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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
Competing interests:
No competing interests
17 November 2004
Assoc. Professor Niyi Awofeso
Public Health Surveillance Officer
NSW Justice Health, P. O. Box 150 Matraville, Sydney, NSW 2036, Australia.
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
Competing interests: No competing interests