Paan Use in South-Eastern Iran: The Associated Factors

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Article Information:

Group: 2011
Subgroup: Volume 13, Issue 9, Sep
Date: September 2011
Type: Original Article
Start Page: 659
End Page: 663
DOI: 10.5812/kowsar.20741804.2249


  • F Rakhshani
  • Department of Public Health, Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
  • Z Sepehri
  • Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Taleghani Hospital, Tehran, Iran
  • M Keikha
  • Department of Public Health, Zahedan University of Medical Sciences, Zahedan, Iran
  • T Rakhshani
  • Department of Health Education, Tehran University of Medical Sciences, Tehran, Iran
  • MR Ebrahimi
  • Fars Red Crescent Society, Shiraz, Iran


      Affiliation: Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Taleghani Hospital
      City, Province: Tehran,
      Country: Iran
      Tel: +98-912-688 0468
      Fax: +98-21-66700517


Background: Smokeless tobacco use is growing among youth in many countries especially developing countries. Paan is one of these products that its use in many cultures is of interest. This study evaluates the use of paan among males school-age and assess the attributed factors.  


Methods: A cross-sectional study was done on 504 high school pupils of Zahedan city, Capital of Sistan va Baluchistan Province, southeastern Iran in June 2007. Samples were selected by multistage sampling method from high school students in different geographic areas. A questionnaire including 43 questions was completed through interviews.


Results: The mean age of participants was 16.2±1.1 years. While 10.4% of the students were current users of paan, 17.9% were ex-users. Mean duration of using paan was 2.5±1.6 years. Number of daily paan consumption was 4.2±3.6/day. Cigar was the most common substance used at least once by pupils (18.6%) followed by paan (17.9%), naas (11.5%) and other illicit drugs. Only 64.7% of our pupils did not use any illicit drug at the time of study. Risk of paan use among students who had a history of taking any other substance was 18-fold more than others. In the case of each attitude, score accretion and risk of paan consumption declined up to 16%.  


Conclusion: Among multiple personal, familial and environmental factors, positive history of using any kind of illicit drugs by students and their attitude had strong association with paan use.


Keywords: Paan;Smokeless tobacco;Attitude;Behavior;Family;Iran

Manuscript Body:



Nowadays, smokeless tobacco (ST) has a huge fan in the world especially among youngsters.1 On the other hand, it was shown that ST consumption was a significant risk factor for deaths because of circulatory, pulmonary, and malignant diseases2 and even coronary heart diseases.3

Deaths from tobacco will double in 2030 comparing with 1999 due to increased tendency to use tobacco. Although, already about 50% of deaths due to tobacco are in high-income countries, but we should expect that tobacco-related mortality and morbidity will move developing countries because of additive tobacco use in these countries. According a research on tobacco in China, in next decades, seventy percent of tobacco-related deaths will occur in developing world.4

All brands of smokeless tobacco including paan which are sold for oral or nasal-use have nicotine and nitrosamines in their ingredients.1 “Paan” components consist of tobacco, areca nut, slaked lime, and spices. These materials are rolled in a betel leaf.5 Subcutaneous or intragastric administration of some of these ingredients such as succulent extracts of betel quids and areca nuts might lead to carcinomas of the cheek pouch and fore-stomach in rodents.6 Nicotin may disturb oral health by inhibition of the aerobic antimicrobial functions of neutrophils and monocytes.7 Level of oral health was lower in tobacco consumers aged 40 years and older comparing those aged 18-39 years.8 Tobacco use is accounted for about half of male’s oral/pharyngeal cancer cases and 11% in females.1 Kurtul et al. analyzed serum total sialic acid levels in smokers and users of oral powder forms of ST since 'oral powder' or 'Maras Powder' of ST is more popular than cigarette smoking in Turkey. They showed that baneful effects of ST use are similar to cigarette smoking ones.9 Cervical cancer10 and squamous cell carcinoma of esophagus11 are other cancers that are associated to paan consumption. Despite these  multiple complications, some young people use paan to help them in smoking cessation.12 Furthermore, all of adolescents lifetime paan users was in East London and originally from South Asia or mixed ethnicities.13

In a study on use of smokeless tobacco among Pakistani medical students by Imam et al., 21.5% had history of using some form of tobacco in their lifetime and 6.4% of them were lifetime users of ST. Naswar, paan and nass were the most common forms of ST which were consumed. Gender, college location and concomitant cigar smoking had no considerable association with lifetime smokeless tobacco using in their study.14

In a study in Russia, the most important factor for smoking was having an intimate friend who smoked.15

Socioeconomic status of the students at 21 and 28 years-old age was another significant factor for smoking in adolescence.16 This issue is so important in the study area from different aspects: at first, majority of this province population are young, strategic location of the province since it is bounded with Afghanistan and Pakistan, and also such studies are not available from most populations in developing countries. Therefore, we decided to study use of paan among school-age males and assess the attributed factors.  



Materials and Methods


This cross-sectional study was done on 504 high school pupils of Zahedan city, Capital of Sistan va Baluchistan Province, southeastern Iran, in June 2007. Samples were selected by multistage sampling method from mannish high schools in different geographic areas. At first, we divided the city to north, south, east, west and central areas. Then, we selected two schools from each area and maximum 54 pupils from each school. We selected pupils randomly from each grade of high school (9, 10 and 11) using list of their names.

The purpose of study was explained for pupils, then they were asked to participate and answer question carefully. We certified them about the confidentiality of the data. The self-administered questionnaire was applied. They were free to leave the study. We selected items which we thought experimentally would cover this condition and after research of the literature and attention to all aspect of the issue, items turned into the question form. Then questions were organized into an appropriate order and structure. A draft of the questionnaire was passed back to the experienced colleagues to check content validity, and made suggestions to resolve any possible defects. The second draft of the questionnaire was reviewed by 15 pupils from different levels and ages to evaluate the validity (simplicity and readability). Difficult questions were reworded and ambiguous questions were excluded. Cronbach's alpha reliability coefficient for questions which had the same answer was 0.75.

The final questionnaire consisted of 43 open and closed questions about individual and demographic information, 10 items on knowledge, 3 items on attitude, 19 items on behavior, 5 items and 6 questions on other information. The knowledge score of the pupils from 3 questions about paan, its ingredients and complications was considered 3. Attitude score was calculated based on 3-point Likert scale; the higher score showed more disagreement about paan. Reverse scoring was applied for question 15 and later because of change in type of the questions. Hence total score of attitude was 57.

Data were analyzed as uinvariate and multivariate analysis by SPSS software (Version 15, Chicago, IL, USA) using Chi Square test and logistic regression with α<0.05. At the first step, a univariate logistic regression was done on these variables: age, educational level of the student, his father and mother, father’s job, number of household member, familial relationship status, previous history of using any kind of tobacco product and/or opium/alcohol and any kind of illicit drugs, family’s knowledge about use of paan, number of paan user friends, pupils idea about number of paan users in their school, use of any kind of illicit drugs by parents, the knowledge and attitude of subjects (categorized variables changed to dichotomous for analysis). In the next step, variables that had P-value less than 0.25 were analyzed in a multivariate model using backward method.

Ethical approval of the study was obtained from local Ethical Committee of  Zahedan University of Medical Sciences.



Overall, 504 male high school pupils participated in this study. The mean age of participants was 16.2±1.1 years which ranged from 13-21 years. Mean number of family members was 7.1±2.4 persons with range of 2-20 persons. Majority of them (86.9%) lived with their parents.

At the time of study, 10.4% of the students were current users of paan, while 17.9% of pupils had an experience of using paan (ex-users). Mean duration of using paan was 2.5±1.6 years with minimum of one year and maximum of 7 years. Number of daily paan consumption was 4.2±3.6/day (at least one time and maximum 15 times). Forty-two cases of paan user (80.7%) mentioned that their parents did not know anything about paan consumption by them. Paan users reported that they felt vertigo (30.5%), calmness (22.3%), impatience (18.6%), headache (5.8%) and nausea (13.5%) after consumption. Twelve pupils did not experience any impression and some of them reported two or more symptoms.

More than one third (38.6%) of students believed that most of their friends used paan and 29.2% of them declared that more than 70% of their classmates consumed this smokeless tobacco. Some data about them (level of education, use of any kind of illicit drugs) and their family (number of household members, educational level of father and mother, familial relationship status, father’s job, and use of any kind of illicit drugs by parents) were shown in the Table 1.



Table 1: Personal and familial characteristics in paan users compared with others.



Paan users


P value

No           %

No        %

Use of any kind of illicit drug



Education level of father






Education level of mother






Familial relationship status



Not good, not bad  

Father’s job


Government Employee






Use of any kind of illicit drug by parents




48            26.8

  4              1.2


  6              7

  8              7.5

11            12.5

20            15

  7              8


16              9

14            11.4

  6              8.1

  7              8.5

  9            20


32              8.9

  3            33.3

17            12.9


  2              3.9

18              9.8

  4              5.6

  2              6.9

  5            18.5

15            19

  6            10.7


  6            12.5

45            10.4   


131       73.2

319       98.8


  80       93

  99       92.5

  75       87.2

113       85

  80       92


161       91

109       88.6

  68       91.9

  75       91.5

  36       80 


327       91.1

    6       66.7

115       87.1


  49       96.1

165       90.2

  68       94.4

  62       81

  27       93.1

  22       81.5

  50       89.3


  42       87.5

386       89.6
























P =0.226








Cigar was the most common illicit drugs which was used at least once by pupils (18.6%) followed by paan (17.9%), naas (11.5%) and other illicit drugs. Only 64.7% (n=324) of our pupils did not used any illicit drugs at the time of study. The mean of knowledge score was 1.2 ± 0.7 ranged from 0 to 2.75 and the mean for attitude score was 50.1±6 ranged from 14 to 57. Responses of the pupils to attitude questions were shown in Table 2.



Table 2: Pupils’ attitude about paan.

Attitude questions


No (%)

No comment

No (%)


No (%)

Using paan will elevate our mood

  21 (4.2)

  82 (16.4)

397 (79.4)

2- Every teenager may use paan once or twice in this age because they think paan will not produce any problem for them

  92 (18.4)

127 (25.4)

281 (56.2)

3- I would like to try paan even for one time

  42 (8.4)

  37 (7.4)

422 (84.2)

4- Using paan once or twice has no disadvantages

  45 (9)

  56 (11.2)

401 (79.9)

5- Using paan has no mental complication

  23 (4.6)

  79 (15.8)

399 (79.6)

6- Using paan is a suitable method for relieving pain

  20 (4)

  92 (18.4)

389 (77.6)

7- Using paan increases tolerance against problems

  28 (5.6)

  90 (18)

382 (76.4)

8- Using paan occasionally is a harmless or low risk entertainment 

  37 (7.4)

  98 (19.5)

367 (73.1)

9-  Using paan keep us calm

  40 (8)

  75 (15)

386 (77)

10- Using paan result in scented mouth

  42 (8.4)

  72 (14.4)

386 (77.2)

11- Persons that do not use paan are timid

  33 (6.6)

  53 (10.6)

415 (82.8)

12- Harms of the paan are untrue

  54 (10.8)

  68 (13.6)

379 (75.6)

13- Paan is available in stores, so use of it should not have any hazard

  18 (3.6)

  57 (11.4)

427 (85.1)

14- I like paan odor

  23 (4.6)

  37 (7.3)

444 (88.1)

15- Paan users are socially worthless persons

301 (59.8)

115 (22.9)

  87 (17.3)

16- I never have tendency to see paan

322 (64)

114 (22.7)

  67 (13.3)

17- If I recognize that one of my near friends uses paan, I will discontinue my friendship

222 (44.1)

149 (29.6)

132 (26.2)

18- I try to have the least communication with paan users

375 (74.6)

  70 (13.9)

  58 (11.5)

19- Using paan is an abnormal social behavior

407 (81.1)

  53 (10.6)

  42 (8.4)



After univariate regression analysis, familial relationship status, father’s job, educational level of father and mother, age, number of paan user students in school, and past history use of illicit drug, were analyzed in a multivariate model using backward method since these variables had P-values less than 0.25. Finally, only attitude and past history of using any kind of illicit drug remained in the model as in students that has had positive history about that, risk of paan use was 18-fold greater than others (OR=18.0; 95% CI: 6-54). In the case of attitude, for each attitude score accretion, risk of paan consumption decline up to 16-fold (OR=16.0; 95% CI: 11-20).  





Our study showed that current users of paan were 10.4% of pupils while more than half of pupils (55%) pointed that they had many paan user friends in their school, so we might underestimate the current users of paan. On the other hand, 17.9% of the students were ex-users of ST. Imam et al. reported that sixty six (6.4%) of Pakistani medical students were lifetime users of ST.14 Age, educational level and socioeconomic level of our sample were different with Imam et al. study.

Two other studies in Pakistan reported that 16.1% of male high school students were current users of paan17 and 11.2% of medical students were smokers.18 These results are somehow compatible with our results. This study showed that paan use among pupils had no association with parent’s educational level, number of family members and use of illicit drugs by parents. Chen study demonstrated the same results except that they showed significant association between smoking behavior and living in families with lower education level.19 However, these results are not compatible with Rozi-Akhtar study17 and Roohafza study,20 so we should pay more attention to other predictive and attributable familial factors which may affect it in our community and consider them in future studies.

History of using any kind of illicit drugs by pupil was associated with use of paan by them in Abdullah et al. study.21 This finding is compatible with current results. This study showed that pupil’s attitude had significant association with consumption of paan which is similar to other studies.22,23 About half of our pupils (46.8%) imagined that 50% of their schoolmates consumed paan and from this proportion, 29.2% speculated that more than 70% of their schoolmates did that. It may be influential on their Paan use. As Rogacheva et al. showed that having a best friend who smoked was the strongest predictor for smoking among adolescents.15

Our study showed that 9% of paan ex-users had used paan as the first illicit drug. This is an important alarm since the lower social class of its consumption and the possibility to use paan more in comparison to cigar, could make it as a favorite illicit drug among youth and this would be a major risk factor for using other substances in future as Imam et al. study revealed such association.14 Availability of paan and low price of it in studied community (about 7-28%) may be another factor that should be considered.

It seems that we should consider short term and long term programs to prevent the onset of substance abuse. Reduced accessibility to tobacco products by banning on tobacco product sales to children and adolescents and increasing price of these products are some of possible short term programs. In long term, we should design programs to drop the desire to begin tobacco product use among the students and change their attitude.

The study had some limitation. One of them is interpretation of the results since social studies have multiple aspects and we assessed prevalence in a cross-sectional study. So we only can report some associated factors not the risk factors.

The study showed that among multiple personal, familial and environmental factors, positive history of using any kind of illicit drugs by students and their attitude have strong association with using paan.





Authors wish to thank head of education officers for their assistance to collect data and students for their participation. Ethical Committee of Zahedan University of Medical Sciences approved the study. This study was funded by Committee of Students Researches of Zahedan University of Medical Sciences.


Conflict of interest: None declared.

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