Taru Hannele Kinnunen, PhDHarvard Medical School

Harvard School Dental Medicine

Department of Oral Health Policy and Epidemiology

Women and Tobacco Use: Global Challenge

The 8th Conference of the International Society for The Prevention of Tobacco Induced Diseases

Presidential Address, September 29, 2010

Overview and Observations

Per Capita Cigarette Consumption United States: 1880-2000

Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census

Note: Among persons >18 years old.

0

2

4

6

8

10

12

1880

1885

1890

1895

1900

1905

1910

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

YEAR

PO

UN

DS

Young Women and Tobacco Use

• decline in smoking rates among adult women stalled while smoking rates rose steeply among teenaged girls

Example: Tobacco Use in Finland

The Opponent in the Challenge

• light cigarettes are less harmful than regular cigarettes

• smoking cigarettes helps staying slim

Marketing

Smoking-related illnesses such as lung cancer and cardiovascular disease are becoming more more

prevalent among women

Concern 1

Cancer Death Rates by Site: Women

0

10

20

30

40

50

60

70

80

1930 1940 1950 1960 1970 1980 1990

Uterus

Breast

Pancreas

Liver

Ovary

Stomach

Lung

Colo-rectal

Source: American Cancer Society, 1999

Rates are adjusted to the 1970 census population

Rate

per

100,0

00 f

em

ale

po

pu

lati

on

Year

United States, 1930-1995

Smoking-Related Diseases Epidemic among Women

" When calling attention to public health problems, we must not misuse the word ‘epidemic.’ But there is no better word to describe the 600 % increasesince 1950 in women’s death rates for lung cancer, a disease primarily caused by cigarette smoking. Clearly, smoking-related disease among women is a full-blown epidemic.“

David Satcher, M.D., Ph.D.

Surgeon General

Concern 2

• despite the fact that women smoke at lower rates than men, their disease risk associated with smoking is higher, and present even with minimal tobacco use

RR of Myocardial Infarction by Tobacco Exposure and Gender

0

0.5

1

1.5

2

2.5

3

3.5

risk

adj.

never ex-

smoker

non-inh. 1-14

g/day

15-24

g/day

> 24

g/day

men womenPrescott et al., 1998, BMJ

PlaqueRuptureThrombosisInfarction

PlaqueIshemia

reduced plasma concentration of

ESTROGEN

ENDOTHELIAL DYSFUNCTION

CHRONIC SMOKING

LIPID ABNORMALITIES

reduced plasma concentration of

ESTROGEN

THROMBOSIS

ATHEROSCLEROTICPLAQUE

FORMATION

PLAQUE INSTABILITY,

RUPTURE

CHRONIC EVENTS,stable angina

ACUTE EVENTS,unstable anginamyocardial infarctionsudden death

NO

platelet aggregationfibrinogenblood viscosity

LDL HDL

Effects of Tobacco and Estrogen on Atherosclerosis

Bolego et al., Cardiovasc Res2002, 53:568-76

The Global Challenge

Concern 3• smoking may increase women’s

vulnerability to gender-specific health consequences such as osteoporosis and reproductive issues

Breast Cancer

• Until recently it was thought that tobacco use contributed very little for breast cancer

• However, it was recently shown that– Current smoking increased breast cancer

risk particularly among those without familial risk

– Smoking during developing years increased the risk

Reynolds et al., 2004 J Natl Cancer Inst

Reproductive Health

• Increased risk for conception delay infertility.

• Pregnancy complications, premature birth, low-birth-weight infants, stillbirth, and infant mortality.

• Increased risk for ectopic pregnancyand spontaneous abortion.

Reproductive Health cont.

• Biochemical changes in fetus (nAChR)

• Developmental consequences from maternal smoking of the offspring

• Menopause at a younger age than do nonsmokers, and more severe menopausal symptoms

• Oral contraceptives and tobacco use increase CVD risk

Second Hand Smoke (ETS) and Mortality

ETS and Lung Cancer

• Dana Reeve dies of lungcancer at 44

• Widow carried on activismafter Christopher Reeve'sdeath

•Dana Reeve, seen at a 2004 event, revealed that she had lung cancer,

• She was a nonsmoker.

Concern 4

• Quitting smoking may be harder for women

Osler et al., 1999, Prev. Med, Perkins 2002, Drugs

Clinical Guidelines for TX

Intensity: Dose-response

Type: Individual/Group/Telephone

Content• Problem solving/Skills training• Intra-treatment social support• Extra-treatment social support

First-line therapies:• NRT (gum, patch, lozenge,

inhlaler, spray, microtab)• Bupropion(Zyban, Wellbutrin)• Varenicline (Champix, Chantix)

• Second-line therapies:• nortriptyline• clonidine

Combination therapies• NRT+NRT• Bupropion SR + NRT• Varenicline + ?

CounselingBehavioral Tx

Pharmacological Tx

Quitting Smoking May Be…

• Nicotine replacement therapy may not be as effective for women.

Osler et al., 1999, Prev. Med, Perkins 2002, Drugs

Quitting Smoking May Be…

• Women more fearful of gaining weight.

• Menstrual cycle

• Depression and smoking cessation

• Lower education and SES

Osler et al., 1999, Prev. Med, Perkins 2002, Drugs

Tobacco Dependence Treatment for Women In General

• Search for barriers to cessation and reduce them

– Weight concerns– Child care– Social support– Etc. etc. etc.

• Educate – globally/locally• Community approach• Map and intervene on other risk factors

– lipids, insulin resistance, weight etc. etc.

Exercise ?

• regular exercise improves mood, reduces stress and cigarette cravings, as well as reduces fear of weight gain associated with smoking cessation exercise may be an especially promising treatment for women who want to quit smoking

The Global Challenge

Thank You!

Funding:NIDANCINIDCRStudyStaffGum+StopStepElderScreeningStudy