Gutka and Tambaku Paan Use Among South Asian Immigrants: A Focus Group Study

Abstract

Smokeless tobacco use is prevalent among South Asian immigrants, particularly in the forms of gutka and tambaku paan. In this paper, we examined (a) gutka and tambaku paan initiation and use patterns among South Asian immigrants, and (b) perceptions related to quitting and tobacco control. Six focus groups were conducted with 39 South Asian adult gutka/tambaku paan users, in three different South Asian languages (Gujarati, Bengali, and Urdu). Participants reported easy availability of gutka and tambaku paan in neighborhood stores, and noted several factors that promoted initiation (including social networks, perceived benefits, and curiosity). Due to awareness of low social acceptance of gutka and tambaku paan in the US, some participants discussed changing patterns of use following immigration. Finally, participants proposed roles of various agencies (e.g., doctors’/dentists’ role, government-led initiatives) for tobacco control in South Asian immigrant communities. This research provides implications for improving tobacco control efforts in the United States, particularly for South Asian immigrants.

Introduction

Use of oral smokeless tobacco products containing areca nut is highly prevalent in India, other South Asia countries such as Pakistan and Bangladesh, and in migrant populations from these countries [1]. Latest national reports from Global Adults Tobacco Survey indicate that 25.9 and 27.2 % of adults from India and Bangladesh, respectively, are current smokeless tobacco users [2, 3]. Community surveys of South Asian immigrants in the United States indicate similar rates of smokeless tobacco consumption [4, 5]. Studies have noted the widespread availability and low cost of smokeless tobacco products in South Asian grocery stores [6, 7], increasing access to South Asian immigrant populations.

Oral smokeless tobacco products represent approximately 30 different types of products including tambaku paan (betel quid with tobacco), gutka (sun-dried finely chopped tobacco, areca nut, slaked lime, catechu, flavorings and sweeteners), and zarda (boiled and dried tobacco leaves with lime and spices, colorings, areca nut, and flavorings). These products are consumed orally, by chewing, sucking, or applying to teeth and gums [1, 8, 9]. Smokeless tobacco has been classified by the World Health Organization as “carcinogenic to humans,” [10] and has been associated with oral and pancreatic cancers, periodontal diseases, cardiovascular disease, adverse reproductive outcomes in women, and aggravated asthma [9, 11, 12].

Despite these hazards and high penetration in South Asians, smokeless tobacco control activities have largely missed addressing smokeless tobacco use in South Asian communities, particularly in the United States [7, 13]. According to Changrani and Gany, “Smokeless tobacco research and interventions have not yet addressed the unique sociocultural circumstances of this rapidly expanding, at-risk community. To prevent an explosion of oral cancer later, the tobacco prevention and treatment research and service delivery agenda needs to be rapidly developed for this growing immigrant community” (p. 106) [7].

Researchers have long recognized the importance of understanding socio-cultural contexts in order to develop theoretically and empirically based tobacco prevention and cessation interventions [14, 15]. Some recent community-based studies have identified socio-cultural factors as contributing to smokeless tobacco use in South Asians in the US For instance, Mukherjea et al. [16] reported that use of smokeless tobacco products was expressed as a symbolic behavior to maintain culture and was an expression of South Asian ethnic identity in a new dominant culture.

Besides strong cultural affinity, lack of information or mis-information regarding health risks also contributes to smokeless tobacco use. Prior studies have found that South Asians have low awareness that paan is harmful to one’s health, and report beneficial properties such as antiseptic, astringent, local anesthetic and nutritional qualities, digestive aids, breath fresheners, oral cleansers, mood enhancers, and tension relievers [4, 16] Other studies conducted with South Asian immigrants outside of the US have reported similar findings regarding lack of awareness about health risks associated with smokeless tobacco use [17]. There remains an obvious need to educate South Asian immigrant populations about the harmful effects of smokeless tobacco use, and develop smokeless tobacco prevention and cessation communication materials.

However, effective public health efforts must be culturally sensitive to the needs of the South Asian immigrant populations [7, 13]. It is important to understand the socio-cultural contexts of smokeless tobacco initiation and patterns of use, particularly if influenced by immigration into a foreign land [5]. Studies have indicated that greater acceptability of the “Western” lifestyle is associated with a decreased likelihood of cigarette smoking among South Asians in general [5, 18, 19]. Thus, the following research questions were addressed:

1. Among South Asian immigrants, what are the commonly cited reasons for gutka and tambaku paan use initiation and how has the pattern of use, if at all, changed with immigration?

2. What are South Asian gutka and tambaku paan users’ perceptions about quitting and US tobacco-control policies?

Methods

Participants and Procedures

In order to explore perceptions regarding gutka or tambaku paan use patterns and changes brought about by immigration, six in-person focus groups were conducted in the Fall of 2011. We utilized focus groups because we wanted to generate discussions among a relatively homogenous group of participants around social and cultural factors that lead to initiation and continuation of gutka or tambaku paan use [20]. A total of 39 South Asian adults, residing in the New York metropolitan area, participated. All data collection procedures were approved by the Institutional Review Board at Memorial Sloan-Kettering Cancer Center. Inclusion criteria included ethnic identification as South Asian, over 18 years old, gutka or tambaku paan user (current user defined as a minimum of weekly gutka or tambaku paan use in the last 12-months, and past user defined as regular use prior to past 12-months; see Changrani et al. [4]) and fluency in one of three South Asian languages, i.e., Gujarati, Urdu, or Bengali. In responding to the ethnic, cultural, and linguistic diversity within the Indian sub-continent, we chose to conduct the focus groups in three different languages, i.e., Gujarati (Indians), Urdu (Pakistanis), and Bengali (Bangladeshis) providing a diverse demographic representation of immigrant gutka or tambaku paan users in the New York metropolitan area [4]. As well, adhering to recommendations from expert focus group practitioners [21, 22], we conducted two focus groups per language, and with four to eight participants in each group. All focus groups were conducted with male participants except one all-women focus group. The sex distribution was not intentional, but what was conveniently accessible.

Participants were recruited by community-based convenience sampling in the New York metropolitan area. We partnered with the South Asian Council for Social Services (SACSS), a not-for-profit organization that provides services to South Asian and Indo-Caribbean communities in New York (http://www.sacssny.org/index.htm). A variety of methods were used to recruit participants. Recruitment occurred through known contacts, in-person contact at venues that were likely to have large South Asian populations, such as temples, gurdwaras, mosques, grocery stores, religious festivals, community and health fairs, taxi stands, and restaurants. Upon recruitment, participants were informed about the nature of the study and invited to a local location for the focus group discussion. At the end of the focus group discussion, participants were thanked and paid $25 to compensate for their time and any travel expenses incurred.

Each focus group session lasted approximately 90 min. Prior to the group discussion, participants provided assent to participate and completed a brief, anonymous survey. Survey questions asked for demographic characteristics including age, sex, country of birth, education level, length of stay in the US, primary language, spoken English proficiency, access to a doctor, health insurance, and ever use of multiple tobacco products (i.e., gutka, tambaku paan, cigarettes, cigars, beedi, and supari).

The focus group sessions were moderated by trained researchers at SACSS. The focus groups were designed based on well-established methods [21]. The moderator guided the groups through a semi-structured focus group guide and made consistent use of the prompts across focus group discussions. After the introductions, the facilitator discussed the topic and purpose of the focus group and reviewed the ground rules of the focus group including turning off mobile phones, referring to each other by initials, and not getting involved in side-conversations. The focus group guide and questions (Table 1) were framed in accordance with the research questions. All sessions were audiotaped, observed by one of the authors, and transcribed and translated by professional services. After each session, the moderator debriefed the participants and provided an opportunity for them to ask questions about the study.

Table 1.

Framework for focus group discussions

Research questions	Issues explored	Example probes
Among South Asians, what are the commonly cited reasons for gutka/tambaaku paan use initiation and how has the pattern of use, if at all, changed with immigration?	Initiation of gutka/tambaku paan use	Let’s first talk about how and why you started using gutka/tambaku paan. At what age did you start using gutka/tambaku paan?
	Availability of gutka/tambaku paan	Where do you get gutka/tambaku paan from? How much does it cost?
	Immigration-related issues with gutka/tambaku paan use	Has the pattern of gutka/tambaku paan use changed over the years or has it remained the same? If the pattern has changed, what are the reasons for change? What about the issue of acceptability of gutka/tambaku paan use in a foreign country?
What are South Asian gutka/tambaku paan users’ perceptions about quitting and tobacco-control policies?	Quitting motivation	We often find people trying to quit gutka/tambaku paan after a cancer diagnosis. What would encourage you to quit?
	Anti-tobacco messages	We get bombarded with anti-tobacco messages from media all the time. Help us understand how you perceive anti-tobacco messages. What is your reaction to these messages?

Data Analysis

Three of the authors (SCB, SB, TD) coded each transcript independently and generated preliminary codes. The research team then met regularly to compare independently coded transcripts and came to agreement on the final codes used for analysis. Summaries describing coding themes and representative quotes were created across all groups and were compared for Gujarati, Bengali, and Urdu focus groups. These summaries were distributed among the three coders and consensus was reached [23].

Results

Table 2 presents demographic details of study participants (N = 39). Participants were predominantly male (n = 35, 87 %), and ranged in age from 25 to 71 years (Mean = 48.13, SD = 11.22). Findings are presented for each of the three research questions including overall summary results across the three different language focus groups. Group differences by language or country of origin were not predominant. To provide evidence that themes were consistent across focus groups, quotes are identified by the focus group language abbreviation, i.e., Gujarati (G), Urdu (U), or Bengali (B), and participant identifying number (P#).

Table 2.

Sociodemographic characteristics of focus group participants (N = 39)

Characteristic	Total N (%) or mean (SD)
Age (SD)	48.13 (11.22)
Sex (%)
Male	34 (87.2 %)
Female	5 (12.8 %)
Country of birth and primary language (%)
India—Gujarati	15 (38.5 %)
Bangladesh—Bengali	13 (33.3 %)
Pakistan—Urdu	11 (28.2 %)
Length of stay in the USa (%)
0–5 months	2 (5.1 %)
6–11 months	0 (0 %)
1–2 years	2 (5.1 %)
3–5 years	6 (15.4 %)
6–9 years	2 (5.1 %)
10–15 years	9 (23.1 %)
>15 years	15 (38.5 %)
Don’t know	2 (5.1 %)
Spoken english fluencya (%)
Fluent	5 (12.8 %)
Proficient	11 (28.2 %)
Limited	17 (43.6 %)
None	4 (10.3 %)
Employed (%)
Yes	25 (64.1 %)
No	14 (35.9 %)
Have a primary care physician/family doctora (%)
Yes	29 (74.4 %)
No	8 (20.5 %)
Have health insurancea (%)
Yes	25 (64.1 %)
No	12 (30.8 %)
Ever use of smokeless tobacco products (multiple-responses) (%)
Gutka	26 (66.7 %)
Tambaku paan	18 (46.2 %)
Cigarettes	14 (35.9 %)
Cigars	2 (5.1 %)
Beedi	4 (10.3 %)
Supari	13 (33.3 %)

^aDue to missing data, the numbers (percentages) do not add up to 39 (100 %)

Perceptions Surrounding Gutka/Tambaku Paan Use and Immigration

Initiation of Gutka/Tambaku Paan Use

Notable variations across age of initiation emerged. Most participants initiated gutka/tambaku paan in their adolescent years (14–17 years), some initiated as young adults (22–26 years), while a handful initiated as adults (40–45 years). There was an evident pattern of early age initiation typically reported in their home country, while later age initiation was typically reported in the United States.

The reasons for initiation varied (see Table 3). First, many participants discussed social acceptability and initiation into social networks made up of South Asian friends, family, and co-workers. Participants also discussed the trickling down effect of gutka/tambaku paan use habit from one generation to the next, i.e., from parents and grandparents to their children. Whereas some participants acknowledged learning about gutka/tambaku paan use by observing their parents, grandparents, and other elders in the family, others reported actively encouraging the younger members of the family to use it.

Table 3.

Themes identified as reasons for initiating gutka/tambaku paan use

Themes	Examples of supporting quotations
Social networks
Initiation in “friends circle”	“So in trying to one-up each other like if you eat one, I’ll eat two.” (G-P#1) “During my first year of college, I used to smoke cigarette with friends. At that time, when we have a break between classes, we would go to the shop that sold gutka and paan, just with friends I started it..I didn’t know its benefits or harmful effects..just started it like that and used it for a long time.” (U-P#3) “I started as a student or in my teenage years. Like when friends meet at home or outside. Then they get out after eating food, go to the market, then let’s go have paan. You can say just for fun, just as fun.” (U-P#10) “When I was 18/19 years old then I ate a little because Mother ate it, I have learned it from her. I don’t have a lot, just a little.” (B–P#10)
Passed through generations (for women only)	“From observing. Mother would have it. Grandmother would have it. Aunts use it. When everyone would have it, I would have it too. To see what it’s like.” (B–P#12) “We have learned it from our mother-in-law. When mother-in-law eats it she tells others to have it too. When everyone is together, eating a little bit feels nice. She tells everyone to have a bit of it. She still says to have a little paan when we are together.” (B–P#7) “I have taught my daughter-in-laws and my daughters. That’s one thing. I would want to teach my grandchildren to have it too.” (B–P#13)
Perceived benefits
As a stimulant	“It’s a way to get nicotine in the body. It gets you alert and it’s a type of addiction.” (G-P#14) “I owned a convenience store, a gas station and three cars and I started due to all the tension and running around on my own.” (G-P#15) “Just the way you feel fresh with tea in the morning you feel fresh when you eat gutka.” (G-P#2) “I use gutka. Why? I have never smoked. But….When I am on duty at night, I feel sleepy. Then I have some…when I do my head becomes hot, and I no longer feel sleepy. But I am not addicted.” (B–P#2) “And there are people who feel good; they think it releases tension/worries. So sometimes I think that having a little can cool your mood if you are feeling angry or annoyed.” (B–P#10)
Taste and/or smell	“I have Paan, jorda for my own liking. I want to eat it. After eating…it tastes good. That’s all.” (B–P#6) “I find the smell of it very pleasant when I chew it. When someone else eats, I am attracted to the smell. That’s why I eat it.” (B–P#10) “I feel good to taste it.” (U-P#4)
Digestive benefits	“In this country, people eat candy, eat mint after eating food. For digestion. We bengalis also eat paan after eating, or after having food. For digestion. That’s it. For digestion.” (B–P#3) “…and also stomach system accelerates a bit. It accelerates the digestive system. So that it is used like a digestive.” (U-P#10)
Cosmetic (for women only)	“It turns lips red too. You don’t have to wear lipstick.” (B–P#10) “That’s why we would eat it when we were young. Lips would turn red. I would see mother having it.” (B–P#11)
Habit/addiction	“You feel curious about how it feels or how it tastes. We don’t have it but you get it from someone and then you feel like you want to have it with you too and then comes a time where you feel that you can live without tea, but not without gutka.” (G-P#5) “It’s an addiction. You pass a certain amount of time and you want it again.” (G-P#12) “I have become like addicted to paan now after having it for so long. I don’t feel well if I don’t have it.” (B–P#5) “The reason is that it has become a habit. That it is a feeling of strength and it makes me feel better a little better.” (B–P#5)

Second, for many participants, multiple perceived benefits of gutka/tambaku paan use led to initiation. For instance, gutka/tambaku paan was used to relieve boredom, reduce stress, and to increase alertness. These perceived benefits were more pronounced for participants who started using gutka/tambaku paan in their adulthood, post-immigration. Other perceived benefits like pleasant sensations of fragrant smell and taste encouraged use for some participants. Some participants reported that gutka/tambaku paan was used as a digestive aid and was therefore used after meals. Finally, only for women, the cosmetic benefits such as red marks on the lips left after chewing tambaku paan made them interested in trying the product.

Third, participants acknowledged that whereas curiosity led to initiation in some cases, they were now dependent on gutka/tambaku paan, and quitting was not an easy option. Infrequent use and group usage was common when gutka/tambaku paan use initiated, but over time, it was used more frequently and as an individual activity.

Availability of Gutka/Tambaku Paan

Participants consistently noted that gutka/tambaku paan was easily available in neighborhood stores, and in specialized paan stalls (stores that only sell paan and other indigenous South Asian tobacco products) where one can customize it according to taste:

“… you can go to any paan stall and order it custom to your taste, the way you like it.” (G-P#2)

“One of my brothers here said that it can be found in Pakistani…I mean Indian and Bangladeshi stores. Other stores don’t sell it, it’s true. Meaning…it is used by Bangladeshi and Indians as well…If someone says it is restricted, I won’t agree. Not so much.” (B–P#2)

Participants also reported that paan/gutka with tobacco was readily available in New York but not necessarily in other US states (not available in NJ, PA, FL). More stringent immigration checks precluded people from easily importing paan/gutka with tobacco in the past, but more relaxed checks now permitted easy import:

“I was in PA for six months and didn’t get it there and now I’m in NY and I get it easily.” (G-P#15)

“Well, years ago… it wasn’t imported so easily, but now it comes in any way in any container.” (G-P#13)

Immigration-Related Issues with Gutka/Tambaku Paan Use

Participants had varied perceptions related to changed patterns of gutka/tambaku paan use behavior due to immigration. Due to low knowledge and social acceptability of gutka/tambaku paan in the United States, many participants reported that people may start swallowing the tobacco as opposed to spitting it out. For those who continue to spit, they do so stealthily.

“Many people who use tobacco don’t spit it out, they’ll swallow it and by swallowing it instead of spitting, it internally increases the intoxication they get from it.” (G-P#1)

“If that situation arises where you have to spit it out, someone will advise you not to do it or threaten to report you to the higher authorities. That’s why some people hide it. My personal experience from when I worked in a medicine factory, I spit out tobacco and my supervisor, a white male, came up from behind and told me what I just did is not good for me nor for them. After that, I felt that what I was doing was wrong. In the future, I was more careful. I’m not sure if it was because I was scared or more aware, but it gave me a break in my habit and behavior.” (G-P#3)

Some participants recommended switching from gutka/tambaku paan use to cigarettes to satisfy nicotine cravings. On the other hand, some participants also acknowledged the opposite, i.e., that they were cigarette smokers, but switched to gutka use because of indoor smoking restrictions.

“If you don’t get it, you will end up quitting automatically but start to smoke.” (G-P#14)

“I smoke cigarette; I have been smoking it constantly, since 20 years. But I have stopped the habit of smoking because I can’t have it in the office or outside, so I have gutka as an alternative.” (B–P#8)

“The reason of using gutka, according to what I understand is- you cannot smoke cigarette just anywhere. Main reason for this is that people can put gutka in their mouth and do anything and be anywhere… in a gathering or in an office..there is no one to stop them, family does not even know that there is gutka in the mouth..so it’s because of the freedom of using it anywhere. But with cigarettes, you cannot just smoke anywhere.” (U-P#1)

Finally, there existed some contradictory perceptions regarding the legal or illegal nature of gutka/tambaku paan use. While some participants discussed that it was illegal to import gutka/tambaku paan, others discussed that gutka/tambaku paan were similar to other smokeless tobacco products (and therefore legal) in the US.

“They smuggle it into the country under a different name. They also have people…who travel to India as a personal trip just to bring it back here and their trip is fully paid for. There are people in every state designated for this purpose of import and distribution of it.” (G-P#1)

“Most of the [customs] officers are familiar with what we eat instead of the tobacco and Skoll that they use here. We don’t use their product because we can easily obtain our own here, so they don’t really have any objection to us using it.” (G-P#5)

Perceptions About Quitting and Tobacco-Control Policies

Motivation to Quit

Participants had many perspectives on quitting (Table 4). First, they generally acknowledged that quitting had to be self-motivated. They believed that unless the motivation to quit was personal, social influence (nagging, advising) to quit will not work. Second, some participants discussed that a driving force for them to quit would be to see their young children getting curious about the products, and trying to use them. Third, doctor’s or dentist’s role in motivating quitting was discussed by a few participants. On the other hand, some participants also pointed out that doctors (particularly, American doctors) lack knowledge about gutka/tambaku paan use among South Asians and so do not advise against use. Fourth, participants highlighted the role of government in curtailing the use of gutka/tambaku paan including imposing fines for use, banning stores from selling the products, introducing restrictions on import, increasing prices (similar to cigarette cost increases), and banning its manufacture.

Table 4.

Themes identified as factors that may discourage gutka and tambaku paan use

Themes	Examples of supporting quotations
Self-motivation for quitting	“Where there is a will there is way. There’s a saying like that. If you have the will, you can quit, if you are willing…” (B–P#3) “… amongst friends, we try to make bets or challenges to give it up for a day or so, but then it happens that we are away from each other, so you cheat.” (G-P#1) “If a person decides to quit, and has the will power, then they can leave it. I think everyone and anyone can quit, the person who doesn’t want to will just say that it’s not possible to quit.” (U-P#3)
Preventing children from learning the habit	“… I stopped because my 3 year old son by mistake touched it and that became the last day that I used it. I had $50 worth of goods at home that I threw out on the spot. That’s also when I fully became aware of the examples I’d seen in my life of my cousins and friends and realized that it’s best to quit. All these examples made little to no impact on my habit but seeing my 3 year old son even touching it was enough to make me quit on the spot. I also made a promise to myself at that moment that I will never touch it again.” (G-P#1)
Doctors’/dentists’ role	“The first time I went to India in 2008, I’d never been to a hospital but my kids forced me to go for a checkup. The doctor said I have no health problems except that I should give up manikchand and that if I don’t stop, there’s a risk of developing cancer. I’d brought two boxes of export quality with me which I then threw out on the spot in front of the hospital. After 40 years of use, I gave it up.” (G-P#2) “My wife won’t eat anything unless she has paan and jorda. She has it day and night. She has pressure, very high pressure. Likelihood of diabetes. Doctor hasn’t told her to stop. Doctor hasn’t told her to stop eating it. Prescribes medicine but doesn’t tell her to stop eating paan, shupari. That’s the first thing you all should tell the doctors to do. They should advise against the complete use of paan, shupari.” (B–P#3) “Now that we go to the doctor, doctor asks do you smoke, do you drink. That’s all, not more than that. But they don’t say that you should not touch this at all. They don’t say that.” (B–P#2) “Actually American doctors don’t know what we eat. People from our culture eat it.” (U-P#10)
Government’s role
Fine its use	“If someone knows that he will be fined for carrying it, then they will automatically leave it at home.” (G-P#4) “Anything that you fine heavily will stop, even if we start to fine the personal carriers in the amounts of five to ten thousand for the stuff that they’re selling for a dollar or two, they’ll stop. It’s not worth it. Or even fine the users heavily.” (G-P#3)
Ban stores	“My suggestion is that the government should ban paan and gutka stores. If they are not readily available, then it is possible to quit and get rid of this habit but if people will find it easily then they will find ways to use it like the metallic container to spit.” (U-P#3)
Import restrictions	“When we bring certain food from back home, they stop us from bringing it. Then why are they allowing paan to be brought into the country? They can stop that. It is for the government to put a stop on it. If they can restrict food, then this poison compared to that. Why can’t they stop this?” (U-P#6)
Price increase	“The prices of these things. The prices of these things must be increased. Like cigarette went from $5 to $12.50. Then we have difficulty in using it. But I buy this packet, two for one dollar. Meaning I can get two packets with one dollar. So it is very inexpensive. Now, if it increases to $5, I won’t buy it.” (B–P#8)
Ban manufacture	“Manufacturers can stop it since they know that it can be very harmful, can cause cancer then why don’t they stop it. …But they are producing it meaning making it available yet they are also advertising against it, that’s two points. If they are concerned for people’s well-being they should ban it. If paan and jorda is bad, they should ban them. If people don’t find them, they can’t eat them…” (B–P#10) “Why has no one stopped and taken measures against those industrialists who are making million and billion dollar profits out of this? Why does no one tell them to stop making these harmful things, they are still available in the stores…This is like telling a thief to go rob and then telling the cops to go catch him.” (U-P#2)

Tobacco-Control Messages

Participants discussed the lack of anti-gutka or anti-paan public health messages despite increasing awareness and messages against the use of cigarettes. Participants acknowledged that anti-gutka/tambaku paan media campaigns may increase awareness and motivate people to quit, but noted the lack of effort in this direction.

“Cigarette is within this country’s mainstream. All of America smokes it. But jorda, paan…only concerns immigrants, only one class of immigrant, the South Asian group. Therefore, unlike the different advertisements on cigarettes there’s no law in this country on jorda. None of the Bengali newspapers have ever said that jorda is harmful. There are no such ads in Bengali newspapers. If ads were used to inform people then they would know that it is harmful.” (B–P#8)

“There are advertisements about health risks of smoking cigarettes, there is awareness, even the cigarette pack has a message on it, I think these things have made a difference; people do smoke less because of the awareness. I have only been here for 2 years and I have never heard anything about gutka and tobacco. Today is the first time that I am attending a workshop that is discussing this.” (U-P#3)

This participant further added,

“In Pakistan, India or Bangladesh, there is not much of an awareness about this. If someone generally finds out that a friend has been diagnosed with cancer because they used gutka or tobacco, it is considered normal. Otherwise, people don’t know much about it. They know about cigarettes but not about tambaku paan and gutka. If someone gets diagnosed with cancer, they definitely quit. So I still think that people need to be made aware about this.” (U-P#3)

Discussion

This study explored South Asian adults’ experiences and perceptions surrounding gutka and tambaku paan use including initiation, availability, immigration-related issues, motivation to quit, and tobacco-control messages. Although recent research has examined factors associated with the social and cultural influences on tobacco-related health disparities [16], this is the first study to qualitatively examine perceptions around gutka/tambaku paan use and immigration, and perceptions around quitting and tobacco control. This is critical because lack of knowledge regarding South Asian users’ tobacco-related knowledge, attitudes, and behaviors has curtailed efforts towards development and dissemination of empirically-sound interventions or campaigns preventing gutka and tambaku paan use among a large immigrant population in the United States (i.e., South Asians). This research adds to the growing literature on gutka and tambaku paan use [5, 16, 18, 24], and provides a foundation for future research to develop and test smokeless tobacco control efforts with South Asians.

As substantiated by prior research [25], our findings identify strong social norms as motivating gutka and tambaku paan use in South Asians. Research in cigarette smoking literature has identified household smoking bans and negative attitudes about the social acceptability of smoking, as two factors that reduce the likelihood of adolescent smoking initiation [26, 27]. Applying the same principles to the development of interventions banning gutka and tambaku paan use in South Asian households may help reduce the likelihood of adolescent initiation of gutka and tambaku paan.

Immigration-related changes in patterns of gutka and tambaku paan use were identified in current research. For instance, South Asians acknowledged the unease around using gutka/tambaku paan in public places, particularly due to spitting restrictions. This uneasiness could be utilized better for motivating quitting efforts and creating a social norm that discourages smokeless tobacco use. However, this issue needs to be addressed with caution because prior research has indicated that South Asians use smokeless tobacco products as a celebration of their culture and an expression of their ethnic identity in a foreign land [16]. Therefore, tobacco control efforts will need to be culturally-tailored and responsive to the existing perceptions and beliefs around usage. This is a ripe area for future research.

Limitations

This study is not without limitations. The survey sample from which the focus group sample was drawn was largely male South Asians from New York, so the results may not be generalizable across all South Asians. We were able to conduct only one women-only focus group and some themes emerged that were relevant only to women such as perceived cosmetic benefits and inter-generational influence as factors leading to initiation. Future research should include more women to understand their perspectives on social contexts of gutka and tambaku paan use. Finally, the data are self-reports. Other approaches like Beach and Anderson’s recordings of naturalistic family conversations around gutka and tambaku paan use or observational data examining gutka and tambaku paan use behavior at weddings or other community events are to a lesser extent associated with bias [28].

Conclusions

The present findings describe South Asian adults’ experiences and perceptions surrounding gutka and tambaku paan use. The relative contributions of social influence and perceived benefits of gutka/tambaku paan use in encouraging initiation must be examined in future work. The present study was conducted with current gutka/tambaku paan users. Future research with South Asian adults stratified on the basis of tobacco use status (i.e., non-users, occasional current users, regular current users, and past users) to examine beliefs and perceptions around gutka/tambaku paan use will provide information to help target gutka and tambaku paan control messages more efficiently and develop counseling strategies for quitting. Tobacco control among South Asians not only presents a national but a global problem [8], and this research is one step forward to inform development of tobacco control strategies for this population.

New Contribution to the Literature

This research has several implications for improving tobacco control efforts in the United States. First, South Asians should be screened for gutka/tambaku paan use in hospitals and other health-care settings, and current users should be identified for cessation or interventions [13]. Given that the health risks of tambaku/paan use are significant [8, 9], health care providers serving large South Asian populations should be made aware about gutka and tambaku paan use so that patient visits can be used as opportunities to discuss risks of persistent use and interest in quitting. Second, tobacco control public health campaigns need to be more visible in neighborhoods with large South Asians populations. For instance, posters raising awareness of health risks associated with gutka and tambaku paan use and encouraging quitting efforts should be displayed in South Asian grocery stores, outside places of worship, and at cultural fairs and festival celebrations where large numbers of South Asians typically congregate. These efforts may not only motivate quitting, but also prevent youth uptake of gutka and tambaku paan. Third, the findings have implications for framing gutka and tambaku paan control messages by considering the social contexts of use and immigration-related issues. For instance, preventing children from using gutka or tambaku paan was seen as a strong reason for adult quitting, and could be used as one of the themes in tobacco control media campaign messages. Finally, this study demonstrates the significance and need for continued research with South Asians around gutka and tambaku paan use.