This report is a supplement to ASH's Tobacco Explained research project which is a survey of thousands of tobacco industry documents that have been revealed in the course of litigation in the United States. For this supplement we have examined the documents that describe the tobacco industry's approach to women. Tobacco Explained is available on the ASH web site at location http://www.ash.org.uk/papers/tobexpld.html

This supplement was the idea of Jean King at the Cancer Research Campaign as a contribution to the Tobacco and Women: understanding the past, changing the future conference held in Paris on 23rd and 24th November 1998. The research was funded by Cancer Research Campaign and was undertaken by ASH.

The work is comprised of summary information and seven sections, each one dealing with a different aspect of the tobacco industry's attempt to target and develop the female market. Section one deals with general marketing strategy; sections two to four deal with the targeting of different ‘segments’; section five looks at the low tar cigarette; section six exposes the industry's attempts to brush aside the health issue, and section seven looks at the targeting of women in the third world.

" … Women smokers are likely to increase as a percentage of the total. Women are adopting more dominant roles in society: they have increased spending power, they live longer than men. And as a recent official report showed, they seem to be less influenced by the anti-smoking campaigns than their male counterparts.

"All in all, that makes women a prime target as far as any alert European marketing man is concerned. So, despite previous hesitancy, might we now expect to see a more defined attack on the important market segment represented by female smokers?"¹

The trade journal Tobacco Reporter gives its vision of the future. (1982)

In 1960, 40% of women in Britain smoked cigarettes. For men the smoking rate was 60%. By the mid-1990s, the rate for men had dropped by nearly half to 32%, while the rate for women had dropped by just one quarter to 30%². In the 1990s, forty years after evidence of the link between smoking and lung cancer first came to light, the rate of female smoking has almost caught up with that of men, (the USA, Australia and other European countries show similar trends). Among teenagers the smoking rate for girls is rising fastest: in some countries they are now out-smoking their male counterparts for the first time in history.

Although still thought of by many as male diseases, rates of lung cancer and heart disease among women have risen to mirror their smoking rate. Women enjoy no mysterious immunity: in some parts of the UK lung cancer now kills more women than any other cancer. Heart disease is Britain's biggest overall killer of women.

The causes of these trends are complex. Factors such as the changing position of women in society, their increasing social and economic independence and the past failures of the anti-smoking lobby and health promotion agencies to present smoking and its effects as a problem relevant to women need to be taken into account.

The key cause, though, is without doubt the vast effort with which the tobacco industry has set out to target women with its products. A specific campaign has aimed to increase the market for cigarettes among women, partly in response to falling demand among men, but also simply to expand the market.

The tobacco industry spends vast sums of money each year persuading people to take up or continue smoking. In its own words, the industry is "a monster which has to be fed"³. The industry sees women as a territory to be conquered and a large portion of this total expenditure is aimed in their direction. Statistics on cessation, uptake and disease reflect this effort.

Tobacco industry statements, and documents subpoenaed in a series of American legal cases, show how:

• The industry's strategy is to segment the market so it can better respond to the "wants and needs of women" - i.e. so it can target its products more effectively.
• The industry has conducted a vast amount of research on women to enable more effective targeting. The industry feels that women are less influenced than men by anti-smoking campaigns, i.e. that once they've started they find it harder to give up.
• The industry views underage women as part of its target market and has aimed products at these women.
• As part of a policy of segmenting the market the industry has developed products aimed specifically at black women and women on low incomes.
• Aware that women are generally more concerned than men about health issues, the industry has largely aimed the low tar brands at women, in an effort to stop women quitting. It promotes these products as less dangerous despite its own evidence which shows that the health benefits are extremely low or zero.
• The industry has attacked and attempted to refute all the health effects that smoking has on women, both those specific to women and those which affect both sexes. It has fostered the idea that the big three smoking diseases - lung cancer, heart disease, and chronic bronchitis (chronic pulmonary obstruction) - are male diseases and that purely because of gender, women may be less at risk.
• The industry has denied and countered evidence that smoking can affect the foetus.

• In UK it is estimated that around 41,000 women die prematurely each year as a result of smoking⁴. Across EU countries the figure is 106,000⁵, and for the world the total is estimated at around 500,000 deaths per year⁶.
• Due to increasing levels of smoking among women, the figure for deaths among women world-wide is set to double by 2020⁷.
• The smoking rate among UK secondary schoolgirls is on the rise and in some age groups the figure is higher than that for boys⁸.
• Women are affected by the main smoking-related killers in the same way as men, but are also at risk of developing a number of gender-specific problems, including cancer of the cervix, a range of problems relating to reproductive health, and osteoporosis⁹.
• The majority of female smokers would like to stop smoking. In 1994, 68% of women who smoked said that they would like to give up smoking altogether¹⁰. More than 80% of women who smoke have tried to quit at some time, especially women aged between 30-49¹¹.
• Across the third world as a whole the smoking rate for women is estimated at around 7%¹², a figure which is fuelling tobacco industry attempts to target these women.

There are no definitive figures on how much the tobacco industry spends world-wide each year on promoting its products. However, some idea can be gained by looking at the figure for a small country like Britain - which ASH estimates to be over £100 million per year¹³. A large portion of this is specifically targeted at women, while much tobacco advertising targeted at men, or which is non-gendered, also has a powerful effect. For instance, Marlboro, promoted as male brand, is the most commonly smoked cigarette among teenage girls in the USA.

Industry efforts to target women are there for all to see. Since the introduction of Virginia Slims in 1968, there has been an explosion of female-only brands. From free introductory samples to the sponsoring of women's tennis, women are - as the industry says - under 'attack'. In the third world, where restrictions are more lax, the industry sponsors raves and discos in which people (often young girls) are employed to hand out free cigarettes to girls and young women.

Smoking rates among young women in countries such as the UK, the USA and Australia show that more than any other group, female teenagers are not responding to public health messages. The smoking rates among these groups is either increasing or decreasing more slowly than in any other group²⁵.

The industry has repeatedly claimed that it does not target people under the age of eighteen. It assures us that its marketing is aimed at persuading those who already smoke to switch brands. Its own documents, however, show that the industry sees young women as a growth area and that it is targeting them accordingly.

Smoking rates follow underprivilege like a shadow, and racial underprivilege is no exception. Statistics show that black people living in a society dominated by whites tend to have a higher smoking rate than their white counterparts. In Canada, only 10% of female university graduates smoke, compared with 40% of unemployed women and 73% of Inuit women. Maori women have the highest rate of lung cancer of any group in the world. In America, rates of lung cancer have increased faster among black women than among white women.

For the tobacco industry, unemployed and low income women represent another market 'segment'. The rate of smoking uptake in this group is higher than for middle class women.

'Lights' are smoked by more women than men. Half (48%) of women smokers in the European Union smoke 'lights', while only one third (32%) of male smokers smoke 'lights'. The use of 'light' cigarettes increases with age. In the critical at-risk 45-64 age group, 60% of women smokers smoke 'lights' but only 33% of men smokers⁴⁴.

In the 1960s, awareness of the cancer risk of smoking became much more widespread. People started to worry about the health effects of smoking and studies show that women were more likely to worry about their health than men. The industry was also worried - worried that people would start to give up smoking. In response, manufacturers developed the 'low tar cigarette', which was promoted not as healthier (to brand one cigarette as healthy would be to admit that the others posed health risks), but as 'smooth', 'mild', 'cool' and even 'refreshing'.

The new cigarettes were targeted largely at women, and as had happened with the filter, women became the majority of users - in 1983, three times as many women were smoking lights in the UK⁴⁵. How many women would have given up smoking had it not been for this 'softer' option we will never know. What we do know is that the low tar cigarette is part of a strategy to stop or delay smokers from quitting. We know that due to the way the measurements of tar are carried out and the way people smoke, the health benefits of these supposedly 'low tar' cigarettes are negligible or zero.

We also know that certain, previously rare types of lung cancer (adeno-carcinomas) are on the increase. This type of cancer afflicts the tiniest airways of the lungs and has been linked with the smoking of light and ultra light cigarettes and smoker compensation⁴⁶. (Smoker compensation is the drawing of smoke more deeply into the lungs to sustain nicotine uptake from cigarettes that would otherwise deliver less nicotine.) The increased incidence is borne mainly by women as they constitute the majority of lights smokers. For some teenage girls, lights work in the opposite fashion - the cigarettes serving as a starter before they move on to 'stronger' cigarettes, once nicotine addiction is established. Whether these cigarettes act as a starter, or prevent people quitting, the marketing of the low tar cigarette constitutes one of the biggest and most lethal health scandals of our time.

Tobacco smoke does not discriminate. Lung cancer, heart disease, and chronic bronchitis end the lives of up to 50% of smokers, irrespective of whether they inhabit a female or male body. However there are a number of serious health effects specific to women.

It is estimated that 29% of deaths from cervical cancer are caused by smoking⁵¹. Smoking and taking the pill in combination can increase the risk of heart disease by up to ten times⁵². Smoking while pregnant can have serious effects on the health of the baby, and in countries where women's smoking rates are low in comparison to men's, passive smoking disproportionately affects women. (Although smokers themselves are the most exposed to second hand smoke, this is not encompassed by the term passive smoking).

All these dangers have been challenged and denied by the tobacco industry which, in a twisted Herculean effort, always attempts to put profit before public health. As is clear in the following extracts, the industry has also attempted to fuel the myth that women are somehow immune to what have been viewed largely as male diseases - lung cancer and heart disease.

In first world countries, smoking rates among women are declining despite the increasing rates among some groups of teenage girls. In third world countries, in which 80% of the world’s population lives, the smoking rate among women is fast on the increase. Between 1970 and 1994, per capita consumption of cigarettes fell by 10% in first world countries while rising 67% in third world nations. By 2030, smoking-related deaths in the third world will have risen a staggering 600% - from one million to seven million deaths per year.

The current uptake of smoking by women will double their death rate by 2020 and could lift the rate of smoking from the current 7%, to 20% by 2024. This preventable epidemic is to a large degree being exported by western companies, which are facing tighter restrictions on advertising and general concerns about the health effects of smoking, which are reducing the cigarette market.

The WHO estimates that, overall, the smoking rate for women in third world countries is around 7% compared with 48% of men. Not surprisingly, women and children are the main target for companies attempting to create new markets. Evidence shows that the companies are using promotional methods illegal in their own countries to target these groups.

China is a particularly interesting case: smoking prevalence among women is among the lowest in the world, and among young women has fallen to just 1%⁶⁰. For the tobacco companies, this probably represents the single largest marketing opportunity in the world. That marketing opportunity also represents the single largest threat to public health in the world.