RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

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					        RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

                BANGALORE, KARNATAKA.

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION.



 1   NAME OF THE CANDIDATE MISS. VINCY MOL K GEORGE
     AND ADRESS            1ST YEAR M.Sc. NURSING STUDENT,
                           RAJEEV COLLEGE OF NURSING
                           K.R.PURAM; HASSAN; KARNATAKA.


 2   NAME OF THE INSTITUTIONRAJEEV COLLEGE OF NURSING,
                            K.R.PURAM; HASSAN; KARNATAKA.


 3   COURSE OF STUDY AND    MASTER OF SCIENCE IN NURSING
     SUBJECT                 CHILD HEALTH NURSING


 4   DATE OF ADMISSION TO     31-05-10
     THE COURSE


 5   TITLE OF THE TOPIC     THE EFFECTIVENESS
                            OF STRUCTURED TEACHING PROGRAM
                            ON ILL-EFFECTS OF PAN MASALA USE
                            AMONG ADOLESCENT BOYS IN SELECTED
                            PRE UNIVERSITY COLLEGES OF HASSAN.


 5.1 STATEMENT OF THE       “A STUDY TO ASSESS THE
     PROBLEM                 EFFECTIVENESS OF STRUCTURED
                             TEACHING PROGRAM ON KNOWLEDGE
                            REGARDING ILL-EFFECTS OF
                            PAN MASALA USE AMONG
                            ADOLESCENT BOYS IN SELECTED
                             PRE UNIVERSITY COLLEGES OF HASSAN




                                1
6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION

        “It is easier to prevent bad habits than to break them”

                                                                  -Benjamin Franklin.

             Adolescence is the age in which the child will have different changes in their
life both physically and mentally. According to the adolescent psychology, the children
who are in this age group feels themselves as an independent creatures and they don’t
feel necessity or importance to take permission from their parents regarding each and
every aspect which they have to perform. Other than this independence, several
behavioral changes can also be observed in them. They pay much interest on the new
things which are not necessary to learn at that age.1

            Stepping in to the 21st century, India has more challenging face, pan masala
being a critical problem among them. The incidence of pan masala use has shoot up
dramatically in the school going children and adolescents .The age group seems too
vibrant that they are easily misled and finally end up in practicing bad habits. At first it is
a matter of fun, joy but they never know these masalas have life threatening effects. . The
fate of majority pan users is lifelong addiction. Even then pan and pan masala products
are easily being sold in the markets at a very low rate making it accessible to people of all
classes.2

            Pan Masala is nothing other than the smokeless tobacco. Pan masala chewing is
a habit of social concerns. In recent decades it has become a major public health problem.
Today it is practiced by 1/3 of the total population. Traditionally it was chewed after food
as a mouth freshener but, in the nineteen seventies, pan masala with all the ingredients of
betel quid except betel leaf, has hit the market in convenient sachets. They are well suited
for the fashionable young Indian middle class and the aggressive marketing of these
products has led to its popularity even among school children.3

            Pan Masala is a balanced mixture of betel leaf, areca nut, clove, cardamom,
mint, tobacco, essence and other ingredients. It is available in the forms of packs and
pouches and this readymade form contains betel quid instead of betel leaf.4 Excessive use

                                              2
may have adverse effect. Mainly pan masalas are of two types plain pan masala and pan
masala containing tobacco otherwise called gutkha. Now a day a wide variety of pan
masalas are available in different names for example pan parag.5

        Pan masala-containing tobacco, commonly known as Gutkha, was introduced in
the Indian market during the 1970s.6They come in attractive foil packs and sachets. The
use of pan masala / gutkha is considered a benign and socially acceptable habit by most
Indians. There is even an element of prestige associated with the habit. The addictive
nature of tobacco compounds the problem, as quitting becomes difficult even for
concerned users. This “socially accepted addiction” is, in fact, proving more dangerous
than other addictions.7So the government should enact new law to regulate companies
that promote the sale of pan masala.8

6.1. NEED FOR THE STUDY
          The use of pan masala has gone up in the past five years and was commonly
found among youngsters particularly among the 13-18year age group 9. According to
WHO estimates, there are nearly 2.5crore tobacco users in India, including both smoked
and chewed forms. In India, tobacco consumption is responsible for half of all cancers in
men and a quarter of all cancers in women. Of the total amount of tobacco produced in
the country, around 48% is in the form of chewing tobacco. Basically pan masala is a
substitute of tobacco products. Users of tobacco products largely converted to use Pan
Masala.10 Among chewed forms of tobacco, use of pan masala contributes to the
highest rates of oral cancer in the India. 7
          Use of 'Gutka' and 'Pan Masala with Tobacco' is a common modality of tobacco
use especially among the youth. It has been reported through large-scale representative
surveys in Uttar Pradesh and Karnataka that 77.25 and 83.1% of users of gutka or pan
masala-containing tobacco, respectively, from the two states, were below the age of
40years.5
          Adolescents are the most vulnerable population to initiate use of pan masala
items. This use in children and adolescents is reaching pandemic levels. It is now well
established that most of the adult users of tobacco products start using them in childhood
or adolescence.11

                                               3
         Study at Regional Cancer Center Trivandrum shows that ingredient used in pan
masala and ghutka could cause genetic deformity among users. Apparently they seem
harmless but they remain direct causes oral cancer, cancer of upper aero digestive tract
and other diseases concerned with cardiac and respiratory system. Studies even says that
pan masala are found to have water soluble mutagens causing chromosomal damages.12

         According to the National Institute of Nutrition, Hyderabad the use of pan
masala and Ghutka if consumed for five to seven years leads to Oral sub mucous
fibrosis. The study by the National Institute of Occupational Health, Ahmedabad, shows
the presence of toxic metals such as lead, cadmium and nickel and pesticide residues in
pan masala.13

        The habit of using pan masala is increasing because of its legality, free
availability and relatively cheap cost. However, studies have confirmed that smokeless
tobacco is as harmful as smoked tobacco. In fact, chewing tobacco could result in
significantly greater deleterious cardiovascular effects due to a larger overall exposure
owing to prolonged absorption. Nearly a third of all cancers can be attributed to use of
pan masala. India has one of the highest rates of oral cancer in the world. These rates are
steadily increasing and oral cancer is detected more frequently among the youth.7
         A study was conducted to assess the practices and knowledge of harmful
effects regarding use of Chaalia and Pan Masala in three schools of Pakistan. Results
shows that the frequency of use of any brand of Chaalia was found to be 94% and that of
Pan Masala was73.8%. Eighty five percent of them were regular users. The frequency of
habits of Chaalia and Pan Masala chewing, by school children in lower socio-economic
areas is extremely high. Knowledge about established harmful effects was variable. The
probable reasons for this high frequency are taste, the widespread use of these
substances by family members and friends, low cost and easy availability.14
       In 2003 the International Agency For Research On Cancer                reached the
conclusion that there is sufficient evidence that the habit of chewing betel quid with or
without tobacco is carcinogenic to humans. Support is provided by a recent study which
found that pan without tobacco is a risk factor for oral cancer. They found pan with and
without tobacco increased oral cancer risk by 9.9 and 8.4 times respectively. The media
has reported that regular chewers of betel leaf and areca nut have a higher risk of

                                            4
 damaging their gums and acquiring cancer of the mouth, pharynx, esophagus and
 stomach. 15

          The National Family Health Survey conducted in 1998-1999, reported a
 prevalence rate of 28.3% for chewing tobacco and 29.4% for smoking tobacco in men
 aged 15 years and above. The relative risk for the development of oral cancer due to pan
 chewing is estimated as 25.3%. Population attributable risk percentage was observed to
 be 66.1 for tobacco chewers for the development of oral cavity cancer.16

          The problems caused by consumption of pan masala are manifold. These
 include loss of ability to communicate and poor functioning of the nervous system,
 lifelong addiction, bad breathe, stained teeth, ulcers, pre cancerous lesions.,
 asthma exacerbation, hypertension, and tachycardia. There may be a higher risk of
 cancers of the liver, mouth, esophagus, stomach, prostate, cervix, and lung with regular
 betel use. Other effects can include a possible effect on blood sugar levels, possibly
 increasing the risk of type 2 diabetis.14. The habit of chewing pan masala not only poses
 a serious health hazard for the individual, but it poses a problem to society at large. 8
           Increase in use of pan masala,a tobacco product among teenagers is alarming.
Mere statutory warning is not enough. So The Government should enact new laws to
regulate companies that promote the sale of pan masalas as this colorful sachet is life
threatening.7 Increasing the awareness of the dangers of pan masala use, building their
competence to resist peer pressure and to manage stress in a healthy manner is effective
in reducing adolescents' motivation for abuse of these item.8

         Use of pan masala is a major health problem in developing countries like India.
Based on much literatures and investigators experience, it is felt that it is essential to give
adequate knowledge regarding ill-effects of pan masala to adolescent boys. The
knowledge will help them to improve their awareness regarding ill-effects of pan masala
and help them to promote healthy habits.




                                              5
6.2. REVIEW OF LITERATURE

          Review of literature is a key step in research process. Review of literature is the
reading and organizing of previously written materials relevant to the specific problems
to be investigated: Framework and methods appropriate to perform the study.
The literature reviewed under following headings:-
Part1: Studies related to incidence and prevalence rate of pan masala use among
adolescent boys.
Part2: Studies related to Ill- effects of pan masala use


Part1:Studies related to incidence and prevalence rate of pan masala use among
adolescent boys.
          A study was conducted to assess Gutka (pan masala containing tobacco)
advertisement and smokeless tobacco use by adolescents in Sikkim, India. The objective
of the study was to investigate tobacco use prevalence and related issues among 13-15
years students. The result of the study shows the overall response rate was over 85%and
the proportion of the boys was 55%.current smokeless tobacco use in boys it is 35.5-
49.5% and in girls it is 27.2-36.4%,and gutka in boys it is 8.4-22.2%,and in girls 14.2-
22.2%.Use and exposure to advertisements was reported equally by boys and girls. And
they concluded the study that there was strong association between exposure to
advertisement and current smokeless tobacco use.17

            A cross-sectional study was conducted to determine Gutkha Consumption,
prevalence rate and its determinants among Secondary School Male Students in two
schools of Mumbai. The sample size consist of 400. The mean age of students in the
study was 15 yrs.The students were interviewed personally during pre test. The result of
the study was the overall prevalence rate of gutka consumption was 10%.Many of the
students consumed more than one brand. Average duration of consumption of gutkha by
the student was 9 months.70% of the students quoted peer pressure as the reason for
initiation of gutkha chewing.46% of the students first heard about gutkha from peers.
Friends consumption of gutkha, stress, academic grading and peer pressure were
significantly associated with gutkha consumption.18

                                              6
         A study was conducted to determine prevalence, age of onset and demographic
relationships of different areca nut habits amongst children in Tower Hamlets, London.
The design of the study was Self-administered questionnaire. Children between the age
group of 11 and 15 were selected for the study and the sample size is 800. The result
shows users of any areca nut habit were exclusively from the South Asian population. Of
this population 77% had engaged in a habit and dependent upon habit between 54 and
92% of these still remained current users. The highest prevalence of current use for boys
and girls respectively was for areca nut alone (36%, 43%), followed by mistee pan (35%,
29%), betel-quid (27%, 26%) and pan masala (14%, 16%). Of the current users, 44%
engaged in one habit only, 24% two, 20% three and 13% all four. Boys had a higher
frequency of usage of these items comparing with girls.19

         A cross sectional study was conducted to assess the level of knowledge of high
school children regarding hazards of Areca nut and tobacco use. Out of 392 participants
62.5% were boys. The prevalence of areca nut usage among boys and girls was 27.3%
and 6.1% .while it was 2.4% for gutka (pan masala containing tobacco) amongst boys.
About 49% of users were chewing these substances regularly for more than a year.
Addictive tendencies were seen in two users. About 3/4th of the participants were
ignorant of associated health hazards or thought these substances to be harmless. Black
staining of teeth was seen in 39.5% of areca nut users. One case of sub mucous fibrosis
was identified among an areca nut chewer. The study Concluded that the awareness level
of health hazards was poor among the students. Health education against these substances
at an early age may help in curbing this problem.20

         A study was     conducted to assess     prevalence of    Oral cancer in 57,518
industrial workers of Gujarat, India. In Gujarat, India, 57,518 industrial workers over 35
years old were examined for oral lesions. At a two-year interval, 43,654 workers were re-
examined. Biopsies were taken from 13,223 lesions. In the initial examination, 29 oral
cancers were diagnosed, representing a prevalence rate of 50/100,000. After two years,
22 new oral cancers were diagnosed, representing an incidence rate of 25/100,000 per
year. Over 90% were squamous carcinomas, with the majority of lesions occurring in the
oropharynx and tongue. All patients who developed squamous carcinomas had tobacco


                                            7
habits, while 85% of the entire study population had oral habits in some form. Their most
common habits were smoking tobacco alone or in combination with chewing
"pan"/"supari." 21

 Part 2:Studies related to ill-effects of pan masala use

            A study was conducted to determine whether Oral sub mucous fibrosis is a
pre-cancerous condition caused by the use of areca nut in various forms such as pan
masalas. A hospital-based case-control study on habits and oral sub mucous fibrosis was
performed in Chennai over a 3-year period. A total of 185 consecutive patients with OSF
were matched with age- and sex-matched controls. History was recorded in a
predetermined format by qualified dental surgeons. The male to female ratio of oral sub
mucus fibrosis cases was 9.9: 1. All areca nut products were associated with oral
submucus fibrosis, with the risk being greatest for pan masala. The duration of the habit
was more significant than the frequency of the chewing habit. The result shows the strong
association between areca nut use and oral submucus fibrosis and the increasing use of
pan masala.22

.          A cross-sectional study was conducted regarding perceptions and knowledge
regarding the Chewing of betel, areca and tobacco and their role in head and neck cancers
in an urban squatter settlement in Pakistan. This study was carried out to establish the
pattern of use of Pan masalas, Chaalia, Gutka, Niswar, Tumbaku and Naas. Through
systematic sampling, 425 subjects were interviewed with a structured questionnaire.
About 40% of the participants were chewing at least one item . This prevalence was 2.46
times higher among males than females and 1.39 times higher among adolescents than
adults. At least 79% of the participants were classified as having poor knowledge about
the carcinogenicity of each of these items .Health hazards of these items were poorly
recognized and about 20% perceived at least one of these items to be beneficial. The
study concluded that deficiency in knowledge and wrong perception of favorable effect
of chewing products is common among the samples.23




                                            8
        A study was conducted to assess hemodynamic effect of pan masala in healthy
volunteers. Fifty one males between the age group of18-38 years were evaluated. One
pouch ie 4gm of pan masala without tobacco was given to each subject under fasting state
and effects on pulse and blood pressure recorded. Result shows marked increase in pulse
and blood pressure. And the Study concluded that the Pan masala intake causes acute
increase in pulse and BP.24

          A study was conducted regarding the role of chewing and smoking habits in the
etiology of oral submucous fibrosis. Two hundred and thirty-six consecutive cases of oral
sub mucus fibrosis were compared with 221 control subjects matched for age, sex and
socio-economic conditions. It was found that chewing of areca nut/quid or pan masala
was directly related to oral submucus fibrosis. Also, pan masala was chewed by a
comparatively younger age group and was associated with oral submucus fibrosis
changes earlier than areca nut/quid chewing. It was also found that frequency of chewing
rather than the total duration of the habit was directly correlated to oral submucus
fibrosis.25

         A comparative clinico-pathological study was conducted regarding oral sub
mucous fibrosis in habitual chewers of pan masala and betel quid in1996. The
background of the study was Oral sub mucous fibrosis associated with chewing of betel
nut products has an estimated prevalence of 0.2-1.2% in India. A prospective study
examined the in vivo effects of pan masala/gutka and betel quid chewing on buccal
mucosal cytology in 50 patients with oral sub mucous fibrosis and 40 controls. The result
shows the percentage of nucleolated intermediate cells or proliferative fraction of buccal
mucosa cells was significantly higher in all habitual chewers than controls. The study
concluded that the habitual chewing of pan masala/gutka is associated with earlier
presentation of oral submucous fibrosis than betel quid use. 26

STATEMENT OF THE PROBLEM
“ A study to assess effectiveness of Structured Teaching Program on knowledge
regarding ill-effects of Pan Masala use among Adolescent boys in selected Pre
university colleges of Hassan.”



                                             9
6.3 OBJECTIVES OF THE STUDY

1. To determine the knowledge of adolescents boys regarding ill-effects of pan masala
use before the intervention.
2. To evaluate the adolescent boys knowledge regarding ill-effects of pan masala use
after the intervention.
3. To associate the post test knowledge score of adolescent boys with selected socio
demographic variables
 .
 6.3.1 RESEARCH HYPOTHESIS

 H1: There will be significant difference between pre test and post Test knowledge score
 of Adolescent Boys regarding ill-effects of pan masala use.

 H2: There will be significant association between the knowledge level of Adolescent
 boys and their selected socio demographic variable.

 6.3.2 ASSUMPTIONS

 1. The adolescent boys will be having lesser knowledge regarding ill-effects of pan
 masala use.
 2. The adolescent boys will be willing to participate in teaching program to enhance
 their knowledge regarding ill-effects of pan masala use.
 3. There will be significant increase in knowledge regarding ill-effects of pan masala use
 among adolescent boys after administering structured teaching program.


 6.3.3 OPERATIONAL DEFINITION

 1. Adolescent boys: The boys between the age group of 16-18 years studying in
 selected PUC colleges of Hassan.

 2. Assess: Determination of knowledge among adolescent boys regarding ill-effects of
 pan masala use.

 3. Effectiveness:It refers to a significant change in the level of knowledge regarding ill-
 effects of pan masala use among adolescent boys after the structured teaching program.
                                            10
4. Structured teaching program: It is a planned instruction which will be given to
educate the adolescent boys regarding ill-effects of pan masala use.

5. Knowledge:The relevant information given to the adolescent boys on ill-effects of
pan masala use

6. Ill-effects:The bad effects results because of use of pan masala.

7. Pan masala : It is a balanced mixture of betel quid, tobacco, areca nut, clove,
cardamom, mint, menthol and other ingredients available in the form of sachets.

6.3.4. CONCEPTUAL FRAMEWORK

“General system theory is planned to apply for this study”

6.3.5. DELIMITATION

This study is delimited to:-

1. Only for adolescent boys between the age group of 16-18yrs.
2. Adolescent boy studying in selected PUC colleges of Hassan.
3. Prescribed data collection is 4-6 weeks.


7. MATERIAL AND METHODS OF STUDY

7.1. SOURCES OF DATA

The data will be collected from adolescent boys in selected PUC colleges at Hassan.

7.1.1. SIGNIFICANCE OF THE STUDY

The study implies the effectiveness of structured teaching programme regarding ill-
effects of pan masala use among adolescent boys in selected PUC colleges of Hassan.

7.1.2. RESEARCH DESIGN

The research design used for the study is Quasi experimental; one group pre test-post
test design. It includes manipulation, randomization and no control group.



                                              11
 Research Design.

    S                 O1              X               O2


Key Words.

S - Study group

O1 – Out come of pretest.

X – Structured teaching program regarding ill-effects of pan masala.

O2 – Outcome of Post test

7.2. METHOD OF DATA COLLECTION

Data is intended to collect by using structured questionnaire regarding ill-effects of pan
masala use.

7.2.1. SAMPLING PROCESS

CRITERIA FOR SAMPLE SELECTION

Inclusion criteria:

Those who were:

1. Studying in selected PUC colleges of Hassan

2. Adolescent boys between the age group of 16-18 years.

3. Those who were present at the time of study.

4. Those who know to read and write English and Kannada

Exclusion criteria

Those who were:

1. Not present at the time of the study

2. Not willing to participate in this study.



                                               12
3. Early Adolescents in the age group of 13-15 years.

7.2.2 SAMPLING PROCEDURE

7.2.2.1 POPULATION

Adolescent boys between the age group (16-18yrs) studying in selected PUC colleges
of Hassan.

7.2.2.2 SAMPLES

Adolescent boys who have fulfilled the inclusion criteria.

7.2.2.3 SAMPLE SIZE

In this study sample size will be 100 adolescent boys between the age group of 16-
18years.

7.2.2.4 SAMPLING TECHNIQUE

Simple random sampling technique will be adopted for this study.

7.2.2.5 STUDY SETTING

The study will be conducted in selected PUC colleges of Hassan.

7.2.2.6 PILOT STUDY

 Pilot study is planned with 10% of population.

72.2.7 VARIABLES

Independent variable: Structured Teaching Program regarding ill-effects of Pan
masala use

 Dependent variable: Knowledge of adolescent boys regarding ill-effects of pan
masala use.

Extraneous variables: Age, type of family, religion, family income, Source of
information, residence

                                          13
7.2.2.8 PLAN FOR DATA ANALYSIS

The plan for data analysis includes descriptive and inferential statistics.

Descriptive statistics

To describe demographic variables and level of knowledge Frequency,Percentage,
Mean and Standard deviation will be used.

Inferential statistics

 1. The Chi Square test will be used to find the association between the      demographic
variables and knowledge scores.

2.Paired’ test value will be calculated to assess the effectiveness of structured
teaching programme.



7.3. DOES THE STUDY REQUIRE ANY INTERVENTIONS TO BE
CONDUCTED ON PATIENTS OR OTHER HUMANS?

Yes, structured teaching program me on ill-effects of pan masala use will be used as
an intervention among adolescent boys.

7.4. HAS ETHICAL CLEARANCE BEING OBTAINED FROM
YOUR INSTITUTION?

       Yes, permission will be obtained from the research committee of Rajeev
college of Nursing and authorities of selected pre university colleges of Hassan.
Informed consent will be obtained from the subjects who are selected for the study.




                                              14
8. LIST OF REFERENCE

1. Learn adolescent psychology to prevent bad habit in your child. Available at
www.theparentszone.com/.../learn-adolescent-psychology-to-prevent-bad-habits-in-
your-child accessed on 18/11/2010.

2. Project Report & Profiles. Tobacco, pan masala, khaini,Gutkha. Available at

www.niir.org/profiles/profiles/...pan-masala.../z.../index.html accessed on 9/11/10.

3.C.C Kartha. Text book of current science. Page no1243 :volume80; 25th may 2001

4.Read more about pan masala. Available at

www.tradeindia.com/about –products/1344/pan masala.html accessed on 18/10/2010.

5.Sushma C Shrang . pan masala advertisements are surrogates for tobacco products.
vol42; year2005.

6.Kumar S. Pan masala chewing induces deterioration in oral health and its implication
in carcinogenisis. 665-677; 18 Jan 2008.

7.Dr.Anannd Balan.Pan masala/Gutkha-Consulting psychiatrist. Available at

www.anandbalan.in/pmgpro.html. accessed on 22/10/2010.

8.ummathooronline.blogspot.com/sideeffects of pan- masala-html              accessed on
25/10/10

9.Dr.T Suresh kumar. Kerala calling- Government to consider ban on pan masala.

page no23;July 2004.

10.M.Rani.Article on tobacco use in India prevalence and preditors of smoking.2003.

11. R K Chadda. Tobacco use by Indian adolescents.Available at

http://www.biomed central.com/content accessed on 24/10/2010.

12.What are the ill effects of using Gutkha.12th August 2008.Available at

                                            15
sawaal.ibibo.com accessed on 28/10/2010.

13. The Hindu article- Repromulgated order on pan masala set aside .1ST July 2002.

14. Shah S, Qureshi R , Azam I. Is Chaalia/Pan Masala harmful for health? practices
and knowledge of children of schools in Mahmoodabad and Chanesar Goth, Karachi.
60(6):515;jun 2010.

15.Areca-nut Wikipedia,the free encyclopedia. Available on
En.wikipededia.org/wiki/Areca-nut accessed on 30/10/2010.
16.J Kuruvilla. Article on utilizing dental colleges for eradication of oral
cancer.:Vol19:Issue 4: page.349-353; Year 2008.
17.D N Sinha. Indian Journal of Community Medicine-Gutkha advertisements and
smokeless tobacco use by adolescents in Sikkim, India. Vol. 30: No. 1;2005-03.
18. K Mukherjee1, R S Hadaye. Indian Journal of Community Medicine- Gutkha
Consumption and its determinants among Secondary School Male Students. Vol. 31:
No. 3:July September 2006.

19.Farrand p , Rowe RM, Johnston A, Murdoch H .Prevalence, age of onset and
demographic relationships of different areca nut habits amongst children in Tower
Hamlets, London.

20.Areca nut and tobacco use among school children in a village in South
India. Articles April 15 2010.

21. Malaovalla AM, Silverman S,Mani NJ , Bilimoria KF , Smith LW .Oral cancer in
57,518 industrial workers of Gujarat, India: a prevalence and followup study. 28 JUN
2006.

22. Ranganathan K, Devi MU, Joshua E, Kirankumar K, Saraswathi TR .Oral sub
mucous fibrosis: a case-control study in Chennai, South India.2006:7(3):79-80.

23.Khawaja MR, Mazahir S, Majeed A, Merchant KA, et al. Perceptions and
knowledge regarding the Chewing of betel, areca and tobacco and their role in head and
neck cancers in an urban squatter settlement in Pakistan .April 26 2006.


                                            16
24.Sharma AK, Gupta R, Gupta HP, Singh AK. Hemodynamic effects of pan masala in
healthy volunteers. 2000 Apr:48(4):400-1.

25. Shah N, Sharma PP. Role of chewing and smoking habits in the etiology of oral sub
mucous fibrosis.1998 Nov:27(10):475-9.

26. Babu S, Bhat RV, Kumar PU, Sesikaran B , Rao KV et al. A comparative clinico-
pathological study of oral submucous fibrosis in habitual chewers of pan masala and
betelquid.1996:34(3):317-22.




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