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Scientific Activities - Actividades Científicas

Honorary Committee Lecture

Tobacco: The assault on women - VIb
Published in ProCOR

Bernard Lown, MD
Awarded with Nobel Prize

Heart disease and reasons for tobacco
Demographics of Women Smokers
Why Women Smoke?

The assault on women VIa: Heart disease and reasons for tobacco

Over the past 35 years, every report of the Surgeon General Advisory Committee on Smoking and Health has identified cigarette smoking as the most important cause of preventable mortality. A total of 418,690 deaths in the US were attributed to smoking  in 1990. Former Surgeon General C. Everett Koop has designated smoking as the most important public health problem of our time, and the leading cause of preventable death in American society. While enormous progress has been registered, with cigarettes no longer a status symbol of either masculinity or high fashion, nonetheless about a quarter of the population continues to smoke. The prevalence is highest among persons 25-44 years of age.(28) Of these, 26% are heavy smokers who consume more than 20 cigarettes daily. While the health risks associated with smoking are legion, of the approximate 140,000 women who die each year from smoking related disease in the USA, the largest toll is exacted by cardiovascular disease.

Heart Disease Ischemic heart disease is responsible for 40% of deaths in industrialized societies, with smoking a major modifiable risk factor, accounting for about one fifth of cardiovascular death in the US. In a study of British doctors, a strong dose -response relation was observed between duration and extent of smoking and the death rate from ischemic heart disease in men younger than 65 years. (29) Similar trends have also been shown in studies of women who smoke.(30) Striking is the exquisite susceptibility of women smokers for developing heart disease. Even as few as one to four cigarettes daily had a 2.5 fold increased risk of fatal coronary heart disease and nonfatal myocardial infarction.

Two contemporary studies from Scandinavia address the gender issue. In a prospective Norwegian study of 11, 843 subjects, the relative risk for current smokers was 3.3 for females and 1.9 for males and the differences persisted after adjustment for total and high density lipoproteins cholesterol concentration, triglycerides, body mass index and systolic blood pressure.(31) The study from neighboring Denmark involved  a very large population sample of nearly 25,000 subjects.(32) The Danish cohort consisted of 11,472 women and 13,191 men, followed for a mean of 12.3 years. The major outcome measure was the first hospital admission or death from myocardial infarction(MI). Compared with nonsmokers, female current smokers had a relative risk of MI of 2.24 (range 1.85-2.71) and male smokers had a risk of 1.43 (1.26-1.62). Relative risk was dose dependent. Women were far more threatened than men whether risk was measured by current or accumulated tobacco exposure and was independent of age. The relative risk of MI in female smokers was not affected by multiple adjustments for major cardiovascular risk factor such as  arterial blood pressure, total and high density cholesterol triglycerides, diabetes, body mass index, alcohol intake, physical activity or level of education. The authors conclude that women may be more sensitive than men to the harmful effects of tobacco.   

The fact that women smokers are more at risk for heart disease is curious since female nonsmokers are substantially less susceptible than men.  The protective factor no doubt relates to estrogen production which, as already discussed, is attenuated by smoking. Estrogen deficiency under diverse circumstances is associated with an enhanced  prevalence of cardiovascular disease. Rates of ischemic heart disease increase sharply in postmenopausal women. Young women with bilateral oopherectomy are at greater cardiovascular risk. Accumulating epidemiological findings confirm that the postmenopausal  hormone replacement therapy lowers incidence of heart disease. Also supportive of this line of argument is the preliminary data indicating that hormone replacement therapy reduces the risk of stroke only in smokers.

Smokers have a 3 to 4 fold increased risk of heart attacks compared with non- smokers, however, half of this risk disappears within 1-2 years after quitting. A similar result has been reported in the above cited Danish study.(32) Unlike the predisposition to cancer, ischemic heart disease was more strongly associated with current smoking than with accumulated exposure to tobacco. In fact, the excess risk of MI was reduced by as much as 50% within the first year of quitting.  

Cessation of smoking has an almost immediate effect on cardiovascular disease, with disappearance of carboxyhemoglobin, a decrease in blood clotting, less arterial spasms, and lower susceptibility to arrhythmias. Additionally smoking cessation partially reverses the effects of tobacco on endothelium. This has been demonstrated in a very recent study in 60 young adults, the majority of whom were women.(33) Endothelial-dependent dilatation was significantly better in former passive smokers(FPS) than in current passive smokers(PS) although both groups were impaired compared with nonsmoking controls. (See Table 1) Nitroglycerine induced dilatation was similar in all three groups.  The maximum improvement in endothelial function was not observed until more than two years after cessation of exposure to passive smoking.


Table 1 (33)












Duration of   Exposure (years)




Endothelium dependent dilatation %

8.9 +/-3.2

5.1+/- 4.1



Demographics of Women Smokers

Socio-cultural factors have dictated that women take up smoking only after the habit has become strongly rooted among men. As smoking is expensive, the earliest victims are urban, affluent, well educated professional women. This may be due to the more liberated environment which exposes them to tobacco advertisements with cigarettes readily accessible. For example in Costa Rica 24% of affluent urban women smoke compared to 10% of rural women.(34) In Spain in 1989, 52% of upper class compared to 12% of working class women smoked.(35) Information of the adverse effects of smoking on health, for similar class and educational reasons, first impacts on the affluent. Advantaged women are also more likely to show the first decreases in cigarette consumption, reflecting both lower rates of initiation and higher rates of cessation. (36)

The social setting both at home and of peers are decisive influences. Adolescents are more likely to turn to cigarettes if their parents either smoke or have permissive attitudes. In developed countries, girls in particular appear to be influenced by their parents smoking habits and attitudes, although the influence diminishes as they grow older. Initiation of smoking among girls, as among boys, is heavily affected by social pressures, psychological needs, environmental influences, the school environment, peer pressures, and knowledge, attitudes and beliefs about smoking. (36) First cigarettes are usually shared with friends. Having a best friend who smokes is a strong predictor of becoming hooked, though this may be more important for boys than girls (37). Adolescent smokers are more likely to be underachievers at school with low academic goals. This is also indicated by the finding that U.S women without a college education were over twice as likely to take up smoking as compared to those who went to college (38). The decisive age range is early teens. For example, a WHO study of 10 European countries found that over one-third of girls have tried smoking by the age of 13, and this increases to around 60% among 15 year-olds.(39)

Affluent smokers readily learn and take to heart the spate of information about the health hazard associated with the resort to tobacco. In countries where tobacco use is in decline,  smoking is increasingly therefore associated with poverty. The typical smoker generally is ill-educated, has a low skilled job or is unemployed, earns a minimum wage or is on welfare and experiences high degrees of social and psychological deprivation.  For example in the UK in 1992, 13% of women in the highest socio-economic group(1) smoked compared to 35% in the lowest (group 6);  and whereas  62% of professional women  who had ever smoked had quit only 36% of unskilled manual working women had succeeded in quitting.(40) Single parents or divorced are more likely to smoke believing that cigarettes help them cope. Cooped up with small children the entire day, women frequently indicate that cigarettes help them maintain their sanity. Many poor women see cigarettes as their only luxury -the only thing they do for themselves. Women in low status insecure jobs may also smoke to break the monotony or deal with the frustration from stupefying repetitive work. In many countries the highest smoking rates are among the disadvantaged ethnic minorities. In Canada in 1989, 77% of intuit women were smokers.(43) In New Zealand Maori women have one of the highest smoking rates in the world. (44).  


Table 2 Modified after (41,42)

Stage countries   

       Gender        Health            Effects
1 Male prevalence low
but increasing rapidly
Males< 15%     
Females < 5%
Not evident        Developing
(sub-Saharan Africa) 
2 Male smoking rising
Females 20 year behind
Males 50-80% Male smoking death  death rates evident China, Japan,
Latin America
3 Male smoking declining female prevalence peaks Europe       Males ~ 40%   
Females plateaus
Clearly evident in both sexes Eastern & Southern
4 Smoking declines in both sexes Males ~ 28%
Females ~ 22%
Male mortality peaks
Female death rising
USA, UK, Canada
Western Europe


Why Women Smoke?

Like many complex social phenomena, smoking among women is propelled by a host of interacting causes. While the first woman smoker is unknown, Chopin's mistress, the Parisian Baroness de Dudevant, circa 1840, is "credited" with this distinction. She was among an avant-garde who disdained custom, donned men's trousers and smoked in public.(45) From the very outset, for women smoking was a declaration of gender equality aimed to convey an image of independence. The practice was, however, slow to catch on except among emancipated upper-class  women. Until World War II, compared to men, less than half as many women were smokers.(46)

It would be a misperception, though, to presume that smoking by women was the result of an informed act of free will. In large measure, it was a habit coaxed and foisted by a carefully orchestrated act of brain-washing by the tobacco companies. The struggle among women for gender equality was not lost on the tobacco industry.  Advertising campaigns  nurtured  cigarettes as symbols of defiance. In 1919, the Lorillard tobacco company was among the first to use images of smoking women, to market its Murad and Helman brands.(46) Marlboro thereafter projected the semblance of fashion and slimness by unveiling its "mild as May" campaign in the sophisticated fashion magazine Le Bon Ton in 1927. The focus on the female figure was further hyped  by Lucky Strike the following year, encouraging women to "Reach for a Lucky Instead of a Sweet."  These advertisements employed  debutantes and fashion models to smoke in public places. Lucky Strike even prevailed on the fashion industry to choose the color of its cigarette package (green) as the fashion color of the year.(46)

As the tobacco industry depends on a mass market, it constantly faces the loss of customers through quitting and death. To maintain profits, large numbers of new devotees need constant recruitment. The goal is reached by concentrating  on susceptible target groups, chief among these are women, the young and people in the developing world.  Effective marketing tailors messages to each particular group and appeals powerfully to perceived weakness, to deficient self-images, to cultural fixations, and to psychological problems. 

In focusing prodigious advertising revenues on women, the tobacco industry employs several interrelated strategies:(a) depicting smoking as glamorous, sophisticated, romantic, sexy, seductive, sporty, cool, relaxing, liberated, feminine, risk-taking, rebellious, anxiety relieving and  the way to retain a slim figure; (b) producing "women only" brands and other types of cigarettes likely to appeal to women; (c) advertising in women's magazines to reach large female audience; and (d) using cult figures to provide role models.(36)

The targeting of women reached a crescendo in 1967. The effectiveness of the massive advertising was demonstrated by a substantial increase in smoking among females especially by callow youth well below the legal age for purchasing cigarettes.(47) The percentage increase in the start-up smoking rates among young people from 1967 to 1973 when it peaked, was 110% in 12-year-olds, 55% in 13-year-olds, 70% in 14-year-olds, 75% in 15-year-olds, 55% in 16-year-olds and 35% in 17-year-olds. The lower the educational level, the higher the resort to smoking. Thus the increase was 120% among those who did not attend college and 70% for those continuing to track to higher education.

Tobacco companies, engaging in extensive research and polling, learned that young women are uniquely vulnerable to the enticements of cigarettes. Girls in American society have a lesser valuation of their physical appearance and a diminished overall sense of self-worth than boys. A reduced self-image is associated with regular smoking.(48) The tobacco companies message was unequivocating, smoking  bolsters self confidence by calming nerves, by controlling mood and by alleviating stress-- all profound concerns of adolescents. By demonstrating beautiful happy young women cavorting with handsome male partners or socializing with successful and confident people, cigarette advertisements linked smoking to high fashion and success. The insecurities of the young are exploited in order to sell the notion that fairy-land dreams are theirs if only they smoke.(46) A further factor favoring this sick habit was societal preoccupation with female thinness, a preoccupation of adolescent girls. (49)

Tobacco has made deep inroads also by designing cigarette brands specifically intended for women. The tobacco industry unashamedly proclaims, "Brands can serve as strong fashion statements" and "Brands are frequently a personal emblem, identifying to others a smoker's status and aspirations."(45) Beginning in the late 1960s, with the introduction of Philip Morris' smashingly successful Virginia Slims brand and it's "We've Come a Long Way, Baby" campaign, fashion has become a powerful route for  reaching young women.(50)  As many women are becoming aware of health consequences, to maintain women smoking tobacco companies are introducing new brands to allay these anxieties.  These range from low tar, reduced nicotine or mentholated or such brands as Natural American Spirit, which proclaims a "pure, unadulterated leaves" (no chemical additives) and is sold along side tofu, granola, and health books in 2000 specialty groceries nationwide in the USA.(46)

With restriction of cigarette advertising on radio and television, women's magazines have become a major vehicle for reaching a mass female audience. Sadly, there exists an inverse relation between these publications devoting space to promoting tobacco use and their coverage of the adverse health effects. Indeed, in France and Sweden, which have banned magazine tobacco promotion, articles on the hazards of smoking have markedly increased. Yet, despite the persuasive evidence that cigarette advertising influences smoking patterns, in a recent survey, ten editors of women's magazines stated that these promotions only affect brand choice.(51) This very discredited argument has been purveyed by the tobacco industry. Research shows that children in developed countries can identify the brands of cigarette advertisements and that awareness of cigarette brands is a strong predictor of future smoking.(36) The most heavily advertised brands are more often bought by teenagers than by adult smokers.(52)




28. Cigarette smoking among adults - United States, 1991. MMWR-Morbidity and Mortality Weekly Report 1993;42:230.
29. Doll R, Peto R: Mortlaity in relation to smoking: 20 years observations on male British doctors. BMJ 1976;2:1525.
30.  Willett WC et al: Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes. NEJM 1987;317: 1303-9.)
31.  Njostad J et al: Smoking, serum lipids, blood pressure and sex differences in myocardial infarction. A 12 year follow-upof the Finnmark study. Circulation 1996;93:450.
32. Prescott E et al: Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ 1998;316:1043.  
33. Raitakari OT et al: Arterial endothelial dysfunction related to passive smoking is potentially reversible in healthy young adults. Ann Int Med 1999;130:578.
34. Rosero-Bixby L, Oberle MW: Tobacco use in Costa Rican women. Gencias Sociales. 1987; 35: 95.
35. Estudio de los estilosde vida de la poblacion adultaespanola. Madrid Ministerion de Sanidad y Consumo. Direcion General de Salud Publica, 1992.
36. Amos A: Women and Smoking: A global issue Wld hlth statist. Quart. 1996;49:127.
37. Charlton A, Blair V: Predicting the onset of smoking in boys and girls. Social Science and Medicine 1987;29:813.
38. Preventing tobacco among young people: a report of the Surgeon General. Atlanta United States Department of Health  and Human Services, 1994.
39. Currie C et al: Health behaviors of Scottish school children: Report 4. The cross-sectional perspective. Scotland compared to other European countries and Canada. Edinburgh, Health Education Board of Scotland, 1994.
40. Office of Population Census and Surveys. General household survey 1992. London Her Majesty's Stationary Office, 1994.
41. Peto R et al: Mortality from smoking in developed countries 1950-2000. Oxford. Oxford University Press, 1994.
42. Lopez AD et al: A descriptive model of the cigarette epidemic indeveloped countries. Tobacco Control 1994;3:242.
43.  Miller W, Peterson J: Tobacco use by youth in the Canadian Arctic 1989. Ottawa. Health and Welfare. Canada and Ministry of Health NWT, 1989.
44. Chollat-Traquet C: Women and tobacco. Geneva, World Health Organization, 1992.
45. Zimmerman C: 120 good things about tobacco. Tobacco Reporter July 1993:56.
46. Kaufman N: Smoking and young women; the physician's role in stopping an equal opportunity killer. JAMA 1994; 271:629.
47. Pierce JP et al: Smoking initiation by adolescent girls, 1944 through 1988 :an association with targeted advertising. JAMA 1994;271:608.
48. Minigawa K et al: Smoking and self-perception in secondary school students. Tobacco Control.  1993;2:215.
49.  Moss AJ et al: Recent trends in adolescent smoking, smoking uptake correlates, and expectations about the future. Advance data from Vital and Health Statistics. Hyattsville, Md: National Center for Health Statistics 1992, No 221.
50. Simpson D: Smoking and fashion. Tobacco Control 1993;2:244.
51. Amos A et al: Women's magazines and tobacco in Europe. The Lancet 1998;352:786.                                    
52. DiFranza JR et al: Nabisco's cartoons camel promotes Camel cigarettes to children.  JAMA 1991;266:3149. 1