| Abstract|| |
Women smokers are likely to increase as a percentage of the total. If the percentage of women who smoke in developing countries rise to the levels of men smokers, there will be more than 500 million women smokers in the next generation. Because women who smoke die from the same tobacco-caused diseases as men, such an increase will have dramatic effects on women's health and on the health and incomes of their families. In addition, women smokers are also at risk for developing cancer of the reproductive organs and osteoporosis. A gender perspective contributes to a better understanding of the epidemiological trends, social marketing strategies, economic policies, and international actions relating to women and the tobacco epidemic.
Keywords: Legislations, marketing strategies, policies, woman and tobacco
|How to cite this article:|
Menon I, Parkash H. Women and tobacco: A total misfit or mis-unfit. Indian J Dent Res 2012;23:537-41
Tobacco kills over five million people each year, including approximately 1.5 million women.  Unless urgent action is taken, tobacco could kill more than eight million people by 2030, of whom 2.5 million would be women.  Cigarette smoking among women is increasing, especially in developing countries.  If the percentage of women who smoke in developing countries rise to the levels of men smokers, the number of women smokers in the next generation will double to more than 500 million.  Because women who smoke die from the same tobacco-related diseases as men, such an increase will have dramatic effects on women's health and on the health and incomes of their families.  In addition, women smokers are also at risk for developing cancer of the reproductive organs and osteoporosis.  Despite the known dangers to women, for decades the tobacco companies have targeted women and girls, using marketing themes that associate tobacco use with independence and freedom and glamour and beauty. There have also been attempts to design products specifically to appeal to women, such as flavored cigarettes and fashionable packaging. However, it is possible to prevent the predicted increase in tobacco use by adopting policies and programs that have already been proven to reduce tobacco use. By curtailing tobacco marketing, adopting strong health warnings, increasing the price and decreasing the affordability of tobacco products, expanding protection against second-hand smoke, and carrying out effective public education and counter marketing campaigns, it is possible to prevent the predicted epidemic of tobacco-related illness and death in women around the world.
The purpose of present review is to examine the trends in tobacco use, the marketing strategies adopted by companies, the health risks due to tobacco consumption, and policies and legislations that can help curb tobacco use.
| Trends of Tobacco use Among Women|| |
At present, women comprise about 20% of the world's more than 1 billion smokers.  However, the epidemic of tobacco use among women is increasing in some countries. Especially troubling is the rising prevalence of tobacco use among young girls. The new WHO report, Women and health: today's evidence, tomorrow's agenda, points to evidence that tobacco advertising is increasingly targeting girls. Data from 151 countries show that about 7% of adolescent girls smoke cigarettes as compared to 12% of adolescent boys. In some countries, almost as many girls smoke as boys.  Of the more than 600000 deaths caused worldwide every year by second-hand smoke, 64% occur in women. Nearly 40% of boys and girls aged 13-15 years are exposed to second-hand smoke in public places.  Cigarette smoking rose rapidly decades ago among women in many developed countries such as Australia, Canada, UK, and the US to levels that were comparable to that in males but are now declining. However, the numbers are still rising in other developed countries where women began smoking in large numbers more recently and, most significantly, this rise is also taking place in developing countries.  The number of women smokers in the developing world will drastically increase if no action is taken to stop the tobacco companies from targeting women and girls. Even if the growth of smoking rates among women can be contained, the growth in the female population in the developing world alone will dramatically increase the number of women smokers.
| Tobacco Companies Target Women|| |
Tobacco companies target women and girls with visions of glamour, independence, and a beautiful life. Globally, the tobacco industry spends billions of dollars each year on advertising. Tobacco companies promote cigarettes through every conceivable medium, including radio, television, magazines and newspapers, billboards and, recently, the internet. The tobacco industry is making huge investments in aggressive advertising targeting women and girls, exploiting ideas of independence, emancipation, sex appeal, and slimness. , Tobacco companies target women and girls with more than just advertisements; marketing campaigns also use packaging, branding, promotion, sponsorship, and integration of the product into popular culture to target women in a variety of ways.  Methods include sponsoring sporting events and teams; promoting rock concerts and discos; placing their brand logos on T-shirts, rucksacks, and other merchandise popular with children; and giving away free cigarettes and brand merchandise in areas where young people gather, such as rock concerts, discos, and shopping malls. Western tobacco companies effectively introduce their brands to women in Asian countries who identify with Western women and Western standards of beauty.  Tobacco advertisements target women's desire for weight loss and appeal to their growing desire for freedom of choice and independence. In India, BAT (British American Tobacco) introduced the cigarette brand, 'Ms' that targeted the 'emancipated women.'  'Low-tar' or 'light' cigarettes were developed by cigarette companies to address the concerns of health-conscious smokers.. Subsequent studies have shown that this marketing startegy was designed particularly to appeal to women  Although scientific evidence has shown that 'light' cigarettes do not decrease the risk of disease among smokers,  tobacco companies have aggressively marketed 'light,' 'ultra-light,' and 'low tar' cigarettes to smokers, especially women. According to an advertising expert in Tokyo, 'tobacco companies are putting a great emphasis on advertising low-smoke cigarettes, which are basically designed for women who hate to have their hair and dresses spoiled with the smell of tobacco smoke.'  In addition to marketing, promotion of events, and sponsorship of women's sports and beauty contests, tobacco companies have made extensive use of the entertainment industry. In India the famous 'Filmfare Awards' are sponsored by Manikchand - a tobacco company.
There should be a global ban on direct and indirect advertising, promotion, and sponsorship by the tobacco industry across all forms of media and in all forms of entertainment; and demand public funding for counter-advertising that disconnects women's liberation and tobacco use and that reaches women and girls in all cultural contexts. The use of a tobacco-registered brand name, logo, or trademark on non-tobacco items as well as vending machines that dispense tobacco products should be banned globally.
| Tobacco at the Cost of Women's Health|| |
The health costs of tobacco are huge. All forms of tobacco are both addictive and life threatening. The scientific evidence is conclusive that smoking causes a wide variety of cancers (including cancer of the lung, mouth, esophagus, larynx, pharynx, stomach, and pancreas), heart disease, stroke, emphysema, chronic bronchitis, precancerous lesions, gum disease, leukoplakia, and nicotine addiction, and a wide variety of other diseases in both men and women. ,,,,,,, Smoking by women increases the risk of spontaneous abortions, stillbirths, infertility, and having children with low birth weights who suffer from serious health problems. Women who smoke may also experience painful menstruation and premature menopause.  Women who smoke during pregnancy are 50%-70% more likely than nonsmokers to give birth to a baby with cleft lip or palate. Smoking mothers produce 690 g of breast milk while nonsmoking mothers produce 960 g. The risk of SIDS (sudden infant death syndrome) is four times higher if the mother smokes during pregnancy as compared with nonsmoking mothers. In addition to SIDS, passive smoking has been linked to increase of colds, asthma attacks, bronchitis, pneumonia, breathing problems, and ear disease.  Women who use oral contraceptives have a significantly higher risk of heart disease if they smoke than if they do not smoke. Women smokers also have an elevated risk of stroke, intracranial hemorrhage, hardening of the arteries, and death from aortic aneurysm.  Smoking also adversely affects the beauty of a woman - smoking increases the development of wrinkles around the eyes and mouth. Besides, smoking reduces the circulation of blood and the uptake of oxygen, affecting not only the skin but also the hair. Some research even relates smoking to premature gray hair and hair loss. Chain smokers develop a yellow-brown discoloration of the fingernails, and the fingers also tend to be tar stained. Smoking, especially in women, leads to poor circulation of blood in the hands and feet. The first ill effects of tobacco smoke are generally seen in the mouth as it is the first line of defense. Besides provoking bad breath, tobacco stains a smoker's teeth and can also be responsible for plaque, tooth loss, dental caries, and gum disease. Smoking also promotes bleeding, the most important warning sign of inflammation in the gums (gingivitis).  The metabolic syndrome (a combination of medical disorders that increase the risk of developing cardiovascular disease and diabetes) are not only seen in smokers but in former smokers too. Studies have showed that individuals who currently smoke have a higher prevalence of metabolic syndrome than those who have never smoked and those who have quit smoking. Former smokers were more likely to have metabolic syndrome than nonsmokers. The adjusted odds ratios also showed that among current smokers the amount of smoking had a statistically significant dose-dependent association with metabolic syndrome. , Thus the only way to avoid this catastrophe is to never start smoking.
Tobacco use often begins by age 16, and girls have more difficulty with stopping smoking, experiencing stronger effects on behavior and more negative emotions during attempts to quit.
| Methods to Quit Smoking|| |
Tobacco contains the chemical nicotine. Behavioral support and medication can together quadruple the chances that a quit attempt will be successful. There are two ways to stop smoking: either the 'cold turkey' method, with abrupt cessation of smoking, or the gradual reduction method.
The US Food and Drug Administration have approved five medications for dealing with nicotine addiction. All of these help the patient manage withdrawal symptoms and cravings. Transdermal nicotine patches (Nicoderm CQ ® , Nicotrol ® patches) deliver doses of the addictive chemical nicotine, thus reducing the unpleasant effects of nicotine withdrawal. These patches deliver smaller and smaller doses of nicotine, slowly reducing dependence upon nicotine and thus tobacco. Others approaches include chewing gums (Nulife ® , Nicorette ® , Nicolet ® , Nicotex ® ), lozenges (Commit ® lozenges), sprays (Nicotrol ® , Nicotrol NS ® ), and inhalers (Nicotrol ® inhalers). Antidepressant drugs like bupropion (Zyban ® ) and varenicline tartrate (Chantix ® ) may help people quit smoking. Alternative medicine approaches are available such as hypnosis, aromatherapy, and acupuncture, but the specific effects and efficacy of these treatments are not yet established. 
| Policies to Help Protect Women and Girls from Tobacco|| |
The same policies that have been proven to reduce tobacco use among men can protect women too. Smoke-free air regulations, anti-tobacco advertising, bans on tobacco marketing and advertising, strong graphic health warnings on tobacco packaging, and increasing tobacco taxes have proven effective in reducing tobacco use and saving lives. , Establishing 100% smoke-free environments in homes and workplaces is the most effective method for protecting people, especially women, from second-hand smoke.  In China, almost 50% of women between the ages of 35 and 74 live with at least one smoker, and more than 15% of these women are exposed to second-hand smoke more for than 4 hours a day at work.  Only tax policies that cover all types of tobacco - not just cigarettes - can effectively protect all people, because women and men buy different types of tobacco in different parts of the world.  Adoption and implementation of the Framework Convention on Tobacco Control (FCTC), which addresses issues important for protecting women and girls from the tobacco companies, and access to cessation support can help protect all people from tobacco. 
| The Indian Scenario|| |
Legislations in India
Warning on cigarette packages/ advertisements: Recognizing the health hazards of tobacco, the Government of India promulgated The Cigarette (Regulation of Production, Supply, and Distribution) Act 1975. Under this Act, all packages and advertisements of cigarettes are to carry a statutory warning, 'Cigarette smoking is injurious to health.' The Parliament Committee on Subordinate Legislation, in its 22 nd report (December 1995) on this legislation, observed that these guidelines were often not followed. Considering the issue of tobacco in totality, the Committee made wide-ranging recommendations, including strong and rotatory warnings in regional languages on tobacco products; ban on direct as well as indirect advertisement of tobacco products; prohibition of smoking in public places; initiation of measures for awareness on tobacco through the health infrastructure, educational institutions, and mass media; and initiation of efforts for persuasion of farmers to switch over to alternate crops. These recommendations of the parliament committee resulted in modification of the proposed comprehensive legislation on tobacco control.
Warning on smokeless tobacco products: In India, nearly half of the tobacco users consume tobacco in the smokeless form. The Prevention of Food Adulteration Rules (1955) were applied in 1990, necessitating that every package and advertisement of smokeless tobacco product should have a warning stating, 'Chewing of tobacco is injurious to health.'
Cabinet guidelines for smoking in public places: he cabinet secretariat by an administrative order in 1990 prohibited smoking in places such as hospitals, dispensaries, educational institutions, conference rooms, domestic air flights, air-conditioned sleeper coaches in trains, suburban trains, air-conditioned buses, etc. A nationwide ban on smoking at workplaces, restaurants, hotels, pubs, public transport, airports, railway stations, educational institutions, cafes, and theaters came into effect on 2 nd October 2008. In 2007, Chandigarh, a city in northern India, became the first city in India to become 'smoke free.'
Multisectoral approach for tobacco control
The situation necessitates a multisectoral approach, wherein different sectors (government as well as non-government) identify themselves as contributors to a radical social change, leading to tobacco control.
Community education on tobacco
Anti-tobacco education needs to be targeted at decision makers, professionals, and the general public, especially the youth. 'No Tobacco Day' (31 st May) activities have been a regular feature since 1988 and generally comprise educational advertisement(s) in newspapers along with a programme/ workshop in Delhi and at other centers in the States as well as dental and medical institutions.
Tobacco control cell
A tobacco control cell with a seven-member advisory board has been established in the Department of Health, New Delhi, since August 2000, with the aim of coordinating the activities related to tobacco control. The current activities initiated through this cell include educational programs through mass media and schools, strategy papers for alternate crops and rehabilitation of bidi workers, advocacy workshops for non-health sectors, and establishment of tobacco cessation clinics.
Framework Convention on Tobacco Control (FCTC)
The FCTC could be considered as a generator of protocols that can establish firm commitments by member countries on key issues. This initiative by the World Health Organization provides countries a platform to sit together and discuss the issue and agree or disagree on a certain set of tobacco control measures for adoption. 
| Our Role as Health Professionals|| |
Health professionals constitute the principal agency through which information on the health consequences of tobacco is communicated to people as well as policy makers. They also provide their direct services for tobacco cessation through counseling and other forms of therapy. Recognizing the importance of their role it is recommended that health professionals:
- Must strongly advocate tobacco cessation among colleagues and provide special cessation services to them as tobacco use among health professionals has a negative influence on the community.
- Keep conferences and other events organized by health professionals completely tobacco free and avoid sponsorship of any kind from tobacco companies or their affiliates.
- Ensure that health facilities are completely tobacco free, beyond what is required by law.
- Evolve guidelines and specific recommendations for tobacco control and implement these with the help of government and the civil society.
- Utilize all opportunities for patient contact to enquire about tobacco use and advice about tobacco cessation.
- Provide services, including counseling for behavioral change and pharmacotherapy, when required.
Health professionals provide broad-based cessation services, which include counseling for behavior change for all tobacco users and pharmacotherapy when essential. This can be done by medication or pharmacotherapy and talk or psychotherapy. Psychotherapy treats psychological or emotional problems through verbal communication, meeting a very basic human need to share problems and connect with others. The cessation interventions can include screening, behavioral counseling, and pharmacotherapy, all of which have been effective in helping tobacco users to successfully quit the habit. 
| Conclusion|| |
A gender perspective on the tobacco problem will contribute to a better understanding of the epidemiological trends, social marketing strategies, economic policies, and international actions. At all levels, a multipronged strategy combining changes in legislation and fiscal policies along with improvements in gender-sensitive health services and cessation programs should be considered. Key measures include raising cigarette taxes, implementing a complete ban on advertising and promotion of tobacco products, restricting smoking in public and workplaces, educating consumers about the health risks of smoking, and increasing smokers' access to cessation programs. Much more gender-specific research is needed to understand the association between women and epidemiological, behavioral, and economic policies, particularly in developing countries. Women's empowerment and leadership should be at the center of all tobacco-control efforts and are essential for the success of national programs and the WHO Framework Convention on Tobacco Control.
| References|| |
|2.||World Health Organization. World Health Report of 1998. Geneva, Switzerland: World Health Organization; 1999. |
|3.||Amos A, Haglund M. From social taboo to 'torch of freedom'. The marketing of cigarettes to women. Tobacco Control 2000;9:3-8. |
|4.||Warren CW, Jones NR, Eriksen MP, Asma S. Patterns of global use. Lancet 2006;367:749-53. |
|5.||Husten CG. Trends and effects of cigarette smoking among girls and women in the United States. J Am Med Wom Assoc 1996;51:1-2. |
|7.||Mackay J, Eriksen M, Shafey O. The Tobacco Atlas, 2nd ed. Atlanta, GA: Am Cancer Soc (ACS); 2006. |
|8.||Women, Girls, and Tobacco: An Appeal for Global Health Action Center for Communications, Health and the Environment [cited July 19, 2007]. Available from: http://www.ceche.org/programs/tobacco/women/appeal.htm. |
|9.||U.S. Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, CDC, 2001. |
|10.||Kaufman NJ, Nichter, M. The Marketing of Tobacco To Women: Global Perspectives. In Samet JM, Yoon S editors. Women and the Tobacco Epidemic: Challenges for the 21st Century [monograph on the Internet]. Canada: WHO; 2001 [cited 22 June 2007]. |
|11.||World Health Organization. Avoiding the Tobacco Epidemic in Women and Youth. International Conference on Tobacco and Health, Kobe. WHO/NCD/TFI/KOBE/99.4. |
|12.||Chaloupka FJ. Cigarette Smoking in Pacific Rim Countries: The Impact of U.S. Trade Policy. National Bureau of Economic Research, Working Paper 5543, 1996. |
|13.||Morris P. Virginia Slims introduces the low tar cigarette made just for women. 1978 (PM 1005064182). www.tobaccofreecentre.org/women_and_tobacco/factsheets. |
|14.||Risks Associated with Smoking Cigarettes with Low Machine-Yields of Tar and Nicotine; Report of the NCI Expert Committee. Bethesda, MD: National Institutes of Health; National Cancer Institute. |
|15.||Azuma N. Smoke and mirrors: Japanese women buying into sweet song of US tobacco companies. Asia Times, 1997. |
|16.||Barry M. Campaign for Tobacco-Free Kids (TFK) Factsheet, Health Harms from Secondhand Smoke [cited 22 June 2007]. Available from: http://www.tobaccofreekids.org/research/factsheets/pdf/0103.pdf. |
|17.||The Smokeless Tobacco Outreach and Prevention Guide: A Comprehensive Directory of Smokeless Tobacco Prevention and Cessation Resources, Applied Behavioral Science Press; 1997. |
|18.||Hatsukami D, Severson H. Oral Spit Tobacco: Addiction, Prevention and Treatment. Nicotine Tobacco Research 1999;1:21-44. |
|19.||The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General (1986), Bethesda, MD: HHS, Public Health Service, NIH Publication No. 86-2874, 1986. |
|20.||HHS. 10th Report on Carcinogens. National Toxicology Program, December 2002 [cited 22 June 2007]. Available from: http://ehp.niehs.nih.gov/roc/tenth/profiles/s176toba.pdf. |
|21.||WHO Scientific Advisory Committee on Tobacco Product Regulation, Scientific Advisory Committee on Tobacco Product Regulation Recommendation on Smokeless Tobacco Products, 2003. |
|22.||Winn D. Snuff dippers and oral cancer among women in the southern United States. New Eng J Med 1981;304:745-9. |
|23.||Mercado-Ortiz G, Wilson D, Jiang DJ. Reverse smoking and palatal mucosal changes in Filipino women. Aus Dent J 1996;41:300-3. |
|24.||Ernster V. Impact of Tobacco on Women's Health. In: Samet JM, Yoon S, editors, Women and the Tobacco Epidemic: Challenges for the 21st Century. Canada: WHO; 2001. |
|26.||Carlsson AC, Wandell PE, Hallidin M, de Faire U, Hellenius ML. Is a unified definition of metabolic syndrome needed? Comparisons of three definitions of metabolic syndrome in 60 year old men and women. Metab Syndr Relat Disod 2009;7:231-41. |
|27.||Chen CC, Li TC, Chang PC, Liu CS, Lin WY, Wu MT, et al. Association among cigarette smoking, metabolic syndrome, and its individual components: the metabolic syndrome study in Taiwan. Metabolism 2008;57:544-8. |
|28.||Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews Art. No.: CD000146. http://www2.cochrane.org/reviews/en/ab000146.html. Retrieved May 22, 2010 |
|29.||Pan American Health Organization. Effective Tobacco Control Measures. Available from: http://www.paho.org/English/ad/sde/ra/Tobmeasures.htm. |
|30.||U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. |
|31.||Task Force on Community Preventive Services. Guide to community preventive services: tobacco use prevention and control. Am J Prev Med 2001;20:1-87. |
|32.||Gu D, Wu X, Reynolds K, Duan X, Xin X, Reynolds RF, et al. Inter ASIA Collaborative Group. Cigarette smoking and exposure to environmental tobacco smoke in China: the international collaborative study of cardiovascular disease in Asia. Am J Public Health 2004;94:1972-6. |
|33.||Bianco M, Haglund M, Matsui Y, Nakano N. The International Women's Movement and Anti-Tobacco Campaigns. In: Samet JM, Yoon S, editors. Women and the Tobacco Epidemic: Challenges for the 21st Century. Canada: WHO; 2001. p. 209-17. http://www.who.int/tobacco/media/en/WomenMonograph.pdf. |
|34.||Abaka C. Strengthening International Agreements. In: Samet JM, Yoon S, editors. Women and the Tobacco Epidemic: Challenges for the 21st Century Available from: http://www.who.int/tobacco/media/en/WomenMonograph.pdf. |
|36.||Anderson JE, Jorenby DE, Scott WJ, Fiore MC. Treating tobacco use and dependence: an evidence-based clinical practice guideline for tobacco cessation. Chest 2002;121:932-41. |
Department of Public Health Dentistry, I.T.S Center for Dental Studies, Muradnagar, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None