Determinants of initiation, continuation and cessation of smokeless tobacco use among pregnant and lactating women: a qualitative study from low-income communities in urban India

Abstract

Smokeless tobacco (SLT) consumption increases the risk of cardiovascular diseases and cancer and leads to adverse reproductive health outcomes among women and newborns. This study examines the factors associated with initiation, continuation and cessation of SLT use among women in the reproductive age so as to formulate and include prevention and cessation interventions from its inception. The study was conducted in urban low-income communities in India. Using snowball and purposive sampling techniques, in-depth interviews were conducted with 20 pregnant and 22 lactating women who currently used SLT products. Data were analysed using thematic analysis with the help of QSR NVivo software. Findings revealed that factors such as people influencing usage change with different life stages including pre-marital and post-marital periods. Perceived health benefits, altered taste preferences during pregnancy and social influences were also studied. Women were found to be more aware of the harmful effects of tobacco during pregnancy than during breastfeeding. Social stigma around women consuming tobacco acted as a major driving factor for cessation. Most of the participants were willing to quit but were not aware of any technique or programme for cessation. The findings of the study highlight the need to develop behavioural change intervention tools, which are culturally and locally appropriate and have a gender-sensitive approach. Different socio-cultural factors associated with initiation/cessation at different life stages should also be taken into consideration while developing these tools.

Smokeless tobacco, women’s health, reproductive health, India

Key messages

• The consumption of smokeless tobacco (SLT) among women can have negative reproductive health effects on women and long-term adverse effects on the foetus with increased risk of cardiovascular diseases, cancer and oral health issues.

• The period of pregnancy or lactation can act as an initiation factor as well as a window of opportunity to quit the consumption of SLT, depending upon the socio-cultural factors.

• There is a need to develop a behavioural change intervention tool for the consumption of SLT, especially tailored for pregnant and lactating women.

• The study emphasizes the role of frontline health workers who can help in the identification of beneficiaries as well as the delivery of the behavioural intervention tool.

Introduction

Smokeless tobacco (SLT) includes a large variety of non-combustible tobacco products that can be used orally or nasally (Boffetta et al., 2008). With its consumption in 127 countries, it caused 0.35 million deaths in 2017 and a loss of >8.6 million disability-adjusted life years (Siddiqi et al., 2020). Nearly 85% of the total burden of diseases attributed to SLT is concentrated in South and South East Asia. Globally, India is the second largest producer and consumer of tobacco (much of it is in smokeless form) and shares 70% of the total disease burden caused by SLT (Nair et al., 2015). More than 50% of oral cancer cases in India are traceable to the usage of SLT (Boffetta et al., 2008).

According to the Global Adult Tobacco Survey (GATS) report 2016–17, nearly 42.4% of men and 14.2% of women consume any form of tobacco in India, with the prevalence of SLT users being 12.8% among women (58.2 million users) and 29.6% among men (141.1 million users) (International Institute of Population Studies, 2016). The preference for using SLT over smoked tobacco can be attributed to the strong social and cultural acceptance of SLT among the South Asian population, particularly in India (Kakde et al., 2012).

SLT products, such as ‘Gutka’, ‘Gul’, ‘Khaini’ and ‘Mishri’, are commonly used by women in India. ‘Gutka’ is a mixture of tobacco, crushed areca nut, spices and other ingredients and is consumed orally. ‘Gul’ is pyrolysed tobacco paste, usually rubbed on teeth and gums, ‘khaini’ is a mixture of sun-dried tobacco and slaked lime and ‘mishri’ is a roasted, powdered preparation made by baking tobacco on a hot metal plate until it becomes uniformly black (Tata Institute of Social Sciences (TISS), Mumbai and Ministry of Health & Family Welfare, Government of India, 2017). Several states in India have banned gutka due to its adverse effects, including serious health consequences and high addiction rates, yet it remains widely and cheaply available (Mehrotra et al., 2020). Despite the widespread use of SLT among women in India, tobacco initiation and use during pregnancy and lactation is highly overlooked, as the primary emphasis is laid on children and teenagers (Narain et al., 2011; Gupte et al., 2020). Relief from health-related issues like gum pain and constipation (Begum et al., 2015) or experimenting with easily available products at home (Ravishankar and Nagarajappa, 2009; Nair et al., 2015) are some factors that have been found associated with the initiation of SLT use, particularly among women.

Women have to bear the double health burden due to SLT consumption. On one hand SLT use increased the risk of cardiovascular diseases, oral health problems including leukoplakia, gingivitis, periodontitis and dental caries on another hand it can also have negative reproductive health effects on women (Savitz et al., 2006). Tobacco consumption, especially during pregnancy and lactation, can increase the risk of low birth weight babies, congenital anomalies (Begum et al., 2015; Torchin and Diguisto, 2021), preterm delivery, sudden infant death syndrome (Horta et al., 2001), respiratory infections and recurrent otitis media in newborns (Guedes and Souza, 2009; Torchin and Diguisto, 2021). In addition to this, studies have shown that consuming areca nut is also associated with negative pregnancy outcomes, including low birth weight and preterm births. Additionally, there is an increased risk of developing oral and liver cancer associated with areca nut use and other consequences like glucose intolerance and type 2 diabetes (Joo et al., 2020). Such implications of tobacco and areca nut use are highly dependent on the consumption pattern/behaviour, frequency of use and dosage (Feodoroff et al., 2018). According to the World Health Organization (WHO), pregnancy can offer a window of opportunity for tobacco cessation. Despite adverse effects and awareness of harmful effects, the cessation rates are quite low among women (Singh et al., 2020).

Behavioural change intervention tools have been found effective for cessation support among women. Studies conducted both in Western countries, such as the USA, and in Indian cities, such as Mumbai, have demonstrated the effectiveness of these tools (Ebbert et al., 2004; Mishra et al., 2014). It is essential to understand the enabling factors of SLT use and barriers to cessation, as they can serve as an entry point for the behavioural change intervention tool (Panda et al., 2014). Although there are studies (Oswal, 2015; Shahjahan et al., 2017; Krishnamoorthy and Ganesh, 2020; Siddiqui et al., 2021) that have tried to understand the factors influencing initiation, continuation and cessation of SLT use, very few studies have focussed on women who are pregnant or lactating. Hence, this qualitative study, which focuses on women of reproductive age in the Indian context, aims to understand the factors influencing SLT initiation and cessation.

Methodology

Sample

The study used snowball and purposive sampling techniques to identify and include participants. Women of the reproductive age, 18–49 years, who were pregnant or lactating (delivery during the preceding 1.5 years and were breastfeeding the child) and were using SLT and/or areca nut (or had consumed during the preceding 6 months), were included in the study. Heterogeneity of the sample in terms of age, caste, education and pregnancy status (currently pregnant/experienced recent pregnancy loss/recently delivered a baby) was also enrolled during the study.

Field visits were made to the Primary Health Centres (PHCs), Urban PHCs and Community Health Centres (CHCs) to identify pregnant and lactating women who had visited the centre for Antenatal Care (ANC) and/or the child’s vaccination. Along with this, home visits were also executed accompanied by Accredited Social Health Activist (ASHA) workers, auxiliary nurse midwives (ANMs), Anganwadi workers and non-governmental organization workers to ensure a better response rate.

During the fieldwork, there was interaction with 322 women, out of which 44 women were found to be eligible for the study and were screened for tobacco and areca nut use. Two women from the total participants screened could not be included in the study, as they refused consent. Thus, in total, 42 participants were enrolled for the present study, which included 20 pregnant women and 22 lactating women who were using SLT or/and areca nut.

Study area

The study was conducted in the urban low-income communities of New Okhla Industrial Development Authority, Gautam Buddha Nagar district, Uttar Pradesh. According to the GATS (GATS-2), Uttar Pradesh shares the highest burden of SLT usage among women after the Northeastern states of India (Tata Institute of Social Sciences (TISS), Mumbai and Ministry of Health & Family Welfare, Government of India, 2017). The district was purposively selected considering the operational feasibility in terms of familiarity with the local socio-cultural and health setting. This study focuses on the low-income area, as SLT consumption among women was found to be higher in the low-income area during the pilot survey of this study.

The areas covered during the fieldwork were Barola (PHC and home visits), Harola (PHC, Anganwadi Worker (ANW) centre, school and home visits), Nithari (ANW centre and home visits), Banghel (CHCs) and Jhundpura (home visits). These areas were chosen based on the institution’s good rapport with the ASHA workers, who helped identify potential participants at health centres and promoted building rapport during home visits.

Study design

In-depth interviews were conducted to collect the data. The interview schedule included the socio-economic and demographic profile of the participant, pregnancy status and post-natal care, factors influencing initiation of tobacco and/or areca nut use, tobacco consumption by other family members, pattern of SLT/areca nut use, awareness regarding health issues including reproductive and maternal health, quitting attempts, awareness about cessation programmes and willingness to quit tobacco in the future. In addition, Fagerström Test for Nicotine Dependence–Smokeless Tobacco (Ebbert et al., 2006), health-seeking behaviour and awareness and other information like decision-making and autonomy-related information were also obtained.

Data collection and analysis

The participants were briefed about the study, its purpose and its objectives. After assurance of confidentiality and participation on a voluntary basis, written consent from the participants was obtained.

A team of trained researchers collected the data over a period of 9 months from March 2022 to December 2022. Each interview lasted from ∼40 to 70 min. All the responses were recorded using a voice recorder for analysis. Unique IDs were generated and allotted to each participant for organizing, managing and storing the collected data and to maintain confidentiality. The IDs included the initials of the interviewer, place of interview, date of interview, serial number and the screening category of the participant. The responses were then transcribed in the vernacular (Hindi) language (with non-verbal observations) and then translated into English.

Thematic analysis was used to analyse the collected data. Two researchers independently read and reread the interviews and then coded the data using QSR NVivo (Release 1.6.1) software. Similarities within the data were traced, categorized and shared among two researchers and there were minimal disagreements. Post initial analysis, the themes that emerged were discussed with the whole research team for better inputs and were then finalized.

Analytical approach

In many earlier papers (Ravishankar and Nagarajappa, 2009; Rosseel et al., 2010; de Vries, 2017), the user’s cycle is described separately for the processes of initiation and cessation. In the current study, our analytical process drew on an Integrated Model (I-Change Model) given by Hein de Vries for exploring motivational and behavioural changes for the initiation and cessation of SLT, as shown in Figure 1 (De Vries et al., 2003). It states that behavioural change is influenced by an individual’s intentions and abilities. The intentions of the individual are determined by several motivational factors, which are derived from various distal factors such as predisposing factors (e.g. behavioural, psychological, biological, social and cultural factors), awareness factors (e.g. knowledge, cues to action and risk perception) and information factors (e.g. messages, channels and sources used). All these factors lead to a change in intention from precontemplation to behavioural state (Figure 1). For a non-user, the intention here could be to initiate SLT consumption. If there is any lack of barriers after trial use, a first-time SLT user would turn into a regular user, entering into the maintenance phase. For an SLT user, the intention could be to quit SLT consumption. If the barriers are surpassed with the help of intrinsic or extrinsic factors, the trial/action of cessation would lead to the maintenance of cessation (Figure 1).

Figure 1.

Interpretation of the I-Change Model by De Vries et al., (2003)

Results

The total number of women participants included in the study is 42, out of which one declined to share the socio-demographic details but participated in the interview. Nearly 58.5% (n = 24) of the total women (N = 41) consumed only SLT, 21.9% (n = 9) consumed only areca nut (without tobacco) and 19.5% (n = 8) consumed both SLT and areca nut. Nearly 85.3% (n = 35) of the women in the 20–35 age group were housewives, and the rest were employed in the unorganized sector in jobs such as daily wage labour and house help. The socio-demographic characteristics of the participants are presented in Table 1.

Table 1.

Socio-demographic profile of the pregnant and lactating tobacco/areca nut users

		Pregnant women	Lactating women	Total	Percentage
Background characteristics		n = 20	n = 21 + 1a	N = 41 + 1a	(N = 41)
Age (years)	16–20	1	3	4	9.76
	21–25	13	10	23	56.10
	26–30	4	6	10	24.39
	31–35	2	2	4	9.76
Religion	Hindu	9	16	25	60.98
	Muslim	11	5	16	39.02
Employment status	Homemaker/wife	16	19	35	85.37
	Employed	4	2	6	14.63
Education	No formal education	8	8	16	39.02
	Primary education	6	7	13	31.71
	Secondary education	5	6	11	26.83
	Senior secondary	1		1	2.44
Consumption category	Only SLT	10	14	24	58.54
	Only areca nut	8	1	9	21.95
	SLT and areca nut both	2	6	8	19.51

n: sample size; N: total sample size.

a

Missing socio-demographic details.

The qualitative findings are grouped into the following themes.

Socio-cultural context of SLT users

Varied responses were found regarding the societal acceptance or unacceptance of SLT, which could influence one to initiate/continue usage or support to quit usage.

Normalized SLT usage among the community

Compared to smoked tobacco, SLT was found to be more prevalent as well as better accepted among women in society. Most of the women who had family members who also consumed SLT did not seem to be worried about being seen using the product in public. One woman said, ‘If they all chew, then what can they say?’ referring to the family members.

Many respondents stated that they were influenced by the social environment to initiate their consumption and gradually became addicted. One of the responses was, ‘I saw people around me who were using it, and so I also started using it.’ Another participant who initiated consuming ‘pan’ masala with tobacco suddenly one day said, ‘I was going somewhere and someone was eating SLT there, I could smell the fragrance which made me want to eat, so I brought it from the shop there.’ Thus, social embeddedness played a salient role in initiation, especially when family members were consuming SLT products themselves.

Social stigma around tobacco use and gender-based differential treatment

SLT use is more socially acceptable among women than smoked tobacco. However, the reality is more complex, and mixed reactions, including stigma around SLT, were observed in the same community. It was found that the cases of non-acceptance of SLT consumption among women were often dependent on various factors, including the non-usage of SLT by family members. Social stigma indirectly regulated the place of consumption, timing and frequency. Many women avoided consuming tobacco in front of their family members/males, which in turn influenced their consumption routine. One said, ‘I don’t do it much in the evening, my husband’s brother and my father-in-law come back, so there are a lot of people at home.’

Few women even consumed SLT secretly, for fear of being scolded or even beaten if the family members came to know about it. One said: ‘I chew it after brushing my teeth, and after that I brush my teeth again so that I do not get scolded by anyone in the house and no one comes to know of it.’

Even for the families where other members consumed SLT, traces of differential treatment based on gender were found. A lady whose husband consumes SLT himself scolds her for consuming it.

When asked about the differential treatment, another woman responded:

Interviewer: They don’t say anything to your husband, but will they ask you to quit?

Respondent: Yes, as I am the daughter-in-law of the house, that’s why they will get angry.

Many cases were found where family members, particularly husbands and mothers-in-law persuaded women to quit SLT, scolded them for consuming or even shamed them because of their gender but not for the ill health effects of tobacco usage. Emotional and social assistance helps in tobacco cessation, but, in our study, it was found that women were made to feel guilty for being SLT users (Khargekar 2017; Daniel et al., 2021). One said, ‘I do not want my child to become like me. Everyone talks negatively about me. People say, I am a girl, I am a lady, and still consume gutka. And so sometimes I also think like that.’ Judgements like ‘If they see, then they will definitely say “see a lady takes intoxicants”’ were common to find in responses. Interestingly, the social stigma associated with gender did not appear to differ significantly from that experienced during pregnancy. In families where daughters-in-law or wives were permitted to consume SLT, their pregnancy status did not seem to make a difference in the acceptance of their habit.

In the course of interviews, it was also noted that women exhibited hesitancy in disclosing their pattern and frequency of SLT consumption, and many of them resorted to giggling or smiling in a dismissive manner to evade the question.

SLT use initiation

Perceived health benefits

Many people in the community believed that SLT has several health benefits. A variety of tobacco products were observed to be used by women in the area, with ‘gutka’, ‘gul’ and ‘khaini’ being the most prevalent. These perceived health benefits included ‘gul’ for toothache, teeth whitening, teeth sensitivity and other gum problems; ‘gutka’ for morning sickness during pregnancy and sometimes for toothache as well. The fragrance of areca nut products, in particular, was known to help women with nausea during pregnancy. In some cases, users were not even aware that the product contained tobacco when they first began using it; rather, they used it unknowingly as a treatment for a health problem and became addicted to it.

Influence

Most of the respondents first consumed SLT when a close friend or relative offered it to them, or sometimes just by watching them consume the product. Some reported that observing ‘people in general using these products’ was a reason for their initiation reflecting normalized usage behaviour in their social network. Apparently, social media and advertisement were not found to have a direct influence when it came to initiation among women participants. In a few cases, people from the older generation especially women also suggested the use of SLT in order to get relief from pregnancy urges or oral health issues. The women in our study relied on the information provided to them by close social acquaintances or the older generation without much discernment.

A woman who started consuming ‘gutka’ at an age of 14 years shared: ‘My aunt [Mother’s sister] told me about it and convinced me to have it. So when my parents used to go on their duty, I started consuming it. I didn’t ask for it though, but she used to give it to me. I used to think that if she is having it, then definitely it must be something nice only.’

Age at initiation

Women started consuming SLT at different ages, beginning from as early as 10 years of age under different influences. Friends at school or in community, cousins, parents, aunties and uncles played a major role during adolescent years. However, due to a limited social circle post-marriage, the major source of influence transitioned to the women’s husbands, in-laws and neighbours living in close proximity.

A woman who started to consume ‘gul’ during adolescence said: ‘I have a sister, she said that it’s a paste which cleans teeth, I did not know then that it was a drug. Out of curiosity I tried it, she used to put a little bit on my palm and then eventually I became addicted, I must have been around 18 years then.’

As mentioned in the above excerpt, curiosity to explore without knowing the consequences often led to initiation. This phenomenon was found to be particularly prevalent during the pre-marital period when adolescents were more willing to experiment, and this argument is also supported by several studies (Ravishankar and Nagarajappa, 2009; Thimmegowda et al., 2022). Our study also revealed that these habits, once initiated during adolescence, often persisted into later stages of life, including pregnancy. Additionally, the study found that the urge to consume substances like chalk or mud, also known as pica during pregnancy, led women to initiate the use of SLT during such a critical period of life. The community believed that consuming chalk/mud might harm the foetus; therefore, the elders advised the women to consume SLT products (majorly ‘gutka’) instead of chalk/mud during that period.

Areca nut in particular was usually suggested by women members family and neighbours to tide over morning sickness during pregnancy. One participant said:

I used to vomit a lot after having food during my fifth month, then some lady in the neighbourhood told me to eat areca nut, and that helped stop the vomiting tendency.

A pregnant lady whose mother suggested the she consume ‘gutka’ until the delivery said:

I told my mother, I am having a weird urge to chew something (gutka), then she herself said to me that till the time you are expecting your child, you can take anything for which you feel the urge, but don’t chew it after that.

Initiation of SLT use during pregnancy resulted in addiction and only a few were able to quit post-delivery on their own. However, a few of the women who had initiated SLT use prior to pregnancy and had received counselling from Frontline Health workers (FHWs) or were aware of the risks were able to quit during pregnancy. Most of these women faced medical complications during pregnancy (primarily reported as anaemia) and in order to prevent harm to the unborn child, reported to have quit tobacco during the last trimester. One woman also mentioned trying to quit SLT due to a recent miscarriage, which was attributed to the use of tobacco by an ASHA worker. Despite such incidences, only a handful of women were able to remain abstinent post-delivery, and the rest relapsed.

SLT use behaviour

The frequency, quantity and type of tobacco products consumed varied widely among users. Tobacco usage is closely intertwined with the daily routine of women, as a digestive after meals, while doing household chores or during leisure. The majority of women consumed their first dose early morning after running a few household chores. However, employed women avoided consuming it at the workplace as it is not acceptable to the employers. Most of the women liked to consume it when they were alone, especially recently married women. The users often confessed to being addicted to tobacco and mentioned consequences like dizziness, nausea, fever, constipation and stomach upset if they skipped its consumption. Below is an example of a woman sharing her extent of addiction:

Yes, I want to quit, but to tell you a secret, I have become addicted to it. Just like if someone consumes roti daily, they can’t go without it even if you give them rice. I try, but it leads to constipation. Now, I am not able to clear my bowel if I don’t eat it.

Source of procurement of SLT products

In most cases, women users did not procure the product themselves in the initiation phase, rather it was offered by someone close or, in some cases, they secretly used it from the packets kept in their homes. Later, they started purchasing it from nearby shops themselves. Residential proximity of tobacco-selling shops and accessibility to products played a vital role in continued usage. Most women did not hesitate while purchasing SLT products. When asked if you are comfortable purchasing it yourself, a woman replied, ‘Yes, I get it myself only, what is the problem in buying, it’s not a theft!’

Asking children in the neighbourhood as young as 5 years to buy it for them seemed to be a normal practice in the community. Few women who were not very open about consuming SLT reported taking it from their family members on a daily basis, especially from their husbands.

Awareness of harmful effects

During the interviews, it was found that women were aware of the health risks of SLT products and yet continued to consume them. The majority of them mentioned cancer, oral cancer, teeth deformities and oral infections as the ill effects. Despite being aware of the harmful consequences of SLT consumption, the thought of being affected themselves seemed very distant to them, as in their opinion no one in direct contact had faced the consequences. Women also believed that if the tobacco was spat out or kept in the mouth for a short period of time, it would have very few or even no adverse effects. Here is an example of a woman trying to justify why SLT usage would not harm her:

I don’t swallow it even a bit and spit it all, so that everything dirty comes out, I just keep the lump in my mouth for taste. I know if I’d swallow it, it would harm me from inside, can even cause cancer, that is why I don’t take it in.

Another woman stated less consumption is not harmful: ‘I eat normally, I don’t consume it too much, like I have seen people, they would keep it in their mouth forever. I just consume it after having food, when I feel like having it.’

It is interesting to note that women were found more aware of the harmful effects during pregnancy than during lactation. However, some of them even came up with arguments that it was not their first pregnancy and nothing adverse had happened to them in earlier pregnancies. Besides, women would use the religious coping mechanism saying that God would save them from any ill effects by saying ‘Those who use it can have the disease, but by God’s grace I am perfectly fine.’

Economics of SLT use

Daily expenditure on SLT products varied drastically from user to user depending on the consumption pattern. Most of the women reported using a portion of money allocated for household expenditure to buy SLT products, while a few of them reported stealing their husband’s SLT products to fulfil their cravings. In a few cases, the cost of the SLT product also influenced the kind of product used. One woman when asked whether her husband consumes ‘gutka’ said, ‘Paan masala is for INR (Indian National Rupees) 15 to 25 (approx. 0.18 to 0.28 USD), who will be able to afford it? We have to feed our children as well. You can get a bundle of bidi for 20 rupees, so he just smokes that.’

‘Gul’ costed much less than ‘gutka’ and was predominately consumed by women in the study area (Nethan et al., 2018). This could be a result of socio-economic constraints faced by women and is also supported by a study, which states that women are more responsive to prices than men (Joseph and Chaloupka, 2014).

In very few cases in our study, the economic constraints served as a motivational factor for attempting to quit SLT use. Women who have quit recently (<6 months) mentioned saving the money they used to spend on tobacco earlier and how it was benefitting their children and for meeting household expenses.

SLT cessation

Social stigma around SLT served as one of the motivating factors towards SLT cessation.

In some cases, family members persuaded the women users to quit SLT, ratiocinating about the child’s health. Medical issues, even the ones not directly related to tobacco usage, also demotivated the users from continuing its use. The spread of SARS-CoV-2 (COVID-19) and lockdown became another factor which limited the users’ quantity due to non-availability of the product and financial crisis (Singh et al., 2021).

Most of the participants were more than willing to quit, but they were not aware of any technique to quit and had not heard of any cessation programme. Some of them even asked researchers for help or any pharmacotherapy, which could help them to quit. Responses like ‘Yes, I will give it up, I swear will give it up completely, I just want something to eat which will stop me from using SLT’ were common. One lady had even tried pharmacotherapy prescribed by the local doctor but did not succeed.

Fennel seeds, coconut kernel, sugar candy, sweet cardamom, chewing gums and ‘chyawanprash (a local Ayurvedic preparation)’ are few things women used as substitutes when trying to quit SLT. However, only a few were able to limit the quantity consumed using these substitutes.

The above-mentioned themes generated are categorized further in Table 2 based on the factors associated with initiation and cessation as elucidated in the I-Change Model (Figure 1). It shows factors that are in a dominant phase during initiation go into a recessive state during cessation, while new factors emerge.

Table 2.

Factors associated with initiation and cessation of SLT based on the I CHANGE Model by De Vries et al., (2003)

Themes	Initiation	Cessation
Predisposing factors
Psychological and behavioural	Curiosity and craving for mud/chalks	Self-motivation and awareness/knowledge of harm to the child
Biological	Pregnancy, remedy for oral health issues and fragrance	Complications in delivery, face aesthetics and oral health consequences
Social and cultural	Social acceptance, rituals and ceremonies and usage by elderly	Gender-based differential treatment for usage and social stigma
Awareness factors
Knowledge	Perceived benefits of using SLT products	Aware about adverse health consequences (via advertisement, health workers and community members)
Cues to action	Peers offering the product for use or using it	Counselling during ANC visits/health check-ups and advice from community members/family members
Risk perception	In recessive phase, risk perceptions ignored despite awareness of harmful effects, remote possibility of harm (low-risk perception to self)	Harmful for the child
Motivational factors
Attitude	Positive due to normalized SLT usage	Negative towards SLT usage
Social influences	Usage by family members/friends/community members	Family unacceptance of SLT usage
Economic influencesa	Affordability	Financial crisis, especially during the COVID-19 lockdown
Ability factors
Implementation plans	Easily accessible and variety of products available, thus preferences based on prices	Lack of awareness of cessation programmes
Barriers	Lack of cessation centres and extrinsic motivational factors to quit	Rationalizing the behaviour of usage, defence and coping mechanism

a

Represents addition to the original factors adopted by De Vries et al. (2003).

Discussion

We found that the consumption of SLT is socially and culturally ingrained in the community. However, the social stigma around women consuming tobacco remains owing to gender bias. This also restricts women from seeking timely and appropriate positive health counselling. People influencing usage change during different life stages: friends and relatives have a major influence during the pre-marital stage, while in-laws, especially elderly female relatives along with women in the community, have considerable influence during the post-marriage period. Our findings are in contrast to a study that shows the significant role of advertisement in women’s consumption behaviour in India and does not find a direct influence of advertizing on women’s initiation of SLT use (Kostova and Dave, 2015).

It is crucial to understand that while the WHO presents pregnancy as an window of opportunity for women to quit tobacco, it was found that many women initiated tobacco during this period itself due to misperceived benefits. This finding is supported by another study that reports high post-partum relapse (Ioakeimidis et al., 2019). It shows the salience of follow-up counselling by FHWs during post-delivery check-ups even if women are able to quit consumption during pregnancy with the help of counselling.

In order to analyse the issue from a broader perspective, it is important to use a two-way approach, developing preventive techniques for non-users to remain abstinent, and a behaviour change intervention tool for users. Factors identified during the initiation cycle can be utilized for developing awareness campaigns and preventive counselling techniques. This can include busting perceived benefits of consuming SLT during morning sickness and pica and involving women’s social network and influences in the counselling sessions. Accessibility and availability of a variety of products in a different price range, which are recognized as ability factors, can be used as policy-level interventions. For pregnant and lactating mothers, psychological, biological and awareness factors can be targeted for the well-being of their child. Apart from adverse health effects, involving a child as young as 5 years in the process of procurement can also serve as a push factor to consume tobacco in his/her youth (Sharma et al., 2021). Thus, strict enforcement of existing laws like section 6 COTPA that prohibits sale to minors is required.

The absence of ability factors during the cessation phase is well recognized in the study. Despite the willingness to quit, it was found that women were not aware of any cessation programme. They were even stigmatized for using SLT not for its harmful effects, but because of their gender. Thus, the need for developing a more gender-sensitive cessation approach arises. These should be culturally appropriate and also acknowledge the desire of a mother to provide the best care to her child. The factors identified in the study are based on the primary data collected and thus are locally appropriate, elucidating that behavioural change tools should take a broader social perspective into account rather than merely motivating the user. An approach similar to this, namely a community-based tobacco cessation programme, has been successfully implemented in Mumbai, indicating its potential effectiveness in addressing this issue(Mishra et al., 2014).

It has also been observed that ASHA, ANM, ANW and other FHWs have a major influence in the social setting, and they should be involved in the process and be provided with professional training for delivering awareness programmes and cessation interventions. ANC visits could act as an entry point for screening and targeting prospective mothers for the cessation programme. With such a dense network of front line health workers, a primary-level intervention can increase the reach of the programme with accessibility to a broader audience and a higher success rate.

Limitations

• Necessary precautions and social distancing had to be maintained due to the COVID-19 pandemic, which hampered mobility during the field visits and could have affected the quality of responses gathered.

• The responses might have also been influenced due to the presence of family members (husbands and mothers-in-law) during the interviews.

• Many of the reported responses could have been socially desirable and may not represent the true picture as the consumption of SLT is stigmatized. Exclusion of cases due to social stigma and denial of SLT usage by some women despite visual evidence may have resulted in a potential sampling bias, as the study only includes women who were willing to openly discuss their SLT consumption patterns and behaviours.

Conclusion

The study highlights that while pregnancy is considered a window of opportunity for women to quit tobacco, many women tend to initiate it during pregnancy and lactation due to socio-cultural perspectives, perceived health benefits and lack of awareness about the negative reproductive outcomes of consuming tobacco. To address this issue, the study advocates for the development of tailored behavioural change intervention tools for pregnant and lactating women that address the contextual factors surrounding tobacco consumption by women, which can be delivered by front line health-care workers. This can be a good starting point and facilitate linkages with the tobacco control programme at the district level.

Funding

The study is supported by the Indian Council of Medical Research (ICMR), New Delhi, India.

Authors contributions

P.K.S., L.S. and S.S. assisted with the conception or design of the work; R.J. and I.J. assisted with the data collection; R.J., I.J. and R.C. assisted with the data analysis and interpretation; R.J., I.J. and R.C. assisted with the drafting the article; P.K.S., L.S. and S.S. assisted with the critical revision of the article and S.S., R.J., I.J., R.C., L.S. and P.K.S. assisted with the final approval of the version to be submitted.

Reflexivity statement

The authors include five females and one male and span multiple levels of seniority.

Data Availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to restrictions e.g. their containing information that could compromise the privacy of research participants.

Ethical approval

This study was reviewed and approved by the ICMR-National Institute of Cancer Prevention and Research Institutional Ethics Committee.

Conflict of interest statement

None declared.