What are women smoking?

“The marketing of low tar cigarettes
constitutes one of the biggest and most lethal health scandals of our time”

Tobacco choices
Our modern cigarettes look the same as those shared by female war-workers. But over the last sixty years or so the contents have changed radically. Filters, reduced tar and nicotine, and a range of additives make the modern cigarette a complex product. These changes were partly driven by health concerns, but current evidence suggests few benefits, and possible new risks. Some changes may also increase addictive potential.  Regulations on tobacco product control and labeling have been accepted by the European Parliament and Council, but not yet finalized.  Most of these regulations should come into force by end 2003.

Women prefer blond
Nearly all European women now choose filter cigarettes with blond tobacco - mainly flue-cured leaf from the States. EU data suggest that in 1988 three-quarters used this type compared with just over half of men (74%-58%) (B). A few used blond rolling tobacco (7%).
Less than a tenth prefer filter black cigarettes (8%), with air-cured, higher tar tobacco. This is the tobacco mainly grown in Europe, despite shrinking local markets.

National patterns
Yet some cultural differences persist (C). For example, the majority of Dutch smokers use rolling tobacco, including half the women (49%). This pattern may have contributed to almost static smoking rates during 1988-97. Danish women use non-cigarette tobacco, and dark tobacco brands are popular with French women. A few Swedish women (1%) use ‘snus’ a moist oral tobacco. This is perhaps becoming more acceptable, especially among young educated women

Some of these differences are linked with price.  For example, German ‘quickies’, rolls of cigarette tobacco plus casing, attract less tax than ready-mades.  Cultural identity also plays a role, for example British women with ‘alternative’ lifestyles may prefer roll-ups.

The changing cigarette

‘Low-tar’
From the 70s ‘low-tar’ cigarettes came onto the global market.  Health concerns and government pressure have continued to reduce tar levels, as measured by machine.   For example, the EC maximum yield was 15mg (1992), then 12mg (1998), and in year 2000 a 10mg limit has just been approved .  Smokers are also choosing lower tar.   For example, In Ireland 16% of smokers have switched over the last five years, but fewer are trying to stop. And the Hungarian low-tar market has increased twenty-fold since 1991-92, when the industry was privatized (2-37%).

Light choices
In 1992 changed EU regulations brought the term ‘Light’ for lower tar cigarettes. This word has obvious appeal to women, and is widely used in marketing foods and cosmetics.

Most ‘Light’ cigarette marketing has also targeted women, sometimes with clear suggestion of slimness or health benefit.

This strategy has largely been successful.  Tobacco industry documents suggest that ‘Lights’ are seen as more feminine, and less risky.   For example, Marlboro Lights are perceived as “refined…upscale…health conscious” according to a Belgian agency. And a BAT report on women’s views concluded that low-tar brands are seen as “a major step in the direction of making smoking less harmful…

By 1995 half of EU women smokers chose ‘Lights’, compared to a third of men (48-31%). Swedish women used the highest proportion at three-quarters, compared to half the male smokers (74-46%)

Older and lighter
‘Light’ cigarettes are mainly chosen by the more affluent and health-conscious.  For example by 1998 almost half the ‘Lights’ smokers in the UK (41%) were from social groups ABC1.   One third of those who’d changed to lower tar (34%) had done so for health reasons

Both in the UK and across Europe, these are mainly older women, who might otherwise quit.  Three-fifths of EU women choose ‘Lights’ in middle age, compared with a third of younger women (60% at 45-64, 36% at 15-24)

Tobacco additives
Modern cigarettes include many additives, around 10% by weight in the US.  These create a product which keeps well, burns evenly, and delivers more nicotine without tasting harsh.    Around 600 additives are permitted in the UK. The impact of most is unknown, but some may increase risk.  For example, cocoa additive opens up airways, delivering nicotine and toxins deeper into the lung.  

Added ammonia increases nicotine yield by increasing pH, as with cocaine ‘free-base’. 
‘Low nicotine’ brands deliver no less nicotine, and the rapid ‘hit’ may increase addictive potential.  This may be particularly important for women, who perhaps smoke for peak nicotine values

A new directive
A proposed EU directive seeks to tighten rules on content and labeling [REF}.  At time of writing (July 2000) the directive is making good progress.  Key proposals include:

The changing evidence
In 1981 a major US report concluded, on data then available, that ‘low-tar’ cigarettes slightly increased life-span. This is now misleading.  Firstly, ‘low-tar’ at that time meant 17.6 mg or less.  Secondly, tar levels are assessed by machine.  But when smokers switch to lower tar they compensate for lower nicotine - people don’t smoke like machines

For example:

As a result, ‘Light’ cigarettes deliver no less toxin, or even more.  But few smokers are aware of compensation.  For example, a British study found only 20% knew about the effect of ventilation holes.

Starting smoking
A few studies suggest that nicotine more often makes girls feel sick.  Milder brands may make it easier for girls to experiment, but the evidence on nicotine and smoking uptake is not clear.  Familiar flavours may also make cigarettes more acceptable to young people.  Brand developments in 1999 included ‘softer’ Symphonia from Hungary, with active carbon filter, and a planned fruity range from Seita in France].

Stopping smoking - or not
Many studies suggest that ‘Lights’ may discourage quitting(C, 4). For example, a Dutch study found that ‘Light’ preference increased ten-fold during early pregnancy, from 2.5% to 29.5% around weeks 13-19.

Lung and heart health
Recent research shows little or no health benefit from ‘low tar’.  For example, low-tar reduces risk of heart attack by less than 10%, compared with medium-tar. Two major studies showed no significant respiratory benefits, and near complete smoker compensation.

Cancer risk
Studies in the 50s showed a dose-response link between tar and cancer risk.  Yet smoker compensation and changes in tar rating now make that misleading.   Nitrate in modern cigarettes may also alter carcinogen levels, increasing N-nitrosamines, and possible risk. A long-term study found that low tar smokers had no reduction in lung cancer mortality.

Some evidence has also linked low tar with previously rare cancers.  For example rates of adenocarcinoma increased 17 fold among American women from 1959-1991, and 10 fold for men. British women now have twice the risk of ‘small-cell’ cancer as men.  Survival rates are poor, with less than a third of cases suitable for operation, compared to half for men.

Less harmful nicotine delivery? See also Other campaigns
Public pressure may encourage development of new cigarette types.  For example, the new US Star brand has reduced nitrosamine, with implied health benefits. Other carcinogens, irritants, and carbon monoxide could be reduced. It is also suggested that oral snuff, as used in Sweden, may be a lower risk option for very dependent smokers, such as those in deprived communities. However, a small US study suggests that smokeless tobacco may greatly increase risk of early-onset breast cancer. So, as with ‘low-tar’, claims of risk reduction must be treated with caution.  The tobacco industry also has a problem in marketing ‘lower risk’, as this suggests that the ‘regular’ product is high risk.

Action points

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