• By Dartington SRU
  • Posted on Thursday 25th June, 2009

Paan is caught in the cultural crossfire

Red saliva stains spattered on walls and pavements are a disconcerting accompaniment to street life in parts of India.The chewing – and spitting – mixture is known as paan and is usually a blend of powdered tobacco, spices and areca nut, wrapped in a betel leaf and tucked into the cheek.Along with cigarettes, the modern varieties of paan have contributed to the rapidly escalating tobacco problem in the sub-continent. The World Health Organisation is unsure of the prevalence of tobacco use, but estimates range from between 30 and 70%. Chewing tobacco makes up a large proportion and its use among young people is increasing rapidly.Over 5,000 are estimated to start using tobacco products every day, and experts are predicting that by 2020, tobacco will account for 13% of deaths across the subcontinent. With these shocking figures in prospect, prevention efforts have been weighing on the minds of researchers, policy makers and advocacy groups in India and abroad. In 2004 Project MYTRI (Mobilizing Youth for Tobacco Related Initiatives in India) was set up as a collaboration between prevention scientists at the University of Minnesota and an Indian NGO (Health-Related Information Dissemination Amongst Youth). The objective was to translate and test expertise in tobacco prevention imported from the US. Project MYTRI was set up in 32 schools with over 8,000 children in Delhi and Chennai. Schools were matched according to type - for example private or public, co-ed or single sex - and then randomly assigned to receive the two-year program. The content included a classroom curriculum, posters around schools, a postcards-to-parents campaign and peer-led health activism.Workers hoped to lower rates of smoking by educating children about the health risks of tobacco, changing their beliefs, increasing skills to resist peer pressure, and promoting tobacco-free norms at home and school. Results at the end of the first year were promising: students allocated to the program had begun to say they did not intend to chew or smoke tobacco in future - although there was no discernible fall in actual smoking rates. Outcomes after two years, recently published in Cancer, Epidemiology, Biomarkers and Prevention, show that young people receiving the program have proved to be less likely to smoke, but the reductions do not translate to reductions in paan chewing. The program designers suggest that attention focused too much on the consequences, influences and social norms relating principally to smoking. Paan use is far older and more ingrained in Indian society than cigarettes. Tobacco was an 18th century addition to the recipe but people have been chewing some form of the mixture for over 2,000 years and it is an aspect of many rituals. MYTRI was based on elements of proven US tobacco prevention programs such as Project Northland and the Minnesota Smoking Prevention Program whose originators were oblivious to this dimension of the Indian tobacco problem. However, the MYTRI designers did draw on social cognitive and social influences theory, as well as in-depth audience research with young people. Several of the mediating factors were found to be working differently in India, however, and the research team is recommending extensive qualitative exploration of the contextual factors that might affect its impact. See:Stigler M H, Perry C L, Arora M, Shrivastav R, Mathur C and Reddy KS (2007), “Intermediate Outcomes from Project MYTRI: Mobilising Youth for Tobacco-Related Initiatives in India”, Cancer Epidemiology Biomarkers and Prevention, 16, 6, pp. 1050-1056Bate S L, Stigler M H, Thompson M S, Arora M, Perry C L, Reddy K S and Mackinnon D P (2009), “Psychosocial Mediators of a School-Based Tobacco Prevention Program in India: Results from the First Year of Project MYTRI”, Prevention Science, 10, 2, pp.116-12Perry C L, Stigler M H, Arora M and Reddy K S (2009), “Preventing Tobacco Use Among Young People in India: Project MYTRI”, American Journal of Public Health, 99, 5, pp 889-906

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