That so many diseases, major and minor, should be related to smoking is one of the most astonishing findings of medical research in this century…less astonishing than the fact that so many people have ignored it. —Sir Richard Doll, 1912–2005

Tobacco transnationals minimize the dangers of smoking in powerful advertising that goes round the globe, while health agencies and institutions strive to counter these media messages on shoestring budgets—an astounding asymmetry that endangers the health of millions.

Globally, 12% of women smoke, 22% in developed and 9% in developing countries. While smoking has peaked in men and begun a slow decline, it is predicted that by 2025, 20% of women worldwide will be smokers, with so many younger women taking up the habit.[1] Closing the “smokers’ gap” between men and women isn’t happening spontaneously: it’s due to worldwide social, economic and political processes, to changes in the image and role of women in society, and to aggressive gender-targeted marketing by the tobacco companies.

As male smokers quit or die of smoking-related illnesses, women—young women in particular—are the market the tobacco industry goes after to survive, and gender-specific research on what motivates women to smoke is aimed at the “feminization of tobacco”.

But there’s more to it, as we can see from the case of Cuba, where tobacco advertising was prohibited as far back as 1960. Yet, the country has among the highest rates of women smokers in Latin America.[2] So, it is worth considering the long-term effects of marketing on our perspectives, but also the roles played by society as a whole, health institutions and women ourselves in this smoking epidemic.

Part of Cuba’s story isn’t unique when it comes to women and smoking: it has to do with the changing gender roles in contemporary society. Related to this, global advertising—to which Cuba isn’t immune—has succeeded in associating smoking with freedom, independence, modernity and empowerment; identifying a cigarette-in-hand with women’s self-esteem, sensuality, and sophistication; a product synonymous with recreation, relaxation and fun. Not to mention those of us who have bought into the “virtues” of smoking to lose weight or alleviate stress.

All these connotations have permeated Cuban women’s social environment, passed down to the present generation. Today in our media, images of female movie and TV characters smoking to play up their status, increase their sex appeal, or just relieve tension, conflict with health promotion spots on the dangers of smoking.

Cuba has the added challenge of producing what many consider the world’s best tobacco: put another way, we are a country of smokers by tradition. Tobacco is in our culture, associated with our music, even our social and political struggles. Tobacco’s role in the Cuban economy is so important that it is critical to understanding the context of Cuban life itself, irrespective of gender, although women are the majority of employees in the domestic tobacco industry.

All these factors contribute to the high rates of smoking in Cuba. Although moderate overall declines occurred from 1984 to 2010, smoking among women actually increased between 1984 and 1995, only later dropping to 2010 levels. Declines since 1995 have been more marked in men (17.0%) than in women (9.7%).[3] Thus, while women have never smoked as much as men, the male–female gap is narrowing. And, alarmingly, women’s morbidity and mortality rates from smoking-related causes are approaching men’s, particularly for cancer.

Clearly we have to go beyond banning tobacco advertising: we have to “demarket” smoking and counter the positive images that permeate our culture with more sophisticated presentations of the threat to health. We also need to create more barriers to tobacco access—in addition to those already banning sales to youngsters and raising cigarette prices—aligning education and legislation for greater effect.

And finally, we need to understand more fully the forces that influence people—particularly young women—to start smoking. Is it enough to increase their knowledge about smoking’s harmful effects? If it were, no health workers would smoke. Yet, a 2008 study in the Habana Vieja municipality of Cuba’s capital found that over 50% of women had smoked at one time; and worse yet, 36.7% of female health professionals who smoked had continued to do so during their pregnancies.[4]

Without doubt, imitation is key to explaining why young people start smoking: parents, teachers, health professionals and other role models need to be aware of our own responsibility for the smoking epidemic, as virtual vectors giving a free ride to propagate tobacco use.

Certainly, fathers and mothers have the same responsibility for their children, but gender roles still place more reliance on women and Cuban society is no exception. Thus, paradoxically, women have the potential to be bigger players in prevention, protecting our children from secondhand smoke and particularly from the example of parental smoking. In essence, as women, we have the opportunity to safeguard not only our own health, but to become the main bulwark against smoking in younger generations; to dismantle and demystify the false images; help teenagers develop capacities to resist peer pressures to smoke; and to provide an example of smoke-free families and environments.

1. Mackay J, Eriksen M, Shafey O, Ross H. The Tobacco Atlas. 3rd ed. Atlanta, GA USA: American Cancer Society, World Lung Foundation; 2009.
2. Regueira G, Suárez N, Jakimczuk S. Estrategias para la prevención del tabaco con perspectiva de género en América Latina. Salud Pública Mex. 2010;52(2):315–30. Spanish.
3. Suárez Lugo N. Paradojas, controversias, discurso y realidad del tabaquismo en Cuba. Rev Cub Salud Pública. 2011;37(1). Spanish.
4. Suárez Lugo N, Negrín ES, Caraballoso HM. El tabaquismo en los profesionales de la salud. Habana Vieja, 2007. Rev Cub Salud Pública. 2008;34(4):1–11. Spanish.