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Excerpts from: Women and Smoking: A Report of the Surgeon General

 
 
Executive Summary

This is the second report of the U.S. Surgeon General devoted to women and smoking. The first was published in 1980 (U.S. Department of Health and Human Services [USDHHS] 1980), 16 years after the initial landmark report on smoking and health of the Advisory Committee to the Surgeon General appeared in 1964 (U.S. Department of Health, Education, and Welfare [USDHEW] 1964). The 1964 report summarized the accumulated evidence that demonstrated that smoking was a cause of human cancer and other diseases. Most of the early evidence was based on men. For example, the report concluded, "Cigarette smoking is causally related to lung cancer in men.... The data for women, though less extensive, point in the same direction" (USDHEW 1964, p. 37). By the time of the 1980 report, the evidence clearly showed that women were also experiencing devastating health consequences from smoking and that "the first signs of an epidemic of smoking-related disease among women are now appearing" (USDHHS 1980, p. v). The evidence had solidified later among women than among men because smoking became commonplace among women about 25 years later than it had among men. However, it was still deemed necessary to include a section in the preface of the 1980 report titled "The Fallacy of Women's Immunity." In the two decades since, numerous studies have expanded the breadth and depth of what is known about the health consequences of smoking among women, about historical and contemporary patterns of smoking in demographic subgroups of the female population, about factors that affect initiation and maintenance of smoking among women (including advertising and marketing of tobacco products), and about interventions to assist women to quit smoking. The present report reviews the now massive body of evidence on women and smoking---evidence that taken together compels the Nation to make reducing and preventing smoking one of the highest contemporary priorities for women's health.

A report focused on women is greatly needed. No longer are the first signs of an epidemic of tobacco-related diseases among women being seen, as was the case when the 1980 report was written. Since 1980, hundreds of additional studies have expanded what is known about the health effects of smoking among women, and this report summarizes that knowledge. Today the Nation is in the midst of a full-blown epidemic. Lung cancer, once rare among women, has surpassed breast cancer as the leading cause of female cancer death in the United States, now accounting for 25 percent of all cancer deaths among women. Surveys have indicated that many women do not know this fact. And lung cancer is only one of myriad serious disease risks faced by women who smoke. Although women and men who smoke share excess risks for diseases such as cancer, heart disease, and emphysema, women also experience unique smoking-related disease risks related to pregnancy, oral contraceptive use, menstrual function, and cervical cancer. These risks deserve to be highlighted and broadly recognized. Moreover, much of what is known about the health effects of exposure to environmental tobacco smoke among nonsmokers comes from studies of women, because historically men were more likely than women to smoke and because many women who did not smoke were married to smokers.

In 1965, 51.9 percent of men were smokers, whereas 33.9 percent of women were smokers. By 1979, the percentage of women who smoked had declined somewhat, to 29.9 percent. However, the decline in smoking among men to 37.5 percent was much more dramatic. The gender gap in adult smoking prevalence continued to close after the 1980 report, but since the mid-1980s, the difference has been fairly stable at about 5 percentage points. In 1998, smoking prevalence was 22.0 percent among women and 26.4 percent among men. The gender difference in smoking prevalence among teens is smaller than that among adults. Smoking prevalence increased among both girls and boys in the 1990s. In 2000, 29.7 percent of high school senior girls and 32.8 percent of high school senior boys reported having smoked within the past 30 days (University of Michigan 2000).

In recent years, some research has suggested that the impact of a given amount of smoking on lung cancer risk might be even greater among women than among men, that exposure to environmental tobacco smoke might be associated with increased risk for breast cancer, and that women might be more susceptible than men to weight gain following smoking cessation. Other research indicated that persons with specific genetic polymorphisms may be especially susceptible to the effects of smoking and exposure to environmental tobacco smoke. These issues remain active areas of investigation, and no conclusions can be drawn about them at this time. Nonetheless, knowledge of the vast spectrum of smoking-related health effects continues to grow, as does knowledge that examination of gender-specific effects is important.

Smoking is one of the most studied of human behaviors and thousands of studies have documented its health consequences, yet certain questions and data needs exist with respect to women and smoking. For example, there is a need to better understand why smoking prevalence increased among teenage girls and young women in the 1990s despite the overwhelming data on adverse health effects; to identify interventions and policies that will prevent an epidemic of tobacco use among women whose smoking prevalence is currently low, including women in certain sociocultural groups within the United States and women in many developing countries throughout the world; to study the relationship of active smoking to diseases among women for which the evidence to date has been suggestive or inconsistent (e.g., risks for menstrual cycle irregularities, gallbladder disease, and systemic lupus erythematosus); to increase the data on the health effects of exposure to environmental tobacco smoke on diseases unique among women; to provide additional research on whether gender differences exist in susceptibility to nicotine addiction or in the magnitude of the effects of smoking on specific disease outcomes; and to determine whether gender differences exist in the modifying effects of genetic polymorphisms on disease risks associated with smoking. Many studies of smoking behavior and of the health consequences of smoking have included both females and males but have not reported results by gender. Investigators should be encouraged to report gender-specific results in the future.

Other recent reports of the Surgeon General have been devoted to smoking and youth (USDHHS 1994), smoking and racial or ethnic minorities (USDHHS 1998), and interventions to reduce smoking (USDHHS 2000). The reader is encouraged to consult those reports for comprehensive reviews of the evidence on these topics. The present report focuses on data specific to women and girls and on comparisons of results by gender.