“Smokeless Tobacco, Oral Pathology Prevention And Awareness Network (STOP PAAN)”

Jyotsna Changrani MD, MPH, Francesca Gany MD, MS, Gustavo Cruz DMD, MPH, Ralph Katz PhD, Ross Kerr DMD

Introduction: Smokeless tobacco and areca nut consumption in various forms is an integral cultural tradition in India, and is also popular among Indian immigrants in the United Kingdom, other parts of Europe, North America, and Australia. The United States is home to over 1.67 million ‘Asian Indians.’ As Indians have emigrated and resettled in countries across the world, they have continued consuming the various culturally-linked tobacco products, including paan and gutka. Studies in the U.K., South and East Africa, and the Malay Peninsula report this pattern. Very limited research exists on South Asians in the United States. Extensive searches on Medline, Pubmed, and the World Wide Web yielded no studies on oral cancer and smokeless tobacco use in South Asian immigrants in the United States. The STOP PAAN pilot study is exploring gutka and paan consumption in South Asian immigrants in New York.

Objectives: The pilot study has developed a questionnaire to: a) explore the social, economic, and cultural context of gutka and paan consumption in the South Asian communities in New York City; b) explore knowledge about health consequences and risk of oral cancer posed by use of gutka and paan; and c) determine attitudes towards, and barriers to, use of dental services, which would contribute to the detection of oral cancer cases. In developing the questionnaire, existing instruments were considered. Focus groups with the community guided the development of the questionnaire. The questionnaire was piloted in New York and at King Edward Memorial Hospital in Mumbai, India.

Results: The questionnaire has been administered in New York at community-based sites, including grocery stores, social organizations, and places of residence. 139 first-generation Indian immigrant adults have been surveyed at these community sites to date. Preliminary data has been analyzed on 41 of these participants, including 22 men and 19 women. Mean participant age was 49.24 years (SD=13.90); mean duration of residence in the United States was 9.8 years (SD=7.23). Over 45% of the men reported current regular use of gutka, and nearly 14% reported past regular use of gutka. Nearly 55% of the sample reported past use of paan; fewer than 5% reported current use of paan. Only 18% reported no regular use of paan or gutka. In contrast, no women reported past or current regular use of gutka. Over 26% reported past use of paan and no women reported current use of paan. Forty percent of the current users of gutka were past users of paan, who cited switching to gutka upon moving to the U.S. as a matter of convenience. Ninety-five percent of all persons either heard of someone getting oral cancer or knew that you could get cancer in the mouth. Of the 85% who replied yes to the question, “Do you think gutka causes oral cancer?,” 90% of the current gutka users said yes to the same question. STOP PAAN is working with biostatisticians at New York University College of Dentistry to complete the data analysis.

Next Steps: The STOP PAAN work has been presented at two conferences to date in New York and Philadelphia. A manuscript, “Paan and Gutka: An Emerging U.S. Threat” has been submitted to the Journal of Immigrant Health. The results of the STOP PAAN pilot will be prepared as a manuscript for publication. Additionally, the following grants are in development, or have been recently funded, building on the STOP PAAN pilot work:

(1) The New York State Department of Health, Office of Minority Health recently funded a project to: (a) increase awareness about the risk of cancer posed by paan and gutka in the South Asian immigrant communities in New York City, and (b) screen South Asian immigrants in New York City for oral lesions related to gutka and paan use. Culturally-appropriate messages on smokeless tobacco prevention for written media broadcast will be developed and a STOP PAAN community campaign will be undertaken in 2004-2005. The impact of these efforts in the community will be measured.

(2) A pilot project has been funded by the Research for Adolescent and Adult Health Promotion Center at New York College of Dentistry to develop a training program for oral cancer screening, and to test the ability of health care providers with minimal background in the diagnosis of oral diseases to independently perform oral cancer screenings in an outreach setting and accurately document oral findings. The pilot is being conducted in India.

(3) An international collaborative planning grant has been prepared to study the rising incidence of cancer of the tongue and mouth among young individuals. The purpose of this “Oral Cancer Among Young” (OCAY) grant proposal is to bring together a group of international researchers from the U.S., Europe, and Asia through collaborative partnerships to conduct research according to a common protocol to address the rising incidence of cancer of the tongue and mouth among youth in different parts of the world. STOP PAAN is working as a part of a team of local and international researchers on oral cancer. It is in the process of being submitted to the National Institute of Dental and Craniofacial Research (NIDCR).

(4) An R21 application, “Gutka Cessation Study,” (GCS) was developed and submitted to the NCI on October 1, 2003. The GCS is designed as an R21 preliminary study to: (a) determine whether gutka chewers are interested in quitting and, if yes, to describe characteristics of those who are motivated to quit, and determine the facilitators and inhibitors to quitting; (b) develop and test a scale to measure dependence in gutka users; and (3) determine the preferred cessation intervention for gutka users according to their readiness to quit.

(5) STOP PAAN is working with the New York State Oral Cancer Control Partnership to develop two projects. The first project is to develop, implement, and evaluate a training intervention to increase the rates of oral cancer examinations for at risk patients at Bellevue Hospital, and to evaluate the impact of disseminating oral cancer educational materials among Bellevue’s outpatient population. The second project is to develop and compare community educational efforts versus community education with targeted oral cancer screenings for populations at high risk for oral cancer; and to develop, evaluate, and widely disseminate culturally-appropriate educational materials and interventions for populations at high risk for oral cancer.