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«Priska Flandorfer, Christian Wegner, and Isabella Buber Gender Roles and Smoking Behaviour Vienna Institute of Demography Austrian Academy of ...»

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Working Papers 7 / 2010

Priska Flandorfer, Christian Wegner, and Isabella Buber

Gender Roles and Smoking


Vienna Institute of Demography

Austrian Academy of Sciences

Wohllebengasse 12-14

A-1040 Vienna · Austria

E-Mail: vid@oeaw.ac.at

Website: www.oeaw.ac.at/vid


The gender gap in smoking prevalence is closing in several developed countries due to decreasing smoking rates among men and increasing among women. Previous studies present a variety of hypotheses with the central argument that the process of gender equality is related to the declining trend regarding sex differences in smoking. We suppose that changes in traditional gender roles have influenced the smoking behaviour among both men and women. Our study focuses on the stereotypical masculine behaviour pattern which is assumed to be a smoking determinant and is increasingly adopted by females now. We applied a triangulation (combination) of qualitative and quantitative methods.

The results indicate a connection between gender roles and health behaviour, especially smoking behaviour. The knowledge and experience of physicians reveal that although the attribute ‘masculinity’ is related to a higher risk of smoking it is increasingly adopted by women. The dynamic is further influenced by factors like age, social norms, workforce participation as well as mediaand leads to a change of perceived gender roles in society.

This fact can partly explain the increasing amount of smoking women. From a methodological point of view the current study is an example for a successful triangulation of quantitative and qualitative methods. Precisely because both methods have different angles-the qualitative one focusing on the knowledge and experiences of physicians and the quantitative one on individual behaviour style-the results complement each other and yield a comprehensive picture.

Keywords Triangulation, gender roles, smoking behaviour, gender gap.

Authors Priska Flandorfer (corresponding author for qualitative part) is research scientist at the

Vienna Institute of Demography of the Austrian Academy of Sciences. Email:

priska.flandorfer@oeaw.ac.at Christian Wegner (corresponding author for quantitative part) is research scientist at the

Vienna Institute of Demography of the Austrian Academy of Sciences. Email:

christian.wegner@oeaw.ac.at Isabella Buber is Research Scientist at the Vienna Institute of Demography of the Austrian Academy of Sciences. Email: isabella.buber@oeaw.ac.at Acknowledgements We thank Marc Luy, Katrin Fliegenschnee and the participants of the VID-colloquium for helpful comments and suggestions on an earlier draft. For language editing we want to thank Heike Barakat and Werner Richter. The work was conducted within the project ‘The Gender Gap in Life Expectancy’, funded by the Austrian Science Fund (FWF) (project P 20649 G14).

Gender Roles and Smoking Behaviour Priska Flandorfer, Christian Wegner, Isabella Buber

1. Introduction Smoking prevalence is patterned by gender. In the early part of the 19th century tobacco consumption was largely restricted to males (Lopez, Collishaw & Piha 1994;

Ramström 1997; Waldron 1991b). The prevalence among men increased rapidly by the mid-20th century while the proportion of female smokers was still low. In the 1970s, men reached their highest level of smoking prevalence across most European countries. Indeed, the gender gap in cigarette consumption has narrowed because smoking among females has been spreading rapidly since the 1920s. Since 1970s the gap in smoking prevalence among women and men has continuously declined in European countries (Graham 1996;

Pierce 1989). Males are supposed to still have the highest level of tobacco use but some recent studies present a higher smoking proportion among women, especially among younger age groups (Ali et al. 2009; USDHHS 2001).

Several hypotheses were presented to explain the gender differences in smoking behaviour. The most prominent ones refer to gender equality (Waldron 1991b) and to diffusion (Pampel 2001). On the one hand the lack in gender equality caused a later increase in female smoker prevalence by social disapproval of female smoking (Pampel 2001), on the other hand, the increase in gender equality due to the emancipation had tended to an adaptation of previously male smoking behaviour by females (Waldron 1991b). The increasing workforce participation of women is a major characteristic of gender equality. In this context, female smoking prevalence increased because ‘employed women have been exposed more to the world of men’s opinions and habits, employed women have been less subject to conventional constrains on women’s behaviour, and employed women have had more access to money with which to buy cigarettes’ (Waldron 1988, p. 196). Up to now, empirical analyses reveal inconsistent results for the association between smoking and workforce participation among females. Nevertheless, the idea that women have adopted men’s opinions, habits and even behaviour as well as the opportunity to backslide from social perceived behaviour raises the following question: What is the association between gender role orientation and sex specific smoking prevalence?

Smoking as one of the most risky health behaviours is perceived to be a masculine phenomenon because of the related smoking pattern, personality traits and endorsement of hegemonic ideals. In comparison to females, men commence to smoke at younger ages, smoke more cigarettes per day, inhale more deeply and consume further tobacco products like pipes, cigars or smokeless tobacco (Haustein 2001; Waldron 1988). Personality traits like extroversion, rebelliousness, antisocial tendencies, risk taking and social deviance are directly related to the occurrence of smoking behaviour and are more frequent among males than females (Grunberg, Winders & Wewers 1991; Waldron 1991a). The hegemonic ideals refer to men’s health beliefs and behaviours which are the denial of weakness or vulnerability, emotional and physical control, the appearance of being strong and robust, the dismissal of any need for help, a ceaseless interest in sex and the display of aggressive behaviour and physical dominance (Courtenay 2000, pp. 1388-1389). This set of health beliefs and behaviours is often used by men to achieve and/or to demonstrate the perceived role of an independent, dominant, self-reliant and strong man. In this way, masculinity is defined by negative health behaviour due to adopting health risks like smoking, heavy drinking or not using or even avoiding health care (Garfield, Isacco & Rogers 2008;

Mahalik, Burns & Syzdek 2007).

The question arises whether the described masculine characteristics also determine smoking behaviour among females. Has the emancipation led to adoption of traditionally male smoking behaviour by females because of social acceptance of female smoking or because of increasing female workforce participation? Numerous studies have used masculinity and femininity scores to empirically analyse gender differences. According to Emslie et al. (2002), high masculinity scores among men and women in non-manual jobs are associated with higher smoking risks, whereas femininity scores are not related to smoking. Indeed, Hunt et al. (2004) did not find any significant association between masculinity or femininity scores and smoking among men. But among women, smoking is associated with increasing femininity scores. Their analysis does not reveal consistent results but offers complex patterns in relation to gender roles and smoke behaviour.

Waldron (2000) suggests that the gender differences in health behaviour have been influenced by the interacting effects of fundamental aspects of traditional gender roles and the contemporary context. Her so-called ‘gender roles modernization hypothesis’ reevaluates the relation between gender roles and health behaviour in the way that females had evolved an own smoking style which evolved from traditional femininity roles and an increase in social acceptance of female smoking. It is – for example-well documented that body weight control is a main reason for smoking among women (USDHHS 2001).

Women are more sensitive to their body constitution so that smoking might be an acceptable opportunity to keep their body weight down. Moreover, women are more likely to smoke in order to reduce stress (Brunswick & Messeri 1984) which generally indicates high mental sensitivity.

The variety of hypotheses about sex differentials in smoking prevalence and the previous results indicate a complex but still inconsistent relationship between gender roles and smoking behaviour. Our analysis will extend the previous research by applying a

triangulation of qualitative and quantitative methods to answer the following questions:

(1) Do gender roles determine sex-specific smoking behaviour?

(2) Does masculinity determine smoking behaviour among both males and females?

Our analyses can be embedded in the more broader context of mortality and the gender gap in mortality which is closing since the 1970s/1980s (Luy, Wegner & Lutz 2010; Luy & Zielonke 2009). The narrowing mortality sex differentials have been accompanied by a fall of the proportion of smokers among males and an increase in smokers among females (Lopez et al. 2006; Pampel 2002). Therefore, our study will reveal new insights in the relation between gender role orientation and sex differentials in smoking behaviour.

2. Method We applied a methodological triangulation of qualitative and quantitative methods for analysing determinants of sex differentials in smoking prevalence. In detail, we used an across-method triangulation (Begley 1996) to combine on the one hand experiences and knowledge of medical professionals about the smoking behaviour of their patients with representative data of individual smoking behaviour on the other hand. The triangulation of quantitative and qualitative methods is highly useful both for the research process and for the epistemological development of a research question. Both methods have different angles, the results complement each other and yield a comprehensive picture of the determinants of sex differentials in smoking prevalence (Flick 2006). The qualitative perspective is based on the methodology of the Grounded Theory strategy including theoretical sampling (Lamnek 1995) and constructing theories and concepts according to the coding paradigm (Corbin & Strauss 1990). Sampling was based on theoretical considerations (theoretical sampling) throughout the entire project (Lamnek 1995).

Using expert interviews 20 general practitioners, five gender medicine researchers, two cardiologists and four geriatric nurses, who make a total of 31 participants, were interviewed in Austria in 2008 and 2009. The majority of them showed work experience of 20 years and more. The use of expert interviews is an appropriate qualitative method for the reconstruction of complex experiences and is used when the research interest has a focus on decision maxims, experiential knowledge, rules for action routines and knowledge relying on systematic problems, which can be mentioned explicitly or implicitly (Meuser & Nagel 1997). It has to be mentioned that the current analysis is embedded in a study on gender differences in mortality. Therefore the expert interviews were designed rather broadly and were carried out in the context of behavioural factors and issues related to the health of men and women. It turned out that in various interviews different gender roles as well as smoking were mentioned by the interviewed experts in the framework of the gender gap in life expectancy.

While the qualitative analysis focused on behavioural sex differences and on the question which factors determine the sex differences in smoking behaviour, the quantitative analysis concentrates on the question how these factors influence the smoking behaviour of women and men. We used data of the western German first wave panel from the German Life Expectancy Survey (LES) of the German Federal Institute of Population Research (Gärtner 2001). The survey includes a representative population sample of 8,474 individuals born between 1914 and 1952 who were interviewed between 1984 and 1986.

Although the qualitative analysis focuses on experiences and quotations of Austrian medical professionals the results can be compared to and extended by German quantitative data as the trends in smoking prevalence, smoking attributable mortality and overall mortality have nearly the same pattern in Austria and Germany (Lopez et al. 2006; Luy, Wegner & Lutz 2010).

The LES was first carried out in 1984/86 and hence includes characteristics of individuals from 30 years ago. It has to be mentioned that the results of the qualitative analysis are based on physicians’ long-term experience of mostly older patients with health problems or former patients who have already died. Based on the life course approach (Kuh & Ben-Shlomo 2004) both the morbidity or survival status of patients are influenced by the accumulation of health risks like smoking during the whole life span. The model of smoking epidemic (Ramström 1997) suggests a time lag of about 30 years between regular smoking and resulting morbidity and mortality status. Consequently, the use of the LES considers the time lag between risk behaviour and caused health status in an appropriate perspective.

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