jmal Soomar Samejo has been lying on a damaged wooden cart outside his home in Buhara, a small town in Sindh’s Thatta district. Last year, he was diagnosed with severe oral cancer at a government hospital in Karachi. He now struggles to open his mouth to speak or eat. He is 29 years old and can no longer speak because of this fatal illness. His father, also physically incapacitated, watches quietly from inside, carrying a pain that is both personal and financial. In homes like his, sickness is rarely an isolated event; it changes the way the whole family lives.

Ajmal’s was relatively young when he formed a habit of chewing on gutka tobacco. Gutka (chewing tobacco) is easy to find and socially acceptable. It is sold in small packets. It can be found at roadside vendors, tiny grocery stores and tea cafés - even near schools, where it is often openly advertised despite an official prohibition. The habit that seems insignificant at first can eventually become an urgent need. Ajmal’s case illustrates a trend that is increasingly evident throughout Sindh.

Gutka is not a safe way to freshen one’s breath; it is a chemical mixture of areca nut, tobacco, slaked lime and flavouring ingredients, sometimes including more substances known only to the people who supply it. The World Health Organisation says that areca nut is a Group 1 carcinogen - a proven cause of cancer. This classification is supported by epidemiological evidence presented in the IARC Monographs (Vol. 100E), which associate areca nut consumption with oral submucous fibrosis and oral cancer.

Recent clinical literature supports this link. A 2022 review published in the International Journal of Environmental Research and Public Health indicated that regular consumption of areca nut and smokeless tobacco markedly increases the risk of malignant transformation in oral tissues, especially among South Asian populations. The Pakistan Medical Association has consistently pointed out that smokeless tobacco is a major cause of mouth cancer in Pakistan. Its addictive nature makes it even more dangerous. Once one starts using it regularly, they can quickly become dependent on it, making it difficult to stop both physically and mentally.

The scale of the crisis becomes clear when examined through district-level data. At Civil Hospital Thatta, records compiled under the supervision of Dr Shayam indicate 553 diagnosed cases of oral cancer in 2024, 395 in 2025 and 95 cases reported up to April 6, 2026. These figures, while significant, do not represent the full burden of disease. They reflect only those patients who received a formal medical diagnosis.

Medical professionals say that underreporting remains a major problem. Many patients, especially those living in rural areas, either wait too long to seek care or never reach diagnostic facilities. This corresponds with a 2023 study published in the Asian Pacific Journal of Cancer Prevention, which found that late-stage presentation remains a problem in Pakistan because of low awareness and inadequate access to screening. Aga Khan University has also observed this pattern, finding that delayed detection greatly reduces the chances of survival for people with oral cancer.

Gutka is not a continuation of ancient culture. It is a commercial reimagining of older chewing habits in South Asia. Historically, chewing betel leaf (paan) was a social ritual associated with hospitality, custom and post-meal tradition. It was freshly prepared and shared across communities. The introduction of tobacco through early global trade routes, especially after the 16th Century, gradually changed this tradition, turning it into more of a habit on which people depended rather than a purely social and symbolic practice.

The present form of gutka, and mawa, a more advanced version of this substance, did not emerge until the late 20th Century, when people in South Asia began producing ready-to-use sachets of areca nut, tobacco, lime and flavourings for public consumption. This marked a shift from cultural preparation to commercial standardisation.

Gutka first came to Pakistan in the late 1980s and 1990s, when trade controls were weak, informal retail networks were common and supply chains crossed borders. This made it easy for the product to spread quickly from India to urban areas, particularly Karachi. It then spread into the interior of Sindh, first reaching Thatta, then Sujawal and the wider Laar region, including Tharparkar, which could not protect itself from refined gutka. It spread further through small-scale distributors and networks of local shops. It quickly reached rural areas because it was cheap, easy to carry and marketed aggressively through informal channels. This turned it from an imported product into a deeply rooted cultural habit.

In communities where gutka use is normalised, its presence becomes almost invisible. Red-stained streets, small sachets displayed in shops and routine consumption create an environment in which harm is absorbed into daily life.

In this coastal belt, political discourse has also intermittently acknowledged the severity of the issue. Haji Ali Hassan Zardari, a member of the Provincial Assembly from the coastal region of Thatta, publicly stated in media interactions that gutka and other toxic chewing substances must be eradicated completely. He linked failures in enforcement to internal corruption within supply chains. He vowed that any law enforcement officer found facilitating the trade in areca nut or receiving bribes would be removed from service, framing the issue as one of institutional accountability rather than isolated criminal activity.

His position also reflected an economic insight often discussed at the local level: gutka and mawa are structurally dependent on the supply of supari (areca nut). Disrupting this key input could significantly weaken the entire informal network. In this view, the system is not made up of separate products but is an interconnected supply chain in which supari is the foundational component.

However, despite these strong public statements, implementation in the coastal districts has not brought about a sustained change on the ground. The continued availability of gutka in local markets suggests a gap between political intent and administrative action, reinforcing the broader challenge of translating policy declarations into consistent enforcement in vulnerable regions.

The Sindh government has consistently recognised the danger posed by gutka and has prohibited its production and sale. These restrictions were particularly stringent around 2017 and were enforced in subsequent years. However, implementation has been inconsistent. The continued availability of gutka in local markets suggests that regulatory enforcement does not consistently reach the ground level.

Iqbal Jakhro, president of the Thatta Press Club, has pointed out that the issue requires a collective effort extending beyond administrative action, as public awareness remains limited. His position reflects a broader understanding that policy alone is insufficient to eliminate a habit deeply ingrained in society.

Research published in The Lancet Oncology (2020) indicates that tobacco control in low- and middle-income countries depends on sustained public engagement and behavioural change, in addition to legislation.

One of gutka’s most defining features is the intensity of its addictive effects. Regular users often experience strong cravings, irritability and physical discomfort when attempting to quit. This makes stopping difficult without sustained support and awareness.

Yet withdrawal is possible. In Thatta, a 47-year-old woman, Zahran Katiar, offers a rare but important example. Through capacity-building initiatives run by the Sindh Rural Support Organization under the People’s Poverty Reduction Programme, she received information about the health risks of gutka and support to quit. Reflecting on her experience, she says that giving up the habit was neither immediate nor easy. The cravings persisted, especially when others around her continued to use it. “It was difficult to withdraw from this gutka,” she recalls, “but I tried and overcame it. Even now, when others use it, I feel the craving, but as a leader of my community organisation, I made a commitment that I will never use it again.”

Speaking to social-sector professionals Khadim Hussain Shar and Tarique Ahmed Korai, TNS was told, “Awareness is compulsory; without advocacy, it is hard to eliminate [the problem].” Shar also stressed, “Humanitarian activities must include an inclusive campaign to raise awareness among people.”

The impact of gutka extends beyond clinical diagnosis. Addiction often begins early, shaping long-term health and economic outcomes. For families, the cost of cancer treatment can be catastrophic. A 2022 World Bank report on non-communicable diseases in South Asia highlights how out-of-pocket healthcare expenses push vulnerable households further into poverty.

In communities where gutka use is normalised, its presence becomes almost invisible. Red-stained streets, small sachets displayed in shops and routine consumption create an environment in which harm is absorbed into daily life.

Oral cancer linked to gutka is widely acknowledged as preventable because its primary cause is documented and avoidable. Early screening can greatly increase the chances of survival, but many cases in Sindh are detected late because people know little about the condition and access to care is difficult. Despite existing bans and public health measures, inconsistent enforcement and inadequate prevention strategies make the situation difficult to control effectively.

Ajmal continues to sit on his wagon as the sun begins to set along the coastal lines of Buhara, bidding farewell to the tides. His condition has not changed. It is not only the disease that causes his silence, but also the delays that have occurred: delays in knowledge, action and the systemic response. Research from global and local institutions, as well as emerging data from Laar (the lower part of Sindh), points in the same direction: this is not an isolated problem but a persistent public health disaster.

Unlike sudden outbreaks, gutka does not create the same sense of urgency. The process is long and gradual, as it becomes embedded in routine, the economy and neglect. By the time the harm becomes visible to the naked eye, it is often irreversible. In this way, gutka use continues in a manner that is unobtrusive, persistent and unmistakable.

The writer, a development sector professional, is the author of Thinking Beyond The Herd. He can be reached at [email protected].