Sir, we read with interest the letter Oral cancer: Indian pandemic where the authors have drawn attention to this deadly disease in India.1 As dental professionals we are participating in the development of an atlas of cancer in Haryana state in North India that focuses on the reporting of each cancer case reported in Haryana state from each medical institution. The smokeless tobacco (SLT) or chewable tobacco market in India is the world's largest market (70.7 million people) with an exponential growth.2 Nearly 80% of global SLT users live in the South Asia region, which has myriad varieties of SLT products (betel quid with tobacco, khaini, gutkha, paan masala, mawa, bajjar, gudakhu and snuff).3 The biggest drawback we have encountered in this registry is the complete lack of awareness of the public perception of the harmful effects of SLT as compared to smoking.

Within rural parts of North India smoking is a taboo for women but conversely it leads to them using SLT as it is easy to hide from others who might disapprove. Women in this area also have a misconstrued belief that chewing tobacco increases energy for daily labour in the face of limited food intake and to suppress hunger.4 Easy availability, poor socio-economic status, illiteracy and the low cost of the SLT are other key factors that promotes SLT use by women.4 Moreover, the use of tobacco-based dentifrices (mishri, gul and lal dant manjan) further aggravates the problem. The quit ratio for SLT is notoriously low (5%) as compared to smoking.2

Dental professionals should be more aware and enquire more specifically about SLT use by their rural female patients. Social marketing campaigns are essential but they will have to focus more on SLT-related health risks in females also. Though there is research on dual usage of smoking and SLT in India among men, there is negligible research as yet on SLT usage and on the patterns and predictors of Indian females' SLT use with its health consequences to explore patterns of usage, especially during pregnancy. The first step in winning the war against tobacco is to acknowledge the unique challenge posed by the usage of SLT in females, which needs to be addressed through social/behavioural and policy level approaches. Eventually, the success of the campaign will depend on women's willingness to be open about their SLT behaviours.