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Today’s panel continues the discussion on tobacco use issues and narrows the focus on a topic commonly left out of the larger conversation around tobacco users, which is women and tobacco. The roundtable includes experts across industries and professions in India, all bringing a different but unique perspective to the broader issues at hand.

Senior Correspondent Dom Garrett serves as the moderator for this dialogue, which includes Dr. Aruna Shanmuganathan, Dr. B. Bhuvaneswari, Dr. R. Pradeep, and Dr. Sree Sucharitha. This panel aims to address issues often excluded from the more extensive discussion around the tobacco industry, with women disproportionately removed from both the data and the overall conversation. 

Dr. Aruna Shanmuganathan, MBBS, MD, is a professor at the Department of Respiratory Medicine at Chettinad Hospital & Research Institute and serves as a member of the Indian Chest Society, American Thoracic Society, and the European Respiratory Society. 

She describes two groups of women within India: emerging tobacco users who are typically younger and rarely seek help from healthcare providers, mostly using smokeless tobacco. 

According to Dr. Shanmuganathan, very few women go to healthcare practitioners, and many aren’t even aware of the harm associated with the products they are using.

“I think as healthcare practitioners, it is our duty, we can’t just sit in our office and wait for women to come to us,” she said. “We have to reach out and identify regions or topics and do some screening camps and go to them first; otherwise, they won’t be receptive.”

She says that healthcare providers need to assume a more active role in their community and that recent studies have shown practitioners spending as little as two minutes with a patient.

“A brief little intervention by the physician goes a long way in the primary step that is cessation,” states Dr. Shanmuganathan.

Dr. R. Pradeep, MD, DPM, is an associate professor in the Department of Psychiatry at Madha Medical College Research Institute, while also serving as a consulting psychiatrist in a private practice. 

He believes a lot of the women’s behavior representative in India is based on a culture and a saturated society with guilt, shame, and fear. This makes it even less likely that a woman would seek a psychiatrist’s help to deal with any issues she is having, not only about tobacco addiction but also far beyond.

“There are women right now who may be having high symptoms of depression and suicide, and still they wouldn’t come to a psychiatrist or any doctor for help because our culture and our society is based on fear and shame and guilt,” said Dr. Pradeep. “Help is not being sought out.”

In his work as a consultant, he has noticed a trend among his peers where senior consultants will avoid the issue of tobacco altogether.

“One reason may be because there aren’t many effective treatments, and the other reason is even after coming to a conclusion, even after coming to a diagnosis of tobacco dependence, the doctor gets to do nothing,” he says. “The doctor doesn’t have an effective way of cutting this habit or cutting this dependent.”

He also addresses a common theme throughout this discussion: the lack of statistics on women as tobacco users.

“In order to take a step against tobacco, I believe that the first step would be acknowledging the problem, knowing how deep the problem is, getting our statistical values, then comes formations of protocols,” states Dr. Pradeep.

Dr. B. Bhuvaneswari, MDS, is a reader within the Department of Periodontics & Implantology at Tagore Dental College & Hospital and serves as a dental surgeon and periodontist at the Birla Dental Clinic, Chennai, Tamil Nadu.

She echoes Dr. Pradeep’s thoughts regarding underlying issues built into India’s culture and society, saying, “When it comes to women, I feel they have started this smokeless tobacco habit because of the depression which they undergo in their family and the suppressiveness of the society.” 

Dr. Bhuvaneswari continues, “We have to make them aware of the effects, and the family has to support them in that way. It’s only when the whole family supports them, the women can come out of the habit.”

One of the ways to address these issues, according to Dr. Bhuvaneswari, is through educating and creating an awareness with both the patients and their family members.

Senior Correspondent, Dom Garrett, states that out of the 248 million smokeless tobacco users worldwide, 232 million of those users are from India and Bangladesh.

Dr. Sree Sucharitha, MD, a professor in the Department of Community Medicine at Tagore Medical College Hospital, chimes in with another harrowing statistic regarding the tobacco users’ population. According to research, Dr. Sucharitha states, “the global smoking epidemic is going to explode in low- and middle-income countries, and it is going to double by 2025.”

She refers back to the topic at hand, women, and tobacco in India, and explains some of her research findings regarding why women start smoking to begin with. Dr. Sucharitha points to celebrities and the media portrayal as a leading cause, showing women who smoke as being empowered, which the audience equates with liberation. In a society already riddled with shame and guilt, this alleged liberation can be viewed as a solution rather than a problem.

Dr. Shanmuganathan agrees by stating, “Young women associate smoking with prestige, with feminism.”

She continues by saying the tobacco industry is losing customers, and they are trying to gain some of that ground back by luring young women with their advertisements.

According to research, one of the main drawbacks of tobacco cessation among women is the growing concern of gaining weight. This is why, according to Dr. Shanmuganathan, it is crucial to link tobacco cessation programs with exercise programs, as a way of offering a potential solution to these concerns.

Dr. Pradeep says this has also been seen as an advertising tactic employed by the tobacco industry, linking smoking to weight loss.

“There was an indirect message, subliminal messaging, we call this effective conditioning, where the message is you can lose weight if you smoke or you are a liberated woman if you smoke,” Dr. Pradeep states. “All these are advantages which tobacco companies have towards women.”

The discussion turns to harm-reduction products and the potential effect they could have on the tobacco user population. Dr. Pradeep believes it is only a matter of time before safe smokeless tobacco alternatives enter the market.

“We do have the technology now; we have the technology for making KFC agree to a vegan burger…We were able to replicate a burger which looks like the original one, which looks like meat, which tastes like meat, which gives the satisfaction of meat, that is a very good alternative,” he says.

He believes developing such an alternative should be the primary motive, and that the technology is available.

This is not the only obstacle that the medical community is facing regarding tobacco users.

Dr. Pradeep believes the first hurdle is spreading awareness.

“No matter how much we explain, no matter how much we advertise, no matter how much we campaign, there’s still a huge population of users and non-users who still believe that this harm is very low,” he states.

Another hurdle is the significant gap in gender-specific data regarding women and tobacco, according to Dr. Sucharitha.

“Where is the data for women tobacco users?” What is happening with women tobacco users?” she asks. 

Researchers know women are using tobacco, but they don’t know to what extent, which products, what kind of health problems they encounter, and a slew of other unanswered questions.

Dr. Sucharitha continues by saying:

“When it comes to research gaps when it comes to women and tobacco, we need to understand what is the social context of smoking or tobacco use, what is the meaning of tobacco use for women in India, what is the function of tobacco use for Indian women, what function is it fulfilling? Is it a mental stress relief? Is it, as we discussed, a tool of liberation? Is it a tool of gender equality? Is it a tool of making certain gender stereotypes?”

She believes all of these factors are determinants for women smoking in India, and that each of these factors has a meaning and a function. The researchers’ job is to study those factors, understand those factors, figure out what role the factors play, and then find a way to approach the problem and develop a solution.

“We need to understand the social context,” says Dr. Sucharitha. “Unless we understand that role of context and meaning, and we figure out how to create these interventions along with them, we may not be able to overcome this particular challenge in India.”

As the conversation comes to a close, Garrett asks the panel how to move forward from here.

Dr. Shanmuganathan believes in a multi-step approach: identifying the burden, specifying the primary reason for initiation, identifying the potential areas to target, and following up with the patient. She believes the follow-up with the patient to be a vital component of this approach, given it’s something health practitioners rarely do.

Dr. Pradeep believes the way forward is by building protocols that target the larger population of women who may be using tobacco:

“To start with, we should build a protocol for women-dominated hospital departments like obstetrics and gynecology where women are regular visitors, they come for screenings, they come for checkups. Build a protocol to check on them, to check on their tobacco usage, so we start with actual harm reduction…so harm reduction, I feel, is the first step, the easiest step, and one of the most effective steps in reducing harm to the future child should start from the hospital and from women-dominated departments.”

Dr. Bhuvaneswari closes the discussion around this question by emphasizing the need to identify why the patient began using tobacco to begin with. In addition to identifying the reasons why a patient has started using tobacco, she also believes in consulting with the patient’s family and friends to support the tobacco user in their quest for tobacco cessation or experimenting with safer alternatives.

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