Unaided Smoking Cessation

Fiore and colleagues (1990) found that the vast majority of smokers who had tried to stop reported doing so on their own, although this has changed in recent years with increased use of pharmacologic aids (Yankelovich Partners 1998). The finding held among women as well as among men, although a slightly higher proportion of women than men (16.8 vs. 13.4 percent) reported using an assisted method to stop smoking (Fiore et al. 1990; Yankelovich Partners 1998). In a study of California smokers, women were 27 percent more likely than men to use assistance (self-help, counseling, nicotine replacement therapy) for smoking cessation. These gender differences remained after adjustment for age, education, ethnicity, and number of cigarettes smoked per day (Zhu et al. 2000). Univariate analysis of the 1986 AUTS data showed that more men than women were successful in smoking cessation. However, in a multivariate logistic regression analysis that controlled for variables of demography and smoking history, gender was not a significant predictor of successfully stopping smoking (Fiore et al. 1990).

Comparable results were seen in other large, population-based studies that used self-reports of smoking cessation. For example, the 1991 NHIS Health Promotion and Disease Prevention Supplement reported that although education, age, and race and ethnicity were significant predictors of adults' attempts to stop smoking and to maintain cessation, gender was not (CDC 1993b). Pirie and colleagues (1991) found that attempting to stop smoking and maintaining abstinence were equally common among women and men in a large Minnesota cohort of young adults, and Salive and colleagues (1992) reported that age-adjusted cessation and relapse rates differed little by gender among smokers aged 65 years or older in three large community cohorts. At variance with these findings, Ward and colleagues (1997) found that among adults who had stopped smoking without assistance, abstinence after one year was significantly greater among men than among women (8.6 vs. 0.0 percent). However, in another longitudinal analysis of smokers who attempted unaided smoking cessation, men who smoked were more likely than women who smoked to achieve initial cessation (1 month) (82 vs. 73 percent); no differences in long-term cessation were found (Marlatt et al. 1988).

In a descriptive comparison of 10 prospective studies of self-quitting, long-term abstinence was calculated among smokers who attempted to stop smoking on their own (Cohen et al. 1989). More than 5,000 smokers participated in the combined studies. Longterm cessation, relapse, and unsuccessful quit attempts were very similar among the studies. A formal meta-analysis of all of the studies did not show a gender effect on either 6-month or 12-month abstinence.

Differences are seen between women and men in the timing of smoking cessation. A higher proportion of women than men had stopped smoking at ages younger than 40 years, and a higher proportion of men than women had stopped smoking between 50 and 65 years of age. Jarvis (1994) postulated that gender-specific differences in life experiences, such as pregnancy and child rearing, may account for such trends. Alternatively, smoking uptake and quitting among U.S. men preceded that of U.S. women in this century. Thus, more men than women were likely to quit among older generations of smokers. Among recent birth cohorts, however, the patterns of uptake and quitting are more comparable among women and men. Gritz and colleagues (1996) suggested that menopause, with its attendant hormonal changes (leading to behavioral events such as fluctuations in affect or difficulty with weight control) and changes in social roles, provides a barrier to cessation.

Methods of smoking cessation vary somewhat by gender. In a survey of smokers at 10 worksites, Sorensen and Pechacek (1987) found that similar proportions of women smokers (70 percent) and men (73 percent) smokers were planning to change their smoking behavior (stop, cut down, or switch cigarette brand) in the next 12 months, but men were more likely to say they wanted to stop smoking entirely, and women were more likely to report wanting to reduce the number of cigarettes smoked. A similar pattern emerged in a larger Minnesota sample: women and men were equally likely to report intentions to change their smoking behavior in the next year, with men more often choosing to stop entirely and women more often choosing to cut down (Blake et al. 1989). Although women and men reported a similar number of previous attempts to stop smoking, women were also less successful in sustaining their attempts for longer than one week. These investigators concluded that women were more tentative and less committed to stopping smoking entirely and postulated that women may be less confident than men in their ability to stop, as well as less persistent in their efforts.

Self-Help Programs

Numerous self-help interventions have been developed for smoking cessation, including manuals, videotapes, and mass-media programs designed to help smokers stop smoking on their own. Although the effects of self-help programs appear to be small and inconsistent (Fiore et al. 2000), they are appealing because they can be easily disseminated to the vast population of smokers who try to stop on their own each year (Fiore et al. 1990; Curry 1993).

Beginning in the mid-1980s, NCI funded seven large-scale controlled trials to develop and assess maximally effective self-help programs and materials. These trials reached more than 200,000 smokers directly or indirectly in communities, worksites, hospitals, HMOs, and voluntary associations (Glynn et al. 1990). A summary of the results of the self-help trials (Cohen et al. 1989) indicated that a higher proportion of women smokers than men smokers enrolled, but no gender-specific differences in outcome were found. To date, little is known about the relationship between smokers' use of self-help materials and the outcomes of self-help treatment or about the impact of various treatment formats on program reach or efficacy (Curry 1993).

Few studies have explored gender-specific differences in self-help treatment methods or adjuncts (i.e., brief telephone counseling, tailored feedback, physician advice). Fewer have explored interactions between treatment and gender. A study of two interventions that used self-help materials targeted to older smokers (> 60 years old) (Ossip-Klein et al. 1997) found an interaction between treatment and gender. Among women, cessation levels were higher among those who received two proactive telephone calls. Among men, however, cessation levels were higher for those who received two mailed prompts to call a stop-smoking hotline. This result suggested that women may be more responsive to personal interaction.

A survey by Lando and associates (1991) also suggested that smoking cessation strategies should be different among women smokers and men smokers. In a study based in one of the Minnesota Heart Health Programs, they reported that women smokers were more interested than men smokers in using filters that successively reduced the amount of nicotine inhaled from a cigarette to help them prepare for smoking cessation.

Several self-help guides and programs have been developed exclusively for women smokers, including pregnant women (Windsor et al. 1985; Ershoff et al. 1989; Mayer et al. 1990), mothers of young children (Cummings et al. 1989; Davis et al. 1992), registered nurses (Gritz et al. 1988), HMO enrollees (Gritz et al. 1992), and women living in a low-SES urban area (Mermelstein and Borrelli 1995). Materials developed for pregnant women have been found to outperform generic materials (Windsor et al. 1985). One self-help study with pregnant smokers suggested that supplying smokers with repeated "cues to action" over time, by mail or phone, would itself have benefit (Ershoff et al. 1989). In a study of nonpregnant mothers of young children, however, cessation levels were similar among young women who used a specially developed tailored guide and among a similar group who used generic materials (both 12.5 percent) (Cummings et al. 1989; Davis et al. 1992).

Gritz and colleagues (1992) evaluated an intervention for women smokers (identified by survey, not volunteers) in a large HMO population who were mailed a six-week series of self-help booklets on smoking cessation. A comparison group of women smokers did not receive self-help material. The overall point prevalence abstinence (at least 48 hours) among all participants was 19 percent at 18 months, with no difference seen between the treatment group, which received an unsolicited, mailed self-help cessation program, and the control group. A more recent study provided support for using personalized messages with self-help material. In this study (Strecher et al. 1994), 359 adult smokers from a large family practice were interviewed briefly, then randomly assigned to receive either a generic letter on smoking cessation or a tailored letter containing advice geared to the smoker's individual health-related beliefs about the benefits of and barriers to smoking cessation, stage of change, and reasons for past failures to stop smoking. Tailoring health letters to the characteristics of each patient allowed the investigators to focus, in clear detail, only on the information most relevant to each smoker. Among light or moderate smokers, self-reported cessation at four months (adjusted for age, education, and gender) was significantly higher for those receiving tailored information than for those receiving generic letters. No significant differences in intervention effects were found between women and men.

Minimal Clinical Interventions

In the past decade or so, efforts have been made to increase the proportion of primary care providers who routinely advise their patients to stop smoking and assist them in that effort (Ockene 1987; USDHHS 1991a; Fiore et al. 1996, 2000; National Committee for Quality Assurance 1997). The 1991 NHIS Health Promotion and Disease Prevention Supplement found that 70 percent of adult smokers reported at least one visit to a physician in the preceding 12 months, with more than two-thirds reporting more than one visit (CDC 1993a). These statistics led to the projection that an additional one million smokers could be helped to stop smoking each year if primary care providers offered brief counseling to all of their patients who smoke (CDC 1993a).

The proportion of adult smokers who reported ever having been advised by a health care professional to stop smoking increased from 26 percent in 1976 to 56 percent in 1991 (CDC 1993a). In 1992, 52 percent of smokers who had seen a physician in the previous year reported receiving advice to stop smoking (Tomar et al. 1996). The likelihood of having been counseled to stop smoking was directly related to the number of health care visits reported and was slightly higher among women, who reported slightly more visits to a physician than did men (39 vs. 35 percent). Among smokers who had seen a dentist in the previous year, 24 percent reported they had received advice to stop smoking (Tomar et al. 1996). As was observed for counseling from a physician, the percentage receiving counseling by a dentist was slightly higher among women (27 vs. 22 percent). Tomar and colleagues (1996) noted that either smokers are less likely to remember the advice received from dentists than from physicians, or dentists are less likely to advise their patients to quit smoking. Additionally, the researchers concluded that dentists and physicians may not be maximizing their opportunities to advise patients who use tobacco to quit or may not be adequately communicating to their patients the importance of quitting.

Numerous controlled trials were launched in the mid-1980s to test the efficacy of "minimal contact" medical interventions, which relied on techniques that could easily be integrated into routine care and delivered to all smokers, regardless of their interest in smoking cessation. The emphasis was on brief counseling by a health care provider, supported by self-help materials on smoking cessation and, if appropriate, nicotine replacement therapy. Results of these trials showed that even brief interventions significantly improved patient outcomes (Glynn 1988; Kottke et al. 1988; Fiore et al. 1996, 2000). No gender-related differences were observed in attempts to stop smoking, cessation, or relapse, by 12-month cessation rates among HMO patients exposed to brief physician advice plus a nurse-assisted intervention (Whitlock et al. 1997). Women who tried to stop smoking used more cessation strategies than did men. This finding suggested that the processes of smoking cessation may differ by gender.

Two studies by the British Thoracic Society examined the effects of cessation advice from physicians, with or without other levels of encouragement, among adult patients (mean age, 51 years for women and 50 years for men) with smoking-related symptoms who were referred to either study by their physicians (Research Committee of the British Thoracic Society 1990). No significant interactions between type of intervention and gender were observed in either of the two studies, although one found significantly higher abstinence at 12-month follow-up among men than among women.

The 1996 publication, Smoking Cessation, Clinical Practice Guideline of the Agency for Health Care Policy and Research (AHCPR), and the 2000 U.S. Public Health Service (PHS) update, recommended that tobacco use be treated as a vital sign with no differential treatment guidelines by gender, except for treatment during pregnancy (Fiore et al. 1996, 2000). The PHS guideline states, "Many women are motivated to quit during pregnancy, and health care professionals can take advantage of this motivation by reinforcing the knowledge that cessation will reduce health risks to the fetus and that there are postpartum benefits for both the mother and the child" (Fiore et al. 2000, p. 93). It goes on to state, "Postpartum relapse may be decreased by continued emphasis on the relationship between maternal smoking and poor health outcomes in infants and children" (Fiore et al. 2000, p. 93). Findings from the Lung Health Study suggested that women with smoking-related disease may benefit from specific treatment (Bjornson et al. 1995); however, few minimal clinical interventions have been designed for women smokers in high-risk medical groups, such as women who use oral contraceptives or those with diabetes, heart disease, smoking-related cancer, osteoporosis, obesity, eating disorder, depression, or chemical dependence (Fisher et al. 1990a; Gritz et al. 1993).

Intensive Clinical Interventions

Intensive clinical interventions involve individual or group treatment in multiple sessions. The most successful treatments have been multicomponent cognitive-behavioral programs that incorporate strategies to prepare and motivate smokers to stop smoking (USDHHS 1988, 1989; Lando 1993; Fiore et al. 1996, 2000). Effective strategies vary in their longterm efficacy, from 14.4 percent for social support delivered in the clinical setting to 19.9 percent for rapid smoking, an aversive conditioning technique (Fiore et al. 1996,2000).

Women are somewhat more likely than men to use intensive treatment programs (Fiore et al. 1990; Yankelovich Partners 1998). Similarly, women have a stronger interest than men in smoking cessation groups that offer mutual support through a buddy system and in treatment meetings over a long period (Lando et al. 1991). A few studies of formal treatment have examined interactions between treatment and gender. Flaxman (1978) found that women fared better with a delayed date to stop smoking than with immediate cessation, whereas the reverse was true among men. Curry and colleagues (1988) compared two theoretical approaches to smoking cessation: a traditional treatment program that emphasized absolute abstinence, enforced with a contingency contract that required those who smoked after their smoking cessation date to send a check for at least $15 to an organization or person they disliked, and a relapse prevention program that focused on the gradual acquisition of skills needed to abstain from smoking. Men had greater success with absolute abstinence and contingency contracting, whereas women were more successful in the relapse prevention program. In a small pilot study, Weissman and colleagues (1987) reported similar findings among adolescent smokers. The majority of the boys who took part in a program awarding money for achieving target (nonsmoking) levels of carbon monoxide stopped smoking, but all the girls who were enrolled dropped out and were unsuccessful. These results agreed with other evidence that women prefer a more gradual approach to smoking cessation (Sorensen and Pechacek 1987; Blake et al. 1989; Lando et al. 1991).

Pharmacologic Adjuncts

Pharmacologic approaches to smoking cessation raise a number of issues specific to women (Pomerleau 1996). As outlined in detail in the Surgeon General's report Reducing Tobacco Use (USDHHS 2000) and confirmed by the AHCPR and PHS cessation guidelines (Fiore et al. 1996, 2000), a number of effective and promising pharmacotherapies for nicotine addiction have emerged in the past decade: nicotine gum (polacrilex), transdermal nicotine patches, nicotine nasal spray, and oral nicotine inhalers (Hughes 1993; Henningfield 1995; Fiore et al. 1996, 2000; Hughes et al. 1999). Nicotine gum and the patch are approved for over-the-counter use (Hughes et al. 1999). Bupropion, a nonnicotine pharmaceutical, showed success in smoking cessation and was approved by the U.S. Food and Drug Administration (FDA) for smoking cessation (Ferry et al. 1992; Ferris and Cooper 1993; Hurt et al. 1997; Jorenby et al. 1999) (see also "Depression" later in this chapter). Two other formulations, clonidine and the antidepressant nortriptyline, have been recommended as second-line pharmacotherapies, but have not yet been approved by the FDA specifically for this purpose (Fiore et al. 2000). Anxiolytics, benzodiazepines, other antidepressants, beta-blockers, silver acetate, and mecamylamine have been studied but are not recommended for tobacco use treatment (Fiore et al. 2000).

Nicotine gum and patches are the best-studied nicotine replacement medications. Surgeon General's reports on smoking and health (USDHHS 1988, 1989, 2000) and several meta-analyses and reviews have concluded that nicotine gum boosts smoking cessation in minimal contact and intensive treatment programs by as much as 50 to 100 percent (Lam et al. 1987; Cepeda-Benito 1993; Hughes 1993; Tang et al. 1994; Fiore et al. 1996, 2000). Use of the gum alone or with brief medical interventions is beneficial (Fiore et al. 1996, 2000), but the gum probably works best with counseling to guide in proper use and chewing technique (Hughes 1993, 1995). Transdermal nicotine patches are easier to use than nicotine gum, cause fewer side effects that might disrupt appropriate use, and result in higher blood levels of nicotine and more stable replacement of nicotine (Killen et al. 1990b; Fiore et al. 1992; Hughes 1993). Moreover, dosing and weaning schedules are better defined and easier to follow with the patch (Fiore et al. 1992; Henningfield 1995). Both nicotine gum and nicotine patches have been found to reduce withdrawal discomfort after smoking is stopped. Some data suggested that nicotine gum (Killen et al. 1990b; Hatsukami et al. 1995; Perkins 1999) and the nicotine patch (Perkins 1996; Wetter et al. 1999a) may be less effective among women than among men, but other research has not reported differences by gender in their effectiveness (Hughes 1993; Fiore et al. 1994; Jorenby et al. 1995). Nevertheless, nicotine replacement has been shown to have value over placebo among women smokers and thus remains recommended for use (Fiore et al. 2000).

On average, women smoke less than do men, but some studies suggested women are more dependent on nicotine than are men smokers. Women's lower body weight and possibly greater sensitivity to nicotine have been proposed to explain comparable levels of repeated samples of plasma nicotine (Grunberg et al. 1991; Pomerleau et al. 1991a). Other studies reported no gender difference in nicotine dependency after adjustment for the intensity of smoking (Gunn 1986; Svikis et al. 1986; Pirie et al. 1991). Perkins and colleagues (1999) noted that women smokers are less dependent on nicotine than are men and suggested that women's smoking is reinforced by factors other than nicotine. Data from the 1991-1992 National Household Survey on Drug Abuse showed that 81 percent of younger female smokers (aged 12 through 24 years) and 79 percent of older female smokers (aged > 25 years) rated themselves as addicted to tobacco on at least one of four different indices of nicotine addiction, including an inability to cut down on their smoking (CDC 1995a). (See "Nicotine Dependence Among Women and Girls" in Chapter 2 for more data on indicators of nicotine addiction.) The Lung Health Study suggested that men smokers may be less aware than women smokers of nicotine dependence and nicotine deprivation or less willing to admit their dependence (Bjornson et al. 1995). Accordingly, women may be more likely to use nicotine replacement therapies (Fiore et al. 1990; Orleans et al. 1994b; Bjornson et al. 1995; Lando and Gritz 1996).

One intervention study of women found that transdermal nicotine replacement therapy or placebo nicotine replacement therapy was less effective in controlling objective withdrawal symptoms among women than among men (Wetter et al. 1999b). However, self-reports of withdrawal symptoms did not reveal any gender-specific differences.

Other evidence suggested that women remember their withdrawal symptoms as being more severe than do men (Pomerleau et al. 1994b). In a randomized trial of women and men smokers, participants were asked to rate withdrawal symptoms during previous quit attempts and during a current quit attempt. Although no differences were observed between women and men for any current withdrawal symptoms reported, three of four retrospectively assessed withdrawal symptoms (irritability, difficulty concentrating, and increased appetite) were reported significantly more often among women than among men. Gritz and colleagues (1996), in a review of the withdrawal distress literature, noted that women are more likely to report withdrawal symptoms than are men when attempting cessation. They also noted that the relapse rate was higher among women who reported intense withdrawal symptoms than among those who reported fewer withdrawal symptoms. That pattern was not found among men.

Sussman and colleagues (1998a) found that adolescent females were more likely than adolescent males to report having difficulty going a day without smoking and to report relying on cigarettes to improve daily functioning. In another study, physiologic differences between women and men who had recently stopped smoking and were exposed to cues to smoke were examined; women had a higher reactivity to cues than did men (Niaura et al. 1998). In a laboratory study that compared responses to smoking among women and men, Eissenberg and colleagues (1999) reported similar physiologic effects by gender but more sensitivity among women than men to some of the subjective effects of smoking.

Because of uncertainties over the safety of nicotine replacement during pregnancy, FDA has assigned a Pregnancy Category C warning to nicotine gum ("risk cannot be ruled out") and a Pregnancy Category D warning to transdermal nicotine ("positive evidence of risk") (Henningfield 1995). Hence, these aids are not routinely prescribed for pregnant or reastfeeding smokers. However, the benefits of nicotine replacement medication may outweigh the risks from smoking among pregnant and lactating mothers (Benowitz 1991; Oncken et al. 1996; Jorenby 1998). Caution is advised because nicotine itself poses risks to the fetus, including neurotoxicity (Slotkin 1998). Therefore, pregnant women should first be encouraged to quit without pharmacotherapy. However, nicotine replacement therapy may be indicated for pregnant women who are unable to quit smoking. If used, doses should be delivered at the lowest effective range, blood levels of nicotine should be monitored, and an intermittent delivery system (such as gum) should be used. More research is needed to determine the effects of nicotine replacement therapy among pregnant women and women using oral contraceptives or estrogen replacement therapy (Pomerleau et al. 1991a).

The action of bupropion (Zyban) is not well understood. Smokers who plan to stop smoking start treatment with bupropion at least 1 week before cessation and take the drug for up to 12 weeks (Hughes et al. 1999). Like nicotine replacement therapy, bupropion doubles smoking cessation rates compared with placebo alone, and one study suggested that a combination of bupropion and the nicotine patch produced cessation rates higher than did either treatment alone (Jorenby et al. 1999). Bupropion works well among smokers with or without a history of depression (see "Depression" later in this chapter), which suggested that its antidepressant effect does not account for its success in smoking cessation. No studies have been published in which the gender-specific effects of bupropion were examined.

Other pharmacologic adjuncts for treatment of tobacco dependence include therapies to block the reinforcing actions of nicotine (e.g., mecamylamine), nonspecific pharmacotherapies aimed at lowering cessation-related stress or depression (e.g., anxiolytics and antidepressants), and therapies for tobacco withdrawal symptoms (e.g., clonidine) (Jarvik and Henningfield 1993; Henningfield 1995; USDHHS 2000). Except for one antidepressant (nortriptyline) and clonidine (Hurt et al. 1997; Hall et al. 1998; Fiore et al. 2000), these approaches have not yet been established as effective adjuncts to standard behavioral treatments. Gender differences have not been examined.

Population-Based Interventions

A number of population-based intervention programs have been developed and tested. Such programs focus on involving an entire population or subgroup of the population in intervention activities. Worksite programs, for example, seek to involve all worksite smokers in cessation activities, and evaluation is based on the entire worksite population (see "Worksite Programs to Reduce Smoking Among Women" later in this chapter). Interventions in religious organizations use the religious community to foster smoking cessation (see "Minority Women" later in this chapter). Community intervention programs such as the Community Intervention Trial for Smoking Cessation (COMMIT) seek to provide constant, inescapable messages about the value of smoking cessation (see "Community-Based Efforts to Reduce Smoking Among Women" later in this chapter). Telephone quit lines provide intensive counseling in a format that is easily accessible by smokers. Unlike many of the individual-oriented approaches discussed in this background section, population-based approaches are still somewhat immature. Generalization between programs and between venues is difficult. Nevertheless, as later sections of this chapter show, some promise exists for such population-based approaches for smoking cessation.

Smoking and Menstrual Cycle

To date, most studies of the endocrine effects on nicotine addiction and withdrawal have focused on the female smoker with regular menstrual cycles. Important questions about the possible mediating role of menstrual phase-related changes in energy regulation, appetite, and weight; depression; and vulnerability or resistance to stress among smokers remain largely unexplored.

Effects of Oral Contraceptives

In 1982-1988, nearly one-fourth of users of oral contraceptives were smokers (Barrett et al. 1994). Cardiovascular responses of oral contraceptive users (Emmons and Weidner 1988; Davis and Matthews 1990) suggested that oral contraceptive use may enhance the reactivity of blood pressure, though not heart rate, to cognitive stress but that its use does not affect reactivity to nicotine. Another study of oral contraceptive users and nonusers, on the other hand, found that the users had larger nicotine-induced increases in heart rate than did nonusers (Masson 1995). These studies suggested differential endocrinemediated sympathetic activation by nicotine. Masson further observed that oral contraceptive use attenuated the reductions in anxiety after smoking among women who menstruated regularly. Lack of random assignment to oral contraceptive use or nonuse, however, complicates interpretation of all these findings, because self-selection into either category may be associated with personality differences that would also affect reactivity or anxiety. Moreover, a consensus panel recently reviewed the evidence on the health effects of oral contraceptive use and smoking and recommended that women older than 35 years who smoke more than 15 cigarettes per day should not be using oral contraceptives (Schiff et al. 1999). Furthermore, to minimize as much as possible the risks for stroke and acute myocardial infarction, the panel suggested that oral contraceptives containing very low doses of ethinyl estradiol be given to smokers, especially women smokers older than 35 years of age.

Effects of Menopause and Aging on Smoking

Most, although not all, studies have shown an earlier age at menopause among women who smoke (see "Menstrual Function, Menopause, and Benign Gynecologic Conditions" in Chapter 3). Menopause, on the other hand, may be an obstacle to stopping smoking. Using data collected in Great Britain, Jarvis (1994) argued that although the percentage of persons who have ever smoked and who became former smokers was higher among men than among women, the difference was accounted for almost entirely by differences in the age distribution in the population that had stopped smoking. For ages 16 through 42 years, the relative risk (RR) for smoking cessation was higher among women than among men. Among women and men aged 43 through 50 years, the RR was about equal, and at ages 51 through 57 years, the RR among women compared with men dropped dramatically, rising somewhat at ages 58 through 64 years and at 65 through 70 years and still further at ages 71 years or older, but not reaching equality. The differences were attenuated slightly by adjustment for sociodemographic variables. However, other investigators have suggested that these findings are a "cohort effect" related to historical gender-specific differences in smoking prevalence and quitting (see "Current Prevalence of Smoking" in Chapter 2).

The effect of HRT may be related to menopausal effects on smoking cessation. Greenberg and colleagues (1987) found an excess of smokers among new HRT users and, among smokers, a relationship between the number of cigarettes smoked and the likelihood of HRT use. Because HRT is often prescribed for the symptoms of menopause, the authors speculated that smoking may initiate or aggravate the symptoms for which HRT is prescribed but conceded that several alternative explanations were possible. Possible alternatives include the effect of weight, affect, osteoporosis, SES, and family on the likelihood that HRT will be prescribed; all of these factors also influence or are influenced by smoking (Matthews et al. 1990). Thus, it seems unlikely that this question can be resolved without studies that include random assignment to receive HRT or placebo.

The Women's Health Initiative is a long-term study that will provide opportunities to address these questions. This study has collected and continues to collect information on ever smoking, current smoking, age at smoking initiation, amount smoked, and other smoking-related variables that can be correlated with the study arm to which women are randomly assigned. The arms include HRT in various formulations (e.g., estrogen alone or estrogen and progestin) versus placebo, offering the opportunity to understand the role of HRT in smoking (Women's Health Initiative Protocol for Clinical Trial and Observational Study Components 1998).

Smoking Cessation

For this review, studies published in English were identified through bibliographies in reviews of the literature, by experts, and in online databases. Trials were excluded unless they were randomized, controlled trials published between 1976 and 1998 and had biochemically confirmed abstinence. The strong "demand" for pregnant women to "not smoke" may compromise the validity of self-report. For example, two trials found high percentages of deception (28 and 35 percent) in late pregnancy (Windsor et al. 1993b; Kendrick et al. 1995) and differential deception between treatment groups (32 vs. 17 percent) and control groups (49 vs. 32 percent).

Multivariate analyses of the effect of participants' baseline characteristics on smoking during late pregnancy were conducted in two trials. Findings from the two studies that used relatively intensive treatment and produced a large overall effect suggested that women who had experienced problems during pregnancy (e.g., vomiting or high blood pressure) had lower saliva levels of thiocyanate in their eighth month, indicating a lower level of smoking (Hebel et al. 1985; Ershoff et al. 1989). Such problems may have increased the women's sense of susceptibility to health effects and may have increased their motivation to stop smoking. Women with more education also had lower levels of thiocyanate during pregnancy. Indicators of higher levels of smoking before and early in pregnancy were related to higher eight-month thiocyanate levels.

Windsor and colleagues (1993b) examined smoking cessation among African American women and among low-income women by using univariate tests. Cessation was significantly higher among African American women in treatment groups than in control groups (18.1 vs. 10.7 percent; p = 0.03) and was lower but not significantly different among white women in treatment groups than in control groups (5.2 vs. 10.0 percent; p = 0.08). A separate analysis of a subsample, with baseline measures of cotinine level, revealed that virtually all women who stopped smoking were those whose saliva samples contained less than 100 ng of cotinine/mL at the first prenatal visit. Thus, the major effect of programs tested to date appears to be among lighter smokers. This finding was replicated in subsequent studies (Hartmann et al. 1996; Woodby et al. 1999).

Estimates of overall effectiveness of cessation programs for pregnant women may underrepresent the impact of these programs. On the basis of a study with multiple validated measures beginning in the 20th week of pregnancy (Ershoff et al. 1989), the difference between treatment and control groups appeared larger in the second trimester (RR, 2.6) than in the eighth and ninth months (RR, 1.5). Although some relapse occurred among women in the treatment group, the chief reason for the smaller difference in the eighth and ninth months was late smoking cessation in the control group. Thus, one effect of intervention may be to advance cessation that might have occurred later in the pregnancy.

In four trials that reported biochemically verified measures (Sexton and Hebel 1984; Windsor et al. 1985, 1993a; Secker-Walker et al. 1994; Hartmann et al. 1996), the number of cigarettes smoked in the eighth and ninth months of pregnancy was significantly reduced. Evidence has shown that reduction confers some protection for the fetus, whether the reduction is defined as a change in mean level of thiocyanate in the treatment group (Hebel et al. 1988) or as a decrease in cotinine level of 50 percent or more from baseline (Li et al. 1993). Hebel and colleagues (1988), however, found that the benefit was almost entirely restricted to those who achieved total abstinence, were smoking less than one cigarette per day, or were smoking one to five cigarettes per day at eight months' gestation.

Preventing Relapse Before Delivery

In 1990, Fingerhut and coworkers (1990) reported that across studies, approximately one-fourth of pregnant smokers had stopped smoking before their first prenatal visit. Published estimates have ranged from 15 percent in a largely African American public maternity clinic population (Windsor et al. 1993b) to 42 percent in a primarily white HMO population (Petersen et al. 1992). Although the majority of these "spontaneous quitters" remained free of smoking throughout pregnancy, as many as 33 percent relapsed before delivery, as evidenced by biochemical confirmation in a population receiving no intervention (Lowe et al. 1997).

To date, five randomized trials with biochemical confirmation of nonsmoking in late pregnancy have tested interventions to prevent relapse among persons who had stopped spontaneously. The RRs were all close to 1.0 and were not significant.

Several of these trials have produced a profile of women at high risk for relapse. The risk factors include stopping smoking only within one or two weeks of beginning prenatal care as opposed to earlier, having low confidence in maintaining cessation, being younger, being a heavier smoker before pregnancy, experiencing less nausea during pregnancy, and having previous children (Quinn et al. 1991; Secker-Walker et al. 1995).

Effectiveness in Improving Birth Outcomes and Associated Economic Benefits

Four studies of whether an intervention during pregnancy increases smoking cessation also evaluated the effect of the cessation intervention on birth outcomes. Although three studies found a lower risk for low birth weight associated with intervention (Sexton and Hebel 1984; Ershoff et al. 1990; Hjalmarson et al. 1991), none of the findings was statistically significant. A fourth study (Secker-Walker et al. 1994) found no lower risks, but it also found no effect of the intervention on smoking cessation. The only study to evaluate the effect of a prenatal smoking cessation program on interuterine growth retardation (Ershoff et al. 1990) found a protective effect that was of borderline statistical significance (RR, 0.2; 95 percent confidence interval [CI', 0.0 to 1.1). Although evaluation of individual cessation programs has not shown a statistically significant reduction in birth outcomes, the relationship between maternal cessation and reduction in low birth weight has been well documented (USDHHS 1990).

The economic benefits of smoking cessation during pregnancy have been estimated in relation to birth outcomes. One analysis, based on a RR of 2.6 for sustained cessation beginning by the 20th week of pregnancy (Ershoff et al. 1989), found a benefit-to-cost ratio of 3:1 (a savings of $300 in costs for the neonates' initial hospital episode for every $100 spent on smoking cessation) (Ershoff et al. 1990). A second analysis was based on a RR of 1.7 for smoking cessation, hospital and physician costs at birth, rehospitalization costs in the first year of life, and long-term health care costs, as estimated by the Office of Technology Assessment (Windsor et al. 1993b). In this analysis, the low estimate of the benefit-to-cost ratio was 18:1, and the high estimate was 46:1. A more recent simulation analysis estimated savings that would derive from reductions in the number of low birth weight babies in the United States if smoking prevalence were reduced before or during the first trimester of pregnancy. It found that an annual decline in smoking prevalence of one percentage point would prevent 1,300 low birth weight babies and save $21 million (in 1995 dollars) in direct medical costs in the first year alone (Lightwood et al. 1999). These analyses suggested that prenatal smoking cessation interventions can provide short-term economic benefit to the sponsoring health care provider.

Postpartum Smoking

Despite successful abstinence for 5 months or more, many women who stop smoking during pregnancy return to smoking within 6 months after the birth. Postpartum relapse has been reported at 32 to 54 percent at six weeks after delivery (Ershoff et al. 1983; Mullen et al. 1990), 45 percent at 3 months (Sexton et al. 1987), 56 to 65 percent at 6 months (Fingerhut et al. 1990; McBride and Pirie 1990; Mullen et al. 1990; McBride et al. 1992), and 67 percent at 12 months (Fingerhut et al. 1990). Most of these studies confirmed cessation biochemically at least once during pregnancy (Ershoff et al. 1983; Sexton et al. 1987; Mullen et al. 1990; McBride et al. 1992).

Conversion of a greater proportion of prenatal abstainers to long-term abstainers is needed. In a test of different ways to prevent women who had abstained from smoking during pregnancy from taking up smoking again in postpartum, 897 pregnant women from two HMOs were enrolled in a study (McBride et al. 1999). Participants received one of three interventions: self-help booklets only, booklet plus prepartum intervention, or booklet plus prepartum and postpartum intervention. All interventions were delivered by mail and telephone. Relapse to smoking at eight weeks postpartum was slightly lower, though not significantly so, among women in the prepartum group (33 percent) and the postpartum group (35 percent) than among women in the self-help booklet only group (44 percent, p = 0.09). Among women who received the postpartum intervention, rate of relapse to smoking was slower; however, at 12 months postpartum the three groups had the same rate of abstinence from smoking. Similarly, little success in long-term abstinence has been reported from cessation programs for mothers of young children (Greenberg et al. 1994; Wall et al. 1995). Wall and colleagues (1995), however, reported that a pediatrician-based program increased self-reported continued abstinence at 6 months after delivery among women who had stopped smoking during pregnancy.

Predictors of postpartum relapse may provide clues for developing smoking cessation programs. Some risk factors include having a partner who smokes, having friends who smoke, lack of confidence at midpregnancy regarding continued nonsmoking, and concern about weight (McBride and Pirie 1990; McBride et al. 1992; Severson et al. 1995; Mullen et al. 1997).

Behavioral Weight Management Programs

Two small intervention studies that combined behavioral weight control and smoking cessation interventions (Grinstead 1981; Mermelstein 1987) have been summarized in a previous report (USDHHS 1990). Neither of those programs succeeded in affecting smoking cessation, although one of them (Mermelstein 1987) succeeded in reducing weight gain after smoking cessation.

More recently, two large clinical trials tested the use of behavioral weight management programs as an adjunct to standard smoking cessation programs. Hall and colleagues (1992) reported on a trial that randomly assigned 131 female smokers and 49 male smokers to one of three groups: (1) an innovative intervention that combined a smoking cessation program with daily monitoring of weight and contingent caloric reduction, an individual exercise plan, and behavioral self-management principles; (2) a nonspecific weight control program oriented toward providing insight into eating styles through discussion groups, nutrition and exercise information, group support, and therapeutic attention; and (3) a standard treatment program consisting of an information packet on good nutrition and exercise. All three groups received a smoking cessation program that combined aversive smoking and relapse prevention skills training in seven sessions. Contrary to the hypothesis, the group receiving only the information packet had significantly better smoking cessation outcomes than did either of the active weight control groups. Validated seven-day abstinence rates were 35 percent in the standard treatment group, 22 percent in the nonspecific treatment group, and 21 percent in the innovative treatment group. At 52 weeks, participants who stopped smoking had gained 3.61, 3.35, and 0.86 kg, respectively. No differences were found by gender. The authors offered two possible explanations for their findings: either the complexity of weight control interventions detracted from simultaneous efforts to stop smoking, or the caloric reduction prescribed in the active weight treatment programs actually encouraged smoking. The second explanation is consistent with the literature on animal studies and the reinforcing value of psychoactive drugs under conditions of caloric deprivation (Perkins 1994).

In the largest trial to date using random assignment (Pirie et al. 1992), 417 women smokers were assigned to (1) a standard smoking cessation program (Freedom From Smoking® for You and Your Family, an American Lung Association program), (2) the standard program plus nicotine gum, (3) the standard program plus a behavioral weight management program, or (4) the standard program plus both nicotine gum and the behavioral weight management program. Both nicotine gum and the weight management program were hypothesized to have effects on controlling weight. The standard program plus nicotine gum produced significantly better smoking cessation outcomes (both point prevalence and continuous abstinence at one-year follow-up) than did the standard program alone. The standard program plus the weight management program did not produce better smoking cessation outcomes than did the standard program alone. When both weight management and nicotine gum were added to the standard program, the combination produced significantly poorer outcomes than did the standard treatment plus nicotine gum. Contrary to the hypothesis, no difference was noted in weight gain across treatments among persons who had abstained from smoking continuously for 12 months. The reasons for the lack of effectiveness of the weight control components are unclear. Compliance with aspects of the weight control programs, such as keeping food records, fell to low levels by the end of the intervention.

Exercise Programs

Exercise programs have been proposed as possible adjuncts to smoking cessation programs, in part because of their effects on weight control (Russell et al. 1988). A large observational study of U.S. nurses found that smoking cessation was associated with weight gain but that this relationship was diminished by spontaneous exercise, with a dose-response effect (Kawachi et al. 1996). Because calorie reduction may enhance the reinforcing value of smoking, exercise programs may be more successful than programs that focus on control of eating. Several reports have described exercise interventions in groups of women, but all these studies were small and short term. Russell and colleagues (1988) found no effect of the exercise intervention on either smoking cessation or weight outcomes in a study of 42 women randomly assigned to three treatment groups (exercise, general support, and a brief-contact control group).

Marcus and colleagues (1991) described an exercise intervention in a study of 20 women randomly assigned to one of two programs: 10 received a smoking cessation program only, and 10 received the smoking cessation program plus a supervised exercise program. At the end of treatment (4 weeks after smoking cessation), five of the exercise participants and none of the other participants were abstinent from smoking; the difference was significant. A second study controlled for the extra time exercise participants spent with counselors by having the non-exercise group spend an equal amount of time with health educators (Marcus et al. 1995). Twenty women were randomized to each of the two groups, but neither weight change nor smoking cessation was significantly different between groups. However, the exercise group had slightly higher rates of abstinence and lost a small amount of weight. A larger study (Marcus et al. 1999) randomly assigned 281 women smokers to a cognitive-behavioral program with exercise or the same program without exercise, but with equal contact time with staff. Compared with smokers in the control group, those in the exercise arm of the study had higher smoking cessation rates immediate ly after the program (19.4 vs. 10.2 percent; p = 0.03), at 3 months after the program (16.4 vs. 8.2 percent; p = 0.03), and at 12 months (11.9 vs. 5.4 percent; p = 0.05). Furthermore, the exercise group had gained less weight than the control group (3.1 vs. 5.4 kg; p = 0.03). To ascertain whether there are differential effects on weight gain among women compared with men, trials that include a weight management component should be conducted among women and men and results analyzed by gender.

Pharmacologic Approaches in Relation to Weight Control

Pharmacologic approaches hold some promise for controlling the weight gain that often accompanies smoking cessation. These approaches are less complex than behavioral weight management programs and can thus more easily be incorporated into smoking cessation programs.

Pathways Linking Depression and Smoking

Overrepresentation of persons with major depressive disorder (MDD) among patients of smoking cessation clinics has been noted (see "Depression and Other Psychiatric Disorders" in Chapter 3). Lifetime rates of MDD in cessation studies conducted at the University of California, San Francisco, have been reported at 46 percent (Ginsberg et al. 1995), 31 percent (Hall et al. 1994), and 22 percent (Hall et al. 1996). In all three of the university samples, women were more likely than men to report a history of depression.

Depression has complex relationships with other behaviors. Cigarette smoking may serve many needs among persons who tend toward depression or who are currently depressed. Among those addicted to nicotine, smoking is reinforcing and produces quick and direct reinforcement intrinsically. Pharmacologically, smoking has a stimulating effect that may indirectly increase one's chance of receiving positive reinforcement for continuing to smoke (Hall et al. 1993).

Studies of the effects of nicotine on mood were summarized in the 1988 Surgeon General's report on nicotine addiction (USDHHS 1988). Depressive mood, anxiety, nervousness, restlessness, irritability, impatience, anger, aggression, fatigue, and drowsiness have all been reported after smoking cessation (Hughes and Hatsukami 1986). Most of these symptoms appear to peak at one to two weeks after smoking cessation and return to baseline after one month (USDHHS 1988).

Theoretically, nicotine replacement therapies for nicotine withdrawal should eliminate these negative affect states; however, not all nicotine withdrawal symptoms are relieved with nicotine replacement. Irritability appears to be the only symptom that is uniformly alleviated; anger, anxiety, and impatience are frequently relieved (Hughes et al. 1991). Less consistently relieved are depressive mood, restlessness, annoyance, and hostility (Hughes et al. 1991).

Antidepressant Interventions in Smoking Treatment

Most studies of antidepressant treatment in smoking cessation have either not addressed gender-specific differences or have found none. In a male-only study using an antidepressant (imipramine hydrochloride, 75 mg) in smoking cessation treatment, Jacobs and colleagues (1971) found no benefit; however, smokers were encouraged to stop smoking within the first two weeks of treatment, before the usual onset of antidepressant efficacy. In a small trial, Edwards and associates (1989) found that patients who received three weeks of doxepin treatment (150 mg) were more likely to be abstinent at two months than were patients who received placebo. No gender-specific differences were reported.

Recent studies of antidepressants in smoking treatment have been motivated by the putative effect of nicotine on neurotransmitters and by the effect of antidepressants on these same neurotransmitters. Hall and colleagues (1998) described the effects of nortriptyline among smokers (110 women and 89 men) with or without a history of MDD. Nortriptyline dose began at 50 mg for all patients; attempts were made to adjust levels to the therapeutic range for MDD (50 to 150 ng/mL). Independent of depression history, the percentage of participants who remained abstinent from smoking was higher among those who received nortriptyline than among those who received placebo, and overall results did not differ significantly by gender. Post hoc analyses found that women with a history of MDD were less likely than women with no such history to be abstinent on follow-up, but this relationship was not found among men. A study by Prochazka and colleagues (1998) also reported that nortriptyline increased cessation among smokers not currently suffering from depression. Although women were included in the study, results were not reported by gender.

Several studies that used bupropion have been reported (Ferry et al. 1992; Ferris and Cooper 1993; Hurt et al. 1997; Jorenby et al. 1999). Although the mechanism of bupropion is unknown, one hypothesis suggested it is primarily noradrenergic (Ferris and Cooper 1993). The majority of the studies found significantly higher smoking cessation rates among those who used bupropion.

Behavioral Interventions Targeted to Smokers with Mood Disorders

Five clinical trials have used behavioral interventions to treat smokers with mood disorders. They either did not report gender-specific differences or did not find such differences.

In the first trial (Zelman et al. 1992), 126 smokers were randomly assigned to one of two psychosocial strategies for smoking cessation, either skills training or support, and one of two "nicotine exposure" categories, either 2-mg nicotine gum or rapid smoking, in which a puff is inhaled from a cigarette every six seconds over a predetermined time period (e.g., 15 or 30 minutes). No differences were found among the four treatment groups at the one-year follow-up. These investigators did not report gender-specific differences.

Hall and associates (1996) classified patients by the presence or absence of a history of MDD. Patients were randomly assigned to either placebo or 2-mg nicotine gum and to either the cognitive-behavioral mood management treatment or an expanded health education program equivalent in time and therapeutic contact. A history of depression was not found to be associated with differences in treatment outcomes. The studies by Hall's group examined the data for gender-specific differences and found none. This result may be because of the level of social support provided (see "Social Support" later in this chapter). Repeating the study, but comparing the 10-session cognitive-behavioral mood management intervention with a 5-session health education control, Hall and associates (1998) showed the cognitive-behavioral intervention to be superior to the control intervention among smokers with a history of depression-a finding consistent with earlier work (Hall et al. 1994).

Another recent study suggested that cognitive-behavioral intervention may have effects among smokers with a history of depression (Muñoz et al. 1997). A self-administered mood management program for smoking cessation was provided to Spanish-speaking Latinos. The intervention resulted in a higher abstinence rate (23 percent) than a smoking cessation guide alone (11 percent). Participants who had a history of MDD but who were not currently depressed reported an even higher abstinence rate in the self-administered mood management program (31 percent). Gender-specific differences were not reported.

The pattern of results noted across the published studies tentatively suggested that increased emotional support may be useful among smokers who want to stop smoking and who have a history of mood disorder or who enter treatment with mood that is poorer relative to other smokers.

Gender and Social Support

On average, women appear to be more responsive to social events in their environment and to be more skillful at developing a range of satisfying and supportive social relationships than are men. However, the substantial responsibility that social networks carry may also increase stress, which in turn may increase the likelihood of smoking and decrease the likelihood of cessation. Perhaps as a result of this susceptibility to social influence, women who live with a smoker are less likely to stop smoking than are men who live with a smoker (Gritz et al. 1996). Cessation efforts may also be compromised by gender-specific stereotypes that discourage women from acting assertively on their own behalf (Blechman 1981). On the other hand, findings have suggested that women are more likely than men to believe that prevention and treatment of substance abuse, including smoking, is effective (Kauffman et al. 1997).

The multiple obligations created by women's social roles also appear to influence smoking cessation. For example, stopping smoking for the sake of a child or newborn is less likely among mothers with many caretaking responsibilities than among mothers with fewer responsibilities (Graham 1992). In qualitative research interviews with women who had smoked throughout pregnancy, Graham (1976) found that continued smoking was frequently attributed to anticipated negative emotional side effects of smoking cessation and to the likely impacts of these side effects on husbands and children.

Several studies indicated that women tend to be more attuned to their social surroundings than are men (Belle 1987; Acitelli and Antonucci 1994). Women are more likely than men to rate highly the importance of social support in stopping smoking (Cormier et al. 1990; DiLorenzo et al. 1990; Gritz et al. 1996), are somewhat more likely to join smoking cessation groups (Shiffman 1982; Fiore et al. 1990; Yankelovich Partners 1998), give higher ratings to the importance of emotional support (e.g., listening, encouragement, and understanding) than to more concrete assistance to reduce stressors and other temptations to relapse, and when successful, are more likely to report having received social support to stop smoking (Cormier et al. 1990; DiLorenzo et al. 1990).

Ratings of social support received from family and friends have been found to predict smoking cessation (Mermelstein et al. 1986; Morgan et al. 1988; Murray et al. 1995; Gritz et al. 1996). Coppotelli and Orleans (1985) studied women's reports of support from their spouses for stopping smoking. Questionnaires were completed an average of 6.4 days after smoking cessation. Supportive acts predicted continued cessation at six to eight weeks after smoking cessation. These acts included response to the woman's request for help, support while she was stopping, and tolerance for the woman's struggles with smoking cessation and with her edginess, mood swings, and anxiety. In another study, women attempting to stop smoking reported both expecting and receiving a higher ratio of positive-to-negative behaviors compared with women not attempting to stop (Cohen and Lichtenstein 1990). This ratio was also predictive of continuous abstinence at 12 months.

Several other relationships make social support important among women who attempt to stop smoking. Depression is related to greater likelihood of smoking and complicates cessation (Glassman et al. 1990) (see "Depression" earlier in this chapter and "Depression and Other Psychiatric Disorders" in Chapter 3). Depression is more prevalent among women than among men, and social support appears to be related to level of depression (McGrath et al. 1990). Women are more likely than men to report smoking to reduce negative affect and stress (Gritz et al. 1996; Secker-Walker et al. 1996; Ward et al. 1997). Women trying to stop smoking have rated emotional or empathic support as more beneficial than instrumental support (Fisher et al. 1993).

Despite the convergence of data that have suggested that social support should be useful in helping women to stop smoking, evaluations of the relationship have remained inconclusive. Murray and colleagues (1995) found that the presence of a support person in cessation attempts had a greater effect among men than among women. Others also reported greater benefits of support among men than among women (Pirie et al. 1997). Other studies, however, suggested that women may benefit from social support more than do men, at least in the short term. In a program that emphasized small-group discussion, buddy systems, and exchange of perceptions and experiences, 71 percent of women were abstinent at the end of the program; only 26 percent in a comparison group were abstinent at the end of a program that emphasized self-management (p < 0.02). Among men in the same study, 47 and 43 percent, respectively, were abstinent at the end of the program (Fisher et al. 1991, 1993). Those findings replicated an earlier study that suggested that programs emphasizing social support might have a short-term advantage for women (Fisher and Bishop 1986). Unfortunately, the greater cessation rate among women was not reflected in follow-up assessments. The fact that such striking changes do not persist over time may not necessarily mean that support is unimportant, but that, as with many important determinants of behavior, its influence is maintained only if it continues to be available (Fisher 1997).

School-Based Smoking Cessation Programs

School-based smoking cessation programs have been evaluated in several studies, with varying degrees of rigor and success. In an early study, St. Pierre and colleagues (1983) trained peer leaders to conduct a six-session program for high school students. The program content reflected standard cognitive-behavioral methods used in adult programs. Intensive recruitment yielded only six girls and six boys (smokers of 6 to 30 cigarettes per day) who completed the program. At the end of the program, none of the participants had stopped smoking, and the five girls for whom data were available tended to reduce their smoking less than the boys did.

The largest and most systematic school-based smoking cessation study (Sussman et al. 1995, 1998a, b) involved rural and suburban high schools in two states. Within each of the 16 schools in the study, students who volunteered to participate in a smoking cessation clinic were randomly assigned to a clinic group or to a wait-list control group. No gender-specific data were reported for cessation outcomes; the percentage who stopped smoking was very low for the total sample.

Participants were asked about 22 possible reasons for wanting to quit smoking. Only four significant gender-specific differences were found (Sussman et al. 1998a). These reasons were "if my girlfriend/ boyfriend asked me to quit" (51 percent of girls vs. 57 percent of boys), "if someone close to me died because of smoking" (42 percent of girls vs. 49 percent of boys), "to look calmer" (14 percent of girls vs. 9 percent of boys), and "to have more endurance" (22 percent of girls vs. 18 percent of boys). Among girls, the four most frequently endorsed reasons for stopping were that a boyfriend asked (51 percent), a significant other had died (42 percent), the girl had a desire to live longer (42 percent), and a physician told her to stop (40 percent).

No gender-specific differences were found in the self-reported stage of readiness to stop smoking or in answers to the questions, "Do you think you will ever quit smoking?" and "Would you be able to quit on your own?" (Sussman et al. 1998a). Girls were more likely than boys to report being tempted to smoke in 9 out of 16 hypothetical circumstances, including circumstances indicating nicotine dependence, and girls were less likely than boys to answer yes to the question, "Have you really tried to quit smoking before?" (65 vs. 59 percent; p < 0.03). Boys were more likely than girls to report that they might participate in a cessation program at school.

Another study by Sussman and colleagues (1998b) assessed self-initiated smoking cessation among adolescents. In the follow-up of a large sample of adolescents in alternative schools, gender did not predict cessation. Similarly, Hu and colleagues (1998) did not find gender to be a predictor of cessation. In an assessment of predictors of smoking cessation among adolescents in New Hampshire high schools, Sargent and colleagues (1998) found a weak association between gender and cessation, with boys more likely to stop smoking than were girls (adjusted RR, 1.3; 95 percent CI, 0.7 to 2.5). When all the predictive factors were entered into a logistic regression, gender no longer was predictive.

A few studies evaluated smoking cessation strategies for adolescents in vocational high schools, settings likely to have a high proportion of smokers (Pallonen et al. 1994, 1998; Smith et al. 1994). The interventions were delivered by computer and featured the expert system adapted from a program used with adult smokers (Velicer et al. 1993). The expert system elicited relevant information from the student (e.g., smoking history and interest in smoking cessation) and delivered feedback and suggestions tailored to this information. Data from 10th- and 11th-grade vocational students indicated that girls rated the computerized intervention program significantly more positively than did boys (Smith et al. 1994). No gender-specific data were reported for cessation.

Balch (1998) conducted focus groups with high school smokers in three states and observed that girls expressed more interest in participating in group programs than did boys. The authors interpreted this observation as a reflection of girls' greater concern about the opinions of others.

Other Smoking Cessation Programs

Biglan and colleagues (summarized in Hollis et al. 1994) used an HMO to identify youth smokers. Adolescents who met the eligibility criteria were randomly assigned to a smoking cessation intervention or to a control group that received no treatment. The focus of the intervention was a 60-minute consultation with a nurse practitioner at a convenient HMO clinic. Incentives were offered for attending these sessions. Alottery with the chance to win $100 was established, and abstinence from smoking was required to win. There was no effect of the intervention overall, and differences by gender were not reported.

Adolescents who received treatment for substance abuse have high smoking rates, and the treatment setting provides an opportunity for smoking intervention (Myers 1999). In a small study, 6 of 35 adolescents were abstinent at the three-month post-intervention follow-up. Gender was not a predictor of response to treatment.

Weissman and colleagues (1987) recruited 11 "hard core" smokers (5 girls and 6 boys) aged 13 through 18 years who were attending an alternative school. The participants were selected from smokers who auditioned for parts in a smoking prevention videotape or who were identified by those who auditioned. Their average age was 15.6 years, they had smoked for an average of 2.5 years, and they smoked an average of 18 cigarettes per day. Monetary rewards were based on achieving target levels of carbon monoxide in expired air samples. Five of the six boys successfully reduced smoking and carbon monoxide levels each month during the reduction and cessation phases. Unannounced probes for four months after the cessation date indicated continued abstinence by two boys, sporadic smoking by two, and low-level daily smoking by one. In contrast, all five girls dropped out during the program and continued smoking.

Hurt and colleagues (2000) tested the efficacy of the nicotine patch in 101 adolescent smokers, of whom 41 percent were female. The nonrandomized trial drew volunteers whose median smoking was 20 cigarettes per day (range, 10 to 40). At the end of therapy (6 weeks), 10.9 percent of participants were abstinent, as verified by expired carbon monoxide and plasma cotinine. At six months, however, only 5.0 percent were abstinent, a rate that appears lower than the secular trend for cessation among adolescents (Sussman et al. 1995, 1998b). Gender differences were not reported.

Characteristics Related to Heavy Smoking

Persons who smoke heavily account for a disproportionately high share of mortality related to smoking (USDHHS 1984). To ensure that the classification of heavy smokers does not include moderate smokers who round up their daily smoking to 20 cigarettes (1 pack) per day, 25 cigarettes per day has been adopted by many researchers as the point at which smokers are considered heavy smokers (Sorensen et al. 1992b; COMMIT Research Group 1995a, b); however, some researchers have used 20 or more cigarettes per day as a definition of heavy smoking (Glassman et al. 1988; Serxner et al. 1992; Thornton et al. 1994).

Research has suggested that those who smoke heavily display characteristics of nicotine addiction that distinguish them from lighter smokers (USDHHS 1988). Using the Fagerström Tolerance Questionnaire, investigators have demonstrated that heavy smokers are more dependent on nicotine than are light or moderate smokers. Heavy smokers also have internal cues that trigger smoking, have more difficulty stopping, and have more withdrawal symptoms (e.g., anxiety and fatigue) during smoking cessation (Killen et al. 1988; Goldberg et al. 1993). Among heavy smokers, females are more likely than males to report feeling dependent on cigarettes and feeling unable to cut down (CDC 1995a), to have lower expectations of stopping in the near future, to report their last attempt to stop as difficult, to want assistance in stopping, and to be more concerned with weight gain (Sorensen et al. 1992b). Women who are heavy smokers may be more likely than men who are heavy smokers to view a reduction in the amount smoked as preferable to smoking cessation (Blake et al. 1989).

Although heavy smoking is inversely related to smoking cessation (Cohen et al. 1989; Wagner et al. 1990; Orleans et al. 1991b; Kozlowski et al. 1994), heavy smokers are more likely than light or moderate smokers to join smoking cessation activities (Cohen et al. 1989; Wagner et al. 1990; Orleans et al. 1991b; O'Loughlin et al. 1997; Thompson et al. 1998). Wagner and colleagues (1990) used a large, defined population of 50,000 smokers in an HMO database to examine rates of participation in self-help activities for smoking cessation. Comparing a 10-percent random sample of smokers drawn 10 months before the project began with smokers who volunteered to participate in the project, they found that heavy smokers were more likely to participate than were lighter smokers (RR, 2.8; 95 percent CI, 1.9 to 3.8). Moreover, women were significantly more likely than men (63 vs. 48 percent) to participate. Women were especially more likely than men to participate if they had symptoms related to smoking (e.g., a cough or shortness of breath) (RR, 5.6; 95 percent CI, 3.01 to 10.4). The authors did not report the proportions who stopped smoking. Sorensen and colleagues (1992b) also found that among women, those who smoked heavily were significantly more likely than light or moderate smokers (64 vs. 47 percent) to state that they wanted assistance to stop smoking.

Unassisted Smoking Cessation Among Women Who Smoke Heavily

Little is known about the natural history of smoking cessation among women who are heavy smokers or about the gender-specific differences in smoking cessation among heavy smokers. The COMMIT study followed cohorts of heavy smokers and light or moderate smokers for five years (COMMIT Research Group, unpublished data). The cohorts in the comparison communities provided data on unassisted smoking cessation among both women and men who smoked heavily. More than one-half of the women (55.6 percent) and men (53.9 percent) who smoked heavily reported decreasing the number of cigarettes they smoked per day during the five years of the study. Men reported slightly more attempts to stop smoking for at least 24 hours (2.9) than did women (2.2). Among persons who sustained cessation for six months or more at the end of the five years, cessation was slightly higher among men than women who smoked heavily (19.6 vs. 17.2 percent). Among heavy smokers, the RR for smoking cessation was 0.6 (95 percent CI, 0.4 to 0.9) among women compared with men after adjustment for age, ethnicity, and education.

Cessation Programs for Women Who Smoke Heavily

As part of a smoking cessation intervention delivered by physicians, women and men who smoked heavily were compared with women and men who were lighter smokers (Goldberg et al. 1993). Among women at baseline, heavy smokers had higher levels of addiction than did lighter smokers. They had also smoked longer, had made fewer attempts to stop smoking, were less confident of their ability to stop smoking, had higher perceptions that others wanted them to stop smoking, and had previous physical symptoms related to smoking (e.g., lung disease and asthma). Interventions consisted of physician advice, counseling specific to the patient, and counseling plus nicotine gum. At the end of six months, continuous cessation for one week was achieved by 10 percent of women who were heavy smokers and 15 percent of women who were light smokers. Among heavy smokers, a comparable percentage of women (10 percent) and men (11 percent) stopped smoking.

The Lung Health Study, an ongoing randomized study of more than 3,900 smokers, examined long-term cessation at 12 and 36 months (Bjornson et al. 1995). Participants received intervention consisting of a message from a physician, a 12-week behavioral change program, nicotine gum, and a maintenance program; 91 percent of participants attended at least one class of the cessation program. For analysis, participants were classified as heavy smokers (> 30 cigarettes per day) or lighter smokers (<30 cigarettes per day). Cessation among women who were heavy smokers was 21 percent at 12 months and 14 percent at 36 months; among men, the quit rate was 28 percent at 12 months and 22 percent at 36 months.

The Lung Health Study also reported that women initially found it more difficult than men to stop smoking. Smoking cessation history, such as previous long-term cessation (6 months), identification of any cigarette other than the first cigarette of the day as being the most difficult to give up, better long-term health (e.g., no asthma or breathlessness), and support for stopping were all predictive of initial cessation. Both women and men were more likely to have an early relapse (within 4 to 12 months) if they reported smoking at all since the cessation day. No other factor was predictive of early relapse among women. Predictors of late relapse (at 12 to 24 months) among women included nicotine gum use at 12 months and having other smokers in the house at 12 months. Predictors for early relapse among men were any smoking since the cessation day and use of nicotine gum at 4 months; men were less likely to relapse if they had a support person at the orientation and lower dependence on nicotine at baseline (Nides et al. 1995). The study also found that women with higher dependence on nicotine, as assessed by smoking when emotionally triggered, feeling deprived when not smoking, being physiologically dependent, and waiting a low number of minutes to the first cigarette of the day, found it harder to stop smoking than did men with similar ratings of nicotine dependence (Bjornson et al. 1995).

In contrast to the Lung Health Study, in a study of 1,044 persons who used nicotine gum for cessation, data were stratified by both gender and amount smoked. This study found no difference in cessation between heavy and light smokers or between women and men (Fortmann and Killen 1995). The researchers also found that persons who smoked heavily were more likely to relapse, but found no gender-specific differences.

Measures of Low Socioeconomic Status

SES is assessed in many ways, most often by using measures of income, education, or occupation. The three factors are strongly correlated, and each has been used separately as a proxy for SES. Income is a good indicator of overall SES, and studies have defined female smokers with low income as those living below the poverty level (Novotny et al. 1988), living below a specified income (Warnecke et al. 1991; Manfredi et al. 1992; Kendrick et al. 1995), or eligible for public housing (Manfredi et al. 1992) or other public services (Albrecht et al. 1994; Brayden and Christensen 1994; Keintz et al. 1994; Rafuse 1994; Lillington et al. 1995). Years of education is the most commonly reported measure of SES (Macaskill et al. 1992; Winkleby et al. 1992; Windsor et al. 1993b; Albrecht et al. 1994; Kendrick et al. 1995), and it appears to be the measure most strongly related to smoking cessation (Pierce et al. 1989; Hatziandreu et al. 1990). Occupational status is also used as an indicator of SES, with blue-collar occupations indicating lower SES than do white-collar occupations (USDHHS 1985; Jeffery et al. 1993; Gritz et al. 1998).

Cessation Programs in Public Health Settings

Smoking cessation programs for low-income women have been instituted in public health clinics and community health centers. Recognizing that women of low SES have severe economic problems that may result in significant stress and that may be partially relieved by smoking, some cessation programs have included a wide range of topics that address stress management, self-esteem, group support, and general activities that improve quality of life (Rafuse 1994). This intensive intervention resulted in a 20- to 25-percent cessation rate. Other efforts have encouraged women of low SES to participate in group classes on smoking cessation and in counseling with a physician (Macken et al. 1991) or in clinic-reinforced, self-help cessation activities (Keintz et al. 1994). Unfortunately, only a small proportion of women of low SES appear to take advantage of these programs. A clinic serving a primarily female, low-income, urban population found that 24 percent of women who smoked were interested in a smoking cessation class with a physician, but only 36 percent of those interested (8.6 percent of all the women who smoked) actually kept their appointments (Macken et al. 1991). Another study in a community primary care health clinic found that half of 55 women smokers surveyed indicated on an initial questionnaire that they would be willing to participate in a smoking cessation program (Pohl et al. 1998). However, only 20 percent of the original group showed up for the first class.

Manfredi and colleagues (1998) identified and surveyed low-income women about a number of issues they thought might be related to motivation to stop smoking. Of all the potential predictors studied, only health effects, not wanting to be addicted, and the expense of cigarettes were related to wanting to stop.

Keintz and colleagues (1994) performed followup on more than 1,200 women in a public health setting in which the women smokers received advice and a self-help guide on cessation. In a retrospective survey administered before the intervention, a random sample of 3,260 women attending the clinics was drawn. Of the survey participants, 5.2 percent of clients who smoked at the beginning of the prior 12-month period were estimated as having been abstinent from smoking for 90 or more days during those 12 months. After one year of exposure to the intervention program, 9.1 percent of women smokers in the clinics had stopped smoking for at least 90 days, a statistically significant difference. An examination of the characteristics of women successful in achieving cessation included those who were lighter smokers (<25 cigarettes per day), were more educated (high school or more), were less addicted (smoked the first cigarette >30 minutes after awaking), and were more confident in their ability to stop smoking. Logistic regression analyses identified three factors related to cessation: confidence in ability to stop smoking, the interaction of lower addiction (Fagerström score) and age, and the interaction of addiction and education- which was the strongest of the multivariate factors.

A Canadian smoking cessation program targeting low-income women was available through local community groups and was delivered free of charge by trained facilitators (O'Loughlin et al. 1997). The materials and content were developed to be specifically relevant to low-income women. Although the cessation program was targeted to women and attracted mostly women (n = 83, 73.5 percent), men (n = 30, 26.5 percent) were also allowed to participate. Despite being targeted to women, cessation rates were higher among men (40.0 percent at 1 month, 26.1 percent at 6 months) than among women (28.2 percent at 1 month, 21.1 percent at 6 months). The statistical significance of these findings was not reported.

Effects of Mass Media

Studies of the mass media suggested that smokers of low SES, especially women, are more likely than smokers of higher SES to seek information from visual sources, especially television, and that such campaigns can be targeted to specific groups. For example, a seven-month media campaign in San Francisco, California, which was designed to change people's level of information, showed that a culturally appropriate, multichannel campaign can improve community knowledge (Marín et al. 1990a).

In a large, televised cessation intervention in the Chicago, Illinois, area, Warnecke and colleagues (1991) found that, overall, women were more likely than men to watch televised smoking cessation programs, attend group sessions, and refer daily to the self-help cessation manual. A multiple regression model of participation in the program showed that gender and income were the only significant variables in predicting whether televised segments would be watched. Women, African Americans, and persons with low income were the most likely to watch the televised segments. Overall, women with low income (<$13,000 per year) were more likely than men with low income to view and recall the televised segments. Gender and education were significant in predicting the frequency with which smokers referred to the self-help manual and the level of recall of the manual. Among those with more than a high school education, women were more likely than men to refer to the manual daily and to recall parts of the manual. Regardless of SES, women smokers were more responsive than men smokers to the media. Cessation rates were high in the intervention group at 12 months after treatment (14 vs. 6 percent) and at 24 months (6 vs. 2 percent). Significantly more men than women had quit at all follow-up points, except at 24 months (Warnecke et al. 1992).

As part of the Chicago televised project, women with very low income (median, $5,000 per year) who lived in subsidized public housing were asked about their smoking behavior six months before the intervention for smoking cessation began (Manfredi et al. 1992). Compared with the general population of smokers who were not residents of public housing, the women residents had a lower desire to stop smoking, reported fewer previous attempts to stop, perceived fewer risks from smoking, had more smokers among their friends, and were less knowledgeable about where to receive information about or assistance with smoking cessation. As in other studies of low-income populations (Rafuse 1994), respondents in eight focus groups reported they had highly stressful lives that they perceived as partially assuaged by smoking (Lacey et al. 1993). Women also reported little social support for stopping, saw smoking as a pleasure, saw few risks from smoking, reported that "everyone" in their environment smoked, had no information about how to stop smoking, and perceived that enough willpower would lead to cessation.

A large mass-media campaign in Sydney and Melbourne, Australia, also concluded that television was a good way to present antismoking messages to smokers of low SES (Macaskill et al. 1992). The researchers assessed smoking prevalence during the first year of the campaign and five years after it, and they used the rate ratio (prevalence after intervention relative to prevalence before intervention) adjusted for age. Among women in Sydney and among men in both Sydney and Melbourne, the rate ratio by educational level was consistently lower after than before the intervention, and no linear trend with increasing education was apparent. Among women in Melbourne, those with some university education had a lower rate ratio than did women with less education.

Cessation Programs for Pregnant Women of Low Socioeconomic Status

A few studies have examined natural smoking cessation patterns among pregnant women of low SES. In a prospective study of approximately 1,900 pregnant women who were smokers just before becoming pregnant or during pregnancy or who had relapsed after giving birth, 41 percent who had smoked before pregnancy stopped during pregnancy (O'Campo et al. 1992). Cessation rates during pregnancy increased substantially with level of education among white women: 13 percent of those with less than 12 years of education but 67 percent of those with more than 12 years of education stopped smoking. Among African American women, 35 percent of those with less than 12 years of education but 49 percent of those with more than 12 years of education stopped. Logistic regression, adjusted for the effects of education, age, parity, marital status, and intention to breastfeed an infant, indicated that white women who had stopped smoking were more likely to be younger than 25 years of age (RR, 3.4; 90 percent CI, 1.3 to 9.0), to have more than 12 years of education (RR, 21.8; 90 percent CI, 5.1 to 92.5), to have no other children (RR, 2.9; 90 percent CI, 1.3 to 9.0), to be married (RR, 2.3; 90 percent CI, 0.8 to 6.3), and to intend to breastfeed (RR, 1.2; 90 percent CI, 0.5 to 2.9). Among African American women, only intent to breastfeed was significantly associated with smoking cessation during pregnancy (RR, 2.7; 90 percent CI, 1.2 to 6.0). A similar study in Sweden that examined all women users of prenatal care clinics in one county (3,678 participants) found that pregnant women with low education were less likely to stop smoking during pregnancy (RR, 1.2 for 9 years of education; 90 percent CI, 1.0 to 1.5) (RR, 0.7 for 12 years of education; 95 percent CI, 0.5 to 0.9) (Cnattingius et al. 1992). Furthermore, spontaneous smoking cessation during pregnancy appears to be lower among women of low SES than among women of higher SES. Two studies that involved pregnant women of higher SES showed that 41 percent had stopped smoking spontaneously (Messimer et al. 1989; Mullen et al. 1990); an earlier study showed that 22 percent of pregnant women of low SES had stopped smoking spontaneously (Windsor et al. 1985).

A review of five randomized, controlled trials on smoking cessation conducted between 1983 and 1993 with a total of 4,277 low-income pregnant women indicated that low-level, minimal contact interventions had some effect in this population. Cessation rates ranged from 3 to 18 percent (Albrecht et al. 1994). The most intensive interventions had much better results (quit rates of 11 to 18 percent) than did low-intensity interventions. In one study, for example, 11 percent of women who received one-to-one counseling and instructions in behavioral change had stopped smoking, whereas only 3 percent of women in the control group did so (Albrecht et al. 1994). A Los Angeles, California, study of low-income pregnant women in four WIC sites (155 intervention women and 400 control women) found that 43 percent of women in the intervention group but 25 percent of women in the control group achieved cessation (Lillington et al. 1995). The proportion of women who maintained cessation after childbirth was 25.3 percent among the treated women and 11.6 percent among the control women.

An intensive intervention program that depended heavily on one-to-one counseling in a clinical setting achieved 30.8 percent smoking cessation among counseled low-income pregnant women; uncounseled control women achieved a 15.4-percent cessation rate (not confirmed by urine testing) (Brayden and Christensen 1994). A study that used only minimal intervention was conducted among low-income pregnant women at WIC sites in three states (Kendrick et al. 1995). Self-reported cessation was significantly higher among women in the intervention group than in the control group (13.0 vs. 9.0 percent). However, when cotinine level was used, the results differed for the subset of participants who provided urine samples for verification (51 vs. 68 percent) and no significant difference was found in cessation (6.1 vs. 5.9 percent). Windsor and colleagues (1993b) reported a study in which 814 low-income pregnant women were randomly assigned to a smoking cessation intervention that consisted of a short counseling session, self-help cessation materials, clinic reinforcement, and social support or to a control group. Cessation was 14.3 percent in the intervention group and 8.5 percent in the control group.

Cessation Activities in Occupational Settings for Women of Low Socioeconomic Status

Currently, women make up 37.7 percent of the workforce in manufacturing companies (Tom Nardone, U.S. Bureau of Labor Statistics, fax to Beti Thompson, November 4, 1997). Although it is not known precisely how many of those women hold blue-collar occupations, a study of 114 manufacturing worksites identified 76.4 percent of their female employees as holding blue-collar jobs (Gritz et al. 1998). Smoking cessation activities in occupational settings attract more women than men in general, but participation by blue-collar workers, regardless of gender, is very low (Schilling et al. 1985; Sorensen et al. 1986; Jeffery et al. 1993). Cessation rates by gender have rarely been reported (Jeffery et al. 1993; Gritz et al. 1998). A recent trial that involved 114 worksites and more than 28,000 workers sought to increase rates of smoking cessation among the employees (Gritz et al. 1998). Comprehensive activities to foster smoking cessation took place in intervention worksites (Abrams et al. 1994a; Sorensen et al. 1996). Although the proportion of employees who stopped smoking was similar overall in the intervention worksites and control worksites, a significantly higher proportion of women in intervention worksites than in control worksites stopped for six months or longer (15.0 vs. 10.6 percent; p = 0.03) (Gritz et al. 1998). When age and occupational status (white collar vs. blue collar) were held constant, the RR for smoking cessation among women in the intervention group was greater than that among women in the comparison group (RR, 1.5; 95 percent CI, 1.01 to 2.2) in worksites where more than 75 percent of the women employees held blue-collar occupations.

African American Women

Data from the 1993 NHIS showed that 74.9 percent of African American women smokers would like to stop smoking (68.9 percent of African American men and 72.4 percent of white women who smoke would like to stop) (USDHHS 1998) (see also Chapter 2). Several studies have attempted to determine psychosocial and environmental factors that may identify an African American woman's degree of readiness to stop smoking, as well as the predictors of readiness, for use in developing cessation programs for this population.

Ahijevych and Wewers (1993) surveyed 187 African American women smokers aged 18 through 69 years in a metropolitan area in Columbus, Ohio, to describe determinants of smoking and smoking cessation. Cessation attempts had been made by 83 percent of these women: 22 percent of the women had tried five or more times to stop smoking, 21 percent three or four times, and 41 percent one or two times.

The Minnesota Heart Survey, a 1985-1986 crosssectional study, described the smoking and cessation behaviors of urban African Americans and whites, aged 35 through 74 years, in Minneapolis-St. Paul, Minnesota (Hahn et al. 1990). Of the 593 African American women in the survey, 18 percent were former smokers and 33 percent were current smokers. No significant differences were found between the African American women and white women regarding intentions to change smoking behaviors in the next year. Crittenden and colleagues (1994) administered a questionnaire on readiness to quit to 495 women who smoked (55 percent African Americans, 42 percent non-Hispanic whites) at four public health clinics in the Chicago area. Race was not related to readiness to change.

Hispanic Women

Little work has been published on smoking cessation among Hispanic women in the United States. NHIS data for 1993 showed that a high percentage of Hispanic smokers wanted to stop smoking-79.3 percent of Hispanic women and 63.8 percent of Hispanic men (USDHHS 1998). Reports have shown smoking among Hispanics in the United States to be positively associated with acculturation (Sabogal et al. 1989; Otero-Sabogal et al. 1995). On the basis of a telephone survey of Hispanics aged 15 through 64 years who were living in the San Francisco, California, metropolitan area, Marín and colleagues (1989) found a gender-specific difference in the relationship of acculturation to smoking: men who were less acculturated and women who were more acculturated were more likely to smoke. Other investigators found that among smokers, more acculturated Hispanics had higher levels of addiction and lower levels of self-efficacy in smoking cessation than did less acculturated Hispanics (Sabogal et al. 1989). The Hispanic population in the United States represents a diverse group of subcultures and stages of immigration and acculturation, all of which should be taken into account in smoking cessation research.

In a study of cultural attitudes and expectations regarding smoking, Marín and colleagues (1990b) found no significant gender-specific differences among Hispanics, except that more women than men reported enjoyment in continued smoking. The study of 263 Hispanic smokers and 150 non-Hispanic white smokers in San Francisco found that Hispanic smokers and non-Hispanic white smokers held some different attitudes and expectations about smoking and cessation. Hispanics were significantly more certain than non-Hispanic whites that stopping smoking would provide a better example to their children, improve family relations, make breathing easier, and result in having a better taste in one's mouth. Hispanics were less likely than whites to smoke at home for relaxation or with meals. Also, fewer Hispanic smokers were certain that smoking cessation would bring withdrawal symptoms.

These findings have been incorporated into a self-help manual. Evaluation of the Rompa con el Vicio: Una Guía para Dejar de Fumar (USDHHS 1993c) self-help manual, which incorporated the findings described above, has shown that it was well received by Hispanic smokers. More than 20 percent of a sample of volunteers who picked up the manual at community stores or clinics reported having stopped smoking at 2.5 months after reading it, but this proportion declined to 13.7 percent after 14 months (Pérez-Stable et al. 1991). Telephone surveys conducted after implementation of a culturally appropriate, community-based smoking cessation program in the Latino community of San Francisco (Programa Latina para Dejar de Fumar) found that women were more likely than men to report awareness of the program and of the availability of printed information (Marín and Pérez-Stable 1995).

Lillington and colleagues (1995) published a report of a smoking cessation intervention for pregnant women that included 234 Hispanics among the 555 enrollees. Contrary to the study's results for African American women, this program did not significantly affect smoking cessation among Hispanic women, either at nine months' gestation or at six weeks after delivery.

A smoking cessation study that involved 93 Hispanic women and men in Queens, New York, found no difference in cessation at 12 months between a multicomponent, culturally specific intervention and a minimal-contact self-help program (Nevid and Javier 1997). Results were not significantly different by gender.

American Indian or Alaska Native Women

A number of factors not only complicate research on smoking patterns among American Indians and Alaska Natives but also seem to preclude generalization from one population to another. Specifically, reported smoking rates have varied widely among American Indian tribal affiliations and by geographic location, from as low as 13 percent among Navajos to as high as 70 percent among Indians outside the Southwest (Lando et al. 1992). Additionally, the type of cigarettes, manner of inhaling, and number of cigarettes smoked vary widely. Moreover, 54 percent of American Indians live in urban settings, and another large percentage live on rural reservations. No studies have addressed factors that may influence smoking cessation among American Indian or Alaska Native women specifically. A few studies that combined results for women and men have been reported.

NHIS data showed interest in smoking cessation among American Indians and Alaska Natives who smoked. In 1993, 70.3 percent of American Indian or Alaska Native women and 57.3 percent of men who smoked indicated that they would like to stop (USDHHS 1998).

A smoking cessation project in four urban Indian Health clinics enrolled 601 Native American smokers; they were randomly assigned to participate in a Doctors Helping Smokers model to increase smoking cessation (Johnson et al. 1997). After one year of treatment, the investigators found a higher rate of self-reported cessation in the treatment group than in the control group (7.1 vs. 4.9 percent), but cotinine levels indicated that cessation rates were comparable for both study arms. Rates were not reported separately by gender.

Recent work with the Lumbee Indians in North Carolina has explored the prevalence and predictors of tobacco use among Lumbee women (Spangler et al. 1997). Data have suggested that a church intervention would be a good approach for Lumbee women who have high rates of tobacco use. In a survey of 400 adult Lumbee Indians, 63 percent were church members, and a dose-response relationship was observed between church attendance and the number of cigarettes smoked per day (Spangler et al. 1998).

Asian or Pacific Islander Women

Because of the small sample sizes of Asians and Pacific Islanders who have participated in epidemiologic surveys and smoking cessation programs, little information has been available on cessation rates and associated factors (King et al. 1997). In one of the few studies that examined racial and ethnic differences in smoking behavior and attitudes among patients at physician practices, Asian smokers (women and men) reported significantly more pressure from friends to stop smoking than did white, African American, or Hispanic smokers. Asians and Hispanics were significantly more likely than the other racial and ethnic groups to report that not exposing their children to smoking was an important reason for quitting (Vander Martin et al. 1990). No studies of smoking cessation interventions among Asian or Pacific Islander women have been reported.

Special Health Concerns and Smoking Cessation Needs Among Older Women Who Smoke

Older women have some unique smoking risks, including increased risk for postmenopausal osteoporosis (see "Menstrual Function, Menopause, and Benign Gynecologic Conditions" in Chapter 3). Although no studies have focused specifically on smoking cessation among older women, some studies have been able to analyze data for this group, with mixed results. Rimer and colleagues (1994) found that older men were more likely to quit than older women. On the other hand, Hill and colleagues (1993) found that older women were more likely to quit than older men. Yet another study found no differences in quitting between older women and older men (Ossip-Klein et al. 1997). More research is needed for this group.

Older women who smoke are less likely than older men who smoke to be married, to have at least a high school education, or to belong to community organizations and are more likely to be widowed, to live alone, to be unemployed, and to report an annual household income of less than $25,000 (King et al. 1990; Orleans et al. 1990, 1991a; Bjornson et al. 1995). King and associates (1990) found that disparities between women and men aged 50 through 64 years in educational level and marital status were associated with continued smoking versus smoking cessation. Bjornson and colleagues (1995) reported similar results for participants in the Lung Health Study (mean age at entry into the study, 49 years).

The age gap in awareness of the health effects of smoking is just as apparent among women as it is among men (Orleans et al. 1990, 1994a), but some gender-specific differences have implications for treatment. In one study, older women aged 50 through 74 years who smoked were significantly less likely than their male counterparts to report that they had ever received advice from a physician to stop smoking (53 vs. 58 percent) (Orleans et al. 1994a). Nonetheless, significantly more of these women than men rated concerns about their future health (77 vs. 69 percent), their present health (62 vs. 52 percent), the effects of their smoking on others (40 vs. 31 percent), and the cost of smoking (38 vs. 26 percent) as important motives to stop smoking. Older women also were significantly more likely than older men who smoked to report weight gain (33 vs. 21 percent) or possible weight gain (30 vs. 18 percent) as important barriers to smoking cessation. As Gritz (1994) pointed out, women's greater difficulty in controlling their weight in the perimenopausal and postmenopausal periods may prove to be an additional barrier to smoking cessation.

Promising Treatment Approaches for Older Women Who Smoke

The 1990 Surgeon General's report on the health benefits of smoking cessation (USDHHS 1990) declared older adults in the United States to be an important target for national smoking cessation initiatives. These initiatives spurred new efforts to develop and evaluate smoking cessation treatments for this population. Several studies have indicated that older adults, both women and men, benefit from a variety of smoking cessation treatments and are at least as likely as younger smokers to succeed in stopping smoking, either on their own or with the aid of a formal clinic, self-help, or pharmacologic treatment (Vetter and Ford 1990; Hill et al. 1993; Orleans et al. 1994b; Rimer et al. 1994; Morgan et al. 1996; Ossip-Klein et al. 1997). No studies have examined treatments specifically tailored for older women, but one study found that Clear Horizons, a self-help guide tailored for all older adults, proved more effective at a 12-month follow-up than did a generic smoking cessation guide designed for smokers of all ages (Rimer et al. 1994).

Evidence of gender-specific differences in smoking cessation outcomes among older smokers has not been consistent. Hill and colleagues (1993) reported a higher percentage of biochemically verified or informant-verified cessation among older women than among older men after an intensive three-month group treatment program that involved behavioral training alone, behavioral training with nicotine gum, behavioral training with physical exercise, or physical exercise only. Participants were aged 50 years or older and had smoked for at least 30 years. Rimer and colleagues (1994) assigned persons aged 50 through 74 years to three study groups: those who received the Clear Horizons guide plus two reinforcing telephone calls, those who received the guide alone, and those who received the generic NCI smoking cessation guide, Clearing the Air (control group). In all three groups combined, the investigators found that the three-month, self-reported cessation was significantly higher among men than among women (13 vs. 8 percent). In a recent study of smokers aged 60 years or older using the Clear Horizons guide, Ossip-Klein and colleagues (1997) found that a higher percentage of women stopped smoking if they received two proactive telephone calls along with the guide, whereas the percentage of men who stopped was higher if they received the guide with two mailed prompts to call a smoking cessation helpline. Orleans and colleagues (1994b) found no gender-specific differences at six-month follow-up in the percentage of smokers aged 65 through 74 years who filled prescriptions for transdermal nicotine.

Two randomized controlled trials of older adults seen in primary care settings found that brief intervention doubled the number of persons who stopped smoking (Vetter and Ford 1990; Morgan et al. 1996). Neither Morgan and colleagues (1996) nor Vetter and Ford (1990) reported gender-specific differences. Dale and colleagues (1997) found a 24.8-percent six-month cessation rate among 615 women and men patients aged 65 through 82 years who received brief smoking cessation consultation that combined behavioral counseling with recommended pharmacologic aids. Orleans and colleagues (1994b) found a self-reported six-month cessation rate of 29 percent among low-income women and men smokers aged 65 through 74 years who had received transdermal nicotine with minimal smoking cessation advice or who had received help from their health care providers. More frequent contact with physicians or pharmacists was associated with more appropriate use of the patch (e.g., less concomitant smoking) and a higher percentage of cessation. Neither study reported results by gender.

Prevalence of Worksite Smoking Control Interventions

Efficacy of Worksite Interventions for Women Who Smoke

Community Studies of Smoking Cessation

Several community studies have been conducted to investigate behavioral risk factors related to cardiovascular disease (Farquhar et al. 1977; Maccoby et al. 1977; Farquhar 1978; McAlister et al. 1982). Smoking cessation was one of the behavior changes addressed. Only one randomized study in the United States, COMMIT, focused exclusively on smoking cessation (COMMIT Research Group 1991, 1995a).

Table 5.2 summarizes the community studies. The types of smoking changes reported in community studies have varied widely. Some studies reported net differences in changes from baseline prevalence between intervention and comparison communities. Others reported before-and-after changes in prevalence for intervention communities only. Still others reported on smoking cessation in a cohort of smokers followed up over time or in a group of smokers asked retrospectively about their smoking behavior. Finally, some studies reported changes in the number of cigarettes smoked. Not all studies reported on smoking cessation or prevalence among women and men separately. The cessation proportion is presented as the percentage of the cohort (intervention or control) that stopped smoking. Significance tests are based on comparisons between intervention communities and control communities in the change in smoking prevalence or cessation proportion.

Table

Table 5.2. Changes in smoking behavior reported in studies of community-based smoking cessation programs.

The Community, Hypertension, Atherosclerosis, and Diabetes Program (CHAD) was initiated in Israel in 1970. It was a community-based program directed at reducing cardiovascular risk factors among residents of four adjacent housing projects (Abramson et al. 1981). Survey assessment at baseline (1970) and 5 years later (1975) showed a net decrease in smoking prevalence among women that was far less than that among men and was not significantly different from that in the control community. By 10 years after intervention, however, net decreases in smoking prevalence were significantly greater in the intervention sites than in the control sites among both women and men, and the declines were greater than those seen in the rest of Israel for the same period (Gofin et al. 1986).

Both the Stanford Three-Community Study and the Finnish North Karelia Project commenced in 1972. Both projects used mass media; Stanford also used intensive face-to-face intervention for persons at high risk for smoking-related diseases (Farquhar et al. 1977; Maccoby et al. 1977), and the North Karelia Project used community organization, environmental modification, and educational programs (Salonen et al. 1981; McAlister et al. 1982; Puska et al. 1983b). The Stanford study did not report overall results among women and men separately. In the North Karelia Project, significant differences between the intervention and control counties in smoking prevalence occurred among men but not among women (Salonen et al. 1981; Puska et al. 1983b).

A series of community-based antismoking campaigns in Australia that began in 1978 used massmedia and community programs to encourage smoking cessation. Significant differences in the change in smoking prevalence among women were found in the North Coast study (Egger et al. 1983) and the Sydney study (Dwyer et al. 1986), but the results for the Melbourne study (Pierce et al. 1990) were less clear. In the North Coast study, women and men aged 18 through 25 years had lower smoking prevalence in both intervention communities than did women and men aged 65 years or older (Egger et al. 1983). The reductions in prevalence in all age groups were more pronounced in the media plus community programs' town than in the media only town. In Melbourne, the prevalence of smoking among women with at least some university education declined by 23 percent, the largest rate of decline among all the groups in either the intervention city or control city (Macaskill et al. 1992).

The Coronary Risk Factor Study (CORIS) conducted in three rural South African cities with both white and black Afrikaner residents used small media (posters, billboards, newspapers, and direct mail) to encourage persons to lower their risk factors for coronary artery disease, including smoking (Steenkamp et al. 1991). The media campaign was supplemented in one of the cities with an interpersonal intervention for high-risk persons. This intervention included an intensive smoking cessation program. Net decreases in the prevalence of smoking among women ranged from 3.0 to 4.0 percentage points in the two intervention communities. Among men, the net difference between the intervention and control cities was an increase in smoking prevalence of 0.9 percentage points in the city with only a media campaign and a decrease of 3.7 percentage points in the city with media plus intervention. The percentage of women who stopped smoking was significantly higher in the intervention cities than in the control city and was also higher than that among men.

Three community-based projects to reduce coronary heart disease were the Stanford Five-City Project, the Minnesota Heart Health Program, and the Pawtucket Heart Health Program (Winkleby et al. 1992, 1997; Fortmann et al. 1993). Each had intervention and control cities and used a variety of community-based programs, such as mass media, community education, and multiple education channels. In the Stanford Five-City Project, smoking cessation increased in cohorts of women and men in both the intervention and control cities, but the difference between cessation rates in these cities was significant only among men. Cross-sectional surveys also found that the prevalence of smoking decreased significantly among men, but not among women. The Minnesota Heart Health Program reported no significant differences in the prevalence of smoking cessation between cohorts in the intervention and control cities. However, cross-sectional surveys conducted annually showed an intervention effect among women of 1.3 percent overall above the secular trend (p < 0.05), but no significant effect among men (Lando et al. 1995; Winkleby et al. 1997). The Pawtucket Heart Health Program found no significant differences in the prevalence of smoking cessation between cohorts in the intervention and control cities followed up over time, but it did not report results of the cohort by gender (Carleton et al. 1995). A joint analysis of the cross-sectional data from these three studies found no significant decreases in smoking prevalence or increases in smoking cessation associated with the intervention among either women or men (Winkleby et al. 1997).

A six-year, three-community study (one intervention community and two control communities), initiated in India in 1986, focused solely on tobacco use. It sought to prevent initiation of tobacco use among nonusers and to encourage cessation among users. Prevalence of tobacco use was higher among women than among men at baseline, but 99 percent of the women tobacco users chewed tobacco or used snuff instead of smoking tobacco. The total prevalence of tobacco use decreased significantly more in the intervention community than in the control communities, and the differences were greater among women than among men (Anantha et al. 1995).

COMMIT recruited 11 pairs of communities, focused exclusively on smoking cessation, and used the community as the unit of both randomization and analysis (COMMIT Research Group 1995a). Cohorts of heavy smokers (>25 cigarettes per day) and light or moderate smokers (<25 cigarettes per day) were followed up annually. A cross-sectional survey also was conducted at baseline and again at the end of the study. In the cohort of heavy smokers, no significant intervention effect on the proportion who had stopped smoking was found. Although men were significantly more likely than women to stop smoking, this difference disappeared when treatment condition, age, and education were controlled for. In the cohort of light or moderate smokers, smokers in the intervention cities stopped smoking in significantly higher proportions than did smokers in the control cities, but fewer women than men stopped. No significant interaction of gender by treatment was observed (COMMIT Research Group 1995b).

A number of smaller, nonrandomized community studies have been conducted in recent years. In a quasi-experimental design, Fisher and colleagues (1998) organized three low-income, predominantly African American neighborhoods in St. Louis, Missouri, to promote nonsmoking, and compared the outcomes with those in three similar neighborhoods in Kansas City, Missouri (see "Other Cessation Programs for African American Women" earlier in this chapter). The investigators found significant treatment effects, and men were significantly more likely than women to stop smoking (RR, 1.6; 95 percent CI, 1.3 to 1.9).

A community-wide cable program used a timeseries design to assess the effectiveness of cable television in promoting smoking cessation (Valois et al. 1996). At one year, the cessation rate was 17 percent. This percentage compared favorably with other televised cessation programs.

A number of other community smoking cessation intervention programs are in progress. These include the American Stop Smoking Intervention Study (ASSIST), which was initially funded by NCI and the American Cancer Society and has now been transferred to CDC; the SmokeLess States program funded by the Robert Wood Johnson Foundation; and Initiatives to Mobilize for the Prevention and Control of Tobacco Use (IMPACT), another CDC-funded program. In combination with concurrent activities at the federal, state, and local levels, these efforts to control tobacco use hold considerable promise for reducing smoking among women. An interim analysis found that by 1996, per capita tobacco consumption was 7 percent lower in the 17 states participating in the ASSIST program than in the 32 non-ASSIST states (Manley et al. 1997). However, results by gender have not yet been published.

Monitoring Public Tobacco-Related Attitudes

Federal, state, and local governments have introduced policies that range from federally mandated health warnings on all cigarette packaging and a ban on smoking on all domestic airline flights, to increases in state tobacco taxes and local ordinances restricting smoking in restaurants. Some organizations and accrediting bodies have instituted tobacco control policies for their members. For example, since 1991 the Joint Commission on Accreditation of Healthcare Organizations has required hospitals to be smoke-free as a condition of their accreditation. Even in the absence of legislation or accreditation requirements, an increasing number of employers are instituting policies restricting or banning smoking at the workplace.

Several caveats must be noted in the interpretation of these studies. Surveys assessing attitudes toward smoking policies have seldom been based on national random samples, thus limiting the generalizability of the findings. The few surveys that have included national random samples (Gallup Organization 1993; Strouse and Hall 1994) are generally of limited scope. In contrast, two surveys in Massachusetts (Biener et al. 1994) and California (California Department of Health Services, public use data tape, 1994) assessed a wide array of attitudes. These are states with progressive legislation supporting tobacco control, and the results of these surveys may not be representative of national opinions. The COMMIT project, representing a diverse set of communities, found little variation across communities in attitudes toward tobacco control policies (CDC 1991). Any differences in attitudes toward such policies among women and men may be related to differential smoking prevalence, which is a confounder that may not be measured in opinion surveys.

Policies Restricting or Prohibiting Smoking

With increasing evidence of the health effects of exposure to ETS, policies prohibiting smoking in public places have multiplied. Restrictions on smoking have been legislated by state and local clean indoor air laws and have been adopted in worksites through the initiatives of individual employers or managers (see "Worksite Programs to Reduce Smoking Among Women" earlier in this chapter). Several studies have reported that women are more likely than men to work in places where smoking is restricted (Borland et al. 1992; Patten et al. 1995b; Gerlach et al. 1997; Royce et al. 1997) and that women report lower levels of workplace exposure to ETS (Borland et al. 1992; Patten et al. 1995b) and higher levels of compliance with smoking policies in their places of employment (Sorensen et al. 1992a).

Attitudes Toward Restrictions and Prohibitions on Smoking

A 1997 poll showed that a majority of women and men in the United States believed that secondhand smoke is very harmful to adults and that this perception differs by gender (61 percent of women and 49 percent of men) (Saad 1997). These prevalences are substantial increases from a 1994 poll in which only 45 percent of women and 27 percent of men thought that second-hand smoke was very harmful to adults (Saad 1997).

In surveys conducted in the early to mid-1990s, only small gender-specific differences were observed in attitudes toward banning smoking in indoor work areas, restaurants, shopping malls, public buildings, and indoor sports or concert arenas (Table 5.3). Other surveys have assessed employee attitudes toward policies restricting or prohibiting smoking in their own worksite. Support for such policies is generally high, and the few studies that have included gender in their analyses have found no differences in women's and men's attitudes toward these policies (Borland et al. 1989).

Table

Table 5.3. Support for policies that prohibit smoking in public places, by gender.

Pricing and Taxation Policies

Cigarette price is a major determinant of cigarette consumption and one that can be influenced by tobacco tax policy (Lewit and Coate 1982; Wasserman et al. 1991; Peterson et al. 1992; Emont et al. 1993; Keeler et al. 1993; Meier and Licari 1997; Biener et al. 1998; CDC 1999). After the 1964 Surgeon General's report on the health consequences of smoking was published, states began to increase the tax on cigarettes as a means of discouraging smoking (Warner 1981). In recent years, some states have used revenues from tobacco taxes toward promotion of tobacco control.

Policies Restricting Youth Access to Tobacco

Smoking is typically initiated during adolescence. Results of the 1991 National Household Surveys on Drug Abuse indicated that among persons who had ever tried a cigarette, 88 percent had tried their first cigarette by 18 years of age. Of those who had ever smoked daily, 71 percent did so by age 18 years (USDHHS 1994).

Attitudes Toward Restrictions on Youth Access

In general, adults strongly and consistently support curbs on minors' access to tobacco products, including access through vending machines. Women are generally more supportive of eliminating vending machines than are men, especially where the machines are accessible to youth (Table 5.4).

Table

Table 5.4. Support for restrictions on vending machines, by gender.

Public opinions toward other restrictions on youth access were assessed in the Robert Wood Johnson Youth Access Survey, a national opinion poll conducted in 1994 (Strouse and Hall 1994). Significantly more women than men supported requiring retailers to keep tobacco products behind the counter to prevent shoplifting by minors (83 vs. 71 percent) and supported allowing sale of cigarettes only in certain stores, as with alcohol (53 vs. 39 percent). No differences by gender were noted in support for requiring clerks to check identification of persons who appear underage or for increasing the legal age for sale of cigarettes to either age 19 years or age 21 years.

Policies Restricting Advertising and Marketing of Tobacco Products

Attitudes Toward Restrictions on Tobacco Advertising and Marketing

In response to growing concern about the effect of tobacco advertising among children and adolescents and in the face of tightening restrictions on tobacco advertising, several surveys have been conducted to assess public attitudes toward marketing restrictions. Five studies have indicated that women are more likely than men to support restrictions on marketing and advertising of tobacco (Table 5.5). An additional study similarly reported higher support from women than from men for other actions to restrict advertising hat are designed to make cigarettes less appealing to children and adolescents, including support for "tombstone advertising" that would prohibit the use of visual appeals (77 vs. 69 percent), mandate plain packaging of cigarettes (51 vs. 42 percent), ban coupons for obtaining promotional items (79 vs. 61 percent), and eliminate the sale of single cigarettes (87 vs. 76 percent) (Strouse and Hall 1994).

Table

Table 5.5. Support for restrictions on marketing and advertising of tobacco products, by gender.

In contrast, two studies have shown similarities in women's and men's support for advertising restrictions. A 1995 poll (Associated Press 1995) that assessed public support for President Bill Clinton's efforts to limit tobacco advertising and promotion aimed at girls and boys found no gender-specific differences in the proportion of respondents who would support tombstone advertising or a ban on "masked" tobacco promotions such as sportswear or event sponsorships. A 1993 poll (Gallup Organization 1993) found negligible differences between women and men in the proportions who thought that tobacco advertising was designed to appeal to children (75 vs. 78 percent), make smoking seem glamorous (65 vs. 63 percent), or encourage young people to smoke (69 vs. 63 percent).

School-Based Interventions

Most intervention studies with adolescents have taken place in schools, which afford easy access to adolescent peer groups. School-based programs offer the opportunity to expose almost all children to the program and to evaluate the program's effects by assessing students over time. The impetus for these prorams has been largely external to school systems and driven by federally funded research (Lynch and Bonnie 1994). Studies have focused on demonstrating the effectiveness of a program to reduce both initiation of tobacco use (primary prevention) and movement from experimental to regular use (secondary or tertiary prevention).

Several well-known projects did not report on gender-specific effects. These projects include the Life Skills Training Project (Botvin et al. 1990, 1995), the Midwestern Prevention Project (Pentz et al. 1989a,b), the Minnesota Smoking Prevention Program (Murray et al. 1987, 1988, 1989), Project ALERT (Ellickson et al. 1993), Project SHOUT (Elder et al. 1993), Project To-wards No Tobacco Use (Sussman et al. 1993), and the Waterloo Smoking Prevention Project (Flay et al. 1985, 1989).

Graham and colleagues (1990) reported one-year follow-up results of Project SMART, which was designed to evaluate the effects of two programs based on social psychology. The study involved three seventh-grade cohorts (5,070 students) in the 1982-1983, 1983-1984, and 1984-1985 school years. Results were examined for six subgroups: male, female, white, African American, Hispanic, and Asian. The program was significantly effective in reducing cigarette smoking among girls (p < 0.0001) but not among boys.

The Oslo (Norway) Youth Study Smoking Prevention Program (Klepp et al. 1993) provided a 10-session smoking prevention program to students in fifth through seventh grades who were enrolled in Oslo schools in 1979 and 1980. The program, which was partly led by older students, encompassed education about the social, political, and health aspects of smoking; skill building to resist social pressures to smoke; and public commitment to remaining nonsmokers. The study included 1,013 students. The 10-year follow-up revealed significant effects of intervention among boys who had never smoked at baseline: 41.6 percent of the boys in the intervention group and 55.8 percent of the boys in the control group had ever smoked since baseline. No intervention effects were found among girls who had never smoked at baseline or among students of either gender who had experimented with smoking or who had smoked regularly (at least once a week) at baseline.

Gilchrist and colleagues (1989) reported on the combined results of two school-based interventions that emphasized skill building and were delivered by health educators in 10 sessions to 1,281 sixth graders in western Washington state between 1981 and 1984. The outcome measure was weekly smoking at the 24-month follow-up. Baseline risk for smoking was determined by previous smoking experience or by intention to smoke in the near future; girls and boys were classified as being at high or low risk. The intervention had a positive effect on each of the four risk-by-gender groups but was least effective among girls at high risk for smoking. Gilchrist and colleagues observed that the "developmental and social dynamics that propel female adolescents into smoking may differ from those operating on young males" (Gilchrist et al. 1989, p. 241). Their conclusions were somewhat at variance with the results of Project SMART discussed above, which was designed to develop social skills for refusing drug use; that program significantly reduced cigarette smoking among girls but not boys (Graham et al. 1990).

In the Southwest Cardiovascular Curriculum Project (Davis et al. 1995), tobacco use prevention was one of five components of a 13-week curriculum taught to Navajo and Pueblo fifth graders at rural elementary schools in New Mexico. Baseline questionnaires were completed by 2,018 students. Follow-up questionnaires that were administered within 3 weeks of the end of the curriculum were completed by 1,766 students (1,352 who had received the curriculum and 414 control students). Students were asked whether they had changed the amount of to-bacco they smoked or chewed since baseline. Boys who participated in the curriculum were significantly more likely than those in the control group to report reducing the amount of tobacco they used (41.2 vs. 22.0 percent). The difference was not significant among girls (25.2 vs. 23.2 percent). Long-term effects of the curriculum cannot be determined from this study.

Community-Based Interventions

Several research programs have supplemented school-based programs with broader community efforts to create an environment that discourages smoking initiation. Such community efforts typically include media components and may also include community organization to support nonsmoking, greater enforcement of laws restricting access of minors to tobacco products, and efforts to educate adults. The North Karelia Youth Project relied on mass media in conjunction with a school-based program geared to dissuade youth from smoking. Vartiainen and associates (1990) found a preventive effect 8 years after the program ended, but at 15 years after intervention, differences between intervention and control schools were no longer statistically significant (Vartiainen et al. 1998). The preventive effect was more pronounced among young men (27 percent) than among young women (24 percent). However, the interaction between study arm and gender was not statistically significant.

A comprehensive community-based smoking prevention program, the Midwestern Prevention Project (Pentz et al. 1989a,b), randomized eight schools in Kansas City to receive an intervention program or a control program. The intervention program provided students with skills to resist social pressures to use tobacco and provided models intended to support the non-use of tobacco. Within all eight schools, a longitudinal sample of sixth- and seventh-grade students was followed for two years. At the end of six months, the prevalence of smoking was significantly lower in the intervention schools than in the control schools for lifetime smoking, smoking in the past month, and smoking in the past week. At the end of two years, a significant difference only in lifetime smoking was found between intervention and control schools. Significant program effects were noted within grade and racial categories, but not by gender.

A smoking prevention component of the Minnesota Heart Health Program (Perry et al. 1992; Kelder et al. 1995) was delivered to 7th-grade students. This six-session program relied on peer leaders to transmit new information, norms, and skills to their fellow students. Each year through 12th grade, students who had been assessed at baseline (6th grade) were reassessed for change in smoking status by selfreport (never smoked, experimental smoker, former smoker, or weekly smoker). They were compared with a control cohort in a reference community, also in Minnesota. The survey of 12th graders included 45 percent of the original cohort of 2,401 6th graders. Cross-sectional analysis included all students who participated in each survey. Throughout the follow-up period, smoking rates were significantly lower among the intervention students than among the control cohort (p < 0.04 for grades 7 through 12). When the data were stratified by gender, the intervention effects were somewhat stronger among girls. The differences in smoking rates were significant in grades 7 through 11 among girls. Among boys the differences were significant in grades 7, 8, and 10; marginally significant in grades 9 and 12 (p = 0.06); and non-significant in grade 11. The authors hypothesized that "girls may be more receptive than boys to social influences models of health education" (Kelder et al. 1995, p. 5-42).

An innovative mass-media intervention for smoking prevention (Flynn et al. 1995; Worden et al. 1996) targeted girls. Participants were fourth-through sixth-grade students in two pairs of communities, one pair in the northeast United States and one pair in Montana. Students in two communities (one from each pair) received a modest school-based intervention (three or four class periods per year over four years). In the other two communities, the school-based intervention was supplemented with a four-year media campaign using paid and donated advertising time on broadcast and cable television programs and on radio stations. The media spots were designed to appeal to high-risk girls and boys at three developmental levels (grades 5 and 6, prepuberty; grades 7 and 8, puberty; and grades 9 and 10, adolescence). The researchers made a special effort to target high-risk girls when purchasing time in the media campaign, which resulted in more media spots targeting girls. Media spots were changed regularly to keep up with changing tastes and styles. The initial cohort of 5,458 students was surveyed annually for four years, then two years later to assess long-term impact. At each assessment point, students were asked the number of cigarettes they had smoked in the past week. Although saliva samples were not analyzed, they were collected from all students in an attempt to increase the accuracy of self-reports.

In grades 8 through 10, the weekly smoking prevalence was 40 percent lower among girls who had received the media-plus-school intervention than among girls who had received the school-only intervention. The difference in smoking prevalence persisted two years later when the students were surveyed in grades 10 through 12: 15.6 percent of girls in communities with the media-plus-school intervention but 29.4 percent in communities with the school-only intervention smoked weekly. Girls receiving the media-plus-school intervention also had lower increases in beliefs in the advantages of smoking, positive attitudes toward smoking, perceptions of peer smoking, and intentions to smoke. The differences in weekly smoking were not significant among boys.

Public Health Initiatives

Few tobacco prevention programs or strategies, particularly those developed around sports and athletics, are designed specifically for girls. Although most tobacco prevention sports strategies appear gender neutral, they historically emphasize maledominated sports such as baseball or football. This historic bias changed in 1996 with the introduction in the United States of the SmokeFree Kids & Soccer Campaign, a tobacco prevention strategy targeted to adolescent girls. This program is unique for its emphasis on the sport of soccer and, more significantly, for its emphasis on an increasingly popular women's sport in the United States and throughout the world.

Through a public health partnership between the U.S. Women's National Soccer team, CDC, and NCI, SmokeFree Kids & Soccer encourages girls to participate in soccer to maintain fitness, make friends, have fun, and resist the pressure to smoke. In appearances at local schools, youth soccer tournaments, and media interviews, members of the U.S. Women's National Soccer team underscore the negative effect of tobacco use on athletic performance and promote participation in soccer as an alternative to smoking. Donna Shalala, then USDHHS Secretary, launched the campaign in advance of the 1996 Olympics in Atlanta by saying, This campaign communicates not only the negative effects of tobacco use on athletic performance, but also promotes participation in sports as a positive alternative to smoking. [The campaign] is an excellent vehicle for reaching young people with the smoke-free message. Athletics give young people the very benefits they often seek from smoking: independence, status with their peers, a chance to make friends and a positive sense of self (Forbes 1996, p. 105).

The campaign also uses health sponsorship, a strategy that has been commonly used by commercial sponsors, including tobacco companies (Corti et al. 1997). By participating in physically strenuous sports like soccer, adolescent girls can reduce their risk of smoking while enhancing self-esteem and helping to broaden community support for a smoke-free society (USDHHS 1997). Work by the Canadian Association for the Advancement of Women and Sport and Physical Activity has underscored the important physical and emotional benefits that being part of an athletic team can play in reducing an adolescent girl's risk for smoking (Canadian Association for the Advancement of Women and Sport and Physical Activity 2001).

In the first year, Smoke-Free Kids & Soccer was introduced to more than one million children and adults through a combination of television, radio, posters, public events, and an interactive Web site (http://www.smokefree.gov). One of the most prominent components of the program was a series of six posters of the U.S. Women's National Soccer team, which were produced and distributed nationwide from 1996 through 2000 to hundreds of thousands of fans, both girls and boys. The posters encouraged girls to participate in soccer and to make "Smoke-Free" an integral part of their personal lifestyle. Messages such as "You don't get to be a champion by taking cigarette breaks," "Keep your engine running clean," "Smoke a defender… not a cigarette," and "My only addiction is the game" resonate with children and the adults who care about them. Program messages were promoted widely during the 1999 Women's World Cup in the United States, and through grants to state health departments for community-based health promotion activities.

At the 11th World Conference on Tobacco OR Health in August 2000, USDHHS and the World Health Organization joined the Federation Internationale de Football Association, the international governing body of soccer, to announce an international SmokeFree Soccer campaign to discourage tobacco use and to promote smoke-free and physically active lifestyles worldwide (11th World Conference on Tobacco OR Health 2000). Australian Health Minister Michael Wooldridge committed soccer players in his country to the initiative, saying it would be helpful in "promoting the benefits of being smoke-free"(Commonwealth of Australia 2000).

Efforts to Raise Awareness and Encourage Action

For many women's and girls' organizations, educating their constituencies about how tobacco affects their lives is the first step to involvement in women's tobacco control. As a result of such education, women and girls may be motivated to participate in further activities to reduce tobacco use among women and girls. Education and mobilization activities vary but generally emphasize health-related issues, prevention of smoking, countering tobacco industry advertising targeted at women, financial sponsorship of women's groups, and legislation.

Counteradvertising and Mass-Media Campaigns

The Women vs. Smoking Network, a project funded by NCI and based at the Advocacy Institute in Washington, D.C., involved women's organizations, leaders, and publications in tobacco control efforts, especially efforts against tobacco advertising and promotion that target women (Women vs. Smoking Net-work 1990). The network catapulted the issue of targeted marketing to the national consciousness by strategically calling attention to the "Dakota Papers" (see text box 2 in "Contemporary Cigarette Advertisements and Promotions" in Chapter 4). These documents, sent anonymously to the network, contained a marketing strategy aimed at the "virile" female, described as a white female 18 through 20 years of age with no more than a high school education and minimal career opportunities and aspirations (Butler 1990). The network granted exclusive stories to certain television networks and newspapers, its members appeared on television with the Secretary of Health and Human Services, and it petitioned R.J. Reynolds to cease marketing the Dakota brand cigarette. As a result of strategies used by the network, the marketing plan for Dakota was changed and had limited test markets (Butler 1990). Unable to market Dakota under the original plan that called for targeting women with low educational levels, R.J. Reynolds ultimately pulled Dakota off the market because of low sales (American Medical News 1992).

Women And Girls Against Tobacco (WAGAT), which was funded by the California Department of Health Services, used the issue of advertising targeted to women and girls to educate and mobilize them (WAGAT 1993). One way WAGAT raised awareness was through purchasing kiosk space in shopping malls that attracted high concentrations of young people. The kiosks featured counterads on the tobacco industry's targeting of women as well as educational information (Regina Penna, Director, WAGAT, memorandum to WAGAT Advisory Board, May 6, 1994).

During the summer of 1998, NOW promoted the "We Have Come a Long Way, So Don't Call Me Baby" campaign at 58 Lilith Fair concerts. T-shirts, postcards, and a display were created to disseminate information about women and tobacco at these women-oriented concerts. Additionally, in September 1998, 1,000 new volunteers promoted the "Love Your Body Day" campaign. This campaign raised awareness about how the tobacco industry manipulates women into using tobacco by playing with popular notions of body image (CDC 1998b).

Women's Magazine Projects

One of the major ways tobacco companies try to reach women is through women's magazines (Amos and Bostock 1992). Research has shown that women's magazines that accept tobacco advertising are significantly less likely to publish articles critical of women and smoking than are magazines that do not accept such ads (Warner et al. 1992) (see "Press Self-Censorship in Relation to Cigarette Advertising" in Chapter 4). The American Public Health Association conducted one of the first campaigns to uncover and attempt to change advertising policies of women's magazines (Johnson 1987). It requested that editors and publishers of 21 popular women's magazines include articles on the health hazards of smoking and wean their publications from tobacco industry advertising accounts. More than 50 women's, girls', and health organizations participated in the campaign. Eleven magazines responded, but none committed to change their advertising policy. Generally, the editors responded that the choice to run tobacco ads was based on the revenues received from the ad and that adult readers have the "freedom to choose" whether to buy a product (Johnson 1987).

As a result of a survey of cigarette advertising and health coverage in British women's magazines in 1984, the British government introduced voluntary advertising restrictions that prohibited magazines with a female readership of more than 200,000 and at least one-third of their readership aged 15 through 24 years from accepting cigarette ads (Action on Smoking and Health [ASH] Working Group on Women and Smoking 1990). A follow-up survey conducted by the ASH Working Group on Women and Smoking in 1989 documented whether the voluntary restrictions in Great Britain had affected cigarette advertising and health coverage in women's magazines. Coverage of smoking and health issues remained largely unchanged between the two surveys (ASH Working Group on Women and Smoking 1990).

In California, WAGAT sponsored the "Golden Handcuffs Challenge" (1993) to reduce the quantity of tobacco ads in national magazines with a large proportion of women readers (Ferris 1994). WAGAT asked the editors of Essence, Glamour, and People to write articles on the effects of tobacco advertising on editorial practice. Glamour and People declined the request after six months, and Essence never responded (Ferris 1994). During this time, the California Department of Health Services tried to place a paid antismoking ad in Essence. Even though the ad was paid for, it was deemed "too controversial" and never appeared (Ferris 1994). As Essence editor Linda Villarosa stated in an article in the Harvard Public Health Review, "alienating a tobacco company means more than kissing off just cigarettes; it may mean alienating a conglomerate" (Villarosa 1991, p. 20). WAGAT's campaign was illuminating in that, even if the tobacco control movement had substantial funds to attempt to "buy out" tobacco ads in magazines, such efforts might be met with resistance.

The Australian National Women's Magazine Project was run by the Quit Victoria project of the Victorian Smoking and Health Program (1991-1992). The objective was to increase the amount and quality of reporting on the health effects of smoking by using paid "advertorials" in a number of popular young women's magazines (Davidson 1991). In the midst of the campaign, legislation to ban tobacco ads in the print media was enacted. The Quit Victoria project surveyed magazines for smoking-related articles six months before and after the ban went into effect. Coverage of the health effects of smoking appeared to increase after Quit Victoria started advertising (before the ad ban went into effect), but little difference in specific editorials was found before and after the ban itself. Quit Victoria noted that magazines contained more photographs of celebrities smoking after the ban than previously (Michelle Scollo, Executive Director, Victorian Smoking and Health Program, letter to Deborah McLellan, September 11, 1992).

The placement of images in women's magazines of models smoking may increase as countries pass advertising bans. For example, although Italy has a ban on tobacco advertising, an issue of an Italian Vogue contained numerous pages of models smoking in ads for non-tobacco products; a cover showcased a world-famous model, Linda Evangelista, smoking (Amos and Bostock 1992; Amos 1993). The Italian case suggested that simply removing paid cigarette ads from magazines may not have the intended effect of entirely eliminating images of persons smoking or increasing coverage of issues related to smoking and health among women (Amos and Bostock 1992).

Countering Tobacco Sponsorship of Women's Tennis

For many years, starting in 1971, Philip Morris sponsored professional women's tennis (Robinson et al. 1992). Public figures who have expressed gratitude for the tobacco industry's sponsorship include Martina Navratilova, perhaps the best known woman tennis player in the world. The loyalty of women's tennis to its tobacco industry sponsor was so great that Proctor and Gamble's offer to support a women's tennis tournament was refused in 1988.

Many communities have held counterevents. Doctors Ought to Care organized a series of Emphysema Slims tennis tournaments as counterevents to the Virginia Slims tournaments (USDHHS 1991b). In 1990, the District of Columbia Interagency Council on Smoking and Health organized a media event to bring attention to the tobacco industry's sponsorship of the Virginia Slims tennis tournament. The event was held at The George Washington University, Washington, D.C. (District of Columbia Interagency Council on Smoking and Health 1990). The highlight of the event was a statement by Secretary of Health and Human Services Dr. Louis W. Sullivan, who urged the tobacco industry to end its sponsorship of sports events (Broder 1990).

The next year (1991), the Virginia Slims tennis tournament returned to Washington, D.C., where it was to be held at an amphitheater on property of the National Park Service. National and local organizations combined efforts to halt the tobacco industry's sponsorship of the tournament on public property. As a result of a lawsuit, local protests, and media attention, the National Park Service agreed to ban tobacco industry-sponsored tennis tournaments on its property (Spolar 1991). As of 1994, Virginia Slims no longer sponsored the major national women's tennis events, although individual events in several cities and the Tennis Legends Tour are still sponsored by Virginia Slims (IEG 1995).

In Australia, sports have not exhibited the same loyalty to the tobacco industry. The Victorian Health Promotion Foundation in Australia has used money raised by taxes on tobacco products to replace tobacco industry sponsorship of sports and arts organizations (Daube 1992; Galbally 1994). Australia's success may reflect economics, because more than five times the budget necessary to replace tobacco sponsorship is available through the foundation (Daube 1992).

Development of Women's Leadership in Tobacco Control

The desire for women to communicate and net-work on a global level was the foundation on which INWAT was built (McLellan 1990). Because one of the objectives of INWAT is to promote women's leadership in the tobacco control movement (INWAT 1994), it developed a training workshop that focused on tools for building such leadership: assessing knowledge, defining roles, enhancing skills, and building networks (McLellan et al. 1992). As a result of INWAT's efforts, the proportion of invited women speakers increased from 8 percent at the 1990 Seventh World Conference on Tobacco OR Health to 30 percent at the Eighth World Conference on Tobacco OR Health in 1992 (Jordan 1992; Gritz 1993). INWAT also succeeded in having world conferences adopt its resolutions on equity in representation and on funding for women at tobacco control conferences (Tobacco Control 1992).

INWAT has regional networks that focus on the needs of women in different parts of the world. The Latin American Women Association on Smoking Control (Associação de Mulheres da América Latina para o Controle do Tabagismo [AMALTA] 1994), the Canadian Network of Women Against Tobacco, INWAT-Europe, and WAGAT have been particularly active regional networks with funds committed to them (INWAT 1995). Other regional networks of INWAT exist in Africa, Asia, and Australia (INWAT 1999).

As a result of a resolution passed at the 1990 World Conference on Smoking and Health in Perth, Australia, the International Union Against Cancer organized the First International Conference on Women and Smoking, which took place in Northern Ireland in October 1992. This landmark event produced a series of recommendations that focused on raising awareness about women and tobacco, countering pressures on women to use tobacco, and organizing women for action in tobacco control (Health Promotion Agency of Northern Ireland and Ulster Cancer Foundation 1993).

In June 1994, the Women United Against Tobacco Workshop was convened by the American Public Health Association to develop a comprehensive national plan to reduce women's use of and exposure to tobacco (McLellan and Wright 1996). The resultant national consensus document included a goal to increase the number and power of women leaders in tobacco control by convening a summit on women and tobacco, promoting women spokespersons, and encouraging women's leadership within tobacco control organizations.

Most recently, in November of 1999, the World Health Organization sponsored an International Conference on Tobacco and Health in Kobe, Japan. It was titled, "Making a Difference to Tobacco and Health: Avoiding the Tobacco Epidemic in Women and Youth." The conference was attended by several hundred leaders of women's organizations and of other governmental and nongovernmental organizations from around the world, as well as by the media, health scientists, and public health advocates. Formal presentations addressed the worldwide prevalence and effects on women's health of active smoking and of ETS exposure, the economic costs of tobacco use, the international marketing of tobacco products to women, and other topics. The resultant Kobe Declaration included a number of strong resolutions, such as a call for a global ban on tobacco advertising, funding for counteradvertising that disconnects women's liberation and tobacco use, and mobilization of many segments of society in the fight against tobacco use (World Health Organization 1999b).

Development of Tobacco Control Advocates in Women's Organizations

The California chapter of NOW launched the "Redefining Liberation" campaign to educate its members about issues related to tobacco use among women and to develop leadership on the subject within NOW's ranks (California NOW 1994). The California chapter used community-based strategies and developed an action guide and training videotape for its campaign to develop young leaders (Elizabeth Toledo, NOW, letter to Deborah McLellan, September 8, 1995). Early in 1998, the videotape was distributed to 40 states and every region throughout the United States (CDC 1998a).

The Strategic Coalition of Girls and Women United Against Tobacco, a project of AMWA with funding from CDC, also has trained leaders in women's organizations on tobacco control issues (AMWA 1995). In particular, AMWA trains women physicians and medical students in tobacco control and media advocacy to be spokespersons for tobacco control (AMWA 1995).

The Swedish National Institute of Public Health sponsors an innovative program with the Miss Sweden beauty pageant, requiring all Miss Sweden candidates since 1996 to be nonsmokers (Steimle 1999). The candidates are also required to work as tobacco educators in their local school districts for at least four to six weeks. One of the purposes of the project is to provide Swedish girls with fashionable role models who do not smoke. By 1997, more than 30,000 students in grades four through six had met a Miss Sweden candidate. The project has been well received by the schools and the media.