A BIOCULTURAL INVESTIGATION OF WOMEN'S TOBACCO USE: TESTING THE FETAL PROTECTION VS GENDER INEQUALITY HYPOTHESES

Tiffany Alexandra Alvarez

doi:10.7273/000007313

Women in low-to-middle-income countries (LMICs) have historically smoked at much lower rates than men and their counterparts in high-income nations. However, rising tobacco use among women in these settings presents an emerging public health challenge. This dissertation investigates the determinants of women’s tobacco use through an integrated evolutionary, biocultural, and socioeconomic lens. It tests two theoretical frameworks—the Gender Inequality Model (GIM) and the Fetal Protection Model (FPM)—across three empirical studies that involve cross-cultural multilevel analyses, longitudinal survey data from the Philippines, and mixed-methods ethnographic fieldwork in Argentina. Together, these studies explore how interactions between sex-specific biological factors, gender norms, and diverse sociocultural features shape women’s smoking behavior. Findings challenge the GIM, which predicts that greater gender equality and increased empowerment lead to higher tobacco use among women. Instead, across all studies, higher educational attainment consistently emerged as a protective tobacco use factor. In one study, gender equality narratives did not elevate smoking risk but instead amplified protective effects—particularly when combined with education. In line with the FPM, the presence of young children, breastfeeding, and cultural attitudes emphasizing maternal responsibility were associated with lower smoking odds. One study extended the FPM by showing that children may actively reinforce maternal aversions to smoking, suggesting a reciprocal protection dynamic. In addition, fieldwork in the south-central Andes further underscored the moderating roles of Indigenous identity and local norms—especially those linked to motherhood and ethnic belonging. Together, these findings challenge current, mainstream, narratives that frame women’s empowerment as a tobacco use risk factor. Instead, they support a rethinking of empowerment as a potential source of health resilience. Revealing that rather than undermining protective norms, educational and economic empowerment can strengthen health-promoting behaviors. This dissertation advances a biocultural framework for understanding women’s tobacco use, situating it within a constellation of evolutionary imperatives, cultural meaning systems, and structural inequalities while accounting for their entanglement. It calls for tobacco control strategies that are both gender-sensitive and culturally competent, recognizing the protective potential of education, maternal roles, and community values. These insights offer theoretical contributions to the study of human health behavior and actionable guidance for reducing smoking prevalence among women in the global South.

A BIOCULTURAL INVESTIGATION OF WOMEN'S TOBACCO USE: TESTING THE FETAL PROTECTION VS GENDER INEQUALITY HYPOTHESES

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