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Promotion of gender equity in tobacco control and in other areas to transform gender relations
There are 1.3 billion smokers among the global population of 6 billion, the majority in low- and middle-income countries (LMICs).1 In all, 12% of the female population smokes regularly,2 estimated to rise to 20% by 2025.3 Although global male smoking rates have reached their peak and are slowly waning, female rates are rising rapidly.4 Women from LMICs are becoming the biggest at-risk group, and tobacco companies describe women from LMICs as an “untapped market resource”.5 The World Health Organization’s (WHO’s) Framework Convention on Tobacco Control (FCTC) has the potential to integrate gender and diversity into all future tobacco control. In the early stages of FCTC development, Ernster et al6 emphasised that the gendered nature of the tobacco epidemic necessitated gender-responsive policies. The FCTC incorporates gender concerns in its preamble and, in Article 4, suggests that countries “address gender-specific risks when developing tobacco control strategies” at national, regional and international levels.
OPTIONS FOR INCLUDING GENDER IN TOBACCO CONTROL
The WHO’s gender policy recommends integrating gender concerns in all of its activities.7 Experience suggests that gender relations and power differences can be exploited, accommodated or transformed8 with different effects. For example, tobacco control efforts could exploit women’s inequality, maintain paternalism and “protect” women from tobacco use using strong proscriptions against its use by women. Simplistic messages that link increased smoking to women’s liberation feed this approach. Women’s gendered roles can be accommodated by focusing on women as nurturers. For example, tobacco control activities that focus on tobacco reduction during pregnancy or around small children rely on and reinforce women’s traditional roles and responsibilities. A strategy to actively transform gender relations would encourage tobacco control efforts that promote critical analysis and seek to reduce inequities between women and men, along with tobacco reduction. Efforts that actively link tobacco control with policies such as housing or child care, engage smokers in planning, confront the stigmatisation of smokers or provide media literacy to enable girls to decode tobacco advertising are examples. We argue that the FCTC presents an opportunity to go beyond gender-specific tobacco control policies and show foresight by adopting a transformative agenda. Such a strategy would reduce vulnerabilities to tobacco use among girls and women as well as achieve progress towards gender equity.
Various policies are combined in comprehensive approaches to tobacco control. The International Tobacco Control Policy Evaluation Project is surveying its implementation and effects in 12 countries to inform the FCTC.9 Although it controls for sex and some diversity variables, the International Tobacco Control Policy Evaluation Project does not include an explicit gender and diversity analysis. Its results will be important in determining differential use patterns and effects on women and men, but future research should also monitor the gendered effects of tobacco consumption and production, especially in LMICs. To provide examples, selected FCTC Articles are discussed and recommendations made for transformative actions that go beyond simply gender-specific policies.
Article 6 endorses price and taxation measures. The gendered effects of taxation and price are mixed according to research from developed countries. Farrelly et al10 indicate that women are more price responsive than men and would be more likely to quit smoking than reduce consumption. A UK study similarly finds that women are more price responsive than men, whereas a Canadian study finds that women and men are equally price responsive.11,12 Although low-income groups exhibit greater price elasticity than higher-income groups, tobacco taxes impose a “regressive burden” on lower-income taxpayers.13 Thus, as the FCTC presses for price increases, supplementing these policies with free cessation aids or social support may be necessary to decrease the greater poverty-related inequities experienced by low-income women.
Article 12 encourages public education and information campaigns on tobacco. Such endeavours may need tailoring when the majority of illiterate people globally are women,14 often without formal education. Tobacco control could work closely with women’s education and literacy programmes to include rights-based messaging and be more accessible through targeted campaigns using diverse forms of media. Female educational empowerment may assist in reducing tobacco use.
Article 12 emphasises the inclusion of non-governmental organisations in developing tobacco control policies. Global networks such as the International Network of Women against Tobacco are vital in placing women’s and girls’ tobacco control needs on the international agenda and linking an equality-seeking agenda with global tobacco control in support of the FCTC.15 Gendered experiences such as depression, poverty or violence influence tobacco use and receptiveness to tobacco control policies.16,17 Linking with non-governmental organisations pursuing social justice and equality-seeking goals will ensure that comprehensive tobacco policies (CTPs) reflect the needs of specific communities, promote women’s rights and diversify leadership.
Article 13 endorses legislation controlling tobacco advertisement, promotion and sponsorship. The tobacco industry spends US$4.6 billion annually on marketing to women and children,18 and has used a gender and diversity approach for decades. Campaigns promoting cigarettes to attain “Western” ideals have led to an upsurge in smoking rates in LMICs. Special products and brands have been developed for women, working class people and various ethnocultural groups.19 Exposing these efforts within an analysis of globalisation and exploitation will generate wider support for tobacco control across a range of movements and empower individuals and populations.
Article 14 of the FCTC supports the integration of CTPs into countries’ national health programmes, which could include educational campaigns and policy endeavours,20 as well as appropriate sex- and gender-specific surveillance, research, training and programming.21 LMICs face economic and political constraints in tobacco control research and policy making,22 which hinder the development of CTPs. Nevertheless, reciprocal learning between LMICs and developed countries can foster gendered CTPs from the start, thereby transforming gender relations by creating specific counteractions to gendered products and messages. Actions resulting from the FCTC should prevent tobacco companies from circumventing advertising bans (eg, by closing loopholes in legislation that permit sponsorships of women’s groups23).
Article 16 encourages laws preventing sales to children. Studies in the USA have shown that the gender of the vendor affects sales to minors,24 and that boys are more likely to acquire cigarettes from commercial sources and girls from social sources, but girls are more likely to be successful in purchasing cigarettes illegally.25 Differences such as these can be highlighted as part of education and counter advertising campaigns, naming the effect of gender and ethnicity.
It is important to enact price and educational policies and to highlight in prevention and cessation strategies that female empowerment cannot be achieved through tobacco use. As a complement to tobacco control policies, women should be provided with culturally sensitive empowerment and decision-making training that will enable them to deal with tobacco use and environmental tobacco smoke in a confident and safe manner. Thus, gender equality is promoted in tobacco control and in other areas, thereby transforming gender relations.
Article 15 of the FCTC specifically mentions tobacco production, primarily the illegal tobacco trade. But the effects of the shift of tobacco production to the LMICs are gendered, with women being most vulnerable to its health and economic harms. The chemicals used in tobacco farming have destructive consequences on maternal and fetal health, as documented in Kenyan workers and indigenous Huichole tribeswomen in Mexico, who experience high rates of miscarriage and birth defects.26
Article 16 encourages the promotion of economically viable alternatives for tobacco workers, growers and individual sellers. Women are less likely than men to be land owners and named in agreements with tobacco companies, but are encumbered with intensive tobacco farming responsibilities. Children from tobacco estates usually cannot attend school.27 Because girls’ education is undervalued in LMICs,28 girls from tobacco estates are further disadvantaged. A report on the tobacco industry in India and Bangladesh exposes the realities of health, sexual and economic abuse faced by female workers.29
The onus is on the signatories to the FCTC to deal with the harms of tobacco production on women and children. Provisions curtailing and controlling tobacco production reflective of gender and diversity concerns should be consciously explored. Signatories could assist in transforming unequal economic and working conditions and in equalising access to education between men and women by tracking these effects of tobacco production. Providing women with educational and employment alternatives to tobacco production will free them from harmful labour conditions. It will also transform gender relations by empowering women to negotiate on their own behalf and increase economic influence in the household,30–32 consequently giving working women more power.
Gender discrepancies reflecting women’s inequality proliferate in responses to tobacco control policies, tobacco use and issues stemming from tobacco production and marketing. However, to achieve sustained and positive effects on future tobacco use and global public health, the signatories and supporters of the FCTC should consciously adopt strategies that will transform gender relations, not continue to exploit or accommodate prevailing gender inequities. This requires a broader framework for tobacco control, informed by social justice and human rights concerns and increased research on the gendered effects of policy. In so doing, longer-term vulnerabilities to tobacco use will be reduced and women’s, men’s, family and community health will benefit.
What this paper adds
Little is known about the differential effects of tobacco policies on women, men and diverse populations. The available evidence suggests that there are actual or potential gender and group-specific differences, but most of that evidence has been collected in the developed world. As the tobacco epidemic spreads across the developing world, potential effects could be mitigated by tobacco control policies and programmes that are gender and diversity sensitive.
This paper discusses the potential of the Framework Convention on Tobacco Control (FCTC) to integrate gender and diversity concerns into its activity. It argues for aiming to transform gender relations instead of merely accommodating or even exploiting gender relations, as the FCTC is enacted.
Promotion of gender equity in tobacco control and in other areas to transform gender relations
Competing interests: None declared.
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