Washington, DC—Following an initial report in 1980 that outlined increases in women’s risks for smoking-related disorders, Surgeon General David Satcher recently issued a second report detailing some alarming statistics.[1]

Lung cancer has surpassed breast cancer as the leading cause of cancer death among women in the United States, with 27,000 more deaths from lung cancer than from breast cancer in 2000. “The report in 1980 warned that the increase in the numbers of women smoking was starting to increase incidence of lung cancer in women, and it predicted an emerging epidemic,” commented Corinne G. Husten, MD, MPH, Chief of the Epidemiology Branch, Office on Smoking and Health at the Centers for Disease Control and Prevention. “Now we are in the full-blown epidemic. More than three million women have died from lung cancer since that report,” she said. About 90% of lung cancer deaths among women smokers and 90% of all deaths from chronic obstructive pulmonary disease (COPD) among women are attributable to smoking.

CLOSING THE GENDER GAP

Gender differences in lung cancer risk seen previously may be attributed to earlier differences in duration and amount of cigarette smoking. But during the past five decades, women have been closing that gender gap. A woman’s lung cancer risk, like a man’s, increases with the duration of smoking and amount smoked: A woman who smokes two or more packs of cigarettes a day has a 20-fold higher risk of dying from lung cancer than has a nonsmoking woman. Accordingly, the Surgeon General’s report notes an approximately 600% increase in lung cancer mortality rates in women since 1950.

ILL EFFECTS NOT LIMITED TO LUNG CANCER

The increase in women’s smoking rates in the last half century has had other tragic consequences. Smoking is also a major cause of coronary heart disease, cerebrovascular disease, and other forms of cancer among women. According to the Surgeon General’s report, the majority of cases of heart disease in women younger than 50 years are attributable to smoking. Women who smoke also have increased risks for ischemic stroke and subarachnoid hemorrhage, as well as for fatal ruptures of abdominal aortic aneurysms. In addition, smoking is a strong predictor of carotid atherosclerosis progression in women, and current smoking increases risk for peripheral vascular atherosclerosis.

Smoking is the primary cause of COPD among women, and mortality rates for COPD have increased markedly in women during the past 20 to 30 years. Lung growth rates are reduced among adolescent girls who smoke, and lung function declines prematurely in adult women who smoke.

Smoking also produces health consequences specific to women: It may increase the risk for menstrual disorders, delayed conception and other forms of infertility, and it lowers the age at which natural menopause occurs. It is also associated with cervical cancer and vulvar cancer.

Smoking by pregnant women threatens their children, who have increased chances of preterm membrane rupture and preterm delivery, lowered birth weight, and increased chances of stillbirth and neonatal death—as well as a higher risk of sudden infant death syndrome. In utero exposure to maternal smoking is associated with reduced lung function among infants.

The Surgeon General’s report remarks that women smokers are more likely to quit smoking during pregnancy than at any other time during their lives. The report advocates pregnancy-specific smoking cessation programs as a cost-effective way to protect both women and infants, although only one third of these quitters remain smoke-free a year after delivery.

Even nonsmoking women and their unborn children may be threatened by environmental tobacco smoke (ETS). “We have fairly limited data on ETS exposure, although there are NHANES [National Health and Nutrition Examination Survey] data suggesting that young nonsmokers are disproportionately exposed to ETS,” said Dr. Husten.

The Surgeon General’s report cites evidence that a woman exposed to ETS is at higher risk for lung cancer and coronary heart disease mortality. During pregnancy, ETS exposure may retard intrauterine growth and result in lower birth weight.

CURRENT SMOKING RATES

About 22% of women smoked in 1998. Estimates of how many pregnant women smoke range from 12.9% to 22%, although Dr. Husten noted, “Smoking during pregnancy has been declining.” Among adult women, higher education level was associated with lowered prevalence of smoking: Smoking rates are threefold higher among women who have not completed high school than they are among women with college degrees.

Young women continue to fill the ranks of smokers. “Smoking rates declined through the early 1990s, but since then, a lot of the progress in reducing smoking rates among girls has been lost,” Dr. Husten remarked. After declining during the 1970s and 1980s, prevalence of smoking among girls “rebounded” back up to 1988 levels in the 1990s. In 2000, almost 30% of girls in their senior year of high school reported having smoked within the past month, according to the Surgeon General’s report.

Girls who start smoking are more likely than are nonsmokers to have parents or friends who smoke, strong peer attachments, a positive image of smokers, and an inclination toward risk-taking behavior. Like boys, girls who smoke tend to be less aware than nonsmokers of the addictiveness and health consequences of cigarette use. Girls who smoke are more likely than are boys to also believe that smoking can be used to control weight and negative moods.

WHAT’S BEHIND THE TREND IN TEEN SMOKING?

“There are a couple of factors we feel might have contributed to a surge of smoking in adolescents. There were some cigarette price reductions in the early 1990s, as well as increased advertising,” remarked Dr. Husten, who was also an editor of chapter 2 of the report, Patterns of Tobacco Use Among Women and Girls.

“Cigarette advertising trends also shifted in favor of promotional gimmicks, like offering merchandise (such as T-shirts) for labels turned in; these marketing strategies appeal particularly to children,” Dr. Husten continued. “Also, a heavy presence of smoking in movies and TV leads to glamorization and an unrealistic assessment of the actual prevalence of smoking—kids think that more people smoke than is actually the case,” she added.

What can be done to reduce smoking rates in women? “Community intervention to prevent smoking initiation seems to be the most effective approach,” suggested Dr. Husten. “Raising the price of cigarettes means fewer kids start to smoke. The Guide to Community Preventive Services[2] also shows that sustained media campaigns combined with other measures were effective methods to reduce initiation.”

CALIFORNIA’S LONG-RUNNING PROGRAM GETS RESULTS

Dr. Husten cited one successful example: “Of the states, California has had the longest-running comprehensive program against smoking. In 1988, the state raised the price of tobacco and used the proceeds to fund the program. There are also more restrictions to limit environmental tobacco smoke.”

Dr. Husten noted, “In California, the rate of lung cancer overall has shown a greater decline than in the rest of the country, and it’s actually declining in California women, even though it’s still increasing in other parts of the US.”

According to the Surgeon General’s report, women are more likely than men are to claim reduced cigarette use—during work and overall—in response to worksite smoking restrictions. “Data show that clean indoor air restrictions are also effective in reducing cigarette use, even if smokers don’t actually quit,” Dr. Husten told RESPIRATORY REVIEWS.

—Mimi Zucker, PhD

References
1. Public Health Service. Women and Smoking: A Report of the Surgeon General. Washington, DC: Public Health Service; 2001.
2. Wasserman MP. Guide to community preventive services: state and local opportunities for tobacco use reduction. Am J Prev Med. 2001;20(suppl 2):8-9.