Report from the CDC
JOURNAL OF WOMEN’S HEALTH Volume 23, Number 11, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2014.4983
The Impact of Smoking on Women’s Health Tim McAfee, MD, MPH,1 and Deborah Burnette, BA1,2
Abstract
Despite half a century of public health efforts, smoking remains the single largest cause of preventable disease and death in the United States, killing 480,000 people a year and inflicting chronic disease on 16 million. Since the early part of the 20th century, tobacco companies’ success in aggressively marketing their products to women has resulted in steady increases in smoking-related disease risk for women. Today, women smokers have caught up with their male counterparts and are just as likely to die from lung cancer, heart disease, and chronic obstructive pulmonary disease (COPD) as are men who smoke. Women’s risk for developing smokingrelated heart disease or dying from COPD now exceeds men’s risk.
Introduction
P
resident of the American Tobacco Company George Washington Hill set the tone for the next half-century of tobacco-industry marketing practices when, in 1928, he dubbed women ‘‘a gold mine right in our front yard.’’1 Capitalizing on changes that, since the end of World War I, had already removed many of the social barriers to women smoking, Hill teamed with public relations pioneer Edward Bernays to sell Lucky Strike cigarettes as an aid to control weight. The campaign—‘‘Reach for a Lucky instead of a sweet’’—was a key reason American Tobacco’s profit more than doubled between 1925 and 1931 and is seen by marketing experts as the most successful single promotion in history to encourage women to smoke.2 In the late 1960s and 1970s, as the women’s movement in the United States gained traction, cigarette companies again saw an opportunity to step up the tempo and intensity of their marketing to women. For the previous 25 years, tobacco advertising aimed at women had sold glamour and sophistication but now sold smoking as part of women’s independence and success. Extending beyond mere advertising, this marketing movement led to the creation of an entire new product line—longer, thinner cigarettes3 that, coupled with marketing imagery, reinforced earlier messages of smoking as a path to a slim and sexy figure. Soon, Philip Morris tied smoking to athleticism and fitness through sponsorship of the Virginia Slims tennis circuit, named for its groundbreaking brand of thin cigarettes designed especially for women. One factor driving the cigarette companies’ focus on women as a highly desirable market for their products was a
decline in smoking by men, spurred by the growing body of evidence that smoking was a health hazard. With the 1964 release of the first Surgeon General’s Report (SGR), which established a causal link between smoking and lung cancer, cigarette smoking by men began an immediate decline, but smoking rates among women increased in the years immediately following the report. For at least the next 15 years, decreases in men’s smoking rates far outpaced declines in smoking prevalence among women, with men’s rates dropping about 27% by 1980 while women’s rates declined only about 14%.4 Today, women’s morbidity and mortality data reflect those trends. For example, while lung cancer rates for men have decreased steadily since the 1990s,5 nationwide lung cancer rates for women continued to increase until around 2004 and, according to the latest data, have persistently decreased more slowly than men’s—especially among older women who, in their youth and young adulthood, were the target of manipulative tobacco-industry marketing.6 In an assessment of the impact of cigarette marketing and advertising, the latest SGR—The Health Consequences of Smoking—50 Years of Progress—concludes that ‘‘[t]he tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which has deliberately misled the public on the risks of smoking cigarettes’’4 (p. 7). The report also examines a broad range of smoking-related diseases and conditions that affect both women’s and men’s health, reaching far beyond lung cancer in its review. In another of its 10 major conclusions, the report finds that, ‘‘[t]he disease risks from smoking by women have risen sharply over the last 50 years and are now equal to those for men for lung cancer, chronic obstructive pulmonary
1 Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. 2 ICF International, Atlanta, Georgia.
881
882
disease, and cardiovascular diseases.’’4 (p. 7). This article examines these higher smoking-attributable health risks for women through a review of relevant findings from the 50thanniversary Surgeon General’s Report. Cancer
The 2014 SGR examines smoking and cancer in significant detail. One of the most important findings is that smoking has negative effects on patient outcomes for all cancers, including ones not caused by smoking. For cancer patients and survivors, including women who are being treated for or who have survived breast cancer, the report finds that smoking causes adverse health outcomes—specifically, higher allcause and cancer-specific mortality and increased risk for second primary cancers known to be caused by smoking. Evidence in the report also suggests that smoking may be linked to higher risk of recurrence of the original cancer, poorer response to treatment, and increased treatment toxicity. According to the report, cancer patients who quit smoking improve their prognosis.4 Another significant cancer-related finding in the 2014 SGR is that smokers have a higher risk of developing adenocarcinoma of the lung than did smokers 50 years ago and that women smokers today have a much higher risk than did women smokers in the 1960s. Data from two American Cancer Society studies (1959–1965, 1982–1988) were compared with data from several large populations followed from 2000 to 2010. The studies showed nearly a tenfold increase in the relative risk for lung cancer for women smokers. In the 1959 study, women smokers were 2.7 times more likely to develop lung cancer than were women who had never smoked. By 2010, the risk had jumped to 25.7. During the same period, male smokers’ relative risk doubled, from 12.2 to 25.0, while in all three studies, the risk for those who had never smoked stayed about the same.4 The lung cancer risks for smokers increased during the same period as a significant decline in the prevalence of smoking and a decrease in the number of cigarettes consumed per smoker. The evidence shows that changes in the design and composition of cigarettes have caused the higher adenocarcinoma risks, and evidence suggests that ventilated filters and higher levels of tobacco-specific nitrosamines have played a role. In total, more than 87% of lung cancer deaths in the United States are attributable to smoking and exposure to secondhand smoke.4 In 2010, more than 130,000 women and men, in about even numbers, were diagnosed with colorectal cancer in the United States; more than 52,000 deaths were attributed to the disease, which is the second most deadly among cancers common to both women and men.7 Smoking is now known to be a contributing cause of both colorectal cancer and liver cancer.4 Aside from nonmelanoma skin cancer, breast cancer is the most frequently diagnosed cancer among women in the United States and is the second most deadly for women, behind lung cancer. In 2009, more than 200,000 women were diagnosed with invasive breast cancer4; the National Cancer Institute projects that in 2014, more than 230,000 women will be diagnosed and 40,000 women will die from the disease.8 Although both breast cancer incidence and mortality have declined since the 1990s, the disease burden remains high, and researchers have aggressively sought to identify factors
MCAFEE AND BURNETTE
that might prevent the disease.4 Since the 2004 SGR on the health consequences of smoking concluded that there was no consistent evidence for an association between smoking and breast cancer,9 12 cohort and 34 case-control studies have been published on this issue. The 2014 SGR provides a detailed synthesis of those studies, in addition to 15 new studies on the association of passive smoking and breast cancer. These new studies have led researchers to conclude in the 2014 report that the evidence is sufficient to identify mechanisms by which cigarette smoking may cause breast cancer. Although evidence is suggestive, the report concludes that it is not yet sufficient to establish a causal relationship between either active smoking or exposure to secondhand tobacco smoke and breast cancer. It often takes longer to establish causality than it does to identify a mechanism by which an exposure such as cigarette smoke can cause a disease. Establishing causality requires large-cohort studies over many years. In fact, the new SGR recommends additional research on the association between smoking and breast cancer, including larger cohort studies.4 These 2014 findings are added to findings of previous SGRs; 13 cancers have now been linked to smoking.4 Of the 585,000 cancer deaths projected to occur in 2014,10 more than 163,700 (28%) will be the result of smoking or secondhand smoke exposure.4 Cardiovascular Disease
More than 16 million Americans have heart disease. Cardiovascular disease kills 800,000 people in the United States every year and is the single largest cause of death in the country. Cardiovascular disease includes narrow or blocked arteries in and around the heart (coronary heart disease), heart attack (acute myocardial infarction), stroke, and heart-related chest pain (angina pectoris). It also includes high blood pressure (hypertension), peripheral arterial and peripheral vascular disease, and abdominal aortic aneurysm.4 Smoking is a major cause of cardiovascular disease, with nearly a third of all deaths from coronary heart disease attributable to smoking and exposure to secondhand smoke. Secondhand smoke exposure is also a cause of heart attack and stroke in nonsmokers, with exposure increasing the risk for stroke by an estimated 20% to 30%. For the first time ever, the relative risk for dying from coronary heart disease among women smokers 35 years of age and older is higher than for men who smoke. Almost all deaths from abdominal aortic aneurysms are caused by smoking and other tobacco use. Women smokers also have a higher risk of dying from an aortic aneurysm than do men who smoke.4 Despite a clear dose-response relationship between smoking and cardiovascular disease, the relationship is not linear. Even smokers who smoke five or fewer cigarettes a day show significant signs of cardiovascular damage.4 Smoking cessation has been found to lower risks of myocardial infarction and coronary heart disease; for women, the declines are somewhat stronger.4 For example, evidence cited in the 2014 SGR shows that women’s relative risk for mortality owing to coronary heart disease decreased by nearly half within 2 to 4 years of quitting.11 Respiratory Diseases
Findings in the 2014 SGR related to respiratory disease have particular relevance to women’s health. Chronic
SMOKING AND WOMEN’S HEALTH
obstructive pulmonary disease (COPD), comprising a range of pulmonary diseases, such as emphysema and chronic bronchitis, is caused predominantly by smoking; nearly 8 of 10 COPD deaths in the United States are attributed to smoking. Although smoking fewer cigarettes now than they did 50 years ago, smokers have a much higher risk of developing COPD today than they did in 1964. Women smokers’ relative risk for COPD has risen dramatically and is now similar to men’s. Today, women smokers are 22 times more likely to develop the disease than are women who have never smoked.4 Mortality from COPD has also increased dramatically since the first SGR and continues to rise. Today, more women die from COPD than do men. Further, evidence suggests that women may be more susceptible for severe COPD at younger ages than men. Finally, smoking is identified as a cause for both tuberculosis disease and death from tuberculosis and is found to exacerbate asthma symptoms in adults.4 Reproduction
Evidence in the first SGR on smoking and health pointed to a link between smoking during pregnancy and delivery of low-birth-weight infants. Since that time, additional SGRs have found that smoking before and during pregnancy causes reduced fertility, increases pregnancy complications, and endangers the health of mother, fetus, and infant. Despite decades of warnings of the dangers of smoking during pregnancy, more than 400,000 live-born infants in the United States are exposed to the chemicals in cigarette smoke in utero every year because their mothers smoke during pregnancy.4 Studies reviewed in the 2014 SGR link maternal smoking to health effects in the oviduct. The report finds that smoking is a cause of ectopic pregnancy, a condition in which the fertilized egg fails to pass through the oviduct to the uterus and instead attaches to the wall of the oviduct or elsewhere outside the uterus. Ectopic pregnancy almost always results in death of the embryo and poses a serious risk to the health of the mother.4 Proper growth and development of the fetus depend on the placenta. Women who smoke have a higher risk of placental abruption, a condition in which the placenta detaches from the uterus before the pregnancy reaches term. Placental abruption leads to preterm delivery and can result in death of the mother or child. Women who smoke while pregnant also have a higher risk for placenta previa, a condition in which the placenta partially blocks the cervix. Placenta previa can lead to preterm delivery or death of the mother or baby.12 Smoking during pregnancy can also cause some birth defects. Women who smoke during early pregnancy are more likely to deliver babies with orofacial clefts, including cleft lip and/or cleft palate, in which the upper lip or palate fails to form completely during fetal development. These conditions are associated with many complications, including an infant’s inability to eat properly, and correction of these conditions requires surgery.4 Cigarette smoke contains more than 7,000 chemicals and chemical compounds.12 Nicotine, the agent primarily responsible for addiction to tobacco, is one of those chemicals. Data in several SGRs strongly support that smoking by pregnant women has damaging effects on lung development in the fetus that last beyond childhood and suggest that nic-
883
otine may contribute to these effects.4 Evidence in the 2014 SGR shows that exposure to the chemicals in cigarette smoke, and specifically to nicotine, has adverse effects on fetal brain development and suggests that nicotine exposure during adolescence may have lasting adverse consequences for brain development. The report also finds that, ‘‘nicotine adversely affects maternal and fetal health during pregnancy, contributing to multiple adverse outcomes such as preterm delivery and stillbirth’’4 (p. 8). With the growing popularity of electronic nicotine-delivery systems, such as e-cigarettes, the implications of findings on nicotine are significant, especially for women of reproductive age. Diabetes
Diabetes is a growing public health issue, with 12.6 million American women and 13 million men over age 20 diagnosed with diabetes. Coexisting conditions and complications among people with diagnosed diabetes include hypertension, heart disease and stroke, and eye disease and blindness. Between 2005 and 2008, over a quarter (28.5%) of diabetic adults aged 40 years or older had diabetic retinopathy that could lead to vision loss. Diabetes was also the primary cause of renal failure; more than 200,000 people with kidney failure resulting from diabetes were living on chronic dialysis or with a kidney transplant.13 Previous SGRs have found that smoking complicates the management of diabetes and that smokers who have been diagnosed with diabetes are at a higher risk for kidney disease, blindness, and circulatory complications that can lead to amputations.12 The 2014 SGR concludes that smoking is also a cause of type 2 diabetes mellitus and that the risk of developing diabetes is 30%–40% higher for active smokers than for nonsmokers. A meta-analysis of 25 studies published since 2007 showed a clear dose-response relationship between smoking and relative risk for diabetes, with higher risk as the number of cigarettes smoked increases.4 Immune and Autoimmune Disorders and Overall Health
Since the mid-20th century, cigarettes have evolved into a highly engineered product containing many chemicals that are harmful in themselves and that produce more than 7,000 compounds when the tobacco is combusted. A major finding of the 2014 SGR is that the death and disease caused by tobacco use in the United States overwhelmingly stem from combusted tobacco, primarily cigarettes. Among the processes affected by the complex chemical mixture created when tobacco is burned are responses of the immune system; both immune-activating and immune-suppressive effects occur as a result of smoking. Altered immunity from smoking is associated with higher risk for pulmonary infections and increased risk for a number of specific immune and autoimmune conditions. For example, smoking is a cause of rheumatoid arthritis and interferes with the effectiveness of some treatments for the disease.4 The prevalence of rheumatoid arthritis is typically about twice as high in women as in men, and onset of the disease is highest among persons in their 60s.14 Smokers have poorer general health than do nonsmokers, starting at an early age and continuing throughout adult life. On average, smokers lose more than a decade of life, report poorer overall health, have higher absenteeism in the workplace, visit doctors more often, and are hospitalized at greater
884
rates than are nonsmokers. More than 16 million Americans live with at least one chronic disease caused by smoking or exposure to secondhand tobacco smoke.4 Conclusion
The 2014 SGR synthesizes data and evidence from thousands of studies and 31 previous SGRs on the enormous negative impact smoking has had and continues to have on the public health of this nation. Smoking-attributable allcause mortality is increasing as the millions of women and men who began smoking as adolescents and continued to smoke throughout adulthood reach older ages and develop serious chronic diseases as a result of their tobacco use. For women, the all-cause death rate in current smokers compared to that of those who never smoked has more than tripled in the past 50 years; for men, the rate has more than doubled.4 The deadliness of cigarette smoke has increased, a fact borne out by increasing disease risk even with reduced smoking prevalence and cigarette consumption. Although smoking rates for both youth and adults are less than half what they were when the first SGR was released, and aggressive tobacco-control measures have prevented an estimated 8 million premature deaths in that period,15 smoking remains the single largest cause of preventable disease and death in the United States. More than 6 million American women died because of smoking between 1964 and 2014. During that period, 2.5 million nonsmokers died of diseases caused by exposure to secondhand smoke, and 100,000 infants died from sudden infant death syndrome, prematurity, or other perinatal conditions caused by exposure to the chemicals in tobacco smoke. Without immediate and dramatic success in achieving significantly lower smoking rates, 5.6 million children under age 18 in the United States today will ultimately die prematurely from smoking-related diseases.4 Strategies that have proved effective at reducing smoking prevalence include higher prices on tobacco products, smokefree policies that protect the health of nonsmokers and reduce the social acceptability of smoking, barrier-free access to cessation assistance for all smokers who want to quit, massmedia campaigns that unequivocally illustrate the dangers of smoking, and state and local tobacco-control programs that provide education and assistance at the local level and reach populations that bear disproportionate health and economic burdens because of higher smoking prevalence. Aggressive and sustained application of these strategies, along with funding of state programs at CDC-recommended levels, hold promise of additional gains in reducing the disease, death, and economic burdens resulting from smoking. Yet additional actions may be required to rapidly reduce the use of combusted tobacco products, especially cigarettes, in the United States. These actions, referred to as end-game strategies, include a variety of options, such as reducing the amount of nicotine in tobacco products to nonaddictive levels and additional restrictions, especially achievable at the local level, on sales of specific tobacco products.4 Former Secretary of Health and Human Services Louis Sullivan told Congress in 1990 that studies examined in that year’s SGR on the health consequences of smoking demonstrated that ‘‘women who smoke like men are going to die like men who smoke’’ (p. 3)16 Today, those words ring truer than ever and are especially significant given that smoking
MCAFEE AND BURNETTE
prevalence among girls 12–17 years of age (6.3%) is similar to that for boys in that age group (6.8%).4 Ultimately, the 2014 SGR concludes, ‘‘The burden of death and disease from tobacco use in the United States is overwhelmingly caused by cigarettes and other combusted tobacco products; rapid elimination of their use will dramatically reduce this burden’’ (p. 7).4 For women, the 2014 SGR provides compelling evidence that smoking is a serious risk factor—and for many diseases, the primary risk factor—in increasing morbidity and mortality.4 Upon releasing the 50th-anniversary SGR, Acting Surgeon General Rear Admiral Boris Lushniak punctuated each finding by proclaiming, ‘‘Enough is enough!’’ Six million preventable, avoidable deaths for American women is an outrage that we cannot and should not allow to be repeated in the next 50 years. As other public health officials have pointed out, ending the tobacco-use epidemic cannot be just a government priority. It must also be a national priority, with solutions aggressively pursued in clinical, public health, education, government, business, legal, and family settings. The findings from the 2014 SGR should serve as a rallying point for our society to rid ourselves of this scourge on our health and well-being once and for all. Author Disclosure Statement
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. No competing financial interests exist. References
1. Brandt A. Recruiting women smokers: The engineering of consent in smoking and women’s health. J Am Med Womens Assoc 1996;51:63–66. 2. ‘‘Lucky Strike—Reach for a Lucky instead of a sweet’’ 1948. Available at: http://tobaccodocuments.org/youth/AmCgATC 19480000.Ad.html (accessed on August 28, 2014). 3. Anderson S, Glantz S, Ling P. Emotions for sale: Cigarette advertising and women’s psychosocial needs. Tob Control 2005:14;127–135. 4. U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress. A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Printed with corrections, January 2014. 5. Henley S, Eheman C, Richardson L, et al. State-specific trends in lung cancer incidence and smoking—United States, 1998–2008. MMWR 2011:60;1243–1247. 6. Henley S, Richards T, Underwood M, Eheman C, Plescia M, McAfee T. Lung cancer incidence trends among men and women—United States, 2005–2009. MMWR 2014:63;1–5. 7. U.S. Department of Health and Human Services. United States cancer statistics: 1999–2010 incidence and mortality Web-based report. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute, 2013. Available at: www.cdc.gov/cancer/colorectal/statistics/index.htm (accessed on August 28, 2014). 8. National Cancer Institute. Available at: www.cancer.gov/ cancertopics/types/breast (accessed on August 28, 2014).
SMOKING AND WOMEN’S HEALTH
9. U.S. Department of Health and Human Services. The health consequences of smoking: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. 10. American Cancer Society. Cancer facts & figures 2014. Atlanta, GA: American Cancer Society, 2014. 11. Thun MJ, Carter BD, Feskanich D, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med 2013;268:351–364. 12. U.S. Department of Health and Human Services. How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. 13. Centers for Disease Prevention and Control. Available at: www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf (accessed on August 28, 2014).
885
14. Centers for Disease Prevention and Control. Available at: www.cdc.gov/arthritis/basics/rheumatoid.htm (accessed on August 28, 2014). 15. Holford T, Meza R, Warner K, et al. Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964–2012. JAMA 2014;311:164–171. 16. Committee on Labor and Human Resources, U.S. Senate (statement of Louis W. Sullivan, MD, Secretary of Health and Human Services, February 20, 1990). Available at: http:// legacy.library.ucsf.edu/tid/ees11a00;isessionid=E92746D46E 12FA86E7171C875B88BBAE (accessed on August 28, 2014).
Address correspondence to: Deborah Burnette, BA Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health 4770 Buford Highway NE, MS F-79 Atlanta, GA 30341 E-mail: [email protected]
JOURNAL OF WOMEN’S HEALTH Volume 23, Number 11, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2014.4983
The Impact of Smoking on Women’s Health Tim McAfee, MD, MPH,1 and Deborah Burnette, BA1,2
Abstract
Despite half a century of public health efforts, smoking remains the single largest cause of preventable disease and death in the United States, killing 480,000 people a year and inflicting chronic disease on 16 million. Since the early part of the 20th century, tobacco companies’ success in aggressively marketing their products to women has resulted in steady increases in smoking-related disease risk for women. Today, women smokers have caught up with their male counterparts and are just as likely to die from lung cancer, heart disease, and chronic obstructive pulmonary disease (COPD) as are men who smoke. Women’s risk for developing smokingrelated heart disease or dying from COPD now exceeds men’s risk.
Introduction
P
resident of the American Tobacco Company George Washington Hill set the tone for the next half-century of tobacco-industry marketing practices when, in 1928, he dubbed women ‘‘a gold mine right in our front yard.’’1 Capitalizing on changes that, since the end of World War I, had already removed many of the social barriers to women smoking, Hill teamed with public relations pioneer Edward Bernays to sell Lucky Strike cigarettes as an aid to control weight. The campaign—‘‘Reach for a Lucky instead of a sweet’’—was a key reason American Tobacco’s profit more than doubled between 1925 and 1931 and is seen by marketing experts as the most successful single promotion in history to encourage women to smoke.2 In the late 1960s and 1970s, as the women’s movement in the United States gained traction, cigarette companies again saw an opportunity to step up the tempo and intensity of their marketing to women. For the previous 25 years, tobacco advertising aimed at women had sold glamour and sophistication but now sold smoking as part of women’s independence and success. Extending beyond mere advertising, this marketing movement led to the creation of an entire new product line—longer, thinner cigarettes3 that, coupled with marketing imagery, reinforced earlier messages of smoking as a path to a slim and sexy figure. Soon, Philip Morris tied smoking to athleticism and fitness through sponsorship of the Virginia Slims tennis circuit, named for its groundbreaking brand of thin cigarettes designed especially for women. One factor driving the cigarette companies’ focus on women as a highly desirable market for their products was a
decline in smoking by men, spurred by the growing body of evidence that smoking was a health hazard. With the 1964 release of the first Surgeon General’s Report (SGR), which established a causal link between smoking and lung cancer, cigarette smoking by men began an immediate decline, but smoking rates among women increased in the years immediately following the report. For at least the next 15 years, decreases in men’s smoking rates far outpaced declines in smoking prevalence among women, with men’s rates dropping about 27% by 1980 while women’s rates declined only about 14%.4 Today, women’s morbidity and mortality data reflect those trends. For example, while lung cancer rates for men have decreased steadily since the 1990s,5 nationwide lung cancer rates for women continued to increase until around 2004 and, according to the latest data, have persistently decreased more slowly than men’s—especially among older women who, in their youth and young adulthood, were the target of manipulative tobacco-industry marketing.6 In an assessment of the impact of cigarette marketing and advertising, the latest SGR—The Health Consequences of Smoking—50 Years of Progress—concludes that ‘‘[t]he tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which has deliberately misled the public on the risks of smoking cigarettes’’4 (p. 7). The report also examines a broad range of smoking-related diseases and conditions that affect both women’s and men’s health, reaching far beyond lung cancer in its review. In another of its 10 major conclusions, the report finds that, ‘‘[t]he disease risks from smoking by women have risen sharply over the last 50 years and are now equal to those for men for lung cancer, chronic obstructive pulmonary
1 Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. 2 ICF International, Atlanta, Georgia.
881
882
disease, and cardiovascular diseases.’’4 (p. 7). This article examines these higher smoking-attributable health risks for women through a review of relevant findings from the 50thanniversary Surgeon General’s Report. Cancer
The 2014 SGR examines smoking and cancer in significant detail. One of the most important findings is that smoking has negative effects on patient outcomes for all cancers, including ones not caused by smoking. For cancer patients and survivors, including women who are being treated for or who have survived breast cancer, the report finds that smoking causes adverse health outcomes—specifically, higher allcause and cancer-specific mortality and increased risk for second primary cancers known to be caused by smoking. Evidence in the report also suggests that smoking may be linked to higher risk of recurrence of the original cancer, poorer response to treatment, and increased treatment toxicity. According to the report, cancer patients who quit smoking improve their prognosis.4 Another significant cancer-related finding in the 2014 SGR is that smokers have a higher risk of developing adenocarcinoma of the lung than did smokers 50 years ago and that women smokers today have a much higher risk than did women smokers in the 1960s. Data from two American Cancer Society studies (1959–1965, 1982–1988) were compared with data from several large populations followed from 2000 to 2010. The studies showed nearly a tenfold increase in the relative risk for lung cancer for women smokers. In the 1959 study, women smokers were 2.7 times more likely to develop lung cancer than were women who had never smoked. By 2010, the risk had jumped to 25.7. During the same period, male smokers’ relative risk doubled, from 12.2 to 25.0, while in all three studies, the risk for those who had never smoked stayed about the same.4 The lung cancer risks for smokers increased during the same period as a significant decline in the prevalence of smoking and a decrease in the number of cigarettes consumed per smoker. The evidence shows that changes in the design and composition of cigarettes have caused the higher adenocarcinoma risks, and evidence suggests that ventilated filters and higher levels of tobacco-specific nitrosamines have played a role. In total, more than 87% of lung cancer deaths in the United States are attributable to smoking and exposure to secondhand smoke.4 In 2010, more than 130,000 women and men, in about even numbers, were diagnosed with colorectal cancer in the United States; more than 52,000 deaths were attributed to the disease, which is the second most deadly among cancers common to both women and men.7 Smoking is now known to be a contributing cause of both colorectal cancer and liver cancer.4 Aside from nonmelanoma skin cancer, breast cancer is the most frequently diagnosed cancer among women in the United States and is the second most deadly for women, behind lung cancer. In 2009, more than 200,000 women were diagnosed with invasive breast cancer4; the National Cancer Institute projects that in 2014, more than 230,000 women will be diagnosed and 40,000 women will die from the disease.8 Although both breast cancer incidence and mortality have declined since the 1990s, the disease burden remains high, and researchers have aggressively sought to identify factors
MCAFEE AND BURNETTE
that might prevent the disease.4 Since the 2004 SGR on the health consequences of smoking concluded that there was no consistent evidence for an association between smoking and breast cancer,9 12 cohort and 34 case-control studies have been published on this issue. The 2014 SGR provides a detailed synthesis of those studies, in addition to 15 new studies on the association of passive smoking and breast cancer. These new studies have led researchers to conclude in the 2014 report that the evidence is sufficient to identify mechanisms by which cigarette smoking may cause breast cancer. Although evidence is suggestive, the report concludes that it is not yet sufficient to establish a causal relationship between either active smoking or exposure to secondhand tobacco smoke and breast cancer. It often takes longer to establish causality than it does to identify a mechanism by which an exposure such as cigarette smoke can cause a disease. Establishing causality requires large-cohort studies over many years. In fact, the new SGR recommends additional research on the association between smoking and breast cancer, including larger cohort studies.4 These 2014 findings are added to findings of previous SGRs; 13 cancers have now been linked to smoking.4 Of the 585,000 cancer deaths projected to occur in 2014,10 more than 163,700 (28%) will be the result of smoking or secondhand smoke exposure.4 Cardiovascular Disease
More than 16 million Americans have heart disease. Cardiovascular disease kills 800,000 people in the United States every year and is the single largest cause of death in the country. Cardiovascular disease includes narrow or blocked arteries in and around the heart (coronary heart disease), heart attack (acute myocardial infarction), stroke, and heart-related chest pain (angina pectoris). It also includes high blood pressure (hypertension), peripheral arterial and peripheral vascular disease, and abdominal aortic aneurysm.4 Smoking is a major cause of cardiovascular disease, with nearly a third of all deaths from coronary heart disease attributable to smoking and exposure to secondhand smoke. Secondhand smoke exposure is also a cause of heart attack and stroke in nonsmokers, with exposure increasing the risk for stroke by an estimated 20% to 30%. For the first time ever, the relative risk for dying from coronary heart disease among women smokers 35 years of age and older is higher than for men who smoke. Almost all deaths from abdominal aortic aneurysms are caused by smoking and other tobacco use. Women smokers also have a higher risk of dying from an aortic aneurysm than do men who smoke.4 Despite a clear dose-response relationship between smoking and cardiovascular disease, the relationship is not linear. Even smokers who smoke five or fewer cigarettes a day show significant signs of cardiovascular damage.4 Smoking cessation has been found to lower risks of myocardial infarction and coronary heart disease; for women, the declines are somewhat stronger.4 For example, evidence cited in the 2014 SGR shows that women’s relative risk for mortality owing to coronary heart disease decreased by nearly half within 2 to 4 years of quitting.11 Respiratory Diseases
Findings in the 2014 SGR related to respiratory disease have particular relevance to women’s health. Chronic
SMOKING AND WOMEN’S HEALTH
obstructive pulmonary disease (COPD), comprising a range of pulmonary diseases, such as emphysema and chronic bronchitis, is caused predominantly by smoking; nearly 8 of 10 COPD deaths in the United States are attributed to smoking. Although smoking fewer cigarettes now than they did 50 years ago, smokers have a much higher risk of developing COPD today than they did in 1964. Women smokers’ relative risk for COPD has risen dramatically and is now similar to men’s. Today, women smokers are 22 times more likely to develop the disease than are women who have never smoked.4 Mortality from COPD has also increased dramatically since the first SGR and continues to rise. Today, more women die from COPD than do men. Further, evidence suggests that women may be more susceptible for severe COPD at younger ages than men. Finally, smoking is identified as a cause for both tuberculosis disease and death from tuberculosis and is found to exacerbate asthma symptoms in adults.4 Reproduction
Evidence in the first SGR on smoking and health pointed to a link between smoking during pregnancy and delivery of low-birth-weight infants. Since that time, additional SGRs have found that smoking before and during pregnancy causes reduced fertility, increases pregnancy complications, and endangers the health of mother, fetus, and infant. Despite decades of warnings of the dangers of smoking during pregnancy, more than 400,000 live-born infants in the United States are exposed to the chemicals in cigarette smoke in utero every year because their mothers smoke during pregnancy.4 Studies reviewed in the 2014 SGR link maternal smoking to health effects in the oviduct. The report finds that smoking is a cause of ectopic pregnancy, a condition in which the fertilized egg fails to pass through the oviduct to the uterus and instead attaches to the wall of the oviduct or elsewhere outside the uterus. Ectopic pregnancy almost always results in death of the embryo and poses a serious risk to the health of the mother.4 Proper growth and development of the fetus depend on the placenta. Women who smoke have a higher risk of placental abruption, a condition in which the placenta detaches from the uterus before the pregnancy reaches term. Placental abruption leads to preterm delivery and can result in death of the mother or child. Women who smoke while pregnant also have a higher risk for placenta previa, a condition in which the placenta partially blocks the cervix. Placenta previa can lead to preterm delivery or death of the mother or baby.12 Smoking during pregnancy can also cause some birth defects. Women who smoke during early pregnancy are more likely to deliver babies with orofacial clefts, including cleft lip and/or cleft palate, in which the upper lip or palate fails to form completely during fetal development. These conditions are associated with many complications, including an infant’s inability to eat properly, and correction of these conditions requires surgery.4 Cigarette smoke contains more than 7,000 chemicals and chemical compounds.12 Nicotine, the agent primarily responsible for addiction to tobacco, is one of those chemicals. Data in several SGRs strongly support that smoking by pregnant women has damaging effects on lung development in the fetus that last beyond childhood and suggest that nic-
883
otine may contribute to these effects.4 Evidence in the 2014 SGR shows that exposure to the chemicals in cigarette smoke, and specifically to nicotine, has adverse effects on fetal brain development and suggests that nicotine exposure during adolescence may have lasting adverse consequences for brain development. The report also finds that, ‘‘nicotine adversely affects maternal and fetal health during pregnancy, contributing to multiple adverse outcomes such as preterm delivery and stillbirth’’4 (p. 8). With the growing popularity of electronic nicotine-delivery systems, such as e-cigarettes, the implications of findings on nicotine are significant, especially for women of reproductive age. Diabetes
Diabetes is a growing public health issue, with 12.6 million American women and 13 million men over age 20 diagnosed with diabetes. Coexisting conditions and complications among people with diagnosed diabetes include hypertension, heart disease and stroke, and eye disease and blindness. Between 2005 and 2008, over a quarter (28.5%) of diabetic adults aged 40 years or older had diabetic retinopathy that could lead to vision loss. Diabetes was also the primary cause of renal failure; more than 200,000 people with kidney failure resulting from diabetes were living on chronic dialysis or with a kidney transplant.13 Previous SGRs have found that smoking complicates the management of diabetes and that smokers who have been diagnosed with diabetes are at a higher risk for kidney disease, blindness, and circulatory complications that can lead to amputations.12 The 2014 SGR concludes that smoking is also a cause of type 2 diabetes mellitus and that the risk of developing diabetes is 30%–40% higher for active smokers than for nonsmokers. A meta-analysis of 25 studies published since 2007 showed a clear dose-response relationship between smoking and relative risk for diabetes, with higher risk as the number of cigarettes smoked increases.4 Immune and Autoimmune Disorders and Overall Health
Since the mid-20th century, cigarettes have evolved into a highly engineered product containing many chemicals that are harmful in themselves and that produce more than 7,000 compounds when the tobacco is combusted. A major finding of the 2014 SGR is that the death and disease caused by tobacco use in the United States overwhelmingly stem from combusted tobacco, primarily cigarettes. Among the processes affected by the complex chemical mixture created when tobacco is burned are responses of the immune system; both immune-activating and immune-suppressive effects occur as a result of smoking. Altered immunity from smoking is associated with higher risk for pulmonary infections and increased risk for a number of specific immune and autoimmune conditions. For example, smoking is a cause of rheumatoid arthritis and interferes with the effectiveness of some treatments for the disease.4 The prevalence of rheumatoid arthritis is typically about twice as high in women as in men, and onset of the disease is highest among persons in their 60s.14 Smokers have poorer general health than do nonsmokers, starting at an early age and continuing throughout adult life. On average, smokers lose more than a decade of life, report poorer overall health, have higher absenteeism in the workplace, visit doctors more often, and are hospitalized at greater
884
rates than are nonsmokers. More than 16 million Americans live with at least one chronic disease caused by smoking or exposure to secondhand tobacco smoke.4 Conclusion
The 2014 SGR synthesizes data and evidence from thousands of studies and 31 previous SGRs on the enormous negative impact smoking has had and continues to have on the public health of this nation. Smoking-attributable allcause mortality is increasing as the millions of women and men who began smoking as adolescents and continued to smoke throughout adulthood reach older ages and develop serious chronic diseases as a result of their tobacco use. For women, the all-cause death rate in current smokers compared to that of those who never smoked has more than tripled in the past 50 years; for men, the rate has more than doubled.4 The deadliness of cigarette smoke has increased, a fact borne out by increasing disease risk even with reduced smoking prevalence and cigarette consumption. Although smoking rates for both youth and adults are less than half what they were when the first SGR was released, and aggressive tobacco-control measures have prevented an estimated 8 million premature deaths in that period,15 smoking remains the single largest cause of preventable disease and death in the United States. More than 6 million American women died because of smoking between 1964 and 2014. During that period, 2.5 million nonsmokers died of diseases caused by exposure to secondhand smoke, and 100,000 infants died from sudden infant death syndrome, prematurity, or other perinatal conditions caused by exposure to the chemicals in tobacco smoke. Without immediate and dramatic success in achieving significantly lower smoking rates, 5.6 million children under age 18 in the United States today will ultimately die prematurely from smoking-related diseases.4 Strategies that have proved effective at reducing smoking prevalence include higher prices on tobacco products, smokefree policies that protect the health of nonsmokers and reduce the social acceptability of smoking, barrier-free access to cessation assistance for all smokers who want to quit, massmedia campaigns that unequivocally illustrate the dangers of smoking, and state and local tobacco-control programs that provide education and assistance at the local level and reach populations that bear disproportionate health and economic burdens because of higher smoking prevalence. Aggressive and sustained application of these strategies, along with funding of state programs at CDC-recommended levels, hold promise of additional gains in reducing the disease, death, and economic burdens resulting from smoking. Yet additional actions may be required to rapidly reduce the use of combusted tobacco products, especially cigarettes, in the United States. These actions, referred to as end-game strategies, include a variety of options, such as reducing the amount of nicotine in tobacco products to nonaddictive levels and additional restrictions, especially achievable at the local level, on sales of specific tobacco products.4 Former Secretary of Health and Human Services Louis Sullivan told Congress in 1990 that studies examined in that year’s SGR on the health consequences of smoking demonstrated that ‘‘women who smoke like men are going to die like men who smoke’’ (p. 3)16 Today, those words ring truer than ever and are especially significant given that smoking
MCAFEE AND BURNETTE
prevalence among girls 12–17 years of age (6.3%) is similar to that for boys in that age group (6.8%).4 Ultimately, the 2014 SGR concludes, ‘‘The burden of death and disease from tobacco use in the United States is overwhelmingly caused by cigarettes and other combusted tobacco products; rapid elimination of their use will dramatically reduce this burden’’ (p. 7).4 For women, the 2014 SGR provides compelling evidence that smoking is a serious risk factor—and for many diseases, the primary risk factor—in increasing morbidity and mortality.4 Upon releasing the 50th-anniversary SGR, Acting Surgeon General Rear Admiral Boris Lushniak punctuated each finding by proclaiming, ‘‘Enough is enough!’’ Six million preventable, avoidable deaths for American women is an outrage that we cannot and should not allow to be repeated in the next 50 years. As other public health officials have pointed out, ending the tobacco-use epidemic cannot be just a government priority. It must also be a national priority, with solutions aggressively pursued in clinical, public health, education, government, business, legal, and family settings. The findings from the 2014 SGR should serve as a rallying point for our society to rid ourselves of this scourge on our health and well-being once and for all. Author Disclosure Statement
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. No competing financial interests exist. References
1. Brandt A. Recruiting women smokers: The engineering of consent in smoking and women’s health. J Am Med Womens Assoc 1996;51:63–66. 2. ‘‘Lucky Strike—Reach for a Lucky instead of a sweet’’ 1948. Available at: http://tobaccodocuments.org/youth/AmCgATC 19480000.Ad.html (accessed on August 28, 2014). 3. Anderson S, Glantz S, Ling P. Emotions for sale: Cigarette advertising and women’s psychosocial needs. Tob Control 2005:14;127–135. 4. U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress. A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Printed with corrections, January 2014. 5. Henley S, Eheman C, Richardson L, et al. State-specific trends in lung cancer incidence and smoking—United States, 1998–2008. MMWR 2011:60;1243–1247. 6. Henley S, Richards T, Underwood M, Eheman C, Plescia M, McAfee T. Lung cancer incidence trends among men and women—United States, 2005–2009. MMWR 2014:63;1–5. 7. U.S. Department of Health and Human Services. United States cancer statistics: 1999–2010 incidence and mortality Web-based report. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute, 2013. Available at: www.cdc.gov/cancer/colorectal/statistics/index.htm (accessed on August 28, 2014). 8. National Cancer Institute. Available at: www.cancer.gov/ cancertopics/types/breast (accessed on August 28, 2014).
SMOKING AND WOMEN’S HEALTH
9. U.S. Department of Health and Human Services. The health consequences of smoking: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. 10. American Cancer Society. Cancer facts & figures 2014. Atlanta, GA: American Cancer Society, 2014. 11. Thun MJ, Carter BD, Feskanich D, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med 2013;268:351–364. 12. U.S. Department of Health and Human Services. How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. 13. Centers for Disease Prevention and Control. Available at: www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf (accessed on August 28, 2014).
885
14. Centers for Disease Prevention and Control. Available at: www.cdc.gov/arthritis/basics/rheumatoid.htm (accessed on August 28, 2014). 15. Holford T, Meza R, Warner K, et al. Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964–2012. JAMA 2014;311:164–171. 16. Committee on Labor and Human Resources, U.S. Senate (statement of Louis W. Sullivan, MD, Secretary of Health and Human Services, February 20, 1990). Available at: http:// legacy.library.ucsf.edu/tid/ees11a00;isessionid=E92746D46E 12FA86E7171C875B88BBAE (accessed on August 28, 2014).
Address correspondence to: Deborah Burnette, BA Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health 4770 Buford Highway NE, MS F-79 Atlanta, GA 30341 E-mail: [email protected]
