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The Price of Silence: Wom

The Price of Silence: Women, Tobacco and Clinical

Gaps in India

BY SREE T. SUCHARITHA NOVEMBER 23, 2020

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The Price of Silence: Wom

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A
s I wait to interview respiratory physicians in a high-end
private medical clinic in Chennai, a sprawling metropolis in
the state of Tamil Nadu, southern India, I look around the
outpatient setting and see few women clients.

After professional introductions, the women clinicians ask me what

has become a standard question in my visits, as a public health
researcher, to five private medical institutions in the city during the
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past four months.
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“Why are you interested in doing this research?” 0
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No one has ever approached them before with such a request: to
participate in an interview-based study intended, shockingly, to
explore issues relating to women and tobacco. And that , I explain to
them, is exactly why I am doing it.
The Price of Silence: Wom

Recognizing the truth of this, four care providers participated in

interviews on the same day.

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But the interviews I conducted throughout the study period with

multi-disciplinary doctors—including psychiatrists, dentists,
obstetricians, respiratory physicians, internal medicine specialists,
surgeons, infertility specialists and ear-nose-throat specialists—about
their clinical experiences with women tobacco users revealed their
very limited experience and knowledge in this area.

Their decades of medical or dental training had left them unprepared

to address tobacco-related issues in general, and they did not see 
helping women in particular in this area as pressing. Less than a
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third of the 41 clinicians I interviewed had ever treated women for
clinical consequences of tobacco use. And they had, between them, 
supported only five women clients with tobacco cessation
counselling. They had prescribed nicotine replacement therapy, or
pharmaceutical medications like bupropion or varenicline, to no
women. (Vaping, it should be remembered, is effectively banned
throughout India.)

The most recently available statistics from India show that 1.7
 percent of women are daily tobacco smokers, with 0.4 percent daily
cigarette smokers and 0.9 percent daily smokers of bidis— a
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traditional form of unprocessed, leaf-wrapped tobacco . (Far more 0
 women in India, 11.1 percent, are daily users of different forms of
smokeless tobacco.)
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While Indian women’s daily smoking prevalence may seem low—and
is far lower than that of men, at 15.2 percent—the country’s vast
population nonetheless means that millions of Indian women
continue to smoke.
The Price of Silence: Wom

Multiple studies, undertaken by the Global Adult Tobacco Survey,

the National Family Health Survey and the National Sample Survey,
have indicated that total smoking among Indian women has roughly
doubled every decade. In 2018, the Social Development Foundation
of ASSOCHAM, India’s leading trade association, surveyed major
cities including Chennai and found casual and social smoking on the
rise among working women aged 22-30.

Shared Silences

The reason India’s healthcare providers so rarely encounter women

who reveal their tobacco use or seek cessation help is a cultural, 
gendered taboo. A 2017 survey found that 64 percent of Indians
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agreed with the statement that “The role of women in society is to be
good mothers and wives.” The stigmatization of women’s tobacco use 
perfectly fits this picture.

Unlike with men, doctors are too often hesitant and reluctant to ask
women patients about their tobacco use or history. There are rare
exceptions: “I ask all young females about their smoking history
whether they find it objectionable or otherwise,” one woman
respiratory physician told me. But only dental professionals and
 psychiatrists, of the categories of clinicians I interviewed, routinely
seek tobacco usage history during consultations. Protocols for
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infertility, endocrine and metabolic disorders evaluations also 0
 require that women patients disclose tobacco use, and routinely refer
people to tobacco management specialists for further care.
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Simply asking women whether they use tobacco comes up against
that taboo, however.

Physicians I spoke with believe that the women they treat tend to
The Price of Silence: Wom
hide their tobacco use or history due to societal stigma. The
conservative cultural conditioning prevalent in southern India
encourages this secrecy. And women are frequently unaware of
tobacco health harms—especially those of chewing tobacco—and
develop health complications earlier than men, in the clinicians’
reported experience.

 She could not recall any woman client seeking such services.
She reflected that this could be due to women’s fear of being
judged.

Psychiatrists who diagnose mental health conditions most often see

women clients who use tobacco along with multiple substances—
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including when they are referred for psychiatry counselling for
tobacco cessation for respiratory diseases, or other diseases where 
tobacco use is found to be a risk factor. One psychiatrist described 
her experiences of men sharing their nicotine dependency openly
with clinicians and seeking support to quit or find safer alternatives
—but she could not recall any woman client ever seeking such
services. She reflected that this could be due to women’s fear of
being judged.

Many women begin smoking as a coping mechanism due to stress or

 trauma, which they may find difficult to discuss. Clinicians’ failure to
understand the roles nicotine plays in women’s lives can result in
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provision of sub-optimal tobacco cessation services, and devalues
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 women’s health. 

 
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Seeking Safer Alternatives

While the majority of the healthcare providers I interviewed were

aware of harm reduction in general, the specific concept of tobacco
harm
The Price reduction
of Silence: Wom (THR) was almost unheard of—except among the

psychiatry professionals. Major reasons for this awareness gap

include a lack of medical education updates, and THR’s omission
from India’s national tobacco control program.

Not one of the 41 clinicians interviewed had attended any

educational session on tobacco in the past year. Those who wished to
educate themselves had done so simply by reading online or viewing
YouTube videos. It’s a stark illustration of the exclusion of THR by
medical professional bodies and medical curricula.

 “We switched over to e-cigarettes. She was actually

comfortable.”
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One dentist was candid enough to admit that “we are negligent 
towards tobacco, both smoking and smokeless tobacco.” It took a
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woman client who used chewing tobacco and developed a clinical
oral mucosal condition, which later turned into a premalignant
condition, to alert him to the need to better protect patients.

One woman pulmonologist introduced a patient to vaping after

nicotine gum had not worked for her. Having “given her this nicotine
chewing gum, she was not happy with it,” she recalled. “So we
switched over to e-cigarettes. She was actually comfortable. But now
 after this COVID lockdown, I have lost her, and follow-up of her.”
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The switch from smoking to vaping that this patient was encouraged  0
 to make took place before the effective national vaping ban kicked in
September 2019. And there is a connected, conspicuous lack of
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publicly available information about the benefits of switching to
vaping.

“We had to prime her right from the beginning,” the pulmonologist
The Price of Silence: Wom
said of her patient, who was an academic with good potential access
to health information. “She had no idea about it.”

That extends to many clinicians, too. One ENT surgeon was asked by
a medical peer about e-cigarettes compared with smoking: “Are they
safer to use?” This happened four years back— after a landmark
review published by Public Health England, among other evidence,
had confirmed the answer.

The pulmonologist who introduced a patient to vaping was

previously asked about online e-cigarettes advertisements by another
of her women patients: “Is it good? Is it safe for women? Why are
they advertising it? Are they promoting female smoking?”

“And only after that,” admitted the clinician, “I came to know that 
something is getting advertised like that.” 
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 “Am I going to get cancer?”

While doctor-patient conversations like these reveal clinicians’ lack

of education about THR advances, they also show, encouragingly,
that women who use tobacco are proactively seeking information
about alternatives.

It is thus all the more imperative that clinicians be constantly

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updated with accurate information—it’s essential if they’re to offer
 emerging, harm-reducing options to their patients, and inform them
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 about the risks and benefits involved.  

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Because women tobacco users in India, however heavily stigmatized,
are aware—even if only vaguely—of the threats smoking poses to
their health. “Am I going to get cancer?” one patient asked another
woman ENT surgeon.
The Price of Silence: Wom

The study described in this article is being prepared for submission

to an international peer-reviewed journal in 2021. The project has
been supported by a scholarship from Knowledge-Action-Change.
The Influence Foundation, which operates Filter , has also received
scholarships from KAC to support tobacco harm reduction reporting.

Photograph of women in Mumbai by Steve Evans via Wikimedia

Commons/Creative Commons 2.0

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Sree T. Sucharitha 

Sree T. Sucharitha, MD, is a professor in the Department of

Community Medicine at Tagore Medical College Hospital in
Chennai, India. She holds a fellowship in HIV medicine
from the CDC (Atlanta)-I-Tech partnership in India.

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