Published: 28/03/2002, Volume II2, No. 5798 Page 18
If you are invited to a Bangladeshi household you may be offered paan to chew.
The basic ingredients are betel leaf, slices of Areca palm nut and lime paste. Other additions commonly include tobacco.
Perhaps not a health risk as a one-off, the problem with paan is that many South Asian men - and even more women - chew it every day. It stains the teeth and hands, the lime paste is corrosive, the nut is potentially carcinogenic and, most important, the tobacco is a major risk factor for oral cancer.
Oral cancer is strongly linked with tobacco use. Each year in the UK, there are 3,800 new cases and 1,700 deaths from oral cancer and 90 per cent of those affected chew tobacco or smoke it. The countries with the highest oral cancer rates are in south Asia, where chewing paan is a common practice.
'We do not have the data to show that oral cancer is disproportionately affecting the south Asian community in the UK, ' says Stuart Boulton, director of dental health in Coventry health authority, where he has been working with the city's large Asian population for some years. But the indicators are there.
Paan use is combined with heavy smoking - 44 per cent of Bangladeshi men in the UK are smokers compared to 27 per cent in the general population. There are also high smoking rates in the Indian and Pakistani communities who also chew paan- though less commonly than in the Bangladeshi community.
'The Bangladeshi community also have a higher incidence of failed attempts to give up smoking. We do not know why, ' adds Mr Boulton.
It adds up to a classic health inequality - a group of people who are socially and economically disadvantaged, further hindered by language barriers. The issue is now being taken seriously nationally and locally.
Earlier this month, Coventry HA organised the first national conference on tobacco use in the south Asian community. Last August, the Department of Health launched a£1m Asian tobacco education campaign. It is set to continue into a second year of funding from April 2002.
Heena Bhatti, smoking cessation specialist adviser in Coventry, says that chewing paan is culturally embedded. 'It is passed from generation to generation, so though it is usually brought to the UK from people's country of origin, the practice continues into the second generation of people born here.' Paan is chewed predominantly, though not exclusively, by women at weddings and other celebrations as well as in the home.
DoH research in 2000 highlighted the complex relationship paan users have with their drug of choice. They were ashamed to admit their addiction, yet felt paan was beneficial to their health, aiding digestion and relieving tooth and gum pain. Women reported chewing more paan on their arrival to the UK, attributing this to the social isolation and boredom of life in England compared to their home village.
The first step to tackling paan use is raising awareness, says Ms Bhatti. 'When dental practitioners look in the mouths of people who chew paan, they say it looks like leather. People will chew it up to six times a day and some will even leave it in their mouths overnight. They are not aware of oral cancer and do not see a problem.'
Coventry has decided to make nicotine-replacement therapy available to paan users and has launched a general awareness campaign that brings in religious and community leaders.
'For example, we have targeted the local mosques, printing a timetable for daily prayers during Ramadan that was distributed free, ' says Ms Bhatti. The timetable carried a health message about tobacco with a quote from the Koran to back it up.
Chapter four, verse 29, says: 'Do not kill (or destroy) yourself for verily Allah has been most merciful to you.'
Meanwhile, the DoH has funded 19 local community and outreach projects. In London's Tower Hamlets, Ray Croucher, professor of community oral health at Queen Mary and Westfield College, London University, is targeting retailers.
'Paan is usually imported, though there is some manufactured here. It is poorly labelled in terms of health warnings and contents, ' he says. The project has trained a group of local men to go to retailers, remind them of their legal responsibilities, tell them about Asian smoking-cessation services and persuade them to repackage paan in free plastic bags with a health warning in Bengali.
'The take-up has been remarkably positive, ' says Professor Croucher.
In Walsall, community workers have targeted antenatal clinics and mother and baby groups to reach the women who do not normally read health leaflets or go to open days, while in Bradford the double-decker NHS no-smoking bus has been taken on a Ramadan tour of local mosques.
Nationally, the DoH has set up a new Asian tobacco helpline, available in five Asian languages plus English. It has launched a massmedia campaign now appearing on Asian cable TV, radio and in the Asian press.
Mr Boulton admits that it will be an uphill battle to stop people chewing paan, or at least to chew it without the tobacco. He says: 'Personally I would not put slake lime or Areca nut in my mouth let alone tobacco, but unfortunately paan chewing appears in the Kama Sutra. What chance do we stand?'
NHS Asian tobacco helplines, 0800-1690 881/2/3/4/5.
Attitudes to Asian Language Tobacco Helpline .
Qualitative Research Report. Philly Desai.
December 2000.
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