Oral cancer in India: Chewed out

Many poor Indians addicted to nicotine are likely to indulge their habit by chewing gutka. In 2010 a survey by the National Cancer Registry Programme (NCRP) found that one in three inhabitants of the state of Madhya Pradesh aged 15 and older—or some 15m people—use the stuff, a preparation of crushed betel nut, tobacco and an acacia extract called catechu. Even more worryingly, a report in 2008 estimated that 5m Indian children were addicted. It is not uncommon for tykes as young as eight to be users. Gutka is also popular among women, in part because smoking among the fairer sex remains frowned upon in much of India. Add cheapness—1 rupee, or 2 cents, buys a sachet, whereas a cigarette costs at least twice as much—and it is little wonder that two-thirds of Indian tobacco users get their fix in chewable form.

As a result, however, India has one of the highest rates of oral cancer in the world. More than 80,000 new cases are reported every year across the country. The NCRP study reported 35,000 cases of oral cancer in Madhya Pradesh alone, equivalent to four times the national average of around 13 cases per 100,000 people—and almost eight times the world’s. The state’s government has now taken a drastic step. On April 1st it introduced a complete ban on the sale of all chewing-tobacco products.

Bhavna Mukopadhyay, who heads the Voluntary Health Association of India (VHAI), an advocacy, has praised the move. Speaking after it was announced in March, she called for a country-wide gutka ban under the rules introduced in August 2011 by India’s Food Safety and Standard Authority. These followed a ruling by the Supreme Court in February that year, banning the use of plastic in gutka sachets and calling the gutka habit a menace to public health. Because it could not ban the sale of gutka without the government’s backing, the court chose to make the manufacturers’ life difficult by prohibiting the use of plastic in packaging. This forces producers to package it in paper instead, making transportation of large quantities trickier.

However, the VHAI has found that many were brazenly flouting the ruling. Others have simply decamped to towns in Nepal and continue to use plastic sachets which are then smuggled into India. There are also troubling reports that some gutka contains waste from perfumeries and tanneries as flavouring, making it even more noxious. The government lacks the labs needed to ascertain adulteration of this kind, Ms Mukhopadhyay laments. It may also be reluctant to enforce its own rules, wary of antagonising a $10 billion industry.

According to a recent paper in the Lancet, 5.6m Indians die of cancer each year. Many live in the countryside; most never seek medical attention. Tobacco, the paper’s authors write, is responsible for a third of those deaths. Getting Indians to spit it out might save millions of lives.

Also published at economist.com.


  1. Most cancer patients in India die without medical attention: studyDown to Earth, March 29, 2012
  2. Madhya Pradesh bans gutkha and other chewing tobacco productsDown to Earth, April 3, 2012
  3. SC bans plastic gutka sachets from March 1Times of India, December 8, 2010
  4. Global Adult Tobacco Survey: IndiaWorld Health Organization, October 19, 2010
  5. Gutka still sold in plastic sachetsThe Hindu, March 13, 2011
  6. 2011 Census Data: Madhya PradeshGovernment of India

 Image credit: The Economist

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