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Women and Tobacco
Corinne G. Husten, MD, MPHOffice on Smoking and Health
National Conference on Tobacco or HealthNovember, 2002
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0
10
20
30
40
50
60
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
Year
Pe
rce
nt
Trends in Cigarette Smoking* Among Adults (18+) by Gender—United States, 1955-2000
Source: 1955 Current Population Survey; 1965-2000 NHIS*Estimates since 1992 include some-day smoking
Males
Females
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0
10
20
30
40
50
60
70
80
1978-1980
1990-1991
1992-1993
1994-1995
Year
Pe
rce
nt
Trends in Cigarette Smoking among Women (18+) by Race/Ethnicity—United States, 1978-2000
Source: National Health Interview Surveys, 1978-2000, selected years, aggregate data
White
AfricanAmerican
Hispanic
Asian
AmericanIndian
1983-1985
1997-1998
1999-2000
1987-1988
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Percentage of Current Cigarette Smoking among Hispanic Women—United States, 1997-1998
13.1 13.99.7
21.0
14.6
0
10
20
30
40
50
Pe
rce
nt
Source: National Health Interview Surveys, 1997 and 1998, aggregate data
CubanAmerican
MexicanAmerican
Mexicana
Puerto Rican
OtherHispanics
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Percentage of Current Cigarette Smoking among American Indians and Alaska Native Women,
by Region—United States, 1995-1998
41.8
26.6
42.1
26.4
17.8
0
10
20
30
40
50
Pe
rce
nt
MMWR 2000: 49(04);79-82, 91Source: Behavioral Risk Factor Surveillance System, 1995-1998
Alaska
East
NorthernPlains
Pacific Coast
Southwest
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Trends in Cigarette Smoking* Among Women Aged 25+ by Education—United States, 1966-2000
Source: NHIS, 1966-2000*Estimates since 1992 incorporate some-day smoking
Years of Education
0
10
20
30
40
50
1966 1970 1974 1978 1982 1986 1990 1994 1998
Pe
rce
nt
0-8 9-11 12 13-15 16+
2000
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Smoking Patterns among Lesbian and Bisexual Women
Limited data on smoking among lesbian and bisexual women
Largely based on convenience samples
Existing studies strongly suggest increased prevalence
– 41% adults (1980 studies)
– Data not broken by gender for youth—59.3%(1995 Massachusetts YRBS)
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Prevalence of Current Smoking among Girls, by Grade in School—United States, 1975-2001
0
10
20
30
40
50
1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001
Pe
rce
nt
8th Grade
10th Grade
12th Grade
Source: Institute for Social Research, University of Michigan, Monitoring the Future Project*Smoking 1 or more cigarettes/day during the previous 30 days
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0
10
20
30
40
50
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
Year
Pe
rce
nt
Females
Males
Source: Institute for Social Research, University of Michigan, Monitoring the Future Project *Smoking 1 or more cigarettes during the previous 30 days
Trends in Current* Cigarette Smoking among 12th Graders by Gender—United States, 1976-2001
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0
10
20
30
40
50
60
70
1976-1979
1985-1989
Year
Pe
rce
nt
1980-1984
1990-1994
Trends in Current Cigarette Smoking* Among Female High School Seniors by Race/Ethnicity—United States, 1976-1994
White
AfricanAmerican
Hispanic
Asian
AmericanIndian
*Smoking 1 or more cigarettes during the previous 30 daysSource: Institute for Social Research, University of Michigan, Monitoring the Future Project
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Trends in Current Cigarette Use Among White, Black, and Hispanic High School Girls—United States, 1991-2001
0
10
20
30
40
50
1991 1993 1995 1997 1999 2001
Year
% S
mo
ke
rs*
*Smoked cigarettes on one or more days in the 30 days preceding the surveySource: CDC Youth Risk Behavior Survey
White
Black
Hispanic
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Percentage of Current Use of Any Tobacco Product* Among High School Students, by Sex and Race/Ethnicity
—United States, 2001
17.4
27.232.3
21.6
31.5
43.4
0
10
20
30
40
50
60
70
African American Hispanic White
Pe
rce
nt
Girls
Boys
*Includes users of cigarettes, cigars, chewing tobacco, or snuffSource: Youth Risk Behavior Survey, 1999
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Percentage of Ever-daily Smokers Who Have Ever Tried to Quit Smoking, grades 9-12, by Sex—United States, 1999
71.0
80.9
0
10
20
30
40
50
60
70
80
90
100
Males Females
Pe
rce
nt
Source: Youth Risk Behavior Survey. 1999
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Prevalence of Cigarette Smoking During Pregnancy— United States, 1989-2000
0
5
10
15
20
25
1989 1991 1993 1995 1997 1999 2000
Per
cen
t
Note: Percentage excludes live births for mothers with unknown smoking status.
Sources: National Center for Health Statistics 1992, 1994; Ventura et al. 1995, 1997, 1999, 2000; Martin et al. 2002.
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Percentage of Live-born Infants' Mothers Who Reported Smoking During Pregnancy, by Race/Ethnicity—
United States, 1989-2000
Source: National Center for Health Statistics, Vol. 49, No. 1. 2001; Vol.50, No. 5, 2002
0
10
20
30
40
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Year
Pe
rce
nt
White
AfricanAmerican
Hispanic
Asian
AmericanIndian
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0
10
20
30
40
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999Year
Pe
rce
nt
Percentage of Live-born Infants' Mothers Who Reported Smoking During Pregnancy, by Asian or Pacific Islander*—
United States, 1989-1999
*Determined by the origin of motherSource: National Center for Health Statistics, Vol. 49, No. 1. April 17, 2001
Japanese
Filipino
Other Asian orPacific Islander
Chinese
Hawaiian andPart Hawaiian
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Percentage of Live-born Infants' Mothers Who Reported Smoking During Pregnancy, by Hispanic—
United States, 1989-1999
*Determined by the origin of motherSource: National Center for Health Statistics, Vol. 49, No. 1. April 17, 2001
0
10
20
30
40
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
Pe
rce
nt
Other andUnknown
Cuban
MexicanAmerican
Central andSouth
American
PuertoRican
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0
10
20
30
40
50
60
1965 1970 1975 1980 1985 1990 1995 2000
Year
% F
orm
er
Sm
ok
ers
Percentage of Ever Smokers Who have Quit* by Gender, Ages 18+—United States, 1965-2000
Men
Women
Source: 1965-2000 National Health Interview Surveys*Also known as "quit ratio"; estimates since 1992 incorporate some-day smoking
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0
10
20
30
40
50
60
70
1978-1980
Year
Pe
rce
nt
Percent of Ever Smokers Who Have Quit* among Women by Race/Ethnicity, Ages 18+—United States, 1978-1998
*The prevalence of cessation is the percentage of ever smokers who are former smokers Source: National Health Interview Surveys, 1978-1998, selected years, aggregate data
White
AfricanAmerican
Hispanic
Asian
AmericanIndian
1997-1998
1983-1985
1987-1988
1990-1991
1992-1993
1994-1995
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Percentage of Women Who Reported that No One is Allowed to Smoke Anywhere Inside the Home, by
Race/Ethnicity—United States, 1998/1999
57.753.9
75.6 75.4
60.5
0
10
20
30
40
50
60
70
80
90
100
Pe
rce
nt
Source: U.S. Bureau of the Census, public use data tapes, 1998-1999: Current Population Survey, aggregated data
White
AfricanAmerican
Hispanic
Asian
AmericanIndian
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Factors Influencing Tobacco Use among Youth
Advertising/promotions Glamorization in movies/TV Price Access Inadequate understanding of health risks
and risk of addiction Social norms around tobacco use Parental and peer smoking Addiction
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Factors Influencing Tobacco Use among Youth: Advertising\Promotions
Youth are a strategically important market for the tobacco industry.
Youth are exposed to cigarette messages through print media and promotional activities (sponsorship of events and entertainment, point-of-sale displays, distribution of specialty items).
Cigarette advertising uses images to portray the attractiveness and function of smoking (independence, healthfulness, adventure-seeking, and youthful activities)– themes correlated with psychosocial factors that appeal to youth.
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Factors Influencing Tobacco Use among Youth: Advertising
Advertisements capitalize on the disparity between an ideal and actual self-image and imply that smoking may close the gap.
Advertising appears to affect young people’s perceptions of the pervasiveness, image, and function of smoking.
Advertising appears to increase young people’s risk of smoking.
Preventing Tobacco Use among Young People, 1994
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Factors Influencing Tobacco Use among Girls: Advertising/Promotions
In 2000, expenditures for domestic advertising and promotion were $9.57 billion, and increase of 42% since 1998.
Tobacco marketing, including product design, advertising, and promotional activities, is a factor influencing susceptibility to and initiation of smoking
FTC report, 2002; Women and Smoking: A Report of the Surgeon General, 2001
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Factors Influencing Tobacco Use among Girls and Women: Advertising
Women have been extensively targeted in tobacco marketing, and tobacco companies have produced brands specifically for women. Marketing is dominated by themes of social desirability and independence, which are conveyed through ads featuring slim, attractive, athletic models.
The dependence of the media on revenues from tobacco advertising oriented to women, coupled with 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 industry by women public figures.
Women and Smoking: A Report of the Surgeon General, 2001
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Factors Influencing Tobacco Use among Girls: Advertising
In 1999, 8 of the 10 top brands reached over 70% of teens (ages 12-17) 5 or more times.
– Kool, Marlboro, and Winston reached over 89% of teens
10 of the 10 top brands advertised in magazines that have higher than 15% teen composition.
– Winston, Camel, Kool, Virginia Slims, and Benson & Hedges advertised in Vibe, a publication with over 42% teen composition
Kool, Winston, Newport, Marlboro, and Doral each spent over 40% of their respective magazine budgets in publications with higher than 15% teen composition.
– Camel spent 33% of its total budget on these magazines
American Legacy Foundation,
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Factors Influencing Tobacco Use among Girls and Women: Glamorization in Movies and TV
Study of most popular movie rentals (200) of 1996/1997
– Tobacco appeared in 89% of movies
– Tobacco use was consistent across movie genres, occurring in 83% of action adventures, and 89% of comedies and dramas
– Tobacco was used in 79% of G or PG movies, 82% of PG-13 movies, and 92% of R-rated movies
– Movies were segmented into 5-minute intervals; of the 4372 intervals, tobacco use occurred in 24%
National Clearinghouse for Alcohol and Drug Information, SAMHSA, 2001
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Factors Influencing Tobacco Use among Girls: Price
Increasing the unit price of tobacco reduces smoking initiation
–State excise taxes range from $.025 to $1.50 per pack
– “Loosies”
– Internet or mail-order sales
– Free samples
Guide to Community Preventive Services, 2001
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Factors Influencing Tobacco Use among Girls: Access
In 1999, high school girls under age 18 reported their usual sources of cigarettes:
– 33.9% gave someone else money to buy them
– 33.3% borrowed from someone
– 17.6% bought them in a store
– 11.4% obtained them in some other way
76.2% were not asked to show proof of age when buying cigarettes in a store
Several studies have found that girls are able to purchase tobacco with greater ease than boys
YRBS, 1999; in press; Women and Smoking: A Report of the Surgeon General, 2001
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Factors Influencing Tobacco Use among Girls: Inadequate Understanding of Health Risks
A 1999 survey of youth ages 14-22 reported that 40% of smokers and 25% of nonsmokers underestimated or did not know the likelihood of smoking-related deaths.
Over 40% did not know or underestimated the number of years of life lost to smoking.
Young people overestimated lung cancer risk, but underestimated the fatality of lung cancer.
Young people were optimistic about their personal risk from smoking.
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Factors Influencing Tobacco Use among Girls: Social Norms
Widespread social norms
–Countermarketing campaigns reduce initiation
Local community norms
Parental smoking
Peer smoking
Guide to Community Preventive Services, 2001Reducing Tobacco Use: A Report of the Surgeon General, 2000
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Individual Factors Influencing Tobacco Use among Girls
Weaker attachment to parents and family
Strong attachment to peers and friends
Perceive smoking as more common than it actually is
Risk taking and rebelliousness
Women and Smoking: A Report of the Surgeon General, 2001
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Individual Factors Influencing Tobacco Use among Girls
Weaker commitment to school and religion
Belief smoking can control weight and moods
Positive image of smokers
Women and Smoking: A Report of the Surgeon General, 2001
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Factors Influencing Tobacco Use among Adults
Physical and psycho-social dependence
Availability of effective treatments
Clean indoor air restrictions
Price
Social norms around tobacco use
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Factors Influencing Tobacco Use among Adults: Nicotine Dependence
Reporting any indicator of nicotine dependence
– 63.1% of girls aged 12-17 years
– 81.2% of young women aged 18-24 years
– 77.5% of all adults women aged 18+ years
Women and Smoking: A Report of the Surgeon General, 2001
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Smoking and Addiction in Women
Addiction processes similar for women and men
Other factors (sensory cues) may play a greater role in smoking among women
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Factors Influencing Tobacco Use among Adults: Availability of Treatment
Among women, biopsychosocial factors such as pregnancy, fear of weight gain, depression, and need for social support appear to be associated with smoking maintenance, cessation, or relapse
Adolescent girls are more likely than boys to respond to cessation programs that include social support from family or peers
Women and Smoking: A Report of the Surgeon General, 2001
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Factors Influencing Tobacco Use among Adults: Availability of Treatment
Telephone cessation quitlines increase quitting
– 40 states have some form of telephone cessation quitline in place or under development; however use may be restricted
Reducing the out-of-pocket costs of treatment increases quitting
– Less than 50% of HMOs and less than 25% of indemnity plans provide any coverage of cessation treatment
– Medicaid coverage:
– 11 states: individual counseling; 10 states: group counseling
– 31 states: some prescription products; 20 states: all prescription meds
– 23 states: some OTC medications; 21 states both OTC medications
– Medicare does not cover cessation treatment
Guide to Community Preventive Services, 2001; NCSL
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Factors Influencing Tobacco Use among Women: Clean Indoor Air Restrictions
Women are more likely than men to affirm that they smoke less at work because of a worksite policy.
Women and Smoking: A Report of the Surgeon General, 2001
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Factors Influencing Tobacco Use among Women: Price
Increasing the unit price of tobacco increases quitting
–Studies on gender-specific differences in the effect of cigarette price on consumption have produced inconsistent results
Guide to Community Preventive Services, 2001Women and Smoking: A Report of the Surgeon General, 2001
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Factors Influencing Tobacco Use among Women: Inadequate Understanding of Health Risks
Popular women’s magazines downplay the hazards of cigarette smoking
A survey of 12 popular women’s magazines from August 1999 - August 2000
– Of 2414 health-related articles, only 24 addressed the health effects of tobacco
– Only 3 discussed lung cancer
– Self accounted for 54% of the anti-smoking articles
– Vogue and Glamour had none
– Family Circle and McCall’s had 2 articles
– The rest had 1 article
American Council on Science and Health
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Factors Influencing Tobacco Use among Women: Social Norms
Countermarketing campaigns increase quitting
Guide to Community Preventive Services, 2001
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Individual Factors Influencing Tobacco Use among Women who Continue to Smoke
Decreased education and employment levels
More addicted
Cognitively less ready to stop
Less social support for stopping
Less confident in resisting temptations to smoke
Women and Smoking: A Report of the Surgeon General, 2001
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A youngnonsmoker
A currentsmoker
A former smoker
Influences on the Decision to Use Tobacco
Pro-tobacco
Psychosocial factors
Peer pressure
Industry influence
Perceived social norms
Advertising
Promotion
Legislation
Regulation
Economic policy
Education
Reducing Tobacco Use: A Report of the Surgeon General, 2000
Anti-tobacco
Health education
Economic policy
Minors’ access
Product regulation
Clean indoor air regulation
Social advocacy
Personal litigation
Advertising restrictions
Promotional restrictions
Widespread social norms
Local community norms
Behavioral treatment
Pharmacologic treatment
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Total Mortality
A women’s annual risk for death is more than double for continuing smokers compared with never smokers in every age group from 45-74 years
Since 1980, 3 million U.S. women have died prematurely from a smoking-related disease
For every smoking attributable death, an average of 14 years of life was lost
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One out of two lifelong smokers will die
from a smoking related disease
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Lung Cancer44,242
Ischemic HeartDisease30,605
Stroke8,850
Chronic Obstructive Pulmonary Disease
49,312
Other Cancer8,735
Other Diagnosis13,031
178,000 Annual Deaths Attributable to Cigarette Smoking in Women—United States
Source: MMWR 2002; 51(14): 300-303
Second-hand smoke22,536
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Lung Cancer
90% lung cancer deaths among women who smoke are attributable to smoking
Risk for dying of lung cancer is 20x higher among women who smoke 2+ packs of cigarettes per day
Lung cancer mortality rates among U.S. women increased 600% since 1950
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Smoking and Female Cancers
Cervical cancer: increased risk
Vulvar cancer: possible increased risk
Endometrial cancer: decreased risk
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Smoking and Cardiovascular Disease among Women
Coronary heart disease: major cause
– For women under age 50, majority of CHD is attributable to smoking
–Risk increases with number of cigarettes smoked per day and duration of smoking
–CHD in oral contraceptive users: further increased risk
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Smoking and COPD in Women
COPD: primary cause
–Risk increases with amount and duration of smoking
– 90% COPD mortality due to smoking
–Mortality rates for COPD in women have increased over the past 20-30 years
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Smoking and Lung Function in Women
In-utero exposure to maternal smoking: decreased lung function in infants
Exposure to SHS during childhood and adolescence: possible decreased lung function
Childhood smoking: decreased rates of lung growth
Adult smoking: premature decrease in lung function
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Smoking and Reproductive Outcomes
Peri-natal mortality(stillbirths and neonatal deaths): increased risk
SIDS: increased risk
Low birth weight: increased risk
SGA: increased risk
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Smoking and Reproductive Outcomes
Conception delay: increased risk
Infertility: increased risk
Ectopic pregnancy: possible increased risk
Miscarriage: possible increased risk
PROM: increased risk
Abruptio placentae: increased risk
Placenta previa: increased risk
Pre-term delivery: increased risk
Pre-eclampsia: decreased risk
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Smoking and Menstrual Function
Dysmenorrhea: increased risk
Secondary amenorrhea: increased risk
Menstrual irregularity: increased risk
Age of menopause: younger
–Also possibly increased symptoms
Uterine fibroids: decreased risk
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Smoking and Body Weight in Women
Smoking appears to attenuate weight gain over time
Cessation is associated with a weight gain (average 6-12 lbs)
Women smokers have a more masculine pattern of fat distribution
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Smoking and Other Diseases in Women
Cataract: increased risk
Wrinkling: increased risk
Hip fracture: increased risk
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Second-Hand Smoke Exposure: Effects on Women
Lung cancer: cause
– It has been estimated that 5-14% of lung cancers in lifetime nonsmoking women are potentially preventable by eliminating ETS exposure
Coronary heart disease: cause
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Second-Hand Smoke Exposure: Effects on Children
Bronchitis and pneumonia
Asthma (induction and exacerbation)
Chronic respiratory symptoms
Middle ear infections
SIDS
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Second-Hand Smoke Exposure by Pregnant Women: Effects on the Fetus
IUGR among infants born to SHS exposed women: increased risk
Low birth weight among infants born to SHS exposed women: possible increased risk
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Benefits of Cessation: Total Mortality
Women who stop smoking greatly reduce their risk of dying prematurely
The relative benefits of cessation are greater when women stop at younger ages, but cessation is beneficial at all ages
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Benefits of Cessation
Former smokers have lower risk for lung cancer; risk declines with number of years of cessation
CHD risk substantially reduced within 1-2 years of cessation; risk is similar to that of non-smokers after 10-15 years of cessation
Higher stroke risk reversible after cessation; after 5-15 years, risk approaches that of never smokers
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Benefits of Cessation
Cessation slows the progression of carotid atherosclerosis
Cessation improves symptoms, prognosis, and survival from peripheral vascular atherosclerosis
Risk of dying from COPD reduced for former smokers
Quitting before or during pregnancy decreases the risk of adverse reproductive outcomes
