The global epidemic of tobacco use among women and girls: How gender-based policies can help limit the spread of tobacco use among girls and women and improve their lives

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From the BC Centre of Excellence for Women’s Health

Tobacco use is increasing its hold and impact on women and girls across the globe. In the 21st century, it threatens to undermine not only women’s physical and mental health but also their economic and social progress. Preventing the full expansion of the tobacco epidemic among the world’s women will be a critical factor in improving the status of women.

While global tobacco-use trends among men are now in a slow decline, the epidemic among women will not reach its peak until well into this century. The World Health Organization predicts that the prevalence of smoking among women worldwide will be 20% by 2025, a sharp contrast to the 12% of the world’s women who smoke today. Yet, even if smoking rates remain unchanged, the number of female smokers will increase simply because the number of women in developing countries will increase by an estimated 1 billion from the current 2.5 to 3.5 billion by 2025.

For a number of decades, the tobacco industry has sold tobacco by exploiting women’s need for liberty and independence. This approach has been, and continues to be, the basis of many advertising and marketing campaigns, and has served to change cultural beliefs about women and smoking. Its message has been tragically ironic -- although smoking has been linked to independence and pleasure, cigarette smoking has had the opposite effect of diminishing both women’s health and material wealth, while also diminishing their independence and quality of life.

It was over eight decades ago, in 1924, that Philip Morris introduced a so-called women’s cigarette that they described being “mild as May.” Forty years later, the United States Surgeon General reported that there were “probable” linkages between tobacco use and cancer for women and “definite” linkages between tobacco use and cancer for men. By this time, there were also emerging concerns about the effects of smoking during pregnancy, although most of these focused primarily on the health of the fetus, not on the health of women.

In more recent history, other tobacco-related issues began to emerge. By the early 1980s, the immense toll of second-hand smoke on women started to become more apparent when research in Japan documented the perils of exposure for women who lived with smokers. In the meantime, the gradual movement of tobacco farming and processing from the Americas to Africa and Asia had an increasing and negative impact on women’s lives, whether they were smokers or not. Women and their families lost valuable food production capacity and were exposed to the various exploitative labour practices of tobacco producers.

It took these events and women’s advocacy before the scientific community and the public took notice of the issues linked to girls, women and smoking. In 1983, women were a group of “special concern” at the Fifth World Conference on Smoking and Health in Winnipeg, Canada. By 1989, the World Health Organization’s “World No Tobacco Day” took on the theme of “Women and Tobacco” and a year later, in 1990, the International Network of Women Against Tobacco (INWAT) was formed in Perth, Australia, to develop women’s leadership, advocacy and education on the issues of women and tobacco.

In 1992, the first international conference on women and tobacco was held in Northern Ireland. Later, in 1999, Japan hosted the first World Health Organization (WHO) International Conference on Tobacco and Health, with the theme “Making a Difference to Tobacco and Health: Avoiding the Tobacco Epidemic in Women and Youth,” which gave rise to the Kobe Declaration (see side-bar).

In related moves, the Global Youth Tobacco Survey (GYTS), developed by WHO and the US Centers for Disease Control and Prevention (CDC), was launched in 1999 to gather data on smoking by girls and boys. In 2000, eight Millennium Development Goals (MDGs) were adopted by United Nations (UN) member states. Two of these specifically focus on improving the status of women, and the WHO has applied these goals to tobacco control.

This early work culminated in May 2003 when the member countries of WHO adopted the Framework Convention on Tobacco Control (FCTC), a historic tobacco control treaty, which came into force with ratifications in 40 countries in February 2005. This international public health treaty recognizes the importance of a gendered approach to tobacco programming, policy and research, and expresses concern about the potential global rise in tobacco use among women. Its progress is being monitored by the Framework Convention Alliance, a civil society organization.

Health, wealth and equality

The issues of improving women’s economic, political and social empowerment and progress are inextricably linked with women’s tobacco use. Without health, women cannot prosper. Without equality, women are at a disadvantage in achieving and maintaining good health.

Indeed, the women and girls experiencing health inequities in developed countries are also most likely to be among the remaining smokers, and smokers in developed countries are those most likely to be disadvantaged or marginalized. Because access to power and resources is gendered, there are numerous female populations that are a priority for tobacco control. In countries with fewer resources and capacity, where women are often just beginning to smoke or increase their smoking rates, tobacco use will impair their long-term health. In these countries, where most of the global growth in women’s tobacco use is occurring, the irony of the marketers’ messages linking smoking to independence has yet to be fully exposed.

This critical connection between women’s equality and women’s health needs to be acknowledged and addressed, along with a gendered analysis of tobacco use, tobacco production and legislation. 

A concerted effort is urgently needed to prevent or reduce the extent of the tobacco epidemic among women around the world. This objective cannot be met in isolation or through unlinked steps and programs. Rather, it will require improvements in girls’ and women’s status, relevant equity based innovations in programs and policy across health, social and economic sectors, as well as truly comprehensive tobacco policies.

The Framework Convention on Tobacco Control is a critical tool for achieving these goals. Its clear commitment to gender and women’s and girls’ issues establishes a basis for action in the 21st century. While article 4 of the FCTC states that gender must be threaded throughout the treaty and its application, it is still difficult to assess what this will really mean. Will the states that ratify the FCTC know how to apply its articles within a women-centred framework, respecting both sex and gender issues? We have emerging evidence that women and girls are affected differently by many of the issues in the articles in the FCTC.

Making tobacco control policies more responsive to women is crucial, but preventing or reducing the scale and impact of the tobacco epidemic in the 21st century will involve more than the traditional set of tobacco control policies. We know that women benefit from a range of policy initiatives and programs that enhance their economic and social status along with their health. It seems likely that these improvements will also strengthen their resistance to tobacco or enable their cessation of its use.

For women smokers, social, housing and economic policies can ensure a reduction in vulnerability to smoking due to stress, double or triple workloads, or lone motherhood. Ensuring adequate incomes for women, and enough support for child and dependent care, are also important to ensure health for women and reduce their vulnerability to tobacco use.

For girls, staying in (or getting to) school, along with positive role models and access to health-promoting activities such as sport and physical activity, also work against tobacco use. Although these issues have often been regarded as outside of the domain of tobacco control, this is far from true any more. A key challenge for women’s health is to widen the efforts of the tobacco control movement to include social justice and human rights perspectives. A key challenge for tobacco control is to engage with the women’s health movement in respecting the goal of women’s empowerment.

For women working in tobacco production, protective labour legislation is urgently needed to promote occupational health. But better yet, women need alternatives for economic survival that are healthier and more productive than working in tobacco production, being manipulated and objectified in tobacco marketing or working in the tobacco-marketing industry.

Tobacco control for women and girls is at a crossroads. How will we use the Framework Convention on Tobacco Control to ensure that gender equity is advanced while tobacco use is reduced, and that existing unequal gender relations are not exploited? How can we ensure the advancement of women and girls along with the eradication of tobacco from our world? This is the challenge for the 21st Century.

Excerpted and abridged from Turning a New Leaf: Women, Tobacco and the Future.  To read the full report in English, French or Spanish, visit: www.bccewh.bc.ca or www.inwat.org or contact: 604-875-2633.

Lorraine Greaves is the President of the International Network of Women Against Tobacco (INWAT) and the Executive Director of the BC Centre of Excellence for Women’s Health; Natasha Jategaonkar is the Manager of Framework Convention Alliance; and Sara Sanchez is the Coordinator of INWAT.