The Price of Silence: Women, Tobacco and Clinical Gaps in India

    As 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 past four months.

    “Why are you interested in doing this research?”

    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.

    Recognizing the truth of this, four care providers participated in interviews on the same day.


    But the interviews I conducted throughout the study period with multi-disciplinary doctorsincluding psychiatrists, dentists, obstetricians, respiratory physicians, internal medicine specialists, surgeons, infertility specialists and ear-nose-throat specialistsabout 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 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 bidisa traditional form of unprocessed, leaf-wrapped tobacco. (Far more women in India, 11.1 percent, are daily users of different forms of smokeless tobacco.)

    While Indian women’s daily smoking prevalence may seem lowand is far lower than that of men, at 15.2 percentthe country’s vast population nonetheless means that millions of Indian women continue to smoke.

    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 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 infertility, endocrine and metabolic disorders evaluations also require that women patients disclose tobacco use, and routinely refer people to tobacco management specialists for further care.

    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 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 harmsespecially those of chewing tobaccoand 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—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 alternativesbut 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 provision of sub-optimal tobacco cessation services, and devalues women’s health. 


    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 reduction (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.”

    One dentist was candid enough to admit that “we are negligent towards tobacco, both smoking and smokeless tobacco.” It took a 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.”

    The switch from smoking to vaping that this patient was encouraged to make took place before the effective national vaping ban kicked in September 2019. And there is a connected, conspicuous lack of publicly available information about the benefits of switching to vaping.

    “We had to prime her right from the beginning,” the pulmonologist 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 backafter 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.”

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

    Because women tobacco users in India, however heavily stigmatized, are awareeven if only vaguelyof the threats smoking poses to their health. “Am I going to get cancer?” one patient asked another woman ENT surgeon.


    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

    • 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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