Tobacco use causes more health problems for women than any other preventable factor, according to a 2001 report released by the U.S. Surgeon General and the Department of Health and Human Services. A small percentage of women use smokeless tobacco products such as chewing tobacco and snuff. However, most women who use tobacco smoke cigarettes.

Tobacco use can have a significant impact on a woman’s reproductive health. For example, women who smoke cigarettes while using oral contraceptives (birth control pills) dramatically increase their risk of heart attack. Smoking can also cause menstrual irregularities, infertility  and delayed conception, early menopause and reduced bone density (osteoporosis).

Women who are pregnant are also at increased risk of health problems if they smoke. These risks include premature birth, ectopic pregnancy and miscarriage. Meanwhile, the fetus may suffer from a number of complications, including low birth weight and lifelong health problems. Tobacco use also increases the risk that a baby will die from stillbirth or conditions such as sudden infant death syndrome (SIDS).

Cigarettes kill an estimated 178,000 women in the United States each year, according to the Centers for Disease Control and Prevention. Since 1980, when the first Surgeon General’s report on women and tobacco use was released, about 3 million women have died prematurely of smoking-related diseases. According to the American Lung Association, lung cancer has surpassed breast cancer as the most deadly cancer among women every year since 1987.

However, women who stop using tobacco at any age are likely to experience health-related benefits. The addictive properties of nicotine can make this a difficult process. Women who try to quit smoking often find themselves struggling to succeed, but treatment techniques may help in this process. Options may include nicotine patches or gum, behavioral treatments, cessation programs or self-help materials.

Tobacco use is the single greatest preventable threat to the health, safety and welfare of women around the world, according to a 2001 report released by the U.S. Surgeon General and the Department of Health and Human Services. Tobacco use also increases several risks related to a woman’s reproductive health.

For example, women who smoke cigarettes while using oral contraceptives (birth control pills) dramatically increase their risk of heart attack. The combination of cigarettes and birth control pills also increases a woman’s risk of having an ischemic stroke by three times, and a hemorrhagic stroke (leak or rupture in a blood vessel in the brain) by up to four times, according to a large World Health Organization (WHO) study.

Smoking can cause other problems for women. These include:

• Menstrual difficulties. Cigarette smoking may increase the risks of painful menstruation (dysmenorrhea), secondary amenorrhea (abnormal absence of menstruation) and menstrual irregularity.
  
  
• Early onset of menopause. Smokers often experience menopause at a younger age than nonsmokers. In addition, symptoms related to menopause may be more severe in smokers than in nonsmokers. Symptoms associated with menopause include hot flashes and night sweats, thinning of vaginal tissue, decreased vaginal secretions, increased risk of heart problems and others.
  
  
• Reduced bone density. Postmenopausal women who smoke have lower bone density than women who never smoked, increasing their risk of developing fractures related to osteoporosis. In particular, the risk of hip fracture appears to be increased in smokers.

Cigarette smoking increases the risk of complications for women who wish to become pregnant or who are already pregnant, including:

• Infertility or delayed conception. Smoking affects ovarian function and decreases the female hormone estrogen. Cigarette smoking may impair a woman’s fertility by adversely affecting ovulatory and tubal function, egg production and implantation.
  
  
• Preterm delivery. Smoking may result in preterm delivery or delivery of a baby prior to the 37^th week of pregnancy. Premature infants can face numerous health challenges, including low birth weight, breathing problems and underdeveloped organs and organ systems.
  
  
• Premature rupture of membranes, placenta abruptio (separation of the placenta from the uterus) and placenta previa (abnormal location of the placenta). The latter two conditions can cause massive hemorrhaging during delivery, and all three are potentially dangerous for both the mother and her baby.
  
  
• Increased risk for ectopic pregnancy and miscarriage.

The dangers of smoking to a developing fetus are well known. Smoking impairs a number of critical developmental processes during pregnancy and contributes to many health complications. The most extensively studied of these is low birth weight, but smoking among pregnant women has also been linked to sudden infant death syndrome (SIDS), respiratory infections, asthma, colic, short stature, hyperactivity disorders, childhood obesity, colic, lower reading and spelling scores, and others. There is even a possibility that smoking increases a child's risk of developing diabetes and certain form of cancer later in life.

The Centers for Disease Control and Prevention (CDC) estimates that the elimination of maternal smoking would lead to a 10 percent reduction in all infant deaths and a 12 percent reduction in deaths from perinatal conditions. Studies have found that smoking during the third trimester is most detrimental to a fetus.

For many years, men used tobacco more frequently than women and were more likely to suffer from tobacco-related health conditions. However, in recent decades, the gap has closed as more women have taken up smoking and – to a lesser degree – are using smokeless tobacco. This increase may be due in part to aggressive advertising campaigns aimed at women. Cigarette ads for women rely on themes of beauty, weight loss and independence to help sell cigarettes. Increasingly, teenage girls are targeted by cigarette advertising. These ads have been distressingly effective: in 2003, 23 percent of high school–age girls were current smokers, meaning they smoked at least one cigarette in the previous 30 days, according to the American Lung Association.

It's almost important to note that "low tar" and "light" cigarettes are no healthier than full-tar cigarettes. Numerous studies have shown that smokers of light cigarettes often compensate by inhaling deeper and smoking more often to obtain adequate blood levels of nicotine. Thus, "light" products aimed at women contain all the same dangers of regular cigarettes.

Today, cigarettes kill an estimated 178,000 women in the United States each year, according to the CDC. Since 1980, when the first U.S. Surgeon General’s report on women and tobacco use was released, about 3 million women have died prematurely of smoking-related diseases. In 1987, lung cancer surpassed breast cancer as the most deadly cancer among women, according to the American Lung Association.

Once a person starts using tobacco, it can be difficult to quit. This is primarily because of the role of nicotine. Nicotine is the chemical in tobacco that is highly addictive. Some studies have shown it to be 10 times more addictive than heroin. Nonetheless, it is the other chemicals in tobacco products that cause most of the health damage associated with tobacco use.

There are two primary ways that people use tobacco:

• Smoking. Women primarily use tobacco through smoking, which involves burning tobacco and inhaling the resulting smoke. Tobacco can be smoked in a variety of ways, including cigarettes, pipes, cigars and water pipes known as hookahs, which filter flavored smoke through a water reservoir. Recent reports indicate that hookah smoking is on the rise among older adolescents and young adults. Many of these smokers believe that hookah smoking is somehow less harmful than smoking cigarettes because the smoke is filtered and flavored. However, studies have shown that hookah smokers tend to inhale more tobacco smoke by volume than cigarette smokers in a single smoking session. Cigarettes, however, remain the most popular form of smoking among women, and an estimated 18 percent of adult U.S. women aged 18 years or older – or about one in five women – are cigarette smokers, according to the Centers for Disease Control and Prevention (CDC). By age group, the percentage of cigarette smokers is as follows:
  
  

  Age	% Smokers
  18 to 24 years	24
  25 to 44 years	24
  45 to 64 years	22
  65 years or older	9

• The number of women who smoke while pregnant has been declining, but it is hard for researchers to accurately measure because pregnant smokers frequently lie during surveys and to their physicians. Estimates range between 11 percent and about 22 percent of pregnant women smoking, and this varies significantly by region. In West Virginia, for example, rates may be as high as 40 percent. The lowest rates are generally found during self-reporting surveys, which are notorious for under-reporting, while the highest rates are found during tests that measure biochemical markers in the blood. Thus, it's likely that more pregnant women smoke than admit to it, and this remains a public health concern.
  
  Age and education contribute to the likelihood that a woman will smoke while pregnant. Women ages 18 and 19 years are most likely to smoke during pregnancy. In addition, women with nine to 11 years of education are more likely to smoke while they are pregnant than those with 16 or more years of education.
  
  
• Smokeless tobacco. Smokeless tobacco comes in two forms: chewing tobacco and snuff. Chewing tobacco is available in the form of loose leaves, plugs or twists that users place between their cheek and gums. Snuff, a finely ground tobacco that is dry, moist or in pouches similar to tea bags, is typically placed between the lower lip and gums. A new form of smokeless tobacco, known as betel quid, has appeared recently from India, Africa and Asia. Betel quid is a mixture of tobacco, areca nuts, catechu (a plant product), and flavoring, which forms a dried paste. The betel quid is then placed between the gum and cheek and sucked or chewed. Only a small percentage of women in the United States use smokeless tobacco. Its use is much higher in men than in women, according to the CDC.

While both sexes can suffer serious health consequences from tobacco use, women have special risk factors. Women may be more susceptible to nicotine addiction than men, according to some research. In addition, women appear to have a slower metabolic clearance of nicotine from their bodies than men. Finally, the carcinogenic (cancer-causing) effects of tobacco appear to be more likely to manifest in women than in men.

Women primarily use tobacco through smoking cigarettes. Cigarettes kill an estimated 178,000 women in the United States each year, according to the Centers for Disease Control and Prevention (CDC). The three leading smoking-related causes of death in women are:

• Lung cancer (44,000). Ninety percent of all lung cancer deaths in women smokers are attributable to smoking, and the number of deaths among women has increased by more than 600 percent since 1950. In 1987, lung cancer surpassed breast cancer as the leading cause of cancer-related deaths in women.
  
  
• Heart disease (41,000). Smoking is a major cause of coronary heart disease among women. Women who smoke double their risk for developing coronary heart disease, which can cause a heart attack. The risk increases with the number of cigarettes smoked and the number of years a woman smokes. This figure is known as “pack years.” For instance, smoking a pack of cigarettes a day for one year is one pack year. Smoking two packs a day for a year equals two pack years, and so on. The more pack years attributed to a woman, the greater her risk of smoking-related death.
  
  
• Chronic  lung disease (37,500). Smoking is the primary cause of chronic obstructive pulmonary disease (COPD) in women.  In 2003, women comprised more than 50 percent of deaths from COPD for the third consecutive year. Women who smoke increase their likelihood of dying from COPD or emphysema, another lung disease, by more than tenfold. The risk increases with the amount and duration of cigarette use (pack years). Studies also show that exposure to maternal smoking may reduce lung function among infants, and that exposure to secondhand smoke during childhood and adolescence may impair lung function among girls.

Women who smoke also have an increased risk for other cancers. Smoking is a major contributor to cancers of the oropharynx and bladder in women, as well as cancers of the:

• Cervix
• Colon and rectum
• Mouth
• Larynx
• Esophagus
• Stomach
• Pancreas
• Kidney
• Breast
• Liver
• Bone marrow and blood (acute myeloid leukemia)

Other health problems related to smoking cigarettes include clouding of the lens of the eye (cataract) and lung inflammation (pneumonia). Some studies also have suggested a link between secondhand smoke and increased risk for glucose intolerance (which increases risk of diabetes), miscarriage and breast cancer. However, more research is needed before these associations can be positively established.

A small percentage of women who use tobacco prefer to use smokeless tobacco. Because it does not produce a smoke that is inhaled, many people have traditionally believed that smokeless tobacco is safer than cigarettes and other forms of smoking. However, this is not the case. Smokeless tobacco contains 28 cancer-causing agents (carcinogens), and a small pouch of smokeless tobacco held in the mouth for 30 minutes may deliver as much nicotine as three or four cigarettes. Smokeless tobacco raises the risk of many different health threats, including:

• Cancer of the oral cavity. Includes cancers of the mouth, throat, cheek, gums, lips and tongue. In many instances, these cancers are fatal or leave patients with permanent disfigurement of the jaw, chin, neck or face. These cancers can also interfere with chewing, swallowing and speech production.
  
  
• Other cancers. Oral tobacco use also may increase the risk of cancers of the esophagus, larynx, stomach and pancreas.
  
  

  

• Leukoplakia. A lesion of the soft tissue that consists of a white patch or plaque that cannot be scraped off. Leukoplakias can begin to develop within a week of using smokeless tobacco, and many users have several within a few months of beginning to use smokeless tobacco. A small percentage of these lesions become cancerous. Red patches – erythroleukoplakia – are even more likely to become cancerous.
  
  
• Recession of the gums or gum disease. Oral tobacco use can cause the gums to pull away from the teeth in the area where the tobacco is held in place. The gums do not grow back. Smoking cigarettes or flavored tobacco through water pipes as well as using smokeless tobacco products can all contribute to tooth decay and staining, and advanced gum disease (periodontitis). The latter can cause a woman to lose her teeth.
  
  
• High blood pressure. High salt concentrations in the products make smokeless tobacco a contributor to high blood pressure.
  
  
• Cardiovascular disease. Smokeless tobacco raises a woman’s heart rate and may increase the risk of heart attack. It may also increase both blood clotting, which can lead to stroke, and high cholesterol, which can lead to heart disease.

Quitting smoking at any age has immediate health benefits. The younger a woman is when she stops smoking, the more likely she is to benefit. Smoking cessation, however, yields benefits at any age. Just one or two years after quitting, a smoker’s risk of coronary heart disease dramatically decreases, regardless of her age.

In addition, women reduce their risk of stroke immediately upon quitting the habit. About 10 to 15 years after stopping, the risk for having a stroke approaches that of a woman who never smoked at all.

It is best for all women to stop smoking for general health reasons. Women who do smoke should be sure to have regular checkups with their physician and follow prescribed medical screening recommendations. In addition, women who are unable to stop smoking should ask about cessation treatment options. These may include nicotine patches or gum, behavioral treatments, anti-smoking programs and alternative methods.

Women who use smokeless tobacco should be monitored closely by their physician and dentist for precancerous sores or other tobacco-related damage to the mouth and neck region. Those who are unable to quit using smokeless tobacco can use many of the same cessation treatments that are used with smokers.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to tobacco use:

1. Which health problems present the greatest risk to me from smoking?
   
   
2. Will smoking interfere with me becoming pregnant?
   
   
3. Can I use birth control pills if I smoke?
   
   
4. What effect will tobacco use have on my pregnancy and childbirth?
   
   
5. Can I pass certain medical conditions onto my baby if I smoke?
   
   
6. What methods do you suggest for me to stop smoking?
   
   
7. Can I use nicotine patches if I’m pregnant or breastfeeding?
   
   
8. How will secondhand smoke affect me during pregnancy?
   
   
9. How will smoking increase my problems associated with menopause?
   
   
10. Am I at greater risk for certain cancers as a woman smoker?