WOMEN’S HEALTH FROM A WOMAN’S POINT OF VIEW

Jane Sprague Zones, Ph.D.

SMOKING WHY DO WE START? WHY DON’T WE STOP?

moking-related diseases are major causes of death in women, S yet they receive little attention from professionals or in the popular press. Because the interests of the tobacco industry make public debate and education about smoking cessation difficult, continuing education professionals have a particular responsibility to raise health professionals’ awareness of the issues involved in smoking for women.

Lung cancer will soon overtake breast cancer as a killer of women in the United States. The rise of lung cancer as a leading cause of death in women reflects the increase in the number of women who have taken up smoking over the past two genera- tions. The lung cancer rate for women has risen 500% in the last 25 years (1). About 85% of lung cancers are attributable to smoking (2), an association which virtually no one except those with vested interest in tobacco sales disputes any more.

Lung cancer is not the only health-related consequence of smoking for women:

Women smokers have more difficulty becoming pregnant. Pregnant women who smoke are more likely to have spon- taneous abortions, give birth prematurely, have stillbirths, ex- perience complications in delivery, and have smaller babies. Children of smokers are more likely to fall prey to respiratory diseases and sudden infant death syndrome (SIDS). Women who smoke and use estrogen-containing oral contra- ceptives have ten times (some reports say up to forty times) the chance of having a heart attack or damaging the blood vessels, compared to women who neither smoke nor use the Pill (3). Smokers’ lives are shortened an average 5% minutes per cig- arette smoked (4) . Smoking kills an estimated 340,000 persons each year through cancer, heart disease and emphysema, cum- ulatively more than all the U.S.’s wars and traffic accidents (5). Although evidence is not conclusive, there are indications that “second-hand smoke” (that inhaled by nonsmokers in

MOBIUS Volume 3, Number 4 00 0 1983 by The Regents o f the University of California

the presence of smokers) is also linked to serious health consequences (6).

Who Smokes About one of every three adult women in the U S . smokes reg- ularly. Although the proportion of smokers has declined in recent years, there has been a significant increase in the number of women who smoke, especially young women who start smoking in their teens. In 1979, for the first time more female adolescents than male adolescents smoked (7).

Not only are more women smoking these days, but they are smoking more heavily. Whereas the number of cigarettes smoked by men has risen only a small amount in the past generation, women are smoking nearly two-thirds more cigarettes a day than they did in the late 1950’s.

Why Do Women Smoke? In The Ladykillem- IWy Smoking b a Feminist Issue (8), Bobbie Jacobson examines the motivations for women’s smoking, com- bining descriptions of published research results with anecdotal case evidence. Jacobson makes a strong case that it is not women’s liberation that has resulted in the increase of women smokers (feminists show up proportionately the same in smoking and non-smoking groups), but rather women’s oppression.

Pointing out that smoking is heaviest among those at the lower end of the social class scale and among racial minorities, Jacobson focuses upon nurses as a group whose oppressive work situation appears to be related to smoking (pp. 50-52). Nurses have higher rates of smoking than any other group of health professionals. Nurses also have higher rates of mental illness than women in most other occupations, which Jacobson and others ascribe to the combination of stressful work content combined with lack of control over work activities. Add to this the class differences between nurses and physicians, and the long periods ofboredom broken by episodic crises, and “smoking becomes one of the few ways a nurse can relieve her boredom or frustration without leaving the ward” (p. 52).

I . . the most striking difference.. . found between male and female smok ers was that the women tended to smoke much more to reduce their negative feelings than the men who, in turn, were more likely to indulge in habitual smoking” (p. 28).

Jacobson relines this observation with a number of personal his- tories: “They smoke not to accompany expressions of frustration or anxiety, but instead of expressing these feelings” (p. 32).

These social-psychological explanations for women’s taking up and continuing smoking in the face of massive evidence of its

In one cited study, with more than 2000 subjects,

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88 MOBIUS destructive potential are only part of the picture. Women, with their increasing purchasing power, have been targeted by the tobacco industry as an important growing market. Cigarette ads make up between 10 and 16 percent of all advertising in women’s magazines, financed by the big six tobacco companies, who spend more than $1 billion a year on cigarette advertising (9).

The importance of this source of revenue affects women’s magazines content related to smoking. In a survey of twelve major women’s magazines between 1967 and 1979, Elizabeth Whelan and her associates found that these magazines ran articles on cigarette smoking very rarely, if at all (10). At the time of the study, Good Housekeeping was the only one of the dozen which did not accept cigarette advertising. (Seventeen, however, also does not carry such ads) (10). A 1978 survey in the Columbia Journalism Review found not one comprehensive article about the dangers of smoking in the previous seven years in any major national magazine that accepts cigarette advertising ( 1 1 ).

When Mother Jones featured a cover story on smoking, adver- tising, and the tobacco industry in January 1979, it lost over $100,000 in cancelled ads from two of its tobacco clients. (Mother Jones also lost $18,000 from another account after pub- lishing a tobacco story the previous year) (12).

Why Don’t W e Stop? Although women are as conscious of smoking’s hazards as men, and make as many efforts to quit, they are less successful than men at kicking the habit within every age and occupational group. Women interviewed about their inability to successfully give up smoking express more feelings of addiction and dependency than do men, who claim control over their habit, even after recidivism. This reflects a pattern of powerlessness and passivity observed in women from the youngest ages in all manner of health behavior. 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 (8, p. 44).

U.S. government action to encourage smoking cessation and discourage assumption of the habit has proved inadequate. Until 1978, the federal government spent less than $1 million a year on preventive efforts against smoking (12). For a brief interlude, when former smoker and Secretary of HEW Joseph Califano (he quit his three-pack-a-day habit for his son on his son’s eleventh birthday) started a national campaign, this investment increased dramatically. But by 1981, the budget for the Office of Smoking and Health had been reduced again to $1.1 million. Some spec- ulated that Califano was prematurely removed from his position

by President Carter in large part because of his strong stand against tobacco (1 3).

For every U.S. death from lung cancer, the government spends about $1000 to support tobacco growing ($70 million a year) and $14 to educate the public about the dangers of smoking. For each lung cancer death, the tobacco industry spends $2857 on promoting cigarette smoking.

It is estimated that the direct health costs attributable to smoking in the US. were $8.2 billion in 1976, and the costs of lost production and wages were $19.1 billion. In spite of these financial and personal costs to U.S. taxpayers (not to mention $29.4 million in 1975 to include tobacco in the US. Food for Peace export program), Congress has not acted to eliminate tobacco price supports or regulate smoking in an effective manner (14). In California two propositions to create designated smoking and non-smoking areas in public places were defeated by a six percent margin in 1978 and 1980 after huge expenditures by four of the largest tobacco companies.

Part of the explanation for this inaction has been the power of the tobacco lobby. Most of the key figures in the House and Senate have close ties to tobacco-producing states or their rep- resentatives. The influence of this lobby in Congress and upon the public through the media is indeed impressive. Action on Smoking and Health (ASH), the anti-smokers’ lobby, is by com- parison weak, ill-financed, and not centrally organized to mount national campaigns.

What Can W e Do? Those involved in continuing education have a range ofoptions

for intervention in this important area. A number of community organizations, such as chapters of the American Lung Association, sponsor smoking cessation groups. Programs like these, which are as effective, and not nearly as costly as their proliferating private enterprise counterparts, can be combined with support groups and workshops to help people understand the external and internal forces that prevail upon them to engage in unhealthy behavior.

KRON-W, in San Francisco, last year obtained and aired twice a pirated video produced in Great Britain which features Marlboro- type “real” cowboys who are riding their last roundup on account of smoking-related disabilities. This is such a powerful analysis of the interplay between advertisfng and smoking behavior that it has been suppressed by the tobacco industry in the United States (12). Dr. Virginia Ernster, a Professor of Epidemiology at the University of California at San Francisco, presents an effective slide show highlighting the issue of how advertising induces women to smoke. Audio-visual aids such as these are particularly

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REFERENCES/FOOTNOTES

1. Unless otherwise noted, sta- tistics on smoking rates and health problems related to smok- ing are from The health con- sequences of smoking for women: A report of the surgeon general, US. Department of Health and Human services. 1980. 2. US. Department of Health

and Human Services. The health consequences of smoking- cancer: A report of the surgeon general, 1982.

ceptive use In relatlon to myo- cardial infarction. Lancet 1979;

4. Smoking and health, sum- mary and report of the Royal College of Physicians of London in relation In relatlon to cancer of the lung and other diseases, London: Pltman Medical, 1962.

3. Shaplro S, et al. Oral contra-

l(8119): 743-77.

90 MOBIUS

5. US. Department of Health and Human Servlces. Smoklng and health: A report of the sur- geon general, 1979 (The Callfano Report]. 6. Mahood G. Risks for a second

hand smoker, May 1979. Non- Smokers’ Rlghts Assoclatlon, Suite 426 A. 455 Spadlna Avenue, To- ronto, Ontario, M5S2G8, Canada. 7, Smoking among youth falls.

The Natlon’s Health; June 1979 7, 8. Jacobson 8. The ladyklilers-

why smoking Is a femlnlst Issue. New York The Contlnuum Publish- ing Company, 1982. 9. Dale KC. ACSH survey: Which

magazlnes report the hazards of smoking? ACSH (Amerlcan Council on Science and Health] News and Vlews, 1982: 3(3]: 1,

10. Whelan EM, et al. Analysis of coverage of tobacco hazards In women‘s magazines. Amerlcan Councll on Science and Health, 1995 Broadway, New York, NY 10023,1980. 11. Smith RC. The rnagazlnes’ smoklng habit. Columbia Journal- ism Revlew 1978: 16(5]. January/ February, 1978. 12. Blalr G. Why Dick can’t stop smoking. Mother Jones January 1979 30 ff. 13. Greenberg DS. Carter’s purge: The Callfano flle. N Engl J Med 1979; 301(8): 451-2. 14. Frledman M. Federal support against the publlc health. Public Citlzens’ Health Research Group, 2000 P Street, N.W., Washlngton, DC 20036.

8-10.

Jane Sprague Zones, Ph.D. Dr. Zones Is a Pew Postdoctoral Fellow in Health Policy at the Aging Health Pollcy Center and the lnstltute for Health Pollcy Studies at the Universlty of Cali- fornla at San Francisco.

appropriate in the context of continuing education courses and should have a solid impact upon participants.

Specific groups, such as nurses, can be targeted for special sessions involving work satisfaction, smoking, and personal as well as patient health behavior. Finally, a challenge for which continuing education would be particularly effective in creative change would be in the policy area. The increasing restriction of smoking in public places, such as educational and health insti- tutions, and the complex politics of the tobacco lobby, anti- regulatory sentiment, and overwhelming health costs are all significant issues worthy of our attention. 00