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March 2005, Volume 55, Issue 3

Original Article

Pattern of tobacco consumption: among adult women of low socioeconomic community Karachi Pakistan

Nighat Nisar  ( Faculty Health Management, Baqai Medical University )
Najma Billoo  ( Baba-Bhitt Health Project )
Amin A. Gadit  ( Department of Psychiatry, Hamdard University Hospital, Karachi )

Abstract

Objective: To assess pattern and to determine risk factors associated with tobacco consumption in various forms among adult women above 18 years of age in a low socioeconomic community of Manora Island, Karachi.

Methods: A cross-sectional survey was conducted and 200 adult women above 18 years of age were selected using systematic sampling with random start from a community of 5000 people in Manora Island, Karachi. There were 400 households in the community. Every 2nd household was visited and a woman above 18 years was selected. A semi-structured pre-tested questionnaire was administered to respondents by investigators. Data on tobacco consumption and other variables such as age, sex, marital status, education, employment and stress and anxiety related symptoms were obtained.

Results: A total of 104 (52%) reported tobacco consumption. Use of huqqa (hubble bubble) was more prevalent (79%). Women above 30 years of age, being married and living in a joint family were more likely to consume tobacco. Illiterate women as compared to women with more than five years of schooling were more likely to consume tobacco (OR=3.16,95% CI=1.13-7.72). Women having household income more than 5000 rupees were more likely to consume tobacco (OR=2.63,95% CI=1.36-5.09) and face more financial difficulties at home (OR=4.72, 95% CI=2.45-9.81). Women consuming tobacco reported anxiety related symptoms more as compared to women who did not consume tobacco.

Conclusion: Our study concluded that in this particular study setting, huqqa is the commonest form of tobacco consumption among women of low socioeconomic class. They start huqqa usually in childhood and after marriage by peer pressure especially in joint families . Women consuming tobacco report more psychosomatic symptoms and financial difficulties at home (JPMA 55:111;2005).

Introduction

Smoking prevalence among women varies markedly across countries; it is as low as an estimated 7 percent in developing countries to 24 percent in developed countries. Tobacco is used in several forms such as huqqa, moist snuff used as an oral dip, chewed with betel nut, and smoking beady made up of rolled dry leaves containing tobacco.1 According to a study conducted in Karachi, the largest city of Pakistan, reported prevalence of 32.7%.2 (National health survey of Pakistan) indicates a prevalence of 6.5% for smoking among Pakistani women.1 Previously it was thought that women belonging to upper class smoke more as they perceive smoking a gesture of liberation, but nowadays many poor women have this habit and find cheapest forms of smoking such as huqqa. Women in squatter settlement enjoy smoking huqqa, which is available at a very low cost. Studies conducted in rural Indian populations reported 9.3% prevalence of smoking among women.3

Tobacco consumption is responsible for innumerable adverse effects on health of an individual like cardiovascular diseases, lung cancer, chronic bronchitis, and respiratory diseases.4 Maternal smoking during pregnancy is a risk factor for very pre-term birth.5

Keeping in mind the adverse effects of tobacco consumption among women, it is necessary to formulate a policy by conducting research in this area. Smoking is a threat to the unborn child as it can cause low birth weight and pre-term births. This warrants a dire need to determine the facts and figures about tobacco consumption among women in Pakistan. This will help in developing preventive strategies to save women from the consequences of tobacco consumption. This study aims to assess pattern of smoking and to determine the risk factors associated with tobacco consumption in various forms among adult women above 18 years age in a low socioeconomic community of Manora Island, Karachi.

Subjects and Methods

Two hundred adult women above 18 years of age were selected using systematic sampling with random start from a community of 5000 people in Manora Island, Karachi. There were 400 hundred households in thecommunity; every 2nd household was visited and women above 18 years were selected randomly. A semi-structured pre-tested questionnaire was administered to respondents by trained interviewers. Data on tobacco consumption and other variables such age, sex, marital status, education, employment, stress and anxiety related symptoms were obtained.

Results

In the study sample 52% of women reported smoking. Among smokers 79% women smoked huqqa, 4.8% cigarette, 5.7% chewed naswar and 10.5% pan suppari. Most of the women reported that they were addicted since childhood (56%) or soon after marriage

Table 1. Socio-demographic characteristics of smoking and non smoking women .
Variables Smokers (n=104) Non smokers (n=94) Odds ratio 95% confidence interval
Age of the women        
>30 years 52 20 3.8 (1.95-7.46)
<30 years 52 76  
Marital status      
Married 66 42 - -
Unmarried 33 52 2.48 (1.33-4.63)
Widow 5 2 0.63 (0.08-3.91)
Ethnicity      
Sindhi 64 58 1.05 (0.57-1.93)
Baluchi 40 38  
Occupation      
Employed 7 6 1.08 (0.31-3.80)
Housewife 97 90  
Type of family      
Joint 67 45 2.05 (1.12-3.77)
Nuclear 37 51  
Duration since marriage
     
>10 years 37 30 1.98 (0.88-4.50)
<10 years 28 20  
Education
     
Illiterate 59 37 - -
Literate 27 19 1.12 (0.52-2.44)
5years schooling 18 40 3.16 (1.13-7.72)
Income of the household
     
>5000 rupees 81 55 2.63 (1.36-5.09)
<5000 rupees 23 41  
Financial difficulties      
Yes 81 41 4.72 (2.45-9.81)
No 23 55  
       
(44%). Cost of smoking per day was less than 5 rupees (90%) while 10% reported more than 5 rupees.

Table 1 describes the socio-demographic characteristics associated with smoking among women. Women above 30 years of age were three times more likely to smoke compared to women below 30 years of age (OR=3.8, 95% CI=1.95-7.46). Married women were twice more likely to smoke compared to unmarried women (OR=2.4, 95% CI=1.33-4.63). No significant difference was found when ethnicity (OR=1.05, 95% CI=0.57-1.93) and occupation (OR=1.08, 95% CI=0.31-3.80) were compared among smokers and non-smokers. Women living in joint families were twice more likely to smoke as compared to women living in a nuclear family (OR=2.0, 95% CI=1.12-3.77). No significant association was noted when duration of marriage was compared between smoking and non-smoking women (OR=1.98, 95% CI=0.88-4.50).

No significant difference was found when illiteracy was compared with literacy. But when illiteracy was compared with more than five years of schooling it showed a significant difference and illiterate women were found three times more likely to smoke as compared to women having more than five years of schooling (OR=3.1, 95% CI=1.13-7.72). Regarding income of the household, smoking was twice in women having household income more than 5000 rupees as compared to women having income less than 5000 rupees (OR=2.6, 95% CI=1.36-5.09). Smokers reported financial difficulties more at home as compared to nonsmokers (OR=4.7, 95% CI=2.45-9.81).

Table 2. Psychosomatic symptoms among smokers and non smokers women.
Variables Smokers (n=104) Non smokers (n=94) Odds ratio 95% confidence interval
Stress
       
Yes 81 38 5.38 (2.77-10.48)
No 23 58  
Fatigue      
Yes 83 56 2.82 (1.44-5.58)
No 21 40  
Disturbed sleep      
Yes 60 31 2.86 (1.54-5.32)
No 44 65  
Disturbed appetite      
Yes 69 34 3.59 (1.93-6.73)
No 35 62  
Pain in body
     
Yes 74 36 4.11 (2.18-7.78)
No 30 60  
       
Table 2 compares the psychosomatic symptoms among smokers and nonsmokers. Smokers reported stress 5 times more as compared to nonsmokers (OR=5.3,95% CI=2.77-10.48). Smoking women were found suffering from fatigue (OR=2.8, 95% CI-1.44-5.58) and having disturbed sleep (OR=2.86, 95% CI=1.54-5.32) as compared to nonsmokers. Smokers reported 3 times disturbed appetite as compared to nonsmokers (OR=3.59, 95% CI=1.93-6.73). Regarding the question of pain in any part of the body, smokers reported 4 times more bodyaches as compared to nonsmokers (OR=4.11, 95% CI=2.18-7.78).

According to Surgeon General’s Report on women and smoking, more women died of lung cancer than breast cancer in 2000. This recommended that a number of things need to be done to curb the epidemic of smoking and smoking-related diseases among women in the United States and throughout the world.6 Twenty percent of women in Pakistan use some form of tobacco on a regular basis. Tobacco use increases with age. The use of chillum, huqqa, chewing tobacco, and snuff are more common among women than cigarette or bidi use. Levels of tobacco and pan use may be underestimated for women. Due to cultural prohibition, women may underreport use of tobacco.1 Our study findings are supportive of these findings; as more than half of the women reported tobacco consumption and among these 79% used huqqa. Smoking is a widely acceptable practice in Pakistan, peer pressure is an important influence which effects behavior of young people and sometimes they hide smoking from adults.7 In our study majority of the women reported that they started tobacco from their childhood or soon after marriage. In a country like ours adolescence and after marriage are the times when women change their behavior and they adopt the environment of the households they enter. If tobacco is being used there, they are more likely to adopt the habit. This is the time when a woman has responsibility of bearing and rearing children. If she is a smoker, the children are exposed to health risks.

National health survey findings report over 7% of women aged 25-64 years smoke chillum or huqqa. Our study showed 79% of wome smokers to use huqqa. A study conducted in northern area of Pakistan reported that 6% of women smoke.8

Women married and above 30 years of age, living in joint family and having low literacy level had a significantly higher tobacco consumption. Smoking increases with age and education is a protective factor, has been reported by several other studies and studies conducted in Pakistan.8,9 Similar findings have been reported by Pakistan National health survey from which a clear smoking pattern emerges. A low socioeconomic status and illiterate women are more likely to smoke chillum and huqqa than educated women of the same age of a higher status. Our study reports that married women smoked more as compared to unmarried women, which is consistent with the findings of another study conducted at Karachi.9 Our study also showed that women consuming tobacco are more likely to suffer from stress and anxiety and financial difficulties at home. Generally it is a misconception among smokers that smoking reduces stress and alleviates anxiety, which is not true. Women who smoke are at more risk of having depression and anxiety. The association of smoking and depression is particularly important among women because they are more likely to be diagnosed with depression than men.6,10

Pakistan has no clear policy on tobacco control therefore tobacco consumption is prevailing in spite of its serious consequences. Successful interventions have been developed to prevent smoking among young people, but little systematic effort has been focused on developing and evaluating preventive interventions, specially for women.

The results of the study stress on the need to focus on anti tobacco consumption campaign or smoking cessation programmes. Adequate knowledge should be provided about the harmful effects of huqqa smoking. Educational status of women should be raised. Stress and anxiety should be alleviated by psychiatric counseling and proper treatment.

References

1. Pakistan Medical Research Council. National health survey of Pakistan. Network Publication service, 1998.

2. Maher R, Devji S. Prevalence of ssmoking among Karachi population. J Ayub Med Coll Abbottabad. 2002;14:23-5.

3. Narayan KMV, Chadha SL, Hanson RL, Tandon R, Shekhawat S, Fernandes RJ, et al. Prevalence and patterns of smoking in Delhi: Cross sectional study. BMJ 1996; 312:1576-9.

4. Marsh DR, Kadir MM, Hussein K, Luby SP, Siddiqui R. Adult mortality in slums of Karachi, Pakistan. J Pak Med Assoc 2000;50:300-6.

5. Burguet A, Kaminski M, Abraham-Lerat L, Schaal JP, Cambonie G, Fresson J, et al. EPIPAGE Study Group the complex relationship between smoking in pregnancy and very pre-term delivery. Results of the Epipage study. BJOG. 2004;111: 258-65.

6. Surgeon General’s Report.Women and smoking. A report of the Surgeon General-2001. CDC publication,2001.

7. Bush J, White M, Kai J, Rankin J, Bhopal R. Understanding influence on smoking in Bangladesh and Pakistan adults: community based, qualitatative study. J Pak Med Assoc 2002;52:389-92.

8. Shah SMA, Arif AA. Prevalence and pattern of smoking in high mountain rural villages of North Pakistan. Tobacco Control 2001;10: el (spring).

9. Alam SE. Prevalence and pattern of smoking in pakistan. J Pak Med Assoc 1998; 48:64-6.

10. Jaleel MA, Nooreen R, Perveen A, Farhana, Nadeem, Hameed A. Comparison of population survey of Multan about cigarette smoking with survey of Abbotabad. J Ayub Med Coll 2002;14:16-19.

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