Women and smoking

DEFINITION: Cigarette smoking in women is a serious public health concern because of the numerous unique medical implications smoking poses for women and their children.

Risk Factors

Despite numerous media campaigns and medical efforts to educate the general population on the health hazards of cigarette smoking, many American women continue to smoke. According to the Centers for Disease Control and Prevention (CDC), in the early 2020s, around 10 percent of all adult women in the United States smoked cigarettes regularly. Furthermore, the CDC reported that around 14 percent of high school females smoked some form of tobacco product in the early 2020s, mainly e-cigarettes. Teen girls are more likely to have peers, parents, or family members who smoke, thereby promoting the activity as acceptable behavior.

Most women smoke cigarettes or e-cigarettes rather than pipes or hookahs, but cigar use is becoming more widespread. Women in general begin smoking for a number of reasons, many of them social and cultural. Many young women start smoking because they believe it to be a weight-loss tool because they are using it as a means to rebel against authority figures such as parents or teachers, or because of peer pressure or depression. Men typically begin smoking to obtain a popular social status or to manage stress. Male athletes tend to chew smokeless tobacco rather than smoke cigarettes or electronic cigarettes.

According to the CDC, educational and ethnic disparities exist among female smokers. In general, cigarette smoking is more common among females who do not have a high school or college diploma. Women in the United States and other developed countries were more likely to smoke than women in developing countries. Historically, women of non-Hispanic American Indian and Alaska Native descent had the highest rates of smoking when compared with Black and White American women. Asian and Hispanic Americans typically have the lowest rate of females who smoke. In early to middle adulthood, from about thirty-three to forty-four, White women are much more likely to smoke than Black or Hispanic women. Additionally, women in the LGBTQ community are more likely to smoke than heterosexual women.

Health Concerns

The original studies of the 1960s documenting the health hazards of smoking were based solely on men because they were the predominant cigarette smokers of that era. As it became more socially acceptable for women to smoke in public, health experts came to recognize that women were experiencing health effects, such as lung cancer, which were similar to those of men; however, women also were experiencing previously unrecognized health concerns specific to women.

The US Department of Health, Education, and Welfare (now the Department of Health and Human Services) reported on these effects in the 1980s, as the US Surgeon General issued the first groundbreaking report on the matter. Since this report was released, a wealth of new medical and scientific research has accumulated, showing, for example, that the health effects of cigarette smoking on women differ from men because of gender differences in body physiology and genetics. It has been suggested that women and men have different genetic predispositions to both initiating cigarette smoking and developing gender-specific, smoking-related medical problems.

In 1991, the National Institute for Occupational Safety and Health, which is part of the Centers for Disease Control and Prevention, released a report that publicized the dangers of secondhand smoke and claimed that even nonsmoking individuals were at risk from the dangers of smoking if they were exposed to what was termed "passive smoking." The report was part of the trend at that time that advocated for the banning of smoking in public places.

The most common health concern for all individuals who smoke is lung cancer, and the risk for developing lung cancer increases with the frequency of smoking and number of years. Lung cancer surpassed breast cancer as the leading cause of cancer deaths among women in 1987, and smoking causes 90 percent of lung cancer cases. Though it is much more common than lung cancer, breast cancer causes fewer annual deaths than lung cancer. The risk also exists for other lung diseases, such as chronic obstructive pulmonary disease (COPD), emphysema, and chronic bronchitis. Women who smoke are twenty-two times more likely to die from COPD than women who do not smoke. While once thought to not be a risk factor, several studies and the US Surgeon General report that there is suggestive evidence that smoking and exposure to secondhand smoke play a role in the development of breast cancer. The risk is highest among certain groups, such as women who started smoking before they had their first child. Women smokers are also at increased risk for developing cancer of the cervix, bladder, mouth, larynx, pharynx, pancreas, esophagus, and kidney and for acute myeloid leukemia.

Since 2015, cigarette smoking has been the leading preventable cause of death in the United States, and it increases the risk of death from all causes. The second largest health danger among female smokers is the risk for cardiovascular disease, including coronary artery disease (CAD), stroke, other aneurysms, and peripheral vascular disease. Women who smoke have twice the risk for CAD as nonsmokers. The younger the woman, the more likely CAD is related to smoking; the risk for CAD is higher for heavy, long-term smokers.

Women who smoke and who take oral hormonal birth control pills have a higher risk for CAD, including blood clots, heart attacks, and strokes. The risk with oral contraceptives is even greater if the woman is older than thirty-five years of age; therefore, smoking is a contraindication to this form of birth control after this age.

Effects on the Menstrual Cycle and Pregnancy

All women who are planning on conceiving or who are pregnant should discontinue cigarette smoking because of the scientifically established consequences on fertility and the developing fetus. Even with these risks, approximately 5 percent of women, especially teens and younger women, continue to smoke during pregnancy.

On average, women smokers take longer to conceive than nonsmokers, both because of infertility and because of irregular menstrual cycles. Menstrual cycles may be absent or abnormal. Smokers experience a decrease in ovulation, impairment of fertilization, and reduced implantation rates of the embryo in the uterus. Smokers also tend to have more vaginal infections.

When pregnancy is achieved, smokers have an increased risk of a miscarriage, stillbirth, or ectopic pregnancy because the tobacco chemicals, including nicotine, are transmitted to the fetus. Additional adverse pregnancy outcomes include a risk for low birth weight and preterm delivery. Maternal smoking also can cause a newborn or infant to have reduced lung function; this is observed with both prenatal and postnatal exposure. If a woman smokes during pregnancy, the nicotine inhaled will be detected in a newborn’s bloodstream, and the newborn may go through nicotine withdrawal after delivery.

Smoking also is discouraged during breastfeeding because of the transfer of nicotine through breast milk. A newborn exposed to nicotine also is at an increased risk of sudden infant death syndrome. Overall, a fetus exposed to cigarette smoking in utero or a newborn exposed to secondhand smoke in the household has a higher risk of developing a common cold or other illnesses such as asthma or ear infections. Even though many women use their pregnancy as motivation to quit, a significant percentage resumes smoking after delivery.

Smoking also affects women before and during menopause. Women smokers enter menopause at a younger age than nonsmokers and may have more symptoms. They have decreased bone density, which places them at an increased risk for fractures. Older women have a greater chance of cataract development or rheumatoid arthritis. Women who smoke also tend to develop more skin wrinkles than nonsmokers. Finally, lower levels of estrogen are noted in smokers.

Prevention and Smoking Cessation

As women are now smoking for longer periods of time and in greater amounts, cigarette smoking has become a well-established risk factor for increased mortality. The US Centers for Disease Control and Prevention reports that cigarette smoking contributes to the deaths of over 200,000 women in the United States annually. If smoking is discontinued, especially at a younger age, this risk decreases dramatically. Additional education on the prevention or discontinuation of cigarette use is critical.

Studies indicate that a majority of women want to quit smoking but they do not know how or feel they cannot because of stress, anxiety, or depression. Treatments for women to help them cope with a possible underlying psychological diagnosis or stressor are necessary for optimal outcomes. Nicotine replacement therapies have been more successful in women than in men.

It also is recommended that women quit smoking at a specific point in the menstrual cycle. The urge to smoke is greatest during the time of premenstrual symptoms, so discontinuing use after these symptoms have subsided shows greater success.

Specific websites and support groups for women trying to quit smoking are abundant. As with the overall general population, continued medical, media, and school involvement is key to educating girls and women about smoking and its consequences.

Bibliography

Bailey, Beth A., et al. “Infant Birth Outcomes among Substance Using Women: Why Quitting Smoking during Pregnancy Is Just as Important as Quitting Illicit Drug Use.” Maternal and Child Health Journal, vol. 9, no. 2, 2011, pp. 162–69.

“Burden of Cigarette Use in the U.S.” Centers for Disease Control and Prevention, 4 May 2023, www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html. Accessed 20 Sept. 2024.

"Current Cigarette Smoking Among Adults in the United States." Centers for Disease Control and Prevention, 4 May 2023, www.cdc.gov/tobacco/data‗statistics/fact‗sheets/adult‗data/cig‗smoking/index.htm. Accessed 20 Sept. 2024.

"Factors with Unclear Effects on Breast Cancer Risk." American Cancer Society, www.cancer.org/cancer/types/breast-cancer/risk-and-prevention/factors-with-unclear-effects-on-breast-cancer-risk.html. Accessed 20 Sept. 2024.

"Health Effects of Cigarettes: Reproductive Health." Centers for Disease Control and Prevention, 15 May 2024, www.cdc.gov/tobacco/about/cigarettes-and-reproductive-health.html. Accessed 20 Sept. 2024.

"Smoking and Tobacco Use." Centers for Disease Control and Prevention, www.cdc.gov/tobacco/index.html. Accessed 20 Sept. 2024.

US Department of Health and Human Services. The Health Consequences of Smoking for Women: A Report of the Surgeon General. Washington, DC: DHHS, 1980.

“Youth and Tobacco Use.” Centers for Disease Control and Prevention, 2 Nov. 2023, www.cdc.gov/tobacco/data‗statistics/fact‗sheets/youth‗data/tobacco‗use/index.htm. Accessed 20 Sept. 2024.