By Dr Firdaus Samad & Arindam Biswas
In Meghalaya, the tradition of chewing betel nut, locally known as Kwai, spans centuries, and is deeply embedded in the cultural fabric of the Khasi community. Offering Kwai to guests symbolizes respect and hospitality, transcending social and economic barriers, making it a universal gesture of goodwill. This practice not only fosters social bonds but also serves as a testament to the egalitarian nature of Khasi society, where Kwai is accessible to all, irrespective of one’s financial standing.
The ritual of consuming Kwai, typically wrapped in a betel leaf with lime, is a community activity that strengthens social ties. However, this tradition also introduces several health concerns, particularly when combined with tobacco and alcohol. Several studies highlight that excessive consumption of Kwai poses significant health risks, including oral health deterioration and a heightened risk of oral cancer. The arecoline alkaloid found in betel nuts, when consumed excessively, increases the risk of oral cancer, especially when paired with tobacco and alcohol. Meghalaya, referred to as the ‘Cancer Capital’ of India by a Times of India article dated June 1, 2022 , exhibits high prevalence rates of esophageal, throat, nose, and lung cancers. According to the National Centre for Disease Informatics and Research report 2021, esophageal cancer affected 31% of males and 22.3% of females. The habitual chewing of Kwai can also lead to mouth ulcers, which, though typically self-healing, can escalate the risk of cancer if recurrent in the same area.
Despite these health implications, Kwai continues to be sold near educational institutions, exposing adolescents and young adults to its risks. This paradox highlights the challenge of balancing cultural practices with public health concerns, emphasizing the need for awareness and intervention to mitigate the adverse health effects associated with Kwai consumption, while respecting its cultural significance in Meghalayan society. India, with its vast adolescent population of nearly 250 million, faces significant public health challenges, particularly in habit formation during these formative years. Adolescents, central to societal development, often adopt habits influenced by societal norms and accessibility to substances like Kwai. This betel nut, deeply ingrained in cultural practices, is readily available and affordable, often sold near educational institutions, which may inadvertently promote early habituation among youth. The Cigarettes and Other Tobacco Products Act (COTPA) 2003, which prohibits the sale of tobacco products to individuals under the age of 18 and within 100 yards of educational institutions, aims to curb youth access to tobacco. Applying similar restrictions to Kwai could significantly reduce its consumption among adolescents without adversely affecting the livelihoods of local vendors, who could diversify their offerings. Moreover, integrating awareness campaigns about Kwai’s harmful effects into the School Health Program under the National Health Mission could enhance education on this issue. Counselling for children and adolescents who consume Kwai should also be considered to support healthier lifestyle choices, thereby addressing this critical public health issue more effectively.
Meghalaya could leverage the essence of Cigarettes and Other Tobacco Products Act (COTPA) to reduce the prevalence of betel nut consumption among its youth. The school authorities could help in designing strategies to reduce sales of Kwai within 100 yards of their premises. Schools and parents, both, should actively report any betel nut sales within the vicinity of educational institutions. Additionally, implementing regular awareness campaigns is crucial to educate children about the detrimental health effects of betel nut consumption. For those children already showing signs of addiction, it’s imperative to provide effective counselling and support for cessation. Parents play a critical role in addressing this issue early on, preventing the escalation to associated habits like smoking and tobacco chewing. Encouragingly, a pilot study across six villages in the Ri-Bhoi district involving 140 households showed a reduction in Kwai consumption, from an average of 10-15 Kwais a day to just 2-3 owing to health issues related to the consumption of Kwai. This positive trend highlights the potential impact of a concerted, multi-stakeholder approach to health education and intervention. By fostering a community-wide effort to reduce Kwai intake, Meghalaya can safeguard its future generations from the health risks associated with betel nut consumption, ultimately leading to a healthier people and state.
(The writers are attached to the Indian Institute of Public Health (IIPH), Shillong)