As an Oral Surgeon and specialist in Oral Medicine with over two decades of clinical experience in Pakistan, I have seen the devastating, life-altering impact of oral cancer firsthand. It’s not just a medical statistic; it’s a patient losing their ability to speak, swallow, or smile, and a family facing immense emotional and financial distress. This reality is what motivates my research, particularly in addressing the primary culprit, Smokeless Tobacco (SLT).

The Unseen Burden of Addiction

In Pakistan, oral cancer is the leading cancer in males and the third most prevalent in females. Despite international efforts, SLT use remains rampant, particularly in rural communities where it is deeply ingrained in the cultural fabric.

My co-authors and I recognized a crucial gap: while we treat the terminal outcome in the hospital, we rarely understand the deep socioeconomic and cultural roots that drive the habit in underserved areas. This led us to conduct a qualitative study in Gadap Town, a rural area near Karachi, to explore the lived experiences of SLT users.

The interviews revealed profound human stories that reflect what I suspect drives many of the cases I see clinically:

• Emotional Dependency: Participants, especially women, described SLT as a coping mechanism for stress or a way to manage daily life challenges. They reported feelings of being trapped, with immediate relief overshadowing the long-term consequences. As one participant stated, "I need some to chew otherwise I don't feel like working".

• The Awareness Gap: Even though participants were acutely aware that SLT "damages your teeth and cause cancer", this knowledge often coexisted with resignation or denial, resulting in a critical disconnect between health awareness and actual cessation behavior. They were simply too addicted to quit on their own.

The Role of Financial Counselling: A Potential Breakthrough Strategy

The most powerful finding in our research emerged from the intersection of addiction and poverty, the significant financial burden of the SLT habit. For low-income families in Gadap Town, where daily wages for unskilled workers may be as low as US$2.50 to US$5.00, the consistent purchase of products like Guthka created acute financial distress.

Participants frequently noted that daily expenditures on SLT detracted from essential family needs such as food, clothing, and education. This trade-off, a constant struggle between addiction and necessity, became a strong motivating factor for people to quit SLT use.

This insight suggests a potentially, highly effective avenue for intervention where traditional health warnings have failed, financial counselling.

Instead of solely focusing on the threat of cancer, interventions in rural settings should adapt behavior change strategies to emphasize the cost-saving benefits of cessation, directly linking quitting to improved quality of life and financial well-being for the entire household. This approach, such as tailoring the BISCA model (Behavioural Support Interventions for Smokeless Tobacco in South Asians), can turn economic strain from a household conflict into a powerful tool for behavioral change.

My team strongly advocates that training local healthcare workers in primary health care centers (PHCs) to routinely screen for SLT use and integrate this financial-focused counselling can make a critical difference in the success of cessation attempts in these marginalized communities.

Ultimately, overcoming Pakistan’s smokeless tobacco epidemic requires more than just clinical treatment; it requires targeted, culturally relevant, and financially sensitive strategies that address the full complexity of addiction as a socioeconomic problem.

Key Takeaways for Researchers and Policymakers:

1. Tailor Interventions: General health awareness campaigns are insufficient. Interventions must be culturally relevant and address emotional dependency and stress management.

2. Utilize Financial Leverage: Integrate financial counselling into cessation programs, emphasizing how quitting frees up household resources for essentials like nutrition and education.

3. Strengthen Regulation: Strict enforcement against the widespread availability of unregulated SLT is essential, as participants themselves believed a ban would be instrumental in helping them quit.

I welcome collaboration with researchers and policymakers interested in advancing these tailored, gender-sensitive interventions to finally reduce the devastating oral cancer burden in rural Pakistan.