Blackwell Science, LtdOxford, UK

RESRespirology1323-77992003 Blackwell Science Asia Pty Ltd

82June 2003
464
Women and tobacco
J Mackay and A Amos
10.1046/j.1323-7799.2003.00464.x
Review Article123130BEES SGML

Respirology (2003) 8, 123130

INVITED REVIEW SERIES: TOBACCO AND LUNG HEALTH

Women and tobacco

Judith MACKAY1,2 AND Amanda AMOS3
1

Advisor, TFI, World Health Organization, 2Asian Consultancy on Tobacco Control, Hong Kong and 3Public
Health Sciences, Department of Community Health Sciences, University of Edinburgh Medical School,
Scotland, United Kingdom

Women and tobacco

MACKAY J, AMOS A. Respirology 2003; 8: 123130
Abstract: Smoking prevalence is lower among women than men in most countries, yet there are
about 200 million women in the world who smoke, and in addition, there are millions more who
chew tobacco. Approximately 22% of women in developed countries and 9% of women in developing
countries smoke, but because most women live in developing countries, there are numerically more
women smokers in developing countries. Unless effective, comprehensive and sustained initiatives
are implemented to reduce smoking uptake among young women and increase cessation rates
among women, the prevalence of female smoking in developed and developing countries is likely
to rise to 20% by 2025. This would mean that by 2025 there could be 532 million women smokers.
Even if prevalence levels do not rise, the number of women who smoke will increase because the
population of women in the world is predicted to rise from the current 3.1 billion to 4.2 billion by
2025. Thus, while the epidemic of tobacco use among men is in slow decline, the epidemic among
women will not reach its peak until well into the 21st century. This will have enormous consequences
not only for womens health and economic wellbeing but also for that of their families. The health
effects of smoking for women are more serious than for men. In addition to the general health
problems common to both genders, women face additional hazards in pregnancy, female-specific
cancers such as cancer of the cervix, and exposure to passive smoking. In Asia, although there are
currently lower levels of tobacco use among women, smoking among girls is already on the rise in
some areas. The spending power of girls and women is increasing so that cigarettes are becoming
more affordable. The social and cultural constraints that previously prevented many women from
smoking are weakening; and women-specific health education and quitting programmes are rare.
Furthermore, evidence suggests that women find it harder to quit smoking. The tobacco companies
are targeting women by marketing light, mild, and menthol cigarettes, and introducing advertising
directed at women. The greatest challenge and opportunity in primary preventive health in Asia and
in other developing areas is to avert the predicted rise in smoking among women.
Key words: action, health, marketing, tobacco, women.

THE GLOBAL PICTURE

There can be no complacency about the current
lower level of tobacco use among women in the
world; it does not reflect health awareness, but
rather social traditions and womens low economic
resources.
Dr Gro Harlem Brundtland, former DirectorGeneral of World Health Organization, 19981

Correspondence: Judith Mackay, Asian Consultancy

on Tobacco Control, Riftswood, 9th Milestone, DD 229,
Lot 147, Clearwater Bay Road, Kowloon, Hong Kong.
Email: jmackay@pacific.net.hk

Smoking is still seen mainly as a male problem, since

in most countries, especially developing countries,
smoking prevalence is much lower among women
than among men (Fig. 1). The prevalence of male
smoking in many countries in Asia, such as China,
Indonesia, Thailand and Korea, and in much of the
Middle East, is 10 or more times greater than the
female prevalence rates, a pattern which contrasts
with that in Europe and the Americas. Only in New
Zealand is the prevalence of female smoking equal to
that of men.
It is currently estimated that there are already 200
million women in the world who smoke, and in addition, in South Asia millions more women chew
tobacco.2 In Mumbai, India, for example, 56% of
women chew tobacco.3

Figure 1

Smoking prevalence for women worldwide. Reproduced with permission from World Health Organization.

124
J Mackay and A Amos

125

Women and tobacco

Figure 2 A model of the cigarette epidemic. Source Lopez et

al. 1994.6

Approximately 22% of women in developed countries and 9% of women in developing countries

smoke,4,5 equivalent to about 250 million women
around the world, but because most women live in
developing countries, there are numerically more
women smokers in developing countries.
Women have traditionally started smoking later,
consumed fewer numbers of cigarettes than men and
smoked lower tar brands. The pattern of smoking
among and between women and men differs according to the stage of the smoking epidemic in each
country (Fig. 2).
Cigarette smoking among women is declining in
some developed countries, notably the USA, UK, Canada and Australia,7,8 but is still increasing or is static
in several Southern, Central and Eastern European
countries.9 More girls than boys are now smoking in
some Western countries, such as the UK, Sweden,
Austria, Denmark, Finland and Germany.
Thus, while the epidemic of tobacco use among
men is in slow decline, the epidemic among women
will not reach its peak until well into the 21st century.
This will have enormous consequences not only for
womens health and economic wellbeing but also for
that of their families.
In developing countries, although women smoke
less, there is great concern that the numbers of
women smokers might rise because:
1. The female population will rise from the present
3.1 to 4.2 billion by 2025, so even if the prevalence
remains low, the absolute numbers of smokers will
increase. This would mean that by 2025 there could
be as many as 532 million women smokers.
2. The spending power of girls and women is
increasing so that cigarettes are becoming more
affordable.
3. The social and cultural constraints that previously prevented many women from smoking are
weakening in some countries.
4. The tobacco companies are targeting women
with well-funded, alluring marketing campaigns,
linking smoking with emancipation and glamour.
5. Many gender specialists, womens organizations,
womens magazines, models, film and pop stars, and

other female role models have failed to recognize that

smoking is a womens issue, or the need to take an
appropriate stance.
6. Women-specific health education and quitting
programmes are rare, especially in developing
countries.
7. Governments in developing countries may be less
aware of the harmful effects of tobacco use and are
preoccupied with other health issues. Where they are
concerned with smoking, they focus on the higher
levels of male smoking. In fact, no developing country
is addressing the emerging female epidemic to the
extent the problem warrants.

HEALTH EFFECTS OF TOBACCO USE

Active tobacco use
The scientific evidence has shown conclusively that
both smoked and smokeless tobacco cause fatal and
multiple disabling health problems throughout the
life cycle.
The younger a girl starts to smoke, the more likely
she is to smoke heavily, become more dependent on
nicotine, and be at greater risk for smoking-related
illness and death.10
Because the health effects of smoking only become
fully evident 4050 years after the widespread uptake
of smoking, the full global impact of smoking on
womens health will not be seen for some decades.
Smoking currently kills around half a million women
in developed countries and 0.3 million in developing
countries each year. In Asia, tobacco accounts for less
than 5% of total female adult deaths, with the exception of Australia, Japan and New Zealand.2 However,
the numbers are increasing rapidly.11 Between 1950
and 2000, around 10 million women died from
tobacco use, but it is estimated that over the next 30
years, tobacco-attributable deaths among women
will more than double.12
Women who smoke have markedly increased risks
of cancer, particularly lung cancer, heart disease,

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stroke, COPD and other fatal diseases. If they chew
tobacco, they risk oral cancer. In addition to these
health risks that women share with men, women face
particular problems linked to tobacco use.1215 These
include:
1. Female-specific cancers, such as cancer of the
cervix.
2. Coronary heart disease: an increased risk with use
of oral contraceptives.
3. Menstruation: irregular cycles, higher incidence
of dysmenorrhoea.
4. Menopause: women who smoke tend to enter
menopause at age 49 years, 12 years before nonsmokers. This places them at a greater risk for heart
disease and osteoporosis, including hip fractures, as
well as an increased incidence of hot flushes.
5. Pregnancy: Smoking in pregnancy causes
increased risks of spontaneous abortion (miscarriage), ectopic pregnancy, low birth weight, higher
perinatal mortality, and long-term effects on growth
and development of the child. Many of these problems affect not only the health of the foetus, but also
the health of the mother. For example, a miscarriage
with bleeding is dangerous for the mother, especially
in poor countries where health facilities are inadequate or nonexistent.
6. Infertility: smoking is linked to infertility in both
sexes and to delay in conceiving.
Many women, even in developed countries, are
unaware of the extent of these risks.16 In a survey
among female hospital employees in the USA, nearly
all were aware of increased complications in pregnancy (91%), but only a minority knew of the
increased risk of miscarriage (39%), and even fewer
knew of the increased risk of ectopic pregnancy
(27%), cervical cancer (24%) and infertility (22%).

ENVIRONMENTAL TOBACCO SMOKE

Professor Takeshi Hirayamas cohort study in 1981 on
lung cancer in 91 000 non-smoking Japanese wives
married to men who smoked was the first conclusive
evidence on the harmfulness of passive smoking,17
and these findings have been confirmed by a myriad
of studies around the world.13,18 Research has also
shown other risks of passive smoking, including heart
disease and stroke. As the majority of smokers in the
world are men, women are at particular risk from
environmental tobacco smoke at home. Women
working outside the home may be exposed to passive
smoking in workplaces where smoking is still
permitted.
Womens smoking may impact on the health of
their families. In addition to a womans smoking during pregnancy impacting on the health of the foetus,
smoking by the father (or other close adult) can also
cause complications during pregnancy, such as low
birth weight.
Children are at particular risk from adults smoking. A WHO consultation in 1999 concluded that passive smoking is a real and substantial threat to child
health, causing death and suffering throughout the
world.19 About 40% of the worlds children are

J Mackay and A Amos

exposed to passive smoking in the home and a further

61% in public places.20 Adverse health effects include
pneumonia and bronchitis, coughing and wheezing,
worsening of asthma, and middle ear disease, and
possibly neurobehavioural impairment and cardiovascular disease in adulthood.14,21 Children of smokers are also more likely to become smokers
themselves.

ECONOMIC IMPACT OF TOBACCO USE

Tobacco use carries a serious economic debit to governments, to employers and to the environment,
which includes social, welfare and healthcare costs;
loss of foreign exchange in importing cigarettes; loss
of land that could grow food; costs of fires and damage to buildings caused by careless smoking; environmental costs ranging from deforestation to collection
of smokers litter; absenteeism; decreased productivity; higher numbers of accidents; and higher insurance premiums.
There are many economic effects related to women
and tobacco, including:
1. Expense of buying cigarettes (diverting money
from other family purchases).
2. Costs of ill-health, which can range from medical
bills to loss of income.
3. Costs of premature death.
4. Costs of looking after relatives affected by
tobacco.
5. Costs of widowhood or even destitution if a male
breadwinner dies from smoking.
The economic costs to the smoker include money
spent on buying tobacco. Farmers near Shanghai
spend more on cigarettes and wine than on grains,
pork and fruits.22 In some countries in Africa and Asia,
20 imported cigarettes cost more than half the average daily income.23 In many developing countries,
there is minimal or no state health care, no unemployment or disability allowances, no pension and
no institutionalized care for the elderly or sick, all
of which place the economic and social burden of
tobacco onto the family.
These effects are particularly severe for poorer
women in poorer countries. Healthcare facilities now
or in future will be hopelessly inadequate to cope with
this epidemic. More than 70% of the estimated 1.3
billion people living in poverty are women.24

SMOKING CESSATION
Several studies have suggested that women may find
it more difficult to quit smoking than men. The reasons are not well understood,25 but it is likely due to
a combination of biological, psychological and social
factors as well as reduced accessibility to quitting
advice and treatment.
Few developing countries have comprehensive
data on the prevalence or numbers of ex-smokers
and data from cessation studies come predominantly
from Western countries. These consistently show

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Women and tobacco

lower quit rates in women compared to men with

nicotine replacement therapy.25 Similarly, studies of
self-quitters have found that women were less likely
to quit initially or to remain abstinent at follow up.
British data show that, despite a similar desire to
quit, women feel more dependent on their smoking
than do men.26 Women are more likely to say that
they would find it very difficult to go without smoking for a whole day than men who smoke the same
amount.
In many developed countries men and women
smokers show similar levels of motivation to quit, but
many women appear to face additional barriers to
quitting, particularly those who are disadvantaged
such as low income mothers. It is becoming more
widely accepted, therefore, that tailored approaches
to cessation are needed.17,2729 These programmes and
services need to be accessible to women throughout
their life course and should be integrated into quality
and affordable health services.
Assistance with cessation is virtually nonexistent in
many developing countries, although most countries
in Asia joined the 2002 Quit & Win Campaign, and all
participated in World No Tobacco Day, which always
carries a quitting perspective. The value of specific
quitting programmes for women remains uncertain,
although there is an untested belief that such programmes may be particularly suited to women in
Asian countries.

THE TOBACCO INDUSTRY

British American Tobacco had a view on gender a
quarter of a century ago.
Smoking behaviour of women differs from that of
men . . . more highly motivated to smoke . . . they
find it harder to stop smoking . . . given that women
are more neurotic than men it seems reasonable to
assume that they will react more strongly to smoking and health pressures . . . there may be a case for
launching a female oriented cigarette with relatively high deliveries of nicotine . . ..30
Following a ruling in the USA law courts, previously
secret and internal industry documents have now
been revealed to the public. These show that on a
global basis, the multinational tobacco industry has
consistently lied or obscured the truth to governments, to the media and to smokers.31,32 Nowhere has
this been more evident than in developing countries,
which often lack the expertise to challenge the
industry.
Their interest in Asia is intense. A search of a website collection of documents shows the industrys
greatest interest in Asia is China, Australia, Japan,
Korea, the Philippines, Thailand, New Zealand, and
Indonesia.3
The industry journal Tobacco Reporter ran an editorial about the Asian market that stated:
Rising per-capita consumption, a growing population and an increasing acceptance of women
smoking continue to generate new demand.31

The tobacco industry promotes cigarettes to

women using seductive images of vitality, slimness,
emancipation, sophistication, and sexual allure.13,3235
Until the 1980s, there was relatively little tobacco
promotion in developing countries. The national
monopolies did not, in general, promote their products, or did so only minimally. But from the 1980s, the
transnational tobacco industry introduced tobacco
advertisements. Many of the initial advertisements
were very masculine, such as the Marlboro cowboy,
but gradually a whole range of advertisements were
produced, moving from men-only advertisements;
through neutral advertisements showing, for example, both men and women enjoying the scenic
outdoors; to women-only advertisements in the
mid-1980s. Some of the monopolies and national
companies, such as in Japan and Indonesia, then
began to copy promotion that targeted women.

Marketing
The tobacco companies also started producing what
could be called feminized cigarettes long, extraslim, low-tar, light-coloured and menthol. Some
companies produced special gift packs and offers
designed to appeal to women. In Taiwan, tobacco
companies launched gift packs for the Lunar New
Year, with the Yves St Laurent luxurious gift pack containing two cartons of cigarettes plus one crystal
item. The 555 gift packs had either a tea set or an
ashtray, and the Virginia Slim Lights gift packs
included stylish lighters suitable for women smokers.
In Australia, there have been Alpine fashion keyrings,
bags and silk underwear. In Japan, purchasers of Mila
Schon cigarettes have had the chance to win handbags and ladies watches. In some countries young
women are being targeted through direct mail shots:
graduates of Tokyo Womens University were sent,
unsolicited, sample packets of Salem to their home
addresses.
Although it is mainly mens sports that are sponsored in developing countries, these are watched by
women. For example, 46% of spectators at the Hong
Kong Salem Tennis event in 1993 were women.
Michael Chang, who plays regularly in Marlboro and
Salem tennis events in China, Japan, the Republic of
Korea and Hong Kong, enjoys idol status with many
teenage girls throughout Asia, who could be forgiven
for believing he smokes Salem.
In Sri Lanka the Ceylon Tobacco Company hired
young women to drive around in Players Gold Leaf
cars and jeeps handing out free cigarette samples and
promotional items. These women also handed out
free merchandise at popular shopping malls and university campuses.36 In a country where only 2% of
women smoke, this seemed to be part of a wider strategy to challenge the social taboo that respectable
women in Sri Lanka should not smoke and certainly
not in the street.
Brand-stretching and sponsorship in Asia includes
womens football, and using cigarette names for travel
holidays, bistros, jewellery shops, etc. Arts sponsorship provides the tobacco industry with an aura

128
of culture, glamour and respectability, sponsoring
events that appeal to women as well as men. Events
in Asia have included Peter Ustinov (Hong Kong,
1992); Tony Bennett Jazz concerts (Thailand, 1993);
Central Ballet of China (1994); Andrew Lloyd Webbers
The Phantom of the Opera sponsored by Philip Morris (Hong Kong, 1995); ASEAN Arts Awards (ASEAN,
1999), and in New Zealand there are the Benson and
Hedges Fashion Design Awards.
Events and activities popular with the young also
receive sponsorship. Admission to films and pop or
rock concerts has been either free, or free tickets have
been given in exchange for empty cigarette packets
(Taiwan 1988, Hong Kong 1994). In 2002, British
American Tobacco organized a huge musical celebration in Indonesia, clearly designed to attract the
young.37 International film stars have accepted
money from the tobacco industry for product placement in their films, and such films are shown around
the world.

J Mackay and A Amos

ber states. It is dedicated to incorporating gender

issues in the convention and its protocol, including
the language used.

The World Bank

The World Banks report, Curbing the Epidemic,
marked the first time a major financial institution
had supported policies designed to reduce tobacco
demand.2 The document argues that tobacco control
is good for the wealth as well as the health of nations;
that it does not lead to loss of taxes or jobs; and that
tobacco control measures (e.g. price increases, advertising bans, smoke-free areas, health education, pharmaceutical assistance in quitting) are cost-effective in
both industrialized and developing countries. Men
and women are not specifically indexed, but the findings have relevance to both.

International non-governmental organizations

ACTION
Tobacco control strategies are highly cost-effective,
and much more cost-effective than treating patients
with lung cancer, chronic obstructive airways diseases and other tobacco-related illnesses. Public policy, legislation, research, and education need to be
geared specifically towards preventing girls from initiating smoking and helping women quit.12 Over the
past 10 years there has been a growing recognition, at
both international and national levels, of the growing
impact of smoking on womens health around the
world. However, action on this issue has tended to be
restricted to those countries with the longest history
of female cigarette smoking.

The International Network of Women Against

Tobacco was founded in 1990 to address the issues
around tobacco and women. It has members in
about 60 countries. Other non-governmental organizations involved with tobacco often include women
and tobacco as part of their work. The Chest Foundation, linked to the American College of Chest
Physicians, has taken a particularly active role in
women and tobacco, producing a speakers kit which
is currently being adapted for Asia. GLOBALink, the
Internet network based at the Union Internationale
Contre le Cancer headquarters in Geneva, links
tobacco control advocates all over the world, and
has a specific website devoted to tobacco and
women.

International and regional level

International conferences

WHO

The 10th World Conference on Tobacco or Health in

Beijing in 1997, pioneered gender equity in world
conferences. Fifty per cent of all committee members,
chairs and invited speakers were women. When funding was offered to developing countries for two delegates, it was suggested that one be female. In 1998,
the European Union, through Europe Against Cancer,
organized the first European conference on women
and tobacco in Paris.

The former Director-General of WHO, Dr Gro Harlem Brundtland, recognized the importance of
tobacco as a womens issue and has initiated programmes, funding and meetings around the world.
An international meeting on women and tobacco
took place in Kobe, Japan in November 1999. This
drew in, for the first time, womens organizations
beyond the traditional tobacco control groups, culminating in The Kobe Declaration on Women and
Tobacco. In the Western Pacific Region, all three 5year action plans on tobacco or health since 1990
have emphasized the importance of preventing a
rise in smoking among women as a high priority.
The Tobacco Atlas, published by WHO, gives considerable prominence to tobacco use among girls and
women.3
The Framework Convention on Tobacco Control,
WHOs first convention, and also the first attempt
to use international legislation to promote public
health, is currently being negotiated between mem-

Asia Pacific Association for the Control of Tobacco

The Asia Pacific Association for the Control of
Tobacco, first established by the late Dr David Yen in
Taipei in 1989, organizes biennial regional meetings.
Delegates from many countries find the smaller
regional meetings more supportive than the large,
international conferences, and such meetings facilitate delegates, especially women, speaking out. Many
papers have been presented on women and tobacco
in the AsiaPacific region.

Women and tobacco

National level
At a national level, governments have a central and
crucial role in tobacco control, especially in the area
of legislation and tobacco tax increases. Without government leadership and commitment, tobacco control measures especially in developing countries
are unlikely to succeed. Many governments are preoccupied with other problems, such as high infant
mortality, communicable diseases, economic difficulties or political conflict; they lack funds; and have
little experience in dealing with the tactics of the
transnational tobacco companies. In addition they
may be reluctant to act because of the mistakenly
perceived economic benefits of tobacco.
The lead government ministry is usually the Ministry of Health, but womens commissions or ministries
should be active. For example, in 2001 the Womens
Commission in Hong Kong concluded that smoking
was a womens issue, and in order to protect women
workers and diners, endorsed the governments legislative proposals to ban all smoking in all workplaces
and restaurants.
Yet many developing countries have implemented
tobacco control programmes, including legislation,
far ahead of many Western countries, without any
severe economic consequences. For example, legislation in Singapore, Fiji, Mongolia, Hong Kong, South
Africa, Thailand and Vietnam is far ahead of many
Western countries. Many tobacco control measures
cost little other than political will; for example, legislation requiring health warnings on cigarette packets;
or the creation of smoke-free areas in government
buildings, public areas, transport, or schools. However, many tobacco control programmes in both
developed and developing countries continue to take
a gender-neutral or gender-blind approach.

CONCLUSION
The challenge facing us at the beginning of the 21st
century is how to stem the female wave of the tobacco
epidemic, particularly in developing countries and
among disadvantaged women in developed countries. There needs to be wider recognition that
womens tobacco use is a global health problem and
that effective women-centred tobacco control programmes should be implemented at international as
well as national levels.
Unless there is a strong, coordinated effort with the
aims of preventing girls from starting to smoke, and
of assisting cessation, the tobacco epidemic will take
a terrible toll on women all over the world. Nowhere
will it be felt more keenly than in Asia.

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