Indian Girl Smoking
Dawn Summerville
Background: The use of cigarettes/tobacco among adolescents is quite high in India. Worldwide, nearly, all (88%) initiation of smoking occurs before the age of 18 years. Smoking caused about 1 million deaths or 10% of all deaths in India, with about 70% of these deaths occurring at the ages of 30-69 years.
Materials and methods: Global Youth Tobacco Survey data collected in India during 2009 were taken. Bivariate analysis, logistic regression, receiver operating characteristic, and nomogram were used to examine association between exposure and outcome variables. Cigarette smoking within the past 30 days preceding the survey was the outcome variable while independent variables were age, education, gender, parental smoking, people smoking at home/smoking in the presence of adolescents, felt boys/girls who smoke have more friends, accepting cigarette offered by one of the best friends, perception of attractiveness of boys/girls who smoke, perception smoking makes one loss or gain weight, and perception cigarettes smoking harmful.
Results: 11768 adolescents participated, of which 9951 (48% males and 52% female) responded on cigarette smoking. Current cigarette smoking was associated with female gender (odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.52-0.90), parental smoking (OR: 1.00; 95% CI: 0.62-1.60), smoking cigarette at home (OR: 3.66; 95% CI: 2.64-5.09), and smoking cigarette in presence of adolescent (OR: 4.14; 95% CI: 2.92-5.87). Observed associations between the outcome and exposure variables reported in this study should be considered in the design of public health interventions.
Conclusion: To eliminate smoking habits, efforts should also be made in the exploration of new ideas and their implementation by the public health experts in collaboration with international agencies, various nongovernmental organizations, and academic and research institutions. Let's plan for active action to make smoke-free environment based on evidence.
This is the second report of the U.S. Surgeon General devoted to women and smoking. The first was published in 1980 (U.S. Department of Health and Human Services [USDHHS] 1980), 16 years after the initial landmark report on smoking and health of the Advisory Committee to the Surgeon General appeared in 1964 (U.S. Department of Health, Education, and Welfare [USDHEW] 1964). The 1964 report summarized the accumulated evidence that demonstrated that smoking was a cause of human cancer and other diseases. Most of the early evidence was based on men. For example, the report concluded, "Cigarette smoking is causally related to lung cancer in men.... The data for women, though less extensive, point in the same direction" (USDHEW 1964, p. 37). By the time of the 1980 report, the evidence clearly showed that women were also experiencing devastating health consequences from smoking and that "the first signs of an epidemic of smoking-related disease among women are now appearing" (USDHHS 1980, p. v). The evidence had solidified later among women than among men because smoking became commonplace among women about 25 years later than it had among men. However, it was still deemed necessary to include a section in the preface of the 1980 report titled "The Fallacy of Women's Immunity." In the two decades since, numerous studies have expanded the breadth and depth of what is known about the health consequences of smoking among women, about historical and contemporary patterns of smoking in demographic subgroups of the female population, about factors that affect initiation and maintenance of smoking among women (including advertising and marketing of tobacco products), and about interventions to assist women to quit smoking. The present report reviews the now massive body of evidence on women and smoking---evidence that taken together compels the Nation to make reducing and preventing smoking one of the highest contemporary priorities for women's health.
A report focused on women is greatly needed. No longer are the first signs of an epidemic of tobacco-related diseases among women being seen, as was the case when the 1980 report was written. Since 1980, hundreds of additional studies have expanded what is known about the health effects of smoking among women, and this report summarizes that knowledge. Today the Nation is in the midst of a full-blown epidemic. Lung cancer, once rare among women, has surpassed breast cancer as the leading cause of female cancer death in the United States, now accounting for 25 percent of all cancer deaths among women. Surveys have indicated that many women do not know this fact. And lung cancer is only one of myriad serious disease risks faced by women who smoke. Although women and men who smoke share excess risks for diseases such as cancer, heart disease, and emphysema, women also experience unique smoking-related disease risks related to pregnancy, oral contraceptive use, menstrual function, and cervical cancer. These risks deserve to be highlighted and broadly recognized. Moreover, much of what is known about the health effects of exposure to environmental tobacco smoke among nonsmokers comes from studies of women, because historically men were more likely than women to smoke and because many women who did not smoke were married to smokers.
In 1965, 51.9 percent of men were smokers, whereas 33.9 percent of women were smokers. By 1979, the percentage of women who smoked had declined somewhat, to 29.9 percent. However, the decline in smoking among men to 37.5 percent was much more dramatic. The gender gap in adult smoking prevalence continued to close after the 1980 report, but since the mid-1980s, the difference has been fairly stable at about 5 percentage points. In 1998, smoking prevalence was 22.0 percent among women and 26.4 percent among men. The gender difference in smoking prevalence among teens is smaller than that among adults. Smoking prevalence increased among both girls and boys in the 1990s. In 2000, 29.7 percent of high school senior girls and 32.8 percent of high school senior boys reported having smoked within the past 30 days (University of Michigan 2000).
In recent years, some research has suggested that the impact of a given amount of smoking on lung cancer risk might be even greater among women than among men, that exposure to environmental tobacco smoke might be associated with increased risk for breast cancer, and that women might be more susceptible than men to weight gain following smoking cessation. Other research indicated that persons with specific genetic polymorphisms may be especially susceptible to the effects of smoking and exposure to environmental tobacco smoke. These issues remain active areas of investigation, and no conclusions can be drawn about them at this time. Nonetheless, knowledge of the vast spectrum of smoking-related health effects continues to grow, as does knowledge that examination of gender-specific effects is important.
Smoking is one of the most studied of human behaviors and thousands of studies have documented its health consequences, yet certain questions and data needs exist with respect to women and smoking. For example, there is a need to better understand why smoking prevalence increased among teenage girls and young women in the 1990s despite the overwhelming data on adverse health effects; to identify interventions and policies that will prevent an epidemic of tobacco use among women whose smoking prevalence is currently low, including women in certain sociocultural groups within the United States and women in many developing countries throughout the world; to study the relationship of active smoking to diseases among women for which the evidence to date has been suggestive or inconsistent (e.g., risks for menstrual cycle irregularities, gallbladder disease, and systemic lupus erythematosus); to increase the data on the health effects of exposure to environmental tobacco smoke on diseases unique among women; to provide additional research on whether gender differences exist in susceptibility to nicotine addiction or in the magnitude of the effects of smoking on specific disease outcomes; and to determine whether gender differences exist in the modifying effects of genetic polymorphisms on disease risks associated with smoking. Many studies of smoking behavior and of the health consequences of smoking have included both females and males but have not reported results by gender. Investigators should be encouraged to report gender-specific results in the future.
Other recent reports of the Surgeon General have been devoted to smoking and youth (USDHHS 1994), smoking and racial or ethnic minorities (USDHHS 1998), and interventions to reduce smoking (USDHHS 2000). The reader is encouraged to consult those reports for comprehensive reviews of the evidence on these topics. The present report focuses on data specific to women and girls and on comparisons of results by gender.
Conclusions from Chapters 2--5 are presented below. Separate conclusions are not included for Chapter 1 because it is a summary of the report. Chapter 6, which presents a vision for the future, is reproduced in its entirety following the conclusions for Chapters 2--5.Chapter 2. Patterns of Tobacco Use Among Women and Girls
- Cigarette smoking became prevalent among women after it did among men, and smoking prevalence has always been lower among women than among men. The gender-specific difference in smoking prevalence narrowed between 1965 and 1985. Since 1985, the decline in prevalence has been comparable among women and men.
- The prevalence of current smoking among women increased from less than 6 percent in 1924 to 34 percent in 1965, then declined to 22 to 23 percent in the late 1990s. In 1997--1998, smoking prevalence was highest among American Indian or Alaska Native women (34.5 percent), intermediate among white women (23.5 percent) and black women (21.9 percent), and lowest among Hispanic women (13.8 percent) and Asian or Pacific Islander women (11.2 percent). By educational level, smoking prevalence is nearly three times higher among women with 9 to 11 years of education (30.9 percent) than among women with 16 or more years of education (10.6 percent).
- Much of the progress in reducing smoking prevalence among girls in the 1970s and 1980s was lost with the increase in prevalence in the 1990s: current smoking among high school senior girls was the same in 2000 as in 1998. Although smoking prevalence was higher among high school senior girls than among high school senior boys in the 1970s and early 1980s, prevalence has been comparable since the mid-1980s.
- Smoking declined substantially among black girls from the mid-1970s through the early 1990s; the decline among white girls for this same period was small. As adolescents age into young adulthood, these patterns are now being reflected in the racial and ethnic differences in smoking among young women. Data are not available on long-term trends in smoking prevalence among high school seniors of other racial and ethnic groups.
- Smoking during pregnancy appears to have decreased from 1989 through 1998. Despite increased knowledge of the adverse health effects of smoking during pregnancy, estimates of women smoking during pregnancy range from 12 percent based on birth certificate data to as high as 22 percent based on survey data.
- Historically, women started to smoke at a later age than did men, but beginning with the 1960 cohort, the mean age at smoking initiation has not differed by gender.
- Nicotine dependence is strongly associated with the number of cigarettes smoked per day. Girls and women who smoke appear to be equally dependent on nicotine when results are stratified by number of cigarettes smoked per day. Few gender-specific differences have been found in indicators of nicotine dependence among adolescents, young adults, or adults overall.
- The percentage of persons who have ever smoked and who have quit smoking is somewhat lower among women (46.2 percent) than among men (50.1 percent). This finding is probably because men began to stop smoking earlier in the twentieth century than did women and because these data do not take into account that men are more likely than women to switch to or to continue to use other tobacco products when they stop smoking cigarettes. Since the late 1970s or early 1980s, the probability of attempting to quit smoking and to succeed has been equally high among women and men.
- Prevalence of the use of cigars, pipes, and smokeless tobacco among women is generally low, but recent data suggest that cigar smoking among women and girls is increasing.
- Smoking prevalence among women varies markedly across countries; the percentages range from an estimated 7 percent in developing countries to 24 percent in developed countries. Thwarting further increases in tobacco use among women is one of the greatest disease prevention opportunities in the world today.
- Cigarette smoking plays a major role in the mortality of U.S. women.
- The excess risk for death from all causes among current smokers compared with persons who have never smoked increases with both the number of years of smoking and the number of cigarettes smoked per day.
- Among women who smoke, the percentage of deaths attributable to smoking has increased over the past several decades, largely because of increases in the quantity of cigarettes smoked and the duration of smoking.
- Cohort studies with follow-up data analyzed in the 1980s show that the annual risk for death from all causes is 80 to 90 percent greater among women who smoke cigarettes than among women who never smoked. A woman's annual risk for death more than doubles among continuing smokers compared with persons who have never smoked in every age group from 45 through 74 years.
- In 1997, approximately 165,000 U.S. women died prematurely from a smoking-related disease. Since 1980, approximately three million U.S. women have died prematurely from a smoking-related disease.
- U.S. females lost an estimated 2.1 million years of life each year during the 1990s as a result of smoking-related deaths due to neoplastic, cardiovascular, respiratory, and pediatric diseases, as well as from burns caused by cigarettes. For every smoking attributable death, an average of 14 years of life was lost.
- Women who stop smoking greatly reduce their risk of dying prematurely. The relative benefits of smoking cessation are greater when women stop smoking at younger ages, but smoking cessation is beneficial at all ages.
- Cigarette smoking is the major cause of lung cancer among women. About 90 percent of all lung cancer deaths among U.S. women smokers are attributable to smoking.
- The risk for lung cancer increases with quantity, duration, and intensity of smoking. The risk for dying of lung cancer is 20 times higher among women who smoke two or more packs of cigarettes per day than among women who do not smoke.
- Lung cancer mortality rates among U.S. women have increased about 600 percent since 1950. In 1987, lung cancer surpassed breast cancer to become the leading cause of cancer death among U.S. women. Overall age-adjusted incidence rates for lung cancer among women appear to have peaked in the mid-1990s.
- In the past, men who smoked appeared to have a higher relative risk for lung cancer than did women who smoked, but recent data suggest that such differences have narrowed considerably. Earlier findings largely reflect past gender-specific differences in duration and amount of cigarette smoking.
- Former smokers have a lower risk for lung cancer than do current smokers, and risk declines with the number of years of smoking cessation.
- International lung cancer death rates among women vary dramatically. This variation reflects historical differences in the adoption of cigarette smoking by women in different countries. In 1990, lung cancer accounted for about 10 percent of all cancer deaths among women worldwide and more than 20 percent of cancer deaths among women in some developed countries.
- The totality of the evidence does not support an association between smoking and risk for breast cancer.
- Several studies suggest that exposure to environmental tobacco smoke is associated with an increased risk for breast cancer, but this association remains uncertain.
- Current smoking is associated with a reduced risk for endometrial cancer, but the effect is probably limited to postmenopausal disease. The risk for this cancer among former smokers generally appears more similar to that of women who have never smoked.
- Smoking does not appear to be associated with risk of ovarian cancer.
- Smoking has been consistently associated with an increased risk for cervical cancer. The extent to which this association is independent of human papillomavirus infection is uncertain.
- Smoking may be associated with an increased risk for vulvar cancer, but the extent to which the association is independent of human papillomavirus infection is uncertain.
- Smoking is a major cause of cancers of the oropharynx and bladder among women. Evidence is also strong that women who smoke have increased risks for cancers of the pancreas and kidney. For cancers of the larynx and esophagus, evidence among women is more limited but consistent with large increases in risk.
- Women who smoke may have increased risks for liver cancer and colorectal cancer.
- Data on smoking and cancer of the stomach among women are inconsistent.
- Smoking may be associated with an increased risk for acute myeloid leukemia among women but does not appear to be associated with other lymphoproliferative or hematologic cancers.
- Women who smoke may have a decreased risk for thyroid cancer.
- Women who use smokeless tobacco have an increased risk for oral cancer.
- Smoking is a major cause of coronary heart disease among women. For women younger than 50 years, the majority of coronary heart disease is attributable to smoking. Risk increases with the number of cigarettes smoked and the duration of smoking.
- The risk for coronary heart disease among women is substantially reduced within 1 or 2 years of smoking cessation. This immediate benefit is followed by a continuing but more gradual reduction in risk to that among non-smokers by 10 to 15 or more years after cessation.
- Women who use oral contraceptives have a particularly elevated risk of coronary heart disease if they smoke. Currently, evidence is conflicting as to whether the effect of hormone replacement therapy on coronary heart disease risk differs between smokers and nonsmokers.
- Women who smoke have an increased risk for ischemic stroke and subarachnoid hemorrhage. Evidence is inconsistent concerning the association between smoking and primary intracerebral hemorrhage.
- In most studies that include women, the increased risk for stroke associated with smoking is reversible after smoking cessation; after 5 to 15 years of abstinence, the risk approaches that of women who have never smoked.
- Conflicting evidence exists regarding the level of the risk for stroke among women who both smoke and use either the oral contraceptives commonly prescribed in the United States today or hormone replacement therapy.
- Smoking is a strong predictor of the progression and severity of carotid atherosclerosis among women. Smoking cessation appears to slow the rate of progression of carotid atherosclerosis.
- Women who are current smokers have an increased risk for peripheral vascular atherosclerosis. Smoking cessation is associated with improvements in symptoms, prognosis, and survival.
- Women who smoke have an increased risk for death from ruptured abdominal aortic aneurysm.
- Cigarette smoking is a primary cause of COPD among women, and the risk increases with the amount and duration of smoking. Approximately 90 percent of mortality from COPD among women in the United States can be attributed to cigarette smoking.
- In utero exposure to maternal smoking is associated with reduced lung function among infants, and exposure to environmental tobacco smoke during childhood and adolescence may be associated with impaired lung function among girls.
- Adolescent girls who smoke have reduced rates of lung growth, and adult women who smoke experience a premature decline of lung function.
- The rate of decline in lung function is slower among women who stop smoking than among women who continue to smoke.
- Mortality rates for COPD have increased among women over the past 20 to 30 years.
- Although data for women are limited, former smokers appear to have a lower risk for dying from COPD than do current smokers.
- Women who smoke have an increased risk for estrogen-deficiency disorders and a decreased risk for estrogen-dependent disorders, but circulating levels of the major endogenous estrogens are not altered among women smokers.
- Although consistent effects of smoking on thyroid hormone levels have not been noted, cigarette smokers may have an increased risk for Graves' ophthalmopathy, a thyroid-related disease.
- Smoking appears to affect glucose regulation and related metabolic processes, but conflicting data exist on the relationship of smoking and the development of type 2 diabetes mellitus and gestational diabetes among women.
- Some studies suggest that cigarette smoking may alter menstrual function by increasing the risks for dysmenorrhea (painful menstruation), secondary amenorrhea (lack of menses among women who ever had menstrual periods), and menstrual irregularity.
- Women smokers have a younger age at natural menopause than do nonsmokers and may experience more menopausal symptoms.
- Women who smoke may have decreased risk for uterine fibroids.
- Women who smoke have increased risks for conception delay and for both primary and secondary infertility.
- Women who smoke may have a modest increase in risks for ectopic pregnancy and spontaneous abortion.
- Smoking during pregnancy is associated with increased risks for preterm premature rupture of membranes, abruptio placentae, and placenta previa, and with a modest increase in risk for preterm delivery.
- Women who smoke during pregnancy have a decreased risk for preeclampsia.
- The risk for perinatal mortality---both stillbirth and neonatal deaths---and the risk for sudden infant death syndrome (SIDS) are increased among the offspring of women who smoke during pregnancy.
- Infants born to women who smoke during pregnancy have a lower average birth weight and are more likely to be small for gestational age than are infants born to women who do not smoke.
- Smoking does not appear to affect the overall risk for congenital malformations.
- Women smokers are less likely to breastfeed their infants than are women nonsmokers.
- Women who quit smoking before or during pregnancy reduce the risk for adverse reproductive outcomes, including conception delay, infertility, preterm premature rupture of membranes, preterm delivery, and low birth weight.
- Initiation of cigarette smoking does not appear to be associated with weight loss, but smoking does appear to attenuate weight gain over time. The average weight of women who are current smokers is modestly lower than that of women who have never smoked or who are long-term former smokers. Smoking cessation among women typically is associated with a weight gain of about 6 to 12 pounds in the year after they quit smoking. Women smokers have a more masculine pattern of body fat distribution (i.e., a higher waist-to-hip ratio) than do women who have never smoked.
- Postmenopausal women who currently smoke have lower bone density than do women who do not smoke.
- Women who currently smoke have an increased risk for hip fracture compared with women who do not smoke.
- The relationship among women between smoking and the risk for bone fracture at sites other than the hip is not clear.
- Some studies suggest that women who smoke have an increased risk for gallbladder disease (gallstones and cholecystitis), but the evidence is inconsistent.
- Women who smoke have an increased risk for peptic ulcers.
- Women who currently smoke have a decreased risk for ulcerative colitis, but former smokers have an increased risk---possibly because smoking suppresses symptoms of the disease.
- Women who smoke appear to have an increased risk for Crohn's disease, and smokers with Crohn's disease have a worse prognosis than do nonsmokers.
- Some but not all studies suggest that women who smoke may have a modestly elevated risk for rheumatoid arthritis.
- Women who smoke have a modestly reduced risk for osteoarthritis of the knee; data regarding osteoarthritis of the hip are inconsistent.
- The data on the risk of systemic lupus erythematosus among women who smoke are inconsistent.
- Women who smoke have an increased risk for cataract.
- Women who smoke may have an increased risk for age-related macular degeneration.
- Studies show no consistent association between smoking and open-angle glaucoma.
- Limited data suggest that women smokers may be at higher risk for HIV-1 infection than nonsmokers.
- Limited but consistent data suggest that women smokers have more facial wrinkling than do nonsmokers.
- Smokers are more likely to be depressed than are nonsmokers, a finding that may reflect an effect of smoking on the risk for depression, the use of smoking for self-medication, or the influence of common genetic or other factors on both smoking and depression. The association of smoking and depression is particularly important among women because they are more likely to be diagnosed with depression than are men.
- The prevalence of smoking generally has been found to be higher among patients with anxiety disorders, bulimia, attention deficit disorder, and alcoholism than among individuals without these conditions; the mechanisms underlying these associations are not yet understood.
- The prevalence of smoking is very high among patients with schizophrenia, but the mechanisms underlying this association are not yet understood.
- Smoking may be used by some persons who would otherwise manifest psychiatric symptoms to manage those symptoms; for such persons, cessation of smoking may lead to the emergence of depression or other dysphoric mood states.
- Women who smoke have a decreased risk for Parkinson's disease.
- Data regarding the association between smoking and Alzheimer's disease are inconsistent.
- Nicotine pharmacology and the behavioral processes that determine nicotine addiction appear generally similar among women and men; when standardized for the number of cigarettes smoked, the blood concentration of cotinine (the main metabolite of nicotine) is similar among women and men.
- Women's regulation of nicotine intake may be less precise than men's. Factors other than nicotine (e.g., sensory cues) may play a greater role in determining smoking behavior among women.
- Exposure to ETS is a cause of lung cancer among women who have never smoked.
- Epidemiologic and other data support a causal relationship between ETS exposure from the spouse and coronary heart disease mortality among women nonsmokers.
- Infants born to women who are exposed to ETS during pregnancy may have a small decrement in birth weight and a slightly increased risk for intrauterine growth retardation compared with infants born to women who are not exposed; both effects are quite variable across studies.
- Studies of ETS exposure and the risks for delay in conception, spontaneous abortion, and perinatal mortality are few, and the results are inconsistent.
- Girls who initiate smoking are more likely than those who do not smoke to have parents or friends who smoke. They also tend to have weaker attachments to parents and family and stronger attachments to peers and friends. They perceive smoking prevalence to be higher than it actually is, are inclined to risk taking and rebelliousness, have a weaker commitment to school or religion, have less knowledge of the adverse consequences of smoking and the addictiveness of nicotine, believe that smoking can control wei