Smoke less tobacco or chewing tobacco ( snuff,
Naswar etc-) is mostly consumed in Afghanistan, Pakistan,
India, Iran and Russian federations. It is held in the
mouth inside the cheek between the gums and cheeks
or lips in the form of lump, pinch or dip for extended
period of time. Snuff is moist powdered available in the
form of pouches. Popular brands are Banuu and Mardan
brands. Sun and heat dried tobacco leave in powdered
form , slaked lime, ash, flavoring agents and coloring
agents are mixed together. Then water is added and
the mixture is packed in pouches. It has a very pungent
and power full smell, resembling that of a fresh bale of
coastal hay and has a suble flavors when it mixes with
saliva. The nicotine effects can occur within 5 minutes
after its intake producing a slight burning sensation on
the inner mucosa and tongue.
Smokeless tobacco is one of the major risk factor
associated with many of oral and systemic disease
in particular with oral Squamous cell carcinoma.1,2,3
Tobacco contains more than 3000 carcinogens and
the most common group is nicotine and N- nitrosamines.
The 5-15 years chewing tobacco habit causes
high frequency mutation in codons 12, 13 and 61 of
H-ras, K-ras and N-ras oncogenes and also causes
keratosis of oral mucosa making favored conditions to
develop carcinoma. 4 Pakistan has one of the highest
incidence rates of oral cancer in the world. 5 It is the
most common cancer among men and the second
most common cancer among women in the country.6
Tobacco use and alcohol consumption are considered
as the leading modifiable risk factors for oral cancer
and account for over 70% of the population attributable
fraction for oral cancer.7 A World Health Organization
report from 2001 suggests that Pakistan has one of the
lowest per capita consumption of alcohol in the world
which might be due to a public ban on consumption
and sale of alcohol.8 Tobacco, therefore, seems to be
a major reason for the high incidence of oral cancer in
Pakistan, this is substantiated by recent evidence from
systematic reviews of literature pertaining to South Asia
which implies that smokeless tobacco is one of the main
factors responsible for a high incidence of oral cancer
in the region.9,10 Results from the Global Youth Tobacco
Survey, carried out recently in Pakistan, show that 5.3%
(approx. 4.2 million) of the country’s youth currently use
smokeless tobacco products and another 4.7% were
past users.11 The results from Global Youth Tobacco
Survey are particularly alarming because the survey
sample consisted of school going children aged 13–15
years. Evidence shows that a social disparity exist with
regards to both oral cancer incidence and smokeless
tobacco use i.e., People from low socioeconomic status,
and lower or no education level, are at a higher of oral
cancer and having an smokeless tobacco habit.12 This
could imply, that potentially the actual prevalence of
smokeless tobacco use might even be higher among
the youth of Pakistan, given that the national literacy
rate is just 46%.13
Pakistan is a signatory of the WHO’s Framework
Convention for Tobacco Control since 2005, and has
taken significant steps to curb smoking in the country.14
Article 16 of the Framework Convention for Tobacco
Control states, “Each Party shall adopt and implement
effective legislative, executive, administrative or other
measures at the appropriate government level to prohibit
the sales of tobacco products to persons under
the age set by domestic law, national law or eighteen”,
an intervention aimed at curbing the use of tobacco
among minors. However, the results of the Global Youth
Tobacco Survey and evidence from more recent studies
suggest that tobacco control in Pakistan may be lagging
in its effectiveness to reduce the prevalence of tobacco
products use among minors.15,16 A 2014 research article
explored public policy gaps with regards to Smoke Less
Tobacco control in four Asian countries including Pakistan,
by conducting a review of policy documents and
interviews with key informants, one of the findings of this
study was that, “the sale of smokeless tobacco to and
by minors is prohibited in Pakistan”.17 The dichotomy between
the alarming prevalence of Smokeless Tobacco
use among minors in Pakistan and the reported findings
of the aforementioned policy review study warranted a
review of the Government of Pakistan policies to identify,
how the issue of sale to and by, and consumption of
Smokeless Tobacco by minors has been addressed in
these policy documents. The “section 8” of the 2002
Ordinance only focuses on “smoking tobacco” products
sales to and by minors without mentioning smokeless
tobacco. On the contrary, the monitoring tool designed
to assess the implementation of the same ordinance

Muhammad Mushtaq
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