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Foreword

Women and girls in the United States are in the throes of an epidemic of tobacco-related diseases. Over time, the once-wide gender gap in smoking---and its health consequences---has narrowed considerably. Cigarette smoking was rare among women in the early part of this century, increased until the 1960s, and finally began to decline in the mid-1970s. During the past decade, however, reductions in smoking prevalence among adult women were minor, and tobacco use among teens increased markedly. By the late 1990s, more than one in five adult women was a regular smoker, and about 30 percent of high school senior girls reported having smoked within the past 30 days. Many of the tobacco-related diseases that have manifested today are the result of the cumulative effects of smoking initiated several decades ago. Unless we succeed in further curbing tobacco use among women and girls, the health effects of tobacco use will remain great for the foreseeable future.

This report reviews in detail what we know about smoking-related diseases among women, and documents that the toll of smoking on women's health is wide-ranging and staggering. Like their male counterparts who smoke, women smokers are at increased risk of cancer, cardiovascular disease, and pulmonary disease, but women also experience unique risks related to menstrual and reproductive function. In the face of so many strides that were made during the twentieth century to improve health outcomes for women, including enormous declines in maternal mortality, heart disease, and cervical cancer, to name but a few, it is tragic that an entirely preventable factor continues to claim so many women's lives.

Through its detailed examination of smoking patterns by demographic and other characteristics, this report confirms that it is often women who are more socioeconomically disadvantaged and girls who perform less well academically who are most likely to smoke in our society today. For example, the smoking prevalence in 1998 among women with 9 to 11 years of education was almost three times higher than that among women who had 16 or more years of education. Once a mark of sophistication among women in the social forefront, then adopted by middle-class women, smoking has increasingly become an addiction borne by women with the least resources in our society. The long history of tobacco marketing targeted to women is also chronicled here. The positive imagery in cigarette advertisements is greatly at odds with the negative health consequences suffered by so many women who smoke.

The importance of vigilance in our efforts to prevent initiation of smoking by girl and to promote cessation among female smokers of all ages is underscored by this report. To be successful, we know that a multipronged approach is necessary, including anti-tobacco media campaigns, increases in tobacco prices, promotion of nonsmoking in public places, curbs on tobacco advertising and promotion, enforcement of legislation to reduce youth's access to tobacco products, and effective tobacco use treatment programs. Women who smoke represent diverse subgroups of the population with unique issues and needs. An important subgroup is pregnant women, among whom smoking has declined in recent years but remains significant. Efforts to assist quitting among pregnant women (and their partners) can greatly impact not only their health but that of their infants and children. We must dramatically accelerate declines in smoking among both women and girls. Exciting models of new tobacco control programs in states show that this can be done. In Florida, where the Tobacco Pilot Program was begun in 1998, the prevalence of current smoking among middle school girls declined from 18.1 percent in 1998 to 10.9 percent in 2000---a 40-percent decline in just two years.

The challenge facing this Nation now is to establish effective tobacco control programs in every state and nationwide. No one who reads this report can help but recognize that combating smoking and the forces that promote it deserves to be among our very highest priorities for women's health.

Jeffrey P. Koplan, M.D., M.P.H.
Director
Centers for Disease Control and Prevention
and
Administrator
Agency for Toxic Substances and Disease Registry
(1998--2002)



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