Rethinking Tobacco Control: The Need for Gender-Responsiveness in Tobacco Control Measures

KUALA LUMPUR, Malaysia — Tobacco use among adults, adolescents, and vulnerable groups of all genders is a preventable cause of all non-communicable diseases (NCDs). Sex-disaggregated data shows clear differences in tobacco use and exposure between men and women. These differences are underpinned by gender constructs, affecting the norms, attitudes, values, and behaviours of boys, men, girls, women, and diverse groups of gender. A lack of a gendered approach in tobacco control – being gender-neutral, or worse, gender blind – allows the manifestation of harmful gender stereotypes, norms, and power structures that perpetuates gender inequalities and have unintended consequences in relation to the use, exposure, and tobacco control measures.

Currently, an estimated 6.5 million deaths among men and 1.5 million deaths among women, globally, are attributed to tobacco use, and of the 1.2 million deaths due to secondhand smoking, a majority (64%) are among women. The rising use of smokeless tobacco among women, particularly across Asia, which is often associated with tobacco farming and livelihoods, is also of grave concern. To make matters worse, the emerging exploitation of gender norms and harmful stereotyping by the tobacco industry is contributing to the prevalence of smoking initiation among boys and girls. Studies have reported that men and women take up smoking for various reasons. Smoking initiation for boys and men is often associated with perceptions of masculinity, power, and independence, whilst smoking for girls and women is associated with perceptions of sexual attractiveness, body image, and empowerment. Targeting the LGBT+ community through predatory social and political campaigns and sponsorship, such as HIV/AIDs campaigns and pride parades, has also increased smoking prevalence among LGBT+ adults.

More recently and in the wake of the COVID-19 pandemic, the stress of lockdowns, income insecurity, and isolation have increased the use and exposure to tobacco, particularly secondhand smoking. Studies reveal that whilst men and women may have been motivated to quit tobacco during the pandemic, the probability of quitting declined due to the impact on health-seeking behaviours. In some contexts, the increase in smoking (and alcohol consumption) during the COVID-19 pandemic was also associated with escalated domestic violence, substance abuse, and high mental stress, particularly among male partners.

Health systems’ response and Tobacco Control

Undoubtedly, there is a need for a stronger consideration of gender equality in the WHO Framework Convention on Tobacco Control (FCTC) framework, and greater political will to enforce harsher laws on tobacco bans and taxation related to advertising, messaging, and packaging. These considerations will play a critical role to overturn some of the destructive gender-biased practices of the tobacco industry. Beyond this, however, health systems’ responses must consider ways to become more gender-responsive to address the underlying gender constructs in tobacco control. Being gender-responsive in tobacco control requires health systems to consider gender-specific differences, needs, priorities, and power structures, and make efforts to provide equal opportunities and participation in tobacco control policies and programs, that benefit all gender groups. In fact, a gender-responsive approach to tobacco control has the dual benefit to safeguard and transform the health and wellbeing of populations, particularly vulnerable and marginalized groups.

First, a gender-responsive approach to tobacco control can help to reduce the exposure to tobacco-attributable diseases such as lung cancers and cardiovascular diseases, and prevent premature mortality amongst the most vulnerable populations, particularly across low-and middle-income countries. Yet current interventions in terms of tobacco cessation programs offered by health systems remain gender-neutral and lack targeted approaches to providing quality, safe and accessible services. Evidence suggests, for example, that while women and LGBT+ individuals have higher attempts of quitting over their lifespan, the rate of success in quitting is significantly lower compared to straight men. These differences in quitting rates are associated with women being more likely to experience cost barriers to nicotine replacement therapies, relapse after childbirth, geographical (accessibility) barriers to government-funded cessation programs in rural areas, lack of health insurance coverage for LGBT+ individuals, and poor acceptance and stigmatization.

Recognizing some of these gendered barriers, some countries have considered targeted, gender-specific tobacco control interventions. These multi-level interventions may offer promising examples that target tobacco control through a gender-responsive approach. For example, the gender-specific tobacco cessation program in Hong Kong implemented a three-phase project that helped women to quit smoking. The project began with the establishment of the Women Against Tobacco Taskforce (WATT), which mobilized 14 women’s groups that helped to understand the needs, attitudes/ values, and behaviours of local women in relation to tobacco use and available cessation programs. This was followed by the development of a gender-specific training and counselling program, which was designed by female nurses and delivered by trained volunteers who were a part of the WATT. Additionally, recognizing women’s reluctance (due to cultural stigmatization and cost barriers) to (physically) access tobacco cessation clinics, the project set up quitting hotlines which found increases in women’s likelihood of seeking advice, higher quit rates, and lower reuptake rates.  Such a multi-level intervention illustrates how a gender-responsive approach by the health system, in collaboration with feminist community groups, can help identify factors associated with tobacco use and inform targeted, gender-specific interventions.

Second, a gender-responsive approach can help reduce unintended consequences related to the use, exposure, and control measures of tobacco. Current tobacco control measures, including gender-biased messaging and advertising, and tobacco control interventions by health systems reinforce the existing harmful gender norms and stereotypes. Whilst anti-tobacco campaigns like ‘If you smoke, your future’s not pretty’ in Queensland, Australia, may try to overrule the body image messaging by the tobacco industry, a focus on young girls’ appearance, in fact, reinforces the harmful stereotyping and gendered expectations of girls and women. Instead, campaigns should focus on ways to transform and promote positive gender constructs whilst also educating populations on the harmful impacts of tobacco. Whilst the campaign may not yet have a gendered approach (i.e., target specific gender groups), the ‘Cigarettes are damaging your body’ campaign by the Ministry of Health of the Government of Indonesia, is a powerful example of how an anti-tobacco smoking campaign could be used as an opportunity to educate populations about the harmful effects of cigarettes and e-cigarettes, the addictiveness of nicotine, and consequential diseases (e.g., lung cancers). Health-promoting anti-tobacco campaigns can challenge people’s perception of social norms, alter behaviour, and most importantly, shift the focus away from harmful gender stereotyping or reinforcing unequal gender norms.

Tobacco control programs across the world that target tobacco smoking in women also predominantly focus on pregnant women, aiming to target women’s smoking and the intergenerational effects of tobacco. Yet such programs reinforce women’s reproductive role and neglect to capture adolescent girls and women who are not pregnant or mothers. Not only that, but some studies also reveal that smoking patterns in pregnant women are associated with toxic masculinity and gendered power dynamics, which have unintended knock-on effects within households, including intimate partner violence (IPV). For example, data from the U.S. shows that women who experienced IPV one year prior to or during pregnancy had a significantly greater prevalence (37.5% among abused women versus 16.1% for non-abused women) of smoking during pregnancy, and were less likely to quit smoking.

Instead, health-promoting initiatives such as the Families Controlling and Eliminating Tobacco research program in Canada, offer promising approaches on how to promote healthy masculinity and shift the onus of tobacco control put on vulnerable individuals (i.e., pregnant women). The project supports men’s tobacco cessation by promoting positive masculine ideals of fatherhood and positive role modelling. Such interventions demonstrate the possibility of not only helping the successful tobacco quitting of male partners, but also reducing secondhand smoking at home, transforming power structures, and reducing unintended consequences (e.g., domestic violence) due to tobacco use.

Any efforts towards addressing gender inequalities, unequal gender power relations, and harmful gender norms in tobacco control will have negative pushback, both socially and politically. However, rethinking tobacco control with a gender-responsive approach gives an opportunity to break down these inequalities and disempowerment, and to better invest in tobacco control measures that are protective and equitable for all genders.