The International Tobacco Control Policy Evaluation Project

ITC Project Working Paper Series

The Bad With the Good?

The Relation Between Gender Empowerment
and Female-to-Male Cigarette Smoking Rates
Across 74 Countries

Sara C. Hitchman1
Department of Psychology, University of Waterloo, Canada

Geoffrey T. Fong1,2
Department of Psychology, University of Waterloo and
Ontario Institute for Cancer Research, Canada

May 27, 2010

Suggested Citation: Hitchman, S. C., and Fong, G. T. (May 2010). The Bad With the Good? The Relation Between Gender Empowerment
and Female-to-Male Cigarette Smoking Rates Across 74 Countries. ITC Project Working Paper Series. University of
Waterloo, Waterloo, Ontario, Canada.
 The Bad With the Good ‐ Page 1 

The Bad With the Good? The Relation Between Gender Empowerment
and Female-to-Male Cigarette Smoking Rates Across 74 Countries
Sara C. Hitchman1 and Geoffrey T. Fong1,2
1
Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
2
Ontario Institute for Cancer Research

Corresponding Author Address: Sara C. Hitchman, University of Waterloo, Department of

Psychology, 200 University Ave West, Waterloo, Ontario, N2L 3G1, CANADA

Funding: Canadian Institutes for Health Research (CIHR) Doctoral Research Award, and
Ontario Institute for Cancer Research

Competing Interests: We have no competing interests to declare.

Keywords: Cigarette Smoking, Gender Empowerment Measure, Cigarette Smoking Prevalence

Rates, Tobacco Control Policy

Word Count: 2,895

 The Bad With the Good ‐ Page 2 

The Bad With the Good? The Relation Between Gender Empowerment
and Female-to-Male Cigarette Smoking Rates Across 74 Countries
Sara C. Hitchman1 and Geoffrey T. Fong1,2
1
Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
2
Ontario Institute for Cancer Research

ABSTRACT

Objective: Worldwide it is estimated that men smoke at nearly five times the rate of
women. However, there is wide variation across countries in the gender smoking ratio (ratio
of female-to-male smoking prevalence rates). Lower smoking rates among women have been
attributed to social norms against women smoking, and women’s lower social status and
economic resources. We tested the hypothesis that in countries with higher gender
empowerment, the gender smoking ratio would be closer to 1.

Methods: We correlated the gender smoking ratio (calculated from the 2008 WHO Global
Tobacco Control Report) and the United Nations Development Programme’s Gender
Empowerment Measure (GEM). Because a country’s progression through stages of the tobacco
epidemic and its gender smoking ratio has been attributed to its level of development, we
also examined this relation partialling on economic development (Gross National Income (GNI)
per capita), and income inequality (Gini).

Findings: The gender smoking ratio was significantly and positively correlated with the GEM.
GEM was also the strongest predictor of the gender smoking ratio when controlling for GNI per
capita and Gini in a multiple regression analysis.

Key Conclusions: The findings identify a challenge for countries undergoing economic
development and greater gender equality: can such progress take place without a
corresponding increase in smoking rates among women? These findings thus highlight the need
for strong tobacco control in countries in which gender equality is increasing.
 The Bad With the Good ‐ Page 3 

INTRODUCTION

Tobacco smoking currently kills five million people a year worldwide, and it has been
projected that it could kill eight million people a year by 2030, and a total of one billion
people in the 21st century.[1, 2] The theme of the World Health Organization’s (WHO) 2010
World No Tobacco Day is gender and tobacco with an emphasis on marketing to women. The
theme was chosen “to draw particular attention to the harmful effects of tobacco marketing
towards women and girls.”[3]

Worldwide it is estimated that men smoke at nearly five times the rate of women. [4] But the
ratios of female-to-male smoking rates vary dramatically across countries. In high-income
countries, including Canada, the United States, Australia, and most of Western Europe,
women smoke at nearly the same rate as men.[5] But in many low-and-middle-income
countries (LMICs), women smoke at much lower rates than men. For example, in China, 61%
of men are reported to be current smokers, compared to only 4.2% of women. Similarly, in
Argentina, 34% of men are reported to be current smokers, compared to 23% of women.[5]

While women’s smoking prevalence rates are currently lower than men’s, it has been
projected that women’s smoking rates will rise in many LMICs. Data from the Global Youth
Tobacco Survey show that worldwide boys’ and girls’ smoking rates are more similar than
women’s and men’s, with 13 to 15 year old boys smoking only 2 to 3 times more than girls. [6]
Additionally, Lopez’s et al. 1994[7] descriptive model of the tobacco epidemic predicts that
female smoking rates will rise relative to those of males in many LMICs where females
currently smoke at much lower rates than males.

Lopez et al.’s [7] descriptive model of the tobacco epidemic proposes four distinct stages (see
Figure 1). In the initial stage, men’s smoking prevalence rates rise first, followed by a more
modest rise in women’s rates 10 to 20 years later. In the next stage, men’s and women’s
prevalence rates continue to rise, with the increase in men’s prevalence rates slightly
outpacing the increase in prevalence among women. The third proposed stage of the model
shows men’s prevalence rates leveling off and then dropping sharply towards women’s rates;
during the same stage, women’s rates only moderately increase and then decrease, although
not as sharply as men’s. In the final stage, women’s and men’s smoking rates continue to fall
until they are nearly equal. Applying the model to different countries indicates their
proposed position in one of the four stages of the epidemic. For example, low income
countries, such as those of sub-Saharan Africa, are proposed to be in the earliest stages of the
model, whereas higher income countries, such as Norway, are in the latest stages.
 The Bad With the Good ‐ Page 4 

Figure 1: Stages of the Tobacco Epidemic (Adapted from Lopez et al., 1994)

 
Reproduced from [A descriptive model of the cigarette epidemic in developed countries. Lopez AD,
Collishaw NE, Piha T., 3, 242-247, 1994] with permission from BMJ Publishing Group Ltd.  

Reasons for the differences between men’s and women’s smoking prevalence rates over time,
and the relatively slower rise of women’s smoking rates in comparison to men’s, have been
attributed to social norms against women smoking, and to women’s lower social status and
economic resources.[8-10] For example, prior to the 1920s in the United States, smoking
among women compared to men was rare, as smoking was not considered to be a respectable
behaviour for women; however, as attitudes towards women smoking became less negative,
women’s smoking rates began to climb, nearly reaching the rates of men’s.[8] Cigarette
smoking among women in Northern Europe has followed a similar pattern.[11]

The rise of smoking among women has not only been attributed to social changes and
increases in women’s economic resources, but also has been said to perhaps be a result of the
tobacco industry marketing cigarettes to women as a symbol of emancipation.[12-14]
Tobacco industry marketing campaign slogans that could be linked to these themes, include
the 1968 Phillip Morris Virginia Slims Cigarettes campaign, “You’ve come a long way baby,”
referring to the progress made in the women’s movement in the United States.[15] A 1991
internal document states the creative strategy behind this brand targeted to women: To
convince fashionable, modern, independent and self-confident women aged 20-34 that by
smoking VSLM, they are making better/more complete expression of their
independence.”[16] Advertising for Virginia Slims has followed similar patterns elsewhere,
with a 1994 advertisement in Japan reading: ‘‘I’m going the right way – keeping the rule of
society, but at the same time I am honest with my own feeling. So I don’t care if I behave
against so called ‘the rules’ so long as I really want to.” [12]

To examine if women’s empowerment is related to current differences in male and female

smoking prevalence rates within countries worldwide, we examined the relation between the
ratio of female-to-male current cigarette smoking rates and the United Nations Development
 The Bad With the Good ‐ Page 5 

Programme’s (UNDP) Gender Empowerment Measure (GEM) across 74 countries at different

stages of the tobacco epidemic. [17] We chose to focus on rates of cigarette smoking, rather
than tobacco use in general, because we were interested in the relation between GEM and
manufactured cigarettes, rather than ‘traditional’ forms of tobacco (smoked or smokeless)
which tend to show different and varied patterns of use among men and women.[10]

The GEM is described as “A composite index measuring gender inequality in three basic
dimensions of empowerment—economic participation and decision-making, political
participation, and decision-making and power over economic resources.” [17] In Klasen’s
(2007)[18] review of gender-related indicators of well-being, the GEM was described as: (1)
providing some useful cross country comparisons on female empowerment, (2) less
problematic than the UNDP’s other Gender Development Indicator, (3) a measure not of the
gender gap or well-being, but a ‘gender sensitive’ measure that penalizes for deviations from
equality, and (4) unique, in that, it gives different insights than other measures of well-being
(Klasen gives the example of South Korea, which scores high on measures of human
development, but scores low on the GEM).

Although there have been several discussions written on the relationship between women’s
smoking rates relative to men’s, few have attempted to investigate this relation empirically
across countries. [8, 10] A previous study by Schaap et al., 2009[19] examined the relation
between the GEM, Gross Domestic Product (GDP), and ever smoking rates among high and low
income women aged 25 to 39 years in 19 European countries. Schaap et al.,2009[19] found
non-significant associations between GEM and ever smoking rates when controlling for GDP,
such that the association for high-income women was negative and the association for low
income women was positive. Another study by Pampel (2006) [20] examined proposed
measures of gender equality (fertility rates, literacy rates, female representation in
parliament, tertiary education levels, etc.), with the ratio of female-to-male smoking in 106
nations. Pampel (2006)[20] found inconsistent associations between the proposed measures of
gender equality and the ratio of female-to-male smoking rates, concluding that the general
level of cigarette diffusion in a country seemed to more consistently explain the gender
difference in smoking rates.

We predicted that the GEM would be strongly related to the ratio of female-to-male current
smoking prevalence across countries, even after controlling for economic development (Gross
National Income per Capita – Purchasing Power Parity Method), and income inequality (Gini
coefficient). It was important to control for level of economic development, because much of
the research literature on the stages of the tobacco epidemic links progression through the
epidemic to a country’s levels of development. [7] We controlled for the Gini in an attempt to
examine the unique impact of GEM (female inequality), controlling for the general level of
income inequality within a country.
 The Bad With the Good ‐ Page 6 

METHODS

Measures

Ratio of Female-to-Male Cigarette Smoking Prevalence Ratio (GSR). To calculate the GSR,
adjusted female and male current cigarette smoking prevalence rates for each country were
taken from the World Health Organization’s (WHO) 2008 Report on the Global Tobacco
Epidemic.[5] These rates are adjusted by WHO to best reflect the prevalence of current adult
smokers over the age of 15 in each country.[5] These smoking rates were available for 130
countries. We chose not to impute smoking rates for countries with missing data from other
sources because the prevalence rates thus obtained would not have been similarly adjusted.
We divided women’s smoking rates by men’s smoking rates to yield a female-to-male gender
smoking ratio (GSR). It should be noted that before choosing to use current smoking rates,
we ran all analyses using both current and daily adjusted smoking prevalence rates. Because
we obtained nearly identical results, we chose to use the adjusted current smoking rates. The
correlation between the ratio of women’s to men’s current smoking rates and women’s to
men’s daily smoking rates was 0.99, p < 0.0001.

Gender Empowerment Measure (GEM). We used the GEM from the UNDP 2009 Human
Development Report statistical tables. [17] The GEM was available for 109 countries. The
measure is derived from several components, including: (1) seats in parliament held by
women, (2) female legislators, senior officials, and managers, (3) female professional and
technical workers, (4) year women received the right to vote and the year women were
allowed to stand for election, (5) year when a women became Presiding Officer of parliament
or one of its houses for the first time,(6) percentage of ministerial positions that were held by
women, and (7) ratio of estimated female-to-male earned income. The GEM ranges from 0 to
1, with values closer to 1 signifying higher empowerment.

Gini Coefficient (Gini). The Gini coefficient is a well-known measure of income inequality
and wealth within a population. A value of 0 signifies perfect equality, whereas a value of 1
signifies perfect inequality.[21] The Gini coefficient was taken from the UNDP 2009 Human
Development Report statistical tables. [17] The Gini was available for 142 countries.

Gross National Income per capita in US$ - Purchasing Power Parities Method (GNI per
capita). GNI per capita for 2008 from the World Bank, expressed in International dollars was
used. [22] PPP methods account for relative prices and provide a better measure for
comparisons across countries.[23] GNI per capita is used by the World Bank to classify
countries into income categories (i.e., low income, lower-middle income, upper-middle
income, and high income).[23] We used the log of the GNI per capita, ln(GNI per capita), in
our analyses because of high positive skew of the GNI per capita data. Data was available for
166 countries.
 The Bad With the Good ‐ Page 7 

Statistical Analyses

SPSS 17.0 was used to conduct all statistical analyses. Correlations between all measures
were first examined. We subsequently tested whether the relation between GEM and GSR
persisted when partialling on GNI per capita, and Gini, in two separate correlational analyses.
Finally, we tested whether the relation between GEM and GSR persisted when controlling for
GNI per capita, and Gini in a multiple regression analysis. Sample size was reduced in some of
the analyses because data were not available on all indices for all countries.

RESULTS

Descriptives. Table 1 presents the descriptive statistics for the four measures.

Table 1. Descriptive Statisticsa

Variable Mean Standard Deviation
GSR (Gender Smoking Ratio) 0.44 0.30
GEM (Gender Empowerment Measure) 0.61 0.16
ln(GNI per capita) 9.30 1.08
Gini 37.75 9.09
a
For cases where data was available on all four measures, N = 74

Correlations between the measures. See Table 2 for the bivariate correlation matrix. All
measures were significantly correlated. The bivariate correlation between GSR and the GEM
was statistically significant, indicating that in countries with higher female empowerment,
female and male smoking rates are closer to being equal. See Figure 2. The correlation
between the GSR and GNI per capita, and Gini, also reached statistical significance. GSR and
GNI were significantly positively correlated, indicating that in countries with higher GNI per
capita, female and male smoking rates are also closer to being equal. The correlation
between GSR and Gini was negatively correlated, indicating that in countries with low income
inequality, female and male smoking rates are again, closer to being equal.
 The Bad With the Good ‐ Page 8 

Table 1. Ratio of Female to Male Current Cigarette Smoking Rates (GSR) - Correlation Matrix of
Measures

(ln)GNI per
Measure GSR GEM Gini
capita

r 1
GSR p
n 130
r 0.680 1
GEM p <0.001
n 88 109
r -0.241 -0.22 1
Gini p 0.014 0.034
n 104 92 142
r 0.659 0.708 -0.325 1
ln(GNI per
p <0.001 <0.001 <0.001
capita)
n 115 102 138 166

Partial Correlations. The correlation between GSR and GEM, partialled on GNI per capita (ln)
remained significant, r = 0.48, p < 0.0001, N=82. The correlation between GSR and GEM,
partialled on Gini increased slightly, r = 0.703, p < 0.0001, N=74. This increase was most likely
due to some countries being excluded from the analysis due to missing data on Gini.
 The Bad With the Good ‐ Page 9 

Figure 2. Female/Male Current Cigarette Smoking Prevalence (GSR) by Gender

Empowerment Measure (GEM)

Multiple Regression Analysis. GSR was set as the dependent variable. We tested whether
GEM predicted the GSR, controlling for GNI per capita, and Gini. Model results (F3,70 = 27.21,
p < 0.0001). Adjusted R square = .519. Table 2 displays the model coefficients. The analysis
showed that GEM remained a very strong and highly statistically significant predictor of GSR
after controlling for GNI per capita and Gini.

Table 2. Multiple Regression Analyses Predicting Gender Smoking Ratio (N=74)

Predictor Beta (Standardized) p
ln(GNI per capita) 0.33 0.01
Gini 0.07 0.41
GEM 0.47 <0.0001
 The Bad With the Good ‐ Page 10 

DISCUSSION

In June 1998, in an editorial for the newsletter of the International Network of Women
Against Tobacco, Former Director General of the WHO, Dr. Gro Harlem Brundtland wrote,
“there can be no complacency about the current lower level of tobacco use among women in
the world; it does not reflect health awareness, but rather social traditions and women’s
low economic resources.”[ 24] The findings presented in this study lend empirical support to
Dr. Brundtland’s warning; in countries where women have higher empowerment (GEM), we
found that women’s smoking rates are higher relative to men’s, independent of the level of
economic development (GNI per capita) and the level of income inequality (Gini). In fact,
GEM was by far the strongest predictor of the gender smoking ratio, even after including the
other two competing predictors in the model.

These findings lend further confidence to previous discussions and studies on the relation
between increases in women’s empowerment and increases in women’s smoking prevalence
rates relative to men, and prompt the following questions: In countries where women’s
empowerment is increasing, can such increases in empowerment take place without a
corresponding increase in smoking rates among women? And in what countries will increases
in women’s empowerment lead to the greatest increases in women’s smoking?

Implications

Evidence-based tobacco control policies should be implemented to attempt to stop the rise of
women’s smoking rates worldwide, particularly in countries where women’s smoking rates are
low, and women’s empowerment is increasing. Policies that prevent the tobacco industry
from targeting women should be emphasized, such as bans on all forms of tobacco advertising
and promotion in accordance with the Guidelines of Article 13 of the FCTC (Framework
Convention on Tobacco Control): Tobacco Advertising, Promotion, and Sponsorship[26,27]
Additionally, as the rise of smoking among women has been linked to increases in their
economic resources, policies to reduce the demand for tobacco through price and tax
measures in accordance with Article 6 of the FCTC should be implemented.[26]

Thus far, discussions and the formulation of guidelines for the provisions of the WHO
Framework Convention on Tobacco Control (FCTC) have not generally been concerned with
specific strategies that might be particularly effective in inhibiting smoking rates among
women. But the current wide gap in men’s and women’s smoking rates, coupled with
evidence that women’s smoking rates may be set to rise in some countries suggests the need
for key policies to prevent women’s smoking prevalence rates from rising.[6,7]

Future Research

Future research should investigate what strategies may be most effective in preventing
smoking among groups of women who have been shown to be the first to take up smoking in
historical investigations of the tobacco epidemic, namely, the younger, and more highly
educated.[8, 11, 28] However, as the course of the tobacco epidemic may not replicate itself
similarly across countries, the tobacco epidemic among women should be heavily monitored.
 The Bad With the Good ‐ Page 11 

As this process takes place (inevitably?), the success, or lack thereof, in preventing women
from taking up smoking in the context of tobacco control policies should be evaluated.

Furthermore, future research should also consider how increases in gender inequality could
be related to the spread of other harmful health behaviours, such as alcohol abuse.

Limitations

Our intent with this paper was not to engage in an in-depth discussion of the relation between
GEM and the GSR within each individual country and region, but rather to attempt to
demonstrate the basic empirical relation between GEM and GSR across countries using
ecological methods. There are limitations to the conclusions that we draw from this study.
First, because this study examined the relation between the GSR and GEM cross-sectionally,
we cannot conclude that increases in women’s empowerment will lead to higher cigarette
smoking rates among women relative to men . Future research could examine the relation
between women’s empowerment and the GSR overtime to provide a stronger test of the
hypothesis that increases in women’s empowerment leads to a higher cigarette smoking rates
among women relative to men. Such research would be dependent on generating suitable and
comparable country level indicators of women’s empowerment and GSR overtime. Second,
because this study was ecological in nature, in that we measured the relation between
country (group) level GEM and GSR, we are unable to make inferences about the effects of
the individual woman’s level of empowerment on their uptake of smoking.

Conclusion

So, does the bad have to come with the good? Will increases in women’s empowerment and
gender equality inevitably be accompanied by increases in women’s smoking prevalence
rates? These findings provide an empirical basis for the need to further explore the nature of
the relation between women’s empowerment and women's smoking rates worldwide, and to
begin to build a fuller understanding of the conditions that may increase or decrease the
effect of gender equality on women’s smoking rates. More importantly, these findings further
alert us to the need to act quickly to prevent the tobacco epidemic among women by
implementing evidence-based policies to prevent the uptake of smoking among women,
particularly policies that prevent the tobacco industry from targeting women.
 The Bad With the Good ‐ Page 12 

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 The International Tobacco Control Policy Evaluation Project

The ITC Project

Evaluating the Impact of FCTC Policies in...
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Australia China (Mainland) Malaysia South Korea

Bangladesh France Mauritius Thailand
Bhutan Germany Mexico United Kingdom
Brazil India Netherlands Uruguay
Canada Ireland New Zealand United States of America

Geoffrey T. Fong, Ph.D.

Department of Psychology
University of Waterloo
200 University Avenue West
Waterloo, Ontario N2L 3G1 Canada

Email: itc@uwaterloo.ca
Tel: +1 519-888-4567 ext. 33597
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