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Smoking cessation: crucial to target women as well as men - editorial
  Matthew A Steliga a, Carolyn M Dresler b
The Lancet, Early Online Publication, 11 August 2011
In The Lancet, Rachel Huxley and Mark Woodward present the largest meta-analysis to date that specifically assesses the different effects of smoking between the sexes, and its implications for coronary heart disease.1 In a database of 2·4 million people, the adjusted relative risk of coronary heart disease, expressed as a ratio of women to men, comparing those who smoked with those who did not, was 1·25 (95% CI 1·12-1·39; p<0·0001).
The main cause of death in the UK, USA, and many other developed countries is heart disease. Although this disease can be caused by valvular abnormalities or non-ischaemic cardiomyopathy, coronary heart disease is the predominant contributor to forms of heart disease that lead to disability and death, and WHO lists ischaemic heart disease as the leading cause of death worldwide.2 By 2030, coronary heart disease will remain the main cause of death globally, and will be responsible for 9·6 million deaths-or 14% of the total-every year.3 Although coronary heart disease can have a strong genetic predisposition, mostly this disease develops because of lifestyle-related risk factors, such as poor diet, lack of exercise, and smoking. Thus, a large proportion of the most common cause of death worldwide is attributable to behaviour or addiction. Although some people might view this statistic as discouraging, it can also be seen as a great opportunity to reduce the burden of disease through behaviour modification and smoking cessation programmes.
Because the relative risk for development of coronary heart disease is greater for women who smoke than it is for men who smoke, in societies with increasing proportions of female smokers the future health effects might be greater than are anticipated. As sanitation improves and communicable diseases are increasingly controlled in developing economies, the effect from smoking-induced coronary heart disease will account for a larger proportion of health-care resources. In most societies, smoking rates are higher for men than for women, but more men than women are giving up, and in some societies the number of female smokers is rising. What makes the realisation that women are at increased risk worrisome is that the tobacco industry views women as its growth market.4 With billions of pounds to spend on marketing-by contrast with paltry funding for tobacco control-the tobacco industry continues to see a rise in profits globally.5, 6 Thus, despite some success in reduction of smoking prevalence in men, the rise or even stabilisation of smoking in women will unfortunately result in substantial, preventable coronary heart disease morbidity and mortality.
Smoking cessation rapidly decreases the risk of death from cardiovascular disease.7 A striking improvement in mortality in developed economies has been attributed to a decrease in smoking prevalence, especially in men. Huxley and Woodward are right to encourage all health professionals to advocate cessation,1 and note that 10-40% of men had stopped smoking compared with only 2-21% of women. Women have less success at quitting and metabolise nicotine faster than do men.8-10 The investigators are again correct that development of techniques that help women to quit is crucial.
As half the people who smoke will die from a tobacco-related disease, and half of those deaths occur in middle age, men and women urgently need help to quit smoking permanently.7 Huxley and Woodward's study1 reports a 2% increase in the female-to-male relative-risk ratio of coronary heart disease for every additional year of smoking, making the drive for cessation even more critical.
Evidence-based measures need to be implemented to assist women and men to quit smoking (or to not start tobacco use). Effective tobacco control, such as full implementation of the WHO's Framework Convention on Tobacco Control, would be one such method. National and international organisations such as the International Network of Women Against Tobacco and the WHO's Tobacco Free Initiative are important reference organisations to promote more effective tobacco cessation in women. Although more men than women smoke, those women who do smoke have a greater risk of coronary heart disease and therefore targeting of both sexes is imperative for smoking prevention and cessation on a global, national, and individual basis.
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