Tobacco smoke and socio-environmental gender differences| Tabaccologia

Introduction

The lack of attention to gender differences has been an important barrier to the evolution of knowledge in the last Century. Gender-specific medicine implies a scientific and therefore ethical duty to achieve appropriateness and equity of care. It is much easier, and also less expensive, to study only one gender (males) and then transpose uncritically the outcomes to the other gender. Scientific research, over the past few decades, shows us that different interactions between environmental, including tobacco industry marketing, biogenetic and sociocultural influences result in phenotypes that can be prevalent either in males or in females.

History of female gender cigarette smoking

The encounter with tobacco smoke is historically much more complex. The introduction of tobacco in the Old World following the discovery of America saw its use mainly as a health herb with many medicinal virtues, until the 1700s. In this century, the damage that tobacco could do to the human body began to be considered. Moreover, tobacco, a voluptuous plant and strictly monopolized by the male gender, continued to be praised by artists and writers, such as Molière, who subjugated it in the comedy Don Juan ou le Festin de Pierre: “No matter what Aristotle says with all his Philosophy, there’s nothing like tobacco: it is the passion of respectable men; and the man who lives without tobacco is not worthy to live. Not only does it replenish and relax the human brain, but it also instructs souls in virtue, for through it one learns how to become a sociable man. Haven’t you ever noticed how obliging someone becomes as soon as he has some tobacco? And how happy he is to hand it out left and right, wherever he might be? Without even waiting to be asked, he anticipates the wishes of others: thus it is true that tobacco inspires sentiments of honor and virtue in those who use it” [1].

Considered a serious taboo for women in Europe until the first half of the last Century, smoking became an expression of women’s emancipation as their demands increased and their desire for social equality grew. In the 19th century, men were the main consumers of tobacco. Cigarettes were introduced on a large scale in the 1840s, with the workforce represented mainly by women, referred to in Italy as tabacchine [2]. Women were legally and economically dependent on their husbands, relatives, or social or charitable institutions. The writer Henry James popularized in Europe and the United States the term “New Woman” [3]. In the Kingdom of Italy, the liberal-monarchist literary and entertainment magazine La scintilla, in its first edition of 1897, described female smoking in a rather lively language: “One might think that a woman, whether unknown or well-known, loses all her charm if she lights a cigar or smokes like an engine in public. But whether the world disapproves of the new fashion or, on the contrary, finds it pleasant, both women and that fashion regain their purity if the cafes, the theatre, the exclusive clubs that replace the private salons, in whose shade and warmth confidential declarations of friendship and love are exchanged”. Subsequently, the trade magazine Il Tabacco was among the first to become a “promoter” of “pink colour” smoking: financed by the Tobacco Monopoly, it counted among its readers tobacco growers, retailers, monopoly officials and, probably, also most of the workers of that same including the large “army” of tabacchine [2].

The magazine considered it acceptable for a woman to smoke in public, but only in exclusive environments or in the living room of the house, a condition comparable to moments of great intimacy. The idea, on the contrary, that a cigarette between a lady’s lips was synonymous with transgression and licentiousness was nevertheless widespread in non-tobacco circles [4]. Matilde Serao wrote in her etiquette manual “Knowing How to Live” (Figure 2) first published in 1900 in the chapter The Cigarette. Should women smoke?: “An idle, useless, disproportionate question, not in step with the times, in the face of the fact that many ladies and young ladies smoke. The cigarette as an only-for-men article is an obsolete consideration! Nowadays, women dedicate themselves to so many male activities, so why ask yourself the question about the possibility of smoking? Just don’t smoke as much! A cigarette can be smoked by a lady, but always as an exception, and not as a constant rule of life” [5].

The progressive spread of cigarette smoking led the State Monopoly of the Kingdom of Italy, in the twenty years following the First World War, to launch a brand of cigarettes for women called “Eva”; in reality, only a few middle-upper middle-class women smoked, often receiving the negative judgment of public opinion.

Between the First and Second World Wars, the image of the femme fatale, embodied by Greta Garbo and Marlene Dietrich, led to the association of cigarettes with an image of a rich, libertine, unhappy woman, often with boyish hair, who smokes with a mouthpiece and has a passion for spirits.

In 1925 the Almanacco included an article dedicated to the ideal wife and the depiction of a smoker was inevitably comparable to a masculine figure, a spokesperson for women’s rights and their emancipation. At the same time, the magazine Il Tabacco continued to support female smoking. Fascism could not tolerate such a free woman and always promoted an ideal of wife-mother-angel of the household that remained even after the war. But the years of the Almanacco continued to be protagonists in Irene Brin’s book as well. In fact, if in Italy Serao was an important and authoritative female figure as a journalist and opinion leader, it was Irene Brin (nèe Maria Vittoria Rossi, born in 1911) who emerged in the male-dominated world of journalism for the generation between the 20s and the end of the Second World War. Her research and work focused on society, culture, and fashion. In her book “Customs and Traditions, 1920-1940”, published in 1944, she reports the image of a woman with her cigarette: “Around 1920 the debate about whether good society ladies could smoke in public reached its peak. Husbands protested fiercely, engaged couples complained of nicotine-stained fingers, yellowed teeth, and heavy breath of smoke, but the novelists of the world continued to write about the feminine habit of blowing sweet, light swirls of smoke into the air”.

Among the overtly anti-feminist voices of dissent, Daria Banfi Malaguzzi Valeri, a Milanese aristocrat and writer of books for children, published in 1928 a manuscript entitled “Contemporary Femininity”, in which she evidences disapproval for the kind of charming and sensual miss with a cigarette between her lips, described by Mrs. Brin. It is clear that in the ‘20s and ‘30s in Italy there were evident contradictions about the so-called women emancipation phenomenon: the woman smoker represented the peak of an iceberg that would ignite the following decades.

The situation was different across the Channel where, in the same years, women smoked without too many objections, as described by Rosemary Elliot in the English periodical The Ladies Realm, in which she documents how female smoking continued to spread and gain terrain in the early years of the twentieth century. In the United States of America, women’s right to vote was granted in 1920: this recognition was remarkably intertwined with a decisive motivation to promote female smoking. Edward Bernay, the grandson of Sigmund Freud, was promoting Lucky Strike cigarettes for the American Tobacco Company. He seized the opportunity to join the Easter Parade in New York, hiring young models to pose as suffragettes, lighting cigarettes and wearing banners describing their cigarettes as “torches of freedom”.

Sales of cigarettes to women skyrocketed and spread across the country. Smoking was associated with women’s liberation, and anyone who opposed smoking was labelled as “against women’s liberation”. With the end of the Second World War, the prejudices in Italy disappeared thanks to the advent of the Allies in Europe and the arrival of the aid of the Marshall Plan: the Europeans became acquainted with the “blondes”, cigarettes tanned with apparently less harsh tobaccos, lavishly bestowed with the humanitarian aid of the Marshall Plan, in which a senator from Virginia, managed to get $1 in cigarettes included in the plan for every $2 in food aid [6]

After 1968, the wide gap between male and female smokers in the 1950s and 1960s was greatly reduced, unfortunately also in the spread of drug abuse, under the pressure of the protest movements that spread in Europe and North America at the end of the 1960s; the context spawned the feminist movement. The number of female smokers increased by more than 10%, reaching peaks of smoking women art 26% in the late 1970s, compared with 6-7% in the 1950s. Meanwhile, the tobacco companies have been engaged for several decades in unbridled marketing to gain the favour of the female sex.

Main factors that cause women to smoke

The world of female smokers has distinct gender indicators: age, psychological, socioeconomic, demographic, and cultural factors, as well as the stimuli provided by advertising promoted by the tobacco industry [7]. The main motivational differences between men and women for starting smoking are, for women, the influence of friends, schoolmates, sexual partner, family and to feel “less stressed”, while for the men the group of friends represents the most important influence. Both sexes start smoking because it is pleasing, because it is “liked”. Early initiation, according to data from the Global Youth Tobacco Survey - GYTS 2018 in Italy [8], and daily tobacco use result in greater difficulty in quitting tobacco smoking. Overall, very young people (13-15 years old) smoke less, but among them, girls smoke much more than boys of the same age. Several studies have shown that there is a strong association between smoking initiation at a young age and the presence of smokers among friends and family members [9]. Other studies have shown a higher level of smoking initiation among girls whose mothers smoked because of a greater access to cigarettes; however, during the teen years, friends have the greatest influence on smoking initiation and maintenance, an influence that is reinforced by the fact that young people’s perception and knowledge of smoking-related health risks are reduced [10]. A study by Oh et al revealed that the main determining factor of smoking initiation was directly associated with the number of friends who smoke: the risk of initiation becomes 12 times greater when half or more of the friends were smokers. The study also showed that divorced women were more likely to smoke than those who had a stable partner [11]. Young people from less privileged socio-economic conditions with a lower level of education are also more vulnerable to enhance tobacco smoking; tobacco industry advertising promises financial success and improved social status, which attracts girls and boys alike [9].

The fact that adolescents are going through a period in which their personality is establishing, often facing problems related to self-esteem, anxiety, depression, and loss of self-confidence, is also associated with an increased risk of tobacco smoking initiation. In an effort to improve their image and become more sociable, teenage girls experiment with cigarettes believing that smoking will make them more feminine, mature, and sexually attractive [10]. Films, which in the past clearly disseminated positive images of smoking, continue to play a role in tobacco initiation among young individuals, regardless of gender, as determined by a study conducted in Germany involving 4000 young people aged 11 to 15 [12].

Psychiatric comorbidities, such as depression, bipolar disorder, and schizophrenia, are also associated with a higher level of tobacco use, as well as greater difficulty in quitting. This difficulty is related to an exacerbation of psychiatric symptoms during the withdrawal period, as the risk of relapse during smoking cessation treatment is extremely high [10].

The increase in the number of smoking women is due, above all, to socio-cultural movement that has seen the cigarette become an instrument of freedom and emancipation for women. Associated with the values of rebellion, fun, power, and security but also sensuality and femininity and supported by advertising and marketing, the cigarette has completely conquered the female world.

In addition, the constant proposals of the mass media, with the advertising not of cigarette brands (which is prohibited) but of smoking associated with various situations of stress, pleasure or conviviality, induce experimentation, the use of cigarettes and the habits that often accompany them [13].

Among pregnant adolescents, levels of smoking cessation during pregnancy are higher in those with higher socioeconomic status, while those with lower socioeconomic status believe that tobacco smoking may reduce pain and duration of labour, resulting in potential promotion of tobacco use during pregnancy [10]. Other studies have shown that smoking during pregnancy is associated with a fear of gaining weight; however, this behaviour has also been well documented in non-pregnant women [14].

Studies have shown that women start smoking after negative life experiences. In recent years, with their increased participation in the world of work, women have taken on further responsibilities, in addition to their role as housewives and mothers. In this sense, tobacco smoking, as well as an emotional escape mechanism, is associated with a stronger feeling of autonomy, of finding one’s place in society [14].

Half of the smokers light a cigarette within half an hour of waking up, 67% within an hour; in general, the indicators of tobacco dependence (the same as those used for the Fagerström test) are medium or high for the majority of respondents. They smoke during evening outings (67%), during work breaks (54%), in the morning before starting daily activities (53%), and while waiting for transport (47.5%). Why did they start? Above all, to “try, driven by curiosity” (58.5%), for company and imitation (“friends, schoolmates, colleagues did it” 46.6%), to “face a difficult period” (15%). The reasons for continuing are the most varied, but the number of smokers who attribute anti-stress properties to cigarettes is increasing, a tool for living with the tensions of everyday life (“it relaxes me”: 42.3%; “calms me down when I’m nervous/angry”: 37%; “helps me switch off for a moment”: 36%) [15-16].

Women and the tobacco industry

Tobacco companies (Big Tobacco) are also partly responsible for encouraging girls and women to smoke. The tobacco industry has been targeting women for almost 100 years, starting with advertising campaigns dedicated to women in the 20s in the United States of America. It is no coincidence that a British American Tobacco document from 1976 states: “We can conclude that there are numerous differences and that, perhaps surprisingly, there is evidence that women are more motivated to smoke than men and that they find it more difficult to quit.” And again: “Men smoke as in a tribal tradition, while women smoke as a symptom of insecurity. That may be, but it’s worth pointing out that women in general are more neurotic than men”. Sexist marketing from another era [16].

The tobacco industry is constantly innovating its products. In the United Kingdom, there is the “click cigarette”, a cigarette with a click in the filter that can give the taste of menthol, of your choice. In Germany, there are mango and /or mojitos-flavoured cigarettes.

Young people like these flavours and there is a need to think about regulatory impositions on these products [16].

The trend towards an increasing approximation between the prevalence of smoking in “men” and “women” is influenced by the aggressive marketing employed by the tobacco industry, which focuses on the female population.

The strategy is to promote ideas of emancipation, as well as false images of vitality, elegance, sophistication, and modernity. In addition, products and campaigns aimed at women – i.e. the cigarette brand “Virginia Slims” (alluding to weight loss) and its marketing campaign (You’ve come a long way, Baby) launched by Philip Morris in the early 1970s – were developed. Over time, many new products have been launched: “light”, “ultra-light” cigarettes, “new light” filters and flavoured cigarettes. In fact, people who are more health-conscious smokers, and therefore looking for less dangerous products, often turn to so-called light cigarettes, thinking that they are less harmful, as portrayed in Big Tobacco advertising. Often, young women, or those who have approached smoking more recently, are more attracted to this “model” smoking light cigarettes [17]. These marketing campaigns have become increasingly aggressive over time. The practice of marketing aimed exclusively at women has continued to the present day and has now spread globally. With gender-targeted marketing, especially “thinner” and “lighter” cigarettes, and the promotion of women smoking in popular movies and TV shows, the tobacco industry has been able to increase the percentage of women who smoke [6]. Actually, this narrative has often become a belief, so much so that the European Union has banned the “light” designation. In fact, there is no reduction in risk for those who smoke cigarettes with a lower tar and nicotine content; studies have shown that, with this type of cigarette, the way of smoking changes, with more intense inhalation and often even an increase in consumption [18]. It is therefore necessary to beware of commercial strategies that, in more or less veiled ways, reintroduce the concept of “less dangerous” smoking, because they lead to underestimate the risk and feed the belief that one is not addicted.

Women’s view on cigarette smoking are not accidental, as they have been preceded by fact-finding surveys and manipulated by the tobacco industry to offer positive advertising images of smoking. Since the tobacco industry began focusing on women in North America and Northern Europe in the 1920s and 1930s, it has become more sophisticated in its marketing strategies, developing a wide range of messages, products, and brands to appeal to different segments of the women’s market. Tobacco smoke marketers tailor their messages to specific targets of demographic and socioeconomic groups.

A 1976 British American Tobacco paper states: “We can conclude that there are many differences and that, perhaps surprisingly, there is evidence that women are more motivated to smoke than men and that they find it more difficult to quit”. And again: “Men smoke as in a tribal tradition, while women smoke as a symptom of insecurity. Maybe, but it’s worth pointing out that women are generally more troubled than men”.

In the 1980s, the tobacco industry was obliged to print the Surgeon General’s warning about the health damage caused by smoking on every pack of tobacco products. This has slowed down the rate of smoking among women, which has increased slightly as a result of more sophisticated advertising, including more attractive packaging, which has brought the younger generations closer to smoking. More recently, cigarette smoking bans in public places have reduced smoking rates in the United States and Western Countries.

Product manipulation has become increasingly important not only in countries where there are advertisement bans, where the package is the primary form of communication with smokers and potential smokers, but more particularly through “women-only” brands and versions of brands designed to appeal to girls and women (e.g. “super slim”, “low tar”). In the U.S., even feminist icons such as Eleanor Roosevelt, the first “First Lady” to smoke publicly, have helped convince tobacco companies to consider women as a lucrative consumer base. They used a number of aggressive tactics to reach this new target audience. One such tactic was Marlboro’s “Mild as May” campaign, an early attempt to make cigarettes appear more feminine. As a result, the percentage of female smokers more than doubled from 1924 to 1929. The link between smoking and liberation became even stronger when women enter the workforce at a record rate during the Second World War.

Encouraged by the rise in the number of smoking women, tobacco companies have been looking for more ways to connect. The American Tobacco Company, for example, responded to calls for independence by featuring prominent women, such as Amelia Earhart, in Lucky Strike advertisements. Another of the first media campaigns aimed at women was the Lucky Strike campaign “Grab a Lucky instead of a candy” in 1925 which exploited concerns about women’s body weight. The message was very effective and more than doubled the market for Lucky Strike, making it a successful brand. Virtually everything women aspire to has been targeted by the tobacco industry. Smoking has been promoted to girls and women as: sophisticated, sporty, glamorous, romantic, healthy, sexy, emancipated, sociable, cool, rebellious, fashionable, liberating, slimming, fun, relaxing.

Responding to women’s increasingly modern sensibilities and ambitious beauty standards, the company has also used advertisements to link smoking with weight loss, highlighting it as one of the many claimed “benefits” that have contributed to a steady increase in female smoking rates.

It would take years for medical research into the effects of smoking to reach the public and counter the aggressive marketing tactics that began during the 1920s. In 1957, the U.S. Surgeon General issued a report advising against smoking, a landmark statement that would strengthen the public health position against smoking. The statement marked the beginning of a decade-long effort by public health officials to educate the public about the dangers of smoking.

The first collection of Federal data on smoking habits began in 1965. In that year, the U.S. Department of Health, Education, and Welfare reported that 41.9% of women smoked. In the same year, the Federal Cigarette Labelling and Advertising Act mandated a warning on cigarette packs that read “Warning: Cigarette smoking can be dangerous to health” and required government agencies to report tobacco advertising practices and the health consequences of smoking to Congress each year.

Despite these enforcement actions by public health bodies, cigarette brands were determined to maintain their business action.

When cigarette advertising was banned from television and radio, companies looked for alternative ways to promote their brands by recruiting actors, entertainment, and sports personalities to promote smoking through the inclusion of cigarette brands in their professional fields (film, Formula 1, motorcycle racing) [6].

In 1998, reports emerged that the R.J. Reynolds Tobacco Company had used advertising to target youth, minorities, and women. In 2002, the U.S. Surgeon General reported that smoking rates were nearly 40% higher among poor women. Further studies pointed to advertising tactics that deliberately targeted poor, uneducated women, such as donating cigarette vouchers shipped along with food stamps, literal advertising language, and credit cards branded for specific cigarette companies.

Investing in consumer marketing is part of an old but highly focused strategy, which includes looking for individual behaviour and reacting to different stimuli, such as colours that evoke tranquillity (blue), power (red) and femininity (pink). These symbolic attributes have proven to be very effective in selling these products. In the 1970s and 1990s, the tobacco industry consolidated its position as the major sponsor of female athletes, particularly tennis players, with the player Martina Navratilova representing the Virgina Slims (Philip Morris) brand at the Wimbledon Championships. In the 1980s, political and ethnic minority organizations in the U.S. received financial support from the tobacco industry. In 1987, Philip Morris sponsored training programs in New York City for female leaders of African American and Hispanic American societies, having contributed significant sums of money [6].

A 2010 study revealed that, following advertising for the Camel No. 9 brand, which began in 2007 and was aimed exclusively at adolescent girls, there was a 10% increase in preference for this brand of cigarettes in the same year [18].

Another study evaluated the exposure of young individuals between the ages of 12 and 17 to cigarette advertising, analyzing, between 1992 and 1998, the five magazines most read by young people. The authors found that there were more than 2000 cigarette advertisements mainly aimed at the female population. In 1992, there were 4 cigarette-related images per issue of those magazines, and the number increased to 16 in 1998. Effective social marketing by public health advocates requires a similar, sophisticated, and personalized response that should be rooted in the local cultural context. This is important, not only because of different social norms, but also because tobacco is consumed in many different forms around the world [19].

Conclusions

Clearly, more research is needed to investigate the cultural, social, and biological factors that lead women to experiment with and eventually adopt cigarette smoking. Effective sociocultural marketing by public health advocates requires a sophisticated, personalized response that should be rooted in the local cultural context. Encouragingly, there is growing evidence that mass media campaigns can be effective in inducing desired behavioural changes. The social marketing response should go hand in hand with other policy tools such as taxation on tobacco products, limitations on advertising, and restrictions on the availability of tobacco products. Mass health awareness campaigns are needed, particularly among the younger generations, and gender-based, using different communication channels, including health education interventions in schools at all levels”.

Figures and tables

Figure 1.Matilde Serao (alias Gibus del Mattino) and cover of the volume Saper vivere in the 1900 edition.

Figure 2.Irene Brin.

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