How much are women smoking?

“…the smoking epidemic is spreading from its original focus, men in high-income countries,
to women in high-income countries and men in low-income regions”.

The 20th century has seen waves of tobacco use rise across Europe.  First among richer men, then poorer.  Then among richer women, then again the poor.  And in some groups the wave is now peaking... These changes can be seen as waves breaking on a beach.  Similar waves of tobacco related disease follow, some only several decades later.

A wave is shaped by many forces, from global weather to the local shore.  Similarly smoking is shaped in complex ways - by individual need, government policy, and wider economic trends.  To look at how the wave develops may help us understand these forces, and limit their impact on women’s health.  The following model shows how the wave may develop.

Figure - Four stages of the tobacco epidemic

How many women smoke?
Comparable data are limited, since different age groups and definitions of smoking are used in various countries.  However, some broad trends are apparent.

After World War II, smoking among European women increased steeply.  For example, during 1946-80 rates increased nearly four-fold among Swedish women (9-33%).  However, in some countries such as the UK post-war rates were already near peak at 40% plus.  Rates are now perhaps stable or falling slowly in most areas.   Generally women’s smoking peaks at a lower level than men’s, but the peak may be longer lasting.

Smoking rates
Generally smoking rates are highest in those Nordic and western states where smoking is long established among women, reaching around a third in Denmark, Norway and the Netherlands. Greenland, an independent region of Denmark, has a uniquely high rate at four-fifths.  Otherwise around one in four or five women smoke, with no clear geographical pattern.   Rates are lowest, at less than a tenth, in Portugal and the Russian Federation.  However, both these countries have considerably higher smoking levels among younger women.  Sweden is the only country to meet the WHO population target of 20% smoking or less, but use of snuff has increased sharply.

Current downward trends
By 1997-8 there was a downward trend in the Nordic countries of Denmark and Sweden.  In Sweden this trend started around the late 1970s.  Austrian rates were falling, after increases in the 70s and 80s.  France had also seen the benefit of a comprehensive prevention policy, though new data show no change.

Stable smoking rates?
However, many countries have stable rates or no clear trend.  These include

Upward trends
Smoking rates are rising in the Russian Federation, particularly among younger women, and more generally across Eastern Europe.  Luxembourg and Spain have also seen gradual increase.  However, younger Spanish women now have the highest smoking rate in this country.   Data on other southern European countries seem unclear.  Information from the European Commission suggests increases among women in Portugal and Greece to 1994-5, again mainly among younger women.  But WHO statistics point to a sharp reduction in Portugal during 1994-95, maintained in 1996, and a possible fall in Greece

Smoking and gender
Differences in smoking rates between women and men show a broad geographical pattern:

Table
·      Table 1 - Adult daily smoking, by female-male smoking difference
     View in this window

An analysis of factors linked to smoking in industrialized nations may offer some explanation of these differences. Historically, women have taken up smoking later, as social acceptance grows.  Higher religious and less military involvement may also play a part in delayed uptake.   But male prevalence also falls earlier, perhaps in response to information more relevant to men.  Concern with weight and stress control may tend to maintain smoking among women.

Gender is obviously a factor in smoking behavior.  But socio-economic status, age and consumption patterns are also important - and may be key factors.

Smoking, plenty and want
Smoking is linked with socio-economic status (SES) both within countries and across the globe.  For example, in developing countries higher prosperity is clearly related to greater cigarette use And in southern Europe smoking is now increasing among younger, richer women

Yet by the time prevalence is roughly similar for women and men, smoking is firmly linked with disadvantage.  For example, in Belgium the poorest pregnant women are five times as likely to smoke as the most affluent (35-7%). Consumption levels show similar trends.  In these ‘mature’ markets smoking accounts for two-thirds of excess mortality in poorer social groups. A similar global trend, with smoking concentrated in poorer nations such as China, would have tragic consequences

Aspects of disadvantage
Across Europe SES is defined in many ways, by education, employment or income source.  Aspects of daily living have also emerged as key issues in smoking behavior.  It is perhaps useful to look directly at these issues, which may also suggest possible action.

Education
Lack of education may be particularly important for women’s health.  For example, across Scandinavia there is a strong link with poor reported health, and in Sweden and Denmark much more so than for men.  Income inequality seems less important.

Education also has clear effects on smoking behavior. For women, smoking is linked with poor education in northern Europe, but good education in the south.   As might perhaps be expected, only men over 45 show this pattern, and more weakly. In general younger Europeans show greater differences in smoking linked to social disadvantage, perhaps suggesting a need for more specific campaigns.

A British analysis showed long-term quitting was half as likely for women who’d left school at 16 (8-20% at 2 year follow-up).  School leaving age and cigarette consumption were the two key predictors of quitting. Smoking education also has less impact on poorer women.

Employment
Across northern Europe there are strong connections between smoking rate and social class as defined by work type. A British study found that women doing ‘unskilled manual’ work had twice the risk of ‘professional’ women (RR 1.88).  This was independent of poor education.  Unemployed women also have greater risk (RR 1.43).  Similarly young British workers are keen to quit, especially women, but the jobless see no relevance.

However, women’s health generally may be more affected by household deprivation, rather than by paid work.  Measures of health inequality based on occupation may therefore underestimate the link for women, especially poorer women.

Money
In a study of new mothers in the UK, only years on income support predicted level of tobacco use. These women are prone to frequent crisis and low mood, both linked to high smoking rates.

Daily living
Other aspects of daily life also predict high smoking rates, for example:

These effects are cumulative.  For example, in the UK smoking is almost universal (75%) among poorly educated lone mothers in council housing. In fact, it is suggested that any marker of disadvantage will have an independent effect on cigarette use. For more on smoking and emotional health see Health and well-being.

Special groups
Ethnic minority groups generally suffer more disadvantage and worse health, but little is known about smoking behavior.  In England smoking rates are generally lower, especially among Asian women.  African-Caribbean women smoke as much as women in general, but some groups such as Turkish women have high smoking rates.

In some countries smoking may be higher than average among other specific groups, including lesbians, women with disabilities, and the homeless. However, information is again scarce, and smoking is seldom on the agenda of relevant health projects.

Smoking and economic trends
Economic changes also affect smoking trends.  For example, increase in smoking among Spanish women may relate to sharply rising unemployment.  Continued heavy smoking among the poorest British women was linked to increased poverty in the 80s, particularly among lone parents.

Social and economic disparity in general is obviously under discussion within the European Commission, and non-governmental groups. Some projects on smoking have also focused on poorer women. For other action on disadvantage see Other campaigns

The generation gap   See also Young women

Smoking among the young would usually reflect adult behavior.  But recently many developed countries have seen increases, especially among girls, even where adult trends are down.  For example, no country showed a downward trend for girls aged 15 during 1983-4 to 1997-98, though not all European countries were included.  Many showed a clear or possible upward trend.

In most Nordic and western states girls are now slightly more likely to smoke than boys.
Detailed evidence, for example from the UK, suggests this difference may be appearing at younger ages.  Trends among boys and girls are also similar, suggesting that being female no longer protects against smoking. 
For discussion see Young women.

Tables 

Table 2 - Daily smoking at age 15 View in this window
Table 3 - Weekly smoking at age 15, 13 and 11 View in this window
Table 4 - Tried a cigarette at age 15, 13 and 11 View in this window

Effects of early smoking
Young smokers have more days off school, though some of this may reflect family crisis. They are more prone to respiratory problems, girls particularly to asthma. Girls lungs mature earlier, so smoking may do more damage to later lung function. Early smoking also increases later cancer risk, again perhaps particularly for women. Teen smoking may cause genetic damage in the lungs, with permanent increased cancer risk. Risk of arterial damage may also be increased, for example by lower HDL cholesterol.

Girls who start early tend to smoke heavily as adults and stop later. Many young smokers will also soon become mothers.  The UK has seen increases in smoking among both young and pregnant women, but Sweden has seen a down trend in both groups.

Smoking among older women

The forgotten smokers?
Average age is rising across Europe, and smoking rates are still high in some older groups.  Older smokers may be less confident about their ability to stop, or the benefits, although menopause or worry over grandchildren may give extra motivation.  There are few relevant projects, and health workers seldom offer advice, though success is possible.

Aging populations have extra need for health services.  Even for this reason alone, helping the elderly stay well should be of concern.  Older women who quit reduce their risk of many disabling conditions including stroke, heart and chest problems, and fractures.  Even despite living longer, non-smokers tend to have lower total health care costs. Smoking among older women is an area which perhaps deserves greater priority.

Smoking rates and consumption
Generally the higher the smoking rate within a country or group, the more tobacco each smoker is likely to use.  Men generally smoke more tobacco than women, and poor women more than the affluent.  For example, among British women both smoking rate and average blood cotinine increase steadily with deprivation. Similarly, measures which reduce smoking rates tend to reduce average consumption.  Cigarette consumption is clearly linked to quitting.  For example, a British study found that smoking 10 or less a day was the key indicator of quitting success for women.

Action points

  • Continue to work with a women-centered approach
  • Clarify whether to focus on tobacco control, or adopt a broader approach
    focusing on inequalities
  • Encourage EU governments to declare they will not support national tobacco companies in promoting business overseas
  • Extend contacts with national and global networks concerned with women’s issues

    • References - View in this window
    Resources - View in this window

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