Dealing with Gutkha menace

India’s attempt to ban gutkha is celebrated as a triumph of public health legislation. Over the past decade, the central and state governments systematically outlawed the toxic blend of chewing tobacco, areca nut and flavourings. Optimism surged when the Global Adult Tobacco Survey (GATS-2) projected a comforting 4.5 per cent decline in smokeless tobacco prevalence. But sweeping prohibitions rarely rewrite ground realities.

A recent working paper from the Economic Advisory Council to the Prime Minister (EAC-PM) dismantles the narrative of a successful ban. Relying on the 2023-24 Household Consumption Expenditure Survey (HCES), Working Paper WP/42/2026 tracks the financial outflow of families rather than relying on self-reported health surveys that are historically skewed by social stigma. The economic data reveals that, rather than declining, the footprint of gutkha has expanded aggressively over the past decade.

In rural India, the share of households reporting gutkha consumption skyrocketed from 5.3 per cent in 2011-12 to 30.4 per cent in 2023-24, a more than five-fold rise. This translates to a jump from 8.9 million to 59.6 million rural households buying the product. Urban centres experienced an identical explosion, as prevalence climbed from 3.1 per cent to 16.8 per cent over the same period. The burden of this unchecked expansion falls disproportionately on lower-income households, where prevalence rose even faster. Despite the ban, gutkha now accounts for 41 per cent of all rural tobacco expenditure, making it the single largest tobacco product by value. Prevalence exceeds 85 per cent among the poorest 40 per cent of rural households in the largest states, such as Madhya Pradesh and Uttar Pradesh, severely misallocating limited resources and pulling critical funds away from food and education.

The public health implications are grave. Gutkha is uniquely deadly, as it combines two highly potent Class I carcinogens: tobacco and areca nut. Regular use is associated with oral submucous fibrosis, leucoplakia, periodontal disease, and increased risks of cardiovascular disease. India already shoulders one of the highest global burdens of head-and-neck cancers, with tobacco and areca nut linked to over 90 per cent of cases. This rising tide of consumption threatens to accelerate the epidemic. The failure of the gutkha ban is the consequence of a flawed regulatory environment. Prohibition has simply driven the industry to innovate its distribution through clever product unbundling. Vendors sell tobacco and areca nut (pan masala) sachets separately, allowing users to mix the gutkha components themselves at the point of sale. Combined with weak enforcement and aggressive surrogate advertising, the habit has become deeply normalised across the labour force as a cheap stimulant to endure gruelling work shifts. The resulting wave of chronic disease will inevitably strain public healthcare initiatives. Policymakers urgently need to pivot towards pragmatic, data-driven alternatives. The current model of strict prohibition and taxation has failed. Punitive taxes do not force low-income users to quit; they simply impoverish them further while enriching a massive illicit market, which is now valued at over $3.3 billion, according to the latest industry data.

A mature regulatory strategy must embrace tobacco harm reduction. The primary objective should be migrating current users away from carcinogenic smokeless tobacco like gutkha. Enabling access to significantly lower-risk alternatives provides a realistic off-ramp, while decreasing pressure on state machinery.

Modern nicotine pouches, nicotine replacement therapies (NRTs), and cytisine-based cessation treatments address chemical dependency without the primary carcinogens. A harm reduction approach is far more effective than prohibition. We can look at global precedents to see this in action. Sweden is on track to become the first formally “smoke-free” nation, reducing its prevalence to near 5 per cent by embracing safer oral nicotine alternatives such as snus and tobacco-free pouches.

Predictive models for countries adopting harm reduction forecast significant public health dividends. Studies in regions such as Africa and Southeast Asia show that adopting safer alternatives could save hundreds of thousands of lives in single nations by 2060. Scaling these projections to India’s 267 million tobacco users indicates that millions of life-years could be saved by simply transitioning users to safer nicotine delivery systems.

We must expand access to these safer options alongside smart regulation, risk-proportionate taxation, and robust cessation support. Prohibition fails when demand and social acceptability remain high. Banning products without providing viable withdrawal plans traps millions of users in a deadly cycle of addiction and fuels a booming black market. Acknowledging a policy failure is difficult for any administration. But ignoring the evidence from national economic surveys guarantees a severe public health disaster. Shifting towards pragmatic harm reduction is the only realistic way to avert a massive future burden of preventable disease and death.

Samrat  Chowdhery is an independent Tobacco Harm Reduction Advocate, Delhi, India. and Derek Yach is former WHO Executive Director, Global Health Consultant, Southport, USA; views are personal