Executive Summary 1

Women and Smoking

This is the second report of the U.S. Surgeon General devoted to women and smoking. The first was

published in 1980 (U.S. Department of Health and

Human Services [USDHHS] 1980), 16 years after the

initial landmark report on smoking and health of the

Advisory Committee to the Surgeon General appeared in 1964 (U.S. Department of Health, Education, and Welfare [USDHEW] 1964). The 1964 report

summarized the accumulated evidence that demonstrated that smoking was a cause of human cancer

and other diseases. Most of the early evidence was

based on men. For example, the report concluded,

“Cigarette smoking is causally related to lung cancer

in men.... The data for women, though less extensive,

point in the same direction” (USDHEW 1964, p. 37).

By the time of the 1980 report, the evidence clearly

showed that women were also experiencing devastating health consequences from smoking and that “the

first signs of an epidemic of smoking-related disease

among women are now appearing” (USDHHS 1980,

p. v). The evidence had solidified later among women

than among men because smoking became commonplace among women about 25 years later than it had

among men. However, it was still deemed necessary

to include a section in the preface of the 1980 report

titled “The Fallacy of Women’s Immunity.” In the two

decades since, numerous studies have expanded the

breadth and depth of what is known about the health

consequences of smoking among women, about historical and contemporary patterns of smoking in

demographic subgroups of the female population,

about factors that affect initiation and maintenance of

smoking among women (including advertising and

marketing of tobacco products), and about interventions to assist women to quit smoking. The present

report reviews the now massive body of evidence on

women and smoking—evidence that taken together

compels the Nation to make reducing and preventing

smoking one of the highest contemporary priorities

for women’s health.

A report focused on women is greatly needed.

No longer are the first signs of an epidemic of tobaccorelated diseases among women being seen, as was the

case when the 1980 report was written. Since 1980,

hundreds of additional studies have expanded what

is known about the health effects of smoking among

women, and this report summarizes that knowledge.

Today the Nation is in the midst of a full-blown epidemic. Lung cancer, once rare among women, has

surpassed breast cancer as the leading cause of female

cancer death in the United States, now accounting for

25 percent of all cancer deaths among women. Surveys have indicated that many women do not know

this fact. And lung cancer is only one of myriad serious disease risks faced by women who smoke.

Although women and men who smoke share excess

risks for diseases such as cancer, heart disease, and

emphysema, women also experience unique smokingrelated disease risks related to pregnancy, oral contraceptive use, menstrual function, and cervical cancer.

These risks deserve to be highlighted and broadly recognized. Moreover, much of what is known about the

health effects of exposure to environmental tobacco

smoke among nonsmokers comes from studies of

women, because historically men were more likely

than women to smoke and because many women

who did not smoke were married to smokers.

In 1965, 51.9 percent of men were smokers, where -

as 33.9 percent of women were smokers. By 1979, the

percentage of women who smoked had declined

somewhat, to 29.9 percent. However, the decline in

smoking among men to 37.5 percent was much more

dramatic. The gender gap in adult smoking prevalence continued to close after the 1980 report, but

since the mid-1980s, the difference has been fairly stable at about 5 percentage points. In 1998, smoking

prevalence was 22.0 percent among women and 26.4

percent among men. The gender difference in smoking prevalence among teens is smaller than that

among adults. Smoking prevalence increased among

both girls and boys in the 1990s. In 2000, 29.7 percent

of high school senior girls and 32.8 percent of high

school senior boys reported having smoked within

the past 30 days (University of Michigan 2000).

In recent years, some research has suggested that

the impact of a given amount of smoking on lung cancer risk might be even greater among women than

among men, that exposure to environmental tobacco

smoke might be associated with increased risk for

breast cancer, and that women might be more susceptible than men to weight gain following smoking cessation. Other research indicated that persons with

specific genetic polymorphisms may be especially

susceptible to the effects of smoking and exposure to

Executive Summary
Surgeon General’s Report

2 Executive Summary

1. Despite all that is known of the devastating

health consequences of smoking, 22.0 percent 

of women smoked cigarettes in 1998. Cigarette

smoking became prevalent among men before

women, and smoking prevalence in the United

States has always been lower among women

than among men. However, the once-wide gender gap in smoking prevalence narrowed until

the mid-1980s and has since remained fairly

constant. Smoking prevalence today is nearly

three times higher among women who have

only 9 to 11 years of education (32.9 percent)

than among women with 16 or more years of

education (11.2 percent).

2. In 2000, 29.7 percent of high school senior girls

reported having smoked within the past 30

days. Smoking prevalence among white girls

declined from the mid-1970s to the early 1980s,

followed by a decade of little change. Smoking

prevalence then increased markedly in the early

1990s, and declined somewhat in the late 1990s.

The increase dampened much of the earlier

progress. Among black girls, smoking prevalence declined substantially from the mid-1970s

to the early 1990s, followed by some increases

until the mid-1990s. Data on long-term trends in

smoking prevalence among high school seniors

of other racial or ethnic groups are not available.

3. Since 1980, approximately 3 million U.S. women

have died prematurely from smoking-related

neoplastic, cardiovascular, respiratory, and pediatric diseases, as well as cigare t t e - c a u s e d

burns. Each year during the 1990s, U.S. women

lost an estimated 2.1 million years of life due to

these smoking attributable premature deaths.

Additionally, women who smoke experience

gender-specific health consequences, including

increased risk of various adverse reproductive

outcomes.

Major Conclusions

environmental tobacco smoke. These issues remain

active areas of investigation, and no conclusions can

be drawn about them at this time. Nonetheless,

knowledge of the vast spectrum of smoking-related

health effects continues to grow, as does knowledge

that examination of gender-specific effects is important.

Smoking is one of the most studied of human

behaviors and thousands of studies have documented

its health consequences, yet certain questions and

data needs exist with respect to women and smoking.

For example, there is a need to better understand why

smoking prevalence increased among teenage girls

and young women in the 1990s despite the overwhelming data on adverse health effects; to identify

interventions and policies that will prevent an epidemic of tobacco use among women whose smoking

prevalence is currently low, including women in certain sociocultural groups within the United States and

women in many developing countries throughout the

world; to study the relationship of active smoking to

diseases among women for which the evidence to

date has been suggestive or inconsistent (e.g., risks for

m e n s t rual cycle irregularities, gallbladder disease, and

systemic lupus erythematosus); to increase the data

on the health effects of exposure to environmental

tobacco smoke on diseases unique among women; to

provide additional research on whether gender differences exist in susceptibility to nicotine addiction or

in the magnitude of the effects of smoking on specific

disease outcomes; and to determine whether gender

differences exist in the modifying effects of genetic

polymorphisms on disease risks associated with smoking. Many studies of smoking behavior and of the

health consequences of smoking have included both

females and males but have not reported results by

gender. Investigators should be encouraged to report

gender-specific results in the future.

Other recent reports of the Surgeon General 

have been devoted to smoking and youth (USDHHS

1994), smoking and racial or ethnic minorities 

(USDHHS 1998), and interventions to reduce smoking 

(USDHHS 2000). The reader is encouraged to consult

those reports for comprehensive reviews of the evidence on these topics. The present report focuses on

data specific to women and girls and on comparisons

of results by gender.
Executive Summary 3

Women and Smoking

4. Lung cancer is now the leading cause of cancer

death among U.S. women; it surpassed breast

cancer in 1987. About 90 percent of all lung cancer deaths among women who continue to

smoke are attributable to smoking.

5. Exposure to environmental tobacco smoke is a

cause of lung cancer and coronary heart disease

among women who are lifetime nonsmokers.

Infants born to women exposed to environmental tobacco smoke during pregnancy have a

small decrement in birth weight and a slightly

increased risk of intrauterine growth retardation compared to infants of nonexposed

women.

6. Women who stop smoking greatly reduce their

risk of dying prematurely, and quitting smoking

is beneficial at all ages. Although some clinical

intervention studies suggest that women may

have more difficulty quitting smoking than

men, national survey data show that women are

quitting at rates similar to or even higher than

those for men. Prevention and cessation interventions are generally of similar effectiveness

for women and men and, to date, few gender

differences in factors related to smoking initiation and successful quitting have been identified.

7. Smoking during pregnancy remains a major

public health problem despite increased knowledge of the adverse health effects of smoking

during pregnancy. Although the prevalence of

smoking during pregnancy has declined steadily in recent years, substantial numbers of pregnant women continue to smoke, and only about

one-third of women who stop smoking during

pregnancy are still abstinent one year after the

delivery.

8. Tobacco industry marketing is a factor influencing susceptibility to and initiation of smoking

among girls, in the United States and overseas.

Myriad examples of tobacco ads and promotions targeted to women indicate that such marketing is dominated by themes of social desirability and independence. These themes are

conveyed through ads featuring slim, attractive,

athletic models, images very much at odds with

the serious health consequences experienced by

so many women who smoke.

Conclusions from Chapters 2–5 are presented below. Separate conclusions are not included for Chapter 1 because it is a summary of the report. Chapter 6,

which presents a vision for the future, is reproduced

in its entirety following the conclusions for Chapters

2–5.

Chapter 2. Patterns of Tobacco Use Among

Women and Girls

1. C i g a rette smoking became prevalent among

women after it did among men, and smoking

p revalence has always been lower among

women than among men. The gender-specific

d i ff e rence in smoking prevalence narro w e d

between 1965 and 1985. Since 1985, the decline

in prevalence has been comparable among

women and men.

2. The prevalence of current smoking among

women increased from less than 6 percent in

1924 to 34 percent in 1965, then declined to 22 to

23 percent in the late 1990s. In 1997–1998, smoking prevalence was highest among American

Indian or Alaska Native women (34.5 percent),

intermediate among white women (23.5 percent) and black women (21.9 percent), and lowest among Hispanic women (13.8 percent) and

Asian or Pacific Islander women (11.2 percent).

By educational level, smoking prevalence is

nearly three times higher among women with 

9 to 11 years of education (30.9 percent) than

among women with 16 or more years of education (10.6 percent).

3. Much of the pro g ress in reducing smoking

prevalence among girls in the 1970s and 1980s

was lost with the increase in prevalence in the

1990s: current smoking among high school senior girls was the same in 2000 as in 1998.

Although smoking prevalence was higher

Chapter Conclusions
Surgeon General’s Report

4 Executive Summary

among high school senior girls than among high

school senior boys in the 1970s and early 1980s,

prevalence has been comparable since the mid1980s.

4. Smoking declined substantially among black

girls from the mid-1970s through the early

1990s; the decline among white girls for this

same period was small. As adolescents age into

young adulthood, these patterns are now being

reflected in the racial and ethnic differences in

smoking among young women. Data are not

available on long-term trends in smoking prevalence among high school seniors of other racial

and ethnic groups.

5. Smoking during pregnancy appears to have

d e c reased from 1989 through 1998. Despite

i n c reased knowledge of the adverse health

effects of smoking during pregnancy, estimates

of women smoking during pregnancy range

from 12 percent based on birth certificate data to

as high as 22 percent based on survey data.

6. Historically, women started to smoke at a later

age than did men, but beginning with the 1960

cohort, the mean age at smoking initiation has

not differed by gender.

7. Nicotine dependence is strongly associated with

the number of cigarettes smoked per day. Girls

and women who smoke appear to be equally

dependent on nicotine when results are stratified by number of cigarettes smoked per day.

Few gender-specific diff e rences have been

found in indicators of nicotine dependence

among adolescents, young adults, or adults

overall.

8. The percentage of persons who have ever

smoked and who have quit smoking is somewhat lower among women (46.2 percent) than

among men (50.1 percent). This finding is probably because men began to stop smoking earlier

in the twentieth century than did women and

because these data do not take into account that

men are more likely than women to switch to or

to continue to use other tobacco products when

they stop smoking cigarettes. Since the late

1970s or early 1980s, the probability of attempting to quit smoking and to succeed has been

equally high among women and men.

9. P revalence of the use of cigars, pipes, and

smokeless tobacco among women is generally

low, but recent data suggest that cigar smoking

among women and girls is increasing.

10. Smoking prevalence among women varies

markedly across countries; the perc e n t a g e s

range from an estimated 7 percent in developing countries to 24 percent in developed countries. Thwarting further increases in tobacco use

among women is one of the greatest disease prevention opportunities in the world today.

Chapter 3. Health Consequences of 

Tobacco Use Among Women

Total Mortality

1. Cigarette smoking plays a major role in the mortality of U.S. women.

2. The excess risk for death from all causes among

current smokers compared with persons who

have never smoked increases with both the

number of years of smoking and the number of

cigarettes smoked per day.

3. Among women who smoke, the percentage of

deaths attributable to smoking has increased

over the past several decades, largely because of

increases in the quantity of cigarettes smoked

and the duration of smoking. 

4. Cohort studies with follow-up data analyzed in

the 1980s show that the annual risk for death

from all causes is 80 to 90 percent greater among

women who smoke cigarettes than among

women who never smoked. A woman’s annual

risk for death more than doubles among continuing smokers compared with persons who

have never smoked in every age group from 

45 through 74 years.

5. In 1997, approximately 165,000 U.S. women

died prematurely from a smoking-related disease. Since 1980, approximately three million

U.S. women have died pre m a t u rely from a

smoking-related disease.

6. U.S. females lost an estimated 2.1 million years

of life each year during the 1990s as a result of

smoking-related deaths due to neoplastic, cardiovascular, respiratory, and pediatric diseases,

as well as from burns caused by cigarettes. For

every smoking attributable death, an average of

14 years of life was lost.

7. Women who stop smoking greatly reduce their

risk of dying prematurely. The relative benefits

of smoking cessation are greater when women

stop smoking at younger ages, but smoking cessation is beneficial at all ages.
Executive Summary 5

Women and Smoking

Lung Cancer

8. Cigarette smoking is the major cause of lung

cancer among women. About 90 percent of all

lung cancer deaths among U.S. women smokers

are attributable to smoking.

9. The risk for lung cancer increases with quantity,

duration, and intensity of smoking. The risk for

dying of lung cancer is 20 times higher among

women who smoke two or more packs of cigarettes per day than among women who do not

smoke.

10. Lung cancer mortality rates among U.S. women

have increased about 600 percent since 1950. In

1987, lung cancer surpassed breast cancer to

become the leading cause of cancer death

among U.S. women. Overall age-adjusted incidence rates for lung cancer among women

appear to have peaked in the mid-1990s.

11. In the past, men who smoked appeared to have

a higher relative risk for lung cancer than did

women who smoked, but recent data suggest

that such differences have narrowed considerably. Earlier findings largely reflect past genderspecific differences in duration and amount of

cigarette smoking.

12. Former smokers have a lower risk for lung cancer than do current smokers, and risk declines

with the number of years of smoking cessation.

International Trends in Female Lung Cancer

13. International lung cancer death rates among

women vary dramatically. This variation reflects historical differences in the adoption of

cigarette smoking by women in different countries. In 1990, lung cancer accounted for about

10 percent of all cancer deaths among women

worldwide and more than 20 percent of cancer

deaths among women in some developed countries.

Female Cancers

14. The totality of the evidence does not support an

association between smoking and risk for breast

cancer.

15. Several studies suggest that exposure to environmental tobacco smoke is associated with an

increased risk for breast cancer, but this association remains uncertain.

16. Current smoking is associated with a reduced

risk for endometrial cancer, but the effect is

p robably limited to postmenopausal disease. The

risk for this cancer among former smokers generally appears more similar to that of women

who have never smoked.

17. Smoking does not appear to be associated with

risk of ovarian cancer.

18. Smoking has been consistently associated with

an increased risk for cervical cancer. The extent

to which this association is independent of

human papillomavirus infection is uncertain.

19. Smoking may be associated with an increased

risk for vulvar cancer, but the extent to which

the association is independent of human papillomavirus infection is uncertain.

Other Cancers

20. Smoking is a major cause of cancers of the

oropharynx and bladder among women. Evidence is also strong that women who smoke

have increased risks for cancers of the pancreas

and kidney. For cancers of the larynx and esophagus, evidence among women is more limited

but consistent with large increases in risk.

21. Women who smoke may have increased risks

for liver cancer and colorectal cancer.

22. Data on smoking and cancer of the stomach

among women are inconsistent.

23. Smoking may be associated with an increased

risk for acute myeloid leukemia among women

but does not appear to be associated with other

lymphoproliferative or hematologic cancers.

24. Women who smoke may have a decreased risk

for thyroid cancer.

25. Women who use smokeless tobacco have an

increased risk for oral cancer.

Cardiovascular Disease

26. Smoking is a major cause of coronary heart disease among women. For women younger than

50 years, the majority of coronary heart disease

is attributable to smoking. Risk increases with

the number of cigarettes smoked and the duration of smoking.

27. The risk for coronary heart disease among

women is substantially reduced within 1 or 2

years of smoking cessation. This immediate

benefit is followed by a continuing but more

gradual reduction in risk to that among nonsmokers by 10 to 15 or more years after cessation. 

28. Women who use oral contraceptives have a particularly elevated risk of coronary heart disese if

they smoke. Currently, evidence is conflicting as
Surgeon General’s Report

6 Executive Summary

to whether the effect of hormone replacement

therapy on coronary heart disease risk differs

between smokers and nonsmokers.

29. Women who smoke have an increased risk for

ischemic stroke and subarachnoid hemorrhage.

Evidence is inconsistent concerning the association between smoking and primary intracerebral hemorrhage.

30. In most studies that include women, the

increased risk for stroke associated with smoking is reversible after smoking cessation; after 

5 to 15 years of abstinence, the risk approaches

that of women who have never smoked.

31. Conflicting evidence exists regarding the level

of the risk for stroke among women who both

smoke and use either the oral contraceptives

commonly prescribed in the United States today

or hormone replacement therapy.

32. Smoking is a strong predictor of the progression

and severity of carotid atherosclerosis among

women. Smoking cessation appears to slow the

rate of progression of carotid atherosclerosis.

33. Women who are current smokers have an

increased risk for peripheral vascular atherosclerosis. Smoking cessation is associated with

i m p rovements in symptoms, prognosis, and

survival.

34. Women who smoke have an increased risk for

death from ruptured abdominal aortic aneurysm.

Chronic Obstructive Pulmonary Disease (COPD)

and Lung Function

35. Cigarette smoking is a primary cause of COPD

among women, and the risk increases with the

amount and duration of smoking. A p p ro x imately 90 percent of mortality from COPD

among women in the United States can be

attributed to cigarette smoking.

36. In utero exposure to maternal smoking is associated with reduced lung function among infants, and exposure to environmental tobacco

smoke during childhood and adolescence may

be associated with impaired lung function

among girls.

37. Adolescent girls who smoke have reduced rates

of lung growth, and adult women who smoke

experience a premature decline of lung function.

38. The rate of decline in lung function is slower

among women who stop smoking than among

women who continue to smoke.

39. Mortality rates for COPD have increased among

women over the past 20 to 30 years.

40. Although data for women are limited, former

smokers appear to have a lower risk for dying

from COPD than do current smokers.

Sex Hormones, Thyroid Disease, and 

Diabetes Mellitus

41. Women who smoke have an increased risk for

estrogen-deficiency disorders and a decreased

risk for estrogen-dependent disorders, but circulating levels of the major endogenous estrogens are not altered among women smokers.

42. Although consistent effects of smoking on thyroid hormone levels have not been noted, cigarette smokers may have an increased risk for

Graves’ ophthalmopathy, a thyroid-related disease.

43. Smoking appears to affect glucose regulation

and related metabolic processes, but conflicting

data exist on the relationship of smoking and

the development of type 2 diabetes mellitus and

gestational diabetes among women.

Menstrual Function, Menopause, and Benign

Gynecologic Conditions

44. Some studies suggest that cigarette smoking

may alter menstrual function by increasing the

risks for dysmenorrhea (painful menstruation),

secondary amenorrhea (lack of menses among

women who ever had menstrual periods), and

menstrual irregularity.

45. Women smokers have a younger age at natural

menopause than do nonsmokers and may experience more menopausal symptoms.

46. Women who smoke may have decreased risk for

uterine fibroids.

Reproductive Outcomes

47. Women who smoke have increased risks for

conception delay and for both primary and secondary infertility.

48. Women who smoke may have a modest increase

in risks for ectopic pregnancy and spontaneous

abortion.

49. Smoking during pregnancy is associated with

increased risks for preterm premature rupture

of membranes, abruptio placentae, and placenta

previa, and with a modest increase in risk for

preterm delivery.

50. Women who smoke during pregnancy have a

decreased risk for preeclampsia.
Executive Summary 7

Women and Smoking

51. The risk for perinatal mortality—both stillbirth

and neonatal deaths—and the risk for sudden

infant death syndrome (SIDS) are incre a s e d

among the offspring of women who smoke during pregnancy.

52. Infants born to women who smoke during pregnancy have a lower average birth weight and

are more likely to be small for gestational age

than are infants born to women who do not

smoke.

53. Smoking does not appear to affect the overall

risk for congenital malformations.

54. Women smokers are less likely to breastfeed

their infants than are women nonsmokers.

55. Women who quit smoking before or during

pregnancy reduce the risk for adverse reproductive outcomes, including conception delay, infertility, preterm premature rupture of membranes, preterm delivery, and low birth weight.

Body Weight and Fat Distribution

56. Initiation of cigarette smoking does not appear

to be associated with weight loss, but smoking

does appear to attenuate weight gain over time.

57. The average weight of women who are current

smokers is modestly lower than that of women

who have never smoked or who are long-term

former smokers.

58. Smoking cessation among women typically is

associated with a weight gain of about 6 to 12

pounds in the year after they quit smoking.

59. Women smokers have a more masculine pattern of body fat distribution (i.e., a higher waistto-hip ratio) than do women who have never

smoked.

Bone Density and Fracture Risk

60. Postmenopausal women who currently smoke

have lower bone density than do women who

do not smoke.

61. Women who currently smoke have an increased

risk for hip fracture compared with women who

do not smoke.

62. The relationship among women between smoking and the risk for bone fracture at sites other

than the hip is not clear.

Gastrointestinal Diseases

63. Some studies suggest that women who smoke

have an increased risk for gallbladder disease 

(gallstones and cholecystitis), but the evidence

is inconsistent.

64. Women who smoke have an increased risk for

peptic ulcers.

65. Women who currently smoke have a decreased

risk for ulcerative colitis, but former smokers

have an increased risk—possibly because smoking suppresses symptoms of the disease.

66. Women who smoke appear to have an increased

risk for Crohn’s disease, and smokers with

Crohn’s disease have a worse prognosis than do

nonsmokers.

Arthritis

67. Some but not all studies suggest that women

who smoke may have a modestly elevated risk

for rheumatoid arthritis.

68. Women who smoke have a modestly reduced

risk for osteoarthritis of the knee; data regarding osteoarthritis of the hip are inconsistent.

69. The data on the risk of systemic lupus erythematosus among women who smoke are inconsistent.

Eye Disease

70. Women who smoke have an increased risk for

cataract.

71. Women who smoke may have an increased risk

for age-related macular degeneration.

72. Studies show no consistent association between

smoking and open-angle glaucoma.

Human Immunodeficiency Virus (HIV) Disease

73. Limited data suggest that women smokers may

be at higher risk for HIV-1 infection than nonsmokers.

Facial Wrinkling

74. Limited but consistent data suggest that women

smokers have more facial wrinkling than do

nonsmokers.

Depression and Other Psychiatric Disorders

75. Smokers are more likely to be depressed than

are nonsmokers, a finding that may reflect an

effect of smoking on the risk for depression, the

use of smoking for self-medication, or the influence of common genetic or other factors on both

smoking and depression. The association of

smoking and depression is particularly important among women because they are more likely to be diagnosed with depression than are

men.
Surgeon General’s Report

8 Executive Summary

76. The prevalence of smoking generally has been

found to be higher among patients with anxiety

disorders, bulimia, attention deficit disorder,

and alcoholism than among individuals without these conditions; the mechanisms underlying these associations are not yet understood.

77. The prevalence of smoking is very high among

patients with schizophrenia, but the mechanisms underlying this association are not yet

understood.

78. Smoking may be used by some persons who

would otherwise manifest psychiatric symptoms to manage those symptoms; for such persons, cessation of smoking may lead to the

emergence of depression or other dysphoric

mood states.

Neurologic Diseases

79. Women who smoke have a decreased risk for

Parkinson’s disease.

80. Data regarding the association between smoking and Alzheimer’s disease are inconsistent.

Nicotine Pharmacology and Addiction

81. Nicotine pharmacology and the behavioral

p rocesses that determine nicotine addiction

appear generally similar among women and

men; when standardized for the number of cigarettes smoked, the blood concentration of cotinine (the main metabolite of nicotine) is similar

among women and men.

82. Women’s regulation of nicotine intake may be

less precise than men’s. Factors other than nicotine (e.g., sensory cues) may play a greater 

role in determining smoking behavior among

women.

Environmental Tobacco Smoke (ETS) and 

Lung Cancer

83. Exposure to ETS is a cause of lung cancer

among women who have never smoked.

ETS and Coronary Heart Disease

84. Epidemiologic and other data support a causal

relationship between ETS exposure from the

spouse and coronary heart disease mortality

among women nonsmokers.

ETS and Reproductive Outcomes

85. Infants born to women who are exposed to ETS

during pregnancy may have a small decrement

in birth weight and a slightly increased risk for

intrauterine growth retardation compared with

infants born to women who are not exposed;

both effects are quite variable across studies.

86. Studies of ETS exposure and the risks for delay

in conception, spontaneous abortion, and perinatal mortality are few, and the results are

inconsistent.

Chapter 4. Factors Influencing Tobacco

Use Among Women

1. Girls who initiate smoking are more likely than

those who do not smoke to have parents or

friends who smoke. They also tend to have

weaker attachments to parents and family and

stronger attachments to peers and friends. They

perceive smoking prevalence to be higher than

it actually is, are inclined to risk taking and

rebelliousness, have a weaker commitment to

school or religion, have less knowledge of the

adverse consequences of smoking and the

addictiveness of nicotine, believe that smoking

can control weight and negative moods, and

have a positive image of smokers. Although the

strength of the association by gender differs

across studies, most of these factors are associated with an increased risk for smoking among

both girls and boys.

2. Girls appear to be more affected than boys by

the desire to smoke for weight control and by

the perception that smoking controls negative

moods; girls may also be more influenced than

boys to smoke by rebelliousness or a rejection of

conventional values.

3. Women who continue to smoke and those who

fail at attempts to stop smoking tend to have

lower education and employment levels than

do women who quit smoking. They also tend to

be more addicted to cigarettes, as evidenced by

the smoking of a higher number of cigarettes

per day, to be cognitively less ready to stop

smoking, to have less social support for stopping, and to be less confident in resisting temptations to smoke.
Executive Summary 9

Women and Smoking

4. Women have been extensively targeted in tobacco marketing, and tobacco companies have produced brands specifically for women, both in

the United States and overseas. Myriad examples of tobacco ads and promotions targeted to

women indicate that such marketing is dominated by themes of both social desirability and

independence, which are conveyed through ads

featuring slim, attractive, athletic models.

Between 1995 and 1998, expenditures for domestic cigarette advertising and pro m o t i o n

increased 37.3 percent, from $4.90 billion to

$6.73 billion.

5. Tobacco industry marketing, including product

design, advertising, and promotional activities,

is a factor influencing susceptibility to and initiation of smoking.

6. The dependence of the media on revenues from

tobacco advertising oriented to women, coupled with tobacco company sponsorship of

women’s fashions and of artistic, athletic, political, and other events, has tended to stifle media

coverage of the health consequences of smoking

among women and to mute criticism of the

tobacco industry by women public figures.

Chapter 5. Efforts to Reduce Tobacco Use

Among Women

1. Using evidence from studies that vary in

design, sample characteristics, and intensity of

the interventions studied, researchers to date

have not found consistent gender-specific differences in the effectiveness of intervention programs for tobacco use. Some clinical studies

have shown lower cessation rates among

women than among men, but others have not.

Many studies have not reported cessation

results by gender.

2. Among women, biopsychosocial factors, such

as pregnancy, fear of weight gain, depression,

and the need for social support, appear to be

associated with smoking maintenance, cessation, or relapse.

3. A higher percentage of women stop smoking

during pregnancy, both spontaneously and with

assistance, than at other times in their lives.

Using pregnancy-specific programs can increase smoking cessation rates, which benefits

infant health and is cost effective. Only about

one-third of women who stop smoking during

pregnancy are still abstinent one year after the

delivery.

4. Women fear weight gain during smoking cessation more than do men. However, few studies

have found a relationship between weight concerns and smoking cessation for either women

or men. Further, actual weight gain during cessation does not predict relapse to smoking.

5. Adolescent girls are more likely than adolescent

boys to respond to smoking cessation programs

that include social support from the family or

their peer group.

6. Among persons who smoke heavily, women are

more likely than men to report being dependent

on cigarettes and to have lower expectations

about stopping smoking, but it is not clear if

such women are less likely to quit smoking.

7. C u r re n t l y, no tobacco cessation method has

proved to be any more or less successful among

minority women than among white women in

the same study, but research on smoking cessation among women of most racial and ethnic

minorities has been scarce.

8. Women are more likely than men to affirm that

they smoke less at work because of a worksite

policy and are significantly more likely than

men to attribute reduced amount of daily smoking to their worksite policy. Women also are

m o re likely than men to support policies

designed to prevent smoking initiation among

adolescents, restrictions on youth access to

tobacco products, and limits on tobacco advertising and promotion.

9. Successful interventions have been developed

to prevent smoking among young people, but

little systematic effort has been focused on

developing and evaluating prevention interventions specifically for girls.
Surgeon General’s Report

10 Executive Summary

This report summarizes what is known about

smoking among women, including patterns and

trends in smoking prevalence, factors associated with

smoking initiation and maintenance, the consequences of smoking for women’s health, and interventions for smoking cessation and prevention. The

report also describes historical and contemporary

tobacco marketing targeted to women. Evidence of

the health consequences of smoking, which had

emerged somewhat earlier among men because of

their earlier uptake of smoking, is now overwhelming among women. Tragically, in the face of continually mounting evidence of the enormous consequences of smoking for women’s health, the tobacco

industry continues to heavily target women in its

advertising and promotional campaigns and is now

attempting to export the epidemic of smoking to

women in areas of the world where the smoking

prevalence among females has traditionally been low.

The single overarching theme emerging from this

report is that smoking is a women’s issue. What is

needed to curb the epidemic of smoking and smokingrelated diseases among women in the United States

and throughout the world?

Increase Awareness of the Impact of

Smoking on Women’s Health and 

Counter the Tobacco Industry’s

Targeting of Women

• Increase awareness of the devastating impact of

smoking on women’s health. Since 1980, when the

first Surgeon General’s report on women and smoking was published documenting the serious health

consequences of smoking among women, the number of women affected by smoking-related diseases

has increased dramatically. Smoking is now the leading known cause of preventable death and disease

among women. Each year during the 1990s it

accounted for more than 140,000 deaths among U.S.

women. By 1987, lung cancer became the leading

cause of cancer death among women, and in 2000

approximately 27,000 more women in the United

States died of lung cancer (67,600) than of breast cancer (40,800). Smoking also claims women’s lives

through deaths due to other types of cancer as well as

to cardiovascular, pulmonary, and other diseases—all

risks shared with men who smoke. In addition,

women experience unique health effects due to

smoking, such as those related to pregnancy. In 1997,

smoking accounted for an estimated 165,000 premature deaths among U.S. women. Exposure to environmental tobacco smoke also contributes to lung

cancer and heart disease deaths among women and

affects the health of their infants. The media, including women’s magazines and broadcast pro g r a mming, can play an important role in raising women’s

awareness of the magnitude of the impact of smoking

on their health and in prioritizing the importance of

smoking relative to the myriad other health-related

topics covered.

• Expose and counter the tobacco industry’s deliberate targeting of women and decry its efforts to link

smoking, which is so harmful to women’s health,

with women’s rights and progress in society. Even in

the face of amassing evidence that a large percentage

of women who smoke will die early, the tobacco

industry has exploited themes of liberation and success in its advertising—particularly in women’s magazines—and promotions targeted to women. Thro u g h

its sponsorship of women’s sports, women’s professional and leadership organizations, the arts, and so

on, the industry has attempted to associate itself with

things women most value (e.g., recent heavily advertised support from a major tobacco company for programs to curb domestic violence against women)

(Levin 1999; Bischoff 2000–01). Such associations

should be decried for what they are: attempts by the

tobacco industry to position itself as an ally of

women’s causes and thereby to silence potential critics. Women should be appropriately concerned by

and speak out against tobacco marketing campaigns

that co-opt the language of women’s empowerment,

and they should recognize the irony of attempts by

the tobacco industry to suggest that smoking—which

leads to nicotine dependence and death among many

women—is a form of independence. Such efforts on

the part of women would be unnecessary if the tobacco industry would voluntarily refrain from targeting

women and associating tobacco use with women’s

freedom and progress.

A Vision for the Future: What Is Needed to Reduce Smoking 

Among Women
Executive Summary 11

Women and Smoking

Support Women’s Anti-Tobacco Advocacy

Efforts and Publicize that Most Women

Are Nonsmokers

• Encourage a more vocal constituency on issues

related to women and smoking. Taking a lesson from

the success of advocacy to reduce breast cancer, concerted efforts are needed to call public attention to the

toll that lung cancer and other smoking-related diseases is exacting on women’s health and to demand

accountability on the part of the tobacco industry.

Women affected by tobacco-related diseases and their

families and friends can partner with women’s and

girls’ organizations, women’s magazines, female

celebrities, and others—not only in an effort to raise

awareness of tobacco-related disease as a women’s

issue, but also to call for policies and programs that

deglamorize and discourage tobacco use. Some excellent but relatively small-scale efforts have already

taken place in this area, but because of the magnitude

of the problem, these efforts deserve much greater

support.

• Recognize that nonsmoking is by far the norm

among women. Although in recent years smoking pre v -

alence has not declined as much as might be hoped,

nearly four-fifths of U.S. women are nonsmokers. In

some subgroups of the population, smoking is relatively rare (e.g., only 11.2 percent of adult women

who have completed college are current smokers, and

only 5.4 percent of black high school senior girls are

daily smokers). Despite the positive images of

women in tobacco advertisements, it is important to

recognize that among adult women, those who are

the most empowered, as measured by educational

attainment, are the least likely to be smokers. Moreover, most women who do smoke say they would like

to quit. The fact that almost all women have either

rejected smoking for themselves or, if they do smoke

now, wish to quit, should be promoted.

Continue to Build the Science Base on

Gender-Specific Outcomes and on How 

to Reduce Disparities Among Women 

• Conduct further studies of the relationship between smoking and certain outcomes of importance

to women’s health. For example, does exposure to

environmental tobacco smoke increase the risk for

breast cancer? Some case-control studies suggested

that possibility, but the link remains controversial,

especially because relatively little evidence exists

thus far supporting an association between active

smoking and breast cancer. Any health effects of

exposure to environmental tobacco smoke may be

particularly important among women in developing

countries, where the vast majority of women are nonsmokers but smoking prevalence among men is high.

Tobacco products, particularly the cigarette brands

that have been most heavily promoted to women

smokers, may vary significantly in the levels of

known carcinogens; however, little data exist on 

how much brands vary in toxicity and whether any 

of these possible variations may be related to the

changes in lung cancer histology over the last

decades. More research is needed to evaluate whether

changes in the tobacco product and increased exposure to tobacco-specific nitrosamines may be related

to the increased incidence rates of adenocarcinoma of

the lung. More data are also needed on the effects of

employment in tobacco production on women’s

health, including data on re p roductive outcomes

among women who work with tobacco during pregnancy. This topic is not covered in the present report

because of a paucity of information. In general, much

better data are needed on the health effects of smoking among women in the developing world. Are the

effects similar to those reported in the literature to

date, which is based largely on studies of women

smokers in the developed world, or are they m o d i f i e d

by diff e rences in lifestyle and environmental factors

such as diet, viral exposures, or other sources of

indoor air pollution?

• Encourage the reporting of gender-specific results

from studies of factors influencing smoking behavior,

smoking prevention and cessation interventions, and

the health effects of tobacco use, including use of new

tobacco products. The evidence to date has suggested

that more similarities than differences exist between

women and men in the factors that influence smoking

initiation, addiction, and smoking cessation. When

differences in smoking history are taken into account,

health consequences also are generally similar. These

conclusions are tempered by the fact that many res e a rch studies are not reporting gender-specific re s u l t s .

However, some studies do report gender differences

in smoking cessation and the health effects of smoking; thus, issues regarding gender differences are not

entirely resolved. For example, it is still not k n o w n

whether susceptibility to lung cancer is greater among

women smokers than among men smokers, or

whether women are more likely than men to gain

weight following smoking cessation. Researchers are

strongly encouraged to use existing data sets to e x a mine results by gender and to do so in future studies.
Surgeon General’s Report

12 Executive Summary

Where these additional analyses suggest important

gender differences, more research is needed to focus

on the development of interventions tailored to the

special needs of girls and women. As new “reducedrisk” tobacco products are marketed in the future, it

will also be important to learn whether gender differences exist in the appeal and use of such products, as

well as the health consequences of their use.

• Better understand how to reduce current disparities in smoking prevalence among women of different

groups, as defined by socioeconomic status, race, ethnicity, and sexual orientation. Women with only 9 to

11 years of education are about three times as likely to

be smokers as are women with a college education.

American Indian or Alaska Native women are much

more likely to smoke than are Hispanic women and

Asian or Pacific Islander women. Limited data also

suggest that lesbian women are more likely to smoke

than are heterosexual women. Among teenage girls,

whites are much more likely to smoke than are

blacks. How can the decline in smoking among women who are less well educated be accelerated? Why

are smoking rates so high among American Indian

women? What contributes to the relatively low smoking prevalence among Hispanic women and Asian or

Pacific Islander women, and what can be done to prevent smoking among them from rising in the future?

What positive influences contributed to the vast

majority of black teenage girls resisting smoking

throughout the 1990s, in stark contrast to the re l a t i v ely high smoking prevalence among white girls during

the same period? The objective is to reduce smoking

to the lowest possible level across all demographic

groups. The answers to these questions will provide

crucial information for intervention efforts.

• Determine why, during most of the 1990s, smoking

prevalence declined so little among women and increased so markedly among teenage girls. This lack of

progress is a major concern and threatens to prolong

the epidemic of smoking-related disease among

women. What are the influences that have kept smoking prevalence relatively stagnant among women and

have contributed to the sharp increases in prevalence

among teenage girls? Tobacco control policies are

known to be effective in reducing smoking, and

smoking prevalence tends to decline most where

these policies are strongest. However, efforts to curb

tobacco use do not operate in a vacuum, and powerful pro-tobacco influences (ranging from tobacco

advertising to the use of tobacco in movies) have promoted the social acceptability of smoking and there b y

have dampened the effects of tobacco control programs. More o v e r, ongoing monitoring of tobacco

industry attempts to target women in this country

and abroad are necessary for a comprehensive understanding of the influences that encourage women to

smoke and for designing effective countermarketing

campaigns. If, for example, smoking in movies by

female celebrities promotes smoking, then discouraging such practices as well as engaging well-known

actresses to be spokespersons on the issue of women

and smoking should be a high priority.

• Develop a research and evaluation agenda related

to women and smoking. As noted above, the impact

of smoking and of exposure to environmental tobacco smoke on the risk of some disease outcomes has

been inadequately studied for women. Determining

whether gender-tailored interventions increase the

effectiveness of various smoking prevention and cessation methods is important, as is documenting

whether any gender differences exist in the effectiveness of pharmacologic treatments for tobacco cessation. A need also exists to determine which tobacco

p revention and cessation interventions are most

effective for specific subgroups of girls and women,

especially those at highest risk for tobacco use (e.g.,

women with only 9 to 11 years of education, American Indian or Alaska Native women, and women

with depression). The sparse data available on smoking among lesbian women suggest that prevalence

exceeds that of U.S. women overall, but better data

are clearly needed. Research designed to reduce disparities in smoking prevalence across all subgroups

of the female population deserves high priority to

help eliminate future disparities in smoking-related

diseases. The components of programs and policies

targeted to individual women, and those targeted to

communities that produce the greatest reduction in

smoking, need to be identified. Progress on these and

other issues will be facilitated by the development of

an agenda of research and evaluation priorities related to women and smoking.

Act Now: We Know More than Enough 

• Support efforts, at both individual and societal

levels, to reduce smoking and exposure to environmental tobacco smoke among women. Proven smoking cessation methods are available for individual

smokers, including behavioral and pharmacologic

a p p roaches that benefit women and men alike.

Tobacco use treatments are among the most coste ffective of preventive health interventions; they
Women and Smoking

should be part of all women’s health care programs,

and health insurance plans should cover such services. Efforts to maximize smoking cessation and maintenance of smoking cessation among women before,

during, and after pregnancy deserve high priority,

because pregnancy is a time of high motivation to

quit and occurs when women have many years of

potential life left. With respect to prevention, the

knowledge that girls who are more academically

inclined or who are more physically active are less

likely to smoke suggests that supporting positive outlets for mental and physical development will contribute to reducing the tobacco epidemic as well.

Because regular cigarette smoking typically is initiated early in the teenage years, effective smoking cessation and prevention programs for adolescent girls and

young women are greatly needed. Societal-level

efforts to reduce tobacco use and exposure to environmental tobacco smoke include media counteradvertising, increased tobacco taxes, laws to reduce

youth access to tobacco products, and bans on smoking in public places.

• Enact comprehensive statewide tobacco control

p rograms—because they work. T h e re are known

strategies for reducing the burden of smoking-related

diseases, but making the investment in these proven

strategies remains a challenge. Results from states

such as Arizona, California, Florida, Maine, Massachusetts, and Oregon have demonstrated that smoking rates among both girls and women can be dramatically reduced. California was the first state to

establish a comprehensive statewide tobacco control

program in 1990, and it is now starting to observe the

benefits of its sustained efforts: between 1988 and

1997, the incidence rate of lung cancer among women

declined by 4.8 percent in California but increased by

13.2 percent in other regions of the United States

(Centers for Disease Control and Prevention [CDC]

2000). Another recent study concluded that the California program was associated with 33,300 fewer

deaths from heart disease between 1989 and 1997

among women and men combined than would have

been predicted if trends like those observed in the rest

of the country had continued (Fichtenberg and Glantz

2000). Enormous monetary settlement payments fro m

state Medicaid lawsuits with the tobacco industry

have provided the resources to fund major new comprehensive statewide tobacco control efforts. However, a recent report found that only six states were

meeting the minimum funding recommendations fro m

CDC’s Best Practices for Comprehensive Tobacco Control

Programs (Campaign for Tobacco Free-Kids 2001). 

Stop the Epidemic of Smoking and 

Smoking-Related Diseases Among 

Women Globally

• Do everything possible to thwart the emerging epidemic of smoking among women in developing countries. Multinational policies that discourage spread of

the epidemic of smoking and tobacco-related diseases

among women in countries where smoking pre v a l e n c e

has traditionally been low should be strongly encouraged. Efforts to disassociate cigarette smoking fro m

p ro g ress in achieving gender equity are particularly

needed in the developing world (Magardie 2000). B e -

cause smoking prevalence among men is already high i n

many developing countries, even women who do not

smoke themselves are already at risk because they are

exposed to environmental tobacco smoke—and because

they suffer the losses of male loved ones who are dying

of tobacco-related diseases. It is urgent that what is 

a lready known about effective means of tobacco contro l

at the societal level be disseminated as soon as possible

t h roughout the world. Amajor measure of public health

victory in the global war against smoking would be the

a r rest of smoking prevalence at its still generally low

level among women in developing countries and a re -

versal of the now worrisome signs of increases in smoking among them. In November 1999, the World H e a l t h

O rganization sponsored an international conference on

smoking among women and youth, which took p l a c e

in Kobe, Japan. The conference resulted in the Kobe

Declaration, which states that, “The tobacco epid e m i c

is an unrelenting public health disaster that spare s no

society. There are already over 200 million women

smokers, and tobacco companies have launched aggre ssive campaigns to re c ruit women and girls worldwide....

It is urgent that we find comprehensive solutions to the

danger of tobacco use and address the epidemic among

women and girls” (World Health Organization 1999b). 

• All national governments should strongly support the

World Health Org a n i z a t i o n ’s Framework Convention

for Tobacco Control (FCTC). The FCTC is an international legal instrument designed to curb the global spread

of tobacco use through specific protocols, currently

being negotiated, that cover tobacco pricing, smuggling,

advertising and sponsorship, and other activities (Wo r l d

Health Organization 1999a). In the words of Dr. Gro

Harlem Brundtland, dire c t o r-general of the WHO, “If we

do not act decisively, a hundred years from now our

g r a n d c h i l d ren and their children will look back and ser iously question how people claiming to be committed

t o public health and social justice allowed the tobacco

e p idemic to unfold unchecked” (Asma et al., in press). 

Executive Summary 13
Surgeon General’s Report

14 Executive Summary

Asma S, Yang G, Samet J, Giovino G, Bettcher DW,

Lopez A, Yach D. Tobacco. In: Oxford Textbook of

Public Health, in press.

Bischoff D. Consuming passions. Ms. 2000–01 (Dec–

Jan):60–5.

Campaign for Tobacco-Free Kids, American Cancer

Society, American Heart Association, and American Lung Association. Show Us the Money: An

Update on the States’ Allocation of the Tobacco Settlement Dollars. Washington: Campaign for TobaccoF ree Kids, Jan 11, 2001; <http:/ /t o b a c c o f re e k i d s . o rg /

reports/settlements/settlement2001.pdf>; accessed: Feb 6, 2001.

Centers for Disease Control and Prevention. Declines

in lung cancer rates—California, 1988–1997. Morbidity and Mortality Weekly Report 2 0 0 0 ; 4 9 ( 4 7 ) :

1066–9.

Fichtenberg CM, Glantz SA. Association of the California Tobacco Control Program with declines in

cigarette consumption and mortality from heart

disease. New England Journal of Medicine 2000;

343(24):1772–7. 

Levin M. Philip Morris’ new campaign echoes medical experts: tobacco company tries to rebuild its

image on TV and online with frank health admissions about smoking and by publicizing its charitable causes. Los Angeles Times 1999 Oct 13; Business Sect (Pt C):1.

M a g a rdie K. Tobacco groups target women. Daily Mail

and Guardian 2000 Oct 26; <http:/ /w w w. m g . c o . z a /

m g / z a / a rc h i v e / 2 0 0 0 o c t / f e a t u re s / 2 6 o c t -

tobacco.html>; accessed: Oct 28 2000.

University of Michigan. Cigarette [press release]. Ann

Arbor (MI): University of Michigan News and

Information Services, 2000 Dec 14. 

U.S. Department of Health, Education, and Welfare.

Smoking and Health. Report of the Advisory Committee to the Surgeon General of the Public Health Service.

U.S. Department of Health, Education, and Welfare, Public Health Service, Communicable Disease Center, 1964. DHEW Publication No. 1103.

U.S. Department of Health and Human Services. 

The Health Consequences of Smoking for Women. A R e -

port of the Surgeon General. Washington: U.S. Department of Health and Human Services, Public

Health Service, Office of the Assistant Secretary

for Health, Office on Smoking and Health, 1980.

U.S. Department of Health and Human Services. Preventing Tobacco Use Among Young People. AReport of

the Surgeon General. Atlanta: U.S. Department of

Health and Human Services, Public Health Service, Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention

and Health Promotion, Office on Smoking and

Health, 1994.

U.S. Department of Health and Human Services.

Tobacco Use Among U.S. Racial/Ethnic Minority

Groups—African Americans, American Indians and

Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics. A Report of the Surgeon General.

Atlanta: 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, 1998.

U.S. Department of Health and Human Services.

Reducing Tobacco Use. AReport of the Surgeon General. Atlanta: 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, 2000.

World Health Organization. Framework Convention on

Tobacco Control. Technical Briefing Series. Papers

1–5. Geneva: World Health Organization, 1999a.

World Health Organization. WHO International Conference on Tobacco and Health, Kobe, “Making a

Difference in Tobacco and Health: Avoiding the

Tobacco Epidemic in Women and Youth.” Kobe, Japan, Nov 14–18, 1999b, Kobe Declaration; <http:/ /

t o b a c c o . w h o . i n t / e n / f c t c / k o b e / d e c l a r a t i o n . h t m l > ;

accessed: Feb 5, 2001.

References