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The 1964 surgeon general’s report1 indicated that smoking was the cause of the increase in men’s lung cancer rates, but only suggested an association with women’s lung cancer rates and with low birthweight. For many years thereafter, women were thought to be at less risk from tobacco. After all, a smaller percentage of women than men smoked, and those who did smoked fewer cigarettes. So while the subject of women’s smoking was a hot topic among tobacco marketing strategists, it often escaped the interest of public health specialists.
When women’s lung cancer mortality rates in the United States started soaring, to eventually become the most important cause of cancer mortality surpassing breast cancer, women’s risks were acknowledged to be the same as men’s. “Women who smoke like men die like men.” said former Surgeon General C Everett Koop. Indeed, recent research indicates that women don’t have to smoke like men to die like men, they may be at as much risk as men with lower smoking patterns.
Just what are the differences between men and women in relation to smoking? Do women smoke differently than men, do they smoke for different reasons, do they suffer health consequences differently, do they encounter more difficulty in quitting? Are the differences important, and will they indicate priorities for health policy makers? These are the questions that are finally being asked. It is therefore timely that a publication has recently been released as a professional teaching monograph, The female smoker: from addiction to recovery, by Joan A Christen and Arden G Christen, two experts with experience in cessation counselling and addiction in the context of social and family dynamics.
This monograph is an easy to read, comprehensive overview of the literature related to women and smoking in the United States, in well-arranged sections covering the social history of female tobacco use, tobacco marketing strategies for women, patterns of female tobacco use, the health consequences of smoking and exposure to others’ smoking, the psychological and behavioural dynamics of female smoking, programmes and strategies for women and girls, and conclusions. Because of the importance of cultural elements in tobacco-smoking behaviour, some of the characterisations of female smoking may not resemble those in countries where few women smoke, or where the phenomenon is relatively new. The sections on tobacco industry strategies, and on health consequences are relevant to women throughout the world. The other sections give a picture of the way women’s smoking may evolve in future.
The first section looks at social trends and how tobacco companies have consistently and cynically manipulated associations between cigarette smoking and emancipation. Once a rebellious behaviour for men only, cigarette smoking became a patriotic duty during the Great War, and then was seized on by adventurous women. If all women could be freed from conventions that did not allow them to smoke in public freely, then the market for tobacco sales would double. This is a theme that has been present in tobacco marketing to women since the 1920s.
The monograph presents a good analysis of the general difficulties that women may face and how these might be related to women’s smoking patterns. The information on the health consequences is clear and complete, with very good coverage of the issues particularly related to the consequences of smoking during pregnancy and the terrible costs involved for women and the babies they carry. Much emphasis is given in the monograph to the tactics of tobacco control in relation to pregnancy.
The monograph looks at the unique ability of cigarette smoking to correspond to a vast range of associations. For young people, smoking can still represent “being bad without being criminal”, being “defiantly rebellious and deliberately naughty”, it can represent belonging to a group or separation from it, it can represent being aggressively virile or feminine. In the United States, women and men smoke for a variety of effects and most want to quit. The monograph reports the various reinforcements for smoking to which many women are particularly responsive in today’s relentless search for thinness, and to stifle angers and frustrations from daily life. This is relevant to other parts of the world not in the meanings that are attributed to smoking among American women and girls, but in that almost any valued attribute can be linked with tobacco use. If young women in the United States start to smoke to show their sexual maturity, young women in Greece, for example, may start smoking to show their financial independence. The authors point out that advertisers seize on what is valued to make the associations with tobacco.
In their desire to use the research available, it seems to me that the authors too easily give equal weight to studies of unequal value or difficult comparability. More importantly, they are reluctant to comment on the inconsistent results, particularly those related to the factors involved in initiation, quitting, and relapse. For example, on page 99, we read that “young girls who resist the lure of cigarette use tend to have a high sense of self-worth and competence. . . . Conversely, young girls who have diminished feelings of value, efficacy, and self-esteem characteristically rebel against authoritarian admonitions, including warnings about smoking.” On page 103, we read that “teen-age girls who smoke are more self-confident, socially experienced, sexually active and rebellious against authority than their non-smoking counterparts.” A number of the inconsistencies could be ascribed to the context of the studies: the population of smokers has changed from the ’70s to the ’90s, and the context of taking up smoking has changed.
This is an important issue, because it is the crux of the argument for women-specific tobacco-control efforts. If men and women are clearly different in their reaction to the forces that encourage or discourage smoking, that would seem to be a clear case for gender-specific treatment or prevention programmes. However, if the literature is full of inconsistent results, and it is not gender that differentiates smokers’ behaviour, but instead education or social class, then the arguments for women-specific responses are much weaker. Policy response should be directed to those most at risk. Is it all women, or is it the women with poor education or limited income? Is the disadvantage of being a woman in American society enough of a reason to group all women together in terms of their needs related to tobacco? This question is not addressed in the monograph. The authors point out that the major predictor of smoking is not gender or race, but education. They indicate the wide disparity of conclusions drawn from information about women’s quitting. In cessation treatment, women tend to have more difficulties than men, but this is not reflected in all trials, and the major nationwide surveys do not indicate that women are stopping any less than men. Nevertheless, the conclusions of the monograph include the statement that women have more difficulty stopping than men, and that women-specific solutions are called for.
In low income areas of the world where there is little equity between men’s and women’s social positions, the evolution of women’s smoking may be different and this would influence the nature of “best” policy options.
As the authors note, there is still a lot we need to learn about women’s entry into and breaking away from tobacco. The reasons for uptake, maintenance, and cessation are myriad. In the United States today, there are many women who are deprived of a full range of behaviour choices; special emphasis should be placed in reaching those most in need, those who are most unlikely to be reached by any of the current tobacco control campaigns. This is true as well for other population groups in the United States. There are more men than women who smoke, even if trends are bringing rates together. In some indigenous populations, large proportions of men and women smoke, and young people of both sexes are smoking at rates reaching as high as 80%. This monograph adds to the arsenal of our understanding and appreciation of the special needs of women, and is a welcome compilation of the literature to date.
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