Tobacco marketing has extensively targeted women, exploiting women's struggle for equal rights by promoting themes that purport an association between smoking and social desirability, freedom, success, glamour and business appeal. In 1968, Philip Morris marketed Virginia Slims cigarettes to women basing their advertising on the emerging women's movement. They used the slogan: ‘You’ve come a long way baby’. However, have women really come such a long way? From some perspectives, the answer is negative.
Currently 8% of women in developing countries and 15% in developed countries smoke , with the prevalence of women's smoking reported to be higher than 25% in 32 countries . World-wide, male smoking rates are significantly higher (around 45%) compared to women, so why an editorial about women and smoking? Editorial space does not allow a detailed exploration of many possible responses to this question. Instead I discuss the severity of the tobacco epidemic among women, associated effects on health and income, the shameless attitudes of the tobacco companies to this health crisis, a theoretical model for looking at smoking rates and stages of related disease development, and the first global strategy to control this epidemic (Framework Convention on Tobacco Control: FCTC).
While tobacco use among men is on the slow decline, tobacco use among women has increased, and is expected to rise to 20% by 2025 . In some industrialized countries such as the United States, Denmark and Germany, more young women aged 14–19 years than men now smoke . Health, income and the family will be greatly affected by this significant increase in the smoking rates among women globally.
In the first half of this century tobacco will kill more people than malaria, maternal and major childhood conditions and tuberculosis combined . Like men, women suffer from tobacco-related health problems such as lung cancer, heart disease, chronic obstructive pulmonary diseases, infertility and many other illnesses. None the less, current research suggests that, dose for dose, women have a significantly higher risk of developing smoking-related illnesses such as lung cancer [4–7] and myocardial infarction  than men. In addition tobacco use results in specific health problems for women. Smoking among women may alter menstrual function [9,10], cause menopause at a younger age [10,11], increase the risk of cervical cancer [10,12] and breast cancer [10,13] and result in a lower bone density among post menopausal women .
Complications in pregnancy such as miscarriage [10,14], premature rupture of membranes [10,15], abruptio placentae [10,15,16], premature labour , intrauterine growth retardation [10,17], stillbirth [10,16], sudden infant death syndrome (SIDS) [10,17] and delayed milk production [10,18] can affect a woman's own health and that of the fetus and newborn baby. Smoking among women also causes a wide variety of adverse health effects in their children , including lower respiratory tract infections, asthma, middle ear infections, decreased auditory processing  and has been linked with maths, language and behaviour problems [21,22].
Existing evidence suggests an aetiological link between fetal exposure to nicotine and antisocial and criminal behaviour as well as substance abuse in male and female offspring [23–25]. While these findings are considered somewhat controversial , molecular animal studies of in utero exposure to nicotine have found disturbances in neuronal path-finding, abnormalities in cell proliferation and differentiation and disruptions in the development of the cholinergic and catecholaminergic systems . Reduced thickness of the cerebral cortex, smaller cerebral cortex neurons, reduced brain weight and an overall decrease in ‘dendritic branching’ was observed in rats following prenatal exposure to varying levels of nicotine .
A new study has found that when both parents smoke, they are more likely to conceive a female than when both parents do not smoke . It has been suggested that this may be because the sperm cells carrying the Y chromosome are more vulnerable to the toxins in the cigarette smoke.
Smoking is linked with socioeconomic status both within countries and across the globe. In developed countries the prevalence of smoking has declined among higher-income groups but has remained static among the lowest income quarter. Smoking is more concentrated among those who can afford it least, and has been cited as one of the principal causes of the inequality in death rates between rich and poor . Smoking has risen among poor women, and studies have demonstrated that poor women have greater difficulty quitting [30–32]. For example, in Britain the prevalence of smoking in unskilled workers’ households is twice as high as that in professionals’ households with even higher rates among unemployed, divorced, separated or single mothers . The lower the income, the higher the opportunity cost of money spent on cigarettes as that money spent on tobacco could feed families . In the United States smoking prevalence is nearly three times higher among women who have 9–11 years of education than those who have had 16 or more years of education .
Tobacco use has a negative impact on the health of economies causing economic losses. Developed countries benefit from tobacco business taking profits away from poor countries and leaving behind the disease. In addition to the utilization of scarce health resources to treat the diseases caused by tobacco use, many countries lose millions of dollars as the cost of importing tobacco far exceeds what is gained from exporting it . Rural women cope with the negative impact of tobacco production on food production and the environment due to deforestation. Further, by diverting part of the family income to buying cigarettes, there is less money available to buy food, which leads to a reduced calorie intake among children of the developing world . A study in Bangladesh found that a typical poor smoker's daily tobacco expenditure could add over 500 calories to the diet of one or two children, if spent on food. At a national level, it was estimated that 10.5 million currently malnourished people could have an adequate diet if the money spent on tobacco was spent on food instead . The economic arguments espoused by the tobacco industry of providing employment for many people have to be balanced against the social and economic drain that tobacco costs the economy in the health field .
MARKETING TO WOMEN
Internal tobacco industry documents released through litigation have exposed the industry's attempts to ‘entice, attract and capture our share of the woman with her new thoughts and independence’. Successful marketing has been attributed (as in the case of Virgina Slims) to be keyed to ‘selecting a definitive target audience and capturing quickly by being the “first with the most”’. The first ever brands to be developed by the Chinese tobacco industry locally are aimed at women .
So while women have indeed ‘come a long way’ in being able to enter and sustain jobs in the work-force, they are being lured to spend their newfound wealth on cigarettes. Notice that the advertisements refer to her still as a ‘baby’. She has developed, but is still somebody's baby. Clearly, after she has smoked regularly for only a short while she will be the baby of the cigarette industry, having become addicted to the nicotine and dependent on their product. Tobacco companies are ‘in the business of selling nicotine, an addictive drug’.
Another powerful ploy utilized by the tobacco companies is the marketing and promotion of ‘mild’ or ‘light’ brands of tobacco to encourage people to start smoking and to keep smoking rather than quitting . ‘Light’ when added to a product name is particularly appealing to women and the promotion of light cigarettes has proven to be even more successful than the development of women-only cigarette brands with more than half of all female cigarette smokers in the EU countries smoking ‘light’ cigarettes . The tobacco industry has, however, known for years that ‘the smoker of a filter cigarette was getting as much or more nicotine and tar as he would have gotten from a regular cigarette’. The Framework Convention Alliance (March 2002) has demanded that one of the 10 key issues for global tobacco control and the FCTC be that clearly misleading brand names using words like ‘light’, ‘mild’ and ‘ultra low’ be banned .
Stages of the tobacco epidemic
The evolution of tobacco use follows the curve of an epidemic in stages, rather than a series of isolated events . Stage 1 is characterized by low uptake of smoking and low cessation rates. Examples of countries in this stage of the epidemic include Nigeria, Malawi, Swaziland, the Democratic Republic of the Congo and Ghana.
These countries have not yet been drawn into the global tobacco economy, and represent a major untapped market for the tobacco industry and are ripe for expansion by multi-national tobacco companies. In the words of a public affairs manager of Rothmans Ltd: ‘It would be stupid to ignore a growing market’.
Current lower levels of tobacco use among women reflect social and religious traditions and women's low economic resources. Stage 1 was apparent in western countries in the early 20th century. However, following tobacco advertising geared towards women, for example in North America and Northern Europe, smoking rates among women aged 19 to 25 years increased significantly, moving the tobacco epidemic into stage 2 in these countries.
Stage 2 of the tobacco epidemic is characterized by increases in smoking rates among women and an increase to 50% or more among men. While tobacco-related mortality rates are high among men, there is little tobacco-related female mortality. This stage of the epidemic is exemplified in some countries in Asia (Philippines, China), North Africa (Yemen) and Latin America (Mexico).
In stage 2, tobacco control activities are not well developed and the health risks of smoking are not widely known. Also, there is low public and political support for the implementation of tobacco control measures. In this stage smoking is used to signal wealth and upward mobility; doctors have high smoking rates in these countries, e.g. among Chinese doctors, 61% of males and 12% of females smoke .
In stage 3 of the tobacco epidemic there is a marked downturn in smoking prevalence among men, and a plateau and then gradual decline in women. However, mortality from smoking continues to increase reflecting the higher prevalence of smoking among men 30–40 years previously in stage 2 of the epidemic. The narrowing of gender-specific differences in smoking prevalence in industrialized countries occurred predominantly between 1965 and 1985. Many countries in Eastern and Southern Europe (e.g. Luxembourg, Switzerland and Turkey) are at stage 3 of the epidemic.
Smoking-attributable deaths comprise 10–30% of all deaths, with about three-quarters of these occurring in men.
In stage 3, health education and media coverage erode public acceptance of tobacco use, and the educated population views smoking as undesirable.
Stage 4 is marked by further declines in smoking prevalence among men and women, with numbers of new smokers starting to decrease. Deaths attributable to smoking among men peak and subsequently decline. Among women, smoking attributable deaths continue to increase. Countries that exemplify this stage include Australia where daily smoking prevalence is 21% (males) and 18% (females)  and where 10% of all deaths among women and 19% among men in 1998 were attributable to smoking . Other countries at this stage of the epidemic include Canada, the United States and the United Kingdom. While overall smoking rates are declining during stage 4, the decline in smoking rates among the poor and unskilled may be much less.
Sustained national commitment to programs that reduce tobacco use is essential for continuing progress. Programmes and policies now deglamourize and discourage tobacco use, and emphasize that non-smoking is the norm among most women. Since 1985 the decline in prevalence among women and men has been comparable. More than three-quarters of women want to quit smoking and nearly half report having tried to quit during the previous year .
Smoking is also related to level of wealth, with cessation rates higher among the more affluent and better-educated countries.
GLOBAL STRATEGIC RESPONSE TO TOBACCO
The challenge at the national level is to translate these stages of the tobacco pandemic into terms that local policy makers will understand. It is important to encourage and support multinational policies that discourage the spread of smoking among women in countries where smoking prevalence has traditionally been low. The long-term goal is to reduce smoking prevalence and consumption in all countries, and thereby reduce the burden of disease caused by tobacco. The FCTC is an important international legal tool of the Tobacco Framework Initiative (TFI) that aims to limit the spread of tobacco use through protocols that cover tobacco pricing, smuggling, advertising, pack markings, misleading claims and descriptors, taxes, tobacco subsidies and other activities.
Further, the TFI is investigating the exploitation and targeting of young women by the tobacco industry. Dr Brundland, Director-General of the WHO calls for gender-sensitive health education and quitting programmes. Many health policies and tobacco control programmes have gender bias. ‘Gender’ is defined as the social, economic and cultural construct of the relations between men and women and, as such, it underlies the social construction of tobacco promotion, consumption and treatment and health services . In many tobacco control programmes, women are seen mainly in terms of reproductive health issues. This reflects a male-biased tradition in which women are valued primarily in their role as reproducers, and as somebody's ‘baby’, rather than functioning productively throughout their life.
It also affects women's lack of participation in health policy decision-making. Women need to be promoted to senior positions in the tobacco control movement, and in governmental and non-governmental organizations that deal with tobacco issues.
Prevention works. So why do we not do it more? The World Bank shows that raising taxes on tobacco results in a reduction in consumption. A 10% increase in price of tobacco would lead to a 7% decrease in demand in developing countries and 4% in industrialized countries . The effect is enhanced if the excise tax is used to fund health promotion campaigns and to reduce smuggling.
One century ago it would never have been envisaged that a stigmatized behaviour such as female smoking would be transformed with clever marketing into a socially acceptable and desirable practice. The challenge now is to develop women-centred tobacco control programmes to stop the epidemic getting past the first stage of the continuum particularly in developing countries, and when it has, to accelerate it into the fourth stage of low smoking rates and low mortality and morbidity.