Smokeless tobacco is manufactured both commercially and by cottage industries. Moreover, smokeless tobacco is available in many package forms, shapes and sizes. Even the material to be consumed differs: it can be mixed with areca nut (Gutka), mixed with slaked lime (Khaini), powdered (snus), raw tobacco (dried leaf), paste (Gul manjan) and ever water-infused (tuibur).

Smokeless tobacco is not a safe substitute for smoking cigarettes. It can cause cancer and a number of noncancerous conditions and can also lead to nicotine addiction and dependence. It is also recognized that nitrosamines and other potentially carcinogenic chemicals, found in Smokeless tobacco products, are not safe at any level.

Some of the non-cancer adverse health effects of smokeless tobacco use include addiction to nicotine, oral conditions such as leukoplakia and oral submucous fibrosis that are potentially malignant and gum disease. Possible increased risks for heart disease, diabetes, and reproductive problems have also been reported.

Supari which is also known as betel nut or areca nut causes various diseases especially cancer of mouth and esophagus. It affects almost all the organ of a human body. It contains arecoline which severely affects nervous and cardiovascular system and also causes various cancer. Areca nut is also classified as Group 1 carcinogens by IARC.

Smokeless tobacco is a tobacco product that is manufactured, prepared and sold to be used for sucking, chewing, snuffing, inhaling, smelling, dipping or masticating and includes chewing tobacco, snuff, gutka, betel quid with tobacco, snus, toombak, iqmik, tobacco lozenges etc. The WHO FCTC definition of tobacco products includes smokeless tobacco as it defines “tobacco products mean products entirely or partly made of the leaf tobacco as raw material which are manufactured to be used for smoking, sucking, chewing or snuffing.”

Out of 180 Parties to the WHO FCTC, 136 Parties have included SLT under the definition of tobacco products in their laws.

• To create awareness about the hazards of smokeless tobacco products a national mass media campaign should be designed and implemented. Such campaigns should be dubbed in all the languages being used in a jurisdiction. A campaign must run for at least 3-6 weeks and the messages should be reiterated through other channels of communications.
• Social media should also be used to create mass awareness on the ill effects of smokeless tobacco use.
• Efforts at school levels should be made to create awareness among students about the hazards of tobacco (including smokeless tobacco) use.
• Training of stakeholders such as health professionals and teachers, on anti-smokeless tobacco awareness and cessation of SLT use is another important way of creating awareness.

There are more than thousands of chemical compounds found in the smokeless tobacco products worldwide. Out of these 28 are known carcinogens (cancer causing agents). Some of the well known carcinogens present in smokeless tobacco are N’-Nitrosonornicotine (NNN), 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), Benzo[a]pyrene. These chemicals are classified as Group 1 carcinogens (as there is sufficient evidence for human carcinogenicity) by International Agency for Research on Cancer (IARC, Lyon France).

Article 14 of the WHO FCTC requires each Member Party to develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and to take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence.

Yes, further guidelines for effective implementation of the article have been developed and adopted at the Conference of the Parties (COP) 4 in 2010.

Literature search shows that only 5 Parties (3%) have experience in SLT cessation.

Evidence has shown that behavioral intervention alone has shown 60% more chance of quitting and is most effective for both low and high resource countries. Even brief advice to quit SLT use, by health care professionals is beneficial. However, findings from various global tobacco surveillance systems from various Parties show that health care professionals advise only a quarter of SLT users as opposed to almost half the number of smokers to quit. A global survey among the health professions students also indicates a lack of formal training in tobacco cessation among medical, dental, pharmacy and nursing students.

Cost coverage of tobacco cessation and support facilities must be provided to make them accessible/affordable to a larger population of tobacco consumers, including SLT users. Very few Parties (12%) have reported full coverage of the costs of tobacco cessation treatment or available pharmaceutical products, at least in one of the tobacco cessation support facilities. Hence, as seen in the literature, behavioural interventions can be employed as a cost-effective modality for SLT cessation. Other new modalities such as mCessation (tobacco cessation via text messages) for SLT cessation can be encouraged as another easy and cost-effective option, especially in the low resource Parties, as for smoking cessation.

The smokeless tobacco products are classified as:

• Chewing tobacco - A type of smokeless tobacco that presents as long strands of loose leaves, plugs, or twists of tobacco. E.g: Zarda, Paan, Gutka, Dohra, Tombol, Iqmik, Mawa, Twist, Naswar.
• Snus – It is a traditional Swedish smokeless tobacco product. It is made from moist, finely ground tobacco.
• Snuff (dry) – It is a finely powdered tobacco product produced mainly from Kentucky and Tennessee fire-cured tobaccos, has moisture content that is less than 10% by weight. E.g: Khaini, Scotch snuff, Rape.
• Moist / dip – It is a damp, finely ground tobacco product that is more commonly used in Western countries. It contains 20%–60% moisture and often is flavored with wintergreen or various fruit flavors. E.g: Toombak, Sauté.
• Tobacco paste - It is made from boiled and flavored tobacco leaves. It is chewed, held in mouth or chewed in betel quid. E.g: Gudakhu, Kiwam, Chimó.
• Dissolvable tobacco - It is completely dissolved during use, with no residual loose tobacco. E.g: Tobacco coated tooth picks, strips, sticks, orbs.
• Tobacco dentifrice – It is a tobacco containing dentifrice used to clean teeth like regular toothpaste. E.g: Mishri, Gul, creamy snuff.
• Tobacco water – It is tobacco smoke-infused water that is gargled or sipped. E.g: Tuibur.

The mode of use of SLT products differs for each product:

• Chewing tobacco is chewed or placed between the cheek and gum or teeth.
• Snus is used orally; while dry snuff is usually used orally, it may also be inhaled through the nostrils.
• Moist/dip is held in the mouth for about 30 minutes and saliva is usually spit out or swallowed.
• Tobacco paste is chewed, held in mouth or chewed along with betel quid.
• Tobacco water (Tuibur) is either gargled or sipped.
• Tobacco dentifrice is rubbed on the teeth and gums.

The most common types of SLT product used in SEAR are Khaini, Gutka, Pan masala, Zarda/Dokta, Paan or Pan, Dohra, Loose Leaf Chew, Sadapata, Kapoori/ Manipuri, Iqmik, Mawa. These are chewed or placed between the cheek and gum or teeth.

They are mostly flavoured with sweets (sugar, honey), spices (Menthol, Mint, Clove, Cinnamon, Chilli, pepper, turmeric and mustard, cardamom, saffron), flowers (Geranium, Hena, Keora, Rose, vine flowers), alcohol (Whisky, Rum, wine, brandy, Gin and Tonic).

Tobacco paste like Gudakhu and Kiwam are used alone or along with betel quid. Mishri, Gul, Creamy Snuff are the tobacco dentifrices used to clean the teeth and gums. Tuibur or Hidakpha is tobacco smoke-infused water that is gargled or sipped, a practice common in the North Eastern part of India (Manipur and Mizoram).

It is a traditional Swedish smokeless tobacco product. It is made from moist, finely ground tobacco and it isused orally. It is commonly used in Sweden, Norway, Iceland, Finland and Denmark.

Yes, several forms of smokeless tobacco products induce and require constant spitting.

Spitting in public places due to SLT use e.g. chewing tobacco, betel quid, gutkha, mawa among others present a grave concern for managing public hygiene.

It is considered as a leading cause behind the spread of communicable diseases like tuberculosis, swine flu, avian flu, pneumonia and gastro-intestinal diseases. Besides, it is also responsible for defacing the public property which increases the cost of maintenance and upkeep of such property and premises.

Several countries, provinces and cities prohibit spitting in public places, with varying intentions. The reasons mainly included are, for controlling communicable diseases, maintenance of public cleanliness and hygiene and as a preventive measure to reduce SLT use. Following jurisdictions have taken steps for implementing prohibition on spitting and/or use of smokeless tobacco in public places.

• Bhutan
• Hangzhou Province in China
• India (several states, districts and cities)
• London Borough of Brent, United Kingdom
• Myanmar
• Nepal
• Papua New Guinea
• Singapore
• Sri Lanka
• Sydney suburb of Fairfield, Australia

Six countries, namely, Australia, Bhutan, Oman, Sri Lanka, Singapore and Thailand have a ban on import of smokeless tobacco products.

Yes. There are four countries that have banned all three. These are:

• Australia
• Bhutan
• Singapore
• Sri Lanka