Transcript No Slide Title

Women and Tobacco
Corinne G. Husten, MD, MPH
Office on Smoking and Health
National Conference on Tobacco or Health
November, 2002
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Trends in Cigarette Smoking* Among Adults (18+)
by Gender—United States, 1955-2000
60
50
Males
Percent
40
30
20
Females
10
0
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
Year
Source: 1955 Current Population Survey; 1965-2000 NHIS
*Estimates since 1992 include some-day smoking
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Trends in Cigarette Smoking among Women (18+)
by Race/Ethnicity—United States, 1978-2000
80
African
American
70
Percent
60
American
Indian
50
40
Asian
30
Hispanic
20
White
10
0
19781980
19831985
1990- 1992- 19941991 1993 1995
19871988
1997- 19991998 2000
Year
Source: National Health Interview Surveys, 1978-2000, selected years, aggregate data
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Percentage of Current Cigarette Smoking among
Hispanic Women—United States, 1997-1998
50
Cuban
American
Percent
40
Mexican
American
30
Mexicana
21.0
20
13.1
10
Puerto Rican
14.6
13.9
9.7
Other
Hispanics
0
Source: National Health Interview Surveys, 1997 and 1998, aggregate data
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Percentage of Current Cigarette Smoking among
American Indians and Alaska Native Women,
by Region—United States, 1995-1998
50
42.1
41.8
Alaska
Percent
40
30
East
26.6
Northern
Plains
26.4
17.8
20
Pacific Coast
Southwest
10
0
MMWR 2000: 49(04);79-82, 91
Source: Behavioral Risk Factor Surveillance System, 1995-1998
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Trends in Cigarette Smoking* Among Women
Aged 25+ by Education—United States, 1966-2000
50
Percent
40
30
20
10
0
1966
1970
1974
0-8
1978
1982
1986
1990
9-11
12
13-15
Years of Education
Source: NHIS, 1966-2000
*Estimates since 1992 incorporate some-day smoking
1994
1998 2000
16+
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Smoking Patterns among
Lesbian and Bisexual Women
 Limited data on smoking among lesbian and
bisexual women
 Largely based on convenience samples
 Existing studies strongly suggest increased
prevalence
– 41% adults (1980 studies)
– Data not broken by gender for youth—59.3%
(1995 Massachusetts YRBS)
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Prevalence of Current Smoking among Girls,
by Grade in School—United States, 1975-2001
50
Percent
40
30
12th Grade
20
10th Grade
10
8th Grade
0
1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001
Source: Institute for Social Research, University of Michigan, Monitoring the Future Project
*Smoking 1 or more cigarettes/day during the previous 30 days
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Trends in Current* Cigarette Smoking among
12th Graders by Gender—United States, 1976-2001
50
Percent
40
Females
30
20
Males
10
0
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
Year
Source: Institute for Social Research, University of Michigan, Monitoring the Future Project
*Smoking 1 or more cigarettes during the previous 30 days
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Trends in Current Cigarette Smoking* Among Female High
School Seniors by Race/Ethnicity—United States, 1976-1994
70
African
American
60
American
Indian
Percent
50
40
Asian
30
Hispanic
20
White
10
0
19761979
19801984
19851989
19901994
Year
*Smoking 1 or more cigarettes during the previous 30 days
Source: Institute for Social Research, University of Michigan, Monitoring the Future Project
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Trends in Current Cigarette Use Among White, Black,
and Hispanic High School Girls—United States, 1991-2001
50
% Smokers*
40
White
30
Hispanic
20
Black
10
0
1991
1993
1995
1997
1999
2001
Year
*Smoked cigarettes on one or more days in the 30 days preceding the survey
Source: CDC Youth Risk Behavior Survey
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Percentage of Current Use of Any Tobacco Product*
Among High School Students, by Sex and
Race/Ethnicity—United States, 2001
70
60
Girls
Boys
Percent
50
43.4
40
31.5
32.3
27.2
30
21.6
20
17.4
10
0
African American
Hispanic
*Includes users of cigarettes, cigars, chewing tobacco, or snuff
Source: Youth Risk Behavior Survey, 1999
White
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Percentage of Ever-daily Smokers Who Have Ever Tried to
Quit Smoking, grades 9-12, by Sex—United States, 1999
100
90
80
80.9
71.0
Percent
70
60
50
40
30
20
10
0
Males
Source: Youth Risk Behavior Survey. 1999
Females
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Prevalence of Cigarette Smoking During Pregnancy—
United States, 1989-2000
25
Percent
20
15
10
5
0
1989
1991
1993
1995
1997
1999
2000
Note: Percentage excludes live births for mothers with unknown smoking status.
Sources: National Center for Health Statistics 1992, 1994; Ventura et al. 1995, 1997, 1999, 2000;
Martin et al. 2002.
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Percentage of Live-born Infants' Mothers Who Reported
Smoking During Pregnancy, by Race/Ethnicity—
United States, 1989-2000
Percent
40
African
American
30
American
Indian
20
Asian
Hispanic
White
10
0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Year
Source: National Center for Health Statistics, Vol. 49, No. 1. 2001; Vol.50, No. 5, 2002
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Percentage of Live-born Infants' Mothers Who Reported
Smoking During Pregnancy, by Asian or Pacific Islander*—
United States, 1989-1999
40
Filipino
Hawaiian and
Part Hawaiian
Percent
30
Chinese
20
Other Asian or
Pacific Islander
10
Japanese
0
1989
1990
1991
1992
1993
1994
Year
1995
1996
1997
*Determined by the origin of mother
Source: National Center for Health Statistics, Vol. 49, No. 1. April 17, 2001
1998
1999
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Percent
Percentage of Live-born Infants' Mothers Who
Reported Smoking During Pregnancy, by Hispanic—
United States, 1989-1999
40
Cuban
30
Puerto
Rican
20
Central and
South
American
Mexican
American
10
Other and
Unknown
0
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
Year
*Determined by the origin of mother
Source: National Center for Health Statistics, Vol. 49, No. 1. April 17, 2001
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Percentage of Ever Smokers Who have Quit*
by Gender, Ages 18+—United States, 1965-2000
% Former Smokers
60
Men
50
Women
40
30
20
10
0
1965
1970
1975
1980
1985
1990
1995
2000
Year
Source: 1965-2000 National Health Interview Surveys
*Also known as "quit ratio"; estimates since 1992 incorporate some-day smoking
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Percent of Ever Smokers Who Have Quit* among Women
by Race/Ethnicity, Ages 18+—United States, 1978-1998
70
African
American
60
American
Indian
Percent
50
40
Asian
30
Hispanic
20
White
10
0
19781980
19831985
19871988
Year
19901991
19921993
19941995
*The prevalence of cessation is the percentage of ever smokers who are former smokers
Source: National Health Interview Surveys, 1978-1998, selected years, aggregate data
19971998
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Percentage of Women Who Reported that No One is
Allowed to Smoke Anywhere Inside the Home, by
Race/Ethnicity—United States, 1998/1999
100
African
American
90
75.6
80
75.4
Percent
70
60
57.7
60.5
53.9
50
American
Indian
Asian
Hispanic
40
White
30
20
10
0
Source: U.S. Bureau of the Census, public use data tapes, 1998-1999:
Current Population Survey, aggregated data
TM
Factors Influencing Tobacco Use among Youth
 Advertising/promotions
 Glamorization in movies/TV
 Price
 Access
 Inadequate understanding of health risks
and risk of addiction
 Social norms around tobacco use
 Parental and peer smoking
 Addiction
TM
Factors Influencing Tobacco Use among Youth:
Advertising\Promotions
 Youth are a strategically important market for the tobacco
industry.
 Youth are exposed to cigarette messages through print
media and promotional activities (sponsorship of events
and entertainment, point-of-sale displays, distribution of
specialty items).
 Cigarette advertising uses images to portray the
attractiveness and function of smoking (independence,
healthfulness, adventure-seeking, and youthful activities)–
themes correlated with psychosocial factors that appeal to
youth.
TM
Factors Influencing Tobacco Use among Youth:
Advertising
 Advertisements capitalize on the disparity between an
ideal and actual self-image and imply that smoking may
close the gap.
 Advertising appears to affect young people’s
perceptions of the pervasiveness, image, and function
of smoking.
 Advertising appears to increase young people’s risk of
smoking.
Preventing Tobacco Use among Young People, 1994
TM
Factors Influencing Tobacco Use among Girls:
Advertising/Promotions
 In 2000, expenditures for domestic advertising and
promotion were $9.57 billion, and increase of 42% since
1998.
 Tobacco marketing, including product design,
advertising, and promotional activities, is a factor
influencing susceptibility to and initiation of smoking
FTC report, 2002; Women and Smoking: A Report of the Surgeon General, 2001
TM
Factors Influencing Tobacco Use among Girls and Women:
Advertising
 Women have been extensively targeted in tobacco marketing,
and tobacco companies have produced brands specifically for
women. Marketing is dominated by themes of social desirability
and independence, which are conveyed through ads featuring
slim, attractive, athletic models.
 The dependence of the media on revenues from tobacco
advertising oriented to women, coupled with sponsorship of
women’s fashions and of artistic, athletic, political, and other
events, has tended to stifle media coverage of the health
consequences of smoking among women and to mute criticism
of the industry by women public figures.
Women and Smoking: A Report of the Surgeon General, 2001
TM
Factors Influencing Tobacco Use among Girls:
Advertising
 In 1999, 8 of the 10 top brands reached over 70% of teens
(ages 12-17) 5 or more times.
– Kool, Marlboro, and Winston reached over 89% of teens
 10 of the 10 top brands advertised in magazines that have
higher than 15% teen composition.
– Winston, Camel, Kool, Virginia Slims, and Benson & Hedges
advertised in Vibe, a publication with over 42% teen composition
 Kool, Winston, Newport, Marlboro, and Doral each spent over
40% of their respective magazine budgets in publications with
higher than 15% teen composition.
– Camel spent 33% of its total budget on these magazines
American Legacy Foundation,
TM
Factors Influencing Tobacco Use among Girls and Women:
Glamorization in Movies and TV
 Study of most popular movie rentals (200) of 1996/1997
– Tobacco appeared in 89% of movies
– Tobacco use was consistent across movie genres, occurring in
83% of action adventures, and 89% of comedies and dramas
– Tobacco was used in 79% of G or PG movies, 82% of PG-13
movies, and 92% of R-rated movies
– Movies were segmented into 5-minute intervals; of the 4372
intervals, tobacco use occurred in 24%
National Clearinghouse for Alcohol and Drug Information, SAMHSA, 2001
TM
Factors Influencing Tobacco Use among Girls:
Price
 Increasing the unit price of tobacco reduces smoking
initiation
– State excise taxes range from $.025 to $1.50 per pack
– “Loosies”
– Internet or mail-order sales
– Free samples
Guide to Community Preventive Services, 2001
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Factors Influencing Tobacco Use among Girls:
Access
 In 1999, high school girls under age 18 reported their usual
sources of cigarettes:
– 33.9% gave someone else money to buy them
– 33.3% borrowed from someone
– 17.6% bought them in a store
– 11.4% obtained them in some other way
 76.2% were not asked to show proof of age when buying
cigarettes in a store
 Several studies have found that girls are able to purchase
tobacco with greater ease than boys
YRBS, 1999; in press; Women and Smoking: A Report of the Surgeon General, 2001
TM
Factors Influencing Tobacco Use among Girls:
Inadequate Understanding of Health Risks
 A 1999 survey of youth ages 14-22 reported that 40% of
smokers and 25% of nonsmokers underestimated or did not
know the likelihood of smoking-related deaths.
 Over 40% did not know or underestimated the number of years
of life lost to smoking.
 Young people overestimated lung cancer risk, but
underestimated the fatality of lung cancer.
 Young people were optimistic about their personal risk from
smoking.
TM
Factors Influencing Tobacco Use among Girls:
Social Norms
 Widespread social norms
– Countermarketing campaigns
reduce initiation
 Local community norms
 Parental smoking
 Peer smoking
Guide to Community Preventive Services, 2001
Reducing Tobacco Use: A Report of the Surgeon General, 2000
TM
Individual Factors Influencing Tobacco Use among Girls
 Weaker attachment to parents and family
 Strong attachment to peers and friends
 Perceive smoking as more common than it
actually is
 Risk taking and rebelliousness
Women and Smoking: A Report of the Surgeon General, 2001
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Individual Factors Influencing Tobacco Use among Girls
 Weaker commitment to school and religion
 Belief smoking can control weight and moods
 Positive image of smokers
Women and Smoking: A Report of the Surgeon General, 2001
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Factors Influencing Tobacco Use among Adults
 Physical and psycho-social dependence
 Availability of effective treatments
 Clean indoor air restrictions
 Price
 Social norms around tobacco use
TM
Factors Influencing Tobacco Use among Adults:
Nicotine Dependence
 Reporting any indicator of nicotine dependence
– 63.1% of girls aged 12-17 years
– 81.2% of young women aged 18-24 years
– 77.5% of all adults women aged 18+ years
Women and Smoking: A Report of the Surgeon General, 2001
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Smoking and Addiction in Women
 Addiction processes similar for women and men
 Other factors (sensory cues) may play a greater
role in smoking among women
TM
Factors Influencing Tobacco Use among Adults: Availability
of Treatment
 Among women, biopsychosocial factors such as
pregnancy, fear of weight gain, depression, and
need for social support appear to be associated
with smoking maintenance, cessation, or relapse
 Adolescent girls are more likely than boys to
respond to cessation programs that include social
support from family or peers
Women and Smoking: A Report of the Surgeon General, 2001
TM
Factors Influencing Tobacco Use among Adults: Availability
of Treatment
 Telephone cessation quitlines increase quitting
– 40 states have some form of telephone cessation quitline in place or
under development; however use may be restricted
 Reducing the out-of-pocket costs of treatment increases quitting
– Less than 50% of HMOs and less than 25% of indemnity plans provide
any coverage of cessation treatment
– Medicaid coverage:
– 11 states: individual counseling; 10 states: group counseling
– 31 states: some prescription products; 20 states: all prescription meds
– 23 states: some OTC medications; 21 states both OTC medications
– Medicare does not cover cessation treatment
Guide to Community Preventive Services, 2001; NCSL
TM
Factors Influencing Tobacco Use among Women: Clean
Indoor Air Restrictions
 Women are more likely than men to affirm that they
smoke less at work because of a worksite policy.
Women and Smoking: A Report of the Surgeon General, 2001
TM
Factors Influencing Tobacco Use among Women:
Price
 Increasing the unit price of tobacco increases quitting
– Studies on gender-specific differences in the effect of
cigarette price on consumption have produced
inconsistent results
Guide to Community Preventive Services, 2001
Women and Smoking: A Report of the Surgeon General, 2001
TM
Factors Influencing Tobacco Use among Women:
Inadequate Understanding of Health Risks
 Popular women’s magazines downplay the hazards of cigarette
smoking
 A survey of 12 popular women’s magazines from August 1999 August 2000
– Of 2414 health-related articles, only 24 addressed the health
effects of tobacco
– Only 3 discussed lung cancer
– Self accounted for 54% of the anti-smoking articles
– Vogue and Glamour had none
– Family Circle and McCall’s had 2 articles
– The rest had 1 article
American Council on Science and Health
TM
Factors Influencing Tobacco Use among Women:
Social Norms
 Countermarketing campaigns increase quitting
Guide to Community Preventive Services, 2001
TM
Individual Factors Influencing Tobacco Use among
Women who Continue to Smoke
 Decreased education and employment levels
 More addicted
 Cognitively less ready to stop
 Less social support for stopping
 Less confident in resisting temptations to smoke
Women and Smoking: A Report of the Surgeon General, 2001
TM
Influences on the Decision to Use Tobacco
Anti-tobacco
Pro-tobacco
Health education
Economic policy
Minors’ access
Product regulation
Clean indoor air regulation
Social advocacy
Personal litigation
Advertising restrictions
Promotional restrictions
Widespread social norms
Local community norms
Behavioral treatment
Pharmacologic treatment
Psychosocial factors
Peer pressure
Industry influence
Perceived social norms
Advertising
Promotion
Legislation
Regulation
Economic policy
Education
A young
nonsmoker
A current
smoker
A former
smoker
Reducing Tobacco Use: A Report of the Surgeon General, 2000
TM
Total Mortality
 A women’s annual risk for death is more than
double for continuing smokers compared with
never smokers in every age group from 45-74 years
 Since 1980, 3 million U.S. women have died
prematurely from a smoking-related disease
 For every smoking attributable death, an average
of 14 years of life was lost
TM
One out of two lifelong smokers will die
from a smoking related disease
TM
178,000 Annual Deaths Attributable to Cigarette
Smoking in Women—United States
Second-hand smoke
22,536
Lung Cancer
44,242
Other Diagnosis
13,031
Ischemic Heart
Disease
30,605
Other Cancer
8,735
Chronic Obstructive
Pulmonary Disease
49,312
Source: MMWR 2002; 51(14): 300-303
Stroke
8,850
TM
Lung Cancer
 90% lung cancer deaths among women who
smoke are attributable to smoking
 Risk for dying of lung cancer is 20x higher among
women who smoke 2+ packs of cigarettes per day
 Lung cancer mortality rates among U.S. women
increased 600% since 1950
TM
Smoking and Female Cancers
 Cervical cancer: increased risk
 Vulvar cancer: possible increased risk
 Endometrial cancer: decreased risk
TM
Smoking and Cardiovascular Disease among Women
 Coronary heart disease: major cause
– For women under age 50, majority of CHD
is attributable to smoking
– Risk increases with number of cigarettes smoked
per day and duration of smoking
– CHD in oral contraceptive users: further increased
risk
TM
Smoking and COPD in Women
 COPD: primary cause
– Risk increases with amount and
duration of smoking
– 90% COPD mortality due to smoking
– Mortality rates for COPD in women
have increased over the past 20-30
years
TM
Smoking and Lung Function in Women
 In-utero exposure to maternal smoking: decreased
lung function in infants
 Exposure to SHS during childhood and adolescence:
possible decreased lung function
 Childhood smoking: decreased rates of lung growth
 Adult smoking: premature decrease in lung function
TM
Smoking and Reproductive Outcomes
 Peri-natal mortality
(stillbirths and neonatal deaths): increased risk
 SIDS: increased risk
 Low birth weight: increased risk
 SGA: increased risk
TM
Smoking and Reproductive Outcomes
 Conception delay: increased risk
 Infertility: increased risk
 Ectopic pregnancy: possible increased risk
 Miscarriage: possible increased risk
 PROM: increased risk
 Abruptio placentae: increased risk
 Placenta previa: increased risk
 Pre-term delivery: increased risk
 Pre-eclampsia: decreased risk
TM
Smoking and Menstrual Function
 Dysmenorrhea: increased risk
 Secondary amenorrhea: increased risk
 Menstrual irregularity: increased risk
 Age of menopause: younger
– Also possibly increased symptoms
 Uterine fibroids: decreased risk
TM
Smoking and Body Weight in Women
 Smoking appears to attenuate weight gain
over time
 Cessation is associated with a weight gain
(average 6-12 lbs)
 Women smokers have a more masculine
pattern of fat distribution
TM
Smoking and Other Diseases in Women
 Cataract: increased risk
 Wrinkling: increased risk
 Hip fracture: increased risk
TM
Second-Hand Smoke Exposure:
Effects on Women
 Lung cancer: cause
– It has been estimated that 5-14% of lung cancers
in lifetime nonsmoking women are potentially
preventable by eliminating ETS exposure
 Coronary heart disease: cause
TM
Second-Hand Smoke Exposure:
Effects on Children
 Bronchitis and pneumonia
 Asthma (induction and exacerbation)
 Chronic respiratory symptoms
 Middle ear infections
 SIDS
TM
Second-Hand Smoke Exposure by Pregnant Women:
Effects on the Fetus
 IUGR among infants born to SHS exposed
women: increased risk
 Low birth weight among infants born to SHS
exposed women: possible increased risk
TM
Benefits of Cessation: Total Mortality
 Women who stop smoking greatly reduce their
risk of dying prematurely
 The relative benefits of cessation are greater
when women stop at younger ages, but cessation
is beneficial at all ages
TM
Benefits of Cessation
 Former smokers have lower risk for lung cancer;
risk declines with number of years
of cessation
 CHD risk substantially reduced within 1-2 years of
cessation; risk is similar to that of non-smokers
after 10-15 years of cessation
 Higher stroke risk reversible after cessation; after
5-15 years, risk approaches that of never smokers
TM
Benefits of Cessation
 Cessation slows the progression of carotid
atherosclerosis
 Cessation improves symptoms, prognosis,
and survival from peripheral vascular
atherosclerosis
 Risk of dying from COPD reduced for former
smokers
 Quitting before or during pregnancy decreases
the risk of adverse reproductive outcomes
TM