Respirology

(2003)

8

, 123130

Blackwell Science, LtdOxford, UKRESRespirology1323-77992003 Blackwell Science Asia Pty Ltd

82June 2003464

Women and tobaccoJ Mackay and A Amos

10.1046/j.1323-7799.2003.00464.xReview Article123130BEES SGML

Correspondence: Judith Mackay, Asian Consultancyon Tobacco Control, Riftswood, 9th Milestone, DD 229,Lot 147, Clearwater Bay Road, Kowloon, Hong Kong. Email: jmackay@pacific.net.hk

INVITED REVIEW SERIES: TOBACCO AND LUNG HEALTH

Women and tobacco

Judith

MACKAY

1,2

AND

Amanda

AMOS

3

1

Advisor, TFI, World Health Organization,

2

Asian Consultancy on Tobacco Control, Hong Kong and

3

Public Health Sciences, Department of Community Health Sciences, University of Edinburgh Medical School,

Scotland, United Kingdom

Women and tobacco

MACKAY J, AMOS A.

Respirology

2003;

8

: 123130

Abstract:

Smoking prevalence is lower among women than men in most countries, yet there areabout 200 million women in the world who smoke, and in addition, there are millions more whochew tobacco. Approximately 22% of women in developed countries and 9% of women in developingcountries smoke, but because most women live in developing countries, there are numerically morewomen smokers in developing countries. Unless effective, comprehensive and sustained initiativesare implemented to reduce smoking uptake among young women and increase cessation ratesamong women, the prevalence of female smoking in developed and developing countries is likelyto rise to 20% by 2025. This would mean that by 2025 there could be 532 million women smokers.Even if prevalence levels do not rise, the number of women who smoke will increase because thepopulation of women in the world is predicted to rise from the current 3.1 billion to 4.2 billion by2025. Thus, while the epidemic of tobacco use among men is in slow decline, the epidemic amongwomen will not reach its peak until well into the 21st century. This will have enormous consequencesnot only for womens health and economic wellbeing but also for that of their families. The healtheffects of smoking for women are more serious than for men. In addition to the general healthproblems common to both genders, women face additional hazards in pregnancy, female-specificcancers such as cancer of the cervix, and exposure to passive smoking. In Asia, although there arecurrently lower levels of tobacco use among women, smoking among girls is already on the rise insome areas. The spending power of girls and women is increasing so that cigarettes are becomingmore affordable. The social and cultural constraints that previously prevented many women fromsmoking are weakening; and women-specific health education and quitting programmes are rare.Furthermore, evidence suggests that women find it harder to quit smoking. The tobacco companiesare targeting women by marketing light, mild, and menthol cigarettes, and introducing advertisingdirected at women. The greatest challenge and opportunity in primary preventive health in Asia andin other developing areas is to avert the predicted rise in smoking among women.

Key words:

action, health, marketing, tobacco, women.

THE GLOBAL PICTURE

There can be no complacency about the currentlower level of tobacco use among women in theworld; it does not reflect health awareness, butrather social traditions and womens low economicresources.

Dr Gro Harlem Brundtland, former Director-General of World Health Organization, 1998

1

Smoking is still seen mainly as a male problem, sincein most countries, especially developing countries,smoking prevalence is much lower among womenthan among men (Fig. 1). The prevalence of malesmoking in many countries in Asia, such as China,Indonesia, Thailand and Korea, and in much of theMiddle East, is 10 or more times greater than thefemale prevalence rates, a pattern which contrastswith that in Europe and the Americas. Only in NewZealand is the prevalence of female smoking equal tothat of men.

It is currently estimated that there are already 200million women in the world who smoke, and in addi-tion, in South Asia millions more women chewtobacco.

2

In Mumbai, India, for example, 56% ofwomen chew tobacco.

3

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J Mackay and A Amos

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Approximately 22% of women in developed coun-tries and 9% of women in developing countriessmoke,

4,5

equivalent to about 250 million womenaround the world, but because most women live indeveloping countries, there are numerically morewomen smokers in developing countries.

Women have traditionally started smoking later,consumed fewer numbers of cigarettes than men andsmoked lower tar brands. The pattern of smokingamong and between women and men differs accord-ing to the stage of the smoking epidemic in eachcountry (Fig. 2).

Cigarette smoking among women is declining insome developed countries, notably the USA, UK, Can-ada and Australia,

7,8

but is still increasing or is staticin several Southern, Central and Eastern Europeancountries.

9

More girls than boys are now smoking insome Western countries, such as the UK, Sweden,Austria, Denmark, Finland and Germany.

Thus, while the epidemic of tobacco use amongmen is in slow decline, the epidemic among womenwill not reach its peak until well into the 21st century.This will have enormous consequences not only forwomens health and economic wellbeing but also forthat of their families.

In developing countries, although women smokeless, there is great concern that the numbers ofwomen smokers might rise because:1. The female population will rise from the present3.1 to 4.2 billion by 2025, so even if the prevalenceremains low, the absolute numbers of smokers willincrease. This would mean that by 2025 there couldbe as many as 532 million women smokers.2. The spending power of girls and women isincreasing so that cigarettes are becoming moreaffordable.3. The social and cultural constraints that previ-ously prevented many women from smoking areweakening in some countries.4. The tobacco companies are targeting womenwith well-funded, alluring marketing campaigns,linking smoking with emancipation and glamour.5. Many gender specialists, womens organizations,womens magazines, models, film and pop stars, and

other female role models have failed to recognize thatsmoking is a womens issue, or the need to take anappropriate stance.6. Women-specific health education and quittingprogrammes are rare, especially in developingcountries.7. Governments in developing countries may be lessaware of the harmful effects of tobacco use and arepreoccupied with other health issues. Where they areconcerned with smoking, they focus on the higherlevels of male smoking. In fact, no developing countryis addressing the emerging female epidemic to theextent the problem warrants.

HEALTH EFFECTS OF TOBACCO USE

Active tobacco use

The scientific evidence has shown conclusively thatboth smoked and smokeless tobacco cause fatal andmultiple disabling health problems throughout thelife cycle.

The younger a girl starts to smoke, the more likelyshe is to smoke heavily, become more dependent onnicotine, and be at greater risk for smoking-relatedillness and death.

10

Because the health effects of smoking only becomefully evident 4050 years after the widespread uptakeof smoking, the full global impact of smoking onwomens health will not be seen for some decades.Smoking currently kills around half a million womenin developed countries and 0.3 million in developingcountries each year. In Asia, tobacco accounts for lessthan 5% of total female adult deaths, with the excep-tion of Australia, Japan and New Zealand.

2

However,the numbers are increasing rapidly.

11

Between 1950and 2000, around 10 million women died fromtobacco use, but it is estimated that over the next 30years, tobacco-attributable deaths among womenwill more than double.

12

Women who smoke have markedly increased risksof cancer, particularly lung cancer, heart disease,

Figure 2

A model of the ciga-rette epidemic. Source Lopez

etal

. 1994.

6

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J Mackay and A Amos

stroke, COPD and other fatal diseases. If they chewtobacco, they risk oral cancer. In addition to thesehealth risks that women share with men, women faceparticular problems linked to tobacco use.

1215

Theseinclude:1. Female-specific cancers, such as cancer of thecervix.2. Coronary heart disease: an increased risk with useof oral contraceptives.3. Menstruation: irregular cycles, higher incidenceof dysmenorrhoea.4. Menopause: women who smoke tend to entermenopause at age 49 years, 12 years before non-smokers. This places them at a greater risk for heartdisease and osteoporosis, including hip fractures, aswell as an increased incidence of hot flushes.5. Pregnancy: Smoking in pregnancy causesincreased risks of spontaneous abortion (miscar-riage), ectopic pregnancy, low birth weight, higherperinatal mortality, and long-term effects on growthand development of the child. Many of these prob-lems affect not only the health of the foetus, but alsothe health of the mother. For example, a miscarriagewith bleeding is dangerous for the mother, especiallyin poor countries where health facilities are inade-quate or nonexistent.6. Infertility: smoking is linked to infertility in bothsexes and to delay in conceiving.

Many women, even in developed countries, areunaware of the extent of these risks.

16

In a surveyamong female hospital employees in the USA, nearlyall were aware of increased complications in preg-nancy (91%), but only a minority knew of theincreased risk of miscarriage (39%), and even fewerknew of the increased risk of ectopic pregnancy(27%), cervical cancer (24%) and infertility (22%).

ENVIRONMENTAL TOBACCO SMOKE

Professor Takeshi Hirayamas cohort study in 1981 onlung cancer in 91 000 non-smoking Japanese wivesmarried to men who smoked was the first conclusiveevidence on the harmfulness of passive smoking,

17

and these findings have been confirmed by a myriadof studies around the world.

13,18

Research has alsoshown other risks of passive smoking, including heartdisease and stroke. As the majority of smokers in theworld are men, women are at particular risk fromenvironmental tobacco smoke at home. Womenworking outside the home may be exposed to passivesmoking in workplaces where smoking is stillpermitted.

Womens smoking may impact on the health oftheir families. In addition to a womans smoking dur-ing pregnancy impacting on the health of the foetus,smoking by the father (or other close adult) can alsocause complications during pregnancy, such as lowbirth weight.

Children are at particular risk from adults smok-ing. A WHO consultation in 1999 concluded that pas-sive smoking is a real and substantial threat to childhealth, causing death and suffering throughout theworld.

19

About 40% of the worlds children are

exposed to passive smoking in the home and a further61% in public places.

20

Adverse health effects includepneumonia and bronchitis, coughing and wheezing,worsening of asthma, and middle ear disease, andpossibly neurobehavioural impairment and cardio-vascular disease in adulthood.

14,21

Children of smok-ers are also more likely to become smokersthemselves.

ECONOMIC IMPACT OF TOBACCO USE

Tobacco use carries a serious economic debit to gov-ernments, to employers and to the environment,which includes social, welfare and healthcare costs;loss of foreign exchange in importing cigarettes; lossof land that could grow food; costs of fires and dam-age to buildings caused by careless smoking; environ-mental costs ranging from deforestation to collectionof smokers litter; absenteeism; decreased productiv-ity; higher numbers of accidents; and higher insur-ance premiums.

There are many economic effects related to womenand tobacco, including:1. Expense of buying cigarettes (diverting moneyfrom other family purchases).2. Costs of ill-health, which can range from medicalbills to loss of income.3. Costs of premature death.4. Costs of looking after relatives affected bytobacco.5. Costs of widowhood or even destitution if a malebreadwinner dies from smoking.

The economic costs to the smoker include moneyspent on buying tobacco. Farmers near Shanghaispend more on cigarettes and wine than on grains,pork and fruits.

22

In some countries in Africa and Asia,20 imported cigarettes cost more than half the aver-age daily income.

23

In many developing countries,there is minimal or no state health care, no unem-ployment or disability allowances, no pension andno institutionalized care for the elderly or sick, allof which place the economic and social burden oftobacco onto the family.

These effects are particularly severe for poorerwomen in poorer countries. Healthcare facilities nowor in future will be hopelessly inadequate to cope withthis epidemic. More than 70% of the estimated 1.3billion people living in poverty are women.

24

SMOKING CESSATION

Several studies have suggested that women may findit more difficult to quit smoking than men. The rea-sons are not well understood,

25

but it is likely due toa combination of biological, psychological and socialfactors as well as reduced accessibility to quittingadvice and treatment.

Few developing countries have comprehensivedata on the prevalence or numbers of ex-smokersand data from cessation studies come predominantlyfrom Western countries. These consistently show

Women and tobacco

127

lower quit rates in women compared to men withnicotine replacement therapy.

25

Similarly, studies ofself-quitters have found that women were less likelyto quit initially or to remain abstinent at follow up.British data show that, despite a similar desire toquit, women feel more dependent on their smokingthan do men.

26

Women are more likely to say thatthey would find it very difficult to go without smok-ing for a whole day than men who smoke the sameamount.

In many developed countries men and womensmokers show similar levels of motivation to quit, butmany women appear to face additional barriers toquitting, particularly those who are disadvantagedsuch as low income mothers. It is becoming morewidely accepted, therefore, that tailored approachesto cessation are needed.

17,2729

These programmes andservices need to be accessible to women throughouttheir life course and should be integrated into qualityand affordable health services.

Assistance with cessation is virtually nonexistent inmany developing countries, although most countriesin Asia joined the 2002 Quit & Win Campaign, and allparticipated in World No Tobacco Day, which alwayscarries a quitting perspective. The value of specificquitting programmes for women remains uncertain,although there is an untested belief that such pro-grammes may be particularly suited to women inAsian countries.

THE TOBACCO INDUSTRY

British American Tobacco had a view on gender aquarter of a century ago.

Smoking behaviour of women differs from that ofmen . . . more highly motivated to smoke . . . theyfind it harder to stop smoking . . . given that womenare more neurotic than men it seems reasonable toassume that they will react more strongly to smok-ing and health pressures . . . there may be a case forlaunching a female oriented cigarette with rela-tively high deliveries of nicotine . . ..

30

Following a ruling in the USA law courts, previouslysecret and internal industry documents have nowbeen revealed to the public. These show that on aglobal basis, the multinational tobacco industry hasconsistently lied or obscured the truth to govern-ments, to the media and to smokers.

31,32

Nowhere hasthis been more evident than in developing countries,which often lack the expertise to challenge theindustry.

Their interest in Asia is intense. A search of a web-site collection of documents shows the industrysgreatest interest in Asia is China, Australia, Japan,Korea, the Philippines, Thailand, New Zealand, andIndonesia.

3

The industry journal

Tobacco Reporter

ran an edi-torial about the Asian market that stated:

Rising per-capita consumption, a growing popu-lation and an increasing acceptance of womensmoking continue to generate new demand.

31

The tobacco industry promotes cigarettes towomen using seductive images of vitality, slimness,emancipation, sophistication, and sexual allure.

13,3235

Until the 1980s, there was relatively little tobaccopromotion in developing countries. The nationalmonopolies did not, in general, promote their prod-ucts, or did so only minimally. But from the 1980s, thetransnational tobacco industry introduced tobaccoadvertisements. Many of the initial advertisementswere very masculine, such as the Marlboro cowboy,but gradually a whole range of advertisements wereproduced, moving from men-only advertisements;through neutral advertisements showing, for exam-ple, both men and women enjoying the scenicoutdoors; to women-only advertisements in themid-1980s. Some of the monopolies and nationalcompanies, such as in Japan and Indonesia, thenbegan to copy promotion that targeted women.

Marketing

The tobacco companies also started producing whatcould be called feminized cigarettes long, extra-slim, low-tar, light-coloured and menthol. Somecompanies produced special gift packs and offersdesigned to appeal to women. In Taiwan, tobaccocompanies launched gift packs for the Lunar NewYear, with the Yves St Laurent luxurious gift pack con-taining two cartons of cigarettes plus one crystalitem. The 555 gift packs had either a tea set or anashtray, and the Virginia Slim Lights gift packsincluded stylish lighters suitable for women smokers.In Australia, there have been Alpine fashion keyrings,bags and silk underwear. In Japan, purchasers of MilaSchon cigarettes have had the chance to win hand-bags and ladies watches. In some countries youngwomen are being targeted through direct mail shots:graduates of Tokyo Womens University were sent,unsolicited, sample packets of Salem to their homeaddresses.

Although it is mainly mens sports that are spon-sored in developing countries, these are watched bywomen. For example, 46% of spectators at the HongKong Salem Tennis event in 1993 were women.Michael Chang, who plays regularly in Marlboro andSalem tennis events in China, Japan, the Republic ofKorea and Hong Kong, enjoys idol status with manyteenage girls throughout Asia, who could be forgivenfor believing he smokes Salem.

In Sri Lanka the Ceylon Tobacco Company hiredyoung women to drive around in Players Gold Leafcars and jeeps handing out free cigarette samples andpromotional items. These women also handed outfree merchandise at popular shopping malls and uni-versity campuses.

36

In a country where only 2% ofwomen smoke, this seemed to be part of a wider strat-egy to challenge the social taboo that respectablewomen in Sri Lanka should not smoke and certainlynot in the street.

Brand-stretching and sponsorship in Asia includeswomens football, and using cigarette names for travelholidays, bistros, jewellery shops, etc. Arts sponsor-ship provides the tobacco industry with an aura

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of culture, glamour and respectability, sponsoringevents that appeal to women as well as men. Eventsin Asia have included Peter Ustinov (Hong Kong,1992); Tony Bennett Jazz concerts (Thailand, 1993);Central Ballet of China (1994); Andrew Lloyd WebbersThe Phantom of the Opera sponsored by Philip Mor-ris (Hong Kong, 1995); ASEAN Arts Awards (ASEAN,1999), and in New Zealand there are the Benson andHedges Fashion Design Awards.

Events and activities popular with the young alsoreceive sponsorship. Admission to films and pop orrock concerts has been either free, or free tickets havebeen given in exchange for empty cigarette packets(Taiwan 1988, Hong Kong 1994). In 2002, BritishAmerican Tobacco organized a huge musical celebra-tion in Indonesia, clearly designed to attract theyoung.

37

International film stars have acceptedmoney from the tobacco industry for product place-ment in their films, and such films are shown aroundthe world.

ACTION

Tobacco control strategies are highly cost-effective,and much more cost-effective than treating patientswith lung cancer, chronic obstructive airways dis-eases and other tobacco-related illnesses. Public pol-icy, legislation, research, and education need to begeared specifically towards preventing girls from ini-tiating smoking and helping women quit.

12

Over thepast 10 years there has been a growing recognition, atboth international and national levels, of the growingimpact of smoking on womens health around theworld. However, action on this issue has tended to berestricted to those countries with the longest historyof female cigarette smoking.

International and regional level

WHO

The former Director-General of WHO, Dr Gro Har-lem Brundtland, recognized the importance oftobacco as a womens issue and has initiated pro-grammes, funding and meetings around the world.An international meeting on women and tobaccotook place in Kobe, Japan in November 1999. Thisdrew in, for the first time, womens organizationsbeyond the traditional tobacco control groups, cul-minating in The Kobe Declaration on Women andTobacco. In the Western Pacific Region, all three 5-year action plans on tobacco or health since 1990have emphasized the importance of preventing arise in smoking among women as a high priority.

The Tobacco Atlas

, published by WHO, gives consid-erable prominence to tobacco use among girls andwomen.

3

The Framework Convention on Tobacco Control,WHOs first convention, and also the first attemptto use international legislation to promote publichealth, is currently being negotiated between mem-

ber states. It is dedicated to incorporating genderissues in the convention and its protocol, includingthe language used.

The World Bank

The World Banks report,

Curbing the Epidemic

,marked the first time a major financial institutionhad supported policies designed to reduce tobaccodemand.

2

The document argues that tobacco controlis good for the wealth as well as the health of nations;that it does not lead to loss of taxes or jobs; and thattobacco control measures (e.g. price increases, adver-tising bans, smoke-free areas, health education, phar-maceutical assistance in quitting) are cost-effective inboth industrialized and developing countries. Menand women are not specifically indexed, but the find-ings have relevance to both.

International non-governmental organizations

The International Network of Women AgainstTobacco was founded in 1990 to address the issuesaround tobacco and women. It has members inabout 60 countries. Other non-governmental organi-zations involved with tobacco often include womenand tobacco as part of their work. The Chest Foun-dation, linked to the American College of ChestPhysicians, has taken a particularly active role inwomen and tobacco, producing a speakers kit whichis currently being adapted for Asia. GLOBALink, theInternet network based at the Union InternationaleContre le Cancer headquarters in Geneva, linkstobacco control advocates all over the world, andhas a specific website devoted to tobacco andwomen.

International conferences

The 10th World Conference on Tobacco or Health inBeijing in 1997, pioneered gender equity in worldconferences. Fifty per cent of all committee members,chairs and invited speakers were women. When fund-ing was offered to developing countries for two dele-gates, it was suggested that one be female. In 1998,the European Union, through Europe Against Cancer,organized the first European conference on womenand tobacco in Paris.

Asia Pacific Association for the Control of Tobacco

The Asia Pacific Association for the Control ofTobacco, first established by the late Dr David Yen inTaipei in 1989, organizes biennial regional meetings.Delegates from many countries find the smallerregional meetings more supportive than the large,international conferences, and such meetings facili-tate delegates, especially women, speaking out. Manypapers have been presented on women and tobaccoin the AsiaPacific region.

Women and tobacco

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National level

At a national level, governments have a central andcrucial role in tobacco control, especially in the areaof legislation and tobacco tax increases. Without gov-ernment leadership and commitment, tobacco con-trol measures especially in developing countries are unlikely to succeed. Many governments are pre-occupied with other problems, such as high infantmortality, communicable diseases, economic difficul-ties or political conflict; they lack funds; and havelittle experience in dealing with the tactics of thetransnational tobacco companies. In addition theymay be reluctant to act because of the mistakenlyperceived economic benefits of tobacco.

The lead government ministry is usually the Minis-try of Health, but womens commissions or ministriesshould be active. For example, in 2001 the WomensCommission in Hong Kong concluded that smokingwas a womens issue, and in order to protect womenworkers and diners, endorsed the governments legis-lative proposals to ban all smoking in all workplacesand restaurants.

Yet many developing countries have implementedtobacco control programmes, including legislation,far ahead of many Western countries, without anysevere economic consequences. For example, legisla-tion in Singapore, Fiji, Mongolia, Hong Kong, SouthAfrica, Thailand and Vietnam is far ahead of manyWestern countries. Many tobacco control measurescost little other than political will; for example, legis-lation requiring health warnings on cigarette packets;or the creation of smoke-free areas in governmentbuildings, public areas, transport, or schools. How-ever, many tobacco control programmes in bothdeveloped and developing countries continue to takea gender-neutral or gender-blind approach.

CONCLUSION

The challenge facing us at the beginning of the 21stcentury is how to stem the female wave of the tobaccoepidemic, particularly in developing countries andamong disadvantaged women in developed coun-tries. There needs to be wider recognition thatwomens tobacco use is a global health problem andthat effective women-centred tobacco control pro-grammes should be implemented at international aswell as national levels.

Unless there is a strong, coordinated effort with theaims of preventing girls from starting to smoke, andof assisting cessation, the tobacco epidemic will takea terrible toll on women all over the world. Nowherewill it be felt more keenly than in Asia.

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