W omen, T obacco, and Cancer: 

An Agenda for the 21st Century 

July 2004 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 

National Cancer Institute 

Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

T able of Contents 

From the Women, Tobacco, and Cancer Working Group................................................................ ii 

Acknowledgments ............................................................................................................................. iv 

Executive Summary ........................................................................................................................... 1 

Summary of Recommendations ....................................................................................................... 3 

Introduction......................................................................................................................................... 5 

Recommendations.............................................................................................................................. 7 

Discovery .................................................................................................................................. 7 

Development .......................................................................................................................... 11 

Delivery................................................................................................................................... 15 

Partnerships ........................................................................................................................... 18 

Evaluation and Surveillance ................................................................................................. 21 

Conclusion......................................................................................................................................... 23 

References......................................................................................................................................... 25 

Appendices 

Appendix A: Reports From Working Group Breakout Sessions ........................................ 29 

Biology and Cancer..................................................................................................... 29 

Addiction...................................................................................................................... 35 

Epidemiology and National Surveillance.................................................................. 49 

Interventions for Prevention and Treatment............................................................. 55 

Awareness, Risk Perception, and Communications................................................. 65 

Community and Policy Interventions ........................................................................ 73 

Global Issues ............................................................................................................... 79 

Appendix B: About the Women, Tobacco, and Cancer Working Group............................ 85 

Appendix C: Working Group Meeting Agendas .................................................................. 87 

Appendix D: Working Group Steering Committee.............................................................. 91 

Appendix E: Working Group Meeting Participants ............................................................. 93 

i 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

From the Leadership 

We are very pleased to submit the Report of the Women, Tobacco, and Cancer Working Group. Currently, in the United 

States, 170,000 women die each year from smoking, and lung cancer has surpassed breast cancer as the leading cause of cancer 

death in women since 1986. The burden of tobacco use is especially high for certain populations of women, including women 

with low levels of education and in certain ethnic groups, such as American Indians. Ominously, rates of tobacco use are rising 

among women in economically developing countries, where women’s tobacco use has traditionally been very low. Despite this, 

tobacco use has not generally been considered a “women’s issue.” 

The 2001 Surgeon General’s report, Women and Smoking, presented a comprehensive overview of the health effects of 

smoking on women and girls, and provided a framework and direction on what is needed to reduce smoking. The Working 

Group builds on the Surgeon General’s report by articulating a set of strategies in five areas: discovery, development, delivery, 

partnerships, and evaluation and surveillance. 

This Report represents the collaborative efforts of the dedicated scientists, clinicians, and advocates who participated in the 

Working Group. We believe that it is possible to reduce and ultimately eliminate tobacco use and tobacco-caused disease in 

the United States and abroad. With sustained, focused efforts that include partnerships and collaborations among researchers, 

practitioners, community advocates, and policy makers, we can implement these recommendations and help make this goal a 

reality. 

Respectfully, 

Ellen R. Gritz, Ph.D. C. Tracy Orleans, Ph.D. 

The University of Texas, M. D. Anderson Cancer Center Robert Wood Johnson Foundation 

Co-Chair Co-Chair 

Women, Tobacco, and Cancer Working Group Women, Tobacco, and Cancer Working Group

Michele Bloch, M.D., Ph.D.

National Cancer Institute, National Institutes of Health National Cancer Institute, National Institutes of Health 

Co-Executive Director Co-Executive Director 

Women, Tobacco, and Cancer Working Group Women, Tobacco, and Cancer Working Group 

Anna T. Levy, M.S.

ii 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Jasjit Ahluwalia, M.D., M.P.H., M.S. Sherry Mills, M.D., M.P.H. 

David Burns, M.D. Mildred Morse, J.D. 

Sharon Carothers

Richard Clayton, Ph.D. 

Ovide Pomerleau, Ph.D. 

Julia Rowland, Ph.D. 

Carolyn Dresler, M.D. Gary Swan, Ph.D. 

Thomas J. Glynn, Ph.D. Kathryn Kahler Vose, M.A.

Donna Grande, M.G.A. Cora Lee Wetherington, Ph.D. 

Corinne Husten, M.D., M.P.H. Judith Wilkenfeld, J.D. 

Cathy Melvin, Ph.D., M.P.H. 

iii 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Acknowledgements 

The Women, Tobacco, and Cancer Working Group is a public/private partnership, with participation and support from 

Federal agencies, nonprofit organizations, and public and private research institutions. We wish to acknowledge and thank the 

following people whose expertise and commitment made this Report possible: 

n The many dedicated scientists, clinicians, and advocates from across the country and around the world who gave 

generously of their time and knowledge. 

n Our partners who provided funding support for the Working Group meeting: 

National Cancer Institute (NCI) 

Office on Women’s Health, Department of Health and Human Services (DHHS) 

Office of Research on Women’s Health, National Institutes of Health (NIH) 

American Legacy Foundation 

American Cancer Society 

Campaign for Tobacco-Free Kids 

n Cherie Nichols, Director of the Office of Science Planning and Assessment (OSPA), NCI, for providing continuing 

encouragement and support and sharing her wealth of planning expertise, and OSPA staff Marilyn Duncan, D. J. Joya, 

and Sandra Williams for coordination and technical assistance. 

n The Federal coordinators who provided their expertise and support in all stages of the Working Group: Wanda Jones and 

Saralynn Mark of the Office on Women’s Health, DHHS; Vivian Pinn and Lisa Begg of the NIH Office of Research on 

Women’s Health; and Nelvis Castro and Julie Cheh of the NCI Office of Communications. 

n Marianne Alciati, of Management Solutions for Health, Inc., who guided the Working Group leadership through the 

complex planning process and facilitated the Steering Committee and Working Group meetings. 

n Lead science writer, Deborah Berlyne, for excellent writing and diligent work through the development and drafting of 

this Report; and her leadership of the team of skilled writers who provided support during the Working Group meeting: 

Lisa Chiu, Randi Henderson, Frances McFarland Horne, Laura Janusik, Eleanor Mayfield, Cheryl Pellerin, and Barbara 

Shapiro. 

n The experts who developed the breakout group reports: Pamela Hershberger, Taline Khroyan, Amy Lazev, Anne Marie 

O’Keefe, Linda Pederson, Kathryn Kahler Vose, and Soon-Young Yoon. 

n The staff of Palladian Partners, Inc., led by Anita Allen, who provided logistical support to the Steering Committee and 

Working Group meetings. 

n The staff of NOVA Research Company, led by Vicki Butz and Ed Rorie, who coordinated the Report’s final editing and 

preparation. 

iv 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Executive Summary 

For far too long, tobacco use has been viewed as a men’s issue, but the use of tobacco among women around the 

world is now common. As a result, women have experienced a 

dramatic upsurge in cancers, cardiovascular and lung disease, 

and other life-threatening conditions caused by tobacco use. 

Currently, it is estimated that approximately 1 in 5 U.S. 

women smoke and 170,000 U.S. women die each year from 

smoking. 

The 2001 report of the Surgeon General, Women and 

Smoking, identified several strategies to reduce smoking 

among women. In addition, in 2001, the National Cancer 

Institute (NCI) highlighted research on tobacco and 

tobacco-related cancers in its annual budget document. 

The Department of Health and Human Services’ (DHHS) 

Healthy People 2010 continues to make smoking cessation and 

prevention a priority. 

The Women, Tobacco, and Cancer Working Group was 

formed to respond to the priorities identified in these and 

other plans and reports. The group focused on identifying 

ways to stimulate scientific research and suggesting 

approaches to translate knowledge into interventions to 

prevent tobacco-related cancers in women in the United 

States and other countries. The Working Group, a 

public/private partnership led by NCI, met in Houston, 

Texas, in February 2003. This Report summarizes the 

recommendations of the breakout groups at the February 

2003 Women, Tobacco, and Cancer Working Group meeting 

(see the Summary of Recommendations, pages 3-4). 

Implementing the strategies described in the report will 

advance our progress toward the following goals: 

Discovery 

Increase our understanding of sex and 

gender differences* across the broad range 

of research on women, tobacco, and cancer. 

A better understanding of the biological, psychological, and 

behavioral mechanisms and processes associated with women’s 

and men’s responses to nicotine exposure is critical to develop 

better prevention and cessation interventions for addiction 

and to prevent and treat tobacco-related cancers. Research 

on genetic factors and hormonal variations throughout 

the life cycle should be emphasized in elucidating women’s 

susceptibility to tobacco-related diseases and addiction, as well 

as responses to pharmaceutical and behavioral interventions. 

We need to understand how the interaction of gender, 

culture, race and ethnicity, and socioeconomic status affects 

women’s and girls’ use of tobacco products, perceptions of 

risk, and responses to relevant health messages. To conduct 

research that can be translated into effective applications, we 

must validate and standardize sex- and gender-appropriate 

definitions and measures of addiction, exposure, injury, and 

recovery. 

Development 

Develop new and more effective 

interventions to prevent and treat tobacco 

use and environmental tobacco smoke 

(ETS) exposure among women and girls, 

especially in populations at greatest risk. 

We must translate basic and applied research into effective, 

evidenced-based prevention and treatment programs by using 

knowledge from animal studies, pilot projects, and small-scale 

clinical and community-based trials. By using or modifying 

existing mechanisms, we can rapidly evaluate promising 

interventions, programs, and policies—such as the World 

Health Organization Framework Convention on Tobacco 

Control—on tobacco use by women and girls, both nationally 

and globally. We need to evaluate and monitor the impact 

of tobacco control policies on tobacco use by women and 

girls, both nationally and globally. State-of-the-art, audiencetailored communication strategies should be used to develop 

and disseminate evidence-based messages that target women 

and girls. 

* “Sex and gender differences” are defined as follows in the 2001 Institute of Medicine (IOM) report Exploring the Biological Contributions to Human Health—Does Sex 

Matter?: “The committee defines sex as the classification of living things, generally as male or female according to their reproductive organs and functions assigned by 

the chromosomal complement, and gender as a person’s self-representation as male or female, or how that person is responded to by social institutions on the basis of the 

individual’s gender presentation. Gender is shaped by environment and experience.” (16) 

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Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Delivery partnerships with organizations that serve women with low 

levels of education and women of low socioeconomic status Ensure the widespread delivery of effective are also a key priority. interventions to prevent and treat tobacco 

use and ETS exposure among women and Evaluation and Surveillance 

girls. Improve national and global evaluation 

The reach and impact of evidence-based tobacco control 

programs, policies, and counter-advertising campaigns must 

be expanded by increasing the appeal, access, affordability, 

and use of effective interventions, particularly among 

and surveillance of the harms of tobacco 

use and ETS exposure and of women’s and 

girls’ knowledge, attitudes, and behaviors 

related to tobacco use and harms. women and girls in populations at greatest risk. We need to 

identify and use targeted strategies to involve individuals, It is essential to monitor and evaluate progress toward 

communities, policy makers, and organizations, especially reducing tobacco use and the impact of tobacco-related 

women’s organizations and those that have not previously cancers on women. This will require further development of 

been involved in tobacco control. standardized measures and surveillance systems to ensure that 

data are comparable within and across nations. Information 

Partnerships obtained will help strategically target funding to ensure that 

gains are maintained while expanding support for tobacco Harness and expand partnerships, control among the general public, including policy makers. networks, and innovative research Identification and dissemination of best practices will platforms to design and launch broad- inform researchers and practitioners about which prevention 

based strategies to eliminate the harms of and cessation interventions are the most effective and 

tobacco use and ETS exposure. help determine how to tailor core interventions to specifi c 

Successfully implementing the discovery, development, and populations. 

delivery recommendations will require capitalizing on existing The Working Group believes that reducing and ultimately 

collaborations and developing new partnerships. To maximize eliminating the harmful effects of tobacco use on women 

the development and dissemination of effective interventions, requires integrating advances in our understanding of basic 

partners must be involved from the beginning, and knowledge biologic, behavioral, and social factors to develop new 

gained from practice should be used to inform future prevention and treatment interventions and ensure the 

research. We need to encourage researchers to investigate delivery of new evidence-based interventions to all women 

common pathways of tobacco-related disease mechanisms by who need them. As interventions are delivered, their impact 

fostering networks of clinical and translational researchers. on individual and public health must be evaluated and 

Community-based participatory research needs to be monitored to inform future research and development. 

conducted through partnerships between research institutions Successful implementation of all of the recommendations 

and community-based organizations, especially those that of the Women, Tobacco, and Cancer Working Group will 

serve populations at greatest risk. Because of the magnitude require many collaborations and partnerships between Federal 

and persistence of the tobacco use problem in American and non-Federal organizations. Such efforts have the potential 

Indian/Alaska Native populations, it is particularly important to rapidly decrease tobacco use and ETS exposure and, 

to develop partnerships between research institutions and ultimately, morbidity and mortality. 

tribal colleges, tribal health departments, and/or American 

Indian health care and community settings. Similarly, 

2 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Summary of Recommendations 

DISCOVERY DEVELOPMENT DELIVERY 

OVERALL GOAL: Increase our OVERALL GOAL: Develop new OVERALL GOAL: Ensure the 

understanding of sex and gender and more effective interventions widespread delivery of effective 

differences*

 across the broad to prevent and treat tobacco interventions to prevent and 

range of research on women, use and ETS exposure among treat tobacco use and ETS 

tobacco, and cancer. women and girls, especially in exposure among women and 

populations at greatest risk. girls. 

A better understanding of sex and gender 

differences is critical to eliminating tobacco 

use and tobacco-related cancer morbidity and 

mortality in women and men. 

Multidisciplinary research is needed on: 

n Sex differences in the mechanisms and 

processes associated with: 

◆ All phases of tobacco addiction—from 

experimentation to regular use and 

addiction to cessation—including the 

natural history of the progression between 

phases and the effects of environmental 

tobacco smoke (ETS) exposure. This 

includes genetic, molecular, cellular, 

neurobiological, biobehavioral, and 

hormonal factors that play a critical role 

in tobacco addiction and in the etiology 

of cancers and other diseases caused by 

tobacco. 

◆ The etiology of cancers caused by tobacco, 

especially those related to gene-hormoneenvironment interactions involved in 

carcinogenic and other disease pathways. 

◆ Methods of prevention and treatment of 

tobacco addiction. 

n Gender-specific factors in tobacco use and 

the components of effective prevention and 

treatment interventions for women and girls, 

especially in populations at greatest risk, to: 

◆ Identify behavioral, psychosocial, 

sociocultural, and environmental 

influences on tobacco use, exposure to 

ETS and disease risk, and prevention and 

treatment interventions. 

◆ Assess women’s and girls’ knowledge of the 

harms of tobacco use and ETS exposure 

and the benefi ts of quitting. 

Multidisciplinary research is needed to: 

n Validate and standardize sex- and genderappropriate definitions and measures of 

addiction, ETS exposure, tissue injury, and 

recovery. 

Translating basic and applied research into 

effective, evidence-based prevention and 

treatment programs and broad public health 

tobacco control policies will require: 

n Using evidence from animal studies, 

pilot projects, and small-scale clinical and 

community-based studies to develop, refi ne, 

and evaluate promising sex- and genderappropriate interventions for prevention, 

cessation, and treatment. 

n Using or modifying existing infrastructures 

to rapidly evaluate the efficacy of promising 

treatments and the effectiveness and 

cost-effectiveness of proven small-scale 

interventions, programs, and policies. 

n Developing and disseminating evidencebased cessation, prevention, and advocacy 

messages targeted to women using state-ofthe-art, audience-tailored communication 

strategies. 

n Conducting research to explore and 

strengthen the positive health impacts of 

public and private tobacco control policies 

on women and girls, especially in populations 

at greatest risk, and improving the adoption 

of evidence-based policies and strategies by 

policy and decision makers. 

n Monitoring the harmful effects of tobacco 

marketing targeted to diverse populations of 

women and girls domestically and globally. 

Expanding the reach and impact of evidencebased tobacco control programs and policies will 

require: 

n Increasing the appeal, access, affordability, 

and use of effective interventions, 

particularly among women and girls in 

populations at greatest risk. 

n Identifying and using targeted messages and 

strategies to involve and activate individuals 

and organizations in effective, sustained 

advocacy for evidence-based tobacco control 

programs and policies. 

n Making data from surveillance and policy 

research, as well as social, economic, and 

cultural studies, available to the health care 

community, policy makers, and the general 

public in a timely and effective fashion. 

n Supporting research and demonstration 

projects to better understand how to convert 

women’s broad-based support for tobacco 

control policies and programs into more 

active involvement in their communities. 

* See footnote on page 1.

3 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Summary of Recommendations (continued) 

PARTNERSHIPS EVALUATION AND SURVEILLANCE 

OVERALL GOAL: Harness and expand partnerships, OVERALL GOAL: Improve national and global 

networks, and innovative research platforms evaluation and surveillance of the harms of 

to design and launch broad-based strategies tobacco use and ETS exposure, and of women’s 

to eliminate the harms of tobacco use and ETS and girls’ knowledge, attitudes, and behaviors 

exposure among women and girls. related to tobacco use and harms. 

Successfully implementing the discovery, development, and delivery 

recommendations will require capitalizing on existing collaborations 

and developing new partnerships. To maximize the development and 

dissemination of effective interventions, partners must be involved from the 

beginning, and knowledge gained from practice should be used to inform 

future research. 

Partnerships are especially needed between: 

n Established networks of clinical and translational researchers that 

can provide the resources and infrastructure needed to foster 

cross-disciplinary interactions and rapidly evaluate treatments and 

interventions. 

n Research institutions and community-based organizations that serve 

populations at greatest risk to conduct community-based participatory 

research. These partners must be committed to joint decision making in 

designing research, sharing ownership of the products of research, and 

disseminating and implementing research results. 

n Research institutions and tribal colleges, tribal health departments, 

and/or American Indian health care and community settings to develop 

effective, culturally appropriate individual, family, and community-level 

tobacco prevention and cessation initiatives. 

n Public and private funding agencies to fully and efficiently support the 

implementation of successful interventions. 

It is essential to monitor and evaluate progress toward reducing tobacco 

use, ETS exposure, and the impact of tobacco-related cancers on women 

and to make midcourse adjustments as needed. This will require further 

development of standardized measures and surveillance systems to ensure 

that data are comparable within and across countries. 

Local, national, and global evaluation and surveillance will be critical for: 

n Monitoring and measuring national and global trends and patterns in 

tobacco use and exposure to ETS using standardized measures. 

n Ensuring that research and programmatic funding are strategically 

targeted and, where appropriate, tailored to specifi c populations. 

n Assessing whether progress has been made and whether it is due to 

specific interventions and policies. 

n Identifying effective interventions through success stories and rigorous 

case studies to inform researchers, encourage broader dissemination, 

and increase public support. 

4 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Introduction 

For far too long, tobacco use has been viewed as a men’s issue, but the use of tobacco among women around the 

world is now common. As a result, women have experienced a 

dramatic upsurge in cancers, cardiovascular and lung disease, 

and other life-threatening conditions caused by tobacco use. 

For example, between 1950 and 1997, lung cancer mortality 

for white women in the United States increased by over 

600 percent (1). Women who smoke also experience higher 

rates of cancers of the mouth, pharynx, esophagus, larynx, 

bladder, pancreas, kidney, and cervix—and possibly other 

sites. In addition, these women have an increased risk of 

developing and dying from cardiovascular disease and chronic 

obstructive pulmonary diseases, including chronic bronchitis 

and emphysema with airflow obstruction. Currently, it is 

estimated that 1 in 5 U.S. women smoke and 170,000 U.S. 

women die each year from smoking (1). 

Smoking prevalence decreased among U.S. women from 

34 percent in 1965 to 20 percent in 2002, but most of 

this decline happened between 1974 and 1990; prevalence 

declined more slowly in the 1990s (1, 2). Smoking rates 

remain alarmingly high among certain U.S. populations. 

In 2002, approximately 22 percent of white women in the 

United States were current smokers, but the rate among 

American Indian/Alaska Native women was 41 percent (2). 

Moreover, smoking prevalence is almost three times higher 

among women who did not finish high school than among 

those with a college degree (3). Smoking rates are signifi cantly 

lower among women in economically developing countries 

(about 9 percent) than in economically developed countries, 

where the average rate is 22 percent (4). 

As might be expected in economically developing countries 

where smoking rates among women are relatively low, lung 

cancer death rates are also low (1). With increased female 

autonomy, increased marketing of tobacco products to 

women, and changes in women’s roles, smoking uptake and 

ensuing disease are expected to increase in economically 

developing countries (5). In addition, women’s use of 

traditional forms of tobacco is already widespread in many 

economically developing countries (6). Reflecting this, a 

recent article notes that “curtailing the increase in tobacco 

use among women in developing countries represents one of 

the greatest opportunities for disease prevention in the world 

today” (7). 

Impetus for This Report 

The 2001 report of the Surgeon General, Women and 

Smoking, identifi es five strategies to reduce smoking among 

women: 

n Increase awareness of the impact of smoking on women’s 

health and counter the tobacco industry’s targeting of 

women. 

n Support women’s antitobacco advocacy efforts and 

publicize that most women are nonsmokers. 

n Continue to build the science base on gender-specifi c 

outcomes and on how to reduce disparities among 

women. 

n Act now: we know more than enough. 

n Stop the epidemic of smoking and smoking-related 

diseases among women globally. 

In addition, in 2001, NCI began to highlight research on 

tobacco and tobacco-related cancers as an Extraordinary 

Opportunity for Research in its annual budget document, 

Plans and Priorities for Cancer Research. The Department of 

Health and Human Services’ Healthy People 2010 continues 

to make smoking cessation and prevention a priority. Relevant 

goals include reducing smoking prevalence and decreasing 

death rates from both lung cancer and cancer overall. 

Working Group on Women, Tobacco, and 

Cancer 

The Women, Tobacco, and Cancer Working Group was 

formed to respond to the priorities identified in these and 

other plans and reports. In particular, the group focused on 

identifying ways to stimulate scientific research and suggesting 

approaches to translate knowledge into action to prevent 

tobacco-related cancers in women in the United States and 

abroad. The Working Group, a public/private partnership led 

by NCI, is a multidisciplinary group of experts from Federal 

and non-Federal research and advocacy organizations. 

The Working Group meeting held in Houston, Texas, in 

February 2003 and this Report are the culmination of the 

dedicated efforts of the Breakout Group Co-Chairs and 

the Working Group’s Steering Committee. A more detailed 

description of the Working Group process, a meeting agenda, 

and the Steering Committee and Working Group rosters can 

be found in the appendices following the Report. 

5 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Organization of This Report 

This Report summarizes the recommendations of the 

breakout groups at the February 2003 Women, Tobacco, 

and Cancer Working Group meeting. These summary 

recommendations are organized under five cross-cutting goals 

in the following areas: 

n Discovery 

n Development 

n Delivery 

n Partnerships 

n Evaluation and Surveillance 

These goals reflect the themes of the breakout group 

discussions, as well as the framework adopted by NCI in 

2001 to meet its Challenge Goal of eliminating the suffering 

and death due to cancer by 2015. 

The recommendations discussed in this Report are drawn 

from the deliberations of the seven breakout groups at the 

Working Group meeting: 

n Biology and Cancer 

n Addiction 

n Epidemiology and National Surveillance 

n Interventions for Prevention and Treatment 

n Awareness, Risk Perception, and Communications 

n Community and Policy Interventions 

n Global Issues 

Complete breakout group summaries are included in the 

appendices at the end of the Report. 

We believe that to reduce and ultimately eliminate the 

harmful effects of tobacco on women, we must integrate 

advances in our understanding of basic biologic, behavioral, 

policy, and social factors. This will lead to the development of 

new prevention and treatment interventions and help ensure 

that the interventions delivered to women are evidence based. 

As interventions are delivered, their impact on individual and 

public health must be monitored and evaluated to inform 

future research and development. Strong Federal, state, local, 

and private partnerships will also be needed to implement the 

recommendations. 

6 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Recommendations 

Discovery understanding of the role of estrogens in premalignant and 

malignant disease progression may lead to the development 

Overall Goal: Increase our understanding of of antiestrogen therapies for lung cancer prevention and 

sex and gender differences across the broad treatment. 

range of research on women, tobacco, and Depression, which is more common in women than in men, 

cancer. is associated with higher dependency on smoking (20). 

Women are more likely than men to smoke in response to 

A better understanding of sex and gender stress and negative affect (1, 21, 22). However, the underlying 

mechanisms of the relationships among tobacco use, negative differences*

 is critical to eliminating tobacco 

use and tobacco-caused cancer morbidity affect, and stress are not fully understood. Research aimed 

at testing interventions to help women with depression quit and mortality in women and men. smoking must take into account the multiple demands and 

Research suggests that women differ from men in their unique stressors in the daily lives of women. 

biological responses to nicotine, progression to nicotine Differences in smoking prevalence and patterns of use dependence, and patterns of intake and that women have among women belonging to different subgroups (as defi ned higher rates of relapse and greater risk of health problems by socioeconomic status, race, culture, and ethnicity) may caused by smoking (8-15). However, the effects of oral affect initiation and cessation. It is important that cultural contraceptives, menopause, hormone replacement therapy, and, potentially, biological differences inform prevention 

Discovery refers to the 

process that generates new 

knowledge about fundamental 

disease processes at the 

genetic, molecular, cellular, 

organ, individual, and 

population levels. 

and other sex- and cessation programs targeting particular groups (23). related factors on Concurrently, understanding what cultural and social factors smoking rates, protect women from tobacco is also valuable, particularly craving, and in cultural groups where traditional roles for women are relapse are not well changing in ways that may facilitate tobacco use. understood. The 

menstrual cycle, Discovery Recommendations 

puberty, pregnancy, 1.a Multidisciplinary research is needed on sex and menopause differences in the mechanisms and processes should be primary foci of research on nicotine dependence 

and tobacco use to determine, for example, whether nicotine 

has a disruptive effect on hormone levels and whether sex 

hormones can affect craving and rates of relapse. Ovarian 

hormones may modulate response to medications, which 

may account for women’s lower success rates in quitting in 

response to certain pharmacotherapies. 

Some case-control studies suggest that women are more 

susceptible to tobacco-induced carcinogenesis than men, 

after taking into account baseline exposure, body weight, 

body height, and body mass index (17). However, cohort 

studies have not supported this observation (18). Estrogen 

or menopausal status has an impact on lung cancer risk in 

women, and some evidence indicates a positive interaction 

between menopausal estrogen therapy, smoking, and the 

development of adenocarcinoma of the lung (19). A better 

associated with all phases of tobacco 

addiction—from experimentation to regular 

use and addiction to cessation—including the 

natural history of the progression between 

phases and the effects of environmental 

tobacco smoke (ETS) exposure. This includes 

genetic, molecular, cellular, neurobiological, 

biobehavioral, and hormonal factors that 

play a critical role in 

tobacco addiction Multidisciplinary 

and in the etiology research integrates 

of cancers and other technologies 

diseases caused by and knowledge 

tobacco. from a variety of 

interrelated fi elds. 

* See footnote on page 1. 

7 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Research is needed to address: approaches in the analysis of early lesions and established 

tumors obtained from both women and men. n Environmental, behavioral, genetic, molecular, cellular, 

neurobiological, and hormonal sources of variation n Common pathways between inflammation and tobaccoin nicotine use and addiction. Sex differences must caused disease. To date, relatively little research has 

also be studied at different stages of life, taking into focused on the interplay between infl ammation and 

consideration biological, behavioral, and environmental the development of lung cancer. Further understanding 

factors. is needed of the effects of oxidative stress on lung 

biology and the n The interactions of the different sources of variation mechanisms In transdisciplinary research, in animals and humans during all phases of nicotine controlling the teams from a variety of addiction, including initiation, maintenance, withdrawal, expression and relevant fields collaborate to and relapse. In particular, the genetic infl uences release of pro- address a common problem on different stages of tobacco use require further infl ammatory using shared concepts and investigation because these influences may vary. In mediators approaches. addition, a better understanding of how genes and the 

environment interact to increase susceptibility to tobacco in the lung. 

Transdisciplinary investigations are also needed to use is needed. understand common pathways of cancer, heart disease, 

n The natural history of tobacco use, including initiation, and lung disease caused by tobacco. 

maintenance, cessation, and relapse (24). Some recent data 

indicate that the patterns of initiation and maintenance n The variety of cellular processes regulated by nicotine and 

may be changing (25), and these apparent changes may other tobacco smoke constituents to identify new therapeutic 

affect tobacco use prevalence and the incidence and targets for intervention in tobacco-related diseases. Further 

prevalence of tobacco-related morbidity and mortality in understanding of the mechanisms by which nicotine 

the future. It is not known whether the observed patterns alters cell growth is also important to further guide 

are similar or different for different subpopulations. pharmacologic therapy. 

Variation in the natural history of tobacco use across 1.c Multidisciplinary research is needed on sex 

populations within a nation and across nations should be differences in the mechanisms and processes 

more fully explored. associated with methods of prevention and 

1.b Multidisciplinary research is needed on sex treatment of tobacco addiction. 

differences in the mechanisms and processes Research is needed to address: 

associated with the etiology of cancers n Whether sex and gender differences exist in prevention and caused by tobacco, especially those related treatment effi cacy. Studies have produced confl icting to gene-hormone-environment interactions results as to whether women have the same, less, involved in carcinogenic and other disease or more difficulty quitting smoking than men (26- pathways. 32). Methodological limitations may account for the 

Research is needed to address: uncertainty. 

n Cross-disciplinary research on mechanisms of tobacco-related 

disease. Estrogen status, for example, is recognized as a 

factor that affects lung cancer risk in women. Estrogen 

or one of its metabolites may be a weak carcinogen, but 

studies have not addressed this in depth, particularly in 

relationship to tobacco use. An understanding of the role 

of estrogens in the pathogenesis of lung cancer should 

facilitate the selection and evaluation of antiestrogen 

therapies for the treatment of this disease. Further insight 

n Whether physiological, psychological, and/or behavioral 

factors mediate or moderate differences between men 

and women in responses to treatment and tobacco use 

cessation. These differences may be due to a number 

of factors, including depression, nicotine dependence, 

withdrawal, demographics, social support, coping styles, 

expectancies, and weight concerns. To date, research has 

not adequately addressed these issues. 

n The influence of factors unique to women—such as the into sex-specific pathways for lung carcinogenesis may menstrual cycle, pregnancy, and menopause—on tobacco use be gained through the use of proteomic and genomic 

8 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

behavior and treatment effi cacy. While some factors, such 

as pregnancy, have been associated with increased quit 

rates, others have not been well explored. Targeting these 

events will make it possible to capitalize on potential 

windows of opportunity. 

n Effective strategies for tailoring interventions to women. 

Identifying whether sex and gender differences exist and 

the factors through which they affect tobacco use will 

lead to the targeting and tailoring of prevention and 

intervention efforts. 

2.a Multidisciplinary research is needed on 

gender-specific factors in tobacco use and 

the components of effective prevention and 

treatment interventions for women and 

girls, especially in populations at greatest 

risk, to identify behavioral, psychosocial, 

sociocultural, and environmental infl uences 

on tobacco use, exposure to ETS and 

disease risk, and prevention and treatment 

interventions. 

Populations at greatest risk for tobacco 

use and tobacco-related disease include 

women with low income and/or low levels 

of education, members of certain racial 

and ethnic groups, pregnant women, 

and women with mental health or other 

substance abuse disorders. 

Research is needed to address: 

n Tobacco use among different populations. Tobacco use 

varies among population subgroups, and increasingly, 

the devastating health effects of tobacco are concentrated 

in certain populations. Race, ethnicity, socioeconomic 

status, age, sexual orientation, disability, and culture 

may all play a role in initiation, maintenance, and 

cessation of tobacco use. Yet, adequate data on tobacco 

use are lacking for many population subgroups. To more 

precisely identify disparities, it is necessary to assess the 

interrelationships of specific population characteristics 

as they influence tobacco use, exposure to ETS, and 

disease risk. Understanding how these differences affect 

tobacco use behaviors will allow us to identify social 

and contextual factors that could aid in prevention 

and treatment for all women and help reduce health 

disparities. 

n The role of gender issues and the interaction of 

gender, culture, and ethnicity in the continuum from 

experimentation to addiction. Experimentation with and 

initial exposure to tobacco occur early, and the time 

from experimentation to addiction is very brief (33, 34). 

Factors that contribute to experimentation and regular 

tobacco use are not well understood. 

n Social contextual factors, such as partner and household 

tobacco use, social networks, social ties, and discrimination. 

Interest in cessation and vulnerability to relapse may be 

influenced by these factors. Family, social, and cultural 

factors may be especially important for minority and 

underserved women who have limited access to care and 

may depend on existing social networks for support. 

2.b Multidisciplinary research is needed on 

gender-specific factors in tobacco use and 

the components of effective prevention 

and treatment interventions, especially 

in populations at greatest risk, to assess 

women’s and girls’ knowledge of the harms 

of tobacco use and ETS exposure and the 

benefits of quitting. 

Research is needed to address: 

n Women’s current levels of knowledge of the risks of 

tobacco use and their assessment of their personal risk. 

More research is needed to determine accuracies and 

inaccuracies in women’s knowledge about tobacco use, 

prevention, and cessation and the interplay of affective, 

experiential, and cognitive approaches to assessing risk 

and deciding what course of action to take. This research 

should identify mechanisms to which women will 

respond and focus on different ethnic, socioeconomic, 

and health status groups across the lifespan. 

n Women’s perceptions of the addictiveness of tobacco and 

their understanding of the process by which people become 

addicted. Further research is needed to explore how 

beliefs about the addictiveness of tobacco are formed 

and how prevention messages can counteract inaccurate 

impressions of individual control. 

n Culturally relevant messages and entry points that respond to 

women’s perceived needs. It is important to understand the 

meaning of tobacco use to women in its historic social 

context, especially in economically developing countries, 

where tobacco use is frequently linked to emancipation 

and “Western” culture. Investigation of the knowledge, 

attitudes, and practices of women who use smokeless 

9 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

and traditional forms of tobacco is also important, 

particularly in some economically developing countries 

where these products are commonly used by women. 

The role of men as positive or negative infl uences on 

women’s health also needs further investigation. 

commonly used to measure nicotine dependence assesses 

all aspects, and the intercorrelation of these instruments 

is surprisingly low (38). Therefore, better measures 

need to be developed to identify differences in nicotine 

dependence between men and women and between 

3. Multidisciplinary research is needed to adults and adolescents. 

validate and standardize sex- and gender- n Validated, biologically relevant measures of tobacco smoke 

appropriate definitions and measures of exposure, injury, and recovery. Validating these measures 

addiction, ETS exposure, tissue injury, and includes linking measures of exposure to those of injury 

recovery. in biological models, linking measures of injury to 

Research is needed to further develop: outcomes, examining modifying factors of injury from 

exposure, and investigating new tobacco products. 

n The defi nition of nicotine addiction/dependence. Reasons 

for tobacco use vary among individuals and, probably, 

across population subgroups, time, and situations. A 

more precise definition of nicotine addiction will make 

it possible to better define sex-relevant experimental 

parameters. 

Intermediate markers between injury and disease must 

be identified. Although several good models are available, 

identifying the effects of tobacco exposure in these 

models is time consuming, pointing to the need for 

accelerated models as well as for mixture and single-agent 

models (39). The biomarkers identified can be used to 

n Appropriate instruments for assessing nicotine dependence. provide a more specific and efficient tool for assessing 

Addiction/dependence appears to be multidimensional biological exposure and effect and, thus, identifying 

and may include physical, behavioral, and physiological persons at risk. 

components (35-38). To date, none of the instruments 

10 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Development development and refinement of interventions. Understanding 

the effects of such variables as sex and gender, culture, 

Overall Goal: Develop new and more ethnicity, educational level, and socioeconomic status is 

critical in designing effective interventions. Community effective interventions to prevent and treat 

tobacco use and ETS exposure among intervention research and community-based research have 

women and girls, especially in populations provided valuable insights for the design of state- and 

community-level interventions that have helped reduce at greatest risk. tobacco use (43-45). Examples include the NCI Community 

Intervention Trial for Smoking Cessation (COMMIT) and To eliminate the harms caused by tobacco the American Stop Smoking Intervention Study (ASSIST) use and ETS exposure among women and (46). 

girls, especially those in populations at 

greatest risk, basic and applied research Increasing communication between researchers and 

practitioners will help ensure that research designs are must be translated into effective, evidence- informed by practitioners’ constraints and that researchers based prevention and treatment programs are investigating issues that reflect population needs. and broad public health tobacco control Increased multidisciplinary collaboration will also aid in policies. the development of the most cost-effective and effi cient 

Knowledge gained from research is critical to developing practices possible. Best practices in the United States should 

effective interventions for both smoking and disease be shared with other countries, but they must be adapted to 

prevention for women and girls, as well as for cessation the cultural, social, and economic needs of local communities. 

and disease treatment. This is especially important because For example, mass media campaigns should be modifi ed in 

evidence indicates that women respond differently to communities and countries where community leaders have 

treatments than men. For example, research has found that more influence than print media among illiterate women. 

Development refers to 

the process of creating 

and evaluating tools 

and interventions using 

knowledge gained through 

research, to reduce the 

cancer burden through the 

prevention, early detection, 

diagnosis, and treatment of 

cancer and its consequences. 

Given the need to strengthen leadership in economically women are more 

responsive than men developing countries, greater effort must also be made 

to telephone quit- to exchange knowledge and success stories between the 

line use and support economically developed and developing worlds. We have 

(40). Research has much to learn from each other. 

also shown that Development Recommendations 

women are more 

concerned about 1. Translating basic and applied research into 

their weight than effective, evidence-based prevention and 

men. Unfortunately, treatment programs and broad public health 

smoking cessation tobacco control policies will require using 

often leads to weight evidence from animal studies, pilot projects, 

gain, and some evidence suggests that women are less likely and small-scale clinical and communitythan men to seek treatment or attempt to quit smoking on based studies to develop, refine, and evaluate 

their own because of this issue (41, 42). Other factors that promising sex- and gender-appropriate 

are unique to women and girls that may infl uence smoking interventions for prevention, cessation, and 

behaviors and treatment efficacy include phase of menstrual treatment. 

cycle, pregnancy, menopausal status, and use of hormone Evidence from the following should be used: 

therapies. Knowledge of sex and gender differences and 

the sequelae of these unique factors will provide a better n Animal studies, pilot projects, and small-scale clinical and 

understanding of how treatments should be designed for community-based studies. Animal studies may be useful in 

women and girls. understanding the role of behavioral, hormonal, genetic, 

neurobiological, and environmental factors in nicotine 

Research findings must be shared between the basic and addiction. These models will help in the development 

applied research communities and integrated into the of potential behavioral and pharmacologic interventions 

11 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

for the prevention and cessation of nicotine addiction. 

For example, pharmacological interventions from the 

field of depression and other psychiatric comorbidities 

could be tested in animal models and perhaps provide 

data to begin pilot clinical and community-based studies. 

In addition, menstrual cycle effects on craving and 

withdrawal symptomatology and cognitive behavioral 

therapy regarding weight gain concerns can be studied in 

pilot or small-scale settings. 

2. Translating basic and applied research into 

effective, evidence-based prevention and 

treatment programs and broad public health 

tobacco control policies will require using or 

modifying existing infrastructures to rapidly 

evaluate the efficacy of promising treatments 

and the effectiveness and cost-effectiveness 

of proven small-scale interventions, 

programs, and policies. 

Promising interventions that need to be evaluated include: 

n Nicotine replacement therapy (NRT). Existing 

infrastructures, such as the National Institute on 

Drug Abuse Clinical Trials Network, may be used for 

investigations on 

how to maximize Translational research is 

the effectiveness the bidirectional exchange 

of NRT for between basic and clinical 

women because science to move research 

women may findings to applied settings 

have different involving patients and 

sensitivity to populations. 

nicotine than men 

during withdrawal. Hormonal effects may alter nicotine 

sensitivity, but few studies have examined hormonal 

influences on the responsiveness to NRT. Additional 

studies are needed to determine whether the menstrual 

cycle should be taken into consideration to maximize the 

effectiveness of NRT. 

n Bupropion, the only non-NRT drug treatment that is 

currently approved for smoking cessation. This treatment 

may be especially useful for women because it may 

reduce withdrawal symptoms and weight gain, a major 

concern for women. Similar research will be needed 

for other pharmacologic agents under development for 

cessation. 

n Combinations of medications and behavioral treatments, 

which may be more effective than single treatments. Women 

who smoke and have a history of depression are less 

likely to quit. Existing research infrastructures should be 

used to examine the application of treatments for other 

disorders, such as depression, to nicotine dependence. 

3. Translating basic and applied research 

into effective, evidence-based prevention 

and treatment programs and broad public 

health tobacco control policies will require 

developing and disseminating evidencebased cessation, prevention, and advocacy 

messages targeted to women using stateof-the-art, audience-tailored communication 

strategies. 

Strategies should include: 

n Advancing the social marketing agenda using qualitative 

and quantitative research methods and focusing on the 

psychological, sociocultural, and economic segmentation 

of women. Simply recognizing the personal health risks 

of tobacco use does not often lead to cessation (47). 

Awareness of risk needs to be combined with decreased 

benefits from tobacco use, increased barriers to tobacco 

use, and social and environmental support for not using 

tobacco. The key is to identify sets of attitudes and values 

of women that can be targeted for prevention, cessation, 

and advocacy messages for environmental change. 

Further research is needed to explore how tobacco 

products fit into women’s views of affordable routine 

pleasure, as well as their perceptions of addiction. 

n Using lifestyle risk factors, sociodemographics, and 

health perceptions to create target audiences for health 

messages. Understanding the diversity of tobacco users’ 

representations of explanations for their own tobacco use 

may also play a role in developing effective antitobacco 

messages. Comprehensive models of tobacco addiction 

that take into account the various influences in women’s 

lives are clearly needed. 

n Methods to decode and debunk tobacco industry messages 

and counter their persuasive power. Redefi ning women’s 

emancipation should be based on women’s own 

perceptions. The tobacco industry must be prevented 

from “owning” gender images of modernity. The 

ultimate goal is to use media and communication 

12 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

strategies to increase the demand for prevention and 

cessation among women. 

n Developing antitobacco campaigns that are based on at least 

the same level of systematic and extensive research as tobacco 

company campaigns. Although some focus group research 

has helped elucidate the benefits of and barriers to 

smoking cessation for particular groups of women (48), 

few large-scale studies have examined the “hot buttons” 

that motivate women to take action against tobacco. The 

research to inform antitobacco campaigns should provide 

a clear picture of the attitudes, values, and needs of target 

groups, including those at risk for tobacco use, current 

tobacco users, and women’s health advocates. 

n A comprehensive feedback system to help researchers hone 

new research quickly and effectively. Although message 

concepts are routinely tested among target audiences, 

large-scale trials of media messages and intervention 

results are not as commonly catalogued and monitored. 

The system should include surveillance and monitoring 

to determine the effectiveness of the messages among 

various segments of the population. 

4. Translating basic and applied research 

into effective, evidence-based prevention 

and treatment programs and broad public 

health tobacco control policies will require 

conducting research to explore and 

strengthen the positive health impacts of 

public and private tobacco control policies on 

women and girls, especially in populations 

at greatest risk, and improving the adoption 

of evidence-based policies and strategies by 

policy and decision makers. 

Policy-related research will help to: 

n Reinforce the positive effects of tobacco control policies on 

the health of women and girls, especially those at greatest 

risk. This will fill major knowledge gaps regarding 

gender differences in attitudes, behavior, and the impact 

of tobacco policies. Research can also clarify the policy 

development process, including models by which policies 

alter social norms and behaviors, and optimal strategies 

for collaboration with policy makers. 

n Educate policy makers in economically developing countries 

about the utility of tobacco control measures. Two major 

areas of concern should be the implementation of 

the World Health Organization (WHO) Framework 

Convention on Tobacco Control (Framework 

Convention) and multicountry studies of national and 

local policies designed for international comparisons. For 

example, research might address the impact on women’s 

health of a total ban on tobacco advertising or the 

impact of comprehensive ETS restrictions. 

n Increase levels of awareness among women. Awareness 

varies widely by social, economic, and cultural context, 

even within a country. Subgroups of women to target for 

raising awareness should be identified in policy-related 

research. 

n Build feasibility studies and evaluation and monitoring 

of policies resulting from enforcement of the Framework 

Convention into a gender-specifi c tobacco strategy. 

Multicountry studies that measure the impact of specifi c 

measures on women’s tobacco use will provide important 

comparative data. Accurate evaluations are also needed 

of new legislation, such as bans on tobacco use in 

workplaces and public places. 

n Improve legal and governance structures for tobacco control. 

Monitoring and evaluating existing and new laws is 

necessary to ensure compliance and identify reasons for 

lack of enforcement. 

n Help advocates work with governments to implement the 

Framework Convention. Nongovernmental organizations 

(NGOs) can also use information to persuade 

governments to take action and increase public awareness 

of the importance of gender-sensitive tobacco strategies. 

Tobacco control programs could target advocacy toward 

policies that work best to reduce tobacco use among 

women and girls. 

5. Translating basic and applied research 

into effective, evidence-based prevention 

and treatment programs and broad public 

health tobacco control policies will require 

monitoring the harmful effects of tobacco 

marketing targeted to diverse populations of 

women and girls domestically and globally. 

Monitoring needs to include: 

n Tobacco advertising and promotion targeted to diverse 

populations of women in the United States and 

internationally. This information will enhance countermarketing programs to educate women and girls and 

policy and program planning to counter tobacco 

industry messages that promote tobacco use. In addition, 

13 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

information on tobacco company advertising and 

promotion activities could be used to show women that 

options are available for becoming emancipated and 

independent other than using tobacco. 

part of their lives (49). Further research is needed to 

explore this positive association, including how women 

experience tobacco use as an affordable pleasure. This 

research can assist in understanding the benefi ts women 

n The perception developed by marketers that tobacco use is associate with tobacco use, provide ways to counter these 

an affordable pleasure for women. Many women smokers benefits, and identify complementary benefi ts associated 

report that tobacco use is a positive and meaningful with quitting tobacco use. 

14 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Delivery and ethnicity, tobacco use status, socioeconomic status, and 

other factors. Meta-analyses of gender-specifi c interventions 

Overall Goal: Ensure the widespread demonstrate that these factors are significantly related to how 

women approach cessation (56-58). delivery of effective interventions to 

prevent and treat tobacco use and ETS Long-term, sustained, and coordinated strategies must be 

exposure among women and girls. devised for incorporating tobacco control into the women’s 

health agenda and engaging women’s and girls’ organizations 

The reach and impact of evidence-based in tobacco control issues. Initiatives are needed that will 

tobacco control programs and policies convert women’s support for tobacco control efforts into 

must be expanded to reduce the harms of active involvement in and advocacy for comprehensive 

tobacco use and ETS exposure. tobacco control programs and policies. 

As a result of these efforts, key information will be Relatively few women receive formal smoking cessation disseminated more rapidly and completely to the general assistance because of lack of interest, time, and resources and public and decision makers. Partnerships will open low availability. Minorities and those of lower socioeconomic communication channels from consumers back to researchers status are disproportionately affected. Women with little to help inform and shape future research agendas and to education are far more likely to smoke than those with more refine and improve current best-practice interventions. education, emphasizing this population’s enormous need for Partnerships will also increase accountability through media services (50). The Surgeon General’s report on tobacco use attention, link local and international networks, help decrease among U.S. racial and ethnic minority groups concluded tobacco use through better treatments, and promote strong that members of minority groups were less likely than other national and local legislation. groups to participate in smoking cessation programs and 

receive cessation advice from health care providers due to Delivery Recommendations 

barriers such as lack of transportation, money, and access to 1. Expanding the reach and impact of evidence- health care (51). 

Delivery refers to the 

process of disseminating, 

facilitating, and 

promoting evidencebased prevention, early 

detection, diagnosis, 

and treatment practices 

and policies to reduce 

the burden of cancer 

in all segments of the 

population. 

based tobacco control programs and 

Research is the key to policies will require increasing the appeal, 

developing best practices access, affordability, and use of effective 

to prevent and reduce interventions, particularly among women and 

women’s tobacco use girls in populations at greatest risk. 

(52, 53), and these 

best practices must be Increasing the use of effective interventions will require: 

promptly disseminated to n

public health practitioners 

and consumers. In 

addition, mechanisms 

must be in place so 

that practitioners and 

consumers can provide 

The development of tobacco control policies and counteradvertising campaigns. Such policies and campaigns can 

substantially increase quitting motivation and demand 

for and use of evidence-based treatments. Effective 

tobacco control policies include increased excise taxes 

on cigarettes, smoke-free indoor air laws, and public 

and private insurance coverage for tobacco dependence 

treatment. 

Finding ways, other than through actual experience, of 

encouraging women to view the dangers of tobacco use 

as personally relevant. Some tobacco users may not be 

aware of the connection between tobacco use and their 

health. Even when women are aware of the health risks 

of tobacco use, they often have a perception of personal 

safety or “self-exemption” from the consequences of 

tobacco use. 

researchers with feedback to ensure that research is useful and 

applicable in the real world. Researchers and public health n

professionals have a responsibility to translate basic research 

into effective smoking cessation and prevention messages 

that can be disseminated by the media and by women’s 

organizations for broad public impact. 

Much research demonstrates that women do not fully 

understand or appreciate the impact of tobacco use on their 

health (54, 55). Effective ways to communicate accurate 

health messages may vary depending on a woman’s age, race 

15 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

n Increasing demand for interventions, which must be 

attractive, affordable, and accessible to all women. 

Campaigns aimed at women tobacco users should 

highlight the unique risks to women of tobacco use, 

risks to infants and children from exposure to ETS, 

and benefits of quitting related to reproductive and 

general health. Campaigns should also address common 

misconceptions about the effects of quitting on women’s 

long-term health. 

n Ways to engage women in tobacco cessation and advocacy. 

Long-term, sustained, and coordinated strategies are 

needed to engage women’s and girls’ organizations in 

tobacco issues and to incorporate the issue of tobacco 

into the women’s health agenda. Women’s and girls’ 

organizations are appropriate partners in determining 

how best to communicate to women the importance of 

the problem of tobacco use and their potential role in 

addressing it. 

n Increasing access to care. It is critical to broaden the 

help offered to women through the health care system. 

Every woman should receive evidence-based tobacco 

use assessment, and women who smoke should receive 

cessation counseling during visits with health care 

providers. Cost barriers must be reduced, and new 

treatments that use technologies such as telephone 

quit lines or the Internet may expand access for many. 

However, interventions that rely on access to Web-based 

resources—or even the telephone—may not reach some 

populations at greatest risk. 

3. Expanding the reach and impact of evidencebased tobacco control programs and policies 

will require making data from surveillance 

and policy research, as well as social, 

economic, and cultural studies, available to 

the health care community, policy makers, 

and the general public in a timely and 

effective fashion. 

Strategies should include: 

n Development of a mechanism to identify individual and/or 

policy-relevant tobacco control research fi ndings and use 2. Expanding the reach and impact of evidence- state-of-the-art communication strategies to maximize based tobacco control programs and policies dissemination to relevant audiences. Materials may come will require identifying and using targeted from peer-reviewed journal articles, conference abstracts, messages and strategies to involve and 

activate individuals and organizations in polling and marketing research reports, and other 

sources. effective, sustained advocacy for evidencebased tobacco control programs and policies. n Outreach to health professional organizations to assist 

them in providing training at national, state, and local Targeted messages and strategies should address: meetings. Primary care providers, including nurses, 

n Ways to more effectively communicate the devastating 

impact of smoking on women’s health. The most effective 

ways may vary depending on a woman’s age, tobacco use 

status, socioeconomic status, and other factors. Studies 

nurse practitioners, social workers, family practitioners, 

obstetrician/gynecologists, internists, dentists, and others 

can benefit from training in best practices for prevention 

and cessation. 

should segment priority audiences and provide insights n Close cooperation between researchers and tobacco control into appropriate channels and tactics to reach them. To activists. General principles of good project planning ensure progress, translation and outreach efforts must be apply, such as ensuring that policy makers and women’s appropriately tracked and evaluated so that best practices leaders are involved from the beginning in identifying can be identified and replicated. research priorities and planning programs. 

n Ways to increase outreach to young women (59). Research n Briefi ngs to educate and inform the media so that they is needed to increase our knowledge of young women’s understand the context in which new fi ndings are released. receptiveness to tobacco industry messages and effective The briefings would not only explain the new research countermarketing messages and to identify appropriate findings, but would also describe the expected impact or channels and tactics to reach young women. We also use of the fi ndings. need a better understanding of the role tobacco plays 

in girls’ and young women’s self-perception and desired n Use of the Internet, one of the most cost-effective techniques 

self-image to help women define these attributes in for rapidly disseminating information. Local groups can 

alternative ways. use new information technologies to receive training 

in how to better use research results. This is especially 

16 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

important in regions where training opportunities are n

limited, such as in the economically developing world. 

4. Expanding the reach and impact of evidencebased tobacco control programs and 

policies will require supporting research and 

demonstration projects to better understand 

how to convert women’s broad-based support n

for tobacco control policies and programs 

into more active involvement in their 

communities. 

Strategies should include: 

n Educating women’s organizations about the toll tobacco 

use takes on women and engaging organizations in tobacco 

control activities. Systemic change requires involvement 

of a wide cross-section of society. Women’s organizations 

have an enormous impact on how society views and acts 

upon what are considered “women’s issues” (60). 

Funding pilot or demonstration projects to determine how 

to effectively engage women leaders and create effective 

grassroots programs. Research on competing issues and 

the overall agenda of various women’s organizations will 

provide insights into how to approach these groups to 

consider adding tobacco control to their agendas. 

Developing appropriate messages and materials for reaching 

out to organizations that have not previously been involved 

in tobacco control. By positioning tobacco cessation as a 

primary factor in overall women’s health and economic 

well-being and showing that coordinated efforts can lead 

to declines in women’s tobacco use, women’s engagement 

with tobacco issues may be increased. 

17 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Partnerships women’s NGOs, health care professionals, national ministries 

for women’s affairs, national centers of excellence that teach 

Overall Goal: Harness and expand gender studies, and women’s studies centers—particularly 

in economically developing countries. Furthermore, many partnerships, networks, and innovative 

research platforms to design and launch international development and funding agencies, such as 

broad-based strategies to eliminate the the WHO, United Nations regional economic and social 

commissions, and the World Bank, can cooperate to advance harms of tobacco use and ETS exposure tobacco control and prevention among women. among women and girls. 

Existing infrastructures, such as the National Institute 

on Drug Abuse Clinical Trials Network, may be used to Successfully implementing the quickly evaluate the efficacy of promising treatments and discovery, development, and delivery the effectiveness and cost-effectiveness of proven small- recommendations will require capitalizing scale interventions. Partnerships among Institutes and 

on existing collaborations and developing Centers of the National Institutes of Health (NIH) can 

new partnerships. To maximize the also make possible cross-disciplinary research in a broad 

development and dissemination of effective range of tobacco-related disease mechanisms, including 

interventions, partners must be involved gene-hormone-environment interactions, sex differences 

from the beginning, and knowledge gained Innovative research platforms are the from practice should be used to inform support structures (e.g., Cancer Centers, future research. Centers of Excellence, Special Populations 

New and expanded partnerships are needed to make progress Networks for Cancer Awareness and Training, 

in tobacco use prevention, control, and treatment. Partners Transdisciplinary Tobacco Use Research 

should identify existing funding mechanisms and increase Centers) and collaborations with other 

awareness among various organizations that tobacco control government agencies, academic institutions, 

is part of their charge. Using models of well-organized activist and industry that make it possible to pursue 

communities, such as those for breast cancer and HIV/ rapidly evolving discoveries. 

AIDS, might yield strategies to provide additional funding 

for tobacco control research and implementation of proven in carcinogenic and disease pathways, and infl ammation. 

strategies. Moreover, partnerships between U.S. Department of Health 

and Human Services agencies that conduct research (such as Partnerships should also be formed with national agencies NIH and the Centers for Disease Control and Prevention 

in economically developing countries, such as the Center [CDC]) and Federal and state agencies that deliver health 

Partnerships are working 

relationships between 

government agencies, 

nongovernmental 

organizations, private 

foundations, corporations, 

academic institutions, 

and community groups to 

accelerate progress. 

for Disease Control in care, as well as community and advocacy organizations, will China and the National be needed to bring the knowledge gained through research Cancer Institute of to the development and dissemination of effective, evidence- Brazil, as these agencies based interventions. 

both use and sponsor 

research. A stimulus Partnership Recommendations 

for global cooperation 1. Partnerships are especially needed between concerning gender and established networks of clinical and 

tobacco will also come translational researchers that can provide the from the Framework resources and infrastructure needed to foster 

Convention, because cross-disciplinary interactions and rapidly the countries that ratify the treaty will be required to report evaluate treatments and interventions. 

on their progress. The linkages between these countries, 

U.S. partners, the international women’s movement, and These partnerships should: 

research centers will be critical to monitoring and evaluating n Encourage transdisciplinary investigations of common 

programs. However, more effort must be made to include pathways of tobacco-caused cancer, heart disease, and 

18 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

lung disease. Smoking causes 140,000 premature deaths 

from cardiovascular disease each year (61). Although 

progress is being made in understanding its pathogenesis, 

the precise mechanisms by which tobacco causes 

cardiovascular disease have not yet been fully elucidated. 

Epidemiologic data support the notion that common 

mechanisms may exist for cigarette smoke-induced 

carcinogenesis and cardiovascular disease. Recent studies 

have defined common biological pathways that may 

be important to the pathogenesis of tobacco-caused 

ownership of the products of research and joint decision 

making regarding protocol development, program 

implementation, data analysis, and dissemination 

of findings. True partnerships are bidirectional: 

Community-based collaborators are trained in research 

methodology, and academic researchers are trained in 

culturally and community-tailored interventions. These 

partnerships also require a commitment to joint decision 

making and shared ownership of the problem. 

n Involve NCI and other NIH Institutes and Centers. These diseases (62). Further characterization of these common collaborations should study such issues as tobacco use pathways, combined with the use of mouse models with in people with diabetes, cancer, hypertension, or other disruptions in genes that confer disease susceptibility, comorbid conditions and the interaction between may allow for the development of targeted intervention alcohol and tobacco prevention and control policies. and treatment strategies for multiple tobacco-caused 

diseases. n Ensure that those who are the subjects of research have a 

voice in determining future research funding allocations. n Support further research into cross-disciplinary interactions Involving people who smoke, community-based in tobacco-caused disease mechanisms. Estrogen may play a organizations, and communities of color in funding role in both premalignant disease and malignant disease allocation decisions will help maximize the impact of progression. An understanding of the role of estrogens research and help counter discrimination based on race in the pathogenesis of lung cancer should facilitate and ethnicity, gender, and social class. the selection and evaluation of potential antiestrogen 

therapies for the treatment of this disease. An exploration 3. Partnerships are especially needed between 

of mechanisms should also include the early preinvasive research institutions and tribal colleges, 

stage and chemoprevention so that pharmaceutical tribal health departments, and/or American 

agents can be developed to treat these early stages of Indian health care and community settings 

tobacco exposure. to develop effective, culturally appropriate 

individual, family, and community-level 2. Partnerships are especially needed between tobacco prevention and cessation initiatives. research institutions and community-based 

organizations that serve populations at These partnerships should: 

greatest risk to conduct community-based n Incorporate culturally competent approaches and language. participatory research. These partners must Because of the magnitude and persistence of the be committed to joint decision making in tobacco use problem in American Indian/Alaska Native designing research, sharing ownership of the populations, tribal colleges, tribal health departments, products of research, and disseminating and and other institutions that serve these communities 

implementing research results. should be especially targeted for research partnerships. 

These partnerships should: 4. Partnerships are especially needed between 

n Support research institutions that partner with communitybased organizations, especially those that serve populations 

at greatest risk. These organizations may include 

community health centers, other community-based 

organizations, and educational institutions that serve 

minority populations. True partnerships will include 

training of community-based collaborators in research 

methodologies and training of academic researchers 

in ways to culturally tailor interventions. Such 

partnerships will also include a commitment to shared 

public and private funding agencies to fully 

and efficiently support the implementation of 

successful interventions. 

These partnerships should: 

n Consider replicating the applied research model used 

for NCI’s American Stop Smoking Intervention Study 

(ASSIST) project. Lessons learned from the ASSIST 

project could be applied to the development of public/ 

private partnerships to decrease women’s tobacco use. For 

19 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

example, clinics in the U.S. Department of Agriculture’s 

Women, Infants, and Children (WIC) program might be 

an appropriate setting for a public-private partnership to 

design and implement women’s quit-smoking programs 

and reduce children’s ETS exposure. Successful projects 

could then be considered for nationwide dissemination. 

effectively mobilize communities to reduce the burden of 

tobacco-caused cancers. This will require a collaborative 

effort to understand why some communities are poised 

for change and others are not. Participatory research 

methodologies can help us understand how to increase 

women’s and girls’ involvement. The community 

n Conduct research and demonstration projects to understand should be involved from the earliest stages, and research 

how to convert broad community support, especially designs should reflect diversity in age, language, and 

sociocultural and economic status. women’s and girls’ support, for tobacco control policies into 

active community involvement in their development and 

enforcement. Researchers, practitioners, and community 

advocates must work together to identify ways to 

20 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Evaluation and Surveillance interventions on tobacco use and exposure to ETS. Tobacco 

control programs must also monitor existing and new 

Overall Goal: Improve national and global laws to ensure compliance and identify reasons for lack of 

evaluation and surveillance of the harms enforcement, where applicable. This information can be 

used to improve legal and governance structures for tobacco of tobacco use and ETS exposure and of 

women’s and girls’ knowledge, attitudes, control. 

and behaviors related to tobacco use and Standardized monitoring of state and local tobacco control 

harms. activities will provide the information needed for optimal 

program development, implementation, and evaluation. 

These measures can then be linked with measures of tobacco 

It is essential to monitor and evaluate use to document pre- and postintervention behavior changes 

progress toward reducing tobacco use, (65). These measures must be easy to use to ensure that they 

ETS exposure, and the impact of tobacco- will be applied. 

related cancers on women and to make Global surveillance is needed of tobacco use and exposure to midcourse adjustments as needed. This ETS among adults and children, by sex, using standardized will require further development of measures so that cross-country comparisons are available. 

standardized measures and surveillance Because of the range of support, both cultural and fi nancial, 

systems to ensure that data are comparable and the differences in infrastructure for surveillance activities 

within and across countries. in different countries (66), this is critically important for 

cross-national programs. Ensuring that surveillance and Surveillance data are needed to monitor tobacco use and monitoring are comparable across countries is a complex and ETS exposure among women and to trace the epidemic as it difficult task (67). Particularly in economically developing develops globally. A comprehensive surveillance system would countries, surveillance systems for monitoring tobacco use include information about the tobacco user or potential and its health consequences are very limited at present. tobacco user, tobacco products, tobacco industry activities, 

and the economic, cultural, political, and historical activities Evaluation and Surveillance 

and interventions that support or discourage tobacco use (63, Recommendations 

64). Local, national, and global evaluation and surveillance will be 

In addition, current surveillance systems focus largely on the critical for: 

smoker and do not systematically collect other important 

information, such as the natural history of smoking or factors n Monitoring and measuring national and global trends 

influencing tobacco use in diverse populations globally (64). and patterns in tobacco use and exposure to ETS using 

standardized measures. Surveillance data are important because they provide the 

basis for designing program and policy interventions and 

health communication messages. For example, information 

on product constituents, product marketing, and tobacco 

n Ensuring that research and programmatic funding are 

strategically targeted and, where appropriate, tailored to 

specifi c populations. 

use prevalence is crucial for monitoring tobacco-related n Assessing whether progress has been made and whether it disease incidence and prevalence. In many cases, however, the is due to specific interventions and policies. methods for such a comprehensive surveillance system still 

need to be developed. n Identifying effective interventions through success 

stories and rigorous case studies to inform researchers, To determine “best practices” for tobacco control encourage broader dissemination, and increase public interventions, we must understand the levels and types of 

interventions being implemented and their effects. support. 

Global evaluation and surveillance should address: To better measure the extent of state and local tobacco control 

activities, tobacco use surveillance must be enhanced at the 

state and local levels, and creative, user-friendly measures 

must be developed to report the impact of tobacco control 

n Trends in tobacco use, changing patterns of use, and factors 

that affect use. Basic information concerning the variety 

of tobacco products used by women, such as chewing 

21 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

tobacco and hookah, is generally absent, as are data n

on changing patterns of use in relation to marketing. 

Little information is available on tobacco use among 

female nurses, physicians, and other health professionals. 

Research that maps national trends is vital to developing 

gender-sensitive counter-advertising campaigns. n

Although using common definitions is often complex, 

the effort to do so will improve comparability on a global 

basis and the ability to perform meta-analyses. 

n Those who do not use tobacco, by gender and age, to obtain 

data on initiation, quitting, and acceptable prevention 

methods. An important supplement to conventional n

epidemiological surveillance is monitoring cultural and 

social factors that protect women against tobacco use. 

These data are needed to maintain as an integral part 

of public policies the current relatively low prevalence 

rates among women and girls in many economically 

developing nations. 

n The impact of tobacco production and processing on women 

tobacco workers. In many tobacco-producing countries, n

women and girls who work on tobacco farms are exposed 

to serious environmental hazards. Epidemiological and 

surveillance data, as well as social, economic, and cultural 

research, are needed to develop appropriate health 

policies and programs for these workers. Priority should 

be given to their knowledge, attitudes, and practices 

related to risk behavior. 

n The creation of baselines for monitoring the progress and 

impact of the Framework Convention and establishing 

global indicators for gender and tobacco. The number of n

high-quality research projects on gender and tobacco 

in economically developing countries could increase as 

more data become available on measurable outcomes. 

Better data can also help persuade children’s rights 

organizations, women’s organizations, and others to 

undertake tobacco control and prevention efforts. 

n The scope of the tobacco epidemic. The prevalence of 

tobacco use in different subgroups of women must be 

assessed to identify high-risk groups of women who 

can be targeted by health education and intervention 

programs. Collecting information on prevalence levels 

can also assist tobacco control advocates in their activities 

in support of tobacco control policies. By collecting data 

on prevalence before and after a tobacco control policy 

is implemented, for example, advocates can demonstrate 

the impact (or lack of impact) of the policy. 

The patterns, extent, and trends in tobacco use among 

women, health and economic consequences of tobacco use 

for women, and underlying sociocultural factors. This 

information can help support the development of 

tobacco control policies and programs. 

Tobacco use within specifi c populations of women. This 

information is needed to increase the effectiveness of 

policies and programs for reducing overall tobacco use 

and subsequent health consequences among women. In 

particular, data need to be collected on women and girls 

of different ages and socioeconomic status levels. 

Morbidity and mortality. Although economically 

developed countries typically have complete and reliable 

vital registration data on causes of death, their data on 

morbidity are much less complete. In economically 

developing countries, data on mortality and morbidity 

are very limited. If reliable data on the health hazards of 

tobacco use for a given population are not available, they 

need to be collected. 

Ways to maximize the effi ciency and completeness of 

existing surveys while minimizing their costs. A number 

of surveys conducted periodically at the national and 

state levels include questions on individual tobacco 

use behavior. Although these surveys serve distinct and 

useful purposes, gaps remain in what is being monitored. 

The efficiency and appropriateness of survey designs 

and sampling strategies must also be improved, and 

information must be generated more quickly to inform 

and shape the policy agenda. 

Global surveillance of tobacco use and exposure to ETS 

among adults and children, by sex, using standardized 

measures so that cross-country comparisons are available. 

Because of the range of support, both cultural and 

financial, and the differences in infrastructure for 

surveillance activities in different countries, collecting 

standardized surveillance data is critically important 

for cross-national programs. Ensuring that surveillance 

and monitoring are comparable across countries is a 

complex and difficult task. Particularly in economically 

developing countries, surveillance systems for monitoring 

tobacco use and its health consequences are very limited. 

22 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Conclusion 

Forty years after the first Surgeon General’s Report conclusively linked smoking to lung cancer in men, 

tobacco use remains the nation’s leading cause of preventable, 

premature death in both women and men. Currently, 

approximately 170,000 American women die from smoking 

each year, and in the late 1980s, lung cancer surpassed breast 

cancer as the leading cause of cancer death in women. Despite 

this, tobacco use is not generally considered a “women’s 

issue.” 

The nation has made enormous progress in reducing tobacco 

use, especially among affluent, educated women; indeed, the 

Healthy People 2010 goal of reducing smoking prevalence 

to 12 percent has already been reached by this group of 

women. In stark contrast, economically disadvantaged, poorly 

educated women and members of some racial and ethnic 

groups, among others, smoke at very high levels. Smoking 

rates are especially high and persistent among American 

Indian/Alaska Native women and girls. 

The 2001 Surgeon General’s Report, Women and Smoking, 

which focused on the devastating toll of tobacco use for 

women, highlighted the importance of continuing to build 

the science base on gender-specifi c research. The Women, 

Tobacco, and Cancer Working Group has identifi ed 

numerous priority research issues across the spectrum 

of tobacco control and prevention disciplines. However, 

generating new knowledge is not sufficient. Greater emphasis 

must be placed on translating knowledge into effective 

program and policy interventions that can be applied to all 

populations, especially populations of women at greatest risk 

for tobacco use and tobacco-caused disease. 

Tobacco use and tobacco-caused cancers are already common 

among women in most economically developed countries. 

However, smoking rates among women in economically 

developing countries are still generally low. There is broad 

agreement that preventing the epidemic of tobacco use and 

tobacco-caused cancers from spreading to women and girls 

in economically developing nations is a critical public health 

priority. Accomplishing this will require generating new 

knowledge and using what we already know to put into place 

effective prevention programs and policies. 

Successful implementation of all of the recommendations 

of the Women, Tobacco, and Cancer Working Group will 

require sustained and focused efforts, including collaborations 

and partnerships among many public and private-sector 

organizations. Reducing, and ultimately eliminating, tobacco 

use and tobacco-caused disease among women is possible, and 

it is a goal worth striving for. 

23 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

24 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

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Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

28 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Appendix A: Breakout Sessions 

Biology and Cancer Breakout Session 

Co-Chairs David Burns 

Participants Lucy Anderson 

Alice Boylan 

Mirjana Djordjevic 

Science Writer Frances McFarland Horne 

Lead Author Pamela Hershberger 

Overview 

Two major barriers to research in lung cancer biology were identified: the diversity of biological processes that 

contribute to lung carcinogenesis, and the stigma associated 

with tobacco-related disease. Relevant research questions are 

often dismissed as too difficult to study, given the complexity 

of the exposure (since tobacco smoke is a complex mixture) 

and other factors (such as underlying lung disease and genetic 

variation in how tobacco carcinogens are metabolized) that 

contribute to lung cancer development. In addition, a sense 

that smokers are behaviorally responsible for their tobaccorelated illnesses inhibits the allocation of suffi cient resources 

to this field of study. Another barrier is that researchers in 

the tobacco field often do their research in isolation. Lack of 

multidisciplinary collaboration can increase research costs 

while limiting the understanding of tobacco injury from the 

cellular through the population levels. 

Tobacco-induced cancers are late-onset diseases resulting from 

chronic long-term exposure to tobacco combustion products. 

The multitude of combustion products results in a complex 

set of possible initiation and promotion events that are also 

affected by individual variation. Neither the steps in cancer 

initiation nor those in cancer promotion are fully understood 

because they involve dynamic interplay between tobacco 

smoke constituents and the susceptible cells of the smoker. 

Most of what we know about the effects of tobacco is based 

on extrapolations of single-agent carcinogen exposure studies. 

However, cigarette smoke is a mixture of more than 4,000 

compounds, more than 60 of which are known carcinogens 

(1). Therefore, focusing on exposure to smoke as a mixture 

would allow investigators to determine what happens in the 

“real world,” although single-agent research is still needed to 

Carolyn Dresler Jill Siegfried 

Joachim Liehr Katherine Pisters 

Assieh Melikian Linda Sarna 

James Mulshine Simon Spivack 

confirm mechanistic insights beyond tobacco carcinogenesis. 

Continued studies on nicotine are especially useful now 

that smoking cessation efforts are moving toward nicotine 

replacement therapy. In addition, the presence of nicotinic 

receptors on lung tumor cells (2) suggests that nicotine can 

affect lung tumor biology directly. 

Across all diseases, tobacco use has been postulated to 

modulate quality of life, comorbidities, response to treatment, 

and overall survivorship of patients with lung cancer. 

However, minimal prospective data are available (reviewed in 

3), and at present, clinical trials do not routinely collect these 

types of data. A recent paper by Videtic and colleagues (4) 

has confirmed a previous study that found signifi cantly better 

outcomes in patients with small-cell lung cancer who do not 

smoke during their combination chemo-/radiation therapy. 

Future studies should include prospective analyses that can 

determine outcome differences and treatment side effects 

related to sex and tobacco use, including tobacco-attributable 

comorbidities as mediating variables in treatment side effects 

and efficacy, and investigate the impact of smoking cessation 

on the physical health and quality of life of cancer survivors. 

Recommendations 

Research 

*1. Support further research into crossdisciplinary interactions in tobacco-related 

disease mechanisms, especially genehormone-environment interactions. 

Estrogen status is recognized as a factor that affects lung 

cancer risk in women. Evidence also indicates a positive 

interaction between estrogen replacement therapy, smoking, 

* Recommendations with an asterisk are those identified by the breakout groups as their top three recommendations. 

Appendix A: Reports From the Working Group Breakout Sessions 29 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

and the development of adenocarcinoma of the lung (5). *2. V alidate biologically relevant measures of

Estrogen or one of its metabolites may be a weak carcinogen, tobacco smoke exposure, injury , and recovery .

but this has not been studied in depth, particularly in relation This includes linking measures of exposure to those of injury to tobacco smoking. Estrogen metabolites can cause various in biological models and measures of injury to outcomes, types of DNA damage (6), and estrogens may induce lung examining modifying factors of injury from exposure, and tumors through these types of DNA alterations. Cigarette investigating new tobacco products. At present, little or no smoking alters the metabolism of endogenous estrogens, data link molecular changes of intermediate biomarkers— although possible interactions among estrogen metabolism, which may be observed prior to the clinical appearance of tobacco exposure, DNA adducts, and lung cells are unclear. disease and bear some relationship to its development (8)—to Lung tumor cells express estrogen receptors and are induced actual tobacco exposure and disease occurrence. Complex to proliferate in response to estrogen exposure both in vitro dose-response relationship phenomena point to a need to and in vivo (7). Thus, once tumors are induced, estrogens identify the intermediate markers between injury and disease. may also drive proliferation of mutated cells. This raises the For example, chemoprevention data from a randomized Phase possibility that estrogen plays a role in both premalignant III trial of isotretinoin suggest that the therapy is effective disease and malignant disease progression. An understanding in those who have never smoked and former smokers but of the role of estrogens in the pathogenesis of lung cancer not in current smokers (9). Pathways of disease progression should facilitate the selection and evaluation of antiestrogen associated with low-level exposures may differ from those therapies for the treatment of this disease. associated with high-level exposures. Although several good

Partners models are available for study (reviewed in 10), identifying

n National Institute of Environmental Health Sciences the effects of tobacco exposure in these models is time 

(NIEHS) consuming. This points to a need for accelerated models, as 

well as for mixture and single-agent models. 

n Environmental Protection Agency (EPA) Partners 

n Centers for Disease Control and Prevention (CDC) n CDC 

n Breast, Lung, and Transdisciplinary Tobacco Use 

Research Centers (TTURCs) n National Cancer Institute (NCI) and Cancer Centers

n Specialized Programs of Research Excellence (SPOREs) n National Heart, Lung, and Blood Institute (NHLBI)

n American Lung Association n National Institute of Child Health and Human 

Development (NICHD)

n American Thoracic Society n National Institute on Drug Abuse (NIDA) 

n Department of Defense Breast Cancer Research Program n TTURCs 

n National Institutes of Health (NIH) n Society for Research on Nicotine and Tobacco 

n Pharmaceutical industry n Society of Toxicology 

n Susan G. Komen Breast Cancer Foundation 

n EPA 

n State health departments n Flight Attendant Medical Research Institute Impact 

n Pharmaceutical industry This area of research can influence recommendations on 

tobacco cessation, chemoprevention, disease prevention, and n Robert Wood Johnson Foundation

issues of hormone replacement therapy and phytoestrogens. n American Lung Association

Researchers can also identify noncancer sex effects and obtain 

biological evidence relating environmental tobacco smoke to n American Heart Association 

breast and other sex-related cancers. This research will affect n American Cancer Society (ACS)

multiple disease processes. n California Tobacco-Related Disease Research Program

30 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Impact 

Research in this area will result in the identifi cation of 

biomarkers that can be used to determine intermediate 

outcomes in long-term studies. This knowledge will provide 

a more specifi c and efficient tool to assess biological exposure 

and effect and, thus, to identify persons at risk. Ultimately, 

this knowledge will influence policy on exposure dosage and 

affect multiple disease processes. 

*3. Support further research into crossdisciplinary interactions in tobacco-related 

disease mechanisms, specifi cally sex 

differences in carcinogenic and disease 

pathways. 

This exploration of mechanisms should include the 

early premetastatic stage and chemoprevention so that 

pharmaceutical agents can be developed to treat these early 

stages of tobacco combustion exposure. Some epidemiologic 

evidence from case-control studies suggests that women are 

more susceptible than men to tobacco-induced carcinogenesis, 

after taking into account baseline exposure, body weight, 

body height, and body mass index (11), although cohort 

studies have not confirmed this. Nevertheless, women 

with lung cancer have been shown to have a higher level 

of smoking-induced pulmonary DNA adducts (12) and 

decreased DNA repair capacity (13) than men with lung 

cancer. DNA adduct levels are determined, in part, by the 

relative activity of phase I and phase II detoxifying enzymes. 

Phase I enzymes, such as cytochrome P4501A1 (CYP1A1), 

activate the carcinogens in cigarette smoke, whereas phase II 

enzymes, such as glutathione-S-transferase M1 (GSTM1), 

convert tobacco carcinogens to inactive conjugates. The 

CYP1A1 mutant/GSTM1 null genotype has been found to be 

more common in women with lung cancer than in controls, 

suggesting that alteration in the activity of these enzymes 

contributes to lung cancer risk (14). Clinical studies are 

required to show that such differences are important. Further 

insight into sex-specific pathways for lung carcinogenesis 

may be gained through the use of proteomic and genomic 

approaches in the analysis of established tumors and early 

lesions collected from both men and women. 

Partners 

n Society of Toxicology 

n Molecular Epidemiology Group, American Association 

for Cancer Research 

n Breast cancer, lung cancer, and TTURC SPOREs 

n NCI 

n NIDA 

n NIEHS 

n Society for Research on Nicotine and Tobacco 

n ACS 

n Office of Research on Women’s Health 

Impact 

Research in this area will uncover real differences and 

potentially identify new targets for interventions. This 

research will affect multiple disease processes. 

4. Support further research into crossdisciplinary interactions in tobacco-related 

disease mechanisms, especially infl ammation. 

Common pathways may exist between infl ammation and 

tobacco-related disease. In addition to the carcinogen 

exposure inherent in tobacco use, chronic injury and 

inflammation may contribute to cancer risk. Consistent with 

this hypothesis, it has been shown that among male smokers, 

airway obstruction is a better indicator of lung cancer risk 

than either age or level of smoking (15). History of prior 

lung disease (asthma, chronic bronchitis) is associated with 

a significantly increased risk of lung cancer in nonsmoking 

women (16). To date, relatively little research has focused on 

the interplay between inflammation and the development 

of lung cancer. In mouse models, a positive correlation 

has been found between inflammation and susceptibility 

to lung tumors (17). However, subsequent studies showed 

that agents that reduce pulmonary inflammation do not 

necessarily suppress lung tumorigenesis (18). Thus, the 

relationship between these two processes requires further 

clarifi cation. Inflammatory cells that migrate into the 

lungs of cigarette smokers may increase the oxidative stress 

produced by inhaling cigarette smoke. Consequently, further 

understanding of the effects of oxidative stress on lung 

biology and the mechanisms controlling the expression and 

release of proinflammatory mediators in the lung may lead to 

the development of new therapies to prevent infl ammation 

and, thus, potentially have an impact on lung tumorigenesis. 

5. Support further research into crossdisciplinary interactions in tobacco-related 

disease mechanisms, especially promotional 

mechanisms. 

Tobacco smoke contains many constituents, such as nicotine, 

that may not be directly carcinogenic but may infl uence 

Appendix A: Reports From the Working Group Breakout Sessions 31 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

disease pathways. Nicotine may protect normal human airway 

epithelial cells and tumor cells from apoptosis (19, 20) and 

stimulate blood flow to tumors (21). Understanding the 

variety of cellular processes regulated by nicotine and other 

2. Maneckjee R, Minna JD. Opioid and nicotine receptors 

affect growth regulation of human lung cancer cell lines. 

Proceedings of the National Academy of Science. 1990;87: 

3294-8. 

tobacco smoke constituents may provide new therapeutic 3. Dresler CM. Is it more important to quit smoking than targets for intervention in tobacco-related diseases. Further which chemotherapy is used? Lung Cancer. 2003;39:119- understanding of the mechanisms by which nicotine alters 24. cell growth will also be important in evaluating nicotine 

supplementation for smoking cessation. Given that such 

approaches can result in serum concentrations of nicotine 

close to those achieved in active smokers (22), determining 

the impact of chronic nicotine supplementation on disease 

processes is required. Since the effects of nicotine alone on 

epithelial and endothelial cells may be different than the 

effect of cigarette smoke, future studies will also be required 

to determine whether single-agent exposure and exposure to 

mixtures will have similar consequences. 

4. Videtic GM, Stitt LW, Dar AR, et al. Continued 

cigarette smoking by patients receiving concurrent 

chemoradiotherapy for limited-stage small-cell lung 

cancer is associated with decreased survival. Journal of 

Clinical Oncology. 2003;21:1544-9. 

5. Taioli E, Wynder EL. Re: endocrine factors and 

adenocarcinoma of the lung in women. Journal of the 

National Cancer Institute. 1994;86:869-70. 

6. Roy D, Liehr JG. Estrogen, DNA damage and 6. Encourage transdisciplinary investigations mutations. Mutation Research. 1999;424:107-15. into common pathways of tobacco-related 

cancer , heart disease, and lung disease. 7. Stabile LP, Gaither Davis AL, Gubish CT, et al. Human 

non-small cell lung tumors and cells derived from Smoking is a well-known risk factor for vascular disease (23- normal lung express both estrogen receptor a and b and 25). Although progress is being made in understanding its show biological responses to estrogen. Cancer Research. pathogenesis, the precise mechanisms by which smoking 2002;62:2141-50. affects vascular disease have not yet been fully elucidated. 

Epidemiologic data support the notion that common 8. Cohen V, Khuri FR. Chemoprevention of lung cancer: 

mechanisms may exist for cigarette smoke-induced Current status and future prospects. Cancer and 

carcinogenesis and cardiovascular disease. For example, Metastasis Reviews. 2002;21:349-62. 

the MspI polymorphism in the cytochrome P450 enzyme 9. Lippman SM, Lee JJ, Karp DD, et al. Randomized phase CYP1A1 increases both lung cancer risk and the risk of III Intergroup trial of isotretinoin to prevent second cardiovascular disease in light smokers (26, 27). Recent primary tumors in stage I non-small-cell lung cancer. studies have defined common biological pathways that may Journal of the National Cancer Institute. 2001;93:605-18. 

be important to the pathogenesis of tobacco-related diseases 

(reviewed in 28); one notable example is nicotine stimulation 10. DeFlora S, Agostini FD, Balansky R, et al. Modulation 

of endothelial cell proliferation in the setting of both tumor of cigarette smoke-related endpoints in mutagenesis and 

growth and atherosclerosis (21). Further characterization of carcinogenesis. Mutation Research. 2003;523-4,237-52. 

these common pathways, combined with the use of mouse 11. Zang EA, Wynder EL. Differences in lung cancer risk models that have disruptions in genes that confer disease between men and women: Examination of the evidence. 

susceptibility, may allow for the development of targeted Journal of the National Cancer Institute. 1996;88:183-92. 

intervention and treatment strategies for all tobacco-related 

diseases. 12. Ryberg D, Hewer A, Phillips DH, Haugen A. Different 

susceptibility to smoking-induced DNA damage among 

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1. Hoffmann D, Hoffmann I, El-Bayoumy K. The less 

harmful cigarette: A controversial issue. A tribute to 13. Wei Q, Cheng L, Amos CI, et al. Repair of tobacco 

Ernst L. Wynder. Chemical Research in Toxicology. carcinogen-induced DNA adducts and lung cancer risk: 

2001;14:768-90. A molecular epidemiologic study. Journal of the National 

Cancer Institute. 2000;92:1764-72. 

32 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

14. Dresler CM, Fratelli C, Babb J, Everley L, Evans AA, 

Clapper ML. Gender differences in genetic susceptibility 

for lung cancer. Lung Cancer. 2000;30:153-60. 

22. Zevin S, Gourlay SG, Benowitz NL. Clinical 

pharmacology of nicotine. Clinics in Dermatology. 

1998;16:557-64. 

15. Tockman MS, Anthonisen NR, Wright EC, Donithan 23. Whisnant JP, Homer D, Ingall TJ, Baker HL, O’Fallon 

MG. Airways obstruction and the risk for lung cancer. WM, Wiebers DO. Duration of cigarette smoking is the 

Annals of Internal Medicine. 1987;106:512-8. strongest predictor of severe extracranial carotid artery 

16. Wu AH, Fontham ET, Reynolds P, et al. Previous 

lung disease and risk of lung cancer among lifetime 

nonsmoking women in the United States. American 

Journal of Epidemiology. 1995;141:1023-32. 

atherosclerosis. Stroke. 1990;21:707-14. 

24. Freund KM, Belanger AJ, D’Agostino RB, Kannel WB. 

The health risks of smoking. The Framingham Study: 34 

years of follow-up. Annals of Epidemiology. 1993;3:417-

24. 17. Bauer AK, Dwyer-Nield LD, Keil K, Koski K, 

Malkinson AM. Butylated hydroxytoluene (BHT) 

induction of pulmonary inflammation: A role in tumor 

promotion. Experimental Lung Research. 2001;27:197-

216. 

25. Humphries SE, Talmud PJ, Hawe E, Bolla M, Day 

INM, Miller GJ. Apolipoprotein E4 and coronary heart 

disease in middle-aged men who smoke: A prospective 

study. Lancet. 2001;358:115-9. 

18. Kisley LR, Barrett BS, Dwyer-Nield LD, Bauer AK, 

Thompson DC, Malkinson AM. Celecoxib reduces 

pulmonary inflammation but not lung tumorigenesis in 

mice. Carcinogenesis. 2002;23:1653-60. 

26. Ishibe N, Wiencke JK, Zuo ZF, McMillan A, Spitz M, 

Kelsey KT. Susceptibility to lung cancer in light smokers 

associated with CYP1A1 polymorphisms in Mexicanand African-Americans. Cancer Epidemiology Biomarkers 

19. West KA, Brognard J, Clark AS, et al. Rapid Akt 

activation by nicotine and a tobacco carcinogen 

modulates the phenotype of normal human airway 

epithelial cells. Journal of Clinical Investigation. 

2003;111:81-90. 

and Prevention. 1997;6:1075-80. 

27. Wang XL, Greco M, Sim AS, Duarte N, Wang J, 

Wilcken DEL. Effect of CYP1A1 MspI polymorphism 

on cigarette smoking related coronary artery disease and 

diabetes. Atherosclerosis. 2002;162:391-7. 

20. Mai H, May S, Gao F, Jin Z, Deng X. A functional role 

for nicotine in bcl2 phosphorylation and suppression 

of apoptosis. Journal of Biological Chemistry. 2003;278: 

1886-91. 

28. Ross JS, Stagliano NE, Donovan MJ, Breitbart RE, 

Ginsburg GS. Atherosclerosis and cancer: Common 

molecular pathways of disease development and 

progression. Annals of the New York Academy of Sciences. 

21. Heeschen C, Jang JJ, Weis M, et al. Nicotine stimulates 2001;947:271-93. 

angiogenesis and promotes tumor growth and 

atherosclerosis. Nature Medicine. 2001;7:833-9. 

Appendix A: Reports From the Working Group Breakout Sessions 33 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

34 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Addiction Breakout Session 

Co-Chairs Gary Swan 

Participants Karen Ahijevych 

Janice Blalock 

Rosemarie Booze 

William Corrigall 

Science Writer Cheryl Pellerin 

Lead Author Taline Khroyan 

Overview 

Tobacco smoke, whether inhaled directly or as secondhand smoke, contains more than 4,000 different compounds, 

many of which are proven carcinogens (1). Substantial 

evidence indicates that nicotine plays a pivotal role in 

mediating the addictive nature of tobacco dependence in 

humans (2). Most research examining nicotine dependence 

has focused on males, since initially, a larger portion of 

the male population smoked (over 50 percent in the mid1960s) (3). However, by 2001, the gender gap between 

adult smokers had narrowed such that 24 percent of women 

smoked, compared with 29 percent of men (4). In light of the 

overwhelming evidence of the negative health consequences 

related to smoking, women are still at risk, and an urgent 

need exists to understand why women become and remain 

nicotine dependent. 

We need to understand the different stages of the nicotine 

addiction process in women, including initiation, 

maintenance, withdrawal, and relapse. Women differ from 

men in their biological responses to nicotine, progression 

to nicotine dependence, and patterns of intake and have 

higher rates of relapse and a greater risk of smoking-related 

health problems (5-12). Thus, the Addiction Breakout 

Group identifi ed specific areas of needed research, including 

understanding sex differences in neuroanatomy; the biology 

of nicotine receptors, particularly in the brain; and the genetic 

basis of nicotine dependence. Of particular importance was 

the overwhelming gap in knowledge of the effects of nicotine 

on the menstrual cycle and on such hormones as estrogen and 

progesterone. 

Other female-related issues regarding nicotine addition 

have not been studied. For example, the effect of oral 

contraceptives on smoking rates, relapse, and craving is not 

Cora Lee Wetherington 

Dorothy Hatsukami Wendy Lynch 

David Kalman Pam Madden 

Denise Kandel Sherry Mills 

Taline Khroyan Scott Rogers 

understood. Also, very little is known about the effects of 

menopause and/or hormone replacement therapy on desire 

for smoking, smoking rates, and relapse. The menstrual cycle, 

puberty, pregnancy, and menopause should be primary foci of 

research on nicotine dependence and smoking to determine, 

for example, whether nicotine has a disruptive effect on 

hormones and whether hormones can affect craving and rates 

of relapse in women. 

In addition, since a large proportion of smokers report being 

depressed (13-17), studies are needed to examine whether any 

gender differences exist in the relationship between smoking 

and depression relative to other psychological factors, 

including anger and personality traits. Studies of smoking 

and depression and the development of interventions must 

take into account the multiple demands and unique stressors 

in the daily lives of women. Examining all aspects of nicotine 

addiction and understanding gender differences will help 

create prevention and cessation programs that are tailored to 

the needs of women. 

Also discussed was the need to address nicotine dependence 

using animal models. Animal models complement clinical 

studies and provide an arena in which various environmental 

and genetic factors can be teased apart and tested in a 

controlled setting (18). The self-administration paradigm has 

been used to examine the reinforcing effects of nicotine in 

male animals (19-22). Only a handful of studies has examined 

the reward effects of nicotine in female animals, and very little 

is known about the effects of the menstrual cycle and gonadal 

hormones such as estrogen and progesterone on nicotine 

addiction. 

Appendix A: Reports From the Working Group Breakout Sessions 35 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Recommendations 

Research 

*1. Understand sex differences in the 

mechanisms and processes involved in all 

phases of nicotine use and addiction. 

The group gave this recommendation the highest priority 

the estrous cycle and ethanol self-administration in rats. In 

females whose estrous cycles were synchronized, ethanol was 

found to be more reinforcing during the diestrus phase than 

during the estrus and proestrus phases (25). The effects of 

hormones have been examined in a more stable condition; 

specifically, self-administration of heroin and cocaine has 

been examined in ovariectomized female animals. When 

ovariectomized rats were treated with estradiol benzoate, because of the many gaps in our understanding of sex these animals initiated heroin self-administration sooner differences in nicotine use and addiction. An examination and consumed greater amounts than ovariectomized rats is needed of the environmental, behavioral, genetic, that did not receive estrogen replacement (26). Animals that molecular, cellular, neurobiological, and hormonal sources were ovariectomized exhibited less response for cocaine, of variation and their interactions in animals and humans and compared to the intact animals, fewer of these animals during all phases of nicotine addiction, including initiation, acquired cocaine self-administration (27). However, nicotine maintenance, withdrawal, and relapse. This recommendation self-administration has not been examined in ovariectomized encompasses a vast array of preclinical and clinical research. 

Preclinical. Animal models make it possible to examine 

the reinforcing effects of nicotine that are highly relevant 

to tobacco dependence in humans and that cannot easily 

female rats. 

As illustrated above, the self-administration paradigm 

can provide a valid measure of the reinforcing effects of 

nicotine in females and can be further extended to examine be studied in human subjects—mainly for ethical reasons. the potential role of gene/environment interactions for In animals, potential behavioral effects of pharmacological nicotine addiction. A recent study has shown that male mice agents can be more fully characterized. Furthermore, these lacking a !2 subunit of the high-affinity neuronal nicotinic animal models allow the investigation of the basic underlying acetylcholine receptor (nAChR) self-administer nicotine at behavioral and neurochemical mechanisms that are relevant to 

nicotine addiction (for reviews, see 5, 18). 

Behavioral studies of rodents suggest that females are more 

sensitive than males to repeated nicotine exposure, as 

demonstrated by a more rapid onset of nicotine-induced 

behaviors (23). The reinforcing effects of nicotine have 

been examined in female rats. In one study, female rats 

self-administered nicotine and, when compared to males, 

much lower levels than wild-type mice following cocaine 

self-administration (28). Thus, the effects of mutations in 

nAChR as well as mutations in other receptor systems, such as the 

dopaminergic system (an important neurotransmitter system that 

is linked to the addiction process), can be further examined in 

relation to the reinforcing effects of nicotine in female knockout 

mice. 

In addition to genetic issues, animal models can be used showed a higher motivation to obtain nicotine because they to examine the effects of environmental factors, such as acquired self-administration capabilities of low doses of stressors. Social stressors have been established in animals, nicotine, whereas male rodents did not (24). In this study, and the effect of one such stressor, social defeat stress, further different stages of the estrous cycle did not affect nicotine sensitizes cocaine-induced hyperlocomotion, activates self-administration. However, since rodents have drastically cocaine-induced self-administration, and increases the rate shortened cycles (4-5 days in length), heterogeneity within of acquisition of cocaine self-administration in male animals each cycle stage (i.e., animals reaching a stage of the cycle at (29-31). The effect of social stressors has yet to be determined different times) may have limited the ability of the authors in female and nicotine-dependent animals. Further down the to find a relationship between the estrous cycle and the line, the development of animal models of gene/environment reinforcing effects of nicotine. interactions in nicotine addiction will provide clues as to 

Research should be conducted in animals that have whether the interactions can be demonstrated (using the 

pharmacologically synchronized estrous cycles to reduce variability stress and nicotine self-administration model in wild-type and 

in hormonal levels, thereby providing a more accurate picture transgenic mice), the magnitude of their effect, the conditions 

of whether hormone levels can affect nicotine intake. This under which the interactions vary in strength, and whether 

procedure has been used to establish a relationship between any sex differences exist. 

* Recommendations with an asterisk are those identified by the breakout groups as their top three recommendations. 

36 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

The Addiction Breakout Group also suggested that these in women across different stages of nicotine addiction (for a 

animal models be extended to examine sex differences in the recent review, see 5). 

neurobiological basis of nicotine addiction. For example, Disparities previous research has shown that sex differences exist in 

dopaminergic function in the brain (32). Finally, different This recommendation entails a vast arena of research that 

stages of addiction, including acquisition, maintenance, could lead to a basic understanding of sex differences in 

extinction, and relapse, can be studied in female animals different phases of nicotine addiction. These approaches 

using the self-administration model, as has been done in male will identify individual differences that may inform effective 

rodents (33, 34). In adolescence, animal research is needed on interventions. 

all phases of the addiction process, and thus, the development Partners 

of adolescent nicotine addiction should be examined as well 

as differences between the sexes. As shown above, much Governmental agencies that fund basic addiction research, 

more research is required to understand nicotine addiction in such as the National Institute on Drug Abuse (NIDA), and 

female animals. other interested funders can help provide funding for the vast 

arena of projects proposed above. Clinical. Naturalistic and epidemiological research in twin, 

family, and adoption studies has addressed the role of genes Impact 

and the environment in complex traits such as nicotine With different research groups examining the various aspects 

dependence. Environmental influences on the development of nicotine addiction in both the preclinical and clinical 

of tobacco dependence are well documented and include models, we will substantially enhance our understanding of 

peer and familial influences as the strongest contributors in basic biological differences in males and females in 2 to 5 

determining how and when cigarette experimentation occurs years. This holds promise for understanding susceptibility to 

among young people (for reviews, see 35, 36). However, nicotine addiction and designing treatments to prevent and 

studies based on twin samples support the hypothesis help alleviate nicotine dependence. 

that genetic influences also underlie the initiation and 2. Gender differences in the measurement/ lifetime use of tobacco (10, 37, 38). Twin studies reveal defi nition of addiction, including novel that approximately 50 percent of the variance in tobacco measurements. dependence is attributable to genetic infl uences (39). 

Interestingly, the majority of twin studies have been carried Several authors have hypothesized that addiction/dependence 

out in male twins, and very few studies have examined sex- is multidimensional and includes physical, behavioral, 

specific differences. In a recent meta-analysis of twin studies, and physiological components (41-44). Assessment of 

it was reported that genetic and environmental factors might tobacco dependence has relied largely upon the Fagerström 

differentially determine smoking initiation and persistence in Tolerance Questionnaire (45) and its more recent variant, 

male and female smokers (39). Further studies are needed to the Fagerström Test for Nicotine Dependence (FTND) (46) 

fully appreciate genetic and environmental factors in all aspects of or the Diagnostic and Statistical Manual of Mental Disorders 

nicotine addiction, as well as delineating gender differences. (DSM) criteria, an approach derived from the need to 

include tobacco dependence in psychiatric nomenclature and In the laboratory, human studies have focused mainly on classification and that attempts to adhere to classic defi nitions relapse and have examined responses to drug cues. Few studies of drug dependence (47, 48). The state of the art in the have fully examined sex-moderating effects in cue reactivity, assessment of nicotine dependence is best summarized in a even though men and women respond differently to internal recent paper by Moolchan et al. (44), who directly tested the and external drug cues. External functions play a greater concordance between dependence as determined by DSM or role in maintenance of and relapse to smoking in women, FTND criteria ("7). The highest kappa value obtained was whereas internal cues are more prominent for males (8). Sex 0.21, which is just beyond the upper end of the “poor” range differences in reactivity among the types of cues have also for agreement (49). The authors concluded that multiple been reported (8, 40). instruments should be used to assess nicotine dependence 

In humans, although ovarian hormones in females may because each may be evaluating separate and independent 

modulate responses to drugs and could potentially explain dimensions. To date, none of the instruments commonly 

different drug responses between males and females, very used to assess nicotine dependence assess all aspects, and their 

few studies have examined the role of hormonal infl uences intercorrelation is surprisingly low (44). 

Appendix A: Reports From the Working Group Breakout Sessions 37 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Research is needed on: 

n The defi nition of nicotine addiction/dependence and the 

development of measurements to identify differences between 

men and women and between adults and adolescents. In 

most behavior genetic and genetic epidemiologic studies, 

“smoking” has been assessed as a static phenotype, as if 

the behavior is a trait that remains constant over time. 

Not only do reasons and motivations for smoking vary 

across individuals, but motivations (biological, social, 

and psychological—individually and in combination) 

probably vary across different population subgroups, as 

well as across time and situations (36, 50, 51), making 

the need for a dynamic definition of nicotine addiction 

more pressing. A more accurate definition of nicotine 

addiction will make it possible to better defi ne sexrelevant experimental parameters. 

n Differences in brain neurochemistry between men and 

women, especially as these differences relate to nicotine 

dependence. Sex differences in brain regions and 

neurotransmitter systems associated with addiction have 

been observed in smokers and nonsmokers. Women have 

higher dopamine and serotonin transporter availability 

than men, regardless of smoking status (52). 

n Gender differences in Fagerström (physiological) and 

Glover-Nilsson (behavioral) measures of dependence. The 

FTND has been used extensively and is thought to be a 

valid measure for physiological assessment (it can assess 

a smoker’s nicotine intake [53]), whereas the GloverNilsson Smoking Behavioral Questionnaire was recently 

developed to assess behavioral dependence (54). Further 

studies with a variety of population subgroups, including 

women and adolescents, are necessary. 

n Biomarkers for nicotine addiction in women versus men 

that could be implemented in the fi eld. 

n Sex differences in nicotine metabolism. 

3. Sex differences in genetic infl uences. 

Biometric Studies of Twins and Families 

It is known that smoking behavior is influenced by both 

genetic and environmental factors (18, 55). Twin studies have 

indicated that heritability rates are as high as 47 to 76 percent 

for smoking initiation and 62 percent for persistence or 

dependence (56, 57). Family studies have also been used 

to assess genetic components of vulnerability to nicotine 

addiction (58). However, sex differences have not been 

thoroughly studied (see below). 

Measured Genetic Studies 

Once it is determined that a complex trait is heritable, 

linkage analysis can be used to determine whether certain 

chromosomal regions may contain genes that contribute to 

the trait of interest. With the advent of the Human Genome 

Project and advances in molecular genetic technologies, 

candidate genes that map to the regions identified by the 

linkage analysis can be tested for association with phenotypic 

data. 

Research is needed on: 

n Genetic studies and microarray technologies. Several 

candidate genes may contribute to nicotine addiction. 

Thus far, research suggests that polymorphisms for genes 

encoding for cytochrome P450 enzymes are involved in 

nicotine and cotinine metabolism (e.g., CYP2A6) (59) 

and affect the dopamine system, especially the DRD2 

receptor and enzymes that control dopamine metabolism 

(a crucial player in the reward effects of nicotine) (60, 

61). For example, an association has been reported 

between variations in genes that infl uence dopamine 

metabolism and smoking; this relationship is stronger 

among whites and women (62). Research in this area 

with respect to sex differences is lacking, and the advent 

of newer techniques, such as microarrays, that provide 

faster screening and detection of multiple gene variations 

may provide answers in a more efficient and costeffective manner. 

n Identifi cation of genetic markers and predictors. Several 

candidate genes are thought to be involved in nicotine 

addiction. We can obtain further insight into other novel 

genes of interest by linkage analysis, which provides 

analysis of chromosomal regions and localization of 

genes that contribute to phenotypes associated with 

smoking. This methodology has provided inconclusive 

data but has the ability to help identify specifi c genes 

involved in nicotine dependence and to further examine 

sex differences (63). 

n Genetic components and predictors of relapse. Genetic 

influences on different stages of smoking, such as 

initiation, maintenance, cessation, and relapse, may not 

be identical. A study examining female twins has shown 

that although risk factors overlap for smoking initiation 

and dependence, a distinct set of factors was specifi c for 

nicotine dependence (64). For cessation treatments, an 

association between genetic variations in the CYP2D6 

gene and increased incidence of bupropion adverse 

effects were reported in female patients (65). Data for 

38 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

genetic predictors of relapse in females and males are 

lacking. 

n Gene/environment interactions. As in other fields, such as 

cancer epidemiology (66, 67), nicotine dependence may 

also be influenced by gene/environment interactions (68, 

69). Nicotine dependence exhibits characteristics of a 

complex genetic trait (e.g., gene/gene, gene/environment, 

and genotypic heterogeneity) (70-72). It has been shown 

that, depending on the nature of the gene/environment 

interaction (e.g., additive, multiplicative, or synergistic), 

the potential impact on the prevention of regular tobacco 

use could be quite high, thereby providing substantial 

motivation for pursuing an integrative understanding 

of how genes and the environment interact to increase 

susceptibility to tobacco use (73). 

4. Sex differences in laboratory-based human 

studies. 

Laboratory-based human studies are needed to investigate 

all aspects of nicotine addiction. These could include cue 

reactivity studies (e.g., 74), nicotine sensitivity studies 

(e.g., 75), functional magnetic resonance imaging (fMRI) 

studies of brain activation (e.g., 76), prepulse inhibition 

(e.g., 77), and some forms of electroencephalogram-based 

studies (e.g., 78). 

Sex-based research is needed on: 

n Neurobiology of relapse and laboratory-based predictors of 

relapse. 

n Risk and protective factors for nicotine dependence/ 

addiction. 

n Nicotine as a reinforcer and non-nicotine aspects of smoking 

reinforcements. 

n An integrated, systematic approach to laboratory-based 

human studies and fi eld studies. 

5. Human research on gender differences in 

natural history. 

Conducting gender-based studies in naturalistic settings 

to understand the progression to dependence, quitting, 

and relapse is important. Thus, gender differences must be 

examined at different stages of life, taking into consideration 

biological, brain, behavioral, and environmental factors. The 

available data suggest that both trajectories of tobacco use 

and dimensions of adult dependence are strongly infl uenced 

by gender. Specifically, girls tended to have greater rates of 

change than boys in the use of tobacco (79); younger females 

had greater development of cigarette use than younger males 

(80) (younger females typically exceeded males in cigarette use 

[81, 82]); and females had higher initial status than males and 

increased less rapidly in their use of tobacco (83). White et al. 

found that while males and females did not differ signifi cantly 

in frequency or quantity of smoking at most ages, females 

began to smoke at younger ages than males and at higher rates 

during adolescence (84). 

Based on the results of a factor analysis of 42 items assessing 

smoking behaviors in 150 French smokers (50 percent 

male), Gilliard and Bruchon-Schweitzer (85) used principal 

components analysis and Varivax rotation to identify 

four factors explaining 52 percent of the total variance: 

dependence (automatism, lack of control, urge to smoke); 

social integration (socially acceptable behaviors, impressing 

other people); regulation of negative affect (management of 

anxiety, sadness, anger); and hedonism (pleasant smokingrelated gestures, seeking relaxation and pleasure). The authors 

then used multiple-regression analysis to examine—separately 

for men and women—the relationships among a variety of 

sociodemographic, personality, and dependence measures. 

Of note is the finding that correlates of smoking factors were 

uniformly different for men than for women. For example, 

being single and being susceptible to boredom were associated 

with dependence in men, while the use of other psychoactive 

substances was most strongly related to dependence in 

women. 

Gender-based research is needed on: 

n Natural history of progression to dependence. 

n Overcoming limitations of current research with adolescents. 

n Brain imaging in adolescents at multiple timepoints to 

monitor smoking and other outcomes. 

n Gender differences in relapse factors. 

n The menstrual cycle as a primary focus in research on 

smoking (puberty, pregnancy, postmenopause). 

n Sex differences in the rate of maturation of the relevant 

metabolic and receptor systems. 

n Gender differences in self-quitting versus treatment-based 

quitting. 

6. Gender differences in depression, stress, and 

coping. 

People with depression have a higher incidence of smoking 

(13-17). High levels of depression are associated with higher 

dependency on smoking (14). Depressed individuals may 

Appendix A: Reports From the Working Group Breakout Sessions 39 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

self-medicate to alleviate symptoms of depression, and this 

behavior could be an important factor in tobacco dependence. 

However, it could also be that a common genetic basis exists 

for the association of the two conditions (14, 86). Since 

females are twice as likely as males to experience mood disorders, 

depression is an especially important factor to consider with 

respect to prevention, treatment, withdrawal effects, and relapse. 

Smokers also report that while stress induces smoking 

behavior, smoking can alleviate stress (2, 87, 88). Women 

are more likely than men to smoke in response to stress and 

negative affect (3, 89, 90). A higher level of perceived stress 

was also identified as a risk factor for smoking in women 

following physician advice and nicotine replacement therapy 

(NRT) for cessation, but not in men (91). However, the 

underlying mechanisms of the relationship between smoking 

and stress are not fully understood. 

Release of glucocorticoid hormones—cortisol in humans and 

corticosterone in rodents—is one of the final steps resulting 

in activation of the hypothalamo-pituitary-adrenal (HPA) 

axis and serves as one of the principal biological responses to 

stress (92-94). Preclinical studies that examine how nicotine 

alters the relationship between sex hormones and the HPA 

axis are lacking. Research has shown that the HPA axis can 

be differentially regulated in female and male rats in response 

to alcohol. For example, relative to males, female rats release 

more corticosterone when they are exposed to alcohol (95). 

Thus, research should identify stressors that are unique to women 

and examine how these stressors affect coping and relapse rates. 

Research is needed on: 

n Depression, stress, and the onset of smoking or differences in 

smoking between adolescent males and females, and between 

adolescent and adult females. 

n The utility of nicotine for young women versus young men. 

n Hormonal factors in nicotine addiction, especially since 

phase of the menstrual cycle can affect mood. 

n Nicotine and stress hormones. 

n The role of psychiatric comorbidities, including subclinical 

comorbidities, and how to provide support and treatment. 

n The relationship between smoking and autoimmune 

diseases, since stress as well as smoking can affect the 

progression and severity of autoimmune diseases. 

n Whether nicotine plays a therapeutic role in depression. 

7. Sociocultural determinants. 

We need to understand disparities in smoking prevalence 

among women by socioeconomic status, race, and ethnicity. 

For example, certain ethnic groups have a higher prevalence 

of smoking than the general population (96), and predictors 

of initiation and persistence of smoking vary across ethnic 

groups (97). Thus, prevention and cessation programs 

targeting these particular groups should take into account 

cultural and potential biological differences, such as nicotine 

metabolism (98). 

Research is needed on: 

n Cultural differences between African Americans and whites 

in cigarette choice. 

n Reasons for the high smoking rate among American Indian 

women, including a better understanding of the social and 

cultural values adolescents attach to smoking (99). 

In addition, naturalistic observation studies are needed of 

smoking in people from different cultures as they enter the 

United States. 

Translation 

*8. Use evidence from animal studies, pilot 

projects, and small-scale clinical studies 

to develop, refine, and evaluate promising 

interventions. 

As illustrated in the above recommendations, animal 

studies can be used to understand the role of behavioral, 

hormonal, genetic, neurobiological, and environmental 

factors in nicotine addiction. These models will help in the 

development of potential behavioral and pharmacologic 

interventions for the prevention and cessation of nicotine 

addiction. For example, treatments based on extinction might 

be more effective for females than for males. 

Research is needed on: 

n Effective treatments from the fi eld of depression and other 

psychiatric comorbidities. Pharmacological interventions 

from these fields can be tested in animal models, and 

these studies can very quickly provide data to start pilot 

clinical studies. 

n Menstrual cycle effects on craving and withdrawal 

symptomatology. Previous research has shown that when 

premenstrual symptoms were highest in the late luteal 

phase of the cycle, women reported an increase in the 

desire to smoke to alleviate negative symptoms and 

40 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

minor weight gain following short-term abstinence; 

thus, women smokers might have better results quitting 

during the follicular phase of the cycle (100-102). 

n Cognitive behavioral therapy regarding weight gain concerns 

versus preventing weight gain. Previous research has 

indicated that weight gain occurring during an initial 

short-term period of smoking cessation can constitute a 

serious barrier to cessation. Weight-concerned women 

are less likely to seek treatment or attempt to quit on 

their own (103, 104). Also, weight-concerned women 

are willing to tolerate only a minimal weight gain, as 

they expect to gain more weight, and this may hamper 

their efforts to quit smoking (105). In fact, cognitive 

behavior therapy that focuses on reducing weight gain 

concerns improves smoking cessation outcome in 

weight-concerned women (106). 

Disparities 

The development of gender-specific treatments should be 

enhanced, with a view toward targeting priority female 

subgroups. 

Partners 

Partners include NIH and private foundations. 

Impact 

Within 2 to 5 years, we will know the limits and promise of 

new treatments and have feedback to refine animal models. 

Application 

*9. Use or modify existing infrastructure 

(e.g., NIDA Clinical Trials Network) to rapidly 

evaluate the efficacy of promising treatments 

and the effectiveness and cost-effectiveness 

of proven small-scale interventions. 

Women are less successful than men at quitting smoking, 

and those who seek help respond differently to cessation 

pharmacotherapies (8, 11, 107, 108). For example, in a 

recent effectiveness trial of bupropion SR (11), the 12-month 

nonsmoking rate for women (25 percent) was signifi cantly 

lower than that for men (32.8 percent; p < 0.01); women 

were 45 percent more likely than men to be smoking at 

12 months post treatment, after adjustment for other 

pretreatment characteristics and form of treatment; odds 

ratio (95 percent confidence interval)=1.45 (1.16, 1.82). 

This finding is consistent with the report by Dale et al. 

(109), in which women were 67 percent more likely than 

men to be smoking at the end of treatment with bupropion 

SR. The finding that women are more likely to return to 

smoking following treatment has also come from studies 

of the effectiveness of unassisted cessation (110-112), 

community-based interventions (113), behavioral treatment 

(9, 110, 114), nicotine replacement therapy (10, 114-118), 

and fluoxetine treatment (119). The basis for lower cessation 

rates among women remains unknown and may be due to 

a number of factors, including the presence of undetected 

subgroups among female quitters that vary with respect to 

treatment outcome (120). Relatively little work has been 

done to identify such subgroups, and no published evidence 

is available within the context of combined bupropion SR 

and behavioral counseling. Such information could be useful for 

understanding whether all, or only certain subgroups of women 

are at increased risk for smoking following treatment and will 

help provide the path to cessation therapies tailored to the needs of 

women. 

Research is needed on: 

n Maximizing the effectiveness of NRT for women, because 

gender differences with respect to nicotine sensitivity 

during withdrawal have been reported. Hormonal 

effects may alter nicotine sensitivity, but few studies 

have examined hormonal influences on responsiveness 

to NRT. Recently, Allen and colleagues (121) reported 

that women treated with transdermal nicotine patches 

reported a decrease in craving in the late luteal phase 

of their menstrual cycles relative to the follicular phase. 

This indicates that to maximize the effects of NRT, the 

menstrual cycle should be taken into consideration. 

n Gender differences in non-NRT pharmacotherapies. In 

this category, bupropion is currently the only non-NRT 

pharmacotherapy approved for smoking cessation (for 

a recent review, see 122). Thus, much work is needed 

to determine, for example, the dose ranges of effective 

medications for females. This pharmacotherapy may be 

especially useful for women, because studies have shown 

that bupropion may reduce withdrawal symptoms and 

weight gain—a major concern for women. 

n Combinations of medications and behavioral treatments. 

In a study of quit rates following nicotine therapy, 

women scored higher on behavioral measures of nicotine 

dependence and lower on physiological measures than 

men, indicating that, ideally, behavioral therapy should 

be combined with nicotine treatment and tailored to the 

individual’s needs (107). 

Appendix A: Reports From the Working Group Breakout Sessions 41 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

n Applying treatments for other disorders (e.g., depression) to 

nicotine dependence, especially since evidence suggests 

that women smokers who have a history of depression 

are less likely to quit (9, 115, 123, 124). 

6. Perkins KA, Grobbe JE, Stiller RL, Fonte C, Goettler 

JE. Nasal spray nicotine replacement suppresses cigarette 

smoking desire and behavior. Clinical Pharmacology and 

Therapeutics. 1992;52:627-34. 

n More-intensive versus less-intensive treatments. This 

research could be expanded to include treatments 

delivered in the “real world.” 

Disparities 

7. Perkins KA, Donny E, Cagguila AR. Sex differences 

in nicotine effects and self-administration: Review 

of human and animal evidence. Nicotine & Tobacco 

Research. 1999;1:301-15. 

Ascertain efficacy and effectiveness in priority subgroups. 8. Perkins KA. Smoking cessation in women. Special 

considerations. CNS Drugs. 2001;15:391-411. 

Partners 

9. Swan GE, Ward MM, Carmelli D, Jack LM. Differential 

n NIDA and Veterans Affairs Clinical Trials Network rates of relapse in subgroups of male and female smokers. 

n NCI’s Clinical Cancer Oncology Program Journal of Clinical Epidemiology. 1993;46:1041-53. 

n Substance Abuse and Mental Health Services 10. Swan, GE, Carmelli, D. Behavior genetic investigations 

Administration of cigarette smoking and related issues. In: Noble EP, 

Blum K, eds. Handbook of Psychiatric Genetics. Boca 

n Foundations (e.g., Robert Wood Johnson Foundation) Raton, FL: CRC Press; 1997:379-98. 

n Pharmaceutical industry 11. Swan GE, Jack LM, Curry SJ, et al. Bupropion SR and 

Impact counseling for smoking cessation in actual practice: 

Predictors of outcome. Nicotine & Tobacco Research. Within 5 years, we may have improved the delivery of 

effective treatments to priority subgroups. 2003;5:911-21. 

12. Westermeyer J, Boedicker AE. Course, severity, and 

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levels. Alcoholism, Clinical, and Experimental Research. smoking cessation outcome in weight-concerned women. 

1993;17:854-9. Journal of Consulting and Clinical Psychology. 2001;69: 

604-13. 96. Lawrence D, Graber JE, Mills SL, Meissner HI, 

Warnecke R. Smoking cessation interventions in U.S. 

racial/ethnic minority populations: An assessment of the 

literature. Preventive Medicine. 2003;36:204-16. 

107. Bohadana A, Nilsson F, Rasmussen T, Martinet Y. 

Gender differences in quit rates following smoking 

cessation with combination nicotine therapy: Infl uence 

97. Griesler PC, Kandel DB, Davies M. Ethnic differences of baseline smoking behavior. Nicotine & Tobacco 

in predictors of initiation and persistence of adolescent Research. 2003;5:111-6. 

cigarette smoking in the National Longitudinal Survey of 108. Swan GE, Jack LM, Ward MM. Subgroups of smokers 

Youth. Nicotine & Tobacco Research. 2002;4:79-93. with different success rates after use of transdermal 

98. Ahijevych K. Nicotine metabolism variability and nicotine. Addiction. 1997;92:207-17. 

nicotine addiction. Nicotine & Tobacco Research. 1999;2: 109. Dale LC, Glover ED, Sachs DP, et al. Bupropion for 

S59-62. smoking cessation: Predictors of successful outcome. 

99. Quintero G, Davis S. Why do teens smoke? American Chest. 2001;119:1357-64. 

Indian and Hispanic adolescents’ perspectives on 110. Fortmann SP, Killen JD. Who shall quit? Comparison 

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Withdrawal and pre-menstrual symptomatology during 111. Godtfredsen NS, Prescott E, Osler M, Vestbo J. 

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101. Allen SS, Hatsukami DK, Christianson D, Brown 112. Kabat GC, Wynder EL. Determinants of quitting 

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Addictive Behaviors. 2000;25:559-72. 

46 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

113. Hymowitz N, Cummings KM, Hyland A, Lynn WR, 119. Borrelli B, Spring B, Niaura R, Hitsman B, 

Pechacek TF, Hartwell TD. Predictors of smoking Papandonatos G. Influences of gender and weight 

cessation in a cohort of adult smokers followed for fi ve gain on short-term relapse to smoking in a cessation 

years. Tobacco Control. 1997;6 Suppl 2:S57-62. trial. Journal of Consulting and Clinical Psychology. 

2001;69;511-5. 114. Ockene JK, Emmons KM, Mermelstein RJ, et al. 

Relapse and maintenance issues for smoking cessation. 120. Wetter DW, Kenford, SL, Smith SS, Fiore MC, Jorenby 

Health Psychology. 2000;19 Suppl 1:17-31. DE, Baker TB. Gender differences in smoking cessation. 

115. Bjornson W, Rand C, Connett JE, et al. Gender Journal of Consulting and Clinical Psychology. 1999;67: 

555-62. differences in smoking cessation after 3 years in the 

Lung Health Study. American Journal of Public Health. 

1995;85:223-30. 

116. Nides MA, Rakos RF, Gonzales D, et al. Predictors of 

initial smoking cessation and relapse through the fi rst 2 

years of the Lung Health Study. Journal of Consulting and 

Clinical Psychology. 1995;63:60-9. 

117. Norregaard J, Tonnesen P, Petersen L. Predictors and 

121. Allen SS, Hatsukami DK, Christianson D, Brown S. 

Effects of transdermal nicotine on craving, withdrawal 

and premenstrual symptomology in short-term smoking 

abstinence during different phases of the menstrual cycle. 

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122. Richmond R, Zwar N. Review of bupropion for 

smoking cessation. Drug and Alcohol Review. 2003;22: 

203-20. reasons for relapse in smoking cessation with nicotine 

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71. 

118. Wetter DW, Fiore MC, Young TB, McClure JB, de 

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American Medical Association. 1990;264:1583-4. 

Appendix A: Reports From the Working Group Breakout Sessions 47 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

48 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Epidemiology and National Surveillance Breakout Session 

Co-Chairs 

Participants 

Science Writer 

Lead Author 

Overview 

Matthew Farrelly 

Lisa Begg 

Naomi Breslau 

Francisco Buchting 

Vilma Cokkinides 

Alyssa Easton 

Randi Henderson 

Linda Pederson 

I

n epidemiology and public health, surveillance systems are 

designed to provide timely information on the occurrence 

of particular diseases and conditions, the presence of risk 

factors for those conditions, and the effects of disease control 

programs (1). Epidemiological and surveillance data are 

necessary to monitor tobacco use in women and trace the 

epidemic as it develops globally. 

More specifically, epidemiology and surveillance data are 

needed to: 

n Understand the natural history and trends of tobacco use 

and the consequences of such use (2, 3). 

n Justify and evaluate policies, programs, and legislation, 

taking into account numerous pro- and antitobacco 

infl uences (4). 

n Set realistic objectives for program goals (4, 5). 

n Assess the consequences of various harm-reduction strategies 

(1). 

n Identify groups that are at high risk for various forms of 

tobacco use (6-8). 

n Justify and conduct research initiatives, including ones 

that examine gender-specifi c differences and similarities in 

outcome and process (6). 

A comprehensive surveillance system would include 

information about the host (the smoker or potential 

Gary Giovino 

Sherry Emery 

Virginia Ernster 

Pat Hysert 

Gary King 

Mildred Morse 

Corinne Husten 

Linda Pederson 

Steve Stellman 

Mike Thun 

David Wetter 

Susan Woodruff 

data are missing even in this area, particularly regarding the 

natural history of smoking and factors infl uencing tobacco 

use in diverse populations globally (6). In addition, our 

current surveillance systems focus largely on the host and 

do not systematically collect information to adequately 

describe the agent, vector, or environment (9). This 

information is important because it provides the basis for 

policy interventions and health communication messages. 

For example, information on product constituents from the 

industry (the agent), marketing of the products (the vector), 

and smoking prevalence (the host) is crucial for monitoring 

smoking-related disease incidence and prevalence. In many 

cases, however, the methods for such a comprehensive 

surveillance system still need to be developed. 

In spite of the increasing amount of research on women 

and tobacco that appeared after the 1980 Surgeon General’s 

report on women and smoking (10), many questions remain 

unanswered. In fact, some issues have not been addressed at 

all (see below). 

Research is needed on both methods and content in: 

n Measurement and sampling issues (e.g., how to access 

samples from diverse populations and how to ensure that 

measurements are culturally and community competent). 

n Better measures of the program capacity of tobacco control in 

each state, assessment of how funds are being used, and what 

capacities are being built to help establish programmatic 

priorities (11-15). 

smoker), agent (tobacco products), vector (tobacco industry n Better measurement of adverse and protective comorbidities 

activities), and the environment (economic, cultural, political, and identifi cation of the impact of comorbidities on disease 

and historical activities and interventions that support or risk and smoking uptake and cessation (e.g., multiple drug 

discourage tobacco use) (3, 9). Although current surveillance use, weight concerns). 

systems have the most information about the host, critical 

Appendix A: Reports From the Working Group Breakout Sessions 49 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

n The natural history of smoking in women (initiation, States and those born elsewhere. Given the host of possible 

maintenance, cessation) versus men, taking into account influences on these diverse groups within one major racial or 

the possibility that natural history varies by population ethnic group, smoking behavior could vary widely (19). 

subgroup. Disparities 

n Psychosocial factors associated with smoking initiation, This recommendation focuses on disparities. Implementing it maintenance, and cessation. will help clearly define who is most at risk for initiation and 

n The differential health and economic effects of smoking on continued use of tobacco products. 

different populations and subpopulations. Partners 

n Disease reduction (i.e., harm minimization) in men and Populations must be involved in the development and women from different subpopulations who are former users. implementation of this initiative. Partners should also include 

n Interactions among infectious diseases, smoking, and cancer. state legislative groups, state tobacco control programs, 

advocates, researchers, community-based organizations, and n Antiestrogenic effects of tobacco. interventionists. 

n Triggers of smoking cessation. Impact 

n Cost-effectiveness of smoking cessation interventions. Within 2 years, this should be established as a priority, and 

n Effective ways to minimize weight gain with cessation. information on what is currently known about tobacco use 

in various populations should be increased. Within 5 years, n Data at the state level on smoking, pregnancy, and teen data should be used to inform interventions; more targeted smokers. interventions should be developed to reduce disparities; 

existing data should be completely analyzed; and better Recommendations surveillance systems should be developed. 

Research *2. State and local monitoring. 

*1. Identify disparities. To better measure the extent of state and local tobacco control 

To more precisely identify where disparities lie, it is necessary activities, tobacco use surveillance must be enhanced at the 

to assess the interrelationships among specifi c population state and local levels, and creative, user-friendly measures 

characteristics (race and ethnicity, sexual orientation, must be developed to report the impact of tobacco control 

socioeconomic status, gender, age, disabilities, and others) as interventions on smoking and exposure to secondhand 

they influence tobacco use, exposure to secondhand smoke, smoke. 

and disease risk. The allocation of resources and programs is Standardized monitoring of state and local tobacco control contingent on the identification of disparities. activities will provide the information needed for optimal 

Tobacco use varies by population group, and the adverse program development, implementation, and evaluation. 

effects of tobacco are concentrated in certain populations. These measures can then be linked with measures of tobacco 

For example, African Americans smoke fewer cigarettes use to document pre- and postintervention behavior changes 

but have a higher prevalence of lung cancer than whites (7, (20). These measures must be easy to use to ensure that they 

16-18). However, adequate data on tobacco use are lacking will be employed. 

for many population groups (e.g., Asian/Pacifi c Islanders, To determine “best practices” for tobacco control American Indians), and even more striking is the absence of interventions, we must be able to understand the levels and 

information on subgroups of these population groups. For types of interventions being implemented and their effects. example, little or no information is available to compare the For example, without adequate measurement of school smoking behavior of women from different American Indian programs and policies, cigarette prices, sales to minors, and groups (Navajo, Ojibwa, etc.) or women with different Asian possession, use, and purchase laws, it will not be clear whether backgrounds (from Japan, Taiwan, mainland China, Hong reductions in the use of tobacco among adolescents are Kong, or Vietnam), including both those born in the United associated with specific state or local programs (21-24). 

* Recommendations with an asterisk are those identified by the breakout groups as their top three recommendations. 

50 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Disparities 

This recommendation will make it possible to assess how 

well tobacco control measures are reaching disparate groups, 

measure progress in different groups, obtain measures of the 

reach of programs to generate interest in participating in 

state and local tobacco prevention and control activities, and 

facilitate buy-in from involved populations. 

Partners 

Partners include all funding agencies, states, health services 

researchers, advocacy groups, purchasers, insurers, and health 

care systems. 

Impact 

Within 2 years, the ability to document activities will 

be increased; methods for assessing programs should be 

developed; funding should be maintained and increased; 

and success stories should be disseminated. Within 5 years, 

funding should be maintained and increased, and more 

rigorous assessment methods developed under the 2-year plan 

should be implemented. 

3. Natural history of tobacco use. 

We must document the natural history and etiology of 

smoking initiation, maintenance, and cessation among 

diverse populations by gender (including rolling cohorts 

with adequate duration and frequency of follow-up and 

documentation of relevant genetic and molecular markers). 

Most current surveillance data are cross-sectional; information 

on tobacco use and risk factors is collected at the same point 

in time. Thus, we lack historical data on the natural history 

of tobacco use, including initiation, maintenance, cessation, 

and relapse (9). Such data are particularly important because 

some recent data indicate that the patterns of initiation and 

maintenance may be changing. Less-than-daily smoking is 

more common in some states and among specifi c groups than 

it was a decade ago (25). This apparent change in behavior 

may be related to future changes in smoking prevalence and 

the incidence and prevalence of tobacco-related morbidity 

and mortality. To determine whether identifi able subgroups 

adopt a behavior, variables associated with the behavior 

must be determined. Furthermore, we must determine if the 

predictions by college students that they will quit when they 

leave college are accurate (26). The question remains whether 

the patterns noted are similar for different subpopulation 

groups. Also, little is known about the relationship between 

the ceremonial use of tobacco among different American 

Indian tribes and the use of manufactured cigarettes. 

Disparities 

Disparities are a focus of this priority. 

Partners 

n Tobacco Etiology Research Network 

n National Organization of Tobacco Use Research Funders 

n Potential to tap into other existing cohort studies 

(e.g., those of the U.S. Environmental Protection 

Agency, National Institute of Child Health and Human 

Development, National Center for Health Statistics, 

U.S. Census Bureau, or Community Intervention Trial 

for Smoking Cessation [COMMIT]) 

Impact 

Within 2 years, methods for the study or studies should be 

developed. Within 5 years, study implementation and data 

collection should begin. 

4. Methodology . 

To achieve the recommendations listed above, methodological 

research needs to be conducted, including questionnaire 

development, sampling strategy development, and validation 

of reported histories of smoking and exposure to secondhand 

smoke. 

Improving current surveillance systems will require the 

development of methods, particularly around measuring 

disparities, and of systems to monitor the host, agent, vector, 

and environment. Surveillance systems needed to monitor 

these factors in diverse populations rapidly become complex. 

Given the cultural diversity of the population, questions 

regarding attempts to determine patterns of tobacco use 

may not be similar. For example, the interpretation may 

vary widely among different subgroups for a question about 

whether someone currently smokes some days, every day, or 

not at all. Moreover, sanctions in different subcultures against 

women who smoke could preclude them from answering 

honestly if they do smoke. In addition, mechanisms must be 

developed to ensure that the individuals who are sampled are 

representative of the target populations, as response rates for 

different groups may vary widely. 

Disparities 

Key methodological gaps exist in survey questions and 

sampling strategies, especially with regard to diverse 

populations. 

Appendix A: Reports From the Working Group Breakout Sessions 51 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Partners 

Partners will include members of specific populations, survey 

methodologists, and survey funders. 

Impact 

Within 2 years, some instruments and sampling strategies 

should be developed, and pilot studies should be conducted. 

Within 5 years, the lessons learned from the pilot studies 

should be implemented through local, state, and national 

surveys. 

Application 

*5. T obacco marketing. 

Tobacco advertising and promotion targeted to diverse 

populations of women domestically and internationally 

need to be monitored and publicized to help stem the tide 

of tobacco use by women. This information is important for 

countermarketing programs to educate women and for policy 

and program planning to address industry messages. 

The tobacco industry spends billions of dollars annually 

to market and advertise its products (27). For example, 

the tobacco industry supports women’s magazines through 

advertising dollars (6). One such ad campaign was the Philip 

Morris Company’s “Find Your Voice” campaign, which 

stressed the liberation of women from a broad range of 

cultures. The impact of the tobacco industry’s efforts can be 

seen in attempts to control advertising through policies at 

the state (28), national (29), and international levels (30). 

Information on tobacco company advertising and promotion 

activities could be used to show women that they have 

options for becoming liberated and independent other than 

smoking cigarettes. 

Disparities 

This recommendation affects diverse groups internationally 

and domestically. 

Partners 

n Women’s organizations 

n Schools 

n Industry researchers 

n Consumer groups 

n Social scientists 

n Community organizations representing specifi c 

populations 

n Tobacco control programs 

n Advocates 

n World Health Organization 

n International Network of Women Against Tobacco 

n American Medical Women’s Association 

Impact 

Within 2 years, partnerships should be built; examples of 

targeted marketing should be documented; and pilot studies 

should be conducted on how to perform more systematic 

studies. Within 5 years, systematic studies should begin and 

hard data should be gathered. 

6. Global surveillance. 

Gender-based global surveillance is needed of tobacco 

use and exposure to secondhand smoke among adults 

and children, using standardized measures so that crosscountry comparisons are available. Because of the range of 

support, both cultural and financial, and the differences in 

infrastructure for surveillance activities in different countries 

(31), this recommendation is critically important for crossnational programs. Ensuring that surveillance and monitoring 

are comparable across countries is a complex and diffi cult 

task (32); particularly in low- and middle-income countries, 

surveillance systems for monitoring tobacco use and its health 

consequences are very limited. One model of a standardized 

and cost-effective approach is the Global Youth Tobacco 

Survey (33), in which standard training is provided for data 

collection and analysis (34, 35). 

Disparities 

This recommendation addresses diverse populations globally. 

Partners 

n World Health Organization 

n Nongovernmental organizations 

n Specifi c governments 

Impact 

Within 2 years, methods for adult surveys should be 

developed. Within 5 years, pilot surveys for adults should 

begin. 

References 

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Clearing the Smoke: Assessing the Science Base for Tobacco 

52 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Harm Reduction. Washington, DC: National Academy 

Press; 2001. 

2. Novotny TE, Giovino GA. Tobacco use. In: Bownson 

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4. MacDonald G, Starr G, Schooley M, Yee SL, Klimowski 

K, Turner K. Introduction to Program Evaluation for 

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13. Centers for Disease Control and Prevention. Investment 

in Tobacco Control: State Highlights—2001. Atlanta, 

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Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health; 2002. 

14. Centers for Disease Control and Prevention. Tobacco 

Control State Highlights 2002: Impact and Opportunity. 

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National Center for Chronic Disease Prevention and 

Health Promotion, Office on Smoking and Health; 

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15. National Women’s Law Center, Oregon Health & 

Science University. Women and Smoking: A National 

and State-by-State Report Card. National Women’s Law 

Center Web site. Available at: http://www.nwlc.org/ 

pdf/Women&SmokingReportCard2003.pdf. Accessed 

December 8, 2003. 

16. Cancer Facts and Figures, 2003. American Cancer 

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17. Cancer Facts and Figures for African Americans, 2003. 

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18. Centers for Disease Control and Prevention. Cigarette 

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21. Centers for Disease Control and Prevention. Usual 

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29. Nixon ML, Glantz SA. Tobacco Industry Activity and 

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30. Neuman M, Bitton N, Glantz S. Tobacco industry 

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33. Global Youth Tobacco Survey. Centers for Disease 

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adults flirt with tobacco addiction. Paper presented at: 34. Global Youth Tobacco Survey Collaborative Group. National Conference on Tobacco or Health; November Tobacco use among youth: A cross country comparison. 2002; San Francisco. Tobacco Control. 2002;11:252-70. 

27. Federal Trade Commission Cigarette Report. Federal 35. Global Youth Tobacco Survey Collaborative Group. Trade Commission Web site. Available at: http:// Differences in worldwide tobacco use by gender: www.ftc.gov/os/2003/06/2001cigreport.pdf. Accessed Findings from the Global Youth Tobacco Survey. Journal December 8, 2003. of School Health. 2003;73:207-15. 

28. Nixon ML, Glantz SA. Tobacco Industry Political 

Activity and Tobacco Control Policy Making in 

Washington: 1996-2000. Center for Tobacco 

54 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Interventions for Prevention and Treatment Breakout Session 

Co-Chairs Richard Clayton 

Participants Lourdes Baezcande-Garbanati 

Paul Cinciripini 

Lisa Dierker 

Pebbles Fagan 

Janet Healy 

Science Writer Lisa Chiu 

Lead Author Amy Lazev 

Overview 

Although many in the tobacco control community assume that the most effective interventions are those that are 

personalized in some manner (targeted or tailored), it is not 

yet known whether women and men respond differently to 

prevention and treatment interventions or would benefi t from 

different intervention strategies. Some clinical studies have 

found gender differences in treatment outcomes, suggesting 

that women have greater difficulty in quitting smoking than 

men. However, other clinical and population-level studies 

have not supported these findings. The majority of studies 

have not been designed to adequately address the issue of sex 

or gender differences in the methods used or preferred by men 

and women or in the outcomes they achieve. The nature of 

the differences, whether they are determined or mediated by 

genetic or biological factors, cultural or learning infl uences, or 

access to care and support during cessation, is not understood. 

Although researchers have not yet collected the data needed 

to resolve this issue, a combination of meta-analysis with new 

research could address the question. 

Smoking is clearly a women’s health issue in that it has a 

unique impact on women. Prevention and intervention efforts 

aimed at the requirements of women are needed. 

Partnering in the area of prevention and treatment should 

focus on finding available funds and increasing awareness 

among various organizations that tobacco control is part 

of their charge. Using models of well-organized health 

activist groups, such as those focused on breast cancer and 

HIV/AIDS, might yield strategies to funnel funds toward 

tobacco control research. While most grassroots organizations 

focused on eliminating specific diseases have attracted large 

Sharon Hall Cathy Melvin 

Felicia Schanche Hodge Saul Shiffman 

Gary Humfl eet Laura Solomon 

Amy Lazev Janice Tsoh 

Jamie Ostroff Jaylan Turkkan 

Julia Rowland Mitch Zeller 

numbers of those affected by these diseases, this has not 

occurred among smokers. Establishing such a “community” 

among smokers might be difficult because of the blame and 

stigma associated with smokers who develop cancer and other 

comorbidities, as well as their socioeconomic characteristics. 

Indeed, the tobacco industry has used this very strategy to 

promote “smokers’ rights” organizations. Working with family 

members of those suffering or dying from tobacco-caused 

diseases might be more a promising approach. 

Recommendations 

Research 

*1. Continue to evaluate whether gender 

differences exist in prevention and treatment 

effi cacy. 

The 1980 Surgeon General’s Report suggested that women 

have more difficulty than men in quitting smoking (1). While 

some studies have supported this finding (e.g., 2-5), others 

have not (e.g., 6-8). Methodological limitations—including 

post hoc analysis, lack of statistical power to identify sex 

differences, and reliance on convenience samples that may 

not be representative of the general population—have 

complicated these analyses. Therefore, studies specifi cally 

designed with adequate statistical power to test for sex 

differences must be conducted to address this issue. 

n Explore the mediating or moderating factors that may 

produce sex differences. Even more important than 

establishing sex differences in outcomes is understanding 

why they occur; this involves examining which 

physiological, psychological, and behavioral factors 

* Recommendations with an asterisk are those identified by the breakout groups as their top three recommendations. 

Appendix A: Reports From the Working Group Breakout Sessions 55 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

mediate or moderate sex differences. A number of factors interventions can be targeted to these events and whether 

may underlie sex differences, including demographics, current interventions can be used or would be more 

addiction (nicotine dependence and withdrawal), mood efficacious if tailored requires additional research. 

(depression), cognitive factors (expectations, weight Disparities concerns), social factors (coping styles, social support), 

and pharmacological factors (differential responses Research on sex differences is anticipated to have a signifi cant 

to agents such as nicotine replacement therapy and impact. Differences exist in sex role socialization, norms, and 

bupropion). These issues have not been systematically cultural influences for women and girls in different income 

addressed. Although most studies examining gender and racial or ethnic groups. These differences need to be 

differences have used post hoc analysis, studies need to be taken into account in developing motivation and treatment 

designed with adequate power, and they must stratify for strategies. In addition, literacy levels need to be taken into 

sex to properly examine these differences. account. While most research examining gender differences 

has been conducted through clinic-based intervention trials, Women may also respond differentially to treatment. For future research should include all modes of intervention and 

instance, Ossip-Klein et al. (9) found differences between prevention work, including community-based interventions, older men and women in response to telephone quit-line self-help-focused interventions, and clinical trials. By use and support, with women showing greater benefi t. conducting research on sex differences across all types of Lerman and colleagues (10) examined the interaction interventions and all settings, we can help ensure that results among sex, genotype, and treatment and found that are generalizable to all women. bupropion attenuated the effect of genotype among 

female smokers. Women also may have health benefi ts Partners 

that differ from men’s. In the Lung Health Study, All research funding organizations and agencies willing to Connett and colleagues (11) found that among persons support primary and secondary analyses can serve as partners 

at risk for chronic obstructive pulmonary disease, women in this research endeavor. Collaborations with appropriate 

who quit smoking showed greater improvement than research networks and other investigators conducting sex men in lung function. research are suggested. 

n Explore factors unique to women that may influence Impact 

prevention and treatment. In addition to identifying 

any sex differences in factors that influence both sexes, Identifying whether gender differences exist and 

a number of factors unique to women may infl uence understanding the factors that contribute to how gender 

smoking behavior and treatment effi cacy. These factors, affects smoking initiation, maintenance, and cessation will 

such as menstrual cycle, pregnancy, and menopause, permit better targeting and tailoring of prevention and 

may influence women’s motivation and ability to intervention efforts. Current interventions targeted to women 

quit smoking. While some factors, such as pregnancy, would benefit from a more comprehensive understanding 

have been recognized as windows of opportunity of differences in the trajectories of tobacco initiation and 

cessation and the mechanisms of addiction and effective for increasing quit rates, others—such as the impact treatment. of menopause or the role of hormone replacement 

therapy (HRT)—have not been well explored. Such *2. Understand if—and how—gender , context, 

factors may play a direct role, or they may infl uence and culture affect prevention and treatment. 

other factors that act as mediators. For example, one Little attention has been paid to the role of gender, context, study found that women taking HRT experienced an and culture in prevention and treatment. Many ethnic increase in depressive symptoms in the second week differences in tobacco use have been established, and race, of smoking cessation (12). Another study found that ethnicity, and culture may all play a role in initiation, women quitting during the luteal phase reported greater maintenance, and cessation of tobacco use. For example, depressive symptoms and increases in withdrawal than in the United States, blacks start smoking at a later age, women quitting during the follicular phase of their cycle smoke fewer cigarettes per day, and are more likely to smoke (13). menthol cigarettes than whites, and Hispanic women smoke 

By targeting these events, we can capitalize on a window at significantly lower rates than Hispanic men. Evidence is 

of opportunity. However, a better understanding of how accumulating that suggests that biological and cultural factors 

56 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

combine to create these differences. Understanding how these 

cultural differences affect smoking behavior and addiction 

will help us reduce disparities and understand social and 

contextual factors that could be used to aid in prevention and 

treatment for all women. 

replacement products. These studies often require that 

participants smoke a minimum number of cigarettes 

per day (such as 10 or more). These studies may 

inadvertently exclude minority or low socioeconomic 

status (SES) populations (with limited fi nancial 

To do this, we must first address these questions: resources) that typically smoke smaller numbers of 

cigarettes per day or use other forms of tobacco (such as 

n Do specifi c protective factors emerge from the interaction chewing tobacco). 

of race, ethnicity, culture, and gender? Social and cultural 

norms may play a significant role in smoking initiation. n Do existing interventions address important cultural 

For example, parental pressure may contribute to the and racial differences? Ethnicity may be correlated 

delay in smoking initiation among black teens (14, 15). with specific concerns about quitting smoking. For 

Cultural factors may also explain the gender difference example, although weight gain has been found to be a 

in smoking rates in the Hispanic community. A better predictor of smoking initiation and a barrier to cessation 

understanding of these factors would inform prevention (e.g., 16-18), this finding has not been replicated in 

several populations, including lower SES groups (19) and intervention efforts. 

Is social pressure the key factor in creating these 

differences, or do biological differences interact with 

social factors? As cultures become more “westernized” 

and accepting of smoking among women (e.g., in China 

and India), will we see increasing smoking rates among 

women worldwide? We need to learn how to capitalize 

on protective factors while fostering independence, 

and minority groups (20). Are some populations less 

concerned about gaining weight, or are they in fact 

gaining less weight following cessation? While concerns 

about weight gain appear to be less prominent among 

black female smokers, obesity is an important health 

concern that needs to be addressed in this population 

(21). 

education, and professional development. For example, n What is the impact of religious injunctions on smoking 

in developing nations with traditionally low tobacco use initiation among women? Some religions specifi cally 

prevalence among women (e.g., China, Korea, Malaysia), prohibit the use of tobacco—usually through an 

smoking is not considered “feminine” or part of women’s injunction against the use of substances that harm the 

approved social behavior. What is greatly needed body, but sometimes directly as well. For example, a 

in such cultures is a way to reframe refraining from fatwa (religious proclamation) against smoking has been 

smoking as liberated, socially responsible, and protective issued by Islamic leaders. Although the Islamic ruling on 

tobacco smoking is not as well defined as the ruling on of the health of women and their families. If this is 

accomplished, as the status of women becomes more alcohol, general guidelines found in the Q’uran and in 

equal to that of men in terms of education, professional the words of Muhammed clearly indicate that smoking is 

opportunity, and human rights, smoking will not be seen forbidden (haram) or considered “strongly abominable.” 

as synonymous with freedom and liberated social roles. However, in many Islamic countries, such as Malaysia 

and Indonesia, smoking remains high among men and 

n Are we excluding individuals from prevention or treatment 

because their patterns of use differ from those of the 

majority populations? Are blacks, for example, being 

excluded or benefiting less than whites from prevention 

very low among women largely because of social custom. 

In the Church of Jesus Christ of Latter-Day Saints 

(Mormons), The Word of Wisdom (a guiding revelation 

and treatment interventions aimed at young children? of faith) proposes that believers abstain from tobacco 

School-based and mass-media campaigns that target and other harmful substances such as tea, coffee, and 

children and young teens and are aimed at prevention whiskey (strong drink or alcoholic beverages). This 

might exclude populations that initiate smoking at older commandment is primarily spiritual, even though it 

ages. More research is needed to ensure that prevention is directed at promoting greater health. Interestingly, 

campaigns reach all appropriate audiences. David O. MacKay, Past President of the Church of Jesus 

Christ of Latter-Day Saints, specifically commented in 

Treatment efforts might also unintentionally exclude 1949 on the history of marketing cigarettes to women 

populations that differ in use patterns from the majority. in the 1920s and 1930s: “I just ask you ... to recall the 

For example, treatment studies typically involve nicotine methods employed by certain tobacco interests to induce 

Appendix A: Reports From the Working Group Breakout Sessions 57 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

young women to smoke cigarettes.” He mentioned 

the early campaign promoting smoking as a means of 

avoiding weight gain, as well as the gradual transition 

in advertisements from portraying men smoking and 

women accompanying them (but not smoking), to 

women smoking overtly. To this day, Utah has the lowest 

smoking prevalence rates in the nation: 14 percent of 

men and 11 percent of women (13 percent overall) (22). 

Interventions delivered through African-American 

churches have also been reported (23, 24), but not in 

terms of differential success between men and women 

(although women go to church more often and are less 

likely to be smokers). 

Disparities 

This recommendation directly addresses the issue of 

population disparities. To reduce disparities, we must fi rst 

understand their causes. Understanding the interactions 

among gender, race and ethnicity, and culture as they affect 

smoking initiation, maintenance, and cessation will aid 

prevention and treatment efforts. 

Partners 

Partners should include research-funding organizations and 

agencies willing to support primary and secondary analyses, 

appropriate research networks, investigators conducting sex 

research, community-based organizations, and government 

entities at all levels. 

n

Impact 

Within 5 years, prevention strategies and treatment effi cacy 

will be enhanced in specific subgroups, reach will increase, 

and disparities will be reduced. 

T ranslation 

3. Understand critical intervention periods in the 

continuum from experimentation to addiction 

and cessation. 

n Experimentation to addiction. Experimentation and 

initial exposure to smoking are occurring at increasingly 

younger ages. In 2002, 13 percent of middle school 

students and 28 percent of high school students reported 

current use of tobacco products (25). However, time of 

initiation differs by ethnicity, with black girls initiating 

smoking later than white girls. Watson and colleagues 

found that the mean age of smoking initiation was 20 

for blacks and 16 for whites (26). About one-half to onethird of teens who experiment with smoking will become 

regular smokers, and 75 percent of teen daily smokers 

will smoke as adults. 

Moreover, the time from experimentation to addiction is 

very brief. Nicotine dependency does not necessarily take 

years to develop and is seen in adolescents (27). Ninety 

percent of adults who smoke began smoking before the 

age of 18 (28). 

Some studies are finding that girls are smoking at higher 

rates than boys. For example, O’Loughlin et al. (29, 

study conducted in Montreal) found that 35 percent 

of females and 29 percent of males were ever smokers 

(p = 0.03) and, among the “ever smokers,” 69 percent of 

females and 46 percent of males had smoked in the past 

3 months (p < 0.000). This gender difference may lead 

to a shift in smoking prevalence such that women may 

eventually smoke at higher rates than men. 

Factors that contribute to experimentation and regular 

tobacco use are not well understood, but research 

examining these issues is increasing. Gender needs 

to be included as an important variable to consider. 

Gender issues and the interaction of gender, culture, and 

ethnicity must be taken into account when exploring 

the continuum from experimentation to addiction. For 

example, susceptibility to nicotine as well as social role 

models (movies, popular figures), peer infl uence, and 

weight and gender issues should all be examined. 

Cessation. Cessation interventions are needed for 

adolescent smokers, and research suggests that 

adolescents are interested in quitting. Over one-third 

of adolescent smokers in one study reported that they 

were considering quitting within the next 6 months, 

and 65 percent had made a quit attempt in the past year 

(30). However, as with prevention efforts, intervention 

efforts must take into account gender and cultural 

differences for this age group. Although the effectiveness 

of adult cessation programs is well recognized, and 

clinical guidelines have established a standard of care 

for this population, little is known regarding adolescent 

cessation; this gap needs to be filled to provide effective 

interventions (31). As we learn more about the unique 

needs of the adolescent population, we must study 

possible gender differences and interactions among 

gender, social, cultural, and biological factors. 

58 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

4. Identify the interpersonal, familial, social and 

cultural contexts for tobacco use by women 

and priority populations of women. 

ratio of positive to negative support may be the most 

important factor in predicting abstinence (41, 42). 

Ginsberg, Hall, and Rosinski’s (43) Partner Support 

Smoking Treatment Program showed that failure to quit Social contextual factors, such as spousal and household smoking was predicted by smokers’ negative behavior smoking, social networks, social ties, and discrimination, (prosmoking statements, interruptions of the partner, may all influence tobacco use by women. Interest in cessation and criticism or rejection of help), and successful and vulnerability to relapse may also be influenced by these cessation was predicted by partners’ reinforcement. factors. Over 90 percent of those who quit smoking do so 

with no formal assistance (32) and depend on their families Social support may be more important for women than men 

and communities for help in achieving and maintaining because rates of depression and negative affect are higher in 

cessation. Family, social, and cultural factors may be especially women. Zelman et al. (44) found supportive counseling to 

important for minority and underserved women who have be more effective than coping skills training for smokers with 

limited access to care and may depend on existing social negative affectivity above the median. 

networks for support. Application 

Some issues have been singled out for further study: *5. Increase access to, demand for, and appeal 

n Role of spousal and household smoking. Spousal and 

household smoking is are important factors in cessation 

and relapse, and this is especially clear in pregnant 

women. Pregnancy significantly increases interest 

and use of effective tobacco dependence 

treatments, especially among women in 

underserved and priority populations. 

Compelling evidence indicates that applying evidence-based in cessation among women who are aware of health treatments to tobacco use and dependence (both counseling concerns related to the fetus. Others in the household, and pharmacotherapy) substantially increases success rates however, may not have the same increased motivation. among smokers trying to quit. Quit rates for smokers using Spousal support for quitting, in terms of both supportive proven treatments—those recommended in the U.S. Public behaviors and the spouse’s own change in smoking Health Service clinical practice guidelines (45)—are two to behavior, has been identified as an influential type of three times higher than those achieved by smokers quitting support for pregnant women (33). Haug, Aaro, and on their own without formal treatments (46). This has been Fugelli (34) found that when pregnant women were demonstrated not only for overall populations of men and encouraged by their partners to stop smoking and women smokers, but for pregnant women specifi cally (47). perceived that their partners were willing to reduce Similarly, studies of unaided quit attempts suggest that their own cigarette use, their rate of smoking cessation, women are more likely to relapse when they quit without negative attitudes toward smoking, and determination to assistance (48). stop smoking were significantly higher. Because smoking 

relapse often occurs when other smokers are present Unfortunately, recent studies indicate that less than 

(35), spouses and partners who continue to smoke 25 percent of quitters currently make use of proven 

may increase the risk of relapse. In pregnant women, treatments or treatment aids (49) and that while most 

socializing or living with a smoker was found to be a primary care providers now advise their patients to quit, 

significant predictor of smoking relapse (36-38). less than half of providers who do so go on to offer needed 

treatment (50). n Role of maternal smoking. Women influence the smoking 

behavior of other family members, especially their Women with little education are far more likely to smoke 

children. The impact of mothers on smoking initiation than those with more education (51). Access to and use 

appears to be stronger than the impact of fathers (39). of effective interventions are lowest among men and 

Interestingly, maternal smoking has been found to women with the least education and lowest incomes in the 

affect the likelihood that their daughters will smoke to a United States, including those in low-income and racial or 

greater extent than that their sons will do so (40). ethnic minority populations (46). The Surgeon General’s 

recent report on tobacco use among U.S. racial and ethnic n Role of social support and social networks. Social support minorities concluded that minority smokers were less likely to for quitting smoking appears to play an important role participate in smoking cessation groups and receive cessation in cessation and the maintenance of abstinence. The 

Appendix A: Reports From the Working Group Breakout Sessions 59 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

advice from health care providers due to such barriers as 

cost, lack of health insurance coverage for proven treatment 

services, and reduced access to health care services generally, as 

well as barriers related to transportation (52). 

(such as cervical cancer, reconstructive procedures for 

breast cancer, oral contraception, hormone replacement 

therapy, menstrual cycle, infertility issues) are also not 

widely known or understood. Thus, smoking risks and 

Tobacco control policies and counter-advertising campaigns quitting benefits related to reproductive health (e.g., 

can substantially increase quitting motivation and quitters’ fertility, pregnancy, fetal and child health outcomes) 

demand for and use of proven treatments. The CDC’s and children’s exposure to environmental tobacco 

Guide to Community Preventive Services (53) showed that smoke should be highlighted. Cessation messages and 

smoking bans and restrictions, increases in the cost of campaigns aimed at woman smokers should also address 

tobacco products, reduction in smokers’ out-of-pocket costs common misconceptions about the effects of quitting on 

for cessation services, and pro-cessation counter-advertising long-term health. 

campaigns significantly increase population quit rates and n Access. Increasing demand for treatment must be 

the use of available quitting services—especially telephone followed by increasing access to care. It is critical to 

quit lines to which access barriers are minimal. The Surgeon broaden the help offered to women through the health 

General’s report Women and Smoking notes that women are care system by ensuring that every woman receives 

more likely than men to state that their smoking patterns evidence-based smoking assessment and cessation 

are influenced by worksite smoking policies (54). A recent counseling during routine health care with primary 

study found that increased cigarette excise taxes had a care, obstetrics and gynecology, pregnancy and prenatal 

disproportionate influence on quitting patterns among care, and pediatric care providers (e.g., the action plan 

pregnant smokers (55). The use of targeted messages and developed by the National Partnership to Help Pregnant 

media to reach smokers in cessation campaigns aimed at Smokers Quit) (58). Cost barriers must be removed, and 

underserved populations, such as African-American smokers, newer treatments that use such technology as targeted 

have been found effective for both men and women (56). To mailings, the Internet, and telephone quit lines may 

generate higher rates of demand and use, the Subcommittee expand access for many. However, interventions that 

on Cessation of the Interagency Committee on Smoking depend on access to Web-based resources, and even 

and Health recently recommended significant tax increases telephones, may not reach the most underserved lowcoupled with the creation of a nationwide tobacco cessation income and priority populations. 

quit line; a multifaceted, paid national media campaign to Disparities promote quitting; public and private insurance coverage for 

tobacco-dependence treatment; and increases in the Federal This recommendation directly addresses the issue of health 

excise tax on cigarettes by $2.00 per pack as part of an disparities and will have a significant impact by increasing the 

unprecedented national initiative to help smokers quit. The number of women with access to treatment. 

Subcommittee projected that 5 million smokers would quit in Partners 

the first year alone as a result of its recommendations, which 

would prevent 3 million premature deaths (46). Partners include traditional and alternative health care 

systems and providers, community-based organizations, Goal areas include: health services payers, media and marketing companies, 

n Demand. The developers of cessation campaigns and pharmaceutical companies, patient advocacy groups, faithmessages designed to boost treatment demand and based groups, and schools. 

use among women smokers should seek to increase Impact 

awareness of the need for and benefits of treatment, 

highlighting the unique health, mood, and cosmetic In 5 years, smoking prevalence will change; quit attempts will 

benefits accrued by women who quit. For example, increase; demand for treatment will increase; awareness of the 

women fear breast cancer more than lung cancer consequences of smoking will grow; and norms governing 

(57), yet more women die annually from lung cancer. smoking will change markedly. 

Similarly, most women underestimate their risk for 

smoking-related cardiovascular disease (57). The role of 

smoking in health concerns that are unique to women 

60 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

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of cancer risks from smoking. Paper presented at: Annual 52. U.S. Department of Health and Human Services. Meeting of the Society for Research on Nicotine and Tobacco Use Among U.S. Racial/Ethnic Minority Tobacco; February 19, 2004; Scottsdale, AZ. Groups—African Americans, American Indians and 

Alaska Natives, Asian Americans and Pacifi c Islanders, 58. Robert Wood Johnson Foundation. The National 

and Hispanics: A Report of the Surgeon General. Partnership to Help Pregnant Smokers Quit: Action Plan. 

Princeton, NJ: Robert Wood Johnson Foundation; 2002. Atlanta, GA: U.S. Department of Health and 

Appendix A: Reports From the Working Group Breakout Sessions 63 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

64 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Awareness, Risk Perception, and Communications 

Breakout Session 

Co-Chairs 

Participants 

Science Writer 

Lead Author 

Overview 

Susan Curry 

Sharon Carothers 

Richard Daynard 

John Finnegan 

Melissa Finucane 

Laura Janusik 

Kathryn Kahler Vose 

Women often act as influencers and gatekeepers in family health (1-3) and thus are an important target audience 

for smoking cessation messages. Informational and persuasive 

messages must be crafted in such a way that women will carry 

these messages through their webs of exposure, affi liation, 

and influence. However, messages must resonate with women 

before they will disseminate them, so the messages must 

reflect the cultural or social groups to which women belong, 

including groups based on ethnicity, race, sexual orientation, 

religion, and worldviews and values. Furthermore, 

effective messages must take into account women’s current 

understanding of the health risks associated with smoking and 

the perceived barriers that counter cessation efforts (4). 

Evidence-based research is the key to developing best 

practices that effect behavioral changes in women’s tobacco 

use reduction and prevention (5, 6). Given that the science 

is rapidly evolving, these best practices must be disseminated 

promptly to practitioners and consumers who can provide 

feedback to ensure that researchers generate information 

that is useful and applicable. A potentially effective means of 

information dissemination is to target existing groups that 

already support women and women’s causes. Such groups will 

need to understand how to process and filter new fi ndings 

and media portrayals of emerging scientific information in 

order to use this information effectively. Researchers and 

public health professionals have a responsibility to translate 

basic research into effective smoking cessation and prevention 

messages that can be disseminated by women’s groups and the 

media for broad public impact. 

Kathryn Kahler Vose 

Jessie Gruman Danny McGoldrick 

Isaac Lipkus Laurie McLeod 

Grace Ma Alexandre Prokhorov 

Colleen McBride Ruth Wooden 

Recommendations 

Research 

*1. Understand knowledge and risk perceptions. 

Basic and applied research are needed on women’s 

current level of knowledge about the risks of smoking 

and their assessment of personal risk. To be effective, risk 

communication needs to be based on an understanding of: 

(a) accuracies and inaccuracies in women’s knowledge about 

tobacco use, prevention, and cessation; and (b) the interplay 

of affective (experiential) and analytic approaches to assessing 

risk and deciding what course of action to take. This research 

should identify mechanisms to which women will respond 

and focus on different ethnic, socioeconomic, and health 

status groups across the lifespan. 

Examples of specific topics include: 

n Knowledge of addiction. Little is known about women’s 

perceptions of the addictiveness of cigarette smoking 

and their understanding of the process by which they 

become addicted. Research does show, however, that girls 

may lack a basic understanding of the power of nicotine. 

In a 2001 study, investigators found that 24 percent of 

girls ages 12 to 18 believed, “Even if I smoke cigarettes 

regularly, I could stop anytime I want” (7). This 

misperception was even more common (41 percent) 

among girls who were already tobacco users. Further 

research is needed to explore how beliefs about the 

addictiveness of tobacco are formed and how prevention 

messages can counteract inaccurate impressions of 

individual control. 

* Recommendations with an asterisk are those identified by the breakout groups as their top three recommendations. 

Appendix A: Reports From the Working Group Breakout Sessions 65 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

n Knowledge of health consequences and risk perception. risk for chronic health conditions. Continual monitoring of 

Some smokers may not be aware of the connection the impact of education efforts will inform researchers as to 

between their behavior and their health. For example, which messages are most effective and help them maximize 

investigators on one study found that current smokers the potency of messages to enhance prevention and cessation 

were less likely than those who had never smoked to efforts. 

agree that health risk behaviors associated with smoking *2. Develop and disseminate targeted messages. may increase risk for breast cancer (8). Are some specifi c 

groups of women simply unaware of the risks associated The social marketing agenda must be advanced using 

with smoking? How do we reach these women who have qualitative and quantitative methods and focusing on the 

not been hearing the message? Even if women are aware psychological, sociocultural, and economic segmentation of 

of the health risks associated with smoking, they often women. On its own, recognition of the personal health risks 

have a perception of personal safety or “self-exemption” of smoking does not often lead to cessation (10). Awareness 

from the consequences. Smokers exhibit more perceived of smoking risks needs to be combined with decreased 

self-exemption than nonsmokers from both smoking and benefits from and increased barriers to smoking and social 

nonsmoking health risks (9). Further research is needed and environmental support for not smoking. The key is to 

to explore how, other than through actual experience, identify sets of attitudes and values in women who can be 

women can be encouraged to view the dangers of targeted for cessation, prevention, and advocacy messages 

smoking as personally relevant. for environmental change. Further research can explore how 

Disparities women experience smoking as an affordable pleasure and how 

tobacco products fit into women’s views of affordable routine 

Research on risk perception can address disparities by pleasure. 

including groups of women who have not typically responded 

to tobacco control messages in the conduct of the research. Some prime areas for research include: 

Application of the research results could make these groups n Identifying target groups. Using lifestyle risk factors, 

more likely to attend to and make use of information to sociodemographics, and health perceptions to group 

induce needed change. people has been considered a useful way to create 

Partners target audiences for health messages (11, 12). Some 

researchers also suggest that understanding the diversity Government needs to play a critical role in providing of smokers’ representations and explanations of their 

funding for basic research and earmarking funding for own smoking may play a useful role in developing the evaluation of communication efforts. Scientists effective messages (13). For particular groups of women, and health researchers should develop proposals for additional factors may play a role. For example, in a 

government research spending and establish partnerships study of pregnant women, depression was found to be a with community-based organizations that have the ability significant predictor of smoking during pregnancy, even to implement education efforts at a grassroots level. These after controlling for other factors such as the desirability community-based organizations must have an active role in of the pregnancy and the presence of other smokers designing and implementing evaluation research to ensure in the household (14). Thus, comprehensive models 

the appropriateness of the programs and create a sense of smoking addiction are clearly needed that take into of ownership that will lead to continued efforts beyond account various influences in women’s lives. 

government funding periods. Nontraditional partners 

(e.g., business, industry, the entertainment fi eld, women’s n Understanding target groups. Although some formative 

groups, ethnic organizations, etc.) can support community- focus group research has helped elucidate the benefi ts of 

based efforts by providing leadership, resources, and and barriers to smoking cessation for particular groups of 

additional funding. women (15), few large-scale studies of the “hot buttons” 

that motivate women to take action against tobacco have Impact been conducted. Reviews of tobacco company literature 

Basic and applied risk-perception research will allow suggest that “systematic and extensive research is carried 

antitobacco groups to effectively target young girls prior to out by tobacco companies to ensure that cigarette 

smoking initiation as well as current smokers who have thus packaging appeals to selected target groups, including 

far been unable or unwilling to define themselves as being at young adults and women” (16). Antitobacco campaigns 

66 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

need to be based on at least a similar level of systematic 

and extensive research. This research should provide a 

clear picture of the attitudes, values, and needs of target 

groups, including those at risk for smoking, current 

smokers, and women’s health advocates. 

n Message and intervention evaluation. Although message 

concepts are routinely tested among target audiences, 

large-scale message and intervention results are not as 

commonly catalogued and monitored. For researchers 

to hone new research quickly and effectively, a 

comprehensive feedback system is needed. 

Disparities 

Specific populations need to be primary target groups. By 

conducting research in different sociodemographic and 

cultural groups, disparities in tobacco use and cessation can be 

addressed through tailored messages to priority populations. 

Partners 

Academic institutions (including schools of public health, 

psychology, communication, and anthropology) should be 

tasked with performing and sharing research. Marketing fi rms 

can assist academic institutions by providing target-audience 

information from national communication databases. 

Marketing firms must also play a strategic role in developing 

and implementing social marketing plans to effect social 

change. Key partners include existing women’s groups that are 

(or are not) already active in tobacco control. Women’s groups 

should be active in both the planning and implementation of 

social marketing efforts. 

Impact 

Within 2 years, this work should make it possible to identify 

priorities, focus resources, and develop specifi c prevention 

and cessation strategies, including effective messages and 

channels for communication. Surveillance over 5 years will 

monitor and evaluate the effectiveness of these interventions 

among various segments of the population. If the work is 

done well, new messages could be delivered that counter 

the effects of tobacco industry messages (e.g., for women of 

low socioeconomic status, the goal would be to counter the 

notion of attractiveness or pleasurable aspects/ideology that 

surrounds tobacco use). 

3. Understand positive positioning of tobacco. 

Tobacco marketers have successfully positioned tobacco 

use as an affordable pleasure for women, and many women 

smokers report that tobacco use is a positive and meaningful 

part of their lives (13). Further research is needed to explore 

this positive association, including how women experience 

smoking as an affordable pleasure and how tobacco products 

fit into women’s views of affordable routine pleasures. This 

research can assist in understanding the benefi ts women 

associate with smoking, provide ways to counter those 

benefits, and identify complementary benefits associated with 

quitting smoking. 

Disparities 

Examining the positive perceptions of tobacco use among 

women in different socioeconomic and cultural groups will 

facilitate the development of tailored messages addressing 

each of these perceptions. 

Partners 

Marketing firms, women’s groups, and businesses that market 

“safe pleasures” to women could partner with academic 

institutions. Marketing firms could assist by providing 

target-audience information from national communication 

databases, and businesses might provide additional insights 

into women’s needs and desires. They might also participate 

by developing alternative low-cost pleasures for women who 

are trying to quit smoking. Women’s groups could work with 

these organizations to design and implement pilot programs 

to counter the “affordable pleasure” aspect of tobacco 

marketing to women. 

Impact 

New messages could be delivered to counter the effects of 

tobacco industry messages that promote the attractive and 

pleasurable aspects of tobacco. 

Translation 

4. Use available evidence and gather additional 

evidence about health- and non-healthrelated messages that would interest women 

and engage them in tobacco cessation and 

antitobacco advocacy. 

It is generally agreed that women do not understand the 

full impact of smoking on their health (17, 18). However, 

effective ways to communicate this message may vary 

depending on a woman’s age, smoking status, and economic 

status and whether or not she is pregnant. Meta-analyses 

of female-specific interventions reveal how these factors are 

significantly related to how women approach cessation (19-

21). 

Available evidence to date and additional ongoing research 

(outlined above) will serve to segment priority audiences and 

provide insights into appropriate channels and tactics to reach 

Appendix A: Reports From the Working Group Breakout Sessions 67 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

them. However, to ensure that progress is made in reducing Association can gather information about current programs 

tobacco initiation among women and increasing successful and provide data to the tobacco control community. Tobacco 

cessation efforts among women who smoke, translation and settlement funds can be used by state health departments to 

outreach efforts must be appropriately tracked and evaluated track results and promote appropriate interventions through 

so that best practices can be identified and replicated. state public health programs. 

Target audiences include: Impact 

n Pregnant smokers. One high-priority audience is pregnant By positioning tobacco cessation as a primary factor in overall 

smokers. The current best-practice intervention is in- women’s health and economic well-being and by showing that 

office counseling by trained providers, which has been coordinated efforts can lead to declines in women’s tobacco 

shown to double, and in some cases triple, successful use, additional attention can be called to tobacco control 

quit attempts by pregnant women (22). Efforts should as an issue of concern for all women. As a result, women’s 

be made to increase use of this intervention among engagement with tobacco issues will increase. 

providers, increase knowledge among women that 5. Fund pilot or demonstration projects and assistance is available, and support public policy efforts related research to understand how to 

to ensure that health insurers pay for such counseling. In convert women’s broad-based support for addition, tobacco use among high-priority populations, tobacco control policy and programs into such as American Indians, must be evaluated. However, active involvement in advocacy. because of the complex physiological and psychological 

issues related to tobacco addiction during pregnancy Systemic change requires involvement from a wide cross-

(23), additional research on alternative approaches section of society. Broad-based women’s groups have an 

must be conducted. Such research should include the enormous impact on how society views and acts upon matters 

investigation of pharmacotherapy for pregnant smokers. that are considered “women’s issues” (25). The tobacco 

control community must do a better job of educating these n Young women. Because the average age at tobacco use groups about the toll tobacco use takes on women and of initiation among women has been declining (24), engaging them in tobacco control activities. outreach to young women is another priority activity. 

Efforts should be made to increase knowledge of young Research on competing issues and the overall agendas of 

women’s receptiveness to tobacco industry messages, various women’s organizations will provide insights into how 

create effective counter-marketing messages, and develop to approach these groups about adding tobacco control to 

channels and tactics through which such messages their programs. By funding pilot or demonstration projects 

can be disseminated. Increased understanding of the with certain organizations, it is possible to ascertain how to 

role tobacco plays in young women’s perceptions of effectively engage women’s leaders, create effective grassroots 

themselves and in defining certain key attributes they advocacy programs in conjunction with women’s groups, and 

crave (e.g., sexiness, adulthood) should also be examined, activate local leaders on the issue. It is especially important 

and mechanisms to define such attributes for young that interventions found to be effective in general populations 

women in alternative ways should be developed. be evaluated in women of specific ethnicities to ensure that no 

unintended consequences of messages or approaches occur or, Disparities if such consequences are found, that appropriate corrections 

Research and evaluation must be designed to determine the are made for these audiences. 

effectiveness of different messages and approaches for different Research to advance this goal might include: subgroups of women and the appropriateness of developing 

tailored messages and strategies to address disparities. n A review of other successful women-led social change 

Partners movements. The review would identify how these 

movements have succeeded in engaging and activating 

The media can be educated about appropriate messages and women. 

materials and urged to promote appropriate messages in 

reaching out to women on this issue. National health and n An analysis of issues on which national organizations are 

advocacy groups such as the American Legacy Foundation, focusing and the reasons for selecting these issues. Target 

the American Cancer Society, and the American Lung organizations might include the National Organization 

68 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

for Women and the National Partnership for Women 

and Families. 

n An analysis of issues in which women are involved at 

the grassroots and “grasstops” levels. This analysis would 

identify why these are considered priority issues and how 

seriously tobacco control is seen in comparison. 

n Evaluation of previous pilot programs directed toward 

women. This will determine which programs might be 

effectively expanded to reach new audiences. 

n Development and evaluation of pilot projects. This would 

enable the tobacco control community to ascertain how 

to effectively engage women leaders, create effective 

grassroots advocacy programs in conjunction with 

women-led community groups, and activate local leaders 

on the issue. 

Based upon the results of this research, appropriate messages 

and materials can be developed for use in reaching out to 

organizations that have not been involved in tobacco control 

to date. 

Disparities 

By reaching out to organizations representing populations 

that are disproportionately affected by tobacco but have not 

heretofore been involved in antitobacco advocacy, policies/ 

programs can be launched to evaluate the effectiveness of 

various interventions with their target populations, eventually 

improving these populations’ health. 

Partners 

National health and advocacy groups, such as the American 

Legacy Foundation, the American Cancer Society, and the 

American Lung Association, can conduct planning research 

and develop templates for pilot programs. To reach new 

audiences, pilot programs can be undertaken by antitobacco 

advocacy organizations in conjunction with nontraditional 

partners such as labor organizations, faith-based 

organizations, businesses, women’s business interests, women’s 

advocacy organizations, and social service organizations. 

These organizations can be galvanized to use their existing 

communication channels to carry tobacco prevention and 

cessation messages to a broader audience of women. 

Impact 

By positioning tobacco cessation as a primary factor in overall 

women’s health and economic well-being and by showing that 

coordinated efforts can lead to declines in women’s tobacco 

use, women’s engagement with tobacco issues will increase, 

and the political base of support for tobacco control will 

expand. 

Application 

*6. Maximize dissemination of tobacco control 

research fi ndings using state-of-the-art 

communication strategies. 

The tobacco control research community is relatively small 

and tightly knit, but the universe of practitioners and tobacco 

users who will benefit from research findings and best-practice 

interventions is much larger. To be effective, research fi ndings 

must be efficiently and quickly disseminated from the tobacco 

control community to the broader health care and media 

communities and, eventually, to consumers. Increasing 

communication between researchers and practitioners will 

help refine interventions by ensuring that research designs are 

informed by practitioners’ constraints and that researchers 

are investigating issues that reflect the target population. 

Increased collaboration will aid in the development of the 

most cost-effective and efficient practices possible. Because 

research findings can at times be contradictory, increasing 

communication to assist practitioners in understanding and 

explaining contradictory information to their patients is also 

important. 

Implementing this recommendation will involve: 

n Creating a clearinghouse. An organization or system 

should be created that is responsible for identifying 

individual and/or policy-relevant tobacco control 

research findings (from within and outside the 

academic community) and for using state-of-the-art 

communication strategies to maximize dissemination 

to relevant audiences. This might include polling and 

marketing research, journal articles, research abstracts, 

and examples of communication materials used to 

support best-practice interventions. 

n Reaching out to health providers. The tobacco control 

community should reach out to health provider 

organizations to incorporate training on best-practice 

cessation interventions at national, state, and local 

meetings. These opportunities should be made 

available to nurses, nurse practitioners, social workers, 

obstetrician/gynecologists, internists, dentists, and all 

other medical specialists who may serve as primary 

care providers. By using effective provider-centered 

communication strategies (26) and making it easy to 

update providers’ skills in counseling and aiding patients 

to successfully quit smoking, the importance of the issue 

Appendix A: Reports From the Working Group Breakout Sessions 69 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

will be elevated among these key audiences, and they will 4. Rosenstock IM, Strecher VJ, Becker MH. Social learning 

be encouraged to keep informed of the latest advances. theory and the health belief model. Health Education 

n Effectively using the media. Media briefings should be Quarterly. 1988;15:175-83. 

designed to both educate and inform the media so that 5. Kelley K, Bond R, Abraham C. Effective approaches to 

they understand the context in which new fi ndings are persuading pregnant women to quit smoking: A metareleased. The briefings would not only explain the new analysis of intervention evaluation studies. British Journal 

research findings, but would also cover the expected of Health Psychology. 2001;6:207-28. 

impact or use of the findings and an overview of other 6. Dino GA, Horn KA, Goldcamp J, Maniar SD, research that the new findings support or refute. Fernandes A, Massey CJ. Statewide demonstration of 

Disparities Not On Tobacco: A gender-sensitive teen smoking 

To establish feedback loops with priority populations, cessation program. Journal of School Nursing. 2001;17: 

outreach is needed to medical professional organizations that 90-7. 

represent minority practitioners, and relationships must be 7. YouthStyles 2002 [communications database on youth 

created with the media and other communication channels behavior]. Washington, DC: Porter Novelli. 

that serve priority populations. 8. Messina C, Kabat G, Lane D. Perceptions of risk factors 

Partners for breast cancer and attitudes toward mammography 

Potential partners include the tobacco control research among women who are current, ex- and non-smokers. 

community to actively present and share information with Women & Health. 2002;36:65-82. 

providers and other target audiences. Mass-media outlets 9. Markowitz LJ. Smokers’ perceived self-exemption from 

would be engaged to provide liaison to and feedback from health risks. Psi Chi Journal of Undergraduate Research. consumers. Funders must be engaged to underwrite the 2000;5:119-24. 

necessary infrastructure, and the advocacy community must 

be empowered and encouraged to share nonproprietary 10. Haug N, Stitzer M, Svikis D. Smoking during pregnancy 

survey, focus group, and opinion poll data. and intention to quit: A profile of methadonemaintained women. Nicotine & Tobacco Research. 2001;3: 

Impact 333-9. 

Key information will be disseminated more rapidly and 11. Schuit A, van Loon A, Tijhuis M, Ocke M. Clustering completely to the general public and among the decision- lifestyle risk factors in a general adult population. making elite. Partnerships will open communication channels Preventive Medicine. 2002;35:219-24. 

from consumers back to researchers to help inform and shape 

future research agendas and to refine and improve current 12. Maibach E, Maxfield A, Ladin K, Slater M. Translating 

best-practice interventions. health psychology into effective health communication: 

The American Healthstyles Audience Segmentation 

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15. Hotham E, Atkinson E, Gilbert A. Focus groups with 

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Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

16. Moran S, Glazier G, Armstrong K. Women smokers’ 

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Women’s Health. 2003;12:363-71. 

22. Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside 

HP, Goldenberg RL. Recommended cessation counseling 

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Appendix A: Reports From the Working Group Breakout Sessions 71 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

72 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Community and Policy Interventions Breakout Session 

Co-Chairs 

Participants 

Science Writer 

Lead Authors 

Overview 

Jasjit S. Ahluwalia 

Victoria Almquist 

Dileep Bal 

Lori New Breast 

Neena Chaudry 

Cynthia Coachman 

Eleanor Mayfi eld 

Michele Bloch 

The Impact of Policy Interventions 

Policy interventions are now a well-recognized component of tobacco control and prevention efforts. In the United 

States, early Federal policy-making efforts focused on 

cigarette advertising and promotion. In the 1970s and 1980s, 

nonsmokers’ rights organizations began pressing for policies 

to protect nonsmokers from environmental tobacco smoke 

(ETS) and, later, for other policy measures (1). Over time, the 

success of these and other policy-focused efforts has helped 

establish public policy as an important component of tobacco 

control and prevention. 

Research now demonstrates the effectiveness of policy 

interventions to prevent and decrease tobacco use. Among the 

most powerful interventions is increasing tobacco excise taxes. 

As noted in Reducing Tobacco Use: A Report of the Surgeon 

General, “Increases in cigarette prices lead to substantial 

reductions in cigarette smoking by deterring smoking 

initiation among youth, promoting smoking cessation among 

adults, and reducing the average cigarette consumption 

among continuing smokers” (2). The impact of price increases 

is not limited to the United States; the World Bank reports 

that, on average, a price increase of 10 percent per pack 

would reduce demand for cigarettes by about 4 percent in 

higher-income countries and by about 8 percent in lower- and 

middle-income countries (3). 

Policies to restrict smoking in indoor locations such as 

workplaces and public areas (“clean indoor air” laws) are 

effective in reducing nonsmokers’ exposure to ETS. These 

policies are also credited with increasing the rate at which 

smokers attempt to quit, increasing the success rates of these 

Linda Bailey Donna Grande 

Marian Fitzgibbon Jeanette Noltenius 

Elaine Ishihara Anne Marie O’Keefe 

Helen Lettlow Monica Scheibmeir 

Debbie Maise 

Deborah McClellan 

Anne Marie O’Keefe 

attempts, and reducing the number of cigarettes smoked per 

day by those who continue to smoke (4, 5). In addition, a 

recent study suggests that the broad decline in the percentage 

of children exposed to ETS in the home is due, in part, to 

efforts to decrease ETS in worksites and public places (6). The 

laws and the effort required to enact them may have helped 

change social norms, including the attitudes of parents who 

smoke toward exposing their children to ETS in the home. 

In addition, many countries have either banned or severely 

restricted tobacco advertising and promotion in response to 

its impact on youth and adults (7). 

Community-Level Programs and Policies 

Community-level intervention research has contributed 

greatly to our understanding of effective state- and 

community-level programs and policies. The North Karelia 

Project (Finland) and the Stanford Three-Community 

Study (United States) were key early community-level 

intervention trials aimed at preventing cardiovascular disease 

(8). These studies, which demonstrated the potential impact 

of community-level interventions, were followed by others, 

including many aimed specifically at reducing tobacco use (9). 

The potential of community-based interventions to provide 

persistent and inescapable messages to quit smoking formed 

the basis for the NCI Community Intervention Trial for 

Smoking Cessation (COMMIT), begun in September 1986 

(10). Its successor, the American Stop Smoking Intervention 

Study (ASSIST), which began in October 1991, focused on 

changing policy to alter the social, cultural, economic, and 

environmental factors that promote smoking (11). More 

recently, increased emphasis has been placed on conducting 

research that is truly “community centered” or “community 

based”—defined as a “collaborative approach to research 

Appendix A: Reports From the Working Group Breakout Sessions 73 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

that equitably involves, for example, community members, white women, 22 percent among black women, 17 percent 

organizational representatives, and researchers in all aspects among Hispanic women, and 9 percent among Asian women. 

of the research process” (12). Community intervention and Variation among different Hispanic and Asian subgroups was 

community-based research have helped make state- and also demonstrated (18). 

community-level interventions, both programmatic and Data on tobacco use by American Indian/Alaska Native policy, an important part of efforts to reduce tobacco use (13, women have some significant limitations; for example, the 14). National Health Interview Study did not identify American 

Community activism and advocacy, including media Indian/Alaska Native respondents until 1978. Despite this, 

advocacy, are a critical part of efforts to implement effective it is clear that American Indian/Alaska Native men and 

tobacco control and prevention policies. Community women have had significantly higher smoking rates than 

activism can be effective even when legislation is not enacted; any other group for many years. Furthermore, the overall 

the process of community activism serves to educate the figure masks significant variation among tribal groups. For 

community and change social norms and, on occasion, example, a threefold variation in prevalence was observed 

results in changes in private policy. For example, many large among American Indian/Alaska Native women of different 

businesses, including several nationwide restaurant chains, geographic regions: 14 percent of women in the Southwest 

have implemented 100 percent smoke-free policies in the were current smokers, compared with 38 percent of women 

absence of laws requiring them to do so. in the Northern Plains (1988-1992 aggregate data). Cigarette 

smoking by American Indian/Alaska Native women of Reducing W omen’ s Risk reproductive age remained at 36 to 44 percent between 

Lung cancer has been the leading cause of cancer death in 1978 and 1995, and even higher rates were observed among 

women for many years, having overtaken breast cancer death American Indian/Alaska Native women of reproductive age 

in white women in 1986 and in black women in 1990 (15). with less than a high school education (47 to 82 percent). 

However, while awareness of the risk of breast cancer is Relatively little quitting behavior has been found in this 

widespread, research suggests that few women are aware of population (19), and some data also indicate high rates of 

the grave danger they face from lung cancer. For example, smokeless tobacco use among specific groups of American 

a January 2001 survey conducted by the American Legacy Indian/Alaska Native women (20, 21). 

Foundation found that 80 percent of women believed that Many challenges exist in reducing tobacco use by American breast cancer is the leading cause of cancer death among Indian/Alaska Native women. These include the community’s U.S. women (16). Few women’s and girls’ organizations enormous diversity, poverty, and deprivation and the fact that are involved in tobacco control and prevention, and this conventional service organizations often do not operate on issue is rarely visible on the agenda of the women’s advocacy Indian reservations. Interventions will need to be tailored to community. the specific community served; partnering with organizations 

Certain groups of women are at increased risk for tobacco that already operate on Indian reservations, especially 

use and tobacco-related disease. Overall, in 2002, 20 percent American Indian/Alaska Native organizations, may be 

of women aged 18 and older were current smokers; however, particularly valuable. 

prevalence varied sharply by level of educational attainment, Research Barriers, Gaps, and Opportunities race/ethnicity, and economic status. Women with a graduate 

degree had the lowest smoking prevalence (6 percent). In Numerous barriers to research on effective community and 

sharp contrast, women with low levels of education had the policy interventions exist, including insuffi cient resources, 

highest prevalence: 31 percent of women with 9-11 years of capacity, infrastructure, leadership, and researchers capable of 

education and 37 percent of women with a GED smoked. conducting community-based research. In addition, research 

Women at or above the poverty level were much less likely on effective community and policy interventions is often not 

to smoke than those living below the poverty level (20 amenable to the use of randomized controlled trials, generally 

percent vs. 30 percent, respectively) (17). Lastly, a recent considered the “gold standard” of research (22). For this and 

study documented enormous variation in cigarette smoking other reasons, community-based researchers often have greater 

among different racial and ethnic groups. In 1999-2001, difficulty than their more traditional counterparts in securing 

the prevalence of cigarette smoking was 40 percent among funding for their work (12). 

American Indian/Alaska Native women, 26 percent among 

74 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Important gaps in this area include the need for a better partnerships between community-based organizations and 

understanding of differences in smoking prevalence among academic researchers. 

ethnic groups and the cultural and gender-specific factors that 

influence exposure to ETS. Often, research fails to consider 

culture; as a result, many “best practices” are not especially 

effective in reaching priority populations. Segmented, targeted 

social marketing research is especially needed to counter the 

extensive qualitative and quantitative research conducted by 

the tobacco industry. Research is also needed to determine 

the effects of tobacco control and prevention policies 

implemented at technical schools and other institutions that 

serve young women who do not attend college. 

Important community and policy research opportunities 

exist in many areas, including lessons learned from changes 

in societal attitudes toward tobacco use; factors that 

motivate policy makers to support tobacco control policies; 

successful strategies to convey smoking cessation messages to 

subpopulations characterized by isolation, low socioeconomic 

status, and/or low literacy; Internet sales of tax-free or lowtax tobacco products by Indian reservations; the impact of 

smoking bans in bars, casinos, and other venues; and whether 

analysis of existing surveillance data can identify gaps in 

knowledge about gender, ethnicity, and culturally specifi c 

issues related to tobacco use. Past research has rarely studied 

the impact of policies and interventions on women; genderspecific research represents an important opportunity for 

future work. 

Recommendations 

Research 

*1. Encourage funding organizations to embrace 

participatory research. 

New funding mechanisms are needed to support culturally 

relevant community-based participatory research. Funding 

organizations should increase their commitment to support 

institutions and organizations that are committed to forging 

research partnerships with community organizations. 

True partnerships are bidirectional—community-based 

collaborators receive training in research methodology 

while academic researchers receive training in culturally 

and community-tailored interventions—and require a 

commitment to joint decision making and shared ownership 

of the project. The breakout group recommends increased 

funding for collaborative research projects, including applied 

research and “community action research,” to encourage 

California’s Tobacco-Related Disease Research Program’s 

Participatory Research Awards may be a useful model for 

other research funding organizations to consider. These 

awards (Community-Academic Research Awards and SchoolAcademic Research Awards) are designed to stimulate and 

support collaborations between academic investigators 

and community-based organizations, local tobacco control 

initiatives, and schools to perform scientifi cally rigorous 

research. 

Because other health conditions are prominent among 

smokers, NCI should consider partnering with other National 

Institutes of Health (NIH) Institutes to study such issues 

as tobacco use in people with diabetes and hypertension or 

the interaction of alcohol and tobacco policies. To counter 

discrimination based on race and ethnicity, gender, and social 

class, research subjects—people who smoke, communitybased organizations, communities of color, and other 

groups—should have a voice in determining future research 

funding. 

Impact 

Within 5 years, an increased level of active participatory 

research will be under way. 

*2. Develop funding mechanisms that foster 

partnerships between research institutions 

and organizations that serve high-risk 

populations. 

At present, funding mechanisms do not often facilitate 

partnerships with community organizations; at times, they 

even create barriers to these partnerships. Partnerships are 

especially needed with organizations serving populations at 

high risk for tobacco use. American Indians/Alaska Natives 

are a particular focus, given the magnitude and persistence of 

the problem of tobacco use in this population. Tribal colleges, 

tribal health departments, and other institutions that serve 

these communities should be especially targeted for research 

partnerships. 

Impact 

Within 2 years, funding mechanisms will incorporate 

culturally competent approaches and language to facilitate 

greater involvement by culturally diverse organizations and 

researchers. 

* Recommendations with an asterisk are those identified by the breakout groups as their top three (or four) recommendations. 

Appendix A: Reports From the Working Group Breakout Sessions 75 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

*3. Fund strategic policy research to increase our lower smoking rates (11). Lessons learned from the ASSIST 

knowledge of the impact of public and private project could be applied to the development of publictobacco control policies on women and girls. private partnerships to decrease women’s tobacco use. For 

example, the NIH Office of Research on Women’s Health, Despite the well-recognized role of policy interventions in the U.S. Department of Agriculture’s Women, Infants, and tobacco control and prevention, relatively little research Children (WIC) program, and a foundation that focuses on has focused on the differential impact of policies, if any, on women’s or health issues could work together to design and women and girls. A better gender-based understanding of the implement programs and policies at WIC clinics to assist impact of current policies (at the community, state, national, women to quit smoking and reduce children’s ETS exposure. and international levels) on attitudes, behaviors, and health Successful projects could then be considered for nationwide effects is needed. Gender-based analyses of newer policy dissemination. Research and demonstration projects are also efforts, such as the impact of family and home-based policies needed to understand how to convert broad community and policies related to health systems change, are needed as support—especially women’s and girls’ support—for tobacco well. Research can also provide and test models to understand control policies into active community involvement in their how various policies alter social norms and behaviors, clarify development and enforcement. the policy development process, and offer an understanding 

of how best to communicate and collaborate with policy References makers to enact and enforce effective policy measures. 

Impact 1. Bloch MH. Tobacco control and prevention. In: Brobeck 

S, ed. Encyclopedia of the Consumer Movement. Santa 

Within 5 years, research findings will be analyzed and Barbara, CA: ABC-CLIO; 1997: 564-8. 

published that will guide the development of evidence-based 

tobacco control policy and its impact on gender differences. 2. U.S. Department of Health and Human Services. 

*4. Support research to identify messages and 

strategies to engage women’s and girls’ 

organizations and their constituents in 

tobacco control and prevention efforts. 

Reducing Tobacco Use: A Report of the Surgeon General. 

Atlanta, GA: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and 

Health Promotion, Office on Smoking and Health; 

Long-term, sustained, and coordinated strategies are needed 2000. 

to engage women’s and girls’ organizations in tobacco 3. Jha P, Chaloupka FJ. Curbing the Epidemic: Governments 

issues and to incorporate the issue of tobacco into the and the Economics of Tobacco Control. Washington, DC: 

women’s health agenda. Women’s and girls’ organizations are World Bank; 1999. 

appropriate partners to determine how best to communicate 

to women the enormity and importance of the problem 4. Hopkins DP, Briss, PA, Ricard CJ, et al. Reviews of 

of tobacco use and their potential role in addressing this evidence regarding interventions to reduce tobacco use 

problem. and exposure to environmental tobacco smoke. American 

Journal of Preventive Medicine. 2001;20(2S):16-66.

Impact 

Within 3 years, a functional, operative network will exist, 

will have established relationships with key women’s and girls’ 

organizations, and will support a growing constituent base. 

5. National Cancer Institute. Population-Based Smoking 

Cessation: Proceedings of a Conference on What Works to 

Influence Cessation in the General Population. Smoking 

and Tobacco Control Monograph No. 12. Bethesda, 

MD: U.S. Department of Health and Human Services, 5. Consider replicating the applied research 

model used for NCI’s American Stop Smoking National Institutes of Health, National Cancer Institute; 

Intervention Study (ASSIST). November 2000. NIH Pub. No. 00-4892. 

ASSIST was a public-private partnership between NCI and 

the American Cancer Society aimed at using policy strategies 

to change the social, cultural, economic, and environmental 

factors that promote smoking. ASSIST demonstrated that 

strong tobacco control programs and effective policies 

6. Soliman S, Pollack HA, Warner KE. Decrease in the 

prevalence of environmental tobacco smoke exposure 

in the home during the 1990s in families with children. 

American Journal of Preventive Medicine. 2004;94:314-

20. 

76 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

7. Roemer R. Legislative Action to Combat the World Tobacco 15. Mortality trends for selected smoking-related cancers 

Epidemic. 2nd ed. Geneva: World Health Organization; and breast cancer—U.S., 1950-1990. Morbidity and 

1993. Mortality Weekly Report. 1993;42:857,863-66. 

8. Sorensen G, Emmons K, Hunt MK, et al. Implications 16. American Legacy Foundation. Women and Lung Cancer 

of the results of community intervention trials. Annual Survey. Washington, DC: American Legacy Foundation; 

Review of Public Health. 1998;19:379-416. January 2001. 

9. Hymowitz N. Community and clinical trials of disease 17. Centers for Disease Control and Prevention. Cigarette 

prevention: Effects on cigarette smoking. Public Health smoking among adults—U.S., 2002. Morbidity and 

Reviews. 1987;15:45-81. Mortality Weekly Report. 2004;53:427-31. 

10. National Cancer Institute. Community-Based 

Interventions for Smokers: The COMMIT Field Experience. 

Smoking and Tobacco Control Monograph No. 6. 

Bethesda, MD: U.S. Department of Health and Human 

Services, National Institutes of Health, National Cancer 

Institute; August 1995. NIH Pub. No. 95-4028. 

18. Centers for Disease Control and Prevention. Prevalence 

of cigarette use among 14 racial/ethnic populations— 

U.S., 1999-2001. Morbidity and Mortality Weekly Report. 

2004;53:49-52. 

19. U.S. Department of Health and Human Services. 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups— 

11. Stillman FA, Hartman AM, Graubard BI, Gilpin EA, 

Murray DM, Gibson JT. Evaluation of the American 

Stop Smoking Intervention Study (ASSIST): A report 

of outcomes. Journal of the National Cancer Institute. 

2003;95:1681-91. 

African Americans, American Indians and Alaska Natives, 

Asian Americans and Pacifi c Islanders, and Hispanics: 

A Report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers 

for Disease Control and Prevention, National Center 

12. Israel BA, Schulz AJ, Parker EA. Review of community- for Chronic Disease Prevention and Health Promotion, 

based research: Assessing partnership approaches to Office on Smoking and Health; 1998. 

improve public health. Annual Review of Public Health. 20. Kaplan SK, Lanier AP, Merrit RK, et al. Prevalence of 

1998;19:173-202. tobacco use among Alaska Natives: A review. Preventive 

13. Siegel M. The effectiveness of state-level tobacco control Medicine. 1997;26:460-5. 

interventions: A review of program implementation and 21. Spangler JG, Case LD, Bell RA, et al. Tobacco use in a 

behavioral outcomes. Annual Review of Public Health. tri-ethnic population of older women in southern North 

2002;23:45-71. Carolina. Ethnicity & Disease. 2003;13:226-32. 

14. Centers for Disease Control and Prevention. Best 22. Sackett DL, Rosenberg WMC, Muir Gray JA, Hanyes 

Practices for Comprehensive Tobacco Control Programs– RB, Richardson WS. Evidence based medicine: What it 

August 1999. Atlanta, GA: U.S. Department of Health is and what it isn’t. British Medical Journal. 1996;312:71-

and Human Services, Centers for Disease Control 2. 

and Prevention, National Center for Chronic Disease 

Prevention and Health Promotion, Office on Smoking 

and Health; August 1999. 

Appendix A: Reports From the Working Group Breakout Sessions 77 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

78 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Global Issues Breakout Session 

Co-Chairs Nancy Kaufman 

Participants Mira Aghi 

Dilyara Barzani 

Beatriz Champagne 

Elif Dagli 

Science Writer Barbara Shapiro 

Lead Author Soon-Young Yoon 

Overview 

An essential tool to combat the tobacco industry’s 

aggressive targeting of women is accurate, timely 

information. But worldwide, the reasons for the relatively 

low prevalence of tobacco use among women (about 

12 percent) and high prevalence among men (about 48 

percent) are difficult to identify, especially in developing 

countries where reliable surveillance and monitoring data 

are generally absent (1, 2). Similarly, little information exists 

on the social, cultural, and economic context of gender and 

tobacco related to the variety of tobacco used and methods 

of tobacco initiation, uptake, and prevention (3). And, while 

recent global surveys have reported data on women and 

smoking, gaps in data collection make it difficult to monitor 

progress or develop national tobacco control plans (4, 5). For 

example, in many regions, including Africa, Asia, and the 

Eastern Mediterranean, other ways to use tobacco, such as in 

hookahs and rolled tobacco, are popular but seldom included 

in national surveys (4). As the rates of tobacco use among 

women and girls rise, improving scientific research about 

gender and tobacco becomes an urgent matter. Adult smoking 

prevalence is higher among women than men in the fi ve 

countries of the Cook Islands, Nauru, Norway, Papua New 

Guinea, and Sweden, and recent increases in female smoking 

prevalence have been reported in Cambodia, Malaysia, and 

Bangladesh (4). 

The World Health Organization (WHO) Framework 

Convention on Tobacco Control (Framework Convention) 

is an international public health treaty that is legally binding 

on all parties. Adopted by the WHO World Health Assembly 

in May 2003, it will go into force once 40 countries have 

Joyal Mulheron Judith Wilkenfeld 

Margaretha Haglund Sallie Petrucci 

C. Anderson Johnson Kimberly Weich Reusche 

Eva Kralikova Soon-Young Yoon 

Cherie Nichols 

ratified it. The Framework Convention promises to stimulate 

demand for better and more data on important issues, 

including price structure and advertising expenditures (6). 

Long-term improvements in national databases will progress 

as governments that ratify the treaty report to an international 

monitoring body. Nongovernmental organizations 

(NGOs), such as the Framework Convention Alliance (an 

NGO network whose primary objective is to support the 

development of a strong Framework Convention and related 

protocols), will also seek to conduct better research in order to 

submit shadow reports. However, gender analysis in tobacco 

control research needs stronger financial and political support 

to ensure high-quality national reporting. The tobacco 

control movement can expand its organizational and fi nancial 

resources by reaching out to new partners among women’s 

organizations, health care professionals, nurses, unions, and 

human rights and environmental groups. 

Funders, government agencies, and NGOs in the United 

States have important roles to play in assisting developing 

countries. Best practices in the United States should be 

shared, but adapted to the cultural, social, and economic 

needs of local communities. For example, mass-media 

campaigns can be modified in countries where community 

leaders have more influence than print media among illiterate 

women. Bearing in mind the need to strengthen leadership 

from developing countries, greater efforts must also be 

made to exchange knowledge and success stories between 

economically developed and developing countries. 

Appendix A: Reports From the Working Group Breakout Sessions 79 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Recommendations 

Research 

*1. Surveillance and monitoring. 

The working group gave highest priority to strengthening 

national surveillance, including monitoring trends in tobacco 

use, changing patterns of use, and factors that affect use (4). 

Possible research questions are: 

n What evidence exists to show that rates of tobacco use are 

increasing rapidly among girls? 

n Do gender differences exist in response to changes in taxation 

policies? 

Research on uptake should cover new patterns, such as 

the use of smokeless tobacco among youth. Standardized 

survey questions could be based on norms for populations 

in industrialized countries—as long as they are adapted to 

developing countries’ cultures and tobacco use patterns. 

Although using common definitions is often a complex 

matter, the effort to do so will improve comparability on a 

global basis, as well as the ability to conduct meta-analyses. 

The Global Youth Tobacco Survey is an example of how 

trends around the world can be monitored (6). 

Examples of specific research topics include: 

n Behavior of the tobacco industry. One area of surveillance 

that is too often omitted by health officials is tracking 

the tobacco industry’s behavior. For example, data on 

advertising and promotion expenditures like those 

reported by the U.S. Federal Trade Commission do 

not exist in most developing countries. As marketing, 

product design, and promotion infl uence susceptibility 

to and initiation of smoking, understanding the behavior 

of the tobacco industry will prove essential in designing 

public policies (7). Such information can also arm 

tobacco control advocates with evidence to mobilize 

women’s organizations and warn them of tactics used by 

the tobacco industry to “buy” their loyalty (8). Another 

justification for further research on this topic is that 

tobacco industry data related to marketing are useful in 

litigation (9). 

n A map of who uses which tobacco products by country and 

changing patterns of use. Basic information concerning 

the variety of tobacco products used by women, such 

as chewing tobacco and that used in hookahs, is 

generally absent, as are data on changing patterns of 

use related to marketing of products. In addition, little 

information is available on tobacco use among female 

nurses and doctors. The WHO has begun to address 

this issue through collaboration with the World Medical 

Association and International Council of Nurses to 

monitor tobacco use among health professionals in 

Bahrain, Iran, Kuwait, Oman, and the Republic of 

Korea (4). Research that maps national trends is vital 

to developing gender-sensitive counter-advertising 

campaigns. 

n Factors contributing to the uptake of tobacco use where 

prevalence is low among women and protective factors 

now exist. Research on nonsmokers by gender and age 

would yield data on initiation, quitting, and acceptable 

prevention methods. Little is known about what makes 

young women choose not to smoke even when they are 

exposed to tobacco advertisements and promotions. A 

research question might be: What factors differentiate 

teenage girls who smoke from those in the same 

social and economic environments who do not? An 

important supplement to conventional epidemiological 

surveillance is monitoring cultural and social factors 

that protect women against tobacco use (keeping in 

mind that the objective is to uphold women’s freedoms 

as well as prevent tobacco uptake). Factors to consider 

are traditional values, lack of disposable income, life 

skills that prevent women from using tobacco, and 

family pressure. A historical perspective is useful, such 

as comparing traditional and new gender norms as they 

relate to changes in tobacco use. These data are needed 

to maintain low prevalence rates among women and girls 

as an integral part of public policy. 

n The meaning of tobacco use to women. In developing 

countries, the meanings of tobacco use to women, such 

as independent self-image and rebellion, are important to 

understand in their historical social context. Researchable 

topics would include: 

◆ How do women interpret package designs that 

promote images of glamorous Western women? 

◆ Do health education programs address gender issues 

adequately? 

* Recommendations with an asterisk are those identified by the breakout groups as their top three recommendations. 

80 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Investigation of the knowledge, attitudes, and practices 

of women who use smokeless tobacco is also important, 

particularly in developing countries. In India, for example, 

some rural women are reported to believe that chewing 

tobacco is healthy (10). 

Disparities 

If more accurate and timely data were available, tobacco 

control advocacy groups could create a call for action based 

on evidence that women are being targeted. National 

programs would know where to intervene for the highest 

impact and how to reduce disparities such as those affecting 

American Indian populations. 

Partners 

Partners should be involved in collecting, funding, 

disseminating, and using research. Among the potential 

partners are these agencies and organizations: 

n Federal Trade Commission 

n Centers for Disease Control and Prevention 

n National Institutes of Health/Fogarty International 

Center 

n American Cancer Society 

n International Union Against Cancer 

n U.S. Agency for International Development 

n American Legacy Foundation 

National agencies in developing countries, such as the 

Centers for Disease Control in China and the National 

Cancer Institute in Brazil, are also partners, both as users 

and sponsors of research. A stimulus for global cooperation 

concerning gender and tobacco will also come from the 

Framework Convention, because the countries that ratify the 

treaty will report on progress made. Linkages of these and 

U.S. partners with the international women’s movement and 

research centers will be critical to monitoring and evaluating 

programs. However, more effort must be made to include 

women’s NGOs, health care professionals, national ministries 

for women’s affairs, national centers of excellence that teach 

gender studies, and women’s studies centers—particularly 

in developing countries. Finally, many international 

development and funding agencies can cooperate, such as 

the WHO, United Nations regional economic and social 

commissions, and the World Bank. 

Impact 

One impact of improving research would be the creation of 

baselines for monitoring the Framework Convention and 

establishing global indicators on gender and tobacco. The 

number of high-quality grant applications from researchers 

in developing countries for research on gender and tobacco 

could increase as more data become available on measurable 

outcomes. Better data can also have a positive political 

impact, since children’s rights organizations and women’s 

groups will need evidence to be persuaded to join the tobacco 

control movement. 

*2. Policy-related research. 

Data are seldom rigorous enough to convince policy makers 

in developing countries that tobacco control measures are 

successful. Two major areas of concern should be the progress 

of Framework Convention implementation (including tax/ 

price, advertising/promotion, labeling, and environmental 

tobacco smoke) and multicountry studies of national and 

local policies designed for international comparisons (11). 

This research would also help answer questions such as: 

n If countries enforce a total ban on advertising, what 

happens? 

n What is the impact of legislation on environmental tobacco 

smoke on women’s health? 

Examples of specific research issues are: 

n Awareness and risk behavior. Levels of awareness and risk 

behavior among women vary widely by social, economic, 

and cultural context—even within a country—and 

subgroups should be identified in policy-related research. 

For example, although many urban dwellers with access 

to modern communication systems may be aware of 

the health hazards of passive smoke, health messages 

may fail to reach the majority of women living in poor, 

rural areas. In addition, ethnic, religious, and linguistic 

diversity can act as communication barriers and affect 

levels of awareness among women and girls. 

n Impact of the Framework Convention. The feasibility 

studies and evaluation and monitoring of policies 

resulting from enforcement of the Framework 

Convention should be built into a gender and tobacco 

strategy. Multicountry studies that measure the impact 

of specific measures, such as changes in taxation and 

price, on women’s tobacco use will provide important 

comparative data. Accurate evaluations are also needed 

Appendix A: Reports From the Working Group Breakout Sessions 81 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

of new legislation, such as bans on smoking in work- and 

public places. Also, women’s health as a human right is 

an important issue in the Framework Convention that 

needs close monitoring (12). 

n The role of law and governance. Tobacco control programs 

should conduct research to improve legal and governance 

structures for tobacco control. For example, the report 

on the history of Thailand’s tobacco control program 

emphasized the importance of accurate reports and 

evaluations of law enforcement (13). Monitoring and 

evaluating existing and new laws is necessary to ensure 

compliance and identify reasons for non-enforcement. 

Questions arise about how to use public opinion to assist 

law enforcement agencies. Other research questions are: 

◆ What do countries need most to draw upon the U.S. 

experience in litigation and corporate responsibility? 

◆ Does women’s participation in decision making help 

improve the implementation of national policies? 

n Communications and media outreach. Research is needed 

to develop culturally relevant messages and entry points 

that respond to women’s perceived needs. For example, 

data concerning the impact of maternal and paternal 

smoking on fetal health in countries such as Korea, 

Kenya, and Vietnam would arouse public interest and 

provide an entry point to maternal and child health and 

tobacco programs. The role of men in the protection 

of women’s health also needs further investigation. 

For example, in many developing countries where 

it is difficult for women to influence public policy 

or defend their right to a smoke-free environment, 

communications research should target men. 

n Media literacy. Counter-advertising can work, but better 

methods are needed to decode and debunk industry 

messages and counter their persuasive power (7). 

Redefining women’s liberation should take into account 

women’s own perceptions, and the tobacco industry 

must be prevented from “owning” gender images of 

modernity. The ultimate goal should be to use media 

and communication strategies to create demand for 

prevention and cessation. An example is the U.K. Health 

Education Authority’s “Put smoking out of fashion” 

project that involved the fashion industry and media in a 

teen antismoking effort (14). 

n Women as tobacco workers. A major gap in research lies 

in the impact of tobacco production and processing 

on women tobacco workers (15). In many tobaccoproducing countries, women and girls who work on 

tobacco farms are exposed to environmental hazards 

such as pesticides, and their labor is exploited under 

poor working conditions (16). Epidemiological and 

surveillance data, as well as social, economic, and cultural 

research, are needed to develop appropriate health 

policies for these workers. Priority should be given to 

their knowledge, attitudes, and practices related to risk 

behavior. Data on reproductive health are also poorly 

collected. 

Disparities 

Improving policy-related research would contribute to earlier 

intervention in the tobacco epidemic curve. Targeting diverse 

groups of women and girls with gender-sensitive interventions 

could be more effectively planned. 

Partners 

Research partners would be similar to those already 

mentioned for surveillance. In addition, United Nations 

(UN) agencies committed to strengthening policies related to 

women’s health as a human right, such as the Commission on 

the Status of Women, the UN Division for the Advancement 

of Women, and funders of women’s and development 

projects, should become more involved. A positive step was 

taken by the Swedish International Development Agency to 

support gender and tobacco research. In cooperation with the 

government of South Africa and the Women’s Health Project, 

the Swedish International Development Agency sponsored 

seven studies in the region and will fund Africa’s fi rst regional 

meeting on gender and tobacco. 

Impact 

As with surveillance, policy-related research would arm 

advocates to hold governments accountable for treaty 

implementation. NGOs can also use information to “shame” 

governments into taking action and increasing awareness in 

the public about the importance of gender-based policies. 

Tobacco control programs could target advocacy to policies 

that work best to reduce tobacco use among women and girls. 

T ranslation 

*3. Make research data available to policy makers 

and the public. 

More efforts are needed to make data on surveillance and 

policy research, as well as those from social, economic, and 

cultural studies, available to policy makers and the public. In 

particular, international cooperation in research must respond 

82 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

to rapidly changing political challenges posed by the tobacco Spanish, Chinese, and Arabic—at little cost; this can 

industry in an attempt to undermine scientifi c evidence. have long-lasting benefi ts. 

General principles of good project planning apply, such as n Cooperation with the Framework Convention Conference of ensuring that policy makers and women leaders are involved Parties to help disseminate research results. The Framework from the beginning in identifying priorities and in planning. Convention Conference of Parties, which will oversee the Knowing how to identify the most effective messengers to implementation and monitoring of the tobacco treaty, reach policy makers depends upon savvy political know-how should be encouraged to provide training and technical and close cooperation among researchers, the media, and assistance to countries for dissemination of gender and tobacco control activists. tobacco research. The Conference of Parties can also be 

Some suggestions for action are: an important catalyst to translate research results into 

n Mobile technical assistance teams. A quick-response policies. NGOs that are actively involved in monitoring 

strategy could involve mobile technical teams in progress would also be important allies in the exchange 

and dissemination of information. responding to national emergency situations, such as 

an impending national law to ban advertising. Led by Disparities 

partners in developing countries, teams would draw The Framework Convention process, the Internet, and mobile upon the expertise of NGOs and governments in the teams would help balance the flow of knowledge between international tobacco control movement. Criteria economically developed and developing countries and for selection of team members would include gender promote rapid diffusion of innovations. Sharing strategies to balance, interdisciplinary mix, and cultural sensitivity. combat tobacco industry tactics could jump-start a movement These technical assistance teams could help national that could act as a catalyst for change. tobacco control leaders train investigators in research 

and evaluation techniques, assist in the transfer of Partners 

treatment technologies, help build a stronger NGO Two important partners in teamwork between economically 

infrastructure, and develop capacity training in advocacy, developed and developing countries would be the NGO communications, and legal counseling. members of the Framework Convention Alliance and 

n Using the Internet and new information technologies to governments represented in the Framework Convention 

reach audiences worldwide. The Internet is one of the Conference of Parties process. As these groups have 

most cost-effective media for rapidly disseminating developed expertise in a wide range of gender and tobacco 

information and can respond to political action and issues, as well as international law and national tobacco 

campaigns internationally. An important initiative has control, they can be drawn upon to work closely with local 

been undertaken by the WHO and the U.S. Centers for leaders. Funders and supporters might include public and 

Disease Control and Prevention to initiate the National 

Tobacco Information Online System (NATIONS). 

Operated in partnership with the American Cancer 

Society, World Bank, UN Children’s Fund, and 

International Union Against Cancer, NATIONS is 

an electronic system for tracking country-specifi c 

information and a potential source of updated data 

on women and tobacco (17). In the future, it will be 

private foundations, government agencies that provide 

international aid, and NGOs, such as those working in 

women’s health and consumer protection. Technical expertise 

can be mobilized through gender research centers and 

international and regional women’s research networks, such 

as FEMNET in sub-Saharan Africa. Litigation consortiums 

may also be established to support national efforts and bring 

expertise related to international law and treaties such as the 

essential to ensure that such Web sites are multilingual Framework Convention. 

if they are to be accessible worldwide. Using new Impact 

information technologies, local groups can also receive 

better training in how to use research results for The impact of a multipronged strategy that includes rapidglobal action. Recent experiences of the Framework response teamwork could be significant. For example, such 

teamwork could help promote speedy exchange of know- Convention Alliance demonstrate that documents can 

be translated into different languages—such as French, how and arm NGOs with examples of industry tactics. A 

train-the-trainers approach could also be supported for rapid 

Appendix A: Reports From the Working Group Breakout Sessions 83 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

diffusion of skills and information. Other positive outcomes 

would be to increase accountability through media attention, 

link local to international networks, decrease tobacco use 

through better cessation treatments, and promote strong 

national and local legislation. If litigation teams are successful, 

national tobacco control programs might also raise revenues 

for tobacco control. 

the 21st Century. Geneva: World Health Organization; 

2001. 

9. Blanke DD. Towards health with justice: Litigation and 

public inquiries as tools for tobacco control. Tobacco 

Control. Reports on Industry Activity. 2002. Available 

at http://repositories.cdlib.org/tc/whotcp/WHO1/. 

Accessed June 23, 2004. 

References 10. Aghi M, Asma S, Yeong CC, Vaithinathan R. Initiation 

and maintenance of tobacco use. In: Samet JM, Yoon 1. World Health Organization. Women and the Tobacco S-Y, eds. Women and the Tobacco Epidemic. Challenges for Epidemic—Challenges for the 21st Century. Geneva: the 21st Century. Geneva: World Health Organization; World Health Organization; 2001. 2001. 

2. Mackay J, Eriksen M. The Tobacco Atlas. Geneva: World 11. The World Bank. Curbing the Epidemic. Washington, Health Organization; 2002. DC: The World Bank; 1999. 

3. World Health Organization. Confronting the Epidemic: 12. Cook R. Women’s Health and Human Rights. Geneva: A Global Agenda for Tobacco Control Research. Geneva: World Health Organization; 1994. Research for International Tobacco Control and World 

Health Organization; 1999. 13. Supawongse C, ed. The Evolution of Tobacco Consumption 

Control in Thailand. Thailand: WHO; 1999. 4. American Cancer Society. Tobacco Control Country 

Profi les. Atlanta: American Cancer Society; 2003. 14. Joossens L. Some like it ‘light.’ Paper presented at: 

European Network for Smoking Prevention conference: 5. Morrow M, Barraclough S. Tobacco control and gender: Tobacco and Women: Understanding the Past, Changing A need for new approaches for the Asia-Pacifi c region. the Future; November 23-24, 1998; Paris, France. Development Studies Network Development Bulletin. 

2001;54:23-6. 15. Christofides N. Gender issues in tobacco control: 

Highlighting some developing country issues. In: 6. Warren W, Riley L, Asma S, et al. Tobacco use by youth: Flowers MK, ed. Smoking and Women’s Health: “Les A surveillance report from the Global Youth Tobacco Liaisons Dangereuses.” New York: Global Alliance for Survey project. WHO Bulletin. 2000;78:868-73. Women’s Health; 1999. 

7. U.S. Department of Health and Human Services. 16. Campaign for Tobacco-Free Kids. Golden Leaf, Barren Women and Smoking: A Report of the Surgeon General. Harvest. Washington, DC: Campaign for Tobacco-Free Rockville: MD: U.S. Department of Health and Human Kids; 2001. Services, Public Health Service, Office of the Surgeon 

General; 2001. 17. NATIONS Web site. Available at: http:// 

apps.nccd.cdc.gov/nations. Accessed October 28, 2003. 8. Kaufman NJ, Nichter M. The marketing of tobacco to 

women: Global perspectives. In: Samet JM, Yoon S-Y, 

eds. Women and the Tobacco Epidemic. Challenges for 

84 Appendix A: Reports From the Working Group Breakout Sessions 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Appendix B: About the W omen, T obacco, and 

Cancer W orking Group 

The Women, Tobacco, and Cancer (WTC) Working Group was formed by the National Cancer Institute 

(NCI) to stimulate scientific research and the translation 

of evidence-based knowledge into effective interventions to 

reduce and ultimately prevent tobacco-related cancers. 

When the Working Group was formed in late 2001, no major 

Federal efforts were addressing the recommendations of the 

2001 Surgeon General’s report, Women and Smoking, and 

other reports on women and tobacco-related diseases. The 

WTC Working Group was the result of meetings between 

staff of the NCI Office of Women’s Health, Tobacco Control 

Research Branch, and Office of Communications and staff 

of the Department of Health and Human Services (DHHS) 

Office of Women’s Health and the National Institutes of 

Health (NIH) Office of Research on Women’s Health. 

Two highly respected experts from the extramural research 

community were invited to serve as Co-Chairs of the Working 

Group. 

Planning for the W orking Group 

The Co-Chairs of the Working Group and the Federal 

coordinators nominated 16 members to serve on the WTC 

Steering Committee, which includes prominent members 

of the scientific, medical, public health, and advocacy 

communities. These individuals were selected for their 

expertise in all areas associated with tobacco-related cancers 

in women. At a June 13, 2002, planning meeting, the 

Steering Committee discussed goals and provided guidance 

for expanding the WTC Working Group and planning a 

Working Group meeting. During subsequent conference 

calls among Working Group meeting organizers, the format 

and agenda for the meeting were finalized; breakout group 

topics were selected; breakout group Co-Chairs (Steering 

Committee and non-Steering Committee members) were 

selected; and plenary session speakers were identifi ed. 

The goals of the WTC Working Group meeting were to: 

n Identify gaps and research priorities. Identify and 

prioritize research needs to increase our understanding 

of the cancer-related biological effects of women’s 

tobacco use and environmental tobacco smoke 

(ETS) exposure and develop better interventions to 

decrease women’s and girls’ tobacco use and ETS 

exposure. Research areas might include the biology 

of addiction, cancer susceptibility and disease-related 

consequences, biobehavioral aspects of tobacco use, 

social/environmental factors affecting tobacco use, and 

communications and interventions research. 

n Identify and prioritize needs in dissemination and 

application. Identify and prioritize ways to disseminate 

and apply current and future research to prevent or 

reduce women’s and girls’ tobacco use and ETS exposure. 

Strategies might include intervention, communication, 

program, and policy. 

During the planning period, several experts were invited to 

serve as breakout group Co-Chairs at the Working Group 

meeting. These experts identified and invited other experts 

from multiple disciplines to join the Working Group and 

participate in its meeting. 

Prior to the meeting, Working Group members were asked 

for preliminary thoughts on priorities and important areas of 

focus. Specifically, they received the following instructions: 

In order to reduce the impact of tobacco and tobacco-related 

cancers on women and girls, identify for your breakout 

session topic: 

Research 

n The three most critical gaps in knowledge. 

n The three most important research opportunities. 

n The three most critical barriers that must be overcome to 

move forward. 

Application 

n The three most critical gaps in available interventions. 

n The three most important opportunities for applying 

what we know. 

n The three most critical barriers that must be overcome in 

order to apply what we know. 

The input of the Working Group members was provided to 

breakout group Co-Chairs to assist in planning their sessions 

and to meeting participants to aid in discussions. 

Appendix B: About the Women, Tobacco, and Cancer Working Group 85 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

As a resource for participants, meeting staff prepared a 

detailed overview of current (2001 and 2002) funded 

grants and activities related to women and tobacco in the 

areas of addiction, use, and cessation, as well as tobaccorelated cancers. These grants and activities were identifi ed 

by querying the database of the National Organization of 

Tobacco Use Research Funders (NOTURF) and the NIH 

Scientific Projects database, searching NOTURF member 

organization Web sites, contacting NOTURF organizations 

directly, and searching the Internet with the Google search 

engine. More than 160 research grants and activities were 

identified and grouped by breakout group topic to assist 

breakout group participants in their discussions. The report 

is available online at http://planning.cancer.gov/whealth/ 

abstract/index.htm. 

W orking Group Meeting 

The WTC Working Group meeting was held in Houston, 

Texas, February 3-5, 2003. At the meeting, participants heard 

presentations on the current state of research on women 

and tobacco, a panel discussion on the three cross-cutting 

themes described below, and reports on relevant activities and 

initiatives by public and private funders. The meeting also 

included an interactive demonstration by Step Afrika, a U.S.-

based percussive dance ensemble, on tobacco risk education 

for African-American youth. 

Participants were asked to consider three cross-cutting themes 

throughout the meeting: 

n Translation. The critical need to translate current 

knowledge and research into practical actions for change. 

n Health disparities. The disproportionate burden of 

tobacco-related issues across population groups and 

the vulnerability of some of these groups to the use of 

tobacco. 

n Global tobacco control. The widening reach of the tobacco 

epidemic internationally and the challenge of translating 

what has been learned from the experiences of developed 

countries into actions to prevent the spread of tobacco 

use and tobacco-related disease in other countries. 

Each of the approximately 125 participants joined one of 

the seven breakout groups. Each of these groups, which were 

selected by the meeting organizers based on the deliberations 

of the Working Group Steering Committee, addressed one of 

the following topics: 

n Addiction 

n Awareness, Risk Perception, and Communications 

n Biology and Cancer 

n Community and Policy Interventions 

n Epidemiology and National Surveillance 

n Global Issues 

n Interventions for Prevention and Treatment 

Breakout group members identified up to nine 

recommendations in three categories (at least one 

recommendation in each category) to: 

n Fill critical knowledge gaps in basic and applied science. 

n Translate what we know into effective interventions. 

n Apply new and proven interventions. 

For each of the recommendations identified, the breakout 

groups addressed: 

n Disparities. How can action on this recommendation 

reduce disparities among women? 

n Partners. Which agencies and organizations can work 

together to implement this recommendation? 

n Impact. What are the expected outcomes at 2 and 5 years 

if this recommendation is implemented? 

The breakout groups developed a total of 42 recommendations. Each breakout group presented its three highest priority 

recommendations for discussion at the final plenary session. 

Report 

Breakout session summary reports were subsequently 

developed by subject matter experts, nearly all of whom 

had participated in those sessions. These summaries provide 

background and justification for the breakout groups’ 

recommendations and are included in their entirety in this 

Report as Appendix A. 

Using the breakout group summaries and recommendations 

as guidance, the Working Group leadership prepared a 

report identifying goals in five cross-cutting areas: Discovery, 

Development, Delivery, Partnerships, and Evaluation and 

Surveillance. All of the recommendations in the Working 

Group’s Report and the corresponding strategies for achieving 

the cross-cutting goals reflect the recommendations and 

deliberations of the seven Working Group breakout groups. 

86 Appendix B: About the Women, Tobacco, and Cancer Working Group 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Appendix C: Working Group Meeting Agendas 

Women, Tobacco, and Cancer 

Steering Comittee Meeting 

Conference Room F1/F2, Natcher Conference Center, 45 Center Drive 

NIH Campus, Bethesda, MD 

June 13, 2002 

7:30 a.m. Continental Breakfast 

8:30 a.m. Welcome and Introductions 

8:50 a.m. Charge to Steering Committee and Meeting Overview 

Marianne H. Alciati, Ph.D., Management Solutions for Health, Inc. 

The goal for this meeting is to develop a clear plan for the fall conference on 

Women, Tobacco, and Cancer, including: 

• Primary and related products 

• Topics to be addressed and their organization 

• Structure of the meeting (plenary and breakout sessions) 

• Guidelines to be provided to participants 

• Techniques for facilitating the conference process 

• Conference participants and roles 

9:00 a.m. Conference Goals

 All participants 

Goal 1: Identify Gaps and Research Priorities 

Identify and prioritize research needs to increase our understanding of the cancerrelated biological effects of women’s tobacco use and ETS exposure, and develop 

better interventions to decrease women’s and girls’ tobacco use/ETS exposure. 

Research areas may include, but are not limited to, the biology of addiction, cancer 

susceptibility, behavioral aspects of tobacco use, social/environmental factors 

affecting tobacco use, and communications and intervention (prevention and 

cessation) research. 

Goal 2: Identify and Prioritize Needs in Dissemination and Applications 

Identify and prioritize ways to disseminate and apply current and future research 

to prevent or reduce women’s and girls’ tobacco use and ETS exposure. Strategies 

may include, but are not limited to, intervention, communication, policy, and 

program. 

Underlying premise: Partnerships and collaborations will be essential to 

implementing recommended strategies. 

Appendix C: Working Group Meeting Agendas 87 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

(June 13, 2002, Agenda, continued) 

9:20 a.m. Conference Product(s) 

10:00 a.m. Conference Topics and Organization 

10:45 a.m. Break 

11:00 a.m. Conference Topics and Organization 

11:45 a.m. Conference Structure (Plenary and Breakout Sessions) 

12:15 p.m. Working Lunch 

12:45 p.m. Techniques for Facilitating the Conference Process 

1:15 p.m. Guidelines for Conference Participants 

1:45 p.m. Conference Participants and Roles 

2:30 p.m. Summary and Next Steps 

3:00 p.m. Adjourn 

88 Appendix C: Working Group Meeting Agendas 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

W omen, T obacco, and Cancer: 

An Agenda for the 21st Century 

Inter -Continental Hotel, Houston, T exas 

February 3–5, 2003 

Monday, February 3rd 

5:30 p.m. Reception 

6:00 p.m. W elcome 

Michele Bloch, Ellen Gritz, C. Tracy Orleans 

Conference Charge and Overview 

Ellen Gritz, C. Tracy Orleans 

Introductions 

Ellen Gritz, C. Tracy Orleans 

6:30 p.m. Presentations

 Virginia Ernster 

V ideo and Presentation 

Cheryl Healton, Circle of Friends (American Legacy Foundation) 

7:30 p.m. Dinner 

8:45 p.m. Adjourn 

Tuesday, February 4th 

7:30 a.m. Breakfast 

8:15 a.m. W elcome and Instructions for Day 2 

8:25 a.m. Panel Moderator

 Julia Rowland 

8:35 a.m. Panel Presentations and Discussions 

Translation: From Research to Practice to Policy 

Presenter, Jessie Gruman; Discussant, Sharon Carothers 

Health Disparities: Narrowing the Gap 

Presenter, Sherry Mills; Discussant, Grace Ma 

Global Tobacco Control 

Presenter, Nancy Kaufman; Discussant, Soon-Young Yoon 

10:20 a.m. Break 

10:35 a.m. Breakout Sessions

 Addiction 

Awareness, Risk Perception, and Communications 

Biology and Cancer 

Epidemiology and National Surveillance 

Community and Policy Interventions

 Global Issues 

Interventions for Prevention and Treatment 

Appendix C: Working Group Meeting Agendas 89 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

(February 4, 2003, Agenda, continued) 

12:15 p.m. Funders Panel and Lunch 

Panel Chair, Wanda Jones 

Federal Programs (including NCI, NIDA, and CDC)

 Michele Bloch 

State of California (Tobacco-Related Disease Research Program)

 Francisco Buchting

 Legacy Foundation

 Helen Lettlow 

Robert Wood Johnson Foundation 

C. Tracy Orleans 

1:30 p.m. Breakout Sessions Continue 

2:30 p.m. Break and Discussion Across Breakout Sessions 

3:00 p.m. Breakout Sessions Continue 

4:30 p.m. Adjourn 

6:00 p.m. Reception

 Introduction

 Mildred Morse 

Presentation: Step Afrika! 

A demonstration presenting tailored health messages through stepping 

7:30 p.m. Dinner 

Wednesday, February 5th 

7:30 a.m. Breakfast 

8:30 a.m. W elcome and Instructions for Day 3 

Ellen Gritz, C. Tracy Orleans 

8:45 a.m. Breakout Session Presentations 

10:30 a.m. Break 

10:45 a.m. Breakout Session Presentations Continue 

12:00 p.m. Concluding Remarks 

Michele Bloch, Ellen Gritz, C. Tracy Orleans 

12:30 p.m. Adjourn 

90 Appendix C: Working Group Meeting Agendas 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Appendix D: Working Group Steering 

Committee 

Co-Chairs 

Ellen R. Gritz, Ph.D. 

The University of Texas 

M. D. Anderson Cancer Center

Co-Executive Directors 

Michele Bloch, M.D., Ph.D. 

National Cancer Institute 

National Institutes of Health 

Members 

Jasjit Ahluwalia, M.D., M.P.H., M.S. 

University of Kansas Medical Center 

David Burns, M.D. 

University of California, San Diego 

Sharon Carothers 

American Legacy Foundation 

Richard Clayton, Ph.D. 

Kentucky School of Public Health 

University of Kentucky 

Carolyn Dresler, M.D. 

GlaxoSmithKline 

Thomas J. Glynn, Ph.D. 

American Cancer Society 

Donna Grande, M.G.A. 

SmokeLess States 

Federal Coordinators 

Lisa Begg, Dr.P.H., R.N. 

Office of Research on Women’s 

Health 

National Institutes of Health 

Nelvis Castro, B.S.

National Cancer Institute 

National Institutes of Health 

Julie Cheh, M.P.H. 

National Cancer Institute 

National Institutes of Health 

C. Tracy Orleans, Ph.D. 

Robert Wood Johnson Foundation 

Anna T. Levy, M.S. 

National Cancer Institute 

National Institutes of Health 

Corinne Husten, M.D., M.P.H. 

Centers for Disease Control and 

Prevention 

Cathy Melvin, Ph.D., M.P.H. 

Smoke Free Families 

University of North Carolina 

Sherry Mills, M.D., M.P.H. 

Abt Associates, Inc. 

Mildred Morse, J.D. 

National Tobacco Independence 

Campaign 

Ovide Pomerleau, Ph.D. 

University of Michigan 

Wanda K. Jones, Dr.P.H. 

Office on Women’s Health 

Department of Health and Human 

Services 

Saralyn Mark, M.D. 

Office on Women’s Health 

Department of Health and Human 

Services 

Julia Rowland, Ph.D. 

National Cancer Institute 

National Institutes of Health 

Gary Swan, Ph.D. 

SRI International 

Kathryn Kahler Vose, M.A. 

Porter Novelli 

Cora Lee Wetherington, Ph.D. 

National Institute on Drug Abuse 

National Institutes of Health 

Judith Wilkenfeld, J.D. 

Campaign for Tobacco-Free Kids 

Cherie Nichols, M.B.A.

National Cancer Institute 

National Institutes of Health 

Vivian Pinn, M.D. 

Office of Research on Women’s 

Health 

National Institutes of Health 

Appendix D: Working Group Steering Committee 91 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

92 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Appendix E: W orking Group Meeting 

Participants 

Mira Aghi, Ph.D. Alice Boylan, M.D. 

Consultant Medical University of South Carolina 

New Delhi, India Naomi Breslau, Ph.D. 

Karen Ahijevych, Ph.D. Case Western Reserve University 

Ohio State University Henry Ford Health Systems 

Jasjit Ahluwalia, M.D., M.P.H., M.S. Francisco Buchting, Ph.D. 

University of Kansas Medical Center Tobacco-Related Disease Research Program 

Marianne Alciati, Ph.D. University of California 

Management Solutions for Health, Inc. David Burns, M.D. 

Victoria Almquist, M.Ed. University of California, San Diego 

Campaign for Tobacco-Free Kids Sharon Carothers 

Lucy Anderson, Ph.D. American Legacy Foundation 

National Cancer Institute Nelvis Castro, B.S. 

National Institutes of Health National Cancer Institute 

Samira Asma, D.D.S., M.P.H. National Institutes of Health 

Office on Smoking and Health Beatriz Champagne, Ph.D. 

Centers for Disease Control and Prevention InterAmerican Heart Foundation 

Global Tobacco Prevention and Control Neena Chaudhry, J.D., B.A. 

Lourdes Baezconde-Garbanati, Ph.D., M.P.H. National Women’s Law Center 

University of Southern California Julie Cheh, M.P.H. 

Linda Bailey, J.D., M.H.S. National Cancer Institute 

Center for Tobacco Cessation National Institutes of Health 

Dileep Bal, M.D., M.S., M.P.H. Paul Cinciripini, Ph.D. 

California Department of Health Services M. D. Anderson Cancer Center 

Dilyara Barzani, M.D., M.P.H. Richard Clayton, Ph.D. 

National Cancer Institute Kentucky School of Public Health 

National Institutes of Health University of Kentucky 

Lisa Begg, Dr.P.H., R.N. Cynthia Coachman, R.N. 

Office of Research on Women’s Health Muscogee (Creek) Nation of Oklahoma 

National Institutes of Health Vilma Cokkinides, Ph.D. 

Janice Blalock, Ph.D. American Cancer Society 

M. D. Anderson Cancer Center William Corrigall, Ph.D. 

Michele Bloch, M.D., Ph.D. National Institute on Drug Abuse 

National Cancer Institute National Institutes of Health 

National Institutes of Health Susan Curry, Ph.D. 

Rose Booze, Ph.D. University of Illinois at Chicago 

University of South Carolina 

Appendix E: Working Group Meeting Participants 93 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Elif Dagli, M.D. 

Marmara University School of Medicine 

Richard Daynard, J.D., Ph.D. 

Northeastern University School of Law 

Lisa Dierker, Ph.D. 

Wesleyan University 

Mirjana Djordjevic, Ph.D. 

National Cancer Institute 

National Institutes of Health 

Carolyn Dresler, M.D. 

Harvard University 

Kennedy School of Government 

Alyssa Easton, Ph.D., M.P.H. 

Centers for Disease Control and Prevention 

Sherry Emery, Ph.D. 

University of Illinois at Chicago 

Virginia Ernster, Ph.D. 

University of California, San Francisco 

Pebbles Fagan, Ph.D. 

National Cancer Institute 

National Institutes of Health 

Matthew Farrelly, Ph.D. 

RTI International 

John Finnegan, Ph.D. 

University of Minnesota 

Melissa Finucane, Ph.D. 

Kaiser Permanente Center for Health Research 

Marian Fitzgibbon, Ph.D. 

Northwestern University Medical School 

Adi Gazdar, M.D. 

University of Texas Southwestern Medical Center 

Gary Giovino, Ph.D. 

Roswell Park Cancer Institute 

Donna Grande, M.G.A. 

SmokeLess States 

Ellen Gritz, Ph.D. 

M. D. Anderson Cancer Center

Jessie Gruman, Ph.D. 

Center for the Advancement of Health 

Margaretha Haglund, B.A. 

National Institute of Public Health 

Stockholm, Sweden 

Sharon Hall, Ph.D. 

San Francisco Veterans Affairs Medical Center 

University of California, San Francisco 

Dorothy Hatsukami, Ph.D. 

Tobacco Use Research Center 

University of Minnesota Medical School 

Cheryl Healton, Dr.P.H. 

American Legacy Foundation 

Janet Healy, B.A. 

Alliance for Lung Cancer Advocacy, Support, and Education 

(ALCASE) 

Felicia Hodge, Dr.P.H. 

Center for American Indian Research and Education 

University of Minnesota 

Garry Humfl eet, Ph.D. 

University of California, San Francisco 

Corinne Husten, M.D., M.P.H. 

Centers for Disease Control and Prevention 

Patricia Hysert, B.A. 

Task Force for Tobacco-Free Women and Girls 

Roswell Park Cancer Institute 

Elaine Ishihara, M.P.A. 

Robert Wood Johnson Smokeless States Initiative 

American Medical Association 

Leslie Jacobsen, M.D. 

Yale University and VA Connecticut 

C. Anderson Johnson, Ph.D. 

Institute of Health Promotion & Disease Prevention Research 

University of Southern California 

Wanda Jones, Dr.P.H. 

Office of Women’s Health 

U.S. Department of Health and Human Services 

David Kalman, Ph.D. 

Boston University 

Denise Kandel, Ph.D. 

Columbia University 

Nancy Kaufman, R.N., M.S. 

Strategic Vision Group 

94 Appendix E: Working Group Meeting Participants 
Women, Tobacco, and Cancer: An Agenda for the 21st Century Working Group Report 

Taline Khroyan, Ph.D. 

SRI International 

Gary King, Ph.D. 

Penn State University 

Ritsuko Komaki, M.D. 

M. D. Anderson Cancer Center

Eva Kralikova, M.D., Ph.D. 

Charles University 

Prague, Czech Republic 

Harry Lando, Ph.D. 

University of Minnesota 

Amy Lazev, Ph.D. 

M. D. Anderson Cancer Center

Frances Leslie, Ph.D. 

TTURC 

University of California, Irvine 

Helen Lettlow, M.P.H. 

American Legacy Foundation 

Anna Levy, M.S. 

National Cancer Institute 

National Institutes of Health 

Joachim Liehr, Ph.D. 

Stehlin Foundation for Cancer Research 

Isaac Lipkus, Ph.D. 

Duke University Medical Center 

Wendy Lynch, Ph.D. 

Yale University 

Grace Ma, Ph.D. 

Asian Tobacco Education and Cancer Awareness Research 

Initiative (ATECAR) 

Temple University 

Pamela Madden, Ph.D. 

Washington University School of Medicine 

Deborah Maiese, M.P.A. 

Office of Women’s Health 

Health Resources and Services Administration 

U.S. Department of Health and Human Services 

Collen McBride, Ph.D. 

Duke University 

Deborah McClellan, M.H.S. 

Dana-Farber Cancer Institute 

Jennifer McClure, Ph.D. 

Group Health Cooperative 

Center for Health Studies 

Daniel McGoldrick, M.A. 

Campaign for Tobacco-Free Kids 

Laurie McLeod, Ph.D. 

University of Wisconsin-Madison 

Assieh Melikian, Ph.D. 

Institute for Cancer Prevention 

Cathy Melvin, Ph.D., M.P.H. 

Smoke Free Families 

Cecil G. Sheps Center for Health Services Research 

Sherry Mills, M.D., M.P.H. 

Abt Associates, Inc. 

Mildred Morse, J.D. 

National Tobacco Independence Campaign 

Joyal Mulheron, B.S., B.A. 

International Tobacco Control Sciences 

American Cancer Society 

James Mulshine, M.D. 

National Cancer Institute 

National Institutes of Health 

Lori New Breast, B.A. 

Blackfeet Tobacco Prevention Program 

Blackfeet Tribe 

Cherie Nichols, M.B.A. 

National Cancer Institute 

National Institutes of Health 

Mimi Nichter, Ph.D. 

University of Arizona 

Jeanette Noltenius, M.A., Ph.D. 

Swartz & Associates 

Anne Marie O’Keefe, Ph.D., J.D. 

Academy for Educational Development 

C. Tracy Orleans, Ph.D. 

The Robert Wood Johnson Foundation 

Jamie Ostroff, Ph.D. 

Memorial Sloan-Kettering Cancer Center 

Linda Pederson, Ph.D. 

Office of Smoking and Health 

Centers for Disease Control and Prevention 

Appendix E: Working Group Meeting Participants 95 
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

Sallie Ane Petrucci, M.P.H., C.H.E.S. 

The Robert Wood Johnson Foundation 

Katherine Pisters, M.D. 

M. D. Anderson Cancer Center

Cynthia Pomerleau, Ph.D. 

Nicotine Research Laboratory 

University of Michigan 

Ovide Pomerleau, Ph.D. 

University of Michigan 

Alexandre Prokhorov, M.D., Ph.D. 

M. D. Anderson Cancer Center

Kimberly Weich Reusché, B.S. 

Campaign for Tobacco-Free Kids 

Scott Rogers, Ph.D. 

University of Utah 

Julia Rowland, Ph.D. 

National Cancer Institute 

National Institutes of Health 

Linda Sarna, R.N., D.N.Sc. 

University of California, Los Angeles 

Monica Scheibmeir, Ph.D. 

University of Kansas Medical Center 

Saul Shiffman, Ph.D. 

University of Pittsburgh 

Piney Associates 

Jill Siegfried, Ph.D. 

University of Pittsburgh School of Medicine 

Laura Solomon, Ph.D. 

University of Vermont 

Simon Spivack, M.D., M.P.H. 

New York State Department of Health 

Steven Stellman, Ph.D., M.P.H. 

Columbia University School of Public Health 

Gary Swan, Ph.D. 

SRI International 

Michael Thun, M.D., M.S. 

American Cancer Society 

Janice Tsoh, Ph.D. 

University of California, San Francisco 

Jaylan Turkkan, Ph.D. 

University of Buffalo 

Kathryn Kahler Vose, M.A. 

Porter Novelli 

Cora Lee Wetherington, Ph.D. 

National Institute on Drug Abuse 

National Institutes of Health 

David Wetter, Ph.D. 

M. D. Anderson Cancer Center

Judith Wilkenfeld, J.D. 

Campaign for Tobacco-Free Kids 

Elinor Wilson, Ph.D. 

Heart and Stroke Foundation of Canada 

Ruth Wooden, B.A. 

Porter Novelli 

Susan Woodruff, Ph.D. 

San Diego State University 

Soon-Young Yoon, Ph.D. 

Campaign for Tobacco-Free Kids 

Mitchell Zeller, J.D. 

Consultant 

Public Health Policy 

96 Appendix E: Working Group Meeting Participants