A gender perspective contributes to a better understanding of the epidemiological trends, social marketing strategies, economic policies, and international actions relating to women and the tobacco epidemic. Evidence is provided in this article for the negative impact of tobacco use by women and of passive smoking on the health of women and children. Use of tobacco by women is increasing and this is related to the tobacco industrys aggressive advertising, sponsorship and promotion strategies.
Policy directions are proposed in this article. At all levels, a multi-pronged strategy including changes in legislation and fiscal policies, improvements in gender-sensitive health services, and cessation programmes should be considered. Much more gender-specific research on tobacco use is needed, particularly in developing countries. Womens empowerment and leadership should be at the centre of all tobacco control efforts and are essential for the success of national programmes and the recently introduced Framework Convention on Tobacco Control.
Keywords: smoking, epidemiology; tobacco, adverse effects; tobacco industry, economics; tobacco smoke pollution, adverse effects; womens health; womens rights.
The focus of the WHO International Conference on Tobacco and Health, which was held in Kobe, Japan, on 14 18 November 1999, was making a difference to tobacco and health: avoiding the tobacco epidemic in women and youth (1). At this conference, scientists, representatives from governments and nongovernmental organizations (NGOs), as well as tobacco control activists called for a global effort to prevent a rising epidemic of tobacco use among women and youth. The Kobe Declaration stated: There are already over 200 million women smokers, and tobacco companies have launched aggressive campaigns to recruit women and girls worldwide. By the year 2025, the number of women smokers is expected to almost triple... It is urgent that we find comprehensive solutions to the danger of tobacco use and address the epidemic among women and girls. Tobacco has been identified as a contributing factor to gender inequity and undermines the principle of women and childrens right to health as a basic human right (1).
The importance of a gender perspective and the empowerment of women were the main messages of the conference, which was marked by an increasing awareness among policy-makers of the need to bring gender into the mainstream of tobacco control policies. This article addresses issues concerning gender and tobacco control and suggests actions for policy-making and implementation. The underlying assumption is that gender relations defined as roles and responsibilities that are socially determined between men and women affect the prevalence, determinants, treatment and eventual outcome of tobacco-related diseases among women (2). Gender is institutionally structured and is a complex array of values and norms that permeate social structures and organizational systems, including legal, political, economic, health and religious systems. A gender perspective in tobacco control policies will contribute to a more accurate epidemiological understanding of tobacco use as well as to making programmes more successful.
Tobacco use by women
Rising prevalence and impact of smoking on womens health
Projections by WHO for the 1990s gave global estimates of the proportions of smokers as 47% among men and 12% among women (3). However, the prevalence of smoking among women is much higher (>20%) in the Americas and Europe, and as much as 30% in Brazil, Denmark, and Norway (4). Even if the rates may be declining in some countries, there are signs that owing to aggressive marketing the rates among women are rising, particularly in developing countries.
Surveys in many industrialized countries have shown that rates of smoking among young women aged 14 19 years are comparable to or higher than those among young men (5). Rates are also rising in many countries in the South-East Asia and Western Pacific Regions, where smoking is a symbol of womens liberation and freedom from traditional gender roles. Moreover, there is a popular belief among some young women that smoking keeps them slim. There is even greater cause for alarm because the statistics on cigarette consumption do not reflect the widespread use of smokeless tobacco among rural women. In India, for example, 22% of rural women in Kerala chew tobacco in pan (betel leaf). Women also smoke bidis (small indigenous cigarettes) and hookahs, as in Bihar and parts of Punjab and Hariyana, and rural women in Goa are known to rub and plug the inside of their mouths with burnt powdered tobacco (6).
Table 1 summarizes the health risks for women who smoke. Compared with non-smoking women, smokers are more likely to experience primary and secondary infertility (7, 8) and delays in becoming pregnant (912). With respect to pregnancy outcomes, women who smoke are at increased risk of premature rupture of membranes, abruptio placentae (premature separation of the implanted placenta from the uterine wall), placenta previa (partial or total obstruction by the placenta of the cervical os), and preterm delivery (1330). Moreover, their infants have lower average birth weights and are more likely to be small for gestational age and are at increased risk of stillbirth and perinatal mortality compared with the infants of non-smoking women. Women who smoke also have an increased risk of cardiovascular diseases, including coronary heart disease (CHD), ischaemic stroke, and subarachnoid haemorrhage. Over a dozen prospective studies and numerous casecontrol studies have reported that smoking is one of the major causes of coronary heart disease in women (3138).
Women who use oral contraceptives have a particularly elevated risk of CHD if they smoke (39, 40). Earlier studies found that the risk was 20-to 40-fold greater among women who both used oral contraceptives and smoked heavily,compared with women who neither smoked nor used oral contraceptives (41, 42). More recent studies based on newer formulations of oral contraceptives show that the overall risk of CHD associated with oral contraceptive use is lower than was observed with the first-generation formulations; however, the relative risk among smokers, particularly heavy smokers, who use oral contraceptives is still considerably higher than that of non-smokers who do not use oral contraceptives (4345).
In 1995, an estimated one-third of all cancer deaths in developed countries (47% of male cancer deaths and 14% of female cancer deaths) was attributable to smoking (46). The proportion of tobacco-attributable cancer deaths is currently lower in developing countries (47), reflecting lower smoking prevalences in these countries in the past. By 1990, lung cancer had become the third ranking cause of cancer mortality among women globally (48). Between 1950 and 1995 the lung cancer mortality rates per 100 000 women in the USA rose steadily (Fig.1). The age-standardized lung cancer mortality rates for women aged 15 64 years in 1990, by world regions, are shown in Fig.2. Risks for many other cancers are increased in women who smoke, including cancers of the mouth and pharnyx, oesophagus, larynx, bladder, pancreas, kidney, cervix, and possibly other sites.
Although an effect of smoking on bone density has not been consistently demonstrated among premenopausal or perimenopausal women, many studies have found that postmenopausal women who smoke have a lower bone density than non-smokers (49 54).Cohort studies of smoking in relation to hip fractures in women have reported multivariate-adjusted relative risks ranging from about 1.2 to 2 (55 59). There are fewer studies, with less consistent results, of the association between smoking and the risk of fracture at sites other than the hip.
Environmental tobacco smoke: a womens issue
Tobacco smoking has been and still is primarily a custom and an addiction of men, leaving women and children as the majority of the worlds passive or involuntary smokers. This is particularly pertinent to women in the developing countries of the South-East Asia and Western Pacific Regions, the Eastern Mediterranean Region, and the Caribbean, where rates of smoking for women have traditionally been low compared with those of men. Smoking (passive or involuntary) is therefore still a womens issue because of the negative impact of environmental tobacco smoke (ETS) on the health of women and children. For women, pregnancies represent a period of particular vulnerability, during which exposure to tobacco smoke may adversely affect the developing fetus. For children, the effects of exposure to ETS also vary from infancy through childhood and adolescence. Infancy and childhood represent periods of vulnerability because of an immature defence mechanism and because organs such as the lung are still growing. Exposure to ETS during early childhood increases the risk of severe lower respiratory illnesses such as bronchitis and pneumonia. While this risk wanes with age, exposure of children to ETS is still associated with increased respiratory symptoms and reports of illnesses during the school-age years and, in addition, adversely affects lung function. Thus, there is a strong rationale for controlling the exposure of children to environmental tobacco smoke throughout childhood.
Persons with asthma are adversely affected by environmental tobacco smoke and their exposure to it should be specifically controlled. On average,10% of children in Asian countries have asthma, which may be exacerbated if their parents smoke. Exposure of women with asthma to ETS is also of concern as a factor that might exacerbate the disease. Involuntary smoking in adults increases the risk of lung cancer in non-smoking women married to smoking men; studies conducted in the USA showed an estimated relative risk of 1:19 (60).
In her study of national tobacco policies, Christofides concluded that: Some measures concerning ETS have benefited non-smokers and indicate a positive direction which governments can take. Sweden has implemented extensive restrictions on smoking in public places and workplaces. South Africa has policies that restrict smoking in public places and workplaces. More than 70 cities in China have introduced legislation that bans smoking in certain places such as theatres, video halls, music venues, indoor sports stadiums, reading rooms and exhibition halls, shopping malls, waiting rooms, public transport, schools and nurseries. There is also provision for municipalities to introduce further restrictions (3).
Empowering women to limit exposure to ETS in their homes is a challenge to public health policy-makers because it addresses gender inequality in the private sphere. Nevertheless, tobacco control policies must tackle such issues or they will fall short of effective implementation at the household level.
Advertising, sponsorship and promotions
The tobacco industry has exploited the image of womens emancipation, through the use of advertising, sponsorship, and promotions, to entice women into becoming new users of tobacco. The proliferation of seductive tobacco advertising worldwide serves to present smoking as normal and may lead women and girls to believe that smoking is a commonplace and socially desirable behaviour among females. Cigarettes that are advertised as light , low smoke, and less smell are attempts to defuse the harmful, addictive effects of tobacco and to reassure present and potential smokers that they can engage in healthy smoking. In many developed and developing countries, lights and low smoke cigarettes are the brands preferred by women, who may believe that they are healthier products. The tobacco industry has exploited this belief and has been promoting the image of some brands of cigarettes as having lower risks.
To sell such images, tobacco companies spend in excess of US$5 billion a year on marketing and promotion in the USA alone. Consumer culture holds out the promise of a beautiful and fulfilling life: the achievement of individuality through the transformation of self and lifestyle (61). Tobacco advertising engages the consumer in a fantasy, inviting one to participate in a promise that the product can do something for you that you cannot do for yourself (62). Although only the elite in the developing world can consume in a truly Western manner, cigarettes fulfil this promise in an inexpensive form. Appeals to Western images of emancipated women are combined with the lure of the modern consumer lifestyle. The linking of womens emancipation with an addictive product is deliberate. As reflected in the industrys own words, ...Women smokers are likely to increase as a percentage of the total. Women are adopting more dominant roles in society: they have increased spending power, they live longer than men. And as a recent official report showed, they seem to be less influenced by the anti-smoking campaigns than their male counterparts. All in all, that makes women a prime target as far as any alert European marketing man is concerned. So, despite previous hesitancy, might we now expect to see a more defined attack on the important market segment represented by female smokers ? (63).
Another report states: There is significant opportunity to segment the female market on the basis of current values, age, lifestyles and preferred length and circumference of products. This assignment should consider a more contemporary and relevant lifestyle approach targeted toward young adult female smokers (64). The rich history of the tobacco industrys targeted marketing to women in the USA provides insight into current and future marketing practices in other parts of the world. At the start of this century, few women smoked. Those who did were labelled defiant or emancipated. The Lorillard Company first used images of women smoking in its 1919 advertisements to promote Murad and Helman brands, but public outcry ensued. In 1926, Chester-field entered the womens market with billboards showing a woman asking a male smoker to Blow Some My Way, resulting in a 40% increase in sales over two years (65). The links to fashion and slimness soon followed. In 1927, Marlboro premiered its Mild as May campaign in the sophisticated fashion magazine Le Bon Ton , and in 1928 Lucky Strike launched a campaign to get women to Reach for a Lucky instead of a Sweet (66).
These advertisements directly associated smoking with being thin: Light a Lucky and youll never miss sweets that make you fat and Avoid that future shadow, when tempted reach for a Lucky, accompanied by a silhouette of a woman with a grossly exaggerated double chin. Another ad showing a slim womans body and then an obese womans shadow said, Is this you five years from now ? When tempted to overindulge, reach for a Lucky instead. Its toasted. By the end of the 1920s, cigarette advertisements regularly featured women, with their new symbols of freedom. Cigarette advertisements appeared in womens fashion magazines, such as Vogue, Vanity Fair, and Harpers Bazaar (67). The new era of targeted marketing of tobacco to women was underway.
The late 1960s and early 1970s brought further development of womens cigarette brands. Philip Morris launched Virginia Slims with the biggest marketing campaign (Youve Come a Long Way, Baby) in company history (68). Its advertising stressed themes of glamour, thinness, and independence. In 1970, Brown & Williamson premiered the fashion cigarette, Flair, while Liggett & Myers introduced Eve. Since that time, other niche brands have appeared. Yet, womens brands account for only 5 10% of the cigarette market (69), with the majority of women smokers (50% of the market share in the USA) smoking gender neutral brands, such as Marlboro or Camel.
As in the USA, womens brands of cigarettes have been introduced in many Asian countries, typically with themes highlighting independence, sophistication,glamour, and sexuality. These image advertisements hold particular appeal to young and impressionable women and girls who seek to emulate or acquire the attributes of the models in the advertisements. Not uncommonly, womens brands in Asia feature Western models. For example, advertisements for Capri Superslim cigarettes in Japan show a blonde woman who is both an executive and an artist, while Salems Pianissimo cigarettes similarly feature a Nordic blonde. Why, we might ask, are foreigners used in these advertisements? What do they lend to the visual image and say about the product that a local model would not ? To put it most simply, Westerners function as signs of the West. According to Japans largest advertising agency, Dentsu, Caucasian models lend a sense of foreignness to Japanese products, serving as symbols of prestige, quality, and modernity (70).
According to an advertising expert in Tokyo, Tobacco companies are putting a great emphasis on advertising low-smoke cigarettes which are basically designed for women who hate to have their hair and dresses spoiled with the smell of tobacco smoke (71). R. J. Reynolds has marketed Pianissimos as a low-smoke, reduced-smell version of Salem and has been popular among women. Recent data from Thailand indicate that young smokers prefer foreign brands and young women in particular show a marked preference for foreign cigarettes, especially Marlboro Lights. Little research to date has identified what underlies these preferences, although it is not difficult to imagine that these cigarettes are popular because they are perceived to be healthier (72).
In India, where smoking among women and girls is generally considered to be culturally inappropriate, a British American Tobacco subsidiary launched a womens cigarette in 1990 named Ms. The introduction of this cigarette involved large-scale advertising and the use of female models who promoted the product and gave away free samples. In response to protests by women activists about the direct targeting of women and girls, company representatives rallied to the brands defence, explaining that it was targeted towards emancipated women; that they were showing models only in Western rather than traditional Indian dress, and that the female models were not actually shown smoking (73). Concerned that ndian women might be hesitant to purchase the cigarettes in shops, advertisement copy proclaimed: Just give us a call and we will deliver a carton at your address!
Virginia Slims, the most successful womens brand, is a master at promotions. For years, Philip Morris has offered a Virginia Slims annual engagement calendar, the Book of Days. Its V-wear catalogues offer clothing items such as blouses, coats, scarves, and accessories in exchange for proofs of purchase from packs of its cigarettes. Each of the catalogues has a theme (e.g. glamour), which is reflected in the catalogue copy, photographs, and print advertising to promote the catalogue. To obtain the items requires amassing large numbers of proofs of purchase. For example, to get a black coat required 325 packs (74), or spending US$621, based on an average per branded pack cost of US$1.91 (75). The theme is carried through in stores, where small plastic shopping baskets feature the advertisement for Virginia Slims and plastic bags with the VS logo hold purchases. Their Fall 1998 catalogue carried a Light up the Night theme for its clothing. Misty Slims, an American Tobacco Company product, has offered clothing, lighters, and even a Rand McNally outlet mall shopping guide. R.J. Reynolds Camel Cash catalogues offer clothing, jewelry, lipstick holders, lighters and other accessories.
In addition to marketing, promotion of events, and sponsorship of womens sports and beauty contests, tobacco companies have made extensive use of the entertainment industry. Tobacco also finds it way into popular culture through exposure in films, television, and music. Several studies note the pervasiveness of tobacco in popular films. One study that examined smoking in movies over four decades (1960 96) found that tobacco depictions increased in the 1990s to levels similar to those in the 1960s (76). The researchers divided the each film into 5-minute segments. In the 1990s, one-third of the 5-minute intervals contained a tobacco reference, with 57% of the major characters smoking. From 1991 to 1996, 80% of the male and 27% of the female leads smoked. They also noted the increasing appearance of cigars, with all five films in their 1996 sample depicting cigar use.
Television also offers opportunities to show characters smoking. One study of prime time television in 1984 found smoking taking place at a frequency of once per hour (77). A similar study in 1992 found the same rate per hour, with 24% of primetime programmes on the three major networks depicting tobacco use (78). Furthermore, the globalization of mass media means that what happens in one country crosses many national borders. For example, many islands in the Caribbean receive most of their television programming directly from the USA and are thus exposed to tobacco use through the media.
Popular music is another medium for portraying tobacco use. Music videos on television make the visual connection between tobacco and music; one study found tobacco use shown in 19% of the music videos shown on four music video networks (79). Posters advertising new music releases and the CD covers themselves show the musicians using tobacco products. Philip Morris sponsored a live music series, Club Benson & Hedges, at clubs in cities such as Los Angeles and New Orleans. In 1997, the company launched its own record label, Woman Thing Music, which matched its print advertisement slogan, Its a Woman Thing. Featuring new women performers, the CDs are marketed with packs of Virginia Slims. A music tour included auditions in the cities where performances were held. Admission to some of the performances was free, and attendees received Virginia Slims items.
The major tobacco companies operate their own web sites, on which company and product information mingles with promotional material. For example, the Brown & Williamson site (http://www.bw.com) includes sections on their sponsor-ship of community organizations and their programmes to reduce youth use of tobacco. Their sponsorship of Fishbone Fred, a Grammy-nominated childrens performer, is noted on the site. Freds performance tours include his song Be Smart Dont Start and his Safety Songs for Kids cassette is marketed on the site.
The Kobe Declaration calls on governments, United Nations agencies, and womens groups to demand a global ban on direct and indirect advertising, promotion and sponsorship by the tobacco industry across all media and in all forms of entertainment; and demand public funding for counter-advertising that disconnects womens liberation and tobacco use and that reaches women and girls in all cultural contexts. It also states: The use of a tobacco-registered brand name, logo, or trademark on non-tobacco items as well as vending machines that dispense tobacco products should be banned globally (1).
Women and the economics of tobacco
Like advertising policies, economic policies are essential to improving tobacco control. According to the World Bank, the use of tobacco results in a net economic loss of US$200 billion per year, with half these losses occurring in developing countries (80). At the heart of the call for tobacco control policies, particularly higher taxes, lies the benefit that can be derived from it in terms of avoiding premature mortality and morbidity. Both price and other measures can help avert millions of premature tobacco-related deaths. In addition, tobacco control policies are a very cost-effective and worthy inclusion in a minimum package of health care.
Unfortunately, gender-specific data on tobacco use are often not available and their absence attests to the need for more gender-sensitive economic research.However, the following analysis is expected to apply to both women and men, even when variations may occur by gender status. The first to gain from reduction of tobacco use would be individual smokers, including women, and their families. Data from Australia, China, Malaysia, Philippines and Viet Nam show substantial expenditures on tobacco by households. For example, in China, it was estimated that 20 cigarettes cost 25% of the daily income in 1990. Also, in the Philippines, the median household income spent on imported brands of cigarettes was 35% in 1989. Poor households tend to spend a higher proportion of their incomes on tobacco expenditures that are only part of the total costs of smoking (81).
Price increases on cigarettes are effective in reducing demand. With a price rise of 10%, the demand would fall by around 4% in high-income countries and about 8% in low-and middle-income countries (81). Children and adolescents are also more responsive to price rises. Price elasticity estimates relating to those with lower income socioeconomic groups or low education levels and minority groups also suggest that these persons will be more responsive to a price increase. More research is needed on how cigarette prices affect low-income women, although we can safely surmise that they will also be more price sensitive.
Taxation is one of the most powerful tools to reduce tobacco use. It is an equally powerful tool to prevent children from ever starting smoking. Since many countries still have extremely low tax rates on tobacco, there is ample scope to raise taxes to levels close to those in countries that have been more successful in tobacco control, where taxation accounts for about two-thirds to three-quarters of the cigarette price. Tobacco tax revenues earmarked for tobacco control measures can generate even greater reductions in tobacco use than tax increases alone.
Economic studies also show that the release of health information about smoking health scares significantly reduces cigarette consumption and has an immediate impact. Clean indoor air laws and restrictions on youth access, which are aggressively and comprehensively enforced, can also significantly reduce smoking among youth.
Smuggling is another economic issue that affects policy-making. Although around 30% of internationally exported cigarettes are lost to smug-gling, the problem has often been overstated by the tobacco industry (81). There are several easy-to-implement policies, including stronger enforcement, the use of tax stamps and greater penalties for smugglers, which could significantly reduce the problem.
Increased funding to support smoking cessation programmes for women, gender-sensitive training of health personnel, and the development of community-based programmes are also important fiscal policies that can help women and girls.
National tobacco policies must be supported by regional and international mechanisms if the multinational corporations are to be held accountable and if transnational issues such as smuggling are to be addressed. Fortunately, there are already some international treaties and policy documents covering women and health such as United Nations agreements on womens and childrens rights to health which can be called upon to strengthen conventions that address specific issues and, aided by the Framework Convention on Tobacco Control (FCTC), can strengthen national programmes. A major complement to the FCTC in addressing women and tobacco issues should be the Convention on the Rights of the Child and the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW).
CEDAW, which has been signed by 163 countries including most in the South-East Asia and Western Pacific Regions, is also concerned with womens rights to health. The CEDAW committee identified compliance by governments with article 12 concerning womens health as central to the health and well-being of women (82). Article 12 requires states to eliminate discrimination against women in terms of access to health care services and to include statistical information disaggregated by sex,age, ethnicity and geographical location in government reports. States should also report on the allocation of resources to womens health and place a gender perspective at the centre of all policies and programmes affecting womens health.
Another important policy document which is concerned with womens rights is the Beijing Plat-form for Action (83). Adopted by more than 180 states in 1995 at the Fourth World Conference on Women, it lists health as one of the Twelve Critical Areas of Concern. Furthermore, in 1999, the Commission on the Status of Women, which oversees implementation of the Beijing Platform for Action, recommended actions to be taken by governments, the United Nations system, and civil society. For example, these bodies must design, implement and strengthen prevention programmes aimed at reducing tobacco use by women and girls; investigate the exploitation and targeting of young women by the tobacco industry; and support action that prohibits tobacco advertising and access by minors to tobacco products. In addition, they must support smoke-free spaces, gender-sensitive cessation programmes, and product labelling to warn of the danger of tobacco use, taking note of the Tobacco Free Initiative proposed by WHO in July 1998 (84).
In order that such treaties and policy documents may be effective, national womens bureaux and ministries supporting women need to be included in decision-making about the FCTC and tobacco control legislation. Womens NGOs and leaders in civil society must also be mobilized as partners. In the women and tobacco movement, some groups such as the International Network of Women against Tobacco (INWAT) and the US National Organization of Women (NOW) have pioneered community-based strategies. NOW distributes a video teaching module which redefines womens liberation and reminds young women of their rights to health. Other groups, such as the Latin American womens health network, have been providing health information on lung cancer and smoking through their newsletters. Around the world, many organizations of women physicians, nurses and scientists, in alliance with the media, have initiated community-based programmes that are contributing to womens involvement in tobacco control.
In all regions, womens mobilization through numerous regional women and health networks has been directed towards tobacco control. In 1984, representatives from 60 womens health groups who attended the First Regional Women and Health meeting in Colombia created the Latin American and Caribbean Womens Health Network (LACWHN) (85). This network is made up of approximately 2000 member groups from Latin America and the Caribbean (approximately 80%), as well as from North America, Europe, Africa, Asia and the Pacific.
A variety of womens organizations can be found in the South-East Asia and Western Pacific Regions. They include local or global womens networks concerned with issues such as women and health, the environment, consumers, human rights, and migration. These groups could also be mobilized as strong advocates to prevent a tobacco epidemic.
In 1987, Womens Action on Smoking was formed in Tokyo by female doctors, teachers, writers and other women who were concerned about the increase of smoking among young women. The main objectives were creating respect for non-smokers rights and preventing young women from starting to smoke. Members activities have focused on anti-smoking education in schools, a hotline for non-smokers to deal with the problem of passive smoking in offices, and a campaign to remove tobacco vending machines.
Another active group is the Consumers Association of Penang (CAP), a well-known consumer advocacy organization in Malaysia, which has conducted anti-smoking campaigns since 1973. Since then, CAP has organized numerous seminars, forums, exhibitions, and other events and also published booklets, educational kits, posters, stickers, and other materials to educate people about the harmful effects of tobacco smoking on health, the environment and the economy.
Examples of international networks include Gabriela, a national coalition of womens organizations in the Philippines, which has a Commission on Womens Health and Reproductive Rights. The Commission has womens clinics in Metro-Manila and two pilot communities. The Asian-Pacific Resource & Research Centre for Women (ARROW), a regional NGO based in Malaysia, aims to reorient the health, population and reproductive health policies of governments and NGOs and to include a womens and gender perspective. The Women in Environment and Development Organization (WEDO) has recently become a leader in mobilization of international networks for women and tobacco.
The recently initiated WHO Framework Convention on Tobacco Control and national tobacco control programmes, committees and institutions must ensure that the above-mentioned womens organizations are included in the formulation and implementation of tobacco control policies. By ensuring gender equality in decision-making, tobacco control policies have the potential to mobilize a bottom-up momentum, which will reach families and communities as well as influence national trends.
A gender perspective on the tobacco problem will contribute to a better understanding of the epidemiological trends, social marketing strategies, economic policies, and international actions. At all levels, a multi-pronged strategy combining changes in legislation and fiscal policies along with improvements in gender-sensitive health services and cessation programmes should be considered. Key measures include raising cigarette taxes, implementing a complete ban on advertising and promotion of tobacco products, restricting smoking in public and work places, educating consumers about the health risks of smoking, and increasing smokers access to cessation programmes. Much more gender-specific research is needed to understand the association between women and epidemiological, behavioural and economic policies, particularly in developing countries. Womens empowerment and leadership should be at the centre of all tobacco control efforts and are essential for the success of national programmes and the WHO Framework Convention on Tobacco Control.§
Les femmes et le tabac : il faut agir
Cet article évoque certains problèmes et aspects du tabagisme selon le sexe et suggère des mesures au plan politique et pratique. Les projections globales de lOMS pour le début des années 90évaluaient les proportions de fumeurs à 47 %parmi les hommes et à 12 %parmi les femmes, mais le pourcentage des fumeuses est en rapide augmentation. Or limpact du tabac sur leur santéest très préoccupant. Ainsi, les femmes qui fument sont davantage susceptibles de souffrir de stérilitéprimaire et secondaire et elles ont plus de mal à être enceinte; de même, en cas de grossesse, elles courent un risque accru de complications, et le poids moyen à la naissance de leurs bébés est inférieur à celui des enfants de non-fumeuses. Les femmes qui fument sont aussi plus exposées aux maladies cardio-vasculaires, y compris les cardiopathies ischémiques, les infarctus cérébraux et les hémorragies sous-arachnoïdiennes.
Hier comme aujourdhui, fumer du tabac est essentiellement une coutume et/ou une dépendance typiquement masculine, si bien que les femmes et les enfants sont en majoritédes « fumeurs » passifs. Cest le cas en particulier des femmes des pays en développe-ment des Régions de lAsie du Sud-Est et du Pacifique occidental, des Caraïbes et de la Région de la Méditerranée orientale, où les pourcentages de fumeu-ses sont traditionnellement faibles au regard de ceux des fumeurs. Pour les femmes, la grossesse constitue une période de vulnérabilitéparticulière, durant laquelle lexposition à la fumée de cigarette peut avoir des effets néfastes sur le foetus. Pour les enfants, les conséquences de linhalation passive de fumée de tabac varie en fonction de lâge. Donner aux femmes les moyens de limiter lexposition de leur famille à linhalation passive constitue un véritable défi pour les responsables des politiques publiques, car cela touche à linégalitéentre les sexes dans la sphère privée.
En exploitant abondamment limage de lémanci-pation de la femme dans ses campagnes de publicité,de sponsorisation et de marketing, lindustrie du tabac contribue à multiplier le nombre des fumeuses. En Inde, par exemple, où il est généralement mal vu pour une femme ou une jeune fille de fumer, une filiale de British American Tobacco a lancéen 1990 une cigarette baptisée Ms spécialement destinée à la clientèle féminine. Le lancement de ce produit a étéentourédune campagne promotionnelle intensive faisant appel à des femmes mannequins et à la distribution déchantillons gratuits. Tout comme les réglementations régissant la publicité, les politiques économiques sont essentielles pour renforcer la lutte antitabac. Selon la Banque mondiale, les pertes économiques découlant de la consommation du tabac se chiffrent à US $200 mil-liards net par an, dont la moitiédans les pays en développement. Les appels au renforcement de la lutte antitabac se justifient essentiellement par les bénéfices à attendre en termes de morbiditéet de mortalité, des mesures de dissuasion financières ou autres pouvant contribuer à éviter des millions de décès prématurés. Qui plus est, les politiques de lutte antitabac offrent un excellent rapport coû t/efficacité, aussi devraient-elles être systématiquement incluses dans tout système de soins de santéde base. Hélas, on ne dispose que rarement de données ventilées par sexe, une lacune qui confirme lurgente nécessitédanalyses économiques capables dexprimer les différences entre les hommes et les femmes.
De fait, une approche intégrant ces différences contribuera à une meilleure compréhension des tendan-ces épidémiologiques, des stratégies de marketing, des politiques économiques et des actions internationales, ainsi que de la relation entre les femmes et le tabac, en particulier dans les pays en développement. Et, surtout, le renforcement des pouvoirs et des responsabilités des femmes devrait être indissociable de tous les efforts de lutte antitabac, car leur engagement et leur participation active sont essentiels pour le succès des programmes nationaux comme de la convention-cadre pour la lutte antitabac récemment élaborée par lOMS.
Las mujeres y el tabaco: de la política a la acción
En este artículo se tratan cuestiones relacionadas con el género y la lucha antitabáquica y se proponen medidas para la formulación y ejecución de políticas. Las proyecciones de la OMS para los primeros años noventa situaban la proporción de fumadores a nivel mundial en un 47% para los hombres y un 12% para las mujeres. Sin embargo, las tasas correspondientes a las mujeres están aumentando rápidamente. Los efectos perjudiciales del tabaco para la salud de la mujer suscitan inquietud. Así, en comparación con las mujeres no fumadoras, las fumadoras corren un mayor riesgo de sufrir infertilidad primaria y secundaria y dificultades para quedarse embarazadas. Las mujeres que fuman presentan un mayor riesgo de complicaciones durante el embarazo y sus hijos tienen al nacer pesos inferiores al promedio. Tienen asimismo un mayor riesgo de sufrir enfermedades cardiovasculares, entre ellas cardiopatía coronaria, ictus isquémico y hemorragia subaracnoidea.
El consumo de tabaco es y ha sido principalmente una costumbre y/o adicción de los hombres, mientras que las mujeres y los niños han formado el grueso de los fumadores pasivos o involuntarios. Esto se aplica en particular a las mujeres de los países en desarrollo de las regiones de Asia Sudoriental y el Pacífico Occidental, el Caribe y el Mediterráneo Oriental, donde las tasas de tabaquismo entre las mujeres han sido tradicionalmente bajas en comparación con las de los hombres. El embarazo representa un periodo de especial vulnerabi-lidad para las mujeres, durante el cual la exposición al humo del tabaco puede perjudicar al desarrollo del feto. En los niños, los efectos de la exposición al humo de tabaco ambiental (HTA) varían a lo largo de las etapas de la lactancia, la infancia y la adolescencia. El empodera-miento de la mujer para que limite la exposición de su familia al HTA en el hogar constituye un reto para los formuladores de políticas públicas, pues ello supone enfrentarse a la desigualdad entre los sexos en la esfera privada.
La industria tabacalera ha explotado la imagen de emancipación de las mujeres mediante la publicidad, el patrocinio y la promoción, actividades que están ayudando a reclutar mujeres como nuevos consumidores de tabaco. Por ejemplo, en la India, donde por razones culturales se considera en general inapropiado que las mujeres y las niñas fumen, una filial de la British American Tobacco Company lanzóen 1990 una nueva marca de cigarrillos bautizada con el nombre de «Ms» («Sra.»). Para introducirlos se organizóuna promoción en gran escala, con la participación de modelos femeninas que distribuían muestras gratuitas. Las políticas económicas, al igual que las relativas a la publicidad, son fundamentales para mejorar la lucha antitabáquica. Según el Banco Mundial, el hábito de fumar provoca una pérdida neta de US$ 200 000 millones al año, y la mitad de esa sangría afecta a países en desarrollo. En el núcleo del llamamiento para que se adopten políticas de lucha antitabáquica, basadas en particular en el aumento de los impuestos, estála perspectiva de los beneficios que se derivan de una reducción de la mortalidad y la morbilidad prematuras. El aumento del precio y otras medidas pueden ayudar a evitar millones de defunciones prematuras relacionadas con el tabaco. Además, las políticas de lucha anti-tabá quica son muy eficaces en relación con el costo y deberían formar parte de los paquetes básicos de atención sanitaria. Lamentablemente, a menudo no se dispone de datos específicos por sexos, lo que revela la necesidad de llevar a cabo nuevas investigaciones económicas que tengan en cuenta ese factor. Sin embargo, se supone que los resultados de los análisis económicos son válidos tanto para las mujeres como para los hombres, aunque haya algunas diferencias entre los sexos.
Así pues, una perspectiva de género nos permitirá comprender mejor las tendencias epidemiológicas, las estrategias de comercialización social, las políticas económicas y las acciones internacionales. Es necesario llevar a cabo muchas más investigaciones en función del sexo para comprender cómo afecta a las mujeres la epidemia de tabaquismo, en particular en los países en desarrollo. Y lo que es más importante, el empodera-miento y el liderazgo de las mujeres deben figurar en el centro de todos los esfuerzos de lucha antitabáquica y son esenciales para el éxito de los programas nacionales y del recientemente emprendido Convenio Marco de la OMS para la Lucha Antitabáquica.
1. Report of the Fourth Meeting of the WHO Centre for Health Development, Kobe, Japan, 1819 October 1999. Kobe, WHO Centre for Health Development, unpublished document, 1999.
2. Gender and health: a technical paper. Geneva, World Health Organization, 1998 (unpublished document WHO/FRH/WHD/ 98.16).
3. Gajalakshmi CK et al. Patterns of tobacco use and its health consequences. In: Jha P, Chaloupka F, eds. Tobacco control policies in developing countries. Oxford, Oxford University Press (in press).
4. Tobacco or health: a global status report. Geneva, World Health Organization, 1997.
5. Chollat-Traquet CM. Women and tobacco.Geneva, World Health Organization, 1992.
6. Aghi M, Asma S, Vaithinathan R. Initiation and maintenance of tobacco use. In: Samet J, Yoon S-Y, eds. Women and the tobacco epidemic. Geneva, World Health Organization, Tobaco Free Initiative (in preparation).
7. Daling J et al. Cigarette smoking and primary tubal infertility. In: Rosenberg MJ, ed. Smoking and reproductive health. Littleton, MA, PSG Publishing Co., 1987: 4046.
8. Joesoef MR et al. Fertility and use of cigarettes, alcohol, marijuana, and cocaine. Annals of Epidemiology, 1993, 3: 592594.
9. Baird DD, Wilcox AJ. Cigarette smoking associated with delayed conception. Journal of the American Medical Association, 1985, 253: 29792983.
10. Curtis KM, Savitz DA, Arbuckle TE. Effects of cigarette smoking, caffeine consumption, and alcohol intake on fecund-ability. American Journal of Epidemiology, 1997, 146: 3241.
11. Howe Get al. Effects of age, cigarette smoking, and other factors on fertility: findings in a large prospective study. British Medical Journal, 1985, 290: 16971700.
12. Spinelli A, Figa-Talamanca I, Osborn J. Time to pregnancy and occupation in a group of Italian women. International Journal of Epidemiology, 1997, 26: 601609.
13. Hadley CB, Main DM, Gabbe SG. Risk factors for preterm premature rupture of the fetal membranes. American Journal of Perinatalogy, 1990, 7: 374379.
14. Harger JH et al. Risk factors for preterm premature rupture of fetal membranes: a multicenter case-control study. Annals of the Rheumatic Diseases, 1990, 57: 451455.
15. Ekwo EE et al. Risks for premature rupture of amniotic membranes . International Journal of Epidemiology, 1993, 22: 495503.
16. Spinillo A et al. Factors associated with abruptio placentae in preterm deliveries. Acta Obstetricia et Gynecologica Scandinavica, 1994, 73: 307312.
17. Williams MA et al. Cigarettes, coffee, and preterm premature rupture of the membranes. American Journal of Epidemiology, 1992, 135: 895903.
18. Ananth CV, Savitz DA, Luther ER. Maternal cigarette smoking as a risk factor for placental abruption, placenta previa, and uterine bleeding in pregnancy. American Journal of Epidemiology, 1996, 144: 881889.
19. Handler AS et al. The relationship between exposure during pregnancy to cigarette smoking and cocaine use and placenta previa. American Journal of Obstetrics and Gynecology, 1994, 170: 884889.
20. Monica G, Lilja C. Placenta previa, maternal smoking and recurrence risk. Acta Obstetricia et Gynecologica Scandinavica, 1995, 74: 341345.
21. Chelmow D, Andrew DE, Baker ER. Maternal cigarette smoking and placenta previa. Obstetrics and Gynecology, 1996, 87: 703706.
22. Zhang J, Fried DB. Relationship of maternal smoking during pregnancy to placenta previa. American Journal of Preventive Medicine, 1992, 8: 278282.
23. Heffner LJ et al. Clinical and environmental predictors of preterm labor. Obstetrics and Gynecology, 1993, 81: 750757.
24. Olsen P et al. Epidemiology of preterm delivery in two birth cohorts with an interval of 20 years. American Journal of Epidemiology, 1995, 142: 11841193.
25. Wen SW et al. Intrauterine growth retardation and preterm delivery: prenatal risk factors in an indigent population. American Journal of Obstetrics and Gynecology, 1990, 162: 213218.
26. Cnattingius S et al. Effect of age, parity, and smoking on pregnancy outcome: a population-based study. American Journal of Obstetrics and Gynecology, 1993, 168: 1621.
27. McDonald AD, Armstrong BG, Sloan M. Cigarette, alcohol, and coffee consumption and prematurity. American Journal of Public Health, 1992, 82: 9193.
28. Meis PJ et al. Factors associated with preterm birth in Cardiff, Wales. I. Indicated and spontaneous preterm birth. American Journal of Obstetrics and Gynecology, 1995, 173: 597602.
29. Wisborg K et al. Smoking during pregnancy and preterm birth. British Journal of Obstetrics and Gynaecology, 1996, 103: 800805.
30. Raymond EG, Mills JL. Placental abruption. Maternal risk factors and associated conditions. Acta Obstetricia et Gynecologica Scandinavica, 1993, 72: 633639.
31. Thun MJ et al. Age and the exposure-response relationships between cigarette smoking and premature death in Cancer Prevention Study II. In: Shopland DR et al., eds. Changes in cigarette-related disease risks and their implication for prevention and control. Rockville, MD, National Institutes of Health, National Cancer Institute, 1997: 383475.
32. Prescott E et al. Smoking and risk of myocardial infarction in women and men: longitudinal population study. British Medical Journal, 1998, 316: 10431047.
33. Burns DMet al. The American Cancer Society Cancer Prevention Study I: 12-year follow-up of 1 million men and women. In: Shopland DR et al., eds. Changes in cigarette-related disease risks and their implication for prevention and control. Rockville, MD, National Institutes of Health, National Cancer Institute, 1997: 1342.
34. Njolstad I, Arnesen E, Lund-Larsen PG. Smoking, serum lipids, blood pressure, and sex differences in myocardial infarction. A 12-year follow-up of the Finnmark Study. Circulation, 1996, 93: 450456.
35. Kawachi I et al. Smoking cessation and time course of decreased risks of coronary heart disease in middle-aged women. Archives of Internal Medicine, 1994, 154: 169175.
36. Paganini-Hill A, Hsu G. Smoking and mortality among residents of a California retirement community. American Journal of Public Health, 1994, 84: 992995.
37. Doll R et al. Mortality in relation to smoking: 22 years observations on female British doctors. British Medical Journal, 1980, 280: 967971.
38. Friedman GD et al. Smoking and mortality: the Kaiser Permanente experience. In: Shopland DR et al., eds. Changes in cigarette-related disease risks and their implication for prevention and control. Rockville, MD, National Institutes of Health, National Cancer Institute, 1997: 477499.
39. Owen-Smith V et al. Effects of changes in smoking status on risk estimates for myocardial infarction among women recruited for the Royal College of General Practitioners Oral Contraception Study in the UK. Journal of Epidemiology and Community Health, 1998, 52: 420424.
40. Rosenberg L et al. Myocardial infarction and cigarette smoking in women younger than 50 years of age. Journal of the American Medical Association, 1985, 253: 29652969.
41. Shapiro S et al. Oral contraceptive use in relation to myocardial infarction. Lancet, 1979, 1: 743747.
42. Croft P, Hannaford PC. Risk factors for acute myocardial infarction in women: evidence from the Royal College of General Practitioners Oral Contraception Study. British Medical Journal, 1989, 298: 165168.
43. DAvanzo B et al. Oral contraceptive use and risk of myocardial infarction: an Italian casecontrol study. Journal of Epidemiology and Community Health, 1994, 48: 324325.
44. Lewis MA et al. Third generation oral contraceptives and risk of myocardial infarction: an international case-control study. British Medical Journal, 1996, 312: 8890.
45. World Health Organization. WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Acute myocardial infarction and combined oral contraceptives: results of an international multicentre case-control study. Lancet, 1997, 349: 12021209.
46. Peto R et al. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet, 1992, 339: 12681278.
47. The tobacco epidemic: a global public health emergency. Tobacco Alert.Geneva, World Health Organization, 1996.
48. Pisani P. Estimates of the worldwide mortality from 25 cancers in 1990. International Journal of Cancer, 1999, 83: 1829.
49. Orwoll ES et al. Axial bone mass in older women. Annals of Internal Medicine, 1996, 124: 187196.
50. Hollenback KA et al. Cigarette smoking and bone mineral density in older men and women. American Journal of Public Health, 1993, 83: 12651270.
51. Nguyen TV et al. Lifestyle factors and bone density in the elderly: implications for osteoporosis prevention. Journal of Bone and Mineral Research, 1994, 9: 13391346.
52. Kiel DP et al. The effect of smoking at different life stages on bone mineral density in elderly men and women. Osteoporosis International, 1996, 6: 240248.
53. Writing Group for PEPI. Effects of hormone therapy on bone mineral density: results from the Postmenopausal Estrogen/ Progestin Interventions (PEPI) trial. Journal of the American Medical Association, 1996, 77: 5356.
54. Burger H et al. Risk factors for increased bone loss in elderly population: the Rotterdam Study. American Journal of Epidemiology, 1998, 147: 871879.
55. Cornuz J et al. Smoking, smoking cessation, and risk of hip fracture in women. American Journal of Medicine, 1999, 106: 311314.
56. Cummings SR et al. Risk factors for hip fracture in white women. New England Journal of Medicine, 1995, 332: 767773.
57. Forsen L et al. Interaction between current smoking, leanness, and physical inactivity in the prediction of hip fracture. Journal of Bone and Mineral Research, 1994, 9: 16711678.
58. Paganini-Hill A et al. Exercise and other factors in the prevention of hip fracture: the Leisure World Study. Epidemiology, 1991, 2: 1625.
59. Kiel DP et al. Smoking eliminates the protective effect of oral estrogens on the risk of hip fracture among women. Annals of Internal Medicine, 1992, 116: 716721.
60. Samet J, Yang GH. Environmental tobacco smoke. In: Women and the tobacco epidemic. Baltimore, MD, WHO/Johns Hopkins University School of Public Health (in press).
61. Featherstone M. Consumer culture, symbolic power and universalism. In: Stauth G, Zubaida S, eds. Mass culture, popular culture, and social life in the Middle East. Frankfurt am Main, Campus Verlag, 1987.
62. Comerford A, Slade J. Selling cigarettes: a salesmans perspective. Paper commissioned by the Committee on Preventing Nicotine Addiction on Children and Youths, 1994.
63. Rogers D. Overseas memo. Tobacco Reporter, February 1982.
64. American Tobacco Company. Internal report (BW ATX040017950/7951), 17 November 1983.
65. Tennant RB. The American cigarette industry: a study in economic analysis and public policy. New Haven, CT, Yale University Press, 1950.
66. Ernster VL. Mixed messages for women: a social history of cigarette smoking and advertising. New York State Journal of Medicine, 1985, 85: 335340.
67. Tilley NM. The RJ Reynolds Tobacco Company. Chapel Hill, SC, University of North Carolina Press, 1985.
68. Jones KE. Womens brands: cigarette advertising explicitly directed toward women. Cambridge, MA, Harvard University Press, 1987.
69. Breast cancer deaths and cigarettes advertising dollars rise. Marketing to Women, 1991, 4 (8): 8.
70. Mueller B. Standardization vs specialization: an examination of westernization in Japanese advertising. Journal of Advertising Research, Jan/Feb 1992: 18; see also: Lin C. Cultural differences in message strategies: a comparison between American and Japanese TV commercials. Journal of Advertising Research, Jul/Aug 1993: 41.
71. Azuma N. Smoke and mirrors: Japanese women buying into sweet song of US tobacco companies. Asia Times, 18 July 1997.
72. Hughes B. Action on smoking and health, Bangkok, Thailand. Globalink communication, June 1999. See also Crossette B. Women in Delhi angered by smoking pitch. New York Times, 18 March 1990, A:18.
73. Prakash Gupta, personal communication, 1999.
74. Virginia Slims advertisement. People, 1995, 44 (7): 12.
75. The tax burden on tobacco. Washington, DC, The Tobacco Institute, 1998: 33.
76. Stockwell TF, Glantz SA. Tobacco use is increasing in popular films. Tobacco Control, 1997, 6: 282284.
77. Cruz J, Wallack L. Trends in tobacco use on television. American Journal of Public Health, 1986, 76: 698699.
78. Hazan AR, Glantz SA. Current trends in tobacco use on prime-time fictional television. American Journal of Public Health, 1995, 35: 116117.
79. DuRant RH et al. Tobacco and alcohol use behaviors portrayed in music videos: a content analysis. American Journal of Public Health, 1997, 87: 11311135.
80. Curbing the epidemic: governments and the economics of tobacco control. Washington, DC, The World Bank, 1999.
81. Jacobs R. Economic policies. In: Women and the tobacco epidemic. Baltimore, WHO/Johns Hopkins University School of Public Health (in press).
82. Abaka C. Strengthening international agreements. In: Women and the tobacco epidemic. Baltimore, WHO/Johns Hopkins University School of Public Health (in press).
83. United Nations Division for the Advancement of Women. A report of the Fourth World Conference on Women. New York, United Nations, 1995.
84. United Nations Division for the Advancement of Women. A report of the Commission on the Status of Women. New York, United Nations, 1995.
85. Bianco M, Matusi Y, Nakano N. The international womens movement and anti-tobacco campaigns. In: Women and the tobacco epidemic. Baltimore, WHO/Johns Hopkins University School of Public Health (in press).
1 Professor and Vice-Chair, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA 94143, USA (email: firstname.lastname@example.org). Correspondence should be addressed to this author.
2Vice-President, The Robert Wood Johnson Foundation, Princeton, NJ, USA.
3 Assistant Professor, Department of Anthropology, University of Arizona, Tucson, AZ, USA.
4 Professor and Chairman, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD, USA.
5 New York Liaison, WHO/Framework Convention on Tobacco Control Project, Campaign for Tobacco Free Kids, Washington, DC, USA.
Ref. No. 00-0604