David Satcher, M.D., Ph.D. U.S. Surgeon General

This year alone, lung cancer will kill nearly 68,000 U.S. women—far more deaths than from breast cancer. Many thousands more women will die prematurely from smoking-related diseases, such as heart and respiratory conditions.

Mortality statistics like these support the grim conclusion that smoking-related disease among women is a full-blown epidemic. Women and Smoking: A Report of the Surgeon General (www.surgeongeneral.gov/library/womenandtobacco/) makes its overarching theme clear—smoking is a women’s issue. Its prevention message is equally clear: Smoking is the leading known cause of preventable death and disease among women.

Released earlier this year, the report summarizes what is known about smoking among women, risk factors, consequences, and effective interventions (see 86 Consequences and Counting). It follows a 1980 Surgeon General’s report on women and tobacco and has been the focus of educational and informational efforts by dozens of anti-tobacco, women’s health, and health-related voluntary and professional organizations (see Resources).

Nearly 40 years have passed since the first Surgeon General’s report on the adverse health effects of tobacco use was released in 1964 (see Key Documents on the Web). Scientific knowledge continues to grow, with the effects of tobacco use reported in more and more areas. Recent studies have linked smoking or secondhand smoke in some way to breast cancer, depression, attention deficit/hyperactivity disorder, sudden infant death syndrome, infertility, and various respiratory diseases, especially asthma in certain racial and ethnic populations.

Women who smoke experience gender-specific health consequences, including increased risk of various adverse reproductive outcomes. Smoking during pregnancy has adverse health effects. Infants born to women exposed to secondhand tobacco smoke during pregnancy face risks, including decreased birth weight.

The evidence that prevention works is compelling, too. Effective tobacco control strategies exist to:

• Increase awareness of the lethal impact of tobacco on women.

• Encourage young women NOT to start smoking. (Nearly 25 percent of teenage girls in this country start smoking by their senior year of high school.)

• Counter the tobacco industry’s targeting of women.

• Promote the benefits of smoking cessation—for all ages.

One very critical strategy is embodied in prevention itself: Publicize that most women are nonsmokers. This message is especially important in reaching young women—high school girls believe smoking among their peers is higher than it actually is. Knowing that it is cool NOT to smoke helps build their resistance. "It is easier not to START than it is to STOP," says cover model/entrepreneur Christy Turlington in communicating a smoke-free message to teens for the Centers for Disease Control and Prevention (CDC) 
(www.cdc.gov/tobacco/christy/). CDC’s countermarketing campaign is offering free posters and a TV spot, because "we need your help to let students know the real deal about tobacco."

The real deal about tobacco is not a good deal for women…or for men either. Or, for youth (see Spotlight). But, as the Surgeon General’s report proclaims, we can "Act now. We know more than enough." In addition to the prevention strategies cited above, these four global acts are recommended:

• Support efforts, at both individual and societal levels, to reduce smoking and exposure to secondhand tobacco smoke among women.

• Enact comprehensive statewide tobacco control programs—because they work.

• Do everything possible to thwart the emerging epidemic of smoking among women in developing countries.

• Encourage all national governments to strongly support the World Health Organization’s Framework Convention for Tobacco Control.

See additional information:

Smoking at the Polls
No Smoke Doesn't Mean No Harm

Partners include Major League Baseball (MLB), the Major League Baseball Players Association, the National Cancer Institute, the National Institute of Dental and Craniofacial Research, the Professional Baseball Athletic Trainers Society, the Centers for Disease Control and Prevention (CDC), American Medical Association’s Smokeless States program, and the American Baseball Coaches Association.

With a $4.8 million grant from the Robert Wood Johnson Foundation for 2001-2003, NSTEP is building on successful efforts with MLB by expanding partnerships with minor league baseball and youth baseball leagues and by working with the Crown Council, an organization of over 1,500 dental practices. These dental practices have stepped up to the plate and are providing oral exams and cessation counseling, as well as support for public awareness activities and educational events with 140 minor league baseball teams. The council sponsors a toll-free number (1-866-ORAL HEALTH) that broadcasts baseball legend and NSTEP National Chairman Joe Garagiola’s message on oral cancer screening. Both leagues are using the program to educate players and help users quit. Regional dental schools and tobacco control programs are involved, as well as CDC’s Impact programs at the State level.

As the only national program focusing on the health risks of spit tobacco use, NSTEP aims to prevent children from starting to use spit tobacco and to educate them about the adverse effects on oral and overall health. The program also is credited with making significant strides in breaking the longstanding link between spit tobacco and baseball.

NSTEP has developed grassroots coalitions of teachers, coaches, dentists, and an array of volunteer groups that work together to integrate spit tobacco education and cessation into the existing tobacco control agendas.

The National Women’s Health Information Web site 
(www.4women.gov/QuitSmoking/index.cfm) has a new section, "A Breath of Fresh Air! Independence from Smoking," aimed at empowering women and girls, and the people they love, to breathe clean. Visitors can learn about the specific effects of smoking on health and how to overcome barriers to quit.

"TIPS…for kids, for teens, for adults…for everyone" announces the Tobacco Information and Prevention Source sponsored by the National Center for Chronic Disease Prevention and Health Promotion (www.cdc.gov/tobacco/). TIPS offers vast resources and links, as well as access to tobacco industry documents. In the spotlight currently is "Seven Deadly Myths," a 17-minute video that addresses some of the common myths about women and smoking. Excerpts are available online at www.thriveonline.oxygen.com/medical/smoking/7_myths/; for example, "Myth #5: It’s better to smoke, because if I quit, I’ll get fat."

The Surgeon General’s site features materials and resources on tobacco cessation (www.surgeongeneral.gov/tobacco/default.htm). The Agency for Healthcare Research and Quality (www.ahrq.gov/consumer/index.html#smoking) provides "Help for Smokers: Ideas to Help You Quit" and a consumer guide, "You Can Quit Smoking."

Web sites hosted by the National Institutes of Health offer comprehensive information for consumers and health professionals. For example, the National Cancer Institute’s CancerNet (cancernet.nci.nih.gov) presents the latest scientific evidence such as the results of the Community Intervention Trial for Smoking Cessation (COMMIT) study to assess a combination of community-based interventions designed to help smokers cease using tobacco. Among the offerings of the National Heart, Lung, and Blood Institute is a brochure on improving the cardiovascular health of African Americans, "Refresh Yourself! Stop Smoking" (www.nhlbi.nih.gov/health/public/heart/other/chdblack/refresh.htm). "Spitting into the Wind: The Facts about Dip and Chew" is posted on the National Institute of Dental and Craniofacial Research site (www.nidcr.nih.gov/health/pubs/index.asp). The National Institute of Environmental Health Sciences publishes "Asthma and Allergy Prevention" (www.niehs.nih.gov/airborne/prevent/alert.html).

Following the release of Women and Smoking: A Report of the Surgeon General (www.surgeongeneral.gov/library/womenandtobacco/), these national organizations hosted an educational briefing in Washington, DC: American Cancer Society, American Heart Association, American Legacy Foundation, American Lung Association, American Medical Association, American Medical Women’s Association, Campaign for Tobacco-Free Kids, National Coalition FOR Women AGAINST Tobacco, and the Robert Wood Johnson Foundation. All sponsor Web sites, including the Campaign for Tobacco-Free Kids, which hosts a special report titled "Smoking Is a Women’s Issue" (tobacco freekids.org/). An additional 27 national organizations were named as sponsor groups for the briefing, reflecting their support of "the goal of bringing an end to the scourge of smoking that endangers the health of women and girls." Many offer Web sites, including the American College of Chest Physicians, which has an award-winning speakers’ kit on "Women & Girls, Tobacco and Lung Cancer" (www.chestnet.org/foundation/speakers. bureau/speakers.intro.html).

Nutrition and Overweight

New Spanish versions of popular 5 A Day brochures, including Snack Your Way to 5 A Day, Take the 5 A Day Challenge, and the 5 A Day My Way kids’ brochure, are now available from the U.S. Department of Agriculture. Call the catalog department at 1-888-391-2100 or download a catalog at www.5aday.com.

Access to Quality Health Services

A comprehensive report on methods used to track health status and quality of life has been published by the Centers for Disease Control and Prevention (CDC). Measuring Healthy Days: Population Assessment of Health-Related Quality of Life describes the validity and use of a set of health-related quality of life (HRQOL) survey measures developed by CDC and its partners. These measures are used to track population health status and HRQOL in States and local communities. The report is available online at www.cdc.gov/nccdphp/hrqol/.

Tracking HRQOL in populations can identify subgroups with poor health, identify unmet needs and disparities, and guide policies or broad community interventions to improve health. Health officials can use these measures and data to more fully assess the public’s health and guide the overall attainment of the Healthy People 2010 goals of increasing the quality and years of life and eliminating health disparities.

Educational and Community-Based Programs

The online Office of Educational Research and Improvement Clearinghouse on Rural Education and Small Schools recently added two new online directories that offer services, publications, and other resources for educators of Latino and rural Americans: www.ael.org/eric/latinoed and www.ael.org/eric/ruraled.

Environmental Health

The Environmental Protection Agency recently announced that the Pesticide Product Label System (PPLS) has been updated. The PPLS, found on the Web at www.epa.gov/pesticides/pestlabels/, is a collection of images, in multipage TIFF format, of pesticide labels that have been approved by the Office of Pesticide Programs under Section 3 of the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA). The collection contains the initially approved label for pesticide products registered under FIFRA Section 3 as well as subsequent versions of labels that have changed via amendment or notification.

HIV

In June, the National Institutes of Health (NIH) launched a new Web site, In Their Own Words: NIH Researchers Recall the Early Years of AIDS (aidshistory.nih.gov/). The site features stories told in the transcripts of interviews conducted with physicians, scientists, nurses, and administrators involved in AIDS research at NIH. The site was launched to commemorate the 20th anniversary of the first report of AIDS.

Mental Health and Mental Disorders

Surgeon General David Satcher joined a coalition of public and private groups to unveil a national blueprint of goals and objectives to prevent suicide, the eighth leading cause of death in the United States. The document, National Strategy for Suicide Prevention, establishes 11 goals and 68 measurable objectives for public and private sector involvement to prevent suicides and reduce suicide attempts. Suicide takes the lives of more than 30,000 Americans a year. The document is on the Web at www.mentalhealth.org/suicideprevention/nsspfull reportfinal.pdf.

Cancer

The National Cancer Institute (NCI) recently announced a report showing overall declines in the rates of new cancer cases and deaths for all cancers, combined, in the United States. The Annual Report to the Nation on the Status of Cancer, 1973-1998 was produced by NCI, the CDC, including the National Center for Health Statistics (NCHS), the North American Association of Central Cancer Registries, and the American Cancer Society. It is online at www.seer.cancer.gov/.

Respiratory Diseases

The American College of Allergy, Asthma and Immunology (ACAAI) has an interactive Allergy Quiz on its Web site at allergy.mcg.edu/quiz/home.html. ACAAI also offers a brochure that can help you get your allergies under control. The brochure, You Can Have a Life Without Allergies, is available at allergy.mcg.edu/patients/newit.html, or call 1-800-842-7777.

Dual Tobacco Use Among Native American Adults in Southeastern North Carolina. J.G. Spangler, et al. Preventive Medicine, 32(2001):521-528.

Studying the special characteristics of a subculture or population can allow professionals to tailor prevention efforts using their knowledge of the population’s unique epidemiology. This study examined the concurrent use of smokeless tobacco and cigarettes in the Lumbee Indians of North Carolina.

Using a telephone survey of 400 Lumbee tribe members who were 18 years and older, data were collected on demographics, history of tobacco use, current tobacco use, social support factors such as church attendance, and family or personal involvement in tobacco-related agriculture. The survey included questions on knowledge of and practices related to Native American ceremonial tobacco use.

People using only cigarettes tended to be younger, and approximately 41 percent were male. Exclusive users of smokeless tobacco were older and more likely to be female (79%). Dual tobacco users had predictably less education than the other two groups: 47 percent had fewer than 12 years of education. This group also had the highest percentage of participants reporting no close friends. Their church attendance fell midway between that of the exclusive smokeless tobacco users and the exclusive cigarette smokers.

Finding out attitudes about tobacco use among this Native American tribe can help in tailoring prevention efforts; for example, the high level of church attendance among all three tobacco user groups could provide a venue for quit efforts. The data also revealed that a high percentage of Lumbees used smokeless tobacco because they thought it was safer than cigarettes; this misconception also can be addressed through intervention efforts.

Variations in Treatment Benefits Influence Smoking Cessation: Results of a Randomised Controlled Trial. H.H. Schauffler, et al. Tobacco Control, 10(June 2001):175-180.

The Agency for Healthcare Research and Quality has recommended that the most effective tobacco dependence treatments should be included as benefits for all insured subscribers. This study examined the influence of offering benefit coverage for tobacco dependence treatment, when the benefits were offered for 1 year.

For this research project, 16 employers agreed to cover tobacco dependence treatment; this treatment included a behavioral group program sponsored by the American Lung Association and nicotine replacement therapy in the forms of patch and gum. Study participants were recruited from California health maintenance organizations (HMOs) and comprised 600 volunteers in the treatment group and 600 in the control group.

Using two followup interviews, researchers collected data on the smoking status, quit attempts, and use of treatment benefits for both treatment and control groups. The quit rate for the treatment group was 18 percent, compared to 13 percent for the control group. Twenty-five percent of the treatment group used nicotine gum and/or the nicotine patch, compared to 14 percent for the control group. The study suggests that coverage of nicotine replacement therapy and elimination of cost barriers to treatment increase the number of smokers who try to quit and the number who do quit successfully. The estimated cost of the treatment benefit was between $.47 and $.73 monthly for the HMO.

High-Risk Behaviors Associated With Early Smoking: Results From a 5-year Followup. P.L. Ellickson, et al. Journal of Adolescent Health, 28(June 2001):465-473.

Early adolescent smokers and experimenters often have other behavioral problems that correlate with their smoking behavior. This study compared the high-risk behaviors of smokers (smoked more than three times in the past year or any time in the past month), experimenters (smoked fewer than three times in the past year and none in the past month), and nonsmokers in the 7th grade and again in the 12th grade.

The sample of more than 4,000 students was recruited from 30 California and Oregon schools that were chosen to represent a range of community types, socioeconomic status, and racial and ethnic diversity. Students self-reported their smoking behavior, which was then validated with a saliva test. In 7th grade, the smokers were consistently and dramatically more likely than nonsmokers to report high-risk behaviors such as skipping class, repeating a grade, getting poor grades, smoking marijuana, using hard drugs, stealing, and engaging in weekly and/or binge drinking. The likelihood of experimenters engaging in these risky behaviors fell about midway in the range between the behavior patterns of smokers and nonsmokers.

Although the gap had narrowed by 12th grade, those designated as smokers in 7th grade were still five times more likely than nonsmokers to drop out of school; they were six times more likely to be weekly marijuana users and four times more likely to use hard drugs. Smokers were also twice as likely to steal or commit a felony and about four times more likely to become teen parents. Experimenters also were more likely than nonsmokers to engage in high-risk behaviors, although the differences were not significant in some areas.

Developing a comprehensive profile of early smokers can help health professionals tailor prevention efforts to meet this group’s needs. This study suggests that targeting other risky behaviors of early smokers may be more effective than concentrating solely on smoking prevention.

Measures of Maternal Tobacco Exposure and Infant Birth Weight at Term. L.J. England, et al. Journal of Epidemiology, 153(2001):954-960.

It is estimated that as many as 800,000 infants are exposed in utero to maternal smoking. This study examined the relationship between urine cotinine levels, self-reported smoking, and infant birth weight at term; cotinine is an indicator of nicotine exposure. If a strong relationship among these factors could be established, reduction in smoking among pregnant women smokers would be a logical first step toward prevention of low birth weight.

Data for the study were obtained from the Smoking Cessation in Pregnancy project, conducted from 1987 to 1991. The study included more than 4,000 white and black women receiving prenatal care from public clinics and enrolled in Women, Infants, and Children programs in Colorado, Maryland, and Missouri.

Researchers found that cotinine levels rose steadily among self-reported light smokers as the number of cigarettes increased but the cotinine concentrations leveled off at 15 cigarettes per day. Average birth weights decreased as the number of cigarettes smoked per day increased but this progression was not linear. In fact, the lowest birth weights were found at low levels of smoking.

The study concluded that, although there was a relationship between self-reported smoking, urine cotinine levels, and birth weight, the relationship explained less than one-fourth of the variability in infant birth weight.

Project Towards No Drug Abuse: Generalizability to a General High School Sample. C.W. Dent, et al. Preventive Medicine, 32(June 2001):514-520.

Drug abuse prevention programs are usually designed either as universal prevention education for all teenagers or selective programs for a high-risk subpopulation or group. This study examined the effectiveness of generalizing a program designed for high-risk youth to the general population of high school teens.

The study sample included more than 1,200 students from three Los Angeles public high schools, which were selected at random. Students were assigned to either the program group or the control group (no prevention education).

The program students attended nine sessions of education programming over 3 weeks. The first week focused on listening, communication, and learning, encouraging students’ rebellion against the stereotype of teenagers as drug abusers. The second week shifted to instruction in chemical dependency, and the third week focused on self-control, implementation of future plans, and commitment regarding drug use.

Students in both control and program groups then received a followup interview 1 year later. Use of drugs and alcohol was dramatically lower among the program students but marijuana and cigarette use was not significantly affected. These results were very similar to the data collected from a high-risk population who had previously received this prevention training.

Sources of Information on the Health Effects of Environmental Tobacco Smoke Among African-American Children and Adolescents. M.E. Kurtz, et al. Journal of Adolescent Health, 28(June 2001):458-464.

Exposure of children and adolescents to environmental tobacco smoke (ETS) has been linked to serious negative effects, including the development of asthma, decreased lung function and development, otitis media, bronchitis, pneumonia, and wheezing. This study sought to determine the sources of information for African-American children about the health effects of smoking and the relationship of these sources to the children’s knowledge, attitudes, and preventive efforts regarding ETS exposure.

All students in grades 5 through 12 attending school in an urban school district of Detroit, MI, were surveyed on a chosen day in November 1995. Using a written questionnaire, researchers found that television, mother, teacher, father and grandmother were the most frequently mentioned sources of information on the health effects of smoking.

Although self-reported rates of smoking were lower than expected (5.7% overall), the students were at high risk of ETS exposure, with parental smoking rates of 45 percent for mothers and 47 percent for fathers.

Students receiving their health information from external sources such as teachers or religious leaders were more likely to dislike smoking around them and to report negative effects from ETS. Family influence on students’ information and attitudes was greater when there was no smoking in the home and had a greater effect on elementary students than on either middle or high school students.

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