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EDUCATION AND DEBATE: David R Marsh, Dirk G Schroeder, Kirk A Dearden, Jerry Sternin, and Monique Sternin The power of positive deviance BMJ 2004; 329: 1177-1179 [Full text]

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The ethics of positive deviance approach to reducing smoking uptake among women in Africa and Asia

Assoc. Professor Niyi Awofeso   (17 November 2004)

The ethics of positive deviance approach to reducing smoking uptake among women in Africa and Asia 17 November 2004
Assoc. Professor Niyi Awofeso, Public Health Surveillance Officer NSW Justice Health, P. O. Box 150 Matraville, Sydney, NSW 2036, Australia. Send response to journal: Re: The ethics of positive deviance approach to reducing smoking uptake among women in Africa and Asia	Marsh et al1 list ‘uncommon positives’ as the major domain Positive Deviance techniques. However, one 'common positive’ for which Positive Deviance has shown promise is in reducing smoking uptake by women in Africa and Asia. In these regions, deeply embedded social pressures and sanctions directed specifically against females have resulted in smoking rates among adult females of less than 10% (with the exception of Japan; 14.2% women Vs. 57.5% men2), compared with European and American countries where smoking rates between genders are fairly similar (www.globallink.org/tcep). In northern Nigeria, where I worked as a general medical practitioner for five years, the cultural notion with the greatest impact on reducing female smoking is the widely held association between female smoking and promiscuity. This association is reinforced by the observation that most prostitutes in northern Nigeria announce the presence on the streets and bars by lighting up. Since over 90% of adult women in most African and Asian societies currently don’t smoke, this female anti-smoking cultural pressure has produced a ‘common positive’, albeit one under relentless pressure from cigarette companies actively promoting female smoking uptake in these regions. As a preventive health tool, this gender-specific cultural sanction is locally available, sustainable, and effective. Given the marketing onslaught by the tobacco industry for greater market share among this cohort, it might be possible to incorporate such culturally acceptable notions into Positive Deviance techniques focused on reducing female smoking uptake. However, this approach is fraught with ethical dilemmas. First, the assumption that female smokers are necessarily promiscuous is a patriarchal – ‘do as I say but not as I do’ – approach that stigmatizes female smokers, while implicitly normalizing smoking among males. Second, females who elect to smoke despite such cultural sanctions are unlikely to gain access smoking cessation programs, partly due to the stigma of female smoking in these societies. Third, as female education increases in these societies, the more ‘positive’ message of tobacco marketers in linking smoking to feminist values of autonomy, independence and equality, are likely to resonate more strongly with female youths, and contribute to increase in their smoking uptake, a trend already apparent among Hong Kong women. Nevertheless, I posit that the use of Positive Deviance technique incorporating deeply embedded cultural sanctions against female smoking is a useful approach to limiting the influence of tobacco marketing on increasing the proportion of female smokers in African and Asian societies, particularly in rural settings. References 1) Marsh DR, Schroeder DG, Dearen KA, Sternin J, Sternin M. The power of positive deviance. BMJ 2004; 329: 1177-1179. 2) Honjo K. Kawachi I. Effect of market liberalization on smoking in Japan. Tobacco Control 2000; 9: 193-200. Competing interests: None declared