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The article on women and tobacco by Amos et al provides a comprehensive overview of issues relating to the use of tobacco and the problems of tobacco control in girls and women.1 The authors highlight the problem of the more disadvantaged women in high income countries and the more complex situation with girls' smoking rates in low and middle income countries (LMICs).
However, the solutions suggested to the women's problems that are highlighted raise issues particularly in LMICs of where the often sparse tobacco control money should be preferentially spent. The authors state that the smoking rates in some developing nations are less than 5%, but given that the regions mentioned where the estimated rates in women are Africa 2.8%, Western Pacific 4.8%, South East Asia 4.6% and Eastern Mediterranean 4.4%, and these are just a fraction of the male smoking rates, would it not be prudent in LMICs with limited resources to implement population-wide smoking measures rather than target a lower prevalence group?
The authors highlight the problem of targeting girls and women in marketing tobacco and rightly recommend implementation of the restrictions on industry marketing required by the Framework Convention on Tobacco Control (FCTC).2 They could have gone further and recommended wide implementation of plain packaging, which has just been passed by the Australian parliament and will not only prevent attractive packaging but prohibit small pack sizes with slim cigarettes (FCTC Article 11).3 Also, over 40 countries are applying graphic health warnings on packs. These can be used to warn of the health risks of smoking, secondhand smoke and specific areas of concern about the risks of smoking during pregnancy and may be the most affordable way low income countries can embark on education, while spending their limited resources on more cost-effective measures such as advertising bans.
The importance of price increases in reducing smoking prevalence is acknowledged by the authors but they indicate that the sale of single sticks can reduce the impact of this measure. Article 16.3 of the FCTC prohibits this and what needs to be stressed is the importance of multiple measures being introduced simultaneously rather than one measure at a time. With children at younger ages starting to smoke, less affordable cigarettes and plain packs with graphic warnings will be required together to address this issue.
In LMICs prioritising anti-tobacco measures to first implement those which will have the greatest impact is vital. While gender-sensitive measures to reduce secondhand smoke and achieve smoke-free homes is an important goal, the issue is whether in countries which have not yet fully implemented FCTC Article 8 to ensure public and work places are smoke-free, emphasis on smoke-free homes may provide a convenient excuse for governments to transfer the responsibility to individual smokers, when increasing numbers of women are in the workforce and protection of work and public places may be initially more effective for them.
Finally, the paper makes a strong case for more research: both quantitative and qualitative research at the individual, community and healthcare settings level. There is no doubt that this would be useful. However, this type of research is expensive and would not be affordable by many LMICs. Fortunately, the FCTC has laid out core cost-effective measures to be put in place. Once they have been achieved, governments will be better positioned to conduct this more detailed research, for which the authors rightly identify the need.