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Gender Gap Narrows in Smoking Prevalence, Deaths

Nancy Tarleton Landis

Women now account for 39% of all smoking-related deaths each year in the United States, a proportion that has more than doubled since 1965, according to the latest Surgeon General's report on smoking. Along with smokers' increased risk for lung cancer and cardiovascular disease, the report details health consequences that are specific to women.

The gap in smoking prevalence between women and men has closed to less than five percentage points. In 1998, 22% of women and 26.4% of men were smokers. Among high school seniors in 2000, 29.7% of girls and 32.8% of boys reported that they had smoked in the past 30 days.

Report at a glance. The 675-page report, Women and Smoking: A Report of the Surgeon General, summarizes patterns of tobacco use among women, factors associated with starting and continuing to smoke, the health consequences of smoking, tobacco marketing targeted at women, and prevention and cessation interventions.

Since 1980, nearly 3 million U.S. women have died prematurely because of smoking. Lung cancer is the leading cause of cancer-related death among women in this country, having surpassed breast cancer in 1987.

"Women not only share the same health risk as men but are also faced with health consequences that are unique to women, including pregnancy complications, problems with menstrual function, and cervical cancer," said Surgeon General David Satcher in issuing the report. For example:

  • Women who smoke have increased risks for conception delay and for both primary and secondary infertility and may have a modest increase in risks for ectopic pregnancy and spontaneous abortion. They are younger at natural menopause than nonsmokers and may experience more menopausal symptoms.
  • Postmenopausal women who smoke have lower bone density than women who do not smoke, and women who smoke have greater risk for hip fracture than nonsmokers.
  • Because women are more likely than men to be diagnosed with depression, the association of smoking and depression is particularly important among women.

Increased marketing by tobacco companies has stalled progress in smoking cessation by women, and recent increases in smoking among teenage girls threaten to wipe out any progress that has been made in the past few decades, Satcher noted.

The report calls for increasing public awareness of the impact of smoking on women’s health; exposing and countering the tobacco industry’s targeting of women; encouraging public health policymakers, educators, medical professionals, and women’s organizations to work for policies and programs that deglamorize and discourage tobacco use; reducing disparities related to tobacco use and its health effects among different ethnic and racial populations; decreasing nonsmokers’ exposure to environmental tobacco smoke (ETS); and mounting comprehensive statewide tobacco control programs.

State programs have proved effective in reducing and preventing tobacco use. In California, for example, the incidence of lung cancer among women declined by 4.8% between 1988 and 1997, compared with an increase of 13.2% in other regions of the United States.

Concerning efforts aimed specifically at reducing tobacco use by women, the report states the following:

  • Using evidence from studies that vary in design, sample characteristics, and intensity of the interventions studied, researchers to date have not found consistent sex-specific differences in the effectiveness of intervention programs. 
  • A higher percentage of women stop smoking during pregnancy than at other times in their lives. Pregnancy-specific programs help increase smoking cessation rates, but only about one third of those who stop smoking during pregnancy are still abstinent one year after delivery. 
  • Successful interventions have been developed to prevent smoking among young people, but little systematic effort has been focused on interventions specifically for girls.

The report, from the Centers for Disease Control and Prevention (CDC), also analyzes the global impact of smoking on women. "We estimate that smoking prevalence among women varies markedly worldwide, from as low as 7% in developing countries to 24% in developed countries," CDC Director Jeffrey P. Koplan said. "The rise in smoking among women around the world has coincided with aggressive Western-style tobacco advertising."

Koplan said there is "firm evidence of a direct association" between tobacco marketing and smoking prevalence in the United States and elsewhere. The Federal Trade Commission reported that cigarette companies spent $8.24 billion on advertising and promotions in 1999 in the United States, a 22.3% increase from the $6.73 billion spent in 1998.

The report is available at, and information for consumers trying to quit smoking is available at

Consequences for women, and for women only. In 200 pages, the report presents research over the past 20 years on links between disease and tobacco use by women. Many of the studies looked specifically at women but involved diseases that affect both women and men (e.g., depression, lung cancer). Other findings pertain exclusively to women.

Some conclusions, as stated in the report:

  • The totality of the evidence does not support an association between smoking and risk for breast cancer. Several studies suggest that exposure to ETS is associated with an increased risk for breast cancer, but this association remains uncertain. 
  • Smoking has been consistently associated with an increased risk for cervical cancer. The extent to which this association is independent of human papillomavirus (HPV) infection is uncertain. 
  • Smoking may be associated with an increased risk for vulvar cancer, but the extent to which the association is independent of HPV infection is uncertain. 
  • Women who use oral contraceptives have a particularly elevated risk of coronary heart disease (CHD) if they smoke. Currently, evidence is conflicting as to whether the effect of hormone replacement therapy (HRT) on CHD risk differs between smokers and nonsmokers. 
  • Conflicting evidence exists regarding the level of risk for stroke among women who both smoke and use either the oral contraceptives commonly prescribed in the United States today or HRT. 
  • 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. 
  • Since thyroid disorders are more common in women than in men, most studies of these disorders have been in women. Cigarette smokers may have an increased risk for Graves' ophthalmopathy, a thyroid-related disease. 
  • Some studies suggest that cigarette smoking may alter menstrual function by increasing the risks for dysmenorrhea, secondary amenorrhea, and menstrual irregularity. 
  • 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. 
  • The risk for perinatal mortality—both stillbirth and neonatal death—and the risk for sudden infant death syndrome 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 their gestational age than are infants born to women who do not smoke. 
  • Some studies suggest that women who smoke have an increased risk for gallbladder disease (which is more common in women overall than in men), but the evidence is inconsistent. 
  • 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 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.

The report also states that nicotine pharmacology and the behavioral processes that determine nicotine addiction appear generally similar between women and men; when standardized for the number of cigarettes smoked, the blood concentration of cotinine (the main metabolite of nicotine) is similar between the sexes. 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.