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Review Article
Women and tobacco: A total misfit or mis-unfit
Ipseeta Menon, Hari Parkash1
Department of Public Health
Dentistry, I.T.S Center for
Dental Studies, 1I.T.S Group of
Dental Colleges, Muradnagar,
Ghaziabad, Uttar Pradesh, India
Received
: 24-07-10
Review completed : 22-09-11
Accepted
: 02-03-12
ABSTRACT
Women smokers are likely to increase as a percentage of the total. If the percentage of women
who smoke in developing countries rise to the levels of men smokers, there will be more
than 500 million women smokers in the next generation. Because women who smoke die
from the same tobacco-caused diseases as men, such an increase will have dramatic effects
on women’s health and on the health and incomes of their families. In addition, women
smokers are also at risk for developing cancer of the reproductive organs and osteoporosis.
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.
Key words: Legislations, marketing strategies, policies, woman and tobacco
Tobacco kills over five million people each year, including
approximately 1.5 million women.[1] Unless urgent action
is taken, tobacco could kill more than eight million
people by 2030, of whom 2.5 million would be women.[1]
Cigarette smoking among women is increasing, especially
in developing countries.[2] If the percentage of women
who smoke in developing countries rise to the levels of
men smokers, the number of women smokers in the next
generation will double to more than 500 million.[3] Because
women who smoke die from the same tobacco-related
diseases as men, such an increase will have dramatic
effects on women’s health and on the health and incomes
of their families.[4] In addition, women smokers are also
at risk for developing cancer of the reproductive organs
and osteoporosis.[5] Despite the known dangers to women,
for decades the tobacco companies have targeted women
and girls, using marketing themes that associate tobacco
use with independence and freedom and glamour and
beauty. There have also been attempts to design products
specifically to appeal to women, such as flavored cigarettes
and fashionable packaging. However, it is possible to prevent
Address for correspondence:
Dr Ipseeta Menon
E-mail: [email protected]
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DOI:
10.4103/0970-9290.104966
537
the predicted increase in tobacco use by adopting policies
and programs that have already been proven to reduce
tobacco use. By curtailing tobacco marketing, adopting
strong health warnings, increasing the price and decreasing
the affordability of tobacco products, expanding protection
against second-hand smoke, and carrying out effective
public education and counter marketing campaigns, it is
possible to prevent the predicted epidemic of tobaccorelated illness and death in women around the world.
The purpose of present review is to examine the trends in
tobacco use, the marketing strategies adopted by companies,
the health risks due to tobacco consumption, and policies
and legislations that can help curb tobacco use.
TRENDS OF TOBACCO USE AMONG WOMEN
At present, women comprise about 20% of the world’s more
than 1 billion smokers.[1] However, the epidemic of tobacco
use among women is increasing in some countries. Especially
troubling is the rising prevalence of tobacco use among
young girls. The new WHO report, Women and health:
today’s evidence, tomorrow’s agenda, points to evidence
that tobacco advertising is increasingly targeting girls. Data
from 151 countries show that about 7% of adolescent girls
smoke cigarettes as compared to 12% of adolescent boys. In
some countries, almost as many girls smoke as boys.[6] Of the
more than 600000 deaths caused worldwide every year by
second-hand smoke, 64% occur in women. Nearly 40% of
boys and girls aged 13–15 years are exposed to second-hand
smoke in public places.[1] Cigarette smoking rose rapidly
decades ago among women in many developed countries
such as Australia, Canada, UK, and the US to levels that were
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Women and tobacco
comparable to that in males but are now declining. However,
the numbers are still rising in other developed countries
where women began smoking in large numbers more
recently and, most significantly, this rise is also taking place
in developing countries.[7] The number of women smokers in
the developing world will drastically increase if no action is
taken to stop the tobacco companies from targeting women
and girls. Even if the growth of smoking rates among women
can be contained, the growth in the female population in
the developing world alone will dramatically increase the
number of women smokers.
TOBACCO COMPANIES TARGET WOMEN
Tobacco companies target women and girls with visions
of glamour, independence, and a beautiful life. Globally,
the tobacco industry spends billions of dollars each year on
advertising. Tobacco companies promote cigarettes through
every conceivable medium, including radio, television,
magazines and newspapers, billboards and, recently, the
internet. The tobacco industry is making huge investments
in aggressive advertising targeting women and girls,
exploiting ideas of independence, emancipation, sex appeal,
and slimness.[8,9] Tobacco companies target women and girls
with more than just advertisements; marketing campaigns
also use packaging, branding, promotion, sponsorship, and
integration of the product into popular culture to target
women in a variety of ways.[10] Methods include sponsoring
sporting events and teams; promoting rock concerts and
discos; placing their brand logos on T-shirts, rucksacks, and
other merchandise popular with children; and giving away
free cigarettes and brand merchandise in areas where young
people gather, such as rock concerts, discos, and shopping
malls. Western tobacco companies effectively introduce
their brands to women in Asian countries who identify
with Western women and Western standards of beauty.[11]
Tobacco advertisements target women’s desire for weight
loss and appeal to their growing desire for freedom of
choice and independence. In India, BAT (British American
Tobacco) introduced the cigarette brand, ‘Ms’ that targeted
the ‘emancipated women.’[12] ‘Low-tar’ or ‘light’ cigarettes
were developed by cigarette companies to address the
concerns of health-conscious smokers.. Subsequent studies
have shown that this marketing startegy was designed
particularly to appeal to women [13] Although scientific
evidence has shown that ‘light’ cigarettes do not decrease
the risk of disease among smokers,[14] tobacco companies
have aggressively marketed ‘light,’ ‘ultra-light,’ and ‘low tar’
cigarettes to smokers, especially women. 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.’[15] In
addition to marketing, promotion of events, and sponsorship
of women’s sports and beauty contests, tobacco companies
have made extensive use of the entertainment industry.
Indian Journal of Dental Research, 23(4), 2012
Menon and Parkash
In India the famous ‘Filmfare Awards’ are sponsored by
Manikchand - a tobacco company.
There should be a global ban on direct and indirect
advertising, promotion, and sponsorship by the tobacco
industry across all forms of media and in all forms of
entertainment; and demand public funding for counteradvertising that disconnects women’s liberation and
tobacco use and that reaches women and girls in all cultural
contexts. 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.
TOBACCO AT THE COST OF WOMEN’S HEALTH
The health costs of tobacco are huge. All forms of tobacco
are both addictive and life threatening. The scientific
evidence is conclusive that smoking causes a wide variety
of cancers (including cancer of the lung, mouth, esophagus,
larynx, pharynx, stomach, and pancreas), heart disease,
stroke, emphysema, chronic bronchitis, precancerous
lesions, gum disease, leukoplakia, and nicotine addiction,
and a wide variety of other diseases in both men and
women.[16–23] Smoking by women increases the risk of
spontaneous abortions, stillbirths, infertility, and having
children with low birth weights who suffer from serious
health problems. Women who smoke may also experience
painful menstruation and premature menopause.[24] Women
who smoke during pregnancy are 50%–70% more likely
than nonsmokers to give birth to a baby with cleft lip or
palate. Smoking mothers produce 690 g of breast milk
while nonsmoking mothers produce 960 g. The risk of
SIDS (sudden infant death syndrome) is four times higher
if the mother smokes during pregnancy as compared
with nonsmoking mothers. In addition to SIDS, passive
smoking has been linked to increase of colds, asthma
attacks, bronchitis, pneumonia, breathing problems, and
ear disease.[25] Women who use oral contraceptives have a
significantly higher risk of heart disease if they smoke than
if they do not smoke. Women smokers also have an elevated
risk of stroke, intracranial hemorrhage, hardening of the
arteries, and death from aortic aneurysm.[24] Smoking also
adversely affects the beauty of a woman – smoking increases
the development of wrinkles around the eyes and mouth.
Besides, smoking reduces the circulation of blood and the
uptake of oxygen, affecting not only the skin but also the
hair. Some research even relates smoking to premature gray
hair and hair loss. Chain smokers develop a yellow-brown
discoloration of the fingernails, and the fingers also tend to
be tar stained. Smoking, especially in women, leads to poor
circulation of blood in the hands and feet. The first ill effects
of tobacco smoke are generally seen in the mouth as it is the
first line of defense. Besides provoking bad breath, tobacco
stains a smoker’s teeth and can also be responsible for
plaque, tooth loss, dental caries, and gum disease. Smoking
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Women and tobacco
also promotes bleeding, the most important warning sign
of inflammation in the gums (gingivitis).[25] The metabolic
syndrome (a combination of medical disorders that increase
the risk of developing cardiovascular disease and diabetes)
are not only seen in smokers but in former smokers too.
Studies have showed that individuals who currently smoke
have a higher prevalence of metabolic syndrome than those
who have never smoked and those who have quit smoking.
Former smokers were more likely to have metabolic
syndrome than nonsmokers. The adjusted odds ratios also
showed that among current smokers the amount of smoking
had a statistically significant dose-dependent association
with metabolic syndrome.[26,27] Thus the only way to avoid
this catastrophe is to never start smoking.
Tobacco use often begins by age 16, and girls have more
difficulty with stopping smoking, experiencing stronger
effects on behavior and more negative emotions during
attempts to quit.
METHODS TO QUIT SMOKING
Tobacco contains the chemical nicotine. Behavioral support
and medication can together quadruple the chances that
a quit attempt will be successful. There are two ways to
stop smoking: either the ‘cold turkey’ method, with abrupt
cessation of smoking, or the gradual reduction method.
The US Food and Drug Administration have approved five
medications for dealing with nicotine addiction. All of
these help the patient manage withdrawal symptoms and
cravings. Transdermal nicotine patches (Nicoderm CQ®,
Nicotrol® patches) deliver doses of the addictive chemical
nicotine, thus reducing the unpleasant effects of nicotine
withdrawal. These patches deliver smaller and smaller doses
of nicotine, slowly reducing dependence upon nicotine and
thus tobacco. Others approaches include chewing gums
(Nulife®, Nicorette®, Nicolet®, Nicotex®), lozenges (Commit®
lozenges), sprays (Nicotrol®, Nicotrol NS®), and inhalers
(Nicotrol® inhalers). Antidepressant drugs like bupropion
(Zyban®) and varenicline tartrate (Chantix®) may help
people quit smoking. Alternative medicine approaches are
available such as hypnosis, aromatherapy, and acupuncture,
but the specific effects and efficacy of these treatments are
not yet established.[28]
POLICIES TO HELP PROTECT WOMEN AND GIRLS
FROM TOBACCO
The same policies that have been proven to reduce tobacco
use among men can protect women too. Smoke-free air
regulations, anti-tobacco advertising, bans on tobacco
marketing and advertising, strong graphic health warnings
on tobacco packaging, and increasing tobacco taxes have
proven effective in reducing tobacco use and saving
539
Menon and Parkash
lives.[29,30] Establishing 100% smoke-free environments in
homes and workplaces is the most effective method for
protecting people, especially women, from second-hand
smoke.[31] In China, almost 50% of women between the ages
of 35 and 74 live with at least one smoker, and more than
15% of these women are exposed to second-hand smoke
more for than 4 hours a day at work.[32] Only tax policies
that cover all types of tobacco – not just cigarettes – can
effectively protect all people, because women and men
buy different types of tobacco in different parts of the
world.[33] Adoption and implementation of the Framework
Convention on Tobacco Control (FCTC), which addresses
issues important for protecting women and girls from the
tobacco companies, and access to cessation support can help
protect all people from tobacco.[34]
THE INDIAN SCENARIO
Legislations in India
Warning on cigarette packages/ advertisements: Recognizing
the health hazards of tobacco, the Government of India
promulgated The Cigarette (Regulation of Production,
Supply, and Distribution) Act 1975. Under this Act, all
packages and advertisements of cigarettes are to carry a
statutory warning, ‘Cigarette smoking is injurious to health.’
The Parliament Committee on Subordinate Legislation,
in its 22nd report (December 1995) on this legislation,
observed that these guidelines were often not followed.
Considering the issue of tobacco in totality, the Committee
made wide-ranging recommendations, including strong
and rotatory warnings in regional languages on tobacco
products; ban on direct as well as indirect advertisement of
tobacco products; prohibition of smoking in public places;
initiation of measures for awareness on tobacco through
the health infrastructure, educational institutions, and mass
media; and initiation of efforts for persuasion of farmers to
switch over to alternate crops. These recommendations of
the parliament committee resulted in modification of the
proposed comprehensive legislation on tobacco control.
Warning on smokeless tobacco products: In India, nearly
half of the tobacco users consume tobacco in the smokeless
form. The Prevention of Food Adulteration Rules (1955)
were applied in 1990, necessitating that every package and
advertisement of smokeless tobacco product should have a
warning stating, ‘Chewing of tobacco is injurious to health.’
Cabinet guidelines for smoking in public places: The cabinet
secretariat by an administrative order in 1990 prohibited
smoking in places such as hospitals, dispensaries, educational
institutions, conference rooms, domestic air flights, airconditioned sleeper coaches in trains, suburban trains,
air-conditioned buses, etc. A nationwide ban on smoking
at workplaces, restaurants, hotels, pubs, public transport,
airports, railway stations, educational institutions, cafes,
and theaters came into effect on 2nd October 2008. In 2007,
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Women and tobacco
Menon and Parkash
Chandigarh, a city in northern India, became the first city
in India to become ‘smoke free.’ •
Multisectoral approach for tobacco control
•
The situation necessitates a multisectoral approach, wherein
different sectors (government as well as non-government)
identify themselves as contributors to a radical social change,
leading to tobacco control.
Community education on tobacco
Anti-tobacco education needs to be targeted at decision
makers, professionals, and the general public, especially
the youth. ‘No Tobacco Day’ (31st May) activities have
been a regular feature since 1988 and generally comprise
educational advertisement(s) in newspapers along with a
programme/ workshop in Delhi and at other centers in the
States as well as dental and medical institutions.
Tobacco control cell
A tobacco control cell with a seven-member advisory board
has been established in the Department of Health, New Delhi,
since August 2000, with the aim of coordinating the activities
related to tobacco control. The current activities initiated
through this cell include educational programs through mass
media and schools, strategy papers for alternate crops and
rehabilitation of bidi workers, advocacy workshops for nonhealth sectors, and establishment of tobacco cessation clinics.
Framework Convention on Tobacco Control (FCTC)
The FCTC could be considered as a generator of protocols
that can establish firm commitments by member countries
on key issues. This initiative by the World Health
Organization provides countries a platform to sit together
and discuss the issue and agree or disagree on a certain set
of tobacco control measures for adoption.[35]
OUR ROLE AS HEALTH PROFESSIONALS
Health professionals constitute the principal agency through
which information on the health consequences of tobacco is
communicated to people as well as policy makers. They also
provide their direct services for tobacco cessation through
counseling and other forms of therapy. Recognizing the
importance of their role it is recommended that health
professionals:
•
•
•
Must strongly advocate tobacco cessation among
colleagues and provide special cessation services to
them as tobacco use among health professionals has a
negative influence on the community.
Keep conferences and other events organized by
health professionals completely tobacco free and avoid
sponsorship of any kind from tobacco companies or
their affiliates.
Ensure that health facilities are completely tobacco free,
beyond what is required by law.
Indian Journal of Dental Research, 23(4), 2012
•
Evolve guidelines and specific recommendations for
tobacco control and implement these with the help of
government and the civil society.
Utilize all opportunities for patient contact to enquire
about tobacco use and advice about tobacco cessation.
Provide services, including counseling for behavioral
change and pharmacotherapy, when required.
Counseling
Health professionals provide broad-based cessation services,
which include counseling for behavior change for all tobacco
users and pharmacotherapy when essential. This can be done
by medication or pharmacotherapy and talk or psychotherapy.
Psychotherapy treats psychological or emotional problems
through verbal communication, meeting a very basic human
need to share problems and connect with others. The cessation
interventions can include screening, behavioral counseling,
and pharmacotherapy, all of which have been effective in
helping tobacco users to successfully quit the habit.[36]
CONCLUSION
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 multipronged strategy
combining changes in legislation and fiscal policies along
with improvements in gender-sensitive health services and
cessation programs 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 workplaces, educating
consumers about the health risks of smoking, and increasing
smokers’ access to cessation programs. Much more genderspecific research is needed to understand the association
between women and epidemiological, behavioral, and
economic policies, particularly in developing countries.
Women’s empowerment and leadership should be at the
center of all tobacco-control efforts and are essential for
the success of national programs and the WHO Framework
Convention on Tobacco Control.
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How to cite this article: Menon I, Parkash H. Women and tobacco: A total
misfit or mis-unfit. Indian J Dent Res 2012;23:537-41.
Source of Support: Nil, Conflict of Interest: None declared.
Indian Journal of Dental Research, 23(4), 2012