Smokeless tobacco use is very high among expectant mothers and this has been associated with negative health effects on their babies
Although many picture young Indian men smoking in social settings to be the quintessential image of tobacco use in India, data suggest differently.
According to data, smokeless tobacco — which consists of tobacco products that do not have to be burnt or smoked in order to be consumed — is a significant part of that picture. India is the greatest consumer of smokeless tobacco products in the world and by extension at the receiving end of its resulting harm. Over a fifth of all Indian adults — nearly 200 million individuals — report using smokeless tobacco. They represent over two-thirds of all smokeless tobacco users globally.
The prevalence of smokeless tobacco use in India is 25.2 per cent for men and 24.5 per cent for women aged 35 years and older. The number of deaths attributable to smokeless tobacco use in India is estimated to be 3,68,127 (2,17,076 women and 1,51,051 men), with nearly three-fifth (60 per cent) of these deaths occurring among women. In fact, the country accounts for over three-fourths of the entire global burden of diseases and suffers over 3,50,000 deaths each year as a result of smokeless tobacco use. Chief among this burden of diseases is oral cancer, with India having a majority of all cases in the world.
An even more insidious part of the picture is smokeless tobacco use among women in India. According to the most recent iteration of the Global Adult Tobacco Survey, nearly 60 million women — more than the entire population of England — report using smokeless tobacco in India. Such use among women in the country dovetails along predictable socio-demographic lines, with a higher rate of use in rural areas, among older adults and those with lower levels of formal education.
To make matters worse, the harm caused by smokeless tobacco use among women is often inter-generational. As authors of a recent study noted, smokeless tobacco use is strikingly high among expectant and nursing mothers and this has been associated with a number of negative health effects for both the mother and the baby. Maternal use of smokeless tobacco has been linked to lower birth weight, higher incidence of still births, higher rates of anaemia and lower nutritional outcomes for both the mother and the child.
Despite the obvious need to reduce these dangers, the risks of smokeless tobacco use are often compounded by poor health literacy, limited access to cessation services and a dearth — if not outright absence — of cessation initiatives, products and therapies that are culturally-sensitive and tailored to women. This may partly explain why the few Indian women, who are able to kick the habit, report doing so with no assistance whatsoever. As public health experts seek to change this reality, four pressing areas for research into the intersection of tobacco use and women in India come into sharp relief: First, a greater understanding of the epidemiology — the proverbial who, what, when, where, and why — of smokeless tobacco use among women. Despite their widespread use, which products are used by which women and why are poorly understood. The need for a more nuanced understanding of the epidemiological contours of smokeless tobacco use among women is thus paramount.
Second, a detailed understanding of the toxicology of smokeless tobacco products is needed as India is home to a plethora of these products. In addition to understanding which ones are used by which women and why, greater insight into what ingredients are present in each product and their potential to cause various diseases must be pursued.
Third, a more thorough understanding of the barriers that women face to tobacco use cessation is important. To date, our collective understanding of these barriers and how to overcome them is predicated on the experience of men. Analogous insights into the experience of women who use tobacco must be gained and in turn, deployed to develop culturally-sensitive, women-focussed tools, therapies, and technologies for cessation.
Fourth, a deeper understanding of the ability of healthcare providers to provide tobacco cessation counselling — especially for women — is needed. Many healthcare providers in India report feeling inadequately trained to deliver existing and potential tools, therapies and technologies to those who use tobacco. Even more strikingly, a substantial number of healthcare providers in India report using tobacco themselves. Research into why this is so and how to facilitate change, for both providers and patients alike, will be critical.
Given the scale, scope and resulting dangers of smokeless tobacco use among people in India, particularly women, research into these areas is needed now more than ever. It is important to recognise, however, that acknowledging the problem will not solve it. Robust research into the areas above will not coalesce spontaneously and even if it did, the synergies between them would likely go unrealised.
As a result, it will be critically important to build and support a literal and figurative community of experts to study tobacco use in India, exchange ideas and work together to identify solutions.
Their collective ideas and experiences will serve as the tip of a spear into a much larger body of work and, in turn will change the image of tobacco use in India for the better. If successful, the picture of tobacco use in idea will no longer contain young Indian men smoking in a social setting or a young mother using a smokeless product. Instead it will be replaced by healthier, longer-living Indian men and women in places and spaces free of smoke.
(The writer is research manager at the Foundation for a Smoke-Free World , USA)