Young women and smoking

 “the answer may lie in the different ways in which males and females
respond to the pressures of adolescence”

Nearly all adult smokers first become regular users as teenage girls or boys.  Preventing youth smoking has therefore been seen as vital to public health.  What young smokers are doing and thinking is heavily researched, and costly interventions have followed.   But reviews of the evidence suggest need for a broader community approach, and stronger tobacco control.  The higher smoking rate among girls in some countries is poorly understood.

Note The term ‘young women’ covers the age range.  Details may relate to early teens or younger (‘girls’), early-late teens (‘teenage girls’), or late teens-early twenties (‘younger women’).

How much are young women smoking?

For young people, taking up smoking may be similar to making a friend:

This comparison emphasizes the complexity of smoking, and the difficulty of research.
Data such as ‘occasional smoker’ say little about which girls will eventually smoke.  However, population data can give an overview of current and future risk. 

Tables

European smoking rates

Comparable WHO data for over twenty European countries show rapid increase in smoking behavior around age 11-15. A study of UK teenage girls finds sharp increases in saliva cotinine at this time.Generally rates are higher in Nordic and western areas, and lowest in southern and Baltic states.  The picture becomes clearer as smoking is established.   However, some groups may start much earlier.  For example, around half of Romanian street children smoke from age five.

Trying cigarettes
These data shows rapid increase in experiment at age 11-13, suggesting that sales laws are not effective. Greenland, an independent region of Denmark, shows extreme rates on this and other measures.

In general less than a fifth have tried by age eleven, but nearly half by thirteen, and around two-thirds by fifteen.  Country differences are more marked at earlier ages.  For example, at eleven almost no Greek girls have tried, but nearly half those in Greenland (3-40%).  This suggests very different cultural contexts, with implications for timing and design of interventions.

Weekly smoking
Both weekly and daily smoking appear around age 13-15, or earlier in some northern countries.  By fifteen around half of those who’ve tried are smoking weekly, with rates clustering around 25-30%, and a range from a tenth in Lithuania to nearly two-thirds in Greenland (10-63%).

Dependence may develop among weekly smokers of both sexes, though there is no agreed definition of addiction at this age.  For example, in the UK only a minority of weekly smokers would find it ‘very easy’ not to smoke for a day, compared with nearly all occasional smokers (20-75%).

Daily smoking
By fifteen most weekly smokers are actually smoking every day.  So data on regular (weekly) smoking may hide the real increase in dependence among girls.  Rates cluster around 20-25%, with Lithuania and Greenland again at the extremes (6-56%). 

These girls may be as nicotine dependent as adult women.  For example, they take as much nicotine from each cigarette, smoke as early in the day, and suffer similar withdrawal effects.

Girls are tops?
In some European countries girls are now more likely to smoke than boys.  Boys experiment first, but by thirteen girls in most western and Nordic states are more likely to smoke weekly and daily.  By fifteen Greenland has the greatest absolute difference, with nearly two-thirds smoking weekly, compared to half the boys (63-52%).  The UK has greatest relative difference, with around a third more girls smoking regularly.

The extent and geographical pattern of this difference suggest more than chance.  However, differences can change or reverse rapidly, as in France.  Nor must we conclude that more women will eventually smoke than men.

Smoking and pregnancy
Smoking rates are high among pregnant teenagers, who tend to have multiple problems - with health, family, partners, housing and money. Quit rates are low and relapse usual.  The UK has seen increased smoking among both young and pregnant women, but Sweden has seen a down trend for both groups.

Yet among young adults pregnancy may give motivation to quit.  First pregnancy has a clear impact on smoking rates, with possible effects for further children, even in poorer groups. 
See also Sexual health and Stopping smoking.  

Trends

WHO data on European girls at 15 show no down trend in any country over the period 1983-4 to 1997-8, though not all countries were included. Many show a clear or possible  upward trend.  The following data relate to teenage girls generally.

Data for younger European women suggest similar trends as for teenagers.

Who will smoke?
Young smokers differ from non-smokers, in ways that may vary across communities. Influences are complex, but studies mainly from northern Europe suggests the following differences:

Obviously these issues are more than a matter of smoking education.  There is increasing interest in whole community responses

Why might more girls smoke than boys?

There is unlikely to be one answer applying to all cultures.  Some factors apply to both sexes, but perhaps affect girls more.  For example:

Other influences may mainly affect girls.  For example:

Yet several reviews conclude that these factors can’t explain the trend - and that we need to understand more about the tensions of adolescence. Child or adult, sexual being or good student, conformist group member or rebel individual?   Girls may feel these tensions most sharply, and smoking perhaps seem to offer some resolution.

What are young women smoking?
British studies suggest that young smokers are more brand aware.  For example, they may stick with their brands following price rises, when older smokers switch to cheaper ‘own-brand’ products.  In 1997 three brands took three-quarters of the UK market for girls aged 11-15. However, each individual may regularly use more than one brand.

Although young women are more likely to smoke in some countries, it is boys who develop a ‘harder’ smoking habit.  For example, German studies show that girls smoke less often, and less often use unfiltered or hand-rolled cigarettes.  Some promotions seem to position ‘Lights’ in the youth market, although ‘low-tar’ brands are still less popular than among older women.

Health - now and later

Health risk
Smoking has little impact on mortality at this age.  But risk builds up, or may be amplified. Both smoking and ETS may promote arterial disease, reducing HDL cholesterol and blood oxygen, and damaging the arterial lining. However, understanding of heart health among young European students is patchy.  Cancer risk is increased by early smoking, independent of amount smoked, and perhaps particularly for women. This may relate to early genetic damage among smokers. Lung development is impaired, again particularly in young women, whose lungs mature sooner. Loss of bone mass is already apparent.

Girls who start early also tend to smoke heavily as adults and stop later, if at all.

Sexual health
Young smokers may suffer more and longer period pain.   There is also concern for later fertility, especially among young women of low body mass.

Health and well-being
Young smokers suffer more respiratory problems, such as cough and wheeze, and more discomfort on exercise.  Young women particularly have greater risk of asthma symptoms. Girls who smoke have more sick-days, and are more prone to disorders such as stomach-ache, headache, poor sleep and tiredness. 

However, these may also reflect emotional problems or family crisis.  From puberty girls are much more prone than boys to the ‘psychosomatic’ problems which often indicate stress.  For example,  European girls aged 12-16 have at least twice the risk of frequent headaches (20-9%), nervousness (11-6%) and dizziness (10-2%).  Young female smokers in particular may have very low self-esteem, perhaps combined with disturbed eating.   The cost of tobacco also limits other choices.  For example, girls around Madrid spend most of their allowance (75%) on cigarettes.

But all these may seem minor in relation to perceived benefits of smoking - in controlling mood, creating an image, making friends, and exploring adult roles.

Stopping smoking

In ‘mature’ markets intent to quit may be high, though perhaps variable.  Quit attempts are also frequent, especially among girls.   For example half of British teen smokers want to stop, and nearly all the rest aren’t sure.  Two-thirds of girls and half the boys have tried (66-50%).   Helplines may be popular, for example around a third of callers to Smokeline in Scotland are girls under 18. Some special projects for girls have looked at emotional skills, or included arts or exercise.   The use of NRT is under review, and France offers pharmacy support for younger women.

WHO has called for better support for young smokers, but proper evaluation is crucial.
And support to quit is unlikely to make a large impact on girls’ smoking.  At this age smoking behavior is fluid, so relapse rates are very high.  It is also difficult to recruit young smokers.  As with adult women, advice from primary care may be a more effective approach.

Campaigns - education and media

Gender differences, and sometimes poorer response, may suggest the need for separate campaigns for girls - but as yet these difference aren’t well understood.

School programmes
A major review concluded that more successful projects:

Yet few interventions have done more than delay regular smoking. Delays of up to five years are possible.  This may be of value, predicting early adult quitting, and reduced health risk.  However most, but not all, schools projects appear less effective for girls.

Most projects also proved impractical for large-scale use.  A broader approach, such as ‘Health Promoting Schools’ projects, may have better impact.

Media campaigns
Apart from a few costly projects,  media campaigns aimed exclusively at young people have generally had little impact.  However, the ‘Truth’ media ads in Florida aimed to discredit the tobacco industry.  Young people were very aware of these ads, and smoking fell significantly among both middle and high-school children (18.5-15.0%, and 27.4-25.2%).  However, the exact role of the ads is not yet clear.  The ‘shock’ media campaign in Australia, aimed at young adults, is also thought to have influenced South Australian teenagers.  

The main role of media is perhaps to set the agenda around smoking, and influence policy and funding decisions.  Both paid and unpaid coverage of smoking generally may also have impact via adult smoking rates.

Other campaigns

Whole population approaches have a key role in reducing smoking among the young.
Control measures reduce adult smoking, give a consistent social message, and may be more effective before smoking is fully established. See also main section Other campaigns.

Products and packets
Slim, smooth and pretty - the look and feel of cigarettes and packs appeal to younger women.  Plain standard cartons, or ‘generic packaging’, have much less appeal.  Experiments also show that plain packs improve recall of warnings.   The effect of pack design on girls is an important subject for further research.

Placing
Research in several countries shows that children find it easy to buy, perhaps especially girls.

Tactics to control under-age sales in Europe have included:

Norway is now to use 1,000 regional health teams to stop under-age sales. A comprehensive approach may give best results.  For example, teen smoking fell significantly after community and legal action, as part of a randomized trial in Minnesota Most other research suggests that prosecutions and linked publicity are more effective than staff training. Licenses may also promote good practice, but although France has a strong license system, a minimum age for purchase is just being considered.

However, many girl smokers get their cigarettes from other people, and enforcing rules may be impractical in some countries.  For example, in Moscow tobacco firms have taken a role in educating kiosk staff, but teenage girls simply buy from ‘babushkas’ at the Metro.

Price
At the population level, trends in teenage smoking follow price changes.  Most but not all studies show the young are more price responsive than adults, especially those who don’t smoke daily. The US National Bureau of Economic Research recently concluded that higher prices are the best way to reduce youth smoking.

But response to price varies by gender and social group, and separate data are scarce.  Girls may respond differently to boys.  For example, COMMIT data showed girls more price-responsive on intent to smoke, boys on actual smoking. US college women stopped when prices rose, young men only smoked less.

The UK has a regular Budget, including tobacco tax.  This has been used to:

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

Promotions
Promotions play an important part in encouraging girls to smoke.  For example, advertising aimed at American women around the late 60s caused a major increase in uptake among girls.  English girls who named heavily advertised brands at age 11-12 were most likely to take up smoking within a year.

Important methods of promotion include:

In various countries promotions have been challenged by:

Young people are also strongly influenced by media images of smoking.  Recent research on cinema images suggests that women are shown smoking twice as often as men - a possible case for action.

Analysis of advertising rules in 102 countries for a World Bank report shows that comprehensive bans more than double the average fall in consumption. However weaker controls may do little.  New EU rules should be introduced from July 30th, 2001.  The report estimates that this will reduce consumption in member states by  around 7% on average.

Public places
School or workplace policies may reduce youth smoking, even if only the number of cigarettes smoked.  Projects on  ‘smokefree areas for kids’ aim to motivate adult smokers and improve public policy.  Public smoking policies are an important part of broad strategy on youth smoking, but may restrict public access, especially for poorer girls and women.

Poverty
Few projects have looked specifically at poverty, though poorer youngsters are seen as ‘high risk’.  For girls, best results may come from better education and training opportunities. Tackling family poverty is also key.  This may include changes in benefits, or access to public housing and childcare, but small improvements can have real impact on smoking rates.

Must young people smoke? 

 Population wide tobacco control measures are essential.  But special youth projects may be complex and costly, with limited long-term impact.   When resources are scarce, these may not be cost-effective, however politically useful.  Some workers now suggest that quitting in early adult life may be more realistic, perhaps at first pregnancy for young women.

Action points

Promote detailed understanding of smoking behavior through:

Promote and publicize health research on the following: 

Improve campaigns, including work on ETS

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