As India continues to grapple with COVID-19, other insidious pandemics ravage millions of lives. Chief among them is tobacco use, which accounts for approximately one out of every ten deaths—over a million each year—in India. Nearly 90 million Indian women aged 15 years and older report using tobacco. Less than two percent of them consume combustible tobacco (such as cigarettes and bidis), while nearly 13 percent consume smokeless tobacco (SLT) such as mishri, gutka and khaini.
There are a number of drivers of tobacco use among women, often varying by product and region as well as coursing along socioeconomic fault lines. Key drivers of tobacco consumption among women include companionship through shared use, use by peer group, and family attitudes. Many women who live in relatively dire circumstances report consuming tobacco to reduce stress, suppress hunger, and increase energy for manual labor. Often women are exposed to tobacco use through the bidi rolling industry, in which women account for the vast majority of workers and are often the most disadvantaged and least compensated in the value chain. Tobacco use is also often abetted by the erroneous perception that SLT products improve oral health, relieve pain, and are safer than smoking.
The high rates of tobacco use compound the risk of death and disease among women in India in devastating but predictable ways. Tobacco use is a substantial contributor to cardiovascular disease, various cancers, and respiratory illnesses. It also significantly increases the risk of morbidity and mortality from COVID-19.
The consequences of tobacco use extend beyond the individual smoker, as consumption often adversely affects the health of smokers’ children. The health risks of tobacco also have an effect on women who do not consume tobacco. As one example, according to the second round of the Global Adult Tobacco Survey (GATS), over 35% of non-smokers, disproportionately women, were exposed to second-hand smoke at home.
The disease risks of tobacco consumption and second-hand smoke are further compounded by lack of access to specialized, timely, and quality healthcare services for women. Such services are even more scarce today than in the past due to the COVID-19 pandemic. A recent survey of medical professionals in Tamil Nadu found that despite decades of medical training, many doctors found themselves poorly equipped to address tobacco-related issues. Similarly, healthcare professionals in rural Maharashtra reported that oral cancer in women due to SLT use is often diagnosed too late to initiate clinical treatment. India accounts for nearly a third of all the oral cancer incidences globally.
Taken together, such observations suggest that the lives of millions of women could be saved through the provision of early screening services, diagnosis, tobacco cessation and tobacco harm reduction programs.
Three things are desperately needed to do exactly that. First, gender-specific insights into tobacco-control efforts in India must be obtained, along with evidence on the drivers of tobacco consumption, the impact of tobacco use on the health of women and their families, and common barriers to accessing tobacco cessation services. To date, collective understanding of these complexities is predicated on the experiences of men. Analogous insights into the experiences of women who use tobacco must be gained and, in turn, deployed to develop culturally sensitive and women-focused interventions. Tobacco-control programs can draw from India’s women-centric nutrition, family planning, tuberculosis, and HIV/AIDS programs, which utilize targeted measures to support women’s access to healthcare and counselling services.
Second, community-led mobilization efforts must be supported by state governments. Many community-led efforts to address substance use (including alcohol and tobacco) in India are successfully led by women’s groups and grassroots organizations. Such groups often require state government support to be effective at a larger scale. There are lessons to be drawn from such efforts. Women’s roles as caregivers could be leveraged to support demand-side interventions for tobacco-free households and communities. At the same time, women’s voices must be amplified in the areas of science and policy making.
Third, a deeper understanding is needed of the potential for healthcare providers to provide tobacco cessation counselling and support, especially for women. Doctors are generally reluctant to ask for details about tobacco consumption, and patients are reluctant to share them. The first basic intervention starts in healthcare settings.
The collective resolve and commitment being deployed to fight the COVID-19 pandemic can and must be leveraged in the battle against tobacco. If successful, India can become a tobacco-free country, promoting better health outcomes for its most vulnerable and saving millions of lives in the process.
 Institute of Human Development. A review of legal and regulatory frameworks for bidi in India. 2020. Unpublished.
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