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. 2016 Jul 4;2016(1):195-211.
doi: 10.1093/emph/eow013. Print 2016.

The low prevalence of female smoking in the developing world: gender inequality or maternal adaptations for fetal protection?

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The low prevalence of female smoking in the developing world: gender inequality or maternal adaptations for fetal protection?

Edward H Hagen et al. Evol Med Public Health. .

Abstract

Background: Female smoking prevalence is dramatically lower in developing countries (3.1%) than developed countries (17.2%), whereas male smoking is similar (32% vs 30.1%). Low female smoking has been linked to high gender inequality. Alternatively, to protect their offspring from teratogenic substances, pregnant and lactating women appear to have evolved aversions to toxic plant substances like nicotine, which are reinforced by cultural proscriptions. Higher total fertility rates (TFRs) in developing countries could therefore explain their lower prevalence of female smoking.

Objective: To compare the associations of TFR and gender inequality with national prevalence rates of female and male smoking.

Methods: Data from a previous study of smoking prevalence vs gender inequality in 74 countries were reanalysed with a regression model that also included TFR. We replicated this analysis with three additional measures of gender equality and 2012 smoking data from 173 countries.

Results: A 1 SD increase in TFR predicted a decrease in female smoking prevalence by factors of 0.58-0.77, adjusting for covariates. TFR had a smaller and unexpected negative association with male smoking prevalence. Increased gender equality was associated with increased female smoking prevalence, and, unexpectedly, with decreased male smoking prevalence. TFR was also associated with an increase in smoking prevalence among postmenopausal women.

Conclusions: High TFR and gender inequality both predict reduced prevalence of female smoking across nations. In countries with high TFR, adaptations and cultural norms that protect fetuses from plant toxins might suppress smoking among frequently pregnant and lactating women.

Keywords: drug toxicity; global health; pregnancy aversions; substance use; tobacco control.

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Figures

Figure 1.
Figure 1.
Cross-national variation in female vs male smoking prevalence in 2012 according to national developmental status. Each dot is one country. Black diagonal line represents equal smoking prevalence. Regression lines fit by ordinary least squares; bands are 95% CI. Smoking prevalence data and development status from Ref. [1]. TFRs for 2005–10 from Ref. [2]
Figure 2.
Figure 2.
Bivariate correlations between study variables and 2012 smoking prevalence for men and women (sorted by correlation with female smoking). Bars are 95% CI. See text for data sources
Figure 3.
Figure 3.
Effect plots of the association of GEM and 2008 male and female smoking prevalence, controlling for the Gini coefficient and log GNI. Each point is one country. Plotted at median values of the Gini and GNI, see Table 3, Model 2
Figure 4.
Figure 4.
Effect plots of the associations of TFR and GGGI on 2012 male and female smoking prevalence, controlling for the GINI index and log GNI. Each point is one country. Plotted at median values of GINI and GNI, see Table 4, Model 2
Figure 5.
Figure 5.
Effect plots of the associations of 2010 TFR and GGGI on log postmenopausal 2012 smoking prevalence, controlling for log pre-menopausal prevalence and log GNI. Each point is one country. Left: female smoking prevalence. Right: male smoking prevalence. Plotted at median values of GNI, see Table 5, Model 2

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