Health promotion initiatives need to focus on women's health rather than perceived images of women.

More than half a million women are killed annually by smoking, of which 2,200 are Irish women.¹ This number will increase as smoking prevalence amongst women is rising. Because of the time lag between smoking and the development of health problems, few countries have yet experienced the full impact of smoking on women's health.² Smoking prevalence among women in different countries ranges from a high of 37% in Denmark to a low of 0.5% in Turkmenistan with Irish women sharing 10th highest place at 28%.³ Unfortunately there is little sign of improvement as a recent study has shown that 36% of 16 year old girls are current smokers.⁴ The main causes of death from smoking, for both sexes, are cancers, heart and respiratory diseases. Women have additional risks over and above those experienced by men. Women who smoke have a higher risk of heart disease and stroke if they use oral contraceptives. They experience detrimental effects on their reproductive health including reduced fertility and early menopause.⁵ Women who smoke during pregnancy have an increased risk of miscarriage, premature labour, low birth weight baby and infant perinatal death.^6,7 Women also suffer from the health effects of both active and passive smoking because of the role women play as carers.³

Women as targets

The initiation of smoking in girls, (as in boys), is influenced by social pressures and psychological needs. Furthermore, the tobacco industry targets women by: promoting smoking using imagery which suggests smoking is glamorous, sophisticated, romantic, sexy, healthy and slimming; producing "women only" brands, such as Virginia Slims and Kim which appeal to women; and advertising in women's magazines which in turn induces a degree of advertising induced self-censorship in covering the serious public health problem of smoking and women.^10,11,l2

Smoking myths perpetuated

Despite the harmful effects of smoking, many women (and indeed men) find it difficult to quit. The principle reason for this is the addictive nature of nicotine itself.³ However, there are other reasons as well. Tobacco companies have targeted low tar/nicotine products at women in an attempt to allay health fears. Rather than quit many women have turned to these products believing that this reduces their health risks. There is little medical evidence to support this view.^l4,15 In countries with a long history of female smoking such as Ireland, smoking is now more common amongst those on low incomes. Many of these women continue smoking in the belief that cigarettes help them cope.³ In reality smoking does little to relieve stress other than the stress induced by a fall in nicotine levels. Many women also believe that smoking helps control their weight and quitting leads to weight gain.¹⁶ The disadvantages of continuing to smoke are far greater to the health of a woman than the additional weight gain. It is important to appreciate that for many women, a small weight gain is a high cost to pay in terms of their self image and it needs to be recognised as a significant factor for women and dealt with accordingly. 

Tabacco control strategies

In order to reduce the burden of tobacco on women (and on men) there are generic strategies which need to be in place. These include: advertising and sponsorship bans, fiscal measures which increase the price of tobacco products above inflation, restriction of tobacco sales to children, licensing retailers and distributors, restricting smoking in public places and in work places, cessation supports and educational programmes. Tobacco control policies also need to encompass gender specific and gender sensitive approaches. For example, women tend to have more contact with health services, thus creating considerable opportunities for health education. It is also important that health promotion strategies focus on women's health as against an image of women. Many women's groups take exception to the portrayal of women as being negligent because they smoke during pregnancy thus harming the foetus. The greatest harm in a woman smoking is being done to the woman herself. In addition, the portrayal of "smoking causes wrinkles" theme, stresses women's superficial beauty, ignoring the many serious life threatening diseases developing on the inside. This type of health promotion does not contribute to healthy body image goals and respective ageing in girls and women.⁸

There is also a need to involve organisations and networks which reach women in different ways in tobacco control, such as youth organisations, community groups and networks, women's organisations, work places and the media including women's magazines, radio and TV. Many of these agencies have been largely silent on this issue. On a positive note, some women have begun to take control. The International Network of Women Against Tobacco (INWAT), formed in 1990, has great potential to improve the health and promote equality of women. Its main objectives are: to counter the ruthless marketing and promotion of tobacco to women, to develop programmes that help girls and women to resist the pressure to start or be able to give up smoking, and to promote women's leadership in the tobacco control movement (INWAT can be contacted at: [email protected]).¹⁷ Irish women could benefit greatly from an alliance with INWAT. 
Fenton Howell,
Specialist in Public Health Medicine,European Medical Association Smoking or Health,1 Victoria Terrace,
Laytown,
Co. Meath.

References

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3. World Health Organisation. Tobacco or Health: A Global Status Report. Geneva: World Health Organisation, 1997. 
4. Department of Health. Smoking and drinking among young people in Ireland. Dublin: Government Publications, 1996. 
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6. Royal College of Physicians. Smoking and the Young. London: Royal College of Physicians, 1992. 
7. Charleton A. Children and Smoking, the Family Circle. British Medical Bulletin 1996;52:90-107. 
8. Greaves L. Smoke Screen: Women's Smoking and Social Control. London: Scarlet Press, 1996. 
9. US Department of Health and Human Services. Preventing Tobacco Use Among Young People: a Report of the Surgeon General. Atlanta: US Department of Health and Human Services, 1994. 
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12. Howell F. Tobacco advertising and coverage of smoking and health in women's magazines. Irish Medical Journal 1994;87:140-41. 
13. Bolliger CT, Fagerstrom KO. (eds.) The Tobacco Epidemic. Progress in Respiratory Research 1997;28. Basel: Karger, 1997. 
14. Amos A. How women are targeted by the tobacco industry. World Health Forum, 1990;11:416-22. 
15. Palmer JR, R