1. Taru Hannele Kinnunen, PhD
Harvard 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

2. Overview and Observations

3. 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
POUNDS

4. Young Women and Tobacco Use
• decline in smoking rates
among adult women
stalled while smoking
rates rose steeply
among teenaged girls

5. Example: Tobacco Use in Finland

7. The Opponent in the
Challenge

9. • light cigarettes are
less harmful than
regular cigarettes
• smoking cigarettes
helps staying slim
Marketing

10. Smoking-related
illnesses such as lung
cancer and
cardiovascular disease
are becoming more more
prevalent among women
Concern 1

12. 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
Rateper100,000female
population
Year
United States, 1930-1995

13. 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 % increase
since 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

15. 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

16. 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

17. Plaque
Rupture
Thrombosis
Infarction
Plaque
Ishemia

18. reduced plasma
concentration of
ESTROGEN
ENDOTHELIAL
DYSFUNCTION
CHRONIC
SMOKING
LIPID
ABNORMALITIES
reduced plasma
concentration of
ESTROGEN
THROMBOSIS
ATHEROSCLEROTIC
PLAQUE
FORMATION
PLAQUE
INSTABILITY,
RUPTURE
CHRONIC
EVENTS,
stable angina
ACUTE EVENTS,
unstable angina
myocardial
infarction
sudden death
NO
platelet aggregation
fibrinogen
blood viscosity
LDL HDL
Effects of Tobacco and Estrogen on Atherosclerosis
Bolego et al., Cardiovasc Res
2002, 53:568-76

19. The Global Challenge

20. Concern 3
• smoking may increase women’s
vulnerability to gender-specific
health consequences such as
osteoporosis and reproductive issues

21. 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

22. Reproductive Health
• Increased risk for conception delay
infertility.
• Pregnancy complications, premature birth,
low-birth-weight infants, stillbirth, and
infant mortality.
• Increased risk for
ectopic pregnancy
and spontaneous
abortion.

23. 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

24. Second Hand
Smoke (ETS)
and Mortality

25. ETS and Lung Cancer
• Dana Reeve dies of lung
cancer at 44
• Widow carried on activism
after Christopher Reeve's
death
•Dana Reeve, seen at a 2004 event, revealed that she had lung
cancer,
• She was a nonsmoker.

26. Concern 4
• Quitting smoking
may be harder
for women
Osler et al., 1999, Prev. Med, Perkins 2002, Drugs

27. 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 + ?
Counseling
Behavioral Tx
Pharmacological Tx

28. Quitting Smoking May Be…
• Nicotine replacement therapy may not
be as effective for women.
Osler et al., 1999, Prev. Med, Perkins 2002, Drugs

29. 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

30. 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.

31. 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

32. The Global Challenge

33. Thank You!
Funding:
NIDA
NCI
NIDCR
StudyStaff
Gum+
StopStep
ElderScreeningStudy