Health Promotion International Advance Access published online on May 9, 2007
Health Promotion International, doi:10.1093/heapro/dam012
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Article |
Sociocultural factors associated with cigarette smoking among women in Brazilian worksites: a qualitative study
1 University of Alabama at Birmingham, Department of Medicine, Birmingham, AL, USA 2 Pontifícia Universidade Católica do Paraná, Department of Psychology, Curitiba, PR, Brazil 3 Universidade Federal do Paraná, Department of Anthropology, Curitiba, PR, Brazil 4 Vanderbilt University, Division of General Internal Medicine and Public Health, Nashville, TN, USA
* Corresponding author. E-mail: scarinci{at}uab.edu
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SUMMARY |
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This study examined the contextual factors associated with smoking initiation and cessation among women in Brazilian worksites (Curitiba, Paraná, Brazil). A total of 22 focus groups were conducted among 108 women in private and public worksites. The most frequently endorsed negative factors that contributed to smoking initiation included exposure to smoking-prompting behaviors through family members, peer pressure, media and easy access/low cost of cigarettes. Positive factors that served as protective mechanisms against initiation included smoking-related health effects and strong influence from parents and family members. The most salient negative factors associated with smoking cessation included stress/anxiety-relieving benefits, weight control, access/low cost of cigarettes, being around smokers and risk-exempting beliefs. Positive factors included smoking restrictions at home and workplace and concerns about appearance. Current and former smokers reported that they had never received any assistance from their physicians to quit smoking, nor did they rely on smoking cessation programs or aids or believe in their effectiveness. There are specific contextual factors that contribute to smoking initiation/cessation among women in Brazilian worksites which have important clinical, research and policy implications.
Key words: women; cigarette smoking; Brazil
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INTRODUCTION |
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Brazil is the largest country in Latin America (Central Intelligence Agency, 2006; https://www.cia.gov/cia/publications/factbook/geos/br.html) and the second largest tobacco producer in the world (Mackay et al., 2006
), with 96% of Brazil's tobacco being produced in three Southern states: Rio Grande do Sul, Santa Catarina and Paraná (Schneider, 2006; http://www.afubra.com.br/diagnostico.ppt#380,9,Slide). Brazil also ranks number one in cigarette consumption in Latin America (131 billion cigarettes per year), which represents almost three times the cigarette consumption in Mexico (49 billion), the second largest cigarette consumer in the region (Souza Cruz, 2006; http://www.souzacruz.com.br/oneweb/sites/SOU_5RRP92.nsf/vwPagesWebLive/2E8C93157B8FF810C12570BB003BEFBB?opendocument&SID=&DTC=).
Although prevalence of cigarette smoking in Brazil is still higher among men than women, a 2002–2003 national survey indicated that the three Southern capitals had highest prevalence of cigarette smoking among women (22.9% in Rio Grande do Sul; 18.9% in Santa Catarina and 19.3% in Paraná, as compared to 
14% of women in the other state capitals combined) (Instituto Nacional do Câncer, 2004; http://www.inca.gov.br/inquerito/docs/completa.pdf).
The Global Youth Tobacco Survey, conducted in 12 Brazilian state capitals among youth in school settings (2002–2003), found that cigarette experimentation was higher among boys than girls, except for the Southern states, where cigarette experimentation was higher among girls than boys (e.g. 51 and 39%, respectively, in Curitiba, capital of Paraná). The same pattern was observed regarding current cigarette smoking (e.g. 16 and 11%, respectively, in Curitiba) (Instituto Nacional do Câncer, 2004; http://www.inca.gov.br/vigescola/docs/vigescola_completo.pdf). Another large survey, conducted in 107 Brazilian cities, found that girls between 12 and 17 years of age were more likely to report lifetime cigarette smoking (16.2%) than boys in the same age bracket (15.2%) (Galduróz et al., 2005).
While studies do not uniformly agree (Caraballo et al., 1998; Osler et al., 1999; Wetter et al., 1999; Stockton et al., 2000; Bohadana et al., 2003), the literature suggests that women are less likely to quit smoking than men (Osler et al., 1999; Wetter et al., 1999; Bohadana et al., 2003). A survey conducted across 15 Brazilian state capitals found that smoking cessation in the three Southern capitals was higher among men than women (48.7 and 42.4%, respectively, in Curitiba) (Instituto Nacional do Câncer, 2004; http://www.inca.gov.br/inquerito/docs/completa.pdf). Furthermore, another study found that, in the past 5 years, 55% of the callers to the Brazilian National Quitline were men (Pinho et al., 2006; http://2006.confex.com/uicc/wctoh/techprogram/P10473.HTM).
Tobacco companies make special efforts to promote cigarette smoking among women by ‘... using seductive but false images of vitality, slimness, modernity, emancipation, sophistication, and sexual allure’ (Mackay et al., 2006). In a review of tobacco industry documents targeting Latin America and the Caribbean, Bialous and Shatenstein found that some of the reasons for launching Virginia Slims in Latin America included: ‘image and beauty are strong elements in Latin American society; females have distinct and different roles than men in the Latin American society; [they] tend to be very involved with fashion ... seem to be comfortable with the concept of femininity’ (Bialous and Shatenstein, 2002; http://repositories.cdlib.org/context/tc/article/1039/type/pdf/viewcontent/).
Nonetheless, Brazil is one of the world's leaders in the development of legislative tobacco control efforts (Cavalcante, 2004; Instituto Nacional do Câncer, 2006; Stillman et al., 2006; http://www.inca.gov.br/english/tobacco_control.html). In 1995, and in subsequent amendments, the federal government approved comprehensive legislation addressing tobacco control in Brazil (e.g. limit the level of tar, nicotine, carbon monoxide allowed in cigarettes to 10, 1 and 10 mg, respectively; ban the use of ‘light’, ‘ultra light’ on cigarette packs; inclusion of graphic pictures on cigarette packs; ban on indoor smoking). Additionally, the Brazilian National Cancer Institute (INCA) has provided capacity building to the municipal and state health departments and established a National Quitline that provides assistance regarding smoking cessation.
In addition to legislative and education efforts, it is important to understand the factors associated with tobacco use among specific populations. Understanding women and their tobacco-related issues as well as developing gender-relevant tobacco control efforts have been highlighted as priorities in recent landmark guiding documents such as WHO's Framework Convention on Tobacco Control, the first international evidence-based treaty to engage the world in a unified effort to globally address tobacco control; participating countries include Brazil (WHO, 2005; http://www.who.int/tobacco/framework/download/en/index.html). Given the lack of information on smoking patterns among Brazilian women, we examined the contextual factors associated with smoking initiation and cessation among women in Brazilian worksites (Curitiba, Paraná, Brazil), with the intention of developing culturally relevant, gender-specific smoking prevention and cessation programs.
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METHOD |
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Conceptual framework
The PEN-3 is a conceptual model for development of health education programs (Airhihenbuwa, 1992
). It consists of three interrelated and interdependent dimensions of health (health education, educational diagnosis of health behavior and cultural appropriateness of health behavior). Each dimension has three components that form the PEN acronym (Figure 1). The first dimension, health education, assists in defining the target audience (person, extended family and neighborhood) for health education efforts. The second dimension, educational diagnosis of health behavior, focuses on determining the factors (perceptions, enablers and nurturers) that influence personal, family and/or community actions. Perceptions include the knowledge, attitudes and beliefs that may contribute or hinder engagement in a particular healthy behavior. Enablers are community or structural factors, such as availability of resources, accessibility, affordability, media and types of services. Nurturers are reinforcing factors received from one's social networks.
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The third dimension, the cultural appropriateness of a health behavior, has positive, negative and exotic components. The ‘positive’ component refers to perceptions, enablers and nurturers that lead the target audience to engage in the healthy behavior. The ‘exotic’ component refers to practices that have no harmful health consequences, which should not be changed, but incorporated in the intervention. The ‘negative’ component refers to perceptions, enablers and nurturers that lead the target audience to not engage in the healthy behavior or to engage in a harmful behavior.
Sample
Worksites were identified through a set of informal criteria: (1) located in Metropolitan Curitiba, (2) having a large percentage of women and (3) willingness to allow employees to participate in focus groups during working hours. Participants were recruited by the worksite's Human Resources and/or medical offices through e-mail, letter, word of mouth and/or flyers. The inclusion criteria were (1) women and (2) at least 18 years of age. Interested participants were asked about their smoking status for proper focus group assignment (N = 108). Separate focus groups were performed with never (N = 37), former (N = 27) and current smokers (N = 44), and participants did not receive any monetary compensation for their participation. This study was approved by the Institutional Review Board at the University of Memphis and the Brazilian National Research Ethics Committee, and data were collected in 2002.
Measures
Based on a literature review and conceptual framework, open-ended questions and probes were developed. For example: ‘How does smoking affect people's health (perception)?’ ‘What is your opinion about smoking advertisements (enabler)?’ ‘What does your husband/boyfriend/significant other think about smoking (nurturer)?’ A questionnaire, addressing demographics and smoking-related variables, was also administered.
Analysis
Data were analyzed in four stages. First, investigators independently read the focus groups transcripts to identify the emerging themes, without taking into account the conceptual framework. Second, investigators discussed the identified themes and agreed on categories. Third, investigators reread the transcripts and placed the identified themes into the categories. When investigators approved the final grouping (fourth stage), comparisons were made between the identified categories and their ‘fitness’ within the conceptual framework. Descriptive statistics were used to generate a profile of the sample, based on the data obtained through the demographic questionnaire. Chi-square and ANOVA analyses were used to examine association among variables, particularly differences between current, former and never smokers.
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RESULTS |
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Demographics and smoking history
Demographic information is summarized in Table 1. Former smokers were significantly older than never and current smokers. Current smokers were significantly more likely to live with other smokers than never and former smokers. There were no significant differences with regard to parental smoking status across the three groups. Current and former smokers did not significantly differ on the age of smoking initiation. Current smokers were significantly more likely to report smoking ‘light’ cigarettes than former smokers.
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Current smokers reported smoking, on average, 9.3 (±5.8; 1–25) cigarettes per day. Approximately 60% of current smokers reported quitting in the past. Out of these, 42.3% had quit once, 38.5% had quit twice, 15.4% had three previous quit attempts and 3.8% had four previous quit attempts.
Qualitative results
As suggested by the PEN-3 model, the emerging themes from the focus groups were classified along two axes. We first identified the perceptions, enablers and nurturers, and then sub-categorized the themes into positive and negative. It should be noted that themes within each category were classified as ‘positive’, if they led to engagement in a healthy behavior (quitting or not smoking), and ‘negative’, if they led to engagement in a harmful behavior (smoking). Given the nature of smoking behavior (all-or-none), exotic sub-categories were not identified.
Although most of the categories were consistent with the PEN-3 model, additional sub-categories emerged. ‘Perceptions’ were sub-divided into knowledge, esthetics, emotional factors and risk-exempting strategies. ‘Nurturers’ were sub-divided into social facilitators and modeling. ‘Enablers’ were sub-divided into assistance from health care providers, availability of smoking cessation methods, environmental factors and media.
Perceptions—Positive
Knowledge
Independent of smoking status, most participants indicated health problems as drawbacks of smoking. ‘I feel it in my body...have a sore throat frequently’. ‘I know it can cause cancer’ (current smokers).
Esthetics
Esthetics was a theme that appeared in all focus groups. Participants (independent of smoking status) indicated that cigarette smoking accelerates the aging process, causes teeth discoloration and an unpleasant body odor. ‘...the smell is horrible, the hair smells, the mouth smells. I think this (smell) is the main disadvantage of smoking among women’ (former smoker). ‘We...take a shower, but we have that smell’ (current smoker).
Emotional factors
Former and never smokers expressed the view that smoking leads to depression and anxiety, while current smokers identified smoking as a relief for depressive and anxiety symptoms. Interestingly, most former smokers believed that cigarette smoking helped them deal with stress, think better, etc. However, after they quit, they realized that that was a misconception. ‘It was an illusion. It was automatic. When I smoked, I felt more relaxed. It was not the smoking itself, because just holding the cigarette calmed me down’ (former smoker).
Perceptions—Negative
Knowledge
Although participants (independent of smoking status) displayed great knowledge regarding the hazards of smoking, it seemed that the link between knowledge and insight or ‘internalization’ of such knowledge did not occur among current smokers. This discrepancy was evident between current and former smokers. ‘Smokers are suicidal. They know the hazards of smoking, but they do not quit’ (former smoker). ‘When you smoke, you know all the hazards because it is in the media, written information, people [talk] about it, particularly with regard to counter-advertising...However, when you smoke, you do not worry about it. Although you have the awareness that these things (illnesses) can happen, they will not happen to you...you continue to smoke. We do not obsess about these things’ (current smoker).
Esthetics
A common theme that emerged among current and former smokers involved the benefits of smoking in terms of esthetics, particularly related to weight loss and/or maintenance. ‘Women are vain. We prefer to smoke and be thin...They say that they prefer to die thin than to die fat...Vanity influences women to... smoke’ (former smoker).
Emotional factors
Former and current smokers agreed that pleasure is the primary emotional reason for smoking. Relaxation, distraction, improved concentration, coping with sadness/shyness/low self esteem were also mentioned as benefits of smoking. ‘...I smoke when I have a problem and I need to think about it...during a moment alone with a cigarette...I stop to think. It is not stress that makes me smoke...I smoke after a stressful situation to think better’ (current smoker).
Risk-exempting strategies
This category only emerged among current smokers, and the themes related to the belief that if one engages in some healthy behaviors (e.g., exercise), decreases the number of cigarettes or smokes ‘light’ cigarettes, they can reduce the harmful effects of cigarette smoking. ‘I exercise...have a healthy diet. Therefore, smoking does not cause much hazard to my health’. ‘I changed brands to decrease my exposure to nicotine’. ‘I do everything right – only one little thing wrong is not a problem’ (current smoker).
Nurturers—Positive
Social facilitators
Current and former smokers reported that recent trends on smoking restrictions have increased social pressure to quit smoking. They reported feeling isolated from others. ‘I feel marginalized. I need to smoke...in the corner by the garbage can’ (current smoker).
Modeling
Most never smokers said their family structure prevented them from smoking, regardless of their parents' smoking status. ‘I do not smoke because of my family's influence. We are very cohesive and supportive of each other...I say this because it is hard during adolescence: the peer pressure’ (never smoker).
Nurturers—Negative
Social facilitators
The majority of current smokers initially smoked due to peer pressure and the glamorous/sophisticated image of smokers in the media. ‘I started smoking very early with my friends at school. All my friends smoked, so why shouldn't I smoke too?’ (current smoker). Peer pressure was mentioned in all focus groups. Most current smokers reported that being around other smokers was a strong social facilitator for maintaining this habit.
Modeling
For former and current smokers, seeing their parents, siblings, family members and individuals they admired smoke contributed to their smoking initiation. ‘My parents smoked and I would get a pen...pretended...to smoke with a pen’ (current smoker).
Enablers—Positive
Smoking cessation methods
Most former and never smokers identified willpower as the main determinant of quitting. ‘It is determination’ (current smoker).
Environmental factors
Participants identified restriction at home and/or workplace as an important environmental factor that contributes to decreasing or quitting smoking. Most participants (independent of smoking status) supported workplace smoking policies. ‘The restrictions help us to train ourselves on when to smoke. You do not have the freedom to smoke anytime’ (current smoker).
Enablers—Negative
Assistance from health care providers
Most former and current smokers reported that their physicians ask them about smoking, but have not provided any assistance regarding quitting smoking. ‘I do not know why they ask. They ask just to ask. Are you a smoker or not a smoker? It is information for the medical records’ (former smoker). ‘When we asked them (physicians) to help us quit, they do not know what to say’ (current smoker).
Smoking cessation methods
Although participants displayed knowledge regarding smoking cessation aids and programs, most lacked confidence in their ability to help women quit smoking. ‘It is a waste of money (current smoker).
Environmental factors
A number of environmental factors, contributing to smoking, were identified: low cost of cigarettes (‘The decrease in the cost of cigarettes has been the major contributor for excessive consumption...’—never smoker), accessibility (‘It is easy to get cigarettes...’—never smoker), employment opportunities (‘It generates a lot of jobs in Brazil’—never smoker). Across all groups, participants identified beer and coffee as habits that go together with cigarettes. ‘Coffee and cigarettes are good, but beer and cigarettes are...best’ (current smoker).
Media
There was a clear distinction between current and never smokers regarding the perceived influence of cigarette advertising and smoking in soap operas/movies. Never smokers unanimously reported that the media contributes to smoking initiation and lack of cessation (i.e. negative influence), while current smokers disagreed. ‘I think you can get more influenced by a close person who smokes than an actor in a movie, advertising, or soap opera’ (current smoker). Interestingly, some current smokers identified counter-advertising as contributors to smoking initiation. ‘One thinks that the intent of ads against smoking is to help people... quit smoking. Don't believe it. They make people want to try cigarettes. People who never thought about smoking start thinking about it’ (current smoker).
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODRESULTSDISCUSSIONREFERENCES |
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To our knowledge, this study represents the first qualitative examination of sociocultural factors associated with smoking initiation and cessation among women in Brazilian worksites. The most frequently endorsed negative perceptions, enablers and nurturers that contributed to smoking initiation included exposure to smoking through parents, siblings or family members as well as peer pressure; easy access to cigarettes and low cost. Studies have consistently shown that family (including parents) and peer influences are two important factors associated with smoking initiation as well as progression to established smoking among adolescents (Flay et al., 1994
; Laniado-Laborín et al., 2002; Beech and Scarinci, 2003; Jackson and Dickinson, 2003; Mowrey et al., 2004). It should be noted that parental smoking per se was not significantly associated with smoking in adulthood, suggesting that parental messages or family influences regarding smoking may be more important than parental smoking habits.
Current and never smokers had different opinions regarding the media's influence on smoking initiation and maintenance. While never smokers believed that the media negatively influenced smoking initiation, current smokers disagreed. It has been documented that tobacco advertising negatively influences smoking initiation and consumption (Pierce et al., 1998; Biener and Siegel, 2000; Wakefield et al., 2003), and that tobacco companies use sophisticated and manipulative marketing strategies targeting specific groups (Anderson et al., 2002). Therefore, it is not surprising that current and never smokers have different perceptions regarding media influence on the decision-making process of smoking.
Current smokers indicated that counter-advertising may contribute to smoking initiation. A study conducted with American adolescents found that exposure to the ‘Truth’ campaign (a national tobacco counter-marketing campaign by the American Legacy Foundation) was associated with an increase in anti-tobacco attitudes and beliefs, whereas exposure to the Phillip Morris counter-advertising campaign was not (Farrelly et al., 2002). Authors attributed the differences to the fact that while the Truth campaign focused on the manipulation by tobacco companies, the Phillip Morris campaign did not draw attention to tobacco industry strategies.
With regard to smoking cessation, the most salient negative factors included stress/anxiety-relieving benefits, weight control, low cost, accessibility, being around smokers and risk-exempting beliefs. The concept of ‘health risk perception’ has received increased attention, particularly due to inaccurate advertising by the tobacco industry about ‘less harmful’ tobacco products (Hastrup et al., 2001; Institute of Medicine, 2001; Shiffman et al., 2001; Farrelly et al., 2002). In a survey among U.S. Air Force recruits, we found that a large percentage of smokers used at least one of the risk-exempting strategies and that smokers who had either changed their diet or exercise to lower their risks from smoking had significantly lower perceived personal risk of developing a tobacco-related disease than other smokers (Haddock et al., 2004).
The positive perceptions, enablers and nurturers associated with quitting included smoking restrictions at home and workplace and concerns about appearance. It has been demonstrated that smoking restrictions at home/workplace are associated with reduction in cigarette consumption and quitting (Chapman et al., 1999; Farkas et al., 1999; Wakefield et al., 2000). It was evident that worksite smoking policies had a great interpersonal/social impact on smoking behavior. These restrictions contributed to the increased perception among smokers and non-smokers that smoking is a socially unacceptable behavior. Interestingly, most participants were very supportive of workplace smoking restrictions, suggesting that implementation and enforcement of strict tobacco control policies at worksites may encounter very little resistance from female employees.
Current and former smokers unanimously reported that they have never received any assistance from their health care providers to quit smoking. A similar pattern was observed in the U.S. in the early 1990s, when only 18–45.5% of patients reported receiving smoking cessation intervention or advice from their providers (CDC, 1993; Goldstein et al., 1997). This scenario changed after the U.S. Agency for Health Care Policy and Research developed clear guidelines regarding smoking cessation in clinical practice (Fiore et al., 1996; Denny et al., 2003). The U.S. experience shows that implementation of guidelines, as well as appropriate training, may have a positive impact on providers' smoking cessation efforts in their medical practices.
We acknowledge that this study has limitations. First, because focus groups are exploratory in nature, definitive conclusions cannot be drawn on the basis of our findings. Second, the worksites and the participants within these sites were not randomly selected and might not capture the heterogeneity of the female population in Paraná.
Despite its limitations, we believe that this study has made some contributions to the understanding of smoking initiation and cessation among women in Brazilian worksites. We believe that, through this qualitative methodology, we obtained useful information that could not be captured through quantitative approaches. For example, standardized surveys (e.g. Adult Tobacco Survey) do not include questions regarding the role of esthetics or risk-exempting beliefs. These qualitative findings also provided information regarding the context in which some of the factors impact smoking initiation or cessation which is crucial for intervention development.
This study also provides some insights on potential directions in augmenting the current national tobacco control policy. It has been well established that increases in taxes and prices have a predictable impact on cigarette consumption (Chaloupka et al., 2002; Emery et al., 2002). Women clearly stated that easy accessibility and low cost of cigarettes contributed to their smoking initiation and lack of cessation. Therefore, legislation on tax and price increases should be considered. Our results also suggest that training health care professionals on smoking cessation is needed. This may represent an opportunity for INCA to expand their ongoing capacity building efforts to train health care providers on gender-relevant smoking cessation strategies.
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ACKNOWLEDGEMENTS |
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This study was supported by the Research for International Tobacco Control (Canada). The authors thank the collaborating Brazilian worksites for their support and Ms. Beverley Palmer for her editing assistance.
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