An Epidemic: Puffing Away Health & Peace from Life

Smoking smokes out the health out of life. As much as the smokers get affected, non smokers (present in the vicinity) too. As much as the men get affected, women too, even more. On the occasion of World Tobacco Day, the Saturday Fare team decided to do an exclusive feature on tobacco's impacts on women's health, in either circumstances where the smoker is a female or the women isn't a smoker but she is a passive smoker. WHO reveals that of one billion smokers, 200 million are women. Approximately, 1.5million women die every year, due to tobacco use. As quoted by Dr. Sanjay Dhudhat- Surgical Oncologist - Nanavati Super Speciality Hospital, "..In females, smoking cigarettes causes more side effects than male. This is possibly because of the constitutional difference between male and female. Females suffer 1.5 times more side effects of smoking than males."

We discussed with the doctors and specialists to understand the factors contributing to the rising numbers of women smokers; health impacts; and psychology linked with it so as to comprehend the possible solutions to uproot tobacco epidemic, with more specific to women as they are affected more.

We started with understanding the possible psychology behind women consuming tobacco. When we asked, Akanksha Pandey-Consultant Clinical Psychologist, Fortis Hospital, Bengaluru, about this, she replied, "Most of the people pick up smoking habit after moving out of their homes.. Nowadays, even women are sharing these roles equally... Moving out of the parental supervision and their homes is one of the first major life transitions from being a child to being an independent adult with increased opportunity to experiment with different lifestyles and behaviors and to make their own decisions about many aspects of their life." She also added, "In the current times, when beauty and attractiveness have been limited to being "fair and slim", it puts women (especially those with low self-esteem, inferiority complex and body-image issues) under the pressure of fitting into the ongoing standards of beauty. Since nicotine kills the appetite, it causes weight loss which fulfills their wish to be slim without much effort. Few may just pick it because of social observational learning. Some women take up smoking only socially or only when they are amongst other smokers to avoid the feeling of being left out. Glorification of smoking thorough media also is a major contributory factor. Just as how smoking makes men feel more 'macho', women feel it adds to their sex appeal."

When we asked her how stress and smoking are related, she reverted, "Major life transition such as joining college, starting work life, getting married, having a child, job change etc. are usually the external causes of stress. Stress is the commonly attributed cause of nicotine addiction. Nicotine is a psychoactive ingredient, when inhaled; it immediately rushes to your brain and alters the flow of two major neuro-chemicals called 'dopamine' and 'noradrenaline'. When dopamine is released in large quantities in the limbic system, the part of brain responsible for reward and motivation, it results in a euphoric state and elevated mood which people find enjoyable. This gets registered in limbic system as a rewarding pleasurable activity. Therefore, whenever that person is in stress, the limbic system starts looking for the same reward to calm down and feel relaxed. This is called as craving which maintains the dependence."

As far as weight loss is concerned, Dr. Sharadi Shreemoyee, Director, Rejuve Aesthetics, Guwahati, remarked, "It's a common notion that smoking helps women lose weight. But it's same as choosing a cancer to lose weight!

Ms Shamantha K-Counseling Psychologist-Fortis Hospitals, Bangalore, added here, "The feminine reasons for smoking are reducing stress and handling negative moods. Women tend to reach out for a smoke more likely than men when in a stressful situation, because nicotine is a mood-altering drug, but this only adds to the problem.

Dr Gaurav Thukral, COO, Health Care at Home talked about why teenage girls choose smoking, "There are multiple reasons behind teenage girls smoking. Peer influence and pressure is the most prominent and common reason. To feel 'part of the group', many kids start emulating their friends or peers who smoke..When teenaged children see their parents, relatives and role models smoking, they begin to perceive smoking as normal behaviour. Many studies have shown that children, who grow up in families with parent(s) who smoke, tend to start smoking early. In the past decade, media and advertising have grown as influencers for smoking among teenage girls. At this age, young girls often take stress for multiple things: their appearance, relationships, studies, etc. And, owing to the media fuelled perceptions, smoking is seen as a stress buster by teenagers, especially girls." He also agreed that Glamour and the idea of luxury is fast becoming a strong trigger for smoking in girls.

Dr. Sivaresmi Unnithan, Consultant Pulmonologist, Apollo Gleneagles Hospital Ltd. threw light on different forms of tobacco that women use. "Globally cigarette smoking remains the most prevalent form of tobacco use in women. In developing countries, however, chewing tobacco and other smokeless tobacco forms are more commonly used. Women in central, southwestern and eastern parts of India use a tobacco contained toothpaste called "mishri" or "gudakhu" and in Mumbai and West Bengal more than 50% women chew tobacco with pan. Nowadays, water pipe smoking is gaining popularity worldwide among the youngsters, especially the female gender." Here, Dr Gaurav Thukral, COO, HealthCare at Home, explains, "There are different forms of tobacco consumption: smokeless and smoked.. Smokeless tobacco includes snuff, moist snuff and chewing tobacco. The latter two are also known as oral tobacco. Moist snuff is also called “snus”, which has been banned in the EU since 1992, except for Sweden. E cigarettes or Electronic cigarettes (an alternate of the regular tobacco contained cigarettes) operated by battery, works by heating a liquid to generate an aerosol, commonly called a "vapor" that is inhaled, and is known as “Vaping”. The vapor includes nicotine, propylene glycol, glycerin and various flavors.

Some studies reveal that on one hand use of tobacco is declining amongst men, but on the other hand it is increasing among women, in many countries. Several countries, including India has women consuming different forms of tobacco such as chewing them. Existing global trends show that smoking by women is increasingly associated with disadvantage (measured by education, income or other indicators of social exclusion).

A recent World Health Survey data from 50 countries shows how tobacco usage is spreading from HICs to LMICs, especially, among disadvantaged groups. We took Dr. Unnithan's opinion on the best ways to deal with this problem, "it is to identify the cause and determinants. Low socioeconomic condition predisposes higher smoking uptake in young adults and adolescents, because there are several influencing factors. Parental role modeling, easy access to cigarettes/tobacco at home, and inability to resist peer pressure (given that more of their peers are likely already smokers). There is lower awareness about the possible risks of tobacco use and poor educational status that allows them to underestimate the harms of tobacco. Moreover, the advertising adds to it. Addressing these factors should help, including, increasing the price of the tobacco products and awareness."

Tobacco & Heart Health

About the impact of tobacco on heart health, Dr. Rakesh Pandit, Senior Consultant, Internal Medicine, Aakash Healthcare Super Speciality Hospital, says, "Women who smoke and use oral contraceptives greatly increase their risk of coronary heart disease and stroke compared with non-smoking women who use oral contraceptives. 30% of all heart disease deaths are caused by cigarette smoking and smoking is the single largest preventable cause of heart disease. Smoking decreases HDL (good) cholesterol. Cigarette smoking combined with a family history of heart disease also increase the risk of Coronary heart disease - blockage in arteries, is among the leading causes of death in India. People who use smoke have an increased chance of getting heart attacks, blood clots, strokes, hemorrhages, aneurysms, high blood pressure, and other cardiovascular disorders."

He added, "Tobacco smoke affects the heart by multiple means. It contains high levels of carbon monoxide, which consequently affects the heart, brain, lungs and other organs as they do not always receive enough oxygen. Nicotine increases the heart rate and blood pressure. Over time, this causes extraordinary "wear and tear" on the cardiovascular system and vascular endothelium i.e. the inner lining of blood vessels."

Tobacco & Cancer

Tobacco can lead to cancer. As Dr. Walia Murshida Huda (MBBS, FICM), Senior Medical Officer, Healthians, says, "Consumption of tobacco, whether smoked or chewed, gives rise to several health issues. Although preventable, tobacco is a major cause of cancer. Smoking produces free radicals that damage the tissues and the ash deposited in the smoker's lungs has carcinogenic properties. Chewing of tobacco has equally harmful effects and is the major cause for oral cancer and tongue cancer." Dr. Walia pursued MBBS from Assam medical college, Dibrugarh, & specialized in medical ICU care (FICM).

Dr. Dudhat added, "Tobacco causes cancers at different sites of the body. These cancers occur not only locally due to its direct action, but also at distant sites after the toxic compounds are absorbed. E.g. jaws, cheeks, tongue, oropharynx, larynx, esophagus lungs, liver, breast, cervix, pancreas, urinary bladder, colon & rectum & blood cancers." We further enquired, how will a pregnant woman's body suffering from cancer due to tobacco react? What are the chances of baby's survival? He answered, "Tobacco or smoking can cause abortions, abnormality in the foetus. It can compromise baby's survival by detrimental effect.

Talking about neurological problems, Dr. Dudhat said, that Tobacco can cause paralysis in the body by which person becomes disable to do the activities and gives set back to his life.

Tobacco and beauty

We asked Dr. Shreemoyee, if smoking tobacco depletes the "pretty-you-look" or the beauty of the women, and she explained, "Smoking causes the skin to age faster and the tobacco in it causes staining of the lips leaving a dark & discoloured look. It gives the skin a dry, dehydrated look which further adds to ageing process and early of onset of fine lines & wrinkles. So definitely smoking doesn't add to the pretty woman look. Rather it makes you look older in no time. She also mentioned that our lifestyle has a great impact on women's health, "Apart from Skin & lungs, it also adds to breast, ovarian and uterine cancers in women. Many women take it initially as social smoking, which then becomes stress reliever n before we even know it becomes an addiction. So it's always better to check yourself & find different ways to relieve stress like exercise & sports rather than becoming a prey to an addiction."

Tobacco and infertility

While women are held accountable for reproductive health and may be blamed for their addiction to tobacco, less attention is paid to the impacts of paternal smoking on fertility and the health of the fetus. We asked Dr. Richa Gupta, Attending Consultant, Obstetrics and Gynaecology, Aakash Healthcare - Super Speciality Hospital, about the impacts of smoking habit of a pregnant woman on her health and whether a partner's smoking habit affects the health of his pregnant wife or pregnant woman in his family? She replied, "Smoking and exposure to second-hand smoke are the major causes of critical and deadly health problems amongst pregnant women." She listed the following high risks that the pregnant women who smoke are at:

* Ectopic pregnancy (pregnancy in the Fallopian tube)

* Placenta previa (placenta lying low in the uterus) or rupture of the placenta

* Premature birth

* Giving birth to a low-weight or stillborn baby, or one with defects

* Pregnant women exposed to second-hand smoke are also at risk of experiencing problems with the birth of their child, including:

* Premature birth

* Giving birth to a low-weight or stillborn baby

* Learning & behaviour deficiencies

* Sudden Infant Death Syndrome or SIDS is a disorder where infant dies unexpectedly while they are sleeping. This condition is somewhat of a mystery as autopsies and medical examinations do not pinpoint a cause of death, and infants seem healthy before they die. In order to reduce the risks associated with cigarettes and cigars smoking, the only option is to eliminate smoking.

* Many other birth defects may occur due to smoking.

* If you're pregnant, you must avoid smoking or being exposed to second hand smoke.

Will a baby born to a smoker woman, have abnormalities? On this, Dr. P K Thomas, Consultant Pulmonologist, Fortis Malar Hospital, Chennai said, "We have enough literature to say that maternal smoking is very clearly associated to birth related defects. It could lead to a wide range of defects, including cardiovascular abnormalities in the baby and various other defects." Dr Thukral added here that women who smoke may also have a harder time getting pregnant & a higher chance of losing their baby before it is born. Studies show there is an increased risk of SIDS (sudden infant death syndrome, also called "crib death") in babies born to women smokers.

Tobacco & SHS

Coming to this, Dr Thukral about how "Second hand smoking" impacts a woman's health. He enlisted the impacts:

* Smoking causes coronary heart disease, cancer, and stroke-the first, second, and fourth leading causes of death for women in the United States.

* Smoking cigarettes causes COPD and have trouble breathing. They slowly start to die from lack of air. Women who smoke cigarettes are up to 40 times more likely to develop COPD than non-smoker females.

* Life expectancy for smokers-both male and female-is at least 10 years less than for non-smokers.

For Babies and Pregnant Moms

* Smoking during pregnancy can affect the baby's health.

* Infants born to mothers who smoked during pregnancy are at a higher risk of low birth weight, birth defects like cleft palate, lungs that don't develop in a normal way, and sudden infant death syndrome.

It also leads to further complications as well-

* Decreased bone density: Women who have gone through menopause and who smoke have lower bone density. This means they have a higher chance of breaking a hip than women who do not smoke.

* Rheumatoid arthritis: Women who smoke are more likely to get rheumatoid arthritis (RA), an inflammatory, chronic disease.

* Cataracts and Gum disease

* Ulcers: Smokers with gum disease are also more likely to get ulcers in the stomach, which can lead to death.

* Surgery: Smokers have worse survival rates after surgery and also more likely to have complications and poorer wound healing effects.

* Depression: There's a link between smoking and women in depression because women are more likely than men to be diagnosed with depression.

* Menstrual problems (irregular or painful periods)

* Menopause: Smokers are more likely to go through menopause at a younger age, and they may have worse symptoms of menopause.

* Pregnancy Complications

Dr. Archana Dhawan Bajaj, IVF Expert, Gynecologist and Obstetrician, Nurture IVF Center, explained that Nicotine has been shown to concentrate in cervical secretions and its metabolites can hamper the egg maturation process and ovulation rates. Passive smoking adds a major risk to pregnant women. They inhale nicotine & carbon monoxide, which reaches the baby through the placenta & prevent the fetus from getting the nutrients and oxygen needed to grow and predispose to premature placental separation, pre-term delivery & intrauterine growth restriction & low birth weight babies. Passive smokers' breast milk often contains nicotine and the baby ingests the nicotine through the breast milk.

Measures to Prevent Addiction

How can we make a tobacco-free society, then world, largely? Dr. P K Thomas, Consultant Pulmonologist, Fortis Malar Hospital, Chennai, shared some of the preventive measures for the same. "To quit smoking, there are the following 3 ways to do that: 1) Cold Turkey: When you inform the patients of the problems of smoking or will face, they take a voluntary decision to quit on their own. Though less than 5% succeed, it could be the first step towards quitting Smoking/tobacco. 2) Nicotine Replacement Therapy: It is a treatment to help people stop smoking. It uses products that supply low doses of nicotine. The goal is to cut down on cravings for nicotine and ease the symptoms of nicotine withdrawal. There are many types of this which comes in forms of supplements like Gum, Inhalers, Lozenges, Nasal spray, and Skin patch among which Nicotine gum is most commonly used because they can control the nicotine dose. The success rate is probably 10%-15%. 3) Pharmacotherapy: It uses drugs and medication to tackle smoking habit. Two complex used in this are: Bupropion (primarily, an antidepressant and smoking cessation aid) and Varenicline (a prescription medication, and reduces cravings and decreases the pleasurable effects). Varenicline has a higher quitting success rate than Bupropion.

The tobacco epidemic is a paid consignment for slow and gradual death of the consumer himself or herself. Since women are falling prey to this negative habit more, its important that controlling measures are taken to curb the issue and reduce the number of women smokers. Needless to say, no matter what nobody can replace a woman who works as a caregiver and life-creator exhausting all the neurons and cells present in her, for she is a beautiful creation of God with a beautiful heart. It goes without saying, tobacco is dangerous for both men and women and its addiction, habit and repercussions need to be addressed. This lethal trend needs to be kicked out as early as possible, for the betterment of all.