Introduction

Smokeless tobacco (SLT) use during pregnancy poses severe risks to both mother and foetus1. SLT exposure leads to nicotine dependence and health hazards, including cancers (oral, throat, pancreatic), gum diseases, heart diseases, and reproductive complications2. Nicotine crosses the placental barrier, triggering nicotinic acetylcholine receptors (nAChRs) in the foetus, leading to neuronal deficits, respiratory center damage, adrenal dysfunction, and intrauterine growth retardation (IUGR)3,4,5,6,7. The likelihood of low-birth weight8,9 and preterm births10,11 is higher among women who consume SLT; the risk of stillbirth among women who had a history of SLT use is particularly higher compared to women who never consumed SLT12. A systematic review of 9 studies has demonstrated a significant association with SLT use in 5 out of 7 studies for Low Birth Weight, in 3 out of 6 studies for preterm births, in all 4 studies for stillbirth, and 1 out of 2 studies examining Small for Gestational Age13. Additionally, SLT use during breastfeeding reduces the protective quality of breast milk, increasing risks of respiratory issues, iodine and thyroid hormone deficits, liver and lung damage, and metabolic disorders in children14,15.

In India, more than 80% of women are consuming smokeless tobacco products among all who consume any form of tobacco16,17. While the various national-level data (Table 2) suggest a gradual reduction in SLT consumption among pregnant and lactating women, the persistent use of SLT in vulnerable groups remains a significant public health concern18. SLT use in India has deep sociocultural roots, as many SLTs as paan, which is a historical normalization, continues to influence current patterns of use, especially among women in traditional settings19. In traditional societies, SLT consumption among women is often seen as a symbol of social bonding and shared experiences20. Studies suggest that women start and continue SLT due to factors like marital stress, socioeconomic burdens, limited support systems, social norms, peer pressure, misconceptions, ignorance, and a lack of awareness about complications and risks21,22,23,24; the lower stigma associated with smokeless tobacco compared to smoking further the urge for consumption25. Recent studies show that first-generation migrant women, from lower socioeconomic backgrounds, are more likely to use SLT in both urban and rural settings26,27,28. Taste preferences and perceived therapeutic benefits of tobacco play a significant role in SLT continuance29. Research from Africa has shown that women often start with flavoured or milder-tasting products before transitioning to stronger varieties25. Additionally, the popularity and convenience of homemade tobacco products make SLT consumption deeply ingrained in certain communities30,31. Long-term consumption is widespread, with many women using multiple SLT products simultaneously, and this is reinforced by its easy availability, affordability, and accessibility32,33. Cultural and seasonal factors, such as community gatherings, festivals, and traditional practices, further contribute to SLT consumption among women in India34,35.

Table 1 National prevalence trend of tobacco use among pregnant and lactating women in India.
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Table 2 Interview Guide.
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Despite these insights, evidence remains scarce, indicating the requirement of additional research from various contexts in India’s highly diverse cultural landscape39,40,41. Qualitative research is crucial for exploring the patterns, sociocultural factors, and behaviors associated with SLT use. Slum settings, characterized by unique social, cultural, economic, and environmental conditions, often have complex migration-related influences. However, the effects of these conditions on the health of slum dwellers remain underexplored. In this scenario, the present study aims to address these gaps and provide a further understanding of SLT use behaviour and the factors influencing tobacco use among women living in low economic settings like slums.

The objectives of the present study are: (1) to qualitatively discuss the consumption pattern of SLT use among pregnant women and lactating mothers; and (2) to explore the sociocultural formation and individual beliefs influencing SLT consumption among the same pregnant and lactating women.

Methods

Study setting

The study was conducted in the slums of Bhubaneswar city, Odisha. The selection of a slum area for this study was guided by existing evidence from prior research, which indicates a significantly higher prevalence of SLT use among the disadvantaged populations, including the women residing in these areas42,43,44,45 A qualitative exploratory study design was employed to investigate the patterns of smokeless tobacco (SLT) use among pregnant and lactating mothers, with a focus on identifying the factors contributing to the continued use of these substances. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for reporting qualitative research46 (Supplementary file 1). in the context of selection of slum setting, it may be noted that the Global Adult Tobacco Survey (GATS) has shown that a majority of the SLT using women in India live in low economic settings like slums; these women are significantly dependant on SLT during their pregnancy47. However, evidence (though limited) indicates that intention to quit is high among these women in the reproductive age group from low economic settings like the slums48; on the other hand, very few studies have ever been undertaken specifically targeting pregnant women from such low economic settings.

Study design and sampling

A qualitative research method was adopted in the present study. We conducted in-depth interviews (IDIs) for the data collection. At first, the study mapped the local target population in selected urban wards in terms of point of sale of SLT, kind of SLT products, extent of SLT use among reproductive age women, based on the key informant interviews of selected persons including, informed members in the community, local school teachers, pan shop sellers, local health workers, older adults. This rigorous practice helped us identify the study areas. Later, with the help of various key informants, like ASHA, we identified and selected the participants.

In this stage, women participants who had a regular SLT consumption habit during their pregnancy and lactation period were identified. A total of 82 eligible pregnant and lactating mothers were initially identified. From this sample pool, in-depth interviews were conducted until thematic saturation was reached- the point at which no new themes or insights emerged. The final sample included 40 participants: 22 pregnant and 18 lactating women. The selection criteria for participants included women residing in urban slum areas of Bhubaneswar and meeting the selected conditions: (i) Ever-married pregnant women aged 18–49 years and actively using any form of smokeless tobacco products during their pregnancy (ii) Lactating mothers who recently delivered (within the past 15 months) and regularly consumed smokeless tobacco products during the study period. Participants who voluntarily consented were included after understanding the study’s objectives and procedures. Efforts were made to include women from diverse socio-economic backgrounds and age groups to provide a broader and more representative perspective on SLT use patterns.

Data collection procedure

Data collection was undertaken from 6th April to 21 st September 2022. Qualitative data were collected through in-depth interviews using an interview guide, which included open-ended questions on SLT use types, patterns and history of smokeless tobacco during pregnancy and lactation, and factors that reinforced such use (Table 3). The detailed interview guide is provided in the supplementary file 2.

Table 3 Socio-demographic characteristics of the participating pregnant and lactating women (N=40).
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The use of in-depth interviews allowed for robust findings, combining the deep, personal insights of the interviewees, which further enhanced the validity and richness of the study findings. Additionally, probes helped to delve further into the details of the experiences and possible associated factors influencing SLT use among the participants. Participants were also administered a short survey about demographic characteristics and occupational history. Before the interviews and the data collection in the field, the field researchers explained the study procedures to the participants and obtained their verbal consent. Addressing the cultural sensitivity and literacy levels, the Participant Information Sheet (PIS) and Informed Consent (IC) forms were read aloud in a local comprehensible language to all participants. The signatures or thumb impressions of respondents were recorded on the IC forms. The consent process emphasized cultural appropriateness, ensuring participants were fully informed and sensitized to the study’s intention, objectives, and topic. The field researchers tried to mitigate participants’ discomfort by addressing their concerns and ensuring a supportive environment during the discussion. Participants interested in quitting smokeless tobacco received guidance on counselling and support services.

The data collection was conducted by a team of researchers (B.N., S.S., A.K.S.) directly in the field. All the interviews were digitally recorded along with the detailed field notes. This was followed by data processing (A.P., J.P.). All audio-recorded interviews were transcribed verbatim, followed by translation for the analysis. Confidentiality was rigorously maintained, with participants assured that their identities and responses would remain private and secure. The in-depth interviews were conducted in the local language (Odia), ensuring ease of communication and authenticity of responses. Each interview spanned 20–50 min, providing adequate time to explore the topic comprehensively.

To enhance reflexivity and minimize bias, all field investigators took systematic field notes immediately after each interview to capture their contextual perspectives, observations, and initial reflections. Regular discussions with peers and supervisors were conducted to critically reflect on the researcher’s role, assumptions, and interactions throughout the study.

Data analysis

The digitally recorded interviews were transcribed verbatim and translated into English to ensure accuracy and facilitate subsequent analysis. The transcriptions underwent a systematic coding process using MAXQDA software to effectively manage and organize qualitative data. The study followed a thematic content analysis approach to identify and understand the underlying patterns and meanings in the data. A two-stage process was followed to capture the meaning behind the transcribed text and develop major themes. First, the researchers thoroughly reviewed each transcript to become immersed in the content, ensuring they understood the context and nuances of the participants’ responses. The transcription and translation of interviews were independently reviewed and cross-verified by multiple authors to ensure clarity and accuracy and to reduce individual interpretive bias. The researchers adopted an open coding approach, systematically examining each transcript line by line (Fig. 1). Key phrases, sentences, or paragraphs reflecting significant ideas, experiences, or perspectives were highlighted. Each highlighted segment was assigned a code that summarized the content or meaning. A deductive approach was employed to identify codes aligned with the study’s initial research questions. In the second stage, the researchers revisited the codes to ensure clarity, relevance, and alignment with the data. Overlapping or redundant codes were merged, while distinct codes were retained to capture specific nuances. The researchers analyzed the codes for patterns, relationships, and recurring concepts across the dataset. Codes sharing similar meanings or addressing related issues were grouped to form preliminary themes. To understand the participants’ experiences and perspectives, the identified themes were systematically reviewed and organized into broader categories, representing overarching concepts. For the better understanding of the findings in different themes, we have given the detailed extended quotes separately (Supplementary file 3).

Fig. 1
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Coding tree for the defining the qualitative themes/subthemes.

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Results

Participants characteristics

A total of 40 participants, including 22 pregnant women and 18 lactating mothers, participated in the present study (Table3). All the participants in the study were married. The majority of the groups (17 or 85% of pregnant women and 9 or 45% of the lactating mothers) were between 15 and 25 years old. A significant proportion (57.5%) of participants had no formal education. The mean age of smokeless tobacco initiation was 14.95 years for pregnant women and 12.58 years for lactating mothers, indicating a more extended tobacco consumption history. Most pregnant (90%) and lactating (60%) women were housewives. Most participants reported a monthly household income ranging between ₹11,000 and ₹15,000.

Theme 1: The patterns of consumption of SLT Productsamong women during the pregnancy and lactation period

The practices, patterns, and influences of SLT use among pregnant and lactating women can be presented under two main sub themes: (1) the initial setting of the SLT habit, including the age of initiation, and (2) the consumption preferences, patterns, and practices of SLT. These themes also brought in the social, cultural, and individual factors that shaped the SLT consumption behaviours among these women.

Fig. 2
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The characteristics and contributing factors of smokeless tobacco (SLT) use among pregnant and lactating women.

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Sub theme 1: the initial setting of the SLT habit, including the age of initiation

Most women initiated SLT consumption during childhood and adolescence, primarily influenced by social, cultural, economic, and personal factors. The study identifies adolescence as the most vulnerable period for SLT initiation, with many of the participating adult women having started tobacco use between the ages of 10 and 19 years.

A lactating mother (IDI-3-L) explains:

I started consuming Dukta at the age of 13–14 years as a group solidarity, under the pressure of my classmates who were already consuming. Gradually, it became a habit. If I don’t have money, I borrow from my friend Jasmine(name changed) or secretly take from my husband’s pocket.

For some women, SLT initiation occurred after marriage. In this context, a pregnant woman (IDI-2-P) who started consuming ‘Khaini’ shared:

I didn’t have the habit before marriage. After seeing my husband using SLT, I started taking khaini—and now I use it regularly.

Among all participants, eight confirmed starting SLT consumption in childhood, continuing through pregnancy and lactation. In this context, some women also reported starting consumption during pregnancy or after childbirth.

A lactating mother (IDI-2-L) explained:

I previously saw my friend consuming paan, but never tried it. After giving birth to my first child, I developed a strong craving and begged my husband to bring it for me.

The study findings highlighted that SLT initiation was predominantly influenced by peer pressure and curiosity during adolescence; on the other hand, cravings and social acceptance drove its initiation during pregnancy.

Subtheme 2: the consumption preferences, patterns, and practices of SLT

The findings of this study revealed that pregnant and lactating women consumed a variety of smokeless tobacco (SLT) products with varying amounts of nicotine content, both locally prepared and commercially available. Commonly used products included Paan, Khaini, Areca Nut, Gundi, Dukta, Gudakhu, and Gutkha. The product switching depended on personal preference, pregnancy-associated cravings, and situational influences. Some started with one product and later shifted to another, while others started new products, increasing frequency and quantity over time. Pregnancy cravings, in particular, played a crucial role in product switching. For instance, some women initially consumed Paan but later switched to stronger forms containing Areca Nut and Slaked Lime. Economic factors also played a role, particularly during the COVID-19 lockdown, when price hikes led some women to switch from Paan to affordable commercial brands or from commercial brands to Khaini to avoid staining their teeth and mouth.

A pregnant woman (IDI-5-P) described her experience:

“I was eating sweet betel leaf during the 3rd month; however, when vomiting happened, I didn’t want to eat anything but “paan” and gradually started adding “areca nut”, and “slaked lime and that became a habit.

The study found that many pregnant and lactating women exhibited stronger addiction, often requiring SLT within five minutes of waking up. Approximately 45% of pregnant women and 55% of lactating women reported using SLT immediately after waking up, while 30% of pregnant women and 20% of lactating women consumed it within an hour of waking up. A pregnant woman (IDI-16-P), describing her routine, said:

“I do not have a fixed time- sometimes after brushing my teeth, or after tea and breakfast. Usually, I take SLT after I wake up, as I feel my mouth tasteless; otherwise, I take it after food. There is no such time when I don’t take it”.

The frequency of SLT usage during pregnancy and lactation was notably influenced by the participants’ daily habits and addiction. These pregnant and lactating women commonly used smokeless tobacco (SLT) throughout the day; the triggers for consumption were multiple, like post-meal craving, during engagement in construction work, household chores, etc. Few consumed one SLT packet over 5–7 days on average. Consumption patterns also varied based on the product and frequency.

Theme 2: influencing factors for consumption of SLT among pregnant and lactating mothers

The present study also aimed to explore the reasons for the initiation and continuation of SLT use habit among pregnant and lactating mothers. Six sub-themes emerged from the analysis: (1) influence and pressure of the peer group, family, and community members; (2) curiosity and personal interest; (3) pregnancy as a significant risk factor for SLT initiation; (4) individual attitude and beliefs; (5) as a perceived source of stress relief; (6) improving interest to remain engaged in work.

Subtheme 1: influence and pressure of the peer group, family, and community members

The findings highlight the significant role of peer groups, family, and community members in shaping the smokeless tobacco (SLT) consumption behavior of pregnant and lactating women in the community. Factors like peer influence, social pressure, and the desire to fit in emerged as key drivers for SLT initiation. Several participants recounted experiences where friends, family, or community members encouraged or even coerced them into using SLT.

A pregnant woman (IDI-8-P) revealed that a friend bullied her, and she was pushed into a pond as she was unwilling to use SLT. After the incident, she started consuming SLT out of fear of her friends, as she did not have any other friends:

My friends pushed me into a pond as I refused to eat Gundi with them. I was hospitalised. After that incident, I started eating Gundi, then moved on to Gutkha, and now, after marriage, I also consume Paan and Safal.

A similar experience was shared by a pregnant woman where her sister-in-law bullied her and threatened to non-cooperate with her in household chores, causing the initiation of her SLT habit. In a similar case, the participant, a lactating mother, was compelled to the habit to get study assistance. Friends, family members, and the close community played significant roles in the initiation and continuation of SLT use, employing tactics such as persistent persuasion, offering free SLT products, and exerting emotional pressure through manipulation, coercion, and the fear of social isolation.

Describing her experience, a lactating mother (IDI-5-L) emphasized the adverse influence of the SLT habit of elder members in the family on quitting efforts and said;

I started using Safal with my sister-in-law. After my elder son’s birth, I quit it thinking it as an unnecessary expense. But six months later, my willpower weakened as I saw my mother-in-law regularly using it, and I started again.

Subtheme 2: curiosity and personal interest

In the present study, curiosity emerged as a key factor in initiating and continuing smoking less tobacco. It mostly got a trigger from family or community members using tobacco, leading to experimentation and eventually developing the habit. The readily available SLT products within the household and the community peers further facilitated this process. A participating lactating mother (IDI-10-L) admitted that her curiosity was fuelled by her husband’s SLT use, leading her to try it, which subsequently developed into the habit she kept secretly:

“Husband eats “khaini” and keeps it at home. So when I saw him, I also wanted to taste. One day I stole some and tested it. Since then, I started consuming”.

The normalization of the availability and use of tobacco products at home created a conducive environment for initiation, making it challenging for individuals to resist or discontinue them.

Subtheme 3: pregnancy as a significant risk factor for SLT initiation

Pregnancy in the present study was observed as a significant factor influencing the initiation and continuation of smokeless tobacco use among participants. Many women reported that they began consuming SLT products during pregnancy to alleviate symptoms such as morning sickness, nausea, and changes in their taste perception; this eventually led to habitual use of SLT that extended into the lactation period. A Lactating mother (IDI-10-L), explaining this in her experience, said,

I didn’t have the SLT habit before marriage. During pregnancy, I had frequent vomiting and such sensations along with developing a bad taste in my mouth. To help with that, my husband gave me Safal, and gradually it became a habit.

So, SLT as a perceived momentary relief from the pregnancy-related symptoms like vomiting, tastelessness, morning sickness, and craving ended up as a habit over the period of pregnancy and later during lactation.

Subtheme 4: attitudes and beliefs related to the use of smokeless tobacco

During the present study, participants strongly believed in the medicinal benefits of smokeless tobacco (SLT); they understood it as an effective remedy for common daily issues like headaches, oral infections, nausea, gastric problems, and pain relief. These beliefs further became stronger due to the influences of family members, peers, and elders, creating an impression that SLT has health benefits.

For example, it was reported by a lactating mother that she used tobacco for pain relief during an oral infection, as suggested by a friend. Similarly, another participant informed that she initiated SLT on her grandmother’s advice to alleviate nausea during fever. Some attempted to quit but reinitiated due to perceived adverse health outcomes. A pregnant woman (IDI-8-P) narrated how after quitting “paan” she started having bad breath, leading to initiating the habit, and said-

At the age of 17–18 years old. I had an infection in my teeth, so my friends suggested using “Gudakhu” for pain relief. That is how I got used to this habit, which is why quitting now is difficult.

Individual beliefs were also observed to play a significant role in product selection. While most women were aware of the link between tobacco and cancer, many failed to distinguish between market-based SLT products, which carry clear cancer warnings, and homemade nicotine products, which they mistakenly believed to be less harmful.

A pregnant woman (IDI-2-P) narrated that after witnessing a person in her village who suffered and died from oral cancer due to consuming Safal, she switched to Gundi. She assumed it was safer due to the homemade nature and said:

“I started consuming “safal” at the age of 18 years, then in our village, one person died from cancer, he used to consume “safal”. So If I consume “safal” then I will suffer from cancer, so I started consuming “Gundi”, it’s homemade”.

Smokeless tobacco (SLT), taken post-meals, was also understood to help digestion, with the perception of its harmlessness. Data revealed pregnant and lactating women consuming SLT products like “Dukta, gundi, and gudakhu” before and after their daily activities. Some narrated a strong urge to consume any available SLT after consuming non-vegetarian food, while a difficult bowel movement was perceived without tobacco consumption.

This attitude and belief often lead to incorporating SLT into daily activities and making it a habit. The association of daily living activities (ADLs) with tobacco consumption was a significant reason for long-term continuation and a cause of difficulties in quitting.

Subtheme 5: conditions for stress relief

The study found stress as a significant factor influencing smokeless tobacco (SLT) consumption among slum-dwelling women, particularly pregnant and lactating mothers. A considerable number of participants attributed their tobacco use habit to their increased stress level, which stemmed from financial crises, household conflicts, and the overburdening of family responsibilities. Many women turned to SLT as a coping mechanism and used it to relieve their stress temporarily.

A pregnant woman expresses frustration with her husband’s lack of responsibility, causing her severe mental pressure in daily life, for which she used tobacco. In this process, she had started to require tobacco more frequently; she had begun to procure it on her own, while previously she was buying through others. Similarly, a lactating mother (IDI-8-L), illustrating her family disturbances, explained tobacco use as her source of relief; narrating tobacco as her coping strategy during times of tension, she said-.

“I am taking tobacco to overcome my tension. My husband is taking all of my money. I never bought Pan and Gutkha on my own. I consumed only if one offered, but now I buy all by myself”.

It was observed that two of the participants tried quitting tobacco for a shorter period; however, their continued stress caused their tobacco dependency by leading them to start it again for relief. Another lady, a pregnant woman (IDI-6-P), narrated;

“Once I swallowed Khaini, after that, I experienced nausea, lightheadedness, and vomiting. I quit it, and I used to take chocolate. But after my mother’s death, I was in serious grief, I started consuming Khaini again, as many do in the same scenario”.

Subtheme 6: continuing interest to remain engaged in work

SLTs, in the present study, were found to act as major driving factors for remaining engaged in routine household chores and other exertional physical activities. Five participants narrated their addiction to SLT use due to similar reasons. So they integrated it into their work routines for their perceived performance enhancement. A pregnant woman (IDI-17-P) narrated:

“When I don’t consume safal, paan, and khaini, I feel irritable and unable to concentrate on my tasks ”.

A lactating woman (IDI-11-L) stated:

Consuming SLT helps me feel more motivated to work, especially in the mornings when I have so much work. That’s why I use more Gundi during that time.

Using smokeless tobacco was observed to be a part of the daily work routine and was found to be used for increasing productivity.

Theme 3: effects of long-term use of SLT products among pregnant and lactating women

Continuous smokeless tobacco (SLT) consumption over an extended period can lead to adverse health issues. Some of the participants shared such experiences due to the prolonged tobacco use, with some acknowledging the poor health conditions. Symptoms such as oral pain, infection, coloured teeth, discolouration of lips, gum decay, formation of pouches in the inner cheeks, tongue ulcer, and toothache were reported. A pregnant woman (IDI-9-P) confirmed that long-term consumption of “safal”, a commercial brand, made her mouth smaller:

“Due to consuming “safal” regularly, my mouth became small, and it is now difficult to open my mouth.

A Lactating mother (IDI-11-L) narrated:

I’ve been chewing Khaini every day since I was 18. I now have a painful oral infection. I’ve tried to quit, but I can’t, for which my pain persists.

Long-term use of SLT products led to multiple oral health complications; the participants, though, realised it in a few cases, they could not give up on it due to addiction, with continued suffering.

Discussion

The present qualitative study explored the patterns and influencing factors of SLT use among pregnant and lactating women in the urban slums of Bhubaneswar. The key findings highlight that these women had two significant milestones for SLT initiation: adolescence and pregnancy. The major factors influencing SLT initiation in adolescence were reported as peer pressure, curiosity, family influence, lack of awareness about SLT-associated adversities, lack of family control and guidance, and easy availability. In contrast, stress, overburden of family responsibilities, excessive hard work, peer pressure, easy availability, pregnancy-associated craving, desire for stress relief, and the desire to stay engaged in work, and weak will power, etc., were identified during the post-marriage time of pregnancy and lactation. Commonly used SLT products included Paan, Khaini, Areca Nut, Gundi, Dukta, Gudakhu, and Gutkha. Many women exhibited strong addiction patterns, consuming SLT multiple times daily, often within minutes of waking up. The findings indicate SLT use as a deeply embedded behaviour in social and familial contexts. Similarly, the association of daily living activities (ADLs) with tobacco consumption was a major reason for long-term continuation and a reason for difficulties in quitting.

These findings are consistent with previous literature highlighting early initiation of SLT consumption, often beginning in adolescence, a vulnerable period characterized by curiosity and exploration49,50. Like previous studies, this research reaffirms early exposure within family environments as a significant risk by increasing the likelihood of long-term habitual use51,52. The current study corroborates prior evidence on high nicotine dependence among women, especially during pregnancy and lactation, when the commonly used multiple SLT types are integrated into daily routines53.

Women from urban slums face unique challenges compared to others, mainly due to the stress associated with low quality of life and living conditions. Several associated factors include overcrowding, poverty, and various culturally embedded superstitious practices. These factors increase their vulnerability to use and the addition of smokeless tobacco as a coping strategy54. Urban slums are characterized by migration and residents living outside their original settings. Such adversities reason in small, monotonous, highly emotionally dependent peer groups; the influence of SLT-dependent peers increases the risks of initiation of SLT and its addiction. Stress relief emerged as a strong motivator for SLT consumption, linking tobacco use to their emotional state. This aligns with previous research, where pregnant and lactating women described using smokeless tobacco as a coping mechanism for stressful life events17,47,55. The dual influence of traditional habits and the easy availability of packed tobacco products in various tastes in urban settings further increases their habits. Lack of proper awareness of associated risks and scopes for quitting is a significant factor for the continuance of the habit for a longer time, resulting in several health risks.

Participants also perceived SLT as a stimulator, mood booster, pain reliever, and remedy for digestion, headaches, and toothaches56. These misconceptions, rooted in cultural beliefs, promote the general acceptability of SLT in the community, encouraging continued use. The ethnographic data revealed that SLT is deeply embedded in local traditions and is used as an offering in rituals and celebrations, symbolizing belonging and social connection. Women often initiate or increase SLT use during festivals, community functions, and ceremonies, reinforcing habitual use over time. Thus, understanding the sociocultural context is crucial for developing interventions addressing traditional practices that contribute to SLT prevalence.

The study also found that some women began SLT use during pregnancy, primarily to relieve symptoms like vomiting, nausea, and gastric discomfort. This pattern reflects family influence, especially from husbands who often consumed SLTs themselves and facilitated access for their wives40,57. In such cases, SLT use was normalised within the household and became part of shared consumption practices. In the community, SLT use among young women is surrounded by stigma and taboos. However, many users received encouragement or support from elder female relatives or had a family history of female SLT use, which served as a form of social bonding and networking. Despite this support, young women often felt stigmatized and attempted to conceal their habit through various excuses.

The findings demonstrated the tobacco consumption patterns and essential influencing factors among pregnant and lactating women, mainly resulting in early initiation, lack of proper knowledge, and awareness of the repercussions of the use of SLT products during pregnancy and lactation.

On the prevention end, previous studies have shown that price hikes and increased taxation have significantly decreased tobacco consumption patterns58,59,60. Banning SLTs, limiting their accessibility, and implementing strict measures such as fines, increased taxes, and price hikes are essential and effective strategies for controlling SLT consumption. However, findings of the present study suggest that due to price hikes, users from low settings like slums switched to cheaper, locally prepared homemade products. The findings of the present paper also underscore the urgent need for comprehensive and culturally sensitive preventive policy implementation for effective tobacco control. In this context, we suggest the following practices at the local level, which have high potential for change in tobacco use behaviour among pregnant and lactating women.

  • Addressing the common misconceptions, such as SLT use as a painkiller, a remedy for pregnancy-related symptoms, or that home-based or locally produced tobacco is less harmful than packaged products, is essential.

  • Integrating structured counselling into Antenatal (ANC) and postnatal care (PNC) visits by routine screening for SLT use among pregnant women by sensitising them against specific harms of SLT for mother and child.

  • Sensitization and engagement with ASHA, Anganwadi workers, ANM, local health and community workers at the institutional and community level, through small, focused IEC practices against tobacco prevention and control, particularly against misinformation.

  • Community awareness among young and newly married women on the risks of SLT use during pregnancy and child health, enabling them to make informed decisions.

  • Using the opportunity of institutional delivery time as a critical point for tobacco cessation counselling and anti-tobacco awareness generation.

  • The visits during child vaccination provide important windows to engage with the mothers and caregivers against SLT use.

  • Village Health and Nutrition Days (VHNDs) may include dedicated SLT counselling and awareness sessions for adolescent girls, women, caregivers, and families in a familiar and accessible community setting.

  • The maternal and child health departments may lead focused Information, Education, and Communication (IEC) campaigns around substance use awareness, prevention, and cessation, tailored for pregnant and lactating women.

  • Engaging local organizations/NGOs in delivering grassroots-level awareness initiatives sensitive to cultural beliefs, traditional practices, and local attitudes toward SLT.

Therefore, strong awareness and communication campaigns are crucial. Community myths and local misconceptions should be clarified through the involvement of the local and credible partners/stakeholders.

Strengths and limitations

The study provides a qualitative contribution to public health and policy research, offering insights that can inform the development of strategies at the individual or community level to stop tobacco consumption. Also, the findings can inform future research and provide a pathway or framework by highlighting the need for culturally sensitive, community-based intervention strategies and robust policy measures. However, the study’s limitations lie in the possible recall bias due to the cross-sectional investigation nature and social response biases due to possible reasons like social desirability bias, self-stigma, peer pressure, etc. Though the researcher bias was minimized through reflexive practices and team validation, it may not be entirely free from influenced data interpretation.

Conclusion

This study underscores the significant public health concern of smokeless tobacco use among pregnant and lactating women in urban slum settings in India. Overall findings highlighted the critical role of socio-cultural context in shaping tobacco use patterns among pregnant and lactating women. The research identified adolescent age and peer pressure as crucial for tobacco initiation, which continued through major milestones in life like pregnancy and lactation. The key factors driving tobacco use include daily habits, stress relief, pain alleviation, mood enhancement, and stimulation. Influences of belief-based practices and misconceptions about the benefits of smokeless tobacco were found to contribute significantly to its initiation and continuation. Context-based or locally adoptable, tailored tobacco control programs addressing the socio-cultural elements and supported by robust anti-tobacco policy measures are essential for effective interventions. The present study provides critical inputs for developing targeted interventions and offers a foundation for future research in similar settings