“I will break my children’s bones if they ever try to smoke,” says 27-years-old Sana (name changed). She tried her first cigarette at the age of 15 and was hooked onto the habit by the age of 17. Since then, except the one year where she quit, this young female journalist has been addicted. From regular to light, from non-menthol to menthol, from blue packs to green ones, and from cigarettes to sheesha and even electronic cigarettes, she has tried it all, but is unable to give up her reliance on one of the most addictive substances in the world.
Research shows that the gender gap between smokers is narrowing, and while smoking among females is on a decline in the developed world, it is on the rise in developing countries. A change in the traditionally defined gender roles has a correlation here, as do the marketing strategies. Use of coined terms like ‘light’ and ‘menthol’ make it more acceptable to women. Sheesha cafes have also made use of this psyche. Fruity smells and seemingly harmless flavours, such as green apple and paan mint make the choice seem more aesthetic and less hardcore. Before one knows it, one is hooked.
Socio-economic reasons seem to have a definite influence. The study “Women and Smoking: A Report of the Surgeon General” states that women whose parents have been to college are more likely to have tried a hand at smoking. “The school one goes to has an impact for sure,” says Sana, adding that certain professions attract the habit, especially among females. The study also shows that women with stronger links with religion are more likely to avoid or discontinue smoking.
Globally, incidence of lung cancer and heart disease among women has gone up, and experts are searching its links back to an increase in use of tobacco. Smoking, in women, lowers their estrogen and their high-density lipoproteins that prevent arteries from blockage.
Getting it from the men
“We seem to have a unique tuberculosis (TB) epidemiology whereby young females appear to have the highest incidence of TB, and comprise more than a third of all our patients,” says Dr Asad Zaidi, who has been working on health initiatives to promote lung health and fight TB, and is associated with International Research and Development (IRD). The Sehatmand Zindagi Centre is the lunghealth and diabetes initiative established through Community Health Solutions (CHS), a social enterprise, in partnership with IRD, with which Zaidi is involved. Working in the peri-urban areas of Karachi, observation of these experts working for Sehatmand Zindagi reveals a definite trend of young women, aged between 15 and 22 years, having higher incidences of TB. “The exact causes for the high rates of TB amongst young women are poorly understood but we can speculate. We already know that nutritional deficiencies are much more common in girls, including widespread anemia and Vitamin D deficiency, often from a very young age. Stunting is more common in girls, they are less likely to be immunised during childhood or be treated once they fall ill. The high numbers of TB in young women, then, could just be another manifestation of the wider gender inequality plaguing this country,” adds Zaidi.
The connection between smoking and TB cannot be ignored, even though the young women being treated at these centres are from underprivileged backgrounds may not be smokers themselves. “We have a girl under treatment at Indus Hospital Karachi as part of our programme. She got married at the age of 20 to a man much older who already was a patient of TB, and smoked, and she acquired the disease from him. It is a complicated case of multi drug-resistant (MDR) TB, and she is expecting a baby. But she is better in the seventh month of her treatment,” says Sajida Qurban Khan who works as a manager in the Sehatmand Zindagi centres. In most cases, in Khan’s experience, these young girls have acquired the disease from fathers or brothers who were smokers and suffered from TB. “Women are actually more eager to come in for treatment and prove to be cooperative patients. But they also give up treatment midway more readily as they are less likely to be able to sustain the side effects of the medications.”
WHO confirms that TB is one of the major public health problems in Pakistan. Pakistan ranks fifth amongst TB high-burden countries worldwide. Pakistan is also estimated to have the fourth highest prevalence of multidrug-resistant TB (MDR-TB) globally.
Sheesha, social smoking and young ladies
“I don’t remember when I started smoking sheesha; I was very young, maybe 15 or 16. I started it because it was really in so I had to try it out. I thought it would make me look cool,” says Khizra Khan, 21-years-old, an undergrad student in Karachi. She says she now knows the health hazards of smoking sheesha or smoking, but defends the habit. “Everyone knows that sheesha and smoking are equally harmful. But you don’t get addicted to sheesha and you can never smoke sheesha alone. I can go on for a month without smoking it. Plus it’s a good thing to hang out with friends over; it’s cheap and affordable compared to going out for lunch or dinner,” says Khizra, and shares that her parents hate the idea of sheesha smoking.
Waterpipe tobacco smoking, despite bans, has gained momentum among Pakistani youth. Women who hesitate smoking in public feel no hesitation smoking sheesha in public. “It is more socially acceptable compared to smoking. It’s the one fun thing I can do publicly,” says Sumera (name changed) who says she and her husband bond over sheesha smoking.
A research paper presented by Professor Javaid Khan, Aga Khan University, states that “Besides lung cancer, sheesha use is also linked with increased risk of mouth and urinary bladder cancer. There is also some evidence that sheesha use may also decrease the sperm count in men. Regular sheesha users have lung functions approximately 25 per cent lower than those who do not use this. One study has also shown that sheesha use increases the risk of pulmonary tuberculosis. Children are particularly vulnerable to the harmful effect of the sheesha use”.
According to the World Health Organization (WHO), sheesha, hookah, goza or hubbly bubbly, is indeed addictive and actually might end up being more harmful than smoking. WHO warns that a one-hour sheesha session can throw in as much nicotine in your system as smoking one hundred cigarettes. While a cigarette smoker typically takes between eight and 12 puffs, inhaling 0.5 to 0.6 litres of smoke, a sheesha smoker during an hour-long session may take up to 200 drags of between 0.15 to 1 litre of smoke each. “Reduced concentration of nicotine in the waterpipe smoke may result in smokers inhaling higher amounts of nicotine,” says the WHO report.
“There is already unequivocal evidence linking tobacco smoke, whether through cigarettes or shisha, to increased risk for TB. The rising trend in smoking then, is clearly a big problem. A lot young people out there don’t know that smoking could give them TB, and because smoking reduces our immunity, the infection is that much harder to cure.”
According to a study called “Prevalence of cigarette smoking among young adults in Pakistan” published in the Journal of Pakistan Medical Association, nicotine addiction and stress were the most common reasons given by students for why they smoked (53 per cent and 50 per cent, respectively). Most of the respondents shared that at least one of their five closest friends smoked cigarettes and more than half mentioned that at least one person in their home smoked cigarettes.
“I wish I had never acquired this habit,” says Sana with regret. For her, it might be too little too late. But creating awareness may potentially save lives of many young Pakistanis, especially women.
Tobacco kills up to half of its users
Tobacco kills nearly 6 million people each year, according to the World Heath Organisation. More than five million of those deaths are the result of direct tobacco use while more than 600 000 are the result of non-smokers being exposed to second-hand smoke. Unless urgent action is taken, the annual death toll could rise to more than eight million by 2030.
Nearly 80 per cent of the world’s one billion smokers live in low- and middle-income countries.