Chapter 6. A Vision for the Future: What Is Needed to Reduce Smoking Among Women

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This report summarizes what is known about smoking among women, including patterns and trends in smoking prevalence, factors associated with smoking initiation and maintenance, the consequences of smoking for women's health, and interventions for smoking cessation and prevention. The report also describes historical and contemporary tobacco marketing targeted to women. Evidence of the health consequences of smoking, which had emerged somewhat earlier among men because of their earlier uptake of smoking, is now overwhelming among women. Tragically, in the face of continually 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 and 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. The single overarching theme emerging from this report is that smoking is a women's issue. What is needed to curb the epidemic of smoking and smoking-related diseases among women in the United States and throughout the world?

Increase Awareness of the Impact of Smoking on Women's Health and Counter the Tobacco Industry's Targeting of Women

  • Increase awareness of the devastating impact of smoking on women's health. Since 1980, when the first Surgeon General's report on women and smoking was published documenting the serious health consequences of smoking among women, the number of women affected by smoking-related diseases has increased dramatically. Smoking is now the leading known cause of preventable death and disease among women. Each year during the 1990s it accounted for more than 140,000 deaths among U.S. women. By 1987, lung cancer became the leading cause of cancer death among women, and in 2000 approximately 27,000 more women in the United States died of lung cancer (67,600) than of breast cancer (40,800). Smoking also claims women's lives through deaths due to other types of cancer as well as to cardiovascular, pulmonary, and other diseases-all risks shared with men who smoke. In addition, women experience unique health effects due to smoking, such as those related to pregnancy. In 1997, smoking accounted for an estimated 165,000 premature deaths among U.S. women. Exposure to environmental tobacco smoke also contributes to lung cancer and heart disease deaths among women and affects the health of their infants. The media, including women's magazines and broadcast programming, can play an important role in raising women's awareness of the magnitude of the impact of smoking on their health and in prioritizing the importance of smoking relative to the myriad other health-related topics covered.
  • 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. Even in the face of amassing evidence that a large percentage of women who smoke will die early, the tobacco industry has unabashedly exploited themes of liberation and success in its advertising-particularly in women's magazines-and promotions targeted to women. Through its sponsorship of women's sports, women's professional and leadership organizations, the arts, and so on, the industry has attempted to associate itself with things women most value (e.g., recent heavily advertised support from a major tobacco company for programs to curb domestic violence against women) (Levin 1999; Bischoff 2000-01). Such associations should be decried for what they are: attempts by the tobacco industry to position itself as an ally of women's causes and thereby to silence potential critics. Women should be appropriately outraged by and speak out against tobacco marketing campaigns that co-opt the language of women's empowerment, and they should recognize the irony of attempts by the tobacco industry to suggest that smoking-which leads to nicotine dependence and death among many women-is a form of independence. Such efforts on the part of women would be unnecessary if the tobacco industry would voluntarily desist with its ongoing efforts to target women and to associate tobacco use with women's freedom and progress.

Support Women's Anti-Tobacco Advocacy Efforts and Publicize that Most Women Choose to Be Nonsmokers

  • Encourage a more vocal constituency on issues related to women and smoking. Taking a lesson from the success of advocacy to reduce breast cancer, concerted efforts are needed to call public attention to the toll that lung cancer and other smoking-related diseases is exacting on women's health and to demand accountability on the part of the tobacco industry. 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. Some excellent but relatively small-scale efforts have already taken place in this area, but because of the magnitude of the problem, these efforts deserve much greater support.
  • Recognize that nonsmoking is by far the norm among women. Although in recent years smoking prevalence has not declined as much as might be hoped, nearly four-fifths of U.S. women are nonsmokers. In some subgroups of the population, smoking is relatively rare (e.g., only 11.2 percent of women who have completed college are current smokers, and only 5.4 percent of black high school senior girls are daily smokers). Despite the positive images of women in tobacco advertisements, it is important to recognize that among adult women, those who are the most empowered, as measured by educational attainment, are the least likely to be smokers. Moreover, most women who do smoke say they would like to quit. The fact that almost all women have either rejected smoking for themselves or, if they do smoke now, wish to quit, should be promoted.

Continue to Build the Science Base on Gender-Specific Outcomes and on How to Reduce Disparities Among Women

  • Conduct further studies of the relationship between smoking and certain outcomes of importance to women's health. For example, does exposure to environmental tobacco smoke increase the risk for breast cancer? Some case-control studies suggested that possibility, but the link remains controversial, especially because relatively little evidence exists thus far supporting an association between active smoking and breast cancer. Any health effects of exposure to environmental tobacco smoke may be particularly important among women in developing countries, where the vast majority of women are nonsmokers but smoking prevalence among men is high. Tobacco products, particularly the cigarette brands that have been most heavily promoted to women smokers, may vary significantly in the levels of known carcinogens; however, little data exist on how much brands vary in toxicity and whether any of these possible variations may be related to the changes in lung cancer histology over the last decades. More research is needed to evaluate whether changes in the tobacco product and increased exposure to tobacco-specific nitrosamines may be related to the increased incidence rates of adenocarcinoma of the lung. More data are also needed on the effects of employment in tobacco production on women's health, including data on reproductive outcomes among women who work with tobacco during pregnancy. This topic is not covered in the present report because of a paucity of information. In general, much better data are needed on the health effects of smoking among women in the developing world. Are the effects similar to those reported in the literature to date, which is based largely on studies of women smokers in the developed world, or are they modified by differences in lifestyle and environmental factors such as diet, viral exposures, or other sources of indoor air pollution?
  • Encourage the reporting of gender-specific results from studies of factors influencing smoking behavior, smoking prevention and cessation interventions, and the health effects of tobacco use, including use of new tobacco products. The evidence to date has suggested that more similarities than differences exist between women and men in the factors that influence smoking initiation, addiction, and smoking cessation. When differences in smoking history are taken into account, health consequences also are generally similar. These conclusions are tempered by the fact that many research studies are not reporting gender-specific results. However, some studies do report gender differences in smoking cessation and the health effects of smoking; thus, issues regarding gender differences are not entirely resolved. For example, it is still not known whether susceptibility to lung cancer is greater among women smokers than among men smokers, or whether women are more likely than men to gain weight following smoking cessation. Researchers are strongly encouraged to use existing data sets to examine results by gender and to do so in future studies. Where these additional analyses suggest important gender differences, more research is needed to focus on the development of interventions tailored to the special needs of girls and women. As new "reduced-risk" tobacco products are marketed in the future, it will also be important to learn whether gender differences exist in the appeal and use of such products, as well as the health consequences of their use.
  • Better understand how 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. Limited data also suggest that lesbian women are more likely to smoke than are heterosexual women. Among teenage girls, whites are much more likely to smoke than are blacks. How can the decline in smoking among women who are less well educated be accelerated? Why are smoking rates so high among American Indian women? What contributes to the relatively low smoking prevalence among Hispanic women and Asian or Pacific Islander women, and what can be done to prevent smoking among them from rising in the future? What positive influences contributed to the vast majority of black teenage girls resisting smoking throughout the 1990s, in stark contrast to the relatively high smoking prevalence among white girls during the same period? The objective is to reduce smoking to the lowest possible level across all demographic groups. The answers to these questions will provide crucial information for intervention efforts.
  • 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 disease among women. What are the influences that have kept smoking prevalence relatively stagnant among women and have contributed to the sharp increases in prevalence among teenage girls? Tobacco control policies are known to be effective in reducing smoking, and smoking prevalence tends to decline most where these policies are strongest. However, efforts to curb tobacco use do not operate in a vacuum, and powerful protobacco influences (ranging from tobacco advertising to the use of tobacco in movies) have promoted the social acceptability of smoking and thereby have dampened the effects of tobacco control programs. Moreover, ongoing monitoring of tobacco industry attempts to target women in this country and abroad are necessary for a comprehensive understanding of the influences that encourage women to smoke and for designing effective countermarketing campaigns. 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. As noted above, the impact of smoking and of exposure to environmental tobacco smoke on the risk of some disease outcomes has been inadequately studied for women. Determining whether gender-tailored interventions increase the effectiveness of various smoking prevention and cessation methods is important, as is documenting whether any gender differences exist in the effectiveness of pharmacologic treatments for tobacco cessation. A need also exists to determine which tobacco prevention and cessation interventions are most effective for specific subgroups of girls and women, especially those at highest risk for tobacco use (e.g., women with only 9 to 11 years of education, American Indian or Alaska Native women, and women with depression). The sparse data available on smoking among lesbian women suggest that prevalence exceeds that of U.S. women overall, but better data are clearly needed. Research designed to reduce disparities in smoking prevalence across all subgroups of the female population deserves high priority to help eliminate future disparities in smoking-related diseases. The components of programs and policies targeted to individual women, and those targeted to communities that produce the greatest reduction in smoking, need to be identified. Progress on these and other issues will be facilitated by the development of an agenda of research and evaluation priorities related to women and smoking.

Act Now: We Know More than Enough

  • Support efforts, at both individual and societal levels, to reduce smoking and exposure to environmental tobacco smoke among women. Proven smoking cessation methods are available for individual smokers, including behavioral and pharmacologic approaches that benefit women and men alike. Tobacco use treatments are among the most cost-effective of preventive health interventions; they should be part of all women's health care programs, and health insurance plans should cover such services. Efforts to maximize smoking cessation and maintenance of smoking cessation among women before, during, and after pregnancy deserve high priority, because pregnancy is a time of high motivation to quit and occurs when women have many years of potential life left. With respect to prevention, the knowledge that girls who are more academically inclined or who are more physically active are less likely to smoke suggests that supporting positive outlets for mental and physical development will contribute to reducing the tobacco epidemic as well. Because regular cigarette smoking typically is initiated early in the teenage years, effective smoking cessation and prevention programs for adolescent girls and young women are greatly needed. Societal-level efforts to reduce tobacco use and exposure to environmental tobacco smoke include media counteradvertising, increased tobacco taxes, laws to reduce youth access to tobacco products, and bans on smoking in public places.
  • Enact comprehensive statewide tobacco control programs-because they work. There are known strategies for reducing the burden of smoking-related diseases, but making the investment in these proven strategies remains a challenge. Results from states such as Arizona, California, Florida, Maine, Massachusetts, and Oregon have demonstrated that smoking rates among both girls and women can be dramatically reduced. California was the first state to establish a comprehensive statewide tobacco control program in 1990, and it 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 percent in California but increased by 13.2 percent in other regions of the United States (Centers for Disease Control and Prevention 2000). Another recent study concluded that the California program was associated with 33,300 fewer deaths from heart disease between 1989 and 1997 among women and men combined than would have been predicted if trends like those observed in the rest of the country had continued (Fichtenberg and Glantz 2000). Enormous monetary settlement payments from state Medicaid lawsuits with the tobacco industry have provided the resources to fund major new comprehensive state-wide tobacco control efforts. However, a recent report found that only six states were meeting the minimum funding recommendations from the Centers for Disease Control and Prevention's Best Practices for Comprehensive Tobacco Control Programs (Campaign for Tobacco-Free Kids 2001).

Stop the Epidemic of Smoking and Smoking-Related Diseases Among Women Globally

  • Do everything possible to thwart the emerging epidemic of smoking among women in developing countries. Multinational policies that discourage spread of the epidemic of smoking and tobacco-related diseases among women in countries where smoking prevalence has traditionally been low should be strongly encouraged. Efforts to disassociate cigarette smoking from progress in achieving gender equity are particularly needed in the developing world (Magardie 2000). Because smoking prevalence among men is already high in many developing countries, even women who do not smoke themselves are already at risk because they are exposed to environmental tobacco smoke-and because they suffer the losses of male loved ones who are dying of tobacco-related diseases. It is urgent that what is already known about effective means of tobacco control at the societal level be disseminated as soon as possible throughout the world. A major measure of public health victory in the global war against smoking would be the arrest of smoking prevalence at its still generally low level among women in developing countries and a reversal of the now worrisome signs of increases in smoking among them. In November 1999, the World Health Organization (WHO) sponsored an international conference on smoking among women and youth which took place in Kobe, Japan. This conference resulted in the Kobe Declaration, which states that, The tobacco epidemic is an unrelenting public health disaster that spares no society. There are already over 200 million women smokers, and tobacco companies have launched aggressive campaigns to recruit women and girls worldwide…. It is urgent that we find comprehensive solutions to the danger of tobacco use and address the epidemic among women and girls (WHO 1999b).
  • All national governments should strongly support WHO's Framework Convention for Tobacco Control. The Framework Convention for Tobacco Control is an international legal instrument designed to curb the global spread of tobacco use through specific protocols, currently being negotiated, that cover tobacco pricing, smuggling, advertising and sponsorship, and other activities (WHO 1999a). In the words of Dr. Gro Harlem Brundtland, director-general of WHO, If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked (Asma et al., in press).


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