Pan Masala Plus Tobacco is Equal to Gutka Square-New Formulation of Tobacco in India after the Gutka Ban

Tobacco is a well known cause of death worldwide. India is considered as second largest tobacco producer and third largest tobacco consumer (Arora and Madhu, 2012). According to the Global Adult Tobacco Survey (GATS India report, 2009-2010), use of smokeless tobacco is outnumbering the smoked form and also its use has increased recently. The report also mentions that large numbers of people are aware of health warnings, the thought of quitting and also were motivated by health workers for quitting. Habit onset in late adolescence and family exposure seems to be hampering quitting (Joshi et al., 2010) Studies by Schensul et al. (2013) supported the concept of availability and accessibility in the promotion of smokeless tobacco. It is also important that we are realistic about situation of many tobacco users. Tobacco delivered nicotine is powerfully addictive and many users cannot or will not give up (Bates et al., 2003). With the existing comprehensive law for tobacco control and various measures of public awareness, ban on gutka, and other tobacco control measures, still tobacco related disease and death are not reduced. As per the Supreme Court order most of the State Governments in India have banned the sale of gutka; however, no restriction on sale of cigarettes. Sale of pan masala, tobacco in loose form, tobacco pouches and mouth fresheners are not banned in many states (Figure 1). Several studies have revealed a large number of local brands being sold without pictorial warnings or not


Introduction
Tobacco is a well known cause of death worldwide.India is considered as second largest tobacco producer and third largest tobacco consumer (Arora and Madhu, 2012).According to the Global Adult Tobacco Survey (GATS India report, 2009-2010), use of smokeless tobacco is outnumbering the smoked form and also its use has increased recently.The report also mentions that large numbers of people are aware of health warnings, the thought of quitting and also were motivated by health workers for quitting.Habit onset in late adolescence and family exposure seems to be hampering quitting (Joshi et al., 2010) Studies by Schensul et al. (2013) supported the concept of availability and accessibility in the promotion of smokeless tobacco.
It is also important that we are realistic about situation of many tobacco users.Tobacco delivered nicotine is powerfully addictive and many users cannot or will not give up (Bates et al., 2003).With the existing comprehensive law for tobacco control and various measures of public awareness, ban on gutka, and other tobacco control measures, still tobacco related disease and death are not reduced.
As per the Supreme Court order most of the State Governments in India have banned the sale of gutka; however, no restriction on sale of cigarettes.Sale of pan masala, tobacco in loose form, tobacco pouches and mouth fresheners are not banned in many states (Figure 1).Several studies have revealed a large number of local brands being sold without pictorial warnings or not Pan Masala Plus Tobacco is Equal to Gutka Square -New Formulation of Tobacco in India after the Gutka Ban Pushparaja Shetty* following the display rule.A large amount of tobacco is consumed or sold loose, which easily escapes these regulations.Large numbers of sellers are not aware of the tobacco regulations (Shetty, 2013).
Availability of gutka in black market, improper and inadequate taxation, replacement of gutka with other similar tobacco products, cigarette and beedi smoking, change in the pattern of use of tobacco are the few reasons why the number of tobacco users have not decreased.
A large number of tobacco users have altered their pattern of tobacco use on the basis of availability, accessibility and affordability.After the ban of gutka, many gutka users have shifted to use of pan with tobacco.Most interestingly, the traditional gutkha is still sold in the open market in a pre-mixed form.Manufacturers are

Figure 1. Photograph Showing few Brands of Tobacco Pouches Available in the Market
supplying pan masala and tobacco in separate pouches (Figure 2 and 3) as there is no restriction for sale of pan masala and tobacco individually in many states.User can mix the content of two packs and gutka is ready to use.Since tobacco is supplied in separate pouches, the tobacco percentage, total quantity of the gutka consumed and harmful effect of tobacco is more than the earlier.
It has also been observed that few pan masala brands marketed as tobacco free contains high level of nicotine.Also these pan masala contain magnesium carbonate which leads to hyper magnesia and thus the need of banning pan masala also becomes significant ( Tribune 2011).
Purpose of tobacco control program is to reduce the burden of tobacco related diseases and death (Bates et al., 2003).According to Joshi et al. (2010), Most of the population at present are aware of the health hazards of tobacco and this is not sufficient to discontinue the habit.They have suggested a multifactorial tobacco quitting strategy focusing on early age intervention.Inclusion of tobacco awareness intervention program in the school curricula may help in preventing the initiation of tobacco habits.The GATS India report (2010) stressed the need of an establishment of a comprehensive implementation and regulatory structure at national and state level.A significant change can be brought about only if the existing law is supported by an effective and independent lawenforcing authority and a separate tobacco control cell at various levels.

Figure 2 .Figure 3 .
Figure 2. Photograph Showing Availability of Pan Masala and Tobacco in the Market as Replacement for Gutka