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Gender equality and smoking: a theory-driven approach to smoking gender differences in Spain
  1. Usama Bilal1,2,
  2. Paula Beltrán2,3,
  3. Esteve Fernández4,5,6,
  4. Ana Navas-Acien1,7,
  5. Francisco Bolumar2,8,9,
  6. Manuel Franco1,2,10
  1. 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2Social and Cardiovascular Epidemiology Research Group, School of Medicine, University of Alcalá, Alcalá de Henares, Madrid, Spain
  3. 3Department of Preventive Medicine, Hospital Universitario La Paz, Madrid, Spain
  4. 4Tobacco Control Unit, Cancer Prevention Program. Institut Català d'Oncologia (ICO). l'Hospitalet de Llobregat, Spain
  5. 5Cancer Control and Prevention Area, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Spain
  6. 6Department of Clinical Sciences, Medical School (Bellvitge), Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
  7. 7Department of Environmental Health Sciences, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  8. 8CIBER Epidemiología y Salud Pública (CIBERESP), Spain
  9. 9Hunter School of Public Health, City University of New York
  10. 10Department of Epidemiology, Atherothrombosis and Cardiovascular Imaging Centro Nacional de Investigaciones Cardiovasculares Madrid, Spain
  1. Correspondence to Dr Manuel Franco, Social and Cardiovascular Epidemiology Research Group, School of Medicine, University of Alcalá, Alcalá de Henares, Madrid 28871, Spain; mfranco{at}uah.es

Abstract

Background The intersection between gender and class can aid in understanding gender differences in smoking.

Aim To analyse how changes in gender inequality relate to differences in smoking prevalence by gender, education and birth cohort in Spain over the past five decades (1960–2010).

Methods The Gender Inequality Index (GII) was calculated in 5-year intervals from 1960 to 2010. GII ranges from 0 to 1 (1=highest inequality) and encompasses three dimensions: reproductive health, empowerment and labour market. Estimates of female and male smoking prevalence were reconstructed from representative National Health Surveys and stratified by birth cohort and level of education. We calculated female-to-male smoking ratios from 1960 to 2010 stratified by education and birth cohort.

Results Gender inequality in Spain decreased from 0.65 to 0.09 over the past 50 years. This rapid decline was inversely correlated (r=−0.99) to a rising female-to-male smoking ratio. The youngest birth cohort of the study (born 1980–1990) and women with high education levels had similar smoking prevalences compared with men. Women with high levels of education were also the first to show a reduction in smoking prevalence, compared with less educated women.

Conclusions Gender inequality fell significantly in Spain over the past 50 years. This process was accompanied by converging trends in smoking prevalence for men and women. Smoking prevalence patterns varied greatly by birth cohort and education levels. Countries in earlier stages of the tobacco epidemic should consider gender-sensitive tobacco control measures and policies.

  • Socioeconomic status
  • Disparities
  • Prevention
  • Priority/special populations

https://doi.org/10.1136/tobaccocontrol-2014-051892

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    Introduction

    Differences in smoking prevalence between men and women are one of the key elements in the four-stage model of the tobacco epidemic in developed countries.1 ,2 This model was described and reproduced in several Western countries showing similar patterns of smoking prevalence but with differences in the magnitude and timing of the epidemic by gender.2

    Several theories have been proposed to explain the differential uptake of smoking by women and men.3 ,4 The theory of diffusion of innovations describes the time lapse between early adopters (highly educated men) and late adopters (highly educated women and less educated men, followed by less educated women), but fails to explain why women are consistently late adopters. Several gender theory concepts apply to the study of the tobacco epidemic and may help inform a theory-driven approach to smoking differences.5 Recently, female empowerment has been shown to be correlated with an increased prevalence of smoking among women relative to men6 and may be one of the factors that—together with industry activity7—shape the population distribution of smoking.

    First, we approach the evaluation of smoking prevalence differences from a gender perspective that treats these differences as the result of social processes operating at an intrapersonal, interpersonal and society level.8 These processes relate to both socioeconomic and gender differentials, which are known to be strong determinants of smoking prevalence.9 Second, we acknowledge that smoking may be one of the pathways that embody unequal power structures.10

    Last, and central to this study, lies the concept of intersectionality,11 or the interaction between inequality dimensions such as social class and gender. Since the population distribution of smoking is heavily influenced by social class and gender,9 we argue that it is of great relevance to include this concept in gender-based research on smoking. Recent analyses in Spain have shown gender and social class interactions in self-reported health.12

    As tobacco control research, policy and practice regarding women remain a challenge worldwide,13 studying the tobacco smoking epidemic in Spain over the past 50 years from a gender perspective may prove useful to understanding the dynamics of the epidemic and the processes behind the adoption of health-related behaviours in a country that underwent rapid social, political and economic transformation in the second half of the 20th century.14

    We developed this study in an attempt to better understand the cumulative influence of gender-related social processes that could result in differential patterns of smoking for women and men. Our aim was to evaluate whether changes in gender inequality correlate with gender smoking ratio (GSR) patterns in Spain over the past 50 years. Special attention was paid to the variation of smoking patterns over five decades by social class and birth cohort. This study can provide valuable information for countries in earlier stages of the tobacco epidemic in order to predict future patterns of smoking associated with developments in gender equality and to better design tobacco control policies.

    Methods

    Study population

    Our population of interest was the entire non-institutionalised Spanish population 16 years of age or older for the period 1960–2010. Nationally representative data sources were used to estimate the Gender Inequality Index (GII, main exposure), and smoking prevalence by gender (GSR, main outcome).

    GII and components

    The GII15 reflects the loss in potential human development due to inequality between female and male achievements in three dimensions: reproductive health, measured by (1) maternal mortality ratio (maternal deaths per 100 000 live births) and (2) adolescent fertility rate (number of births per 1000 women aged 15–19); empowerment measured by (3) female and male population with at least secondary education (percentage of female and male population ages 25 and older that had attained a secondary or higher level of education) and (4) shares of parliamentary seats held by each gender (ratio of seats held by a respective gender in the lower house of parliament); and labour market measured by (5) labour force participation rates (percentage of female and male working-age population (ages 15–64) that actively engaged in the labour market). Each dimension and its components were obtained in 5-year intervals for the years 1960–2010. All data were obtained from the National Institute of Statistics (INE), except for the share of female and male parliamentary seats, which was obtained from the National Parliament's historical archives (only the lower house of parliament was considered). Census data on secondary education and labour force participation were available only in 10-year intervals from 1960 to 1990. Values for 1965, 1975 and 1985 were imputed as the mean of the adjacent values.

    The GII value was computed for each selected year following the guidelines of the 2011 Human Development Report Technical Notes.15 The GII ranges from 0 to 1, with values closer to 0 indicating lower gender inequality (higher gender equality).

    Smoking prevalence

    Data were obtained from the National Health Interview Survey (Encuesta Nacional de Salud) conducted in Spain in 2011 (n=21 007). The smoking prevalence rate for each calendar year from 1960 to 2010 was reconstructed using a method described previously.16 This method has been validated for estimating smoking prevalence trends.16 Birth year and highest level of education attained (defined as no formal education, primary education (less than high school), secondary education (high school), or tertiary education (college) or above completed) were obtained for each respondent in the surveys.

    A female-to-male GSR was obtained by dividing women's smoking prevalence by men's smoking prevalence. Values for the GSR below 1 indicate a higher prevalence of smoking among men, and values above 1 mean a higher smoking prevalence among women.

    Statistical analysis

    We performed a log-log linear regression to estimate the per cent change in GSR by per cent change in GII. Moreover, we also checked if this association between GSR and GII varied by birth cohort or education attainment. For this, we fitted a linear model with generalised estimating equations (GEE with exchangeable correlation structures) with the natural logarithm of GSR as the dependent variable and the natural logarithm of GII, dummy variables for education and cohort and their interaction with GII as independent variables. We then checked if the association of GSR with GII was different across groups (p value for statistical significance <0.05).

    We used STATA statistical software V.13.1 IC (STATACorp, College Station, Texas, USA) to conduct all the statistical analyses.

    Results

    GII: dimensions and trends over time

    The composite GII showed an overall downward trend from a maximum value of gender inequality at 0.65 to a minimum of 0.09 in the period 1960–2010 (figure 1, right). The maternal mortality ratio was reduced by 80% from 1960 to 1985, down to 11.0 deaths per 100 000 live births. The adolescent fertility rate increased by 35% with two peaks in 1980 and 2005 (figure 2 and see online supplementary table S1). The female and male population with at least a secondary education increased 10-fold from 1960 to 2010, both following a similar pattern, although men consistently held higher percentages than contemporary women. The female and male shares of parliamentary seats followed opposite trends, with very few women (<1%) holding parliamentary seats before 1980 and there being a steady increase to 36% in 2005. Female and male labour force participation rates followed completely different patterns throughout the study period. The male labour force participation rate decreased over time, from 90% in 1960 to 80% in 2010, while the female labour force participation rate more than tripled from 18% in 1960 to 67% in 2010.

    Figure 1
    Figure 1

    Female and male smoking prevalence, female-to-male smoking ratio (gender smoking ratio, GSR) and Gender Inequality Index (GII) trends in Spain from 1960 to 2010.

    Figure 2
    Figure 2

    Trends of the dimensions of the Gender Inequality Index: reproductive health, empowerment (includes shares of parliamentary seats and secondary education) and labour force participation in Spain 1960–2010.

    Smoking prevalence and GSR

    The GSR (female-to-male) increased consistently from 0.06 in 1960 to 0.75 in 2010, meaning that the female and male smoking prevalence converged over time (figure 1, right). In 1960, fewer than 3% of women regularly smoked cigarettes compared with approximately 53% of men (figure 1, left). Female smoking prevalence increased, especially during 1970–1985, reaching a maximum of 27% in 1990–1995; the prevalence then remained stable until the early 2000s, when a decline in prevalence rates began, reaching 21% in 2010. Male smoking prevalence plateaued around 55% from 1960 to 1980, with a further decline to 27% in 2010.

    Association between GII and GSR

    The bivariate Pearson's correlation coefficient between GSR and GII was −0.99. The results of the log-log linear regression show that for each 10% decrease in GII towards equality (a 0.1 decrease in the index), the GSR increases by 10.6% (p<0.001). This means that each 10% increase in gender equality was associated with 1.06 additional smoking women per 10 smoking men in Spain during the period 1960–2010.

    Smoking prevalence by birth cohort and education

    In men, the oldest cohorts do not show a clear educational gradient while new cohorts (born after 1960) show a gradient whereby men with lower levels of education have a consistently higher smoking prevalence (figure 3A). When stratified by education, a clear cohort gradient is apparent as younger cohorts of men have a lower smoking prevalence, with this effect being especially marked in men with tertiary education (figure 4A).

    Figure 3
    Figure 3

    Male (A), female (B) smoking prevalence in Spain 1960–2010 by birth cohorts. A reference line at 30% prevalence has been added.

    Figure 4
    Figure 4

    Male (A), female (B) smoking prevalence in Spain 1960–2010 by level of education. A reference line at 30% prevalence has been added.

    Women born before 1940 have a very low smoking prevalence regardless of education, while those born 1940 through 1980 show an inverse education gradient with highly educated women having the highest smoking prevalence rates. Women born after 1980 show the same educational gradient as men—that is, smoking prevalence is higher among women with lower levels of education (figure 3B). Following stratification by education, smoking prevalence increases over time in women with low education levels (no or primary education), shows no cohort effect for women with secondary education, and shows declining prevalence in younger women with tertiary education (figure 4B).

    Comparing men and women, men born before 1940 have a consistently higher smoking prevalence compared with women, regardless of attained education. For people born between 1940 and 1960, there is an apparent convergence of smoking prevalence of men and women that is more marked in people with higher levels of education (figure 5A). Men and women born after 1960 have a similar smoking prevalence regardless of education level (figure 5B). In the statistical analysis of the association between GSR and GII, we found that there was a cohort/education interaction in this association. For the cohorts born before 1940, between 1940 and 1960 and between 1960 and 1980, we found that the association between GII on GSR differed by education (p<0.001, p<0.001 and p=0.001, respectively), while for the cohort born between 1980 and 1996, this association was similar across education groups (p=0.25). For all educational groups, there was a statistically significant cohort effect (p<0.001 for all tests), driven mostly by the cohort born before 1940 which had consistently low GSR.

    Figure 5
    Figure 5

    Gender smoking ratio by birth cohort (A) and level of education (B). A reference line has been added at 1 (equal smoking prevalence by gender).

    Discussion

    We found a strong negative correlation between gender inequality as measured by the GII and the female-to-male smoking ratio (GSR) in Spain over the past 50 years. In other words, increasing gender equality was associated with higher female-to-male smoking ratio. Patterns by birth cohort and education were apparent.

    Our findings are consistent with previous findings on the relationship between the Gender Empowerment Measure and GSR across 74 countries.6 These results are to be expected given that the GII complements the Gender Empowerment Measure by taking into account other aspects of gender equality in addition to empowerment. Our findings are also consistent with those of Pampel17 on the association between women's smoking prevalence relative to that of men and gender equality in 106 countries. Our findings regarding the intersectionality between class and gender are similar to those of other smoking studies conducted in other countries.18

    Our results support the interpretation of class and gender differences from a intersectional perspective given the apparent interaction11 between class and gender in smoking transitions.9 Therefore, it seems appropriate to include both axes in adaptations of the theory of diffusion of innovations to the smoking epidemic.3 Early adopters (men in the gender axis, people with higher education in the class axis) are followed by late adopters (women in the gender axis and people with a lower educational level in the class axis) in both smoking uptake and cessation. This is apparent in figures 3 and 4, where there is a shift in the class composition of smokers, occurring around the birth cohort of 1961–1980 in men and 1981–1996 in women. Moreover, the contextual effect of gender inequality is evident in the stratification by birth cohorts as the largest changes in GSRs occur across birth cohorts and do not vary by educational level (GSR=∼1) in younger cohorts. The observed intersectionality between class and gender may be of particular interest for countries in the early stages of the smoking epidemic, when smoking prevalence among women is low. Recognition of this phenomenon may help inform the development of more effective tobacco control policies aimed specifically at low SES (socioeconomic status) women. The observed cohort effect in both male and female smoking prevalence patterns suggests that women born in a more gender equal context have smoking prevalence patterns that emulate those of men.

    The association between gender inequality and GSR can be explained by the rapid social, political and economic transformation that took place in Spain over the past 50–60 years, including a rapid evolution and improvement in the living conditions and opportunities of women living in Spain.14 These changes created opportunities for the tobacco industry to specifically target women using emancipation imagery, depicting smoking as a symbol of success and gender equality.7 Previous analyses of internal documents and advertisements in Spain19 have shown that tobacco companies started targeted advertising towards women in the early-to-mid 1980s, an era of enormous social change in Spain that included an increase in women's participation in the labour market and the loosening of social constraints on smoking.14 In the early 1980s, two-thirds of all television tobacco advertising expenditure was dedicated to promotion of ‘light’ cigarettes, smoked predominantly by women; by 1986, this proportion had increased to 90% of all television tobacco marketing expenditure. Women born between 1960 and 1980 (aged 6–26 in 1986) were thus exposed to large amounts of targeted advertisement—an experience likely to have been influential in shaping their subsequent behaviours, since most experimentation with cigarette smoking happens between the ages of 10 and 24.20 Cigarette advertising targeting low SES women is likely to have contributed to the recent increase in smoking among low SES women compared with high SES women. While there are no specific analyses of such practices in Spain, a recent report21 has shown that, in the USA, advertising targeting low SES women started in the late 1970s and continued all through the 2000s. Given the delayed opening of the Spanish market to global tobacco brands, it is plausible that advertising targeting low SES women may not have occurred in Spain until the 1990s, corresponding with the reversal of the SES gradient among female smokers.

    The health impacts of Spain's social smoking patterns are evident in a recent report22 that found that socioeconomic inequalities in mortality due to cardiovascular diseases are smaller in Spain compared with other European countries. One hypothesised mechanism is the smaller socioeconomic inequalities in smoking prevalence between women and men observed in Spain. Our study shows that these reduced inequalities in smoking are the by-product of the late adoption of smoking by less educated women in Spain compared with highly educated women. Given the trends shown in our analysis, disparities in smoking by educational level in Spain are likely to increase in future years. Therefore, the relatively modest socioeconomic inequalities seen to date may increase in the future.

    In societies undergoing social, political and economic transformation affecting women, public health efforts need to be directed towards the protection of vulnerable subpopulations from well-known risk behaviours,23 in line with the WHO Framework Convention on Tobacco Control and other international public health efforts. Gender-sensitive policies13 are needed in countries in earlier stages of the epidemic in order to keep smoking prevalence low in both men and women. Moreover, special focus should be given to low SES women.

    Limitations and strengths

    Our study has some limitations. As with any ecological study, causality cannot be inferred from our findings. Given the study design, we cannot predict the probability of smoking of a woman given a certain level of gender equality. Nonetheless, gender equality is an important contextual exposure and ecological studies are therefore the appropriate tool for population-level inferences.24

    The GII is a complex index, mixing absolute measures with relative female-to-male shares, as well as indicators of empowerment with indicators of well-being. The resulting index may be difficult to interpret as the data have undergone many transformations and include different dimensions.25 Other possible limitations of the GII include its low specificity to capture gender equality processes once a country has passed a given level of development. In Spain, given the enormous social and economic changes during the study period, the index was able to appropriately measure gender inequality trends, as Spain only reached considerable levels of development in the last decades of the study period.

    The major strengths of our study include the consistency of the data, criteria and indicators used to estimate the GII and its components, as well as smoking prevalence in Spain over time. Our analyses incorporated a multidimensional measure of gender inequality that includes SES and education, which are known determinants of smoking.

    Conclusions

    Our findings indicate that an increase in gender equity in Spain throughout the five decades studied (1960–2010) was followed by an increase in the female-to-male smoking ratio, with differential effects by birth cohort and education level. Given the health effects of smoking, gender-sensitive tobacco control measures, policies and programmes are necessary to protect women, especially those of low SES, from the burden of smoking.

    What this paper adds

    • Smoking prevalence in Spain has tended to converge by gender over time. This social phenomenon has been strongly modified by birth cohort and educational level. Tobacco control policies in countries at earlier stages of the tobacco epidemic should aim to protect younger women with lower educational levels.

    Acknowledgments

    UB was supported by a La Caixa Fellowship (2012 edition) and by the Enrique Nájera grant for Young Epidemiologists (10th edition) awarded by the Sociedad Española de Epidemiología and the Escuela Nacional de Sanidad. The authors would like to thank Emily Knapp for her help in language editing the manuscript. They would also like to thank the editor and the three anonymous reviewers for their helpful comments that greatly improved this paper.

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    Supplementary materials

    • Supplementary Data

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    Footnotes

    • Contributors UB designed and conceptualised the study, conducted the statistical analyses, interpreted the results, and drafted and revised the manuscript. PB and MF designed and conceptualised the study, interpreted the results, and drafted and revised the manuscript. EF, AN-A and FB interpreted the results, and drafted and revised the manuscript. MF is the guarantor. UB and PB contributed equally to this manuscript.

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement All data were obtained from publicly available sources.

    • Acknowledgements Dr. Esteve Fernández was supported by the Instituto de Salud 390 Carlos III, Government of Spain (grants RTICC RD06/0020/0089 and RD12/0036/0053), and the Ministry of Universities and Research, Government of Catalonia (grant 2009SGR192).