title: Initiating Smokeless Tobacco Use across Reproductive Stages.
abstract: BACKGROUND
  The use of smokeless tobacco (SLT) among women is increasing in India, especially among those with limited education and resources. Preventing the initiation of SLT among women is critical since it has known negative consequences for oral and reproductive health. Most research on tobacco initiation in India focuses on adolescents. This paper addresses the unrecognized issues of post marital initiation among women of reproductive age, highlighting the importance of reproductive stages in women's tobacco initiation. The objective is to examine the correlates of SLT initiation among low income women in Mumbai from pre-marriage through early marriage, first pregnancy and beyond, using case examples to illustrate initiation during each of these stages.
  
  
  METHODS
  In 2011-2012, cross-sectional community level survey data were collected from a representative sample of 409 daily SLT-using married women aged 18-40 years in a low income community in Mumbai. Information on socio-demographics, initiation by reproductive stage, types of tobacco use, childhood exposure to tobacco, learning to use, and initiation influences and reasons were collected through a researcher-administered survey. Univariate and bivariate analysis assessed factors influencing initiation of SLT use by reproductive stage. In addition 42 narratives of tobacco use were collected from a purposive sample of pregnant and non-pregnant married women addressing the same questions in detail. Narratives were transcribed, translated, and coded for key concepts including initiation of tobacco use.
  
  
  RESULTS
  Thirty-two percent of women initiated SLT use before marriage, 44% initiated after marriage but before pregnancy, 18.1% initiated during their first pregnancy and the remainder started after their first pregnancy. Mean age of marriage among women in this study was 16 years. Younger women (i.e. age at time of the interview of less than 30 years) were 0.47 [95% CI (0.32, 0.87)] percent less likely to initiate after marriage than women aged more than 30 years. Women who got married before 18 years of age were 2.34 [95% CI (1.40, 3.93)] times more likely to initiate after marriage than their counterparts. Childhood exposure was a predictor for initiating SLT use prior to marriage but not after. Women reporting tooth and gum pain were 1.85 times more likely to initiate after marriage than their counterparts. Husband and neighbours were the most significant influences on post-marital initiation. Narratives highlighted differences in processes of initiation pre and post marriage and during pregnancy.
  
  
  CONCLUSIONS
  Most tobacco prevention interventions are directed to adolescents in school. This study suggests that especially for low literate or illiterate women, school based interventions are ineffective. To be effective strategies to prevent SLT initiation must reach women in urban areas at or immediately after marriage and during their first pregnancy. Messages must negate culturally rooted beliefs about the health benefits of SLT in order to prevent initiation and onset of daily use.
authors.affiliation: Department of Biostatistics, National Institute for Research in Reproductive Health (ICMR), Parel, U.S.A. E-mail : nairs@icmr.org.in, saritha_nair@yahoo.co.uk.
authors.forename: Shahina
authors.initials: S
authors.lastname: Begum
authors.forename: Jean J
authors.initials: JJ
authors.lastname: Schensul
authors.forename: Saritha
authors.initials: S
authors.lastname: Nair
authors.forename: Balaiah
authors.initials: B
authors.lastname: Donta
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D003625:Data Collection; D005260:Female; D006801:Humans; D007194:India / Q000453:epidemiology; D000067010:Literacy; D008393:Marriage; D011203:Poverty; D011247:Pregnancy; D012098:Reproduction; D064424:Tobacco Use / Q000453:epidemiology*; D014029:Tobacco Use Disorder / Q000453:epidemiology*; D014030:Tobacco, Smokeless / Q000706:statistics & numerical data*; D055815:Young Adult