Betel chewing main cause of oral cancer – Dr. Hemantha Amarasinghe
By Rathindra Kuruvita
Around 2,400 new oral cancer patients are recorded each year in Sri Lanka, majority of these cases are related to chewing betel with areca nut, tobacco and slaked lime, said Dr Hemantha Amarasinghe, of the Institute of Oral Health Maharagama, speaking to Ceylon Today and emphasised on the need to control smokeless tobacco products to combat cancer.
Excerpts of the interview:
Q: When we think of the impact of tobacco use we automatically think about cigarettes. However, as the use of smokeless tobacco also has an adverse effect on health, can you elaborate on what are smokeless tobacco and the health implications of use?
A: Tobacco is commonly consumed in two ways. People smoke it or they usually chew it and the chewing is called smokeless tobacco.
For example bulath wita (betel leaf with areca nut, tobacco and slaked lime) is a common smokeless tobacco used in Sri Lanka. There are also products like babul, beeda, parampara which are often imported and sometimes there are similar products made in Sri Lanka. Since the imports of such products were banned a few years ago some unscrupulous people obtained them through illegal means and sell them under different names. Almost all of these products have tobacco and most of them include areca nut, both are highly cancerous.
We have seen a significant number of cases reported, each year, result of smokeless tobacco. Around 2,400 new oral cancer patients are recorded each year in Sri Lanka with majority of them being related to the chewing of betel (bulath wita) with areca nut, tobacco and slaked lime. Three people die each day from oral cancer in Sri Lanka. There is also research that indicates that the use of smokeless tobacco causes several other types of cancer. That is why we are trying to prevent people from consuming these products.
In September 2016 the Government gazetted the ban on import, sale and manufacture of smokeless tobacco products. Police, Public Health and Excise department officials are now implementing them. Those who manufacture concoctions like babul and beeda and sell them will be targeted. We need to stop the production and sale of these products which often target youngsters. We also try to reach out to those who manufacture concoctions like babul and beeda and sell them and make them aware that they are producing and selling a product that has been banned and to stop it before severe legal action is taken.
Q: Have you estimated the number of people who consume smokeless tobacco products?
A: There was a study conducted by the Health Intervention and Technology Assessment Programme (HITAP) in 2015 which showed that 25 per cent of men and 5 per cent of women use smokeless tobacco products. This study was done in collaboration with the National Authority on Tobacco and Alcohol (NATA) and was supported by the Sri Lanka Medical Association (SLMA).
The other study is Global Youth Tobacco Survey (GYTS) 2015, which is done on students in the relevant grades associated with the age group 13–15 years. This study was conducted in 65 class rooms in 30 schools where a total of 1505 students participated. The study showed smokeless tobacco use among males was 4.2 per cent and 0.5 per cent among females. This is a significant number.
Q: As you said most of these products have been banned. However, we all know that these are still easily available. How is this possible?
A: These products are not openly available, but, those who use them know how to get them. Thus it is obvious that either these products are being manufactured here or that these are being brought from abroad. Health officials are continuously educating the implementing officers as well as the general public about the dangers of these products. A lot of people assume that the bulath wita is a habit only with the elderly. Young bus and trishaw drivers are also known to chew tobacco products as stimulants. I have even seen university students are addicted. We need to address all these issues and keep on educating the people. And we also need to shut down the places that sell these products.
Q: Bulath wita has been consumed for a long time and because of that familiarity, people might ignore the warnings given by health authorities. How do you plan to overcome this challenge?
A: The impact of bulath wita is extremely serious. At the outset I told you that there are around 2400 new cases of oral cancer reported each year and out of that 95 per cent were habitual chewers of bulath wita. So you can see that there is a strong link between the two and people must stop this habit because they are playing with fire.
When the Government issued a directive to combat smokeless tobacco products, the initial action was targeted at products like babul and beeda because they are marketed to school children. However, as the next step I believe that bulath wita should also be banned at least in proximity to schools.
And unlike some I don't believe that bulath wita is consumed only by the elderly. I see a lot of trishaw and bus drivers using bulath wita as a stimulant. I have even seen university students consume bulath wita. And as surveys show a lot of school children are vulnerable to smokeless tobacco products. So we need to keep educating the people about the dangers of bulath wita and also take steps to remove the product from the market.
Q: Moving away from smokeless tobacco to cigarettes, after the tax on cigarettes was increased; the tobacco company has started a campaign to say that this increase in price has driven people to smoke beedi. Is there any truth in that?
A: Not at all. There is no evidence at all to prove that. There has been a lot of research done on this matter at the global level and there is hardly any evidence to say it is happening. When someone tells you that increase in price has driven people to smoke beedi, ask yourself do you know anyone, who smokes cigarettes, shifting to beedi. I don't think you will be able to find someone who has made that shift.
What has happened for most part is that people have cut down on smoking and we expect the consumption to go down by 20 per cent this year. The other possibility is that they could shift to cheaper brands. As you know there are several brands of cigarettes and there are some brands which sell for around Rs 20, while the most consumed brand costs about Rs 50. Thus some smokers might shift to the cheaper brand, which is very dangerous because these cheaper brands don't have a filter. NATA is aware of that possibility and we believe that those cheaper brands should be taxed more so that it is not attractive to make that switch/downgrade.
So what is actually happening is that the tobacco industry is trying to fight back. This is a highly profitable industry, even with the tax hikes, the industry won't take our attacks sitting down. Therefore they are spreading false information and sadly it seems that some media institutions and journalists are spreading these lies although they are well aware of the truth.
Q: There are also people who say that the tax on tobacco has failed because it has not reached the expected estimates. What is your take on that?
A: This is false. At a recent press conference Dr. Palitha Abeykoon, chairman, National Authority on Tobacco and Alcohol (NATA), said that the Sri Lankan Government is expected to generate Rs 103.8 billion from tax on tobacco, which is almost identical to the estimates made by the Authority. We estimated that the tax revenue this year will be Rs 104.5 billion and the expected revenue is Rs 103.8 billion. The Government has collected Rs 51.9 billion from January to June 2017. And we made our calculations expecting tobacco consumption to drop by around 20 per cent and our estimates seem correct.
What happened was that there was some confusion created by the manner in which the Finance Ministry officials behaved. When NATA presented the proposals to increase taxes Finance Ministry officials initially said that this will have a drastic impact on prices.
They didn't agree with our estimates that the price elasticity for cigarettes was about 0.5 per cent. But then they came up with a projection saying that the tax revenue will be as high as Rs 126.8 billion, and they have come up with this number by assuming that there will be no drop in consumption. And now some media institutes call Finance Ministry officials and report that the tax has failed to achieve its objectives based on this extremely ambitious and baseless figure.
There is a Framework Convention on Tobacco Control (FCTC), which Sri Lanka has ratified, and this highlights the importance of protecting policy makers from the influence of the tobacco industry. In Sri Lanka the Finance Ministry officials get data for calculations from the CTC and there is no transparency of the meetings. NATA does not meet representatives from the tobacco industry. We must ensure that when Finance Ministry officials meet representatives from the tobacco industry, the minutes are available to the people so that we know what is discussed. This is the only way to prevent this kind of confusion from repeating in the future.
The truth is that when we calculate the health and productivity cost of tobacco consumption, this cost far exceeds the tax revenue.
Moreover, everything is not about money and good health can't be measured in monetary means.
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