Quitting smoking may be harder for women than men

Quitting smoking is on the top of many people’s resolution lists for the New Year. However, it is a difficult process and smoking cessation is dependent on a variety of factors, not the least of which is withdrawal. 

“Abstinence from nicotine self-administration in a drug-dependent or addicted individual results in withdrawal effects,” writes the Encyclopedia of Behavioral Neuroscience.

A group of scientists has analysed data from the World Health Organization’s Global Adult Tobacco Survey (2008–2012), looking at adults who have tried to quit at least once in a 12-month period in low- and middle-income countries (LMICs). Specifically, they were trying to determine if there were any sex differences in smoking cessation.

They had a big sample size, 16,576 individuals. Running adjusted logistic regression models for female sex effects on one-day relapse, they adjusted for nine individual-level demographics (e.g. age, education, the age when the subject started smoking) and smoking cessation variables (e.g. exposure to health warnings, receipt  of counseling).

Then they carried out a meta-analysis adjusted for national level and policy measures through meta-regression (e.g. cigarette consumption per capita, percent of cigarette box covered with warning labels).

The researchers found that the first day of smoking cessation is more challenging for women than men in 12 LMICs. Around 60 percent of the world’s smokers live in low- and middle-income countries according to the news release.

Researchers say this is a particularly significant finding because the first day of abstinence is “one of the most critical predictors of long-term smoking cessation.”

The study also showed that larger health warning labels on cigarette packaging helped women overcome their urges to smoke on the first day of quitting and were associated with “reduced odds of one-day relapse” among women.

“A successful first day of abstinence is one of the most important predictors for prolonged smoking cessation, and little is known about why women may find this period more challenging than men,” said Joao Mauricio Castaldelli-Maia, MD, PhD, NIDA-INVEST Postdoctoral Fellow in the Department of Epidemiology at Columbia Mailman School, and first author.

“It may be that withdrawal syndrome, which typically presents on the first day of abstinence and is cited by smokers as the main reason for relapse, may play an essential role in one-day quit attempt outcomes among women who typically report more withdrawal symptoms than men.” 

Women also have a hard time “maintaining long-term abstinence than men” – while “drivers for smoking initiation and cessation differ between men and women.” For example, women cite weight control as a reason to start smoking, but they are also more likely to be “motivated by health concerns” than men to attempt to quit smoking, especially during pregnancy.

The 12 low- and middle-income countries included in the study were: Bangladesh, Brazil, China, Egypt, India, Indonesia, Mexico, Russia, Thailand, Turkey, Ukraine, and Vietnam.

Symptoms of nicotine abstinence include “craving for nicotine, irritability, difficulty concentrating and paying attention, sleep difficulties, dysphoria, impatience, increased appetite, and weight gain. Most of these symptoms begin within 24 hours after nicotine abstinence, peak between 36 and 72 hours, and gradually subside after several days. However, urges or craving for nicotine and increased appetite and weight gain can persist for 6 months to a year,” the Encyclopedia of Behavioral Neuroscience explains.

Overall reports of one-day relapses ranged from three percent to 14 percent, with the prevalence of women reporting at least one quit attempt varying considerably across countries – from slightly over one percent in Egypt to 43 percent in Brazil, the news release notes.

Health warning labels in general “have been shown to effectively reduce tobacco smoking” and they worked for women too. 

“Compared to male smokers, women tend to rate graphic warning labels overall as more credible, evoking more negative emotions, and eliciting higher motivation to quit,” noted Silvia Martins, MD, PhD, professor of epidemiology at Columbia Mailman School, and senior author. “Yet, as of 2013, less than half of low-middle income countries included in the Global Adult Tobacco Survey had implemented these warning labels on cigarette boxes.”

Since little research on sex differences in warning label effectiveness has been conducted in low-middle income countries, “more inquiry is needed into how interventions can be tailored to address these barriers to sustained abstinence,” according to Castaldelli-Maia and Martins.

“Incorporating national policies, in addition to counselling and pharmacotherapy, could play an essential role in supporting women during the initial abstinence phase of smoking cessation in low- and middle-income countries,” said Castaldelli-Maia. “Medication and/or psychotherapy may be critical in increasing the chance of successfully quitting smoking especially because studies in high-income countries showed that women tend to receive less pharmacological treatment even though they seek treatment more often.”

The other authors of the paper published in the journal Addictive Behaviors (The first day of smoking abstinence is more challenging for women than men: A meta-analysis and meta-regression across 12 low- and middle-income countries) are Elizabeth Nesoff, University of Pennsylvania Perelman School of Medicine; Danielle Lima, Medical School, University of Sao Paulo (USP); and Zila Sanchez, Medical School, Universidade Federal de Sao Paulo (UNIFESP).