Tobacco and South Asians

Prepared by:

South Asian Network

18173 S. Pioneer Blvd., Suite I, Artesia, CA 90701 www.southasiannetwork.org 562-403-0488

Who are South Asians?

South Asians are usually defined as individuals with origins from Bangladesh, India, Nepal, Pakistan, Sri Lanka as well as other regions from the Indian subcontinent¹. South Asians have immigrated to many regions around the globe, including the United States. In the U.S., South Asian subgroups have shown rapid increases in population, ranging from 249% for Bangladeshis to 84% for Sri Lankans in the decade between 1990 and 2000². There are over 300,000 South Asians residing in both California and New York, followed by New Jersey, Texas, and Illinois, all with populations over 100,000².

Specific information about South Asians in the U.S. is often combined into an Asian and Pacific Islander (API) ethnic category, despite a distinct set of cultural, religious, geographic, and linguistic backgrounds. This lack of demographic separation often does not allow specific cultural behaviors, including those pertinent to health outcomes, to be elucidated for research, program planning, and intervention. As with many API groups, the “model minority” myth which labels South Asians as “healthy and wealthy”, also contributes to lack of attention paid to health behaviors and disease outcomes by health researchers, educators, and practitioners. Despite marked health disparities in South Asians globally, little is known about the health status of South Asians in the U.S.

Do South Asians use tobacco?

With the recent backlash against tobacco marketing in the U.S., tobacco companies have begun targeting specific communities as potential markets for commercial tobacco sales^3;4. One such advertising target is the Asian and Pacific Islander community^5;6. Much of that advertising is specifically geared toward South Asians⁷, both domestically and internationally. Initial studies have suggested that U.S. residents of Asian Indian origin (the predominant South Asian ethnic group in the U.S.) have lower rates of smoking than other Asian groups⁸. Most population-based studies inquire about traditional “Western” tobacco products, such as cigarettes and snuff. However, little is known about culturally-specific tobacco products used by South Asians in the U.S., and potential differences in tobacco-use behavior across various subgroups, such as gender, generational status, geographic region of origin, era of migration, and influences of acculturation.

What tobacco products are used commonly by South Asians?

In addition to cigarettes, snuff, and other “Western” products, there is a class of South Asian indigenous tobacco products that are in common use in the subcontinent and in densely-populated South Asian areas worldwide. Some of the more commonly known products, both smoked and smokeless, are known as bidis, zarda, and paan masala. Bidis are small, hand-rolled cigarettes, wrapped together in a tendu leaf and smoked without a filter⁹. Zarda is a tobacco mixture with betel nut, lime, and other spices which are usually chewed¹⁰. Paan masala is a similar chewable tobacco product, which can be commercially manufactured or homemade. It consists of sweet tobacco, betel nut and other flavoring ingredients, wrapped together in a betel-leaf and chewed as a quid¹¹. Many other manifestations and names are used for these and other South Asian tobacco products. In addition, certain products are socially sanctioned for specific purposes (as a digestive aid or breath freshener) or culturally important events (weddings, religious festivals), while others may have value or stigma attached to their use by various South Asian subgroups¹².

Why is this important?

South Asians in the Indian subcontinent and the United Kingdom have a high occurrence of tobacco-related diseases. The leading cause of death for South Asians in the U.S. is cardiovascular (heart) disease¹³. Likewise, oral cancer accounts for 30% of all South Asian cancers, approximately 5-7 times that of the U.S. population¹⁴. Additionally, ninety percent of oral cancers in India are estimated to be tobacco-related¹⁵. Similarly, the British Dental Association and Queen County (New York) Dental Society have expressed concern over the early onset of oral cancer in South Asian patients¹⁶. Tobacco use contributes to both these conditions. For instance, bidis have been shown independently to cause various cancers of the mouth (in addition to lung cancer), while also contributing to high blood pressure and coronary heart disease, both risk factors for cardiovascular disease¹⁷. The chewed products zarda and paan masala, which contain tobacco and betel-nut, have been shown to be cancer causing, especially to the oral tissues next to which they sit^{18; 19}, resulting in a high rate of oral cancers by users. In addition, South Asian subgroups (such as gender and region of origin) in the U.K. have been shown to use different products and for different reasons²⁰. Although large-scale studies about culturally-specific tobacco products used by South Asians has not been conducted in the U.S., a study in three South Asian communities in Northern California have suggested differences by gender, place of residence, and region of origin in types of tobacco products used and how often these products are used¹². In addition, data from focus groups conducted with South Asian women in Los Angeles, revealed that the majority of participants chewed zarda regularly and almost half of the participants had used bidis and other smoked products in their families²¹.

What are the implications?

South Asians are one of the fastest growing ethnic groups in the U.S. Most information about tobacco-related health issues pertaining to South Asians has generally come from other countries or smaller studies done in the U.S. Little is known about South Asian American values, behaviors, and practices relating to health, especially regarding culturally-specific tobacco products and patterns of use. Likewise, there is little information available about the tobacco content and commercial manufacturing of these products as well as the trade routes in which these products enter the U.S. This lack of information makes it difficult for policy makers and health practitioners to develop culturally appropriate and targeted intervention strategies to reduce or prevent the use of tobacco in this population. Similarly, there is little knowledge about protective cultural behaviors or effects of acculturation which need to be better understood for health education and program planning.

Recommendations:

Given the necessity for information about South Asian tobacco products and use patterns, the following are recommendations for policy makers, public health professionals, and clinicians to effectively reduce or prevent the use of tobacco in this population.

• Separate collection of data for South Asian ethnic groups (along with others) from the larger Asian and Pacific Islander (API) demographic category.
• Research targeted toward understanding the scope of tobacco products used by South Asians as well as the value and stigma ascribed to use of various products by South Asian subgroups (such as gender, region of origin, generational status, era of migration and level of acculturation).
• Policy research about which manufacturers produce South Asian tobacco products internationally, the mechanisms in which these tobacco items enter the U.S., and potential targeting of South Asians for advertising and sale.
• Culturally appropriate surveillance of tobacco use, related health behaviors, and pertinent health outcomes at the statewide and national level for South Asians.
• Design and implementation of community driven and targeted intervention strategies geared toward reducing the prevalence of tobacco-related diseases and establishment of culturally-appropriate methods to curb tobacco-use in South Asian subgroups.

About South Asian Network:

The South Asian Network (SAN) is a non-profit grassroots community-based organization dedicated to promoting the health, empowerment, and solidarity of persons of South Asian origin. Fundamental to SAN’s mission is the promotion of equality to all.

This document was made possible by funds received from the California Department of Health Services, Tobacco Control Section in partnership with APITEN, under grant # 00-91584.

Authors*:

Arnab Mukherjea, MPH (School of Public Health; University of California, Berkeley)

Punam Parikh, MPH (South Asian Network)

Reviewers*:

Zul Surani (National Cancer Institutes' Cancer Information Service; University of Southern California-Norris Comprehensive Cancer Center)

Susan L. Ivey, MD, MHSA (Center for Family and Community Health; School of Public Health; University of California, Berkeley)

The authors gratefully acknowledge Ms. Dipa Shah, MPH, for her help with the design and formatting of this document.

*The information and opinions represented in this document are those of the authors and not necessarily of the organizations with which they are affiliated.

Citations:

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² U.S. Census Bureau 2000. Available at: http://www.census.gov/

³ Pollay RW, Lee JS, Carter-Whitney D. Separate, but not equal: racial segmentation in cigarette advertising. J Advertising. 1992;21:45–58.

⁴ Smith EA, Malone, RE. The Outing of Philip Morris: Advertising Tobacco to Gay Men. American Journal of Public Health 2003;93: 988-93

⁵ Lew R. Tobacco Industry Documents, the AAPI Community, and the Need for Social Justice. Asian Pacific Partners for Empowerment and Leadership (APPEAL). Presented at: 2003 Asian American Network for Cancer Awareness, Research, and Training (AANCART) Academy, Los Angeles, CA; October 24-25 2003.

⁶ Muggli ME, Pollay RW, Lew R, Joseph AM. Targeting of Asian Americans and Pacific Islanders by the tobacco industry: results from the Minnesota Tobacco Document Depository. Tobacco Control, September 2002; 3(11).

⁷ Anand, B. Philip Morris sees India as next Marlboro country. The Economic Times. November 6, 2003.

⁸ McCarthy W, Hanson T, Zheng H, Dietsch B, Beddo V. Divergent Tobacco Use Patterns Among Californians of Asian Indian, Korean, and Filipino Ancestry. Presented at: 2002 National Conference on Tobacco or Health, San Francisco, CA; November, 2002.

⁹ Robbins, LT. Flavored Cigarettes (Bidis) Popular Among Youth. Legislative Brief 9(45), National Conferences of State Legislatures; November/December 2001.

¹⁰ Puttaiah R, Carley K, Holavanahalli R. Tobacco, betel-quid chewing, and oral health. In: Bedi R, Jones P. (eds) Tobacco and betel-quid chewing among the Bangladeshi community in the United Kingdom. Centre for Transcultural Oral Health, London, 1995.

¹¹ Wasnik KS, Ughade SN. Tobacco consumption practices and risk of oro-pharyngeal cancer: a case-control study in Central India. Southeast Asian J Trop Med Public Health 1998; 29(4): 827 – 834.

¹² Mukherjea A, Ivey SL, Moskowitz J. Tobacco use patterns in the Cardiovascular Health in Asian Indians (CHAI) Study. Center for Family and Community Health, School of Public Health, University of California, Berkeley. Presented at: 2003 American Public Health Association (APHA) National Meeting and Exposition; November 15-19, 2003.

¹³ Ivey, SL, Khatta M, Vedanthan, R. Cardiovascular Disease. In: A Brown Paper: The Health of South Asians in the United States. South Asian Public Health Association, Baltimore, MD; October 2002.

¹⁴ Shire N. Studying Tumors Around the World. Texas Medical Center News, University of Texas- Houston Medical School. March 1, 1999.

¹⁵ Babu, KG. Oral Cancers in India. Semin Oncol 2001; 28: 169-173

¹⁶ Knight D. NEIGHBORHOOD REPORT: JACKSON HEIGHTS; To Asians a Spicy Chew, to Doctors a Deadly Habit. New York Times, November, 10, 2002.

¹⁷ Greene A. “Bidis Are More Dangerous Than Cigarettes.” Greene Ink Inc. May, 1999. Accessed at http://askdrgreene.org/

¹⁸ International Agency for Research on Cancer. IARC monograph on the evaluation of carcinogenic risk of chemicals to humans. Tobacco habits other than smoking; betel quid and areca-nut chewing: and some related nitrosamines. Lyons: IARC, 1985.

¹⁹ International Agency for Research on Cancer. IARC Press Release 2003. IARC Monographs Programme finds betel-quid and areca-nut chewing carcinogenic to humans. Lyons: IARC, August 7, 2003.

²⁰ Vora AR, Yeoman CM, Hayter JP. Alcohol, tobacco and paan use and understanding of oral cancer risk among Asian males in Leicester. British Dental Journal. 2000;188: 444-450.

²¹ Parikh, P. Preliminary findings from focus groups conducted with South Asian Bangla, Hindi and Gujarati speaking women from October – December 2003. Unpublished data, South Asian Network; School of Public Health, University of California, Los Angeles; 2003.