On March 8, 2012, Global Bridges presented the webinar "Women and Smoking," which featured Ivana Croghan, Ph.D., coordinator of the Mayo Clinic Nicotine Dependence Center's Research Program.

1. Smoking Among Women:
An Update
Ivana T. Croghan, Ph.D.
Associate Professor in Medicine
Mayo Clinic Nicotine Research Program
Global Bridges Webinar
08 March 2012

2. The Coming Epidemic
Rise in Smokers Worldwide
2 1.7
Billions of smokers
1.5
1.1
1
0.5
0
2000 2030
http://tobacco.who.int/en/treatment/index.html

4. Current Smoking
Country Region Male Female
Youth Adult Youth Adult
Nigeria* Africa 5.6 9.0 1.3 0.2
Argentina Americas 21.1 32.4 27.3 22.4
Mexico Americas 26.3 24.8 27.1 7.8
USA Americas 9.7 31.2 7.9 23.0
Egypt Eastern Mediterranean 15.5 37.6 2.8 0.5
France Europe 13 33.3 16 26.5 17,317,750
Italy Europe 19.4 29.5 21.6 17.0
Ukraine Europe 27 50.0 12 11.3
India* Southeast Asia 5.8 24.3 2.4 2.9 35,095,609
Thailand Southeast Asia 20.1 45.6 3.8 3.1
China Western Pacific 2.7 52.9 0.8 2.4 32,153,396
Japan Western Pacific 2.1 38.2 1.8 10.9
More countries: http://www.who.int/tobacco/surveillance/policy/country_profile/en/

5. Global Trends
http://www.who.int/tobacco/global_data/country_profiles/en/

7. Profile of a Female Tobacco
User
 Have role models who use tobacco
 Have weaker attachment to parents/family
 Have weaker commitment to school/religion
 Stronger attachment to peers and friends
 Perceive tobacco use prevalence to be higher then
what it really is
 Less knowledge of adverse consequences of
tobacco use & nicotine addiction
 Believe tobacco use can control weight, negative
mood and stress
 Have positive image of tobacco users
 Are risk takers
 Rebellious

8. Hormones, Menstruation,
Reproduction
 Antiestrogenic effect
 ↑ estrogen-deficiency disorder – e.g. osteoporosis
 ↓ estrogen-dependent disorder – e.g. endometrial cancer
 ↓ risk for uterine fibroids
 Alters menstrual function
 ↑ risk for dysmenorrhea (painful menstruation)
 ↑ secondary amenorrhea (lack of menses)
 ↑ menstrual irregularity
 Earlier age of natural menopause
 More severe menopausal symptoms
 ↑ risk for conception delay (primary & secondary infertility)

9. Pregnancy
 1 out of 10 (10.7%) female
smokers continue smoking through
pregnancy (can change based on race, ethnicity and age)
 Of those who stop smoking during
pregnancy, 2 out of 3 (67%)
relapse at end of pregnancy
 In the US, yearly cost of maternal
smoking is $366 million per year for
neonatal care
 $740 per maternal smoker

10. Pregnancy
 ↑ risk of in utero:
 Premature birth
 Placenta previa
 Abruptio placenta
 Ectopic pregnancy
 Spontaneous abortion
 Preterm premature rupture of membranes
 ↑ intrauterine growth retardation
 ↓ physical stature
 ↓ intellectual development in children
 ↓ lung function
 ↑ risk of perinatal and infant death
 ↑ risk of SIDS through loss of neonatal hypoxia tolerance

11. Body Weight and Fat
Distribution
 Tobacco use initiation is NOT associated with weight
loss
 Continued tobacco use DOES attenuate weight gain
over time
 Average weight of tobacco users is MODESTLY lower
than non-users
 Tobacco cessation CAN be associated with weight
gain (6-12 pounds)
 Female tobacco users have a more masculine pattern
of body fat distribution (higher waist-to-hip ratio)

12. Psychiatric Disorders
 Female tobacco users are more likely to be depressed
 ↑ prevalence of tobacco use in people with:
 Anxiety disorders
 Bulimia
 Attention deficit disorders
 Alcoholism
 Schizophrenia
 ↓ Parkinson’s
 ↑ ↓ Alzheimer’s

13. Other
 Affects glucose regulation & related metabolic processes
 ↓ Bone density (↑ risk of hip fracture)
 ↑ risk of Graves’ ophthalmopathy (thyroid-related
disease)
 ↑ age-related macular degeneration
 ↑ risk for rheumatoid arthritis
 ↑ risk for osteoarthritis
 ↑ cataracts
 ↑ facial wrinkling

14. Female ↑ ovarian
Cancers cancer
↓ endometrial ↑ cervical
cancer cancer
↑ smoking
↑ breast ↑ vulvar
cancer risk cancer

15. Benefits of Quitting
 Overall:
 Women who quit smoking reduce their risk of infertility
 Pregnant women who quit early in their pregnancy reduce the
risk of the baby being born too early and with an abnormally
low weight
 Quitting smoking dramatically reduces the risk of developing
an illness caused by smoking
 Reduces the risk of fractures that would be caused by
smoking in old age
 For women who have already developed cancer:
 Quitting smoking helps the body to heal and respond to
cancer treatment
 Quitting reduces the risk of developing a second cancer

16. Benefits of Quitting (cont.)
 Within a few hours:
 The level of carbon monoxide in the blood begins to decline
 The former smoker's heart rate and blood pressure, which were
abnormally high while smoking, begin to return to normal
 Within a few weeks:
 Women who quit smoking have improved circulation
 Don’t produce as much phlegm
 Don’t cough or wheeze as often
 Significant improvements in lung function within several months of
quitting
 Within 1-2 years:
 The risk of death from heart disease is substantially reduced
 5 years after quitting:
 The risk of death from lung cancer and other lung diseases declines
steadily

17. Studies Review
Study In study Quit Rates (%)
Men Women Men women
*Bjornson et al (NG) 2448 1475 29 25
*Gourlay et al (NP) 823 658 25 18
*Glassman et al (Clonidine) 132 161 31 34
*Hall et al(Nortiptyline) 89 110 31 18
*Covey et al (naltrexone) 24 44 58 39
Dale et al (Bupropion 300) 77 79 51 38
Piper et al (Placebo) 78 111 23 21
Piper et al (Bupropion) 223 297 34 30
Piper et al (NL) 228 293 44 26
Piper et al (NP) 232 311 35 34
Piper et al (Bup+NL) 224 306 36 31
Piper et al (NP+NL) 235 311 42 38
Perkins et al CNS Drugs 15:391+, 2001;
Dale et al CHEST 119:1357+, 2001;
Piper et al NTR 12:647+, 2010

18. Why Do Females Have Lower Stopping Rates
& Higher Relapse Rates?
 Negative mood during menstrual cycle phase
 Women react more to triggers involving negative
emotions (conflict, stress) vs. men, who react more to
triggers involving positive situations (social events)
 Women use more palliative coping strategies (men use
more active coping strategies)
 Women have better outcomes in programs that emphasize
social support (men do better in self-management and
control groups)

19. Barriers to Tobacco Cessation
in Women
 Intense withdrawal symptoms and cravings
 Depression
 Irritability
 Anxiety
 Lethargy
 Tension
 Weight changes
 Lower mental concentration
 Hormone influences
 Phase of the menstrual cycle
 High levels of emotional & physical dependence on
cigarettes
 < high school education
 Lack of social support
 Lower self-efficacy
 Living with a tobacco user

20. Barriers to Tobacco Cessation
in Women (cont)
 Situations involving negative effects or stress
 Lessened expectations about ability to quit
 Cognitively less ready to stop smoking
 Less confident in resisting temptation to smoke
 <6 months of abstinence in past attempts
 Previous failed cessation attempts
 Depression
 Weight gain concerns
 Lower socioeconomic status

21. Smoking Cessation Intervention
Men and women have equal
number of previous quit
attempts
BUT
Women are less successful in
sustaining abstinence more
than 1 week

22. Interventions: What Do We
Know?
 Self-help manuals are more popular and least effective among
women
 Telephone quitlines are effective for females who are homebound
 Females have greater success when receiving proactive calls
 Brief physician advice is more effective in females (39% vs. 35%)
 Tailored feedback by health care provider
 More females visit doctors than males
 Females are more responsive to personal interaction
 More females than males use assisted methods for smoking cessation
 More females have greater success in gradual approaches
 Females who reduce gradually by scheduled smoking at regular intervals
have better success rates than those who self-taper or quit cold turkey

23. Multicomponent Intervention
 Cognitive behavioral therapy incorporates strategies
to prepare and motivate smokers to stop smoking
 Combining behavioral therapy with
pharmacotherapeutics
 Multiple sessions, which provide long-term support
 Cognitive behavioral approach
 Prepare and motivate
 Provide social support (e.g., “buddy system”)
 Problem solving

24. Nicotine Dependence Center:
Treatment Program Data
 3,398 patients (January 2004 – December 2005)
 Ambulatory
 1,156 females
 983 males
 Hospitalized
 512 females
 747 males
Croghan IT, Ebbert JO, Hurt RD, Hays JT, Dale LC, Warner N, Schroeder DR. Gender
differences among smokers receiving tobacco use interventions. Addictive Behaviors 34
(2009) 61-67.

25. Females vs. Males
 Statistically significant differences
 Males smoked more
 Males more likely to be married
 Males more likely to be more highly educated
 Males more likely to have a history of alcoholism
 Females more likely to have a history of depression
 Tobacco abstinence outcome at 6 months:
 After controlling for above variables – no difference
Croghan IT, Ebbert JO, Hurt RD, Hays JT, Dale LC, Warner N, Schroeder DR. Gender
differences among smokers receiving tobacco use interventions. Addictive Behaviors 34
(2009) 61-67.

26. Abstinence Rates: Females
vs. Males
 Observed differences in tobacco abstinence outcomes between female
and male smokers may not be due to inherent differences
between genders, but rather may be explained by other
characteristics.
 Individual assessment by tobacco treatment specialists allows for
the elicitation of these factors as potential barriers to the achievement
or maintenance of smoking abstinence. With this knowledge, the
skilled tobacco treatment specialist can develop an individualized
treatment plan.
 Clinical treatment programs may be more adept at addressing
the needs of individual patients compared to the protocolized
interventions used in clinical trials.
Croghan IT, Ebbert JO, Hurt RD, Hays JT, Dale LC, Warner N, Schroeder DR. Gender
differences among smokers receiving tobacco use interventions. Addictive Behaviors 34
(2009) 61-67.

27. CONCLUSION:
Best smoking cessation program for female smokers is
MULTICOMPONENT
 Behavioral support
 Long-term follow-up
 Pharmacotherapy

28. Contact
Mayo Clinic Nicotine Dependence Center
Research Program
200 First St. SW
Rochester, MN 55905
Phone: 800-848-7853
Fax: 507-266-7900
http://ndc.mayo.edu/
nicotineresearch@mayo.edu