Other campaigns

"The World Bank comprehensively dismisses the arguments of the tobacco industry that tobacco control measures impair freedom of choice."

Individual women need health information, and support to quit.  These are an important part of total strategy.  But national or international control measures, for example through legislation, can have more powerful impact.  These developments are the real concern of the tobacco industry.

The challenge
Tobacco is a mood-altering drug which is generally acceptable, widely available - and highly addictive. Women may smoke, or relapse to smoking, in response to more diverse needs than men. The industry has worked hard to understand women, and satisfy these needs with affordable products.

On a national level tobacco is tied up with jobs, exports, tax revenues, and the funding of sports and arts.  The industry has therefore considerable political and social power. New initiatives include ‘Tobacco House’, a Europe-wide PR and lobbying body. In many countries controls are weak, and Eastern Europe in particular promises new markets.

The successes
The full health and economic effects of smoking are now better understood. New findings on passive smoking and the addictive nature of nicotine have been particularly important. These make smoking a matter of public responsibility, rather than personal liberty - a key legal difference. Following successes in the USA, the industry faces further legal challenges.

We also understand more about creating effective cessation and control strategies.   Tobacco now has greater priority, and several European countries have a full control strategy.
During 1999-2000 stronger national frameworks were announced for Finland, Ireland, France, Russia, Hungary, Poland and Croatia.  At the global level, the WHO has launched the Tobacco Free Initiative, with women and tobacco a key issue. An international Framework Convention is also being developed.

Campaign issues
There are four classic aspects of   marketing, all relevant to tobacco control:

To this we will add a fifth campaign topic - poverty, a key issue for women.  The following sections give basic information and some campaign options.  Individual countries will have their own initiatives and priorities.

Products and packets  See also What are women smoking?

Current marketing of tobacco conflicts with basic consumer rights - to be protected from harm, and informed of product content. Ideally, better regulation will save lives, as smokers are encouraged to smoke less, or products are perhaps made less hazardous. 

But the subject is complex, and after the ‘low tar’ experience health agencies are cautious about ‘safer’ nicotine delivery..

The confusion around tar and tar labeling is crucial for women.   In general women have responded more strongly to implied health benefits.  For example, around a quarter of women smokers in both France and the Netherlands switch to ‘low tar’ when pregnant. Yet health benefits are few, if any.  And women ‘low tar’ smokers may be at particular risk from some lung cancers, such as adenocarcinoma.

Tobacco production
Although a slightly different issue, this is a concern in some areas.  For example, there are 135,000 tobacco farms in France, Italy, Spain and Greece.  Local economies may need government support, such as rural development and training, to move away from tobacco dependency. 

Product regulation
Total regulation would require all cigarette constituents to be fully tested, modified and disclosed.  This is obviously unlikely, though some Canadian provinces now have product standards. Current EU strategy aims to reduce toxin levels.  Further toxin reduction is possible, but the industry may be reluctant. Cigarettes sold in non-EU countries may also have higher levels of tar, nicotine and specific carcinogens.  For example, Polish Marlboro and Mocne brands deliver high levels of carcinogens NNK and NNN.

At time of writing (July 2000) the Directive is making good progress. 
Most regulations would come into force from end December 2003.

Product information
Current European tar levels are a poor guide for consumers.   Firstly, the ISO machine test is not a good measure of how people smoke.  Real-life smokers compensate in various ways, to get their nicotine ‘hit’.  For example, fully blocking ventilation holes can give ‘high-tar’ yield from an ‘ultra-low’ brand (1>12mg). So there may be little or no toxin reduction from using ‘low tar’ brands. 

Secondly, smokers may not understand what tobacco constituents do.  For example, a third of British smokers don’t know that tar is the main source of cancer risk, even after forty years of health messages.

Health warnings
Evidence suggests that health warnings play a part in health awareness.  For example, around a fifth of Polish women tried to quit in response to new larger warnings in the late 90s.
But there has been concern that messages for women actually focus on children. Warnings also simply mention better-known risks, and packs sold outside the EU may comply only with local regulations.  Canada now proposes to include large pictures of smoking-related damage and quit information, even with imported products.  Linked research suggests that warnings which cover 50% of the pack face will have significant effect.

Plain facts
The look and feel of cigarettes play an important role for women.  Being displayed or offered, they become part of an image, perhaps especially for the young.  Cigarettes aimed at women tend to be long and slim, with luxury filters and packaging. The effect of pack design on girls is an important subject for further research.  Several Canadian provinces now have the legal framework to introduce plain cartons, or ‘generic packaging’.  These packs don’t appeal to young smokers, and are likely to be resisted by the industry.

Placing

Across Europe, tobacco is available in a wide variety of outlets - from vending machines and street kiosks, to hypermarkets and expensive clubs.  Finland has recently acted to stop Internet sales.

Action on sales to children
Research in several countries shows that even children find it easy to buy, and girls may have least problem. Tactics to control under-age sales in Europe have included:

Norway is to mobilize 1,000 regional health teams, to prevent sales to under-18s. Tobacco companies have also tried to take a role, by visiting Moscow kiosks, but children easily buy from ‘babushkas’ at the Metro. The increase in black-market cigarettes is also a major concern, as smugglers will sell to children of any age.

A comprehensive approach may give best results.  For example, the randomized trial in Minnesota found daily teen smoking down significantly, following a range of community and legal action. Most other research suggests that staff training has little effect, but prosecutions and linked publicity may have impact.

Other controls
There have been various proposals to limit tobacco outlets, perhaps to pharmacies.  If sales continue from a range of outlets, licenses could make it easy to support and monitor good practice, or remove the right to sell.  However, younger girls may get their cigarettes mainly from other people.  And although France has a strong license system, a minimum age for purchase is just being considered.

Price

A World Bank report states that price increases are highly effective in reducing demand, for countries at all income levels]. Countries with effective tobacco control generally tax at around two-thirds to four-fifths of final price.  Yet detailed evidence on women, girls and poorer smokers is not consistent.  This is important where reducing inequality is central to health policy.

Women, money and tobacco
Women generally earn less than men, and spend less on themselves.  Particularly for poorer women, the ‘affordable luxury’ of cigarettes can seem very important. There has been concern that tobacco tax is regressive, having most impact on the poor.  However, increases may be politically acceptable if combined with anti-poverty moves, and better support to quit.  From 2000 the UK will ‘hypothecate’ tax increases, marking them for health care.

Price and smoking level
Surveys give very variable estimates of price response.   In general a 10% price rise will reduce consumption by around 6-10% in low-middle income countries, but nearer 4% in high-income countries like the US.  Around half of this change may be due to reduced smoking rate (participation), and the remainder to cutting down.  Permanent tax increase may double initial response.  Increases also affect intent to smoke, and relapse after quitting. 

But effects on different groups are unclear.  Most but not all studies show young people more responsive than adults, especially those who don’t smoke daily. Data from the US COMMIT intervention suggest that girls intent to smoke is more price responsive. But some studies show boys more responsive than girls on participation.

American research indicates that women don’t respond strongly to price changes. Yet British research found women consistently more responsive than men, with the strongest response for both sexes in social group 5, or ‘unskilled workers’. Other research suggests the poorest don’t respond to higher prices, but spend less on other goods, including food.

Tax in Europe
In the EU tobacco tax has three elements: 

The rules for applying these elements are very variable.  So tobacco prices vary widely across Europe, although much less so in recent years.

EU policy requires new measures to increase ‘health protection’, and the current aim is to harmonize taxes by bringing up lower prices.  For example, Lithuania, Latvia and Estonia are working together to increase taxes, in order to join the EU.

Smuggling
There is now a huge tobacco smuggling operation across Europe, with the UK alone losing £2.5B in revenue a year. Around a third of this is small scale, taking advantage of cross-border tax differences.  But two-thirds is diverted in huge containers, with no tax paid.  So lower taxes would be a poor response to smuggling, besides damaging health and revenue. 

Action on tobacco tax
Some European countries have a regular Budget.  This can be used to:

In other European countries tax changes are slow and complex, perhaps
needing separate legislation.

Promotions

“All in all, that makes women a prime target as far as any alert European marketing man is concerned."

Promotions play an important part in keeping populations smoking.  But approaches vary according to the stage of tobacco uptake.   For example, Spanish ads still show smoking as liberated for women, but Dutch and German images may be sensual.   Methods of delivery also vary, from high-budget movies to cheap packaging.  For example, in Moscow nearly three-quarters of plastic bags carry tobacco ads.

The evidence
Promotions clearly increase teen smoking[. For example, smoking increased sharply among American girls, following new ads which targeted American women. Young women were also the target for German ads in the 1990s, many promoting smoking as ‘modern’ and ‘liberated’.  In the former East Germany smoking among young women aged 12-25 nearly doubled during 1993-97 (27-47%), and desire to quit fell sharply (62-42%).  The smoking rates among young men of this age changed much less (38-45%).

The immediate effect on adults is less clear.  But analysis of 102 countries for the World Bank report found consumption fell over twice as fast where comprehensive bans were in force. Young people, perhaps particularly girls, responded best to bans in Finland and Norway. 

A new European directive to ban tobacco advertising is currently under challenge.  Estimates suggest this could reduce EU tobacco consumption by around 7% on average.

Women’s magazines
Women’s magazines are a trusted source of health information.  Yet magazines which carry tobacco ads are less likely to cover health risks.  Over 40% of EU magazines also show models with cigarettes. Some British magazines with very young readers, though not taking adverts, still present smoking as normal or stylish.

Goods and services
Cigarette names are also linked to other services or goods, particularly clothes.  In UK nearly a tenth (7%) of girls under 16 own clothing with a tobacco logo. Children may be given free promotional cigarettes, and Eastern Europe is seeing increase in this type of promotion.  Exchange of goods for cigarette tokens also allows indirect promotion - as when Marlboro Lights distributed a stylish brochure for unisex street fashions. 

Sponsorship
Tobacco funding of events or groups generates publicity, and creates powerful allies.  Global communications mean this form of promotion is difficult to control.  There is evidence that smoking has increased again in major films, and that the industry paid for ‘product placement. The American tobacco industry has also supported ‘minority groups’ including feminist, gay and ethnic organizations.

Control of promotions
In various countries promotions have been challenged by:

 The European Directive 98/43/EC aims to introduce a comprehensive ban.  National laws would need to be in place by end July 2001, with full implementation by October 2006.   But the ban has loopholes, for example on sponsorship of global events.  And at time of writing (July 2000) there have been a series of legal challenges. Some countries are seeing rapid increases in promotions.  For example, the Spanish tobacco advertising budget increased by nearly half (45%) over 1997-98.

Poverty and policy

Public policy has a key role in reducing smoking among women.  This may involve changes to tax and benefits systems. Or it may provide better access to housing and childcare, or education, training and employment. However, poorer communities may see direct work on tobacco as judging, class based, or restrictive.  Projects in Scotland are now developing new responses for work with low-income women. 

Developing policy on smoking obviously involves a complex range of issues.  A recent model of influences on smoking may help give an overview of the options for action. Canada has also recently developed a policy structure which locates smoking prevention within a broad focus on inequality.

Action points

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