Warning that tobacco-related diseases are still a major cause of illness and death among women, a new report by the surgeon general is calling for stronger measures nationwide to discourage women and girls from smoking and to curb tobacco industry adverti

The 675-page report, "Women and Smoking," issued yesterday, is the first report on the subject since 1980. Although smoking has declined among women since the 1960's, the rate of decline has been slow, and the number of deaths remain high. In teenage girls, much of the earlier decline was canceled out by an increase in the 1990's, though the rate in girls has begun to decline again. The report says 165,000 women died prematurely in 1997 from smoking-related diseases, chiefly cancers, heart and lung disease and strokes. The average loss of life was 14 years. And the women most likely to suffer the consequences were those with the least education. Women with less than a high school education were three times as likely to begin smoking as women who went to college. Less educated women were also less likely to quit. For men and women combined, the health costs of smoking-related diseases are $73 billion a year. Senator Richard J. Durbin, Democrat of Illinois, introduced a bill yesterday to require Medicare, Medicaid and the Maternal and Child Health Program to pay for smoking cessation therapy, including counseling as well as prescription and nonprescription drugs like nicotine patches and chewing gum. Lung cancer killed 67,600 women in 2000; it has been the leading cause of cancer death in women since 1987, when it overtook breast cancer, which caused 40,800 deaths in 2000. More than 90 percent of lung cancer cases are because of smoking. The number of cases peaked during the 1990's and is not increasing. Smoking also raises the risk of cancer of the bladder, kidney, pancreas and oropharynx. It is associated with an increased risk of cervical cancer as well, but that disease is almost always caused by a sexually transmitted virus, and the role of smoking is not clear. Smoking plays a major role in heart disease and stroke, the leading causes of death in women. It also leads to about 90 percent of the deaths from chronic lung diseases like emphysema, which kill 56,000 women a year. In 1998, 22 percent of women smoked; the rate has dropped steadily since 1965, when it was 33.9 percent. But men had a sharper decline in the same period, from 52 percent to 26 percent. American Indian or Alaska Native women were the heaviest smokers, with a rate of 34.5 percent, followed by white women at 23.5 percent, black women at 21.9 percent, Hispanics at 13.8 percent and Asians and Pacific Islanders at 11.2 percent. The most worrisome figures, the report says, are the percentages of girls who smoke. In 2000, 30 percent of high school seniors said they had smoked within the last month, and 20 percent said they smoked every day. The rates are the same as in 1988. Rates for boys are similar. Among young girls, American Indians smoked the most. The highest rates were found on or near reservations in Montana, where smoking rates as high as 65 percent have been reported among high school girls. Navajos and other tribes from the Southwest have much lower rates. The report harshly criticizes efforts by the tobacco industry to market cigarettes to women via advertising campaigns that link smoking and tobacco companies with women's autonomy, career success, professional sports, the arts and, most recently, programs to stop domestic violence against women. Noting that preliminary tests had shown that a cigarette brand marketed specifically to women, Virginia Slims, had levels of cancer-causing nitrosamines 10 times higher than other cigarettes, the report called for rigorous testing of brands popular with women.

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