Tobacco chewing poses cancer threat

A street vendor in Mumbai makes paan, a South Asian chewing tobacco product made from the leaf of the Betel tree packed with a lime paste and spices, decorated with coconut shavings and cherries on top.

HACKENSACK, N.J. — South Asian men are more likely than any other group in New Jersey to use chewing tobacco — and health officials are concerned that many actually believe it is good for them.

In the first study of its kind, researchers at the Cancer Institute of New Jersey drilled down through reams of federal data about tobacco use to learn about the smoking and tobacco use of South Asian immigrants.

They found that 2.7 percent of South Asian men use smokeless tobacco, compared with 1 percent of white men and 0.3 percent of black men.

Indian men were more likely to chew tobacco than Pakistani or Bangladeshi men, and Pakistanis were more likely to smoke cigarettes than the other immigrant groups.

Women from South Asia were more likely to take up smoking, upon immigrating to the northeastern United States, while men were more likely to quit.

“What we know about South Asians is that tobacco use is very deeply rooted in their culture,” said Cristine D. Delnevo, the lead author of the study published in the most recent issue of Journal of Oncology, a special edition about smoking and cancer. She is director of the center for tobacco surveillance and evaluation research at the University of Medicine and Dentistry of New Jersey’s School of Public Health.

South Asian chewing tobacco products, often referred to as paan, are so popular that caterers supply it at weddings.

“Paan is usually offered to guests as a sign of hospitality at weddings,” said Rajiv Ulpe, a community health educator at the Cancer Institute and a co-author of the study. “It’s not seen as something harmful, which is why it may be consumed regularly in South Asian homes.”

In Indian enclaves in Jersey City and Edison, N.J., prepared paan is sold in some Indian markets, he said, but most South Asian users carry it from their home country in suitcases or buy it from people who did so. More than 30 different types of smokeless tobacco products — tobacco that is chewed and not lit — are available in the Asian subcontinent.

Some users consider paan, especially when flavored with cardamom, saffron, or cloves, as a mouth freshener, he said.

Public health workers must contend with the commonly held belief that substances like paan help with digestion and are good to use after dinner, Ms. Delnevo said. “How do you create messages about the harms of these products and take into consideration that they might consider it positive?” she said.

“They are certainly not without harm and should not be marketed to the South Asian community as a safe alternative to smoking,” the study said. Their use increases the risk of oral and pancreatic cancer and periodontal disease, and creates risk factors for heart disease and diabetes.

Mr. Ulpe worked as a dentist in India and diagnosed many cases of oral cancer, he said. Patients would walk in with a cancer in one cheek, and chewing tobacco in the other cheek, and be unaware of the connection between them, he said. “That shocked me a bit.”

Tobacco use in India, Pakistan, and Bangladesh is a big health problem, Ms. Delnevo said. The question is what happens when people from those countries immigrate to the United States.

The Indian population is among the fastest growing immigrant groups in New Jersey, having tripled — to nearly 300,000 — since 1990. They make up the largest group of foreign-born residents of the state.

In survey research, “They’re usually lumped in the race/ethnicity section with Asians,” Ms. Delnevo said. “You don’t know if you’re looking at tobacco use patterns among Koreans, people of Chinese descent, or South Asians.”

Such broad groupings mean “we miss important information” about cigarette smoking and various tobacco alternatives, she said.

“A lot of people talk about Asians as a monolithic group, a model minority,” said Shawna Hudson, a sociologist who directs community research at the Cancer Institute and co-author of the study. “They think they have fewer health issues. The take-away is: No, there are health issues. And tobacco usage is different with different South Asian groups.”

This study was the first to use “country of origin” information to analyze cigarette smoking and smokeless tobacco use. The data came from national surveys from 2003 through 2007.

It found that the overall rate of cigarette smoking among South Asians was similar to, or lower than, the rate for the general population — currently about 16 percent of adults in New Jersey. South Asian men had the highest smokeless tobacco rate, and its use was more common among immigrants of lower income or educational status.

Ms. Delnevo suspects this study significantly underestimated the use of smokeless tobacco among South Asians, because it relied on questions about products such as  Skoal and Copenhagen, and didn’t use the terms for indigenous tobacco products, such as paan, paan masala, zarda, gutka, and betel quid with tobacco. Paan refers to a betel leaf envelope that contains a combination of crushed betel nut mixed with lime paste and flavorings and sometimes tobacco. The quid is chewed gently and sucked.

Follow-up studies will ask about use of these products here in New Jersey, Ms. Delnevo said.

The National Cancer Institute funded an outreach effort at the Cancer Institute of New Jersey, located in New Brunswick, to reduce tobacco use among the state’s South Asians. This study used part of that funding to size up the need and figure out how best to tailor the tobacco-cessation message. Programs that mainly target cigarette use will not be as relevant in South Asian communities, Mr. Ulpe said.

India is one of the top tobacco producing nations in the world. Yet manufactured cigarettes are less popular than hand-rolled cigarettes, known as bidis, and smokeless tobacco in that nation, Ms. Delnevo said.

Hookah smoking was not included in the study.