The Complete Report
The
Surgeon General's Report on Women and Smoking
The
Surgeon General's report on smoking in 1980 correctly predicted
that women were the second wave of victims of the tobacco epidemic—the
second wave because women began smoking in large numbers 25 years
later than men. A new report released in March 2001 follows up
on that prediction with details of the tobacco epidemic's now
fully realized effects on women. Surgeon General David Satcher,
MD, PhD, summarized the report: "Women not only share the
same health risk as men, but are also faced with health consequences
that are unique to women, including pregnancy complications, problems
with menstrual function, and cervical cancer."
Women
now account for 39% of all smoking-related deaths each year in
the United States, a proportion that has more than doubled
since 1965, according to Women and Smoking: A Report of the Surgeon
General. Said Virginia Ernster, PhD, Associate Director for Epidemiology,
Prevention, and Control at the University of California at San
Francisco Comprehensive Cancer Center and senior scientific editor
of the report, "The overarching theme of the report is that
smoking is a women's health issue. What drives this point home
is that in 1987 lung cancer surpassed breast cancer as the leading
cause of cancer death in women. Last year, 27,000 more women in
the United States died of lung cancer than of breast cancer."
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What
Women Don't Know
One of the major recommendations of the report is to increase
public awareness of the impact of smoking on women's health. Women
simply don't know that if they smoke, they
could have trouble getting pregnant, go through menopause at a
younger age, or suffer increased risk of ectopic pregnancy and
miscarriages.
Why
are women misinformed about their own health risks? The media
are partly to blame. A study by the American Council on Science
and Health found that women's magazines carry a high number of
cigarette advertisements and few health articles that address
the negative aspects of smoking. The magazines examined in the
study were found to be self-committed to general health, but failed
to cover the number one cause of cancer death in women: lung cancer.
Why
do girls start smoking? "A big reason is marketing,"
answered Corinne Husten, MD, MPH, CDC medical officer and chief
of the Office on Smoking and Health's Epidemiology Branch. "Images
of thin, glamorous models in ads resonate with girls. They feel
that cigarettes can increase their social competence." Movies
and television programs that glamorize smoking add to the power
of such images. A review of the top 200 video rentals of 1996–1997
reports that characters smoked tobacco in 89% of movies. Cigarette
brands were identified in 13% of movies that showed tobacco use;
Marlboro (the most popular U.S. brand) was identified 5 times
more often than any other brand. Seeing their idols with a cigarette
gives young people the impression that more people smoke than
do. "They tend to believe that ‘everyone' is smoking,"
said Dr. Husten. Young women also underestimate how addictive
smoking is.
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In
advertising and entertainment media, like TV and movies, women
smokers are portrayed as thin, athletic, and independent.
"Cigarette ads depict women smokers as free-spirited, attractive,
glamorous, and athletic," commented Dr. Ernster. "In
reality, many women who smoke are victims of smoking related-diseases
that are often painful and fatal."
The
tobacco industry promulgates the same themes in other countries.
"We estimate that smoking prevalence among women varies markedly
worldwide, from as low as 7% in developing countries to 24% in
developed countries," said CDC Director Jeffrey P. Koplan,
MD, MPH. "The rise in smoking among women around the world
has coincided with aggressive Western-style tobacco advertising.
One of the most common themes used in developing countries is
that smoking is both a passport to and a symbol of a woman's emancipation,
independence, and success."
Deglamorizing
the Habit
The rise of smoking prevalence among teenage girls in the 1990s
is alarming. CDC surveillance reports show that 30% of high school
senior girls have smoked in the past 30 days. To counter the increase,
tobacco use must be deglamorized and discouraged. Secretary of
Health and Human Services Tommy Thompson said, "Smoking is
a critical women's health issue that must be addressed on all
fronts. We must begin this battle in schools and in our communities
before girls even begin to smoke, and we must share with teenage
girls that smoking is not only harmful, but it is not glamorous.
Society must not glorify smoking."
Sports
may help girls resist the appeal of smoking, noted Alyssa Easton,
PhD, MD, CDC epidemiologist. Not only does participating in
sports improve self-esteem, it also provides young women with
positive role models and good reasons not to take up smoking.
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The
report also addresses health disparities related to gender.
Because most of the research on smoking-related disease does not
specifically look at gender differences, more research is needed.
"Some studies suggest that women may have a higher risk of
developing lung cancer than men, but other studies do not show
this pattern and conclusions cannot be drawn yet," said Dr.
Easton. Although men and women are equally likely to quit, questions
also remain about whether nicotine replacement therapies such
as the patch or gum affect women differently from men. "We
need more intervention studies that look at gender differences,"
said Dr. Husten.
Comprehensive
statewide tobacco control programs are effective in reducing and
preventing tobacco use, says the report. "States should
be enacting comprehensive statewide programs," noted Dr.
Easton. "However, settlement money is not being effectively
utilized, as described in CDC's Best Practices for Comprehensive
Tobacco Control Programs. Only seven states—Arizona, California,
Florida, Maine, Massachusetts, Mississippi, and Vermont—are
meeting or exceeding Best Practices lower-bound funding recommendations."
Where smoking rates have been reduced, dramatic public health
benefits have been observed. In California, for example, declines
in the rate of lung cancer among women were recently observed,
even though nationally lung cancer rates are still increasing.
"Anything that kills as many women
from as many diseases as smoking does is clearly a women's issue."
Tobacco Control : A Women's Issue
One aim of the report is to encourage a more vocal constituency
on issues related to women and smoking. Efforts from women's and
girls' organizations, magazines, policymakers, medical groups,
and advocacy groups are needed to highlight lung cancer and other
smoking-related diseases among women. Said Dr. Satcher, "We
know more than enough to prevent and reduce tobacco use. Now we
must commit the attention and resources to translate this knowledge
into action to save women's lives."
"Anything
that kills as many women from as many diseases as smoking does
is clearly a women's issue," said Dr. Ernster. "We shouldn't
tolerate the targeting of women by the tobacco industry any longer."
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Quitting
Smoking Harder for Women than for Men
Review of Research Finds Variety of Reasons for Why It Is Harder
for Women to Break Free of Nicotine Addiction
A review of numerous research studies focusing on
smoking cessation has concluded that while women may suffer greater
relative risks of smoking-related diseases than do men, they tend
to have less success than men in quitting smoking. Dr. Kenneth
A. Perkins from the University of Pittsburgh School of Medicine
who conducted the review offers several reasons for this disparity
in a paper published in the May 2001 issue of CNS Drugs.
These research-based findings include:
"According to the recent report on women
and smoking by the Surgeon General, three million women have died
from smoking-related diseases since 1980. Currently, women
suffer 39 percent of all smoking related deaths," says NIDA
Director Dr. Alan I. Leshner. "Given the greater relative
risk of women to incur smoking-related diseases, it is clear that
we must find better approaches to help women break their nicotine
addiction."
Dr. Perkins says that one of the intriguing observations
that emerged from his review is that some forms of nicotine replacement
therapy may not be as effective in women as in men. In some of
the studies he reviewed, women had less treatment success using
nicotine gum or nicotine patches than did men.
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In contrast, other stop-smoking medications may
more effective in women than men. Because negative mood is more
likely to precipitate smoking relapse in women than in men, Dr.
Perkins suggests that use of antidepressant medications for smoking
cessation could be more effective in women than men.
Dr. Perkins concludes that developing smoking cessation
interventions that address the gender-specific concerns of women
smokers could increase the success rate among women who are trying
to stop smoking.
The health risks associated with smoking for
both men and women are well known, and include a two-fold increase
in risks of heart disease and of cancers of the bladder, stomach,
and pancreas, a 10-20 fold increase in lung cancer, and a
10-fold increase in chronic obstructive pulmonary disease. Smoking
also significantly increases risks of stroke and pneumonia.
But women may suffer greater relative risks of
smoking-related diseases than do men. For example, in one
study cited by Dr. Perkins in his review, women who smoked had
almost double the risk of myocardial infarction than did men.
The increased risks of heart attack and stroke due to smoking
are further exacerbated in women who also use oral contraceptives.
Some studies have also pointed to the conclusion that women also
may have nearly double the risk of lung cancer as men.
There is also some evidence that breast cancer
risk may be increased among women who smoke. Smoking is associated
with greater menstrual bleeding and duration of dysmenorrhea,
as well as greater variability in menstrual cycle length. Women
who smoke have a more difficult time becoming pregnant, and reach
menopause on average a year or two younger than women who do not
smoke.
Most health risks associated with smoking are
reduced or eventually eliminated when smoking abstinence.
