Public Submission by Women’s Health Victoria - Draft National Tobacco Strategy 2010 — 2018
Draft National Tobacco Strategy 2012-2018
Women’s Health Victoria,
GPO Box 1160, Melbourne, 3001
Telephone: (03) 9664 9300
Contact: Rita Butera, Executive Director
14 June 2012
Draft National Tobacco Strategy 2012
Health Management Advisors
PO Box 1311
Fitzroy North VIC 3068
IntroductionWomen's Health Victoria is a statewide women’s health promotion, information and advocacy service. We are a non government organisation with most of our funding coming from various parts of the Victorian Department of Human Services. We work with health professionals and policy makers to influence and inform health policy and service delivery for women.
Our work at Women’s Health Victoria is underpinned by a social model of health. We are committed to reducing inequities in health which arise from the social, economic and environmental determinants of health. These determinants are experienced differently by women and men. By incorporating a gendered approach to health promotion work that focuses on women, interventions to reduce inequality and improve health outcomes will be more effective and equitable.
Women’s Health Victoria’s vision is for a society that takes a proactive approach to health and wellbeing, is empowering and respectful of women and girls and takes into account the diversity of their life circumstances.
Women’s Health Victoria’s ways of working are guided by four principles:
- We work from a feminist framework that incorporates a rights based approach.
- We acknowledge the critical importance of an understanding of all of the determinants of health and of illness to achieving better health outcomes.
- We understand that the complexities involved in achieving better health outcomes for women require well-considered, forward thinking, multi-faceted and sustainable solutions.
- We commit to ‘doing our work well’; we understand that trust and credibility result from transparent and accountable behaviours.
Priority and action areas
1. Are the priority areas, action areas, and the supporting evidence appropriate and sufficient?
1.1 Smoking is a gendered issueWomen’s Health Victoria commends the priorities set out in the draft National Tobacco Strategy 2012-2018 (‘the Strategy’). The focus on partnerships, inequity and prevention among disadvantaged groups is welcome. Tobacco use is the single most preventable cause of ill health and death in Australia, and this strategy sets out a clear, ongoing direction for the prevention of smoking in Australia.1 However smoking is a gendered issue and there are multiple ways that gender differences and gender inequities influence smoking uptake, behaviours and cessation, requiring a different approach to policies and programs for women and men.i These are not considered in the priority areas, action areas and supporting evidence of the draft Strategy. For example:
- Approximately 17% of Victorian women are current smokers,2 which is slightly less than the national rate of 20%.3
- The prevalence of smoking in Victorian women is highest in the 18-24 year age group, at 22%.2
- Over the past few decades, women and men’s smoking behaviour has become more similar. Female smoking rates are generally lower than those for males but this gap has reduced over time.4
- Despite the overall declining rates of tobacco use, tobacco experimentation and uptake among Victorian adolescents remain high. Of girls aged 17 years, 51% have ever smoked and 15% are current smokers.5
- Adolescent girls are experimenting with smoking at a slightly higher rate than boys, and are more likely to continue smoking.5
When considering the current rates of adolescent female smoking uptake, along with findings that women are less likely to succeed in quitting than men, it is possible that we could see a higher smoking prevalence in women than in men, and tobacco-related morbidity and mortality in females could eventually surpass that of males.6
Smoking in linked to inequality, with people with low socio-economic status, Indigenous peoples, those with mental health issues, same-sex attracted women and young mothers exhibiting higher levels of smoking. 7 These patterns are often gendered in the way that poverty and equity are gendered, with women having lower incomes, more childcare responsibilities and less power in relation to men. 7
This research means that the National Tobacco Strategy must be gendered, and must take into account the different patterns of smoking for women and men, if it is to be effective. The priority areas and action areas need to reflect this, and the supporting evidence must be strengthened to demonstrate how the smoking and its impact differs for women and men.
Recommendation: Ensure the Strategy demonstrates a commitment to women’s health.
Recommendation: Ensure that the priority areas, action areas and supporting evidence include information about how smoking differs for women and men.
1.2 Women at risk of demonizationOne group that is at risk of ‘demonisation’ from the Strategy is pregnant women. A number of actions relate to women smoking when they are pregnant (particularly 6.3.9 and 6.8.2.) This focus on the policing of pregnant women is problematic. Smoking is generally associated with poverty and inequality.8-9 It is not a ‘lifestyle’ choice. For example, studies in the UK have shown that pregnant women under the age of 20 are three times more likely to smoke than pregnant women over 35. Women in routine or manual occupations are four times more likely to have smoked during pregnancy than those in managerial or professional roles.10
A difficulty with delivering smoking cessation messages during pregnancy is the primary focus on the wellbeing of the foetus. While this is an important message, it is liable to foster the low self-regard that often contributes to women’s smoking in the first place.11-12 Not surprisingly, there is a high rate of relapse among women post-partum 19, 71, particularly in those with low socioeconomic status.13 This affects the mother’s health as well as the health of her family. One UK study demonstrated how women were reluctant to access smoking cessation services for reasons that included unsatisfactory information, only short-term support, and, significantly, ‘lack of enthusiasm or empathy from healthcare professionals’. This may be exacerbated if prevention measures demonise and stigmatise certain population groups for ‘non-compliance’.10
Although pregnancy can be a motivator to stop smoking, cessation during this time is usually only temporary. Canadian research shows that about one-fifth of women who quit smoking during pregnancy return to smoking before delivery and 70% to 90% return to smoking within one year after the birth of their child. 14 UK research shows similar results. 10 Furthermore, pregnancy-focused campaigns ignore all other women, and at any given time, more women are not pregnant than pregnant.
Sensitivity and innovation is needed. For policy responses to be effective, they need to move away from a stigmatising focus on the harm to the foetus and instead, should incorporate harm reduction; supporting families; and supporting effective social services. 15
Strategies that place a value on women’s health in and of itself are crucial. Expecting to Quit, a Canadian best practice review of smoking cessation interventions for pregnant and postpartum women, sets out a number of recommendations for a women-centred approach to smoking cessation. 14 These include the need to:
- Reduce stigma;
- Prevent relapse;
- Practice harm reduction;
- Engage partner and family support; and
- Integrate social issues.
Recommendation: Ensure the Strategy does not demonise and stigmatise segments of the population.
Recommendation: Ensure that a woman-centred approach to smoking cessation by pregnant women is used, using Expecting to Quit as a model.
2. Are there any gaps in priority areas or action areas?The priority areas and action areas are robust and clear. For Women’s Health Victoria, however, it is crucial that the gendered nature of each of the priority areas and action areas are addressed.
One example of the need for tobacco policies and programs to address gender in order to be effective relates to the barriers to smoking cessation. Research has found that women may find it more difficult to quit smoking than men and have a higher number of relapses. 11, 16 Common barriers women face when quitting smoking are:
- The association between smoking and stress relief. Stress related to financial problems is linked to women’s continued smoking and relapsing, more so than for men. 17 A survey of North American women found the biggest perceived barrier to cessation is stress (63%).18
- Concerns about weight-gain post cessation which lessens the desire to quit. 11,19 In the same North American survey, fear of weight gain was listed as the second major concern at 41%.18
- Partner smoking, creating a difficult environment for quitting. 20
- Side effects in using nicotine replacement therapy. Women who quit smoking often express unbearable cravings for nicotine 18 which can be combated by nicotine replacement products. However, women report more side effects from using nicotine replacement products than men. 21
This research highlights the importance of using a gender analysis framework.
2.1 Gender analysis frameworkA gender analysis framework is a tool that encourages the development of policies and programs which take account of and are responsive to gender. It is predicated upon the following:
- All policies and programs have an impact on women and men;
- Policies and programs affect women and men differently; and
- Diversity exists between individual women and men, and within groups of women and men.
The framework can help identify, understand and address the various and overlapping factors that influence the experience of smoking for women and men. There are substantial differences in the lives of women and men, even within the same cultural, ethnic, age, and religious groupings. Gender differences in our society can influence both women's and men's:
- Exposure to risk factors;
- Access to and understanding of information about disease management, prevention and control;
- Subjective experience of illness and its social significance;
- Attitudes towards the maintenance of one's own health and that of other family members;
- Patterns of service use; and
- Perceptions of quality of care.
Policies and programs that do not account for gender differences may have a detrimental impact on both women and men.
The gender analysis framework consists of three elements:
- Gendered data: Use gender-disaggregated statistics proactively in planning to gauge the extent to which women and men benefit or are affected by the policy or program.
- Gender impact assessment: Monitor new and existing policies and programs for their gender impact and use knowledge to adapt existing or proposed policies and programs to promote gender equity in both planning and implementation.
- Gender awareness raising: Take opportunities to build capacity and understanding of how policies and programs can cause or lead to discriminatory effects.
These stages will help to ensure that policies and programs reflect the experiences of women in Victoria. ii
Recommendation: A gender analysis framework is applied to ensure that policies and programs that aim to prevent smoking are responsive to gender.
Monitoring and progress
3. Are there any gaps in outcome indicators?Evidence shows that gender plays an important role in the issue of smoking. Therefore, research into the factors that influence girls and women to smoke is required to inform programs that address the needs and interests of women. Gender sensitive research practice is achieved through:
- A systematic and consistent collecting and reporting of sex-disaggregated data: This is critical in gauging how women and men behave and are impacted differently.
- A gender analysis of evidence: This leads to policies and programs that are targeted to the varying needs and concerns of women and men, so that outcomes can be improved for both.
Recommendation: Ensure that sex-disaggregated data is collected and analysed to inform research and practice.
Recommendation: Carry out gendered research into tobacco cessation and the barriers and supports to quitting.
4. Are there any potential barriers to implementation not discussed in the report that may impact on the effectiveness of the strategy?Tobacco consumption is an indicator of inequality in our society – this must form the foundation of the Strategy. Nicotine addiction plays a central role for most smokers, however:
- Smoking is intimately linked with poverty8, isolation and the care-giving role9.
- Poverty and low income is associated with higher rates of smoking among adults22, and women constitute a disproportionate share of people living in poverty.
- Women account for more than 80% of sole parents in Australia. Around 46% of single mothers smoke and the highest smoking rate in this group are single mothers between the ages of 19 and 29 at 59%23.
Studies have found that adult women smoke to cope with the stress in their lives that is caused by gender inequalities of economics, multiple roles and violence against women24. This research reinforces how tobacco consumption in Australia is linked with low income, disadvantage and gender.
Recommendation: The complexity of reasons for taking up, maintaining and quitting make smoking much more than a ‘lifestyle choice’ and smoking policy in Australia must reflect this.25
5. How should these barriers be overcome?Recommendation: Ensure the Strategy focuses on health inequalities.
Recommendation: Ensure the Strategy actively addresses the prevalence of tobacco consumption in low income and disadvantaged groups.
Recommendation: Integrate and address a range of social, environmental and economic determinants and policies that contribute to tobacco consumption within the Strategy.
Referencesi In this submission, Women’s Health Victoria will be drawing from a Gender Impact Assessment on Women and Tobacco that we produced in 2010 (For more information please visit : Women’s Health Victoria Website)
ii For more information on Women’s Health Victoria’s Gender analysis framework, please visit Women’s Health Victoria Website
1. Australian Institute of Health Welfare. Australia's health 2008: the eleventh biennial health report of the Australian Institute of Health and Welfare: chapter 4: determinants: keys to prevention. Australia's Health. 2008 2008;11(2008):107-71.
2. Victoria. Department of Health. Victorian population health survey report 2008. Melbourne: Victoria. Department of Health; 2010.
3. Australian Bureau of Statistics. Tobacco smoking in Australia: a snapshot. Canberra: Australian Bureau of Statistics; 2006.
4. Australian Institute of Health and Welfare. 2007 National drug strategy household survey: first results. Canberra: Australian Institute of Health and Welfare; 2008.
5. Victoria. Department of Health. Victorian secondary school students’ use of licit and illicit substances in 2008: results from the 2008 Australian secondary students alcohol and drug survey. Melbourne: Victoria. Department of Health; 2009.
6. Morley KI, Hall WD. Explaining the convergence of male and female smoking prevalence in Australia. Addiction. 2008;103(3):487-95.
7. Greaves L. Gender, equity and tobacco control. Social Equity and Health. 2007;16(2):115-29.
8. Junor W, Collins D, Lapsley H. The macroeconomic and distributional effects of reduced smoking prevalence in New South Wales. Sydney: Cancer Council of NSW; 2004.
9. Atlantic Health Promotion Research Centre. Disadvantaged Women and Smoking Project (1994-1995). Toronto: University of Toronto; 2006 [cited 6 October 2009]; Available from: http://www.ahprc.dal.ca/1994-1995.html (This website link was valid at the time of submission).
10. Bauld L. Smoking during pregnancy and smoking cessation services. Journal of Smoking Cessation. 2008;4(2-5):2-5.
11. Broom D. Gender in/and/of health inequalities. Australian Journal of Social Issues. 2008;43(1):11-28.
12. Thompson KA, Parahoo KP, McCurry N, O'Doherty E, Doherty AM. Women's perceptions of support from partners, family members and close friends for smoking cessation during pregnancy: combining quantitive and qualitative findings. Health Education Research. 2004;19(1):29-39.
13. Crittenden KS, Manfredi C, Cho Young I., Dolecek Therese A. Smoking cessation processes in low-SES women: the impact of time-varying pregnancy status, health care messages, stress, and health concerns. Addictive Behaviors. 2007;32(7):1347-66.
14. 'Expecting to Quit' Research Team. Better practices for smoking cessation with pregnant and postpartum women. In: Highs & Lows: Canadian perspectives on women and substance use. Toronto: Centre for Addiction and Mental Health; 2007.
15. Greaves L, Poole N. Pregnancy, mothering and substance use. In: Highs & Lows: Canadian perspectives on women and substance use. Toronto: Centre for Addiction and Mental Health; 2007.
16. Mackay J, Amos A. Women and tobacco. Respirology. 2003;8(2):123-30.
17. McKee SA, Maciejewski PK, Falba T, Mazure CM. Sex differences in the effects of stressful life events on changes in smoking status. Addiction. 2003;98(6):847-55.
18. Reichert V, Seltzer V, Efferen L, Kohn N. Women and tobacco dependence. Obstetrics and gynecology clinics of North America. 2009;36(4):877-90.
19. Levine MD, Marcus MD, Perkins KA. A history of depression and smoking cessation outcomes among women concerned about post-cessation weight gain. Nicotine and Tobacco Research. 2003 February 2003;5(1):69-76.
20. Rohrbaugh MJ, Shoham V, Dempsey CL. Gender differences in quit support by partners of health-compromised smokers. Journal of Drug Issues. 2009;39(2):329-46.
21. Carter SM, Chapman S. Smokers and non-smokers talk about regulatory options in tobacco control. Tobacco Control. 2006;15(5):398-404.
22. Bobak M, Jha P, Nguyen S, Jarvis M. Poverty and smoking, 'tobacco control in developing countries'2000: Available from: http://www1.worldbank.org/tobacco/tcdc/041TO062.PDF (This website link was valid at the time of submission).
23. Siahpush M, Borland R, Scollo M. Prevalence and Socio-economic Correlates of Smoking Among Lone Mothers in Australia. Australian and New Zealand Journal of Public Health. 2002;26(2):132-5.
24. Greaves L, Barr V. Filtered Policy: women and tobacco in Canada. Winnipeg: British Columbia Centre of Excellence for Women's Health; 2000 [cited 7 October 2009]; Available from: Canadian Women's Health Network Website.
25. Greaves L, Barr V. Filtered Policy: women and tobacco in Canada. Winnipeg: British Columbia Centre of Excellence for Women's Health; 2000 [cited 2009 7 October]; Available from: Canadian Women's Health Network Website.
Page currency, Latest update: 29 January, 2013