Population-Based Strategies for Controlling the Tobacco Epidemic Among Women
Patterns of tobacco use in developed countries have followed a predictable progression with regard to gender differences: smoking rates among men tend to increase and peak first, followed by increased smoking rates among women while men’s smoking rates decline. Men’s smoking rates also tend to peak at a higher level than women.
Developing and more recently industrialized countries are halfway into the epidemic. In many Asian, African, and Middle Eastern countries, where men’s smoking rates are very high, women’s rates remain low in comparison, often below 10%. At the same time, in many countries women’s smoking rates are increasing, signalling the beginning of a tobacco epidemic among females that could rival that of the developed world.
There is both an opportunity and a challenge to anticipate tobacco control needs in developing countries before this epidemic occurs. This paper briefly describes the most successful tobacco control measures in the developed world and discusses how these strategies are particularly relevant for women in developing countries.
LESSONS FROM THE DEVELOPED WORLD AND APPLICATION TO DEVELOPING NATIONS
The World Health Organization and many national health ministries generally agree that a comprehensive approach comprised of health education, health promotion, legislation, and tobacco tax policies is the best way to reduce tobacco use. However, there is also general agreement that health education and promotion measures have minimal impact when used in isolation, particularly in the face of aggressive marketing activities and other strong pro-tobacco messages by tobacco companies.
Legislative measures such as bans on tobacco advertising, strong warnings on tobacco packages, high tobacco taxes and restrictions on smoking indoors are seen as necessary to effectively reverse the social acceptability of tobacco use. In the absence of such measures, broad-based reductions in smoking are unlikely to occur.
Advertising and Advertising Restrictions
A growing body of evidence shows that tobacco advertising is effective at recruiting new customers. Recent U.S. research has correlated smoking initiation rates among adolescents and young adults since the beginning of this century with advertising expenditures.(1),(2) Another study shows a correlation between women’s smoking initiation rates and female-target advertising campaigns in the U.S. over a span of forty years.(3) Most recently, research shows that U.S. adolescents are three times more susceptxble to tobacco advertising than adults.(4)
Conversely, countries which have restricted or banned tobacco advertising have experienced greater than projected declines in tobacco use,(5),(6) leading governments and health organizations to conclude that advertising bans are an effective means of reducing smoking. For example, smoking rates in Canada declined an average of 1.35% per year prior to significant policy interventions, 2.08% per year when tobacco taxes were increasing, and 3.60% per year following the introduction of an advertising ban and other regulatory measures in conjunction with high taxes.
Advertising is a critical component of the tobacco industry’s strategy to expand emerging female markets in developing and recently industrialized countries. Advertising activity has increased in many parts of Asia where female smoking rates are still very low but show signs of increasing.(7),(8)
While some advertising specifically targets women, advertising in general conveys images of western affluence, economic independence and women’s liberation. These images mirror the North American advertising campaigns of the 1970s, when issues of economic and social equality for women were emerging issues. As women in developing countries strive for these same goals either in the near or distant future, advertising campaigns which equate smoking with the attainment of these goals will resonate strongly.
Combatting tobacco advertising with health promotion messages and media awareness training has proven difficult considering the vast amount of money available to tobacco companies compared with health ministry budgets. Banning all tobacco promotion is the most desirable option. Alternative approaches include restrictions on promotion, requiring prominent health messages on all forms of tobacco promotion, or requiring equal space for health advertisements, paid for by tobacco companies.
Health Warnings on Tobacco Packages
The goal of tobacco advertising bans is to remove misleading information and images provided by tobacco companies. The removal of these images should, wherever possible, be combined with the provision of accurate health and other information about tobacco.
One of the most cost-effective ways of ensuring that this information reaches consumers on a broad scale is to incorporate health warnings on tobacco packages. Package warnings have the added benefit of detracting from the alluring image of the tobacco package itself. Countries which have used tobacco packages most successfully to convey health information include Canada, Australia and Thailand.
Despite the potential of package warnings to target specific subsets of the population, very few countries have used warnings to target women, with the exception of warnings about the effects of smoking on pregnancy. In developing nations, where little money is available for health education programmes and many women are hard to reach, targeted messages on packaging represent a cost-effective education tool. In areas where illiteracy is a problem, word of mouth would work to disseminate the information on tobacco packages to the population or, visual messages could be used.
Targeted Package Messages
Package messages could help correct the underappreciation of the nature and magnitude of health risks of tobacco use common among smokers. In western countries, women commonly place breast cancer among the leading causes of death among women, even though lung cancer deaths are more common, and heart disease surpasses both.
While the implementation of effective package warnings nearly always relies on legislation and regulation, the positioning of warnings as a health education measure can sometimes increase political and public support beyond what might exist for other regulatory measures. In addition, educating the public through package warnings can help build support for further regulation in the future.
Tobacco Taxation Policy
Of all of the measures used to reduce smoking in the developed world, no single intervention has proven as effective as the use of tobacco taxation policy to decrease the affordability of tobacco.
Canada experienced world precedent-setting declines in per capita consumption of tobacco as a result of tobacco taxes. Prior to 1982, when the affordability of tobacco was increasing, per capita consumption increased or remained relatively flat, despite declines in smoking rates. Beginning in 1982 and continuing until 1993, as affordability decreased, per capita consumption declined significantly, as did smoking rates. In 1994, when reduced tobacco taxes cut the price of tobacco in half in most of the country, this trend was reversed and a 7.7% single-year increase in per capita consumption was observed.
Impact of Taxation on Young Women
Prior to the early 1980s, the real price of tobacco in Canada was dropping. When tax increases began to reverse the situation, the impact was reflected strongly in the acceleration of decline in smoking among young women.
Ironically, it is women’s poverty and low social status that has thus far prevented a tobacco epidemic among women in many developing countries. As women’s incomes and economic independence increase, their ability to purchase tobacco will also increase. Developed countries learned rather late the importance of price in reducing tobacco use. The tobacco epidemic among both men and women was in full swing before such policies were put in place.
It is important that high tobacco taxation policies be implemented in developing countries before a women’s epidemic occurs. Almost accidentally, price already serves as an effective deterrent in countries with relatively low GNP/GDP per capita(9): Even in countries where men’s smoking rates are very high, per capita consumption is low in comparison to wealthier nations. As incomes increase for both men and women, it is important that tobacco prices rise even more rapidly in order to ensure decreased affordability.
Smoking Restrictions in the Workplace and Public Places
Increasingly, developed countries are recognizing the value of restricting or banning smoking in workplaces and public places, not only to protect non-smokers from the effects of environmental tobacco smoke (ETS), but also to help change the acceptability of tobacco use. Smoking restrictions have been found to be extremely effective in reducing tobacco use, motivating smokers to reduce consumption or to quit altogether.(10)
Some smoking restrictions have taken place on a broad scale. Many national airlines have banned smoking on all flights, and the International Civil Aviation Organization (ICAO) passed a resolution to ban smoking on all international flights by July 1, 1996. Other forms of public transportation and transportation terminals are increasingly becoming smoke-free. The move toward smoke-free public transportation, particularly air travel, will have an impact on smoking in the developing world. As a symbol of western wealth, air travel influences notions of desirable behaviour. Banning smoking on airlines decreases the perceived link between smoking and affluent lifestyles.
The role of smoke-free environments in protecting women’s health and reducing their smoking behaviour has not been discussed in enough detail as a strategy for the developing world. However, in nations where women’s smoking rates are very low and those of men very high, and where women spend time indoors with men, ETS may present an aggregate health risk to women comparable with that of direct smoking.
The places where smoking is allowed sends a powerful message about the harmfulness and acceptability of tobacco use. One reason why women’s smoking rates have increased following those of men is because women’s smoking behaviour is emulatory of men. Smoking is seen as a symbol of other advantages that men have: power, liberation, wealth. If places where men congregate and where women aspire to congregate restrict or ban smoking, smoking becomes less associated with the advantages which women may wish to achieve.
The strategies described here will not, on their own, guarantee the prevention of a women’s smoking epidemic in developing countries. However, the experience of developed countries indicates that unless most or all of these measures are part of a comprehensive strategy to reduce tobacco use, countries will have limited success in containing the tobacco epidemic among men and preventing it among women.
Further health education and promotion programmes targeted specifically at women can support the measures described here and maximize smoking reductions in particular segments of the population. However, they should not be relied upon in isolation to prevent tobacco use among women.
(2) Public Health Service, U.S. Department of Health and Human Services. Trends in Smoking Initiation Among Adolescents and Young Adults — United States, 1980-1989. Morbidity and Mortality Weekly Report, 44 (28), 522 525.
(3) Pierce JP., Lee L, Gilpin EA. Smoking Initiation by Adolescent Girls, 1944 Through 1988: An Association With Targeted Advertising. Journal of the American Medical Association, 271(8), February 23, 1994, 608-611.
(4) Pollay RW, Siddarth S, Siegel M, Haddix A, Merritt RK, Giovino GA., Eriksen MP. The Last Straw? Cigarette Advertising and Realized Market Shares Among Youths and Adults, 1979-1993, Journal of Marketing, 60 (April 1996), 1-16.
(6) Department of Health, Economics & Operational Research Division. Effect of Tobacco Advertising on Tobacco Consumption: A Discussion Document Reviewing the Evidence. London, U.K., 1992. (The “Smee Report,” named for Clive Smee, Chief Economic Advisor)