Tobacco’s War on Women

When a young paralegal in Mumbai or Hanoi lights up, it feels so good in so many ways. She loves the nicotine hit, of course, but she loves even more to exhale in the sexy way Scarlett Johansson did in A Love Song For Bobby Long. All over the developing world, young women with rising incomes and new freedom to make their own decisions are taking up smoking to chase their dreams — and, in turn, making the dreams of cigarette marketers no longer welcome in rich industrialized countries come true. This gives the folks at the World Health Organization nightmares.

According to the new edition of The Tobacco Atlas, about 200 million women smoke cigarettes worldwide, compared to 800 million men. This gender gap is widest in Africa, Asia and the Middle East. In Vietnam, for example, more than half the men smoke — but fewer than 2 percent of the women do.

Cigarettes killed almost 6 million people in 2011, 80 percent of them residents of low and-middle-income countries. And the toll is sure to rise in next few years, as the rising tide of men who’ve been smoking heavily for a lifetime pay the piper. But looking decades down the road, the magnitude of the body count will largely depend on the choices made by women in the developing world.

The battle for their hearts and lungs is already raging. On one side, tobacco companies are spending billions of dollars in less-exploited markets to portray women who smoke as liberated, sexy and slender. On the other is the World Health Organization, which, in league with local activists, is attempting to head off Big Tobacco with campaigns to educate women about the decidedly unsexy consequences of inhaling.

No small challenge. Public health campaigns in developing countries have traditionally been focused on the infectious diseases associated with poverty. These diseases are (relatively) easy to fight — you can, for example, contain malaria by bombing mosquitoes with pesticide and handing out nets. But fighting the diseases of affluence, like heart disease and cancer, means playing the Grinch, asking people to deny themselves a modest perquisite of affluence.

Countries typically experience the tobacco epidemic in four stages. In the first, wealthy and educated people start using. In the second, tobacco use spreads through the population. In the third, smoking starts to fall among the early adopters, while lower-income, less-educated groups persist. In the fourth, the overall rates of smoking decline, even as the delayed effect of smoking increases tobacco-related deaths.

The United States is now moving through the fourth stage. The percentage of Americans who smoke declined from 42 percent in 1965 (the year after the US Surgeon General’s famous report) to 19 percent in 2010. Only 6 percent of Americans with graduate degrees now smoke (though 25 percent of high school dropouts are still puffing). Some 23 percent of deaths in the US are tobacco-related.

Americans consumed 315 billion cigarettes in 2009. But the promised land for tobacco companies is Asia. Chinese men (plus a few women) smoked nearly 2.3 trillion cigarettes that same year. Indeed, of every 100 cigarettes sold on the earth today, 38 are sold in China.

China is either in stage two or stage three of the epidemic — the male market for cigarettes is saturated, so much turns on whether women decide to take up the habit. Today, cigarettes kill about one million people a year in China. By 2030, that number will almost surely reach 3.5 million, and could be much higher if Chinese women join in the fun.

The China National Tobacco Company is the biggest tobacco company in the world, and it is also a highly profitable (if typically sluggish), state-owned monopoly. This means China will resist efforts to allow the multinational tobacco companies to compete — but it also means that the Chinese government has a big conflict of interest.

In 2009, 50 percent of men and 2 percent of women in Shanghai smoked, along with 3 percent of boys and 1 percent of girls aged 13 to 15. But serious efforts at marketing, combined with the universal yearning to follow global fashion, could change that number fast. Consider, for example, South Korea in the 1980s, which had high import tariffs on tobacco and few women smokers. In response to threats from Washington, Korea lowered its trade barriers and multinational tobacco companies set up shop. Between 1988 and 1989 – that’s right, in one year — smoking among teenage boys in Korea increased from 18 percent to 30 percent; for girls, it rose from 2 to 9 percent.

Like China, Vietnam has a state-owned monopoly cigarette manufacturer that markets in very limited ways. Thomas Bollyky, a fellow at the Council on Foreign Relations who specializes in trade and global health, warns that the Trans-Pacific Partnership, the free trade agreement now being negotiated between the US and seven Asian countries, could send Vietnam down Korea’s path. Four private companies – Philip Morris, British American Tobacco, Imperial Tobacco Group and Japan Tobacco – make and sell about half of the world’s cigarettes. They also employ some of the world’s best marketers because, as RJ Reynolds executive Chris Reiter famously said in 2003, ” If you can market a product that kills people, you can sell anything.”

Many people in Asian and Muslim countries still view women smoking as déclassé. The portion of women who smoke in China — where, as noted earlier, the state tobacco monopoly does not advertise heavily, at least not yet — has actually declined in recent years. But advertising is powerful, and the tobacco industry has used it on women for decades. In 1925, American magazines suggested that to stay slender, women could “Reach for a Lucky Instead of a Sweet;” the campaign was so successful that one executive likened the women’s market to “a gold mine right in our front yard.”

Today, young Filipina women are the target for Hope cigarettes. One recent television ad shows bikini-clad Caucasian women and attractive young men skydiving, surfing, and lighting up together; the images are intercut with shots of the brand. It’s about hope – the hope young women have for Western-style affluence, fun, and popularity – and how smoking is an easy way to taste that dream.

The real focus of the battle in these countries is young, educated women, who are more likely to see cigarettes as emblems of sophistication and independence. In India, after protestors repelled one marketing campaign aimed at women, British American Tobacco returned with “Project Kestrel,” the goal of which was, according to internal documents, to develop a brand that “breaks the rules” and encourages the “literate youth of today” to try a brand that is “completely unconventional, which set(s) new standards encouraging their rebellion, not necessarily just against parents.”

Developing countries contemplating tobacco control – in particular, prevention of growth in smoking among women – have a troika of reasons to look the other way. First, lower sales means less tax revenue/profit, an especially important consideration for countries lacking the means to collect income or property taxes. Second, they face opposition from powerful interests, ranging from foreign governments demanding market access for their exporters, to multinational tobacco companies skilled at winning friends in high places, to local stakeholders — everybody from workers in tobacco factories to local shop owners who anchor their businesses on cigarette sales. Third, the costs of smoking are back-loaded: Young smokers rarely worry about health issues many decades down the road, and neither do politicians focused on economic growth and political stability.

Anti-tobacco activists in poor and middle-income countries thus have their work cut out for them. And if the experience of the West is any indicator, trillions will be spent on coping with tobacco-related illness and hundreds of millions more will die before they succeed in putting tobacco in its place.