Women, Tobacco, and Cancer:

An Agenda for the 21st Century

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

National Cancer Institute

July 2004
Working Group Report Women, Tobacco, and Cancer: An Agenda for the 21st Century 

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

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.

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

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