In Pakistan, extensive use of several precarious chewable tobacco formulations has made oral cancer the second leading malignancy. Selection of literature was done by a survey of studies published from 1990 to 2017 mainly, from PUBMED and few from other search engines, on naswar, gutka, areca nut and betel quid, which included published reviews, original articles and other data sources on chewable tobacco, its epidemiology, pathological implications, and psychological effects. These studies have revealed that the chemicals in these formulations bind and mutate DNA of oral mucosa through down regulating cellular repair pathways and upregulating genetic networks associated with pathogenesis. Areca nut, having aercoline (the major alkaloid) causes carcinogenicity, mutagenicity, and genotoxicity of oral mucosa through increased production of growth factors and corticotrophin-releasing hormone, and genetic alteration in expression of CASP8, APAF-1, BAX, BAD, and upregulation of caspas-3. Gutka addiction leads to precancerous lesions resulting in characteristic facial abnormalities, following trismus. Naswar, in addition to oral cancer, causes adverse cardiovascular events by reducing glutathione per oxidase (GPx) and super-oxide dismutase (SOD), serum levels of HDL, whereas, increasing the ratio of cholesterol, LDL, triglycerides and LDL-C/HDL-C. Betel quid (Paan), causes psychoactivity affecting central and autonomic nervous systems leading to dependence with decreased cognition, euphoria, sweating, salivation, palpitation, heightened alertness and zest to work. Metabolically, cardio-acceleration, cortical desynchronisation of EEG, elevated plasma noradrenaline and adrenaline were found. This review highlights the corrosive effects of various most popular chewable tobacco formulations; and damage done by their cocktail of carcinogenic substances and added ingredients, leading to oropharangeal cancer.

Background: The phenomenon of smoking among schoolchildren has been observed to stem from lenient attitudes of teachers towards smoking. Smoking, a health hazard, proven over years of research, leads to increase in morbidity and mortality rates. This study determined the role of school policies and teacher attitudes towards the perception and adoption of smoking habits by students of private and public schools. Method: This was a cross-sectional study in which 632 school personnel in various private and public schools of South Karachi filled a questionnaire. Informed consent was obtained from all participants; ethical approval for this study was obtained from the Ethical Review Committee of JPMC before the study was conducted. Data was collected via survey forms after consent from individuals. Statistical analysis was done using SPSS v.17. Results: The prevalence of teacher smoking within school premises was found to be 8.8% and 5.9% in private and public sectors, respectively. A significant difference was found between the school policies enforced in private and government schools against personnel found smoking (p=0.00016). Even though private school personnel smoked more in school premises than government but 32.6% of private school teachers felt responsible for teaching about health compared to only 21.5% public school teachers (p=0.0072). Conclusion: There is a pressing need for awareness and education of teachers regarding their attitude towards smoking on school grounds and its significant link with students adopting smoking. Other exposures and risk factors influencing student tobacco usage needs to be studied in more depth.

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