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Women’s Health and Smoking
Women’s Health and Smoking
This report summarizes what is now known about smoking among women, including patterns and trends in smoking habits, factors associated with starting to smoke and continuing to smoke, the consequences of smoking on women’s health and interventions for ending and prevention. What the report also makes clear is how the tobacco industry has historically and contemporarily created marketing specifically targeted at women. Smoking is the leading known cause of preventable death and disease among women. In 2000, far more women died of lung cancer than of breast cancer. A number of things need to be acted on to control the epidemic of smoking and smoking-related diseases among women throughout the world.
Factors Influencing Tobacco Use Among Women
Cigarette smoking was rare among women in the early 20th century. Cigarette smoking became prevalent among women after it did among men, and smoking prevalence has always been lower among women than among men. However, the gender-specific difference in smoking prevalence narrowed between 1965 and 1985. Since 1985, the decline in prevalence among men and women has been comparable.
Smoking prevalence decreased among women from 33.9% in 1965 to 22.0% in 1998. Most of this decline occurred from 1974 through 1990; prevalence declined very little from 1992 through 1998.
The prevalence of current smoking is three times higher among women with 9-11 years of education (32.9%) than among women with 16 or more years of education (11.2%).
Smoking prevalence is higher among women living below the poverty level (29.6%) than among those living at or above the poverty level (21.6%).
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.
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.
The level of nicotine dependence is strongly associated with the quantity of cigarettes smoked per day.
When results are stratified by the number of cigarettes smoked per day, girls and women who smoke appear to be equally dependent on nicotine, as measured by first cigarette after waking, smoking for a calming and relaxing effect, withdrawal symptoms, or other measures of nicotine dependence.
Of the women who smoke, more than three-fourths report one or more indicators of nicotine dependence, and nearly three-fourths report feeling dependent on cigarettes.
History of Advertising Strategies
One of the most common advertisement themes in developed countries is that smoking is both a passport to and a symbol of the independence and success of the modern women.
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.
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 from $4.90 billion to $6.73 billion. Tobacco industry marketing, including product design, advertising, and promotional activities, is a factor influencing susceptibility to and initiation of smoking.
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.
Tobacco advertising geared toward women began in the 1920s. By the mid-1930s, cigarette advertisements targeting women were becoming so commonplace that one advertisement for the mentholated Spud brand had the caption "To read the advertisements these days, a fellow'd think the pretty girls do all the smoking."
As early as the 1920s, tobacco advertising geared toward women included messages such as "Reach for a Lucky instead of a sweet" to establish an association between smoking and slimness. The positioning of Lucky Strike as an aid to weight control led to a greater than 300% increase in sales for this brand in the first year of the advertising campaign.
Through World War II, Chesterfield advertisements regularly featured glamour photographs of a Chesterfield girl of the month, usually a fashion model or a Hollywood star such as Rita Hayworth, Rosalind Russell, or Betty Grable.
The number of women aged 18 through 25 years who began smoking increased significantly in the mid-1920s, the same time that the tobacco industry mounted the Chesterfield and Lucky Strike campaigns directed at women. The trend was most striking among women aged 18 though 21. The number of women in this age group who began smoking tripled between 1911 and 1925 and had more than tripled again by 1939.
In 1968, Philip Morris marketed Virginia Slims cigarettes to women with an advertising strategy showing canny insight into the importance of the emerging women's movement. The slogan "You've come a long way, Baby" later gave way to "It's a woman thing" in the mid-1990s, and more recently the "Find your voice" campaign featuring women of diverse racial and ethnic backgrounds. The underlying message of these campaigns has been that smoking is related to women's freedom, emancipation, and empowerment.
Initiation rates among girls aged 14 though 17 years rapidly increased in parallel with the combined sales of the leading women's-niche brands (Virginia Slims, Silva Thins, and Eve) during this period.
In 1960, about 10% of all cigarette advertisements appeared in popular women's magazines, and by 1985, cigarette advertisements increased by 34%.
Evidence suggests a pattern of international tobacco advertising that associates smoking with success, similar to that seen in the United States. This development emphasizes the enormous potential of advertising to change social norms.
As western-styled marketing has increased, campaigns commonly have focused on women. For example, in 1989, the brand Yves Saint Laurent introduced a new elegant package designed to appeal to women in Malaysia and other Asian countries. National tobacco monopolies and companies, such as those in Indonesia and Japan, began to copy this promotional targeting of women.
One of the most popular media for reaching women—particularly in places where tobacco advertising is banned on television - is women's magazines. Magazines can lend an air of social acceptability or stylish image to smoking. This may be particularly important in countries where smoking rates are low among women and where tobacco companies are attempting to associate smoking with Western values.
A study of 111 women's magazines in 17 European countries in 1996-1997 found that 55% of the magazines that responded accepted cigarette advertisements, and only 4 had a policy of voluntarily refusing it. Only 31% of the magazines had published an article of one page or more on smoking and health in the previous 12 months. Magazines that accepted tobacco advertisements seem less likely to give coverage to smoking and health issues.
Events and activities popular among young people are often sponsored by tobacco companies. Free tickets to films and to pop and rock concerts have been given in exchange for empty cigarette packets in Hong Kong and Taiwan. Popular U.S. female stars have allowed their names to be associated with cigarettes in other countries.
Many countries have banned tobacco advertising and promotion. In 1998, the European Union adopted a directive to ban most tobacco advertising and sponsorship by July 30, 2006. Other countries have banned direct advertising, and still others have instituted partial restraints. Such bans are often circumvented by tobacco companies through various promotional venues such as the creation of retail stores named after cigarette brands or corporate sponsorship of sporting and other events. Moreover, national bans on tobacco advertisements may be rendered ineffective by tobacco promotion on satellite television, by cable broadcasting, or via the Internet.
Health Consequence of Tobacco Use Among Women
Women who stop smoking greatly reduce their risk of dying prematurely. The relative benefits of smoking ending are greater when women stop smoking at younger ages, but smoking ending is beneficial at all ages.
Women who stop smoking greatly reduce their risk of dying prematurely, and quitting smoking is useful 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 sex differences in factors related to smoking initiation and successful quitting have been identified.
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 no exposed women.
A dozen diseases are waiting for women-smokers.
Cigarette smoking is the major cause of lung cancer among women. About 90% of all lung cancer deaths among U.S. women smokers are attributable to smoking.
In 1950, lung cancer accounted for only 3% of all cancer deaths among women; however, by 2000, it accounted for an estimated 25% of cancer deaths.
Since 1950, lung cancer mortality rates for U.S. women have increased an estimated 600%. In 1987, lung cancer surpassed breast cancer to become the leading cause of cancer death among U.S. women. In 2000, about 27,000 more women died of lung cancer (67,600) than breast cancer (40,800).
Smoking is a major cause of cancer of the oropharynx and bladder among women. Evidence is also strong that women who smoke have increased risk for cancer of the pancreas and kidney. For cancer of the larynx and esophagus, evidence that smoking increases the risk among women is more limited but consistent with large increases in risk.
Women who smoke may have a higher risk for liver cancer and colorectal cancer than women who do not smoke.
Smoking is consistently associated with an increased risk for cervical cancer. The extent to which this association is independent of human papillomavirus (tumor caused by virus) infection is uncertain.
Several studies suggest that exposure to environmental tobacco smoke is associated with an increased risk for breast cancer; however, this association remains uncertain.
More research is needed.
Smoking is a major cause of coronary heart disease among women. Risk increases with the number of cigarettes smoked and the duration of smoking.
Women who smoke have an increase risk for ischemic stroke (blood clot in one of the arteries supplying the brain) and subarachnoid hemorrhage (bleeding in the area surrounding the brain).
Women who smoke have an increased risk for peripheral vascular atherosclerosis.
Smoking cessation reduces the excess risk of coronary heart disease, no matter at what age women stop smoking. The risk is substantially reduced within 1 or 2 years after they stop smoking.
The increased risk for stroke associated with smoking begins to reverse after women stop smoking. About 10 to 15 years after stopping, the risk for stroke approaches that of a women who never smoked.
Chronic Obstructive Pulmonary Disease (COPD) and Lung Function
Cigarette smoking is the primary cause of COPD in women, and the risk increases with the amount and duration of cigarette use.
Mortality rates for COPD have increased among women for the past 20 to 30 years. About, 90% of mortality from COPD among U.S. women is attributed to smoking.
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.
Smoking by girls can reduce their rate of lung growth and the level of maximum lung function. Women who smoke may experience a premature decline of lung function.
Some studies suggest that cigarette smoking may alter menstrual function by increasing the risks for painful menstruation, secondary amenorrhea (abnormal absence of menstrual), and menstrual irregularity
Women smokers have natural menopause at a younger age than do nonsmokers, and they may experience more severe menopausal symptoms.
Women who smoke have increased risk for conception delay and for both primary and secondary infertility.
Women who smoke during pregnancy risk pregnancy complications, premature birth, low-birth-weight infants, stillbirth, and infant mortality.
Women who smoke may have a modest increase in risks for ectopic pregnancy (fallopian tube or peritoneal cavity pregnancy) and spontaneous abortion.
Studies show a link between smoking and the risk of sudden infant death syndrome (SIDS) among the offspring of women who smoke during pregnancy.
Bone Density and Fracture Risk
Postmenopausal women who smoke have lower bone density than women who never smoked.
Women who smoke have an increased risk for hip fracture than women who never smoked.
Women who smoke may have a modestly elevated risk for rheumatoid arthritis.
Women smokers have an increased risk for cataract, and may have an increased risk for age-related macular degeneration.
The prevalence of smoking generally is higher for women with anxiety disorders, bulimia, depression, attention deficit disorder, and alcoholism; it is particularly high among patients with diagnosed schizophrenia. The connection between smoking and these disorders requires additional research.
Health Consequences of Environmental Tobacco Smoke (ETS)
Exposure to ETS is a cause of lung cancer among women nonsmokers.
Studies support a causal relationship between exposure to ETS and coronary heart disease mortality among women nonsmokers.
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.
Smoking and Reproductive Outcomes, Cigarette Smoking Among Pregnant Women
Women smokers, like men smokers, are at increased risk of cancer, cardiovascular disease, and pulmonary disease, but women smokers also experience unique risks related to menstrual and reproductive function.
Women who smoke have increased risk beginning delay and for major and secondary infertility.
Smoking during pregnancy remains a major public health problem despite increased knowledge of the adverse health effects of smoking during pregnancy. Although the occurrence 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.
Women who smoke may have a modest increase in risks for ectopic pregnancy and spontaneous. abortion.
Smoking during pregnancy is associated with increased risk for premature break of membranes, abruptio placentae (placenta separation from the uterus), and placenta previal (abnormal location of the placenta, which can cause massive hemorrhaging during delivery; smoking is also associated with a modest increase in risk for preterm delivery.
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 infants born to women who do not smoke. Low birth weight is associated with increased risk for neonatal, perinatal, and infant morbidity and mortality. The longer the mother smokes during pregnancy, the greater the effect on the infant’s birth weight.
The risk for perinatal mortality, both stillbirths and neonatal deaths, and the risk for sudden infant death syndrome (SIDS) are higher for the offspring of women who smoke during pregnancy.
Women who smoke are less likely to breast-feed their infants than are women who do not.
Environmental Tobacco Smoke and Reproductive Outcomes
Infants born to women who are exposed to environmental tobacco smoke (ETS) during pregnancy may have a small decrement in birth weight and a slightly increased risk for intrauterine growth retardation than infants born to women who are not exposed to ETS.
Smoking Prevalence and Smoking Cessation during Pregnancy
Despite increased knowledge of the adverse health effects of smoking during pregnancy, estimates of women smoking during pregnancy range from 12% (based on birth certificate data) up to 22% (based on survey data). However, smoking during pregnancy appears to have decreased from 1989 through 1998.
Eliminating maternal smoking may lead to a 10% reduction in all infant deaths and a 12% reduction in deaths from perinatal conditions.
Women who quit smoking before or during pregnancy reduce the risk for adverse reproductive outcomes, including difficulties in becoming pregnant, infertility, premature rupture of membranes, preterm delivery, and low birth weight.
Most relevant studies suggest that infants of women who stop smoking by the first trimester have weight and body measurements comparable with those of nonsmokers’ infants. Studies also suggest that smoking in the third trimester is particularly detrimental.
Women are more likely to 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. However, only one-third of women who stop smoking during pregnancy are still abstinent 1 year after the delivery.
Programs that encourage women to stop smoking before, during, and after pregnancy — and not to take up smoking ever again — deserve high priority for two reasons: during pregnancy women are highly motivated to stop smoking, and they still have many remaining years of potential life.
Despite increased knowledge of the adverse health effects of smoking during pregnancy, survey data suggest that a substantial number of pregnant women and girls smoke. Cigarette smoking during pregnancy declined from 19.5% in 1989 to 12.9% in 1998.
Smoking prevalence during pregnancy differs by age and by race and ethnicity. In 1998, smoking prevalence during pregnancy was consistently highest among young adult women aged 18 through 24 (17.1%) and lowest among women aged 25 through 49 (10.5%).
Smoking during pregnancy declined among women of all racial/ethnic populations. From 1989 to 1998, smoking among American Indian or Alaska Native pregnant women decreased from 23.0% to 20.2%; among pregnant white women from 21.7% to 16.2%; African American pregnant women from 17.2% to 9.6%; Hispanic pregnant women from 8.0% to 4.0%; and Asian American or Pacific Islander pregnant women from 5.7% to 3.1%.
In 1998, there was nearly a 12-fold difference among pregnant women who smoke—ranging from 25.5 percent among mothers with 9-11 years of education to 2.2 percent among mothers with 16 or more years of education.
What Is Need to Reduce Smoking Among Women – Fact Sheet
· Increase awareness of the devastating impact of smoking on women’s health. Smoking is the leading known cause of preventable death and disease among women — In 1997, smoking accounted for about 165,000 deaths among U.S. women. In 1987, lung cancer became the leading cause of cancer death among women, and by 2000, about 27,000 more women in the United States died of lung cancer (about 68,000) than of breast cancer (about 41,000).
· 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 — In 1999 tobacco companies spent more than $8.24 billion,— or more than $22.6 million a day — to advertise and promote cigarettes. To sell its products, the tobacco industry exploits themes of success and independence, particularly in its advertising in women’s magazines.
· Encourage a more vocal constituency on issues related to women and smoking — Taking a lesson from the success of advocacy to reduce breast cancer, we must make concerted efforts to call public attention to the toll of lung cancer and other smoking-related diseases on women’s health. 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.
· Recognize that nonsmoking is by far the norm among women— Publicize that most women are nonsmokers. Nearly four-fifths of U.S. women are nonsmokers, and in some subgroup populations, smoking is relatively rare (e.g., only 11.2 % of women who have completed college are current smokers, and only 5.4 % of black high school seniors girls are daily smokers). It important to recognize that among adult women those who are most empowered, as measured by educational attainment, are the least likely to be smokers. Moreover, most women who smoke want to quit.
· Conduct further studies of the relationship between smoking and certain outcomes of importance to women’s health — Additional research is needed to explore these issues:
§ The link between exposure to environmental tobacco smoke and the risk of breast cancer.
§ Cigarette brand variations in toxicity and whether any of these possible variations may be related to changes in lung cancer histology during the past decade.
§ Changes in tobacco products and whether increased exposure to tobacco-specific nitrosamines may be related to the increased incidence rates of adenocarcinoma (malignant glandular tumor) of the lung.
§ Health effects of smoking among women in the developing world.
· Encourage the reporting of gender-specific results from studies of influences on smoking behavior, smoking prevention and cessation interventions, and the health effects of tobacco use, including use of new tobacco products — Research is needed to better understand and to reduce current disparities in smoking prevalence among women of different groups as defined by socioeconomic status, race, ethnicity, and sexual orientation. Women with only 9 to 11 years of education are about three times as likely to be smokers as are women with a college education. American Indian or Alaska Native women are much more likely to smoke than are Hispanic women and Asian or Pacific Islander women. Among teenage girls, white girls are much more likely to smoke than are African American girls.
· Determine why, during most of the 1990s, smoking prevalence declined so little among women and increased so markedly among teenage girls — This lack of progress is a major concern and threatens to prolong the epidemic of smoking-related diseases among women. More research is needed to determine the influences that encourage many women and girls to smoke even in the face that all that is known of the dire health consequence of smoking. If, for example, smoking in movies by female celebrities promotes smoking, then discouraging such practices as well as engaging well-known actresses to be spokespersons on the issue of women and smoking should be a high priority.
· Develop a research and evaluation agenda related to women and smoking — Research agendas should focus on these issues:
§ Determining whether gender-tailored interventions increase the effectiveness of various smoking prevention and cessation methods.
§ Documenting whether there are gender differences in the effectiveness of pharmacologic treatments for tobacco cessation.
§ Determining which tobacco prevention and cessation interventions are most effective for specific subgroups of girls and women.
§ Designing interventions to reduce disparities in smoking prevalence across all subgroups of girls and women.
· Support efforts, at both individual and societal levels, to reduce smoking and exposure to environmental tobacco smoke among women. Tobacco-use treatments are among the most cost-effective of preventive health interventions at the individual level, and they should be part of all women’s health care programs. Health insurance plans should cover such services. Societal strategies to reduce tobacco use and exposure to environmental tobacco smoke include counteradvertising, increasing tobacco taxes, enacting laws to reduce minors’ access to tobacco products, and banning smoking in work sites and in public places.
· Enact comprehensive statewide tobacco control programs proven to be effective in reducing and preventing tobacco use — Results from states such as Arizona, California, Florida, Maine, Massachusetts, and Oregon show that science-based tobacco control programs have successfully reduced smoking rates among women and girls. California established a comprehensive statewide tobacco control program more than 10 years ago, and is now starting to observe the benefits of its sustained efforts. Between 1988 and 1997, the incidence rate of lung cancer among women declined by 4.8% in California but increased by 13.2% in other regions of the United States.
· Increase efforts to stop the emerging epidemic of smoking among women in developing countries — Strongly encourage and support multinational policies that discourage the spread of smoking and tobacco-related diseases among women in countries where smoking prevalence has traditionally been low. It is urgent that what is already known about effective means of tobacco control at the societal level be disseminated throughout the world.
· Support the World Health Organization’s Framework Convention for Tobacco Control (FCTC) — The FCTC is an international legal instrument designed to curb the global spread of tobacco use through specific protocols – currently being negotiated – that relate to tobacco pricing, smuggling, advertising, sponsorship, and other activities.
New European anti-smoking campaign
The European Commission is launching a new multi-million dollar anti-smoking campaign. It comes as the world's first ever treaty aimed at dissuading children from smoking and helping adults kick the habit enters into force this week.
The European Commission will spend about ninety five million dollars over the next four years trying to prevent children and young adults from smoking. That's a big increase on the twenty five million dollars it spent on its last anti-smoking campaign.
But it's an amount that's dwarfed by the multi-billion dollar financial clout of the tobacco industry, even though companies like British-American tobacco say they support efforts to reduce the incidents of youth smoking across Europe.
The Commission's latest campaign ties in with a global anti-smoking treaty which came into force on Sunday and which requires that governments take tough measures against the promotion of tobacco. The Commission's already spent money on a logo and slogan both of which will be unveiled at the launch of the anti-smoking campaign on Tuesday and which will be followed up by a series of EU wide TV and cinema adverts.
The campaign comes on top of existing efforts to curb tobacco use. The Commission is encouraging countries to put picture warnings on cigarette packets which would feature photos of blackened lungs and from July this year tobacco firms will be banned from advertising at sporting events such as formula one car racing.
Quitting Smoke and Attempts to Quit
More than three-fourths (75.2%) of women want to quit smoking completely, and nearly half (46.6%) report having tried to quit during the previous year.
In 1998, the percentage of people who had ever smoked and who had quit was lower among women (46.2%) than among men (50.9%). This finding may be because men began to stop smoking earlier in the 20th 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.
Since the late 1970s or early 1980s, the probability of attempting to quit smoking and succeeding has been equal among women and men.
Smoking is need to be reduced not only among women, but also among young people, children and men. Anti-smoking campaigns should be held in schools and universities, in offices and factories. Reducing and absence of smoking among the youth is one of the main factors of healthy generation. People should understand the harm of this bad habit to do everything for smoke quitting, and such first step will bring health and good future.
1. Smoking and youth, A.Gorin, Moscow, Publishers - Alta-Press, 2001
2. D.Satcher: "A Report of the Surgeon General”, the article from the magazine "National Geographic”, 05.1998
3. Tobacco against people. People against tobacco, F.Healey, London, Penguin Group, 2002
4. Woman’s Health, A.Documentova, Moscow, Publishers – EKSMO, 2005
1. New Russian-English dictionary, V.Muller, Publishers – Alta-Press, 2003
2. English-Russian dictionary, V.Muller, Moscow, Publishers – Russian Language, 1999
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