Risk of illness

“if women are equally exposed to tobacco as men were, they are going to be equally and even more affected by it"

Estimates suggest that, among women who start smoking regularly as teenagers, around half will die as a result of tobacco use, mainly from cardiovascular disease and cancers.
Yet ‘women’s health’ is still seen largely in terms of reproductive and breast health, with other health research sometimes excluding women

Total risk
Smoking-related deaths total around 200,000 European women, including over 110,000 in the EU. For the EU this represents a ten-fold increase 1955-95 and a doubling 1975-95

Four key points stand out in the mass of health research:

Across the EU smoking is responsible for around one in fourteen of all deaths (7%) among women, or one in eight before age 70 (12%).  However this rises to around one in six in the UK (17%) and Ireland (16%), and one in five in Denmark (19%), where there is a large burden of accumulated risk.

 Most excess risk is from cardiovascular disease (81,000 attributable deaths across Europe), cancers (55,000 attributable), and respiratory disease.  In this text risk is given by both population and personal measures.  This is important, since smokers are motivated by belief in personal risk and benefit, rather than public health indicators.

Risk and disadvantage
Many studies suggest that poorer smokers suffer multiple health risks. For example,poorer women generally have a less nutritious diet, and less chance to get exercise. Poor education and social exclusion may increase risk, and create barriers to health services, including health education and support to quit.

Spending on tobacco also limits money for other necessary items, including food.  For example, a British study found that poor British families where both parent smoke spend a fifth of available income on tobacco.

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Are women at greater risk?
Recent evidence suggests that, given the same smoking pattern, women may be at greater risk of serious illness. This greater health risk may show in life expectancy data, for example for Danish female and male smokers.

Heart disease
Women have smaller arteries, which block more easily. An Italian study found risk nearly double that for men (RR 5.6-3.2). Fewer women survive a first heart attack, or major heart surgery, but for various reasons early heart disease among women is also less often diagnosed or treated.

Women’s health generally may be more influenced by aspects of daily life - diet, activity, employment, and social support. But this may also offer hope of greater health gain through better health promotion and health policy.

Lung cancer
American Cancer Society studies show greater risk of lung cancer for 1982-88 than 1959-65, even adjusting for tar and smoking habits.  The increase was greater for women. A recent study showed women with nearly three times the risk for men (RR 28-10). Most of the increase has been in unusual types, such as adenocarcinoma and ‘small-cell’ cancer, again especially for women.  Women now form the majority (80%) of lung cancer patients under 50.

Several causes have been suggested:

Lung disease
Early smoking may have more effect on lung growth, which finishes earlier for women.  Lung function worsens more rapidly among women smokers, and death rates are higher. This may be because women tend to lack specific lung enzymes which may protect against lung disease.  Women are also more susceptible to smoking-related asthma.

Respiratory disease
Chronic obstructive pulmonary disease (COPD) or respiratory disease includes a range of conditions.  Chronic bronchitis and asthma affect the upper airways, and emphysema destroys the alveoli.  Symptoms may not show until the lung is badly damaged, and health decline is slow, which may give little incentive to quit.

Risk
COPD claims around 30,000 lives a year among European women. Again rates vary greatly, from under 10 deaths a year per 100,000 women in Greece and Finland, to 30+ in Ireland and Denmark, a reflection of long-term smoking rates.

Data for the UK suggest that around two-thirds of respiratory disease among women is smoking related.  Risk of death is increased roughly ten fold (RR 10.5) Research indicates that women smokers lose lung function more rapidly than men,and death rates are higher, perhaps because protective lung enzymes are more often missing.  Low tar cigarettes offer little or no benefit for respiratory health].

Smokers also have roughly twice the death rate from pneumonia, asthma and TB, and greater risk from flu.  This may be of concern during flu outbreaks, and as TB rates rise in central and eastern Europe, and in some other European cities. 

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Trends in lung disease
Lung disease among women shows variable trends across Europe. As with lung cancer, rates are generally higher where smoking among women is well-established, but the pattern is less clear.  Rates increased markedly in France and Scandinavia from 1973-92, with a three-fold increase in Denmark.   Mortality fell in Ireland, Belgium, and the UK, and in southern Europe, especially Greece.

Effect of disadvantage
Poorer women have much greater risk of respiratory diseases.  For example, British women classed as ‘unskilled manual’ have around five times the risk of ‘professional’ women.  However, this excess is only partly smoking related.

Quality of life
Smokers are more prone to cough and wheeze, and tolerate exercise poorly.  Asthma symptoms are made worse by smoking, or smoky air, and women seem more affected than men.   Respiratory infections are more frequent, and recovery slower.  Established lung disease has a huge impact on daily life.  For example, among British women respiratory symptoms are most closely linked with poor reported health.

Benefits of quitting]
Short and long-term benefits include:

However, although decline is slowed, it is not clear whether existing lung damage can be reversed.

Action points
Promote and publicize:

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Arterial disease

Summary
Smoking has complex effects on the circulation, promoting atherosclerosis, and increasing risk of arterial spasm.  The disease category of CVD (cardiovascular disease) includes a range of smoking related disorders, in particular:

Total risk depends on other factors, in particular diet, exercise and high blood pressure.  For women risk may be more closely linked to these factors.   For example, a British study found that arterial damage was twice as strongly linked to ‘lifestyle’ as for men, but less strongly linked to biological factors.

Risk of CVD
Ischaemic heart disease (IHD) is the main cause of death among European women.  Mortality is currently 300,000 a year, or nearly a third of a million.  Yet research among young people suggests very patchy understanding of circulatory risk across Europe.

Death rates vary greatly, from around 20 a year for each 100,000 French women, to 200+ in former Soviet states.  UK data suggests that around a tenth of heart disease among northern European women can be attributed to smoking. The measure ‘proportion attributable to smoking’ indicates accumulated population risk, relative to other risk factors.

Smoking triples risk among women under 65, and doubles risk generally (RR = 3.0, 1.8).

Younger women show even more marked effect.  Recent research on women under 45 shows 25-fold increase in risk for those smoking 20+ a day, and double risk from 5 cigarettes or less.   Risk may also be greater for women than men.  For example, an Italian study found women’s risk to be nearly double that for men, among those smoking 15-24 a day (RR 5.6-3.20)

Risk of stroke is doubled by smoking, but again younger women have greater relative risk, with five-fold increase under age 65 (RR = 1.8, 4.8).

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Death rates from CVD among women are falling in most countries, but more slowly than for men. The WHO MONICA project recently concluded that trends in heart disease are linked to changes in the classic risk factors.

Multiple risk
Smoking and other risk factors for CVD interact in complex ways.  For example a Finnish study found that combining physical inactivity with smoking or high dairy fat intake was more risky for women than men.

 In northern Europe there are steep class gradients in heart disease, perhaps particularly for women].  Nordic countries have the steepest gradients, both in heart disease and smoking rates.   Again risks combine.  For example, poorer northern European smokers:

Poor education is strongly linked with risk of heart disease, again particularly in women.  A Swedish study suggests that job stress and isolation among less educated women may be key factors.

Hormonal effects
Use of contraceptive pills increases risk of arterial disease around ten-fold, with risk particularly great for women over 45

Quality of life
Women who survive heart attack or stroke may suffer considerable disability, and adapt less well than men.  Working and social life are also limited by circulatory problems, such as cardiac angina, leg pain on exercise (intermittent claudication), and vasospastic disease, to which women are more prone.

Benefits of quitting
Some benefits are felt more rapidly than for other systems. For example:

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Women, tobacco and cancer

Summary
Smoking is an established risk factor for the following cancers:

There is also a causal link to myeloid leukemia, and cervical, ovarian and possibly breast cancer.  Excess risk of liver cancer risk may be due to heavier drinking among smokers, but nicotine slightly reduces risk of endometrial cancer.

 In ‘mature’ tobacco markets around one in six of all cancer among women is linked to tobacco use, and a fifth (22%) in Denmark.  Data on relative risk below are taken from a major analysis, giving best estimate for women in developed countries. Smoking attributable risk is taken from US data, unless stated.

How tobacco causes cancer
Tobacco smoke has direct effects on cancer risk.  For example, the gene p-53 usually prevents division of damaged cells.   The tobacco carcinogen BPDE alters or mutates this gene at specific sites, the very mutations linked to lung cancer (BPDE, benzoapyrene-diol-epoxide).  Cancers usually develop only after several genes mutate, which may explain the long delay between smoking and peak risk, both for individuals and groups.  Generally risk is greatest where smoke toxins have most contact, such as at the larynx and bladder.

Smoking also damages immune function, and increases ‘central obesity’, when fat is stored round the waist.  This body shape has been linked to risk of cancers and cardiovascular disease.

Lung cancer
Every year lung cancer claims the lives of around 37,000 European women. Around two-thirds of mortality is attributable to smoking, with risk increased more than ten-fold among women in developed countries (RR 11.9).  Risk increases with number of cigarettes smoked, and with smoking at earlier ages, possibly because of early genetic damage.  Risk may be greater for women than men, again perhaps linked to genetic differences, or to low-tar compensation.

 Death rates vary from less than 10 a year per 100,000 women in France, Spain and Portugal to 30+ in Denmark, Iceland and the UK].  In general female lung cancer rates are higher where smoking rates are similar for men and women.  Sweden is unique in that even women under 45 are now more at risk than men.

European trends
There has been a sharp increase in lung cancer among European women, with mortality doubling during 1973-92.  Some countries have seen even greater increase, for example mortality among Dutch women increased nearly four-fold.  Over this time male death rate increased by a third, and is now falling in Austria, Finland and the UK.

Female mortality has risen in all countries, although British data show a slight recent fall. From present trends, lung cancer will become the main cause of cancer deaths among 21st century European women, overtaking breast cancer. This has already happened among older women in Scotland and northern England. Countries at an earlier stage in the epidemic may see such a change around 2020, for example around 2025 in France

Other cancers

Respiratory and digestive tract
Other parts of the respiratory tract are also at risk, particularly the larynx (RR 17.8).  The majority of these cancers among women are smoking linked, and again rates are rising.

Smoking also promotes cancers of the digestive tract - mouth and pharynx, esophagus, stomach, duodenum, and pancreas.  The esophagus is most affected (RR 10.3), and alcohol use multiplies risk where it comes into contact.  This may be a concern as drinking increases among some younger European women.  A study of Danish women suggests beer and spirits pose greatest risk.

Pancreatic cancer is more common among women, and has high linked mortality.  A Scandinavian study also found risk of anal cancer increased five-fold among younger women smokers.  Some studies suggest links between smoking and colon cancer.

Other cancers
Smoking increases risk along the urinary tract - at the urinary pelvis, kidney (RR 1.4), and bladder (RR 2.6).  The bladder is particularly affected by tobacco constituents in stored urine.   Myeloid leukemia is also causally linked to tobacco use.

Reproductive system
There are causal links to cervical, ovarian, and possibly breast cancer.  Nicotine itself is protective against endometrial cancer, since oestrogen activity is lower. This may be because less active oestrogen metabolites are formed, or because androgen levels are higher.

Cervical cancer
Infection with HPV (human papilloma virus) is an important cause of cervical cancer. So differences in sexual behavior may increase risk. But smokers also have fewer protective Langerhans cells, so infection may linger. There is more damaged DNA, and infected cells more quickly become malignant. Risk of death is roughly doubled, with 29% of deaths attributable in the UK. Stage of disease and smoking are independent risk factors, and smoking also increases risk of recurrence. Cervical screening may give opportunity to encourage quitting.

Breast cancer
Breast cancer has long been seen as the classic ‘woman’s cancer’. It has been suggested that nicotine has a weak protective effect, as with endometrial cancer, but reviews have not supported this. More recent studies show clearly increased risk in some women smokers, perhaps of particular genetic type

Benefits of quitting
There are both immediate and long-term benefits.  For example:

A major study of American women showed rapid decrease in lung cancer risk after quitting. After 15 years risk was no more than for women who never smoked

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