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Tobacco, TB and female mortality

Rupa took to chewing tobacco five years ago.

Tobacco, TB and female mortality

Poor awareness of the insidious impact of smoking and the social acceptability of chewing tobacco are the primary reasons for the worrying trends.

Swapna Majumdar

Rupa took to chewing tobacco five years ago. She thinks it is less harmful than smoking beedis, (tobacco wrapped in tendu leaves) an Indian smoke she had done for over a decade. It is also cheaper and doesn’t dent her monthly income of Rs 3,000 she earns as a cleaner. So, unlike before when she restricted smoking to just one packet of beedis a day, now she doesn’t bother to keep a count of the number of packets she consumes. 

Rupa is not the only one. Tobacco consumption among Indian women doubled during the period 1995-96 to 2009-10 from 10 to 20 per cent. Much of this increase was due to the use of smokeless tobacco among women, which rose from 8.6 per cent in 1995-96 to 18 per cent in 2009-10. In fact, one in every five female tobacco users in the country consumes the smokeless form, as against one in 10 who smoke.

Studies have found the initiation for smokeless tobacco is higher among the poor and those with no formal education. Poor awareness of the insidious impact of tobacco and the social acceptability of chewing tobacco are the primary reasons for this worrying trend, say experts. Tobacco consumption is the cause of more than half of cancer deaths and a majority of the cardio-vascular and lung disorders.

Worrying trends

A direct consequence of the increase in smokeless tobacco is increased burden of disease and mortality in the country. Women's share in the economic burden of diseases related to tobacco was highest for cancer, at 38 per cent vis a vis respiratory diseases, tuberculosis (TB) and cardiovascular diseases according to a recent 2014 study by the World Health Organization (WHO) in India and the Delhi-based Public Health Foundation of India (PHFI). It also found women contributed 29 per cent of the total burden for smokeless tobacco, including gutka, pan masala and khaini. 

The sale, manufacture and distribution of gutka, khaini and pan masala containing tobacco has been banned by 23 states, including Himachal Pradesh, Haryana and Punjab after the 2011 regulation issued by the Food Safety and Standards Authority of India, a statutory body under the Health Ministry.

However, gutka, a popular concoction of tobacco, areca nut, slaked lime, catechu, and flavouring is among the 22 different types of smokeless tobacco products that are readily available. Its consumption along with other chewable forms like khaini and zarda is not a taboo, hence it is high among women. 

Reproductive health 

Ironically, talking about women’s sexual and reproductive health remains a taboo which means that little or nothing is discussed about the impact of smokeless tobacco on the reproductive health of women, including infertility and delays in conception. In particular, poor women in rural areas with little or no education who consume smokeless tobacco are rarely counselled about the adverse effect of continuing with smokeless tobacco during pregnancy. They are not told they risk complicated pregnancies and adverse outcomes, including sudden death, pre-eclampsia, and pre-term delivery. Neither are they informed why their babies are low weight or stunted.

According to the latest National Family and Health Survey (NFHS-3,) the proportion of births with a low birth weight is greater among children born to women who use tobacco. In the northern region, Haryana has the highest percentage of low-birth weight babies followed by Punjab. It is estimated that  in Punjab, 91 per cent of female tobacco users use smokeless products; betel quid with tobacco,  followed by gutkha and khaini, according to Voice of Tobacco Victims , a nongovernmental  organisation working to raise awareness on the impact of tobacco use.

Mother and child care

Nicotine reaches the brain within 10 seconds after the smoke is inhaled and can be found in all parts of the body, including breast milk. It would help to incorporate easy to understand information related to tobacco use in maternal and child health programmes and provide related services. Antenatal clinics should include appropriate screening and ensure pregnant women are counselled about the negative effects of tobacco use and exposure to passive smoking.

The link between smoking and TB is well established. Over 1,000 Indians die of TB each day and two million develop it each year, making the country among the top 10 countries with the highest burdens of tuberculosis and tobacco use. With over 12.1 million women smokers, India is home to the second highest number of women smokers globally. Also, an average woman in India is starting to smoke at 17.5 years compared to 18.8 years among men, according to a Lancet study. However, there are no recent figures on how many female smokers died of TB. Women fall through the cracks as they tend to stay at home and have a lower awareness of TB symptoms. More than 3,00,000 children leave school each year on account of parental TB.

Stigma and TB

Lack of proper data also stems from the stigma associated with TB that prevents women from coming forward to seek treatment. They are often reluctant to reveal they might have TB due to potential rejection from their families. Women also delay seeking care because they are hesitant to use family resources, often meagre. They wait until they are severely ill and more likely to die. Many times, even when they do access the health services, women tend to discontinue treatment early in the absence of a strong healthcare support system to ensure follow up.

An innovative use of technology has shown that this problem can be overcome. Operation Asha, a NGO based in Delhi, has developed a biometric system that has taken TB treatment to the doorsteps with local community health workers, also known as Directly Observed Therapy (DOTS) providers and making sure they take their medicine as part of DOTS model for tuberculosis treatment introduced by the WHO. A cadre of trained, well-compensated, full-time counsellors ensure compliance. If a patient misses a dose, a counsellor goes to the patient's home to bring him or her back into the system. The counsellors receive a cash incentive for tracking missed doses and administering them to the patient. They are also responsible for linking patients with hospitals, taking them for sputum testing, and getting boxes of medicine allotted, which is more helpful to  women. 

Innovative approach 

At the time of swallowing the medicine under DOTS guidelines, the provider identifies the patient with the fingerprints saved in the system. The data is then sent by SMS several times per day to a server located in Delhi, and if patients miss doses, text messages are sent at the end of the day to the appropriate counsellors and health workers when non-compliance is detected. Those who do not show up to take their medication are sent reminders and tracked down.

The eCompliance system is highly interactive and easy to use even for semi-illiterate health workers and illiterate micro-entrepreneurs. The system is linked to an electronic medical system at the back-end, which improves transparency and reliability. So far, 1,75,000 visits have been logged in at the 58 centres with eCompliance terminals located in various states, including Punjab and Haryana. About 1600 patients are tracked by the system bringing down the default rate considerably.

The Nepal experiment 

It’s success also lies in its working in close coordination with the government and following its Revised National Tobacco Control Programme (RNTCP) guidelines. The RNCTP is the largest TB control programme in the world. However, merely having DOTS services in a district does not necessarily translate into ensuring that all those who have symptoms of the diseases are being diagnosed and treated by DOTS services.

lf the eCompliance  technology can be scaled up to reach out to marginalised populations living in remote areas, it would give women a chance to seek treatment and save their lives. 

Another good initiative that needs to be adapted is the integration of tobacco control into a TB control programme as shown in Nepal by the WHO Tobacco Free Initiative (TFI) and the WHO Stop TB programme, in collaboration with the International Union Against Tuberculosis and Lung Diseases. This integration showed improved detection and management of TB cases. 

Every 40 seconds a person adds to the numbing statistic on death from tobacco in India. The number of people dying of tobacco-related diseases annually is higher than the combined toll from AIDS, accidents, alcohol and other addictions according to the World Health Organisation. 

The killer chulhas

The indoor air pollution caused by chulhas is a killer.

What about those women who have no connection with tobacco but face risk equivalent to smoking 400 cigarettes a day? Unbelievable as it may sound, the indoor air pollution caused by fuels burnt to light chulhas or traditional stoves emit smoke which is deadly; a typical chulha emits smoke equal to 400 cigarettes per day according to the Delhi based Centre of Science and Environment. Nearly 75 per cent of rural and 22 per cent of urban households still use biomass for daily cooking. Reports by the National Solar Energy Federation of India state 130 million people in India still use cook stoves with unclean energy sources, despite indoor air pollution being identified as India’s biggest health hazard.

Research has proven that the mothers with higher exposure to indoor air pollution give birth to low-weight babies. A recent study published in the medical journal Lancet estimated that indoor air pollution from chulhas causes 4,00,000 premature deaths every year in India. This means more than one-quarter of four million premature deaths annually caused by household air pollution from such fires take place in India.

A National Biomass Cookstove Programme (NBCP) was proposed by the Ministry of New and Renewable Energy during the 12th Plan to support research and development of standards and scale up demonstration of improved biomass cookstoves on a cost-sharing basis. The objective was to replace the existing traditional chulhas by improved biomass cookstoves for domestic and community cooking, thus saving fuel and reducing health hazards 


The NBCI launched by Ministry in 2009 is still testing the improved biomass cookstoves in several states including Jammu & Kashmir, Uttar Pradesh, Bihar, Madhya Pradesh, Jharkhand, Chhattisgarh, Karnataka and Odisha. The programme will cover the remaining states in the next phase.

The writer, an independent journalist, writes on development and gender issues.

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