Women: Smoking's new victims

More and more women are starting to smoke and they find it harder to stop than do men. The result will be a new epidemic of the diseases of smoking by the end of the century-unless health educators realize the need for new approaches to help women kick the habit.

The proportion of men who smoke is going down in many industrialized countries, yet it is not easy to find a country where the same is true of women. In Britain, men seem to have responded to the anti smoking campaigns of the past 15 years, so that the proportion of men who smoke has decreased from nearly 60 per cent in 1961 to 47 per cent in 1975. Over the same period, the proportion of women who smoke has remained unchanged at about 40 per cent. Why? The reason for this discrepancy between men and women is twofold. First, men have stopped smoking in larger numbers than women, and secondly, fewer boys are now starting while the proportion of girls who start is increasing. So the total proportion of women smokers has hardly changed because the women who have stopped have been cancelled out by the increasing numbers of young women recruited.

Not only is the proportion 'of smokers who are women increasing in many countries, but so also is the amount they smoke. Until the Second World War, excessive "indulgence" in cigarettes was considered unladylike and those who did smoke were expected not to inhale too deeply or to leave too short a stub. Indeed, keeping to feminine etiquette was probably partly responsible for holding down female lung-cancer rates until recently. In 1950 the average British woman -smoker got through half as many cigarettes as her male contemporary. Now, she has almost caught him up and smokes, on average, more than 15 cigarettes a day.

Smoking patterns also reflect the politics of a class society. Irrespective of whether you are male or female, the lower your status, income and educational achievements, the more likely you are to smoke. But class alone cannot explain smoking trends in women: women within every social group have lower rates of stopping than do men. Thus, women's smoking patterns reflect underprivileged of a different kind: that of sex. Smoking rates among women are high at both ends of the social scale. Why should this be?

Women are as aware of the risks of smoking as men, and they certainly try to stop smoking as often as or more often than men. But they have lower success rates in every occupational and age group-except the very young, where there are no real differences between the sexes. As the 1980 US Surgeon-General's report on women and smoking put it: "Across all treatments, women have more difficulty giving up smoking than men. No studies have been reported in which women do significantly better than men. Several of the larger studies show higher abstinence rates by men."

Counting the Cost

In 1977, more than 8,500 British women died of lung cancer-which means that one woman dies of lung cancer every hour of the day, every day of the week, to maintain Britain in its unenviable third position in the Women's World Lung Cancer League. Although lung cancer is the most clear-cut example of an illness caused by smoking, cigarettes are also a major cause of coronary heart disease in which the arteries feeding the heart muscle become blocked-often causing a heart attack. In numerical terms, coronary heart disease is the number-one killer of both women and men in the Western world. In/ 1979, more than 65 000 women in England and Wales died of coronary heart disease, which claims more women than all forms of cancer combined. Although smoking is not the only cause of heart disease, and dietary and other factors are also of key importance, the woman who smokes 20 cigarettes a day is twice as likely to die of a heart attack as her non-smoking contemporaries-irrespective of any other risk factors. Moreover, women who smoke and take the oral contraceptive pill face the risk of heart disease due to the pill itself, multiplied by that of smoking. Smoking is also the main cause of chronic bronchitis and emphysema-two disabling and ultimately fatal chest diseases. Although milder cigarettes, cleaner air and improved medical treatment have contributed to the steady decline of these illnesses in both men and women, they still kill more British women than the total number of people killed on the roads.

Why Women Smoke

Tanya is a 30-year old housewife, and smokes 20 cigarettes a day. She remembers her first cigarette very well: "I started when I was 12. My father had remarried and although my stepsister was only a year older than me, she seemed so much more mature in her dress and her ways. My stepmother let her smoke, and she took the Mickey out of me because I couldn't smoke properly. I got my own back by stealing her cigarettes and going into the bedroom to practice smoking until I could do it without looking stupid." Smoking is one of the forbidden fruits of adulthood. It also appeals to a child's sense of curiosity. The girl who tries on her mother's lipstick and clothes when she is out may find her cigarettes lying around and try them too.

Annie is 28 and smokes 20 cigarettes a day. When she feels bored or "under stress" she smokes an extra 10. "I couldn't contemplate stopping," says Annie, "because my biggest fear would be having nothing to rely on in a stressful or frightening situation." Like Annie, Pauline also smokes at emotional high-points in the day: "Cigarettes are a comfort and a cover-up for the many fears and embarrassments I encounter in my life. The moment I feel under any kind of stress, my first thought is to resort to smoking." Pauline and Annie, like so many women and some men use their smoking as a safety valve, an alternative to letting off steam. They smoke not to accompany expressions of frustration or anxiety, but instead of expressing these feelings.

As a secretary, Claudia often felt powerless and frustrated at work: "If you watched me with a cigarette, you could see that I usually smoked when I was feeling anxious or distressed. I always found it difficult to express my anger and anxieties. Cigarettes were important to me because they helped to suppress a lot of these feelings. They were the only outside evidence of my feelings I was able to tolerate."

"We have an investment"

Women have a bigger emotional investment in smoking than men. Cigarettes represent one of the few ways of uncorking those feelings that society teaches them to suppress. Mrs. X, who is 64 and smokes 20 cigarettes a day, puts it another way: "Cigarette smoking not so much calms the nerves as dulls the sensibilities so that I, at least, do not care so much that I am frustrated." Men do not, of course, escape similar frustrations, but there are more channels through which they can express these pent-up emotions. Society may not like a drunken man, but it disapproves even more of a drunken woman. Aggressive behavior - whether desirable or not-is always an easier avenue for the release of tension for men. This does not necessarily mean that women are innately less aggressive than men, but rather that women are expected to be so. Despite living in an age of "sexual liberation" sexual freedom does not apply equally for men and women. Even exercise – a seemingly innocuous outlet is still a more acceptable activity for men than for women.

Not only do women smoke to keep their emotions in check, many dare not stop for fear of what may happen if they can't prevent their emotions from leaking out. Will her boss sack her if she answers him back next time instead of having a cigarette? Will her husband leave her if she gets fed up and irritable about holding down a job as well as running a home? Will her children stop loving her if she turns from the loving mother into a momentarily angry woman?

The ritual we know so well.

According to the experts, smoking in women is an inevitable result of their growing emancipation. The cigarette is, in their view, "a symbol of emancipation" and "a defiant gesture of independence". It would, of course, be naive to assume that changing attitudes toward women have had no influence on women's smoking habits, for they have certainly contributed to removing the old taboos against female smokers. But it is quite wrong to condemn the growth of the women's movement for the rise in women's smoking, and to assume that women want to become like men and, therefore, smoke like men.

There are two processes shaping women's smoking pat terns today. First, there are the factors that have led girls to catch up and even to overtake boys in. the frequency with which they are starting to smoke. The influences at work here owe much to the new climate of liberation. But we must not confuse them with the factors influencing the difficulties women have in giving up smoking. The key to understanding this second part of the problem stems not so much from new equalities, but from continuing inequalities.

Our kind of society makes it much easier for a woman to fall into the role of the helpless dependent addict than for a man. Women's addiction training starts early in life. Girls are more convinced than boys that smoking is an addiction. Behind this attitude lie the roots of the difficulty women experience in stopping smoking. Research into general attitudes to health indicates that as early as six years old, boys see themselves as strong and less susceptible to illness than are girls. Girls, by contrast, feel more vulnerable, and are more likely to seek help. Every boy learns quickly that he must "take his pain like a man"- crying is for sissies and girls. By the time children leave school. girls are already well-primed for addiction and dependence.

A smoking woman and her cigarettes are unseparable.

Once a confirmed "addict", a woman incorporates her smoking into her constant battle for control over her emotions and so-called "irrational" feelings. Feeling in control of their lives, is, of course, just as important to men as it is to women. But the ways open to women to exert this control are more limited than for men. A man has greater scope for control through his job and the associated status and responsibility he derives as the. "breadwinner". He may also exert it at home, over how his pay packet is spent or how often he and his wife have sex. Even though increasing numbers of women-especially married women-also have their jobs, persistent inequalities both at work and at home mean that the spheres of potential control open to a woman lie largely within the family and the personal. It is more important for a woman to be seen to be keeping her emotions in check than for a man, because she has, in political terms, so little influence over other aspects of her life.

The fear of gaining weight is another factor that prevents women giving up. Nearly all women-smokers and non-smokers alike-want to be thin. Being thin has a meaning for women that it does not have for men. Women are under constant pressure to squeeze themselves into clothes that are too small, because we live in a society that values women largely for what we look like-not what we do. Current Western fashions dictate that to be beautiful you have to be thin; thus thinness is one of the few sources of self-esteem society allows women. Although smoking is not a passport to weight loss, and giving up does not necessarily result in weight gain, women smokers often equate smoking with being thin and in control. Giving up, therefore, represents a threat to a woman's badly needed self-esteem. She sees her smoking as a means of maintaining her self-confidence in a world where she feels she has to be thin to be successful in her relationships with men. It is easy to see why she might believe that being thin is more important than stopping smoking. It is not because she doesn't recognize that smoking is far more damaging to health than the possibility of putting on/ weight, but that she has been forced to view controlling her weight as a more immediate priority. The thought of being fat, undesired and unsuccessful seems far more difficult to face than the prospect of becoming ill from smoking at some undefined future date.

An Advertiser's Dream

Would somebody please cigarette me?

Of the many personal and social factors promoting cigarette dependence, cigarette advertising is, perhaps, the most obvious. Because in the US, cigarette advertising is almost as uncontrollable today as it was 50 years ago, it provides us with the clearest insight into the tactics tobacco companies use. American advertisers are typically blunt about the steadily-growing purchasing power of the so-called "new woman". "She is," according to the trade papers, "the hottest marketing target in the US today."

The tried and proven penis size joke

Cigarette advertisements increasingly directed at women have escaped the notice of feminists campaigning to remove sexist stereotyping in advertising. Ironically, this is because cigarette advertisements rarely portray women in overtly "dumb blonde" or passive roles. Although there are still many cigarette ads that portray women as sex objects, the cigarette advertisers have done what many other advertisers-and nearly all health educators-have not yet managed to do: they take women seriously. The women in the most successful advertisements are depicted as independent people with their own lives and interests. Today's woman, say the adverts, knows how to get her own cigarette.

All smoking women are Virginia Slims girls at heart

First to use this theme was "Virginia Slims", masterminded by Philip Morris which launched its product at exactly the right time-1968. Feminism was gathering momentum, and, as cigarette advertising had not yet been banned on TV, it did much to boost sales. The advertising agency responsible for the campaign knew what was at stake: "You are competing with every other advertiser for a share of the consumer's mind," it said. And so Philip Morris went after women with its slogan, "You've come a long way baby." The early Virginia Slims girls were depicted as slightly coy and giggly, but Philip Morris's confidence soared along with sales. Today's ads are hard-hitting and aggressive, usually comparing the poor oppressed wives of the past with today's jet-setter or woman executive.

"Lights" aren't supposed to be as unhealthy

The Virginia Slims girls may have come a long way, but she is still someone's baby. She's only playing at being the independent woman. It's suggested that her cigarettes are her passport to slimness because they are "slimmer than the fat cigarettes men smoke". By appealing to women in two conflicting ways, the campaign captures both the strength and the vulnerabilities of women and sells them nearly nine-thousand million cigarettes every year. Women did not figure independently in any of the early health - education campaigns. The health educators intended their message for all smokers, but the major response was from men. Women later became the focus of anti-smoking fervor-as wives and mothers. The British Medical Journal described the woman-smoker as "imposing a threat to her procreative role". "The young mother who smokes," according to the Journal of the Royal College of General Practitioners, "is throwing away her child's birthright by increasing its chances of death and malnutrition."

The philosophy behind these health-education approaches is a reflection of society's view of men and women - that men will always be men, but women can be only wives, mothers or sex objects. The underlying assumption is that a woman's motives for doing anything are always to satisfy others. She must, therefore, stop smoking to protect her unborn child, her husband or her sex appeal. The messages directed at women depend largely on generating sufficient guilt and anxiety to make her stop. Thus health educators reinforce ideas about the proper way for women to behave. So far, their tactics have been remarkably unsuccessful-they have done little more than undermine the self-confidence of the woman who is trying to stay off cigarettes.

Bobbie Jacobson worked for Action on Smoking and Health. She is a feminist and active anti-smoking campaigner.

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