Women and Smoking: A Report of the Surgeon General

A report focused on women [and smoking] 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 [first such report from the US Surgeon General in 1980] 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, is now the leading cause of female cancer death in this country, accounting for 25% 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.

Smoking Trends

Despite all that is known of the devastating health consequences of smoking, 22% 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 with only 9 to 11 years of education (32.9%) than among women with 16 or more years of education (11.2%).

In 2000, 29.7% 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.

Smoking-Related Deaths

Since 1980, approximately 3 million US women have died prematurely from smoking-related neoplastic, cardiovascular, respiratory, and pediatric diseases, as well as cigarettecaused burns. Each year during the 1990s, US 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 adverse reproductive outcomes.

Lung cancer is now the leading cause of cancer death among US women; it surpassed breast cancer in 1987. About 90% of all lung cancer deaths among women who continue to smoke are attributable to smoking.

Smoking and Pregnancy

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.

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 1 year after the delivery.

Smoking Initiation and Quitting

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.

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.