Doctors spread awareness against gutkha consumption

"Thank you bidis. Thank you cigarettes. You made us what we are today," reads the text above the faces of two men in an advertisement released by the Healis Sekhsaria Institute of Public Health. No, the institute isn't changing their anti-tobacco stand. Instead, it is just their way of protesting against pro-gutkha advertisements that have been appearing on the front pages of major newspapers across the country. These ads, placed by the Smokeless Tobacco Association, protest against the ban on gutkha in 14 states, including Maharashtra. They also claim the ban is unfair since four crore people will lose their livelihood if they cannot make and sell gutkha any longer. And that's just in one advert. Other ads claim that cigarettes are more harmful than gutkha but are not banned, and gutkha is being discriminated against. Gutkha is composed of areca nut and spices (among other food products) along with tobacco but by the Food Safety Act, 2006, it is illegal for tobacco to be mixed in any food product.

Victims speak: This advertisement tells the other side of the story

Dr Pankaj Chaturvedi, Consultant Surgeon at Tata Memorial Hospital, is understandably upset with these pro-gutkha advertisements. "Eighty per cent of the cancer patients who visit the Head and Neck department at Tata Memorial are suffering because of consumption of tobacco," says Dr Chaturvedi, who is also the leader of Healis's campaign Voice of Tobacco Victims (VoTV). The campaign has come up with their own set of advertisements rebutting the claims made by the gutkha manufacturers. These advertisements use irony to spoof the pro-gutkha ads and feature cancer victims whose misshapen faces - due to cancer surgery - are clearly visible.

Making a point: In this advertisement, the Healis Sekhsaria Institute uses sarcasm to bring forth the plight of cancer victims

Adds Dr Chaturvedi, "We are fighting for cancer patients, cancer survivors and their families. The gutkha manufacturers came up with a nationwide campaign and spent crores of rupees on it. They are distorting the facts with misleading data." He says he and the Healis Sekhsaria Institute made a deliberate attempt to feature cancer victims and survivors in their rebuttal ads to refute the claims of the gutkha manufacturers. "Cancer patients, cancer survivors and their families have to be important stakeholders in the process. We want to give them a platform so that they are not a mere statistic for policy makers," he says. "We are fighting a powerful lobby who have political connections and financial power. All we can do is bring the victims of tobacco to the forefront and make their voices heard."

Fighter: Dr Pankaj Chaturvedi

According to Dr Chaturvedi, one million die in India every year from cancer due to tobacco, while crores develop the disease. "Every third tobacco user in India gets a serious illness. There are 27 crore users in India, which means nine crore are risking their lives. According to the gutkha industrialists' advertisements, four crore earn their livelihood through tobacco. Should nine crore people risk their lives to provide livelihood for four crore people? No. It is simple mathematics." He is also against these pro-gutkha ads because he believes that policy makers are going to use these facts to push for a campaign to dilute the Food Safety Act.

Crusader: Dr Prakash Gupta

Gutkha vs ciggies
He adds that the gutkha manufacturers' claim that gutkha is banned and cigarettes are not, even though gutkha contains lesser tobacco than cigarettes, doesn't really hold water. "Gutkha is banned because it is considered a food product. Cigarettes are not banned because they are legally not a food product. They fall under the Cigarettes and Other Tobacco Products Act (COTPA), 2003. Gutkha manufacturers have till now been operating with a food operator licence. If they had said, why gutkha is banned when other pure smokeless tobacco products such as masheri and khaini are not banned under the Food Safety Act, even though they fall in the category of food, then it makes sense. But they are comparing it with cigarettes instead, which are not a food product. They claim gutkha has 3,000 chemicals, while cigarette has 4,000, but even what gutkha has is more than enough to damage the DNA, make cells vulnerable to overgrowth, and grow in an abnormal fashion, resulting in cancer. Unlike alcohol, there is no safe level for tobacco. Even one puff or one packet can do genetic damage." Dr Sourav Dutta, Ear-Nose-Throat surgeon and clinical fellow, Head and Neck surgery, Tata Memorial Hospital, puts it in simpler terms: "It is like asking which is more dangerous - jumping from the 100th floor or from the 110th floor. The outcome is the same."

Turning into addicts
Agrees Dr Prakash Gupta, head of the Healis Sekhsaria Institute of Public Health. "No amount of tobacco is safe. In the case of smokeless tobacco, the tobacco is chewed and so the carcinogens come into direct contact with the mouth and oesophagus, which is extremely dangerous. Nicotine changes the entire system of our body and not just one organ. Our brain is the safest part of our body, because hardly anything can penetrate the blood-brain barrier. But nicotine penetrates that, which leads to receptors specific to nicotine to develop in the brain. These receptors compel an addict to take tobacco in some form. That's why even if someone wishes to quit tobacco, they cannot. The majority of addicts develop the habit in their adolescent years, when they cannot appreciate the adverse effects tobacco consumption will have on their health or on their family members."

End of superrman
Dr Gupta cites the example of Shafique Shaikh, the actor better known as Malegaon ka Superrman. "The irony is that in the movie, he fights against tobacco, but in real life, he was a consumer of tobacco. He got oral cancer due to his tobacco use. That's when he got involved in the Voice of Tobacco Victims campaign. He saw his movie in a special screening and died a couple of days later, much before the film was released." Shaikh, in his superman costume, now appears on Healis' rebuttal advertisements, with a line about how gutkha addiction killed the young actor in September 2011.

According to Dr Gupta, the pro-gutkha advertisements are portraying a wrong picture. "What the gutkha ban actually affects is profit. Gutkha industry doesn't really employ that many people (as mentioned in the advertisements). Most of the packaging is done by machines. Farmers and retailers are the majority.

We have done surveys with retailers. They told us that they stock the product because there is public demand. They also sell other small items such as soaps. If tobacco products are really bad, why doesn't the government ban it, they ask. And if the government banned it, they will stock more of other products, they said. Farmers' asset is their land. They can cultivate other crops, and the government can help them make the switch."

Role of govt
But why should the onus of regulation always fall on the government? Isn't there a limit to what the government can do? Shouldn't adults be sensible enough to realise they should stay away from harmful products? "Yes, but for that, people need to be informed," says Dr Gupta. "Who can do it? Globally, it has been found that policy approach is most effective for controlling tobacco and reducing consumption. India has ratified the World Health Organization's Framework Convention on Tobacco Control, making the government legally bound on an international level to implement control policies."

Ask Dr Chaturvedi if he thinks the pro-gutkha ads are unethical and he says, "Yes. The advertising code of ethics has not been judiciously employed. I have all respect for newspapers, but when the commercial team pushes for an ad, the editorial team should review it. It can be construed as contempt of court, since the courts are the ones who agreed that gutkha should be banned." Agrees Dr Dutta, "Next, some heroin company will place an ad. These ads are disturbing. Placing them may not be illegal, but it is definitely immoral."

Who placed the pro-Gutkha advertisements?
The ads mention the New Delhi-based organization, Smokeless Tobacco Association (STA). A representative said, "Ads released by us are an appeal against discrimination and injustice done to one form of tobacco consumption. Gutkha falls under COTPA. The decision to ban it has been initiated by the Food Safety Standards Authority of India which has never prescribed a standard for Gutkha. Ironically, the same authority in a communication dated 29.06.12, confirmed, ‘As per extant Food Safety Standards Act and regulations Gutkha has not been defined as food'. It is therefore not the nodal authority to regulate tobacco products. Even WHO and Framework Convention on Tobacco Control treat all forms of tobacco equally. A unilateral ban on gutkha will send out an erroneous message that the government considers cigarettes to be a safe and healthier product over gutkha and provide a competitive advantage to cigarettes".

The ads also mention The Central Areca Nut and Cocoa Marketing and Processing Co-operative Limited (CAMPCO), based in Mangalore. Its president, K Padmanabha, said, "Areca nut is 100 per cent not carcinogenic. We represent areca nut farmers and are not for tobacco and other such substances. I don't know who is STA. I have made enquiries with the concerned people but I will not talk to the press about it."

Cancer factsu00a0

Explains Dr Sourav Dutta

>> Cancer patients who have been treated are never called 'cured' or 'not cured' since there is no cure for cancer. They are termed 'survivors' - either long-term or short-term.

>> The effect of tobacco consumption remains in the body for 10 years after quitting.

>> The oesophagus of gutkha chewers gets adversely affected. In 15-20 per cent of the cases, carcinogens come in contact with other sites, resulting in second primary cancer in a different part of the body.

>> Worldwide, lung cancer is the cancer that affects the most number of men. However, in India, it is oral cancer. Chewing tobacco is two times more dangerous than smoking.

A doc's open, satirical letter
The gutkha manufacturers' lobby has inserted front-page advertisements in newspapers. One ad says that the tobacco ban threatens the livelihood of four crore growers, processors, labourers, etc. and 40 lakh petty vendors. As a medical professional, I would like to add to this the livelihood of 17,000 doctors and over one lakh nursing staff, ward boys, chemist shop owners etc. About 26 per cent of India's 121 crore population are tobacco-chewers, as against 5.7 per cent cigarette smokers and 9.2 per cent bidi smokers. Many smokers use gutkha-paan masala as mouth fresheners, doubling their cancer risk. If the gutkha ban is implemented in all the states, then all these people will be safeguarded from cancer and other chronic ailments. Can you imagine what a disaster that will be for the medical community?

The chewable tobacco industry directly gives income to about 1,000 cancer surgeons all over India, and one lakh hospital staff, nurses and ward boys.

Gutkha addicts suffer from poor oral and digestive health, and so they also provide continual income to 10,000 general practitioners and 6,000 dentists.

Please consider my own example. I am an Ear-Nose-Throat (ENT) surgeon, working as a Clinical Fellow at Tata Memorial Hospital (TMH) at Mumbai. I check about 150 cancer patients per week, assist senior surgeons in the operation theatre and oversee the post-operative care of hundreds of patients.

Out of every 10 cancer patients that I admit for surgery, seven are gutkha addicts. Another two-three are cigarette or bidi smokers. Patients who have neither smoked nor chewed tobacco are extremely rare for me. Our operation theatres are always running housefull, and we have a waiting list of 30 to 45 days for surgery. We refer dozens of patients every week to outside doctors and clinics.

We simultaneously perform around 10 major surgeries every day, such as entire removal of upper and lower jaw, voicebox etc, permanently disabling the patient from eating and speaking normally. These surgeries take six to eight hours each, and involve a large team of surgeons and staff. We also perform smaller operations such as partial tongue removal. Even after surgery, radiotherapy and chemotherapy, 60 per cent of such patients don't survive more than five years. Rakesh Kumar Dixit, a 40-year-old farmer from Uttar Pradesh is a typical patient. He mixed tobacco and lime and ate them for 20 years.

Today, his condition is such that we must surgically remove his entire cheek. Our clientele consists of 31 crore tobacco addicts like him, and some are children and collegians.

My patients are generally accompanied by caring parents, spouses, children, brothers and sisters - innocent bystanders and "collateral damage". They foot the bill for the tobacco industry's marketing success.

Is it the government's duty to safeguard 31 crore cancer victims and their families? Or is it a greater duty to continue allowing four crore tobacco growers and factory workers, 40 lakh pan shop vendors etc., to earn a livelihood by pushing 31 crore persons closer to a horrible death? (I assume there are these many people in the business as the ad states, but I have my doubts.) Which way must our nation's balance tilt?
- Dr Sourav Dutta

This letter was addressed to several newspapers