Zulekha Latif, a housewife, does not remember exactly when she started chewing gutka. But she remembers that for the last three decades, she has been using one or the other form of chewable tobacco. She can hardly open her mouth, her gums hurt, there is occasional bleeding, but she does not want to stop. “It’s a habit and a life-long support,” she smiles without telling me what kind of support it is. She spends about Rs.50 daily for the gutka that is not easily available in her city Badin. “I used to chew betel nuts when I was just seven years old. It was replaced with paan and then gutka.”
Kiran, a home-based worker, spends Rs100 daily for mawa, a form of gutka popular in Karachi. Like other women in her family, Kiran does not remember exactly when she started chewing gutka. “I cannot function without taking mawa. It stimulates my body and helps me to finish my tasks easily and quickly.” Showing the mawa packet in her hand, Kiran shares that her total earning in a day is just Rs.350 for six to eight hours of work. “Everyone chews mawa. It’s a habit and no one considers it a bad thing, at least in our area,” she adds.
According to health professionals, factory workers, electricians, mechanics, drivers of public transport vehicles, rickshaw drivers, maids, security guards, and workers at restaurants, mostly, chew one or the other form of chewable tobacco.
The common gutka is made of different ingredients, some of which are harmful—crushed betel nut, tobacco, catechu, lime, and sweet or savoury flavourings. Despite the knowledge that it is illegal to carry gutka, the majority of the addicts carry stocks of the gutka or mainpuri while travelling from one place to another as they cannot live without it.
Doctors say that the constant use of mainpuri or gutka is one of the root causes for oral cancer. They also warn that a patient develops a non-healing ulcer in oral cancer, which is initially painless, but as time passes, it results in severe pain, occasional bleeding, and perforations. Its treatment becomes very difficult in an advanced stage. “Users know it is very harmful, but they do not give it up,” said Dr S M Qaisar Sajjad, Secretary General of Pakistan Medical Association (PMA). “In any form it causes oral cancer,” he added. He said that the PMA has been running campaigns for banning [chewable] tobacco and chhalia in all forms to save the lives of people because these are hazardous for health.
According to the data shared by the PMA, in Pakistan, 166,000 people die every year due to the use of tobacco in different forms. “It is also clinically proven that the juice of the good quality chhalia is carcinogen, and when it is mixed with tobacco, other hazardous items and chemicals, it becomes more dangerous for human health,” Dr Sajjad explained. Carcinogen is defined as a substance that causes cancer. PMA data shows that approximately, 200,000 new cases of cancer are reported every year, out of which 40,000 cases are of oral cavity cancer, which includes lips, gums, tongue, buccal cavity, and pharynx.
A research conducted in Pakistan shows that smokeless tobacco is the number two cause of cancer related deaths in both men and women.
“Not only men but even teenage boys and girls are using gutka without taking care of their health,” Dr Sajjad said. He said that in some of the areas of Badin, Thatta and Sujawal, children under the age of ten, copying their parents, chew gutka.
“It is very common, and no one considers it harmful,” Abdul Sattar, a resident of Gharo, said. He said that most of the people he knows in his area use gutka. “It’s a poor man’s favourite thing,” he smiled. “We do not feel bad if it causes a disease or people do not like our smiles. It does not matter,” he said.
Interestingly, different forms of chewable tobaccos are popular in different areas. Gukta is common everywhere. In some areas, like Tando Ghulam Ali, Gulab Laghari, Nao Dubalo and Tando Allahyar, choro is common, a form of tobacco mixed with betel nuts and clove. In Badin, Safina - an India product - is famous, and is even being used by educated people who neither consider it a bad habit or harmful for their health.
“Gutka users cannot even easily open their mouths,” Abdul Aziz, a shopkeeper in Seerani, a town in Badin district, said. “I know people who really want to give it up but cannot. It is a bad habit.”
Understanding the severity of the problem, and on the recommendations by the health department and health experts, the Sindh government, after consultation with different stakeholders, passed a bill on December 18, 2019. The Sindh Assembly’s bill, “Sindh Prohibition of Preparation, Manufacturing, Storage, Sale and Use of Gutka and Manpuri Bill, 2019”, bans the import, export, manufacturing, sale, and purchase of gutka, mainpuri and their derivatives in the province. The bill states: “Tobacco consumption is one of the biggest challenges confronting the people today. Out of ninety percent tobacco related oral cancer cases, eighty-two percent pertain to mouth and throat. The survival ratio among cancer patients, who live for five years, is fifty-one percent, while forty-eight percent live for ten years after they are diagnosed.”
Legally, no person can produce, prepare or manufacture any mixture or substance, which, apart from gutka and mainpuri, include pan parag or other such mixtures that are prepared or obtained by any series of operations from these ingredients: any of the forms of chhalia (betel nut), catechu, tobacco, lime and other materials, which are “injurious to health and not fit for human consumption within the meaning of Section of the Sindh Pure Food Ordinance, 1960 and is also in contravention to the provisions of Rule 11 of the Sindh Pure Food Rules, 1965.”
The new law bars anyone from possessing, offering for sale, distributing, or delivering any such substance that is prohibited. The bill also prohibits owning, operating or controlling premises or machinery for the manufacture of mainpuri, gutka and their derivatives. There are also punishments given in the bill for contravention of the aforementioned provisions: “Whoever contravenes these provisions …. shall be punishable with imprisonment, which may extend to three years but shall not be less than one year and shall be liable to fine, which shall not be less than two hundred thousand rupees.”
On the directives of the Sindh High Court, top police officials have issued orders to initiate a crackdown against the sellers and manufacturers of gutka, mainpur and mawa. Media reports confirm that the police have launched several raids and arrested some people involved in the crime, but the number of users is still increasing regularly. “I do not see the number of users declining,” Dr Sajjad said.
“Yes, the number is not going down,” a senior police official said on the condition of anonymity. He said that even some politicians patronize this business. “It is a good business, people earn good money within months,” he explained.
Although users of betel nuts are found across Pakistan, but gutka and mainpuri users are mostly concentrated in lower Sindh’s three divisions: Karachi, Hyderabad and Mirpurkhas. The situation is comparatively pathetic in the lower parts of Sindh, the coastal belt. Officials and health professionals say that the majority of the people in Thatta use chewable tobaccos.
A PMA health professional said that betel nut is the main cause of oral cancer and sub-mucous fibrosis. Approximately, 122 brands of chhalia (sweet Supari) are easily available everywhere; chhalia is prepared by artificial colour and artificial sugar. It is proven that artificial color is also carcinogen. Gutka is a more hazardous item, freely available, and prepared by chhalia and other hazardous chemicals. He added, “Due to the excessive use of chhalia, sub-mucous fibrosis is very common in teenagers, particularly school and college going students. It is a non-treatable disease, in which the mucosa of the oral cavity is fibrosed, resulting in the limitation of the opening of the mouth and severe burning in mouth.”
It is important to note that chhalia does not grow in Pakistan, and a fungal infected chhalia is being imported. According to doctors, any fungal infected food eaten for a long time can cause liver cancer. Speaking to Express Tribune, Dr Sajjad said, “It is very unfortunate that even in the presence of law, gutka, mawa, manipuri, chhalia and their derivatives are freely available in markets, and people are consuming them openly. And as a result, cases of oral cancer and sub-mucous gibrosis are increasing in the country, particularly in Sindh.”
“Half of the population uses either gutka, mainpuri or Safina,” said Badin district’s Senior Superintendent of Police Shah Nawaz Chachar. According to Badin’s police’s claims, over 300 persons have been arrested for selling or supplying gutkas in the last six months. Police also claim that there is not a single factory in the district that produces chewable tobaccos. “It is being supplied to my district from different routes,” Chachar said. He narrated an interesting story of the supply mechanism of gutka in his district. “Suppliers use family as shelter and transport Safina while travelling with their family members; it is difficult to have every vehicle checked,” he added.
High level police officials have issued an order that a policeman will be dismissed or punished if found using a chewing tobacco. Over twenty policemen were dismissed, and forty were transferred from Badin to other districts for violating the orders.
Chachar is of the views that it’s a social issue. “I have faced at least twenty-five protests for taking action against sellers and consumers in the district,” he said. “There is a need of mass awareness across lower Sindh,” he urged.
Another senior police officer told The Express Tribune that the manufacturers and sellers were like mafias. “It is not easy to take action against them, and they will stop their business forever,” he explained. “This is not just gutka, it is an economy that people involved in it do not want to leave.”
Noman Khatri, an electrician and a gutka user in Karachi, is of the opinion that he has been seeing different forms of chewable tobacco since his childhood. “I am thirty-five now, and I have heard it causes dangerous health issues, but I do not see people taking the warnings seriously,” he said. He also mentions some of his acquaintances who died of mouth cancers. “I have seen their condition, and how they gave up gutka for a few days.” But, he added, it is hard to disconnect for long from this addiction.