Women & children at risk.

The good news is there has been a steady drop in the number of smokers in this country. In 1964, when the first surgeon general's report was issued, half of all adult Americans smoked. By 1974 that number had dropped to 37 percent, and by 1991 about a quarter of adult Americans were smoking. There are now more than 40 million ex-smokers in the United States, and an average of around 2 million Americans quit every year.

In 1966 cigarette packages were required to display the label "Caution--cigarette smoking may be hazardous to your health." In 1971 cigarette advertising was banned from radio and television.

The bad news is that the drops in sales and the advertising setbacks have caused a radical shift in policy for cigarette advertising. Now much more money is being allocated to advertising than was spent in radio and TV days (almost $4 billion a year), and women and children are the prime targets.

Unfortunately, it appears that the unscrupulous methods to reach them are having huge success. Fifty percent of all new smokers in this country are under 14 years of age. Seventy-five percent are under 18. Only 10 percent of new smokers begin to smoke after age 20. Forty-five of our 51 states have laws prohibiting the sales of cigarettes to minors (under 18 years of age). Nevertheless, the Centers for Disease Control and Prevention reports that more than half (57.5 percent) of underage smokers buy their own cigarettes.

Marketing to youth. In recent years cigarette advertisers have spent billions to promote adolescent-oriented themes and images. Using motorcycling, surfing, skiing, and all forms of active sports, tobacco companies attempt to associate smoking with an adventurous, vigorous lifestyle. To uncritical thinking youth, such widespread promotional advertising implies "smoking can't be that bad." The average age of new smokers is 12.5 years. More than 3,000 minors start smoking every day.

Candy and bubble gum were packaged to resemble cigarette brands. A recent Pediatrics article reported that 20 percent of 4- and 5-year-olds had eaten candy cigarettes, and 42 percent of 6- to 8-year-olds and 78 percent of 9- to 11-year-olds had tried candy cigarettes.

"Old Joe Camel" advertising was certainly aimed deliberately at the very young. The Journal of the American Medical Association reports that 30 percent of 3-year-olds recognize him, and 91 percent of 6year-olds. Between 1988 and 1991 illegal sales of Camels (to those under 18 years of age) rose from $6 million a year to $476 million a year.

Smokeless tobacco. Smokeless tobacco is another method of attack on children. (See article on page 40.) The use of snuff, chewing tobacco, and plug tobacco has become so common that 30 percent of professional baseball players use them. Almost all began in their teens. Young people read (and perceive) that smokeless tobacco is a safe alternative to smoking.

As many as 22 million Americans use smokeless tobacco--88 percent of them had started by age 14. A recent study showed 24 percent of 8to 9-year-old boys have used it.

Tobacco use also opens the way for use of other dangerous drugs. Eighty percent of teenage cigarette smokers have tried marijuana, compared to 17 percent of nonsmokers. Smoking teens are 14 times more likely than nonsmokers to use cocaine or amphetamines.

Impact on women. After children, women are the next most targeted segment of our society. They're sold the idea in ladies' magazines that women's liberation comes with smoking Virginia Slims. They're told on wayside billboards that their hassled lives deserve a moment to themselves to light up and relax with the advertised brand.

It seems this directed advertising is having a detrimental impact. In the Rhode Island High School studies, 26.5 percent of the female students were smoking, while 17.5 percent of the male students smoked.

In adult ages, the percent of women smokers continues to increase, while the number of men smokers is decreasing. In pregnancy studies, 50 percent of teenage mothers smoked during pregnancy and/or the nursing period, while 29 percent of adult mothers were smokers. The sad results of women smoking are being reported almost daily.

In 1993, 56,000 women will die of lung cancer and 70,000 new cases will be diagnosed. For several years now, lung cancer has passed breast cancer (46,000 deaths estimated for 1993) to remain the number one cancer killer in women. Four thousand more will die of mouth, throat, and laryngeal cancers caused by smoking. And 3,000 women who have never smoked die each year of lung cancer. They receive their carcinogens secondhand from smoking spouses.

Smoking increases the odds of developing many diseases, and these odds are expressed in risk ratios. Risk ratio is the chance a smoker has of developing a condition, compared to the nonsmoker. For example, a two-pack-a-day woman smoker under 50 years of age has a risk ratio of 10:1 of suffering a heart attack. Note the risk ratios for women in the box on this page. Smoking also results in premature aging. A woman smoker increases her odds for facial wrinkles almost 5 times (risk ratio 4.7:1).

Children at risk. Some of our greatest concerns are for the children of smoking mothers. Nicotine, hydrogen cyanide, and numerous other toxic substances in cigarette smoke cross the placenta to affect the fetus directly. Carbon monoxide is transported into the fetal blood and deprives the growing baby of oxygen. These toxic substances in the mother and fetus explain the increase in premature births and spontaneous abortions, abruptio placentas, and fetal and neonatal deaths observed in smoking mothers. At least 13,700 neonatal deaths a year are smoking-related.

After birth, nicotine passes into the breast milk (1/2 milligram per liter) and adds to the inhaled nicotine (passive, or secondhand, smoke) from the mother's cigarettes.

While perhaps 7 percent of children in nonsmoking homes will have colic, up to 61 percent of children in smoking homes will be colic sufferers. Sudden infant death syndrome (SIDS) is the greatest cause of babies dying in the first months of life. The risk ratio of a smoking mother losing her newborn baby to SIDS is 4.4: 1.

As many as 12 million children under the age of 5 are exposed daily to secondhand smoke. More than 60 percent of homes with young children have at least one smoker. Involuntary smoking (perhaps our most frequent and damaging form of child abuse) brings on a host of health problems for young children. The risk ratio table (on this page) sums up some of the health risks of growing up in a smoking home.

More than physical threats exist for the child growing up in a smoking home. An increasing number of studies show that children whose mothers smoke during pregnancy, infancy, and childhood show modest but statistically significant impairment of learning ability and school performance. A number of studies show that tobacco-exposed children demonstrate more than anticipated attention deficit disorder or hyperactivity.

Recently, behavioral problems in children of smoking mothers were reported for the first time. The behavior problems studied included

1. Antisocial (cheating, destructive, bullying, disobedient)

2. Anxious/depressed (mood changes, fearsome, worries too much)

3. Headstrong (argues, stubborn, temper)

4. Hyperactive (impulsive, restless, trouble concentrating)

5. Peer conflict (not liked, withdrawn, combative)

6. Immature (clings, cries, demanding)

Maternal smoking during and after pregnancy was associated with two times greater rate (risk ratio 2:1) of extreme behavior scores, which persisted in 8- to 11- year-olds.

A male child who was also premature had a risk ratio of 8:1 of having extreme scores of behavioral problems. Problem scores in the anxious/depressed and peer conflict areas continued into the 12-to 17year-old group.

What can we do? How much more evidence do we need? How long must we wait for our former surgeon general Dr. C. Everett Koop's dream of a smoking-free society to become reality? Former surgeon general Antonia Novello reported that 126,000 American women die each year of smoking-related disorders and 13,700 infants die each year just because their mothers smoke.

What can concerned Americans do?

1. Legislate an end to all cigarette advertising and sports sponsorship.

2. Outlaw cigarette vending machines, where most children illegally buy their cigarettes.

3. Enforce the present penalties for selling to minors.

4. Begin tobacco education in grade school, where a high percentage of new smokers now start.

5. Use the same hazard labeling and sales and penalties for smokeless tobacco as for smoking tobacco.

6. Greatly increase the sales tax on all tobacco products and use the proceeds for drug education.

7. Remove smoking from the workplace and where people travel and congregate.

8. Establish smoke-free hospitals and health facilities through leadership from the medical profession. Physicians need to take a smoking history on every patient and offer some smoking cessation program options for every smoker. Free smoking-cessation literature should be available in every doctor's waiting room and hospital lounge.

9. Recognize parental responsibility to protect children. Three fourths of new child smokers have a smoking parent. Many smoke cigarettes their parents have purchased. Parents unwilling or unable to quit must refrain from smoking in the house or automobile. Smoking during pregnancy and lactation must be considered child abuse and stopped.

Herald Habenicht, M.D., FA.A.P., FA.A.A., is a practicing pediatric allergist in Berrien Springs, Michigan. He is a fellow of the American Academy of Pediatrics and the American Academy of Allergy and Clinical Immunology. He takes great satisfaction in having persuaded several magazines to drop all tobacco advertising.

  Risk Ratios for Selected Diseases for Women

Condition      Smoking Frequency    R/R (Risk Ratio)
Heart attack     2 packs/day             10:1
                 1 to 2 packs/day        8.3:1
                 less than 1 pk/day      4.3:1
Stroke                                   2.6:1
                 If taking birth
                 control pills           7.6:1
Invasive Cervical
Cancer           2 packs/day               2:1
Peptic Ulcer                               2:1

[TABULAR DATA OMITTED]

Herald Habenicht, M.D., F.A.A.P., F.A.A.A., is a practicing pediatric allergist in Berrien Springs, Michigan. He is a fellow of the American Academy of Pediatrics and the American Academy of Allergy and Clinical Immunology. He takes great satisfaction in having persuaded several magazines to drop all tobacco advertising.