Until this century, tobacco use in Western society had been predominantly a male preserve. Most tobacco was smoked in pipes, or rolled into cigarettes by hand, but the new factory made cigarettes, developed in the late 19th century, soon became commonly used. The advent of the First World War accelerated their popularity, as they were comparatively convenient to use at the Front.(3)
The woman who dared to smoke in public, even at the time of the War, risked social disapprobation. Early sightings of a woman with a cigarette apparently attracted outrage,(3) the adoption of a masculine behaviour signalling loose morals.(3,4) The social changes of the 1920s brought women a greater degree of freedom, and smoking became openly practised among the young and fashionable.(3,5) During the 1920s in the United States, women in colleges commonly smoked as an explicit statement of their equality with men (although more recent research has shown that the connection between female smoking and views on sexual equality is no longer consistent).(4)
Through the 1920s and 1930s more women entered the workforce, and having their own income, were better able to afford to smoke. Around this time, cigarette advertising also became more directly aimed at women (see Section 16.6 below), which doubtless increased smoking's desirability and acceptability to women.
The outbreak of the Second World War in 1939 brought many societal changes. Smoking among women became more widespread, probably due to the leap in numbers of women in both the civil and military workforces.(3) By the end of the Second World War, 26% of adult women smoked, around the same prevalence shown by the most recent national surveys (see Table 16.1 below). By contrast, men's rates have more than halved since the Second World War.
The comparative resistance of women's smoking rates to change has attracted much attention. Why did they not enter a significant downturn in the early 1960s, when the medical evidence about smoking became widely publicised? A number of theories have emerged. First, most early publicity concerning the health effects of smoking appeared in newspapers and magazines, more likely to be accessed by educated white males. It was not until following decades that health messages about smoking appeared on television or in campaigns directed at other population subgroups.(6)
Further, because men had smoked for longer, more heavily and in far greater numbers than women, ill health was most often observed among them. This gave rise to the fallacy that women were somehow immune to the effects of cigarettes, a myth no longer sustainable in the light of disease trends among women.(5) As has been said before, 'women who smoke like men, die like men who smoke'.(7,8)
Not surprisingly, the early disparity in disease trends meant that anti-smoking education was typically directed at the male smoker, and was probably more salient to men, given that they were more likely to know someone of their own sex who had died or been otherwise affected by smoking.(4) This may have distorted some women's perceptions of their own disease risk, and contributed to maintenance of smoking.
Another factor for some women in sustaining their smoking is the well documented effect of smoking on bodyweight. Nicotine affects body metabolism and food intake, meaning that smokers weigh on average 3 kg less than non-smokers(9) (see also Chapter 12, Section 7). Because of societal pressure for women to be slim, women may be more likely to take up and persist with smoking as a means of achieving this goal. On the other hand, fitness may be important to more men than women, who may therefore be more likely to quit smoking to enhance physical performance.(4)
A more general theory describes the way that in our society, men have traditionally adopted 'innovative' behaviour before women have, due to their typically higher education, affluence, and social status. Thus men adopted cigarette smoking around 20 years before women did, and as smoking became publicly recognised as dangerous, also adopted the innovation of stopping smoking before women. Adoption of innovations is stratified not only by sex, but by education and affluence within gender groups: this theory would also explain why across both genders, smoking is more prevalent among the less educated and the lower socioeconomic groups(4) (see also Chapter 1).
Another factor to consider is the role of tobacco advertising (discussed in more detail in Section 16.6 below). As women became increasingly important to the tobacco industry, they were the target of aggressive promotional activity. It is likely that for many women, tobacco advertising created an illusion of desirability for smoking and encouragement to continue smoking, and has undermined health education campaigns. This effect can be expected to diminish now that most avenues of tobacco advertising have been blocked.
Given the complexity of smoking behaviour, it is likely that all of these elements have had some degree of influence on women's smoking habits. What is most encouraging, however, is recent Australian research which shows that women and men are equally likely to intend to quit,(10,11) and to do so successfully.(12)
Women in many developing countries are now seen by the tobacco industry as a vast, previously untapped market. Traditionally non-smoking, in many cases for cultural reasons, these groups are increasingly being targeted by tobacco companies.(13,14)