situations. The 12 high-arousal items involved either emotional
strain and anxiety or demanding mental activity; the ten low-
arousal items concerned boredom and relaxation or repetitive
tasks and physical fatigue. A factor analysis of the entire ques-
tionnaire and t-tests performed on male versus female scores
for the most extreme situations on the continuum led Frith to
state that men had a greater desire to smoke in situations in-
ducing boredom and tiredness and women had a greater desire
to smoke in stress-inducing situations. However, men rated the
desire to smoke significantly higher than did women on all three
of the questions representing low-arousal situations, whereas
women rated the desire to smoke significantly higher on only
one of the three questions representing the high-arousal ex-
treme of the continuum (69).

Using Frith’s questionnaire, Barnes and Fishlinsky were un-
able to replicate his findings in a sample of Canadian under-
graduates (12). Within the male sample, there was no significant
relationship between desire to smoke and the arousal value of
the situation in the question, and female subjects indicated a
greater desire to smoke in the low-arousal situations. The au-
thors point out the possible importance of sampling differences.

Elgerot studied light, medium, and heavy smokers in an at-
tempt to control potential differences in inhalation patterns be-
tween men and women (cited by Frith as a possible explanation
for his results) (57). Subjects were Swedish university students.
The 42-item questionnaire was similar, but not identical, to
Frith’s. There was no gender difference for low-arousal situa-
tions. There was no sex difference in the light and medium
smoker subgroups, but women in the heavy smoker subgroup
expressed a greater desire to smoke in stress-inducing circum-
stances.

Russell and his colleagues devised a 34-item questionnaire
covering a wide variety of smoking motives. It was adminis-
tered to 175 normal smokers and then subjected to factor
analysis (160). Six factors, representing six types of smoking,
were identified. Women scored significantly lower on what was
termed “sensorimotor” smoking, and significantly higher on
“sedative” smoking. Thus, the sex difference on “sedative”
smoking (reduction of arousal) was supported.

Ikard and Tomkins (96) found evidence that women smoke in
situations involving negative affect. Negative affect smoking is
defined as smoking which serves to reduce unpleasant feelings.
It includes smoking to reduce the dysphoric feelings accom-
panying rejection by a social group as well as smoking to satisfy
a craving for a cigarette (i.e., deprivation negative affect). Posi-
tive affect smoking involves the arousal of pleasant feelings.

301
For example, smoking from curiosity would be classified this
way because of the feelings of excitement and interest gener-
ated. Ikard and Tomkins showed two films, one intended to
evoke positive affect (a slapstick comedy), and another to evoke
negative affect (a documentary on Nazi atrocities) to college
students who smoke. To be characterized as either positive- or
negative-affect smokers, the subjects had to smoke during the
appropriate film and indicate a congruent mood on an affect
checklist. The major finding was that 73 percent of the female
sample of 15 subjects exhibited solely negative-affect smoking
compared to only 36 percent of the sample of 39 males. While 80
percent of the females indicated that they were likely to smoke,
in positive as well as negative-affect conditions, their behavior
did not match the self-report in this experiment. It is difficult to
determine if the environment of the experiment altered normal
behavior patterns, or if perhaps smokers are not accurate in
describing the types of situations in which they smoke.

Nationwide surveys conducted in 1964, 1966, and 1970 also
suggested that a higher percentage of women than men are
negative-affect smokers and that little or no difference exists
between men and women in the percentage who are positive-
affect smokers (192,193). A greater percentage of women cur-
rent smokers endorsed the statement, “It relaxes me.” (192).
This supports the hypothesis that reduction of negative affect is
a more important factor for women smokers. The statements
assessing positive-affect smoking did not show a clear gender
difference. In 1964, slightly more men than women endorsed the
statement “enjoys it” as a reason for smoking, but in 1966 there
was no difference between sexes and in 1970 slightly more
female than male current smokers agreed that “cigarettes are
pleasurable” (79.6 percent of women versus 77.0 percent of
men).

To summarize: smoking affects arousal; it is not known
whether women smoke to maintain a given arousal level, to
change that level, or to adjust a physical blood level of nicotine.
There are a number of studies which suggest that women use
cigarettes more in high-arousal situations than do men. Studies
which combine self-report with experimental situations provid-
ing a good approximation of natural smoking conditions are
needed to shed some light on the validity of evaluation by ques-
tionnaire alone.

Smoking Cessation

There is an assumption in the treatment literature that men
have greater success than women in quitting smoking. The

302
basis of this assertion lies partially in the demographic analyses
of cessation rates and partially in the literature on smoking
cessation clinics and experimental programs.

This section presents the results of both demographic and
experimental analyses of smoking cessation. A critical ap-
praisal is made of the relative success of men and women in
giving up smoking and in remaining ex-smokers. Psychosocial
and behavioral factors relating to abstinence and difficulties
encountered in quitting are discussed. Finally, recom-
mendations are presented for treatment and future research.

DEMOGRAPHICS

The quitting rates of smokers are calculated by dividing the
number of former smokers by the number of ever smokers
within each relevant demographic category. The following
statistics are taken from the 1975 U.S. Department of Health,
Education, and Welfare (USDHEW) survey on Adult Use of To-
bacco (194). Former smokers are defined as those who once
smoked but no longer do so. The term “former smokers” in-
cludes both those who have quit on their own and those who
have received outside help. Quitting rates of women lag behind
those of men, for each category reviewed.

Age

The USDHEW tables divide adult age groups into six
categories: ages 21 to 24, 25 to 34, 35 to 44, 45 to 54, 55 to 64, and
65 and over (194). There is a trend toward increasingly larger
percentages of former smokers in each successive age group for
both men and women. However, within each age group, the per-
centage of smokers who have quit is higher for men than it is for
women. For example, in the youngest age category, the per-
centage of female smokers who have quit is 22.6 percent while
that for males is 27.9 percent. For a middle-aged category (45 to
54), the female and male percentages are 32.0 percent and 46.7
percent respectively. In the oldest age group, 51 percent of
female ever smokers are former smokers, whereas the percent-
age is 60 percent for males. Bosse and Rose state that the
sex differences in quitting are vanishing at younger ages, but
Dicken argues persuasively that the absolute amount of con-
vergence is small, and that men remain substantially more
likely to stop smoking than women (21,45).

Education

Higher levels of education are associated with higher rates of
quitting for both men and women. Among those with a college

303
TABLE 8.—Most frequently endorsed reasons for resuming
smoking: Fall 1964 and Spring 1966 household
interview survey, responses of current smokers

 

Q: People give all sorts of reasons for either not being able to or not wanting to
stay off cigarettes. What were your reasons for going back to cigarettes?
(Asked if made a serious attempt to stop smoking.)

 

Current Smokers

 

 

 

1964 1966
N % N %
Selected total M 705 55.7 112 §4.9
F 542 50.6 588 57.1
No will power M 291 23.0 278 19.8
F 209 19.5 191 18.5
It relaxes me M 212 16.8 181 12.9
F 245 22.9 192 18.6
Enjoys it M 144 11.4 123 8.7
F 102 9.5 90 8.7
Helps keep weight down M 65 5.1 40 2.8
F 15 7.0 57 5.5
Smoke to be sociable M 98 U7 43 3.1
F 70 6.5 46 4.5

 

NOTE: More than one answer was allowable for each respondent.
SOURCE: U.S. Department of Health, Education, and Welfare (192).

education or higher, 52.1 percent of the men and 48.1 percent of
the women who have ever smoked have quit. For all other levels
of education, 40.5 percent of men smokers and 31.3 percent of
women smokers have given up smoking. Although the discrep-
ancy is less in the most advanced education category, the per-
centage of female quitters is smaller at both levels of schooling.

Income

Higher levels of income are associated in both sexes with
higher rates of cessation. For those ever smokers with incomes
under $10,000, the rates of quitting for men and women are 34.7
percent and 30.3 percent respectively. For those with incomes of
$10,000 or above, the rates are 45.7 percent for men and 36.2
percent for women. Quitting rates of men exceed those of
women for all but one ($5,000 to $7,499) of the seven income
levels.

Occupation

There is a difference of only 7.6 percentage points between the
proportion of male and female quitters in the category of pro-
3804
fessional, technical, and kindred workers, with the male quit-
ting rate at 49.4 percent and the female quitting rate at 41.8
percent. A dramatic increase in this difference occurs, however,
among managers, officials, and proprietors. In this category the
quitting rate for men is 47.1 percent and that for women is only
26.5 percent. Among sales and clerical workers, 40.1 percent of
the men and 25.8 percent of the women have quit. The quitting
rate of homemakers (33.9 percent) is in the mid range of the
rates for women in other occupations.

In general, then, women are quitting at lower rates than men
across the major demographic categories.

PSYCHOLOGY OF CHANGING SMOKING HABITS

A two-year follow-up of over 500 former smokers identified in
the 1964 nationwide survey provides support for the demo-
graphic data showing higher proportions of ex-smokers among
males than females (56). Men were significantly more likely
than women to remain successful abstainers. Men and women
made approximately the same number of attempts to quit, and
current smokers made more attempts than former smokers
(168). Furthermore, successful quitters have usually made at
least one abortive attempt to quit before succeeding. A survey
of young women, aged 18 to 35, revealed that light smokers had’
the greatest success in stopping smoking (216). This finding is
not entirely consistent with that of Eisinger (56), however, who
reported that long-term smoking was a predictor of successful
abstinence. The difference in study samples may account for the
lack of “fit” of the two results, as Eisinger’s survey included all
adults 21 years of age and older. The “reinterview” (follow-up)
aspect of Eisinger’s study gives further credence to his conclu-
sions since they are based on data actually obtained at two
points in time.

Those factors which consistently seem to differentiate be-
tween those who can quit or reduce intake and those who can-
not are: the presence of strong motivation and commitment to
change; the use of behavioral techniques; and the availability of
social support. Those who successfully quit or reduce smoking
use behavioral techniques such as substituting candy and gum
for cigarettes, and some form of self-reinforcement of desirable
behaviors to maintain abstinence (140,216). Successful reducers
use behavioral techniques more consistently and for a longer
period of time than those who fail to reduce smoking (140). Suc-
cessful quitters experience cravings when they stop, but the use
of substitutes seems partially to alleviate these feelings (139).
Furthermore, those smokers who do reduce intake are more

305
motivated and committed to personal change (140), and long-
term abstainers have more confidence in their ability to remain
ex-smokers (56). Successful reducers receive more positive rein-
forcement from others and the best known acquaintances of
successful abstainers are former smokers (56,140). Warnecke, et
al. reported female relatives to be the primary role models for
women who quit smoking (201).

TREATMENT STUDIES

Most smokers who attempt to quit do not seek outside help to
stop smoking. The population that seeks treatment may be one
that experiences severe difficulty in giving up smoking.
Thirty-nine treatment studies on smoking have reported suc-
cess rates for males and females, and have used the criterion of
total abstinence. Two exceptions were made for programs that
reported “success” in terms of 90 to 100 percent reduction.

The studies reviewed here fall into five categories of treat-
ment: education, physician advice, pharmacotherapy,
psychotherapy, and behavior modification (Tables 9-13). The
categorization is, by necessity, only a rough separation of
treatment modalities. Evaluation of the gender difference ques-
tion, however, does not rest directly on the categorization
schema.

Many of the studies listed in the tables did not report significant
evaluations for male/female quitting rates. Therefore, a chi
square statistic or Fisher exact probability test was calculated
wherever sufficient data were available. Because of the limited
number of studies identified for analysis and the often limited
sample size, results of borderline (0.05 <p <0.10) and acceptable
(p <0.05) levels of significance are reported for the reader’s infor-
mation.

The end-of-treatment cessation rates are high for all types of
treatment, but the maintenance of cessation tends to be much
lower. In 1971, Hunt, et al. demonstrated that recidivism curves
of heroin, alcohol, and smoking are almost identical, with long-
term cessation falling off steeply from the end of treatment (94).
Within three months approximately 35 percent of successful
quitters are still not smoking, and by one year, the figure is
closer to 20 percent. In 1978, another reviewer cited virtually
the same figures (147). There have been reports of improvement
in techniques for obtaining abstinence and in maintaining it,
using rapid smoking (an aversive conditioning technique), hyp-
nosis, and group therapy. The long-term cure rates of 60 percent
or higher at six months claimed in some studies have not been
reproducible in other settings. The smoking cessation literature
has been recently reviewed in detail (80,147,168, 198).

306
Across all treatments, women have more difficulty giving up
smoking than men, both at the end of treatment and at long-
term points of measurement. No studies have been reported in
which women do significantly better than men. Several of the
larger studies show higher abstinence rates by men, but many
show no difference. Results in the tables are based primarily on
those who complete treatment programs. Attrition rates are
very difficult to evaluate because most studies do not discuss
the issue of subjects who drop out of treatment.

Because of the emphasis placed on the role of physician advice
in increasing smoking education and promoting cessation, an
estimate of its effectiveness is relevant. From retrospective
data, it is estimated that 35 percent of people who have been
advised by a doctor either to quit or to cut down sharply, actu-
ally do quit (139). Twenty-five percent of those who have not
talked to a physician about smoking quit, and only 12 percent
who have been told by a physician that it was permissible to
continue smoking quit.

The prospective treatment literature yields varying esti-
mates of the impact of physician advice. Ten to 25 percent of
patients advised by a physician to quit or cut down actually do
so (198). Gender does not seem to exert a particular influence.
The primary variables associated with the ability to quit after
physician admonition were good psychosocial assets, psycholog-
ical stability, and the ability to verbalize depression (54).

Success in treatment in general seems to relate to personal
characteristics. A shorter smoking history and lower cigarette
consumption also predict a greater likelihood of cessation
(104,144,204). In addition, those subjects most likely to succeed
in treatment are highly motivated, believe they will succeed,
and are confident of their ability to stop smoking (82,136,187).

One group of women that seems to have great difficulty in
giving up smoking in treatment is homemakers. Homemakers in
the age range of 18 to 35 tend to be heavy smokers, and heavy
smoking is one predictor of failure in treatment (216). Kanzler, et
al. found that homemakers were less successful at quitting, par-
ticularly at long-term follow-up (104). However, as previously
discussed, homemakers have quit rates in the mid-range of
those of women in other occupations; therefore, the difference
may apply only to those homemakers who seek help through
treatment programs.

Wilhelmsen found significant male/female differences in
treatment success rates and stated that the poorer performance
of women related almost exclusively to the unsuccessful results
of homemakers (209). These women explained that cigarettes
served as companions and they reported the difficulties of being

307
& TABLE 9.—Education-Smoking cessation treatment results by sex

8

 

Percent Abstinence

 

 

 

 

 

End-of- Six
Treatment Months Long Term
Study Treatment N (%) (%) (%)
1. Guilford, 1967** (82) Five-Day Plan* unaided 75M 23M \ 2
100F 12F
Aided 82M 27M |
91F 29F
2. Peterson et al., Five-Day Plan 134M&F 7T9M&F 19M (18 mo. follow-up
1968** (141) 19F on 121 Ss)
3. Berglund, 1969** (4) Five-Day Plan 895M&F 87M 382M } 31M }
R4F o7F 2 23F 1 (4-18 mo.)
4. Delarue, 1973 (44) Education, small groups 472M&F 34M (12 mo.)
21F
5. Danaher et al., Education; skill training group 11F 50 (of 8 Ss 50 (9 mo.)
1978f (41) finishing
treatment)
6. Ochsner & Damrau, Pamphlets* 20M sort i
1970 (136) 33F 52F
7. Pyszka et al., American Cancer Society Clinics 131M 39M&F 28M (18 mo.)

19738** (146) 223F 20F

 
608

TABLE 9.—Education— Smoking cessation treatment results by sex—(Continued)

Percent Abstinence

 

 

 

End-of- Six
Treatment Months Long Term
Study Treatment N (%) (%)
8. Kanzler et al., 1976 (104) Smokenders 210M 70M om 1 (48 mo.)
343F 69F 30F ,
9. Dubren, 1977* (53) T.V. spots 92M eM 1
218F TF

 

ly <0.05

20.05 <p <0.10

*Success = 90-100% reduction in smoking.

**Results based only on those completing treatment or contacted for follow-up.

+Pregnancy intervention study.
OTs

TABLE 10.— Physician advice— Smoking cessation treatment results by sex

 

Percent Abstinence

 

 

 

 

 

 

End-of-
Treatment Six Months Long Term
Study Treatment N (%) (%) (%)
1. Burns, 1969 (27) M.D. advice to resp. dis. pts. 66M 53M 1(3mo.)
28F 32F
2. Handel, 1973 (87) Anti-smoking message in 45M 388M 1 (12 mo.)
med. exam 55F 11F ,
3. Burnum, 1974 (28) M.D. advice 84M 29M
40F 18F
4. Baric et al., 1976 (112) M.D. advice 134F
(spont. quitters) 24 83
(intervention) 63 14
(control) 47 14
5. Donovan, 19771(49) M.D. advice 552F 50%
reduction

 

1p <0.05
+Pregnancy intervention studies.
without adult company all day and of being deprived of outside
activities as obstacles to giving up smoking. Cigarettes have
also been described as a means of temporally partitioning the
day, of achieving physical autonomy from children, and of pro-
viding role differentiation (74).

Frieze, et al. reported women face more life stress than men
and have more symptoms of psychological distress (68). Waters
reports that women show more overt signs of neuroticism than
men (203). Furthermore, he finds an association in women be-
tween degree of neuroticism and amount smoked. Burns also
found that female smokers had higher neuroticism scores than did

female nonsmokers. No such differences were found in men (27).
Some studies have shown that women who smoke are both

more subject to psychological stress and more outgoing than
women who do not smoke. In a prospective study on women and
smoking, Cherry and Kiernan measured personality traits in
young women before the onset of smoking (31). They found that
smokers had high neuroticism and extroversion scores before
taking up the habit. They add that current women smokers are
more extroverted and also more neurotic than nonsmokers.
There is evidence that women smokers are more independent-
minded, assertive, self-opinionated and forthright (151,216). The
latter authors report that women smokers are also charac-
terized by apprehension and tension, and that these character-
istics are related to an inability to give up smoking.

The presence of psychological distress has also been shown to
affect the success of women in treatment. Peterson, et al. found
that, while 23 percent of the men who had participated in a
smoking program cited nervousness as the principal reason for
resuming smoking, 43 percent of the women cited this reason
(141). Russell reports that the presence of depression was re-
lated to dropping out of treatment, and that depression was
more frequent and severe among the women in his sample (156).
In a later study, Russell found that within the treatment group,
women had worse psychiatric adjustment scores than did men
(159). Furthermore, although the degree of psychiatric adjust-
ment did not differ between male treatment successes or fail-
ures, treatment successes among women were significantly
more likely to have good adjustment scores. Rode found that
success in a smoking withdrawal program was related to lack of
tension and apprehension for women (150). That smoking might
indeed act as a method of coping with psychological and social
stress is illustrated by the fear reported by many women that
they will engage in symptom substitution—specifically
overeating—if they stop smoking (14,23,27). It is also possible
that underlying stress in women impedes the strength of the

311
nw

wo
TABLE 11.—Pharmacotherapy—Smoking cessation treatment results by sex

 

Percent Abstinence

 

 

 

 

 

 

End-of- Six
Treatment Months Long Term
Study Treatment N (%) (%) (%)
1. Turle, 1958* (191) Hydroxyzine 23F 4F
2. Whitehead and Methylphenidate 10M 20M 0M a2
Davies, 1964 (208) Diazepam 6F OF OF mo.)
3. Wilhelmsen, 1968 (209) Methylscopolamine 291M 56M\, (12 mo.)
tranquilizer 200F 41F ,
4. Wetterqvist, 1971* (207) Methylscopolamine 192M 50M 19M 9M
1973* (206) 98F 33F {) jap (12m) oF (60 mo.)
5. Arvidsson, 1971* (5) Anticholinergics, 50M 85M 48M 1 (12 mo.)
Group aversion therapy 50F 85F 22F .
6. Merry and Preston, Lobeline 45M 29M
1963* (127) 31F 32F
7. Golledge, 1965* (72) Lobeline & placebo 19M 63M
8F 73F
8. Ross, 1967* (152) Lobeline 728M 40M 21M
Amphetamine 745F 29F 1 12F 1 (10-57 wks.)
STs

TABLE 11—Pharmacotherapy—Smoking cessation treatment results by sex— Continued

Percent Abstinence

 

 

End-of- Six
Treatment Months Long Term
Study Treatment N (%) (%) (%)
9. Schauble et al., Lobeline 33M 18M 1

1967* (164) Amphetamine 35F 26F
Lobeline, amphetamine 14M 57M
and education 17F 26F

10. West et al., Lobeline, amphetamine 255M 43M 22.0M

288F 33F |! 13.4F EY mo:)

1977* (204)

 

1p <0.05

*Results based only on those completing treatment or contacted for follow-up.
VIE

TABLE 12.— Psychotherapy —Smoking cessation treatment results by sex

Percent Abstinence

 

 

 

 

 

End-of- Six
Treatment Months Long Term
Study Treatment N (%) (%) (%)
1. Moses, 1964 (129) Hypnosis, discussion 35M 83M 2 11M 8M (12
15F 53F 12F 12F (12 mo.)
2. Mann and Janis, 1968 (119) Emotional role-playing 26F 23-50F (18 mo.)*
3. Streltzer and Koch, 1968 (185) Emotional role-playing 30F OF (4 wks.
post)
4. Lichtenstein et al., 1969 (115) Emotional role-playing 54F 9F (1-5 wks.
post)
5. Fee and Benson, 1971 (62) Group therapy 306M 56M 1 16M
204F 38F oF { } 6-12 mo.)
6. Bozzetti, 1972 (23) Group therapy 7™M 57M 85M (12 mo.)
TF 43F 57F ,
7. Tamerin, 1972 (187) Group therapy 16F 69F
1p <0.05
20.05 <p <0.1

*% reduction in smoking.
determination required to cease such behaviors as smoking and
overeating. Weight gain is a frequently reported consequence of
giving up smoking (173).

THE SMOKING WITHDRAWAL SYNDROME

Few of the studies reviewed here mentioned gender as a con-
nection with withdrawal symptoms, and none suggested that
men and women differ in the severity of smoking withdrawal
symptoms. However, Shiffman (173) analyzed Guilford’s raw
data (82), and stated that 15 of the 18 major symptoms reported
by subjects demonstrate sex differences (80,173). Thirteen of
those 15 symptoms were more frequently reported by women.
Other studies show similar, although not statistically signifi-
cant, trends. (141,190,215).

Factors contributing to relapse, such as craving and nervous-
ness, were reported to be similar for men and women (141).
Women who experienced the greatest craving during the initial
five days of abstinence were most likely to relapse (82). Since
women score higher than men on measures of anxiety as a gen-
eral rule, it is possible that they would be more susceptible to
relapse if smoking had been their customary means of reducing
such dysphoria. Women may also pay more attention to somatic
symptoms than men, as they make more frequent use of all
health care services, and specifically (because of the relative
symptomatology) for headache and and weight gain (114).

It is likely that the abstinence syndrome is a major factor in
recidivism during the first few weeks of cessation when relapse
is most common, and that the number of cigarettes smoked per
day is an important variable in determining the severity of the
withdrawal. The issue of a gender difference in withdrawal se-
verity is a major area where research is needed.

SMOKING AND WEIGHT CONTROL

Women who smoke are, on the average, thinner than women
who do not smoke. The reported mean weight difference ranges
from 1.2 to 4.5 pounds (7,17,93). Weight gain has been a fre-
quently documented consequence of quitting smoking, both in
males and females, (17,37,65,71,141,190,209,215).

Studies of males have reported weight gains among former
smokers which range from 1 to 12 pounds greater than those
who continue to smoke. In one such study, the authors observed
that, while 60 percent of continuing smokers gained weight,
among quitting smokers the observed proportion was 85 percent
(37). These figures gave rise to an observed-to-expected ratio of
1.4, suggesting that those who quit are 40 percent more likely to

315
= TABLE 13.— Behavior modification— Smoking cessation treatment results by sex

 

Percent Abstinence

 

 

 

 

 

 

End-of- Six
Treatment Months Long Term
Study Treatment N (%) (%)
1. Keutzer, 1968 (105) Breath holding, coverant 73M 18M
control, negative practice, 73F 29F
attention placebo
2. Suedfeld and Ikard, 1973 Sensory deprivation 3M 100M 67M 3
(186) 2F 50F 50F ( mo.)
8. Delahunt and Curran, Negative practice or self-control 50F 61 22
1976 (43) Negative practice and self- 89 56
control 1
Control 15 0
Nonspecific treatment 56 11
4. Tongas et al., 1976* Covert sensit., smoke aversion, 88M WM 2 sor} 2 (12 mo.)
(189) group therapy, combined 34F 39F 32F .
treatment 48M
18F } 2 (24 mo.)
5. Russell, 1970 (156) Electric shock aversion 10M 70M 40M (12 mo.)
4F 50F 50F °
LT&

TABLE 13.—Behavior modification— Smoking cessation treatment results by sex—(Continued)

Percent Abstinence

 

 

End-of-
Treatment Months Long Term
Study Treatment N (%)
6. Chapman et al., 1971 (30) Electric shock, self-
management, post-treatment
therapist monitoring: 2 weeks: 4M 75M 25M 25M
8F 100F 37F 29F
(12 mo.)
11 weeks: 4M 100M 50M 50M
TF 86F 57F 57F
7. Berecz, 1972 (13) Electric shock aversion, 56M sed
imagined vs. real smoking 32F
8. Russell et al., 1976 (159) Electric shock and controls 28M 64Mt
28F 57Ft

 

tp <0.05
20.05 <p <0.10
*Results based only on those completing treatment.

**Percent reduction, little for F; more for M in imagined-smoking condition.

tTwo weeks post-treatment.
gain weight than those who continue to smoke; but a significant
proportion of observed weight gain among men who quit smok-
ing would have occurred even if they had continued to smoke.

The single major report on lifetime smoking and weight pat-
terns in women examined data provided by approximately
57,000 female members of a national weight-reduction program
(17). Cross-sectional analysis indicated that current smokers
weighed less than nonsmokers by 1.2 pounds and 4.0 pounds less
than former smokers. Inhalers were significantly less obese by
5.7 pounds than current smokers who did not inhale. A 40-year
longitudinal analysis of weight in relation to reported lifetime
smoking history revealed that between ages 30 and 50 (the two
decades after the majority of those who quit had discontinued
smoking), the former smokers gained more weight than continu-
ing smokers, both for inhalers and non-inhalers. The calculated
weight gain after cessation varied substantially by amount
smoked; heavy smokers who inhaled ( > 41 cigarettes) gained 30
Ibs., while light smokers who inhaled (1 to 10 cigarettes) gained
only 4 pounds. The observed differences in weight persisted
through age 60. Conclusions of this study may not, in fact, be
directly applicable to the total female population. This study
raises the issues of reporting and recall bias among this obese
population (mean group weights ranging from approximately
171 to 180 pounds), as well as self-selection into continuing or
former smokers.

The implications of such studies are important. The image of
the slender, attractive female pervades our culture and is cer-
tainly present in tobacco advertising (84). Do women perceive
weight gain as a significant and unavoidable sequel to discon-
tinuing smoking? There is evidence suggesting that fear of
weight gain may keep women from quitting smoking. Women
are more concerned with weight than men are. In the 1975
NCSH survey, the percentages of female and male smokers who
responded “strongly agree” or “mildly agree” to the statement,
“Being afraid of gaining a lot of weight keeps people from quit-
ting cigarettes” are shown in Table 14.

Attempts have been made to examine the cause of such re-
ported weight gains. The mechanism of weight gain with cessa-
tion of smoking has not, however, been elucidated. Trahair and
others have reported that appetite increased with smoking ces-
sation, and the resulting increased caloric intake caused weight
gain (190). Other studies have suggested that smoking may, in
fact, directly affect metabolism. Glauser, et al. studied seven
males before and one month after cessation. Body weight and
surface area increased, while heart rate, serum calcium, sugar,
and oxygen consumption decreased (71). Conversely, however,

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TABLE 14.—Percent affirmative responses to statement: “Being
afraid of gaining a lot of weight keeps people from
quitting cigarettes”

 

 

Smoking Status Women (%) Men (%)
Never Smoked 59.0 51.5
Formerly Smoked 63.1 53.6
Currently Smoked 59.9 47.3

 

SOURCE: National Clearinghouse for Smoking and Health (194).

Sims observed no change in resting metabolic rate, thermic re-
sponse to exercise or meals, and no change in serum T3 or T,4
(175).

Further research is necessary to define the degree of weight
gain after cessation of smoking, the mechanisms by which it
occurs and the ability to modify it by educational or behavioral
interventions during and after cessation attempts.

TREATMENT RECOMMENDATIONS

Perri, et al. recommend that smoking cessation programs with
a behavioral emphasis be comprehensive, multifaceted, long-
term, and that they include self-reinforcement and problem-
solving procedures (140). Given the difficulty for some women in
simultaneously dieting and attempting to quit smoking, smoking
withdrawal programs should adopt a total approach to health,
including advice on dieting, exercise and the immediate benefits
of abstinence (150).

Marlatt and Gordon write that relapse potential is greater for
individuals whose daily schedule fails to include some rewarding
or pleasurable activity (120). It would appear useful to attend to
this issue in smoking treatment programs.

A social support hypothesis is frequently cited in the treat-
ment literature to explain gender differences in quitting. It is
often suggested that women do better than men in programs
that provide amaximum amount of social support, and tend to do
worse in situations where program support is low or outside
factors militate against quitting. For example, Resnikoff, et al.
were able to differentiate between those women (but not men)
who did poorly in group-plus-medication treatment and those
who did well using the Social Introversion Scale of the Minnesota
Multiphasic Personality Inventory (149). This scale measures
the degree of discomfort in social situations and the presence of
outgoing tendencies. Women scoring high on this scale (shyer,
more socially introverted) were less likely to quit than low-

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scoring women. This study provides just one example of th
observation that social support seems to be of lesser consequenc
to men in quitting smoking, although spousal support is impo
tant (170).

As the overall categories in Tables 9-13 show, women do mor
poorly in treatments characterized by less individual attentior
such as education and pharmacotherapy, compared with th
categories of psychotherapy and behavior modification, wher
contact is usually maximized in a small group or in a
individual-to-therapist setting.

Dubren reports that twice as many women as men participate
in a television stop smoking campaign, but that fewer wome
stopped smoking—presumably because of a lack of support (52
Guilford found that when men and women participated in grou
programs, success and failure rates were the same for both sexe
(78). When they did not attend group programs, men maintaine
the same success rates, but women achieved markedly lowe
rates. There is also support for the notion that groups are pa
ticularly effective for women if they are sexually homogeneot
(44,78). Tamerin writes that the group can provide support, en
pathy, and shared identification with others going through
similar process (187). The group also provides an avenue fi
affective expression, so that the relevance of cigarettes to psyc!
osocial events and the personal meaning of giving them up can }
discussed. Given the differential reaction of men and women *
quitting smoking, as well as the traditionally greater willingne:
of women to discuss affective issues, it is not surprising th:
all-female smoking-cessation groups have been particularly a
tractive.

Marlatt and Gordon studied the circumstances under whic
smoking relapse is most likely to occur (120). They claim th:
experiencing stress in the form of a negative emotional stat
social pressure, or interpersonal conflict is likely to lead to smo
ing among those who are attempting to abstain. The occurren:
of a full-blown relapse, however, can be attributed to the cogr
tive reaction to stress-induced smoking. Many individuals wl
are trying to abstain view a single slip as evidence that they ha:
failed, rather than as a natural and predictable reaction to
stressful situation. Marlatt and Gordon advocate teaching tho
who are trying to quit the importance of not viewing relapse in :
all-or-none manner. Rather, they suggest teaching smokers
“plan for a relapse,” to become psychologically prepared to a
cept a slip as a natural part of the difficult process of quitting

Another factor that appears to influence the success of wome
in treatment programs is smoking by significant others in the
environment. Kanzler, et al. found a significant trend for wom

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to give up smoking if no one in their daily environment was a
regular smoker (104). This trend was only slight for men, al-
though spousal encouragement was related to success in one
large study of smoking cessation treatment in men (170). The
influence of the smoking behavior of significant others on female
_ attempts to quit has been repeatedly pointed out (14,201,204).
Sensitizing friends and relatives who are smokers to this prob-
lem, and advising discretion in smoking behavior on their part,
might increase treatment effectiveness for women.

CONCLUSIONS

‘Treatment programs should specifically deal with means of
handling anxiety and tension, ways to combat weight gain, and
should prepare smokers for mini-relapses. Social support should
be maximized. It may be increased through choice of treatment
modality, networks of “buddies,” friends and relatives, and the
involvement of spouses.

It should be possible to capitalize on the heavy commitment of
women to the health care system, both in terms of their own use
and their role as family providers. Health professionals need to
devise targeted interventions for women with this in mind.

Dissemination of Information About Smoking

HEALTH ATTITUDES AND BEHAVIORS

The extraordinarily serious health consequences of smoking
have not deterred almost 30 percent of the adult female and 37
percent of the adult male population from smoking regularly.
Seventy to 80 percent of these smokers agree that cigarette
smoking is harmful, is a health hazard that requires action, and
causes disease and death (194). Former smokers and nonsmokers
take a much stronger stand on these three points, ranging from
87 to 96 percent agreement. Gender differences are very slight.

The value placed on health compared to other positive life
goals was slightly lower for smokers than nonsmokers, and high-
est for ex-smokers (194). Out of a maximum factor score of six,
current smokers averaged 4.66 (M = 4.55, F= 4.81), and nonsmok-
ers averaged 4.82 (M = 4.68, F = 4.9) and ex-smokers averaged 4.89
(M = 4.78, F = 5.06). The higher scores of women support their
traditional concern with health in our culture but they are in-
congruent with recent smoking trends (114).

Fewer current smokers than nonsmokers and ex-smokers re-
port having personally known someone with coronary heart dis-
ease, lung cancer or emphysema/chronic bronchitis. This finding
may be attributable to a process of denial. Only about one-third

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of current smokers admitted knowing someone personally whose
“health” was adversely affected by smoking while over 60 per-
cent of nonsmokers knew such a person. Clearly, mechanisms
must be operating in smokers to reduce cognitive dissonance
caused by their behavior and their knowledge of the health con-
sequences of their behavior. One of these mechanisms may be to
deny that the health problems of others are connected to smok-
ing.

A related issue is that of compliance. The term encompasses a
host of behaviors, all related to following medical recom-
mendations: seeking care when serious symptoms appear, tak-
ing medications, having follow-up examinations and procedures,
and doing breast self-examination, to name only a few. A large
number of studies have been performed in this area, and there is
no evidence that one sex shows greater propensity to be com-
pliant than the other (90,114).

Thus, we would have no reason to expect that women and men
would respond differentially to doctors’ advice to change their
smoking behaviors, at least from this literature.

Women in our society are more involved with health care serv-
ices (114). They arrange for those services and act as role-models
for children. This function would have great information deliv-
ery potential.

SOURCES OF INFORMATION

There are a variety of ways that people can learn about the
health consequences of tobacco use. The information gathered
from and effects of tobacco company advertising will be dis-
cussed separately below. The major sources of information fall
into a number of categories.

Health Care Providers

The influence of physicians and nurses as communicators of
information and as exemplars of healthy life styles has been the
subject of much research (198). The greater concern about health
among women, and their greater contact with health profession-
als, provides an obvious avenue of intervention (114). Health
professionals should be continuously reminded of their potential
impact and advised to use it to influence women to reduce smok-
ing. Physicians are considered the most authoritative source,
with the greatest potential for influencing patient behavior.

From the self-report of adults, physicians are not delivering
enough anti-smoking information and advice. In 1975, a full 64.6
percent of male and 60.8 percent of female current smokers

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claimed that they had never received advice from any doctor
about quitting, cutting down, or continuing smoking (194). About
19 percent of male and 21 percent of current female smokers had
been advised to quit. Combining advice to quit and/or cut down,
the percentages rose to 34.8 percent of men and 37.7 percent of
women. In 1970, the percentages of men and women who re-
ported such advice were 30.2 percent and 34 percent, respectively
(193). A somewhat lower estimate of physician advice was ob-
tained from an ongoing nationwide study involving approxi-
mately 8,000 people (184). Advice to quit or cut down was reported
by 22.4 percent of the subjects, and lack of advice by 77.6 percent;
there were no significant gender differences.

A survey of physicians’ opinions about smoking and health in
the mid-1960s revealed that 38 percent claimed they advised
“all” or “almost all” (95 to 100 percent) of their patients who did
not have smoking-related disorders to quit or cut down (76).
Eighty-eight percent of physicians claimed they gave such ad-
vice to patients with lung and pulmonary conditions.

Nurses spend more time in direct patient contact than do
physicians and can exert a major role in delivering information
as well as serving as exemplars. Most nurses are aware of this
responsibility (60,75,135,195). Only 10 percent of nurses claimed
to discuss smoking and health with “almost all” or “most” (65 to
99 percent) of their patients or students (135), Another 21.5 per-
cent claimed to have discussed it with 35 to 64 percent of patients
or students. Only 50 percent of current smokers, compared to 65
percent each of former smokers and nonsmokers, suggested
stopping to 5 percent or more of their patients and students.

While the identical question was not asked of nurses in the 1975
survey, a number of valuable questions relating to exemplar
status were posed (196). In almost every case, current smokers
took the weakest position on exemplar role, former smokers were
in between, and nonsmokers were strongest. For all questions,
the proportion of nurses who agreed “strongly” or “somewhat”
with the statements of exemplar role is reported here. Regarding
their own behavior, 69.5, 91.7, and 94.5 percent of current, former
and nonsmoking nurses respectively felt that they should set a
good example by not smoking. This percentage varied according
to work location. Lowest percentages were given for hospital
duty (70.0, 83.8, and 89.2 percent for current, former and
nonsmokers respectively), intermediate for private physician’s
office (79.9, 86.7, and 90.5 percent, respectively, and highest for
private duty (91.1, 91.4, and 94.4 percent, respectively). A much
lower rate of agreement about not smoking in public while in
uniform was obtained; only 44.4 percent of current smokers, 67.1
percent of former smokers, and 72.8 percent of nonsmoking

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nurses concurred. Nurses believe that it is their responsibility to
convince people to stop smoking (64 percent of smokers, 74 per-
cent of former smokers, and 64.8 percent of nonsmokers). Approx-
imately 54 percent of smokers, 81.3 percent of former smokers,
and 82 percent of nonsmokers said they had tried to persuade
someone other than patients to quit, and a much higher percent-
age reported convincing someone not to start (83.4, 78.6, and 75.8
percent, respectively). Finally, 52.1, 78.2, and 85.4 percent of the
respective groups agreed strongly or somewhat that nurses
should be more active in speaking to lay groups.

Given the possible role modeling effect of female nurses, a need
exists for adequate preparation of all health professionals in
smoking and health counseling. This preparation should include
education on the health hazards of smoking as well as effective
methods of counseling patients.

There is little information available about the role played by
other health care providers in dissemination of information or
discouragement of smoking behavior. Nationwide campaigns are
currently being aimed at physicians and dentists to increase
their commitment to and involvement with this task. Other
health care providers should be encouraged to take a more active
role and adopt exemplar status as well.

Educators

Adult educators include those in schools and colleges, job
training, community organizations (churches and other reli-
gious groups, Young Women’s Christian Associations, and Red
Cross, civic organizations, social service groups, cultural groups)
and in school-based programs for parents. There are large
number of sources of information about smoking available from
educators in adult settings and in programs for parents. These
have been studied in-depth and reviewed elsewhere (188, 198).
The frequent contact with and involvement of women in the
school system should provide excellent opportunities to provide
female-oriented information.

Peer Group

This group is an important, influential source of information
on behavior. Evidence is strongest for the effect on initiation
(addressed earlier in this Part). In two studies of British work-
ing class women, the peer group was an important source of
information about smoking and pregnancy (11,74). Other strong
relationships within the lay adult community have also been
reported (118,201).

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Family

Significant others, especially within the family, have been
shown to be primary sources of information to pregnant women
(11,74). The female relative may serve as a particularly impor-
tant role model for black women (201). Smoking initiation is
strongly influenced by parental smoking habits in teenagers
(addressed earlier in this Part). In married couples, smoking
patterns tend to be congruent; this almost enforces a sharing of
information and makes it especially important in quitting ef-
forts that couples stop together or are very supportive of the
new ex-smoker (77,118,170,216).

Media: Television, Radio, Film, Newspapers, Magazines

The use of the mass media as a source of information as well
as a tool in effecting cessation has been extensively developed
in recent years (55,188,193,198,202,214).

Since women are almost exclusively the target audience of
women’s service magazines, effort should be devoted to using
this medium to provide information on smoking and health, ces-
sation techniques, and clinic availability. These magazines
have not adequately disseminated information on smoking and
health.

One of the principal reasons suggested for this failure is the
power that tobacco companies wield through the economic in-
centive of advertising (178). Only one women’s service magazine
does not accept cigarette advertising in the United States.
Frank admission of the economic dependency upon such adver-
tising has been made. Not a single leading national woman’s
magazine that accepts cigarette advertising in 7 years of publi-
cation printed an article “... that would have given readers any
clear notion of the nature and extent of the medical and social
havoc being wreaked by the cigarette-smoking habit’ (178).
Smith goes on to point out that those magazines that do not
accept cigarette advertising, or have no advertising at all, have
done considerably better at informing their readers of the
health risks of smoking.

Advertising

In recent years, advertising in the United States has been
directed specifically towards the women’s market, with themes
as diverse as the emancipation of women, the first woman (bi-
blical reference), romantic love, and the independent single
woman. Most girl smokers have a positive impression of the

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