Gender empowerment and female-to-male smoking prevalence ratios

Because a country’s progression through the various stages of the tobacco epidemic and its gender smoking ratio (GSR) are thought to be inﬂuenced by its level of development, we explored this correlation as well, with economic development deﬁned in terms of gross national income (GNI) per capita and income inequality (Gini coefﬁcient). Findings The GSR was signiﬁcantly and positively correlated with the GEM ( r = 0.680; P < 0.001). In addition, the GEM was the strongest predictor of the GSR ( β , adjusted: 0.47; P < 0.0001) after controlling for GNI per capita and for Gini coefﬁcient. Conclusion Whether progress towards gender empowerment can take place without a corresponding increase in smoking among women remains to be seen. Strong tobacco control measures are needed in countries where women are being increasingly empowered.


Introduction
Tobacco smoking currently kills ve million people a year worldwide and, according to estimates, will probably kill eight million people a year between now and 2030 and one billion over the course of the 21st century. 1,2 In 2010, the World Health Organization (WHO) chose as the theme of World No Tobacco Day the relation between gender and tobacco, with an emphasis on marketing cigarettes to women. is theme was chosen "to draw particular attention to the harmful e ects of tobacco marketing towards women and girls". 3 Worldwide it is estimated that men smoke nearly ve times as much as women, 4 but the ratios of female-to-male smoking prevalence rates vary dramatically across countries. In highincome countries, including Australia, Canada, the United States of America and most countries of western Europe, women smoke at nearly the same rate as men. 5 However, in many lowand middle-income countries women smoke much less than men. In China, for example, 61% of men are reported to be current smokers, compared with only 4.2% of women. Similarly, in Argentina 34% of men are reported to be current smokers, compared with 23% of women. 5 While women's smoking prevalence rates are currently lower than men's, they are projected to rise in many low-andmiddle-income countries. Data from the Global Youth Tobacco Survey show that worldwide smoking rates among boys and girls resemble each other more than smoking rates among adult women and men, with boys between the ages of 13 and 15 years smoking only 2 to 3 times more than girls. 6 Additionally, Lopez et al.'s 1994 descriptive model of the tobacco epidemic predicts that the female-to-male ratio in smoking prevalence will rise in many low-and-middle-income countries where females currently smoke at much lower rates than males. 7 According to Lopez et al.'s descriptive model of the tobacco epidemic, countries fall into one of four stages. 7 In stage 1, men's smoking prevalence rates rise rst, followed 10 to 20 years later by a more modest rise in women's rates. In stage 2, men's and women's prevalence rates continue to rise, with the increase in prevalence among men slightly outpacing the increase in prevalence among women. In stage 3, men's prevalence rates level o and then drop sharply to resemble women's rates; during the same stage, women's rates increase moderately and then decrease, although not as sharply as men's. In stage 4, women's and men's smoking rates continue to fall until they are nearly equal. e relatively slower rise of smoking among women in comparison with men has been attributed to social disapproval of women who smoke and to women's lower social and economic status. [8][9][10] For example, before the 1920s in the United States, smoking among women was much less common than among men because women who smoked were not viewed as respectable. However, as society became increasingly tolerant of women who smoked, women's smoking rates began to climb towards levels nearly as high as those seen among men. 8 Cigarette smoking among women in northern Europe followed a similar pattern. 11 e rise of smoking among women has been attributed not just to social factors and to women's increasing economic resources, but also to the tobacco industry's marketing of cigarettes to women as a symbol of emancipation. 12-14 is theme inspired a variety of marketing campaign slogans, including Phillip Morris' well known 1968 advertisement for the Virginia Slims cigarettes campaign, "You've come a long way baby", which underlined the achievements of the women's movement in the United States. 15 A 1991 internal industry document describes the creative strategy behind this brand, targeted speci cally to women: "To convince fashionable, modern, independent and selfcon dent women aged 20-34 that by smoking VSLM, they are making better/more complete expression of their independence." 16 Abstracts in ‫,ﻋﺮ‬ 中文, Français, Pусский and Español at the end of each article.
Objective To determine whether in countries with high gender empowerment the female-to-male smoking prevalence ratio is also higher. Methods Bivariate and multiple regression analyses were performed to explore the relation between the United Nations Development Programme's gender empowerment measure (GEM) and the female-to-male smoking prevalence ratio (calculated from the 2008 WHO global tobacco control report ). Because a country's progression through the various stages of the tobacco epidemic and its gender smoking ratio (GSR) are thought to be influenced by its level of development, we explored this correlation as well, with economic development defined in terms of gross national income (GNI) per capita and income inequality (Gini coefficient). Findings The GSR was significantly and positively correlated with the GEM (r = 0.680; P < 0.001). In addition, the GEM was the strongest predictor of the GSR (β, adjusted: 0.47; P < 0.0001) after controlling for GNI per capita and for Gini coefficient. Conclusion Whether progress towards gender empowerment can take place without a corresponding increase in smoking among women remains to be seen. Strong tobacco control measures are needed in countries where women are being increasingly empowered. Sara C Hitchman & Geoffrey T Fong Women's empowerment and smoking

Research
Advertising for Virginia Slims followed similar patterns elsewhere. Here is a 1994 advertisement in Japan: "I'm going the right way -keeping the rule of society, but at the same time I am honest with my own feelings. So I don't care if I go against the so-called 'rules' so long as I really want to." 12 Today we can takes steps to prevent women's smoking rates from increasing, but only if we understand the factors leading to their rise. To examine if women's empowerment is related to current differences in male and female smoking prevalence rates within countries worldwide, we looked for a potential association between the ratio of female-to-male current cigarette smoking prevalence rates and the gender empowerment measure (GEM) developed by the United Nations Development Programme (UNDP), as manifested across 74 countries at di erent stages of the tobacco epidemic. 17 While it is imperative that women's empowerment continue, attention must be paid to its potential link to increased smoking among women and to the ways in which the tobacco industry is capitalizing on societal changes to target women.
In this study we focused on cigarette smoking rather than on tobacco use in general because the use of "traditional" forms of tobacco (smoked or smokeless) shows widely varying patterns between men and women. 10 Furthermore, current cigarette smoking rates probably best re ect the burden of current smoking within a country and are more likely to be associated with the current GEM. e GEM is described as "a composite index measuring gender inequality in three basic dimensions of empowerment -economic participation and decision-making, political participation and decision-making and power over economic resources". 17 In a 2007 review of gender-related indicators of well-being, Klasen described the GEM as providing some useful cross-country comparisons on components of female empowerment, less problematic than UNDP's genderrelated development index, and a measure not of well-being, but of the "relative empowerment of males and females in the political, economic and household sphere". 18 Much has been written on the relation between women's and men's smoking rates, but few authors have attempted to investigate it empirically across countries. 8,10 In a study conducted in 2009, Schaap et al. examined the relation between the GEM, gross domestic product (GDP) and ever-smoking rates among high-and low-income women aged 25 to 39 years in 19 European countries. 19 ey found non-signi cant associations between GEM and ever-smoking rates when controlling for GDP; the association was negative for high-income women and positive for low-income women. In 2006 Pampel 20 studied female-to-male smoking prevalence ratios in 106 nations as a function of various proposed measures of gender equality (fertility rates, literacy rates, female representation in parliament, tertiary education levels, etc.). e author found inconsistent associations between these variables and arrived at the conclusion that the general level of cigarette di usion in a country seemed to more consistently explain the gender di erence in smoking rates than did the level of gender equality. e present study assesses the relation between the GEM and the femaleto-male current smoking prevalence ratio across countries, with adjustment for established measures of economic development and general inequality.

Measures
Gender smoking ratio To calculate the GSR, current female and male cigarette smoking prevalence rates for each country were taken from the WHO report on the global tobacco epidemic, 2008. 5 ese rates are adjusted by WHO to best re ect the prevalence of current smoking among people over 15 years of age in each country, current smoking being de ned by WHO as "smoking at the time of the survey, including daily and non-daily smoking". 5 ese rates were available for 130 countries. We chose not to impute smoking rates for countries with missing data from other sources because the prevalence rates thus obtained would not have been similarly adjusted. We divided women's smoking rates by men's smoking rates to yield a female-tomale gender smoking ratio (GSR).

Gender empowerment measure
We used the GEM given in statistical tables in the UNDP's Human development report 2009. 17 e measure is derived from several components, including : (i) seats in parliament held by women, (ii) female legislators, senior o cials, and managers, (iii) female professional and technical workers, (iv) year women received the right to vote and year they were allowed to stand for election, (v) year when a woman became Presiding O cer of parliament or of one of its houses for the rst time, (vi) percentage of ministerial positions held by women, and (vii) ratio of estimated female-to-male earned income. e GEM ranges from 0 to 1, with values closer to 1 signifying higher empowerment. e GEM was available for 109 countries.
Gini coefficient e Gini coe cient, a well known measure of income inequality and wealth within a population, was controlled for in an attempt to examine the unique impact of the GEM (female inequality), independent of the general level of income inequality within a country. A value of 0 signi es maximal equality, whereas a value of 1 signi es maximal inequality. 21 e Gini coe cient was taken from statistical tables in the UNDP's Human development report 2009. 17 It was available for 142 countries.

Gross national income per capita
It was important to control for level of economic development because much of the research literature on the stages of the tobacco epidemic links progression through the epidemic to a country's level of development. 7 We used GNI per capita for 2008, as given by the World Bank and expressed in international or purchasing power parity dollars, 22 which account for relative prices across countries and provide a suitable measure for international comparisons. 23 GNI per capita is used by the World Bank to classify countries into income categories (i.e. low, lower-middle, upper-middle and high). 23 In our analyses we used the logarithm of the GNI per capita [ln(GNI per capita)], because GNI per capita data are highly skewed in a positive direction. GNI per capita was available for 166 countries.
Statistical analyses SPSS 17.0 (SPSS Inc., Chicago, USA) was used to conduct all statistical analyses. We rst performed Pearson correlations between all measures. Subsequently we tested whether the relation between GEM and GSR persisted when partialling on GNI per capita and Gini coe cient

Results
Descriptive statistics rates. e correlation between the ratio of women's to men's current smoking rates and the ratio of women's to men's daily smoking rates was 0.99 (P < 0.0001). Table 2 displays the bivariate correlation matrix. e positive and statistically signi cant correlation found between GSR and the GEM suggests that in countries with higher female empowerment, female and male smoking rates are closer to being equal (Fig. 1). GSR and GNI per capita were also found to be signi cantly and positively correlated. us, the higher a country's GNI per capita, the closer the female and male smoking rates come to being equal. e GSR and the Gini coefcient were negatively correlated, which shows that in countries with low income inequality, female and male smoking rates are also closer to being equal.

Correlations between measures
Partial correlations e correlation between GSR and GEM remained signi cant a er adjusting for ln(GNI per capita) (r = 0.480; P < 0.0001; n = 82). Some countries could not be included in the analyses due to missing data on GNI per capita. e correlation between GSR and GEM, adjusted for the Gini coe cient, increased slightly (r = 0.703; P < 0.0001, n = 75), most likely because some countries were excluded from the analysis due to missing data on their Gini coe cient.

Multiple regression analysis
With GSR as the dependent variable, we tested whether GEM predicted the GSR while controlling for GNI per capita and for Gini coe cient (model results, F 3,70 = 27.21; P < 0.0001; adjusted R 2 = 0.519). e analysis showed that GEM remained a very strong and highly signi cant predictor of GSR a er controlling for GNI per capita and Gini coe cient. Table 3 displays the model coe cients.

Discussion
In a June 1998 editorial for the newsletter of the International Network of Women Against Tobacco, former Director General of the WHO, Dr Gro Harlem Brundtland, wrote that "there can be no complacency about the current lower level of tobacco use among women in the world; it does not re ect health awareness, but rather social traditions and women's low economic resources". 24 e ndings presented in this study lend empirical support to Dr Brundtland's warning. We found that in countries where women have higher empowerment, women's smoking rates are higher than men's, independent of the level of economic development and of the level of income inequality. In fact, GEM was by far the strongest predictor of the gender smoking ratio, even a er including the other two competing predictors in the model. at is, women's empowerment as measured by economic participation and decision-making, political participation and decision-making, and power over economic resources, was found to be associated with the ratio of female-to-male cigarette smoking prevalence.

Research
The findings of this study are supported by historical trends of the tobacco epidemic in developed countries and by previous discussions of the associations between social changes, women's rising economic resources and the rise in women's smoking rates relative to men's. [8][9][10][11] The one study that explored the reasons for the difference between women's and men's smoking rates across multiple nations did not find strong support for a relation between such rates and its proposed measure of gender inequality; however, this measure captured gender equality rather than women's empowerment and included constructs that are not components of the GEM (fertility rates, tertiary education rates, literacy rates, etc.). 20 Another study that examined the relation between the GEM and eversmoking rates among women in Europe yielded findings consistent with those of this study, although not statistically significant. 9,11 Implications Evidence-based tobacco control policies should be implemented to stop the rise in women's smoking rates worldwide, particularly in countries where rates are low at present but where women are being    [25][26][27] Furthermore, because this study found an association between women's smoking rates relative to men's and the GEM, which includes components measuring women's economic participation and decision-making and power over economic resources, policies to reduce the demand for tobacco through increasing the price of cigarettes and levying taxes on tobacco products should also be implemented, in accordance with Article 6 of the WHO FCTC. 26 Future research should monitor and evaluate how price and tax measures a ect the uptake of smoking among girls and women in countries where the tobacco epidemic is currently in its early stage. e articles and guidelines of the WHO FCTC have not yet outlined speci c strategies to keep smoking prevalence rates among women from rising, although the preamble emphasizes the need for gender-speci c tobacco strategies. 26 However, there is clearly a need to specically outline policies to prevent women's smoking prevalence rates from rising, as shown by the currently wide gap in men's and women's smoking rates coupled with evidence that women's smoking rates are rising in some countries. 6,7 Emphasizing that bans on advertising, promotion and sponsorship are key to preventing women from taking up smoking, as indicated in the WHO FCTC guidelines, may be helpful in alerting countries to the importance of taking action and the opportunity to do so. As stated in WHO's 2008 and 2009 reports on tobacco control, the tobacco industry targets women and "advertising, promotion, and sponsorship can make smoking more socially acceptable", with a resulting breakdown of traditional norms that discourage women from using tobacco. 5,28 A recent report on the WHO Operational Planning Meeting for Gender and Tobacco Projects recommended, among other things, educating people about gender-speci c tobacco marketing, monitoring advertising by the tobacco industry, using gender arguments to advocate for enactment of Article 13, and involving women's civil society groups when appropriate. 29

Future research
Future research should investigate what strategies may be most e ective in preventing uptake among groups of women who tend to be the rst to take up smoking, as shown by historical investigations of the tobacco epidemic, namely, those who are younger and more highly educated. 8,11,30 However, as the course of the tobacco epidemic may not evolve in exactly the same way across countries, the tobacco epidemic among women should be carefully monitored. As the epidemic continues to unfold, the impact of WHO FCTC policies and other tobacco control e orts to prevent women from taking up smoking should be evaluated, particularly in those countries where women are gaining in empowerment. 31

Study limitations
is paper was not intended as an indepth discussion of the relation between GEM and GSR within each country and region, but rather, as an attempt to demonstrate the basic empirical relation between GEM and GSR across countries by using ecological methods. ere are limitations to the conclusions we can draw from this study. First, because the relation between the GSR and GEM was examined cross-sectionally, we cannot conclude that increases in women's empowerment will lead to an increase in the female-to-male smoking prevalence ratio. is hypothesis should be tested by examining the correlation between women's empowerment and the GSR over time, provided suitable and comparable country-level indicators of both variables have been generated. Second, because this study was ecological in nature (i.e. focused on the relation between GEM and GSR among groups of countries), no inferences can be drawn about a speci c woman's level of empowerment and the chances that she will take up smoking.
We did not control for several potential confounders. Educational level, for instance, is a potential confounder, but adjusting for the many ways in which it can relate to the GEM is not possible. e United Nations Educational, Scienti c and Cultural Organization (UNESCO) lists lower priority for girls' education, early marriages and pregnancies, and high opportunity costs/lower rate of return as just some of the factors a ecting gender equality in education. 32 e female employment rate is another possible confounder that would have entailed a similar problem. e extent to which public health regulation and government support for tobacco control exist in a given country can also in uence smoking behaviour, along with women's empowerment. However, di erences in men's and women's smoking rates cannot be explained by regulation alone.
Finally, the GEM measure has been criticized for several reasons. Although it captures certain aspects of women's empowerment, it fails to account for informal economic and political empowerment (i.e. informal work, political involvement at the community level). [33][34][35][36] Klasen has also identi ed and discussed at length several shortcomings in the implementation of the components of the GEM and its calculations, including some that may make it di cult for poor countries to achieve high scores on the income component of the GEM. 35

Conclusion
Women's empowerment must continue, but does the bad necessarily have to follow from the good? Will increases in women's empowerment inevitably be accompanied by increases in women's smoking prevalence rates? e ndings of this study provide an empirical basis for further exploring the nature of the relation between women's empowerment and women's smoking rates worldwide. More importantly, they highlight the need to act quickly to curb smoking among women by implementing tobacco control policies as outlined in the WHO FCTC and its guidelines. ■ Вывод Остается наблюдать, может ли прогресс в области расширения гендерных прав и возможностей происходить без сопутствующего роста распространенности курения среди женщин. В странах, где права и возможности женщин расширяются, необходимо применять жесткие меры по борьбе с табаком.