MRC policy briefs to government

Tobacco use by black women in Cape Town

Dr Amy Seidel Marks*, Dr Krisela Steyn#, Eleni Ratheb*

*Graduate School of Business, University of Cape Town. Tel.: +27 21 406-1414; Fax: +27 21 406-1412; e-mail: amymarks@gsb.uct.ac.za
#Chronic Diseases of Lifestyle Programme, Medical Research Council Cape Town. Tel.: +27 21 938-0345; Fax: +27 21 933-5519; e-mail: krisela.steyn@mrc.mrc.za

Black women are a strategically important market for tobacco companies. They comprise over 39% of the South African population and constitute a key market for ‘fast-moving-consumer-goods' products like cigarettes and snuff.

Traditionally, black African women, have had among the lowest rates of smoking in South Africa — with estimates of their smoking incidence ranging from 7% to 12%.
However, they are increasingly being targeted by tobacco companies and exposed to tobacco marketing aimed at them.

Tobacco usage by women is disturbing, not only because of the diseases and early death it produces, but also because women have a significant influence on the consumption behaviour of their children, family and community members. It also results in the exposure of household members to secondhand smoke. In addition, it increases the incidence of tobacco-related harm inflicted upon children during their mothers' pregnancies.

This brief discusses key findings of a research project that surveyed 1314 black Xhosa-speaking women aged 15 to 64 years living in the Cape Town metropolitan area. The project studied the knowledge, attitudes and practices of black women regarding tobacco use. This information is essential for the development of interventions to empower black women against the messages of the tobacco companies that reach them

The study was designed to interview women who were smokers and/or snuff users so as to compare them with tobacco non-users. A quarter of those interviewed were smokers, 27% snuff users, 2% used both cigarettes and snuff and just under half (46%) did not use tobacco.

Tobacco users were found to be older and less educated than the non-users. Tobacco use is perceived to be taboo for black women and those who use it do so secretly or only with trusted others. Prior research among black people in Cape Town found that, although it was generally acceptable for black men to smoke in most settings, it was unacceptable for black women to smoke anywhere.

Over three-quarters of the women said that most Xhosa people would not approve of women smoking, and even the majority of the smokers agreed with this. Most of the reasons the women offered (80%) for why men should not smoke focused on the negative effects of cigarettes on the health of the smoker and those around him. By contrast, most of the reasons they gave for why women should not smoke (72%) were that it is disgraceful, shameful and taboo for women to do so.

Smokers surmounted these barriers by smoking in private settings, the majority said they smoked secretly, alone or with friends, and 20% said they smoked in toilets. The overwhelming majority said they did not smoke in front of elders or parents. Snuff users were similarly circumspect about pursuing their practice. The overwhelming majority of all the women (96%), and even 87% of the smokers, felt that people should not be allowed to smoke in public places like shops, taverns and train stations.

Tobacco marketers aim to change societal norms against black women using tobacco. Although social norms within the black South African society currently work against women becoming tobacco users, similar norms that previously existed in other countries have been over-powered by tobacco marketing. This occurs to the extent that worldwide tobacco non-users in industrialised economies swim against social trends that pull them toward tobacco use. Tobacco marketers can be expected to focus on altering the norms prohibiting black women's smoking and snuff usage, and tobacco-control strategists can no longer rely on traditional restraints to keep black women's tobacco-usage rates low.

Tobacco marketing is currently successful in reaching black women as the majority of the participants reported personal exposure to tobacco marketing. A third of all the women had recently seen cigarette advertisements, with 42% of smokers reporting this. Three-quarters had purchased cigarettes as children on behalf of adults and the vast majority knew the current price of a single cigarette. All the women had a worrying lack of awareness of the health hazards of tobacco usage.

The majority of the women were conscious that tobacco use was unhealthy. However, the smokers drastically underestimated the real health hazards of smoking and 33% of the non-smokers also showed a worrying lack of knowledge about the true harmful effects of smoking. The findings suggest that a segment of the non-smoking women as well as a majority of the smokers still need to be properly convinced of the health hazards of smoking.

Over 70% of all the women had been exposed to smokers in the family as children. However, smokers were much more likely currently to be surrounded by other smokers such as husbands or partners and other family members who smoked. Over half of their close female friends were smokers, compared to only 20% of the snuff users' friends and 10% of the non-users' friends. Snuff users were also more likely to be surrounded by other users of snuff. The daughters of smokers were significantly more likely to smoke and use snuff.

Most worrisome, however, was that over a quarter of the whole sample's female children was reported to smoke, with the female children of the women smokers showing a significantly higher rate of 36%. These daughters of female smokers were themselves being exposed not only to their mothers' smoking but also to that of other family members compared to the daughters of the other women interviewed. The same was found for the daughters of smokers and of snuff users regarding the use of snuff.

Beneficial associations
Those who used tobacco had rationales for why tobacco use was beneficial. Smoking was associated with weight loss in most smokers' minds. Snuff users thought that snuff had medicinal value and particularly that it relieved pain. Interventions are needed to respond to tobacco users' incorrect perceptions so that, at the very least, users recognise the health hazards and do not inflate tobacco's value as a source of weight control or pain reduction.

Among the smokers there was a dangerously high level of tobacco use during pregnancy.
Over half the smokers said that they had smoked during pregnancy and over a third of the snuff users said that they took snuff while pregnant.

Conservative estimates indicate that, on average, the women who were smokers spent at least 10% of their disposable income on their own cigarettes. This is only part of the picture of how tobacco affected the economic status of households with smokers, since the majority of women smokers had partners and other family members who also smoked and their expenditures are not reflected in this estimate.

A commercial marketing research tool called the Conversion Model, which has been used by the tobacco industry to segment its markets, was used to determine how committed the women who did not use tobacco were to remaining non-smokers. Overall the results of this analysis showed that the majority of women in this sample who did not use tobacco were at risk of converting to smoking.

Five per cent were found to be pro-smoking in orientation and on the verge of smoking. These women had a more urban and less traditional identity, were less sensitive to others' disapproval, had more exposure to cigarette advertising and female friends who were smokers, and were more hedonistic and less health-oriented than the other women non-users. They tended to live in informal, serviced areas.

Another 53% were found to have only a shallow commitment to remaining non-smokers. Although they had a more traditional sense of Xhosa identity, they lived in informal areas without services. They were the most economically disadvantaged and in the midst of social transition. These women were significantly desensitized to social taboos against black women smoking and were surrounded by smokers in their families and among female acquaintances. They showed more of a tendency to go against conventional practices and to use alcohol than did the other non-users of tobacco.

Marketing and social science theory would predict that these women's commitment to not smoking is liable to erode because of their vulnerability to influence by the smokers around them and by tobacco marketing.

Policy implications

• Tobacco users were found to be somewhat older and less educated than non-users. This suggests that school-based tobacco control interventions do not reach significant portions of the older black women who are deciding on whether or not to use tobacco or on whether and how to quit. The fact that snuff users tended to be the oldest and to have somewhat higher incomes further emphasises the need for intervention programmes that speak to adult women in addition to those that target young women.
• Many aspects of the current tobacco-control legislation in South Africa were supported by findings from this study. All the women were aware of and had experience with tobacco marketing. This argues for continued efforts to ensure that the regulations of the tobacco control legislation are implemented particularly in regard to the banning of advertising. Also the sales to minors should be monitored as this study found that many of the women had bought tobacco products as children and that this experience was significantly related to current tobacco usage. The women's solid rejection of smoking in public places, even by the smokers, support the legislation.
• Tobacco-control efforts need to inform smoking adults about the impact of their behaviour on the next generation and others around them At the very least, there is an urgent need to educate and motivate adults to counteract the impact on children of their own and others' modeling of tobacco usage. The data showed that smokers' own children were much more prone to be both smokers and snuff users than were the children of those who did not use tobacco. Smokers were more prone to have been exposed to family members' smoking while growing up and to have been sent to buy tobacco for others as a child.
• All the women, but particularly the tobacco users, underestimated the real health risks of tobacco usage. This suggests a widespread ignorance of tobacco's actual health hazards among black women in peri-urban areas. Tobacco-control efforts need to develop strategies to counter smokers' beliefs that smoking helps with weight-loss and snuff users' beliefs that snuff has specific medicinal properties. They also need to enable tobacco users to identify and understand which of their own health problems are related to their tobacco usage and the health risks of their tobacco usage.
• Tobacco-control strategy must address the fact that smokers are not deterred by traditional social taboos against smoking. Trying to implicitly or explicitly enforce current taboos or call upon traditional cultural authority will not convince urbanised women to remain tobacco free but probably drive them towards tobacco. The women were very clear that traditional mores condemned tobacco, which makes tobacco an obvious vehicle for a woman to use to symbolise a move away from tradition towards a modern lifestyle. There is an urgent need for tobacco control policies and interventions that delink smoking from modernity and being progressive, a relationship that tobacco marketing pushes.
• Tobacco control efforts need to link being tobacco free with the things black women value most, whether it be personal dignity, family welfare, upward mobility or access to personal and social development.
• Tobacco-control initiatives are needed that would help smokers and those contemplating smoking to understand what they forfeit financially when they buy cigarettes and that the money could be better spent on things they value more, such as children's school fees, a better quality of housing and lifestyle. Programmes and interventions should be developed to offer easily accessible mechanisms for choosing, at the point of cigarette purchase, to spend money on alternatives that directly benefit the women and their families.
• It is important to remember that the majority of black women are not yet tobacco users and that resources invested in helping female smokers and snuff users to quit must be carefully targeted so as not to draw needed resources away from prevention policies and interventions. However, one form of cessation that is warranted is to target women tobacco users of childbearing age with interventions aimed at stopping smoking and snuff usage during pregnancy.
• These findings suggest that the majority of the Black South African women who do not yet use tobacco are at risk of converting to smoking, some almost immediately and others by more gradually slipping into a smoking lifestyle. They also shed light on how to reach such women. Women in informal, under-serviced areas must be targeted in to order reach those who are only non-smokers with interventions that forestall them from moving into a pro-smoking orientation and then into smoking.

Acknowledgements
This project was carried out with the aid of a grant by Research for International Tobacco Control (RITC), an international secretariat housed within the International Development Research Centre (IDRC) in Ottawa, Canada.