Alcohol gets awareness campaigns, warning labels, and a permanent seat in India’s public health conversation. Gutka, khaini, and paan masala get almost none of that - despite being used by more Indian adults than cigarettes are smoked. This is one of the largest and quietest addiction burdens in the country, and it deserves the language it’s rarely given.
The scale of it
According to the Global Adult Tobacco Survey (GATS-2, 2016-17) - India’s most comprehensive national tobacco use survey - roughly 21.4% of Indian adults use smokeless tobacco products in some form. That’s larger than the proportion who smoke cigarettes, which the same survey estimated at approximately 10.7%.
In practical terms: for every Indian who smokes, roughly two Indians use smokeless tobacco. And yet the public health messaging, warning labels, and cultural conversation around tobacco in India remains heavily weighted toward cigarettes.
The oral cancer link
Oral cancer is among the top three cancers by incidence in India. Studies estimate that more than 50% of Indian oral cancer cases are attributable to smokeless tobacco use specifically. This is a substantially higher attributable fraction than what is seen in most other high-income countries, where cigarette smoking dominates tobacco-related cancer risk.
The mechanism is direct: repeated exposure of the oral mucosa to the carcinogens in these products drives cellular changes that progress to oral cancer over years.
Why the nicotine load can exceed a cigarette
Nicotine’s addictive mechanism is identical regardless of delivery route. It binds nicotinic acetylcholine receptors in the brain - most notably in the ventral tegmental area - triggering dopamine release in the nucleus accumbens. This is the same final common pathway of reward that nearly every addictive substance operates through.
What differs between routes is pharmacokinetics - how fast and how much nicotine gets to the brain. Cigarette smoke delivers nicotine quickly through the lungs, producing sharp arterial peaks. Smokeless tobacco is absorbed slowly through the oral mucosa, producing lower peaks but often much longer exposure durations.
Because the “hit” from smokeless tobacco is slower to arrive, users often hold the product in for longer to sustain the sensation. The cumulative nicotine load per session can end up higher than what a single cigarette delivers - with the same reinforcement of the dependence pathway.
Why it stays invisible
Several factors keep smokeless tobacco from being culturally named as addiction:
- It doesn’t produce the obvious social signals of smoking (smell, visible smoke, coughing).
- Sachets are cheap, small, and easy to use discreetly at work or between conversations.
- It’s often introduced early - sometimes in adolescence - and normalised within family and workplace contexts.
- The dependence pattern is often quiet: no dramatic intoxication, no blackouts, few overt warning signs, until oral cancer or dependence itself becomes clinically obvious.
This is not accidental. It’s how a substance stays under public health radar despite affecting hundreds of millions of people.
The takeaway
If you or someone in your family uses gutka, khaini, or paan masala regularly, and the phrase “it’s just a habit” gets used - that’s a cultural framing, not a clinical one. It’s a nicotine dependence syndrome with a serious, well-documented cancer risk.
Naming it correctly is the first clinical step. “Just a habit” delays intervention by years.
References
- Global Adult Tobacco Survey (GATS-2), India, 2016-17. Ministry of Health and Family Welfare, Government of India.
- Sinha, D. N., et al. (2018). Global burden of all-cause and cause-specific mortality due to smokeless tobacco use: Systematic review and meta-analysis. Tobacco Control, 27(1), 35-42.
- Gupta, P. C., & Ray, C. S. (2003). Smokeless tobacco and health in India and South Asia. Respirology, 8(4), 419-431.
About the author: Dr. Sidharth Sood is a super-specialist in Addiction Psychiatry, trained at the All India Institute of Medical Sciences (AIIMS), New Delhi — one of a handful of DM-level Addiction Psychiatry consultants in India. He practises at Umang Mind and Brain Clinic and consults across Delhi NCR. His clinical work focuses on ADHD, addictions, and disorders of impulse, reward, and control — including complex cases involving neuromodulation (rTMS/TBS).
Decoding impulse, addiction, and the brain.
For consulting, corporate wellness programs, media requests, and speaking engagements: connect on LinkedIn or write to contact@drsidharthsood.com.