Critical concern of tobacco consumption among pregnant and lactating women in India: A call for comprehensive data and intervention strategies

Tobacco smoking, a pressing global concern as emphasised by World Health Organization(WHO) causes 8 million annual deaths, with more than 1.2 million attributes to passive smoking worldwide. [1] Low and middle-income countries (LMICs) constitute 80% of the 1.3 billion tobacco users, consequently conferring a disproportionate burden of tobacco related illness and deaths in these nations. [1] Owing to ineffective tobacco control policies,10 million annual deaths are projected by 2030 including 2.5 million female deaths. [2] Global data has evidenced the highest smokeless tobacco consumption in pregnant women of Southeast Asian countries at 5.1% with 75% of the projected female deaths in LMICS. [2] India witnesses over 1 million adults death annually due to tobacco consumption accounting to 9.5% of total deaths. [3] There are 71 million female users of exclusively smokeless tobacco(SLT) in India. [4] Despite the implementation of the National Tobacco Control Programme (NTCP) under the WHO Framework Convention on Tobacco Control since 2007, a highly vulnerable subset of population of pregnant and lactating women have remained neglected due to the inadequate data on their tobacco consumption. It was only in 2005–2006 of the National Health Family Survey(NFHS-3) that the data pertaining to the above subset began to be collected. [5] Government data from NFHS-4 and Global Adult Tobacco survey-2 (GATS-2) indicate 4% to 7.4% of pregnant women and about 5% of lactating women in India consume any form of SLT. [1] Referring to the latest Lancet study by Virk et al. based on the data from 2019 to 2020 NFHS, the study revealed prevalence of diverse tobacco use patterns, emphasizing regional disparities in usage among pregnant and lactating women in the country. [1] However, the question is whether simply estimating the prevalence data alone adequate at this stage.

Maternal tobacco use is associated with an increase in serious adverse pregnancy-related outcomes, specifically in the early gestational stages, with its effects extending into childhood. The majority of women who quit smoking during the gestational period revert to the habit during the lactation period. [2] Regrettably, there are no data to estimate relapse rates after pregnancy and to analyse extent of second-hand smoke exposure. Both the factors are crucial for designing intervention strategies to promote maternal and child health. Moreover, infants born to smoking mothers face a higher risk of neonatal mortality due to conditions like sudden infant death syndrome, respiratory infections, and developmental issues. Unfortunately, majority of data primarily quantifies the number of children born to pregnant and lactating mothers using smokeless, smoking tobacco, or both without estimating the percentage of children born with birth defects, limiting our understanding of the impact of various forms of tobacco on child morbidity and mortality. In addition, the latest NFHS-4 does not include an indicator for child mortality in this population. [5]

Globally, 52.9% of women smokers continue this habit during pregnancy making it imperative to understand the rate of tobacco consumption and to identify a critical gestational quitting time influenced by prior behaviour. [3] Research in New Zealand and Australia reveals that smoking cessation before 15 weeks of gestation lowers preterm birth risks similar to those of non-smokers. [6] While timely cessation is crucial for maternal and child health care, it takes 15 years post-cessation for the body to fully recover from the adverse effects. [7] This demystifies the beliefs of women regarding lower nicotine doses, reducing tobacco harm. [2] Therefore, in a country with a huge disparity in tobacco consumption, mere recording the prevalence among pregnant and lactating women will not suffice. Comprehensive database becomes very vital in the training of maternity care professionals in tobacco cessation support and counselling, timely addressing of conditions in obstetrical consultations and understanding of physical and psychological smoking cessation challenges in women. The knowledge is instrumental to customize preconceived preventive interventions and strategies in pre and postnatal periods with the goal of achieving complete cessation.

Contributors

SS and GS drafted the initial manuscript. SS, SCS, RA, NS and GS critically reviewed the draft. All authors approved the final manuscript.

Funding

Not applicable.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.