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Action on Smoking and Health
A National Legal-Action Antismoking Organization Entirely Supported by Tax-Deductible Contributions Search | Info About | ash.org | To Join | Email Page |
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
common-place 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, where-as 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.
Major Conclusions
1. Despite all that is known of the devastating health
consequences of smoking, 22.0 percent of women smoked
cigarettes in 1998. Cigarette smoking became prevalent among
men before women, and smoking prevalence in the United States
has always been lower among women than among men. However,
the once-wide gender gap in smoking prevalence narrowed until
the mid-1980s and has since remained fairly constant. Smoking
prevalence today is nearly three times higher among women who
have only 9 to 11 years of education (32.9 percent) than among
women with 16 or more years of education (11.2 percent).
2. In 2000, 29.7 percent of high school senior girls reported
having smoked within the past 30 days. Smoking prevalence
among white girls declined from the mid-1970s to the early 1980s,
followed by a decade of little change. Smoking prevalence then
increased markedly in the early 1990s, and declined somewhat in
the late 1990s. The increase dampened much of the earlier
progress. Among black girls, smoking prevalence declined
substantially from the mid-1970s to the early 1990s, followed by
some increases until the mid-1990s. Data on long-term trends in
smoking prevalence among high school seniors of other racial or
ethnic groups are not available.
3. Since 1980, approximately 3 million U.S. women have died
prematurely from smoking-related neoplastic, cardiovascular,
respiratory, and pediatric diseases, as well as cigarette-caused
burns. Each year during the 1990s, U.S. women lost an estimated
2.1 million years of life due to these smoking attributable
premature deaths. Additionally, women who smoke experience
gender-specific health consequences, including increased risk of
various adverse reproductive outcomes.
4. Lung cancer is now the leading cause of cancer death among
U.S. women; it surpassed breast cancer in 1987. About 90
percent of all lung cancer deaths among women who continue to
smoke are attributable to smoking.
5. Exposure to environmental tobacco smoke is a cause of lung
cancer and coronary heart disease among women who are lifetime
nonsmokers. Infants born to women exposed to environmental
tobacco smoke during pregnancy have a small decrement in birth
weight and a slightly increased risk of intrauterine growth
retardation compared to infants of nonexposed women.
6. Women who stop smoking greatly reduce their risk of dying
prematurely, and quitting smoking is beneficial at all ages.
Although some clinical intervention studies suggest that women
may have more difficulty quitting smoking than men, national
survey data show that women are quitting at rates similar to or
even higher than those for men. Prevention and cessation
interventions are generally of similar effectiveness for women and
men and, to date, few gender differences in factors related to
smoking initiation and successful quitting have been identified.
7. Smoking during pregnancy remains a major public health
problem despite increased knowledge of the adverse health
effects of smoking during pregnancy. Although the prevalence of
smoking during pregnancy has declined steadily in recent years,
substantial numbers of pregnant women continue to smoke, and
only about one-third of women who stop smoking during
pregnancy are still abstinent one year after the delivery.
8. Tobacco industry marketing is a factor influencing susceptibility
to and initiation of smoking among girls, in the United States and
overseas. Myriad examples of tobacco ads and promotions
targeted to women indicate that such marketing is dominated by
themes of social desirability and independence. These themes are
conveyed through ads featuring slim, attractive, athletic models,
images very much at odds with the serious health consequences
experienced by so many women who smoke.
Chapter Conclusions
Conclusions from Chapters 2–5 are presented below. Separate
conclusions are not included for Chapter 1 because it is a
summary of the report. Chapter 6, which presents a vision for the
future, is reproduced in its entirety following the conclusions for
Chapters 2–5.
Chapter 2. Patterns of Tobacco Use Among Women and Girls
1. Cigarette smoking became prevalent among women after it did
among men, and smoking prevalence has always been lower
among women than among men. The gender-specific difference in
smoking prevalence narrowed between 1965 and 1985. Since
1985, the decline in prevalence has been comparable among
women and men.
2. The prevalence of current smoking among women increased
from less than 6 percent in 1924 to 34 percent in 1965, then
declined to 22 to 23 percent in the late 1990s. In 1997–1998,
smoking prevalence was highest among American Indian or Alaska
Native women (34.5 percent), intermediate among white women
(23.5 per0cent) and black women (21.9 percent), and lowest
among Hispanic women (13.8 percent) and Asian or Pacific
Islander women (11.2 percent). By educational level, smoking
prevalence is nearly three times higher among women with 9 to 11
years of education (30.9 percent) than among women with 16 or
more years of education (10.6 percent).
3. Much of the progress in reducing smoking prevalence among
girls in the 1970s and 1980s was lost with the increase in
prevalence in the 1990s: current smoking among high school
senior girls was the same in 2000 as in 1998. Although smoking
prevalence was higher among high school senior girls than among
high school senior boys in the 1970s and early 1980s, prevalence
has been comparable since the mid-1980s.
4. Smoking declined substantially among black girls from the
mid-1970s through the early 1990s; the decline among white girls
for this same period was small. As adolescents age into young
adulthood, these patterns are now being reflected in the racial
and ethnic differences in smoking among young women. Data are
not available on long-term trends in smoking prevalence among
high school seniors of other racial and ethnic groups.
5. Smoking during pregnancy appears to have decreased from
1989 through 1998. Despite increased knowledge of the adverse
health effects of smoking during pregnancy, estimates of women
smoking during pregnancy range from 12 percent based on birth
certificate data to as high as 22 percent based on survey data.
6. Historically, women started to smoke at a later age than did
men, but beginning with the 1960 cohort, the mean age at
smoking initiation has not differed by gender.
7. Nicotine dependence is strongly associated with the number of
cigarettes smoked per day. Girls and women who smoke appear to
be equally dependent on nicotine when results are stratified by
number of cigarettes smoked per day. Few gender-specific
differences have been found in indicators of nicotine dependence
among adolescents, young adults, or adults overall.
8. The percentage of persons who have ever smoked and who
have quit smoking is some-what lower among women (46.2
percent) than among men (50.1 percent). This finding is probably
because men began to stop smoking earlier in the twentieth
century than did women and because these data do not take into
account that men are more likely than women to switch to or to
continue to use other tobacco products when they stop smoking
cigarettes. Since the late 1970s or early 1980s, the probability of
attempting to quit smoking and to succeed has been equally high
among women and men.
9. Prevalence of the use of cigars, pipes, and smokeless tobacco
among women is generally low, but recent data suggest that cigar
smoking among women and girls is increasing.
10. Smoking prevalence among women varies markedly across
countries; the percentages range from an estimated 7 percent in
developing countries to 24 percent in developed countries.
Thwarting further increases in tobacco use among women is one
of the greatest disease prevention opportunities in the world
today.
Chapter 3. Health Consequences of Tobacco Use Among
Women
Total Mortality
1. Cigarette smoking plays a major role in the mortality of U.S.
women.
2. The excess risk for death from all causes among current
smokers compared with persons who have never smoked increases
with both the number of years of smoking and the number of
cigarettes smoked per day.
3. Among women who smoke, the percentage of deaths
attributable to smoking has increased over the past several
decades, largely because of increases in the quantity of
cigarettes smoked and the duration of smoking.
4. Cohort studies with follow-up data analyzed in the 1980s show
that the annual risk for death from all causes is 80 to 90 percent
greater among women who smoke cigarettes than among women
who never smoked. A woman’s annual risk for death more than
doubles among continuing smokers compared with persons who
have never smoked in every age group from 45 through 74 years.
5. In 1997, approximately 165,000 U.S. women died prematurely
from a smoking-related disease. Since 1980, approximately three
million U.S. women have died prematurely from a smoking-related
disease.
6. U.S. females lost an estimated 2.1 million years of life each
year during the 1990s as a result of smoking-related deaths due
to neoplastic, cardiovascular, respiratory, and pediatric diseases,
as well as from burns caused by cigarettes. For every smoking
attributable death, an average of 14 years of life was lost.
7. Women who stop smoking greatly reduce their risk of dying
prematurely. The relative benefits of smoking cessation are
greater when women stop smoking at younger ages, but smoking
cessation is beneficial at all ages.
Lung Cancer
8. Cigarette smoking is the major cause of lung cancer among
women. About 90 percent of all lung cancer deaths among U.S.
women smokers are attributable to smoking.
9. The risk for lung cancer increases with quantity, duration, and
intensity of smoking. The risk for dying of lung cancer is 20 times
higher among women who smoke two or more packs of cigarettes
per day than among women who do not smoke.
10. Lung cancer mortality rates among U.S. women have
increased about 600 percent since 1950. In 1987, lung cancer
surpassed breast cancer to become the leading cause of cancer
death among U.S. women. Overall age-adjusted incidence rates
for lung cancer among women appear to have peaked in the
mid-1990s.
11. In the past, men who smoked appeared to have a higher
relative risk for lung cancer than did women who smoked, but
recent data suggest that such differences have narrowed
considerably. Earlier findings largely reflect past gender-specific
differences in duration and amount of cigarette smoking.
12. Former smokers have a lower risk for lung cancer than do
current smokers, and risk declines with the number of years of
smoking cessation.
International Trends in Female Lung Cancer
13. International lung cancer death rates among women vary
dramatically. This variation reflects historical differences in the
adoption of cigarette smoking by women in different countries. In
1990, lung cancer accounted for about 10 percent of all cancer
deaths among women worldwide and more than 20 percent of
cancer deaths among women in some developed countries.
Female Cancers
14. The totality of the evidence does not support an association
between smoking and risk for breast cancer.
15. Several studies suggest that exposure to environmental
tobacco smoke is associated with an increased risk for breast
cancer, but this association remains uncertain.
16. Current smoking is associated with a reduced risk for
endometrial cancer, but the effect is probably limited to
postmenopausal disease. The risk for this cancer among former
smokers generally appears more similar to that of women who
have never smoked.
17. Smoking does not appear to be associated with risk of ovarian
cancer.
18. Smoking has been consistently associated with an increased
risk for cervical cancer. The extent to which this association is
independent of human papillomavirus infection is uncertain.
19. Smoking may be associated with an increased risk for vulvar
cancer, but the extent to which the association is independent of
human papillomavirus infection is uncertain.
Other Cancers
20. Smoking is a major cause of cancers of the oropharynx and
bladder among women. Evidence is also strong that women who
smoke have increased risks for cancers of the pancreas and
kidney. For cancers of the larynx and esophagus, evidence among
women is more limited but consistent with large increases in risk.
21. Women who smoke may have increased risks for liver cancer
and colorectal cancer.
22. Data on smoking and cancer of the stomach among women
are inconsistent.
23. Smoking may be associated with an increased risk for acute
myeloid leukemia among women but does not appear to be
associated with other lymphoproliferative or hematologic cancers.
24. Women who smoke may have a decreased risk for thyroid
cancer.
25. Women who use smokeless tobacco have an increased risk for
oral cancer.
Cardiovascular Disease
26. Smoking is a major cause of coronary heart disease among
women. For women younger than 50 years, the majority of
coronary heart disease is attributable to smoking. Risk increases
with the number of cigarettes smoked and the duration of
smoking.
27. The risk for coronary heart disease among women is
substantially reduced within 1 or 2 years of smoking cessation.
This immediate benefit is followed by a continuing but more
gradual reduction in risk to that among non-smokers by 10 to 15
or more years after cessation.
28. Women who use oral contraceptives have a particularly
elevated risk of coronary heart disease if they smoke. Currently,
evidence is conflicting as to whether the effect of hormone
replacement therapy on coronary heart disease risk differs
between smokers and nonsmokers.
29. Women who smoke have an increased risk for ischemic stroke
and subarachnoid hemorrhage. Evidence is inconsistent
concerning the association between smoking and primary
intracerebral hemorrhage.
30. In most studies that include women, the increased risk for
stroke associated with smoking is reversible after smoking
cessation; after 5 to 15 years of abstinence, the risk approaches
that of women who have never smoked.
31. Conflicting evidence exists regarding the level of the risk for
stroke among women who both smoke and use either the oral
contraceptives commonly prescribed in the United States today or
hormone replacement therapy.
32. Smoking is a strong predictor of the progression and severity
of carotid atherosclerosis among women. Smoking cessation
appears to slow the rate of progression of carotid atherosclerosis.
33. Women who are current smokers have an increased risk for
peripheral vascular atherosclerosis. Smoking cessation is
associated with improvements in symptoms, prognosis, and
survival.
34. Women who smoke have an increased risk for death from
ruptured abdominal aortic aneurysm.
Chronic Obstructive Pulmonary Disease (COPD) and Lung
Function
35. Cigarette smoking is a primary cause of COPD among women,
and the risk increases with the amount and duration of smoking.
Approximately 90 percent of mortality from COPD among women in
the United States can be attributed to cigarette smoking.
36. In utero exposure to maternal smoking is associated with
reduced lung function among infants, and exposure to
environmental tobacco smoke during childhood and adolescence
may be associated with impaired lung function among girls.
37. Adolescent girls who smoke have reduced rates of lung
growth, and adult women who smoke experience a premature
decline of lung function.
38. The rate of decline in lung function is slower among women
who stop smoking than among women who continue to smoke.
39. Mortality rates for COPD have increased among women over
the past 20 to 30 years.
40. Although data for women are limited, former smokers appear
to have a lower risk for dying from COPD than do current smokers.
Sex Hormones, Thyroid Disease, and Diabetes Mellitus
41. Women who smoke have an increased risk for
estrogen-deficiency disorders and a decreased risk for
estrogen-dependent disorders, but circulating levels of the major
endogenous estrogens are not altered among women smokers.
42. Although consistent effects of smoking on thyroid hormone
levels have not been noted, cigarette smokers may have an
increased risk for Graves’ ophthalmopathy, a thyroid-related
disease.
43. Smoking appears to affect glucose regulation and related
metabolic processes, but conflicting data exist on the relationship
of smoking and the development of type 2 diabetes mellitus and
gestational diabetes among women.
Menstrual Function, Menopause, and Benign Gynecologic
Conditions
44. Some studies suggest that cigarette smoking may alter
menstrual function by increasing the risks for dysmenorrhea
(painful menstruation), secondary amenorrhea (lack of menses
among women who ever had menstrual periods), and menstrual
irregularity.
45. Women smokers have a younger age at natural menopause
than do nonsmokers and may experience more menopausal
symptoms.
46. Women who smoke may have decreased risk for uterine
fibroids.
Reproductive Outcomes
47. Women who smoke have increased risks for conception delay
and for both primary and secondary infertility.
48. Women who smoke may have a modest increase in risks for
ectopic pregnancy and spontaneous abortion.
49. Smoking during pregnancy is associated with increased risks
for preterm premature rupture of membranes, abruptio placentae,
and placenta previa, and with a modest increase in risk for
preterm delivery.
50. Women who smoke during pregnancy have a decreased risk
for preeclampsia.
51. The risk for perinatal mortality—both stillbirth and neonatal
deaths—and the risk for sudden infant death syndrome (SIDS) are
increased among the offspring of women who smoke during
pregnancy.
52. Infants born to women who smoke during pregnancy have a
lower average birth weight and are more likely to be small for
gestational age than are infants born to women who do not
smoke.
53. Smoking does not appear to affect the overall risk for
congenital malformations.
54. Women smokers are less likely to breastfeed their infants than
are women nonsmokers.
55. Women who quit smoking before or during pregnancy reduce
the risk for adverse reproductive outcomes, including conception
delay, infertility, preterm premature rupture of membranes,
preterm delivery, and low birth weight.
Body Weight and Fat Distribution
56. Initiation of cigarette smoking does not appear to be
associated with weight loss, but smoking does appear to
attenuate weight gain over time.
57. The average weight of women who are current smokers is
modestly lower than that of women who have never smoked or
who are long-term former smokers.
58. Smoking cessation among women typically is associated with
a weight gain of about 6 to 12 pounds in the year after they quit
smoking.
59. Women smokers have a more masculine pattern of body fat
distribution (i.e., a higher waist-to-hip ratio) than do women who
have never smoked.
Bone Density and Fracture Risk
60. Postmenopausal women who currently smoke have lower bone
density than do women who do not smoke.
61. Women who currently smoke have an increased risk for hip
fracture compared with women who do not smoke.
62. The relationship among women between smoking and the risk
for bone fracture at sites other than the hip is not clear.
Gastrointestinal Diseases
63. Some studies suggest that women who smoke have an
increased risk for gallbladder disease (gallstones and
cholecystitis), but the evidence is inconsistent.
64. Women who smoke have an increased risk for peptic ulcers.
65. Women who currently smoke have a decreased risk for
ulcerative colitis, but former smokers have an increased
risk—possibly because smoking suppresses symptoms of the
disease.
66. Women who smoke appear to have an increased risk for
Crohn’s disease, and smokers with Crohn’s disease have a worse
prognosis than do nonsmokers.
Arthritis
67. Some but not all studies suggest that women who smoke may
have a modestly elevated risk for rheumatoid arthritis.
68. Women who smoke have a modestly reduced risk for
osteoarthritis of the knee; data regarding osteoarthritis of the hip
are inconsistent.
69. The data on the risk of systemic lupus erythematosus among
women who smoke are inconsistent.
Eye Disease
70. Women who smoke have an increased risk for cataract.
71. Women who smoke may have an increased risk for age related
macular degeneration.
72. Studies show no consistent association between smoking and
open-angle glaucoma.
Human Immunodeficiency Virus (HIV) Disease
73. Limited data suggest that women smokers may be at higher
risk for HIV-1 infection than nonsmokers.
Facial Wrinkling
74. Limited but consistent data suggest that women smokers
have more facial wrinkling than do nonsmokers.
Depression and Other Psychiatric Disorders
75. Smokers are more likely to be depressed than are nonsmokers,
a finding that may reflect an effect of smoking on the risk for
depression, the use of smoking for self-medication, or the
influence of common genetic or other factors on both smoking and
depression. The association of smoking and depression is
particularly important among women because they are more likely
to be diagnosed with depression than are men.
76. The prevalence of smoking generally has been found to be
higher among patients with anxiety disorders, bulimia, attention
deficit disorder, and alcoholism than among individuals without
these conditions; the mechanisms underlying these associations
are not yet understood.
77. The prevalence of smoking is very high among patients with
schizophrenia, but the mechanisms underlying this association are
not yet understood.
78. Smoking may be used by some persons who would otherwise
manifest psychiatric symptoms to manage those symptoms; for
such persons, cessation of smoking may lead to the emergence of
depression or other dysphoric mood states.
Neurologic Diseases
79. Women who smoke have a decreased risk for Parkinson’s
disease.
80. Data regarding the association between smoking and
Alzheimer’s disease are inconsistent.
Nicotine Pharmacology and Addiction
81. Nicotine pharmacology and the behavioral processes that
determine nicotine addiction appear generally similar among
women and men; when standardized for the number of cigarettes
smoked, the blood concentration of cotinine (the main metabolite
of nicotine) is similar among women and men.
82. Women’s regulation of nicotine intake may be less precise
than men’s. Factors other than nicotine (e.g., sensory cues) may
play a greater role in determining smoking behavior among women.
Environmental Tobacco Smoke (ETS) and Lung Cancer
83. Exposure to ETS is a cause of lung cancer among women who
have never smoked. ETS and Coronary Heart Disease.
84. Epidemiologic and other data support a causal relationship
between ETS exposure from the spouse and coronary heart
disease mortality among women nonsmokers.
ETS and Reproductive Outcomes
85. Infants born to women who are exposed to ETS during
pregnancy may have a small decrement in birth weight and a
slightly increased risk for intrauterine growth retardation compared
with infants born to women who are not exposed; both effects
are quite variable across studies.
86. Studies of ETS exposure and the risks for delay in conception,
spontaneous abortion, and perinatal mortality are few, and the
results are inconsistent.
Chapter 4. Factors Influencing Tobacco Use Among Women
1. Girls who initiate smoking are more likely than those who do not
smoke to have parents or friends who smoke. They also tend to
have weaker attachments to parents and family and stronger
attachments to peers and friends. They perceive smoking
prevalence to be higher than it actually is, are inclined to risk
taking and rebelliousness, have a weaker commitment to school or
religion, have less knowledge of the adverse consequences of
smoking and the addictiveness of nicotine, believe that smoking
can control weight and negative moods, and have a positive
image of smokers. Although the strength of the association by
gender differs across studies, most of these factors are
associated with an increased risk for smoking among both girls and
boys.
2. Girls appear to be more affected than boys by the desire to
smoke for weight control and by the perception that smoking
controls negative moods; girls may also be more influenced than
boys to smoke by rebelliousness or a rejection of conventional
values.
3. Women who continue to smoke and those who fail at attempts
to stop smoking tend to have lower education and employment
levels than do women who quit smoking. They also tend to be
more addicted to cigarettes, as evidenced by the smoking of a
higher number of cigarettes per day, to be cognitively less ready
to stop smoking, to have less social support for stopping, and to
be less confident in resisting temptations to smoke.
4. Women have been extensively targeted in tobacco marketing,
and tobacco companies have produced brands specifically for
women, both in the United States and overseas. Myriad examples
of tobacco ads and promotions targeted to women indicated that
such marketing is dominated by themes of both social desirability
and independence, which are conveyed through ads featuring
slim, attractive, athletic models. Between 1995 and 1998,
expenditures for domestic cigarette advertising and promotion
increased 37.3 percent, from $4.90 billion to $6.73 billion.
5. Tobacco industry marketing, including product design,
advertising, and promotional activities, is a factor influencing
susceptibility to and initiation of smoking.
6. The dependence of the media on revenues from tobacco
advertising oriented to women, coupled with tobacco company
sponsorship of women’s fashions and of artistic, athletic, political,
and other events, has tended to stifle media coverage of the
health consequences of smoking among women and to mute
criticism of the tobacco industry by women public figures.
Chapter 5. Efforts to Reduce Tobacco Use Among Women
1. Using evidence from studies that vary in design, sample
characteristics, and intensity of the interventions studied,
researchers to date have not found consistent gender-specific
differences in the effectiveness of intervention programs for
tobacco use. Some clinical studies have shown lower cessation
rates among women than among men, but others have not. Many
studies have not reported cessation results by gender.
2. Among women, biopsychosocial factors, such as pregnancy,
fear of weight gain, depression, and the need for social support,
appear to be associated with smoking maintenance, cessation, or
relapse.
3. A higher percentage of women stop smoking during pregnancy,
both spontaneously and with assistance, than at other times in
their lives. Using pregnancy-specific programs can increase
smoking cessation rates, which benefits infant health and is cost
effective. Only about one-third of women who stop smoking
during pregnancy are still abstinent one year after the delivery.
4. Women fear weight gain during smoking cessation more than do
men. However, few studies have found a relationship between
weight concerns and smoking cessation for either women or men.
Further, actual weight gain during cessation does not predict
relapse to smoking.
5. Adolescent girls are more likely than adolescent boys to
respond to smoking cessation programs that include social support
from the family or their peer group.
6. Among persons who smoke heavily, women are more likely than
men to report being dependent on cigarettes and to have lower
expectations about stopping smoking, but it is not clear if such
women are less likely to quit smoking.
7. Currently, no tobacco cessation method has proved to be any
more or less successful among minority women than among white
women in the same study, but research on smoking cessation
among women of most racial and ethnic minorities has been
scarce.
8. Women are more likely than men to affirm that they smoke less
at work because of a worksite policy and are significantly more
likely than men to attribute reduced amount of daily smoking to
their worksite policy. Women also are more likely than men to
support policies designed to prevent smoking initiation among
adolescents, restrictions on youth access to tobacco products,
and limits on tobacco advertising and promotion.
9. Successful interventions have been developed to prevent
smoking among young people, but little systematic effort has been
focused on developing and evaluating prevention interventions
specifically for girls. This report summarizes what is known about
smoking among women, including patterns and trends in smoking
prevalence, factors associated with smoking initiation and
maintenance, the consequences of smoking for women’s health,
and interventions for smoking cessation and prevention. The
report also describes historical and contemporary tobacco
marketing targeted to women. Evidence of the health
consequences of smoking, which had emerged somewhat earlier
among men because of their earlier uptake of smoking, is now
overwhelming among women. Tragically, in the face of continually
mounting evidence of the enormous consequences of smoking for
women’s health, the tobacco industry continues to heavily target
women in its advertising and promotional campaigns and is now
attempting to export the epidemic of smoking to women in areas
of the world where the smoking prevalence among females has
traditionally been low. The single overarching theme emerging
from this report is that smoking is a women’s issue. What is
needed to curb the epidemic of smoking and smoking-related
diseases among women in the United States and throughout the
world?
A Vision for the Future: What Is Needed to
Reduce Smoking Among Women
Increase Awareness of the Impact of Smoking on Women’s Health
and Counter the Tobacco Industry’s Targeting of Women
• Increase awareness of the devastating impact of smoking
on women’s health.
Since 1980, when the first Surgeon General’s report on women
and smoking was published documenting the serious health
consequences of smoking among women, the number of women
affected by smoking-related diseases has increased dramatically.
Smoking is now the leading known cause of preventable death and
disease among women. Each year during the 1990s it accounted
for more than 140,000 deaths among U.S. women. By 1987, lung
cancer became the leading cause of cancer death among women,
and in 2000 approximately 27,000 more women in the United
States died of lung cancer (67,600) than of breast cancer
(40,800). Smoking also claims women’s lives through deaths due
to other types of cancer as well as to cardiovascular, pulmonary,
and other diseases—all risks shared with men who smoke. In
addition, women experience unique health effects due to smoking,
such as those related to pregnancy. In 1997, smoking accounted
for an estimated 165,000 premature deaths among U.S. women.
Exposure to environmental tobacco smoke also contributes to lung
cancer and heart disease deaths among women and affects the
health of their infants. The media, including women’s magazines
and broadcast programming, can play an important role in raising
women’s awareness of the magnitude of the impact of smoking on
their health and in prioritizing the importance of smoking relative
to the myriad other health-related topics covered.
• Expose and counter the tobacco industry’s deliberate
targeting of women and decry its efforts to link smoking,
which is so harmful to women’s health, with women’s rights
and progress in society.
Even in the face of amassing evidence that a large percentage of
women who smoke will die early, the tobacco industry has
exploited themes of liberation and success in its
advertising—particularly in women’s magazines—and promotions
targeted to women. Through its sponsorship of women’s sports,
women’s professional and leadership organizations, the arts, and
so on, the industry has attempted to associate itself with things
women most value (e.g., recent heavily advertised support from a
major tobacco company for programs to curb domestic violence
against women) (Levin 1999; Bischoff 2000–01). Such
associations should be decried for what they are: attempts by the
tobacco industry to position itself as an ally of women’s causes
and thereby to silence potential critics. Women should be
appropriately concerned by and speak out against tobacco
marketing campaigns that coopt the language of women’s
empowerment, and they should recognize the irony of attempts
by the tobacco industry to suggest that smoking—which leads to
nicotine dependence and death among many women—is a form of
independence. Such efforts on the part of women would be
unnecessary if the tobacco industry would voluntarily refrain from
targeting women and associating tobacco use with women’s
freedom and progress.
Are Nonsmokers
• Encourage a more vocal constituency on issues related to
women and smoking.
Taking a lesson from the success of advocacy to reduce breast
cancer, concerted efforts are needed to call public attention to
the toll that lung cancer and other smoking-related diseases is
exacting on women’s health and to demand accountability on the
part of the tobacco industry. Women affected by tobacco-related
diseases and their families and friends can partner with women’s
and girls’ organizations, women’s magazines, female celebrities,
and others—not only in an effort to raise awareness of
tobacco-related disease as a women’s issue, but also to call for
policies and programs that deglamorize and discourage tobacco
use. Some excellent but relatively small-scale efforts have already
taken place in this area, but because of the magnitude of the
problem, these efforts deserve much greater support.
• Recognize that nonsmoking is by far the norm among
women.
Although in recent years smoking prevalence has not declined as
much as might be hoped, nearly four-fifths of U.S. women are
nonsmokers. In some subgroups of the population, smoking is
relatively rare (e.g., only 11.2 percent of adult women who have
completed college are current smokers, and only 5.4 percent of
black high school senior girls are daily smokers). Despite the
positive images of women in tobacco advertisements, it is
important to recognize that among adult women, those who are
the most empowered, as measured by educational attainment, are
the least likely to be smokers. Moreover, most women who do
smoke say they would like to quit. The fact that almost all women
have either rejected smoking for themselves or, if they do smoke
now, wish to quit, should be promoted.
Continue to Build the Science Base on Gender-Specific