Fresh flower in an Ashtray is the symbol of World No Tobacco day.

May 31 is celebrated every year by WHO as the “WORLD NO TOBACCO DAY”. World Health Assembly in the year 1988 passed a resolution to celebrate this day every year on 31st     May with a new theme each year. This year the theme being “Gender and tobacco with an emphasis on marketing to women”. In essence, this day is marked by urging people all over the world to abstain from all forms of tobacco for a 24 hour period. Besides, it intends to create awareness globally regarding the ill effects of tobacco consumption and its widespread prevalence across the globe [1]. The theme has been chosen to highlight and prevent the use and marketing of tobacco products amongst women and girls.

Tobacco use in all forms is the most important preventable cause of mortality in today’s times. It is the commonest cause of cardiovascular mortality, cancers, stroke, respiratory diseases and many other conditions.

It has been estimated that there are 1.1 billion tobacco users in the world out of which 240 million users are in India alone (195 million males and 45 million females) [2]. According to World Health Organization report (2009), current tobacco users in India in the age group 15-49 years is 57% and 10.8% in males and females respectively whereas current cigarette or bidi smokers is 32.7% and 1.4% respectively [3]. 36.5% men and 8.4 % women consume Paan in India [3]. It is also observed that tobacco use is more prevalent in rural areas as compared to the urban population [4]. Similar findings have been reported in the study published from District Jhunjhunu of Rajasthan, India wherein 38.67% of the urban males surveyed smoked as against 22% of rural males [5].

This year’s theme has a gender perspective. But why focus on women? The reasons for tobacco use in men and boys are different than those for women and girls. It’s a sign of masculinity and social status for men whereas women in India, especially in rural areas are mostly into smokeless tobacco consumption. In rural population, use of tobacco, more so in the smokeless form is a common cultural practice which is accepted as “Normal” by men and by and large, the society also. It is perceived to have certain beneficial effects like relieving constipation, toothache etc.  In Mizoram, the prevalence of smokeless tobacco use in females has been reported to be as high as 61% [6].  Nevertheless, in some countries the prevalence of smoking in girls is increasing especially in urban area as girls think smoking is a sign of liberation and independence. For example, in New Zealand, the percentage of girls aged 13-15 years who smoke has gone up from 23.9% in 2007 to 39.9% in 2009 [7]. Similarly, in Federation of Russia the prevalence of smoking in women has increased recently where more than 100 special Tobacco brands (“light”, “slim”, “superslim”) for women have been introduced [8]. So the tobacco control strategies will not only be directed towards men but also have a special emphasis on tobacco use and marketting strategies towards women. Tobacco companies are now trying to lure young girls and women into tobacco use as they would form the major consumers of tobacco products in the coming years. Out of a total of 5 million deaths due to tobacco use, nearly 30% are women [7]. The number of women smokers is projected to increase three times by 2050, from the current 200 million to over 500 million and more so the prevalence of smoking in women will increase in less developed countries [9].

The harmful effects of tobacco in women are enormous. Majority of women are passive smokers. They are exposed to Second Hand Smoke (SHS) at home, work place or at various public places. According to the International Agency for Research on Cancer (IARC) and the US Environmental Protection Agency, Second Hand Smoke has been recognized as a major cause of morbidity and mortality and has also been identified as a ‘carcinogen’[10,11]. In the last 20 years or so, enough data has been generated that SHS causes lung cancer, asthma, heart disease, nasal sinus cancer among other conditions [12]. The tobacco exposure in women is both direct as well as indirect. The case of China is particularly important wherein nearly 50% women in reproductive age group are exposed to passive smoking (SHS) [7]. Nowadays, attention is also drawn towards “Third Hand Smoke” where children are exposed to toxic residues on clothes, furniture and flooring [13].

The harmful effects of tobacco use are more disastrous especially in pregnant women. It can cause miscarriage, pre-term births, intra-uterine growth retardation, preterm premature rupture of membranes, foetal mortality and morbidity, post-partum infant death, infertility etc. [14]. Hence, the prevention strategies for tobacco use in women need to be directed against both direct as well as indirect smoking.

Keeping all these factors in mind, the theme for the current year has been chosen. Hence the World No Tobacco Day 2010, aims to set policies for the prevention of use of tobacco by women by bringing about changes in regulation and controlling through advertisements and awareness programmes. So, what have we done so far? Tobacco control in India is a very complex problem as tobacco not only is consumed on a large scale but also produced and exported. The first policy initiative of the Government of India came as The Cigarettes Act, 1975 which made a statutory warning mandatory on all cigarette packs. Thereafter, in 1990, a directive was issued by Central Government banning smoking in public places, prohibiting advertisements in national radio and television and mandatory statutory health warnings on chewable tobacco products. In 2003, India passed the Cigarettes and Other Tobacco Products Act (COTPA) which is applicable to all Tobacco products. India was among the first eight countries to ratify the Framework Convention on Tobacco Control (FCTC) in the year 2004.

On 2nd October 2008, smoking was banned in all public and work places. Pictorial health warnings on all Tobacco products became mandatory from 31st May 2009. This was specially targetted for those who are illiterate and not able to read the statutory warnings. But now the big question is: Who pays heed to these warnings? Until and unless the people themselves realise that tobacco use in any form is a health risk, no amount of legislation will bring in a change. So, primary prevention has a key role in tobacco control. Adolescents, both boys as well as girls who initiate tobacco use early should be the target audience for counselling. Health promotion and Behaviour Change Communication (BCC) activities should be focussed on them. WHO has also advocated that tobacco control activities be integrated in Reproductive and Child Health Services. Equally important is Secondary prevention where people who have already started using Tobacco products need counselling and strong motivation to quit. Some smokers could benefit from “Nicotine vaccine” which is under early clinical trials and if effective, could help in lasting abstinence for some smokers [13].

The above legislations are applicable for all be it men or women. But now ,the need of the hour is to focus on women by an integrated  approach. It could be by legislation, increased taxation on tobacco products, banning advertisements in all forms especially which portray women in a poor taste, protecting women from second hand smoke and Behaviour Change Communication.

The WHO had introduced the concept of “MPOWER” measures to control the use of tobacco encompassing Monitoring of tobacco use, Protecting people from its use, Offering help to those who want to quit tobacco, Warning about dangers of tobacco, Enforcing ban on advertisements and Raising the taxes on tobacco products. 

The ultimate motive of all these measures is to make our earth a “Tobacco Free World” and improve the quality of life of all mankind. So, Let us join hands to empower WOMEN and protect them from tobacco use, involving them at all levels of tobacco control....

A cross-sectional, community based study done in Jhunjhunu, Rajasthan [5] in a convenient sample of 300 males (150 each from rural & urban area) reports the usage of tobacco in rural areas as 38.6% and urban as 22% which is quite high and reflects the health problems posed by tobacco in our country. The commonest form of tobacco in rural areas was bidi and zarda, whereas cigarettes and gutka were more popular in the urban areas. It is important to realise that smokeless form of tobacco poses a peculiar problem in the Indian context as has been amply demonstrated by this particular study wherein smokeless form of tobacco consumption was almost equal to smoking variety in the rural areas.

References:

1. World No Tobacco Day. http://en.wikipedia.org/wiki/World_No_Tobacco_Day. Accessed on August 9, 2010. Last updated on August 6, 2010.
2. Prasad DS, Kabir Z, Dash AK, Das BC. Smoking and cardiovascular health: A review of the epidemiology, pathogenesis, prevention and control of tobacco. Indian J Med Sci 2009; 63: 520-33.
3. WHO report on the global tobacco epidemic, 2009: Implementing smoke-free environments. WHO-Tobacco Free Initiative.
   http://www.who.int/tobacco/mpower/2009/full_dataset/en/index.html. Accessed on July 14, 2010.
4. Gupta V, Yadav K, Anand K. Patterns of tobacco use across rural, urban and urban-slums in a north Indian community. Indian J Community Med 2010; 2: 245-51.
5. Singh P, Juneja T. Patterns of tobacco use and rural-urban variations in Jhunjhunu, Rajasthan. Indian J Medical Specialities 2010; 1 (Published online ahead of print Aug 11, 2010)
6. Reddy KS, Gupta PC (eds) on behalf of Ministry of Health and Family Welfare, Govt. of India. Report on Tobacco Control in India (New Delhi, India), 25 Nov. 2004. http://www.whoindia.org/LinkFiles/Tobacco_Free_Initiative_03-Chapter-03.3.pdf
   Accessed on August 9, 2010.
7. WHO. Women and Tobacco.
   http://www.wpro.who.int/media_centre/fact_sheets/factsheet_20100527.htm. Accessed on July 26, 2010. Last updated May 27, 2010.
8. Haglund M. Women and tobacco: a fatal attraction. Bull World Health Organ 2010; 88:563.
9. World Health Organization (WHO). Tobacco or health: A Global Status Report. WHO Geneva 1997.
10. Tobacco smoke and involuntary smoking. IARC Monographs on the Evaluation of the Carcinogenic Risks to Humans, vol. 83. WHO, International Agency for Research on Cancer; Lyon, France: 2004.
11. Respiratory health effects of passive smoking: lung cancer and other disorders. Office of Health and Environmental Assessment, Office of Research and Development, U.S. Environmental Protection Agency, Washington DC, USA; 1992.
12. Vinnikov D, Brimkulov N, Shahrir S, Breysse P, Navas-Acien A. Excessive exposure to second hand tobacco smoke among hospitality workers in Kyrgyzstan. Int J Environ Res Public Health 2010; 7: 966-74. Epub 2010 Mar 10.
13. Schroeder SA, Warner KE. Don’t Forget Tobacco. N Engl J Med 2010; 63: 201-4.
14. Karcaaltincaba D, Kandemir O, Yalvac S, Güven ES, Yildirim BA, Haberal A. Cigarette smoking and pregnancy: results of a survey at a Turkish women's hospital in 1,020 patients. Obstet Gynaecol 2009; 29: 480-6.

Anita S Acharya
Department of Community Medicine,
Lady Hardinge Medical College,
New Delhi. India

Abhinav Dixit
Department of Physiology,
University College of Medical Sciences,
Delhi. India.