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Learn More. Smoking cigarettes is a gendered activity with sex- and gender-specific uptake trends and cessation patterns.
While global male smoking rates have peaked, female rates are set to escalate in the 21st century, especially in low and middle income countries. Hence, smoking cessation for women will be an ongoing issue and requires refreshed attention. Public health and health promotion messages are being challenged to be increasingly tailored, taking gender into. Women-centred approaches that include harm-reduction, motivational interviewing and trauma-informed elements are the new frontiers in interventions to encourage smoking cessation for women.
These approaches respect gender and sex-related factors that affect smoking and smoking cessation and respond to these issues, not by reinforcing destructive or negative gender norms, but with insight. This article discusses a women-centred approach to smoking cessation that could underpin initiatives in Smoking hot non lady, community or public health settings and could inform campaigns and messaging. Smoking cigarettes remains one of the key global health risks for disease and premature deaths [ 1 ].
Global rates of male cigarette smoking have peaked and are declining [ 2 ], while female global rates are set to escalate dramatically in this century. Hence, responding to, preventing or treating smoking in women takes on a high priority in public health and health care. Women-specific and women-centred approaches are gaining ground, in a bid to respond to the gendered meanings of smoking, and to tailor treatment initiatives more specifically with women in mind. They also recognize some of the sex and gender specific challenges to cessation that many women face, such as biological differences in level of dependence, hormonal influences, lack of social support, high caregiving pressures, influence of partner smoking, co-occurrence of depression and mental health issues, and the experience of stigma particularly among pregnant women and mothers [ 9 ].
In most Western populations, smoking manufactured cigarettes among women emerged some years after smoking cigarettes among men had taken hold [ 11 ]. These gendered patterns of uptake were also reflected in consumption levels and prevalence rates of smoking among women with women generally smoking fewer cigarettes per day than men [ 12 ], and, with few exceptions, female prevalence rates usually peaking lower than male prevalence [ 11 ]. Despite such powerful social barriers, consistent and powerful gendered messaging and marketing by tobacco industries over the past century has led to the pervasive uptake of smoking among girls and Smoking hot non lady in middle and higher income countries [ 1314 ].
In addition, and more pervasively, the Smoking hot non lady succeeded in changing gender roles and norms through the use of tobacco in a range of ways. This gendered approach to smoking behaviour and uptake was very successful in these contexts, changing the cultural meaning of smoking from negative associations such as prostitution, manliness and rebellion, to positive images of independence, success, health and self-care [ 1315 ] over the course of several decades.
These cultural meanings of smoking to women, while generated externally, eventually affect the psychosocial processes of creating meaning by women who smoke, and become internalized [ 18 ]. However, in this century, similar targeted techniques are being used to involve women in low income countries in smoking cigarettes, with ethnoculturally-specific marketing and advertising to women i. In addition, tobacco growing and cigarette production has relocated, or is relocating to low income countries, and many women and children are laborers in tobacco growing and production activities [ 22 ]. These economic activities engage and change the local economies in ways that render smoking and tobacco growing and production increasingly important, and more difficult to resist.
ificant growth and profits for the industry exist in these locations where comparatively under-resourced responses from societies and governments remain the norm. Ironically, and sadly, health system and health promotion efforts addressing cigarette use in the past 50 years in western countries did not adopt a similarly marked gender analysis and did not investigate women-specific and context specific approaches or messages, despite the stark example of success of this approach by the tobacco industry [ 1520 ]. Other than this extraordinary attention to pregnancy and smoking, little gendered or sex-specific research or programming emerged until well into the s [ 192025 ].
This was a lost opportunity and delayed any thoughtful gendered responses to smoking among women that ought not to be prolonged in this century in high income countries or, mistakenly repeated in low income countries in the 21st Century. At the same time, the patterns of smoking among women in high income countries, while generally declining, are doing so in inequitable ways. Social and economically marginalized women and girls, Indigenous women and girls, those with histories of violence, mental health problems and other addictions, and those living in poverty with burdens of care giving and stress are most likely to be new and persistent smokers.
These vulnerabilities to taking up or continuing the use of cigarettes are increasingly well-documented [ 262728293031323334353637383940 ]. It is these vulnerabilities and population-specific uses of cigarettes that concern us now, along with rapidly growing rates in new regions of the world. These groups in high income countries that are vulnerable to smoking are often marginalized, of low socioeconomic status, are indigenous, have experienced trauma, violence or mental health issues, other substance use issues [ 2641 ]. One avenue to understanding the persistence of smoking in these settings is through analyses of the meanings of smoking to women.
This section addresses some key themes in those investigations with a range of groups of women, including post partum, low income, adolescent, abused women, feminists, and women with chronic obstructive pulmonary disease COPD. Some research on meanings include my work, published inwhere I identified five major themes for women in Canada and Australia who smoke by conducting interviews with women who had experienced abuse, indigenous women and women who self-described as feminists, to generate a range of perspectives on the meaning of smoking in their lives [ 15 ].
For all of these women, there were five main themes: organizing social relationships, creating an image, controlling emotions, exercising dependency and creating identity [ 15 ].
All of these meanings have various manifestations. Two women illustrate this:. I was using cigarettes to create a sense of space around myself, to mark time for myself, to mark time out for myself, to mark a to be isolated. The issues surrounding image creation are perceived to be directly attributable to the efforts of the tobacco industry, and indeed, women report elements of risk-taking, rebellion, differentiation from others or independence in their self-images, an echo of many of the advertising themes directed at women in the 20th century.
For example:. It was also wrong, so I did it. Because I like to be nice. All of these meanings suggest that smoking cigarettes functions in some very practical ways for women, particularly for women in difficult life circumstances. Cigarettes assume the role of friend and offer solace and comfort. The essence of smoking for women is that smoking offers a route to controlling various emotions, images or circumstances, but, as its addictive qualities increase, smoking itself controls and is controlling of women. In the early s, Graham conducted interviews with women with children living in manual occupation households.
One example Graham reports suggests that smoking prevented lashing out at :. I have to do things for the baby and my husband, but smoking is about the only thing I can do for myself. She conducted interviews with women in the UK and offers some telling quotes about how the women she interviewed interpreted their smoking. Some of these reflections were extremely practical:.
So Smoking hot non lady try and have some peace, I used to prop my library book on the top of the black fireplace, and have my cup of tea and cigarette standing up. Other researchers have also investigated meanings, such as those associated with adolescent smoking [ 4445 ], suggesting that these contradictions develop fairly early and quickly in smokers. The older female adolescents were more reflective about addiction, and identified control as a meaning of smoking [ 46 ].
Many of the adolescents reflected on the stigma that they already experienced as smokers and how much they notice it. These insights with adolescents suggest that reflections and insights into the meaning of smoking begin early, and could be elicited and capitalized on by practitioners as openings for conversations about smoking.
Sometimes these interpretations of smoking remain strong, even in the face of acquiring a serious smoking related illness such as COPD. Jonsdottir and Jonsdottir [ 47 ] report findings from interviews held with a small group of seven Icelandic women smokers between the ages of 47 and 65 years who had been hospitalized for COPD, many of whom had quit and relapsed. The women often felt that the utility of smoking in helping them deal with their life problems and issues, particularly stress, mixed with the addiction to nicotine, prevented them from quitting and staying quit.
These sentiments speak to the tenacity of the meanings and functions of smoking for women, persisting for some even in the face of serious, chronic, disabling disease. These selected examples from the literature on meanings of smoking for women allows us to gain insight into the meanings of smoking for many women. The details they offer on how smoking functions in daily life for many women points to some of the issues and approaches required from smoking cessation interventions. These functions appear to be largely adaptive: offering solace in face of difficulty, dangling a symbol of better things, or serving as a solution to everyday circumstances that may be difficult or may need enhancement.
Understanding these aspects of cigarette smoking is essential for acknowledging these elements, and developing appropriate responses in cessation interventions or health promotion campaigns. Certainly, the tobacco industry has understood these women-specific concerns and desires for some time, and has harvested considerable Smoking hot non lady from this understanding. It is important to consider how a health-oriented response might look. Typical mainstream cessation advice often focuses on brief interventions or standard tips for quitting [ 4849 ].
One common, tested approach is the 5As, which underpins many cessation programs or is used in the context of other health promotion or health care programming, such as prenatal care [ 50 ]. Nicotine replacement therapy NRT is also a low cost and useful cessation aid, in some jurisdictions supplied to low income smokers at reduced or no cost [ 5152 ]. Cessation advice and assistance are part of comprehensive tobacco control, which also includes surveillance, policy, taxation and pricing initiatives, advertising and promotion bans, prevention and reduction of exposure to secondhand smoke [ 53 ].
Comprehensive tobacco control has been largely successful in high income countries in addressing and reducing prevalence of smoking across populations.
But these declines have often masked high rates of smoking in some specific vulnerable groups of women and men. In response, tobacco policies and programs have been challenged to respond in more tailored ways to certain vulnerable sub populations in recent years [ 262829395455 ]. Linking the meanings of smoking to women to these issues and contexts in a direct manner may help in addressing smoking cessation for women in more realistic ways. Indeed, more qualitative research, engagement with cigarette smokers, their families, households and communities and co creating cessation initiatives are all measures that could be useful going forward.
For example, women who experience intimate partner violence IPV are more likely to smoke [ 60 ] and women who have a range of mental health concerns are more likely to smoke Smoking hot non lady 71 ]. This recognition of social context also demands that we engage with approaches such as harm reduction and trauma-informed initiatives.
Being trauma-informed is a stance that providers and systems can take, that is not dependent on disclosure of trauma by individuals [ 73 ]. Research has identified four main principles in women-centred care for tobacco use [ 9 ].
First, women-centre care is tailored specifically for women, including taking into biological and psychosocial factors affecting care and intervention. Second, women-centred care builds confidence and increases motivation, through identifying barriers to change, as well as opportunities and enacting stigma reduction and social support. Third, women-centred care incorporates social justice issues, such as recognizing that other socioeconomic concerns such as violence and poverty also factor into decision making about tobacco use and health.
These approaches recognize the realities of being lone mothers who smoke, address immediate child health concerns, while offering support, space for change, and an opportunity to build on strengths to develop insight among single mothers who smoke. Interestingly, although not a cessation program, the majority of the women who participate in a program such as STARSS end up trying cessation [ 74 ]. Groups such as these can create the support for gradual changes, and offer social networks to assist [ 7677 ]. A group program developed in Northern Smoking hot non lady aimed at disadvantaged women called Stopping for Medivided its program into a three week course that created space for women to discuss their smoking freely, in a supportive atmosphere.
This section included reflections on smoking, their relationship to the health system, impact of advertising and family histories. The facilitators reported that this phase could often give rise to anger at these external factors, which was important in diverting the blame from women to larger pressures [ 78 ]. The second phase, not necessarily taken up by all the women in phase one, was a 12 week cessation oriented program where the women were in control of the agenda that included sessions on conflict resolution, stress, and coping.
There was no pressure to Smoking hot non lady, however, and the women reported that this was their first positive experience with cessation [ 78 ]. In this setting women were offered the opportunity to name their most problematic drugs, and often named nicotine as one of their top three, alongside cocaine and alcohol. They were then given opportunities to address their smoking in an integrated manner, and asked to reflect on three themes: the health effects of smoking on women; the links between smoking and victimization, trauma and coping, and the effects of tobacco advertising aimed at women, [ 79 ].
These collaborative, non-threatening approaches created a non judgmental atmosphere, and integrated a discussion and response to smoking into a treatment environment that had ly ignored tobacco use among its clientele. There are models for intervention for health care providers to invite openness to counseling and to address difficult substance use issues with women [ 80 ]. For example, the typical 5As approach [ 49 ] can be augmented with a trauma-informed, motivational interviewing approach [ 81 ]. Motivational interviewing encourages a conversation about smoking, keeps it aflame at each encounter and moves it toward points of insight and change that women, not practitioners, can claim and control [ 82 ].
A Cochrane systematic review of motivational interviewing MI for smoking cessation revealed modest but ificantly greater rates of smoking cessation among participants receiving MI compared to brief advice or usual care [ 83 ]. Practitioners using these approaches act as partners in change, assisting with the provision of information and recognizing that building toward change is a matter of building confidence and working through ambivalence.
These interactions need to be trauma-informed, recognizing that may women experience trauma, whether revealed or not, and benefit from safe, trusting, non-punitive and non-authoritarian approaches. Detailed approaches to a brief intervention using these approaches, with explicit advice for practitioners on how to phrase their questions are available [ 9 ].
Trauma informed practice for women with co-occurring substance use and mental health disorders has been found to decrease substance use, depression and trauma symptoms [ 8485 ].
Indeed, decision-making tools encourage women to assess their smoking against these two elements, in order to clarify and identify points for change [ 9 ]. Social context and women-specific and women-positive understandings of smoking are also important in health promotion. In mainstream health promotion activities, gender has long been absent [ 86 ] and attempts to integrate gender have often fallen short by generating messages or programs that play on destructive gender stereotypes or norms and focus on individual behaviour change as opposed to recognizing the effects of social context [ 87 ].
In smoking cessation interventions, there are past and current examples of tobacco campaigns or Smoking hot non lady that do this. Even tobacco control experts who recognize these subtleties argue that using gendered stereotypes in prevention and cessation is justifiable if they resonate with the target audience [ 91 ]. But certainly the bar on elevating and interpreting gender can be raised, and tobacco control can lead, not follow. Improvements in health promotion would not only integrate women and gender, but do so in a transformative and empowering manner.
The field is ripe for the development of such approaches. It is still unclear if the four stages of the tobacco epidemic that Lopez and colleagues described in will roll out in the same ways in the low income countries in the 21st century [ 9495 ]. Many factors have emerged or changed since the model was developed, such as increased globalization, urbanization and migration, as well as rapidly changing global communications and shifting gender norms.
How these pressures will affect gender, equity and tobacco use remains to be seen [ 96 ].Smoking hot non lady
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