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Gender, smoking and tobacco reduction and cessation: a scoping review Bottorff, Joan L; Haines-Saah, Rebecca; Kelly, Mary T; Oliffe, John L; Torchalla, Iris; Poole, Nancy; Greaves, Lorraine; Robinson, Carole A; Ensom, Mary H; Okoli, Chizimuzo T; Phillips, J C Dec 12, 2014

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REVIEWGender, smoking and tobwohCokeeokithterexposed to second- and third-hand smoke and reduce wanting to quit, long-term abstinence rates followingBottorff et al. International Journal for Equity in Health  (2014) 13:114 DOI 10.1186/s12939-014-0114-2high-risk subgroups [10]. Given this, it is critical toAustraliaFull list of author information is available at the end of the articlethe likelihood of influencing children, partners and peersto smoke [2] Although general smoking prevalence inCanada, the USA and many other Western countries de-creased steadily from over 60% in 1965 to 16.7% in 2010[3,4], declines have stalled and tobacco use remains highsmoking interventions that combine counseling withmedication decrease to 20-35% after 12 months [8,9],pointing to the need to develop and modify TRCprograms.While a multidisciplinary body of research addressinggender-related influences has slowly emerged, the vastmajority of that work is descriptive. Among other foci,there remains the need to transition gender-focused re-search toward evaluated TRC interventions targeted to* Correspondence: joan.bottorff@ubc.ca1Institute for Healthy Living and Chronic Disease Prevention, University ofBritish Columbia, 3333 University Way, Kelowna, BC V1V 2V7, Canada2Faculty of Health Sciences, Australian Catholic University, Melbourne,spanned the social, psychological and medical sciences. To incorporate these gender-related factors into tobaccoreduction and cessation interventions, our research team identified the need to clarify the current theoretical andmethodological interpretations of gender within the context of tobacco research. To address this need a scopingreview of the published literature was conducted focussing on tobacco reduction and cessation from the perspectiveof three aspects of gender: gender roles, gender identities, and gender relations. Findings of the review indicate thatthere is a need for greater clarity on how researchers define and conceptualize gender and its significance for tobaccocontrol. Patterns and anomalies in the literature are described to guide the future development of interventions thatare gender-sensitive and gender-specific. Three principles for including gender-related factors in tobacco reduction andcessation interventions were identified: a) the need to build upon solid conceptualizations of gender, b) the importanceof including components that comprehensively address gender-related influences, and c) the importance of promotinggender equity and healthy gender norms, roles and relations.Keywords: Tobacco, Smoking cessation, Gender, Gender relations, Gender analysis, Scoping reviewIntroductionTobacco reduction and cessation (TRC) are among themost important health promoting changes that men andwomen who smoke can undertake to reduce their risk oflung, breast, and cervical cancers and cardiovascular dis-ease [1]. Smoking cessation is also an important mech-anism to protect the health of others who might beamong many subgroups, in particular gendered groupswho may be socially and/or economically disadvantaged.For example, low-income mothers [5], men who work inconstruction, trades or “blue collar” occupations [6], andmen and women who identify as lesbian, gay, bisexual,and transgender (LGBT) [7] have smoking rates that farexceed the overall population prevalence. For thosecessation: a scoping revieJoan L Bottorff1,2*, Rebecca Haines-Saah3, Mary T Kelly3, JLorraine Greaves5, Carole A Robinson6, Mary HH Ensom7,AbstractConsiderations of how gender-related factors influence smand feminist scholars. This scholarship highlighted the nwomen’s tobacco use and the relationships between smsmoking and masculinities has only recently emerged wmen’s tobacco use. Since that time, a multidisciplinary li© 2014 Bottorff et al.; licensee BioMed CentralCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.Open Accessacco reduction andn L Oliffe3, Iris Torchalla4, Nancy Poole5,hizimuzo TC Okoli8 and J Craig Phillips9ing first appeared over 20 years ago in the work of criticald to consider the social and cultural context ofing and gender inequity. Parallel research on men’ssome attention being given to gender influences onature addressing women and men’s tobacco use has. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Bottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 2 of 15clarify the theoretical and methodological interpretationsof gender in the context of tobacco research. In this art-icle, we review the evidence regarding gender-related in-fluences on tobacco smoking and cessation, and proposesome ways forward by which gender may be interpretedand better incorporated into TRC interventions.Current approaches in tobacco interventionsIn the medical community, tobacco dependence is typic-ally viewed as a “chronic disease” [11,12]; and classifiedas a mental illness, tobacco use disorder, in the 5th edi-tion of the Diagnostic and Statistical Manual of MentalDisorders (DSM-5) [13]. By compartmentalizing smok-ing as a physical dependence and addiction, this biomed-ical definition neglects the social contexts that promoteand prohibit smoking [14,15]. While biomedical ap-proaches to tobacco use comprise part of the picture,they fail to integrate findings from the social sciences ad-dressing gender-related influences on smoking as linkedto both women’s and men’s social roles, identities, andrelationships, and the influence of gender as a determin-ant of health and source of health inequity.The approach to TRC interventions in the past twodecades has often promoted the use of treatment match-ing strategies, whereby subgroups of people who smokereceive different treatments depending on individual vul-nerabilities to treatment failure or relapse, and adaptedto individual needs [16]. Treatment matching strategieshave three major foci, often used in combination: 1)stepped-care programs where all people who smoke re-ceive initial low-intensity interventions, and those whodo not succeed are stepped-up to more intensive inter-ventions until they succeed [17]; 2) stage-matched pro-grams where intervention components are individualizedto match the smoker’s current stage of change [18]; and3) tailored interventions which are modified with exist-ing standard treatments designed to address the needsof certain at-risk smoker subgroups (e.g., people thatsmoke with medical or psychiatric diagnoses such ascardiovascular diseases, diabetes, depression, or schizo-phrenia) [19]. Further, in the 53 Cochrane reviews ofinterventions to help people quit tobacco [20] “specificgroups of smokers” were also identified by diagnoses,such as schizophrenia, depression or other substanceuse, and gender-related factors were not disaggregatedor explicitly considered in interventions.Conceptualizing gender for TRCGender is defined as a multidimensional, social con-struct that refers to the processes by which we enact ourbelonging to various categories of being a woman, man,or transgendered person. The concept of gender is cul-turally and socially specific and changes over time. Inthis scoping review, we explore gender from a socialconstructionist perspective [21,22] which includes: so-cially prescribed roles and responsibilities (the genderingof social norms that influence who smokes and how,where, and when); aspects of individual identity andalignment with femininity or masculinity (smoking as“feminine rebellion” or “masculine cool”); gender rela-tions (the tobacco-related micro-interactions among andbetween women and men that contribute to the construc-tion, maintenance or contesting of gender); and institu-tional gender (the ways in which social organizations suchas the tobacco industry or governments construct gender)[23]. In addition to expanding the concept of gender,awareness of the diversity and plurality of gender is alsosignificant for tobacco research and interventions becausesubgroups of individuals, such as LGBT communities, canshow a high prevalence of tobacco use [10].aThe tobacco industry has systematically and consist-ently marketed cigarettes from a gendered perspective,(representing women’s smoking as a means to enhancedfemininity, heterosexual appeal, or rebellion [24] andmen’s smoking as a means to masculine strength, manli-ness and freedom [25]), continuing to refine ads for targetgender groups [26]. In comparison to the tobacco indus-try’s long-time exploitation of femininity and masculinityto sell cigarettes, the consideration of gender-related influ-ences on TRC is a relatively recent development in to-bacco control and health behavior research [27,28].National guidelines for treating tobacco dependence[11,12] have not attended to the multifaceted elementsof gender. In fact, it has been argued that clinical frame-works and guidelines for treating tobacco dependence[11,12] are somewhat gender neutral and/or genderblind despite burgeoning evidence that gender (as it in-tersects with culture, class and age) influences tobaccouse [29,30]. For instance, women have been labeled as a“special population” in treatment guidelines and pre-sumed to benefit from the same interventions as men.Likewise, despite men’s long historical connection to to-bacco use and dependence, men receive no specificmention or discussion in treatment guidelines. Tobaccodependence treatment guidelines appear to reflect thenotion of gender as, primarily, a medical and biologicalconstruct affecting women’s health; as a result, interven-tions for women are considered gender-specific within thecontext of enhancing interventions with components thataddress sex/biology and reproductive health (i.e., preg-nancy, fertility, osteoporosis, hormones and other medicalconcerns).A systematic review identified 39 intervention studiesdeveloped specifically for women [31]; however, amongthese interventions, the concept of gender was oftenlimited to women’s assignment to subgroups based on asingle characteristic (e.g., abnormal pap smears, themenstrual cycle, depression, or sedentary lifestyle). Anunderstanding or conceptualization of gender as a com-plex set of influences connected to social power rela-tions and/or social constructs of femininity was absent.Another systematic review identified 11 interventionstudies targeting men [32]; however, among these inter-ventions only two included treatment components tai-lored specifically for men (expectant fathers and gaymen) [33,34]. The other interventions delivered stand-ard (non-gendered) TRC treatments in settings provid-ing health and social services specifically to men.The purpose of this scoping review is to take stock ofdevelopments in the consideration of gender-related in-fluences in smoking and TRC. Our objectives were to: a)examine how gender-related influences have been takenup in the wide-ranging literature on women and men’ssmoking and tobacco reduction and cessation, 2) de-scribe current knowledge related to gender-related influ-scoping reviews refined by Levac, Colquhoun, & O’Brien[35], we employed an iterative approach for determiningstudy inclusion and data extraction; thematic qualitativeanalyses of the results; implications for policy; and theutilization of a consultative process to obtain additionalinsights [35]. Inclusion criteria were: items published inEnglish after 1990 that addressed tobacco use or reductionand cessation within the context of gender roles, genderidentity, or gender relations. We excluded items that con-flated gender with sex (e.g., gender differences with sexdifferences); confined the concept of gender to biologicalcategories of females and males; or focused on tobaccouse prevalence, epidemiology; or demographic characteris-tics of tobacco users and their smoking patterns withoutconsideration of gender-related influences.In addition, we developed an original four step strategyto identify the relevant literature (Table 1). First we per-tic, 2al.n,inges,t a6, 2ugkFet ankbi20120koBottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 3 of 15ences on smoking and the associated implications forTRC interventions, and 3) propose principles to guidethe development of gender-sensitive and gender-specificTRC interventions.bMethodsWe conducted a scoping study [35,36] of the publishedliterature to capture the relevant articles and books ad-dressing smoking and TRC from the perspective of threeaspects of gender: gender roles, gender identities, and/orgender relations. Scoping reviews allow researchers tomap a specific field of research to determine its breadthand depth, summarize an area of research, identify gaps,and analytically assess the state of the literature. Unlikesystematic reviews, scoping reviews do not assess thequality of the individual studies [35]. Adhering to theArksey and O’Malley methodological framework forTable 1 Scoping review processStep ResultingreferencesReferences identified alphabe1. Database Keyword Search 13 Bottorff et al. 2006a, 2006b,2009Haines et al. 2010a; Johnson et2. Ancestry Search 31 Amos & Haglund 2000; AndersoBottorff et al. 2010a; Cortese & LGreaves & Hemsing 2009a; HainMichel & Amos 1997; Morrow eÖhman, 2007; Nichter et al. 200Westmass & Dougherty 2011; RWearing 2000;Westmass, Wild &3. Descendancy Search 13 Alexander et al. 2010; Bottorff eBullock, 2011; Greaves & Jategao2012; Jackson & Tinkler, 2007; Ro4. Manual Inclusion 23 Amos et al. 2012; Bottorff et al.& Tungohan 2007; Haines-SaahNichter et al. 2010; Oaks 2001; OTinkler 2006; Wakefiled et al. 1998;Total: 80formed electronic searches in the databases CINAHL, Psy-chInfo, PubMed Sociological Abstracts, and EMBASE, forall citations occurring since 1990 using the search terms:smoking cessation, cigarette smoking, gender relations,gender identity, gender roles, masculinity, and femininity.After excluding citations that did not meet the inclusioncriteria, we identified 13 articles that investigated smokingfrom at least one of the three aforementioned aspects ofgender. Second, we manually “hand searched” the refer-ence lists of these 13 articles (i.e., ancestry searching orsearching backwards), and this yielded 31 relevant pub-lished articles. Third, we carried out a descendancy searchin Google Scholar (i.e., searching forwards) to identifymore recently published articles that may have cited anyof the 13 retrieved articles from the aforementioned stepone search strategy. This strategy produced an additional13 articles for inclusion. Lastly, the authors and tobaccoally by author(s)012a; Gage, Everett, & Bullock, 2007; Gilbert 2007; Greaves et al. 2010;2009; Oliffe et al. 2010; Roberts 2006; Tan 2011; Tinkler 2003Glantz, & Ling 2005; Barraclough 1999; Bottorff et al. 2005a, 2005b;2011; Cullen 2010; Dutta & Boyd 2007; Greaves, Kalaw & Bottorff 2007;Poland & Johnson 2009; Kohrman, 2007; Macdonald & Wright 2002;l. 2002; Morrow & Barraclough 2003a, 2003b, 2010; Nawi, Weinehall &009; Oliffe et al. 2008; Oliffe, Bottorff & Sarbit 2012a; Pachankis,asa et al. 2003; Tinkler 2001a, 2001b; Toll & Ling 2005; Wearing &rrence 2002l. 2010b, 2010c; Burgess, Fu & Van Ryn, 2009; Cook 2008; Gage, Everett &ar 2006; Greaves & Hemsing 2009b; Haines et al. 2010b; Hemsing et al.nson et al. 2010; White, Oliffe & Bottorff 2012a2b; Cook 2012; Ernster et al. 2000; Graham 1994; Greaves 1996; Greaves11; Hunt, Hannah & West 2004; Mao, Bristow & Robinson 2012; Mao 2013;li et al. 2011; Oliffe, Bottorff & Sarbit 2012b; Rudy 2005; Schmitz 2000;White, Oliffe & Bottorff 2012b, 2012c, 2013a, 2013bBottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 4 of 15experts from our larger research team were polled for pos-sible additions to the list of 57 [37] articles generated bySteps 1 to 3. This generated 23 new references includingbooks, in press articles and peer-reviewed journal articlesaddressing tobacco and gender that we “hand-picked.” Intotal, 80 articles met our scoping review criteria.cOnce the final list of studies was complete, we under-took a process of extraction, analysis and categorizationfor each of these items. We developed a data extractionkey and a standardized table in order to systematicallyassess how each journal or article defined and theorizedgender. Extraction sub-headings included entries de-scribing the references’ focus, the methods and measuresemployed (e.g., qualitative, historical analysis, etc.), thelanguage and terms used to describe gender (i.e., women,men, feminism, masculinity, etc.), and also noted whetheror not there was a consideration of sex-related factors. Wealso used this table to determine whether the focus ongender in the text was implicit or assumed, or made expli-cit with clear and identifiable definitions and/or theoriesof gender used within the text. We then grouped each ofthe 80 articles into broad categories, based on the topicsor themes we observed across this set of articles: genderrelations and tobacco (n = 24); women’s smoking and gen-der identities, roles and norms (n = 25); men’s smokingand gender identities, roles and norms (n = 21); and gen-der issues in tobacco and policy (n = 10).Members of the multidisciplinary research team par-ticipated in analyzing the articles, extracting and chart-ing the data, and assigning each item to a category.After the completion of data extraction, two of the au-thors (MK, RH-S) undertook the analysis of items byassigning each article to one of four thematic categories.Below we present a critical analysis and qualitative syn-thesis of gender issues and tobacco as seen within eachof these four categories.ResultsThe majority of articles in our review were from the do-mains of nursing science and social science research onsmoking and health. As a set, the 80 articles were di-verse and far-reaching in terms of their foci, methods,and theoretical orientations. The majority of the itemsreported on the results of empirical studies (n = 59),employed qualitative methods (n = 53) and primarilyused one-to-one interviews and focus groups withpeople who smoke or who were engaging with cessation.Six articles reported findings from quantitative (n = 4) ormixed method (n = 2) studies, using survey instrumentsor psychological measures to assess the relationship be-tween gender and smoking at an individual level. Elevenarticles comprised literature reviews of varying scope,and two articles were based on the development of father-specific interventions [38,39]. There were 8 items, booksor book chapters, which looked broadly at women’s andmen’s smoking, and gender identities in the social and cul-tural history of tobacco use.For each of these thematic categories, we describe thegeneral features of the assigned articles, how they defineand address gender issues, their theoretical approach togender, and their potential implications for gender-sensitive and gender-specific TRC and interventions.Women’s smoking and gender identities, roles and norms(n = 25)DescriptionThere were 25 items addressing women’s smoking andfeminine identities, roles or norms that met the criteriafor inclusion in our review. These articles were pub-lished between 1994 and 2012.In this category, 11 of the articles and books focusedretrospectively on gender norms and the social and cul-tural history of women and smoking in the context of20th century Canada, the United States and the UnitedKingdom [40-50]. Two groups of scholars looked specif-ically at how the tobacco industry has used gendered im-agery to market cigarettes to women in the late 20thcentury [24,51]. These works highlighted the relationshipbetween women’s smoking and the social context of gen-der inequality and changing gender roles. Nine empiricalarticles addressed gendered social norms and women’ssmoking vis-à-vis a more contemporary context [52],with most centred on the gendered experiences of ado-lescent and young adult women who smoke [53-57], andconsiderations of how gender shapes young women’s re-sponses to cessation and prevention campaigns [57-59].There were two items that adopted a critical stance to-wards the gendered politics of smoking during preg-nancy and by women who are mothers. Oaks’ [44] bookinterrogated public health’s use of “fetus-centric” rhet-oric and approaches to smoking cessation that neglectthe health of women beyond gestation and their roles asmothers. Likewise, Graham’s monograph established amore complex relationship between gender and tobaccouse, illustrating how smoking by low-income, lone-parent women is a function of their living in poverty andexperiencing social marginalization [60].Almost all of the retrieved items employed historical(archival research, industry document analysis) or quali-tative methods (interviews and focus groups) to addresswomen’s smoking. A handful of articles were quantita-tive studies: Graham’s [60] cross-sectional survey ofmothers who smoked, Michel & Amos’ [53] sociometricanalysis of adolescent girls’ peer relationships and smok-ing, Barraclough’s [61] use of small scale and nationalsurvey findings in Indonesia, Morrow et al.’s [62] surveyof women factory workers and students in Vietnam, andBottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 5 of 15MacDonald and Wright’s [54] use of cross-sectional sur-vey data from a Canadian high school.The gendered visual culture of women and tobaccoIt was notable that over half of the articles on womenand smoking – both contemporary and historical – drewfrom visual analyses and addressed how images ofwomen and smoking have been gendered within mediaand popular culture, in tobacco advertising, and also intobacco prevention campaigns. As confirmed by Tinkler[45,46,48,49] and Cook [47], visual analyses are criticalfor revealing how smoking has been historically linkedto gender and class, and how the cultural symbolism ofsmoking has changed alongside gains in women’s eco-nomic, political, and social status. In this visual context,both the tobacco industry’s use of feminine sexuality tosell cigarettes [24,51] and tobacco control’s “deglamouri-zation” approach to denormalizing smoking as ugly andunattractive for women [41,59] were critiqued, as theycommunicate a one dimensional or stereotypical presen-tation of beauty as essential to femininity and women’sidentities. These authors explore how dominant socialnorms have contradictorily positioned women’s smokingas both a source of femininity and sexual attractivenessas well as an unfeminine behaviour (i.e., not “ladylike”),depending upon the historical period, social status andclass background of the woman who smokes [41,42,49].Oaks [44] likewise explored how the body of the preg-nant woman and fetal imagery have been mobilized incessation messaging that intends to evoke women’s guiltand shame (i.e., as “bad” mothers) about the healthharms that smoking causes.Understandings of genderIn the majority of items, the approach to gender in rela-tion to smoking is implicit, in that it was not explicitlytheorized but linked broadly to a feminist or woman-centered stance that prioritizes gender equality. In thiscontext, women’s empowerment was seen as “freedomfrom smoking.” This runs counter to the gender-basedtactics of the tobacco industry, wherein the “freedom tosmoke” has been mobilized within cigarette advertisingas an act of women’s liberation, intended to symbolizetheir equality with men [42]. Young women were seenas particularly vulnerable to cultural messages and tomedia messaging that aligns smoking with a sophisti-cated and/or fashionable identity, or as an expression ofheterosexual femininity [43,53,55].In several works, feminine gender identities or normsaround smoking were seen as complex and socially con-tingent, suggesting that perceptions of smoking as a fem-inine identity are changeable, bound up in the broadercultural representations of women’s smoking and to pat-terns of gendered consumption. These items took acritical view of attempts to exploit gender-based differ-ences and to the objectification of femininity and women’sbodies and sexuality. This type of analysis rests upon anassumption that gender identities are socially constructedand linked to social power differentials, and seeks to de-link essentialist notions of femininity and women’s iden-tities. Explicit uses of gender theory/theorists were seen inabout one-fifth of the articles in this category and in-cluded: Bourdieu’s masculine domination, symbolic vio-lence and feminine appearance imperatives [59,63],Butler’s gender performativity [50,55], and Connell’semphasized femininity [58].Implications for interventionsIn the collection of items in this category, there were noresearch studies that pilot- or systematically-tested awomen-specific or women-sensitive TRC intervention.In one sense, providing a detailed account of women’ssmoking might be considered a type of cultural or histor-ical intervention, in that such social science scholarshipaddresses the invisibility of women from the research lit-erature and critically interrogates sexism and genderstereotyping. It might also be inferred from the feminist orwoman-centered approach seen within much of thisscholarship, that there is a need to engage women in TRCin ways that are positive or empowering for gender –primarily by focusing on smoking cessation as awomen’s health issue in its own right, above and be-yond the domains of pregnancy or mothering [41,44].In addition to the need to challenge portrayals of smokingas glamorous or “sexy” feminine practice by Hollywoodfilms or in tobacco advertising [49,50,55], scholarship ad-dressing the social history of women and smoking alsomakes it clear that there have been contradictory or“mixed” messages about smoking, gender and femininitywithin visual and popular culture. As such, there is a needto think critically about how non-smoking has been linkedto women’s attractiveness and prioritize beauty over healthin anti-tobacco campaigns directed towards women[41,49]. Finally, researchers addressing tobacco interven-tions at the structural level also made a strong argumentfor considering the social context of gender-related influ-ences on smoking as they intersect with poverty and socialdisadvantage, and the broader conditions of women’s lives[60,62]. As argued by feminist researchers such as Oaks[44], even “positive” gender-specific anti-tobacco messagesthat are geared towards empowering women to make“better” health decisions can have the moralistic effect of“blaming the victim,” in that they emphasize health as per-sonal/individual responsibility and choice. Indeed, as wasfirst argued by Greaves [41] almost two decades ago, “It istoo easy to think of women smokers as simply agents oftheir poor health or instruments of their own addiction”,leading to a “sexist and disrespectful approach” to tobaccoBottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 6 of 15control policy and programming (p. 120). As such, “thechallenge is to appeal to women and girls who smoke byusing methods that do not blame them” [44], in designingmessaging and tobacco interventions that are “woman-specific” and “woman-positive”, recognizing the complex-ity of tobacco use in women’s lives beyond a psychosocialor behavioural approach [41].GapsOnly two of the articles in this sub-category addressedgender-related factors and smoking by women outside ofWestern contexts, in countries including Vietnam [62]and Indonesia [61]. In their commentary and historicalreview, Amos and Haglund [42] also made a strong casein support of a 21st century tobacco control approachthat is more global in its gender focus, citing the factthat women in the developing world are vulnerable togrowing rates of smoking due to shifts in gender rolesand targeting from the tobacco industry.In addition to the absence of accounts of women’s ex-periences with tobacco and cessation outside of NorthAmerica and the United Kingdom, the gender and to-bacco research literature might benefit from intersec-tional analyses of gender and smoking as advocated bycontemporary feminist theories of health. This would in-clude emphasis on interventions that recognize diver-sities within gender, and that consider how genderintersects with other identity categories, social factorsand/or systems of inequity (e.g., sexuality, race, socioeco-nomic status). Most notable, however, is that despite de-cades of descriptive research focussed on the linksbetween women, femininity, and smoking, interventionefforts have not responded adequately by incorporatingthis knowledge in women-centered cessation programs.Men’s smoking and gender identities, roles and norms(n = 21)DescriptionWe identified 21 items focussed on men’s smoking andmasculine identities, roles and relations that met the in-clusion criteria. All of these articles were published after2005.Nine articles explored men’s smoking and fathering inCanada as an aspect of masculine identities. Six articles in-vestigated contemporary or historical constructions ofmasculinity in American tobacco advertisements and/orlifestyle magazines, such as the Philip Morris MarlboroMan, associated cowboy and Wild West motifs [25,27,64]“new lad” representations of masculinity [65], and an ana-lysis of the cultural and political articulation of cessationby willpower with the male body and masculine idealsof self-control and autonomy [28]. There were fourculturally-specific studies of men’s smoking and masculineideals. For instance, Roberts [66] explored connectionsbetween cigarette smoking and masculine role models forDutch youth in the early 17th century. Korhman [67]questioned the tobacco-related epidemic of men’s deathsin China, invoking a socio-political frame on gender andAsian social pressure to “live the good life” that smokingrepresents. Focus-group researchers in Java, exploring thevalues and beliefs that Indonesian teenage boys hold abouttobacco, concluded that smoking is a symbol of masculineidentity, representing risky behaviour [68]. One group ofresearchers analyzed how the content in Canadian schooltextbooks was modified between 1880 and 1960, shiftingthe representation of masculinity, men and smoking andthe associated health risks of tobacco (Cook) [69].The lone quantitative study in this subsample com-pared sexual orientation and measures of masculinityand gender conformity among gay men and the generalpopulation, concluding that constructs of masculinitypredict smoking among both gay and heterosexual men[70]. Finally, Okoli et al.’s [32] systematic review of men-specific tobacco cessation interventions noted how fewinterventions address the role of masculine ideals andnorms in men’s tobacco use.Fathering and tobacco cessationSix of the nine articles focussed on fathering were em-pirical findings from qualitative research investigatinghow ideals of masculinity, such as provider and pro-tector identities [71-73], can conflict with men’s desiresto continue an autonomous smoking practice as a “fam-ily man.” The longstanding history of interventions thathave focussed on mothers and tobacco cessation framesan article addressing the importance of understandingfatherhood as an expression of masculine identity tosupport men’s cessation efforts [74]. Key program princi-ples to include in interventions for new fathers whosmoke are detailed by Oliffe, Bottorff & Sarbit [39]. Inan intervention casebook chapter, Mobilizing Masculin-ity to Support Fathers to be Smoke-free, the authors illus-trate how positive aspects of men’s masculine identitiescan be used to assist new dads who are interested in re-ducing or quitting smoking [38].Understandings of genderHalf of these articles, in particular the articles focussedon fathering, are guided by social constructionist theor-ies of gender and masculinity, as described in the workof Creighton and Oliffe [75]; Kimmel [76]; Courtenay[77,78] and Connell [79,80]. Social constructionist theor-ies of gender view masculinity as social phenomenaenacted and maintained by the interplay and perfor-mances of individuals and groups within and across socialstructures. Central to this view of gender and social power,are hegemonic masculinities, the dominant expressions ofmasculinity which are socially sanctioned at any particularBottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 7 of 15time and locale. Within this framework, cigarette smokingmay be theorized as a social reproduction of masculinityor declaration of masculine identity. Because masculinityis socially constructed, it is dynamic and changeable, influ-enced and taken up in nuanced ways according to varioussocial factors such as culture, race, socio-economic class,age, and sexual identity.Tobacco use is theorized as a hegemonic masculineactivity or response to hegemonic power within this per-spective, because smoking fulfills constructed manlyideals of risk-taking, neglect of self-health, and strengthand toughness associated with dominant masculinity. Nget al. [68] and Kohrman [67] make these links betweenmasculine identities and Asian men’s smoking; however,masculinity is ultimately presented as a detrimentalpractice or pathology that endangers men’s health. Severalarticles, especially White, Oliffe and Bottorff [27,64,74,81],Cortese and Ling, [65], and to a lesser extent Johnsonet al. [82] make theoretical linkages between tobacco as aconsumer, cultural commodity, and the use and repre-sentation of such commodities in the construction ofmasculinities. From this perspective, gender becomesco-constructed by individuals’ tobacco consumptionand media images in a recurring loop, providing com-pelling evidence of the need for program interventionsto understand the constructed nature and power ofgendered imagery.In contrast, there is evidence for an approach to genderand tobacco cessation among these articles that accessesand amplifies the positive connections between masculineideals and cessation, rather than vilifying dominant mas-culinity as a liability. In the context of fatherhood for ex-ample, masculine identity then becomes an opportunity tofulfil roles of protector, caregiver and breadwinner, ex-pressing ruggedness and toughness as strong health andwell-being, thereby motivating and sustaining smokingcessation [39,64,74].Pachankis et al. [70] provide the only article under thistheme that theorized gender as a psychological construct.The researchers employed multiple measures such as theBoyhood Gender Nonconformity scale, a masculinityLikert scale, and a measure of sexual orientation conceal-ment to compare gay and heterosexual men’s smokingpractices, concluding that constructs of masculinity pre-dicted and motivated smoking for both gay and straightmen.Implications for interventionsIn a comprehensive literature review, Okoli, Torchalla,Oliffe and Bottorff [32] identified men-specific smokingcessation programs, locating 11 studies that deliveredinterventions to men only. In addition, only 2 of theseintervention studies were actually tailored specificallyfor men [32]. Theoretically, the review positions men,masculinity and tobacco use from the perspective of so-cially prescribed gender norms, and notes how most to-bacco research reports sex differences in interventions,but lacks an understanding of the intersectionality ofgender-related factors, and how masculinity is always em-bedded in a social context, layered and connected to socialclass, ethnicity, occupation and age factors to influencemen’s smoking and cessation.In regard to creating content for men-specific inter-ventions, the historical analysis of how willpower andthe notion of quitting smoking became a presumed mas-culine virtue is important and practical research [64]. In-tegrating the philosophical origins of willpower withfeminist approaches to the body, and social construc-tionist perspectives on masculinity, the authors demon-strated how the tobacco industry exploited longstandinggendered assumptions about male power, and men’s pre-sumed ability to easily quit smoking before gettingaddicted to nicotine. This research is convincing interms of the need for cessation messaging to skilfully ad-dress the deep-seated cultural ideals about men, quittingand willpower.These articles as a set also underscore the opportunityand need for men-specific tobacco interventions to dem-onstrate an understanding of gender messaging to thesame degree as the tobacco industry. Interventions couldincorporate the appeal of masculine ideals into their pro-gramming by integrating content about men’s smoke-freeidentities with references to masculine strength, auton-omy, freedom and the ability to take action.GapsMost remarkable about this subsample of articles are thelimited historical accounts of men’s smoking from theperspective of changing masculine identities over time.This is surprising for two reasons: 1) thorough accountsof women’s smoking and identity exist that have docu-mented the feminization of cigarettes throughout the19th and 20th centuries and its movement through socialclasses [41,47,49]; 2) smoking was first taken up in largenumbers by men across all cultures; in general, smokingprevalence has always remained higher among men, andthe international tobacco epidemic, thus far, has killedfar more men than women. That more complete historicalaccounts documenting men’s smoking culture and mascu-linity are lacking is perhaps indicative of how well-laminated and entrenched the cultural constructions ofmen’s smoking with masculinity have remained in our col-lective understanding. Cook’s [69] analysis supports thisview by documenting how regulated and controlled publicsmoking for men became synonymous with codes of goodcitizenry and social character, reflecting congruence be-tween school health studies and the messaging in to-bacco ads.Bottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 8 of 15Gender relations and tobacco cessation and reduction(n = 24)DescriptionGender relations research refers to the study of theinterplay of masculinities and femininities within and be-tween genders [83]. We identified 24 items focussed ongender relations within the context of tobacco cessationor reduction. Over half of these items (n = 14) werestudies investigating couple relations and tobacco use infamily households. Among these, 8 were also focussedon couple relations and smoking in the context of preg-nancy and/or the postpartum. Friendship interactionsamong young women were the focus of a study that dem-onstrated how diverse femininities are co-constructed andperformed through daily cigarette-related interactions[84]. Two articles compared the gendered ways in whichyoung people perceived smoking [85-87]. Two systematicreviews [88,89], and one book chapter about methods ingender relations research with a case study on couples’ to-bacco use [83] focussed on gender relations.In a NIH Quit Tobacco International initiative article[85], the authors explored men’s smoking and masculin-ity within the context of Indonesian tobacco advertising,and proposed a cultural intervention based in commu-nity gender relations to destabilize tobacco norms. In acritical commentary, Tan [90] denounced the Westernemphases on binary categories of feminine and masculinein tobacco research, arguing that such approaches canperpetrate gender ideology and stereotypes in connectionwith Asia and global smoking trends. He proposed, in-stead, culture- and location-specific research that ex-amines smoking in the context of polyvalent gendersubjectivities along intersecting axes such as class andage.Two articles were based on the historical research offemininity and masculinity in conjunction with tobaccouse patterns. In a longitudinal, quantitative survey of threegenerations of smokers in Scotland, Hunt, Hannah andWest [91] showed how tobacco patterns differed in rela-tion to social class and gender role identity during differ-ent periods of the 20th century. In an analysis of cigaretteads within the context of cultural values of the 1880s,Schmitz [92] discussed the shifting gendered meaning ofcigarette smoking, arguing that the tobacco industry de-veloped new markets for cigarettes at the end of the 19thcentury by redressing the long standing associations ofcigarettes with women, effeminacy, and urbanism andintroducing a more masculinist stance into their advertis-ing content.Gender relations and household smokingAmong the 6 studies investigating barriers to cessation infamily households, we found little cohesion in terms ofhow the researchers approached gender relations [93-98].The studies explored gender relations in households inCanada, China, Indonesia and Scotland; gender relationswere sometimes implicit, and often the analytic categorywas simply women and men, rather than femininity andmasculinity. For instance, Westmaas, Wild and Ferrence[98] in comparing women and men smokers and the roleof partner influence on tobacco cessation, found thatwomen were more successful in changing men’s health be-haviours than men were in influencing women. The au-thors proposed that although social network influencesmay be beneficial for men, they may be perceived as anadditional burden by women and as a criticism of howthey fulfil their role as a woman and mother. Robinsonet al. [97] invoked a gender-based analysis; however, theirprimary unit was the individual, in-home smoker, andamong their sample, the women smokers were comparedto the men smokers to derive findings. The authors werecareful to distinguish gender from sex factors. They con-cluded that it was the gendered and class-based role ofcaring for others, not the sex of the person, which ex-plained women’s indoor smoking, despite bans on homesmoking. Although we would argue that Robinson et al.[97] are investigating gender relations within a broad con-text of social class, their lack of conceptualizing femininityand masculinity also contributed to the strong emphasison social class factors. Nichter et al. [96] designed theirinterview-based study with the couple as the unit of ana-lysis (n = 530); however, these researchers also confinedtheir discussion to the gender roles of wives and husbands,or women and men, bypassing gender constructs of fem-ininity and masculinity.Similarly, disparate approaches to gender relationsemerged among the household smoking articles focussedon pregnancy. Male support for pregnant partners andmen’s participation in tobacco cessation during pregnancyinformed non-theoretical approaches to gender relations inthree studies [99-101]. Spousal relations allowed for the in-vestigation of power and control related to tobacco useduring pregnancy in three studies [37,102,103]. A groundedtheory analysis of interviews with 28 couples yielded dis-tinct typologies that categorized couples’ interaction stylerelated to the women’s tobacco reduction during pregnancyand postpartum [104]. A grounded theory analysis of fem-ininities and masculinities among 27 couples revealed howwomen may adopt feminine positions as both defendersand regulators of their husband’s smoking [105].Understandings of genderIn many of these studies researchers did not overtly de-fine gender or they communicated ambiguous meaningsin regard to gender relations. This collection of itemsworked with gender from diverse, theoretical perspec-tives: social constructionism, cultural commodification,feminist and individual health behaviours.improving gender equity as well as health), as it perpetu-femininities and masculinities mapped onto tobacco re-Bottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 9 of 15We assessed eight articles as conceptualizing genderfrom the perspective of individual health behaviours andthe interactions of women and men related to tobacco.The authors may have acknowledged the influence of so-cial norms on these health behaviours, but overall gen-der was not theorized beyond the level of individualbehavioural patterns. Six articles employed a feministlens, emphasising the influence of social class factors inwomen’s tobacco use, and conducting tobacco researchwithin the context of gender as a factor that was tied tocultural ideologies of power and social power relations.For example, ethnographic research in households inChina showed how culturally defined gender roles lim-ited the ability for mothers to create smoke-free homes,and changes related to tobacco use were contained byfamilial and generational power relations, which couldreadily become a source of conflict in families with chil-dren [93,94].Two articles [95,105] and a book chapter [83] drew onsocial constructionist theories of gender [79,106] to ex-plore how femininities and masculinities mapped ontocouples’ smoking patterns and reduction efforts. Nichteret al. [85] did not define their theoretical perspective ongender; however, a social constructionist framework wasevident in their efforts to affect community-wide to-bacco reduction by shifting the smoking identities ofyoung men. Four articles showed how tobacco, as a cul-tural commodity, was taken up by smokers in the con-struction of gendered identities, providing a means tosocially enact various femininities or masculinities, ad-here to gender norms, or reproduce gender ideology[84,86,87,92]. Tan’s [90] commentary called for new to-bacco and gender theory, and Nichter et al. [96] did nottheorize gender overtly; however, their work suggested aunique approach that we discuss below.Implications for interventionsThe integration of knowledge of gender relations andsmoking in the design of TRC interventions is at a nas-cent stage. Efforts to denormalize tobacco use inIndonesia at the household level were described byNichter et al. [96] in qualitative work with 530 couples.The researchers planned to influence the epidemic ofmen’s smoking and launch a community-based tobaccocessation movement by encouraging Indonesian womento demand smoke-free homes, promoting awareness andchanged tobacco norms at the community level. Theunderlying theoretical implication here was that gendernorms (i.e., men’s reified smoking practices) can be chal-lenged at the local, community level and, if culturallyrelevant, a gender relations approach to research maybe helpful for devising effective interventions for en-tire communities. Nonetheless, enlisting Indonesianwomen to promote smoke-free masculine identities,duction and cessation efforts [95]. In gender relations re-search with pregnant women and their partners, the wayscouples responded to women’s efforts to reduce or stopsmoking depended on the couples’ established inter-action patterns with respect to tobacco (i.e., disengaged,conflictual, or accommodating styles) [104]. As a result,the authors recommended de-linked, women-centered,couple-informed TRC interventions for pregnant women[37,104]. These findings were also translated into an inter-vention booklet for women and distributed online and incommunity clinics [109].GapsWe were unable to identify interventions in the litera-ture that have incorporated a gender relations approachand knowledge of femininities and masculinities intotobacco cessation programming for people who are notparenting or living in family households, perhaps reflect-ing a long held concentration on tobacco use andreproduction, especially for women, to the exclusion ofaddressing individuals as women (or men). An inter-generational approach to gender relations and tobaccouse would also be beneficial to refocus interventionsbeyond the context of the heterosexual nuclear family.Gender issues in tobacco control policy (n = 10)DescriptionTen articles identified by our review addressed genderissues at the broader, structural level of tobacco controlpolicy. Seven of these articles focussed on gender issuesin women and girls’ tobacco use, and represented rela-ates women’s responsibility for health management anddoes not shift gender norms [107,108]. However, the im-portance of messaging young men differently than maturemen [85] is an important conceptual tool for practitionerscreating interventions, and implies a social constructional-ist stance that views gender identity as plural and change-able and intersecting with multiple factors such as age andsocial location.By employing social constructionist gender theories[79,106], parallel research with couples in Canada identi-fied how women adopted specific femininities in regardto men’s smoking [105] and how parenting styles andor purposely linking young men’s popularity to the ap-proval of smoke-free women [85] is a controversialstrategy from the perspective of feminist politics inthe West, as well as potentially loading responsibilityfor initiating change onto women’s shoulders with un-known risks. This approach is not transformative (i.e.,tively newer additions to the field, published in the years2003–2012.Bottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 10 of 15The gender- and policy-focussed items we retrievedfell into three categories: articles that inferred policy im-plications from empirical studies of specific or compara-tive tobacco policy contexts [110,111]; review articlesthat provided summary and critical analysis of policy-relevant research through a gender lens [112-114]; andmanuscripts that provided a more general description ofcurrent policy gaps and options [29,115-117]. However,recommendations towards the development of tobaccocontrol policies that addressed gender issues cut acrossall of these categories.Understandings of genderThe policy-focused literature for the most part containedclear and explicit definitions of gender, clearly distin-guished gender from sex, and prioritized the complex in-teractions between sex and gender as they influencetobacco use. In addition to citing the need for betterprevalence and policy data on smoking that is disaggre-gated by gender and sex, policies were critiqued foradopting a “gender blind” or “one size fits all” approachto tobacco control, when there is a need for gender-specific or gender-sensitive approaches [29,111] thatcontextualize gender beyond the level of individual iden-tity, role, or relational influences, as a broader “up-stream” or macro-level social determinant of health. Inthis context, gender was placed on a continuum (as op-posed to a male/female binary) and was one of severalintersecting categories that influenced smoking [29]. Fi-nally, Morrow and Barraclough [117] made a compellingargument for policy informed by a theory of gender associally constructed, and argued that within the tobaccopolicy literature “gender” has typically implied womenand girls, with the influence of men’s gender and mascu-linities on smoking conspicuously absent.Implications for interventionsPolicy-focussed articles underscore the need to advo-cate for changes to broader social and economic struc-tures and to redress gender-related inequities throughimplementing gender-sensitive tobacco control policies[117]. Recommendations towards a gender-sensitive policyframework range from refining measurement tools to en-sure the collection of sex and gender data in policy re-search, to engaging with gendered subpopulations incollaborative, participatory policy development (i.e. be-yond community consultation) [118]. There is also con-sideration of how gender-specific policies might worktowards a broader aim of social justice, through trans-forming gender inequities (empowering women sociallyand economically) as opposed to accommodating gender(playing to women’s roles as nurturers or mothers) orexploiting gender (paternalistic approaches that “protect”women from smoking) [116].In this literature, there is also critical consideration ofthe “unintended” – and often decidedly gendered –consequences of adopting particular policy interven-tions [113]. For example, Greaves and Hemsing [114]have argued that measures such as price and taxationincreases create an undue burden on subpopulations ofwomen with higher smoking prevalence such as low-income and lone-parent mothers, without the corre-sponding supports and programming for cessation.Likewise, Burgess et al. [112] provide review evidenceto support their argument that tobacco control policiesdesigned to protect children from second-hand smokehave the unintended effect of stigmatizing their mothers,blaming an already socially marginalized group of women,and perhaps worsening their health status. As thepolicy-focused work makes clear, it is vital to considergender-related factors in relation to socioeconomic sta-tus, racialization, mental health, and sexual minoritystatuses, because they can be associated with an in-creased vulnerability to tobacco use and with fewer re-ductions in smoking prevalence from policy measures[113,114,118]. As gender-related factors differ by social andcultural context, policy solutions also need to vary accord-ing to localized gender-based norms and cultural variationsin social roles for women and men [110,111,117]. The ana-lyses of women and tobacco policy advocate for what theyterm “gender and diversity” analysis that considers genderas it intersects with other social categories [116,118].GapsTo date, comprehensive or systematic analyses of tobaccopolicies and their potentially differential effects by sex andgender have been few. Clearly, the policy-focussed litera-ture on men, masculinities and tobacco would benefitfrom greater attention and development. Additionally, asthe current policy literature is situated within the Westernor post-industrial context, greater attention needs to beafforded to gender and tobacco policy in developingcountries where smoking rates are rising and the “firstand second waves” of the tobacco epidemic are in pro-gress [115-117].Principles and recommendationsIn summary, after incorporating these analyses of variousgroups of literature related to gender and tobacco, we de-veloped three key principles and recommendations toguide the inclusion of gender-related factors when devel-oping tobacco reduction and cessation interventions.Principle 1: Tobacco interventions need to be built uponsolid conceptualizations of genderRecommendation: All too often, gender has been ab-sent from the research literature on smoking cessation,Bottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 11 of 15and when it is present gender remains poorly defined.To advance TRC interventions, we recommend that to-bacco researchers adopt a theoretical framework thataccounts for gender in the following ways: 1) gender isrelational and dynamic; 2) gender identities are diverseand fluid; and 3) gender is shaped by social context andits interaction with other social determinants of health(e.g. age, rurality, socioeconomic status, race and ethni-city). For example, interventions that consider genderand its intersection with social and/or economic disad-vantage may have increased effectiveness and relevanceto specific populations of women and men, rather thanassuming relevance based on gender alone. Theorizinggender in these ways adds definitional clarity, assists indistilling gender from sex, acknowledges the culturaland temporal nature of gender, and promotes a view ofgender in relation to other social influences on tobaccouse and cessation.Principle 2: Tobacco interventions must includecomponents that comprehensively address gender-relatedinfluencesRecommendation: Tobacco researchers in both women’sand men’s health have called for gender-specific andgender-sensitive interventions to better accommodatethe needs of subgroups of individuals. Gender-sensitiveinterventions are those that prioritize gender-related in-fluences or needs within the context of an interventiondelivered to both men and women. Gender-specific in-terventions are designed specifically, or only for, men orwomen. In the past, sex and gender-specific interven-tions have been designed primarily for pregnant women;however, when we conceptualize gender as it intersectswith other social factors such as age, ethnicity, sexualidentity, disadvantage and social class, or relationshipand marital influences, we find the opportunity to im-prove tobacco interventions by tailoring them for morespecific and diverse audiences of smokers.An example of a gender-specific intervention that doesnot stigmatize pregnant women who smoke can be foundin the booklet, Couples and smoking: What you need toknow when you are pregnant [109]. This woman-centredapproach to reduction and cessation is based in gender-sensitive research that has identified couple interactionsand couple typologies that emerge when women whosmoke become pregnant, removing the focus from initiat-ing change in the woman’s behaviour to the social contextof tobacco in pregnancy and couple relations.Principle 3: Tobacco interventions should promotegender equity and healthy gender norms, roles andrelationsRecommendation: In order to counter the exploitativeapproach to gender in tobacco industry marketing andpromotion campaigns, we recommend an approach togender identities and gender relations that is based onprinciples of equity and empowerment. For example,interventions seeking to address gender should con-sider how alignment with particular gender identitiesand constructs of femininity and masculinity influencecessation and/or continued smoking. As examples, thiscould include notions of masculinity and “cold turkey”quitting methods, and the perceived links between fem-ininity and sexual attractiveness, rebelliousness or inde-pendence. A gender-sensitive approach to interventionswould generate or acknowledge positive representationsof masculinity and femininity in countering the stereo-types the tobacco industry continuously perpetrates,even if they are not the most popular representations.An example of a gender-specific intervention that doesnot promote negative representations of femininity ormasculinity is available in the booklet The Right Time,The Right Reasons: Dads talk about reducing and quit-ting smoking [119]. This material is based on gender re-search with fathers who smoke and assists their desire toquit by appealing to masculine ideals such as strength,decisiveness, and being healthy for one’s family.Gender role research can be challenging because ofits tendency to pre-determine norms and thereforereinforce static, conventional notions of gender [11].Contemporary constructivist gender theories groundedin performativity and plural masculinities and feminin-ities provide an inductive means for building targetedTRC interventions [80,120]. Related to this, when de-signing interventions there is a need to be cognizant ofthe local values of sub-groups and their influence ongendered practices in the context of tobacco use.Current approaches to gender and health theory ac-knowledge that gender “depends” on other social cat-egories and practices for its meaning and through theseintersections create inequalities and power relationsthat affect both women and men [121,122]. These con-siderations need to be taken into account in under-standing smoking trends and the way they intersectwith other social factors including regional and globalgendered ideals and structural controls as a means topromoting gender equity among and across men andwomen.Strength and limitations of methodConducting this scoping review enabled us to provide asynthesis of the emergent field of gender-related influ-ences in TRC and propose how these influences mightbe integrated in smoking interventions. Highlighted arerich gendered contexts to extend sex differences re-search and afford nuanced understandings about theneed for targeted TRC interventions. The strength ofscoping review methods resides in its capacity to captureBottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 12 of 15the essence of an emergent body of knowledge amidmaking recommendations for how best to build uponand apply those understandings. In addition, the scopingreview neatly fits with the ontological and epistemo-logical frames of social constructionist theories whereinthe interpretive and iterative nature of the findingsdrawn from the current scoping review relay and reflectgender as diverse but with prevailing patterns embeddedin social structures and power dynamics. In terms oflimitations, by scoping gender-related influences onlysex influences on tobacco use are less visible. To addressthis future research might integrate sex and gender tofurther develop targeted TRC interventions.ConclusionThis scoping review demonstrates the wide range of ap-proaches to researching gender and smoking cessation. Byconsidering the gender literature on women and smokingand men and smoking side-by-side, we have identified im-portant gender gaps in knowledge as well as some strat-egies toward improving future TRC interventions.This knowledge and evidence for how masculinities,femininities and the interplay of those conventions shapeand are shaped by smoking practices are key to the ef-fectiveness of TRC interventions. Integrating sex andgender, and advancing gender to explicitly include socialfactors including class, race and culture will go somedistance in achieving health equity and empowermentalong with tobacco reduction, cessation and prevention.While improving the way in which gender is integratedinto TRC interventions and tobacco control literaturemore widely is necessary, it is not sufficient for ensuringor improving gender equity and reducing health inequi-ties. Indeed, contemporary thinking in gender and tobaccocontrol articulates the goal of doing gender transformativework [107,108]: that is improving health and genderequity at the same time in intervention or policy design,thereby taking responsibility for not just acknowledginggender, but rather, shifting gender and its enactment, ef-fects, performance and meaning, in the context of tobaccoreduction or cessation.EndnotesaWhile this scoping review is focused on gender, wepay close attention to the interplay between gender andsex, in regards to how the biological sciences distinguishsex by various anatomies, physiologies, genes and hor-mones (Johnson & Repta) [23]. We employ the distinc-tions of gender and sex with the awareness that suchcategories are intimately connected to social and culturalideologies of power, in constant negotiation, often artifi-cially dichotomous, and often conceptually elusive. There-fore, key to our work is the knowledge that sex andgender are continua and change across time and historyand vary within and between individuals and groups. Ac-knowledging and anticipating both sex and gender as op-erating outside of female–male binaries in dynamic waysreminds us that smoking patterns and cessation effortsvary across time and within subgroups of women andmen.bGender specific interventions are those designed ex-clusively for women or men. Gender-sensitive interven-tions can be designed for women or men, but are sensitiveto how the approach and outcomes may be influenced bygender-related factors.cIt is notable that close to half (45% or 36/80) of thetotal items were published by an author of this articleand/or a member of the Investigating Tobacco andGender (iTAG) research team.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsJLB Study conception and design, data extraction, results analyses/interpretation,manuscript writing and revisions. RH-S Study conception, literature retrieval, dataextraction, results analyses/interpretation, manuscript writing and revisions. MKStudy conception, literature retrieval, data extraction/interpretation, resultsanalyses, manuscript writing and revisions. JLO Study conception and design,data extraction/interpretation, manuscript writing and revisions. IT Studyconception, literature retrieval, data extraction, manuscript writing and criticalreview. NP Study conception, data extraction, critical reviews. LG Studyconception, critical reviews. CAR Study conception, data extraction, criticalreviews. MHHE Study conception, manuscript writing and critical reviews.CTCO Study conception, critical reviews. JCP Study conception, critical reviews.All authors read and approved the final manuscript.Author details1Institute for Healthy Living and Chronic Disease Prevention, University ofBritish Columbia, 3333 University Way, Kelowna, BC V1V 2V7, Canada. 2Facultyof Health Sciences, Australian Catholic University, Melbourne, Australia.3School of Nursing, University of British Columbia, 302-6190 Agronomy Road,Vancouver, BC V6T 1Z3, Canada. 4Centre for Health Evaluation and OutcomeSciences, Room 620, 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.5British Columbia Centre of Excellence for Women’s Health, E311 – 4500 OakStreet, Box 48, Vancouver, BC V6H 3N1, Canada. 6School of Nursing,University of British Columbia, 3333 University Way, Kelowna, BC V1V 1V7,Canada. 7Faculty of Pharmaceutical Sciences, University of British Columbia,2405 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada. 8College of Nursing,315 College of Nursing Building, University of Kentucky, Lexington, KY40536-0232, USA. 9RGN 3249A, School of Nursing, University of Ottawa,Guidon Hall, 451 Smyth Road, Ottawa, ON K1H 8M5, Canada.Received: 15 May 2014 Accepted: 8 November 2014References1. 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J Men ’s Health2012, 9(2):106–112.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionBottorff et al. International Journal for Equity in Health  (2014) 13:114 Page 15 of 15Submit your manuscript at www.biomedcentral.com/submit


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