9 Social and Cultural Aspects of Tobacco and Arecanut Use in Gujarat-A Sociological Study PDF

CONTENTS
Chapter
no.
---------------
Title
Preface
Acknowledgement
List of Tables
List of Graphs
List of Figures
List of Annexures
Abstract
Introduction
About Gujarat State
Review of Literature
Socio-cultural aspect
Changing Social Values
Research Methodology
Results & Observation
Discussion
Conclusion
10
Bibliography & References
---
Annexure
Page
No.
I
V
VII
VIII
IX
X
XI
1
Preface
Acknowledgement
List of
tables
List of
figures
List of
graphs
Annexures
Abstract
INTRODUCTION
About
Gujarat
state
Review of
literature
Sociocultural
aspect
Changing
social
values
Research
methodology
Results and
observation
Conclusion
Discussion
Bibliography
Annexures
Chapter- 01
INTRODUCTION
Pages would tell, Lines would show that Science may have Advanced but Man
still has a long way to go, Clinician might state the standard bar, its only
Epidemiology that shows how keen Observer we are
From time immemorial man has been interested in trying to control

disease. The medicine man, the priest, the herbalist and the
magician, all undertook in various ways to cure mans disease
and/or to bring relief to the sick. In the course of its evolution,
which preceded by stages, with advances and halts, medicine has
drawn richly from the traditional cultures of which it is a part and
later from biological and natural sciences, in the crucible of time,
medicine has evolved itself into a social system heavily
bureaucratized and politicized.
A glaring contrast in the state of health between the developed

and developing countries, between the rural and urban areas, and
between the rich and poor have attracted the world wide criticism
as social injustice. Currently the commitment of all countries
under the banner of WHO, is to wipe out the inequalities in the
distribution of health resources and services and attain the goal of
health care for all. The goal of modern medicine is no longer
merely treatment of sickness. The other more important goals
which have emerged are prevention of disease, promotion of

health and improvement of the quality of life of individuals and
groups or communities. In other words, the scope of medicine has
considerably broadened during recent years. It is also regarded as
an essential component of socio-economic development.
Health is a common theme in most cultures. In fact, all

communities have their concepts of health, as part of their culture.
Modern medicine is often accused for its preoccupation with the
study of disease and neglect of the study of health. Consequently,
our ignorance about health continues to be profound, as for
example, the detriments of health are not yet clear, the current
definitions of health are elusive, and there is no single yardstick
for measuring health. There is thus a great scope for the study of
epidemiology of health.
The term lifestyle is rather a diffuse concept often used to

denote the way people live, reflecting a whole range of social
values, attitudes and activities. It is composed of cultural and
behavioral patterns and lifelong personal habits e.g. smoking,
alcoholism, that have developed through process of socialization.
Life styles are learnt through social interactions with parents, peer
groups, friends and siblings and through school and mass media.
Health requires the promotion of healthy life style. In the last 20
years, considerable evidence has accumulated which indicates
that there is an association between health and lifestyle of

individuals. Many current day health problems especially in the
developed countries e.g. oral precancer, oral cancer, lung cancer,
obesity, drug addiction, coronary heart disease are associated
with lifestyle changes. In developing countries such as India
where traditional life style still persists, risks of illness and death
are connected with lack of sanitation, poor nutrition, personal
hygiene, elementary human habits, customs and cultural patterns.
The lack of parental attention in the nuclear families and peer

pressure may provoke the child into deleterious habits like
smoking, alcoholism, drug addiction, dating etc at an early age (a
common practice seen in most developed countries). These
adverse cultural practices in turn increase the incidence of oral
cancers, venereal diseases and mental illnesses.
Offering pan having betel leaf, slaked slime, areca nut, and
catechu is a way of welcoming the guests in North Indian states
like Rajasthan, Uttar Pradesh, Maharashtra and West Bengal.
Rejecting pan is taken as an insult. This may encourage the people
to get into the habit of chewing pan, which is a proven risk factor
for periodontal diseases, oral sub mucous fibrosis and oral
malignancies.
Various customs, cultural pattern and life styles have lead to use
of tobacco and betel nut in human beings. Various forms of
tobacco and betel nut are available in every corner of the country.
Such harmful habits have always caused precancerous and
cancerous lesions in these human beings and hence the graph of
occurrence of cancer is steadily increasing.
Tobacco and arecanut use has been linked to the Indian Culture.
The smoking of hookah was considered as a mark of respect.
Similarly using areca nut (supari) in various Indian traditions and
customs has survived through ages and still prevalent in India.
Sharing a puff of smoke or prepared Tobacco quid was
considered as a part of friendly bondage. It is also considered as a
mark of respect to not puff or chew a tobacco in front of seniors
and elders. The above discussion clearly indicates that Tobacco is
a part of the very Indian culture since ages.
Understanding culture is an essential key to reducing tobacco and

arecanut use. Conceptualizations of culture vary across scientific
disciplines and theoretical orientations. Because of the complexity
of the causes and effects of tobacco and arecanut use, no single
discipline has sufficient capacity to undertake a comprehensive
approach to studying culture and tobacco. Trans-disciplinary
research offers a means of bridging disciplinary perspectives. This
study reviews epidemiological data on observed variation in use of
tobacco and arecanut patterns across different age groups,

gender and socio-demography, presents reasons for studying
culture in tobacco control research. This study also discusses
and contrast conceptualizations and specific definitions of culture
and identify aspects of each conceptualization that are relevant to
research on tobacco and arecanut use.
The present
study presents a multilevel,
multidimensional
conceptual framework for trans-disciplinary research teams to use

to think together about the influence of culture on tobacco and
arecanut and of tobacco and arecanut on culture. The conclusion
challenges researchers to think about how the socio-cultural
context influences tobacco and arecanut use at micro, meso and
macro levels. Finally, the study offers suggestion for improving
trans-disciplinary research on culture, tobacco and arecanut.
The inclination to get into the habits of smoking, alcoholism, drug

addiction in the name of civilization among the younger generation
needs to be countered at the earliest, otherwise, it may have a
huge deleterious impact on the health status of the generation to
come. Keeping in mind, the very significant role, the culture plays
on health and oral health, this research study is an attempt to
assess the effects of key cultural factors on health and oral health.
Chapter- 02
ABOUT GUJARAT STATE

Gujarat The Land of the Legends, is one of the most diverse
states in India. Gujarat derives its name from the word 'Gujaratta'.
Gujaratta means the land of gurjars. The gurjars were a sub-tribe
of the Huns who ruled the area during the 8th and 9th centuries
AD. They passed through Punjab and settled in some parts of
western India, which came to be known as Gujarat. Stone Age
settlements around Sabarmati and Mahi rivers indicate the same
time as that of the Indus Valley Civilization while Harappan centres
are also found at Lothal, Rampur, Amri and other places. Rock
Inscriptions in the Girnar Hills show that the Maurya Emperor
Ashoka, extended his domain into Gujarat in about 250 BC. With
its fall, the control of the region came under the Sakas or
Scythians. During the 900s the Solanki Dynasty came to power
and Gujarat reached its greatest extent.
Then followed a long period of Muslim rule Ahmed I, the first

independent Muslim ruler of Gujarat, found Ahmedabad in 1411.
The Mughal Emperor Akbar conquered Malwa and Gujarat in
1570s.The British East India Company set its first footsteps in
Surat in 1818 and the State came in control of their rule. Gujarat
was divided into princely states.
After the Indian Independence in 1947, all of Gujarat except

Saurashtra and Kutchh became part of Bombay State until May 1,
1960, when the Government split Bombay state into the States of
Maharashtra and Gujarat. Ahmedabad became the chief city of the
new State and housed the State Government Offices. They
remained there until they were transferred to Gandhinagar in 1970.
Gujarat is situated on the west coast of India. Gujarat is bounded
by the Arabian Sea in the west, by Rajasthan in the north and
northeast, by Madhya Pradesh in the east and by Maharashtra in
the south and south east. The state has an international border
and has a common frontier with Pakistan at the north-western
fringe. It covers an area of 196,024 square km. It has the longest
coast line of 1290 kms. Gandhinagar, located near Ahmedabad is
the state capital of Gujarat. The people of Gujarat are also known
to be a successful business community. At present, Gujarat
comprises of 26 districts. The official and primary language
spoken is Gujarati. The state of Gujarat is known all over the world
for its holy temples, historic capitals, wildlife sanctuaries,
beaches, hill resorts, fascinating handicrafts, mouth watering
cuisine and colourful lifestyle of the people of Gujarat.
The state of Gujarat is an
industrially advanced state and
holds an important place in
India. The state comprises of
three
geographical
regions.
The peninsula, traditionally known as Saurashtra, is essentially a

hilly tract sprinkled with low mountains. Kutch on the north-east is
barren and rocky and contains the famous Rann (desert) of Kutch,
the big Rann in the north and the little Rann in the east. The
mainland extending from the Rann of Kutch and the Aravalli Hills
to the river Damanganga is on the whole a level plain of alluvial
soil.
Districts in Gujarat1. Ahmedabad

2. Amreli District
3. Anand
4. Banaskantha
5. Bharuch
6. Bhavnagar
7. Dahod
8. The Dangs
9. Gandhinagar
10. Jamnagar
11. Junagadh
12. Kutch
13. Kheda
14. Mehsana
15. Narmada
16. Navsari
17. Patan
18. Panchmahal
19. Porbandar
20. Rajkot
21. Sabarkantha
22. Surendranagar
23. Surat
24. Tapi
25. Vadodara
26. Valsad
The North part of Gujarat is called North Gujarat. It includes
Gandhinagar, Banaskantha, Sabarkantha, Mehsana and Patan
districts. The South Gujarat region includes Surat, Navsari , Dang ,
Valsad and the newly formed Tapi District. The East Gujarat region
includes Panchmahal and Dahod districts.
Chapter- 03
REVIEW OF LITERATURE
He who would learn to fly one day must first learn to stand and walk
and run
- Friederich Nietzsche
The Review of literature provides a background for understanding

current knowledge and illuminates the significance for the new
study. The understanding of the literature also prevents repeating
previous errors or redoing work which has already been done. It
will also give insights into aspects of research which might be
worthy of exploration and future research.
TOBACCO
Tobacco Weapon of Mass Destruction
Introduction:
Adolescents are the most vulnerable population to initiate tobacco
use. It is now well established that most of the adult users of
tobacco start tobacco use in childhood or adolescence. There has
been a perceptible fall in smoking in the developed countries after
realization of harmful effects of tobacco. The tobacco companies
are now aggressively targeting their advertising strategies in the
developing countries like India. Adolescents often get attracted to
tobacco products because of such propaganda. There has been a
10
rapid increase in trade and use of smokeless tobacco products in

recent years in the country, which is a matter of serious concern
to the health planners. It is important to understand various
factors that influence and encourage young teenagers to start
smoking or to use other tobacco products. The age of first use of
tobacco has been reduced considerably. However, law enforcing
agencies have also taken some punitive measures in recent years
to curtail the use of tobacco products.
History:
The word tobacco is reported to derive from the Spanish word
tobago or tobaca-a a term used by the Spanish to describe a Y
shaped instrument used by early American Indians to inhale snuff
of various types into the nostrils. Similar instruments may be
found in use today in Central and South America.36
The world-wide distribution and cultivation of the plant did not

occur until the Spanish and Portuguese introduced the plant to the
world in the late Fifteenth century. The tobacco plant is thought to
have originated in the region of Central America. Use of the plant
for a variety of therapeutic and non- therapeutic purposes was well
known to the Indians of Central and South America by the time
Europeans arrived in their country. Tobacco (picietl) was used by
the early American Indians to relieve toothache, to treat skin
wounds and insect bites, as an anti-fatigue agent, and as a tooth-
11
whitening agent. After the 'discovery' of tobacco by the Spanish,

the plant was rapidly disseminated throughout, both the nontropical and tropical world where it remains the basis of major
industry in many countries and forms the basis of a variety of
habits in many cultures. For many decades during this century,
tobacco habits have been the focus of international concern with
respect to the causation of disease in the world's population (WHO
1985, 1986).36 These diseases include respiratory diseases,
cardiovascular disease, lung and other visceral cancers, and oral
diseases such as Leukoplakia, Nicotina stomatitis, Periodontal
disease and Oral squamous cell carcinoma. Concern about
tobacco usage is not new.
At various times during the sixteenth and seventeenth centuries

various governmental and religious groups in Japan, China,
Turkey, Russia, and several countries in Europe passed laws
prohibiting the use of tobacco. Punishments for those found using
tobacco sometimes were severe and included jail, loss of property,
physical punishment, and death by hanging, beheading or
starvation. Tobacco is referred to as kaddipudi and hogesoppu
in Karnataka, kadapan in Orissa and West Bengal, and pattiwala
in Uttar Pradesh.
12
Constituents of Tobacco:
Tobacco is manufactured in various forms of smoking tobacco,
chewing tobacco and tobacco snuff. It is chiefly derived from two
species of the plant Genus Nicotina. The two species are N.
tabacum and N. rustica. The addictive property of tobacco is due
to one of its component alkaloids, Nicotine. Raw & processed
tobacco has been shown to contain over 2500 different chemical
constituents.
Constituents of tobacco37
Nicotine
Specific Nitrosamines
Polycyclic Aromatic Hydrocarbons
N- Nitrosonornicotine
Volatile Nitrosonor Compounds
Tar
Carbon Monoxide
Phenol
Hydrogen Cyanide
Benzopyrine
Nitrogen Oxide
Formaldehyde
Indole
Carbazole
Catecol Vinyl Chloride
Ammonia
Metals- Nickel, Arsenic, Lead
Radioactive Compounds
13
Forms of Tobacco:36,37,38
The main forms of Tobacco habit encountered around the world
are
1. SMOKING TOBACCO
2. SMOKELESS TOBACCO
1. SMOKING TOBACCO:38
The smoking of tobacco is a widespread habit practised by people
from most cultures and societies throughout the world. While the
custom of tobacco smoking is almost universal in its occurrence,
there is considerable variation with respect to the amount of
tobacco smoked, the form in which it is smoked and the gender
distribution of the habit. Tobacco smoke contains over 3800
individual chemical constituents including known carcinogens.
The association between tobacco smoking and human disease
was first formally recognized in the late eighteenth century.
However, little interest in the association between tobacco
smoking and disease was evinced until the 1920s. Since that time
an enormous quantity of research has established causal links
between the habit of tobacco smoking and a range of human
diseases.
Tobacco is smoked in the following form36,37,38

1. Bidi
2. Cigarette
3. Cigar
14
4. Pipe
5. Hookah
6. Chilam
7. Chutta Smoking
2. SMOKELESS TOBACCO:
The term smokeless tobacco is used to describe tobacco that is
consumed without heating or burning at the time of use.
Smokeless form is available in Dry form & in Moist form.
Smokeless tobacco can be used orally or nasally.
A. Dry form of smokeless tobacco 1. Snuff
2. Mainpuri tobacco
3. Tobacco and slaked lime (khaini)
4. Chewing tobacco
5. Snus
B. Moist form of smokeless tobacco 1. Betel quid (Paan with tobacco)
2. Tobacco quid (tobacco, arecanut & slaked lime)
3. Mawa
Tobacco products for application 1. Mishri (mashiri)
2. Gul
3. Bajjar
4. Lal dantmanjan
5. Gudhaku
6. Creamy snuff
7. Tobacco water
8. Nicotine chewing gum.
15
ARECANUT
Introduction:
Arecanut is a compound of natural substances chewed for its
psycho stimulating effects. Because of its ancient history, its use
is socially acceptable among all sections of society, including
women and quiet often, children.23 Approximately 200 million
persons chew arecanut regularly throughout the western Pacific
basin and south Asia.24,25 Arecanut is the fourth most common
psychoactive substance used in the world after nicotine, ethanol,
and caffeine.26,23
Ancient History:
The origin of the habit of chewing areca nut is Southeast Asia,
possibly Malaysia where the name of the province of Penang
means Arecanut. Ancient writings describe well-established betel
practices from China and India more than two millennia ago.
Betelnut is a misnomer used for Arecanut. In traditional Indian
medicine, or Ayurveda, betelboth the quid collectively and the
areca nut aloneis recommended for its laxative and carminative
effects. Other traditional attributes of arecanut are listed below 27,28
Uses of Areca nut in Industry:
Building materials (palm trunks)
Dye (red and black)
Housing insulation (areca husks)
Leather tanning
Roofing materials (palm leaves)
16
Uses of Areca nut in Traditional Medicine (e.g. Ayurveda)
Antihelmintic and vermifuge
Aphrodisiac
Appetite stimulant
Astringent
Breath freshener
Cardiac tonic
Carminative (expels flatus)
Dentifrice
Diarrhoea prevention
Diuretic
Emmenagogue (induces or increases menstrual flow)
Laxative
Nervine tonic
Strengthen gums
Treat urinary disorders
Epidemiology of Use of Areca nut:

Areca nut is used as a masticatory substance by approximately
600 million people worldwide. It is estimated that 10 20% of the
worlds population chew areca nut in some form, often mixed in
betel quid. A challenge facing researchers documenting the
prevalence of areca nut use in populations is the difficulty in
documenting patterns of areca nut use as separate from betel quid
chewing which often contain a variety of ingredients, including
tobacco. Thus estimating the population frequency of areca use by
itself is often frustrating, as some authors do not record this
explicitly in their publications. As areca is often the primary
ingredient in betel quid many studies describing population data
17
for betel quid chewing is taken as a valid reference value. While

there are no nationwide surveys reported on the prevalence of this
habit. India has the largest areca-consuming population in the
world. Much of the data arise from extensive population studies
conducted by the TIFR group9 in the 1960s and 1970s. Data were
collected in a series of house-to-house surveys conducted in rural
areas from individuals aged 15 years or over with approximately
equal proportions of males and females. Interviews were
conducted in five districts in India, Gujarat, Andhra Pradesh, Bihar
and Kerala, involving 50915 people. The proportion of chewing
betel quid varied from 3.3% in Srikakulam in Andhra Pradesh to
37% in Ernakulam in Kerala. Among 50915 people surveyed in five
districts, 0.6% of those chewed areca nut alone (supari), compared
with 11.6% who chewed betel quid with tobacco. The other largescale study conducted in India by Malaowalla et al29 on 57,518
industrial workers in Ahmedabad, Gujarat. a population different
to the above studies in that these were mostly urban male textile
workers reported pan and supari chewing by 26% of 85% who
admitted to an oral habit. In a study of 99598 adults ( > 35 years) in
Mumbai, some 32.1% reported chewing betel quid with tobacco,
whereas only 0.5% reported chewing areca nut or betel-quid
without tobacco.30
Botanical Aspect:
There are several palms under the genus Areca native to South,
South-East Asia and Pacific islands. This tropical palm tree bears
18
fruit throught out the year. Areca nut for chewing is obtained from
Areca catechu. It is believed that Areca catechu may be native to
Ceylon (Sri Lanka), West Malaysia and Melanesia.31 Areca nut is
consumed in large variety of ways and can be used by itself. When
ripe it is orange-yellow in colour and the seed (endosperm) is
separated from fibrous pericarp. The nut may be used fresh, or
dried and cured before use, by boiling, baking or roasting. In some
areas, especially Eastern India and southern Sri Lanka, fermented
Areca nut is also popular. In Taiwan, areca nut is often used in the
unripe stage when it is green, like a small olive. Areca nut is
known colloquially in the Indian subcontinent in Hindi and Bengali
as Supari, in Sri Lanka it is called Puwak, in Thailand as Mak, in
Sarawak as Pinang and in Papua New Guinea as Daka. Areca
nut chewing is practiced in several different ways in various
countries and often mixed with several ingredients to make up a
betel
quid
known
as
Pan
in
Hindi.
The
most
popular
accompaniments are the leaf of Piper betle (betel leaf), lime,

catechu and tobacco. The most common accompaniment globally
is the leaf of Piper betle. This has led to Areca nut being labelled
erroneously as betel nut in the English literature. Apart from the
leaf other parts of the betel vine such as stem, inflorescence
(flower; pods) or catkins are also consumed with the nut. Lime
(calcium hydroxide) is often used with areca nut in combination.
Lime is obtained in coastal areas by heating the covering of
shellfish (sea shells) or harvested from corals. In central areas of a
19
country, it is quarried from limestone. In the Asian markets, lime is

sold as a paste mixed with water which is white or pink. In Papua
New Guinea lime is available in the powdered form. Catechu is an
extract of the Acacia tree A. catechu or A. suma. Catechu is often
smeared on the betel leaf that is used to wrap areca nut flakes. Cut
tobacco is consumed with areca nut often in the quid mixture. This
type of chewing tobacco is made from sun-dried and partly
fermented coarsely cut leaves without further processing. Pan
Masala is the generic term used for areca nut-containing products
that are manufactured industrially and marketed commercially.
These are available in small convenient sachets for individual use.
Pharmacology & Systemic Effects:

The active ingredient of the arecanut is arecoline , an alkaloid with
properties that mimic acetylcholine. The hydrolyzing action of lime
on arecoline produces arecaidine, a central nervous system
stimulant, which in combination with the betel piper produces mild
euphoria.28 Along with the mild euphoria, chewers experience
cholinergic effects such as diaphoresis, lacrimation, pupillary
constriction, and occasionally diarrhea.32 Arecoline can cause
bronchoconstriction and may trigger asthma attacks.33 Excessive
salivation leads to the expectoration of red betel juice. Betel
appears to be psychologically and physiologically addictive.34
"Amateurs in betel chewing usually experience a disagreeable
combination
of
symptoms
including
20
constriction
of
the
oesophagus, sensation of heat in the head, red and congested

face and dizziness."35 More acculturated chewers acquire a
"suffused appearance, feeling of well being, good humour and the
undoubtedly increased capacity for activity."28
Effect on Oral Health

Effect on Hard Tissue:
The habitual chewing of areca may result in severe wear of incisal
and occlusal tooth surfaces, particularly the enamel covering. The
degree of attrition is dependent upon several factors, which
include the consistency (hardness) of the areca, the frequency of
chewing and the duration of the habit. this is likely to be a
consequence of the increased masticatory load that is placed
upon the teeth and is not direct effect of areca.66 Among areca
chewers, extrinsic staining of teeth due to areca deposits is often
observed particularly when good oral hygiene prophylaxis is
lacking and where regular dental care is minimal. The masticatory
forces generated during chewing areca may be transmitted to the
TMJ and subsequently may give rise to joint arthrosis.67
Effect on Soft Tissue:

In vitro studies have demonstrated that Areca extracts containing
arecoline inhibit growth and attachment of, and protein synthesis
in, human cultured periodontal fibroblasts.68,69 On the basis of
these findings the investigators proposed that areca may be
21
cytotoxic to periodontal fibroblasts and may exacerbate preexisting periodontal disease as well as impair periodontal
reattachment.
there
is
an
increased
risk
of
developing
precancerous condition like Oral Submucous fibrosis in subjects

consuming areca nut preparations. The relative risk was noted to
rise with an increasing frequency of the areca chewing habit,
suggesting a dose response relationship.70,71 There is historical
evidence dating back nearly a century that suggests that the areca
nut may be involved in the development of Oral squamous cell
carcinoma. Due to these ill effects of Arecanut chewing, early
prevention is required.
Areca nut Preparations:

Some Areca nut preparations are chewed without the inclusion of
tobacco, but this practice may be present concurrently with the
use of Smokeless Tobacco or Tobacco Smoking. Alkaloids
present in Areca nut are known to give rise to carcinogenic
nitrosamines and Areca nut has recently been evaluated as a
human carcinogen by the World Health Organization (WHO)22. The
use of Areca nut by itself appears to be mildly addictive but when
used with Tobacco, the effect multiplies manifold. Chewing of
areca nut products is very common in India.
1. Plain Areca nut (raw/ baked)
2. Sweet / Flavoured Supari
3. Pan masala
4. Gutkha
5. Mawa
22
6. Paan with arecanut

7. Paan with arecanut and tobacco
Definitions of various tobacco habits and products:

Habits
Beedi
Cigarette
Hookah
Pipe
Chillum
Definitions
Beedi is a cheap smoking stick,
handmade by rolling a dried,
rectangular piece of temburni
leaf (Diospyros melanaxylon)
with 0.15-0.25 g of sun-dried,
flaked tobacco filled into a
conical shape and the roll is
secured with a thread. The
length of a beedi varies from
4.0-7.5
cm.
Beedis
are
commercially available in small
packets.
Cigarette smoking is the second
most popular smoking form of
tobacco used in India. The
prevalence
varies
greatly
among different geographic
areas and subgroups such as
rural-urban.
Hookah (a hubble bubble Indian
pipe) is an indigenous device,
made out of wooden and
metallic
pipes,
used
for
smoking tobacco. The tobacco
smoke passes through water
kept in a spherical receptacle, in
which
some
aromatic
substances may also be added.
Hookah smoking is a common
method of socializing among
the village folk, especially in the
northern and eastern parts of
India.
Pipe is a tube with a hollow
bowl at one end used for
smoking tobacco.
Chillum is a conical clay-pipe of
about 10 cm long. The narrow
end is put inside the mouth,
often wrapped in a wet cloth
that acts as a filter. This is used
to smoke tobacco alone or
23
Cigars
Ganja
Charas
Gutka
Khaini
Zarda
tobacco mixed with ganja

(marijuana) in northern parts of
the country.
Cigars are made of air cured,
fermented tobacco, usually in
factories, and are generally
expensive. Cigar smoking is
predominately
an
urban
practice.
Marijuana, the most commonly
used illicit drug; considered a
soft drug prepared from the
flowering tops and leaves of the
hemp plant; smoked or chewed
for euphoric effect.
Charas is the name given to
hand-made
hashish
in
Afghanistan, Pakistan, Nepal
and India. It is made from the
extract of the cannabis plant
(Cannabis sativa).
Gutka
is
a
manufactured
smokeless tobacco product
(MSTP), a mixture of areca nut,
tobacco and some condiments,
marketed in different flavours in
colourful pouches.
Khaini consists of roasted
tobacco flakes mixed with
slaked lime. This mixture is
prepared by the user keeping
the ingredients on the left palm
and rubbing it with the right.
The prepared pinch is kept in
the lower labial or buccal
sulcus. Its use is common in
eastern India.
Zarda is hygienically processed
& packed chewing tobacco.
24
Chapter- 04
SOCIO-CULTURAL ASPECTS OF TOBACCO

AND ARECANUT USE
Culture is defined as learned behavior which has been socially
acquired and in other words it is the shared and organized body
of customs, skills, ideas and values, transmitted socially from one
generation to other. Culture plays an important role in human
societies. It
lays down norms
of behavior and
provides
mechanisms which secure for an individual, his personal and

social survival. Culture includes everything which one generation
can tell, convey or hand down to the next. Culture has three parts.
It is an experience that is learned, shared and transmitted.
Acculturation refers to culture contact. There are various ways by
which the acculturation can occur, like in the way of trade and
commerce, industrialization, propagation of religion, education
and conquest to name some.
An Indian is said to be the next best Englishman as the Britishers

brought their culture to India through conquest. Cultural factors in
health and disease have engaged the attention of medical
scientists and sociologists. Every culture has its own customs
which may have significant influence on health and oral health.
The increased incidence of lung cancer because smoking,
cirrhosis because of alcoholism in many developed countries, the
25
surge in the incidence of oral cancer in India due to pan chewing

habits are some classical examples to demonstrate the influence
of culture on health and oral health. It is now fairly established that
the cultural factors are deeply involved in the whole way of life,
like in the matters of nutrition, immunization, personal hygiene,
family planning, child rearing, seeking early medical care, disposal
of solid wastes and human excreta etc. All cultural practices are
not harmful. The level of education, per capita income and
occupation determine the overall socio-economic status of an
individual.
The advent of tobacco in the early seventeenth century in India

evoked mixed responses from a traditional society. While the
curiosity to experiment with a novel product aroused interest in its
use, the taboos that forbade the use of a culturally alien and
potentially noxious substance resisted its acceptance among
many sections of the people. The widespread uptake of the
tobacco habit over the next four centuries represented a victory
for commercial forces which aggressively created a mass market
through engineered addiction. There was also a complex interplay
of socio-cultural factors which influenced not only the acceptance
or rejection of tobacco by sections of society but also determined
the patterns of use. Some of these factors, especially the
ethnographic features, are described in this section.
26
Tobacco as a system of relation: TTTT

One aspect common to all forms of tobacco consumption across
all societies is the infusion of symbolic and often moral over
tones. Just as the symbolic nature of consumption is not identical
among different individuals, groups or cultures, similarly the
morality intrinsic to tobacco consumption varies. Even the most
private, individual act of consumption has social and cultural
aspects. This section examines the symbolic aspect of tobacco
consumption, or the meanings and codes underlying its use.
The acceptance or rejection of tobacco consumption as a practice

must be viewed in the context of the Indian value system which
has traditionally emphasized social hierarchies based on factors
such as age, gender, caste, wealth, education, professional
standing or celebrity status. The use of psychotropic drugs is set
in an atmosphere of social values and expectations. The drug may
be used to improve social relationships by bringing an individuals
behaviour in line with an ideal of normal behaviour. However, a
critical aspect of tobacco consumption is that normality is not
uniform over different social settings or groups. For example, in a
traditional family setting, smoking may be perceived as illicit,
immoral or bad. To smoke in such an atmosphere would be to
deviate from the norm. However, the same individual, when with
friends in a pub, may smoke to keep to the norm.
27
Patently, socio-cultural factors are crucial in determining who

consumes tobacco, when, where, how and why. Furthermore, the
consumption of tobacco has a symbolic aspect that must be
explored in terms of the individuals lifestyle, self-image and social
relationships. For instance, a younger person putting out a
cigarette on seeing a senior is understood (conveyed and
received) as a mark of respect and modesty. The gesture
communicates that juniors are expected to behave in a certain way
in the presence of seniors. It is accepted that compartment is
arranged on the axis of authority by age and kinship. In this, the
example are conflated both- the manner of consumption of
tobacco as well as authority structures. In traditional Indian joint
family structures, smoking at home was initially taboo. Later, as
the addictive nature of tobacco compelled the user to smoke
frequently, the use of tobacco at home became more common.
Here too, it was restricted to the dominant male members of the
family. The younger members of the family would desist from
using it in the presence of the elders and even the master of the
house would not use it when an elderly relative, especially an
aged parent, was around. The conviviality of members of different
generations smoking together, in a home setting, is rare even
today, though modernity has led to some relaxation of these rules.
The increasing replacement of the joint family by nuclear families,
especially in the urban setting, has provided a more permissive
atmosphere to use tobacco at home.
28
Smoking and alcoholism: The habit of alcoholism in prohibited

among Muslims and high caste Hindus. This may promote the oral
health. The younger generation and the population in the western
world consider the habits of smoking, alcoholism etc as a reward,
status symbol or something glamorous. This may have an adverse
consequence on the health as well as oral health. The habits of
smoking and alcoholism, are culturally acceptable among some
tribal population. Here, males and females have almost the equal
frequency of these habits. The habit of reverse smoking is highly
prevalent among the fishing communities in the districts of
Srikakulam
and
Vishakhapatnam
in
Andhra
Pradesh. This
increases the risk of palatal malignancies.
Pan chewing as a custom: Offering pan having betel leaf, slaked

slime, areca nut, and catechu is a way of welcoming the guests in
North Indian states like Rajasthan, Uttar Pradesh, Maharashtra and
West Bengal. Rejecting pan is taken as an insult. This may
encourage the people to get into the habit of chewing pan, which
is a proven risk factor for periodontal diseases, oral sub mucous
fibrosis and oral malignancies.
Ritual Aspects of Tobacco use:

Tobacco use, though perceived as an individual habit, often
acquires a ritualistic character involving group behaviour. This is
true of India, in both rural and urban settings. An emphatic
example of the ritual aspect of tobacco consumption would be the
29
use of the hookah. The habit of rural north Indian men, usually
assembled in caste-based or social class based groups, sharing a
hookah in daily gatherings, is a common example of fellowship,
solidarity and the consultative process. In some areas, this
extends to the women too. In the Nindana village in Haryana, for
example, women go out in groups to fetch water late in the
afternoon. During this time, away from the men and the immediacy
of household responsibilities, they settle down for gossip, rest and
the commensality and community of the hookah. In urban
cultures, young professionals (who have their own .yuppie
culture.) are often characterized by specific rituals of bonding and
sharing. These include visiting pubs, meeting particular groups of
friends, sharing a few drinks and smokes, and generally
unwinding. Such rituals, for example, have become part of the
group identity of young professionals from the information
technology industry which is burgeoning in India. Similarly, a
prohibition of certain caste groups from sharing a hookah, or a
proscription of women from tobacco use in traditional Indian
contexts further illustrates the establishment of ritual or social
superiority through the manipulation and control of objects of
material culture. The consumption of tobacco and thereby
construction of a certain kind of community identity can be found
in the consumption behaviour of the Muria Gonds of the northcentral part of Bastar district in Madhya Pradesh. For them,
consumption is basically a demonstration of the ability to come up
30
to the collective mark, be it in case of fashion, jewellery, or display

on social occasions. In this case, therefore, the construction of
identity through consumption is not to be different, but to be
same. Hence, both men and women consume tobacco and alcohol,
not as a mark of distinction, or indulgence, but as a part of the
Muria tradition of commensality. Furthermore, borrowing from
Douglas and Isherwoods notion of code, it becomes evident that
the Muria only accept those goods to which they can relate and
thereby assign certain values that form a part of Muria
Weltanschauung. Therefore, while they consider tobacco leaf as a
precious item, they reject cigarettes, which are more popular
among the local Hindus and project a modern image.
The above example implies that as the process of consumption is

a social phenomenon, the consumption of tobacco is not devoid of
it. The idea of smoking a cigarette or chewing tobacco, to project a
certain kind of identity, however depends upon the culture to
which one belongs. Hence, in one situation it may be an act of
rebellion against the traditional notions of morality, while in
another situation, it is an act of conformity. The diversity of Indian
society and the complexity of its social evolution have seen the
use of tobacco symbolizing both of these, in different social and
temporal settings.
31
Tobacco consumption and social status:

Status is constituted through power, prestige and wealth and
maintained by shared cultural practices in terms of material
culture, possession of wealth and acquisition of the paraphernalia
required to display status (wherein wealth is the underlying
precondition). Having tobacco and a hookah is one thing;
however, being surrounded by a group of men and having
someone to fill and light it to be shared by the group, is quite
another. This, in turn, is likely to create, enhance or maintain ones
prestige and ability to exercise power over others, especially other
groups. This was typical of the rural Indian scene, where the large
farm owners or former zamindars had stylistic and ritualistic
methods of tobacco consumption. In that feudal set up, the power
of being served extended to the privilege of the serfs or bonded
men offering and refilling tobacco to the master and his friends.
Such traditions continue to linger in rural areas, as evidence of
persisting social inequality.
Commensality is an act of solidarity and, in India, where there are

ritual rules around eating and drinking, commensality acquires an
even more significant hue. Such being the case, the consumption
of tobacco then acquires a whole range of symbolic connotations.
Louis Dumont, when referring to the notion of pollution and purity,
avers that sharing of a pipe among individuals depends upon the
caste (or subcaste) to which one belongs. According to him,
32
ranking of castes includes the notion of contact and is therefore

based on certain criteria; one of them is that of sharing of a pipe,
which he equates to that of acceptance of water from only certain
castes. Citing the example of the Uttar Pradesh region, he states
that men smoke only with the members of their own caste. Adrian
Mayers study of a village in Southern Malwa, in Central India,
elaborates how among the 23 castes in this village, sharing of the
same pipe defines, along with other rules of commensality such as
food and water, their ranking. Therefore, higher castes share the
pipe with almost all castes, apart from the untouchables, such as
weavers, tanners, sweepers and so on. Among these socially
discriminated groups as well, there are well defined rules
regarding with whom one can smoke a pipe. So while on the one
hand, individuals become a part of an .in-group. By coming
together on various occasions to smoke a pipe as a sign of
brotherhood, on the other, they also define the out-group with
whom they cannot do the same. Even if different caste members
sit together to smoke a common pipe, distinct caste status is
maintained wherein a separate cloth is used by each individual to
cover the mouthpiece. In fact, Dumont also points out that in the
case of south Indians, who are even more conservative about the
caste rules, even this sharing of the tobacco pipe with other
castes cannot be conceived of. When it is only with people of
ones own caste that one believes in sharing of the pipe, it
establishes as well as maintains caste solidarity and caste
33
differentiation. The inclusionary aspect of tobacco use may be

most clearly depicted through the exclusionary aspect, clearly
exemplified in the statement of hookah-pani band (temporary
exclusion). Literally, this means stopping of hookah and water, i.e.
barring someone from sharing social life with other equals. In
most cases, this implies designating a person and his family as an
outcaste, by refusing to share a hookah with him or accepting or
giving him water. Consequently, the commensual aspect, not only
of tobacco, but also of village life, is denied to him and his family.
They are, effectively, excommunicated. J.H. Hutton equates the
cessation of commensality, which includes prohibition of pipe and
water, upon an individual, to cessation of the specialized services
provided by that individual. However, Dube mentions that there
has been a weakening of commensal rules.64 Ostracism or
excommunication from ones caste is rarely affected these days if
commensal restrictions are broken. Inclusion and exclusion of
individuals or castes, communities or classes from shared
consumption, be it smoking, drinking or eating together, act to
maintain equality or inequality. Tobacco has been a consumption
good consistently associated with this kind of symbolic value.
During the heyday of caste-based discrimination, Dalits who were
designated as low caste. Persons by the socially dominant caste
groups, were not allowed to smoke in the presence of a .high caste
person. They therefore consumed tobacco only in the privacy of
their homes or in the presence of members of their own caste. As
34
Dalits liberated themselves from social oppression and began to

assert their equality, they began to smoke openly in front of other
caste groups.
Tobacco consumption and Gender: Tobacco consumption and

Across the world, more and more women are taking to tobacco. In
India, while the number of women using tobacco may be a small
fraction of the total, it is nevertheless a large absolute number.
The use of tobacco by women is often considered, by different
sections of society, in different ways from that of men.
Till quite recently tobacco use among women was rare, especially
in
traditional households. Though
rural women consumed
tobacco, in some parts of India, tobacco use by women was not

socially sanctioned. Even in the early decades after Independence,
Indian films portrayed the occasional women smoker only in the
role of vamp or bad woman. However, advertising and alternate
image creation by the tobacco industry has, in recent years,
changed those perceptions among sections of urban women. For
example, among urban women, smoking is now more often seen
as a symbol of the emancipated, modern woman. Amos suggests
that two images, that of the woman smoker and the emancipated
woman,
have
been
linked
in
popular
perception
through
advertising. She states that while smoking among women has

declined in many developed countries, she predicts an increase in
35
smoking rates in developing regions as women achieve greater

spending power, and socio-cultural and religious constraints
decrease. Such a picture is currently emerging in urban India.
Smoking habits, which might have their origins in rebellion, or the
thrill of illicit experimentation, become linked with freedom,
equality and the overcoming of subjection. In many cases,
smoking is a defiant act, a rejection of cultural restraints and an
affirmation of a womans identity as a free person with control
over her decisions. Further, women and men smokers are viewed
differently. In most cases, male smokers do not evoke specific
comment. Smoking is acceptable, seen as .normal. and therefore
not something that specifically strikes the eye. Women smokers,
however, do get noticed and are viewed in different ways. From
overwhelmingly negative perceptions of women smokers as loose
women the associations are changing to a cool or modern
image as educated young women and attractive models light up.
Women smokers view other women smokers as part of a
sisterhood of sorts, as someone like me. This suggests the
creation of a particular group identity around smokers, not just as
a group who share a common activity, but also in terms of a small
subgroup, that of women smokers. This group is always aware of
itself and its tenuous identity. The cultural baggage associated
with tobacco use also tends to affect where and when women use
it. Most women smokers tend to smoke in atmospheres in which
they feel safe in pubs, in zenana areas (where only women are
36
permitted), among friends, in anonymous surroundings. For

example, smoking is usually avoided in front of the family, elders,
or in areas where it may invite comment. On the contrary, some
women smokers make a defiant point of lighting up wherever and
whenever they feel like, as an expression of their independent selfidentity. The rules are a little less stringent for smokeless tobacco,
perhaps because it is relatively odourless and less perceptible,
less stigmatized for women and easier to conceal. Tobacco use,
which among younger groups and women is nearly always a
covert activity, is in its smokeless form rendered even more covert
by the very nature of smokeless tobacco. These factors, perhaps,
contribute to the greater use of smokeless tobacco by women. The
betel leaf is a particularly acceptable vehicle for tobacco
consumption. The advent of paan masala as a readily edible
powder, sold in conveniently sized sachets, has made it especially
easy for the addition of tobacco. Many women, even in traditional
middle
class
households,
became
quickly
habituated
to
consuming paan masala and some of them also made the

transition to the tobacco-added form. Carrying a paan masala tin
has even become a status symbol, and offering paan masala is
accepted as implying hospitality and equality. The availability of
gutkha has also made it easier for women to chew tobacco without
attracting social sanction.
37
For many years in Indian society, the reference point for evolving
social norms, for both women and young persons, remains the
image of the dominant adult male. So long as tobacco use was
seen as a pattern of acceptable or even desirable male behaviour,
the urge to attain the same social status made tobacco use
attractive to women as well as to young persons. Whether as a
symbol of emulation or as a gesture of rebellion, tobacco use
became associated with gaining or challenging the power status of
the adult male. Such images have been cleverly exploited by the
tobacco industry to gain customers among new target groups
such as women and children.
Women as generators of Tobacco Water: tobacco water

In the traditional Mizo society, in northeast India, tobacco and
women have been associated as part of a social custom which
requires the housewife to serve tobacco water to the husband as
well as to visitors. Tobacco water has been in use since the
nineteenth century; definite recording of its use is available since
1907. Men and women alike sip tobacco water although in the past
it was said to be predominantly used by women. Traditionally,
tobacco water was offered to guests/ visitors both at family and
social levels and it was considered very rude to omit this greeting.
Tobacco water was one of the essential items especially in rural
parties. A family generally owned three tobacco water flasks, one
carried by the husband, one by the wife and a spare one kept in
the house. No grown man or woman went around without a flask.
38
This was common feature among the Lakhers (tribal community in

Mizoram) in both urban and rural areas. Men as well as women
smoke tobacco using different types of pipes (vaibel and tuibur,
respectively).The tuibur has a water receptacle, through which
smoke is drawn. The nicotinerich tobacco water that remains in
the bowl after a woman smokes her pipe is used as a favoured
beverage to serve family members and visitors. The women are,
therefore, expected to smoke frequently and produce sufficient
quantities of the tobacco water. This is stored in a hollow gourd
and offered as sips to others. The reputation of a woman as a
housewife and as a hostess is often dependent on her ability to
serve adequate amounts of nicotine water. During the process of
courting, the girl offers tobacco water to the boy. If the boy
refuses, it is understood that he has no interest in the girl.Indeed,
the ability of a young woman to make and serve tobacco water has
been an important criterion during bride selection. For that reason,
even young girls are taught to smoke to attain a desired level of
proficiency in making and serving tobacco water. Education
among the Mizos, now a highly literate society, and the
commercial availability of bottled tobacco water are making this
custom less common now.
39
Chapter- 05
CHANGING SOCIAL VALUES
Values, which influence conduct, change over time as the social

milieu is re-configured by social, economic and cultural shifts that
occur over time, both within and across societies. This holds true
of tobacco consumption as well. As traditional values slacken
their stranglehold in rural societies and are rapidly substituted by
increasingly modern codes of behaviour in urban societies, the
socio-cultural influences that encourage or discourage tobacco
use are altering. These require to be studied and racked by
advocates of tobacco control who must not only identify but also
influence
these
processes
to
curb
tobacco
consumption.
Otherwise, they would leave the field open to the tobacco industry
which avidly studies these socio-cultural indicators and their
determinants to manipulate them to its advantage. The paucity of
studies in this area is a cause for concern but should also be
stimulus for concerted action by social scientists and health
professionals.
KEY MESSAGES:
Historically, tobacco consumption has been linked with

social status and commensality.
40
Tobacco consumption is associated with different symbolic

and often moral overtones across all societies.
The habit of rural men, usually assembled in caste-based or

social class-based groups, sharing a hookah in daily
gatherings, is an example of fellowship, solidarity and the
consultative process.
The use of tobacco by women is often considered, by

different sections of society, in ways different from that of
men. Among urban women, smoking is often seen as a
symbol of emancipation and modernity.
Smoking habits, which might have their origins in rebellion

or the thrill of illicit experimentation, have become linked
with freedom and equality among those who have suffered
social or gender inequality.
The greater use of smokeless tobacco by women is

associated with less stigma compared to smoking.
As traditional values slacken their stranglehold in rural

societies and are rapidly substituted by modern codes of
behaviour in urban societies, the socio-cultural influences
that encourage or discourage tobacco use are altering.
These need to be studied carefully to control tobacco
consumption.
41
Chapter- 06
RESEARCH METHODOLOGY
I. STUDY DESIGN:
Place of the study:
The present study was conducted in all the Twenty six districts of
Gujarat state. The state was divided into Four Parts- Region I, II,
III & IV.
Type of the study:

Epidemiological and Cross-sectional study
Sample size:
250 Participants
Sample Design:
Random Sampling
Study group:
Region I.
Region II.
Region III.
Region IV.
Selection criteria:
Inclusion criteria1. Voluntary participants were included in the study.
2. Participant who have/had history of consumption of
tobacco and/or arecanut in any form were included in the
study .
42
3. Person using Tobacco and/ or Arecanut in any form from

atleast three months.
4. Any person who have discontinued consumption of
tobacco and/or betel nut in any form within 10 years.
5. Any age group patient.
Exclusion criteria1. Participants who are not willing to sign the informed
consent form / to participate in the study will be excluded
from the study.
2. Participants with Severe illness, Unable to communicate,
lunatic and uncooperative patients will be excluded from
the study.
II. MATERIAL & EQUIPMENTS :
1. Set of Diagnostic Instruments Mouth mirror
Probe
Explorer
Tweezer
2. Materials Cotton Rolls
Gauze Pieces
3. Accessories Head strap focus Light / Torch
Magnifying Lens
43
ASSESSMENT OF:
1. Deleterious effects on oral and general health.
2. Any complaint pertaining to the deleterious effect.
3. More common age groups indulging in the habits.
4. Causes of harmful habits.
5. Most common gender involved.
6. Various types of habits in age groups, gender, region.
7. Any social and cultural factor associated in consumption of
tobacco and/or betel nut.
8. Prognosis of the lesions noticed in the oral (mouth) cavity.
9. Common types of lesions found in the rural and urban
population of Gujarat.
III. METHODOLOGY :
1. The Permission to undertake this Study was obtained from
the Head of the Dept., Dept. of Sociology, M.S.University,
Vadodara.
2. Information about this Study was to each participant in the
local language- Gujarati or in Hindi. The Participation in this
study was Voluntary.
3. The Informed Consent form (in Gujarati) was signed by each
participant who wished to participate in this study, before
Examination.
4. Each
Participant was interviewed whereby
structured
questions related to vital statistics, education, Income,

Occupation, Medical & Family history, social and cultural
44
aspect and other details were asked to each participant and

the outcome for the same was recorded in the pretested
Proforma designed for this study.
5. Thorough Oral and Maxillofacial Examination was performed
and the findings were recorded in the Proforma. The Oral
examination was performed with the help of Diagnostic
instruments with necessary aseptic precautions and with
both- Direct and Indirect light.
6. The collected data was then entered at the end of the study
in the Master chart prepared in Microsoft Excel 2007 on the
computer. Statistical analysis was conducted by using SPSS
soft ware.
45
Chapter- 07
RESULTS AND OBSERVATIONS
Table 1: Distribution of Participants according to region:

Region I
Region II
Region III
Region IV
Total
60
65
60
65
250
Graph 1: Distribution of Participants according to region:
Table 1 & Graph 1 shows Distribution of Participants according to

region.
Out of 250 (100%) participants, 60(24%) participants were from
Region I, 65(26%) participants were from Region II, 60(24%)
participants were from Region III & 65 (26%) participants were from
Region IV.
From Table 1 & Graph 1, it is observed that maximum numbers of
participants were from Region II & IV.
46
Table 2: Gender wise distribution of participants:

Gender
Male
Female
Region I
35
25
Region II
30
35
Region III
39
21
Region IV
29
36
Graph 2: Gender wise distribution of participants:
Table 2 & Graph 2 shows Gender wise distribution of Participants.

Out of total 250 (100%) participants, 35(14%) male participants and
25(10%) female participants were from Region I, 30(12%) male
participants and 35(14%) female participants were from Region II,
39(15.6%) male Participants and 21(8.4%) female participants were
from Region III & 29(11.6%) male participants and 36(14.4%) female
participants were from Region IV.
From Table 2 & Graph 2, it is observed that Male participants were
more as compared to Female participants.
47
Table 3: Age wise distribution of participants:

Age
group
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Region I
male female
02
00
04
02
08
05
06
03
05
04
03
02
02
01
01
02
02
03
02
02
00
01
00
00
00
00
00
00
Region II
male female
01
01
05
03
05
05
04
03
06
04
02
03
00
02
02
02
01
02
00
08
01
01
02
01
01
00
00
00
Region III
male female
00
01
05
00
09
02
07
02
06
03
04
05
01
01
02
02
00
03
01
01
00
01
02
00
01
00
01
00
Region IV
male female
01
00
04
02
04
05
05
03
02
05
03
02
02
02
01
04
02
05
02
03
01
04
02
00
00
01
00
00
Graph 3: Age wise distribution of Participants:
Table 3 & Graph 3 shows Age wise distribution of Participants. Out

of total 250(100%) participants:
48
06 (2.4%) participants were from the age group of 10-14 years. Out
of them, 02 were from region I ( male 02 & female 00 ), 02 were
from region II ( male 01 & female 01), 01 were from region III ( male
00 & female 01) & 01 were from region IV ( male 01 & female 00).
25 (10%) participants were from the age group of 15-19 years. Out
of them, 06 were from region I (male 04 & female 02), 08 were from
region II (male 05 & female 03), 05 were from region III (male 05 &
female 00) & 06 were from region IV (male 04 & female 02).
43 (17.2%) participants were from the age group of 20-24 years.

Out of them, 13 were from region I (male 08 & female 05), 10 were
from region II (male 05 & female 05), 11 were from region III (male
09 & female 02) & 09 were from region IV (male 04 & female 05).
33 (13.2%) participants were from the age group of 25-29 years.

Out of them, 09 were from region I (male 06 & female 03), 07 were
from region II (male 04 & female 03), 09 were from region III (male
07 & female 02) & 08 were from region IV (male 05 & female 03).
35 (14%) participants were from the age group of 30-34 years. Out
49
of them, 03 from region I (male 02 & female 01), 02 were from
of them, 04 were from region II (male 02 & female 02), 08 were from
50
of them, 01 were from region I ( male 00 & female 01), 02 were from
region II ( male 01 & female 01), 01 was from region III ( male 00 &
female 01) & 05 were from region IV ( male 1 & female 4).
of them, there were no participants in region I (male 00 & female
00), 03 were from region II (male 02 & female 01), 02 were from
region III (male 02 & female 00) & 02 from region IV (male 02 &
female 00).
of them, there were no participants in region I (male 00 & female
00), 01 from region II (male 1 & female 0), 01 from region III (male
01 & female 00) & 01 from region IV (male 00 & female 01).
of them, there were no participants in region I, II and IV (male 00 &
female 00), and whereas 01participant was present in region III
(male 01 & female 00).
From Table 3 & Graph 3, it is distinctly observed that maximum

number of the participants were in the Age group of 20-24 years.
51
Table 4: Distribution of Participants according to with or without

Habit:
Subjects Region I
M F
With
19 08
habit
Without 16 17
habit
Region II
M
F
12
14
Region III
M
F
21 07
Region IV
M
F
17 16
18
18
12
21
14
20
Graph 4: Distribution of Participants according to with or without

Habit:
Table 4 & Graph 4 shows distribution of participants according to

with or without Habit. Out of total 250 (100%) participants-In region I - 27 (10.8%) participants (19 males & 8 females) were
having harmful oral habits associated with Tobacco & Arecanut
use (Habitual) and 33 (13.2%) participants (16 males & 17 females)
were having No habits (non-habitual).
In region II - 26 (10.4%) participants (12 males & 14 females) were
52
In region III - 28 (11.2%) participants (21 males & 07 females) were

In region IV - 33 (13.2%) participants (17 males & 16 females) were
From Table 4 & Graph 4, it was observed that maximum number of
the participants had No harmful oral habits. This observation was
statistically significant.
53
Table 5: Correlation of Age with or without Harmful oral Habit:

Age
Region I
group With With
(yrs.) habit out
habit
10-14 01
01
15-19 04
02
20-24 07
06
25-29 04
05
30-34 03
06
35-39 01
04
40-44 01
02
45-49 00
03
50-54 02
03
55-59 03
01
60-64 01
00
65-69 00
00
70-74 00
00
75-79 00
00
Region II
With With
habit out
habit
01
01
03
05
04
06
03
04
04
06
02
03
01
01
01
03
01
02
03
05
01
01
01
02
01
00
00
00
Region III
With With
habit out
habit
00
01
02
03
05
06
04
05
04
05
05
04
02
00
01
03
01
02
01
01
01
00
01
01
01
00
00
01
Region IV
With
With
habit out
habit
00
01
03
03
05
04
05
03
03
04
02
03
03
01
02
03
03
04
02
03
02
03
02
00
01
00
00
00
Graph 5: Correlation of Age with or without Harmful oral Habit:
54
Tables 5 & Graph 5 shows Correlation of Age with or without

Harmful oral Habit.
Out of total 06 (2.4%) participants in the age group of 10-14 years:
In region I - 01 participant had harmful oral habit associated with
Tobacco & Arecanut use and 01 participant had No
habits.
In region II - 01 participants had harmful oral habit associated
with Tobacco & Arecanut use and 01 participant had
No habits.
In region III - Participant having harmful oral habits associated
with Tobacco & Arecanut use was not present but 01
participant had No habits.
In region IV- Participant having harmful oral habits associated
with Tobacco & Arecanut use was not present but 01
Out of total 25 (10%) participants in the age group of 15-19 years:

In region I - 04 participants were having harmful oral habits
associated with Tobacco & Arecanut use and 02
participants had No habits.
In region II - 03 participants were having harmful oral habits
55
In region III - 02 participants were having harmful oral habits

In region IV - 03 participants were having harmful oral habits
Participants had No habits.
Out of total 43(17.2%) participants in the age group of 20-24 yrs.:

Out of total 33 (13.2%) participants in the age group of 25-29 yrs.:

56

Out of total 35 (14%) participants in the age group of 30-34 years:

57
In region I - 01 participant was having harmful oral habit

In region IV- 02 participants were having harmful oral habits
Out of total 11(4.4%) participants in the age group of 40-44 years:

In region I - 01 participant had harmful oral habit associated with
Tobacco & Arecanut use and 02 participants had
No habits.
In region II - 01 participant had harmful oral habit associated with
habits.
In region III- 02 participants were having harmful oral habits
associated with Tobacco & Arecanut use and No
participant had habits.
58


In region I -
No participants had harmful oral habits associated

with Tobacco & Arecanut use and 03 participants
had No habits.
In region II- 01 participant had harmful oral habits associated

had No habits.
In region III- 01 participant had harmful oral habits associated
had No habits.

In region I -
02 participants were having harmful oral habits

In region II-
01 participant had harmful oral habit associated

had No habits.
59
In region III- 01 participant had harmful oral habit associated

had No habits.

In region I-
03 participants were having harmful oral habits

In region II- 03 participants were having harmful oral habits

In region III- 01 participant had harmful oral habit associated with
habits.

In region I- 01 participant had harmful oral habit associated with
Tobacco &
Arecanut use and No participant had
any habits.
60
In region II- 01 participant had harmful oral habit associated with

habits.
In region III- 01 participant had harmful oral habit associated
with Tobacco & Arecanut use and there were No
participants having habits.

In region I- There were No participants having harmful oral habits
nor participants having No habits, associated with
Tobacco & Arecanut use.
had No habits.
In region III- 01 participant had harmful oral habit associated with
Tobacco &
Arecanut use and 01 participant had No
habits.
associated with Tobacco & Arecanut use and No
participants having No habits.
61

with Tobacco & Arecanut use and No participants
having No habits.
In region III- 01 participant had harmful oral habits associated
having No habits.
In region IV- 01 participant had harmful oral habits associated
having No habits.

In region II- There were No participants having harmful oral
habits nor participants having No habits, associated
with Tobacco & Arecanut use.
In region III- There were No participants having harmful oral
habits associated with Tobacco & Arecanut use but
01 participant had No habits.
62
In region IV- There were No participants having harmful oral

habits nor participants having No habits, associated
with Tobacco & Arecanut use.
63
Table 6: Co-relation of Gender according to Habit:

Habit
Tobacco
habit
Arecanut
habit
Region I
M
F
09 02
Region II
M
F
05
04
Region III
M
F
11 02
Region IV
M
F
07
06
10
07
10
10
06
10
05
10
Graph 6: Co-relation of Gender according to Habit:
Table 6 &
Graph 6 shows Co-relation of Gender according to
Habit. Out of total 114 (100%) habitual participants, 46(40.35%)

participants had habit of using tobacco in various forms &
68(59.65%) participants had habit of chewing arecanut in various
forms:
In region I, 11 (9.64%) participants (09 males & 02 females) had
habit of using tobacco in various forms and 16 (14.03%)
participants (10 males & 06 females) had habit of chewing
arecanut in various forms.
64
In region II, 09 (7.89%) participants (05 males & 04 females ) had

participants (07 males &10 females) had habit of chewing arecanut
in various forms.
In region III, 13 (11.4%) participants (11 males & 02 females) had

In region IV, 13 (11.4%) participants (07 males & 06 females) had

From Table 6 & Graph 6, it was observed that maximum number of

male participants were involved in the chewing of arecanut and its
related
commercial
products.
65
These
observations
were
Table 7: Distribution of Participants according to different types of

tobacco Habit:
Tobacco
Smoking
Smokeless
Type
Region I
M
F
Bidi
04 01
Cigarette 02 00
Mishri
00 00
Tobacco 03 00
quid
Tobacco 00 01
paste
Region II
M
F
03 00
01 00
00 01
01 01
Region III
M
F
04
01
03
00
00
00
04
00
Region IV
M
F
02
01
03
00
00
02
02
02
00
00
00
02
01
01
Table 7 shows Distribution of participants according to tobacco

habit.
Out of Total 46 (100%) participants having habit of tobacco use
in different forms, 25 (54.34%) participants had habit of smoking
tobacco and 21 (45.66%) participants had a habit of smokeless
tobacco.
Out of total 25 (100%) participants who had habit of smoking

tobacco, 16 (64%) participants had habit of Bidi smoking.
Amongst them, 05 participants were from region I ( 04 males &
01 female), 03 participants were from region II ( 03 males & No
females), 05 participants were from region III (04 males & 01
female) & 03 participants were from region IV (02 males & 01
female).
Total 09 (36%) participants had habit of Cigarette smoking.
Amongst them, 02 participants were from region I (02 males &
No females), 01 participants was from region II (01 male & No
females),03 participants were from region III (03 males & No
66
females ) & 03 participants were from region IV ( 03 males & No

females).
Out of total 21 (100%) participants having habit of smokeless

tobacco in various forms, 13 (61.9%) participants had habit of
Tobacco Quid. Amongst them, 03 participants were from region
I (03 males & No females), 02 participants were from region II (01
male &01 female), 04 participants were from region III (04 males
& No females) & 04 participants were from region IV ( 02 males
& 02 females).
Total 03 (14.28%) participants had habit of Mishri application.
Amongst them, there were No participants in region I, 01
participant was from region II ( 00 male 0 & 01 female), there
were No participants in region III & 02 participants were in
region IV ( 00 male & 02 females)
Total 05 (23.8%) participants had habit of Tobacco paste
application. Amongst them, 01 participant was from region I ( 00
male & 01 female), 02 participants were from region II (00 male &
02 females), 01 participant was from region III (00 male & 01
female) & 01 participant was from region IV ( 00 male & 01
female)
In nutshell, bidi smoking was seen in 16 participants (34.78%),

cigarette smoking in 09 participants (19.57%), mashiri application
67
in 03 participants (6.52%), tobacco quid in 13 participants

(28.26%) and tobacco paste application in 05 participants(10.87%).
From Table 7, it is distinctly observed that maximum number of
participants had Bidi smoking and Tobacco quid habit, altogether
in each region.
68
Table 8: Distribution of Participants according to different types of

Arecanut Habit:
Arecanut habit
Gutkha
Region I
M
F
07 02
Region II
M
F
04 02
Region III
M
F
05
02
Region IV
M
F
06
04
Sweet supari
00
04
00
06
00
01
00
05
Mawa
02
00
02
00
04
00
03
00
Pan masala
01
00
01
02
01
02
01
01
Graph 8: Distribution of Participants according to different types

of Arecanut Habit:
Table 8 & Graph 8 shows distribution of participants according to

Arecanut habits. Out of Total 68 (100%) participants having habit
of arecanut chewing in various forms:
Total 32 participants (47.05%) had habit of chewing Gutkha.
Amongst them, 09 participants were from region I (07 males
& 02 females), 06 participants were from region II (04 males
&02 females), 07 participants were from region III (05 males
69
& 02 females) & 10 participants were from region IV (06

males & 04 female).
Total 16 (23.52%) participants had habit of chewing Sweet

supari. Amongst them, 04 participants were from region I (00
male & female 04), 06 participants were from region II (00
male & 06 female), 01 participants were from region III ( 00
male
& 01 female) & 05 from region IV (00 male & 05
female).
Total 11 (16.17%) participants had habit of chewing Mawa.

Amongst them, 02 participants were from region I ( 02 males
& 00 female), 02 participants were from region II ( 02 males &
00 female), 04 participants were from region III ( 04 males &
00 female) & 03 participants were from region IV( 03 males &
00 female).
Total 09 (13.23%) participants had habit of chewing Pan

Masala. Amongst them, 01 participant was from region I (01
male & 00 female), 03 participants were from region II (01
male & 02 females), 03 participants were from region III ( 01
male & 02 females) & 02 participants were from region IV (01
male & 01 female).
70
In nutshell, Ghutka chewing was seen in 32 participants (47.05%),

chewing of sweet supari in 16 participants (23.52%), mawa in 11
participants (16.17%) and pan masala chewing in 09 participants
(13.23%),
From table 8 & Graph 8, it was distinctly observed that maximum

number of participants had harmful oral habit of chewing Ghutka
equally in all the region. These observations were statistically
significant.
71
Table 9: Distribution of Participants according to Age of First Use

(Initiation) of Habit :
Age group
(yrs.)
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
No. of
participants
13
29
31
28
06
03
02
01
01
Graph 9: Distribution of Participants according to Age of First Use

(Initiation) of Habit:
Table 9 & Graph 9 shows Distribution of Participants according to

the Age of first use (Initiation) of habit. The Age groups were
grouped with the difference of five. The total numbers of
participants with harmful oral habits were 114 (100%). Out of them:
72
Total 13 (11.4%) participants had initiated the harmful oral

habit in between the age of 10-14 years.








From table 9 & Graph 9, it was observed that maximum number of

Participants had initiated the harmful oral habit in the age group of
20-24 years followed by the age group of 15-19 and 25-29 years.
Thus, according to the present study, the critical age group for
initiation of harmful habits is 15-29 years. These observations
were statistically significant.
73
Table 10: Distribution of participants according to Factors

influencing initiation of tobacco and arecanut use
S.No.
Factors
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Friends
Social Status
Culture
Family History
Stress
Pleasure
Occupation
Work load
Hobby
Advertisement
Imitation
Sign of Manliness
Non specific
No. of participants
18
18
19
04
24
04
03
11
03
03
01
02
04
Graph 10: Distribution of participants according to Factors

influencing initiation of tobacco and arecanut use
Table 10 & Graph 10 shows Distribution of Participants according

to Factors or Reasons responsible in initiating the habit. Out of
total 114 (100%) participants having various harmful oral habits:
74

habit due to influence from friends.
Total 18 (15.78%) participants had started the harmful oral
habit due to social status.
habit due to culture.
Total 04 (3.5%) participants had family history as reason to
initiate the harmful oral habit.
Total 24 (21.05%) participants had initiated the habit due to
stress factor.
Total 04 (3.5%) participants had started the harmful oral habit
for pleasure.
Total 03 (2.63%) participants had started the harmful oral
habit due to occupation.
Total 11 (9.64%) participants had to initiate the habit due to
workload.
Total 03 (2.63%) participants initiated the harmful oral habit as
a hobby.
Total
03 (2.63%)
participants were influenced
by the
advertisement in initiating the habits.

Total 01 (0.87%) participant initiated the harmful oral habit by
means of Imitation.
Total 02 (1.75%) participants had started the habit as Sign of
Manliness.
75
Total 04 (3.5%) participants had initiated the harmful oral habit

without any specific reasons.
From table 10 & Graph 10, it was evident that the most common
factor responsible for initiating the habit was Stress followed by
Culture, Friends and Social status. These observations were
76
Chapter- 08
DISCUSSION
Thunder is good, thunder is impressive. But it is lightening
that does the work.
- Mark Twain.
Tobacco is the worlds biggest preventable killer. Our universe is

in a state of tobacco epidemic, with larger population of tobacco
users emerging day by day. Arecanut use is also a leading cause
of deaths especially in developing countries. In India, nearly one in
ten adolescents in the age group 13-15 yrs. have ever smoked
cigarettes and almost half of these reports initiating tobacco use
before 10 years of age.
The tobacco and arecanut situation in India is unique because

vast spectrum of products are easily available. Tobacco smoking
particularly bidi; chewing tobacco, chewing arecanut is an age-old
practice in India. However, according to anecdotal evidence with
the changes in the dynamics of societies, the prevalence of
smoking among women and young children has increased many
folds and is at present a significant public health problem. The risk
of tobacco and arecanut use is highest among those who start
early and continue its use for a long period. The early age of
initiation underscores the urgent need to intervene and protect
77
this vulnerable group from falling prey to this addiction. The most
common reasons cited for children to start using tobacco are peer
pressure, parental tobacco habits and pocket money given to
children.
According to World health organization (WHO), nearly 1/3 rd of the

global adult population (1.2 billion people, with female population
being 200 million) are tobacco users. In India, there are 240 million
tobacco users (195 million men and 45 million women) accounting
for one fifth of the worlds tobacco consuming population.
India is the worlds third largest tobacco growing country, which

produces an average of 5, 80,000 tones every year. Nearly 0.2% of
all available land is used for tobacco growing and 4 million people
are estimated to be engaged in manufacturing tobacco. Millions of
people work in growing and curing tobacco. According to National
Family Health Survey (NFHS) 1998-1999 data, 5% - 10% is the
prevalence rate of tobacco in Gujarat. According to Global Youth
Tobacco Survey (GYTS), Gujarat, 3.8% of students had ever
smoked cigarettes (Boys 5.1% & Girls 1.7%), 18.7% population
currently use any tobacco product (Boys 29.3% & Girls 0.5%) and
17.7% population currently use other tobacco products (Boys
27.9% & Girls 3.9%).
78
The wicked tobacco industry has not spared innocent children too.
Each day 55,000 children in India start using tobacco and about 5
million children under the age of fifteen are addicted to tobacco.
Smoking as well as smokeless tobacco is consumed in urban as
well as rural population of our country. Cigarettes are specifically
aimed at our young generation. Therefore, the evidence of early
onset of the tobacco habit and reports of increase in the
prevalence of oral precancer & cancer among children raise
serious concerns of an impending oral cancer epidemic in our
country. The age incidence of oral cancer in India is going down
and is significantly lower than reported in the rest of the world.
Areca nut is the fourth most commonly used substance of abuse

in the world after tobacco, alcohol & caffeine. A substantial
proportion of the worlds population is engaged in chewing areca
nut and the habit is endemic throughout the Indian subcontinent,
large parts of south Asia, Melanesia Asian pacific region for a long
time and is common among migrated communities in Africa,
Europe & North America. Because of its ancient history, its use is
socially acceptable among all sections of society, including
women and quite often children. During the last two decades, with
the availability of commercially available products, the pattern of
use of arecanut has changed rapidly and the practice of chewing
areca nut has received a boost. The adverse health effects
associated with arecanut use include premalignant lesion &
79
condition, oral & oro-pharyngeal cancer, periodontal disease and

addiction.
Arecanut chewing habit has drastically changed from a simple

arecanut to commercially prepared flavoured forms of arecanut in
the last two to three decades. Pan masala and gutkha are
extremely popular in urban parts of India where as sweet supari,
mawa and plain arecanut are popular in rural parts of India. But
these observations are not static and evolve as per the
atmosphere in the society. This may be due to effect of electronic
and print media and peer group where it is projected as a harmless
mouth freshener. Today adolescents and young adults are actively
indulging in chewing of gutkha and pan masala ignoring the
deleterious effects on the health.
It is well known that tobacco smoking, arecanut and alcohol

consumption are risk factors for head & neck cancer. In this era of
global travel, these habits have crossed borders & their
detrimental effects are now being seen throughout the world.
Since tobacco use has been reported to be higher among the poor
& less educated people, both disease burden as well as economic
burden due to tobacco use will disproportinately affects them.
The present cross-sectional study was undertaken in Gujarat

state, India, to determine the prevalence of tobacco and arecanut
80
use and its relation to the sociological factors- culture, custom,

age at initiation of these habits and habit influencing determinants.
In the present study, 250 subjects from various parts of Gujarat
state, voluntarily participated. The area of study i.e state of Gujarat
was equally divided into four regions. The numbers of participants
in all these regions were more or less equal.
The participants included in this study were of 10 years and above.

The total males were 133 (53.2%) and the total females were 117
(46.8%). The total number of participants having tobacco and
arecanut related harmful habits were 114(45.6%) and the remaining
136 (54.4%) participants did not had any harmful habit. The most
risk age group was 20-29 yrs.
The total numbers of male participants having harmful habits were

69 (60.52%) and the total numbers of female participants having
harmful habits were 45 (39.48%). The findings were similar to the
various previous studies conducted in the other parts of India and
world. These findings may be due to the social norm of India. The
Indian society being a male dominating and easy availability of
money with males is the major causative factor for harmful habit.
The correlation of age with the participants having or not having
harmful oral habit was statistically significant, in which it was
observed that maximum number of participants belonged to the
age group of 20-24 years. This age is most commonly affected
81
because people generally start the habit under peer pressure,

family members, social culture, stress etc. Various stressful
factors which arise at every stage of life plays a vital role in the
initiation of one or the other habits. This is done so as to avoid the
stressful factors in the routine and for easier life.
The correlation of gender with the participants according to

tobacco and arecanut related habit was statistically significant, in
which it was observed that maximum number of male participants
were involved in the chewing of arecanut and its related
commercial products. The reason for our findings may be due to
low market price, easy availability, easy to carry and good
euphoric effect has lead to more consumption.
The type of tobacco related habit which was distinctly observed in

participant was Bidi smoking and Tobacco quid. This can be
explained by cheaper cost and easy availability of bidis in rural
areas
along
with
lack
of
education/knowledge
regarding
deleterious effects of smoking tobacco on health in general and

oral health in particular, may be the probable cause for more use
of bidis.
The type of arecanut related habit which was distinctly noticed in

maximum number of participant was chewing of Ghutka. The
findings may be related with the attractive packaging, easy
82
availabily, affordable cost and easy to carry and storage has lead
to high use of gutkha especially by young and adults. Also the
reasons for our findings may be due to the curious attitude of
young adults to try new things in life and are mostly influenced by
the peer groups and electronic & print media.
The critical age group for initiation of harmful habits was 15-29
years. At the early stage of initiation, the habit is occasional which
subsequently becomes addiction. The findings may be due to
family influence and tobacco use by friends, exposure to
advertisements in the media and community, access and
availability of tobacco products in the area of residence.
The most common factor responsible for initiating the habit was
Stress followed by Culture, Friends and Social status. Our findings
may be because at very young age friends can influence very
easily, more exposure to advertisements in the media and
community and attractive packaging may attract the youth.
83
Chapter- 09
CONCLUSION
Winners dont do different things, they do things differently.
- Shiv Kher
Health is a consequence of an individuals lifestyle as well as a

factor in determining it. Every one of us, have our own beliefs and
practices concerning health and disease irrespective of the area of
residence (whether residing in urban or rural areas). Not all
cultural practices are harmful. Some of these practices like
adequate nutrition, good sleep, regular physical exercise etc are
based on centuries of trial and error and have positive values. We
have to identify the cultural factors that are deleterious and
beneficial. The primary health workers and school teachers can
play a vital role in creating the awareness on the adverse effects of
deleterious cultural practices among the general population and
students. The mass media in the form of radio, television,
newspapers, health exhibitions, role plays etc. go a long way in
changing the attitude and behaviour of the people and this
demands more patience as well as persistence from the health
care workers, as the cultural practices are deep rooted and
requires a very long time to change or modify.
Tobacco and Arecanut use in Gujarat is almost at the same level

as rest of India but significantly higher among the poor. Smoking
84
is comparatively low among women compared to men. The

commercial products of Tobacco and Arecanut chewing is
increasing among men, children and adolescents possibly due to
the smoking ban in public places and also tobacco industry
strategies to shift their focus to smokeless tobacco products
which is not affected by current tobacco control policies. Tobacco
use leads to many chronic non-communicable diseases, treatment
of which puts economic burden on the people pulling them below
the poverty line. Tobacco control therefore should be a top priority
not only as a health issue but as a poverty reduction issue. Any
poverty alleviation programme
cannot ignore the potential
impoverishment associated with tobacco use. Gujarat with a very

strong decentralized government has a very good opportunity to
address tobacco control as a priority at the grass root level.
In conclusion, the observations of the present survey indicate a

downward shift in the age at uptake of tobacco and arecanut habit
by children and a rising prevalence among females. More such
research surveys need to be carried out in other large cities and
states of the country in order to build a comprehensive database
for future policy decisions on anti-tobacco arecanut campaigns.
To tackle these problems, few recommendations are suggested:
1. Oral health education programmes in regional /vernacular
languages should be organized & must be projected in the
electric & pint Media.
85
2. People at large should be educated about adverse effects of

Tobacco and its consequences on oral health as well as
general health of an individual.
3. Educational institutions should be advised to implement
Tobacco & Arecanut related education in schools and
colleges.
4. Documentary films on Tobacco and Arecanut and their
harmful effects should be telecasted frequently. The
projection of this films should be made at public places
such as railway stations, bus stands etc.
5. Government should impose ban on advertisement of
promotion of Tobacco and Areca nut products in media and
in cinema theatre.
6. Heavy taxes should be imposed on sales of Tobacco and
Areca nut related products.
7. Tobacco cultivation should be reduced. The farmers should
be encouraged to go for other alternative crops.
8. The subjects who sell Tobacco products should be provided
with viable alternatives to earn their livelihood.
9. Use of Tobacco and Arecanut related products should be
banned in public places.
10. Slogan like Say No to Tobacco and Arecanut - should be
used / implemented for awareness.
86
Chapter- 10
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110
PREFACE
Health is a consequence of an individuals lifestyle as well as a factor

in determining it. Every one of us, have our own beliefs and practices
concerning health and disease irrespective of the area of residence
(whether residing in urban or rural areas). Not all cultural practices
are harmful. Some of these practices like adequate nutrition, good
sleep, regular physical exercise etc are based on centuries of trial
and error and have positive values. Achievement of optimum health
demands adoption of healthy lifestyles. We have to identify the
cultural factors that are deleterious and beneficial. We, the health
professionals have to discourage the unhealthy practices through
intensive health education and promote the adoption of healthy
practices. The primary health workers and school teachers can play
a vital role in creating the awareness on the adverse effects of
deleterious cultural practices among the general population and
students. The mass media in the form of radio, television,
newspapers, health exhibitions, role plays etc. go a long way in
changing the attitude and behavior of the people and this demands
more patience as well as persistence from the health care workers,
as the cultural practices are deep rooted and requires a very long
time to change or modify.
Man has been using Plant derived Drugs and Alcohol for thousands of
years. The recorded history indicates that some of these drugs were used
not just for their presumed therapeutic effects, but also for Recreational
purposes to enhance Pleasure and Relieve Stress. New and often more
harmful drugs and patterns of use are replacing Traditional Practices. In
recent years the consumption of Licit (Tobacco, Alcohol) as well as Illicit
substances have increased greatly throughout the world. The Epidemic of
tobacco use is one of the greatest threats to global health today.
Particularly, alarming is the fact that the age of initiation into substance
abuse is progressively falling. Substance abuse especially amongst youth
has been an issue of concern throughout the world. Adolescence is the
critical period when the first initiation of substance use takes place.
Worldwide the Prevalence of Tobacco & Arecanut use is highest amongst
people of Low Educational background and among the Poor and
Marginalized. In several Developing countries there have been sharp
increases in Tobacco & Arecanut use especially among Men and as the
Tobacco industry continues to target Youth and Women there are also
concerns about rising Prevalence rates in these groups. No authentic study
has been done till date to reveal the status of substance abuse among
general population as well as student population.
The Tobacco and Areca nut habit has a major Social and Cultural role in
communities throughout the Indian subcontinent, South-East Asia and
Parts of the Western Pacific. Percentage of users and frequency of use
increases with Age and the Retrospective report indicates that the Betelquid habit predominantly begins between age 11 and 15. Countrywide
II
surveys on the use of areca nut have not been conducted, nor have any
other surveys been conducted to investigate specifically the use of areca
nut. Surveys of habits have been conducted on the use of tobacco and
other chewing habits, especially betel-quid chewing, in limited populations.
Studies of adults are presented first, followed by those of children and
adolescents. Within these categories, Rural studies are presented first,
followed by available urban studies. Tobacco use is responsible for five
million deaths in the world every year and 50 per cent of these deaths
occur in the middle age (35-69 yr) population. Mortality attributable to
tobacco has been estimated to be one million every year in India , projected
to 1.5 million by 2020.
Countries with a high prevalence of the Areca nut habit have higher rates
of Oral cancers. However it is the addition of Tobacco, rather than simply
the habit itself, which may be associated with such rates. Associations
between Areca nut without Tobacco and Oral lesions such as Oral
Submucous Fibrosis (OSMF) and Leukoplakia are well-established. A
relationship between the risk of developing OSMF and habit has also been
documented. Given that the relative risk of developing OSMF varies
tremendously by areca nut habit, it is important to establish the prevalence
and frequency of use across the various habits - Tobacco & Areca nut
habits (Ever used, Age of first use, Current use, Frequency of use). India
too, is facing a similar situation that has attracted attention of Policy
makers and Researchers in recent time.
The Adverse Health effects associated with Areca (betel) nut use include
Oral
and
Oro-pharyngeal
Cancer,
III
Oral
Premalignant
Lesions
and
Conditions (Oral Leukoplakia and Submucous Fibrosis), Gum disease and

Addiction. Chewing areca nut is widespread in south Asia and in the
Pacific region.
The Tobacco, Arecanut & Alcohol use during adolescence commonly leads
to Dependence and Chronic disease. As adolescence is the most
susceptible time for initiation of tobacco use and adolescent tobacco
smoking has been found to be a major predictor of adult smoking,
preventing this use requires intervention in early adolescence prior to the
time when these behaviors have already become ingrained. Lack of
adequate information to form a basis of effective preventive strategies,
prompted us to conduct this study with the objective of studying the
correlates of tobacco use amongst the general population of Gujarat state.
The ultimate aim of this study is to provide information to Planners and
Program managers in designing an appropriate Preventive Strategy.
IV
ACKNOWLEDGEMENT
The blessings of God Almighty have showered abundantly over

me for all my initiatives during the endeavor. The divine grace
was always guiding my conscience, showing me the right path
and directing me to the right person whenever and wherever
needed. It was during this study period I felt the enhancement of
spiritual feeling that will remain with me for the rest of life.
A good teacher is not only one who teaches, but also inspires by
his abilities.I take this opportunity of expressing my most
sincere and warm gratitude to my revered and esteemed teacher,
guide and philosopher, Dr. Pradeepsingh Choondavat, Professor
& Head of department, Department of Sociology, Faculty of Arts,
M.S.University of Baroda, Vadodara, Gujarat, without whose
sagacious guidance, constructive criticism, ceaseless efforts,
immense encouragement and valuable suggestions, this study
would not have been completed. Its really a proud privilege to
work under his patronage and to be his student. I wish to place
on record, through this acknowledgement, my deepest sense of
indebtedness to him and look forward for his continuous
support and encouragement in future.
I express my deep sense of gratitude to my dearest friend cum
brother Shri. Ranjit Chavan, who stood along with me during
all the time
of turbulence and roughness in my life, and
his wife Mrs. Rutuja, whose suggestions, valuable guidance and

support was a source of constant inspiration for successful
completion of this study.
I thankfully acknowledge the support and encouragement &
valuable suggestions and support provided by the teaching staff
members of Department of Sociology, M.S.University of Baroda.
My sincere thanks to the Administrative and Library staff of
Department of Sociology, M.S.University of Baroda for their kind
cooperation throughout my study.
I am indebted to all the participants of this study for their
cooperation and for sparing valuable time amidst their busy
schedule and for patiently giving me the relevant and required
data for the study.
I would be failing in my duties if I dont mention my gratitude to
statistician Mr. Dhanjay Shigotra, and Ms Jhanvi Thakkar who
helped me to do statistical analysis of my study.
Finally I am thankful to all the members of my family- Parents,
Sisters- Sujata & Sucheta, my brother-in-law Mr.Anand Sonde,
who have always motivated me to pursue research, that has
resulted in the completion of the work.
Dr Chandramani More
VI
LIST OF TABLES
Table
No.
Title
01
Distribution of Participants according to region.
02
Gender wise distribution of participants.
03
Age wise distribution of participants.
04
Distribution of Participants according to with or without Habit.
05
Correlation of Age with or without Harmful oral Habit.
06
Co-relation of Gender according to Habit
07
Participants according to different types of tobacco Habit
08
Participants according to different types of Arecanut Habit
09
Participants according to Age of First Use (Initiation) of Habit
10
Participants according to Factors influencing habit
VII
Page
No.
LIST OF GRAPHS
Graph
No.
Title
01
Distribution of Participants according to region.
02
Gender wise distribution of participants.
03
Age wise distribution of participants.
04
Distribution of Participants according to with or without

Habit.
05
Correlation of Age with or without Harmful oral Habit.
06
Co-relation of Gender according to Habit
07
Participants according to different types of tobacco Habit
08
Participants according to different types of Arecanut Habit
09
Participants according to Age of First Use (Initiation) of Habit
10
Participants according to Factors influencing habit
VIII
Page
No.
LIST OF FIGURES
Fig.
No.
Title
01.
Various Brands of Bidis
02.
Various Brands of Cigarettes
03.
Preparation of bidis
04.
Cigar / Cheroot / Chutta
05.
Dhumti preparation
06.
Chillums
07.
Preparation of Tobacco quid / khaini
08.
Tobacco products used for application or inhalation
09.
Various brands of Tobacco
10.
Plain Arecanut & Mawa
11.
Betel quid or Pan
12.
Areca nut bunch hanging from the palm & ripe areca nut
13.
Various brands of Gutkha
14.
Various brands of Pan Masala & Zarda
15.
Vendor selling Tobacco & Areca nut products
16.
Women smoking Chillum
17.
Group of people engaged in bidi smoking
IX
Page
No.
LIST OF ANNEXURES
Fig.
No.
Title
01.
Research Proforma / Questionnaire
02.
Informed Consent Form
03.
Figures / Photographs
Page
No.
ABSTRACT
Background and Objectives:

The Tobacco and Areca nut habit has a major Social and Cultural
role in communities throughout the Indian subcontinent, South-East
Asia and Parts of the Western Pacific. Various customs, cultural
pattern and life styles have lead to use of tobacco and arecanut in
human beings. Various forms of tobacco and arecanut are available
in every corner of the country. Such harmful habits have always
caused precancerous and cancerous lesions in these human beings
and hence the graph of occurrence of cancer is steadily increasing.
Percentage of users and frequency of use increases with age. Health
is a consequence of an individuals lifestyle as well as a factor in
determining it. Not all cultural practices are harmful. It has become a
need to identify the cultural factors that are deleterious and
beneficial. The roles of health and social professionals have to
discourage the unhealthy practices through intensive education and
promote the adoption of healthy practices. The social and health
workers and school teachers can play a vital role in creating the
awareness on the adverse effects of deleterious cultural practices
among the general population and students.
XI
The research study titled social and cultural aspects of tobacco and
arecanut use in gujarat : a sociological study was carried out to
assess various tobacco and arecanut related habits and the social
and cultural factors related to the habits of these substances in rural
and urban population of Gujarat state.
The present cross-sectional study was undertaken in Gujarat state,
India, to determine the prevalence of tobacco and arecanut use and
its relation to the sociological factors- culture, custom, age at
initiation of these habits and habit influencing determinants.In the
present study, 250 subjects from various parts of Gujarat state,
voluntarily participated. The area of study i.e state of Gujarat was
equally divided into four regions. The numbers of participants in all
these regions were more or less equal. The data was collected by
conducting interviews and clinical examination. It was entered in the
specially designed Proforma, and later on to an Microsoft 2007
excel sheet on the computer. The collected data was subjected to
statistical analysis by the statistician.
Results, Interpretation and Conclusion:
It was observed from this study that, various tobacco and arecanut
related habits were more prevalent in males. Habit of smoking bidi
was very common among rural population when compared to
cigarette smoking in urban population. Habit of chewing tobacco
quid and Ghutka was more common when compared to the other
XII
preparations. The critical age group for initiation of harmful habits

was 15-29 years. The most common factor responsible for initiating
the habit was Stress followed by Culture, Friends and Social status.
To conclude from this study, use of arecanut and tobacco in various
form does exist within our society and social and cultural factors do
play an important role in initiating these habits.
XIII
Sr.No.____
Dept. of Sociology, Faculty of Arts, M.S.University of Baroda, Vadodara
PROFORMA / QUESTIONAIRE FOR PHD RESEARCH
Title- SOCIAL AND CULTURAL ASPECTS OF TOBACCO AND ARECANUT

USE IN GUJARAT : A SOCIOLOGICAL STUDY
..
Participants name :(Mr/Mrs/Ms)
_____
Age- ____Sex-______
Marital Status - ___________ Occupation-___________Education - ______________

Address-_______________________________________________________________
Chief complaint (if any)Past & present medical / dental historyH/o diagnosis/Rx of oral precancer &/or cancer Family h/o diagnosis/Rx of oral precancer / cancer Personal History1) Food Habits - Bland diet / Moderately spicy / Very spicy
Consumption of green chilIies - Occasional / Daily. Quantity Duration
2) H/o Oral Harmful Habit - PAST / PRESENT
Age of First Use of Harmful Habit - _____Reasons for Starting the Habit- _____
HABIT
BRAND
FREQUENCY/
DAY
QUANTITY
DURATION
H/o Teeth Cleaning Habit- By - Tooth brush / Finger / Datun /

- Dentifrice -Tooth paste /powder / Mashiri / Tobacco Paste / Any
other
General examination:
Gait: ___ Ht.: ___Built : __Wt. :__Nutritional Status: ____Mental status: ______
SIGNIFICANT EXTRA ORAL FINDINGS -
Intra oral Examination Oral Hygiene Status : Poor / Fair / Good
Any other:
Place: ___________
Date:________
Name of P.I. and signature: Dr.Chandramani More.

*******************************************
INFORMED CONSENT FORM
Sr. No. :___________ Date : _______________ Place:_________________________
I, _____________________________________________, exercising my Free will &
power of choice, hereby give consent to be included as a subject in the Research Study
of SOCIAL AND CULTURAL ASPECTS OF TOBACCO AND ARECANUT USE IN
GUJARAT : A SOCIOLOGICAL STUDY. I have been informed, in a language I
understand Gujarati / Hindi / Marathi / English / other, to my full satisfaction by the
attending Doctor, the Purpose and Nature of the Research Study. I am also aware of my
right to opt out of this study at any stage during the course of the study without having to
give the reason for doing so.
I hereby allow the attending Doctor to record the details required for this Research Study.
I have also been informed that the confidentiality of the name will be maintained and the
Data and Photographs collected will be used for Publication, Presentations, Record
keeping, etc. I do not have any objection for all the above. Also nor me or my any Family
member will raise any objection in future.
Name and Sign. of the Participant :
Name and Sign. of Principal Investigator/ PhD Student : Dr. Chandramani More
Signature of GUIDE & HOD, Dept. of Sociology, M.S.University of Baroda
****************************************************************************************
Note : For any Queries, kindly contact Dr. Chandramani More , Principal Investigator, Department of Sociology,
Faculty of Arts, M.S.University of Baroda, Vadodara
Phone No. (M) : 9974900278. (Hosp. ) : 02668 245262 Extn. 315, 316
***************************************************************************************
Notes-
ii
Figure 1 : Various Brands of Bidis
Figure 2 : Various Brands of Cigarettes
iii
Figure 3 : Preparation of bidis: a) prepared bidis.

b)temburni leaf.c) tobacco on a cut
temburni leaf. d) thread to tie a bidi.
e) bidi bundles
Figure 4: Cigar / Cheroot / Chutta
iv
Figure 5: Dhumti preparation
Figure 6: Chillum
Figure 7: Preparation of Tobacco quid / khaini
Figure 8: Tobacco products used for application

or inhalation: (a) mishri; (b) gudhaku; (c) bajjar;
(d) twig for application of bajjar; (e) creamy snuff /
tobacco paste
vi
Figure 9: Various brands of Tobacco
Figure 10: a) Plain Arecanut & b) Mawa
Figure 11: Betel quid or Pan
vii
Figure 12: a) Areca nut bunch hanging from the palm. b) ripe
areca nut
Figure 13: Various brands of Gutkha
Figure 14: Various brands of Pan Masala & Zarda
viii
Figure 15 : Vendor selling Tobacco & Areca nut products
Figure 16 : Women smoking Chillum
ix
Figure 17 : Group of people engaged in bidi smoking

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CONTENTS

About Gujarat State

Changing Social Values

Results & Observation

Bibliography & References

From time immemorial man has been interested in trying to control

A glaring contrast in the state of health between the developed

which have emerged are prevention of disease, promotion of

Health is a common theme in most cultures. In fact, all

The term lifestyle is rather a diffuse concept often used to

that there is an association between health and lifestyle of

The lack of parental attention in the nuclear families and peer

Understanding culture is an essential key to reducing tobacco and

tobacco and arecanut patterns across different age groups,

study presents a multilevel,

conceptual framework for trans-disciplinary research teams to use

The inclination to get into the habits of smoking, alcoholism, drug

ABOUT GUJARAT STATE

Then followed a long period of Muslim rule Ahmed I, the first

After the Indian Independence in 1947, all of Gujarat except

The peninsula, traditionally known as Saurashtra, is essentially a

Districts in Gujarat1. Ahmedabad

The Review of literature provides a background for understanding

rapid increase in trade and use of smokeless tobacco products in

The world-wide distribution and cultivation of the plant did not

whitening agent. After the 'discovery' of tobacco by the Spanish,

At various times during the sixteenth and seventeenth centuries

Polycyclic Aromatic Hydrocarbons

Volatile Nitrosonor Compounds

Catecol Vinyl Chloride

Metals- Nickel, Arsenic, Lead

Tobacco is smoked in the following form36,37,38

Building materials (palm trunks)

Dye (red and black)

Housing insulation (areca husks)

Roofing materials (palm leaves)

Uses of Areca nut in Traditional Medicine (e.g. Ayurveda)

Antihelmintic and vermifuge

Carminative (expels flatus)

Emmenagogue (induces or increases menstrual flow)

Treat urinary disorders

Epidemiology of Use of Areca nut:

for betel quid chewing is taken as a valid reference value. While

accompaniments are the leaf of Piper betle (betel leaf), lime,

country, it is quarried from limestone. In the Asian markets, lime is

Pharmacology & Systemic Effects:

oesophagus, sensation of heat in the head, red and congested

Effect on Oral Health

Effect on Soft Tissue:

precancerous condition like Oral Submucous fibrosis in subjects

Areca nut Preparations:

6. Paan with arecanut

Definitions of various tobacco habits and products:

tobacco mixed with ganja

SOCIO-CULTURAL ASPECTS OF TOBACCO

lays down norms

mechanisms which secure for an individual, his personal and

An Indian is said to be the next best Englishman as the Britishers

surge in the incidence of oral cancer in India due to pan chewing

The advent of tobacco in the early seventeenth century in India

Tobacco as a system of relation: TTTT

The acceptance or rejection of tobacco consumption as a practice