Up in smoke

IMAGINE that cigarettes were a brand new product. How would you market them? They're expensive, addictive, will give you twice as many wrinkles as a non-smoker and in the long term they'll ruin your health. Surely it would take an advertising genius to sell even a single packet?

If only it were that simple. The health message is out there, stamped on every packet that's sold. Cigarettes are deadly, but they're also legal. And for Scotland's young women, they're not just available - they're irresistible.

Recent figures show that 14% of Scotland's 15-year-old boys are regular smokers. For girls the figure rises to 24%. This might sound like a straightforward case of girls growing up faster, but there are repercussions. Women are also catching up with men at the far end of the smoking story. The incidence of lung cancer in men has fallen by more than 40% in the last two decades, but for women it continues to rise. In fact, lung cancer kills more British women than breast cancer does. Feminism has brought many perks, but when it comes to smoking, do women really want equality?

"The overall trend is away from tobacco in society, but it's slow because it has such a pervasive hold," says Maureen Moore, chief executive of ASH (Action on Smoking and Health) Scotland. "It's the only legally available consumer product that kills half the people who use it in the way the manufacturers intend."

Moore points out that although advertising tobacco is banned, there is a well-resourced industry doing its best to promote cigarettes. "There's still a hangover from smoking being considered a cool and glamorous thing to do, the way you see it in the films of the 1940s and 1950s."

Flick through any glossy magazine and you'll find images of musicians and actors looking rebellious, nonchalant and, yes, cool with a cigarette as an accessory. Whether it's Scarlett Johannsen puffing her way through Lost in Translation, Kate Moss having a fag backstage at a fashion show or Johnny Depp being interviewed about his plan to set up an airline where smoking would be mandatory, the link between smoking and glamour is a hard one to break.

It's too easy to say that teenagers start smoking because that's what their favourite stars do, but it is part of the overall picture. Professor Amanda Amos, head of health promotion at the University of Edinburgh's medical school, recently completed an extensive investigation into Scotland's teenage smokers. She says that many factors influence someone's decision to take up smoking, including the beliefs and attitudes of the individual, the immediate role models of friends and family, and physiological factors in terms of addiction to nicotine. At a societal level, she says that media images of smoking, the cost and accessibility of cigarettes and the government's smoking policy all play a part.

One of Professor Amos's key findings was that most young people who take up smoking never imagine they will still be doing it later in life. "Young people will say, 'Well, I'm only a social smoker,' and that means they smoke at weekends, at parties and friends' houses. Then they start to say, 'I'm becoming a real smoker,' when they begin to smoke daily and they move into smoking on their own."

Ben Youdan, chief executive of No Smoking Day, points out that two-thirds of smokers start before the age of 16. He says that one of the primary reasons for this is that smoking is an expression of being grown-up and taking risks. "Girls are becoming much bigger risk-takers than boys in all sorts of different health and social behaviours. Smoking is just one of these risks," he says.

"If you talk to young women about their smoking and ask them if they think they will still be smoking when they're 30, the vast majority say no. But the reality is that one or two cigarettes borrowed off a mate who's old enough to buy them, or pinched out of your mum's packet at home, very quickly becomes an addiction, and suddenly it becomes very hard to stop."

The research suggests that there are differences between teenage girls' and boys' attitudes to smoking. Sport plays a large part in dissuading young men from smoking, says Professor Amos. "They're more involved in sport. They watch it, talk about it and are therefore concerned about the impact smoking might have on their fitness," she says.

Being successful in sport helps form part of teenage boys' identities; it's a source of friendships and has an importance in their lives to a much larger extent than for girls. For young women, appearance and creating an image are more important. "Girls might use cigarettes to look older. They mature physically earlier and also tend to get older boyfriends, so going out and smoking fits in with that. We've also seen far more girls drinking far more alcohol. Smoking just fits in with that whole lifestyle."

One long-held belief that keeps women of all ages hooked is that smoking keeps you slim. Faced with a craving for both a Twix and a Marlboro Light, the cigarette wins on the basis that it has fewer calories. Certainly, the many photos of supermodels existing on cigarettes and champagne seem to provide anecdotal evidence that this theory works.

Moore says that believing in cigarettes as a slimming aid is misguided. "What actually happens is that smoking interferes with the metabolism so that a girl doesn't reach the weight she would normally have reached, and she may tend to put on more weight when she stops," she says.

Unlike calorie-counting, smoking is a lifestyle choice that has abysmal health repercussions. But when you're 16, these risks can seem distant. "Many smoking-related diseases take a long time to develop, so someone who starts smoking might only begin to show symptoms after ten or 20, or even 30, years," says Moore. "For a teenager, that's quite hard to get your head round, whereas looking cool and being slim and fitting in with the right crowd now is powerful."

Ann Kerr, the health improvement programme manager for NHS Health Scotland, specialises in tobacco misuse, and she says that the issue of girls and smoking is an area of major concern. "I don't think that young people realise just how addictive cigarettes are until they try to stop," she says. "We have always run two strands of campaigns, one addressing adults and one addressing younger people. That is something we will continue to develop."

Moore agrees that some of these strategies have been highly effective, such as the Stinks campaign, which made much of the fact that smoking makes you smell bad - not an attribute any self-respecting teenager would want. "But I think the tobacco industry has been very astute about targeting its messages and its market," she says. "The health promotion side is just catching up and countering it with positive images and information."

But some would argue that demonising smoking simply makes it more attractive. For example, Death Cigarettes - a brand launched in the early 1990s that featured a skull and crossbones on the packaging, along with the warning 'Cigarettes are addictive and debilitating. If you don't smoke, don't start' - enjoyed huge cult success among teenagers. Neil Rafferty, of pro-choice group Forest, says that many anti-smoking measures have served to make children more curious. "It will go full circle. Smoking will become fashionable again because so many figures in authority are telling you that it's wrong," he says. "A more sensible approach would be to say to kids, 'Smoking is something that some people do. It's not cool, there's nothing particularly good about it, but there's nothing particularly evil either. It's a normal thing, but it's really bad for you.'"

Curiosity and rebellion are not the only reasons why young people start smoking. Professor Amos's research found that for teenage girls smoking was a way of dealing with stress, relationship problems and low self-esteem. Research carried out for No Smoking Day shows that this trend continues into adulthood, with 48% of women smokers, compared with only 35% of men, reporting that they would not be able to cope without cigarettes. The same research found that stress is a significant trigger for women who have already quit to start smoking again.

Tobacco might help women cope with stress, but the benefits are wiped out by smokers having reduced fertility, a greater risk of osteoporosis, a higher risk of miscarrying, and babies that will be on average 0.25kg (8oz) lighter than those born to non-smoking mothers. In terms of sheer vanity, the fact that smoking results in extra wrinkles is enough to make most women regret that they ever started.

The longer you smoke, the more the health risks grow. While breast cancer is a disease that is openly talked about and sees plenty of fundraising to help fight it, lung cancer kills more women in Britain. Smoking causes up to 90% of lung cancer cases, and - although it's not polite to say so - there seems to be a blame culture, which hints that developing lung cancer is your own fault.

Some 4,500 people are diagnosed every year with lung cancer in Scotland, and incidence rates here are 48% higher in women and 34% higher in men than in the rest of the UK. Only one in five patients will still be alive one year after diagnosis. New drugs mean progress is being made in treating lung cancer, but health promoters hope that similar gains will be made in persuading people not to take up smoking or to quit if they do. There has recently been serious discussion about raising the legal age for purchasing cigarettes from 16 to 18, while the ban on smoking in public places has led to a huge increase in calls to smoking-cessation helplines. "Nearly all smokers are ambivalent about smoking. They see pluses and negatives," says Professor Amos. "But these wider things - not seeing tobacco ads, not being so exposed to smoking, the price of cigarettes, providing cessation support - make a difference. We have really moved forward in the last few years in Scotland."

Moore backs the notion that it will take wider cultural change to really make an impact on women and smoking. "Every household in the country has someone or knows someone who has been affected by tobacco-related illness," she says.

"But it has been accepted for so long. The overall picture is that smoking rates are dropping, and 70% of smokers who are surveyed say they want to quit. Tobacco would never make the shelves today as a consumer product. But as a nation we have grown up with it and now we're having to wean ourselves off it." r

Lung cancer: the facts

• Lung cancer is the biggest cancer killer in Scotland and was responsible for almost 15,000 deaths in 2004.

• Each year, around 4,500 people are diagnosed with the disease, and incidence rates are 48% higher in women living in Scotland than in the rest of the UK.

• Lung cancer is rarely diagnosed in people under 40, but the incidence rises greatly thereafter, peaking in the 75-84 age group.

• Although the overall incidence of lung cancer in men has fallen by more than 40% in the last 20 years, in women the figures are increasing. More women in the UK die of lung cancer than of breast cancer.

• Symptoms of lung cancer include breathing difficulties, coughing up blood and chest pain, symptoms that are often confused with those of other illnesses.

• Smoking causes 85% to 90% of lung cancer cases. Your chances of developing lung cancer depend more on the length of time you have been a smoker than on the number of cigarettes you smoke each day.

• X-rays and CT scans can be used to diagnose lung cancer, but it takes about ten years for a lung cancer tumour to become detectable.

• Treatment options include surgery, radiotherapy, chemotherapy and new treatments such as Tarceva. About 85% of patients will be in the advanced stages of the disease and will not be suitable for curative surgery.

• For most patients with lung cancer, the prognosis for survival is poor. Only 20% will be alive one year after diagnosis, falling to 6% five years after diagnosis.

• As soon as someone stops smoking, the risk of developing lung cancer starts to drop. About 15 years after stopping smoking, the risk of getting lung cancer is down to that of a non-smoker.

Smoke and mirrors

MANY products have been recommended over the years as being essential in a beauty regime, but a cigarette isn't one of them. Smokers have about ten times as many wrinkles as non-smokers. Squinting through tobacco smoke and puckering your lips around cigarettes speed up the appearance of lines near the eyes and mouth. A smoker in her 40s could have as many wrinkles as a non-smoker in her 60s.

Smoking decreases the flow of nutrients to the hair, leaving you with dank, lacklustre and smelly locks. It also reduces the amount of blood flowing to the skin and dries it out. Over time, this means it loses elasticity, and the lack of essential nutrients results in a dull, unhealthy complexion. And as for your fingers, it will take more than fake tan to hide those yellow stains.

Smoking also has some unexpected effects on the shape of your body. It causes changes in the glands that secrete hormones, meaning that smokers store more body fat around the waist and upper torso than on the hips. The resulting high waist-to-hip ratio is associated with a heightened risk of developing diseases such as diabetes, coronary heart disease and high blood pressure.

It's not just the colour of your teeth that can be affected by smoking. Cigarettes also increase your chances of developing gum disease, which can lead to bad breath and premature tooth loss.

Quitting smoking lowers your chances of developing psoriasis, a chronic skin condition that can be uncomfortable and disfiguring.

Benefits of quitting smoking

• Within 20 minutes, blood pressure and pulse return to normal and circulation improves, making hands and feet warmer.

• Within eight hours, the chances of a heart attack start to fall.

• Within 20 hours, carbon monoxide clears from the body and oxygen levels rise, increasing energy.

• Within 48 hours, the body is free of nicotine and senses of taste and smell improve.

• Within three days, breathing is easier as bronchial tubes begin to relax.

• Within a few weeks, fingers lose yellow stains and skin looks better.

• Within three months, circulation is improved.

• Within three to nine months, lungs are clear of most of the mucus and tar that have accumulated over the years. You feel fitter and are free of coughs and wheezing.

• Within five years, the risk of a heart attack has fallen to about half that of a smoker.

• Within ten years, the risk of contracting lung cancer has fallen to half that of a smoker, and the risk of heart attack is the same as for a non-smoker.

Celebrity smokers past and present

FROM Audrey Hepburn daintily puffing away in Breakfast at Tiffany's to Uma Thurman using cigarettes as a chic accessory in Pulp Fiction, smoking has always been associated with on-screen style. Some of the strongest film and TV characters ever created would be lost without a cigarette - look at Sybil Fawlty, Patsy Stone in Ab Fab and Carrie Bradshaw in Sex and the City for starters. And for many of the actresses in question, being a smoker isn't just part of the act.

Before the Second World War, when the dangers of smoking were not fully realised, many Hollywood stars were known for their love of cigarettes. Marlene Dietrich advertised Lucky Strike and Lucille Ball was sponsored by Philip Morris cigarettes, while Rita Hayworth and Lana Turner used smoking to help them perfect the femme fatale look. As for notorious smoker Bette Davis, actor Henry Fonda once said, "I've been close to Bette Davis for 38 years, and I have the cigarette burns to prove it." Unfortunately, many of this generation of leading ladies had to face the repercussions of tobacco-related diseases, including Barbara Bel Geddes and Betty Grable, as well as Jackie Kennedy.

Today's icons have continued to smoke, despite knowing all about the damage it will do to their famous faces. Kate Moss, Charlize Theron, Sienna Miller, Kate Winslet and Cameron Diaz are just a few glamour girls who have been photographed fag in hand, while Drew Barrymore admits that she started at the age of just nine.

But there are a few who have managed to quit. Salma Hayek gave up, despite developing a taste for nicotine while filming Frida Kahlo. Charlotte Church quit after realising it was affecting her voice, and former model Christy Turlington not only gave up but became a high-profile anti-smoking campaigner.

Case studies

Dorothy Boyle

Lung cancer research nurse, Western General Hospital, Edinburgh

ASK anybody what causes lung cancer, and they'll say smoking. Cigarette packets spell it out - 'Smoking kills' and 'Smoking causes cancer' - so the feeling often seems to be that if you smoke it's your own fault if you get lung cancer. But what people don't look at is the reasons why smokers take up the habit in the first place.

Research has found that women start smoking early due to the need for social status among their peer group. This pressure to conform and look good means that girls often continue smoking as a way to help them stay slim. Adult women smoke to help boost their confidence - one survey found that 61% of women in Scotland who smoked felt they were emotionally dependent on cigarettes, while 48% said they felt more confident in social settings with the aid of a cigarette.

Back in the 1970s, the tobacco industry investigated why women smoke, and used the results to produce female-orientated cigarettes - slimline, menthol and low-tar versions, with packets in light colours - and sponsored events such as the Virginia Slims tennis tour.

There is a ban on advertising tobacco in the UK now, but you still see cigarettes in films and magazines. Younger girls taking up smoking now don't use low-tar cigarettes, so they get hooked more easily. Research shows that women develop an addiction to nicotine and an addiction to habitual smoking more quickly than men, and when trying to stop the withdrawal symptoms are worse.

Here at the hospital, people who have been diagnosed with lung cancer do talk about smoking, and we always offer them smoking-cessation classes and nicotine patches. It's never too late to quit: even after getting lung cancer, stopping smoking will increase your chances of survival.

We need to tackle the issue of teenage girls and smoking. Giving up is difficult, but we will do everything to help people who want to. The one message I would like to get across is that there's no blame culture here for smokers with lung cancer. We won't tolerate a blame culture within the NHS.

Lucy Caldwell, 33

Marketing manager, Edinburgh

I STARTED smoking at 19, when I was at university. I was a social smoker to start off with, and then it became a habit. When I was a student I was probably smoking about 20 cigarettes a day, but I cut back to about ten after I graduated and started working.

I did enjoy smoking for a while, but when I wanted to stop I realised that it wasn't going to be easy to give up. I was 25 when I made my first attempt. I was getting ahead in my career and had started to live a healthier lifestyle, going to the gym and all that, and smoking was affecting my fitness. I wasn't able to quit at the first attempt - I tried a couple of times with nicotine-replacement patches, but I didn't have much success. Then a friend recommended Allen Carr's How to Give up Smoking, and that's what worked for me.

I didn't quite believe the book would work while I was reading it. You are supposed to keep smoking up until you finish the last page. But then, miraculously, I did stop when I finished it, and I have never felt like starting again. I found that the book attacked all the beliefs I held about smoking and how difficult it was to give up, and it convinced me that I could quit without side-effects.

That was seven years ago, and it does feel like a major achievement. But I do really understand how difficult it is for people to quit. I think that the smoking ban in public places is fantastic - I never liked sitting in smoky restaurants even when I was a smoker, and I think it'll go a long way towards helping other people give up as well.

Jenine Armand, 34

Retail merchandiser, Earlston

I FIRST tried smoking when I was 13, but I didn't start properly until I was 15. My parents didn't smoke, although my grandparents did.

Young people copy what older people do, and seeing celebrities smoking can glamorise it. I remember having one cigarette, then buying a pack of ten, which lasted a week. Then a pack of ten lasted a day, then I went on to 20 a day. I got hooked at quite an early age.

I enjoy smoking, but I want to stop for health, financial and cosmetic reasons. I have tried to give up many times. I had hypnotherapy in my mid-20s, which worked, temporarily at least. I've also tried nicotine-replacement patches - I'm just about to have my third attempt with those. I stopped for a year and a half about three years ago, after doing patches, but it must have been a crisis or stress that made me start smoking again. Cigarettes are the first thing you go for when you're stressed.

I definitely think I have an addiction to nicotine, but I know smoking is also a habit - from buying cigarettes and carrying a packet with you, to smoking when you're on a night out, to just having something in your hand. Not having cigarettes on me would be like going out without my jewellery.

I spend a fortune on cigarettes, but if you're a smoker you will always find money to smoke.

Health-wise, 19 years of smoking are going to take their toll, and that's a concern. I've read about wrinkles and seen photos in magazines of 60-year-old women smokers, and I don't want to end up looking like that. I eat fruit to be healthy, but then the cigarettes deplete your vitamin C.

The smoking ban has affected my smoking pattern - I've got a company car, so I can't have a cigarette in that any more. But it doesn't stop me - I just light up at different times. I think that if you have an addictive personality, you'll be all or nothing, regardless.