Naswar Dipping, Shift in Behavior in Multi Ethnicity Setting

ORIGINAL ARTICLE chewing habits.2 thorough examination of oral cavity. of interleukin 1β, however, no differences in the disappear if its use is stopped.20. The use of levels of serum IL-6 were observed by the smokeless tobacco in Sweden has been found to Naswar, unlike other chewable tobacco, is used by Oral rinse was collected from 998 subjects in Karachi researchers. Similarly, Naswar was also found to be about 10-fold higher than the rest of Europe (17 NASWAR DIPPING, SHIFT IN BEHAVIOR IN ‘dipping’ placing a pinch either under the lower lip and Peshawar who were habitual of chewable alter thyroid function by significantly increasing countries) and more popular amongst men than or tongue, or inside the cheek from few minutes to tobacco after an informed consent. Samples of serum FT3 and FT4 levels.14 Regarding levels of trace women.21 MULTI ETHNICITY SETTING hours. Naswar is made from sundried tobacco oral-rinse were collected by giving the subjects 20 elements in blood, serum copper levels in naswar leaves of specie Nicotina rustica. After fine grinding ml distilled water to swish in their mouth for one addicts were significantly raised with a mean of 5.1 Toombak is another naswar like product which is Haya Naveen1, Saeeda Baig2, Wasfa Farooq2, Hira Attique3 these are mixed with calcium oxide and wood ash. minute and then spit in the 50 ml corning tubes. A ± 2.4 µg/dl compared to mean of 2.6 ±0.1 µg/dl in marketed in Sudan. Unlike naswar a lot of research 1 2 Dorset County Hospital, NHS Foundation Trust, UK, Department of Biochemistry, Later cardamom and menthol are added for flavor dental floss with a small brush was handed over to healthy control group(P = 0.005).15 has been found on Toombak where 40% of males 3 Department of Physiology, Ziauddin University and finally packed in the size of small tea bags. subjects to gently sweep around oral cavity and are addicted to toombak dipping.22 Toombak like During the course of the day a pinch of Naswar is over lesions to collect mucosal cells. This floss was Evaluation of toxicity of multiple heavy and Naswar is used through dipping method. Similarly ABSTRACT placed in the mouth several times for about 30 min left in the corning tube which was stored at 4°C till carcinogenic metals, noxious ingredients in naswar women users comprise only older women which 3 before being spat out. DNA extraction. of 30 Pakistani brands showed that calculated make up 10% of the users. HPV research on Background: Easy availability of various chewable options in big cities has lead to a shift in behavior in the PCR for general HPV was done using Gp5+/Gp6+. lifetime risk of cancer from the ingredients present in Toombak revealed that its frequency of use is linked Naswar is commonly used in India, Iran, Afghanistan DNA was extracted and PCR was performed as 23 ethnicity specific habit of smokeless tobacco (SLT). This study was designed to find out the usage of naswar these SLT products was much higher than the 'target to the high risk HPV related oral cancer in Sudan. and South Africa4 whereas a very similar product is previously reported.7 The primers, Gp5+/Gp6+, for and other SLTs in naswar specific ethnicity as well as non naswar ethnicities and frequency of Human range' for potentially hazardous substances, marketed in Sudan known as toombak and in amplification of HPV were purchased from Gene according to the US Environmental Protection Nass, another similar form of chewable tobacco, is Papilloma virus (HPV) in their oral cavities. Sweden as snus. These products have a high pH and Link, USA. Agency.3 marketed in northern Pakistan, Iran and the Central contain unionized nicotine and carcinogenic Data was entered on Statistical Package for Social Asian Republics with the same mode of dipping. Methods: Oral rinse (20-40ml) was collected and questionnaire was filled by 293 multiple ethnicity subjects tobacco-specific N-nitrosamines (TSNAs), which Sciences (SPSS) version 20.0. Frequencies and Other studies on other SLT products in Pakistan The manufacturing procedure is also quite similar habitual of naswar dipping, from Karachi and Peshawar after an informed consent. They were given dental impact negatively on oral and general health.5 percentages were taken out for the qualitative showed a significant rise (p < 0.001) in the levels of except it is only partially cured, with addition of ash, floss with brush to gently sweep around oral cavity and over lesions. Floss was left in oral rinse and stored at World Health Organization (WHO) analyzed 53 oral data. Association between the qualitative variables heavy metals such as Cd, Ni, and Pb, in their cotton or sesame oil and lime.24 4°C. DNA was extracted and PCR was performed using HPV consensus primers Gp5+/Gp6+. tobacco products from 5 regions worldwide and was calculated using Pearson chi-square. At 95% blood.16,17 they also found that some products have very high confidence level, p-value less than 0.05 was taken The oral lesions in Peshawar naswar users showed culture from times unknown is due to the reason Trismus or dysphagia [21(35.6%)], ulcers, cuts or that there is a general perception that it is pH and high concentrations of unionized nicotine as significant. The powdered SLT popular in Ghana when tested CONCLUSION Results: The 293 subjects selected were divided into 3 groups; i. Original naswar users (56, Pathan residents of swelling [14(25.0%)] and pain [19(33.9%)]. Karachi completely harmless.9 Naswar, unlike other and its stimulated nitrosamines (e.g., gul powder, for concentration of thirty-four elements showed Peshawar), ii. Settler naswar users (79, Pathan residents of Karachi), and iii. adapted naswar users (158, 6 had high frequency for leukoplakia [(30(37.9%)], chewable tobacco products is not chewed, rather chimó, toombak, zarda, khaini). RESULTS potentially toxic levels of Cr, Cd, Sb and Cu in the Epidemiological shift in behavior occurred due to various non naswar ethnicities). Peshawar subjects were not positive for leukoplakia or rough mucosa Rough mucosa [43(54.4%)], Pain [17(21.5%)], Trismus placed in oral vestibule where after continuous samples which approximately was two to eight change in ecology. Naswar dippers (Pathans) (40%) or dysphagia [18(22.8%)] and ulcers, cuts or swelling exposure an oral wart develops. Since oral warts are compared to rough mucosa in 43(54.4%) and leukoplakia in 30(37.9%) in subjects living in Karachi. Due to easy availability of various chewable options The 293 subjects selected were divided into 3 times higher than dried tobacco leaves.18 developed other addictions, whereas, subjects [25(31.6%)]. not painful naswar dippers consider them harmless Genetic testing for HPV showed 15(18.9%) samples from Karachi and 20(35.7%) samples from Peshawar, in big cities, SLT is also not ethnicity restricted groups; i. Original naswar users (56, Pathan residents (22%) of other ethnicities became habitual to and do not accept its association with oral or lung positive for HPV with significance difference of p-value of 0.029. anymore and a shift is being observed in the ethnici- of Peshawar), ii, settler naswar users (79, Pathan Looking at the typography of oral lesions in Naswar naswar. HPV frequency was found higher in native DISCUSSION cancer.9,10 Nicotine along with other carcinogens in ty specific habit of smokeless tobacco (SLT). This residents of Karachi), iii. secondary naswar users dippers in this study there were differences in lesions chewers (35.7%) compared to settlers and non these products, corrode the oral mucosa making Conclusion: Epidemiological shift in behavior occurred due to change in ecology. Naswar dippers (Pathans) study was designed to find out the usage of naswar (158, divided ethnicity naswar users, Bengali 31, in dippers of two cities. Karachi dippers had high naswar ethnicities (18.9%), this may be due to their In our study we observed that 42% of Pathans the surroundings favorable for viruses such as HPV to and other SLTs in naswar specific ethnicity as well as Punjabi 51, Sindhis 32, Balochi 25, Muhajir 13, others frequency of leukoplakia (37.9%) and rough other social practices. More comparative studies (40%) developed other addictions, whereas, subjects (22%) of other ethnicities became habitual to naswar. settlers in Karachi developed SLT habits of other settle in the epithelium and start replicating in non naswar ethnicities and frequency of Human (Kachi, Burmi) 06) (Table 1). mucosa (54.4%) which was not observed in are required to investigate this further. The medical, More comparative studies are required to further prove this. ethnicities, whereas, 21% subjects of other synchrony with the S-phase of the host. Oral cancer Papilloma virus (HPV) in their oral cavities. Peshawar dippers. This probably was due to dental, and public health communities need to join ethnicities became habitual to naswar who have a is becoming an epidemic in Pakistan affecting The Pathan naswar users were further assessed addiction to other SLT products such as Gutka, forces to combat this emerging threat.25 KEYWORDS: Mouth Neoplasms; Tobacco; Smokeless; Carcinogens; Global health; Nicotine; Non-cigarette totally different culture and SLT practices. Karachi is people younger than the ones earlier reported. METHODS about habits involving other forms of chewable another advanced variety of SLT product which is a the biggest metropolitan city of Pakistan and tobacco products tobacco along with their naswar dipping habit cause of high frequency of premalignant lesions, people from all four provinces have migrated to A recent study on naswar in KPK revealed 68% of This study was carried out in the Research Laborato- (Table 2). The symptoms and lesions present in leukoplakia and erythroplakia.15 Rests of the lesions REFERENCES Karachi for better livelihood. Their chewable oral cancer in men and 38% in women are Corresponding Author: ry of Ziauddin University, Karachi, from December naswar users was compared between Pathan were the same in both cities with surprisingly similar tobacco habits have also crossed borders with attributed to naswar dipping.11 Comparative HPV Dr. Saeeda Baig, 2013 to 2015. Approval was taken from Ziauddin subjects from Karachi and Peshawar (Figure 1). frequency. 1. McClave-Regan AK, Berkowitz J. Smokers who them and have become part of shops in their testing in this study done on oral rinse samples of Department of Biochemistry, Ethics Review Committee before the start of study. are also using smokeless tobacco products in the comfort zones, where all these products such as Pathan naswar users from Karachi and Peshawar Prior to samples collection approval and consent None of the subjects living in Peshawar were Clinical and radiographic periodontal parameters US: a national assessment of characteristics, Ziauddin University, Karachi. Gutka, Naswar, Paan and Arica nut are available, also revealed a declining trend in pathogenesis, was taken from the subjects and a questionnaire positive for leukoplakia or rough mucosa. In com- in Naswar dippers has been observed significantly behaviors and beliefs of 'dual users'. Tob Control Email: [email protected] generally in the squatter settlements around the 18.3% in Karachi and 35.7% in Peshawar with a was filled. All subjects exposed to chewable tobac- parison, subjects from Karachi had rough mucosa in elevated (P <0.01) compared to control group with 2011;20(3):239-42. city. This movement has also been reported from significant difference (p-value <0.02). However, HPV co with or without oral lesions having no febrile 43(54.4%) and leukoplakia in 30 (37.9%). Raman spectrum sharpest band at 1260 cm1 and 2. S Baig, MM Arif, M Obaid, Z Rubab. Pattern of other countries showing how human globalization frequency was found higher in subjects who pathological conditions were included in the study. Raman band at Amide I. whereas, rate of release substance abuse in multi ethnic groups in different has compelled ethnicity specific SLT customs to developed trismus after continuous use of SLT Subjects addicted to stuff other than chewable Genetic testing for HPV was done on each sample. from dentin matrices of C-telopeptides pyridinoline localities of Karachi. Pak J Med Dent 2013; 1(1): travel with them. In London, borough Naswar of suggesting a high risk of oral squamous cell tobacco were excluded. Among specific ethnicity naswar 15(18.9%) samples cross-links of type I collagen (ICTP) and C-terminal 47-54. INTRODUCTION these products where peer pressure (63.2%) and Pakistani origin was found freely available in 15 carcinoma.12 from Karachi and 20(35.7%) samples from Peshawar crosslinked telopeptide (CTX) from gingival 3. Zakiullah, Saeed M, Muhammad N, Khan SA, Gul curiosity (14.4%) are two main reasons for starting Sampling: different outlets and purchasers were men of 32±10 2 trained medical volunteers were were found positive for HPV. Chi square applied to collagen was found significantly higher (P < .05) F, Khuda F, et al. Assessment of potential toxicity of Worldwide popularity of chewable tobacco is the habit. years of age with limited education who had little or Naswar has also been found to cause adverse employed to record data regarding demographics HPV testing done on samples of Pathan naswar compared to controls showing a higher degree of a smokeless tobacco product (naswar) available ethnicity specific and this habit is part of global no knowledge of health related issues of Naswar, its cardiovascular affects by altering various and SLT history through a structured Questionnaire. users from Karachi and Peshawar showed a signifi- collagen breakdown in the connective tissue with on the Pakistani market. Tob Control history, tradition, and culture. A paradigm shift in In Pakistan, Naswar dipping is interwoven into the dependency or devastation related to behavioral biochemical markers when compared to controls. Any kind of oral pathology was recorded after cance difference with a p-value of 0.0288. both bone and attachment loss due to naswar 2012;21(4):396-401. chewing habit has been observed globally due to cultural fabric of a particular sect of Pakistani and socio-demographic factors.8 Such as levels of serum total cholesterol, LDL-C, dipping19. 4.ARC Monographs on the Evaluation of availability of multiple chewable tobacco population from times unknown, belonging to triglycerides and LDL-C/HDL-C ratio have been Carcinogenic Risks to Humans, No. 89. Smokeless formulations. Studies on lifestyle habits and high risk Khyber Pakhtoon Khaw (KPK). Karachi being mini Since, all these chewable products such as Gutka, found significantly increased (P<0.01), whereas, In Sweden, snus is the most popular SLT which tobacco and some tobacco-specific of oral cancer in UK and US, report that chewable Pakistan represents all 4 provinces including a large Naswar, Paan and Arica nut contain Nicotine and Glutathione per oxidase, super oxide dismutase surprisingly resembles naswar in manufacturing and N-nitrosamines: International Agency for Research habits are infiltrating into other ethnicities and can number of settlers from KPK. All ethnicities live hence people fall easy prey to its dependence, and HDL-C significantly reduced (P<0.01) in naswar 1 dipping practices. A comprehensive review on on Cancer; 2007. be a cause of oral cancer. The situation of SLT alongside in various squatter settlements, yet they especially the new generations. In Pakistan, the dippers.13 Naswar dipping compromises the adverse effects showed that Snus dipping, leads to 5.Niaz K, Maqbool F, Khan F, Bahadar H, Ismail consumption is grave due to easy availability of are glued to their legacy and customs including unraveled popularity of Naswar in the Pathan Immune system by significantly lowering the levels non-malignant lesions that are reversible and Hassan F, Abdollahi M. Smokeless tobacco (paan

PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2019, VOL. 8 (02) 15

chewing habits.2 thorough examination of oral cavity. of interleukin 1β, however, no differences in the disappear if its use is stopped.20. The use of levels of serum IL-6 were observed by the smokeless tobacco in Sweden has been found to Naswar, unlike other chewable tobacco, is used by Oral rinse was collected from 998 subjects in Karachi researchers. Similarly, Naswar was also found to be about 10-fold higher than the rest of Europe (17 ‘dipping’ placing a pinch either under the lower lip and Peshawar who were habitual of chewable alter thyroid function by significantly increasing countries) and more popular amongst men than or tongue, or inside the cheek from few minutes to tobacco after an informed consent. Samples of serum FT3 and FT4 levels.14 Regarding levels of trace women.21 hours. Naswar is made from sundried tobacco oral-rinse were collected by giving the subjects 20 elements in blood, serum copper levels in naswar leaves of specie Nicotina rustica. After fine grinding ml distilled water to swish in their mouth for one addicts were significantly raised with a mean of 5.1 Toombak is another naswar like product which is these are mixed with calcium oxide and wood ash. minute and then spit in the 50 ml corning tubes. A ± 2.4 µg/dl compared to mean of 2.6 ±0.1 µg/dl in marketed in Sudan. Unlike naswar a lot of research Later cardamom and menthol are added for flavor dental floss with a small brush was handed over to healthy control group(P = 0.005).15 has been found on Toombak where 40% of males and finally packed in the size of small tea bags. subjects to gently sweep around oral cavity and are addicted to toombak dipping.22 Toombak like During the course of the day a pinch of Naswar is over lesions to collect mucosal cells. This floss was Evaluation of toxicity of multiple heavy and Naswar is used through dipping method. Similarly placed in the mouth several times for about 30 min left in the corning tube which was stored at 4°C till carcinogenic metals, noxious ingredients in naswar women users comprise only older women which before being spat out.3 DNA extraction. of 30 Pakistani brands showed that calculated make up 10% of the users. HPV research on PCR for general HPV was done using Gp5+/Gp6+. lifetime risk of cancer from the ingredients present in Toombak revealed that its frequency of use is linked Naswar is commonly used in India, Iran, Afghanistan DNA was extracted and PCR was performed as these SLT products was much higher than the 'target to the high risk HPV related oral cancer in Sudan.23 and South Africa4 whereas a very similar product is previously reported.7 The primers, Gp5+/Gp6+, for range' for potentially hazardous substances, marketed in Sudan known as toombak and in amplification of HPV were purchased from Gene according to the US Environmental Protection Nass, another similar form of chewable tobacco, is Sweden as snus. These products have a high pH and Link, USA. Agency.3 marketed in northern Pakistan, Iran and the Central contain unionized nicotine and carcinogenic Data was entered on Statistical Package for Social Asian Republics with the same mode of dipping. tobacco-specific N-nitrosamines (TSNAs), which Sciences (SPSS) version 20.0. Frequencies and Other studies on other SLT products in Pakistan The manufacturing procedure is also quite similar impact negatively on oral and general health.5 percentages were taken out for the qualitative showed a significant rise (p < 0.001) in the levels of except it is only partially cured, with addition of ash, World Health Organization (WHO) analyzed 53 oral data. Association between the qualitative variables heavy metals such as Cd, Ni, and Pb, in their cotton or sesame oil and lime.24 tobacco products from 5 regions worldwide and was calculated using Pearson chi-square. At 95% blood.16,17 they also found that some products have very high confidence level, p-value less than 0.05 was taken The oral lesions in Peshawar naswar users showed culture from times unknown is due to the reason Trismus or dysphagia [21(35.6%)], ulcers, cuts or that there is a general perception that it is pH and high concentrations of unionized nicotine as significant. The powdered SLT popular in Ghana when tested CONCLUSION swelling [14(25.0%)] and pain [19(33.9%)]. Karachi completely harmless.9 Naswar, unlike other and its stimulated nitrosamines (e.g., gul powder, for concentration of thirty-four elements showed 6 had high frequency for leukoplakia [(30(37.9%)], chewable tobacco products is not chewed, rather chimó, toombak, zarda, khaini). RESULTS potentially toxic levels of Cr, Cd, Sb and Cu in the Epidemiological shift in behavior occurred due to Rough mucosa [43(54.4%)], Pain [17(21.5%)], Trismus placed in oral vestibule where after continuous samples which approximately was two to eight change in ecology. Naswar dippers (Pathans) (40%) or dysphagia [18(22.8%)] and ulcers, cuts or swelling exposure an oral wart develops. Since oral warts are Due to easy availability of various chewable options The 293 subjects selected were divided into 3 times higher than dried tobacco leaves.18 developed other addictions, whereas, subjects [25(31.6%)]. not painful naswar dippers consider them harmless in big cities, SLT is also not ethnicity restricted groups; i. Original naswar users (56, Pathan residents (22%) of other ethnicities became habitual to and do not accept its association with oral or lung anymore and a shift is being observed in the ethnici- of Peshawar), ii, settler naswar users (79, Pathan Looking at the typography of oral lesions in Naswar naswar. HPV frequency was found higher in native DISCUSSION cancer.9,10 Nicotine along with other carcinogens in ty specific habit of smokeless tobacco (SLT). This residents of Karachi), iii. secondary naswar users dippers in this study there were differences in lesions chewers (35.7%) compared to settlers and non these products, corrode the oral mucosa making study was designed to find out the usage of naswar (158, divided ethnicity naswar users, Bengali 31, in dippers of two cities. Karachi dippers had high naswar ethnicities (18.9%), this may be due to their In our study we observed that 42% of Pathans the surroundings favorable for viruses such as HPV to and other SLTs in naswar specific ethnicity as well as Punjabi 51, Sindhis 32, Balochi 25, Muhajir 13, others frequency of leukoplakia (37.9%) and rough other social practices. More comparative studies settlers in Karachi developed SLT habits of other settle in the epithelium and start replicating in non naswar ethnicities and frequency of Human (Kachi, Burmi) 06) (Table 1). mucosa (54.4%) which was not observed in are required to investigate this further. The medical, ethnicities, whereas, 21% subjects of other synchrony with the S-phase of the host. Oral cancer Papilloma virus (HPV) in their oral cavities. Peshawar dippers. This probably was due to dental, and public health communities need to join ethnicities became habitual to naswar who have a is becoming an epidemic in Pakistan affecting The Pathan naswar users were further assessed addiction to other SLT products such as Gutka, forces to combat this emerging threat.25 totally different culture and SLT practices. Karachi is people younger than the ones earlier reported. METHODS about habits involving other forms of chewable another advanced variety of SLT product which is a the biggest metropolitan city of Pakistan and tobacco along with their naswar dipping habit cause of high frequency of premalignant lesions, people from all four provinces have migrated to A recent study on naswar in KPK revealed 68% of This study was carried out in the Research Laborato- (Table 2). The symptoms and lesions present in leukoplakia and erythroplakia.15 Rests of the lesions REFERENCES Karachi for better livelihood. Their chewable oral cancer in men and 38% in women are ry of Ziauddin University, Karachi, from December naswar users was compared between Pathan were the same in both cities with surprisingly similar tobacco habits have also crossed borders with attributed to naswar dipping.11 Comparative HPV 2013 to 2015. Approval was taken from Ziauddin subjects from Karachi and Peshawar (Figure 1). frequency. 1. McClave-Regan AK, Berkowitz J. Smokers who them and have become part of shops in their testing in this study done on oral rinse samples of Ethics Review Committee before the start of study. are also using smokeless tobacco products in the comfort zones, where all these products such as Pathan naswar users from Karachi and Peshawar Prior to samples collection approval and consent None of the subjects living in Peshawar were Clinical and radiographic periodontal parameters US: a national assessment of characteristics, Gutka, Naswar, Paan and Arica nut are available, also revealed a declining trend in pathogenesis, was taken from the subjects and a questionnaire positive for leukoplakia or rough mucosa. In com- in Naswar dippers has been observed significantly behaviors and beliefs of 'dual users'. Tob Control generally in the squatter settlements around the 18.3% in Karachi and 35.7% in Peshawar with a was filled. All subjects exposed to chewable tobac- parison, subjects from Karachi had rough mucosa in elevated (P <0.01) compared to control group with 2011;20(3):239-42. city. This movement has also been reported from significant difference (p-value <0.02). However, HPV co with or without oral lesions having no febrile 43(54.4%) and leukoplakia in 30 (37.9%). Raman spectrum sharpest band at 1260 cm1 and 2. S Baig, MM Arif, M Obaid, Z Rubab. Pattern of other countries showing how human globalization frequency was found higher in subjects who pathological conditions were included in the study. Raman band at Amide I. whereas, rate of release substance abuse in multi ethnic groups in different has compelled ethnicity specific SLT customs to developed trismus after continuous use of SLT Subjects addicted to stuff other than chewable Genetic testing for HPV was done on each sample. from dentin matrices of C-telopeptides pyridinoline localities of Karachi. Pak J Med Dent 2013; 1(1): travel with them. In London, borough Naswar of suggesting a high risk of oral squamous cell tobacco were excluded. Among specific ethnicity naswar 15(18.9%) samples cross-links of type I collagen (ICTP) and C-terminal 47-54. INTRODUCTION these products where peer pressure (63.2%) and Pakistani origin was found freely available in 15 carcinoma.12 from Karachi and 20(35.7%) samples from Peshawar crosslinked telopeptide (CTX) from gingival 3. Zakiullah, Saeed M, Muhammad N, Khan SA, Gul curiosity (14.4%) are two main reasons for starting Sampling: different outlets and purchasers were men of 32±10 2 trained medical volunteers were were found positive for HPV. Chi square applied to collagen was found significantly higher (P < .05) F, Khuda F, et al. Assessment of potential toxicity of Worldwide popularity of chewable tobacco is the habit. years of age with limited education who had little or Naswar has also been found to cause adverse employed to record data regarding demographics HPV testing done on samples of Pathan naswar compared to controls showing a higher degree of a smokeless tobacco product (naswar) available ethnicity specific and this habit is part of global no knowledge of health related issues of Naswar, its cardiovascular affects by altering various and SLT history through a structured Questionnaire. users from Karachi and Peshawar showed a signifi- collagen breakdown in the connective tissue with on the Pakistani market. Tob Control history, tradition, and culture. A paradigm shift in In Pakistan, Naswar dipping is interwoven into the dependency or devastation related to behavioral biochemical markers when compared to controls. Any kind of oral pathology was recorded after cance difference with a p-value of 0.0288. both bone and attachment loss due to naswar 2012;21(4):396-401. chewing habit has been observed globally due to cultural fabric of a particular sect of Pakistani and socio-demographic factors.8 Such as levels of serum total cholesterol, LDL-C, dipping19. 4.ARC Monographs on the Evaluation of availability of multiple chewable tobacco population from times unknown, belonging to triglycerides and LDL-C/HDL-C ratio have been Carcinogenic Risks to Humans, No. 89. Smokeless formulations. Studies on lifestyle habits and high risk Khyber Pakhtoon Khaw (KPK). Karachi being mini Since, all these chewable products such as Gutka, found significantly increased (P<0.01), whereas, In Sweden, snus is the most popular SLT which tobacco and some tobacco-specific of oral cancer in UK and US, report that chewable Pakistan represents all 4 provinces including a large Naswar, Paan and Arica nut contain Nicotine and Glutathione per oxidase, super oxide dismutase surprisingly resembles naswar in manufacturing and N-nitrosamines: International Agency for Research habits are infiltrating into other ethnicities and can number of settlers from KPK. All ethnicities live hence people fall easy prey to its dependence, and HDL-C significantly reduced (P<0.01) in naswar 1 dipping practices. A comprehensive review on on Cancer; 2007. be a cause of oral cancer. The situation of SLT alongside in various squatter settlements, yet they especially the new generations. In Pakistan, the dippers.13 Naswar dipping compromises the adverse effects showed that Snus dipping, leads to 5.Niaz K, Maqbool F, Khan F, Bahadar H, Ismail consumption is grave due to easy availability of are glued to their legacy and customs including unraveled popularity of Naswar in the Pathan Immune system by significantly lowering the levels non-malignant lesions that are reversible and Hassan F, Abdollahi M. Smokeless tobacco (paan

16 PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2019, VOL. 8 (02)

of interleukin 1β, however, no differences in the disappear if its use is stopped.20. The use of levels of serum IL-6 were observed by the smokeless tobacco in Sweden has been found to Table 1: Naswar dipping among different ethnicities living in Karachi researchers. Similarly, Naswar was also found to be about 10-fold higher than the rest of Europe (17 with frequency of HPV in their oral cavity. alter thyroid function by significantly increasing countries) and more popular amongst men than serum FT3 and FT4 levels.14 Regarding levels of trace women.21 elements in blood, serum copper levels in naswar Chewable tobacco addicts were significantly raised with a mean of 5.1 Toombak is another naswar like product which is HPV ± 2.4 µg/dl compared to mean of 2.6 ±0.1 µg/dl in marketed in Sudan. Unlike naswar a lot of research Nasw Naswa Users Ethnicity Niswar +ive healthy control group(P = 0.005).15 has been found on Toombak where 40% of males Niswar Niswar ar r Niswar Niswar + + are addicted to toombak dipping.22 Toombak like + +Areca +paan +paan alone Gutka Cigare paan Nut +gutk +gutka Evaluation of toxicity of multiple heavy and Naswar is used through dipping method. Similarly -tte a +cig carcinogenic metals, noxious ingredients in naswar women users comprise only older women which Pathan 45 07 16 04 02 03 02 15 of 30 Pakistani brands showed that calculated make up 10% of the users. HPV research on Naswar (Karachi) (57.0%) (9.21%) (20.2%) (5.0%) (2.5%) (6.3%) (2.5%) (18.9% lifetime risk of cancer from the ingredients present in Toombak revealed that its frequency of use is linked 23 Specific (n=79) ) these SLT products was much higher than the 'target to the high risk HPV related oral cancer in Sudan. Ethnicity Pathan 42 0 2 0 0 13 0 20 range' for potentially hazardous substances, (n=135) (Peshawar) (75.0%) (0.0%) (3.6%) (0.0%) (0.0%) (23.2%) (0.0%) (35.7% according to the US Environmental Protection Nass, another similar form of chewable tobacco, is (n=56) ) Agency.3 marketed in northern Pakistan, Iran and the Central Bengali 01 01 02 0 21 0 06 06 Asian Republics with the same mode of dipping. (n=31) (3.2%) (3.2%) (6.45%) (0.0%) (67.7%) (0.0%) (19.3%) (19.3% Other studies on other SLT products in Pakistan The manufacturing procedure is also quite similar NonNas ) showed a significant rise (p < 0.001) in the levels of except it is only partially cured, with addition of ash, war Punjabi 15 13 02 03 07 03 09 14 heavy metals such as Cd, Ni, and Pb, in their cotton or sesame oil and lime.24 Ethnicitie (n=51) (29.4%) (25.4%) (4.0%) (5.8%) (13.7%) (5.8%) (17.6%) (27.4% 16,17 ) blood. s of The oral lesions in Peshawar naswar users showed culture from times unknown is due to the reason Sindhi 06 12 03 03 06 01 01 11 Trismus or dysphagia [21(35.6%)], ulcers, cuts or that there is a general perception that it is Karachi The powdered SLT popular in Ghana when tested CONCLUSION (n=32) (18.7%) (37.5%) (9.3%) (9.3%) (18.7%) (3.1%) (3.1%) (34.3% swelling [14(25.0%)] and pain [19(33.9%)]. Karachi completely harmless.9 Naswar, unlike other N=158 ) for concentration of thirty-four elements showed had high frequency for leukoplakia [(30(37.9%)], chewable tobacco products is not chewed, rather Balochi 06 04 01 02 04 03 05 04 potentially toxic levels of Cr, Cd, Sb and Cu in the Epidemiological shift in behavior occurred due to Rough mucosa [43(54.4%)], Pain [17(21.5%)], Trismus placed in oral vestibule where after continuous (n=25) (24.0%) (16.0%) (4.0%) (8.0%) (16.0%) (12.0%) (20.0%) (16.0% samples which approximately was two to eight change in ecology. Naswar dippers (Pathans) (40%) or dysphagia [18(22.8%)] and ulcers, cuts or swelling exposure an oral wart develops. Since oral warts are ) times higher than dried tobacco leaves.18 developed other addictions, whereas, subjects Urdu 04 02 04 0 01 0 02 03 [25(31.6%)]. not painful naswar dippers consider them harmless (22%) of other ethnicities became habitual to speaking (30.7%) (15.4%) (30.7%) (0.0%) (7.7%) (0.0%) (15.4%) (23.0% and do not accept its association with oral or lung Looking at the typography of oral lesions in Naswar naswar. HPV frequency was found higher in native (n=13) ) DISCUSSION cancer.9,10 Nicotine along with other carcinogens in dippers in this study there were differences in lesions chewers (35.7%) compared to settlers and non Others* 01 01 0 0 04 0 0 02 these products, corrode the oral mucosa making in dippers of two cities. Karachi dippers had high naswar ethnicities (18.9%), this may be due to their (n=06) (16.0%) (16.0%) (0.0%) (0.0%) (66.6%) (0.0%) (0.0%) (33.3% In our study we observed that 42% of Pathans the surroundings favorable for viruses such as HPV to frequency of leukoplakia (37.9%) and rough other social practices. More comparative studies ) settlers in Karachi developed SLT habits of other settle in the epithelium and start replicating in mucosa (54.4%) which was not observed in are required to investigate this further. The medical, Total 293 ethnicities, whereas, 21% subjects of other synchrony with the S-phase of the host. Oral cancer Peshawar dippers. This probably was due to dental, and public health communities need to join ethnicities became habitual to naswar who have a is becoming an epidemic in Pakistan affecting addiction to other SLT products such as Gutka, forces to combat this emerging threat.25 totally different culture and SLT practices. Karachi is people younger than the ones earlier reported. another advanced variety of SLT product which is a the biggest metropolitan city of Pakistan and cause of high frequency of premalignant lesions, people from all four provinces have migrated to A recent study on naswar in KPK revealed 68% of leukoplakia and erythroplakia.15 Rests of the lesions REFERENCES Table 2: Contrast in SLT habits of original naswar dippers in Peshawar and settlers in Karachi. Karachi for better livelihood. Their chewable oral cancer in men and 38% in women are were the same in both cities with surprisingly similar tobacco habits have also crossed borders with attributed to naswar dipping.11 Comparative HPV frequency. 1. McClave-Regan AK, Berkowitz J. Smokers who them and have become part of shops in their testing in this study done on oral rinse samples of are also using smokeless tobacco products in the comfort zones, where all these products such as Pathan naswar users from Karachi and Peshawar PATHAN Niswar Niswar Niswar + Niswar + Naswar Niswar Naswar P HPV P Clinical and radiographic periodontal parameters US: a national assessment of characteristics, Gutka, Naswar, Paan and Arica nut are available, also revealed a declining trend in pathogenesis, NASWAR alone + Paan Areca +paan + +paan value positive value in Naswar dippers has been observed significantly behaviors and beliefs of 'dual users'. Tob Control generally in the squatter settlements around the 18.3% in Karachi and 35.7% in Peshawar with a Gutka Nut +gutka Cigaret +gutka elevated (P <0.01) compared to control group with 2011;20(3):239-42. USERS city. This movement has also been reported from significant difference (p-value <0.02). However, HPV te +cig Raman spectrum sharpest band at 1260 cm1 and 2. S Baig, MM Arif, M Obaid, Z Rubab. Pattern of other countries showing how human globalization frequency was found higher in subjects who Raman band at Amide I. whereas, rate of release substance abuse in multi ethnic groups in different has compelled ethnicity specific SLT customs to developed trismus after continuous use of SLT Karachi 45 07 16 04 02 03 02 15 from dentin matrices of C-telopeptides pyridinoline localities of Karachi. Pak J Med Dent 2013; 1(1): travel with them. In London, borough Naswar of suggesting a high risk of oral squamous cell N=79 (57.0%) (9.21%) (20.2%) (5.0%) (2.5%) (6.3%) (2.5%) (18.9%) cross-links of type I collagen (ICTP) and C-terminal 47-54. Pakistani origin was found freely available in 15 carcinoma.12 crosslinked telopeptide (CTX) from gingival 3. Zakiullah, Saeed M, Muhammad N, Khan SA, Gul 0.000 0.028 different outlets and purchasers were men of 32±10 Peshawa 42 0 2 0 0 13 0 20 collagen was found significantly higher (P < .05) F, Khuda F, et al. Assessment of potential toxicity of years of age with limited education who had little or Naswar has also been found to cause adverse r (0.0%) compared to controls showing a higher degree of a smokeless tobacco product (naswar) available N=56 (75.0%) (0.0%) (3.6%) (0.0%) (23.2%) (0.0%) (35.7%) no knowledge of health related issues of Naswar, its cardiovascular affects by altering various collagen breakdown in the connective tissue with on the Pakistani market. Tob Control dependency or devastation related to behavioral biochemical markers when compared to controls. both bone and attachment loss due to naswar 2012;21(4):396-401. and socio-demographic factors.8 Such as levels of serum total cholesterol, LDL-C, dipping19. 4.ARC Monographs on the Evaluation of triglycerides and LDL-C/HDL-C ratio have been Carcinogenic Risks to Humans, No. 89. Smokeless Since, all these chewable products such as Gutka, found significantly increased (P<0.01), whereas, In Sweden, snus is the most popular SLT which tobacco and some tobacco-specific Naswar, Paan and Arica nut contain Nicotine and Glutathione per oxidase, super oxide dismutase surprisingly resembles naswar in manufacturing and N-nitrosamines: International Agency for Research hence people fall easy prey to its dependence, and HDL-C significantly reduced (P<0.01) in naswar dipping practices. A comprehensive review on on Cancer; 2007. especially the new generations. In Pakistan, the dippers.13 Naswar dipping compromises the adverse effects showed that Snus dipping, leads to 5.Niaz K, Maqbool F, Khan F, Bahadar H, Ismail unraveled popularity of Naswar in the Pathan Immune system by significantly lowering the levels non-malignant lesions that are reversible and Hassan F, Abdollahi M. Smokeless tobacco (paan

PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2019, VOL. 8 (02) 17

of interleukin 1β, however, no differences in the disappear if its use is stopped.20. The use of levels of serum IL-6 were observed by the smokeless tobacco in Sweden has been found to researchers. Similarly, Naswar was also found to be about 10-fold higher than the rest of Europe (17 alter thyroid function by significantly increasing countries) and more popular amongst men than serum FT3 and FT4 levels.14 Regarding levels of trace women.21 elements in blood, serum copper levels in naswar addicts were significantly raised with a mean of 5.1 Toombak is another naswar like product which is ± 2.4 µg/dl compared to mean of 2.6 ±0.1 µg/dl in marketed in Sudan. Unlike naswar a lot of research healthy control group(P = 0.005).15 has been found on Toombak where 40% of males are addicted to toombak dipping.22 Toombak like Evaluation of toxicity of multiple heavy and Naswar is used through dipping method. Similarly carcinogenic metals, noxious ingredients in naswar women users comprise only older women which of 30 Pakistani brands showed that calculated make up 10% of the users. HPV research on lifetime risk of cancer from the ingredients present in Toombak revealed that its frequency of use is linked these SLT products was much higher than the 'target to the high risk HPV related oral cancer in Sudan.23 range' for potentially hazardous substances, according to the US Environmental Protection Nass, another similar form of chewable tobacco, is Agency.3 marketed in northern Pakistan, Iran and the Central Asian Republics with the same mode of dipping. Other studies on other SLT products in Pakistan The manufacturing procedure is also quite similar Figure 1: Disparity in oral lesions observed among naswar dippers of two cities showed a significant rise (p < 0.001) in the levels of except it is only partially cured, with addition of ash, heavy metals such as Cd, Ni, and Pb, in their cotton or sesame oil and lime.24 blood.16,17 The oral lesions in Peshawar naswar users showed culture from times unknown is due to the reason Trismus or dysphagia [21(35.6%)], ulcers, cuts or that there is a general perception that it is The powdered SLT popular in Ghana when tested CONCLUSION swelling [14(25.0%)] and pain [19(33.9%)]. Karachi completely harmless.9 Naswar, unlike other for concentration of thirty-four elements showed had high frequency for leukoplakia [(30(37.9%)], chewable tobacco products is not chewed, rather potentially toxic levels of Cr, Cd, Sb and Cu in the Epidemiological shift in behavior occurred due to Rough mucosa [43(54.4%)], Pain [17(21.5%)], Trismus placed in oral vestibule where after continuous samples which approximately was two to eight change in ecology. Naswar dippers (Pathans) (40%) or dysphagia [18(22.8%)] and ulcers, cuts or swelling exposure an oral wart develops. Since oral warts are times higher than dried tobacco leaves.18 developed other addictions, whereas, subjects [25(31.6%)]. not painful naswar dippers consider them harmless (22%) of other ethnicities became habitual to and do not accept its association with oral or lung Looking at the typography of oral lesions in Naswar naswar. HPV frequency was found higher in native DISCUSSION cancer.9,10 Nicotine along with other carcinogens in dippers in this study there were differences in lesions chewers (35.7%) compared to settlers and non these products, corrode the oral mucosa making in dippers of two cities. Karachi dippers had high naswar ethnicities (18.9%), this may be due to their In our study we observed that 42% of Pathans the surroundings favorable for viruses such as HPV to frequency of leukoplakia (37.9%) and rough other social practices. More comparative studies settlers in Karachi developed SLT habits of other settle in the epithelium and start replicating in mucosa (54.4%) which was not observed in are required to investigate this further. The medical, ethnicities, whereas, 21% subjects of other synchrony with the S-phase of the host. Oral cancer Peshawar dippers. This probably was due to dental, and public health communities need to join ethnicities became habitual to naswar who have a is becoming an epidemic in Pakistan affecting addiction to other SLT products such as Gutka, forces to combat this emerging threat.25 totally different culture and SLT practices. Karachi is people younger than the ones earlier reported. another advanced variety of SLT product which is a the biggest metropolitan city of Pakistan and cause of high frequency of premalignant lesions, people from all four provinces have migrated to A recent study on naswar in KPK revealed 68% of leukoplakia and erythroplakia.15 Rests of the lesions REFERENCES Karachi for better livelihood. Their chewable oral cancer in men and 38% in women are were the same in both cities with surprisingly similar tobacco habits have also crossed borders with attributed to naswar dipping.11 Comparative HPV frequency. 1. McClave-Regan AK, Berkowitz J. Smokers who them and have become part of shops in their testing in this study done on oral rinse samples of are also using smokeless tobacco products in the comfort zones, where all these products such as Pathan naswar users from Karachi and Peshawar Clinical and radiographic periodontal parameters US: a national assessment of characteristics, Gutka, Naswar, Paan and Arica nut are available, also revealed a declining trend in pathogenesis, in Naswar dippers has been observed significantly behaviors and beliefs of 'dual users'. Tob Control generally in the squatter settlements around the 18.3% in Karachi and 35.7% in Peshawar with a elevated (P <0.01) compared to control group with 2011;20(3):239-42. city. This movement has also been reported from significant difference (p-value <0.02). However, HPV Raman spectrum sharpest band at 1260 cm1 and 2. S Baig, MM Arif, M Obaid, Z Rubab. Pattern of other countries showing how human globalization frequency was found higher in subjects who Raman band at Amide I. whereas, rate of release substance abuse in multi ethnic groups in different has compelled ethnicity specific SLT customs to developed trismus after continuous use of SLT from dentin matrices of C-telopeptides pyridinoline localities of Karachi. Pak J Med Dent 2013; 1(1): travel with them. In London, borough Naswar of suggesting a high risk of oral squamous cell cross-links of type I collagen (ICTP) and C-terminal 47-54. Pakistani origin was found freely available in 15 carcinoma.12 crosslinked telopeptide (CTX) from gingival 3. Zakiullah, Saeed M, Muhammad N, Khan SA, Gul different outlets and purchasers were men of 32±10 collagen was found significantly higher (P < .05) F, Khuda F, et al. Assessment of potential toxicity of years of age with limited education who had little or Naswar has also been found to cause adverse compared to controls showing a higher degree of a smokeless tobacco product (naswar) available no knowledge of health related issues of Naswar, its cardiovascular affects by altering various collagen breakdown in the connective tissue with on the Pakistani market. Tob Control dependency or devastation related to behavioral biochemical markers when compared to controls. both bone and attachment loss due to naswar 2012;21(4):396-401. and socio-demographic factors.8 Such as levels of serum total cholesterol, LDL-C, dipping19. 4.ARC Monographs on the Evaluation of triglycerides and LDL-C/HDL-C ratio have been Carcinogenic Risks to Humans, No. 89. Smokeless Since, all these chewable products such as Gutka, found significantly increased (P<0.01), whereas, In Sweden, snus is the most popular SLT which tobacco and some tobacco-specific Naswar, Paan and Arica nut contain Nicotine and Glutathione per oxidase, super oxide dismutase surprisingly resembles naswar in manufacturing and N-nitrosamines: International Agency for Research hence people fall easy prey to its dependence, and HDL-C significantly reduced (P<0.01) in naswar dipping practices. A comprehensive review on on Cancer; 2007. especially the new generations. In Pakistan, the dippers.13 Naswar dipping compromises the adverse effects showed that Snus dipping, leads to 5.Niaz K, Maqbool F, Khan F, Bahadar H, Ismail unraveled popularity of Naswar in the Pathan Immune system by significantly lowering the levels non-malignant lesions that are reversible and Hassan F, Abdollahi M. Smokeless tobacco (paan

18 PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2019, VOL. 8 (02)

of interleukin 1β, however, no differences in the disappear if its use is stopped.20. The use of levels of serum IL-6 were observed by the smokeless tobacco in Sweden has been found to researchers. Similarly, Naswar was also found to be about 10-fold higher than the rest of Europe (17 alter thyroid function by significantly increasing countries) and more popular amongst men than serum FT3 and FT4 levels.14 Regarding levels of trace women.21 elements in blood, serum copper levels in naswar addicts were significantly raised with a mean of 5.1 Toombak is another naswar like product which is ± 2.4 µg/dl compared to mean of 2.6 ±0.1 µg/dl in marketed in Sudan. Unlike naswar a lot of research healthy control group(P = 0.005).15 has been found on Toombak where 40% of males are addicted to toombak dipping.22 Toombak like Evaluation of toxicity of multiple heavy and Naswar is used through dipping method. Similarly carcinogenic metals, noxious ingredients in naswar women users comprise only older women which of 30 Pakistani brands showed that calculated make up 10% of the users. HPV research on lifetime risk of cancer from the ingredients present in Toombak revealed that its frequency of use is linked these SLT products was much higher than the 'target to the high risk HPV related oral cancer in Sudan.23 range' for potentially hazardous substances, according to the US Environmental Protection Nass, another similar form of chewable tobacco, is Agency.3 marketed in northern Pakistan, Iran and the Central Asian Republics with the same mode of dipping. Other studies on other SLT products in Pakistan The manufacturing procedure is also quite similar showed a significant rise (p < 0.001) in the levels of except it is only partially cured, with addition of ash, heavy metals such as Cd, Ni, and Pb, in their cotton or sesame oil and lime.24 blood.16,17 The oral lesions in Peshawar naswar users showed culture from times unknown is due to the reason Trismus or dysphagia [21(35.6%)], ulcers, cuts or that there is a general perception that it is The powdered SLT popular in Ghana when tested CONCLUSION swelling [14(25.0%)] and pain [19(33.9%)]. Karachi completely harmless.9 Naswar, unlike other for concentration of thirty-four elements showed had high frequency for leukoplakia [(30(37.9%)], chewable tobacco products is not chewed, rather potentially toxic levels of Cr, Cd, Sb and Cu in the Epidemiological shift in behavior occurred due to Rough mucosa [43(54.4%)], Pain [17(21.5%)], Trismus placed in oral vestibule where after continuous samples which approximately was two to eight change in ecology. Naswar dippers (Pathans) (40%) or dysphagia [18(22.8%)] and ulcers, cuts or swelling exposure an oral wart develops. Since oral warts are times higher than dried tobacco leaves.18 developed other addictions, whereas, subjects [25(31.6%)]. not painful naswar dippers consider them harmless (22%) of other ethnicities became habitual to and do not accept its association with oral or lung Looking at the typography of oral lesions in Naswar naswar. HPV frequency was found higher in native DISCUSSION cancer.9,10 Nicotine along with other carcinogens in dippers in this study there were differences in lesions chewers (35.7%) compared to settlers and non these products, corrode the oral mucosa making in dippers of two cities. Karachi dippers had high naswar ethnicities (18.9%), this may be due to their In our study we observed that 42% of Pathans the surroundings favorable for viruses such as HPV to frequency of leukoplakia (37.9%) and rough other social practices. More comparative studies settlers in Karachi developed SLT habits of other settle in the epithelium and start replicating in mucosa (54.4%) which was not observed in are required to investigate this further. The medical, ethnicities, whereas, 21% subjects of other synchrony with the S-phase of the host. Oral cancer Peshawar dippers. This probably was due to dental, and public health communities need to join ethnicities became habitual to naswar who have a is becoming an epidemic in Pakistan affecting addiction to other SLT products such as Gutka, forces to combat this emerging threat.25 totally different culture and SLT practices. Karachi is people younger than the ones earlier reported. another advanced variety of SLT product which is a the biggest metropolitan city of Pakistan and cause of high frequency of premalignant lesions, people from all four provinces have migrated to A recent study on naswar in KPK revealed 68% of leukoplakia and erythroplakia.15 Rests of the lesions REFERENCES Karachi for better livelihood. Their chewable oral cancer in men and 38% in women are were the same in both cities with surprisingly similar tobacco habits have also crossed borders with attributed to naswar dipping.11 Comparative HPV frequency. 1. McClave-Regan AK, Berkowitz J. Smokers who them and have become part of shops in their testing in this study done on oral rinse samples of are also using smokeless tobacco products in the comfort zones, where all these products such as Pathan naswar users from Karachi and Peshawar Clinical and radiographic periodontal parameters US: a national assessment of characteristics, Gutka, Naswar, Paan and Arica nut are available, also revealed a declining trend in pathogenesis, in Naswar dippers has been observed significantly behaviors and beliefs of 'dual users'. Tob Control generally in the squatter settlements around the 18.3% in Karachi and 35.7% in Peshawar with a elevated (P <0.01) compared to control group with 2011;20(3):239-42. city. This movement has also been reported from significant difference (p-value <0.02). However, HPV Raman spectrum sharpest band at 1260 cm1 and 2. S Baig, MM Arif, M Obaid, Z Rubab. Pattern of other countries showing how human globalization frequency was found higher in subjects who Raman band at Amide I. whereas, rate of release substance abuse in multi ethnic groups in different has compelled ethnicity specific SLT customs to developed trismus after continuous use of SLT from dentin matrices of C-telopeptides pyridinoline localities of Karachi. Pak J Med Dent 2013; 1(1): travel with them. In London, borough Naswar of suggesting a high risk of oral squamous cell cross-links of type I collagen (ICTP) and C-terminal 47-54. Pakistani origin was found freely available in 15 carcinoma.12 crosslinked telopeptide (CTX) from gingival 3. Zakiullah, Saeed M, Muhammad N, Khan SA, Gul different outlets and purchasers were men of 32±10 collagen was found significantly higher (P < .05) F, Khuda F, et al. Assessment of potential toxicity of years of age with limited education who had little or Naswar has also been found to cause adverse compared to controls showing a higher degree of a smokeless tobacco product (naswar) available no knowledge of health related issues of Naswar, its cardiovascular affects by altering various collagen breakdown in the connective tissue with on the Pakistani market. Tob Control dependency or devastation related to behavioral biochemical markers when compared to controls. both bone and attachment loss due to naswar 2012;21(4):396-401. and socio-demographic factors.8 Such as levels of serum total cholesterol, LDL-C, dipping19. 4.ARC Monographs on the Evaluation of triglycerides and LDL-C/HDL-C ratio have been Carcinogenic Risks to Humans, No. 89. Smokeless Since, all these chewable products such as Gutka, found significantly increased (P<0.01), whereas, In Sweden, snus is the most popular SLT which tobacco and some tobacco-specific Naswar, Paan and Arica nut contain Nicotine and Glutathione per oxidase, super oxide dismutase surprisingly resembles naswar in manufacturing and N-nitrosamines: International Agency for Research hence people fall easy prey to its dependence, and HDL-C significantly reduced (P<0.01) in naswar dipping practices. A comprehensive review on on Cancer; 2007. especially the new generations. In Pakistan, the dippers.13 Naswar dipping compromises the adverse effects showed that Snus dipping, leads to 5.Niaz K, Maqbool F, Khan F, Bahadar H, Ismail unraveled popularity of Naswar in the Pathan Immune system by significantly lowering the levels non-malignant lesions that are reversible and Hassan F, Abdollahi M. Smokeless tobacco (paan

PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2019, VOL. 8 (02) 19

and gutkha) consumption, prevalence, and Tobacco) Addicts Using Flame Atomic Absorption contribution to oral cancer. Epidemiol Health 2017; Spectroscopy. Arch Iran Med 2017;20(10):649. 39: e2017009. 16.Kazi TG, Arain SS, Afridi HI, Naeemullah, Brahman 6.Stanfill SB, Connolly GN, Zhang L, Jia LT, KD, Kolachi NF, et al. Analysis of cadmium, nickel, Henningfield JE, Richter P, et al. Global surveillance and lead in commercial moist and dry snuff used in of oral tobacco products: total nicotine, unionised Pakistan. Environ Monit Assess 2013;185(6):5199-208. nicotine and tobacco-specific N-nitrosamines. Tob 17.Arain SS, Kazi TG, Afridi HI, Brahman KD, Control 2011;20(3):e2. Naeemullah, Khan S, et al. Preconcentration and 7.MH Lucky, S Baig. Isolation of DNA from Oral Rinse determination of lead and cadmium levels in blood in HPV Positive Patients. J Coll Phys Surg Pak 2013; 23 samples of adolescent workers consuming (7): 455-8. smokeless tobacco products in Pakistan. Environ 8.Basharat S, Kassim S, Croucher R. Availability and Monit Assess 2015;187(5):309. use of Naswar: an exploratory study. J Public Health 18.MA Addo, J K Gbadago, H A Affum, T Adom, K 2011;34(1):60-4. Ahmed, GM Okley. Mineral profile of Ghanaian 9.Ali S, Wazir K, Rahman MA, Qadir S. NASWAR. dried tobacco leaves and local snuff: A Professional Med J 2017;24(3). comparative study. J Radioanal Nucl Chem 2008; 10.Baig S, Z Rubab, MM Arif, MH Lucky. Chewable 277 (3): 517. risk factors-Threatened oral cancer HPV's Looming 19.Daood U, Abduljabbar T, Al‐Hamoudi N, Akram Z. Epidemic in Pakistan. European J Biotechnol Biosci Clinical and radiographic periodontal parameters 2015; 3(1): 39-45. and release of collagen degradation biomarkers in 11.Khan Z, Dreger S, Shah SMH, Pohlabeln H, Khan S, naswar dippers. J Periodontal Res 2018;53(1):123-30. Ullah Z, et al. Oral cancer via the bargain bin: The 20.Ahlbom A, Olsson U, Parshagen G. Health risk of oral cancer associated with a smokeless hazards of moist snuff. Report of the National Board tobacco product (Naswar). PloS One of Health and Welfare, Sweden, 1997. 2017;12(7):e0180445. 21.Leon ME, Lugo A, Boffetta P, Gilmore A, Ross H, 12.Z Rubab, AM Mughal, S Baig, MH Lucky, MA Schüz J. Smokeless tobacco use in Sweden and Khan. Relationship of Human Papilloma Virus with other 17 European countries. Eur J Public Health Trismus in Chewable Tobacco Users Pakistan. J Med 2016;26(5):817-21. Dent 2013; 2(01): 3-11. 22.Idris A, Prokopczyk B, Hoffmann D. Toombak: a 13.Sajid F, Bano S. Effects of smokeless dipping major risk factor for cancer of the oral cavity in tobacco (Naswar) consumption on antioxidant Sudan. Preventive Med 1994;23(6):832-9. enzymes and lipid profile in its users. Pak J Pharm Sci 23.Ahmed HG. Aetiology of oral cancer in the 2015;28: 1829-33. Sudan. J Oral Maxillofac Res 2013; 4(2): e3. 14.Sajid F, Bano S. Pro inflammatory interleukins and 24.Gupta PC, Ray CS. Smokeless tobacco and thyroid function in Naswar (dipping tobacco) users: health in India and South Asia. Respirology a case control study. BMC Endocr Disord 2003;8(4):419-31. 2016;16(1):47. 25.Changrani J, Gany F. Paan and Gutka in the 15.Ullah A, Khan A, Iqbal Z, Khan I. Evaluation of United States: an emerging threat. J Immigrant Serum Copper Level in Naswar (Smokeless Health 2005;7(2):103-8. of interleukin 1β, however, no differences in the disappear if its use is stopped.20. The use of levels of serum IL-6 were observed by the smokeless tobacco in Sweden has been found to researchers. Similarly, Naswar was also found to be about 10-fold higher than the rest of Europe (17 alter thyroid function by significantly increasing countries) and more popular amongst men than serum FT3 and FT4 levels.14 Regarding levels of trace women.21 elements in blood, serum copper levels in naswar addicts were significantly raised with a mean of 5.1 Toombak is another naswar like product which is ± 2.4 µg/dl compared to mean of 2.6 ±0.1 µg/dl in marketed in Sudan. Unlike naswar a lot of research healthy control group(P = 0.005).15 has been found on Toombak where 40% of males are addicted to toombak dipping.22 Toombak like Evaluation of toxicity of multiple heavy and Naswar is used through dipping method. Similarly carcinogenic metals, noxious ingredients in naswar women users comprise only older women which of 30 Pakistani brands showed that calculated make up 10% of the users. HPV research on lifetime risk of cancer from the ingredients present in Toombak revealed that its frequency of use is linked these SLT products was much higher than the 'target to the high risk HPV related oral cancer in Sudan.23 range' for potentially hazardous substances, according to the US Environmental Protection Nass, another similar form of chewable tobacco, is Agency.3 marketed in northern Pakistan, Iran and the Central Asian Republics with the same mode of dipping. Other studies on other SLT products in Pakistan The manufacturing procedure is also quite similar showed a significant rise (p < 0.001) in the levels of except it is only partially cured, with addition of ash, heavy metals such as Cd, Ni, and Pb, in their cotton or sesame oil and lime.24 blood.16,17 The oral lesions in Peshawar naswar users showed culture from times unknown is due to the reason Trismus or dysphagia [21(35.6%)], ulcers, cuts or that there is a general perception that it is The powdered SLT popular in Ghana when tested CONCLUSION swelling [14(25.0%)] and pain [19(33.9%)]. Karachi completely harmless.9 Naswar, unlike other for concentration of thirty-four elements showed had high frequency for leukoplakia [(30(37.9%)], chewable tobacco products is not chewed, rather potentially toxic levels of Cr, Cd, Sb and Cu in the Epidemiological shift in behavior occurred due to Rough mucosa [43(54.4%)], Pain [17(21.5%)], Trismus placed in oral vestibule where after continuous samples which approximately was two to eight change in ecology. Naswar dippers (Pathans) (40%) or dysphagia [18(22.8%)] and ulcers, cuts or swelling exposure an oral wart develops. Since oral warts are times higher than dried tobacco leaves.18 developed other addictions, whereas, subjects [25(31.6%)]. not painful naswar dippers consider them harmless (22%) of other ethnicities became habitual to and do not accept its association with oral or lung Looking at the typography of oral lesions in Naswar naswar. HPV frequency was found higher in native DISCUSSION cancer.9,10 Nicotine along with other carcinogens in dippers in this study there were differences in lesions chewers (35.7%) compared to settlers and non these products, corrode the oral mucosa making in dippers of two cities. Karachi dippers had high naswar ethnicities (18.9%), this may be due to their In our study we observed that 42% of Pathans the surroundings favorable for viruses such as HPV to frequency of leukoplakia (37.9%) and rough other social practices. More comparative studies settlers in Karachi developed SLT habits of other settle in the epithelium and start replicating in mucosa (54.4%) which was not observed in are required to investigate this further. The medical, ethnicities, whereas, 21% subjects of other synchrony with the S-phase of the host. Oral cancer Peshawar dippers. This probably was due to dental, and public health communities need to join ethnicities became habitual to naswar who have a is becoming an epidemic in Pakistan affecting addiction to other SLT products such as Gutka, forces to combat this emerging threat.25 totally different culture and SLT practices. Karachi is people younger than the ones earlier reported. another advanced variety of SLT product which is a the biggest metropolitan city of Pakistan and cause of high frequency of premalignant lesions, people from all four provinces have migrated to A recent study on naswar in KPK revealed 68% of leukoplakia and erythroplakia.15 Rests of the lesions REFERENCES Karachi for better livelihood. Their chewable oral cancer in men and 38% in women are were the same in both cities with surprisingly similar tobacco habits have also crossed borders with attributed to naswar dipping.11 Comparative HPV frequency. 1. McClave-Regan AK, Berkowitz J. Smokers who them and have become part of shops in their testing in this study done on oral rinse samples of are also using smokeless tobacco products in the comfort zones, where all these products such as Pathan naswar users from Karachi and Peshawar Clinical and radiographic periodontal parameters US: a national assessment of characteristics, Gutka, Naswar, Paan and Arica nut are available, also revealed a declining trend in pathogenesis, in Naswar dippers has been observed significantly behaviors and beliefs of 'dual users'. Tob Control generally in the squatter settlements around the 18.3% in Karachi and 35.7% in Peshawar with a elevated (P <0.01) compared to control group with 2011;20(3):239-42. city. This movement has also been reported from significant difference (p-value <0.02). However, HPV Raman spectrum sharpest band at 1260 cm1 and 2. S Baig, MM Arif, M Obaid, Z Rubab. Pattern of other countries showing how human globalization frequency was found higher in subjects who Raman band at Amide I. whereas, rate of release substance abuse in multi ethnic groups in different has compelled ethnicity specific SLT customs to developed trismus after continuous use of SLT from dentin matrices of C-telopeptides pyridinoline localities of Karachi. Pak J Med Dent 2013; 1(1): travel with them. In London, borough Naswar of suggesting a high risk of oral squamous cell cross-links of type I collagen (ICTP) and C-terminal 47-54. Pakistani origin was found freely available in 15 carcinoma.12 crosslinked telopeptide (CTX) from gingival 3. Zakiullah, Saeed M, Muhammad N, Khan SA, Gul different outlets and purchasers were men of 32±10 collagen was found significantly higher (P < .05) F, Khuda F, et al. Assessment of potential toxicity of years of age with limited education who had little or Naswar has also been found to cause adverse compared to controls showing a higher degree of a smokeless tobacco product (naswar) available no knowledge of health related issues of Naswar, its cardiovascular affects by altering various collagen breakdown in the connective tissue with on the Pakistani market. Tob Control dependency or devastation related to behavioral biochemical markers when compared to controls. both bone and attachment loss due to naswar 2012;21(4):396-401. and socio-demographic factors.8 Such as levels of serum total cholesterol, LDL-C, dipping19. 4.ARC Monographs on the Evaluation of triglycerides and LDL-C/HDL-C ratio have been Carcinogenic Risks to Humans, No. 89. Smokeless Since, all these chewable products such as Gutka, found significantly increased (P<0.01), whereas, In Sweden, snus is the most popular SLT which tobacco and some tobacco-specific Naswar, Paan and Arica nut contain Nicotine and Glutathione per oxidase, super oxide dismutase surprisingly resembles naswar in manufacturing and N-nitrosamines: International Agency for Research hence people fall easy prey to its dependence, and HDL-C significantly reduced (P<0.01) in naswar dipping practices. A comprehensive review on on Cancer; 2007. especially the new generations. In Pakistan, the dippers.13 Naswar dipping compromises the adverse effects showed that Snus dipping, leads to 5.Niaz K, Maqbool F, Khan F, Bahadar H, Ismail unraveled popularity of Naswar in the Pathan Immune system by significantly lowering the levels non-malignant lesions that are reversible and Hassan F, Abdollahi M. Smokeless tobacco (paan

NASWAR DIPPING, SHIFT IN BEHAVIOR IN MULTI ETHNICITY SETTING

INTRODUCTION chronic cough, which leaves the sufferer with progressively deteriorating respiratory function and The term Chronic Obstructive Pulmonary Disease a severe decrease in their quality of life 3. The Global (COPD) was first used by Dr. William Briscoe at the 9th Initiative for Obstructive Lung Disease (GOLD) has Aspen Emphysema Conference in 1965, and was a recommended that COPD be diagnosed based on nomenclature coined to encompass the two the clinical symptoms of chronic bronchitis (cough diseases previously known as Emphysema and and sputum production for at least 3 months/year Chronic Bronchitis1. COPD presents as chronic for at least two years) or emphysema inflammation of the lungs with the eventual (breathlessness and coughing), confirmed by sequelae of respiratory compromise and distress 2-4. obstructed airflow measured with spirometry4. This disease has the hallmark symptoms of breathlessness, excessive sputum production and a COPD is an emerging burden on the global

20 PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2019, VOL. 8 (02)

healthcare system as it is quickly climbing to self-administered questionnaires we hope to raise until they felt comfortable. Participants were asked 63.3% of subjects with COPD presented with cough, become a leading cause of morbidity and awareness about this debilitating disease and to to refrain from smoking for at least 1 hour prior to the both statistically significant (p-value 0.000). 71.4% of mortality. In a study done it was found that COPD promote a system of early diagnosis and finding procedure. Spirometry was conducted in standing subjects who had obstruction produced phlegm alone is responsible for approximately 2.75 million and eliminating contributing risk factors. position without nose clips and ATS repeatability that was statistically significant( p-value 0.000) 76.2% deaths worldwide and the World Health criteria were used for quality assessment of the of subjects with COPD had phlegm but was not Organization (WHO) has estimated that by the year METHODS spirometry maneuver. Results of three acceptable statistically significant( p-value 0.376) Obstruction 2020, COPD will be the 5th leading cause of death readings were recorded and best of the three was present in 82.2% of those with wheeze and and disability5-6, In 2012 an international survey This cross sectional study was conducted in Primary readings was used for analysis in this study. A trained 33.9% of subjects with COPD were wheezers, both BREATHE was carried out in 11 countries from North Health Care center Sikanderabad where majority is technician who was also well versed with local statistically significant results ( p-value 0.000) 100% of African regions and the Middle East including Pashtun population comprising 100000 people language conducted spirometry. subjects with COPD had grade 4 dyspnea. 80%, Pakistan7 . The survey revealed that the prevalence approximately. Study was conducted between 56.2, 54.0 and 92% of subjects with COPD had rate of COPD in those 11 countries was 3.6% and the June 2017 till May 2018. Sample size was calculated Data was analyzed using SPSS 20. Mean and mrcdyspnea score of 3,2,1 an0 respectively but the prevalence rate in Pakistan of COPD was 2.1% in the from WHO calculator that came out to be 150. standard deviation were taken out for numerical results were not statistically significant p-value 0.049 population aged 40 years and above. According to data. Categorical data was shown in frequency (Table 2). a retrospective case series study conducted at the A modified version of the American Thoracic and percentage. Chi-square was taken out to see Aga Khan University Hospital Karachi, the Society division of lung disease questionnaire was association of risk factors with the outcome. P-value 39.3% of those with obstructive pathology had pets prevalence of airflow obstruction is 5.7%8. used to record the presence of respiratory <0.05 was considered significant. in their houses and 73.2% of COPDers were pet symptoms. It included questions regarding frequent keepers but the results were not statistically The truth of the matter is that the epidemiological cough (defined as presence of cough on most days RESULTS significant, p-value 0.565 and 0.368 respectively. findings regarding COPD are severely for 3 consecutive months or more during the year), 75% , 61.5 %, 68.2% and 77.8% of those who had underestimated due to the fact that patients are chronic cough (defined as presence of cough for 3 Mean age of the study population was 27.67 years COPD had formal education of more than 11 years, not diagnosed as having the disease until it is consecutive months in 2 consecutive years), with standard deviation of 19.53. 57% of males and 6-10 years, 1-5 years and 0 years respectively but clinically apparent and fairly advanced5. A good frequent phlegm (defined as bringing up phlegm 16.7 % of females had some sort of obstruction. the results were statistically insignificant (p value example of this circumstance comes from a on most days of month, for 3 consecutive months or Result was statistically significant (p-value 0.000) 0.589). Swedish study that estimated that only 20-30% of more in a year), chronic phlegm (presence of 55.6% and 84.6% of those who had COPD were subjects with COPD who met the COPD criteria had phlegm for 3 consecutive months in 2 consecutive males and females respectively. Again statistically Frequency of Restrictive Lung Disease was 4.7% in been diagnosed as having COPD . It is due to this years), frequent wheezing (whistling sound heard significant (p-value0.000). our study. Of those with restriction 6 were females reason that epidemiological data on COPD in the on expiration within 2 years), chronic wheezing and there was only 1 male. In the diseased Middle East and North African regions is confined (whistling sounds heard on expiration more than 2 32.9% of subjects participating in the study had population, 1 (1.3%) had past history of restrictive and limited to small areas and does not reflect years). MRC dyspnea scale is categorized into 5 obstruction P -value 0.402 so result was not disorder with p- value 0.05 that is statistically national prevalence estimates. grades. Grade 0 is not troubled by breathlessness statistically significant. 69.7% of those with COPD significant. Most people with restrictive lung disorder except on strenuous exercise. Grade 1 is short of had past history present but the results were belonged to Pushtoon community 6 (5.7%) and In contrast to COPD, restrictive lung disease is a breadth when hurrying on a level or walking up a insignificant (p-value0.471). 1(1.3%) was Urdu speaking but the result is significant lung pathology characterized by slight hill. Grade 2 is walks slower than most people statistically insignificant (p value 0.719). 1 person reduced lung volumes. Lung volumes can be on a level, stops after a mile or so, or stops after 15 77.8% of those with obstruction had chemical (5.6%) had exposure to chemicals, again statistically reduced either because of intrinsic factors such as min walking at own pace. Grade 3 is stops for exposure in the past, which was statistically insignificant (p-value 0.599) Subjects with restrictive an alteration in lung parenchyma, or because of breadth after walking 100 yards or after a few significant (<0.00). 61.1% of those with COPD had lung disease were mostly illiterate i.e. 5(11.1%), extrinsic factors including disease of the pleura, minutes on level ground. Grade 4 is too breathless chemical exposure but it was not statistically 2(2.3%) had primary education but the relation is chest wall, or neuromuscular apparatus. Most to leave the house or breathless while undressing. significant (p-value 0.246)(Table 1). statistically insignificant (p-value 0.196). There was commonly they occur due to interstitial disease of only 1 smoker (2.5%) identified with restriction ( p the lung following fibrosis. In case of intrinsic lung The age, height and sex predicted values of Forced 82.5% of those who had obstruction were smokers, value 0.701), but the duration of smoking was less disease, the physiological effects of diffuse Vital Capacity (FVC), forced expiratory volume in which was statistically significant. (p-value <0.00) than 1 year(p value 0.57), both statistically parenchymal disorders reduce all lung volumes by one second (FEV1) and their ratio (FEV1/FVC) were 42.5% of those with COPD were smokers which was insignificant. When clinical presentation was looked the excessive elastic recoil of the lungs, relative to recorded in milliliters (ml) and percentages. also statistically significant (p-value <0.00) 80% of upon, cough, phlegm and wheeze was present in 6 the outward recoil forces of the chest wall. Predicted lung volumes i.e. forced vital capacity those with obstructive lung pathology smoked more (5% p-value 0.9), 1 (4.8% p-value 0.9) and 5 (8.1% Expiratory airflow is reduced in proportion to lung (FVC), forced expiratory volume in one second than 11 years .87.5% , 71.4% and 24.5% with p-value 0.104) subjects respectively. MRC dyspnea volume. Intrinsic factors include; pneumonia, (FEV1) and their ratio (FEV1/FVC) were recorded obstruction had smoked 6-10 yrs, 1-5 years and 0 score came out to be statistically significant tuberculosis, lung cancers and sarcoidosis. Diseases using portable spirometer. Predicted percentage of years respectively which is statistically significant (p-value 0.001). Most of the people with restriction of extrinsic structures result in lung restriction, ≥ 80% for FVC and FEV1 and FEV1/FVC ratio of ≥0.7 (p-value 0.000) Similarly statistically significant results had Grade 2 level dyspnea in which one walks impaired ventilatory function, and respiratory failure were considered as cut off for lung function tests to were seen (p-value 0.00) with those who did not slower than most people on a level, stops after a (e.g., non-muscular diseases of the chest wall, be normal. These cut-offs are generally used achieve reversibility and were labeled COPD. 100%, mile or so, or stops after 15 min walking at own neuromuscular disorders). Pleural effusion, kyphosis, internationally for categorizing lung volumes as 37.5%, 28.6% and 75.4% of those who had COPD pace. They were 4 individuals (25%). 2 (2.1%) had no obesity, ascites and muscular dystrophy are a few normal or abnormal10. smoked more than 11 years, 6-10 yrs, 1-5 years and dyspnea and 1 (10%) was identified with grade 3 examples of pathologies that can cause restricted 0 years respectively. dyspnea in which an individual stops for breadth lung capacity. Obstructive lung function was defined as having after walking 100 yards, or after a few minutes on FEV1<80% and FEV1/FVC <70% and restrictive lung 45% of those who had obstructive lung disease and level ground. The aim of our study therefore is to determine the function was defined as having FEV1<80% and prevalence of COPD and Restrictive Lung FEV1/FVC >70% .Those whose FEV1 did not improve pathologies and to associate key risk factors with >12% post bronchodilation were labeled COPDers. them. Any targeted research specific to the prevalence and risk factors of COPD and Restriction Participants were explained the procedure of in Pakistan is scarce. With the help of spirometry in detail and were allowed to practice