Women and smoking

Picture for a moment this all-too-common scene: A man and a woman about your age — let’s call them Tom and Marg — are standing on the sidewalk taking a cigarette break. Let’s say they have identical smoking histories: about half a pack a day for 10 years. Same history, same dangerous health effects, right? Not even close.

Simply by virtue of the fact that she’s a woman, Margo is already twice as likely as Tom to develop depression, but her cigarette habit increases her risk even more. And when it comes to cervical cancer — an illness Tom never has to worry about — her risk jumps to five times that of a nonsmoker. What’s more, if Margo should happen to be pregnant, there’s a good chance her baby will suffer from a laundry list of health problems and be especially prone to becoming a smoker herself when she grows up — risks that would be lower for a child of Tom’s, according to Denise Kandel, Ph.D., professor of public health in psychiatry at Columbia University in New York City.

Now fast-forward and revisit that sidewalk again, many years later. The dangers for Margo are even more startling. Cigarettes may have induced early menopause — putting her at risk for osteoporosis and heart disease a lot sooner than if she’d skipped the smokes. In fact, a woman who puffs increases her chance of a heart attack by 40 percent no matter what her age. And given that smoking half a pack a day doubles the chance of breast cancer, Margo could be facing a lumpectomy or even a mastectomy in the not-too-distant future. If she escapes breast cancer, another disease that’s far more often fatal is lurking right behind: Margo is three times more likely than Tom to be standing there with lung cancer.

What makes this scenario so chilling is that although a handful of researchers have long suspected that cigarette smoking is particularly dangerous for women, no one has paid much attention to their work. Until now.

Women smokers: Big risks

Despite the increasing attention paid to the special health risks women face, smoking addiction has traditionally been treated as equally damaging to both sexes. Luckily, women’s distinctive needs are finally beginning to be addressed. The results of several pioneering studies are starting to roll in, and the U.S. Surgeon General is shortly expected to release a hard-hitting report on the health consequences of smoking for women — the first since 1980.

The jump in interest comes not a moment too soon. A whopping 22.4 million women still smoke, according to the latest statistics from the Centers for Disease Control and Prevention in Atlanta. In 1998 alone, 67,000 women died of lung cancer — 13 times the number who died in 1960. And unfortunately, the trend shows little sign of reversing itself: Lung-cancer rates for women are on the rise.

No one knows exactly why women are at heightened risk, but our biology undoubtedly plays a role. For instance, there’s a hypothesis that estrogen may boost the body’s metabolism of tobacco carcinogens and even help the toxins bind to—and therefore mutate — the DNA in lung cells, says Adi Gazdar, M.D., deputy director of the Hamon Cancer Center at the University of Texas Southwestern Medical Center in Dallas.

Another well-regarded theory centers on women’s penchant for low-tar filtered cigarettes. “Women think they’re smoking a ‘safer’ cigarette,” says Neil Grunberg, Ph.D., a professor of psychology and neuroscience at the Uniformed Services University in Bethesda, Maryland, who has been studying gender differences in smoking since the early 1980s. “And it does make intellectual sense that less tar [all the chemicals in the tobacco and fillers except the nicotine] makes a cigarette safer.” But the problem, Grunberg says, is that people who smoke “light” cigarettes tend to make up for the less intense nicotine rush by taking deeper breaths and holding them in longer; they also take more puffs per cigarette — behaviors that are all deeply damaging to the lungs and may cancel out any purported benefit.

Compounding the problem, researchers suspect, is that many women tend to have an out-of-sight, out-of-mind attitude when it comes to smoking’s connection to heart disease. Young women’s high estrogen levels tend to mask the effects of smoking on the heart until they’re in menopause — a protection men don’t have. So when young female smokers see other women smokers with heart trouble, those women are usually older — women who are “more likely” to be sick anyway. “Most people growing up knew lots of men who smoked and had heart attacks at a young age,” says Grunberg. “But very few people knew women who died young of smoking-related causes. That gives a tremendous misimpression that women don’t suffer heart and respiratory problems from smoking. It’s simply not true.”

Why women get so hooked

The research is still preliminary, but some scientists now think that women develop a stronger need to smoke than men, even though the physiological process that sparks addiction is the same for both sexes: You take a hit and inhale. Smoke enters the lungs, is picked up by the capillaries and travels to the heart and brain. In the 7 to 10 seconds after that first puff, the brain releases a rush of chemicals — and you get an immediate high. The surge of brain chemicals heightens your sense of alertness and ability to concentrate and leaves you bathed in pleasure — for all of 20 minutes.

After you finish the cigarette, levels of nicotine in the blood and chemicals in the brain drop off to lower than normal, leaving the brain starving for pleasure and craving more. Eventually, the brain actually stops producing these pleasure chemicals on its own and relies on cigarettes to stimulate their release, says David P.L. Sachs, M.D., clinical associate professor of medicine at Stanford Medical School in California.

For some reason women are more sensitive to this chemical roller coaster, says Denise Kandel, Ph.D., professor of public health in psychiatry at Columbia University in New York City, who recently analyzed data about nicotine dependence for more than 20,000 smokers. A key finding: A higher percentage of women smokers reported symptoms of addiction than men. So scientists are now trying to find out exactly which parts of the smoking experience women and men can’t get enough of — and they hope their work will lead to sex-specific quitting strategies.

Kenneth Perkins, Ph.D., professor of psychiatry at the University of Pittsburgh, devised a study where men and women were “preloaded” with nicotine from an inhaler and then observed, to determine how much they smoked. The results were clearly divided: The men smoked significantly less than usual, while the women puffed away at almost their usual rate. Satisfying a woman’s craving for nicotine, it would seem, isn’t necessarily enough to stop her from smoking.

So if it’s not just the nicotine rush that drives women, what is it? In a nutshell, practically everything else — the smell, the taste, the time, the place, their state of mind. Researchers think women are more influenced by smoking cues and rituals than men. For instance, in another of Perkins’s studies, smokers were outfitted with nose clips that blocked the smell and taste of a cigarette. They were allowed to smoke as much as they wanted, and scientists counted the number of times they puffed.

When the clips were in place, men took as many puffs as when they weren’t wearing them. Women, however, took significantly fewer drags wearing the clips — indicating that they smoked not just for the nicotine high but also for the smell and taste of the cigarette. These cues are powerful motivations to smoke, says Perkins, because women tend to be more aware of their surroundings than men. “Constantly pairing nicotine intake with the smell of cigarettes or the sight of the pack can set up a strong conditioned effect,” says Perkins.

Furthermore, other studies have shown that women simply smoke for different reasons than men. Men are more likely to light up because they want to look manly or like a risk taker — and they often keep smoking because they don’t want to endure withdrawal symptoms, says Linda Hyder Ferry, M.D., an associate professor of family and preventative medicine at Loma Linda University School of Medicine in California, who recently completed a survey of 1,000 smokers and the motivations behind their habits. “But the results from my research show that women smoke to control mood, stress, irritability and anger,” she says. That creates a particularly deep addiction — and may make it especially tough to quit.