The Facts and the Projections

Among the greatest health threats facing women and girls around the globe today is tobacco use, and the tobacco industry is aggressively marketing to increase the number of women and girls who smoke, especially in developing countries. Worldwide, about 47% of men smoke compared to about 12% of women. But the low rates in women are c hanging fast. Tobacco-control advocates project that without strong government and private sector intervention, smoking prevalence among women will nearly triple over the next generation, the number of women smokers will rise from the current 187 million to over 530 million—80% of whom will live in the developing world, and half of whom will die prematurely from tobacco-related causes.

Most women live in developing countries, and between 2% and 10% of them smoke cigarettes. These low levels of tobacco use among women compared to men do not reflect health awareness; rather they are a function of tradition and women's low economic status in developing countries. There is also a wide range in smoking rates, and underreporting may be significant because in many countries it is culturally less acceptable for women to smoke. In some regions women more commonly chew rather than smoke tobacco.

Pictorial depiction of a smoking woman’s dilemma

• In Africa, about 10% of women are estimated to smoke; In Latin America, surveys estimate a low of 3% to a high of 49%;
• In Central and South Asia, only 3% of women presumably smoke manufactured cigarettes; but, 50% to 60% of women chew tobacco in many parts of India, and rural women smoke the water pipe or "reverse smoke" with the lighted end in the mouth;
• In Asia-Pacific, the overall female smoking rate is less than 10% with only 7% in China, and less than 5% in Hong Kong, Malaysia, Singapore, and Thailand. But, rates in the Pacific Islands, for example, among Papua New Guinea women are 80%;
• In Eastern Mediterranean, smoking in women is culturally taboo, even considered immoral and smoking rates among women range from 2% to about 8%;
• In Central and Eastern Europe, the prevalence of female smoking is estimated to range from a low of 1% in Romania, and 8-13% in Russia to a high of 20%-30% in the Czech and Slovak Republics, Hungary, Poland, and Yugoslavia.

Marketing of Tobacco to Women and Girls

As the US market levels off, the tobacco industry is aggressively targeting women and girls in developing countries with seductive advertising that blatantly exploits ideas of independence, power, emancipation, and slimness. The industry claims that cigarette advertising merely encourages brand switching. But, the launching of Virginia Slims in Hong Kong—at a time when less than 2% of Hong Kong women under the age of 40 smoked— exemplifies industry attempts to create a market. The tobacco companies sponsor tours by female pop stars to developing regions and produce yearly calendars in the Philippines—a deeply religious country—featuring the religious Madonna amidst cigarettes packs. In Taiwan, for the Lunar New Year, the industry produced the Yves St. Laurent luxurious gift pack containing two cartons of cigarettes, some crystal, and the Virginia Slim Lights gift packs with stylish lighters for female smokers. Fashion conscious Indian girls and women—traditionally nonsmokers—are special targets of such marketing appeals. In the Asia Pacific, direct and indirect advertising is widespread. Tobacco sponsorship of sports, prominent ads for bistros, boutiques, travel companies and TV films, all bearing industry logos, are commonplace.

Camel poster panders to youth in Poland

Several comprehensive studies show that tobacco advertising revenue discourages the media from reporting the risks of smoking. This is of special concern between 2% and 10% of them smoke cigarettes. These low levels of tobacco use among women compared to men do not reflect health awareness; rather they are a function of tradition and women's low economic status in developing countries. There is also a wide range in smoking rates, and underreporting may be significant because in many countries it is culturally less acceptable for women to smoke. In some regions women more commonly chew rather than smoke tobacco.

Smoking Among Women is Rising

The number of women smokers will increase as the female population in developing countries increases. As women's economic status improves, cigarettes will become more affordable for women (and girls) if regulatory measures are not taken to increase tobacco prices. Historically, in industrialized countries the female smoking epidemic has followed the male epidemic within a few decades. This in now in progress in Central and Eastern Europe. Furthermore, there are already strong indications that in almost all countries, smoking rates among women are rising, especially in urban areas, due to increasing disposable income and advertising campaigns and product promotions by the tobacco industry that especially target women. Global female mortality due to smoking is also increasing and is projected to more than double over the next generation.

Consequences for Women in Developing Countries

Health Hazards. The health consequences of the recent tobacco epidemic among women in developing countries are not yet evident. Women are at special risk from passive smoking, as some 50% to 60% of men in emerging nations smoke, and extended families live in close proximity. Non-smoking Russian women married to smokers face a 50% increase in risk of lung cancer. Lung cancer, currently the 5th leading cause of cancer deaths among women in the world, is likely to rise to number one as it is for men.

Tobacco-use in developing countries such as India is particularly devastating when superimposed on malnutrition and infectious diseases that are prevalent among women. This combination tends to hasten the 90% of lung cancer deaths, 75% of the deaths from chronic bronchitis and a quarter of the deaths from coronary diseases that are caused by tobacco in India, for example.

Women in developing countries have extremely limited, if any, access to health care. In the poorest countries, more than 20,000 people have to share one physician and women are traditionally the last to be attended. Poor, sick, pregnant women and the fetus exposed to tobacco smoke are at especially high risk. If a husband dies from smoking, the family can be left in poverty. If the woman dies, the children can be left destitute. Half a million women still die each year in childbirth, 99% of them in poor countries. Problems associated with smoking and oral contraceptive use are also compounded by lack of education and access to health care. The decrease in fertility associated with smoking may affect a woman's marital status in countries where large families—and the birth of sons—are important.

Economic Impact. Smoking also has a profound economic impact on in poor countries. In India, low income smokers are spending up to 60% of their income buying cigarettes or chewing tobacco, diverting family money from food and education. Philippine smokers of 20 cigarettes a day can spend 35% of median household income on their habit. The China Daily estimated that the $6.9 billion spent on cigarettes each year in China would buy 71 million tons of grain, or 11 millions tons of edible oil, several millions tons of pork, or 7.5 million tons of eggs. The economic impact is felt most by the homemaker—women in poorer countries.

The Challenge

Studies in China show that young girls are unaware of the dangers of smoking; in Hong Kong, only one-third of girls who smoked were aware of the association between smoking and cardiovascular disease. Cigarettes are also increasingly affordable and accessible, and restrictions on tobacco advertising and other promotion are often lacking.

The biggest challenge is the US government’s threat of trade sanctions to Asian countries to persuade them to open their markets. If carried out, a simple rural industry would be replaced by powerful, sophisticated transnational companies. China has already found that a sharp increase in market share of foreign cigarettes was accompanied by increased smoking among girls. The national monopolies in Japan and Indonesia have already learned from the transnational companies how to advertise and target women. Transnational companies deny evidence of adverse health effects of tobacco, that advertising affects consumption, and that they attempt to interfere with national tobacco control measures.

Governments, the public health community, and women in developing countries lack the skills, the resources and the experience in dealing with the US tobacco industry. There is often less awareness of the hazards of smoking and the special risks that women face. Tobacco control programs in many countries are absent or inadequate, and those that exist are often directed to men. Woman-specific campaigns are rare and principally concentrate on the effects of a woman's smoking on a fetus or child. Few programs have encouraged women to quit smoking for their own sake.

There are very few women in senior, decision-making positions in the tobacco control movement. There are few women on editorial boards of medical journals, in senior government jobs with responsibility for tobacco control or in senior roles in non-governmental organizations focused on tobacco control.

Recommendations for US Government Action

As the world’s leading exporter of tobacco products, the United States has a moral responsibility as well as a special opportunity to reduce the global burden of premature disease and death worldwide through support of programs and policies to prevent a rise in smoking among women, especially in developing countries. As a part of any effort to address tobacco use, Congress should enact legislation that will:

• End U.S. Government Support for Tobacco Abroad. The United States should actively seek to halt the global transfer of the problem to developing countries and prevent the imminent epidemic of tobacco deaths, by refraining from attempts to weaken any foreign tobacco regulation unless the regulation discriminates against U.S. products in an arbitrary and unjustifiable manner and is not a reasonable means of protecting public health.
• Adequately Fund Global Tobacco Control Efforts. A private, nonprofit organization should be established to assist public health organizations in other countries through public education programs, technical assistance to health professionals, mass media campaigns, grants and other general assistance. Significant funding should be provided for this NGO as well as for global tobacco control efforts by U.S. federal agencies and multilateral organizations such as WHO, UNICEF and the World Bank.
• Establish a Code of Conduct for Labeling and Advertising Overseas. U.S. tobacco companies should be required to print health warning labels on tobacco products sold overseas that are as stringent as those required in the United States. U.S. tobacco companies should also be prohibited from selling, advertising or marketing tobacco products to children in other countries, with the same standards applied to their overseas conduct as at home.
• Stop International Tobacco Smuggling. The Bureau of Alcohol, Tobacco and Firearms, which currently regulates alcohol smuggling, should be given authority to deter tobacco smuggling through, among other things, a system of export permits and increased record keeping.
• Fund International Tobacco Control Through a Tobacco Control Fee. Every U.S. tobacco company should pay a fee for cigarettes it sells over seas. The funds thus raised should be used for tobacco control efforts by governmental and non-governmental entities.

The U.S. Congress should also support the development, adoption, and implementation of the International Framework Convention on Tobacco Control through all available resources.

The next century will bring the full burden of the tobacco epidemic to young girls and women in Asia, Africa and other developing regions. As women’s disposable income increases and cigarettes become even more affordable, the tobacco companies will strengthen their grip on the most vulnerable populations—young girls and women who look to the West for the latest in lifestyle. American leadership and support are urgently needed to launch a global effort and win the war against tobacco.