women, tobacco & cancer

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Women, Tobacco and Cancer: An Agenda for

the 21st Century

Michele Bloch, MD, PhDMedical Officer

Tobacco Control Research Branch

Behavioral Research Program

Division of Cancer Control and Population Sciences

National Cancer Institute (USA)

Frauen und Rauchen: Was wirkt, was fehlt? 13. ± 14. Oktober, 2008

Langenbeck-Virchow-Haus, Berlin



U.S. Women¶s Smoking Prevalence, 2006

Source: CDC, Cigarette Smoking Among Adults ± US, 2006. MMWR 2007; 56 (44):1157-1161.

Prevalence data from 2006 NHIS

19.7 19.2

10.1

29.0

4.6

31.4

20.4

17.8

8.4

5.8

17.8

28.0

18.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

White,

non-Hispanic

Black,

non-Hispanic

Hispanic AI / AN Asian Grades 9-11 H.S. Diploma Assoc.

Degree

Undergrad.

Degree

Graduate

Degree

At or above

Federal Poverty Level

Below

Federal Poverty Level



Reports of the U.S. Surgeon General

www.surgeongeneral.gov/library/reports/index.html



The Health Consequences of Smoking for

Women, A Report of the Surgeon General (1980)

Women are not immune to the damaging effects of

smoking already documented for men.

The apparently lower susceptibility to smoking-related

diseases among women smokers is an illusionreflecting the fact that women lagged one-quarter

century behind men in their widespread use of

cigarettes.

Women may not start smoking, continue to smoke, quit smoking or fail to quit smoking for precisely the same

reasons as men. Unless research clarifies these

differences, we will find it difficult to prevent initiation

or to promote cessation of cigarette smoking amongwomen.



Women and Smoking, A Report of the

Surgeon General (2001)

³The single overarching theme emerging fromthis report is that µsmoking is a women¶s

issue.¶´

Ag e-ad

justed death rates for lun g cancer and breast cancer amon g women, U.S. 1930-1997



Women and Smoking, A Report of the

Surgeon General (2001)

Exposure to SHS causes lung cancer and heart disease

among women who are lifetime nonsmokers.

Women who stop smoking greatly reduce their risk of

dying prematurely, and quitting smoking is beneficial at all ages.

Smoking during pregnancy remains a major public

health problem.

Tobacco industry marketing is a factor influencing

susceptibility to and initiation of smoking among girls

in the U.S. and overseas.



Recommendations of Women and Smoking,

A Report of the Surgeon General (2001)

Increase awareness of the devastating impact of

smoking on women¶s health.

Expose and counter the tobacco industry¶s deliberate

targeting of women; decry its efforts to link smoking«with women¶s rights and progress in society.

Support women¶s anti-tobacco advocacy efforts and

publicize that most women choose to be nonsmokers.

Continue to build the science base on gender-specific outcomes and on how to reduce disparities among

women.

Act now: we know more than enough.

Do everything possible to thwart the emerging epidemic

of smoking among women in developing countries.



Women, Tobacco, and Cancer Working

Group (2003)

Respond to recommendations of Women and Smoking, A Report of the Surgeon General (2001)

Convened experts in:

± Biology and cancer

± Addiction

± Epidemiology and national surveillance

± Interventions for prevention and treatment

± Awareness, risk perception, and communications

± Community and policy interventions ± Global issues

Focus:

± Identify research recommendations

± Suggest ways to translate knowledge into interventions



Working Group¶s Recommendations (2004)

Increase our understanding of sex and gender differencesacross the broad range of research on women, tobacco, and cancer.

Develop new and more effective interventions to prevent and treat tobacco use and SHS exposure among women and girls,

especially in populations at greatest risk. Ensure the widespread delivery of effective interventions to

prevent and treat tobacco use and SHS exposure amongwomen and girls.

Expand partnerships, networks and innovative research

platforms to design and launch broad-based strategies toeliminate the harms of tobacco use and SHS exposure amongwomen and girls.

Improve national and global evaluation and surveillance of theharms of tobacco use and SHS exposure and of women¶s and girls¶ knowledge, attitudes, and behaviors related to tobacco

use and harms.



Biology and Cancer

Neither the steps in cancer initiation nor those in cancer promotion are fully understood because they involvedynamic interplay between tobacco smoke constituentsand the susceptible cells of the smoker.

The diversity of biological processes that contribute tolung carcinogenesis, and the stigma of tobacco-related disease are major barriers to research in lung cancer biology.

Recommendation:

Support further research into cross-disciplinary interactions in tobacco-related diseasemechanisms, especially gene-hormone-environment

interactions.



Addiction

Women differ from men in their biological responses tonicotine, progression to nicotine dependence, and

patterns of intake, and have higher rates of relapse.

Recommendations: Better understand sex differences in the

mechanisms and processes involved in all phasesof nicotine use and addiction.

Consider environmental, behavioral, genetic,

molecular, cellular, neurobiological, and hormonal factors.

Consider gender differences in depression, stress,and coping, as regards tobacco use.



Epidemiology and Surveillance

A comprehensive surveillance system should encompass: Host (smoker or potential smoker)

Agent (tobacco product)

Vector (tobacco industry)

Environment (economic, cultural, political, and historical activities)

Recommendations: Assess interrelationships among specific population

characteristics (race/ethnicity, sexual orientation,socioeconomic status, gender, age, disabilities) as they influence tobacco use, exposure to SHS, and disease risk.

Monitor tobacco advertising and promotion to women

Increase awareness of targeted marketing to women



Interventions for Prevention and Treatment

It is not yet known whether women and men respond differently to prevention and treatment interventions or would benefit from different intervention strategies.

Recommendations: Continue to evaluate whether gender differences exist in

prevention and treatment efficacy.

If gender differences are found, understand why they occur.

Explore factors unique to women that may influence prevention and treatment outcomes.

Understand if and how gender, context, and cultureaffect prevention and treatment.



Awareness, Risk Perception, and

Communication

Women are an important target audience because they often act as influencers and gatekeepers in family health.

Recommendations: Basic and applied research are needed on women¶s

level of knowledge about the risks of smoking and their assessment of personal risk.

Understand ³positive positioning´ of tobacco.

Develop and disseminate targeted messages to priority populations.



Graphic package warning messages



³Letters´ Campaign of

American Legacy Foundation



Community and Policy Interventions

Policy interventions are now a well-recognized component of tobacco control and prevention efforts.

Recommendations:

Better understand the impact of public and privatetobacco control policies on women and girls.

Support research to identify messages and strategies to engage women¶s and girls¶ organizations and their constituents in tobacco

control and prevention efforts. Increase support for culturally relevant community-

based participatory research.



Global Issues

As rates of tobacco use among women and girls rise,improving scientific research about gender and tobaccobecomes an urgent matter.

Recommendations: Strengthen national surveillance, including

monitoring trends in tobacco use, changing patterns of use, and factors affecting use, around the world.

Understand risk/protective factors for women and girls, especially in countries where female tobaccouse is still low.

Conduct gender-sensitive policy research.



Pregnant Women in

Developing Nations

Establish research priorities in:

Epidemiology of non-cigarette products used

during pregnancy

Interventions to promote tobacco cessation and to

reduce secondhand smoke exposure in pregnancy

Socio-cultural and environmental factors affecting pregnant women¶s use of tobacco and exposure to

secondhand smoke



Conclusions

High income nations are making slow but steady progress towards reducing women¶s tobacco useoverall, but specific populations remain at high risk.

³We know enough to act, but there is more we need to know.´

Lack of knowledge, apathy, complacency, stigma,tobacco industry, hamper progress.

Research, including sex and gender specific research, is a critical component of tobacco control agenda.

Research findings can also be a useful tool to

conduct outreach to women.



³Women may not start smoking, continue to

smoke, quit smoking or fail to quit smoking

for precisely the same reasons as men.

Unless research clarifies these differences,we will find it difficult to prevent initiation or

to promote cessation of cigarette smoking

among women.´

The Health Consequences of Smoking for Women, A

Report of the Surgeon General (1980)

women, tobacco & cancer

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