At a tiny kiosk on a Mumbai lane choked with rickshaws, Chandrabhaan Chaurasia is selling paan – betel leaves sprinkled with spices. They're a cheap street snack across South Asia.
Chaurasia, 51, spreads a leaf with spicy herbal paste and then sprinkles it with dried tobacco. He folds the leaf into an edible little parcel, and sells it for 8 rupees — about $0.11. He also sells single-serving packs of chewing tobacco. Another kiosk nearby sells hand-rolled leaf cigarettes, called beedis.
India banned electronic cigarettes last month. With about 100 million smokers, India has the second-largest smoking population in the world, after China. Amid global reports of deaths and illnesses linked to vaping, India decided to ban e-cigarettes preventatively. They had yet to become popular.
But other forms of tobacco already are. In fact, twice as many Indians (about 200 million) use smokeless tobacco — like paan or chewing tobacco — than cigarettes. That's the most in the world. Those products are harder to regulate because they're mostly sold at street kiosks, for a fraction of the price of cigarettes.
Chaurasia's tobacco kiosk is right outside Tata Memorial Hospital, one of the best cancer research facilities in India. Inside the hospital, Dr. Gauravi Mishra, a preventative oncologist, sees the harmful effects of those tobacco products on a daily basis.
"India has the highest number of oral cavity cancers. In fact, one-third of the global burden comes from only one country — and that's India," Mishra notes.
When NPR visited her office, Mishra had just biopsied a boil inside the mouth of a patient who's been chewing tobacco for 10 years.
"I had some idea that it was bad, but I didn't know it could be so serious," says Madhukar Patil, 42, his mouth filled with sterile gauze.
Patil is waiting for results to determine whether he has oral cancer. A father of two, he vows to quit tobacco now, for good.
"I realize now that if you want to be there for your family and enjoy precious moments with them, then you must leave this bad habit," Patil says.
More than one in five Indians over the age of 15 uses some form of smokeless tobacco. (The figure is nearly one-third for men.) Poor laborers often chew tobacco as a stimulant, like chewing gum, to kill their appetite. Some even use tobacco ash as toothpaste. Patil used to chew gutka, a mixture of granular tobacco, betel nuts and spices.
Part of the problem is awareness.
"If someone is smoking, they might be looked down upon. But smokeless tobacco is culturally accepted. If you visit any rural area, people will greet you with paan," Mishra says.
Another part of the problem is packaging.
Indian law requires cigarette companies to print health warnings on cigarette packs. Often, they carry graphic photos of tobacco-related tumors. So people know that smoking cigarettes is bad.
But other tobacco products are sold loose. Hand-rolled leaf cigarettes, or beedis, are green. They look organic. And they're seven to eight times more common in India than conventional cigarettes, according to the World Health Organization.
Beedis also provide a livelihood to millions of mostly female, first-time workers.
In Mumbai's oldest red light district, Balamani Sherla rolls beedis on the floor of her one-room home. At 60, Sherla has been doing this for half a century. It's the only job she's ever held.
She buys the ingredients wholesale: tendu leaves, dried loose tobacco, and string to tie off the rolled beedis. Sherla soaks the leaves in water to soften them, then cuts them round with giant shears, lines them with tobacco, and rolls them into short green cigarettes. She sells them to a middle man who then distributes them to street kiosks.
"It's tedious work," she says. "My arms ache, trying to roll the beedis very thin."
Sherla doesn't smoke. But studies show that beedi rollers often suffer from respiratory problems, burning eyes and asthma – just from breathing tobacco dust.
Nevertheless, it's considered such a lucrative skill that women who can roll beedis are coveted as brides. Sherla makes about $0.14 an hour, which is a big help for her family, she says.
But wages used to be higher. The Indian government has repeatedly hiked tax on all tobacco products, including beedis -- and that has cut into Sherla's profits.
Most of the revenue India collects from taxing tobacco comes from packaged cigarettes, even though they're less popular than beedis and smokeless tobacco. Tax rates on all tobacco products in India fall below the WHO's recommendation of 75-percent of retail price.
Levying taxes on tobacco has long been considered an effective strategy to discourage its use and improve public health. But in India, where beedi workers often come from very low socio-economic backgrounds, that tax itself could be deadly, says Umesh Vishwad, general secretary of the Akhil Bharatiya Beedi Mazdoor Mahasangh (All India Beedi Workers Union).
If taxes on beedis keep rising, workers could "become homeless and starve to death," Vishwad says.
They live that close to the bone, he says. His group wants the Indian government to retrain beedi workers for other jobs, before it chips away at their livelihood.
While Sherla and some of her neighbors roll beedis at home in urban Mumbai, the industry employs more people in rural areas, especially in the southern Indian states of Telangana and Andhra Pradesh. In central India, some of the beedi workers come from tribal areas where communist guerrillas are active. Vishwad worries that if their livelihoods are threatened, they could be vulnerable to insurgent recruiters.
"If these people lose their jobs as beedi rollers or beedi leaf collectors, they could be forced to join the militancy and pick up arms to survive," he warns.
For Sherla, rolling beedis is a calculated decision. She knows that handling tobacco may not be good for her health. But she's trading a long-term health risk for the ability to feed her family tomorrow.
"What other job can I do? I'm an old lady," Sherla says. "This is the only option for me."
As she works, Sherla's 10-year-old granddaughter Siri bounces around the dank little room. The girl goes to school, and has learned English well. She interrupts often to tease her grandmother and translate for her. She's the same age Sherla was when she started doing this work.
Will Siri follow in her grandmother's footsteps?
"No way!" Sherla exclaims. "This little girl wants to be a doctor."
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