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• More than 4,000 chemical compounds have been identified in tobacco smoke. Of these, at least 43 are known to cause cancer.¹

• Current tobacco product regulation requires cigarette manufacturers to disclose levels of magnify tar and nicotine. Smokers receive very little information regarding chemical constituents in tobacco smoke, however, and the use of terms such as "light" and "ultra light" on packaging and in advertising may be misleading.¹

• Cigarettes with low tar and nicotine contents are not substantially less hazardous than higher–yield brands. Consumers may be misled by the implied promise of reduced toxicity underlying the marketing of such brands.¹

• Vents are used in cigarette filters to lower tar and nicotine yields in smoke, but they may be difficult to see. To examine the vents in some brands, the smoker would have to take off the filter wrapping, hold the filter up to a bright light, and look through magnifying glass.²

• The potential health benefit of low tar cigarettes has been challenged. Smokers who switch to lower–tar and lower–nicotine cigarettes frequently change their smoking habits. They may block the vents in the filter portion of a cigarette, puff more frequently, inhale more deeply, or smoke more cigarettes per day, thus negating any risk reduction from low–tar and low–nicotine cigarettes.²

• Early data showed a lower cancer risk from low–tar cigarettes; however, more recent data suggest otherwise. Lower–yield cigarettes may be somewhat better than very high–yield cigarettes; but, when comparing full–flavor cigarettes and current light cigarettes, there is no evidence to suggest a lower cancer risk from the low–tar cigarettes.¹

CIGARETTE ADDITIVES

• Federal law (the Comprehensive Smoking Education Act of 1984 and the Comprehensive Smokeless Tobacco Health Education Act of 1986) requires cigarette and smokeless tobacco manufacturers to submit a list of ingredients added to tobacco to the Secretary of Health and Human Services.¹

• Hundreds of ingredients are used in the manufacture of tobacco products. Additives make cigarettes more acceptable to the consumer — they make cigarettes milder and easier to inhale, improve taste, and prolong burning and shelf life.¹

• In 1994 six major cigarette manufacturers reported 599 ingredients that were added to the tobacco of manufacture cigarettes. Although, these ingredients are regarded as safe when ingested in foods, some may form carcinogens when heated or burned.¹

• Knowledge about the impact of additives in tobacco products is negligible and will remain so as long as brand-specific information on the identity and quantity of additives is unavailable.¹

SMOKELESS ADDITIVES

• In 1994 ten manufacturers of smokeless tobacco products released a list of additives used in their products. The additives list contained 562 ingredients approved for foods by the FDA.¹

• The list of additives to smokeless tobacco includes sodium carbonate and ammonium carbonate, which increase the level of "free" nicotine in moist snuff by raising the pH level. Unprotonated (free) nicotine is the chemical form of nicotine that is most readily absorbed through the mouth into the blood-stream. Therefore, increases in pH can increase the snuff user’s nicotine absorption rate. Studies with nicotine and other addictive drugs suggest that the absorption rate of drugs into the body is an important determinant of their addiction potential.³

• Moist snuff products with low nicotine content and pH levels have a smaller proportion of free nicotine. In contrast, moist snuff products with high nicotine content and pH levels have a higher proportion of free nicotine.¹

• The epidemiology of moist snuff use among teenagers and young adults indicates that most novices start with brands having low levels of free nicotine and then "graduate" to brands with higher levels.¹

• Sweeteners and flavorings, such as cherry juice concentrate, apple juice, chocolate liqueur, or honey are used in various smokeless tobacco products. As with manufactured cigarettes, these additives increase palatability and may increase the use of smokeless tobacco, at least among novices.¹

REFERENCES

U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2000.
Centers for Disease Control and Prevention. Filter ventilation levels in selected U.S. cigarettes, 1997. MMWR 1997; 46:1043-47.
Centers for Disease Control and Prevention. Determination of nicotine, pH, and moisture content of six U.S. commercial moist snuff products — Florida, January–February 1999. MMWR 1999; 48:398-401.

Women and Smoking

1. Cigarette smoking plays a major role in the mortality of U.S. women.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

Lung Cancer

8. 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.

9. 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.

10. 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.

11. 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.

12. 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 Trends in Female Lung Cancer

13. 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.

Female Cancers

14. The totality of the evidence does not support an association between smoking and risk for breast cancer.

15. Several studies suggest that exposure to environmental tobacco smoke is associated with an increased risk for breast cancer, but this association remains uncertain.

16. 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.

17. Smoking does not appear to be associated with risk of ovarian cancer.

18. 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.

19. 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.

Other Cancers

20. 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.

21. Women who smoke may have increased risks for liver cancer and colorectal cancer.

22. Data on smoking and cancer of the stomach among women are inconsistent.

23. 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.

24. Women who smoke may have a decreased risk for thyroid cancer.

25. Women who use smokeless tobacco have an increased risk for oral cancer.

Cardiovascular Disease

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. Women who are current smokers have an increased risk for peripheral vascular atherosclerosis. Smoking cessation is associated with improvements in symptoms, prognosis, and survival.

34. Women who smoke have an increased risk for death from ruptured abdominal aortic aneurysm.

Chronic Obstructive Pulmonary Disease (COPD) and Lung Function

35. 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.

36. 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.

37. Adolescent girls who smoke have reduced rates of lung growth, and adult women who smoke experience a premature decline of lung function.

38. The rate of decline in lung function is slower among women who stop smoking than among women who continue to smoke.

39. Mortality rates for COPD have increased among women over the past 20 to 30 years.

40. Although data for women are limited, former smokers appear to have a lower risk for dying from COPD than do current smokers.

Sex Hormones, Thyroid Disease, and Diabetes Mellitus

41. 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.

42. 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.

43. 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.

Menstrual Function, Menopause, and Benign Gynecologic Conditions

44. 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.

45. Women smokers have a younger age at natural menopause than do nonsmokers and may experience more menopausal symptoms.

46. Women who smoke may have decreased risk for uterine fibroids.

Reproductive Outcomes

47. Women who smoke have increased risks for conception delay and for both primary and secondary infertility.

48. Women who smoke may have a modest increase in risks for ectopic pregnancy and spontaneous abortion.

49. 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.

50. Women who smoke during pregnancy have a decreased risk for preeclampsia.

51. 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.

52. 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.

53. Smoking does not appear to affect the overall risk for congenital malformations.

54. Women smokers are less likely to breastfeed their infants than are women nonsmokers.

55. 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.

Body Weight and Fat Distribution

56. Initiation of cigarette smoking does not appear to be associated with weight loss, but smoking does appear to attenuate weight gain over time.

57. 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.

58. Smoking cessation among women typically is associated with a weight gain of about 6 to 12 pounds in the year after they quit smoking.

59. 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.

Bone Density and Fracture Risk

60. Postmenopausal women who currently smoke have lower bone density than do women who do not smoke.

61. Women who currently smoke have an increased risk for hip fracture compared with women who do not smoke.

62. The relationship among women between smoking and the risk for bone fracture at sites other than the hip is not clear.

Gastrointestinal Diseases

63. Some studies suggest that women who smoke have an increased risk for gallbladder disease (gallstones and cholecystitis), but the evidence is inconsistent.

64. Women who smoke have an increased risk for peptic ulcers.

65. 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.

66. 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.

Arthritis

67. Some but not all studies suggest that women who smoke may have a modestly elevated risk for rheumatoid arthritis.

68. Women who smoke have a modestly reduced risk for osteoarthritis of the knee; data regarding osteoarthritis of the hip are inconsistent.

69. The data on the risk of systemic lupus erythematosus among women who smoke are inconsistent.

Eye Disease

70. Women who smoke have an increased risk of cataract problems.

71. Women who smoke may have an increased risk for age related macular degeneration.

72. Studies show no consistent association between smoking and open-angle glaucoma.

Human Immunodeficiency Virus (HIV) Disease

73. Limited data suggest that women smokers may be at higher risk for HIV-1 infection than nonsmokers.

Facial Wrinkling

74. Limited but consistent data suggest that female smokers have more facial wrinkling than do nonsmokers.

Depression and Other Psychiatric Disorders

75. 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.

76. 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.

77. The prevalence of smoking is very high among patients with schizophrenia, but the mechanisms underlying this association are not yet understood.

78. 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.

Neurological Diseases

79. Women who smoke have a decreased risk for Parkinson’s disease.

80. Data regarding the association between smoking and Alzheimer’s disease are inconsistent.

Nicotine Pharmacology and Addiction

81. 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.

82. 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.

Environmental Tobacco Smoke (ETS) and Lung Cancer

83. Exposure to ETS is a cause of lung cancer among women who have never smoked. ETS and Coronary Heart Disease.

84. Epidemiologic and other data support a causal relationship between ETS exposure from the spouse and coronary heart disease mortality among women nonsmokers.

ETS and Reproductive Outcomes

85. 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.

86. Studies of ETS exposure and the risks for delay in conception, spontaneous abortion, and perinatal mortality are few, and the results are inconsistent.

Source: CDC.Gov (Center For Disease Control)