Madam, Contrary to the popular belief, smokeless tobacco (ST) use is not just a South- Asian but a global public health problem. Although cigarette smoking has seen a decline in western countries, use of ST is rising worldwide especially in the young. Hundreds of millions of people use smokeless tobacco worldwide. In US alone an estimated 10-12 million people are ST users.¹
The misconception that smokeless tobacco is less harmful than smoking is widespread. Due to this ST has not received as much attention as cigarette smoking. In fact ,it has been marketed as an alternative to cigarette smoking in some smoking cessation programmes because of presumed lesser harm.²
Smokeless tobacco use is a huge public health problem in Pakistan. In Pakistan, a wide variety of ST products are used and include Paan, Gutka, Naswar, Mewa Tumbaku, Naas etc. ST production in Pakistan is unregulated. Products vary in content and composition and do not carry the health warnings mandatory for cigarette packs. A cross-sectional survey in a squatter settlement of Karachi (n=425) found that nearly 40% of the participants were using at least one form of ST product on a daily basis.³ Our own findings suggest an even higher use (70%) [Iqbal et al, unpublished data]. Another study of 502 adults from family practice clinics across Karachi found that 52.4 % of the subjects had used a ST product.⁴
This rising nuisance of ST use calls for urgent attention of policy makers and public health professionals. Various interventions are identified in the literature and include both pharmacologic and behavioural approaches. A Cochrane review of randomized trials of pharmacologic and behavioural interventions for ST use cessation found the behavioural interventions to be much more effective.⁵ These interventions were successfully used in community, workplace and dental clinic settings.
Community based interventions are the preferred choice to reach out to a larger group of people in Pakistan. An effective community based smokeless tobacco prevention and cessation programme must have all the three components i.e. education, information and counseling (EIC). Those willing to quit should be given targets and deadlines. Progress over the time should be monitored by doing a baseline survey and a resurvey, one year after the intervention. Strict laws should be made to control the unregulated spread of ST products.

Muhammad Imran Nisar,1 Romaina Iqbal2
MSc Epidemiology and Biostatistics Student,1 Department of Community Health Sciences,2 Aga Khan University, Karachi.

1.Smokeless Tobacco or Health: An International Perspective. (Online) 2003 (Cited 2011 Jan 10). Available from URL: http://cancercontrol.cancer.gov/tcrb/monographs/2/m2_1.pdf.
2.Hatsukami DK, Lemmonds C, Tomar SL. Smokeless tobacco use: harm reduction or induction approach? Prev Med 2004; 38: 309-17.
3.Mazahir S, Malik R, Maqsood M, Merchant KA, Malik F, Majeed A, et al. Socio-demographic correlates of betel, areca and smokeless tobacco use as a high risk behavior for head and neck cancers in a squatter settlement of Karachi, Pakistan. Subst Abuse Treat Prev Policy 2006; 1:10.
4.Ali NS, Khuwaja AK, Ali T, Hameed R. Smokeless tobacco use among adult patients who visited family practice clinics in Karachi, Pakistan. J Oral Pathol Med 2009; 38: 416-21.
5.Ebbert JO, Montori V, Vickers KS, Erwin PC, Dale LC, Stead LF. Interventions for smokeless tobacco use cessation. Cochrane Database Syst Rev 2007: CD004306.