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Women and Smoking: Time for a Change
Clinical Oncology (2002) 14: 78–79 doi:10.1053/clon.2001.0016, available online at http://www.idealibrary.com on
Personal View Women and Smoking: Time for a Change DAVID CUMMINS Harefield Hospital, Middlesex, U.K. Received: 5 September 2001
The U.S. Surgeon General recently published a remarkable report on the health consequences of smoking for women [1]. The work of nine federal health officials, 11 editors, 62 authors, 88 reviewers, and 27 other contributors, the document runs to 700 pages and weighs an impressive 2.7 kg [2]. Central among its numerous disturbing findings is that between 1950 and 2000, death rates from lung cancer among white women in the United States increased by a staggering 600%. Cigarette smoking is now the leading cause of preventable death in U.S. women and results in loss of an estimated 2.1 million years of female life each year. What I found alarming, however, was the view expressed by Mr Tommy Thompson, secretary of the U.S. Department of Health and Human Services, on how the problem should be addressed. I had hoped that, by now, senior U.S. health officials would have accepted at least one inescapable fact: that as a means of reducing the prevalence of smoking in young women, traditional health education has been spectacularly ineffective. Young women know more about the risks of smoking than ever before but are taking up the habit in record numbers [1]. The need for a new approach is thus both urgent and overwhelming. Yet Mr Thompson is quoted as saying: ‘We must be aggressive in educating [teenage girls] that smoking is very addictive, harmful and lethal. [They] must know that once they start, it will be difficult to stop — and that the health risks are very real and costly.’ [2] This policy will fail — utterly — for one simple reason: young women are not concerned about their long-term future health. They never have been and they never will be. Adolescents believe they are almost indestructible [3]. They perceive that smoking-related diseases affect old people [4], and for the young, old age is as remote as Ancient Greece. Young women’s brains have evolved to focus not on longevity, but on reproAuthor for correspondence: Dr David Cummins MD FRCP FRCPath, Clinical Tutor, Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex UB9 6JH, U.K. Tel: 01895 823737 Ext 5875; E-mail: [email protected] 0936–6555/02/010078+02 $35.00/0
Accepted: 19 September 2001
duction. Thus, to be effective, antismoking strategies aimed at women must be rooted in sex, not risk of disease. From puberty onwards, women have a strong, biologically determined need to feel physically attractive [5]. This has long been recognised by the tobacco industry, which has continually sought to link smoking with glamour, sex appeal, and physical beauty [6,7]. The reality may be different. Several studies have shown that, on facial appearance alone, smoking causes a range of adverse effects, including premature wrinkling, loss of skin turgor, pallor, and in severe cases, flabbiness and greying of the facial skin [8–12]. Furthermore, these changes are reported to develop more frequently and at an earlier age in females than in males [8,12]. But from a health education perspective it is not evidence for these effects but the relationship between smoking and attractiveness that is important, and this remains largely undefined. Developing the sort of evidence-based propaganda that might stand any chance of changing young women’s attitudes to smoking will require exploration of two sensitive but crucially important issues: Do men perceive female smokers of reproductive age to be less physically attractive than nonsmokers? Does the knowledge that a woman of reproductive age smokes adversely affect male perceptions of her physical attractiveness?
Investigation of these issues would pose some major logistical challenges but, I believe, should be attempted nonetheless. What is required is a study in which a large number of heterosexual men subjectively rate, under controlled conditions, the physical attractiveness of a large number of white female smokers and nonsmokers (standardized facial photographs would suffice) aged between, say, 32 and 40 (an age range in which there has been sufficient time for the adverse cosmetic effects of smoking to develop but which is not too far removed from the age at which most women take up smoking). 2002 The Royal College of Radiologists
To increase the probability of obtaining a positive outcome, the female subjects could be heavily dichotomized: for example, recruitment could be restricted to women who have never smoked and those who have smoked an average of 15 cigarettes a day or more for at least 15 years. The study could be performed first in the absence and then (after a suitable time interval) in the presence of information about which of the women are smokers. The attractiveness ratings attained by the smokers could be compared with those attained by the non-smokers, and the ratings attained by the smokers before their smoker-status was revealed could be compared with those attained after it was revealed. (The analysis would, of course, need to establish whether and to what extent the ratings awarded by the smokerassessors differed from those awarded by the nonsmoker-assessors.) More important than the issue of study design, however, is this issue: if unequivocal evidence were obtained that cigarette smoking by women of reproductive age is significantly associated with physical unattractiveness (as judged by men), how should such information be used in antismoking health education programmes aimed at adolescent girls? I suggest that, to be successful, the mode of presentation would need to satisfy three main criteria. It would need to: Be indirect. Adolescents are by nature rebellious [13], and so direct approaches tend to produce the opposite of that intended. One way of achieving indirectness would be to target females by appearing to target males. Avoid reference to risk. For many adolescents, risk is part of what makes smoking exciting [13]. Young women should be encouraged to associate smoking with physical unattractiveness in the context of the present, not the (risk-laden) future. Influence young men as well as young women. Teenage girls will only be discouraged from smoking if they perceive that their habit renders them physically unappealing to (a large proportion of) the opposite sex.
This type of approach undoubtedly has weaknesses. Feminists will argue it is sexist, smokers will claim it victimizes smokers, others will think it politically incorrect. All will have a point, but the issue is far too important to allow such views to hold sway. Sceptics, of course, will argue that no educational strategy could seriously affect young women’s smoking behaviour, and they may be right. But before dismissing my proposal, sceptics should reflect on the following:
79
First, reducing the prevalence of smoking in young women will require major attitudinal change among both young women and young men; my suggested approach should be regarded as but one way of assisting that process. Second, because the scale of morbidity that smoking causes is so vast, any approach that is able to exert even a small effect in percentage terms would benefit large numbers of women at the population level. Third, what young men think about women who smoke matters to young women: in one survey [14], for instance, the belief that their boyfriend would like them to give up was what young women considered to be the factor most likely to get them to quit. Finally, there is no question that the desire to reproduce successfully can influence female smoking behaviour: women are more likely to give up smoking while pregnant than at any other time of life [15]. REFERENCES 1 Women and Smoking. A Report of the Surgeon General– 2001. US Department of Health and Human Services. (www.surgeongeneral.gov/library). 2 Charatan F. Lung cancer death rates rise 600% in US women. Br Med J 2001;322:752. 3 Bootzin RR, Bower GH, Crocker J, Hall E, eds. Psychology Today. An Introduction. 7th edn. New York: McGraw-Hill, 1991:598–604. 4 Elkind D. Children and Adolescents. New York: Oxford University Press, 1970. 5 Etcoff N. Survival of the Prettiest. The Science of Beauty. Little Brown and Company, 1999:57–71. 6 Albright CL, Altman DG, Slater MD, Macoby N. Cigarette advertising in magazines: Evidence for a differential focus on women’s and youth magazines. Health Educ Quarterly 1988;15:225–234. 7 Altman DG, Slater MD, Albright CL, Macoby N. How an unhealthy product is sold: Cigarette advertising in magazines, 1960–1985. J Communication 1987;37:95–106. 8 Ippen M, Ippen H. Approaches to a prophylaxis of skin aging. J Soc Cosmetic Chemists 1965;16:305–308. 9 Daniell HW. Smokers’ wrinkles. Ann Intern Med 1971;75:873–880. 10 Model D. Smokers’ faces: an underrated clinical sign?. BMJ 1985;291:1760–1762. 11 Kadunce DP, Burr P, Gress R, Kenner R, Lyon ZL, Zone JJ. Cigarette smoking: risk factor for premature facial wrinkling. Ann Intern Med 1991;114:840–844. 12 Ernster VL, Grady D, Miike R, Black D, Selby J, Kerlikowske K. Facial wrinkling in men and women by smoking status. Am J Public Health 1995;85:78–82. 13 Murray M. Smoking in childhood. In: Hart C, Bain J, eds. Child Care in General Practice. 3rd edn. London: Churchill Livingstone, 1989:144–154. 14 Mori Schools Omnibus — a survey of school children. MORI, London: 1996. 15 Barec L, MacArthur C, Sherwood M. A study of health education aspects of smoking in pregnancy. Int J Health Educ 1976;19(Suppl 1):1–17.
Personal View Women and Smoking: Time for a Change DAVID CUMMINS Harefield Hospital, Middlesex, U.K. Received: 5 September 2001
The U.S. Surgeon General recently published a remarkable report on the health consequences of smoking for women [1]. The work of nine federal health officials, 11 editors, 62 authors, 88 reviewers, and 27 other contributors, the document runs to 700 pages and weighs an impressive 2.7 kg [2]. Central among its numerous disturbing findings is that between 1950 and 2000, death rates from lung cancer among white women in the United States increased by a staggering 600%. Cigarette smoking is now the leading cause of preventable death in U.S. women and results in loss of an estimated 2.1 million years of female life each year. What I found alarming, however, was the view expressed by Mr Tommy Thompson, secretary of the U.S. Department of Health and Human Services, on how the problem should be addressed. I had hoped that, by now, senior U.S. health officials would have accepted at least one inescapable fact: that as a means of reducing the prevalence of smoking in young women, traditional health education has been spectacularly ineffective. Young women know more about the risks of smoking than ever before but are taking up the habit in record numbers [1]. The need for a new approach is thus both urgent and overwhelming. Yet Mr Thompson is quoted as saying: ‘We must be aggressive in educating [teenage girls] that smoking is very addictive, harmful and lethal. [They] must know that once they start, it will be difficult to stop — and that the health risks are very real and costly.’ [2] This policy will fail — utterly — for one simple reason: young women are not concerned about their long-term future health. They never have been and they never will be. Adolescents believe they are almost indestructible [3]. They perceive that smoking-related diseases affect old people [4], and for the young, old age is as remote as Ancient Greece. Young women’s brains have evolved to focus not on longevity, but on reproAuthor for correspondence: Dr David Cummins MD FRCP FRCPath, Clinical Tutor, Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex UB9 6JH, U.K. Tel: 01895 823737 Ext 5875; E-mail: [email protected] 0936–6555/02/010078+02 $35.00/0
Accepted: 19 September 2001
duction. Thus, to be effective, antismoking strategies aimed at women must be rooted in sex, not risk of disease. From puberty onwards, women have a strong, biologically determined need to feel physically attractive [5]. This has long been recognised by the tobacco industry, which has continually sought to link smoking with glamour, sex appeal, and physical beauty [6,7]. The reality may be different. Several studies have shown that, on facial appearance alone, smoking causes a range of adverse effects, including premature wrinkling, loss of skin turgor, pallor, and in severe cases, flabbiness and greying of the facial skin [8–12]. Furthermore, these changes are reported to develop more frequently and at an earlier age in females than in males [8,12]. But from a health education perspective it is not evidence for these effects but the relationship between smoking and attractiveness that is important, and this remains largely undefined. Developing the sort of evidence-based propaganda that might stand any chance of changing young women’s attitudes to smoking will require exploration of two sensitive but crucially important issues: Do men perceive female smokers of reproductive age to be less physically attractive than nonsmokers? Does the knowledge that a woman of reproductive age smokes adversely affect male perceptions of her physical attractiveness?
Investigation of these issues would pose some major logistical challenges but, I believe, should be attempted nonetheless. What is required is a study in which a large number of heterosexual men subjectively rate, under controlled conditions, the physical attractiveness of a large number of white female smokers and nonsmokers (standardized facial photographs would suffice) aged between, say, 32 and 40 (an age range in which there has been sufficient time for the adverse cosmetic effects of smoking to develop but which is not too far removed from the age at which most women take up smoking). 2002 The Royal College of Radiologists
To increase the probability of obtaining a positive outcome, the female subjects could be heavily dichotomized: for example, recruitment could be restricted to women who have never smoked and those who have smoked an average of 15 cigarettes a day or more for at least 15 years. The study could be performed first in the absence and then (after a suitable time interval) in the presence of information about which of the women are smokers. The attractiveness ratings attained by the smokers could be compared with those attained by the non-smokers, and the ratings attained by the smokers before their smoker-status was revealed could be compared with those attained after it was revealed. (The analysis would, of course, need to establish whether and to what extent the ratings awarded by the smokerassessors differed from those awarded by the nonsmoker-assessors.) More important than the issue of study design, however, is this issue: if unequivocal evidence were obtained that cigarette smoking by women of reproductive age is significantly associated with physical unattractiveness (as judged by men), how should such information be used in antismoking health education programmes aimed at adolescent girls? I suggest that, to be successful, the mode of presentation would need to satisfy three main criteria. It would need to: Be indirect. Adolescents are by nature rebellious [13], and so direct approaches tend to produce the opposite of that intended. One way of achieving indirectness would be to target females by appearing to target males. Avoid reference to risk. For many adolescents, risk is part of what makes smoking exciting [13]. Young women should be encouraged to associate smoking with physical unattractiveness in the context of the present, not the (risk-laden) future. Influence young men as well as young women. Teenage girls will only be discouraged from smoking if they perceive that their habit renders them physically unappealing to (a large proportion of) the opposite sex.
This type of approach undoubtedly has weaknesses. Feminists will argue it is sexist, smokers will claim it victimizes smokers, others will think it politically incorrect. All will have a point, but the issue is far too important to allow such views to hold sway. Sceptics, of course, will argue that no educational strategy could seriously affect young women’s smoking behaviour, and they may be right. But before dismissing my proposal, sceptics should reflect on the following:
79
First, reducing the prevalence of smoking in young women will require major attitudinal change among both young women and young men; my suggested approach should be regarded as but one way of assisting that process. Second, because the scale of morbidity that smoking causes is so vast, any approach that is able to exert even a small effect in percentage terms would benefit large numbers of women at the population level. Third, what young men think about women who smoke matters to young women: in one survey [14], for instance, the belief that their boyfriend would like them to give up was what young women considered to be the factor most likely to get them to quit. Finally, there is no question that the desire to reproduce successfully can influence female smoking behaviour: women are more likely to give up smoking while pregnant than at any other time of life [15]. REFERENCES 1 Women and Smoking. A Report of the Surgeon General– 2001. US Department of Health and Human Services. (www.surgeongeneral.gov/library). 2 Charatan F. Lung cancer death rates rise 600% in US women. Br Med J 2001;322:752. 3 Bootzin RR, Bower GH, Crocker J, Hall E, eds. Psychology Today. An Introduction. 7th edn. New York: McGraw-Hill, 1991:598–604. 4 Elkind D. Children and Adolescents. New York: Oxford University Press, 1970. 5 Etcoff N. Survival of the Prettiest. The Science of Beauty. Little Brown and Company, 1999:57–71. 6 Albright CL, Altman DG, Slater MD, Macoby N. Cigarette advertising in magazines: Evidence for a differential focus on women’s and youth magazines. Health Educ Quarterly 1988;15:225–234. 7 Altman DG, Slater MD, Albright CL, Macoby N. How an unhealthy product is sold: Cigarette advertising in magazines, 1960–1985. J Communication 1987;37:95–106. 8 Ippen M, Ippen H. Approaches to a prophylaxis of skin aging. J Soc Cosmetic Chemists 1965;16:305–308. 9 Daniell HW. Smokers’ wrinkles. Ann Intern Med 1971;75:873–880. 10 Model D. Smokers’ faces: an underrated clinical sign?. BMJ 1985;291:1760–1762. 11 Kadunce DP, Burr P, Gress R, Kenner R, Lyon ZL, Zone JJ. Cigarette smoking: risk factor for premature facial wrinkling. Ann Intern Med 1991;114:840–844. 12 Ernster VL, Grady D, Miike R, Black D, Selby J, Kerlikowske K. Facial wrinkling in men and women by smoking status. Am J Public Health 1995;85:78–82. 13 Murray M. Smoking in childhood. In: Hart C, Bain J, eds. Child Care in General Practice. 3rd edn. London: Churchill Livingstone, 1989:144–154. 14 Mori Schools Omnibus — a survey of school children. MORI, London: 1996. 15 Barec L, MacArthur C, Sherwood M. A study of health education aspects of smoking in pregnancy. Int J Health Educ 1976;19(Suppl 1):1–17.