Despite more than half a century of public health efforts, smoking continues to be responsible for many preventable diseases and deaths in the United States. In the United States, smoking causes 480,000 deaths and 16,000,000 chronic diseases each year. As tobacco manufacturers aggressively and successfully marketed their products to women in the early 20th century, smoking-related diseases continued to rise among women. Today, the female smoking population has caught up with the male smoking population, and smoking-related lung cancer, heart disease, and chronic obstructive pulmonary disease (COPD) are also occurring. Women are more likely than men to have heart disease caused by smoking and to die from COPD.
Preface
In 1928, George Washington, chairman of the American Tobacco Company
Hill predicted the tobacco market for the next half century, comparing women to “the gold mine before us. After the end of World War I, social barriers to women smoking had been removed, and Hill teamed up with public relations personality Edward Bernays to market a product called “The Good”.
Bernays teamed up with public relations personality Edward Bernays to market a cigarette called “Good Luck,” claiming it would help control weight. The campaign, with the slogan “Touch of luck, not sweetness,” led to a more than twofold increase in profits for American Tobacco between 1925 and 1931 and is considered by marketing experts to be the most successful marketing campaign in history to encourage women to smoke.
In the late 1860s and 1970s, the cigarette market again targeted women consumers as the American women’s movement took hold. For the first 25 years, tobacco advertising promoted smoking as a symbol of femininity and sophistication, while now it was promoted as a symbol of female independence and success. In addition to these campaigns, the tobacco market introduced an entirely new product – longer, thinner cigarettes – as a nod to its earlier propaganda that smoking would give you a long, sexy body. Soon after, Philip
Morris linked smoking to sports and bodybuilding through its sponsorship of the Virginia Tennis Tour, and in doing so named the slender cigarettes specifically designed for women.
One of the major factors that brought the cigarette market to women was the decline in the male smoking population. There is growing evidence that smoking is harmful to health. The first Surgeon General’s Report (SGR), published in 1964, suggested a causal relationship between smoking and lung cancer. Immediately thereafter, the number of smokers among men decreased significantly, while the number of smokers among women increased significantly that year. Over the next period of at least 15 years, the rate of decline in smoking was significantly greater for men than for women. Until 1980, smoking prevalence among males declined by 27%, whereas it declined by only 14% among females.
These facts are corroborated by changes in current female prevalence and mortality rates. For example, while the incidence of lung cancer in men has steadily decreased since the 1990s, the incidence of lung cancer in women continued to increase until about 2004. According to recent data, the incidence of lung cancer in women has declined but significantly more slowly than in men, especially for older women, who were young at a time when tobacco companies were promoting female smoking. The recent SGR assessed the impact of cigarette marketing and advertising: 50 Years of Progress – The Health Effects of Smoking. The report notes that tobacco manufacturers used aggressive promotional strategies to initiate and sustain the popularity of cigarettes, while also contributing to the public harm of smoking. The report also found that a range of smoking-related diseases (well beyond lung cancer) seriously affect the health of men and women. “Over the past 50 years, the risk of smoking-related diseases has increased significantly in women, and the incidence of lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease in women is now comparable to that of men.” This article analyzes the impact of smoking on women’s health through the SGR 50th Anniversary Report.
Cancer
The 2014 SGR report analyzes the relationship between smoking and cancer in detail. One of the most important findings is that smoking has a negative impact on all cancers (including those not caused by smoking). The report found that for cancer patients as well as cured patients (including women with breast cancer who were being treated or cured), smoking increased smoking-related or cancer-related mortality, as well as the incidence of smoking-related second cancers. The report also found that smoking may be associated with cancer recurrence, poor treatment outcomes, and toxic effects of treatment. And patients who quit smoking had a better prognosis.
Another important finding in the 2014 SGR report was that the risk of lung adenocarcinoma was higher in the current smoking population compared to 50 years ago, and the risk was higher in the female smoking population compared to women in the 1960s. This finding was made by comparing data from two American Cancer Society studies (1959-1965,1982-1988) with data from certain large-scale surveys (2000-2010). The results found an almost 10-fold increase in the relative risk of lung cancer in the female smoking population. In the 1959 study, the risk of lung cancer in women who smoked was 2.7 times higher than in non-smoking women. Until 2010, this risk increased to 25.7 times. The relative risk of lung cancer among male smokers doubled from 12.2 to 25.0 over the same time period, while the incidence of lung cancer among non-smokers remained unchanged over either period.
The incidence of lung cancer among smokers remained elevated during the period when the number of smokers decreased and personal cigarette consumption decreased. Evidence suggests that changes in cigarette design (vented filters) and composition (higher concentrations of tobacco-related nitrites) contributed to the increased incidence of lung adenocarcinoma. Overall, more than 87% of lung cancer deaths in the United States can be attributed to smoking and secondhand smoke exposure.
In 2010, more than 130,000 men and women were diagnosed with colorectal cancer in the United States, resulting in more than 52,000 deaths. Rectal cancer has the second highest mortality rate among men and women with co-morbid cancers. Smoking has now been shown to be a cause of colorectal and liver cancers.
In the United States, besides cutaneous melanoma, breast cancer is the most prevalent cancer in women and the second most deadly cancer after lung cancer. In 2009, more than 200,000 women were diagnosed with invasive breast cancer. The National Cancer Center states that in 2014, 230,000 women will be diagnosed with breast cancer and 40,000 women will die as a result.
Although breast cancer incidence and mortality rates have declined since the 1990s, the burden of the disease remains high and researchers are actively searching for key factors to prevent breast cancer. Since the SGR reported in 2004 that there was no conclusive evidence linking smoking to the development of breast cancer, 12 cohort studies and 34 case-control studies have analyzed and published findings on this issue. 2014’s SGR synthesizes these findings and 15 new studies on the association between breast cancer and secondhand smoke.
These new data led researchers to conclude that there is sufficient evidence to suggest that a range of mechanisms caused by smoking may contribute to breast cancer. But despite this evidence, the 2014 SGR concludes that the causal relationship between exposure to either smoking or secondhand smoke and breast cancer is still not fully established. Determining a causal relationship between a factor and the development of disease usually takes longer and larger cohort studies. In fact, the new issue of the SGR recommends that large cohort studies continue to be conducted to determine the relationship between smoking and breast cancer.
These findings from 2014 combined with previous SGR reports have identified 13 cancers whose occurrence is associated with smoking. It is predicted that 585,000 patients will die from cancer in 2014, with more than 163,700 (28%) of these deaths due to smoking or secondhand smoke exposure.
Cardiovascular Disease
More than 16,000,000 Americans suffer from heart disease. Cardiovascular disease is responsible for 800,000 deaths each year in the United States and is also the largest independent contributor to death. Cardiovascular disease includes: narrowing or blockage of blood vessels in and around the heart (coronary artery disease), sudden heart attack (acute myocardial infarction), stroke, and heart-related chest pain (angina). Also included are: hypertension, peripheral arterial and venous disease, and abdominal aortic aneurysm.
Smoking is a major contributor to cardiovascular disease. Almost one-third of deaths due to coronary heart disease are caused by smoking and secondhand smoke exposure. Secondhand smoke exposure is also a cause of acute heart attacks and strokes in non-smokers, with a 20-30% increased risk of stroke with secondhand smoke exposure. For the first time, we found that the relative risk of death from coronary heart disease was higher in women than men who smoked at age 35 and older. Almost all deaths from abdominal aortic aneurysms are associated with smoking as well as other tobacco use. Similarly, the risk of death from abdominal aortic aneurysm was higher in the female smoking population than in the male smoking population.
Although there is a clear dose-response relationship between smoking and cardiovascular disease, the relationship is not linear. Significant cardiovascular damage can be found even when smoking 5 cigarettes or less per day. Quitting smoking reduces the risk of myocardial infarction and coronary heart disease, and for women, this risk reduction is even more pronounced. For example, data cited by the SGR in 2014 showed that the relative risk of dying from coronary heart disease in women who smoked was greatly reduced to half of what it would have been 2-4 years after quitting.
Respiratory disease
The 2014 SGR report found that respiratory disease was strongly associated with women’s health. Chronic obstructive pulmonary disease (COPD), as well as most lung diseases (including emphysema as well as chronic bronchitis), are primarily caused by smoking. In the United States, almost 8 out of 10 deaths from COPD are caused by smoking. Although smoking today is less than it was 50 years ago, the risk of COPD is significantly higher among smokers than it was in 1964. The relative risk of COPD is significantly higher in the female smoking group and is now comparable to that of men, with a risk 22 times higher than that of women who have never smoked.
Mortality from COPD has increased significantly and consistently since the first SGR. Today, more women die from COPD than men. In addition, smoking has been identified as a cause of tuberculosis and death from tuberculosis, and smoking can also exacerbate asthma symptoms in adults.
Reproduction
The first report of SGR suggested that smoking during pregnancy was associated with low birth weight babies. Since then, more SGR reports have found that smoking before and during pregnancy is associated with lower pregnancy rates, increased complications during pregnancy, and risks to maternal, fetal, and infant health. Despite years of raising the risks of smoking during pregnancy, a significant number of women in the United States continue to smoke during pregnancy, resulting in more than 400,000 newborns being exposed to tobacco-related chemicals in their mothers each year.
The 2014 SGR report presented the effects of maternal smoking on tubal health: smoking can lead to tubal ectopic pregnancy, in which a fertilized egg does not successfully pass through the fallopian tube to the uterus and colonize the uterus. Ectopic pregnancy often results in the death of the embryo and a number of harmful effects on the mother.
The fetus depends on the placenta for its growth and development, and women who smoke are at higher risk for placental abruption. Placental abruption occurs when the placenta detaches from the uterus earlier than expected, leading to premature labor and the death of the mother or fetus. Pregnant women who smoke during pregnancy are also at increased risk of placenta previa, which is when the placenta partially or completely blocks the cervical opening and can lead to preterm labor or death of the mother or fetus.
Smoking during pregnancy may also lead to fetal malformations. Women who smoke early in pregnancy are more likely to have fetal orofacial clefts (including cleft lip and cleft palate), which means that the complete development of the fetal lip and palate is affected. Cleft palate can cause a number of problems, including difficulty in feeding the baby, and this deformity can only be treated surgically.
Cigarette smoke contains 7,000 chemicals, one of which, nicotine, is an important contributor to smoking addiction. In some SGR reports, women who smoke during pregnancy have been found to affect fetal lung development, and this effect continues into childhood, and it has been found that this effect is likely caused by nicotine. In the 2014 SGR report, it was shown that chemicals in cigarette smoke, specifically nicotine, can affect fetal brain development and that exposure to nicotine in young adulthood can cause ongoing brain developmental impairment. The report also states that nicotine can affect maternal as well as fetal health during pregnancy, leading to premature birth or stillbirth. With the popularity of nicotine electronic delivery devices such as e-cigarettes, the side effects caused by nicotine are even more pronounced, especially for women of gestational age.
Diabetes
Diabetes is becoming a public health disease, with approximately 12,600,000 women over the age of 20 in the United States and 13,000,000 men over the age of 20 with diabetes. Co-morbidities and complications of diabetes include high blood pressure, heart disease, brain attacks, eye disease, and blindness. Between 2005 and 2008, more than a quarter (28.5%) of people aged 40 years or older with diabetes had diabetes-related retinopathy, which can eventually lead to blindness. Diabetes is also the most important cause of kidney failure, with more than 200,000 patients with diabetic nephropathy being kept alive by long-term dialysis or kidney transplantation.
Previous SGR reports have found that smoking affects the treatment of diabetes, and that smokers with diabetes are at increased risk for complications of kidney disease, blindness, and peripheral circulatory disease. 2014 SGR also reported that smoking causes type 2 diabetes, and that the risk of developing diabetes is 30-40% higher in smokers than in non-smokers. A meta-analysis that included 25 studies from 2007 found a significant dose-response relationship between smoking and the risk of diabetes, with the risk of diabetes increasing with higher smoking.
Immunity, autoimmune disease, and general health
Since the mid-20th century, cigarettes have evolved into a highly industrialized product containing a large number of harmful chemicals, with more than 7,000 substances released when tobacco is burned. 2014 reported a significant finding that almost all tobacco-induced deaths and illnesses in the United States are due to the burning of tobacco, most notably cigarettes. The large and complex chemical mixture of tobacco combustion affects the body’s immune system (both immune activation and immune suppression), which in turn leads to a range of diseases. Smoking-induced immune abnormalities lead to an increased risk of lung infections and can cause a range of specific immune and autoimmune diseases. For example, smoking is a cause of rheumatoid arthritis and can affect the outcome of rheumatoid arthritis. The incidence of rheumatoid arthritis is twice as common in women as in men, and the age of onset is most commonly over 60 years.
The overall health of smokers is poorer than that of non-smokers, and the effects begin at a young age and continue into adulthood. On average, smokers have more than 10 years shorter life expectancy, poorer overall health, higher absenteeism, more frequent doctor visits, and higher hospitalization rates than non-smokers. More than 16,000,000 Americans suffer from at least one chronic disease caused by smoking or secondhand smoke exposure.
Summary
The 2014 SGR report summarizes and analyzes thousands of studies and 31 previous SGR reports on the literature on how smoking has affected and continues to affect people’s health. All-cause mortality caused by smoking continues to rise in the United States as millions of men and women begin smoking in adolescence and continue into old age, eventually developing serious chronic conditions. Over the past 50 years, the all-cause mortality rate among women smokers has been more than three times that of non-smokers, compared to more than two times that of men. The fact that the risk of associated diseases remains elevated despite the reduced prevalence of smoking and reduced consumption of cigarettes is evidence of the significantly higher pathogenicity of smoking. In the United States, although smoking prevalence among both minors and adults has been cut in half since the first SGR was published, along with aggressive tobacco control measures that have saved 8 million people from early death, smoking remains the largest contributor to preventable disease and death.
Between 1964 and 2014, more than 6 million American women died from smoking. During the same period, 2,500,000 nonsmokers died from diseases caused by secondhand smoke exposure, and 100,000 babies died from sudden death syndrome, preterm birth, or other perinatal conditions caused by chemicals in tobacco smoke. Because smoking rates have not been reduced in a timely and significant manner, 5,600,000 children younger than 18 years of age in the United States will now die prematurely from smoking-related illnesses.
A number of strategies have been shown to be effective in controlling the smoking epidemic, such as increasing the price of tobacco products, smoking bans to protect non-smoking populations, reducing the social acceptability of smoking, unconditional help for people who want to quit, mass media to clearly communicate the dangers of smoking, and state and local tobacco control programs to educate the public about the health risks and economic burden of smoking. Aggressive and consistent implementation of these strategies, along with support from state funds at the CDC-recommended level, is expected to reduce the disease, death, and economic burden of smoking. However, additional measures are needed to rapidly reduce the use of tobacco products (especially cigarettes) in the United States. This initiative, known as the “end game” strategy, includes a number of measures, such as reducing the nicotine content of tobacco products to non-addictive levels and imposing stricter regulations on the sale of certain tobacco products.
Louis Sullivan, former secretary general of the Health and Human Services
Sullivan said at a 1990 conference, citing research reported by the SGR that year, that women who smoke like men will die like men who smoke. He couldn’t be more right today, as the current smoking rate among girls aged 12-17 (6.3%) is already comparable to that of boys (6.8%). Finally, the 2014 SGR report concluded that the vast majority of the burden of disease and death from tobacco use in the United States can be attributed to cigarettes rather than other tobacco products, and that a rapid and effective reduction in cigarette consumption would significantly reduce these burdens.
For women, the 2014 SGR report presented surprising evidence that smoking is a significant risk factor for morbidity and mortality from a variety of diseases. Following the release of the 50th anniversary SGR report, Acting Surgeon General Rear Admiral Boris
Lushniak snapped, “That’s enough!” . The preventable, avoidable deaths of 6 million American women are an insult to us (the United States), and we cannot and will not allow a repeat of that in the next 50 years. As other public health officials have suggested, ending tobacco use is not just a top priority for government, it should be a top priority for all of society, and must be a joint effort among clinics, public health, education, government, business, law, and families. We should use the findings of the 2014 SGR report as a rallying point for society to work together to eradicate this “plague” of public health and well-being once and for all.