Abstract: Smoking prevalence is lower among women than men in most countries, yet there are about 200 million women in the world who smoke, and in addition, there are millions more who chew tobacco. Approximately 22% of women in developed countries and 9% of women in developing countries smoke, but because most women live in developing countries, there are numerically more women smokers in developing countries. Unless effective, comprehensive and sustained initiatives are implemented to reduce smoking uptake among young women and increase cessation rates among women, the prevalence of female smoking in developed and developing countries is likely to 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 the population of women in the world is predicted to rise from the current 3.1 billion to 4.2 billion by 2025. Thus, while the epidemic of tobacco use among men is in slow decline, the epidemic among women will not reach its peak until well into the 21st century. This will have enormous consequences not only for women's health and economic wellbeing but also for that of their families. The health effects of smoking for women are more serious than for men. In addition to the general health problems common to both genders, women face additional hazards in pregnancy, female-specific cancers such as cancer of the cervix, and exposure to passive smoking. In Asia, although there are currently lower levels of tobacco use among women, smoking among girls is already on the rise in some areas. The spending power of girls and women is increasing so that cigarettes are becoming more affordable. The social and cultural constraints that previously prevented many women from smoking 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 companies are targeting women by marketing light, mild, and menthol cigarettes, and introducing advertising directed at women. The greatest challenge and opportunity in primary preventive health in Asia and in other developing areas is to avert the predicted rise in smoking among women.
“There can be no complacency about the current lower level of tobacco use among women in the world; it does not reflect health awareness, but rather social traditions and women's low economic resources.”
Dr Gro Harlem Brundtland, former Director-General of World Health Organization, 19981
Smoking is still seen mainly as a male problem, since in most countries, especially developing countries, smoking prevalence is much lower among women than among men (Fig. 1). The prevalence of male smoking in many countries in Asia, such as China, Indonesia, Thailand and Korea, and in much of the Middle East, is 10 or more times greater than the female prevalence rates, a pattern which contrasts with that in Europe and the Americas. Only in New Zealand is the prevalence of female smoking equal to that of men.
It is currently estimated that there are already 200 million women in the world who smoke, and in addition, in South Asia millions more women chew tobacco.2 In Mumbai, India, for example, 56% of women chew tobacco.3
Approximately 22% of women in developed countries and 9% of women in developing countries smoke,4,5 equivalent to about 250 million women around the world, but because most women live in developing countries, there are numerically more women smokers in developing countries.
Women have traditionally started smoking later, consumed fewer numbers of cigarettes than men and smoked lower tar brands. The pattern of smoking among and between women and men differs according to the stage of the smoking epidemic in each country (Fig. 2).
Cigarette smoking among women is declining in some developed countries, notably the USA, UK, Canada and Australia,7,8 but is still increasing or is static in several Southern, Central and Eastern European countries.9 More girls than boys are now smoking in some Western countries, such as the UK, Sweden, Austria, Denmark, Finland and Germany.
Thus, while the epidemic of tobacco use among men is in slow decline, the epidemic among women will not reach its peak until well into the 21st century. This will have enormous consequences not only for women's health and economic wellbeing but also for that of their families.
In developing countries, although women smoke less, there is great concern that the numbers of women smokers might rise because:
1The female population will rise from the present 3.1 to 4.2 billion by 2025, so even if the prevalence remains low, the absolute numbers of smokers will increase. This would mean that by 2025 there could be as many as 532 million women smokers.
2The spending power of girls and women is increasing so that cigarettes are becoming more affordable.
3The social and cultural constraints that previously prevented many women from smoking are weakening in some countries.
4The tobacco companies are targeting women with well-funded, alluring marketing campaigns, linking smoking with emancipation and glamour.
5Many gender specialists, women's organizations, women's magazines, models, film and pop stars, and other female role models have failed to recognize that smoking is a women's issue, or the need to take an appropriate stance.
6Women-specific health education and quitting programmes are rare, especially in developing countries.
7Governments in developing countries may be less aware of the harmful effects of tobacco use and are preoccupied with other health issues. Where they are concerned with smoking, they focus on the higher levels of male smoking. In fact, no developing country is addressing the emerging female epidemic to the extent the problem warrants.
HEALTH EFFECTS OF TOBACCO USE
Active tobacco use
The scientific evidence has shown conclusively that both smoked and smokeless tobacco cause fatal and multiple disabling health problems throughout the life cycle.
The younger a girl starts to smoke, the more likely she is to smoke heavily, become more dependent on nicotine, and be at greater risk for smoking-related illness and death.10
Because the health effects of smoking only become fully evident 40–50 years after the widespread uptake of smoking, the full global impact of smoking on women's health will not be seen for some decades. Smoking currently kills around half a million women in developed countries and 0.3 million in developing countries each year. In Asia, tobacco accounts for less than 5% of total female adult deaths, with the exception of Australia, Japan and New Zealand.2 However, the numbers are increasing rapidly.11 Between 1950 and 2000, around 10 million women died from tobacco use, but it is estimated that over the next 30 years, tobacco-attributable deaths among women will more than double.12
Women who smoke have markedly increased risks of cancer, particularly lung cancer, heart disease, stroke, COPD and other fatal diseases. If they chew tobacco, they risk oral cancer. In addition to these health risks that women share with men, women face particular problems linked to tobacco use.12–15 These include:
1Female-specific cancers, such as cancer of the cervix.
2Coronary heart disease: an increased risk with use of oral contraceptives.
3Menstruation: irregular cycles, higher incidence of dysmenorrhoea.
4Menopause: women who smoke tend to enter menopause at age 49 years, 1–2 years before non-smokers. This places them at a greater risk for heart disease and osteoporosis, including hip fractures, as well as an increased incidence of hot flushes.
5Pregnancy: Smoking in pregnancy causes increased risks of spontaneous abortion (miscarriage), ectopic pregnancy, low birth weight, higher perinatal mortality, and long-term effects on growth and development of the child. Many of these problems affect not only the health of the foetus, but also the health of the mother. For example, a miscarriage with bleeding is dangerous for the mother, especially in poor countries where health facilities are inadequate or nonexistent.
6Infertility: smoking is linked to infertility in both sexes and to delay in conceiving.
Many women, even in developed countries, are unaware of the extent of these risks.16 In a survey among female hospital employees in the USA, nearly all were aware of increased complications in pregnancy (91%), but only a minority knew of the increased risk of miscarriage (39%), and even fewer knew of the increased risk of ectopic pregnancy (27%), cervical cancer (24%) and infertility (22%).
ENVIRONMENTAL TOBACCO SMOKE
Professor Takeshi Hirayama's cohort study in 1981 on lung cancer in 91 000 non-smoking Japanese wives married to men who smoked was the first conclusive evidence on the harmfulness of passive smoking,17 and these findings have been confirmed by a myriad of studies around the world.13,18 Research has also shown other risks of passive smoking, including heart disease and stroke. As the majority of smokers in the world are men, women are at particular risk from environmental tobacco smoke at home. Women working outside the home may be exposed to passive smoking in workplaces where smoking is still permitted.
Women's smoking may impact on the health of their families. In addition to a woman's smoking during pregnancy impacting on the health of the foetus, smoking by the father (or other close adult) can also cause complications during pregnancy, such as low birth weight.
Children are at particular risk from adults’ smoking. A WHO consultation in 1999 concluded that passive smoking is a real and substantial threat to child health, causing death and suffering throughout the world.19 About 40% of the world's children are exposed to passive smoking in the home and a further 61% in public places.20 Adverse health effects include pneumonia and bronchitis, coughing and wheezing, worsening of asthma, and middle ear disease, and possibly neurobehavioural impairment and cardiovascular disease in adulthood.14,21 Children of smokers are also more likely to become smokers themselves.
ECONOMIC IMPACT OF TOBACCO USE
Tobacco use carries a serious economic debit to governments, to employers and to the environment, which includes social, welfare and healthcare costs; loss of foreign exchange in importing cigarettes; loss of land that could grow food; costs of fires and damage to buildings caused by careless smoking; environmental costs ranging from deforestation to collection of smokers’ litter; absenteeism; decreased productivity; higher numbers of accidents; and higher insurance premiums.
There are many economic effects related to women and tobacco, including:
1Expense of buying cigarettes (diverting money from other family purchases).
2Costs of ill-health, which can range from medical bills to loss of income.
3Costs of premature death.
4Costs of looking after relatives affected by tobacco.
5Costs of widowhood or even destitution if a male breadwinner dies from smoking.
The economic costs to the smoker include money spent on buying tobacco. Farmers near Shanghai spend 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 average daily income.23 In many developing countries, there is minimal or no state health care, no unemployment or disability allowances, no pension and no institutionalized care for the elderly or sick, all of which place the economic and social burden of tobacco onto the family.
These effects are particularly severe for poorer women in poorer countries. Healthcare facilities now or in future will be hopelessly inadequate to cope with this epidemic. More than 70% of the estimated 1.3 billion people living in poverty are women.24
Several studies have suggested that women may find it more difficult to quit smoking than men. The reasons are not well understood,25 but it is likely due to a combination of biological, psychological and social factors as well as reduced accessibility to quitting advice and treatment.
Few developing countries have comprehensive data on the prevalence or numbers of ex-smokers and data from cessation studies come predominantly from Western countries. These consistently show lower quit rates in women compared to men with nicotine replacement therapy.25 Similarly, studies of self-quitters have found that women were less likely to quit initially or to remain abstinent at follow up. British data show that, despite a similar desire to quit, women feel more dependent on their smoking than do men.26 Women are more likely to say that they would find it very difficult to go without smoking for a whole day than men who smoke the same amount.
In many developed countries men and women smokers show similar levels of motivation to quit, but many women appear to face additional barriers to quitting, particularly those who are disadvantaged such as low income mothers. It is becoming more widely accepted, therefore, that tailored approaches to cessation are needed.17,27–29 These programmes and services need to be accessible to women throughout their life course and should be integrated into quality and affordable health services.
Assistance with cessation is virtually nonexistent in many developing countries, although most countries in Asia joined the 2002 Quit & Win Campaign, and all participated in World No Tobacco Day, which always carries a quitting perspective. The value of specific quitting programmes for women remains uncertain, although there is an untested belief that such programmes may be particularly suited to women in Asian countries.
THE TOBACCO INDUSTRY
British American Tobacco had a view on gender a quarter of a century ago.
“Smoking behaviour of women differs from that of men . . . more highly motivated to smoke . . . they find it harder to stop smoking . . . given that women are more neurotic than men it seems reasonable to assume that they will react more strongly to smoking and health pressures . . . there may be a case for launching a female oriented cigarette with relatively high deliveries of nicotine . . .”.30
Following a ruling in the USA law courts, previously secret and internal industry documents have now been revealed to the public. These show that on a global basis, the multinational tobacco industry has consistently lied or obscured the truth – to governments, to the media and to smokers.31,32 Nowhere has this been more evident than in developing countries, which often lack the expertise to challenge the industry.
Their interest in Asia is intense. A search of a website collection of documents shows the industry's greatest interest in Asia is China, Australia, Japan, Korea, the Philippines, Thailand, New Zealand, and Indonesia.3
The industry journal Tobacco Reporter ran an editorial about the Asian market that stated:
“Rising per-capita consumption, a growing population and an increasing acceptance of women smoking continue to generate new demand.”31
The tobacco industry promotes cigarettes to women using seductive images of vitality, slimness, emancipation, sophistication, and sexual allure.13,32–35
Until the 1980s, there was relatively little tobacco promotion in developing countries. The national monopolies did not, in general, promote their products, or did so only minimally. But from the 1980s, the transnational tobacco industry introduced tobacco advertisements. Many of the initial advertisements were very ‘masculine’, such as the Marlboro cowboy, but gradually a whole range of advertisements were produced, moving from ‘men-only’ advertisements; through ‘neutral’ advertisements showing, for example, both men and women enjoying the scenic outdoors; to ‘women-only’ advertisements in the mid-1980s. Some of the monopolies and national companies, such as in Japan and Indonesia, then began to copy promotion that targeted women.
The tobacco companies also started producing what could be called ‘feminized’ cigarettes – long, extra-slim, low-tar, light-coloured and menthol. Some companies produced special gift packs and offers designed to appeal to women. In Taiwan, tobacco companies launched gift packs for the Lunar New Year, with the Yves St Laurent luxurious gift pack containing two cartons of cigarettes plus one crystal item. The 555 gift packs had either a tea set or an ashtray, and the Virginia Slim Lights gift packs included stylish lighters suitable for women smokers. In Australia, there have been Alpine fashion keyrings, bags and silk underwear. In Japan, purchasers of Mila Schon cigarettes have had the chance to win handbags and ladies watches. In some countries young women are being targeted through direct mail shots: graduates of Tokyo Women's University were sent, unsolicited, sample packets of Salem to their home addresses.
Although it is mainly men's sports that are sponsored in developing countries, these are watched by women. For example, 46% of spectators at the Hong Kong Salem Tennis event in 1993 were women. Michael Chang, who plays regularly in Marlboro and Salem tennis events in China, Japan, the Republic of Korea and Hong Kong, enjoys idol status with many teenage girls throughout Asia, who could be forgiven for believing he smokes Salem.
In Sri Lanka the Ceylon Tobacco Company hired young women to drive around in ‘Players Gold Leaf’ cars and jeeps handing out free cigarette samples and promotional items. These women also handed out free merchandise at popular shopping malls and university campuses.36 In a country where only 2% of women smoke, this seemed to be part of a wider strategy to challenge the social taboo that respectable women in Sri Lanka should not smoke and certainly not in the street.
Brand-stretching and sponsorship in Asia includes women's football, and using cigarette names for travel holidays, bistros, jewellery shops, etc. Arts sponsorship provides the tobacco industry with an aura of culture, glamour and respectability, sponsoring events that appeal to women as well as men. Events in Asia have included Peter Ustinov (Hong Kong, 1992); Tony Bennett Jazz concerts (Thailand, 1993); Central Ballet of China (1994); Andrew Lloyd Webber's ‘The Phantom of the Opera’ sponsored by Philip Morris (Hong Kong, 1995); ASEAN Arts Awards (ASEAN, 1999), and in New Zealand there are the Benson and Hedges Fashion Design Awards.
Events and activities popular with the young also receive sponsorship. Admission to films and pop or rock concerts has been either free, or free tickets have been given in exchange for empty cigarette packets (Taiwan 1988, Hong Kong 1994). In 2002, British American Tobacco organized a huge musical celebration in Indonesia, clearly designed to attract the young.37 International film stars have accepted money from the tobacco industry for product placement in their films, and such films are shown around the world.
Tobacco control strategies are highly cost-effective, and much more cost-effective than treating patients with lung cancer, chronic obstructive airways diseases and other tobacco-related illnesses. Public policy, legislation, research, and education need to be geared specifically towards preventing girls from initiating smoking and helping women quit.12 Over the past 10 years there has been a growing recognition, at both international and national levels, of the growing impact of smoking on women's health around the world. However, action on this issue has tended to be restricted to those countries with the longest history of female cigarette smoking.
International and regional level
The former Director-General of WHO, Dr Gro Harlem Brundtland, recognized the importance of tobacco as a women's issue and has initiated programmes, funding and meetings around the world. An international meeting on women and tobacco took place in Kobe, Japan in November 1999. This drew in, for the first time, women's organizations beyond the traditional tobacco control groups, culminating in The Kobe Declaration on Women and Tobacco. In the Western Pacific Region, all three 5-year action plans on tobacco or health since 1990 have emphasized the importance of preventing a rise in smoking among women as a high priority. The Tobacco Atlas, published by WHO, gives considerable prominence to tobacco use among girls and women.3
The Framework Convention on Tobacco Control, WHO's first convention, and also the first attempt to use international legislation to promote public health, is currently being negotiated between member states. It is dedicated to incorporating gender issues in the convention and its protocol, including the language used.
The World Bank
The World Bank's report, Curbing the Epidemic, marked the first time a major financial institution had supported policies designed to reduce tobacco demand.2 The document argues that tobacco control is good for the wealth as well as the health of nations; that it does not lead to loss of taxes or jobs; and that tobacco control measures (e.g. price increases, advertising bans, smoke-free areas, health education, pharmaceutical assistance in quitting) are cost-effective in both industrialized and developing countries. Men and women are not specifically indexed, but the findings have relevance to both.
International non-governmental organizations
The International Network of Women Against Tobacco was founded in 1990 to address the issues around tobacco and women. It has members in about 60 countries. Other non-governmental organizations involved with tobacco often include women and tobacco as part of their work. The Chest Foundation, linked to the American College of Chest Physicians, has taken a particularly active role in women and tobacco, producing a speakers kit which is currently being adapted for Asia. GLOBALink, the Internet network based at the Union Internationale Contre le Cancer headquarters in Geneva, links tobacco control advocates all over the world, and has a specific website devoted to tobacco and women.
The 10th World Conference on Tobacco or Health in Beijing in 1997, pioneered gender equity in world conferences. Fifty per cent of all committee members, chairs and invited speakers were women. When funding was offered to developing countries for two delegates, it was suggested that one be female. In 1998, the European Union, through Europe Against Cancer, organized the first European conference on women and tobacco in Paris.
Asia Pacific Association for the Control of Tobacco
The Asia Pacific Association for the Control of Tobacco, first established by the late Dr David Yen in Taipei in 1989, organizes biennial regional meetings. Delegates from many countries find the smaller regional meetings more supportive than the large, international conferences, and such meetings facilitate delegates, especially women, speaking out. Many papers have been presented on women and tobacco in the Asia–Pacific region.
At a national level, governments have a central and crucial role in tobacco control, especially in the area of legislation and tobacco tax increases. Without government leadership and commitment, tobacco control measures – especially in developing countries – are unlikely to succeed. Many governments are preoccupied with other problems, such as high infant mortality, communicable diseases, economic difficulties or political conflict; they lack funds; and have little experience in dealing with the tactics of the transnational tobacco companies. In addition they may be reluctant to act because of the mistakenly perceived economic ‘benefits’ of tobacco.
The lead government ministry is usually the Ministry of Health, but women's commissions or ministries should be active. For example, in 2001 the Women's Commission in Hong Kong concluded that smoking was a women's issue, and in order to protect women workers and diners, endorsed the government's legislative proposals to ban all smoking in all workplaces and restaurants.
Yet many developing countries have implemented tobacco control programmes, including legislation, far ahead of many Western countries, without any severe economic consequences. For example, legislation in Singapore, Fiji, Mongolia, Hong Kong, South Africa, Thailand and Vietnam is far ahead of many Western countries. Many tobacco control measures cost little other than political will; for example, legislation requiring health warnings on cigarette packets; or the creation of smoke-free areas in government buildings, public areas, transport, or schools. However, many tobacco control programmes in both developed and developing countries continue to take a gender-neutral or gender-blind approach.
The challenge facing us at the beginning of the 21st century is how to stem the female wave of the tobacco epidemic, particularly in developing countries and among disadvantaged women in developed countries. There needs to be wider recognition that women's tobacco use is a global health problem and that effective women-centred tobacco control programmes should be implemented at international as well as national levels.
Unless there is a strong, coordinated effort with the aims of preventing girls from starting to smoke, and of assisting cessation, the tobacco epidemic will take a terrible toll on women all over the world. Nowhere will it be felt more keenly than in Asia.