Dear Editor,

Tobacco use disorder is an important public health problem. According to the World Health Organization (WHO), 1.3 billion people use tobacco. Two-thirds of the smokers in the world live in 10 countries, one of which is Turkey, where in recent years, the composition of state policies related to tobacco use, the increase in the number of policlinics devoted to the cessation of smoking, and a frequent emphasis on the subject promoted by the media have encouraged people to seek treatment for tobacco use disorder (1). On the other hand, prohibitions of tobacco use in public places have led people to seek alternatives that are cheaper and easier to access. In fact, it is possible to see people who are inclined to use these products give up the use of cigarettes. In addition, the tobacco industry has accelerated this process by suggesting that these alternative products are harmless (2).Therefore, it is imperative for psychiatrists to develop an awareness of smokeless tobacco (ST) products, whose names and composition may vary widely according to different geographic regions. The aim of this letter is to inform psychiatrists about ST and its use in Turkey. Tobacco being chewed in the mouth or brought into contact with the oral mucosa without generating smoke is referred to as ST. Various blends of ST products are available in different countries under different names. Among the ST variations reported by the WHO are products referred to as “chimo” in Venezuela, “toombak” in Sudan, “Mawa” or “Gutkha” in India, and “Snus” in Europe (3). These products are consumed by at least 300 million people in 70 countries, with 89% of ST users living in Southeast Asia. A study in the United States in 2012 detected that 3.5% of the population aged 12 years and above (9 million) had used ST in the last 1 month; in India, ST utilization was above that of normal cigarettes, with 26% of the population consuming ST, while a study in Sweden in 2013 demonstrated that 20% of men and 4% of women used ST daily or on a regular basis (2). The consumption of ST in Turkey emerges in the form of a widely used type of ST that is commonly called “Maras powder,” found especially in the environs of Kahramanmaras, Gaziantep, and Adiyaman. It is also referred to as “Hasankeyf tobacco” or “crazy tobacco.” Maras powder consists of dried leaves of Nicotiana rustica L. and a mixture of ashes from oak, vine wood, or walnut trees. This mixture has an alkaline nature and is easily absorbed through the oral mucosa. The users wrap this product into a small piece of paper and insert it between the lower labial mucosa and the gingiva, and after a certain amount of time remove it (4). Unfortunately, many users of Maras powder believe that this form of ST is less harmful than smoking cigarettes. However, the Nicotiana rustica found in Maras powder contains 5 to 8 times more nicotine compared to the amount in cigarettes. By now, a number of studies are available demonstrating the negative effects of Maras powder on the respiratory, circulatory, hematologic, and immune systems. It was also demonstrated that this form of ST causes leukoplakia, which is a precursor to oral cancer (5). In Turkey, there is an insufficient amount of studies regarding the widespread use of ST. A study made by Orhan et al. (4) detected that the use of Maras powder was seen in 10.1% of the patients who presented to the psychiatric outpatient clinic, which was 2 times the frequency seen in the control group from family medicine outpatients with no psychiatric disease. However, this study being performed in Kahramanmaras, one of the cities where Maras powder use is most common, means that its results might not be generalizable to the entire country. In addition, there are no studies in Turkey regarding the use of other ST products defined by the WHO. In conclusion, Maras powder is a type of ST that is often normalized among its users in Turkey and represents an area of substance use disorder that is not sufficiently known or researched by psychiatrists. The attempts in recent years to treat tobacco use disorder should also encompass the use of ST products such as Maras powder. All clinicians should consider the use of all smokeless tobacco products including Maras powder, especially in areas where is widely used.

REFERENCES

1.Celik S, Guven M. Management and treatment of smoking. Update in Psychiatry 2014; 2:207-208. (Turkish)

2.Ebbert JO, Elrashidi MY, Stead LF. Interventions for smokeless tobacco use cessation. Cochrane Database Syst Rev 2015; 10:CD004306.

3.International Agency for Research on Cancer Monographs Online Volume 100e. Supplementary Web Tables Smokeless Tobacco. https://monographs.iarc.fr/iarc-monographs-volume-100e-smokeless-tobacco. Accessed October 15, 2018.

4.Orhan OF, Ozer UG, Celik M, Biter E, Karaaslan MF. Maras powder usage among Turkish psychiatric outpatients. Subst Use Misuse 2011; 46:486-491.

5.IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Smokeless tobacco and some tobacco specific N-nitrosamines. IARC Monogr Eval Carcinog Risks Hum. 2007; 89:1-592. https://monographs.iarc.fr/iarc-monographs-on-the-evaluation-of-carcinogenic-risks-to-humans-32/ Accessed October 15, 2018.