Smokeless tobacco use among women of reproductive age and during pregnancy in low and middle income countries - distribution and sociocultural characteristics

Aim: Despite widespread use of smokeless tobacco in nearly 140 countries, research in this area is limited., especially that focusing on women and during pregnancy. To reduce smokeless tobacco use among women especially during pregnancy, the aim of my thesis was to understand the distribution (recent prevalence estimates and socio-demographic distribution) and socio-cultural determinants of smokeless tobacco use among women of reproductive age and during pregnancy in low- and middle-income countries (LMICs). Methods: This was a multi-method thesis that comprised three different studies; a secondary data analysis of the Demographic and Health Surveys (DHS) to estimate the prevalence rates and relative risk ratios (RRR) of tobacco use among pregnant and non-pregnant women in 42 LMICs, a mixed-method systematic review to understand the socio-cultural determinants, beliefs and attitudes related to smokeless tobacco use among women (and in pregnant women) in LMICs, and in-depth qualitative interviews with pregnant women in India to understand the influence of family members on initiation and/or change in practice of smokeless tobacco use during pregnancy. Implications: The cumulative evidence from all the three studies I conducted suggests that tobacco control among women of reproductive age should be a public health priority in LMICs despite the low prevalence estimates as this may be that LMICs are earlier in epidemiological transition and if ignored may cause an increase in tobacco use later. The norms and general acceptability of smokeless tobacco use among women during pregnancy is changing and a possible approach could be to explore if pregnancy can be an opportunity for targeted and tailored interventions for smokeless tobacco cessation. Furthermore, ASHA workers are an integral part of maternal and child health in India and their inclusion in the tobacco control interventions may be beneficial.