Democracy Lab

Tobacco's War on Women

The global tobacco industry is targeting women in emerging markets. Can public policy rise to the challenge?

When a young paralegal in Mumbai or Hanoi lights up, it feels so good in so many ways. She loves the nicotine hit, of course, but she loves even more to exhale in the sexy way Scarlett Johansson did in A Love Song For Bobby Long. All over the developing world, young women with rising incomes and new freedom to make their own decisions are taking up smoking to chase their dreams -- and, in turn, making the dreams of cigarette marketers no longer welcome in rich industrialized countries come true. This gives the folks at the World Health Organization nightmares.

According to the new edition of The Tobacco Atlas, about 200 million women smoke cigarettes worldwide, compared to 800 million men. This gender gap is widest in Africa, Asia and the Middle East. In Vietnam, for example, more than half the men smoke -- but fewer than 2 percent of the women do.

Cigarettes killed almost 6 million people in 2011, 80 percent of them residents of low and-middle-income countries. And the toll is sure to rise in next few years, as the rising tide of men who've been smoking heavily for a lifetime pay the piper. But looking decades down the road, the magnitude of the body count will largely depend on the choices made by women in the developing world.

The battle for their hearts and lungs is already raging. On one side, tobacco companies are spending billions of dollars in less-exploited markets to portray women who smoke as liberated, sexy and slender. On the other is the World Health Organization, which, in league with local activists, is attempting to head off Big Tobacco with campaigns to educate women about the decidedly unsexy consequences of inhaling.

No small challenge. Public health campaigns in developing countries have traditionally been focused on the infectious diseases associated with poverty. These diseases are (relatively) easy to fight -- you can, for example, contain malaria by bombing mosquitoes with pesticide and handing out nets. But fighting the diseases of affluence, like heart disease and cancer, means playing the Grinch, asking people to deny themselves a modest perquisite of affluence.

Countries typically experience the tobacco epidemic in four stages. In the first, wealthy and educated people start using. In the second, tobacco use spreads through the population. In the third, smoking starts to fall among the early adopters, while lower-income, less-educated groups persist. In the fourth, the overall rates of smoking decline, even as the delayed effect of smoking increases tobacco-related deaths.

The United States is now moving through the fourth stage. The percentage of Americans who smoke declined from 42 percent in 1965 (the year after the US Surgeon General's famous report) to 19 percent in 2010. Only 6 percent of Americans with graduate degrees now smoke (though 25 percent of high school dropouts are still puffing). Some 23 percent of deaths in the US are tobacco-related.

Americans consumed 315 billion cigarettes in 2009. But the promised land for tobacco companies is Asia. Chinese men (plus a few women) smoked nearly 2.3 trillion cigarettes that same year. Indeed, of every 100 cigarettes sold on the earth today, 38 are sold in China.

China is either in stage two or stage three of the epidemic -- the male market for cigarettes is saturated, so much turns on whether women decide to take up the habit. Today, cigarettes kill about one million people a year in China. By 2030, that number will almost surely reach 3.5 million, and could be much higher if Chinese women join in the fun.

The China National Tobacco Company is the biggest tobacco company in the world, and it is also a highly profitable (if typically sluggish), state-owned monopoly. This means China will resist efforts to allow the multinational tobacco companies to compete -- but it also means that the Chinese government has a big conflict of interest.

In 2009, 50 percent of men and 2 percent of women in Shanghai smoked, along with 3 percent of boys and 1 percent of girls aged 13 to 15. But serious efforts at marketing, combined with the universal yearning to follow global fashion, could change that number fast. Consider, for example, South Korea in the 1980s, which had high import tariffs on tobacco and few women smokers. In response to threats from Washington, Korea lowered its trade barriers and multinational tobacco companies set up shop. Between 1988 and 1989 - that's right, in one year -- smoking among teenage boys in Korea increased from 18 percent to 30 percent; for girls, it rose from 2 to 9 percent.

Like China, Vietnam has a state-owned monopoly cigarette manufacturer that markets in very limited ways. Thomas Bollyky, a fellow at the Council on Foreign Relations who specializes in trade and global health, warns that the Trans-Pacific Partnership, the free trade agreement now being negotiated between the US and seven Asian countries, could send Vietnam down Korea's path. Four private companies - Philip Morris, British American Tobacco, Imperial Tobacco Group and Japan Tobacco - make and sell about half of the world's cigarettes. They also employ some of the world's best marketers because, as RJ Reynolds executive Chris Reiter famously said in 2003, " If you can market a product that kills people, you can sell anything."

Many people in Asian and Muslim countries still view women smoking as déclassé. The portion of women who smoke in China -- where, as noted earlier, the state tobacco monopoly does not advertise heavily, at least not yet -- has actually declined in recent years. But advertising is powerful, and the tobacco industry has used it on women for decades. In 1925, American magazines suggested that to stay slender, women could "Reach for a Lucky Instead of a Sweet;" the campaign was so successful that one executive likened the women's market to "a gold mine right in our front yard."

Today, young Filipina women are the target for Hope cigarettes. One recent television ad shows bikini-clad Caucasian women and attractive young men skydiving, surfing, and lighting up together; the images are intercut with shots of the brand. It's about hope - the hope young women have for Western-style affluence, fun, and popularity - and how smoking is an easy way to taste that dream.

The real focus of the battle in these countries is young, educated women, who are more likely to see cigarettes as emblems of sophistication and independence. In India, after protestors repelled one marketing campaign aimed at women, British American Tobacco returned with "Project Kestrel," the goal of which was, according to internal documents, to develop a brand that "breaks the rules" and encourages the "literate youth of today" to try a brand that is "completely unconventional, which set(s) new standards encouraging their rebellion, not necessarily just against parents."

Developing countries contemplating tobacco control - in particular, prevention of growth in smoking among women - have a troika of reasons to look the other way. First, lower sales means less tax revenue/profit, an especially important consideration for countries lacking the means to collect income or property taxes. Second, they face opposition from powerful interests, ranging from foreign governments demanding market access for their exporters, to multinational tobacco companies skilled at winning friends in high places, to local stakeholders -- everybody from workers in tobacco factories to local shop owners who anchor their businesses on cigarette sales. Third, the costs of smoking are back-loaded: Young smokers rarely worry about health issues many decades down the road, and neither do politicians focused on economic growth and political stability.

Anti-tobacco activists in poor and middle-income countries thus have their work cut out for them. And if the experience of the West is any indicator, trillions will be spent on coping with tobacco-related illness and hundreds of millions more will die before they succeed in putting tobacco in its place.

Koichi Kamoshida/Getty Images


Why America Must Save Chen Guangcheng

Now is one of those times when the United States must live up to its ideals.

During a visit to Asia early in her tenure as secretary of state, Hillary Clinton famously said that U.S .concern with human rights issues in China "can't interfere with the global economic crisis, the global climate change crisis, and the security crisis."

Her statement garnered shock and dismay from human rights activists at home, and I would venture, abroad -- the very people who historically have looked to America to champion their cause, rather than relegate it to the backburner.

But now, with the daring escape last week of blind legal defender and activist Chen Guangcheng, human rights will "interfere" with the agenda outlined for this week's Strategic and Economic Dialogue with China, which is bringing Clinton and Treasury Secretary Timothy Geithner to Beijing for high-level talks.

And interfere it must. America's reputation as a beacon of freedom -- the "last best hope of man on Earth" hangs in the balance. The Obama administration must rise to the occasion and allow the U.S. Embassy in China to fulfill its obligation as an island of freedom in a sea of repression.

On Feb. 10, I was one of several members of Congress to sign a letter to President Obama on the eve of his visit with Chinese Vice President Xi Jinping. We urged the president to follow the time-tested model of President Ronald Reagan during the height of the Cold War, when he spoke out on behalf of specific dissidents by name, linking human rights and religious freedom to every other facet of U.S.-Soviet relations, rather than sidelining the very principles that make this country unique. We urged President Obama to raise the cases of six prominent Chinese citizens who had suffered greatly at the hands of their own government, among them Chen Guangcheng.

China's abysmal human rights record is well known. The government is an equal opportunity oppressor of people of faith, including Catholic bishops, Protestant house church leaders, Tibetan monks and nuns, Uyghur Muslims, and Falun Gong practitioners. Harassment, intimidation, and imprisonment are the order of the day. Our own State Department's annual Human Rights Report found that China is "an authoritarian state" where the government continues to muzzle freedom of speech and press and "rein in" civil society. Chen's case is not an anomaly, but symptomatic of pervasive, well-documented government abuse.

While much remains unknown regarding the specifics of Chen's escape, it is quickly becoming apparent that Chen's heroism is matched only by that of the brave individuals who, at great personal risk to themselves, assisted Chen in breaking free from the captors who had tormented, isolated and mistreated him for more than 18 months. His brutal house arrest, which garnered worldwide attention and outrage, came on the heels of his release from prison on trumped-up charges of damaging property and "organizing a mob to disturb traffic."

Tellingly, many who dared to assist Chen have subsequently been detained, arrested and brought in for extensive questioning. While no negotiations have been officially confirmed, we can assume that State Department officials are presently engaged in discussions with the Chinese government regarding the Chen case.

These diplomats must be ever-mindful of how the Chinese government has responded thus far and refuse to accept vague assurances of Chen's future safety. They need look no further than He "Pearl" Peirong, one of those who provided key logistical support for Chen in his flight for freedom. She is presently under house arrest, location unknown.

The unceasing advocate Bob Fu, president of China Aid Association and himself a Tiananmen Square student leader, noted in the Washington Post Monday that Chen has never "established a political party or organization. He has never advocated overthrowing the Communist Party." Instead, Chen wants "to live a normal life as a Chinese citizen" with his family. He has joined the hallowed ranks of individuals like the Soviet dissidents Natan Sharansky and Aleksandr Solzhenitsyn, whose courage in the face of tyranny captured the world's imagination.

Now, a different type of courage will be required: political courage. If Chen is indeed in U.S. diplomatic protection, will he remain there? Will Chen decide to stay in China? Will his safety and that of his family be guaranteed? Will his case, and others like him, be central in any future bilateral engagement?

The situation is complicated, but Chen's case is not. There is a place for pragmatism in diplomacy -- perhaps that is what motivated Deputy National Security Advisor John Brennan when asked this weekend about Chen's case to say that the president will aim to "balance our commitment to human rights" while maintaining "our relationships with key countries overseas." But pragmatism must not result in Chen's abandonment in the name of good relations.

Chen represents China's future. He is bright and bold. He loves his family and cares deeply about his fellow citizens. But until there is a fundamental change on the part of the Chinese government, Chen, like his compatriots, Nobel Laureate Liu Xiaobo, writer and academic Yu Jie, and so many others whose names we do not yet know, will be viewed as enemies by the country that they love. We can be certain that they are watching closely as Chen's fate unfolds.

Much has been written about the timing of Chen's escape. Coming on the heels of the embarrassing Bo Xilai scandal and this fall's Communist Party leadership transition, in most diplomatic and foreign-policy circles the conventional wisdom is that the timing couldn't have been worse.

But for an opportunity for the United States to show its commitment to freedom, the timing couldn't be better.

Chen's escape is the stuff of history.  All that remains to be seen is whether America will be on the right side.

Ed Jones/AFP/GettyImages