant diseases in the country. [15] The report of Ministry of Health shows that the incidence of diseases related to tobacco use, such as ischemic heart disease, neoplasms, cerebrovascular accidents, is on the rise. [16,17] Tobacco use is the second biggest cause of all deaths and disabilities arising from non communicable diseases in Sri Lanka. [15] Oral cancer is often preceded by premalignant lesions or oral potentially malignant lesions and conditions (OPMC)/Oral Potentially Malignant Disease (OPMD). [18] The global prevalence of OPMD is reported to be between 1 and 5%. [19] A high prevalence of OPMD is reported from South and East Asia with male preponderance, and with malignant transformation rates of over 2% per year. [11, 17-20] According to the Sri Lankan National Oral Health Survey 2002/2003, it is estimated that more than 2,84,000 people are alive with OPMD, a prevalence of 3.4% (Ministry of Health Sri Lanka, 2009). [21] The nature and prevalence of risk factors for OPMDs differ by country and region. In the developing world, tobacco and arecanut used either singly or in various combinations of betel quid or pan, account for the vast majority of the most common OPMD, leukoplakia [22] have recently shown that, in Sri Lanka, the population attributable risks for OPMD of daily betel quid chewing and of regular consumption of alcohol can be estimated at 84 and 25%, respectively. Further, recent meta analyses of the available literature have shown that socioeconomic status (SES) can be considered a significant risk marker for oral cancer, presumably as a surrogate for poor diet, and for heavier use of arecanut, tobacco, and perhaps alcohol. [23] A study among tea estate laborers found that 92% with oral mucosal lesions reported betel quid chewing. [11] Betel chewing has been associated with a high risk 361

of pre cancerous lesions including oral sub mucous fibrosis (OSF). [24] One study based on hospital based cancer registry reports showed a decline in the age standardized incidence of lip and oral cavity cancers between 1985 and 2005 and an increase in cancer of the oropharynx incidence over the same period. [Ariyawardana and Warnakulasuriya, 2011] [25] However, National Cancer Control Programme showed an increase and oral cancer tops the list of all cancers in Sri Lanka in 2005. [16] Economic impact of smokeless tobacco use in Sri Lanka A majority of the smokeless tobacco users were reported from low socioeconomic groups in Sri Lanka. A betel quid in the market would cost around Rs. 10, and on average a betel quid user would spend Rs. 280 per month. [1] One study found that the rural and urban area prevalence was significantly associated with income (P < 0.05). In both study areas ((Polonnaruwa and Colombo), the prevalence was highest among those with a monthly income <Rs 5,000. In rural areas, 23.8% of those with a monthly income <Rs 5,000 chewed betel, while only 4.7% of those earning >Rs 25,000 a month chewed betel. Among income categories, odds were highest for those with monthly income of <Rs 5,000. Of the betel chewers, 93.8% used it daily while only 5% used it less than 10 days a month. The mean number of betel quid used per day was 5.9 (SD 4.06). Rural betel users spent significantly more on betel monthly (mean = Rs. 883) than urban users (mean = Rs 371) (t = 3.75 P < 0.001). The highest mean expenditure on betel quid of Rs 962 was by users in the rural areas earning <Rs 5,000. This accounts for 19.2% of their income. The amount spent by urban user in the same income category was only Rs 307 per month. [8] Policy Intervention A study conducted by Warnakulasuriya et al., 1984 in Sri Lanka in the early 1980 s using Primary Health Care (PHC) staff in detection of OPMD and oral cancer reported a sensitivity of 89%. As a result, this approach has been included in the National Health Policy of Sri Lanka since 1990. The main obstacles to effective oral cancer screening over the intervening three decades include: The lack of adequate guidelines for PHC staff, particularly concerning which individuals should be examined, an excessive workload including their duties with mothers and babies, and with immunization programs, devolution of all vertical preventive programs to the provincial level; and lack of quality continuing education and assessment systems for health workers. [26-29] 362 Comments The core issue is the easy availability of domestically and internationally prepared smokeless tobacco products at a very affordable price added by continuing myths about smokeless products and shifting business tactics of tobacco industry from smoking tobacco products to smokeless tobacco products in its different form, named as mouth freshener, makes the issue more complex for tobacco control. New lucrative products conceived as Babul among Sri Lankan adolescents will hook them to experiment to come under nicotine trap making them daily smokeless tobacco user or smoker in future. Hence, it is imperative to monitor tobacco use prevalence at periodic interval using standard protocol such as Global Tobacco surveillance System (GTSS) [30] or Tobacco Questions for Surveys (TQS). [31] Public health awareness programs need to be intensified including educating about harms of all tobacco products. Media advocacy programs best suited for the country should be established in sustainable way. Reach of the programs should be wider so that it reaches to all corners most importantly to rural areas. Health alarms, like the effect on reproductive life and sexual impotence, are very effective ways to approach youth. Some appropriate strategies should also be developed targeting men and school boys to reduce the use of tobacco among them. It is equally necessary to make general public and sellers of smokeless tobacco products aware of the existence of policy framework and regulations (NATA) [32] on smokeless tobacco products. Multi sectoral efforts are needed to enforce the laws and regulations on smokeless tobacco products effectively and continue to monitor the key indicators of MPOWER policy package. Another vital approach should be to levy higher taxation and ban advertisement and import of arecanut preparations. References 1. WHO SEARO, Current situation of smokeless tobacco in Sri Lanka ( unpublished ) 2. Babul Beeda seized, OnLanka News. 2010 Oct 28. Available from: http://www.onlanka.com/news/babul-beeda-seized.html [Last accessed on 2012 Dec 12] 3. Full-scale, islandwide war on drugs mafia. The Sunday Times. 2010 Oct 31. Available from: http://sundaytimes.lk/101031/news/ nws_10.html [Last accessed on 2012 Dec 12] 4. Warnakulasuriya S. Smoking and chewing habits in Sri Lanka: implications for oral cancer and precancer. In: Gupta PC, Hamner JE, Murti PR, editors. Control of tobacco related cancers and other diseases. Bombay: Oxford University Press; 1992. p. 113-8. 5. Ministry of Health. National Oral Health Survey 1994/1995. Colombo: Ministry of Health; 1998. 6. Ministry of Health and Nutrition, Government of Sri Lanka, STEPS NCD Risk Factor Survey; 2007. 7. World Health Organization. The WHO report on the global tobacco epidemic, 2011. Geneva; 2011 8. de Silva VA, Hanwella DR, Gnawardena N. Prevalence of betel chewing among males in Colombo and Polonnaruwa districts. J Coll Commnity Phys Sri Lanka 2009;14:20-3. 9. Lee CH, Ko AM, Warnakulasuriya S, Yin BL, Sunarjo, et al.

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