Smokeless Tobacco come in various forms and referred to as chewing tobacco, oral tobacco, spit or spitting tobacco, dip, chew and snuff. Areca nut is the primary ingredient in betel quid and is proven to be carcinogenic.

Use of Smokeless Tobacco and areca nut is common in Sri Lanka. Most people chew or suck the tobacco in their mouth and spit out the tobacco juice. During the process the nicotine in tobacco is absorbed through the lining of the mouth. At least 28 chemicals in Smokeless Tobacco (ST) have been found to cause cancer.

Oral cancer is a major killer and the commonest cancer among Sri Lankan males with up to 50 percent dying of the disease within five years of diagnosis. Sri Lanka has one of the highest incidences of oral cancer in the world and it is predominantly due to ST and areca nut use.

Commercially prepared areca nut products are a serious emerging health hazard. These agents are known to be psychoactive, and have been proven to be addictive. They are the major causes of oral disease, other systemic conditions, disability and death. Compared to non-users, studies reveal that there is up to a fivefold increase in incidence of oral cancer among tobacco and areca nut chewers.

Worldwide ST has not received the attention it deserves from policy-makers, researchers and health professionals. Increasing taxes on ST products can have significant negative impact on its use. The increase should take into account inflation and affordability. The taxes on smokeless products should not be less than taxes on smoked tobacco products.

The Asian region has over 290 million ST users and several different methods of use. Traditionally betel quid has been the most commonly used product. However, in recent years, there has been a shift towards manufactured ST products, such as gutkha and khainee. The incidence of oral cancer is increasing in South East Asia Region (SEAR) especially among the younger generation. Many SEAR countries have initiated steps to regulate ST products.

The sixth session of the Conference of the Parties (COP6) that took place in Moscow, in 2014, recommended stronger WHO Framework Convention on Tobacco Control (FCTC) compliant policies to reduce ST product use. A meeting of experts from SEAR Member States was convened last year by WHO-SEARO in Mumbai, to collate and discuss the available published data on ST use and efficacious interventions for ST control in the SEARO.

Subsequently a report was released by the National Cancer Institute, US, titled Smokeless Tobacco And Public Health, A Global Perspective (2014), by 32 experts from around the

world, which revealed that ST is used by about 300 million people in at least 70 countries, 89 percent of whom live in the SRARO of the WHO, all low- and middle-income countries. In some countries, ST use prevalence exceeds cigarette smoking.

ST is a special problem among vulnerable populations such as youth, women and indigenous populations. Globally there is a wide range of ST products, with different ingredients. Data on these show complexity but are limited. Novel products are being released to the market, with focus on smokers and youth. This is resulting in an impact on youth and development of a fraction of mixed users (dual users). Treatment options for addicted users are limited.

ST marketing is sophisticated, and products are evolving. Marketing strategies often appeal to youth and tend to circumvent tobacco control measures. ST marketing is increasingly dominated by multinational cigarette companies. ST is being marketed in new forms and new ways to different audiences. New marketing strategies may promote dual use and increase uptake among youth.

Use of small single-use packaging makes products inexpensive and more easily available to youth and may dilute the impact of tobacco taxes. There are many different newer forms that include dissolvable types that look like breath-mints, strips and sticks of smokeless tobacco that melt in your mouth.

Professor WM Thilekeratne, Director, Centre for Research in Oral Cancer, reveals that oral cancer leads in the list of cancer in men followed by lung cancer in Sri Lanka. Majority of the victims are from low income families. There is increasing incidence of precancerous lesions among youth due to increase in areca nut and tobacco chewing. The village population is not aware of how harmful areca nuts are, which too has carcinogenic substances.

In Sri Lanka a new betel tray concept, among religious leaders has been established, to add nutmeg, mace, cardamom, clove and aromatic ginger to continue the tradition, instead of using tobacco, areca nut and lime.

Dr. Hemantha Amarsinghe, Head, Tobacco and Oral Cancer Control Unit, NCC Programme, spoke of the existing legislations in Sri Lanka, the gaps in the acts and the plans that they have with the Government of Sri Lanka, for example, to classify areca nuts as a hazardous substance, to be deemed equally dangerous as tobacco products.

Strengthening of the National Authority on Tobacco and Alcohol Act towards effective control of the use and sale of ST and areca nut products and raising taxes on ST and areca nut products are also in the pipeline.