Patna/New Delhi, April 18: Bihar's decision to ban liquor appears to have been pushed more by social compulsions than health concerns, according to public health experts, who, however, cautioned that it would still be inappropriate to compare the risks of alcohol and tobacco.

Relatives of patients suffering from tobacco-related diseases, especially those caused by chewing khaini (raw tobacco), and doctors say the state government should go a step ahead and ban all variants of tobacco.

The Bihar government banned the manufacture, sale, distribution and storage of gutkha and its variants in 2012. Two years later, in 2014, the government banned scented areca nut, scented tobacco (pan masala) and zarda. However, cigarette and khaini have still been kept out of the purview of the ban though government records show that a large amount of money is being spent on tobacco-related diseases.

While chewing tobacco is a popular habit across Bihar and is likely to contribute to tobacco-associated cancers, experts say alcohol comes with a set of risks - liver damage, cirrhosis, oesophageal damage, among others - that do not always overlap with those of tobacco use.

"Both alcohol and tobacco are public health hazards," said Pankaj Chaturvedi, a surgical oncologist at the Tata Memorial Hospital, Mumbai, who has long studied associations between oral cancer and the use of tobacco, particularly chewing tobacco.

"It's not fair to compare the hazards of one with another, but there are differences - health authorities have used medical studies in some countries to declare a small but safe level of alcohol, but no country or health authority anywhere in the world has ever declared a safe level of tobacco," Chaturvedi said.

Alcohol has far quicker and more visible impacts on consumers than it takes for the health effects of tobacco to show up in tobacco-users. "Alcohol abuse can affect families on a daily basis and contributes to traffic accidents," said Chaturvedi.

Deepak Mishra, executive director of Socio Economic and Educational Development Society (SEEDS), a non-government organization involved in creating awareness on the ill-effects of tobacco consumption, explained the rationale for a ban on all tobacco variants, especially khaini.

"According to a study jointly conducted by the Union ministry of health and family welfare, Public Health Foundation of India and World Health Organisation in 2011, the Bihar government spends Rs 1,341 crore annually on tobacco-related diseases but collects only around Rs 155 crore as revenue from the tobacco industry per year. Therefore, the expenditure on tobacco-related disorders is far more than the government's revenue collection from tobacco industries," he said.

Mishra added: "In another finding of Patna's Mahavir Cancer Hospital, the state gets around 80,000 new cancer patients every year while around 55,000 people lose their lives battling cancer annually. As per the Global Adult Tobacco Survey (GATS)-2010 report, 54 per cent of the state's population consume tobacco in one form or the other. Of this 54 per cent, 49 per cent consume chewing tobacco, including khaini. Besides, cases of oral cancer are highest in the state at around 90 per cent."

But so far the government of chief minister Nitish Kumar has been silent on banning khaini. Experts say a reason for this could be that alcohol is easier to clamp down on because its effects are more visible.

"Policy-makers find it easier to impose bans on alcohol because there are precedents to experiments in prohibition, unfortunately, most of them have been unsuccessful," said Prakash Gupta, a cancer epidemiologist formerly at the Tata Institute of Fundamental Research, Mumbai, and now director at the Healis-Sekhsaria Institute of Public Health, Navi Mumbai.

Public health specialists concede that while the evidence that links chewing tobacco to several cancers is incontrovertible, it is harder for policy-makers to act against tobacco, primarily because tobacco is yet to generate social concerns the way alcohol does.

"The ban in Bihar follows an election promise," added Gupta of Healis-Sekhsaria Institute.

Through a review of medical studies across the country, Gupta and his colleagues last year estimated that smokeless (primarily chewed) tobacco contribute to about 49,000 cancers of the mouth, 14,000 cancers of the pharynx, 11,000 cancers of the larynx, and 14,000 cancers of the oesophagus each year.

Shyam Sunder Devi (72) can't keep away her tears as she speaks about the ordeal of her son Ashok Kumar, battling mouth cancer at Mahavir Cancer Hospital.

Ashok (40) started consuming khaini at a very young age. He is now suffering from a rare kind of mouth cancer - his tongue has completely come out and he is unable to swallow anything. Ashok has been put on liquid diet for the last three months.

"My son is surviving on milk and other liquids. Being a mother I feel helpless for my son. Like alcohol, the government should ban khaini as well," said Shyam Sundar Devi, her eyes welling up.

Amitabh Ranjan, a cancer specialist at Mahavir Cancer Sansthan, demanded a ban on khaini. "The government must ban khaini or it will continue to show its perils," he said.

Mishra of SEEDS said that four districts were mainly involved in tobacco production - Vaishali, Samastipur, Bhagalpur and Nalanda. "These districts produce the best quality of tobacco. If the government intends to ban tobacco, it has to ban its production as well."

While the experts advocated for banning khaini production, those who were involved in its farming said it was impractical, given that a large chunk of the population depended on it for livelihood.

Bhola Rai, a farmer at Mahnar in Vaishali district whose family has been into khaini farming for decades, said: "How will we earn food for our family if the government bans khaini also? Tobacco being a cash crop, we get to make easy profit with its cultivation. We don't get to make much profit from foodgrain cultivation. If the government bans it in future, it should first provide employment to all who are involved in its cultivation. The government has no right to snatch our livelihood." Bhola said that 80 per cent farmers of Mahnar were involved in tobacco production.

In a report in the International Journal of Cancer, the researchers said about 90,000 cases of cancers could be avoided by implementing measures to control smokeless tobacco consumption.

"Although the health effects of smoking and smokeless tobacco are equally dangerous, the socio-political and public health response has been tilted towards the smoking epidemic for far too long," researchers said, adding that their estimates will can help convey warnings to the public and to policy-makers.