Awareness and Use of South Asian Tobacco Products Among South Asians in New Jersey

Abstract

South Asians are the third largest Asian group in the US and among the fastest growing racial groups in New Jersey. Tobacco consumption among South Asians is characterized by several smoked and smokeless tobacco products indigenous to the Indian subcontinent. However, there is a paucity of research on tobacco use behaviors among South Asians in the US. The goal of this study was to examine the awareness and use of South Asian tobacco products such as bidis, gutkha, paan, paan masala, and zarda as well as other potentially carcinogenic products such as supari, their context of use, and their cultural significance among South Asians living in the US. Eight focus groups were conducted with South Asian adults living in Central New Jersey. Overall, participants were aware of a wide variety of foreign and American tobacco products with older South Asians identifying a greater variety of indigenous products compared to younger South Asians. Hookah was consistently recognized as popular among the younger generation while products such as paan or paan masala were more commonly identified with elders. Use of tobacco-related products such as paan and supari were described as common at social gatherings or after meals. In addition, light or social users of South Asian tobacco products, including products not consistently defined as tobacco, may not report tobacco use on a survey. Better understanding of the use of these products among South Asians and how some may classify tobacco usage can inform future research and public health interventions in these communities.

Introduction

Tobacco use is the leading cause of preventable death, accounting for over six million annual deaths globally. [1-2] In particular, smokeless tobacco consumption was recently estimated to cause over 250,000 deaths worldwide, with the vast majority (85%) occurring in Southeast Asia [3]. In the United States, South Asians are among the largest Asian subgroups, comprising 1.89 million people. [4]

Tobacco use surveys in the U.S. have shown that Asians exhibit lower cigarette smoking prevalence rates (10.7% in 2012) compared to Caucasians (19.7%) as well as other racial/ethnic minority groups including Native Americans (21.8%), African Americans (18.1%), and Latinos (12.5%). For smokeless tobacco, prevalence was lower than cigarette smoking across all groups, and ranged from 8.8% to 33% within major racial/ethnic minority groups. [5] However, these aggregate categorizations mask considerable differences among population subgroups. For instance, analysis of tobacco use patterns from the 2009 – 2010 National Adult Tobacco Survey (NATS) found considerable heterogeneity among prevalence, consumption, and frequency of use of various tobacco products among Asian Indians and other Asian subgroups residing in the U.S. [6] However, a major drawback of NATS and other national surveys is that surveillance of tobacco products is limited to conventional U.S. tobacco products, thus neglecting surveillance of tobacco products which are popular among particular racial and ethnic minority populations such as South Asians including indigenous smoked (e.g., bidis, hookah) and smokeless (e.g., paan, paan masala, gutkha) tobacco products. [7-8] In the rare case when tobacco use surveillance includes distinct tobacco products popular among the South Asians in the U.S., current tobacco use prevalence among South Asians is comparable to cigarette smoking rates found among the general U.S. population. [9]

Exploratory studies in the densely-populated South Asian regions in Chicago and the San Francisco Bay Area have demonstrated that use of cultural tobacco products serves, among other purposes, as a mechanism to express ethnic identity and pride. [10] Qualitative research conducted in ethnic enclaves in New York suggests cultural tobacco use patterns are influenced by the composition of South Asian social networks as well as the perceived benefits of tobacco. [11]. So in addition to the need for improved tobacco surveillance among this population, preliminary evidence suggests that tobacco use warrants a targeted and comprehensive public health response, particularly in South Asian ethnic enclaves in the U.S.

In New Jersey, South Asians are one the fastest growing racial groups and the state contains the third largest number of South Asians in the U.S. overall. [4] The purpose of this study was to ascertain if tobacco use patterns among South Asians in New Jersey mirrored those observed in other enclaves throughout the U.S., and to describe unique contextual factors surrounding use of these cultural products in this densely-populated region. Such findings could inform the development of prevention and cessation programs for South Asians in the U.S. while targeting unique determinants of use among New Jersey's large South Asian population.

Methods

Study Design and Population

This qualitative research study examined the awareness and use of South Asian tobacco-related products (SATP), the context of use, and the cultural significance of these products in New Jersey using focus group methodology. Institutional Review Board (IRB) approval was received from Rutgers University. Eight focus groups were conducted from March 2013 to January 2014 among South Asians living in New Jersey. Participants were identified through community-based organizations in Central New Jersey. Eligibility requirements included ethnic identification as South Asian, being over 18 years of age, and English language proficiency.

Participants and Procedures

Eight focus groups were conducted with adult South Asians, and were loosely organized by age, gender, and birthplace given that the knowledge and use of SATP may differ based on demographics. Three focus groups consisted of South Asian college students, primarily male, who were U.S. born or came to the U.S as children. Two focus groups (one of males and one of females) were comprised of older, native born South Asians, some of whom had resided in the U.S. for more than 20 years. Finally, three focus groups consisted of mixed gender, young working professionals or graduate students, some of whom were born in the U.S. while some were born in South Asia.

Each focus group consisted of a 60 minute session conducted by a trained facilitator, with 8 to 10 participants per group. Sessions were conducted in English and refreshments were provided. At the beginning of each group, the study procedures were explained, participants were assured anonymity, and informed consent was obtained. All participants completed a separate de-identified survey to collect data on demographics and tobacco product use. The interview guide explored awareness and use of SATP among ethnic enclaves in New Jersey and possible benefits and functions of use. Focus group discussions began with identifying common SATP. The SATP discussed and reported here include products that may or may not contain tobacco (e.g., paan masala) since participants inconsistently categorized some products as tobacco. Participants were asked to discuss their opinions of these products and occasions for use as well as access and availability. Probing was used to elicit additional information including questions and topics that could potentially inform a future survey of cultural tobacco use among South Asians. Focus group participants received a $50 gift card for their participation.

Analysis

All focus groups were audiotaped. English-language focus groups were transcribed by research assistants at the Rutgers School of Public Health. Transcripts were coded for the presence of themes using ATLAS.ti 7.0 qualitative software. Coding was based on deductive themes linked to the study's aims and research questions and inductive themes arising from repeated transcript readings. Coded text were examined for these major themes and representative quotes to illustrate these themes. Coded transcripts were reviewed by investigators for agreement in assignment and discrepancies were identified, discussed, and resolved. Frequencies from survey data were analyzed using SPSS 21.0 quantitative software, and associations of demographics with SATP use were assessed by Fisher's Exact tests, where two-sided p-values less than 0.05 were considered statistically significant.

Results

Brief Survey

Table 1 provides the demographic characteristics for the 78 South Asians participating in eight focus groups. Their mean age was 32.2 (range, 18– 67) and the majority of participants were male (60.3%). All were of South Asian ethnicity; 83.3% were of Indian origin, which is consistent with the demographics of the New Jersey population. [12] The majority of participants were foreign-born and had attained a college degree or higher.

Table 1. Demographics of focus group participants (n=78).

Gender	Number (%)
Male	47 (60.3%)
Female	31 (39.7%)
Ethnic Origin
Indian	65 (83.3%)
Pakistani	8 (10.3%)
Sri Lankan	4 (5.1%)
Bangladeshi	1 (1.3%)
Birthplace
United States	29 (37.2%)
Foreign-born	48 (61.5%)
Education
HS graduate or some high school	17 (22.4%)
Some college	14 (18.4%)
College graduate	17 (22.4%)
Post college	28 (36.8%)

Respondents were aware of or used many smoked and smokeless South Asian tobacco-related products (SATP) such as bidis, gutkha, hookah, paan, paan masala, and supari as well as) as well as other potentially carcinogenic products (e.g., supari) definitions of products are provided in the Table 2. As shown in Table 3, awareness of most SATP was high. On average, over 70% of respondents reported having tried at least one SATP and more than half (51.5%) currently use a SATP.

Table 2. Definitions of South Asian tobacco-related products.

Bidis: finely ground, sun dried tobacco rolled in a brown, tendu leaf; similar in appearance to hand rolled marijuana cigarettes or joints; most are unfiltered, although a few are filtered. [13]

Gutka/gutkha: a dry, relatively non-perishable, commercial preparation containing areca nut, slaked lime, catechu and condiments and powdered tobacco. [14]

Paan: betel quid with tobacco that consists of four main ingredients: (1) betel leaf (Piper betle), (2) areca nut (Areca catechu), (3) slaked lime and (4) tobacco. [15]

Paan masala: a commercial preparation containing areca nut, slaked lime, catechu and condiments, with or without powdered tobacco; contains almost all of the ingredients that go into making paan, but dehydrated so it is not perishable; comes in foil packets (sachets) and tins, which can be stored and carried conveniently. [14]

Qiwam/kiwam: a thick tobacco paste; also available as granules or pellets; to prepare kiwam, the midribs and veins of tobacco leaves are removed, and the remaining matter is boiled in water; powdered spices (saffron, cardamom, aniseed and musk) are added, and the mixture is stirred and allowed to macerate until it becomes a paste, from which granules and pellets are made. [14]

Hookah: water pipes that are used to smoke specially made tobacco that comes in different flavors; a typical modern hookah has a head (with holes in the bottom), a metal body, a water bowl, and a flexible hose with a mouthpiece; hookah smoking is typically done in groups, with the same mouthpiece passed from person to person. [16-18, 13, 18-20]

Zarda: prepared by cutting tobacco leaves into small pieces and boiling them in water with slaked lime and spices until the water evaporates; then dried, and coloring and flavoring agents are added; may be chewed by itself, with areca nut or in betel quid quid; available in small packets or tins. [14]

Supari: a naturally crud areca nut that may or may not be mixed with other ingredients. [20]

Table 3. Awareness and use of South Asian tobacco-related products among focus group participants (n=78).

	Awareness	Ever	Current Use
Bidis	87.0%	14.1%	2.8%
Gutkha	62.3%	7.1%	2.8%
Paan	93.4%	38.4%	6.9%
Pan Masala	97.4%	34.2%	5.6%
Qiwam	38.7%	7.1%	1.4%
Hookah	96.1%	51.4%	32.4%
Zarda	49.3%	4.2%	1.4%
Supari	86.8%	37.0%	11.1%

Males, relative to females, reported significantly higher rates of ever use of bidis (24.4% vs. 0%, p=0.004), paan (50.0% vs. 22.6%, p=0.03), paan masala (47.6% vs. 16.1%, p=0.006), and hookah (71.4% vs. 23.3%, p<0.0001). Current use of hookah was also significantly more prevalent among males relative to females (46.5% vs. 12.9%, p=0.003). Age was significantly associated with current hookah use (p<0.0001), such that use was most prevalent among young adults aged 18 to 24 years (60.5%) relative to those aged 24 to 44 years (5.3%) and those aged 45 years or more (0%). Meanwhile, current use of gutkha, zarda, and supari were least prevalent among the 18 to 24 year olds; however these associations were not statistically significant. Ever and current hookah use was significantly associated with education (p=0.024 and p=0.025, respectively), such that prevalence was inversely associated with education attainment. Nativity (i.e., foreign vs. U.S. born) was not correlated with use of these products.

Content Analysis

Popularity

The most common SATP reported in the survey results were also reflected in focus group discussions: bidis, gutkha, hookah, paan, paan masala, and supari. In addition, focus group participants described several more novel SATP such as chillum (a smoked tobacco, although this may also refer to the smoking instrument), [21] mishri (tobacco containing teeth cleaning powder), [7] and naswar (a moist, powdered tobacco snuff) [7].

Subgroup differences

Popularity of SATP products differed by demographics. In focus groups of young college students, hookah was cited as the most common SATP by far. Young working professionals or graduate students also described hookah as the most popular SATP. Native born older males described gutkha as the most common SATP while native born older females described paan/paan masala as the most popular product. Many focus group participants described paan as a product available with and without tobacco. One participant after reviewing the survey said:

“I think supari is the most popular, that's not on the [survey]…. When I was younger I never even knew it was tobacco…I might have even put one in my mouth because I didn't know. It didn't even taste that bad from my memory. I would say supari and gutkha.”

(Focus group of mixed gender, young professionals/graduate students).

Perceptions of Use Patterns

Participants inferred there were differences in the type of tobacco products used among specific subgroups. In most focus groups, participants described the increased and widespread popularity of hookah. Hookah use was generally agreed to be largely restricted to younger South Asians and the trend was considered to be more strongly influenced by the social context of college rather than cultural or ethnic identity.

In focus groups with U.S. born young adults, participants believed that older South Asians were more likely to use smokeless products such as paan or paan masala compared to products like hookah, which was more common among their peers. In addition, young South Asian adults believed that males used hookah at higher rates than females, although if born in the U.S. then rates among South Asian males and females were likely to be similar.

“… younger generations probably smoke more tobacco while the older generations use smokeless tobacco like paan masala, paan.”

(Focus group of college students)

“I think it depends on age group…. Hookah is probably amongst ages…like 15 16…to be honest with you, I've known a lot of younger kids that have done it…. And then 30 and up is probably more, you know, paan.”

(Focus group of mixed gender, young professionals/grad students).

“I'd say for smokeless tobacco would be [used] more [on] female side and smoked tobacco would be more on the men side.”

(Focus group of mixed gender, young professionals/grad students).

In the group of older, native born female South Asians, participants believed that most everyone used paan without tobacco and mostly men, in particular men over 40 or 50, would use paan with tobacco.

There was also the suggestion that there were differences in use of various products based on country of origin as well as socio-economic differentials. Bidis were typically characterized as SATPs used by the socially disadvantaged groups:

“…there's a difference between what's popular amongst the Pakistani community and what's popular amongst the Indian community. The more Muslim dominated areas, like Bangladesh, Pakistan, Kashimir, hookah is more popular, naswar is more popular. I would even say paan is more popular…like within the Punjabi culture, paan would be more common. I feel like it's different wherever you go in Pakistan. Even in India its different among people who are economically [disadvantaged]…inclined to get bidis if you have less money…or if you have more money, you would spend more money on a more expensive product.”

(Focus group of mixed gender, young professionals/graduate students).

“They say it's poor people's cigarette.”

(Focus group of mixed gender, young professionals/grad students).

“If you cannot afford [cigarettes], then you usually smoke bidis.”

(Focus group of mixed gender, young professionals/grad students).

Context of use

Use of SATP such as hookah, paan, or supari was described as common at social gatherings or after meals. As one young college student said “I think paan is always a tradition at parties and weddings. A lot of these chewing things like supari and gutkha, I've seen when I was in India… the older men, after they eat their food or if they're going on a walk they just pack a lip….” Younger participants identified hookah as facilitating socialization while older participants mentioned paan and paan masala as also used in social groups. As another college student explained, “I don't think I know anybody who just lights a hookah by themselves.”

Some respondents asserted that gutkha was also a substitute for smoking, both because of price and indoor/public use.

“Basically a substitute for the public smoking like you know the gutkha is a substitute for smoking. People who use a smoke product or a leaf tobacco in the form of gutkha…it shows respect to the elders. If you eat gutkha…elders won't mind much. If you smoke, its like an insult to them.”

(Focus group of native born, older males)

Perceived benefits

In addition to socialization, there were other perceived benefits to using certain tobacco and tobacco-related products including stress relief, relaxation, and relieving boredom. Many native born South Asian adults described using paan and supari, typically without tobacco, after meals for cleansing the mouth and as an aid for digestion.

“The tobacco paan is not good, but sweet paan is good.”

(Focus group of native born, older females)

For others groups, the ‘buzz’ associated with tobacco products, including gutkha and hookah which were specifically mentioned, was a perceived benefit.

“To feel good or get a buzz. I'm sure that's why people use it.”

(Focus group of college students)

There were differing opinions about the perceived benefits of supari. In particular, the focus group of native born, older females debated the idea that supari had certain health or therapeutic benefits with some saying “It has benefit; it can be therapeutic too sometimes,” and “For heart problem, it's good for that,” while others said, “Supari has no benefit.”

Connection to culture or homeland

There were mixed feelings about whether SATP served as a connection to culture or homeland. Some U.S. and native born young adult focus group participants felt that older South Asians used cultural tobacco products as a way to connect to homeland.

“I know women, especially here in the United States they'll use paan because it is a connection back the homeland.”

(Focus group of college students).

“…If you go to Jersey City or Iselin [cities in New Jersey with large South Asian populations], you'll see it's something that's so deeply rooted in their culture that its ok for us to do it. It justifies everything.”

(Focus group of mixed gender, young professionals/grad students).

However, many participants born outside of the U.S. did not believe that these tobacco products provided a connection to their homeland in South Asia. Most believed that current users likely started in their native country and simply continued using the product in the U.S, the result of habit or addiction rather than an attempt to maintain cultural identity. But as previously mentioned, some SATP were still utilized at traditional cultural events like wedding or religious ceremonies.

Tobacco use classification

Focus group participants were asked about how they or someone they knew would classify the use of a SATP if asked about tobacco use on a survey. There were a variety of opinions about the classification of cultural tobacco consumption based on frequency of use, the specific product used, and whether tobacco was the primary or complementary ingredient. For example, some participants expressed that less frequent users might be less likely to classify themselves accurately.

“I feel like it's how often you do it. Not the number of bidis, but how often. If you're doing it for a year, yeah you're considered a smoker. If you did it for a day or two, I don't think you're a smoker. I don't think you'd be labeled as a smoker.”

(Focus group of college students)

Participant: “I smoke hookah sometimes, I wouldn't consider myself a smoker…”

Moderator: “Is it because you think there is no tobacco in it?”

Participant: “It's just the fact that I only use it sometimes”

(Focus group of college students)

In regards to the use of gutkha, a participant in the focus group of young professionals said that if a gutkha user were asked generally about whether they used tobacco, the answer would likely be ‘no’ unless the user were asked specifically if the gutkha contained tobacco.

Many participants also felt a tobacco user was perceived as someone who smokes conventional cigarettes and in addition, that standard tobacco use questions could not capture commonly used SATPs.

“if it said smoker, I don't think so. Because I think with people being smokers, they kind of correlate that with cigarettes. and a bidi and a cigarette aren't the same thing. Like if you said do you regularly smoke a bidi, then they'd say yes, but if you said are you a smoker, they'd say no unless they smoke cigarettes.”

(Focus group of mixed gender, young professionals)

“I think when a lot of people hear are you a smoker they relate it to cigarettes, so I don't know if they would list it…as a smoker”

(Focus group of mixed gender, young professionals)

“I'll say I had an experience [at] a doctor appointment and I decided to be honest. And when she asked me if I smoked and I said yes… one of my friends had a hookah and we were probably smoking weekly… So I decided to be honest and say yes and then she just kept grilling me, like “OK, how many times a day?” I'm like “No, I don't smoke cigarettes, I smoke hookah” and so like it was just really hard to answer the rest of the questions and so from then on I always said no…”

(Focus group of mixed gender, young professionals)

Some participants also believed that classifying oneself as a tobacco user might vary by demographics such as age or education:

“…the older generation, I feel like they wouldn't want to classify themselves as users, but like younger generations, they know and are accepting that they are using these products, so they are going to say that “Yeah, I am a user, I do smoke,” you know? But older generations I feel like it's frowned upon to use it, so they don't say they're using it, when in reality they may use it once or a few times a week. So they might not classify themselves at users, but they actually are.”

(Focus group of college students)

The observation that the stigma associated with use of tobacco might play a role in whether older South Asians identified as a tobacco users, was confirmed by at least some older focus group participants. For example, an older female participant said, “people don't want to associate [with bidis], even if they are [using], they just don't want to disclose that.”

In terms of education, it was suggested that those with lower levels of education might be less likely to report tobacco use on a survey:

I think it's also level of education so if they have a higher level of education, they would say yes, and if they don't, they'd say no. People are in denial. People who smoke bidis are usually working class and on their way to work they'll smoke without even realizing it, it will be a habit for them. So they won't even realize “I engage in this type of behavior”

(Focus group of mixed gender, young professionals)

Another participant believed that risk perception may play a role in identifying as a tobacco user: “I think they just don't know how bad it is for them, because smoking out of a hookah, I think there's an assumption that its just not as bad for you than smoking…a cigarette or…a cigar or something else like that. They just don't consider themselves as tobacco users.” (Focus group of college students)

In addition, in focus groups with native born older females, participants assumed that paan masala users would not classify as tobacco users since the product might not contain nicotine or tobacco.

Perceived harm

Focus group participants identified many health risks associated with SATP use including cancer, cardiovascular problems, tooth decay, asthma, and passive smoking. However, the degree of risk varied by products depending on whether it clearly contained tobacco (e.g., cigarettes) or inclusion of tobacco was uncertain (e.g., supari). Generally speaking, focus group participants believed most SATP were equally harmful but some native born older female participants described bidis as safer than conventional tobacco.

Some focus group participants described seeing SATP with warning labels in other languages including Indian, Guajarati, Punjabi, and Hindi. Most participants believed all or most products carried warning labels but there were differing opinions about whether warning labels work or could work.

“Nobody even notices warning labels”

(Focus group of mixed gender, young professionals)

“They won't stop by just reading it”

(Focus group of mixed gender, young professionals)

“Someone who has not used it, it is good for them, but one who is using, it doesn't matter”

(Focus group of mixed gender, young professionals)

Discussion

Our study qualitatively examined a variety of issues related to the use of SATP among South Asians in New Jersey. Similar to previous research conducted in other ethnic enclaves in the U.S., we found high rates of awareness and ever use of certain SATPs such as paan and supari. [22] Not surprisingly, hookah was identified as a hugely popular product among young South Asian adults but this appeared to more influenced by the college setting than ethnic background. Paan or paan masala was cited as more commonly used among older Asian adults. Use of qiwam and zarda was reported least frequently, however, this could be attributed to the majority of focus group participants being of Indian origin. Although discussed in less depth, other sociodemographic factors such as education and native country might also shape patterns of use. [23]

It was clear that social events often encouraged use of SATP among South Asians. Despite their use at functions like weddings and religious ceremonies, there did not appear to be consensus that SATP played a role in maintaining or expressing ethnic identity in contrast to focus group respondents in Mukherjea, et al. (2012) who expressed that use of such products provided a powerful connection to cultural roots. [10] This may be the result of variation in community demographics such as nativity or length of stay in the U.S. Many foreign-born focus group participants reported having lived in the U.S. for two to three decades and thus perhaps find less need to connect back to their home country or do so through other mechanisms.

There were multiple perceived benefits to SATP included socialization, relaxation, and use as a mouth freshener or digestive aid, consistent with studies in New York, Chicago, and the San Francisco Bay Area. Similar to focus groups of current gutkha/tambaku paan (paan with tobacco) users in New York [11], some of our participants in New Jersey described indoor smoking restrictions and price as factors that promote use of culturally specific smokeless products. In addition, perceived harm varied by products but participants generally agreed that SATP use carried various health risks. This tension between perceptions of benefits and awareness of risks is important to disentangle in order to understand how these beliefs contribute to motivating quitting behaviors or continued use. [22]

Finally, the accuracy of self-reported tobacco use among South Asians may be problematic given our findings in the focus groups. As discussed, the rate of tobacco use misclassification may be higher for light or social users of SATP as well as for specific products which are not consistently defined as tobacco. There is some fluidity to the terms used to identify SATP, such as supari, paan, and paan masala, and users may not always distinguish between products that contain tobacco and those that do not.

This study had several limitations. Our study sample was comprised of South Asians living in central New Jersey and the majority of the participations were of Indian origin so the results may not be generalizable to communities beyond the study population. Also, given the stigma that may be associated with tobacco use, the sensitive nature of the topic may have hindered open discussion; however, we attempted to stratify groups by age and gender when possible to mitigate this effect.

Despite these limitations, the main strength of the present study is that it provides insight into the awareness and use of culturally specific tobacco products among South Asians, including factors that may impact how or whether they identify as tobacco users, which is an important issue not addressed in the current literature. These findings suggest that traditional survey measures may yield biased estimates of tobacco use among South Asians who may continue to use culturally specific tobacco products, but may not consider and report their use when asked about tobacco products mainstream to the U.S. One recommendation is that paan or paan masala be considered as smokeless tobacco products in population-level surveillance, along with other cultural smoked and smokeless tobacco products (bidis, hookah, gutkha), given the high likelihood that the products include tobacco even when advertised or perceived as tobacco-free. [24] Future methodological research should consider how best to improve the quality of data collected on tobacco use behavior among South Asians. However, a small but consistent literature base now points to several key contextual factors that can inform targeted cessation interventions for South Asian Americans including perceived benefits that influence initiation and maintenance.