Tobacco was considered as an alien product in India and was not welcome to begin with. However, the widespread uptake of tobacco habit as we see it today marks a huge victory for the tobacco promoters. In a milieu of social changes in India, fuelled by foreign news media, influence of foreign films and global economic players, a tug of war is going on in the women’s minds between the tobacco pushers on one hand and societal values on the other. In a country where smoking is generally not socially acceptable for women, it is increasing among certain social groups. The aspirations of some independent and so called liberated women match with what the tobacco companies are promoting and they are getting hooked to smoking cigarettes.
While attitudes about smokeless tobacco use by women are more ambivalent, its consumption by girls and women has been increasing. It must be partially due to this that the prevalence of smokeless tobacco use among women is on the increase. GATS, India (2009) has reported 18.4% women currently using smokeless tobacco in India. The poor and not so poor; the illiterate and the educated; all are finding solace in something which is socially acceptable and costs next to nothing—the ubiquitous chewing tobacco in its various popular avatars—gutkha, zarda, gul, khaini, etc.
One needs to understand what chewing tobacco does to the user. The continuous chewing process elevates the mood and gives a small, temporary relief from stress and anxiety. This makes the person use it more frequently and before one can realize it, the addiction begins. The amount of nicotine absorbed per dose from chewing tobacco is not only 3 to 4 times more than that delivered by a cigarette; it is also absorbed more slowly. Until a few decades ago, smokeless tobacco was used either in inexpensive processed forms or processed at home by the users into snuff or burnt tobacco powder or incorporated into betel quid (paan). Since the 1970s processed smokeless tobacco has been manufactured and sold in foil sachets. The best selling form is gutka, a scented chewing tobacco (claimed to be ‘zarda’) mixed with all the flavorful ingredients used in paan, (areca nut, spices and resins) along with calcium hydroxide paste and other chemicals like magnesium hydroxide. Since it is extremely inexpensive (cost in pennies) and is sold anywhere and everywhere in small, convenient-to-carry packs, its use has become common place. Another fact that might be contributing to an increase in the use of smokeless tobacco is the belief held by several women that as it is promoted so much, smokeless tobacco just cannot be bad for the user. Such is the power of persuasion that people start believing anything which is promoted day in and day out in any society with the full knowledge of the government and other responsible people and think that it is bound to be good. They are, at times, either too naïve or too foolish to see through the aggressive promotional tactics of the tobacco industry which actually promotes something (tobacco) which can be lethal for its users.
These and other anecdotal reasons for the wide spread use of smokeless tobacco prompted the undertaking of a study with the disadvantaged women who work as labourers in South Delhi. The findings from the focus group research and in-depth interviews with these women were brutally interesting. Most of these women reported that their first encounter with smokeless tobacco was far from being a great experience, a finding which has been observed with smoking tobacco as well. They started its use because their friends were using it. They enumerated countless reasons for using smokeless tobacco-- right from liking its taste, to its ability to instil energy, taking their mind off worries, helping them to relax when tired and even providing relief from gastric troubles. It helped them to control hunger and anger when mistreated. True it cost money, but surely they could spend some money on themselves too and not all on the family. Their community accepted its use. Those few, who had objections from their employers, had considered leaving that job--- “I would rather change the job than give it up”.
They reported no ill effects due to chewing smokeless tobacco, and attributed the occasional discomfort of sores or boils in the mouth to the bad quality of the chew material. The body pain that they suffered from time to time was, according to them, due to their hard work, and not because of tobacco. In other words, they did not associate any negative impact on their health with their use of tobacco. They right away dismissed any possibility of quitting tobacco, and were amused even at suggestion of going to a doctor to get help to discontinue its use. According to them tobacco was not something for which you see a doctor; it had no ill-effects on health; rather it helped them to digest food, to get rid of constipation and also prevented bad breath. One of the women was worried that the pouches of tobacco were becoming expensive and she was advised by her peers to ask for a raise in salary instead of contemplating quitting. Another woman was confused and concerned when she saw the scorpion on the pouch and thought that this is just one of the gimmicks of the government.
These perceptions and attitudes show complete ignorance of the masses about the health effects of chewing tobacco which causes much morbidity and mortality among its users. This indeed is a sad commentary on the existing scenario, and a source of worry for the public health professionals. So Article 12 of the FCTC (Using Education, Communication and Training to Advance Tobacco Control Goals) needs to be implemented with utmost sincerity and urgency right away, if we want a tobacco free healthy society. We should approach this task on a war footing and everyone should be trained with a brief advice to impart this education to everyone and anyone who is potentially vulnerable, like youth, children, and the uneducated by making sure that the advice is related to the information needs of the users. We should work on the premise of EACH ONE, REACH ONE, TEACH ONE. This alone will address the issue and achieve the goal of Health for All. We have a moral responsibility to implement the most relevant and easy to comprehend pictorial warnings based on the risks attached to the tobacco-users’ behaviour. We should mould our advice by recognizing the information needs of the users by first listening and then speaking to them. If the line of advice does not seem to move the users, it is not the fault of the one getting the advice but the one giving it.
According to me a logical sequence could be:
1: Imparting knowledge of relationship between the use of smokeless tobacco and diseases caused by it, so that the person becomes well informed of the ill-effects of tobacco usage on health
2: Strengthening this knowledge further through visual reinforcements and deliberate introduction of element of fear, so as to convince the user to start questioning the tobacco habit
3: Sharing knowledge about the health and other benefits of quitting smokeless tobacco, to make the user resolved and determined to discontinue its use
4: Explaining the various possible methods of discontinuing the habit and then suggesting the most appropriate one, depending on the psychological profile of the user and characteristics of use of smokeless tobacco. This would result in the user making concrete attempts to discontinue tobacco usage
5: Explaining the manifestations and the temporary nature of withdrawal symptoms in order to minimize any reversal to addiction
6: Giving appropriate praise and reinforcement to prevent any restart of the habit, and also to create model and leadership roles acting as examples to others.
Dr Mira Aghi
(The author is a winner of 2012 Luther L Terry Award for her outstanding community service. Dr Aghi has been on the forefront of the fight against tobacco)