Surgeon General’s Report Calls Smoking ‘A Women’s Issue’

WASHINGTON—Cigarette smoking has inflicted an enormous toll on American women during the last two decades, according to the latest Surgeon General’s report. "The single overarching theme emerging from this report is that smoking is a women’s issue," said Surgeon General David Satcher, MD.

Since 1980, the year of the first Surgeon General’s report to focus on health issues of women and smoking, some 3 million American females have died of smoking-related diseases, and in 1987, lung cancer replaced breast cancer as the leading cause of cancer deaths among US women. Last year alone, 67,600 women died of lung cancer, 27,000 more than succumbed to breast cancer.

The evidence now linking cigarette smoking with a range of cancers and other adverse health effects "compels the nation to make reducing and preventing smoking one of the highest contemporary priorities for women’s health," the new report contends. (See Table for specific recommendations.)

The Surgeon General’s Recommendations on Smoking and Women

 Increase awareness of the impact of smoking on women’s health and counter the tobacco industry’s targeting of women.

 Support women’s antitobacco advocacy efforts and publicize the fact that most women do not smoke.

 Continue to build the science base on gender-specific outcomes and on how to reduce disparities among women.

 Support attempts at both the individual and societal levels to reduce smoking and exposure to environmental tobacco smoke among women.

 Stop the epidemic of smoking and smoking-related diseases among women globally.

The new report, Women and Smoking: A Report of the Surgeon General—2001, was prepared at the Centers for Disease Control and Prevention. It extensively reviews smoking prevalence data and the adverse health effects of smoking on women.

"Women not only share the same health risks as men, but are also faced with health consequences that are unique to women, including pregnancy complications, problems with menstrual function, and cervical cancer," Dr. Satcher said. The report also singled out for special criticism the efforts of tobacco companies to entice women to smoke. "Tragically, in the face of continued 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," the report said.

Further, the report contends that the tobacco industry "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."

Release of the report brought renewed demands from health groups, including the American Cancer Society (ACS) and the American Heart Association, that Congress enact legislation empowering the FDA to regulate tobacco products.

Smoking prevalence for women has dropped significantly since the landmark first report on smoking by the Surgeon General. In 1965, 34% of American women smoked. That figure dropped to 30% in 1979 and to 22% in 1998. Yet cigarette smoking by teenage girls remains a continued concern. In 2000, 30% of high school senior girls said they had smoked at least once within the 30 days prior to being surveyed, compared with 33% of 12th grade boys.

"Smoking prevalence among white girls declined from the mid-1970s to the early 1980s, followed by a decade of little change," the report noted. "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.

Adult women appear to have reduced cigarette usage between 1989 and 1998. However, estimates of smoking by expectant mothers ranges from 12%, based on birth certificate data, to 22%, based on survey data. Prevalence of cigar, pipe, and smokeless tobacco remains low among women, although recent data indicate an increase in cigar smoking by both women and girls.

Since 1980, numerous studies have significantly expanded the breadth and depth of what is known about the health consequences of cigarette smoking among women. Studies show, for example, that nicotine pharmacology "and the behavioral processes that determine nicotine addiction appear generally similar among women and men." However, the body’s regulation of nicotine intake appears less precise in women than in men.

Smoking ranks as a major cause of certain cancers and coronary heart disease in women, and it is the primary cause of chronic obstructive pulmonary disease, the report said. Smoking also increases a woman’s risk of stroke, peptic ulcers, estrogen-deficiency disorders, conception delay, infertility, ectopic pregnancy, spontaneous abortion, reduced bone density, and cataracts.

Studies also suggest that smoking increases the risk of developing gallstones, cholecystitis, and rheumatoid arthritis. Finally, smokers are more likely to be depressed, and to suffer anxiety disorders, bulimia, and alcoholism.

In its review of scientific data related to cancer, the report cited cigarette smoking as the major cause of lung cancer deaths in women and said the risk increases with the quantity, duration, and intensity of smoking.

Lung cancer mortality increased 600% among US women in the second half of the 20th century. "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," the report stated.

However, women who stop smoking lower their risk of lung cancer, and the risk declines with each passing year after cessation. Although men previously appeared to have a higher relative risk of lung cancer than women, recent data indicate a significant narrowing of that gender gap in the United States.

Internationally, women’s lung cancer mortality rates show dramatic variations. "In 1990, lung cancer accounted for 10% of all cancer deaths among women worldwide and more than 20% of cancer deaths among women in some developed countries," the report said. It attributed this variation to differences in the rates at which women adopted cigarette smoking in different countries.

Other Cancer Findings

The report’s other tobacco-related cancer findings include:

Although several studies have indicated a possible association between breast cancer and exposure to environmental tobacco smoke, the evidence to date fails to support an increased risk of breast malignancy among women who smoke.

Smoking is a major cause of oro-pharynx and bladder cancers among women. It also increases the risk of pancreatic and renal cancers, and evidence is consistent for a large increase in risk for cancers of the larynx and esophagus, and for an increased risk of liver and colorectal cancers.

Cigarettes increase the risk of cervical cancer and may increase the risk of vulvar cancer. The extent to which these risk associations are independent of the human papillomavirus (HPV) remains uncertain.

Smoking may increase a woman’s risk for myeloid leukemia, but it does not appear to increase the risk for other lymphoproliferative or hematologic malignancies.

The use of smokeless tobacco increases the risk of oral cancers in women.

Cigarette smoking apparently does not affect the risk of ovarian cancer one way or the other.

Risk data linking smoking and stomach cancer are inconsistent.

Smoking may reduce the risk of thyroid and endometrial cancer. However, the effect in endometrial cancer appears limited to postmenopausal disease.