Cigarette advertising and female smoking prevalence in Spain, 1982–1997

Abstract

BACKGROUND

Compared with northern Europe and the U.S., the widespread initiation of cigarette smoking began 20–40 years later among young women in Spain because of strong cultural prohibitions against female smoking. In this study, the authors examined the correlation between the rapid increase in female smoking prevalence and tobacco industry cigarette marketing practices in Spain during a period of rapid social liberalization.

METHODS

The authors examined age-specific, period-specific, and birth cohort-specific increases in cigarette smoking among young women in Spain in relation to internal documents from Philip Morris beginning in 1971, cigarette advertising from 1982 to 1997, and the increase in the market share of blond tobacco and “light” cigarettes preferred by women.

RESULTS

Some increase in cigarette smoking occurred among Spanish women before 1970, but the increase was substantially smaller and occurred later than in many Western countries. However, after 1970, the prevalence of cigarette smoking increased rapidly in Spanish women of all ages < 50 years. The rapid increase in female smoking coincided with massive increases in television advertising, especially to women, and increases in the market share of blond tobacco, “light cigarettes,” and international tobacco brands.

CONCLUSIONS

The increase in cigarette smoking among young Spanish women illustrates how aggressive marketing can exploit periods of social liberalization and rapidly increase cigarette smoking among women, even in countries in which female smoking traditionally has been unacceptable. Strategies are needed to prevent similar increases in smoking by women elsewhere. Cancer 2004. © 2004 American Cancer Society.

Cigarette smoking was rare among Spanish women prior to the 1960s.1, 2 Even by 1970, only 5.8% of females ages 16–44 years regularly smoked cigarettes in Spain,1 whereas by 1950, more than 40% of women in the same age range were regular smokers in Britain,3 and 33.9% of women age < 18 years reported regular smoking in the U.S. in 1965.4

The protracted delay in the uptake of smoking among Spanish women is particularly notable when compared with the long history of a high smoking prevalence among Spanish men (Fig. 1A, B).1 Nearly 50% of men born in the early 20th century in Spain became current smokers by mid-century, whereas less than 2% of women in any birth cohort were regular smokers in 1950. Spanish women did not take up smoking in large numbers after World War II, unlike women in northern Europe and North America. The traditional social roles for women encouraged by the conservative government of General Francisco Franco from 1939–1975 reinforced cultural prohibitions against female tobacco use in Spain. Not until the period of liberalization and democratization after Franco's death in 1975 did cigarette smoking increase rapidly in young Spanish women (Fig. 1B). By 1990, the prevalence of smoking in young males (24.6%) and females (23.7%) born between 1970 and 1979 was essentially equal (Fig. 1A, B). In this case study, we examined the relation between rapidly increasing female smoking prevalence and the strategic efforts of multinational tobacco companies to gain access to the Spanish market, including large increases in tobacco advertising (especially television advertisements for blond tobacco and “light” cigarettes).

Figure 1

The prevalence of current cigarette smoking among successive birth cohorts of (A) males and (B) females in Spain, 1910–1990. Reprinted with permission from: Fernández E, Schiaffino A, Borras JM, et al. Prevalence of cigarette smoking by birth cohort among males and females in Spain, 1910–1990. Eur J Cancer Prev. 2003;12:57–62.

Background

The International Tobacco Surveillance Program of the American Cancer Society (ACS) is developing a series of case studies to illustrate the use of surveillance data to evaluate common problems in tobacco control. A previous case study considered cigarette smuggling in Brazil.5 These case studies complement the monograph Tobacco Control Country Profiles 2003, published collaboratively by ACS, the World Health Organization (WHO), and the International Union Against Cancer to document tobacco production, consumption, and trade in 196 countries and territories worldwide.6

Spain is currently in Stage III of the WHO model of the evolving epidemic.7 Smoking prevalence is high in men (52.4%) and is increasing in women (39.4%) ages 16–44 years according to serial national health surveys.8 Lung cancer mortality is much higher in men (47.9 per 100,000 population, standardized to the world population) compared with women (8.4 per 100,000 population),9 reflecting the more recent uptake of regular tobacco smoking by Spanish women compared with Spanish men. Lung cancer incidence and mortality rates among women, however, have begun to increase in the last decade.10-12

Historically, the uptake of smoking by Spanish women was delayed by social conditions that prevailed during the Spanish Civil War (1936–1939) and World War II (1939–1945), and by the fascist government of General Francisco Franco. The Franco government promoted traditional social roles for women that, among other things, discouraged tobacco use.13 The period of liberalization after Franco's death in 1975 is known as the “restoration of democracy.” Women entered the workforce in large numbers and rapidly gained parity in education.14

The restoration of democracy in Spain coincided with efforts by Philip Morris and other transnational tobacco companies to gain entry into the Spanish cigarette market. The manufacture of cigarettes on the Spanish mainland was restricted to Tabacalera, the former state-owned tobacco monopoly, which was incorporated in 1945.15 Historically, foreign imports to the Spanish mainland were expensive and were limited by the national monopoly. However, cigarettes manufactured on the Canary Islands could be imported in larger quantities if they were registered with and distributed by Tabacalera. In 1971, Philip Morris leased facilities on the Canary Islands and created two tobacco companies, PM España S.A. and PM Iberia S.A.16 In 1974, Philip Morris and Tabacalera initiated a joint venture to manufacture Fortuna cigarettes for sale on the Spanish mainland.17 The two companies also agreed to begin production of Marlboros at a plant in the North of Spain in 1977 for distribution by Tabacalera.18 Philip Morris currently has the second largest share of the tobacco market in Spain. It increased its share from 1.6% in 1982 to 31.9% in 2001.19

The incursion of Philip Morris and other transnational tobacco companies into the Spanish market resulted in a major change in the type of cigarettes being smoked. Until the late 1970s, most of the cigarettes consumed in Spain were made from black tobacco19, 20 rather than the blond tobacco in American blended cigarettes. Black tobacco is produced by sun curing with little or no use of artificial heat,21 whereas blond tobacco is cured in flues and has relatively higher sugar content.19 Cigarettes made from black tobacco traditionally were smoked primarily by Spanish men, and cigarettes made from blond tobacco currently are smoked widely by both genders. Market share of blond tobacco serves as an indicator of the penetration of international brands into the Spanish cigarette market and increasing cigarette consumption by women.

Tabacalera was privatized in 1998 and was renamed Altadis after its merger with Seita of France in 1999. The combined company is now the world's fourth largest multinational tobacco company.22

MATERIALS AND METHODS

Temporal trends in smoking prevalence by age and birth cohort have been estimated previously for men and women in Spain1 based on cross-sectional National Health Interview Surveys8 in 1993, 1995, and 1997 (Fig. 1A, B). These prevalence estimates are adjusted for the differential mortality among smokers but may be subject to reporting bias, especially among older women who may have been reluctant to admit transgressing historic social norms. We plotted the increase in smoking prevalence among women by age (Fig. 2) as well as by birth cohort to assess period increases in female smoking in relation to cigarette advertising. We also compared the market share of black and blond cigarettes from 1978 to 200119 to determine the extent to which international cigarette brands (blond tobacco) have displaced traditional Spanish cigarettes (black tobacco).

Figure 2

Temporal trends in age-specific female smoking prevalence, Spain 1930–1990.

We purchased information concerning cigarette advertising expenditures for all tobacco companies in Spain from 1982 (the first year for which data were available) to 1997 from INFOADEX, a market research firm.23 We analyzed temporal trends in advertising expenditures by type of media (television, billboard, radio, cinema, magazine, and newspaper supplement) and by cigarette brand (“light” vs. “regular”). Monetary values in pesetas were adjusted for inflation using constant 2000 Euros, known as “real Euros” (2002 exchange rate: $1.00 U.S. = 1.0026 Euros).24

Population data for individuals age ≥ 15 years used to calculate per capita cigarette consumption were derived from the 2000 Revision of the United Nations Population Division World Population Prospects.25 We conducted a systematic search of websites that contained internal documents pertaining to Spain from the tobacco industry. These documents, which were obtained through lawsuit settlements and judgments against the tobacco industry, reveal previously confidential information concerning strategic planning by tobacco companies. Internal industry documents were available for Philip Morris, the second largest tobacco company in the Spanish market, but not for Tabacalera, the Spanish national monopoly. Industry documents were searched for qualitative information regarding multinational cigarette sales and marketing in Spain using a standard protocol for searching industry documents.26 Our search was conducted between January 2002 and July 2003 using combinations of keywords such as “Spain,” “women,” “advertising,” “new smokers,” and “ marketing strategies” and names of key executives involved in Philip Morris' expansion into Spain's cigarette market.27

RESULTS

Smoking Prevalence

Smoking prevalence increased rapidly after 1970 in all cohorts of Spanish women born after 1940 (Fig. 1B).1 When the trends in prevalence of female smoking were examined in relation to age (Fig. 2) rather than birth cohort (Fig. 1B), the earliest and largest increase was seen among women ages 21–30 years. Much of the increase occurred during the period of the 1970s and 1980s. Smoking prevalence also continued to increase through the 1980s in older age groups (ages 31–40 years, 41–50 years, and 51–60 years), although much of the apparent increase reflected aging of women who had begun smoking at younger ages. Some initiation of smoking continued to occur in the group ages 41–50 years among women born between 1930 and 1939 and until ages 31–40 years among women born between 1940 and 1949 (Fig. 2).

Type of Cigarettes Smoked

Coinciding with the increase in female smoking was a shift in the market share of cigarettes in Spain from black tobacco to blond tobacco (Fig. 3). Cigarettes made from black tobacco decreased from 82.3% of the Spanish cigarette market in 1978 to 25.4% in 2001. Conversely, the percentage of cigarettes made from blond tobacco increased to 74.6% of the Spanish cigarette market by 2001.19

Figure 3

Market share of black and blond cigarettes in Spain, 1978–2001.

Advertising

Per capita expenditures on cigarette advertising by all tobacco companies in Spain increased nearly 8-fold between 1982 and 1988, from 0.23 real Euros per capita in 1982 to a peak of 1.77 in 1988 (a total of approximately $54.5 million U.S.) (Fig. 4). Cigarette advertising through televised media represented the bulk of the large increase in advertising expenditures between 1982 and 1988. Television advertising for cigarettes was banned in Spain in September, 1988. However, total expenditures for cigarette advertising increased after 1990 to a level of 1.31 real Euros per capita (a total of approximately $50.0 million U.S.) in 2001, with billboard, newspaper, Sunday supplement, magazine, cinema, and radio advertising compensating for the restrictions on television advertising.

Figure 4

Per capita expenditures on cigarette advertising by all tobacco companies in Spain, 1982–2001.

Further analyses indicated that greater than two-thirds (73.9%) of tobacco industry expenditures on television advertising between 1982 and 1988 were spent to promote “light” cigarettes. Light cigarette brands are smoked extensively but not exclusively by women.28 The percentage of television expenditures devoted to “light” cigarettes increased rapidly from a reported 0.0% in 1982 to 10.8% in 1983 and to a peak of 90.0% in 1986. In 1988, when television advertising was banned, “light” cigarette advertising expenditures accounted for only 0.67% of advertisement expenditures in newspapers, Sunday supplements, magazines, and movie theaters. The importance of “light” cigarettes in these advertising campaigns increased rapidly and peaked in 1995, when 43.4% of expenditures were devoted to “light” cigarette advertising.

Industry Documents

Internal papers document Philip Morris' long-term strategy to gain access to the Spanish cigarette market. A memorandum dated October 25, 1971 from George Weismann, a Philip Morris executive, refers to the leasing of facilities in the Canary Islands in 1971, to provide “a foothold in the Spanish market.”28 Motivating this initiative was “the hope of entering the Spanish market with blond cigarettes.”28 This memorandum, which was written 4 years before Franco's death, reflects the company's initial effort to penetrate Spain's untapped market of potential female smokers.29

In February, 1982, a 5-year plan from Philip Morris explicitly linked blond cigarettes produced in the Canary Islands with Philip Morris' efforts to increase market share on the Spanish mainland. The plan proposes to “take advantage of” television advertising in anticipation of a future ban.29 Philip Morris and other tobacco companies, as noted previously (Fig. 4), increased cigarette advertising aggressively on Spanish television from 1982 until 1988, when such advertising was banned.30

In December 1985, a 3-year plan for 1986–1988 specified that “the last period of television advertising will be dedicated to Marlboro Lights”; that “two-thirds of next year's budget” would be spent on television advertising; and that “radio, outdoor, magazine campaigns, and promotions will represent an important element of our strategy.”31 In January 1987, a Philip Morris report described marketing techniques for blond cigarettes, “taking advantage of its modern American image and capitalizing on young smokers.”31 The report calls for “a special presence on female activities such as fashion shows” to market Hilton Slims to women.32

DISCUSSION

The explosive increase in cigarette smoking that occurred among young Spanish women after 1970 illustrates the rapidity with which cultural prohibitions against tobacco use by women can be eclipsed by aggressive tobacco marketing aimed at women during periods of dramatic social change. Although multiple factors, including higher education and increased purchasing power, likely contributed to the rise in female smoking, the period of democratization and social liberalization that accompanied the end of the Franco regime created a window of opportunity for tobacco companies to equate cigarette smoking with positive images of emancipation, success, and gender equality, themes that previously have proven effective in marketing cigarettes to women.33 Philip Morris and other tobacco companies vigorously exploited the opportunity for television advertising in Spain until 1988, capitalizing on “the modern American image” and its appeal to “young smokers.”32 The incursion of the transnational tobacco companies into the Spanish market relates directly to the increase in smoking among women and the displacement of traditional Spanish cigarettes made from black tobacco by American-style cigarettes made from blond tobacco.

The implications of the Spanish experience are profound, in that there are many countries in the world in which women do not smoke because of strong cultural prohibitions against female tobacco use.34 Globally, the prevalence of cigarette use is nearly 4 times greater in men (47%) compared with women (12%).35 Women represent a vast, untapped market for the tobacco industry36 and increasingly are targeted in promotional campaigns that associate female smoking with images of sophistication, Western-style independence, weight control, and feminism.33, 34, 36

The critical message of this study is that strong cultural and traditional prohibitions against female smoking are not sufficient to withstand aggressive tobacco marketing in the context of social liberalization. Global progress toward increasing independence and gender equality has been hijacked by the tobacco industry to promote its products. There is an urgent need to develop strategies to prevent the industry from exploiting democratization and modernization to foster tobacco dependence among women. The Framework Convention on Tobacco Control (FCTC), which to our knowledge is the first global public health treaty, outlines a comprehensive set of tobacco-control strategies, including bans on tobacco advertising, promotion, and sponsorship.37 The FCTC was adopted on May 21, 2003 by the 192 member states of the World Health Assembly. Ratification and enforcement of the FCTC by countries throughout the world is an important step in limiting the advance of the tobacco pandemic and the resulting burden of death and disease in future generations.

Acknowledgements

The authors acknowledge the contributions of the following persons: Marlo Corrao, M.P.H. (GlaxoSmithKline, Inc.), collected and analyzed data on cigarette advertising expenditure in Spain. Emmanuel Guindon (World Health Organization) provided economic calculations for conversion of currency and inflation adjustment of cigarette advertising expenditures. Anu Radha Gupta, M.P.H. (Emory University), assisted with literature review, tobacco industry document searches, and article development. Muhammad Samer Rastam, M.D. (Syrian Center for Tobacco Studies), conducted statistical analysis for advertising expenditure and smoking prevalence data. Amanda Amos, Ph.D. (University of Edinburgh), contributed critical comments and suggestions.