Women and smoking: the cursed alliance

While the number of male smokers is falling, the number of female smokers continues to rise. However, their health is more severely affected and they find it more difficult to give up cigarettes than their male peers.

In Switzerland, 21% of women smoke, less than men, who are 27% in this case, and this figure is decreasing, according to the latest Swiss Health Survey covering the year 2022[1]. But behind this apparent progress lies a less rosy reality. Among females ages 15 to 24 and those over 55, the proportion of smokers is increasing.

The proportion of smokers grew between 0.5% and 7.1% from 1992 to 2022, depending on the age category[2]. Conversely, among men, all age groups have had a marked decline. The proportion of young female smokers (ages 15 to 24) has now reached a record level of 26%, compared to 25% for their male peers.[3]

This discrepancy is also found in other European countries. In Greece, Denmark, Ireland, the Netherlands, the United Kingdom, Norway, and Sweden, in particular, the gap between men and women is tending to narrow.[4] In the United States, the smoking rate has fallen by 25% among women since 2005, compared to 27% among men.[5]

“Smoking among women remains a relatively recent phenomenon, dating back only around 30 years, at least on a large scale,” notes Evelyne Laszlo, tobacco specialist and director of the Tobacco Information and Prevention Center (CIPRET) in Geneva. Smoking prevalence among females is therefore lagging behind that of males. While tobacco consumption peaked among men several decades ago, this is not yet the case among women.

In emerging countries, where female smoking was until recently frowned upon or even banned, the number of female smokers is sometimes just beginning to rise. In Mozambique and Argentina, more adolescent girls than adolescent boys now smoke.[6]

“And since it takes around 30 years between the first cigarette and the peak of mortality associated with smoking, the effects of this increasing consumption among women are only just beginning to be felt,” notes Regina Dalmau, who chairs a smoking prevention organisation in Spain. Tobacco currently kills some 200,000 women per year in the United States, a figure that is increasing, while tobacco-related mortality has been decreasing for a number of years among US men.[7]

Added to this are the harmful effects of second-hand smoke to which women – often confined inside their home with smokers – are more exposed. This represents 64% of deaths caused by this disease.[8]


Impact on health

The female body reacts differently to tobacco. “Women who smoke have more cardiovascular problems than men,” notes cardiologist Regina Dalmau. “Their vascular system and clotting mechanisms function differently, which increases their risk of forming a blood clot that can lead to thrombosis, stroke, heart attack, or peripheral arterial disease.”

A study of 2.4 million smokers showed that this risk is 25% higher in women who smoke than in men.[9] Females also tend to develop cardiovascular diseases at a younger age, even when they consume only a small number of cigarettes per day, specifies the expert.

In women who take the birth control pill, the association with tobacco can be fatal, especially for those over age 35. “We multiply the risk of cardiovascular accident by 26, probably because of the interaction between the estrogen contained in the pill and the woman's coagulation system,” emphasizes Evelyne Laszlo.

Women are also more likely to contract chronic obstructive pulmonary disease (COPD), developing the disease at a younger age and having more damaged lungs than their male peers.[10] This is due in particular to the smaller size of their lungs and airways, as well as a more powerful expiratory flow.[11]

Their behaviour towards cigarettes also differs, since they take more puffs than men, but of shorter duration. As a result, between 1980 and 2000, the mortality rate of women due to COPD increased by 291%, while it only increased by 60% among men.[12] In the United States, more women now die of COPD than men.

Added to this are dangers that concern only women, such as an increased risk of breast, cervical, or ovarian cancer.[13] Their reproductive cycle is also particularly affected. “Smoke can cause infertility problems, accelerate the onset of menopause, increase the risk of osteoporosis, and pose risks during pregnancy,” explains Evelyne Laszlo.

An estimated 7% to 10% of pregnant women continue to smoke. Yet nicotine increases the risk of miscarriage, ectopic pregnancy, premature birth, congenital anomalies such as a cleft lip, vision problems, breathing difficulties, and sudden infant death syndrome (SIDS).[14]

Smoking cessation

Women are also not equal to men when it comes to quitting smoking. “Women don't differ much in terms of their desire to quit or the number of attempts made,” notes Liz Klein, a specialist in tobacco health behaviours at Ohio University (USA). “On the other hand, their success rate is lower, especially in the medium and long term.” The female relapse rate is 31% higher.[15]

How to explain these differences? “Women don't smoke for the same reasons as men,” emphasizes Sherry McKee, professor of psychiatry at Yale School of Medicine. “They use cigarettes to regulate their negative emotions, whether stress, depression, or anxiety. Conversely, men are driven by the reinforcing effect that tobacco gives them.” Less dependent on nicotine than their male peers, female smokers particularly appreciate the gestures, smells, and sensations associated with smoking.

This is verified when looking at the parts of the brain that are activated in response to a cigarette. “In women, it’s the amygdala, where emotions are processed,” explains Sherry McKee. “In men, this is the striatum, the area that controls the sensations of pleasure and reward.”

Dependence also sets in more quickly in female smokers than in male smokers and it takes them less time to metabolize nicotine, specifies the expert. “This is due to the presence of estrogen in their system, a hormone that promotes the elimination of nicotine by the body,” she adds. The phenomenon is accentuated in those who take the pill or are pregnant, because their estrogen levels are even higher.[16]

When women quit smoking, the stress and anxiety that cigarettes helped them control resurface, compounded by the difficulty of giving up the addiction, and relapse occurs. “Many women also perceive cigarettes as a tool to regulate their weight and fear gaining weight if they stop smoking,” explains Evelyne Laszlo.

Cessation strategies should take into account these gender differences. “Women benefit more from behavioural approaches,” notes Liz Klein. Likewise, they are less responsive to nicotine substitutes such as patches, which are generally offered as an initial treatment.

However, varenicline is one exception. “This drug has demonstrated greater effectiveness in women than men,” says Sherry McKee, who conducted a study on this subject. “But doctors lack information and do not always think about offering it to their patients as a first choice.”

Women as a target of the tobacco industry

Smoking differences between men and women have long been exploited by the tobacco industry. Capitalising on the emancipation of women during World War I, during which women adopted the attributes of men – their pants, their short hair, and their cigarettes – the tobacco giants began to create advertising campaigns targeting women in the 1920s, presenting smoking as a source of autonomy and power.[17]

In 1929, Great American Tobacco had young women march in a New York parade, smoking Lucky Strikes nicknamed “torches of liberty” to protest gender inequality. In the 1960s, the Virginia Slims brand, (which, like Eve, Misty, and Capri brands, was created expressly for the women's market), adopted the slogan, "You've come a long way, baby."

A second, more traditional, line of communication focused on the portrayal of young, beautiful, and slim women, emphasizing the benefits of cigarettes for weight loss. “Certain brands even put 'slim' cigarettes on the market whose name and thin packaging were supposed to evoke thinness,” recalls Evelyne Laszlo. “A Lucky Strike campaign launched in the 1920s featured the slogan, ‘Reach for a Lucky and not for a sweet.’ The campaign allowed the brand to increase its market share by more than 200%.[18]


The tobacco industry is increasingly targeting a female audience, playing with sexist clichés, as in these advertisements for two well-known Swiss cigar brands.

But in the 1970s and 80s, the United States and Europe became aware of the harmful effects of cigarettes. So big tobacco began to target new markets, particularly those that emerged at the end of the Cold War. The brands L&M, Kim, Virginia Slims, and Capri have taken over the former East Germany, Hungary, the Czech Republic, post-Franco Spain, and Japan with advertisements extolling the merits of liberated and westernised women.[19] In Japan, the rate of female smokers increased from 8.6% to 18.2% between 1986 and 1991.[20]

In the Western world, drawing on new knowledge about the motivations of female smokers, tobacco companies have begun to mount campaigns focused on the stress-relieving effects of smoking. “A cigarette for the career woman, to help her relax, to calm her nerves when tensions rise, serving as a socially accepted tranquiliser,” details the Brown & Williamson brand in leaked internal documents.[21]

Traditionally masculine brands have also put feminine variations on the market, such as Camel No 9, in reference to the famous Chanel perfume, or Davidoff's red, white, and silver packet, described as "the ultimate fashion accessory".

At the dawn of the 21st century, faced with tougher national legislation on tobacco advertising, tobacco companies once again had to expand their consumer base. “They are now targeting women in Africa and Asia, an almost virgin market since it has long been frowned upon for women to smoke in these countries,” notes Sherry McKee. To reach these new clients, whose tobacco consumption continues to attract criticism, they had to develop clever strategies. In India, some brands offer to deliver cigarettes to one’s home.[22]

In Western markets, they instead try to circumvent the law by investing in less regulated spaces like social networks. “In Switzerland, many influencers like Melanie Winiger or Tamy Glauser promote Iqos (editor: Philip Morris product based on heated tobacco),” notes Evelyne Laszlo.

Vaping has also opened up new perspectives for them. “The design of the devices, the tastes, and the colours are primarily aimed at women,” says the expert. The strategy seems to have borne fruit: in Switzerland, 6% of females ages 15 to 24 used electronic cigarettes in 2022, compared to 3% of the general population.[23]

> Female smoking in Switzerland: an epidemiological perspective

[1] https://www.bag.admin.ch/bag/fr/home/das-bag/aktuell/news/news-03-11-2023.html

[2] https://www.bfs.admin.ch/bfs/fr/home/statistiques/catalogues-banques-donnees.assetdetail.28725086.html

[3] Ibidem

[4] https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-20/women-and-tobacco-a-gender-perspective

[5] https://truthinitiative.org/sites/default/files/media/files/2019/03/Truth_Women%20and%20Tobacco_FactSheet_final.pdf

[6] https://www.bmj.com/content/374/bmj.n1516#:~:text=These%20packages%20include%20not%20only,of%20policy%20making%20and%20implementation

[7] https://www.lung.org/quit-smoking/smoking-facts/impact-of-tobacco-use/women-and-tobacco-use

[8] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30752-2/fulltext

[9] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60781-2/fulltext

[10] https://www.sciencedirect.com/science/article/abs/pii/S0272523104000176?via%3Dihub

[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058892/#:~:text=Women%20consistently%20show%20less%20confidence,stress%20during%20the%20cessation%20period

[12] Ibidem

[13] https://truthinitiative.org/sites/default/files/media/files/2019/03/Truth_Women%20and%20Tobacco_FactSheet_final.pdf et https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3818570/

[14] https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/what-are-risks-smoking-during-pregnancy et https://women.smokefree.gov/quit-smoking-women/what-women-should-know/smokings-impact-on-women

[15] Smith PH, Kasza KA, Hyland A, et al. Gender differences in medication use and cigarette smoking cessation: results from the International Tobacco Control Four Country Survey. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2015;17(4):463-472. doi:10.1093/ntr/ntu212

[16] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058892/#:~:text=Women%20consistently%20show%20less%20confidence,stress%20during%20the%20cessation%20period

[17] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1748294/

[18] Ibidem

[19] Ibidem

[20] https://assets.tobaccofreekids.org/global/pdfs/en/WT_essential_facts_en.pdf

[21] https://www.jstor.org/stable/20747788

[22] https://www.who.int/publications/i/item/9789240004849

[23] https://www.bag.admin.ch/bag/fr/home/das-bag/aktuell/news/news-03-11-2023.html

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