Tobacco smoking and gender differences: epidemiological aspects| Tabaccologia

Abstract

This article is the first in a series that Tabaccologia is dedicating to ‘Tobacco Smoking and Gender Medicine’. It delves into the epidemiological aspects, while other topics will be explored in future issues. Smoking is a complex issue that requires a gendered approach to fully understand its impact on men and women. Consumption patterns, comorbidities and response to treatment are influenced by gender, which in turn is influenced by social roles. As social norms changed, particularly with the increase in female employment, the acceptance of female smoking has increased and the gender prevalence gap has decreased. In Italy, historically trends in male smoking prevalence have decreased over time, while female smoking rates have increased. A concerning consequence of these diverging trends is the rise of female mortality from smoking-related diseases, such as lung cancer. Worldwide, the total number of smokers has increased due to population growth and smoking among women is expected to increase due to the tobacco industry’s very aggressive marketing strategies linking smoking to women’s rights, attractiveness and success. The increase will mainly occur in countries with low or medium human development indexes and where an increase in smoking prevalence among adolescent girls has been observed. Also, tobacco related mortality is expected to raise since it is closely linked to past consumption trends with a time lag of several decades. Tobacco consumption is responsible of more than 8.5 million deathsmainly due to active smoking but also due to secondhand smoke. China, with its high number of smokers, plays a significant role in the tobacco pandemic. Gender gap in smoking prevalence is vast in China and the prevalence of smoking among Chinese women decreased for most of the 20th century due to cultural and socio-economic factors. Tobacco smoking represents the leading preventable cause of morbidity and mortality worldwide among non-infectious causes. Efforts to control tobacco smoking have made progress globally, but there has been a recent slowdown in the decline, especially among women. A gender perspective is necessary in scientific research to identify differences in smoking patterns and develop targeted actions for prevention and treatment.

Introduction

Smoking is a condition that requires a gendered approach to understand the different susceptibilities and clinical manifestations between men and women and ensure treatment equity. It is increasingly evident that gender influences consumption patterns, comorbidities, and treatment response among smokers. Medicine, biomedical research, and specialized services can no longer ignore these gender differences [1].

In the past, literature on gender differences in smoking has primarily focused on the social roles traditionally associated with men and women. These roles have historically translated into rules or lifestyles in the community that were considered more appropriate based on gender. For example, there has been a shift from initial social disapproval of female smoking to its progressive tolerance parallel to the increase in female employment. Additionally, smoking as an act of rebellion has been more accepted in males, especially among adolescents, leading to a higher prevalence of smoking among males [2].

Currently, countries have very different experiences in the fight against the tobacco pandemic [3].

The social norms that limited tobacco consumption among women have gradually decreased in most countries, including developing ones, and many women have been able to make their own choices and pursue them with their own economic resources. The negative effects of this otherwise positive empowerment are reflected in the reduction of the gender gap in smoking prevalence [4]. In response to the growing tobacco dependence in females, the World Health Organization (WHO) dedicated the theme of World No Tobacco Day to women in 2010 (see below) [5].

To formulate effective policies, it is necessary to better understand gender differences in the adoption, intensity, and cessation of smoking. In fact, socioeconomic characteristics such as education, occupation, and income seem to explain only a small part of the gender differences in smoking, even in countries like Germany where female emancipation is high [6,7,8].

Italy, thanks in part to being the first country in the world to enact a law on the application of gender medicine (Law 3/2018), has developed greater sensitivity to this issue in recent years. This has been accomplished through awareness-raising and training sessions that could have practical applications in the clinical practice of smoking [9].

Women’s smoking in Italy

Since 1957, the National Institute of Health (ISS) has been collecting annual data on smoking prevalence among adults through the DOXA demoscopic agency [10,11].

In the late 1950s, there was a significant gap between the number of female smokers (6.2%) and male smokers (65%), as shown in Figure 1. This gender difference remained relatively unchanged until the late 1960s. However, in conjunction with feminist movements in Italy and around the world, as well as extensive tobacco industry marketing specifically targeted at women, the prevalence of female smokers increased dramatically, reaching 16% in the mid-1970s and 26% by the late 1990s. Subsequently, the trend started to decline until 2008, when the percentage of female smokers reached 17.9%. Since then, the percentage of female smokers in Italy has remained largely unchanged (Figure 1).

Concurrently, smoking prevalence among men has significantly decreased. This pattern is typical in many high-income countries and has been studied by Lopez in 1994, proposing the model of the global epidemic that describes the trends in cigarette consumption and its effects on mortality [12]. According to this model, smoking prevalence first increases significantly among men and later among women. Similarly, the model shows that tobacco-attributable mortality, closely linked to past consumption trends, initially increases among men and then among women, with a latency period of approximately 3-4 decades following the increase in prevalence. This model still provides a useful description for many developed countries, while for developing countries, it may be more useful to describe the epidemic stages separately for men and women [13].

The result of these diverging trends between men and women is becoming evident in Italy with an increase in female mortality from smoking-related diseases such as lung cancer, which was once extremely rare among women.

The ISS-DOXA 2022 data on women are of great interest [10,11]:

1. Gender distribution shows 4.9 million women (18.5%) compared to 7.5 million men (30.2%) out of a total of 12.4 million smokers (24.2% of the population, almost one in four Italians, a percentage that had not been recorded since 2009).
2. The decreasing trend observed in the 2017-2019 period, where there was a constant decrease in female smokers, is not confirmed in 2022, as there is an increase in the percentage of smokers in both genders (Figure 1).
3. The distribution of prevalence by gender and macro-geographical area shows that female smokers are mainly present in the southern regions of Italy, with 21.6% compared to 14.1% in the central region and 18.2% in the north.
4. In Italy, 73% of girls start smoking between the ages of 15 and 20 (5.3% before 15 years old, 31.2% between 15 and 17, 41.8% between 18 and 20; 4.7% between 21 and 24, and 14.0% at 25+ years old, with 3% not remembering), on average at 19.3 years old (boys at 18.0 years old).
5. The highest prevalence of female smokers (24.5%) is found in the 45-64 age group, while the lowest (9.4%) is among women aged 65 and older. It is concerning to observe that in the 15-24 age group, the prevalence of female smokers is higher than in the 25-44 age group (21.6% versus 19.5%).
6. On average, women consume 10.4 cigarettes per day compared to men who smoke 12.2 (the national average in 2022 was 11.5 cigarettes per day).
7. The vast majority of women (86.6%) smoke fewer than 20 cigarettes per day (36% smoke 1-9 cigarettes, 50.6% smoke 10-19 cigarettes), while female "heavy smokers" (those who smoke 20 or more cigarettes per day) account for 13.4%.
8. Smoking is predominant among women with a medium to high level of education (higher education 21.4% and medium education 19.5%); the percentage drops to 8.8% among those with a low level of education.

These are the data on traditional tobacco smoking, to which the data on the consumption of new products, namely electronic cigarettes (e-cigs) and heated tobacco ("heat not burn" or HTP), should be added.

Heated tobacco was introduced to the market only recently (sold firstly in Japan in 2016 it then spread worldwide) as a potentially less harmful alternative to conventional cigarettes. It works by inserting a small tobacco stick into a device that, according to the manufacturer, heats the tobacco to temperatures between 250°C and 350°C without combustion.

There is no gender-specific data available regarding the consumption of these new products.

The number of people using heated tobacco and electronic cigarettes is increasing: for heated tobacco, the percentage was 1.1% in 2019 and reached 3.3% in 2022, while for electronic cigarettes, it was 1.7% in 2019 and reached 2.4% in 2022 [10].

These new products do not seem to change the percentage of conventional cigarette smokers significantly because in most cases, smokers become "dual consumers," using both conventional cigarettes and the new products. In fact, many smokers report using these new products to quit smoking but end up using both or even start smoking by trying e-cigarettes [10].

The smoking of women worldwide

The Global Burden of Diseases (one of the most reliable resources for international comparisons, which are otherwise difficult, due to methodological and socio-economic-cultural reasons) estimated that 32.7% of men and 6.6% of women aged 15 years and older (totaling over 1.1 billion people), smoked tobacco products in 2019 [14].

Between 1990 and 2019, the global age-standardized prevalence of smoking tobacco decreased by 27.5% among males and 37.7% among females, with varying progress across countries. It decreased in 135 countries for males and only in 68 countries for females, while it increased in 20 countries for males and in 12 countries for females (Afghanistan, Albania, Kyrgyzstan, Saudi Arabia, Lebanon, Mongolia, Bosnia and Herzegovina, Belarus, Portugal, Lithuania, Russia, and Serbia) [14].

Although the prevalence of smoking has decreased, the total number of smokers has increased due to population growth, and unfortunately, the global number of female smokers is projected to increase unless effective countermeasures are implemented. The tobacco industry still has margins to increase the prevalence among women, especially among those living in countries with a low or medium Human Development Index (HDI, an indicator that takes into account life expectancy, level of education and income) where the prevalence of smoking among women is still lower than among men (Figure 2) [15].

There are at least two additional reasons that reinforce the prediction of an increase in the number of female smokers in the near future. In fact, it has been observed that: a) in 20% and 34% of countries with very high and high HDI, respectively, there has been an increase in the prevalence of female smoking, and b) in many countries, the increase in smoking prevalence among adolescent girls is more frequent than among adult women [15].

It has long been known that the tobacco industry targets the growth of tobacco addiction in females [6]. The strategies are always the same: linking smoking to women’s rights and gender equality, as well as to attractiveness, sociability, fun, success, and recently even to thinness. The marketing is very aggressive, and already in 2010, the World Health Organization (WHO) chose the theme "Gender and tobacco" for World No Tobacco Day in order to encourage policies to counter marketing strategies targeting women [5,15].

Regarding mortality, tobacco kills more men than women simply because historically smoking prevalence has been higher among men. However, as smoking rates among women, especially young women, are increasing, the gap in mortality rates for tobacco-related diseases between men and women is narrowing. In 2019, tobacco consumption caused over 8.67 million deaths worldwide (6.53 million in adult males, 2.14 million in adult females). The majority of these deaths (7.37 million) were attributable to active smoking, with the rest due to secondhand smoke (1.30 million) [15]. Tobacco smoking accounted for 20.2% of all male deaths and was the leading risk factor for both deaths and DALYs (disability-adjusted life years) among males. Among women, tobacco smoking accounted for approximately 5.8% of all deaths due to its lower prevalence, shorter duration, and lower intensity compared to males [14].

Although countries with high HDI have seen a decline in smoking prevalence, tobacco-related deaths are still significant due to the time lag of several decades between changes in smoking prevalence and changes in tobacco-related mortality rates. In 2019, nearly half of all tobacco-related deaths occurred in countries with high HDI. However, it is predicted that in the coming years, deaths from tobacco-related diseases will increase in countries with lower HDI, as smoking prevalence is on the rise [15].

China

A particular focus is warranted on the Chinese scenario due to the high number of smokers and the significant gender gap between males and females. More than 500 million smokers live in just three nations: China, India, Indonesia (Figure 3), and one-third of all male smokers in the world reside in China. There are over 300 million Chinese smokers, accounting for a quarter of the Chinese population, and they smoke an average of 22 cigarettes per day [14,15].

China is referred to as the “Celestial Empire of Tobacco” precisely due to the high number of smokers, the resulting business generated for the industry, and tobacco production (China is the global leader, holding 40% of cigarette production) [16].

In China, 49.7% of men smoke, while only 3.5% of women do [14]. The reason for the gender difference is generally attributed to strong and persistent social norms against female smoking. What may be less known is that female smoking rates in China actually decreased for most of the 20th century. The prevalence of smoking among Chinese women born in 1908-1912 was 25%, but it dramatically decreased in subsequent female cohorts. In contrast, the prevalence of smoking among male birth cohorts in 1908-1912 was 70%, and the prevalence remained high in subsequent male cohorts [20].

The widespread female smoking in China in the 1930s was at least partly linked to the mass availability of affordable cigarettes and aggressive advertising that used female models depicting the modern Chinese woman asserting herself in a rapidly changing world. The subsequent reversal in the prevalence of female smoking appears to have been caused, in part, by cultural and socioeconomic forces that countered the trend of mass marketing. For instance, Madame Chiang Kai-Shek’s New Life Movement emphasized traditional Confucian values and disapproved of unhealthy behaviors like smoking [17,18]. Furthermore, the low number of female smokers could be a result of the decline in female birth rates throughout much of the 20th century [17,18].

Conclusions

Tobacco smoking pandemic represents the leading preventable cause of morbidity and mortality worldwide among non-infectious causes. Tobacco addiction, as a chronic and relapsing condition, is increasingly affecting the female population, with significant implications for quality of life and survival.

Although efforts to control tobacco began in some countries as early as the 1960s, following the first documented evidence of the harmful effects of smoking on health, global progress in tobacco control was catalyzed by the approval of the so-called Framework Convention on Tobacco Control (FCTC) by the WHO in 2005. The following decade witnessed the most rapid decline in tobacco smoking prevalence in the largest number of countries [14]. However, there has been a recent global slowdown in the decline of prevalence, especially among women, with several countries experiencing an increase, particularly among younger individuals.

Tobacco smoking is a pathological condition that should be addressed in scientific research with a gender perspective to identify bio-genetic, socio-economic-cultural, and clinical differences to be utilized for targeted actions, both preventive and health-promoting, and to ensure treatment equity.

Figures and tables

Figure 1.Prevalence of cigarette smoking - historical series.

Figure 2.Distribution of smokers according to gender and Human Development Index (HDI).

Figure 3.The top three countries with the highest number of smokers in the world (millions).

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