With an annual increase of 16000 new cases each year, oral cancer is the second most common cancer in Pakistan. There is conflicting evidence regarding the carcinogenicity of different forms of smokeless tobacco (SLT) from different countries.The carcinogenicity of Naswar, a form of smokeless tobacco used extensively in Pakistan, Afghanistan, and Central Asia, has yet to be recognized by the International Agency for Research on Cancer (IARC), partly due to the lack of evidence on the association of Naswar use and cancer.
Additionally, Naswar is yet un-regulated in Pakistan and evades the tax net, resulting in it being freely available to both adults and children at very cheap prices compared to cigarettes, which has been the main focus of tobacco control in Pakistan.
A research “Compliance of Oral Snuff (Naswar) Packaging and Sales Practices with National Tobacco Control Laws and the Relevant Articles of Framework Convention on Tobacco Control in Khyber Pakhtunkhwa analyzed 133 and 49 unique Naswar products sold in 229 general points of sale (GPOS)and by 57 Exclusive Naswar sellers (ENS), respectively.
None of the local products had any written or pictorial health warning. More than half of retailers used one or two methods of advertising Naswar inside the shops while only 9% advertised outside the shops. ENS were more likely to non-compliantiant with tobacco advertisement and promotion compared with General Point of Sale (GPOS).
Recent estimates suggest that more than 250 million people in South Asia use smokeless tobacco (SLT) products and Pakistan is no stranger to these products with 13.3% of the population using either Naswar, Paan,Gutkha and other SLT products.Naswar use is a major public health challenge in Khyber Pakhtunkhwa, where an estimated 15% of the province’s population is addicted to this mixture of tobacco, ash and lime.
Naswar use is associated with a variety of conditions including upper aerodigestive tract cancers, cardiovascular and gastrointestinal disease.Oral cancer has become the most common cancer among men and the second most common cancer among women in Pakistan. An estimated 6000 Pakistanis lose their lives to oral cancer every year.
According to official statistics more than 70 per cent of the people in K-P are in the habit of chewing naswar. According to the Pakistan Tobacco Board, there is a huge market for naswar in the province estimated at around Rs6 billion annually.Famous for quality naswar ,Dera Ismail Khan and Bannu, also export the product to Punjab and Sindh. There is a huge demand for naswar in Karachi, which has a large population of migrants from K-P.
Naswaris made from fresh tobacco leaves, calcium oxide and wood ash. According to health experts “the use of naswar directly causes lung, stomach and mouth cancer besides causing bronchitis, kidney, heart and other diseases”.Medical experts arealso of the view that the diseases caused by naswar are more fatal than those caused by smoking. The health department has been engaged in a fierce campaign against smoking through the print and electronic media but has failed to run a similar campaign against the use of naswar.
The Khyber Pakhtunkhwa Government is currently in the process of devising a new tobacco control legislation for the province and it is right time that “Smokeless Tobacco” is a recognized term by the World Health Organization and hence should be used as such, rather than vague terminologies like “other tobacco”, which can be misleading and may be misinterpreted. The use of smokeless tobacco, explicitly citing “Naswar”, shall be prohibited in public places, offices and educational institutions, akin to the prohibition of tobacco smoking,sale of all forms of tobacco (smoking and smokeless), to and by a person who is younger than 18 years of age shall be prohibited.
The newly propose legislation must make it mandatory for the Naswar packaging to contain health warnings and as opposed to an absolute ban on Naswar, the Government should try to introduce regulatory legislation regarding the composition of Naswar. The content of carcinogenic agents in Naswarcould be reduced using the “Swedish Snus” model.
The author is a human rights activist and Tweets @QamarNaseemPak