By Teresa Moore
In the Jazz Age, flappers wielded foot-long cigarette holders as emblems of panache and independence. During World War II, monthly ads with Chesterfield cigarette girls featured such stars as Betty Grable and Rita Hayworth. Twenty years later, the U.S. Surgeon General linked smoking and death, but images of cigarettes as symbols of feminine freedom, mystery, and sex appeal were by no means extinguished. At the height of the women's movement in the 1970s, Virginia Slims attempted to unite liberation and nicotine with their slogan, "You've come a long way, baby."
And now, in the 21st century, when few remain ignorant about how deadly smoking can be, the tobacco industry is successfully hunting down a new source of female revenue: women of color. In response to the rising buying power of ethnic markets, a recent series of Virginia Slims ads featured full-page portraits of black, Asian, Latina, and white models.
Smoking gap declines
There appears to be no end to the pool of women who can be lured to smoke, especially at a tender age. Although male smokers have always outnumbered female smokers, over the past 40 years -- as greater numbers of men have quit and more adult women and teenage girls have started -- the gap has narrowed. In 1965, nearly 52 percent of men and 34 percent of women smoked. A half-century later, the figures were 23 percent for men and 18 percent for women.
In marketing to women of all ages, tobacco companies have linked smoking and independence, smoking and sexiness, smoking and liberation, smoking and athleticism, and -- perhaps most seductive -- smoking and slimness.
"Tobacco does help keep your weight down -- especially if you get cancer," says Dr. Stanton Glantz, professor of medicine and Director of the Center for Tobacco Control Research and Education at the University of California at San Francisco. He lists just a few of the lesser-known effects of smoking on women: "Earlier menopause, accelerated aging, low-birth weight babies, more difficulty conceiving, cancers. It makes osteoporosis worse. And of course, it does a real job on a woman's heart and lungs. Alcohol is responsible for about 75,000 deaths a year. Tobacco kills five times as many people as alcohol every year. "
In the face of all the pain that smoking creates, how are cigarette companies able to continue recruiting thousands of new female smokers every year?
"The impact of popular culture cannot be underestimated, " said Alyssa Easton, an epidemiologist at the Centers for Disease Control and Prevention (CDC) in Atlanta. "I recently saw Uma Thurman smoking in a movie. She's about my age and she's very glamorous. She'd encourage me to smoke -- if I were ever going to smoke."
Easton notes there's a difference between knowledge and behavior. "Most everyone knows that smoking is bad for you, just as we know that fatty foods are bad and driving fast is bad," says Easton. "People can be highly educated, but changing behavior is hard."
Deadlier than breast cancer
Because breast cancer activists have done such a good job of raising awareness, many people believe that the disease is the deadliest among American women. But more women die from heart disease -- much of it from smoking -- than from any other ailment. According to "Women and Smoking: A Report of the Surgeon General -- 2001," smoking is the major cause of heart disease among women under 50 and the leading cause of lung cancer death among all women.
The increase in the number of women who die from lung cancer has been meteoric: Since 1950, deaths from lung cancer among women increased by more than 600 percent, according to the American Cancer Society. Here's what that means in terms of real women's lives: A report in the Journal of the American Medical Association estimates that each year more than 80,000 women are diagnosed with lung cancer, and 68,000 women die from the disease.
"We need to learn from breast cancer advocates and call attention to lung cancer as a women's disease," said epidemiologist Virginia Ernster, the lead scientific editor of the Surgeon General's report at the time it was released. "The leading cause of lung cancer is smoking, and if women didn't smoke, we could eliminate 85 to 90 percent of all lung cancer cases in women."
Famous breast cancer survivors -- Carly Simon, Gloria Steinem, Linda Ellerbee, Sandra Day O'Connor, Peggy Fleming -- put a face on that disease. But the ranks of female celebrities "coming out" about lung cancer have been pretty thin. After losing her father to lung cancer, supermodel and former smoker Christy Turlington became the first glamorous female anti-smoking crusader since Brooke Shields posed with cigarettes in her ears in a famous early-1980s anti-smoking poster. Few celebrities have followed.
Although women and men who smoke share risks for cancer, heart disease, and emphysema, women have their own brand of smoking-related disease risks related to pregnancy and oral contraceptive use, according to the Surgeon General's report. Women smokers are also at increased risk for cancers of the cervix, pancreas, and bladder and tend to enter natural menopause one to two years earlier than nonsmokers. With menopause comes a loss of the estrogen that protects women's hearts and makes it possible for their bones to absorb calcium. Smoking also decreases blood flow to the skin and accelerates wrinkling by damaging the collagen and elastin that give skin its resiliency -- a condition known as "smoker's face."
Women who smoke during pregnancy are more likely to give birth to smaller babies. Low birth weight is associated with increased risk for disease and death in newborns. And SIDS (sudden infant death syndrome) deaths are more common among the smokers' infants. The Surgeon General estimates that if all mothers quit smoking, 10 percent fewer infants would die.
What makes matters worse for women is that more of them are picking up smoking as teenagers. Nearly 28 percent of high school seniors smoked in 2005, compared to 18 percent of female adults, according to the Centers for Disease Control.
'You'll never smoke alone'
Doctors Joel Killian and Steve Fortmann, researchers at Stanford University Medical Center have studied the factors that cause people -- especially teenagers -- to start smoking. Among boys, smoking tends to be associated with undiagnosed depression and antisocial behavior. "The boys who were smoking tended to be loners and on the fringe, but with girls that wasn't the case," Killen says. "The girls who smoked were more social and more extroverted. "
Sarah Smith, a smart, genial 19-year-old college sophomore, thinks smoking aids her social life. "I have a crutch theory about smoking. If you're smoking alone, you're not really alone. If you want to meet people, it's a way to open a conversation -- ask for a light or offer a cigarette." Smith started smoking about four years ago when she was visiting friends in London. "It was a lot more socially acceptable there," she says. "Also, I started smoking a lot when my parents were getting divorced. It was a release and a little defiance. "
A dancer, Smith has noticed that her endurance is waning, and she gets congested more easily. But she's not sure if that's due to smoking or getting less exercise. "At the moment, when I think about quitting, I see it sometime in the future," she says. "I hate being chemically dependent on something, but I have so much on my plate right now that smoking is a release. I'm not ignorant about what it does to your health, but it's my personal choice and when I choose to change, I will. I certainly would encourage younger women not to start. "
More than 20 years ago, when Janet Meyer (not her real name) was Smith's age, smoking was socially acceptable on campus. But her smoking habitat -- and her smoking habit -- have constricted with time.
As a college student in the mid-1980s, Meyers developed a number of nicotine-centered rituals. "I started with clove cigarettes and Dunhills, and it was down a slippery slope from there," says the lawyer, now in her 40s, who recalls her freshman-year initiation in the company of a friend from dance class. "After dance rehearsal, we'd go to the dining clubs and play pool and smoke and check out the juniors. "
While studying, she became a human chimney. "I smoked the most when I was writing. It got so bad that I would carry this heavy metal fan around to the reading rooms. I'd have my cigarettes, candy, my fan, and my teddy bear -- all of my comfort items -- and I'd write and smoke steadily. "
Five years later, when Meyers entered law school, she found herself on a no-smoking campus and began working summers at law firms with no-smoking policies. One summer she quit. Meyers was smoke-free for almost four years. Since then, she's smoked sporadically -- anywhere from a couple a day to a handful a week. "Few of my friends smoke anymore and we don't go to smoking venues. And many of my friends have children -- I'd never smoke around children," she says.
According the Surgeon General's report, women tend to respond well to situations that force them to curb their smoking. A few times a week, at the end of the day or first thing in the morning, Meyers will sit on her terrace (smoking is prohibited in her apartment building) and savor a single cigarette. "It's more of a treat than a routine," she says.
Meyers thinks she's reached a workable compromise in her relationship with smoking, but Fortmann isn't so sure. He says it's extremely hard to stay a "chipper" -- someone who smokes occasionally -- when you have a history of addiction to nicotine.
"At some point in her life she was dependent. She's playing with fire every time she hits her brain with nicotine," he says. "It's hard to maintain that limited level of exposure."
Easton, the CDC epidemiologist, says it is important to remember that even though women are better educated than ever about the perils of smoking, it's often wrenchingly hard to quit. Before she moved to Atlanta, she worked in the cancer ward of a hospital in Ohio. "I saw cancer patients sitting outside in the cold, hooked up to IVs, and smoking through holes in their throats. The head of the oncology unit was a smoker," she says. "This kind of behavior speaks to the incredibly addictive nature of smoking. It has an incredible grip, and it's really hard to understand how addictive it is if you've never smoked. "
Many of the negative effects of smoking are reversible -- once a woman quits. Women who stop smoking before getting pregnant or during the first trimester manage to avoid most of the smoking-related risks to the developing fetus. Heart function starts to improve within hours of quitting, and within months lung function can return to normal.
"It's normal to quit and relapse and quit again," Easton says. "But quitting at any age is beneficial." There's hope for every addiction. If you can keep up your quitting strategies until you gain control and reap the health benefits of being tobacco-free -- that's really coming a long way, baby.
Centers for Disease Control. Youth and Tobacco Use: Current Estimates. May 29, 2009. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm
Centers for Disease Control. Adult cigarette smoking in the US: Current estimates. November 2007. http://cdc.gov/tobacco/data_statistics/Factsheets/adult_cig_smoking.htm
American Cancer Society. Women and Smoking. October 2006.
"Women and Smoking: A Report of the Surgeon General, 2001, http://www.cdc.gov/tobacco/sgr/sgr_forwomen/Executive_Summary.htm
University of California, San Francisco press release, http://ftp.pku.edu.cn/www.ucsf.edu/www.ucsf.edu/pressrel/2001/03/032901.html
Interview with Stanton Glanz, professor of medicine and Director of the Center for Tobacco Control Research and Education at the University of California at San Francisco
Interview with Alyssa Easton, an epidemiologist at the Centers for Disease Control and Prevention
Women and Smoking Fact Sheet: Tobacco Use and Reproductive Outcomes, http://www.cdc.gov/tobacco/sgr/sgr_forwomen/factsheet_outcomes.htm
Killen, J.D., Fortmann, S.P., Newman, B. (1990). Weight change among participants in a large sample minimal contact smoking relapse prevention trial. Addictive Behaviors, 15, 323-332.
Patel JD, et al. Lung cancer in U.S. women: A contemporary epidemic. JAMA. 2004;291:1763-1768.
Campaign for Tobacco-Free Kids. Tobacco Use Among Youth. September 2006. http://www.tobaccofreekids.org/research/factsheets/pdf/0002.pdf
World Health Organization. Gender in Lung Cancer and Smoking Research. 2005. http://www.who.int/gender/documents/LungCancerlast2.pdf
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Last Updated: March 11, 2013
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