Ask a patient chewing khaini whether they smoke and the honest answer is no. Gutkha, khaini, zarda, paan masala with tobacco, mishri rubbed on the gums — none of it is smoking, and a question about smoking will not find it. Yet smokeless tobacco is the dominant form of use in much of India, and it carries its own oral, oesophageal and cardiovascular risk.
Ask instead: do you use tobacco in any form, including chewing or applying it. Then ask what, how many times a day, and for how long. Record it in the same place you record smoking status, because a blank smoking field is read by the next clinician as a negative tobacco history.
While the mouth is open, look. Leukoplakia, an erythroplakic patch, restricted mouth opening from submucous fibrosis — these are visible in a routine examination, and the patient who has been chewing for twenty years has never been asked to open their mouth for anyone but a dentist.
- Ask about tobacco in any form, naming chewed and applied products, rather than asking about smoking.
- Record the form, frequency and duration, not just yes or no.
- Examine the buccal mucosa and check mouth opening in any long-term user.
- Offer cessation treatment for smokeless tobacco — it is treatable, and varenicline is recommended for it.
- Ask again at the next visit; people who have quit smoking often continue chewing.
Why it matters
A negative smoking history is routinely recorded for patients using the most common form of tobacco in the country.
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