Stopping smoking

“Asking women not to smoke without examining the pressures
that lead to the desire for a cigarette is problematic.”

 “cigarettes… are as addictive as drugs such as heroin and cocaine”

A range of approaches contribute to reduced tobacco use.  This section focuses on activities which directly help women stop, and discusses whether men and women stop smoking in a different way. The quotes above illustrate the wide range of perspectives on nicotine use.

Help with stopping - overview

In terms of public health there are three key questions.  What is the success of this method, how many smokers can it reach, and how much does it cost?  These measures give cost per long-term success.  However, ‘cost-effective’ methods may be impractical, or fail to answer women’s needs. 

And all methods are very cost effective, compared to other medical treatments. For example, stop-smoking treatments cost a few hundred pounds per life-year gained, compared with many thousand pounds for ‘statin’ drugs to lower cholesterol.  UK estimates give £200-£900 compared with £5,400-£13,300 per life year.

Current methods fall into five basic groups:

A few major community-wide interventions have combined a range of approaches.
The ‘best’ approach depends on the situation in each country.  Health information and access to NRT and other therapies may be key global strategies.  A British review concluded that doctors’ advice and unpaid media were most cost-effective. But low-income or pregnant smokers may need special attention, and ‘woman-centered’ approaches are being explored.

Countries where smoking is greater among the poor have other choices to make.  Population targets are most easily reached by focusing on those who are ready to stop.  However, this approach may increase health inequality.  A broader anti-poverty approach is more complex, but promises greater long-term health gain, perhaps especially for women.

Stopping without help
Most women who try to stop do so without formal help.  These attempts may be triggered by quit events, price rises, or health information.  For example ‘information shocks’ have been shown to prompt quit attempts in Finland, Switzerland, the UK and Greece, but perhaps with more benefit to men.  In ‘mature’ tobacco markets around half of all smokers may try to quit in any year, but 98% typically relapse within a year.  Self-help materials provide slight extra benefit, especially personalized materials.   Better relapse prevention could bring major health gain, perhaps especially for women, but as yet there are no proven approaches.

Brief advice
Women are more frequent users of primary care, especially for reproductive and child health care.  Brief advice of around 3 minutes from health workers can reduce the rate of smoking by around 2% above natural quit rate.  This modest result is very cost-effective, as many smokers are reached.  Health workers who smoke may feel less willing and able to advise patients, so Spanish health workers are being encouraged to quit.   But the support offered by smokers can be just as effective.

Success partly depends on very basic issues.  Do health workers know who smokes, and is advice actually given?  Simple reminder stickers on medical notes can improve advice rates.  But workers often feel ineffective, and lacking in time and skills.  This work may need to be part of ‘core contracts’ for health workers.   The UK strategy for tobacco control now includes cessation guidelines, and pilot schemes are starting, mainly in deprived areas. Norway will introduce a tobacco adviser in each municipality, to co-ordinate health workers, following a similar scheme in Sweden.

Success can also be improved by longer intervention with follow up over a longer period, and advice relevant to women’s needs.

Helplines
Well publicized helplines get many callers.  For example, around 1 in 25 (4.2%) of all English smokers call the Quitline in any year.  The adjusted one-year quit rate for callers who are current smokers compares well with other interventions (15.6%). Women and girls are in the majority.  For example, around a third of callers to Smokeline in Scotland are girls under 18.  Helplines also offer flexible personal support, which is valued by women.  ‘Proactive’ helplines make active contact, and a series of long (50 minute) calls with motivated smokers can be effective.  A network of European helplines has now been established.

Mass media

Evidence on paid media campaigns suggests this is the best way of reaching difficult groups, including low-income smokers.  For example, half of all callers (50%) hear about the California Smokers' Helpline through the media programme.  Callers have higher than average nicotine dependency, more often live with other smokers, and around one third are from ethnic minority groups.  Yet the Helpline has well-established effectiveness.   Humorous TV adverts for the English Quitline were also effective in reaching low-income smokers.

Linked support such as information on coping and relaxation can improve success.Effective messages are seen as relevant and personal, and look at the role of smoking for women.  What is said and how, and who gives the message are all important.  Inappropriate messages may be ignored, so women should be involved with design and delivery of messages.  In summer 1999 women smokers were the focus of French broadcasts, and a UK poster campaign.

Unpaid mass media can also be a cost-effective approach. For example, Finnish smoking rates fell in the 1970s, linked to intense media coverage of the Tobacco Act.  But smoking among women and young people rose again in the 80s, as the media lost interest. American health publicity around the 1960-70s was linked to reduced male smoking - information at this time mainly focused on male risk.  Coverage of ‘health shocks’ can reduce average population consumption by up to 5% initially. Campaigns such as No Smoking Day also have their main impact via media coverage.

Such coverage is particularly important for poorer countries, where paid media campaigns may be impractical.  New information may also have more impact where risks are less familiar.   Finally, such ‘media advocacy’ has a key role in setting the public agenda, and influencing decision makers. 

Nicotine replacement therapy (NRT) and other aids

In some countries NRT is widely available - as gum, patch, pill, nasal spray, or inhaler. For example, since December 1999 French smokers can get most types without prescription, and sales are expected to rise sharply. All have different benefits, though patches currently seem most acceptable. A review of 81 trials found that NRT roughly doubles quit rates over controls (OR 1.73). This applies in all sorts of treatment situations. But combining NRT with group behavioral treatment may be highly effective, perhaps achieving quit rates four times control (35-9% at one year).

Benefits may differ for women and men.  One study found women were 60% more likely to have used the patch, and stopped for significantly longer than men.  Nicotine gum may reduce weight gain, which women value, but the evidence on patches is unclear.  Patches may also help women with previous emotional problems do just as well as others, a real advance.  But women may feel less benefit for some withdrawal symptoms, such as sleep problems.

NRT is not yet advised for pregnant women, as it’s not clear whether nicotine damages the foetus. However, risks and benefits should perhaps be weighed against known risks of smoking[.   Poorer women may also feel the initial cost of NRT is too high.   British schemes now offer a weeks’ free supply to some low-income smokers.

Other aids
The antidepressant buproprion (Zyban) has been shown to be an effective aid for smokers, whether depressed or not.  The two major trials have shown double or triple quit rate, compared with placebo, in the context of intensive support.  

By summer 2000 the drug had won approval in all EU countries except France and Finland, and in Iceland and Norway.

A range of other drugs have been tested, but only clonidine has well established effect.  Glucose tablets may reduce symptoms linked to low blood sugar.  Early results are good, with possible reduction in weight gain, which appeals to women smokers.  If proved effective, this could be a low-cost aid for poor countries, and safe in pregnancy.

Inhalers of ascorbic or citric acid replace the sensation of smoking, and results are promising. Smokers also use a range of other aids, but none has proven value.

More intensive support

In terms of public health, first choice should be the cheapest treatment likely to be effective. This choice depends on how motivated and nicotine dependent the smoker is.  However, motivation is not a clear predictor of who will stop.  Scotland proposes a ‘stepped care’ approach, with more intensive support given if simpler approaches fail.

Very dependent women, and those who’ve made several attempts may need special help.
This may look at motivation, coping with urges to smoke, relapse prevention, and social support.   Quit rates improve with both longer and more intense support, i.e. length and content of sessions. (Popular therapies such as acupuncture and hypnosis may provide this support, but are not shown to have specific effect.)  Group-based support is more cost effective, and more popular with women, but reaches very few smokers.

Smokers with depression  See also Health and well-being
Women are much more likely than men to suffer from depression and anxiety, including clinical depression.   Women who tend to depression may be more nicotine dependent, and more likely to relapse, though patch use may break this link. Antidepressant drugs and cognitive-behavioral therapy may benefit smokers generally. But a study of young people suggests that smoking causes depression, not the reverse.

Community wide interventions

Major community projects, such as COMMIT, Minnesota, and Pawtucket in the USA, have included a range of tobacco control - posters, media, helplines and quit competitions. The largest, COMMIT involved at least 58 activity types. These programmes are complex and costly, compared to health programmes with a single focus. They have had limited impact on quit rates. For example, COMMIT had no impact on the target group of heavy smokers targeted, though some effect on lighter smokers. Multi-focus campaigns are now running in Sweden and Israel.

Stopping during pregnancy

Who will stop?
In ‘mature’ tobacco markets pregnant smokers are usually poor smokers. For example, in Belgium the poorest women are five times as likely to smoke in pregnancy as the most affluent (35-7%). These pregnant smokers are likely to be young and unmarried.  They often live with a partner who smokes and have little education. Some workers feel that the months around birth may not be the best time to stop, and advice may simply cause guilt. Others argue that high relapse calls for better support for women generally.

Up to a quarter of women smokers do stop before first antenatal visit, and more during pregnancy.  For example, UK surveys during 1992-99 found nearly a third stop (30%), a tenth before pregnancy (10%). Over a third cut down (37%), mainly during pregnancy (33%).  But in Italy over half will stop, perhaps because this group are better educated.

Currently there is debate over whether pregnant smokers should stop or cut down.  Cutting down may improve birthweight, although some studies show no benefit.  Women who do stop have usually tried before, and believe more strongly in health risks.  They often have a non-smoking partner and more general support for stopping.  Yet as many as two-thirds will relapse soon after the birth.

Advice and support
Pregnancy is seen as an ideal time to help women stop, when they are in contact with health services, and may be very motivated.   Advice and support for pregnant smokers can increase the percentage of smokers abstinent for 6 months or more by 7-8% Women are more likely to stop in first than later pregnancies.  But Canadian research suggests that intervention before pregnancy may be most effective.

Tailoring support to women’s concerns and experiences has sometimes led to greater acceptance and success. Support for pregnant women should:

But these principles should perhaps ideally apply to all women smokers.

Training
Some health workers, particularly midwives, may not see smoking as a priority.  Or workers may feel they haven’t the information or skills, or worry about damaging relations with the woman.  Good training can do a lot to improve workers’ skills and confidence.  For example, a national Swedish programme has trained nearly all health care staff  (85%+).  Workers use a specific counseling approach, which fits easily into everyday work, with the focus on women’s own health.  Smoking among pregnant women has fallen more rapidly than among peers, halving during 1992-98 (31-15%).  Child-health nurses may also visit within the first four weeks, to talk over the benefits of staying stopped.  Relapse then falls to 20% at 8 months, and fathers also benefit.

Other support
Women whose partners smoke are less likely to quit, and more likely to relapse after the birth.  Pregnancy can be seen as a chance for couples to give up smoking long term, however partner support may be of little value.  Support from friends or other people at home is also important.  Peer support, for example ‘buddy programmes’ may help pregnant teenagers.

Low income communities

Smoking is linked to poor education, rented housing, crowding, unemployment and for women only, lone parenthood.  In fact it is suggested that smoking is independently linked to any measure of deprivation. In the UK those coping with such multiple deprivation have smoking rates around 75%. Poorer women themselves identify stress, boredom, isolation, and addiction as key issues - often linked to problems with family, housing and money.
These women are just as likely to want to quit. But there is a clear increase of both tobacco consumption and blood cotinine with increasing deprivation, with a similar link found in Czech smokers.

Projects over the last 25 years have largely failed to help poorer smokers - and to focus just on tobacco may ignore the factors that keep poor women smoking.  However, the projects below may give some pointers.  General quit services should also meet the needs of poorer women.

Community based programmes
Small scale ‘community development’ approaches aim to involve communities, and help them find solutions.   Such programmes may look at social pressure and the role of smoking, or stress and weight gain, or other health issues.  They may try to improve women’s coping skills and self-esteem.  One British project of this type helped twice as many pregnant women stop or cut down as in the control group (47-25%).

This is a promising approach, and peer education may also have potential.  This involves training local women on how to offer support, and how to train or educate others.  For example, ‘women centered’ approaches in Canada have included making a video or educational kit for other women.

Scotland has supported a range of initiatives with low-income women, including those coping with domestic abuse or poor mental health. This project has generated a lot of interest.  However, community workers often struggled with competing priorities, and lack of management support.   Such work also needs long-term funding.

Broader approaches
The Scots project report concluded that smoking should be seen in a broad context - both within women’s lives and in relation to strategies on poverty and inequality.  Reducing the burden of caring, and improving women’s welfare may sometimes be more effective than quit campaigns.  This approach may include initiatives on tax and benefits, education and training, and access to housing and childcare.  Canada has recently developed a policy structure which locates smoking prevention for women within a broad focus on inequality.

Young smokers

Young women are often keen to quit, though motivation may be fluid, and increased smoking rates have prompted interest in support methods.  This group may benefit from similar support to other smokers - brief advice, perhaps NRT, and helplines, which are popular with girls.  For example, a quarter of Scottish girls who smoke have called the ‘Smokeline’. However, there is not yet clear evidence of good practice. And young smokers are often already nicotine dependent, even those who don’t smoke daily. More information is needed on addiction in young women and how to address this. 

Young women and girls are very concerned about body image and often see themselves as overweight.  For example, European girls are two or three times as likely as boys to feel they should diet.  Girls are also as likely as adults to feel that smoking controls weight, and say this prevents stopping.   This suggests linking tobacco with other health issues, which may generally be a more effective approach.

Older smokers

European populations are aging, with many more women in the oldest groups, who have extra need for health services.  Older women who quit reduce their risk of many disabling conditions including stroke, heart and chest problems, and fractures.  And despite living longer, non-smokers tend to have lower total health care costs.  Even for this reason alone, smoking among older women perhaps deserves more attention.

Smoking rates are still high in some older groups, for example in Denmark.  Yet health workers seldom offer advice. Older smokers may be less confident about their ability to stop, or the benefits, although menopause or worry over grandchildren may give extra motivation.   However, success is possible.  In particular the ‘Clear Horizons’ materials, with perhaps telephone follow-up for women, have shown good results.

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