• 8/13/2002
  • Bombay, India
  • Amy Waldman
  • Tata Memorial Hospital

Promoted by a slick and many-tentacled advertising campaign, gutka, an indigenous form of smokeless tobacco, has become a fixture in the mouths of millions of Indians over the last two decades. It has spread through the subcontinent, and even to South Asians in England.

But what has prompted particular concern here is the way that in the last 10 years, gutka – as portable as chewing gum and sometimes as sweet as candy – has found its way into the mouths of Indian children. Young people have become gutka consumers in large numbers, and they have become an alarming avant-garde in what doctors say is an oral cancer epidemic. That, among other factors, has prompted the state of Maharashtra, which includes Bombay, to take an unusual step. It enacted a five-year ban, the longest permitted by law, on the production, sale, transport and possession of gutka, a $30 million business in the state, effective Aug. 1. Several other states have undertaken similar bans, although some have been stayed by the courts.

It is easy, on the streets of Bombay, to find young men like Raga Vendra, now 19, a railway worker who began taking gutka at age 11. It is also easy to find gutka sellers, like Ahmed Maqsood, who say they have had customers as young as 6.

Dr. Surendra Shastri, the head of preventive oncology at Tata Memorial Hospital, noticed about five years ago that his patients were getting younger, by about eight to 10 years. “High school and college students were coming in with precancerous lesions,” he said. “Usage was starting much earlier.” India has 75,000 to 80,000 new cases of oral cancers a year – the world’s highest incidence, and about 2,000 deaths a day are tobacco related.

A 1998 survey of 1,800 boys ages 13 to 15 from a wide range of socioeconomic groups found that up to 20 percent were already using three to five packets of gutka daily. The price is low: sometimes less than two cents a packet. The contents, a mixture of ingredients including tobacco, are usually placed in the cheek lining, savored, then expelled.

Gutka was the product of a packaging revolution that made an Indian tradition portable and cheap. Many Indians have long chewed paan, a betel leaf wrapped around a mixture of lime paste, spices, areca nut and often tobacco. But obtaining paan required a visit to a paanwallah – it was too messy to be transported. All of that changed with gutka, a dried version of the concoction, but without the betel leaf, preserved and perfumed with chemicals and sealed in a plastic or foil pack.
Gutka could be used at will, at work or at home or at school, and it was used, in very large quantities. Sales of gutka and its tobaccoless counterpart, paan masala, are now more than $1 billion a year, having quintupled during the
1990’s. “What caused this boom of oral cancers was this packaging of tobacco,” said Dr. A. K. D’Cruz, the lead head-and-neck surgeon at Tata Memorial Hospital. “Convenience got them hooked.”

Many consumers say they welcome the ban, because they see no other way to curb their addiction. Even some vendors like Mr. Maqsood have embraced it, saying they felt they were trading in toxins. “The chemicals used in gutka were poisonous,” he said. “I have seen some customers who can’t open their mouth.”

The ban’s critics, gutka manufacturers among them, argue that countless other tobacco products remain on the market. While vendors, fearing large fines, are largely observing the ban for now, gutka can easily be bought just a state away. Gutka manufacturers contend that the ban stemmed less from concern about children than from a desire to protect cigarette makers, who are fighting for market share. The gutka makers have begun running an ad that argues that if gutka is banned, cigarettes should be as well. “No government in the world has been able to stop cigarettes,” Dr. Shastri countered. The gutka ban, he noted, is possible only because of a law allowing the state to ban harmful foodstuffs.

“The gutka makers say the ban will have spurious effects,” he continued. “I don’t care – 70 to 80 percent of children won’t have access to the black market, or to smugglers. We will prevent children from taking it up.”

Gutka is seen by doctors as particularly insidious because it contains many unhealthful additives, like magnesium carbonate, and is cheap. For children and teenagers, smoking cigarettes remains taboo. Gutka has no social stigma among peers, and it is easy to hide from parents.

Padmini Samini, who started an antitobacco advocacy group after her father got oral cancer, said she had found cases in which gutka makers had given free samples to children after school. Some of it was sweetened so much to mask the harsh tobacco taste, she said, that children considered it candy. Gutka manufacturers managed to erase whatever stigma was tied to using tobacco with paan by marketing campaigns that made gutka use glamorous and socially acceptable.

For about a decade India’s version of the Oscars has been sponsored by Manikchand, one of the top-selling brands. Gutka manufacturers have sponsored religious festivals, distributing free samples. In television commercials, gutka
gives actors the power to perform superhuman feats. That may be why Abinash Parab, an ordinary laborer, thought he needed gutka to do his heavy lifting job. Until two weeks ago he was using 20 to 25 packets of Manikchand a day. “There was a sense of intoxication” from gutka, he said. What stopped him was not the ban; it was the wards he passed through at Tata Memorial Hospital when he went to get ulcers in his mouth checked out. Tumors bulge from cheeks and jaws. There are holes where larynxes used to be.

About 30 percent of the cancers in India are in the head and neck, compared with 4.5 percent in the West. Furthermore, Dr. D’Cruz added, “most of our cancers come a decade earlier than the West.” They come in the cheek and jaw, often preceded by submucosal fibrosis, a hardening of the palate that can make it almost impossible to open the mouth.

Rasiklal Manikchand Dhariwal, the founder of Manikchand and the country’s king of gutka, says he has no such health problems, despite being a user himself. The fruits of gutka’s popularity are visible at his 14,000-square-foot home in Pune, where he lives behind guarded gates in immodest opulence. He exports gutka to 22 countries, and calls his product a health promoter and job producer, noting that hundreds of thousands of Indians farm tobacco for their livelihood.

Manikchand, he said, is made with the highest level of quality control. He compared its scent to a “French perfume.” As long as the brand is of high quality, he said, it is fine for children, although his product is now marked “not for minors.” He disparaged his competitors for making shoddy, possibly injurious products. He also blamed consumers for overdoing it. “If you take anything in excess it will also harm, no?” he said. “Even milk.”