|TOBACCO CONTROL ISSUE - ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 5 | Page : 78-82
Women and tobacco: A cross sectional study from North India
S Kathirvel, JS Thakur, S Sharma
Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||19-Dec-2014|
J S Thakur
Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
Background: Tobacco is a leading risk factor for different types of diseases globally. Tobacco smoking by women is culturally unacceptable in India, but still women smoke tobacco at various times of their life. Aims: The aim was to estimate the prevalence and pattern of tobacco use among women and to study the associated sociodemographic factors. Settings And Design: This cross-sectional study was conducted among women aged 30 years or over in an urban resettlement colony for the migrant population at Chandigarh, India. Methodology: The study included women used tobacco products on one or more days within the past 30 days. Through systematic random sampling, 262 women were studied. As a part of the study 144 bidi smoking women were interviewed using detailed semi-structured questionnaire. Statistical Analysis: Descriptive statistics and hypothesis testing with Chi-squared test and logistic regression were done using SPSS 16.0 version. Results: Overall, the prevalence of tobacco use was 29.4% and that of bidi, zarda and hookah were 19.8%, 8.8%, and 2.7%, respectively. Around 6.2% women used tobacco during pregnancy. Teenage was the most common age of initiation of bidi smoking. Logistic regression analysis showed that the prevalence of tobacco use was high among Hindu unemployed women with no formal education belonged to scheduled caste, and those having grandchildren. Conclusions: This study highlighted high rates of tobacco use and explored both individual and family factors related to tobacco use among women. Affordable, culturally acceptable, sustainable and gender-sensitive individual and community-specific interventions will reduce the prevalence and effects of tobacco use.
Keywords: Prevalence, tobacco, women
|How to cite this article:|
Kathirvel S, Thakur J S, Sharma S. Women and tobacco: A cross sectional study from North India. Indian J Cancer 2014;51, Suppl S1:78-82
| » Introduction|| |
Globally 20% of smokers are women; tobacco causes 1.5 million deaths in women. Among them, more than 75% live in low- and middle-income countries. , Global modeled age-standardized prevalence of daily tobacco smoking estimate for 2012 among women ≥15 years of age is 6.2%, and the same for Indian women is 3.2%.  Tobacco use among women is getting more attention currently. There is scarcely available data on tobacco use in women from low- and middle-income countries. These countries record low smoking prevalence among women, which can be due to under-reporting.  Different cultural, psychosocial and socioeconomic factors can be the reasons for tobacco use. Use of traditional tobacco products like bidi smoking, khaini, chutki, betel quid use by women in India is poorly understood and studied. The traditional practices of tobacco use vary according to the region in India due to the difference in social norms, family life and cultural influence on behavior. This study estimated (i) the prevalence and pattern or type of tobacco use among women above 30 years of age in an urban resettlement colony of Chandigarh, the smoke free city of India, and (ii) explored the different cultural, psychosocial, socioeconomic and demographic factors associated with tobacco use.
| » Methodology|| |
Study design and area
This is a cross-sectional study conducted in an urban resettlement colony of Chandigarh, with a population of nearly 27,000 in 5,699 households consisting mainly of migrants from Uttar Pradesh (UP), Punjab, Haryana, Himachal Pradesh (HP), Uttarakhand and Bihar in descending order. Unskilled labors working in vegetable market is their main occupation.
According to the recent annual survey (March, 2014), the study area has 6,522 women in this age group.  Women aged 30 years and above and residing in the study area for the past six months or more were enlisted for the study.
Sampling and sample size
Sample size to estimate the prevalence of any tobacco product use among the study population was calculated assuming 12% prevalence (four times the national average) with the design effect of 1.5 at 5% precision. Systematic random sampling was done in which every twentieth household was sampled. Written informed consent was obtained from all participants. All women aged 30 and above from each sampled household were asked questions from the pretested semi-structured questionnaire (Pearson correlation coefficient 0.721, P < 0.001) on tobacco use. The eldest woman of the household was tagged as "women 1 (W1)" and the next youngest women were tagged as "women 2 (W2)" and so on. If there was no woman in the target age group, the next household in ascending order was visited to get the target age women. Totally, 262 women (W1) were sampled for prevalence estimation. Apart from 55 bidi smoking women from prevalence group, through snowball sampling another 89 bidi smoking women (totally 144) from the same area were studied in detail about their characteristics related to bidi use.
The use of any tobacco product, including both smoking (bidi, cigarette, cigar, hookah) and smokeless tobacco (khaini, chutki and others) for one or more days within the past 30 days from the day of survey was classified as tobacco users. 
Statistical analysis was performed using SPSS 16.0 version. Descriptive statistics like mean, median and percentages were calculated. Hypothesis testing was done using Chi-squared test and logistic regression to determine the association of various socio-demographic characteristics with tobacco use among women.
| » Results|| |
[Table 1] shows the sociodemographic characteristics of the sampled women. Totally, 297 women were included in the study and of these, 262 belonged to W1 and 35 to W2. Around 60% of W1 were aged <50 years. There were no other women in any of the families. The average age of women, number of years since migration and their annual income of W1 were 46 years, 19 years and INR. 14351.14, respectively. Some 85% women were Hindus. Caste-wise, 22% belonged to general category, and 39% each belonged to other backward class (OBC) and scheduled class (SC).
Totally, 254 (96.9%) families were migrants from nearby states like Uttar Pradesh (61.1%), Haryana (13.7%), Himachal Pradesh (8%), Bihar (6.9%), Punjab (3.8%), Uttarakhand (2.7%) and one each from Madhya Pradesh and Tamil Nadu. There were 30 (11.5%) households where widowed women were the head of the family. Among these, 19 (63%) were housewives and the remaining 11 (37%) women were earning money through different occupations most commonly working in vegetable market as a daily wage laborer (52%). The study also included tobacco use profile of 158 males from these households.
[Table 2] shows the prevalence of various forms of tobacco used by W1, W2 and males. The overall prevalence of tobacco use among W1, W2 and in men was 29.4%, 8.6%, and 72.8%, respectively. The most popular tobacco habit was bidi in W1 (19.5%), W2 (8.6%) and also in men (62%). Sixteen (6.2%) women (W1) used some tobacco during pregnancy. These families also reported high prevalence of some tobacco product use among their male members (72.8%).
After inclusion of more women (89) belonged to same study area who smokes bidi through snowball sampling, the total number of bidi smoking women is increased to 144. Among W1, mean age for initiation of bidi smoking was around 23 years and on average they smoked for 23 years. On average, W1 smoked 12 bidis/day and spent around INR. 10/day [Table 3]. The mean age of initiation of hookah, zarda, and khaini was 25, 16 and 25 years, respectively. Similarly, mean duration of use of hookah, zarda and khaini was 28, 10 and 15 years, respectively. Average daily use of hookah, zarda and khaini in W1 was 2-3.
|Table 3: Details of the tobacco use characteristics of women bidi smokers |
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Women learned to use tobacco mainly from their friends/neighbors (50%) and also from their parents/in-laws (21%) and husband (8%). Rest of the women (21%) picked-up the habit on their own. Seventy-three percent of the bidi smoking women have a female relative with the same habit; mother, mothers-in-law, sister and sister-in law were the other main relatives. In 71% of cases there was a place for group smoking. Around 51% women smoked tobacco during special occasions. Friends, neighbor followed by husband, in-laws and mother were the persons who gave company for smoking since friends and neighbors (97%) were more aware of their smoking status than their family members (85%).
Binary logistic regression analysis [Table 4] showed that tobacco use among women (W1) was significantly high in those who had no formal education (odds ratio [OR]-14.6), belonged to scheduled caste (OR-5.6), Hindu religion (OR-3), had any grandchild (OR-3.2), unemployed (OR-2.8), and Uttar Pradesh (OR-1.35) as their native place compared with other groups.
|Table 4: Binary logistic regression of determinants of tobacco use in women 1 |
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Relaxation (74%) was the main reason for initiation of bidi smoking. Other reasons included are for Fun (50%), to cope up frustration (29%), relief from diseases (26%), reduce anger (21%), to maintain the social image (12%), unemployment (5%) and to show the power or dominance over other family members (1%). After smoking, majority of the women reported feeling relaxed and or relieved of symptoms, and they became more anxious, if they did not smoke.
Bidi smoking was common in women who did not have any formal education, working women, earning more than INR. 30,000 and presence of the smoking habit of the male member. The use of tobacco among W1 is not dependent upon W2. Less prevalence of smoking among W2 may be because of prevailing culture of not smoking in front of elders (W1) and dominance by others (W1).
Nearly, all women contemplated thoughts and also tried to quit smoking because of non-acceptance by the family members, fear of cancer, doctors' advice, sickness in her and others, fear of respiratory diseases and due to financial problems. Since they tried and failed with cardamom, toffee/sweet and tea/coffee as a replacement to bidi they now feel that self-control alone or in combination with medications work better. They were also aware of ill-health effects of smoking bidi such as cancer, respiratory, cardiac and reproductive tract problems.
Diseases such as tuberculosis, bronchial asthma, chronic obstructive lung diseases (chronic obstructive pulmonary disease), and hypertension were reported more in bidi smokers than non-smokers (<0.001) significantly and diabetes and infertility were not reported significantly. Infant deaths were reported significantly (<0.001) more in bidi smoking women but not abortions.
Doctors, television, radio and cinema theater advertisements, nurses, word of hearing from others, books or magazine and posters were mentioned as the sources of information. Only 26% of women mentioned the tobacco product carton display as a source of information for ill-health effects caused by smoking.
| » Discussion|| |
This cross-sectional study from an urban resettlement colony with majority of the migrant population explored the cultural, psychosocial, sociodemographic and economic determinants of tobacco use among women. The distribution of the sampled population about religion and caste is similar to the original population of the study area. This study reported high prevalence of tobacco smoking (20.6%) than smokeless tobacco use (11.5%) among women in contrast to national surveys and other studies where smokeless tobacco use is predominant among women. ,,,,,,, These estimations are also higher than the reported tobacco prevalence of individual states like Uttar Pradesh, Haryana, Punjab and others in National Family Health Survey 3 and also in the same study area compared with past. , The estimated tobacco prevalence among women of this study is comparable with the overall (both male and female) prevalence estimations given for a slum of the same region. , The types of smoking tobacco used were bidi, cigarette and hookah and smokeless tobacco were zarda, pan, chutki and khaini. The study also highlighted the reasons for using tobacco, one of which was the perceived medicinal value. There were also identified places for group smoking and during special occasions that can be used for starting group therapy to quit tobacco use. 
Tuberculosis treatment outcomes are poor among patients who are smoking tobacco. , No tobacco cessation intervention was provided at tuberculosis clinic or directly observed treatment short course clinic, which is remaining as a missed opportunity.  Similarly, women were asked about their smoking status rarely during their visits to health facilities since smoking is not culturally acceptable among women in India. The reproductive and child health component of National Health Mission is also missing the opportunity to identify the antenatal and postnatal women tobacco users and provide cessation intervention since this study reported 6.2% of prevalence during pregnancy. There is scope to streamline this aspect through necessary changes in the policy and program.
Women in this study showed adequate knowledge on the ill-effects of tobacco use, especially bidi. The information disseminated through various media measures reached the women, but there was no gender sensitive tobacco cessation program available with the public health services. Around 55% of adolescent girls started smoking before the age of 20 and 70% them started with bidi smoking, but the adolescent health service component is not addressing this issue. Daily average money spent on tobacco was INR. 10/day which amounts to INR. 3,600/year. In a woman earning INR. 10,000/year where her major portion will be used to buy tobacco and basic needs like food, clothes and so health will go compromised. This can be one of the reasons for pushing the population directly into poverty and indirectly by the ill health effects of tobacco resulting in catastrophic out of pocket expenditures. The study also found that the prevalence of tobacco product use is high among poor and less educated as in previous studies. 
The cultural, psychological, socioeconomic reasons for tobacco use body image and peer pressure should be addressed through population-based and individualized tobacco cessation interventions. ,, Stigma present in Indian society when a woman visits psychiatrists for de-addiction and poor availability of the de-addiction services at primary health centers make its' acceptability and accessibility more difficult. Involvement of family members, neighbors and friends is necessary for sustainable cessation. Though the women tried multiple alternatives, due to poor knowledge they are less preferring for medical advice. These women were already crossed precontemplation stage of trans-theoretical model of behavior change and most of them gone ahead to preparation and action stage.  Since they were neither aware nor use appropriate method for quitting smoking, they should be given awareness and necessary services at their nearest health facilities for quitting tobacco. The affordability of medications for tobacco cessation is high because women may need long-term maintenance therapy, which is another important aspect to be addressed. Gender and age-specific health services along with sustainable and affordable medical advice and medications in the background of population level interventions can reduce the tobacco prevalence. , This study also emphasizes the need for necessary changes in displaying warning labels on tobacco packages to create awareness among more population.
The main limitation of the study is possibility of social desirability bias since tobacco smoking by women is not culturally accepted in India and so underestimated prevalence. Under reporting of daily frequency of use of any tobacco product, money spent and any disease status like cancer is the next limitation. Possibility of recall bias in ascertaining characteristics like age of initiation, years of use, abortion and other diseases cannot be ruled out. Information given by one member on other member of the family may vary. The cross-sectional type of data limits its scope for causal inference. Prevalence of tobacco use estimated for male may be high since only 60% of households reported tobacco status of the male and the rest found missing.
| » Conclusions|| |
This study explored the tobacco product use related characteristics comprehensively both at individual and family level including cultural and economic factors along with assessment of knowledge on ill-effects of tobacco use and presence of tobacco related co-morbidities. This study also explored the stages at which all tobacco users were for to intervene. Since almost all study participants tried quitting tobacco product use, they are at advanced stage of trans-theoretical model of change. Study of these factors will help to plan gender specific intervention for this population, which should be affordable, culturally acceptable and sustainable one.
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[Table 1], [Table 2], [Table 3], [Table 4]