Abstract
Background: Female smoking prevalence is dramatically lower in developing countries (3.1%) than developed countries (17.2%), whereas male smoking is similar (32% vs 30.1%). Low female smoking has been linked to high gender inequality. Alternatively, to protect their offspring from teratogenic substances, pregnant and lactating women appear to have evolved aversions to toxic plant substances like nicotine, which are reinforced by cultural proscriptions. Higher total fertility rates (TFRs) in developing countries could therefore explain their lower prevalence of female smoking.Objective: To compare the associations of TFR and gender inequality with national prevalence rates of female and male smoking.Methods: Data from a previous study of smoking prevalence vs gender inequality in 74 countries were reanalysed with a regression model that also included TFR. We replicated this analysis with three additional measures of gender equality and 2012 smoking data from 173 countries.Results: A 1 SD increase in TFR predicted a decrease in female smoking prevalence by factors of 0.58–0.77, adjusting for covariates. TFR had a smaller and unexpected negative association with male smoking prevalence. Increased gender equality was associated with increased female smoking prevalence, and, unexpectedly, with decreased male smoking prevalence. TFR was also associated with an increase in smoking prevalence among postmenopausal women.Conclusions: High TFR and gender inequality both predict reduced prevalence of female smoking across nations. In countries with high TFR, adaptations and cultural norms that protect fetuses from plant toxins might suppress smoking among frequently pregnant and lactating women.
Highlights
Preventing an epidemic of tobacco-related diseases among women in the developing world presents one of the greatest public health opportunities of our time
Because an increase in gender smoking ratio (GSR) could be due to an increase in the numerator or a decrease in the denominator, or both, we modeled smoking prevalence as an interaction of sex and gender empowerment measure (GEM), controlling for Gini coefficient of income inequality (GINI) and log gross national income per capita (GNI)
Our most important finding is that total fertility rates (TFRs) had a significant negative association with female smoking prevalence in all models, and a smaller negative association with male smoking prevalence, even after controlling for multiple indices of gender inequality
Summary
Preventing an epidemic of tobacco-related diseases among women in the developing world presents one of the greatest public health opportunities of our time. Female smoking prevalence is dramatically lower in developing countries (3.1%) than developed countries (17.2%), whereas male smoking is similar (32% vs 30.1%). Objective: To compare the associations of TFR and gender inequality with national prevalence rates of female and male smoking. Methods: Data from a previous study of smoking prevalence vs gender inequality in 74 countries were reanalysed with a regression model that included TFR. We replicated this analysis with three additional measures of gender equality and 2012 smoking data from 173 countries. Increased gender equality was associated with increased female smoking prevalence, and, unexpectedly, with decreased male smoking prevalence. TFR was associated with an increase in smoking prevalence among postmenopausal women
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