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from the Surgeon General, 
U.S. Department of Health and Human Services

Two decades have passed since the first Surgeon General's report on women and smoking was published in 1980. That report pointed out the first signs of an epidemic of smoking-related disease among women. This report documents that the epidemic became full-blown.

Cigarette smoking is the leading cause of preventable death in the United States, and women's share of tobacco-related disease has risen dramatically over the past half century. The point is underscored by the 600-percent increase since 1950 in women's death rates for lung cancer, a disease that is primarily attributable to smoking. Lung cancer accounted for only 3 percent of all female cancer deaths in 1950, whereas in 2000 it accounted for an estimated 25 percent. Already in 1987, lung cancer had surpassed breast cancer as the leading cause of cancer death in U.S. women, and in 2000 nearly 27,000 more women died of lung cancer (67,600) than breast cancer (40,800). In fact, more women are estimated to have died of lung cancer in the year 2000 than of cancers of the breast, uterus, and ovary combined. Of course, lung cancer is but one of the many diseases for which risk is greater among smokers than nonsmokers.

Despite these facts, 22.0 percent of U.S. adult women smoked in 1998. Moreover, between 1992 and 1997, the percentage of high school senior girls who reported smoking within the past 30 days increased from 26.1 percent to 35.2 percent before declining to 29.7 percent in 2000.

Since the first Surgeon General's report on women and smoking in 1980, thousands of studies have expanded both our knowledge of the effects of smoking on women's health and our understanding of the myriad factors that influence smoking initiation, maintenance, and cessation. The need for an updated compendium on women and smoking is great, and this report addresses that need.

Ironically, in the face of the overwhelmingly negative health effects of smoking, tobacco marketing has always used positive imagery and has attempted to capitalize on issues important to women and to exploit the women's movement. The same tobacco brand that for so long featured the slogan "You've come a long way, baby" more recently launched an advertising campaign with the theme "Find your voice." Tobacco advertisements suggest that women who smoke are liberated, sexually attractive, athletic, fun loving, and slim, whereas in reality women who smoke are often nicotine dependent, physically unhealthy, socioeconomically disadvantaged, or depressed. Tobacco companies also have tried to ingratiate themselves with women's causes, providing funding for women's sports, for women's professional organizations, and for anti-domestic violence programs and other issues of salience to women, not to mention providing huge sums in advertising revenues to women's magazines. Perhaps such support has contributed to the fact that women's lung cancer does not have a voice, in contrast to breast cancer, which has such a well-developed and effective advocacy community.

Although the Healthy People 2000 objective of reducing the prevalence of current smoking among U.S. adult men and women to 15 percent is unlikely to be met, we should emphasize that nearly 80 percent of adult women in this country choose not to smoke. Nonsmoking is now by far the accepted norm. If the recommendations in this and previous reports were fully implemented, the Healthy People 2010 objective to reduce the rate of tobacco use among girls and women in the country by more than 50 percent could be met. Hopeful signs now exist that the lung cancer epidemic may have peaked among U.S. women. As this report goes to press, encouraging news comes from a report issued by the Centers for Disease Control and Prevention based on data from California and from the National Cancer Institute. In California, which has been at the forefront of tobacco control activities and where smoking prevalence has declined more rapidly than in the rest of the country, the lung cancer incidence rate among women has actually declined in recent years. Another report from California found that 33,300 fewer heart disease deaths occurred in the state between 1989 and 1997 among women and men combined than would have been expected during that time had earlier trends in heart disease mortality relative to the rest of the United States continued. California was the first state to implement a comprehensive statewide tobacco control program funded by a cigarette surtax that began in 1989. Today all states have enormous monetary settlement payments from the state lawsuits with the tobacco industry to recover the cost of smoking-related disease; unfortunately, few states have used these new resources to make the level of investments in the proven tobacco control strategies that could reduce the disease and death rates related to smoking.

Women in the United States and a number of other developed countries are less likely to be smokers than was the case 30 years ago. However, just the opposite trend is feared for women in many other parts of the world, particularly women in developing countries where smoking prevalence has traditionally been low but where the tobacco industry now recognizes tremendous market potential and is aggressively pursuing females. Thwarting increases in the use of tobacco among women around the world represents one of the greatest public health opportunities of our time.

David Satcher, M.D., Ph.D.
Surgeon General (1997--2002)

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