Tobacco repackaged: Paan Parag and hookah and their unappreciated risks

Rizwan Syed seldom enjoys the luxury of a good night’s sleep. Often, his mind is conscious and different thoughts race through his head. He tries to sleep, he gets up, he plays around with the computer, but he knows only one thing will satiate his craving: Paan Parag.

“I gotta have it,” he says.

Syed, 29, has been chewing tobacco for ten years. He came to America from India at the age of three and now works at a Halal meat store on Devon Avenue, a strip teeming with Indian and Pakistani shops and restaurants on Chicago’s north side. He says his parents chewed tobacco as well.

“The family thing is the first thing, but the second thing is that all your friends eat it so you’ll eat it,” he says.

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This story is part of a unique collaboration with nine Chicago area ethnic news media exploring some of the health care options and risks for immigrants who live here. The stories were released in June 2011 by Extra (Hispanic), Reflejos (Hispanic),  Pinoy Newsmagazine (Filipino), Al Moustaqbal – Future newspaper (Arab), India Tribune, Korea Daily News, Draugas – The Lituanian World-wide Daily, Reklama (Russian) and the Urdu Times (Pakistani). Click here to access the other stories: Tobacco repackaged: Paan Parag and hookah and their unappreciated risks, Seeking closure after Chernobyl, Medical tourism lures Korean immigrants home, Lithuanian patients have a hard time letting go of the past, The silence of diabetes threatening the health of the African community, Promoting healthy eating from the ground up in Little Village’s Hispanic community, Community programs needed to fight obesity among Latinos, Filipino elders find “family” in caretakers, A look into the complexities of refugee and immigrant health care coverage, and Is the South Asian vegetarian diet bad for the immigrant heart?

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Health risks

Constant tobacco intake has affected Syed’s physical and mental health. Syed says his mind focuses on so many things that he cannot rest properly at night. He estimates he eats 11 packets every day and chews tobacco every other hour. His mouth muscles have atrophied, constricting his jaw movement. He also cannot eat spicy food because it burns his mouth and tongue, particularly in the areas that come in contact with the tobacco.

Chewable tobacco comes in different forms, but the most common brand is Paan Parag, says Akram Mohammed, 22, a salesman at New Sabah Connection, a South Asian convenience store. Mohammed says he had a customer who ate 18 packets of tobacco each day.

“I heard news that he developed oral cancer,” he says.

Chewing tobacco is worse than other forms of intake because it causes fibrosis, which is when the elasticity in the jaw goes away and patients cannot use their mouth muscles normally, says Dr. Anand Thakkar, an internist at Prism Medical Center, which serves the South Asian community.

Fibrosis can only be cured by extensive laser surgery to cut the damaged tissue, he says.

On top of dental diseases and mouth cancer, chewing tobacco can also cause throat cancer and in worse cases, pancreatic cancer, according to Dr. Richard Hurt from the Nicotine Dependence Center at Mayo Clinic.

Like any form of tobacco intake, chewable tobacco is highly addictive, Thakkar says.

“A habit forms and it has psychological hold on the patient,” he says. “Treatment is basically will power. They have to want to leave it. They have to understand the risks.”

Despite the health risks related to chewing tobacco, a lot of users are focused on the benefits Paan Parag brings.

“Health wise [Paan Parag] is bad, but it keeps your mind active,” says Monhsin Andha, 32, who has been chewing tobacco for 16 years.

Andha, who works at a rug store on Devon Ave., says chewing tobacco makes his mind work at double speed and remember things better. Apart from sometimes being short of breath, Andha is convinced he does not have any major health issues because he eats tobacco “with a style.”

“I rinse my mouth thoroughly before I chew,” he says. “I eat it in small quantities. I split it up in halves. I also don’t binge eat, I just finish my packet and then move on.”

Aware of the risks of mouth and throat cancer, Andha says he tries to use gum as a substitute. However, weaning off the tobacco addiction is very difficult.

People who are addicted to chewing tobacco want the taste in their mouth constantly, according to Dr. Alamdar H. Bader, a dentist practicing on the south side of Chicago. Though mouth rinsing helps remove the tobacco residue, only about 5 percent of users do it, Bader says.

Bader says he had a patient who could not open his mouth, had lost all his teeth, had tobacco in his sockets, but still could not stop chewing tobacco.

“It’s in your blood circulation. You’ve already had a taste,” Andha says. “After so many years, if you leave it, you’ll become sick.”

Hooking a generation on hookah

Unlike smoking cigarettes, Syed says it is difficult to chew tobacco at work or even at social settings like the bar.

“If you drink [at the bar], you cannot chew tobacco,” he says.

Andha says smoking is a fashion while chewing tobacco hinders social interaction. It is also common for people to pick up other forms of tobacco use, such as hookah here in America, he says.

Iman Aziz, 48, owner of a rug store on Devon Ave., says hookah is getting increasingly popular among the younger generation of Indians and Pakistanis, many of whom smoke hookah mistakenly believing that it is better for their health than cigarettes, he says.

Monica, 22, who declined to give her full name, has been working at The Hookah Joint on Devon Ave. for a month. She says they get a mixed age range of customers but most are young people, who are often there for social events such as birthday parties.

According to Monica, some customers smoke hookah as a means of giving up cigarettes. She believes the water in the pipe mixes and purifies the tobacco.

“You know when you like steam water and it kills the germs in the water, that’s basically distilled water,” she says. “When you put charcoal on hookah, it’s heating it up, so it’s kind of like the same thing, you know. I guess I can’t really explain it.”

However, Hurt of the Mayo Clinic says one hookah session for an hour is the equivalent to smoking one pack of cigarettes.

Hookah smokers may actually inhale more tobacco smoke than cigarette smokers do because of the large volume of smoke they inhale in one smoking session, according to reports from the Nicotine Dependence Center.

Hurt counsels that hookah is just as bad if not worse than cigarettes.

“Along with all the carcinogenic chemicals are heavy metals that are in the tobacco and the delivery device for hookah smoking,” he says.

Youssef, 28, who declined to provide his full name, says he is aware that hookah may be more harmful than cigarettes.

“There’s no filter. It’s all physics 101,” says the regular hookah smoker who is originally from Morocco and now works as a salesman in Chicago.

Aziz says a lot of kids in the South Asian community, like his 18-year-old son, are unaware of the health risks regarding hookah.

“The kids, they love it. Oh strawberry flavored, this flavor— this is no flavor, this is a game,” he says.

Youssef says hookah flavors are more for marketing purposes.

“Mix this, mix that,” he says, “it’s how potato chips came up.”

Youssef thinks hookah is not as popular as cigarettes because of its relative inaccessibility.

“You gotta prepare so much before smoking,” he says.

Naeem Mohammad, a real estate agent, who used to own The Basement, a hookah bar in Chicago, says hookah is more like a form of entertainment for most people. He says people use different ways to smoke hookah, such as adding weed to it for long-lasting highs. Despite the harms of tobacco in hookah, Mohammad says hookah is not taxed like cigarettes.

I don’t think the government knows enough about the harms caused by hookah and the amount of income generated by it, he says.

Community Awareness

Unlike alcohol, there is not much public awareness in the community about the side effects of tobacco use in hookah and chewable tobacco, Youssef says.

“People need to hear real life stories,” he says. “If they read about a drunk guy killing a family, they will pay attention to it.”

While ads targeted to prevent smoking and cigarettes are common, Vipul Patel, 25, and Ronak Dharji, 25, say most of the health ads are on American TV channels. There are hardly any  on popular South Asian networks like Zee TV or TV Asia, they note.

Some tobacco manufacturers in Pakistan and India have started to include warnings on their tobacco packets. Popular brand RMD puts in large bold letters that their product “can cause gum disease and tooth loss.”

Though both the Indian Medical and Dental Associations in India have called for a ban on Paan Parag, lawmakers in India have failed to follow through because of its high popularity and demand, according to Bader. As a result, large amounts of Paan Parag are still exported to the American market.

Efforts to control hookah usage are more apparent. Mohammad says kids under 21 go to hookah bars because they can’t get into clubs. But because minors have been caught illegally smoking and drinking in hookah bars, the City of Chicago has made it costly and difficult for people to get hookah licenses.

According to the city’s ordinances, businesses that provide services and devices for hookah smoking on its premises are required to have a “special use” tobacco license. The “special use” is a zoning requirement, according to Efrat Dallal Stein, spokesman for the Department of Business Affairs and Consumer Protection of Chicago.

Stein says hookah businesses must notify its surrounding community of its presence through the zoning board of appeals, which is a complicated process.

Apart from that, Chicago and the state of Illinois have not passed any laws to limit hookah businesses. In California, Connecticut and Oregon, lawmakers have introduced bills that will ban or limit hookah bars, according to a recent New York Times article.

Though no laws have been passed against hookah, there are efforts to reduce tobacco usage in Chicago. In March 2010, the Respiratory Health Association launched the Chicago Tobacco Prevention Project that, among other things, endorses smoke-free housing policies and advocates a ban on cigarette vending machines, says Dr. Bechara Choucair, Commissioner of the Chicago Department of Public Health.

However, Thakkar says there still isn’t much awareness about the various health risks related to such alternative uses of tobacco as chewing tobacco and smoking hookah.

The issue is complex and people need to be aware that they can affect you more than cigarettes, he says.

Hurt says though eating tobacco is riskier than smoking cigarettes, no form of tobacco is safe.

People sometimes do things that harm their bodies even though they are conscious of the consequences, Youssef says.

“The biggest battle is not among people, it’s among ourselves,” he warns.