Smokeless tobacco under gender lens

Dr Sophia Thomas, CNS Correspondent, India
The first World No Tobacco Day (WNTD) was observed on 31 May 1988, a year after this global campaign was created during the World Health Assembly by the World Health Organization. The objective of WNTD was to encourage all persons worldwide who smoke or chew tobacco to quit for at least 24 hours. Ironically, a simple google search of “World No Tobacco Day” brings up a series of images showing cigarettes being shunned in creative ways. The current theme of WNTD focuses on effects of tobacco on cardiovascular health and is depicted as smoke rising from the blood vessels of the heart. Unfortunately, most of the images, depicting the health hazards of tobacco, fail to showcase the harmful effects of ‘smokeless’ forms of tobacco, which are equally harmful.

Smokeless Tobacco (SLT) seems to have got masked in the anti-tobacco campaign, much like it does in real life.

Smokeless tobacco & southeast Asian countries

Discourse around smokeless tobacco is imperative, especially in South-East Asian countries - which constitute 90% of global smokeless tobacco users. Most of these countries are from low-middle income economies. By 2030, tobacco is estimated to kill more than 8 million people globally, and more than 80% of those deaths will be in low- and middle-income countries. India is the largest manufacturing country of smokeless tobacco in the region. It is estimated that 33% of men and 18% of women use smokeless tobacco in India, although this usage could vary regionally. Amongst women users of SLT, over 85% of them use smokeless or chewing tobacco exclusively.

Smokeless tobacco (SLT) is available in various forms in India and has a wide subscriber base among all social groups. SLT use is more prevalent among the disadvantaged and people who live in rural areas and urban slums. It is a common practice among women of all ages, including reproductive age. Mortality rate among women consuming SLT is higher, with about three-fifths of deaths attributed to SLT use among women in 2010. The trend continues to remain the same. This calls for gender-specific policies and interventions targeting women of all ages, especially the disadvantaged groups.

Women, tobacco use and cardiovascular diseases in India

The causes of death report by the Registrar General of India reported cardiovascular diseases (CVD) as the most important cause of death in women. More than half of the 800,000 annual CVD deaths in women occur prematurely. Key risk factors for Coronary Heart Disease (CHD) and stroke among women include diabetes, dyslipidemia, tobacco and hypertension. Tobacco is a modifiable risk factor and quitting it can lower the prevalence of CVDs. A recent report from the Ministry of Health and Family Welfare in India stated that, around 70 million women aged 15 and older used Smokeless Tobacco (SLT). The reasons for this high usage are: ease of availability, low cost and better social acceptability (compared to smoking). Women from the disadvantaged start of society are said to chew tobacco to curb hunger while performing difficult and laborious tasks. The report further stated that risk of developing oral cancer and CVDs is 8 times higher and 2-4 times higher respectively, in women.

Drivers of SLT among women

As per a study Increased consumption of SLT by females has been cited as being due to ease of availability and lower cost, as well as social acceptability. Husbands are a crucial influence in enabling women to use SLT. Moreover, women consume SLT even during pregnancy despite knowing health risks for her and the baby. There is no difference in consumption patterns of SLT between pregnant and non pregnant women. Tobacco use is very well accepted socially among Indian communities, a classic example being during marriage celebrations. Geographically too, different types of tobacco are preferred by women in the country. For example, Mishri is used by Maharashtrian women and Gudakhu is popular in Orissa, Bihar, Uttar Pradesh and Uttaranchal. Lal dantmanjan, a red coloured tooth powder, which contains 20% tobacco, claims to improve oral health and is commercially distributed in the country. Therefore, despite awareness of adverse effects, use of SLT continues at a high level in India.

Affordability of SLT products facilitates consumption among the poorer section, with India’s poor consuming SLT three times more than the rich. SLT is very common among the young, whereas smoking is more common among the older age groups. SLT use is very common among urban slum dwellers (in both men and women), compared to rural areas. Pressures  of making a day to day living on urban slum dwellers, often makes way for SLT use —  to reduce tension and suppress hunger. The urban poor are already at a high-risk for developing tobacco-related diseases. This disease burden is exacerbated by poor health status and inadequate health care. Illiteracy is a major risk factor associated with both increased tobacco consumption and poly-SLT (using multiple forms of SLT) users. Among the various caste groups, the scheduled tribes show the highest prevalence of chewing tobacco and pan masala, with lower levels of use observed among other backward classes and forward castes.

Addressing the gendered use of SLT

Presenting his views on this topic during the CNS webinar on WNTD 2018, Professor (Dr) Rishi Sethi, Department of Cardiology, King George's Medical University (KGMU), expressed that global anti-tobacco campaigns have stressed a lot on anti-smoking. It is indeed true that smokeless tobacco is widely prevalent in the country and smoking may be considered as social taboo. But as oral tobacco can be easily hidden, this lack of visibility will not show up as a social taboo. Prof Rishi Sethi is the national Chairman of Cardiological Society of India's STEMI Sub-Speciality Council, and chaired a nationwide team of heart disease researchers that developed India's first-ever national guidelines on management of heart attacks.

Executive Editor of Journal Heart India Prof Rishi Sethi, sharing from his clinical experience, highlighted that SLT use can lead not only to oral cancer, but a lot many other diseases too. It affects cardiovascular health and this fact has to be over-emphasized and people have to be educated on that front. We require more social awareness about the ill-effects of oral tobacco. Rather than insisting on ‘quit smoking’, we should be stressing on ‘quit tobacco’ in whatever form it may be.

Some gender-specific recommendations suggested by the India’s Health Ministry are:
  • All studies and national data should report data disaggregated by gender.
  • Factors that may influence SLT use among women before, during, and after pregnancy should be examined in order to design evidence-based intervention models and guidelines for cessation across the life course.
  • Research on tobacco industry tactics targeting women could help to better inform programme and policy interventions to protect girls and women from initiating use and help those who already use SLT to quit.
  • Further investigation is needed of the health effects of SLT use on women throughout the life course.
SLT needs more traction in the global anti-tobacco campaigns which are dominated by anti-smoking signages. There have been women focussed WNTD themes in the past- ‘Women and tobacco: the female smoker at added risk’ in 1989 and ‘Gender and tobacco with an emphasis on marketing to women’ in 2010. Perhaps, a new theme in the future, focusing on women and providing balanced perspectives of smoking and smokeless tobacco, would increase the relevance of these campaigns in regions world-wide.

Dr Sophia Thomas, CNS (Citizen News Service)
4 June 2018

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