Tobacco smoking: a public health threat
Tobacco smoking is a major preventable cause of morbidity and mortality worldwide. Tobacco smoking is related to several health conditions including cancers such as lung, upper aero-digestive tract, pancreas, and stomach cancers 1, coronary heart diseases, and stroke 2. Tobacco is particularly harmful for women not only due to female-specific cancers but due to the reproductive health and potential pregnancy complications (e.g. low birth weight, miscarriage, sudden infant death syndrome and underdevelopment of fetus) 2,16.
Tobacco smoking kills more than 7 million people every year, and nearly 900,000 deaths are caused by second-hand smoking, which affects children and females in particular 3,4,9. Almost 80% of the one billion smokers live in low and middle-income countries (LICs and MICs) where burden caused by tobacco use fall the heaviest 3. The global tobacco epidemic continues to persist, especially in LICs and MICs where tobacco companies are active. World Health Organization (WHO) has estimated that without effective tobacco control policies, the tobacco-related mortality will increase up to 8 million people by 2030, of which 80% live in LICs and MICs.2
31st May marks the World No Tobacco Day 2018, and this year the focus is on “Tobacco and heart disease” 13. The aim is to raise awareness of the link between tobacco and heart and other cardiovascular diseases (CVDs). In fact, tobacco use is the second leading cause of CVD, after high blood pressure 2,13.
Besides the detrimental health impacts of tobacco smoking, the World No Tobacco Day allows to raise awareness of how tobacco companies interfere with tobacco control strategies (e.g. lobbying, contributing to political funding and campaigns, funding research, manipulating the media, and promoting false messages), and how they target their products directly to females 18. In fact, female-targeted tobacco products represent the single largest product marketing opportunity in the world6. In some countries, there are no differences in the number of male and female smokers or the number of female smokers outweigh the number of male smokers 9,19.
Targeted marketing to females
The first marks of the tobacco industry’s targeted marketing to females can be found in the 1920s from the USA when advertisements of women smoking cigarettes started to appear in women’s magazines such as Vogue and Vanity Fair. The targeted advertisements portrayed smoking as feminine and linked it to fashion 17. The themes of ‘weight loss’ or slimness (e.g. “To keep the slender figure, reach for the Lucky [the cigarette] instead of a sweet”) were commonly used 15-17, and cigarettes were advertised as weight reduction products 17. Famous persons such as actresses were recruited to promote tobacco smoking 6. However, women’s smoking gained social acceptability only after the World War II, and tobacco companies started to target women more directly 17. Themes of fashion, beauty, and sophistication were used and smoking was portrayed as a way of achieving independence, while still staying attractive (to men in particular) 12,17.
The targeted marketing continued through the years, but in the 1960s, partly boosted by the women’s liberation movement in the USA, women became a major target of the tobacco industry. Taglines addressing women as independent and successful, yet sexy and stylish were used (e.g. “You’ve Come A Long Way Baby”) 17. Few years after the introduction of the female-targeted brands, the smoking initiation rate among females increased remarkably in the USA 10, and similar trends have been found in Europe 20. Later in the 1970s, as women became more aware of the health risks related to smoking, so-called light tar or light cigarettes were misleadingly promoted for women as a “safer” or “softer” option 6,11. These new types of cigarettes did not reduce harm, rather discouraged to quit smoking, especially among women who more often smoked “light” cigarettes 6.
Besides direct advertisements, tobacco companies have used sponsorships to reach women for many years. Tobacco companies have sponsored sporting events, music festivals, concerts, women’s tennis, and fashion shows. Tobacco companies have even sponsored beauty contests in the USA, and the winner of the contest has become the promoter of tobacco products for the reigning year 6. The sponsorships are an effective way for tobacco companies to advertise their products and gain television exposure, for example 6. Tobacco companies have also directly sponsored women’s organizations and supported groups that represent racial/ethnic minorities or women’s groups that promote women’s leadership in business and politics 6.
Furthermore, tobacco companies have paid to place their tobacco products in films or on television 16. Besides films, and television, exposure to tobacco smoking can be found in music, and even in children’s animated movies 6. Studies have shown that the number of smokers is overestimated in film 17,18.
Today, tobacco companies continue to use the same strategies to target their products to women. The image of tobacco smoking is still tied to independence, weight control, power, and stylishness, and the themes can be found in many advertisements and women’s magazines. Tobacco companies even suggest that women are empowered by smoking 16. Positive imaginary (e.g. models engaged in sporting pursuits) are used in the advertised messages 6. In addition to advertising strategies, two types of cigarettes are marketed to women: female brands (e.g. “slim cigarettes”) and dual sex brands. Finally, so-called “purse packs” (i.e. small, narrow boxes that look like cosmetic cases) have been released to attract women 16,17.
Strategies for action
Several policy practices have proven to be effective in reducing tobacco smoking 2,9. The apparent policy best buys include increasing taxation, offering cessation services, monitoring tobacco use, and implementing mass media campaigns to educate the public about the harms of smoking 14. WHO has also introduced MPOWER* measures to help to implement WHO’s Framework Convention on Tobacco Control (WHO FCTC) 7-9.
More specifically, direct and indirect tobacco advertising should be banned 2,6 and any kind of sponsorships should be impermissible 6. As suggested by Kaufman and Nichter, the use of registered brand names, logos or trademarks should be forbidden 6. The tobacco packages should include health warning labels and/or pictures, and tobacco products should be sold as plain and standardized packages 6,18. Educational campaigns regarding dangers of tobacco smoking, and media literacy skills educating particularly women and girls to analyze the messages the companies use are essentials 6,19.
A global monitoring system to track and report tobacco companies’ revenues spent on advertising, promotion, sponsorship or product placements, targeted to females, in particular, should be established 6. In addition, global alliances are needed to tackle the tobacco industry’s strategies 6.
Actions on all levels are urgently needed: individual-level actions (e.g. never taking up smoking, quitting smoking, and cessation services), family and community level interventions, and policy actions on the national and global level, especially in LICs and MICs which are the “new targets” of the tobacco industry.
*MPOWER stands for Monitoring tobacco use and prevention policies, Protecting people from tobacco smoke, Offering help to quit tobacco use, Warning about the dangers of tobacco, Enforcing bans on tobacco advertising, promotion, and sponsorship, Raising tobacco taxes
- Vineis, P., Alavanja, M., Buffler, P. et al. (2004). Tobacco and Cancer: Recent Epidemiological Evidence. Journal of the National Cancer Institute, 96(2), 99-106.
- West, R. (2017). Tobacco smoking: Health impact, prevalence, correlates and interventions. Psychology & Health, 32(8), 1018-1036. Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5490618/>.
- WHO (2018). Tobacco, fact sheet. Available at: <http://www.who.int/mediacentre/factsheets/fs339/en/> [Accessed 10 May 2018].
- Samet, J.M & Yang, G. (2001). Passive Smoking, Women and Children. In Samet, J.M & Yoon, S-Y., ed., Women and the Tobacco Epidemic – Challenges for the 21st Century. Canada, World Health Organization, 17-45.
- Aghi, M., Asma, S., Yeong, C. C. & Vaithinathan, R. (2001). Initiation and Maintenance of Tobacco Use. In Samet, J.M & Yoon, S-Y., ed., Women and the Tobacco Epidemic – Challenges for the 21st Century. Canada, World Health Organization, 49-68.
- Kaufman, N. J. & Nichter, M. (2001). The Marketing of Tobacco to Women: Global Perspectives. In Samet, J.M & Yoon, S-Y., ed., Women and the Tobacco Epidemic – Challenges for the 21st Century. Canada, World Health Organization, 69-98.
- WHO (2013). MPOWER in action – Defeating the global tobacco epidemic. Available at: <http://www.who.int/tobacco/mpower/publications/mpower_2013.pdf?ua=1>.
- WHO (2008). MPOWER: a policy package to reverse the tobacco epidemic. Geneva, World Health Organization. Available at: <http://www.who.int/tobacco/mpower/mpower_english.pdf>.
- WHO (2017). WHO report on the global tobacco epidemic 2017 – Monitoring tobacco use and prevention policies. Geneva, World Health Organization. Available at: <http://apps.who.int/iris/bitstream/handle/10665/255874/9789241512824-eng.pdf?sequence=1>.
- Pierce, J. P. (1994). Smoking Initiation by Adolescent Girls, 1944 Through 1988. JAMA The Journal of the American Medical Association, 271(8), 608-611.
- Tindle, H. A., Rigotti, N. A., Davis, R. B., Barbeau, E. M., Kawachi, I. & Shiffman, S. (2006). Cessation Among Smokers of “Light” Cigarettes: Results From the 2000 National Health Interview Survey. American Journal of Public Health, 98(8), 1498-1504.
- Amos, A. & Haglund, M. (2000). From social taboo to “torch of freedom”: the marketing of cigarettes to women. Tobacco Control, 9, 3-8.
- WHO (2018). World No Tobacco Day. Available from: <http://www.who.int/campaigns/no-tobacco-day/2018/en/>. [Accessed 20 May 2018].
- WHO (2017). ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. World Health Organization. Available at: <http://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf?sequence=1>.
- WHO in collaboration with the Institute for Global Tobacco Control Johns Hopkins School of Public Health (2001). Women and the tobacco epidemic – Challenges for the 21st Century. Samet, J. M. & Yoon, S-Y. ed. Available at: <http://apps.who.int/iris/bitstream/handle/10665/66799/WHO_NMH_TFI_01.1.pdf;jsessionid=8642D0AD490F2E16EC09EB21D42E24D3?sequence=1>.
- WHO (2010). Empower Women – Combating Tobacco Industry Marketing in the WHO European Region. The Regional Office for Europe, World Health Organization. Available at: <http://www.euro.who.int/__data/assets/pdf_file/0014/128120/e93852.pdf>.
- Tobacco Free Kids (2009). Tobacco Industry Targeting of Women and Girls. Available from: <https://www.tobaccofreekids.org/assets/factsheets/0138.pdf> [Accessed 22 May 2018].
- WHO (2018). Tobacco Industry Interference with Tobacco Control. Geneva, World Health Organization. Available at: <http://apps.who.int/iris/bitstream/handle/10665/83128/9789241597340_eng.pdf?sequence=1>.
- Kaleta, D., Usidame, B. & Polanska, K. (2011). Tobacco advertisements targeted on women: creating an awareness among women. Central European Journal of Public Health, 19(2), 73-78.
- Graham, H. (1996). Smoking prevalence among women in the European community 1950-1990. Social Science and Medicine, 43(2), 243-254.
Niina-Maria Nissinen is a public health professional from Finland and the news coordinator at GHNGN. She currently works as a research coordinator in Finland, and her work focuses on the long-term effects of prenatal alcohol/drug exposure.
Cover picture: WHO Infographics, social media materials: Tobacco threatens us all. Available from: <http://www.who.int/campaigns/no-tobacco-day/2017/social-media/en/> [Accessed 23 May 2018].