Special effects: tobacco policies and low socioeconomic status girls and women.

T obacco use is a global public health problem of epic proportion, which threatens to kill one of two smokers and harm many non-smokers along the way. The World Health Organisation views both tobacco use and tobacco production as a dire threat to world health, contributing to early death, chronic diseases, poverty, environmental degradation, and labour exploitation. Tobacco use has typically been patterned along gender and class lines, with higher class males typically beginning to smoke before females and those in lower socioeconomic classes. In developed countries, there have been great successes in tobacco control, reducing rates of smoking by half in countries such as the USA, Canada, Sweden, Australia, and the United Kingdom over the past 40 years. These achievements reflect the success of the comprehensive tobacco policy approach, linking several key regulatory and legal policies together in the effort to reduce tobacco use. These policies include taxation, limits on advertising and sponsorship, restrictions on smoking locations, and prohibitions of sales to children. However, despite these successes, declining rates of tobacco use at the population level may mask high rates and persistent health issues for many disadvantaged groups, such as women and girls of low socioeconomic status (SES), within the same societies. The combination of three issues, gender, class, and tobacco policy, coalesce to underpin this special supplement of the Journal of Epidemiology and Community Health. In particular, the authors of this issue, its funders, the National Cancer Institute and the American Legacy Foundation, and its sponsor, the Tobacco Research Network on Disparities (TReND), are concerned with the effects of comprehensive tobacco policies on low SES girls and women. There is little known about the specific effects of tobacco policies on low income girls and women. However, it is vital that we probe the effects of policies on various subpopulations around the world, both in developed and developing countries. As the authors in this special issue show, several factors underscore this concern. Firstly, low SES people are especially susceptible to starting or continuing to smoke, even in developed countries when overall rates are rapidly declining. Levy et al point out that lower education and employment are linked with lower quit success, especially among women. Low SES women may bear a disproportionate health burden related to tobacco use, and experience a constellation of social and economic issues that contribute to inequity in health, as both Greaves and Jategaonkar and Graham et al point out. 7 Several of the authors, including Shavers et al and Moore et al suggest that creating a smoke free environment is potentially more difficult for low SES girls and women, as they may more often live in households with smokers or work at jobs where smoking is permitted. 9 Additionally, as Moore et al and Greaves and Jategaonkar suggest, domestic power differentials between women and men may limit low SES women’s ability to control their home environment. All of these issues are of concern, but the overriding theme of this supplement is how do tobacco policies affect women and girls in these situations? Can their ‘‘biographies of disadvantage,’’ as Graham et al label the pathways of many low SES girls and women toward smoking, be changed into biographies of advantage and trajectories free of smoking? Several key research questions emerge. Firstly, are low SES girls and women affected differentially by tobacco policies, when compared with other groups? Secondly, how do these broad policies interact with individual characteristics? Thirdly, are the effects positive or negative in terms of improving health? Fourthly, are these effects positive or negative in the context of improving social and economic health? Fifthly, how are low SES girls and women, both smokers and non-smokers, affected by tobacco policies? Sixthly, how do diverse low SES women, such as those in various ethnocultural and/or racialised groups, or those working or living in specific environments, experience tobacco policies? Seventhly, what new approaches could be developed to tailor tobacco policies for low SES girls and women that reflect the realities of their lives? And finally, how can we mitigate and reduce the unanticipated negative effects of tobacco policies on disparate groups, while increasing their positive effects? These are complex questions, many of which are difficult to answer using existing data. Indeed, the authors of the special issue show that direct evidence pertaining to these questions is often lacking as these questions have rarely been asked in research. Both Kim et al and Shavers et al show that new data are needed to better answer these questions. We also need to ask new questions of existing data. Levy et al show the value in re-analyses of large datasets. Both Moore et al and Balbach et al illustrate how qualitative methods or mixed qualitative and quantitative methods can be used to assess the full effects of tobacco policies on low SES girls and women. Finally, as Greaves and Jategaonkar and Graham et al suggest, new conceptual frameworks for designing ethical and truly comprehensive tobacco policies need to be used to assess and respond to the issues. Given the large gaps in our knowledge, there is a lot that remains to be done to adequately address the issues raised here. However, the evidence presented here suggests that further research is needed, and the authors suggest some specific future directions to pursue. Levy et al declare that the relation between low SES and smoking is not immutable, and that media campaigns as well as tax and price increases will continue to assist in reducing smoking prevalence among low SES girls and women. Shavers et al conclude that home based smoke free policies show promise reducing smoking among low SES women, and Shopland et al suggest that smokefree homes are linked to higher rates of quitting. Kim et al encourage future research and policy on individual level factors such as the availability of cigarettes to young girls at home as a predictive factor for initiation. EDITORIAL ii1