Gender and smoking habit: Are women the “sleeping giant of the global smoking market”?
Francesco Tosetto1, Giovannella Baggio2
1. Student of the Medical School of the University of Padua;
2. Chair of Gender Medicine, Department of Molecular Medicine, University of Padua, Italy.
Received on 26 January 2016.
*Francesco Tosetto is a student of the Medical School of the University of Padua (Italy) and this article is a summary of his short thesis prepared for the examination of the Gender Medicine Course.
Summary. Cigarette smoking was a male habit in the first half of the 20th century but after the decrease in smoking prevalence in men during the 1960s, tobacco companies chose women as their new target. Many products with particular features such as cigarette size (slim and extra slim cigarettes) and ‘taste’ were introduced and an aggressive global advertising targeted to women linked smoking to desirable female attributes, such as independence, glamour, stress relief and weight control. This gendered messaging has led to the massive uptake of smoking among girls and women in middle and higher income countries. In the past 50 years the health system in Western countries has not investigated women-specific cigarette use despite the success of these approaches by the tobacco industry. This mistake should not be repeated in low income countries, where women are now considered “the sleeping giant of the global smoking market” by tobacco companies. The global prevalence of smoking is currently far higher among men than women but in the last few decades the decrease in smoking prevalence was lower among women than among men and now more girls than boys are smokers. The prediction is that 20% of the female population will be smokers by 2025. Women-centered approaches are necessary to avoid this large uptake of smoking especially among women in low income countries. These approaches include recognizing the influence of gendered tobacco industry marketing, the social and cultural contexts in which women’s smoking occurs and the functions that it performs in their lives.
Il genere e il fumo di sigaretta: le donne sono “il gigante addormentato del mercato globale delle sigarette”?
Riassunto. Il fumo di sigaretta all’inizio del XX secolo era un’abitudine prevalentemente maschile, ma dopo gli anni 60, con il diminuire della prevalenza del fumo nell’uomo, le compagnie produttrici di tabacco identificarono le donne come nuovo target. Si realizzarono quindi molti prodotti con caratteristiche particolari per quanto riguarda le dimensioni (sigarette sottili ed extrasottili) e il “gusto”, inoltre veniva programmata una reclamizzazione aggressiva che collegava l’abitudine al fumo della donna con caratteristiche come l’indipendenza, il fascino, l’azione antistress e il controllo del peso. Questi messaggi finalizzati al genere femminile hanno portato a un massivo aumento dell’abitudine al fumo tra ragazze e donne di paesi a medio e alto reddito. Nei paesi occidentali i sistemi sanitari nazionali, negli ultimi 50 anni, non hanno studiato il problema dell’abitudine al fumo di sigaretta in modo genere-specifico, malgrado il successo che le industrie produttrici avevano ottenuto nel mondo femminile. Questo errore non deve essere ripetuto per i paesi in via di sviluppo, dove le donne sono ora considerate “i giganti addormentati del mercato globale delle sigarette”. La prevalenza globale al fumo di sigaretta è ancora maggiore tra gli uomini, ma negli ultimi decenni la diminuzione dell’abitudine al fumo è inferiore tra le donne che tra gli uomini, inoltre attualmente molte ragazze e ragazzi sono fumatori. Si prevede che nel 2025 il 20% della popolazione femminile sarà fumatrice. Una prevenzione finalizzata al mondo femminile è dunque necessaria per evitare, soprattutto nei paesi in via di sviluppo, l’abitudine al fumo delle donne. Questo approccio deve passare attraverso il riconoscere l’influenza che ha il marketing orientato al genere delle industrie del tabacco, il contesto sociale e culturale nei quali la donna inizia a fumare e il significato che il fumo assume nella loro vita.
History of cigarette smoking
Cigarettes were first introduced in 1840 in the United States, but they were not very widespread, because they were hand-made products. In 1885 the American businessman James Buchanan Duke started to produce and sell modern cigarettes made with machinery invented by James Albert Bonsack.
During the 20th century cigarette consumption increased and substituted other forms of tobacco use (pipe, cigar, smokeless tobacco) and for this reason was defined “the cigarette century”1.
The tobacco industry was the main responsible of this diffusion thanks to a technological and industrial innovation, resulting in large-scale production of cigarettes and their features (a cheap and easy-to-inhale mass product) helped distribution.
There was also an aggressive advertising campaign. In the 1950s athletes, doctors, celebrities, and famous actors publicized cigarettes as popular, classy and refined. Cigarettes were also introduced in films and TV shows and tobacco brands were sponsors of the main TV networks.
At the beginning of the 20th century, smoking was a male habit but some women of the high society began to smoke (also secretly)2. Smoking among women began to increase in Great Britain and in the US, and some women smoked openly in the 1920s, as social and cultural changes lessened the taboos which had discouraged tobacco use by women2. In other industrialized countries, smoking in men and women began a few decades later. Cigarette consumption increased until the 1960s (50% of men and 33% of women were smokers in the US)3.
In the 1920s the rise of lung cancer prompted research on its causes and these initial studies found an association between lung cancer and tobacco smoking that was confirmed in research studies in the 1940s and 1950s. In these years, the industry followed strategy of denying the harm of its product, discrediting scientific evidence that showed this harm, funding research that was intended to divert attention from cigarettes, and marketing new products with implied lower risks than existing products3.
The first official document that underlined the health risk of smoking was the “Report of the Surgeon General” in 1964. This report stated that “Cigarette smoking is causally related to lung cancer in men” and that “The data for women, though less extensive, point in the same direction”4.
After the publication of this report, smoking prevalence in men started to decrease in the 1960s and tobacco companies chose women as a new target for their products. In that period many brands and products designed for women were introduced and were publicized through the mass media and female magazines (in the 1968 there was the introduction of the first female brand “Virginia Slim”). Global advertising to women sought to link smoking to desirable female attributes such as independence, modernity, glamour, stress relief and weight control. Brands also employed particular features such as cigarette size (slim and extra slim cigarettes), ‘taste,’ images and packaging to attract women5. Cigarettes were represented as the “torch of freedom”6.
After the discovery of drug addiction there was a shift from the earlier science of smoking. In fact, researchers studying the health effects of smoking during the 1960s and 1970s were primarily epidemiologists and pathologists who were focused on the consequences of smoking and not on why people smoked. During the 1970s, scientists who had studied other drug addictions turned their attention to cigarette smoking, developing methods to measure nicotine intake and smoking behavior. These researchers found that nicotine causes addiction3.
In 1988 the Report of the Surgeon General stated that “cigarettes are addicting, similar to heroin and cocaine, and the nicotine is the primary agent of addiction.”7 Before the publication of this document, smoking was considered a form of habituation rather than addiction4. At the same time, as regular smoking was so widespread and socially accepted during the 1960s, scientists were reluctant to portray smokers as addicts or as presenting a threat to society3.
In 1981 came the publication of the first research study that linked secondhand smoking to increased risk of lung cancer8. The discoveries of diseases linked to secondhand smoke prompted the introduction of several laws regulating ambient smoking in public places.
From the 1980s there has been a decrease in smoking prevalence and cigarette consumption through many types of measures. The most cost-effective ways of reducing tobacco consumption have been price increases through tobacco taxes and the creation of smoke-free environments. Other non-price measures, such as comprehensive bans on tobacco advertising, sponsorship and promotion, strong warning labels and wide dissemination of information in support of these key policy interventions, have also been effective.
Globally, tobacco use killed 100 million people in the 20th century, much more than all the casualties in World War I and II combined5.
There are 1 billion smokers in the world (820 million men and 176 million women)5.The highest smoking prevalence is in China (one third of smokers are Chinese) followed by Russia and the US5.
The global prevalence of smoking is currently far higher among men than women (41% versus 12% in 2005) but globally it is declining in men and rising in women9. Cigarette prevalence is declining in men and women in high-income countries but is increasingly concentrated among disadvantaged women9. For example, in Britain in 2009, 13% of women in the highest socio-economic group smoked compared to 30% in the lowest group10. In these countries the gap between men’s and women’s smoking prevalence is narrow9.
In low-income and low-middle income countries (and in the regions of Africa, Southeast Asia, Eastern Mediterranean and Western Pacific) women’s smoking prevalence remains under 5% and there is a huge gap in smoking prevalence between men and women9.
The tobacco industry thinks that women in these countries are “the sleeping giant of the global smoking market,” a giant that once awakened will mean huge profits for the companies that can attract them. For this reason, tobacco companies are promoting slim and super-slim brands with aggressive marketing campaigns that portray smoking as attractive and stylish10 and the diffusion of the idea of tobacco as a symbol of equality and independence11. The prediction is that by 2025, 20% of the female population will be smokers, up from 12% in 200512.
Tobacco use kills more than 5 million people a year, and it is expected to rise to 8.3 million by 2030. Eighty per cent of these deaths will be in low and middle income countries13.
Gender and smoking
Women started to smoke later than men but the gender gap in cigarette smoking has been closed over the years. In the last few decades the decrease in smoking prevalence was lower among women than among men and now more girls than boys are smokers. Female smoking prevalence rates are usually lower than male prevalence14, but there are some exceptions such as Sweden and Iceland.
Historically, women started to smoke at a later age than men, but from the 1960 cohort the age of smoking initiation has not shown any gender difference2.
There are differences between men and women in cigarette smoking patterns, biological response to nicotine, progression to dependence, maintaining abstinence, efficacy of smoking treatment, and health consequences of tobacco smoking15.
Women smoke fewer cigarettes a day than men14 and use cigarettes described as “light,” “mild,” or “low-tar” that are specifically targeted at women and can raise the belief that they are consuming safer tobacco products12. Women become nicotine-dependent with less tobacco use compared to men. However, the degree of dependence is similar in males and females15. Some studies have attributed this increased sensitivity to developing nicotine dependency to women’s smaller size, higher percentage of body fat and slower clearance of nicotine from the body2.
Women and men perceive the function of smoking differently15. Cigarette smoking in women has the role of controlling emotions, creating an image and identity14. Negative mood states play an important role in modulating tobacco use in women16. Women usually smoke to “cope” with stress, anger, anxiety, boredom or feelings of unhappiness11 and to produce positive moods2. For women, cigarettes are “best friends”, sources of dependable comfort or support that offer anchorage and a source of control of negative emotions14. Women tend to smoke more than men when they are stressed to induce a state of relaxation16 and they do not quit because cigarettes help them cope with anxiety16. Tobacco use produces dependence that is driven in large part by avoiding anxiety due to the removal of nicotine during abstinence16.
Men report enjoyment and liking being a smoker as the main motives to keep smoking15 and they smoke more out of habit or to enhance positive sensations17.
Depression and anxiety disorders are about twice as common among women as among men11. Depression is strongly associated with smoking17 and this makes the association between smoking and depression a critical issue for women’s health11.
Women quit smoking more than men when they are between 16 and 42 years old, equally between 43 and 50 and less after 50 years old. Menopause, with its changes in mood and difficulties to maintain weight, is seen as an obstacle to smoking cessation2.
Moreover, women are more likely than men to try quitting smoking2, but have more difficulty in giving up and in staying abstinent after quitting. Nicotine replacement therapy may be less effective among women than men12. Many studies have stated that it is more difficult for women to quit because they have more symptoms of nicotine dependence, more severe withdrawal symptoms or longer duration of withdrawal symptoms than men2. Women tend to relapse faster and have more difficulties in sustaining abstinence in the first 1-2 days of smoking cessation15.
There are also gender differences in the reason for quitting smoking. Women want to stop smoking to improve their health, to avoid smoking-related diseases (for them and for their children during pregnancy)2, to be a good model for their children and for cosmetic reasons such as skin problems15. Men want to give up smoking to improve their physical fitness15.
The most frequent reasons given for relapse are generally similar for women and men2. They equally report addiction or craving for cigarettes and the pleasure of smoking as the reason for relapse2. Women usually relapse for the symptoms associated with nicotine withdrawal or because they are irritated or nervous and they find smoking relaxing. During smoking abstinence, women experience more negative mood states such as depression, stress and anxiety than men and the anxiety-reducing effects of smoking are the main reason for relapse16. Women are more likely than men to report fear of weight gain as a reason for relapse2. Men usually give up during positive events such as party or special events.
There is a strong relationship between smoking, body weight and self-image among women. Many women think that smoking is good for weight control because it reduces appetite2. Women’s concerns about weight may encourage smoking initiation, may be a barrier to smoking cessation, and may increase relapse rates among women who stop smoking2 because women tend to gain more weight than men after quitting18.
The tobacco industry has marketed cigarettes from a gendered perspective19 and this gendered messaging has led to the massive uptake of smoking among girls and women in middle and higher income countries14. It has presented women’s smoking as a symbol of rebellion, independence and femininity and men’s smoking as a sign of masculine strength, manliness, coolness and freedom19.
Over the past 50 years the health system in Western countries has not adopted a similar gender analysis and has not investigated women-specific cigarette use despite the success of these approaches by the tobacco industry14. In fact, the early responses to women’s smoking in high income countries were focused only on the effects of smoking on women’s reproductive abilities and on smoking and pregnancy14.
Sex-specific research emerged only in the 1990s14. This was a lost opportunity and it delayed any gender-specific responses to smoking among women. This should not continue in this century in high income countries or repeated in low income countries.
The knowledge and evidence of how masculinities, femininities, and the interplay of those conventions shape and are shaped by smoking practices are key to the effectiveness of TRC (Tobacco Reduction and Cessation) interventions19.
Women-specific and women-centered approaches are gaining ground to respond to the gendered meanings of smoking, and to tailor treatment initiatives more specifically with women in mind14. These approaches include recognizing the influence of gendered tobacco industry marketing, the social and cultural contexts in which women’s cigarette smoking occurs and the functions that it has in their lives14.
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