Women and smoking: current trends and issues for the 1990s

REPRINT OF: Racism, Sexism, and Social Class: Implications for Studies of Health, Disease, and Well-being

Editor's Note: This article is a reprint of a previously published article. For citation purposes, please use the original publication details: Krieger N, Rowley DL, Herman AA, Avery B, Phillips MT. Racism, sexism, and social class: implications for studies of health, disease, and well-being. Am J Prev Med. 1993;9(6 suppl):82-122.

The predictive value of intake questions on informing tailored quitline services

The Minimal Data Set are demographic and tobacco use questions asked during enrollment at many quitlines. We tested whether these questions can be used to predict program engagement and success, and to evaluate whether findings can inform the tailoring of protocols to disparate populations. We analyzed 7,920 Arizona Smokers' Helpline treatment records to test a Structural Equation Model of the mediating effects of quitline services and short-term cessation outcomes on the relationship between intake questions and 7-month quit rate. Education (b = 0.05), gender (b = 0.03), Medicaid (b = −0.09), longest length of previous quit attempt (b = 0.05), confidence in quitting for 24 h (b = 0.04), environmental risk (b = −0.05), and life stress (b = 0.04) all significantly (P < 0.05) predicted engagement in quitline services. Program engagement had a direct effect on an in-program cessation outcomes construct (b = 0.47) and 7-month quit rate (b = 0.44). This in-program cessation outcomes construct had a significant direct effect on 7-month quit rate (b = −0.12). This model showing the relationship between program engagement and outcomes suggests that tailoring protocols can focus on engaging clients who have historically not taken full advantage of quitline services.

Why is Virginia Slim? Women and Cigarette Advertising

Despite increasing efforts to reduce smoking among young women, they remain one of the fastest growing groups of cigarette smokers in the United States. A Means-end Chain framework, derived from marketing theory, is presented as a way to create effective anti-smoking messages. The intent is to explain how advertisers influence women to smoke in spite of repeated health warnings and public knowledge of the problems associated with tobacco products. After describing this marketing framework, a Means-end Chain analysis is applied to contemporary Virginia Slims advertisements, highlighting the associations between product attributes and women's values. The usefulness of this framework in developing anti-smoking messages is then demonstrated.

Smoking in College Women: The Role of Thinness Pressures, Media Exposure, and Critical Consciousness

There are strong social pressures for U.S. females, particularly those of European heritage, to achieve and maintain an extremely low body weight. These pressures are reflected in a variety of media sources, including advertising. We argue that valuing thinness, exposure to thinness-depicting media, and lacking skepticism about tobacco advertisements have adverse effects on young women's decisions about smoking, particularly smoking for weight control. We tested these hypotheses in a study of 188 female undergraduates, both never-smokers and daily smokers. Believing that smoking controls weight, exposure to thinness-depicting media, and low levels of skepticism about tobacco advertising were associated with being a smoker. Among smokers, believing that smoking controls weight, internalizing thinness pressures, and low levels of feminist consciousness were associated with smoking for weight control. Results are discussed with the aim of encouraging public health anti-smoking campaigns targeted at women, and smoking cessation programs that are responsive to the needs of weight-concerned female smokers.

Factors associated with successful smoking cessation in the United States, 2000

OBJECTIVES

Each year, nearly 2 in 5 cigarette smokers try to quit, but fewer than 10% succeed. Taking a multifaceted approach to examine the predictors of successfully quitting smoking, we identified factors associated with successful quitting so that cessation programs could be tailored to those at highest risk for relapse.

METHODS

Using data from the 2000 National Health Interview Survey, we employed multiple regression analysis to compare demographic, behavioral, and environmental characteristics of current smokers who tried unsuccessfully to quit in the previous 12 months with characteristics of those able to quit for at least 7 to 24 months before the survey.

RESULTS

Successful quitters were more likely than those unable to quit to have rules against smoking in their homes, less likely to have switched to light cigarettes for health concerns, and more likely to be aged 35 years or older, married or living with a partner, and non-Hispanic White, and to have at least a college education.

CONCLUSIONS

Programs promoting smoking cessation might benefit by involving family or other household members to encourage smoke-free homes.

An intervention study of smoking cessation with feedback on genetic cancer susceptibility in Japan

BACKGROUND

To evaluate whether feedback of genetic information regarding an L-myc polymorphism, identified as impacting on tobacco-related cancer risk, has an influence on smoking cessation, an intervention study was conducted.

METHODS

We recruited smokers from first-visit outpatients at Aichi Cancer Center Hospital. Six hundred and seventeen participated and were allocated into two groups: the biomarker feedback group (BF) and the follow-up smoking status group (FS). The subjects were asked for their smoking status at enrolment and at 3- and 9-month follow-ups. BF subjects were notified about their L-myc genotype.

RESULTS

The smoking cessation rate at 9-month follow-up was essentially the same for both BF and FS cases, at 18.8% and 17.0%, respectively (P = 0.798). However, a difference in the rate was evident with non-cancer subjects (12.7% and 8.4%, respectively, P = 0.237), especially in females (15.0% and 4.2%, respectively, P = 0.024). The non-cancer subjects informed of their genotype were more likely to quit smoking than the FS patients; particularly in those having a risky genotype, this was significant (odds ratio: 2.87, P = 0.003). Again it was most prominent in females.

CONCLUSION

Feedback regarding an L-myc polymorphism did not impact on smoking cessation overall but appeared to benefit smokers without cancer. In addition, gender could affect the response to the feedback.

A means to an end: slim hopes and cigarette advertising

Alarming increases in the number of women smokers have focused attention on the tobacco industry's efforts to appeal to women who are likely to try and/or adopt tobacco products. The authors discuss the past 30 years of Virginia Slim advertisements and explore the link between consumers' values such as beauty and independence and tobacco use. A brief history of tobacco advertising efforts to appeal to women is followed by an exploratory study of Phillip Morris's advertising campaign for Virginia Slims. The authors use a means-end interpretation to explain the success of the advertisements and then discuss how a means-end framework can be used to create more effective antismoking messages.

The addition of social support to a community-based large-group behavioral smoking cessation intervention: improved cessation rates and gender differences

OBJECTIVE

To determine the effects on cessation rates of adding a partner support group component to a large-group community-based behavioral smoking cessation program.

METHODS

During the past eight smoking cessation programs at the Tom Baker Cancer Centre in Calgary, Alberta, Canada, separate support group sessions were offered for support persons of prospective quitters. Six hundred smokers brought 156 support people with them to the groups. Cessation rates were calculated at 3, 6, and 12 months postquit.

RESULTS

Those smokers who had support people attending at least one of the support group sessions had higher cessation rates at 3, 6, and 12 months (56%, 46%, and 43%) compared to those without a support person in attendance (36%, 35%, 32%). This effect was especially strong for men, with 3-, 6-, and 12-month cessation rates for those with support of 58%, 54%, and 56%, compared to 52%, 41%, and 36% in the women with support. For men without a support person, the rates were 34%, 35%, and 33%, compared to 38%, 35%, and 31% in women without support. This indicates that although support was initially effective for women, it had no effect on sustained abstinence.

CONCLUSIONS

The addition of a support person group to a large-group behavioral smoking cessation program was effective in improving 3-month cessation rates in both men and women, but over 1-year of follow-up support was only associated with greater sustained abstinence in men.

Feminism meets the "new" epidemiologies: toward an appraisal of antifeminist biases in epidemiological research on women's health

This essay explores an alternative paradigm for epidemiology, one which is explicitly informed by a feminist perspective. We intend to expand upon recent critiques and debates within the emergent fields of "critical", "popular", and "alternative" epidemiology to examine how epidemiology's conceptual models--which are meant to contribute to the prevention of social inequalities in health, but may instead reinforce social hierarchies based on gender, race, and class--constrain our understanding of health and disease. Specifically, we examine persistent antifeminist biases in contemporary epidemiological research on women's health. Issues highlighted include: problem definition and knowledge production in women's health: biological essentialization of women as reproducers; and decontextualization and depoliticization of women's health risks. As part of this critique, we include suggestions for an emancipatory epidemiology that incorporates an alternative feminist framework.

Smoking acquisition among adolescents and young Latinas: the role of socioenvironmental and personal factors

This paper examined the effects of socioenvironmental and personal factors on two stages of the smoking continuum--onset of smoking and regular smoking--among a sample of 1411 Latina clients, ages 14-24, at two federally funded family planning clinics. The socioenvironmental factors included cultural indicators, smoking behavior of family and peers, and norms. The personal factors were risk-taking behaviors and intention to smoke in the future. Results showed that the indicators associated with experimentation were different than those linked with regular smoking. Socioenvironmental factors associated with the transition from never having smoked to trying cigarettes included acculturation, as measured by language and familialism, and peer smoking behavior. Among the personal factors, risk-taking behavior (past use of drugs, alcohol, and general risk attitude) and smoking intentions were correlates of experimentation. The transition from experimenter to regular smoker was associated with peer smoking behavior (P< .05) in the socioenvironmental domain and drug use and intention to smoke in the future among the personal factors (both P values <.001). Age, years of education, marital status, norms, and parental smoking did not independently predict either of the smoking outcomes. Intention to smoke was the strongest predictor of experimentation (OR = 8.3, Cl 5.87-11.60) and regular smoking (OR= 19.9, CI 12.31-29.21) and could help identify those most likely to benefit from smoking prevention and cessation interventions.

Influences of gender and weight gain on short-term relapse to smoking in a cessation trial

Few researchers have studied whether weight gain has an impact on short-term relapse to smoking. The authors of this study investigated predictors of relapse among 989 participants (60% women) in a randomized, double-blind, 10-week multicenter trial to determine the effect of fluoxetine (30 or 60 mg) versus placebo in combination with behavioral counseling for smoking cessation. Medication compliance and smoking status were biochemically verified. At Visit 2, participants were asked to set a quit date within the subsequent 2 visits. A proportional hazards regression model was used to predict risk of relapse within the first 3 months of quitting. Weight gain predicted relapse, but for men only. Female gender also predicted relapse. The results led the authors to question whether postcessation weight gain interventions should be restricted to women smokers.

Maximizing qualitative responses about smoking in structured interviews

This article addresses the important methodological issue of whether face-to-face or self-administered interviews elicit better qualitative data on reasons for smoking and quitting among 173 current and former smokers. The data are from a study of smoking behaviors among 601 African American and Latina women age 14 to 21 years recruited from family planning clinics in Los Angeles from 1995 to 1996. Results suggest that responses to closed questions about smoking behavior are similar in both methods but that self-administered surveys elicit more responses to open-ended questions than face-to-face interviews. The authors encourage the use of self-administered surveys in smoking research because they are cheaper to administer, yield similar data on closed-question items, and elicit richer and more provocative responses to open-ended questions.

The process of pregnancy smoking cessation: implications for interventions

OBJECTIVE

There is a growing body of knowledge about the pregnant smoker and what happens as she goes through the pregnancy and postpartum periods. This article reviews the process of smoking cessation in the context of pregnancy.

DATA SOURCES

Epidemiological data, extant reviews of the literature, and current original research reports are used to examine characteristics of the women and of the change process for those women smokers who quit, stop, or modify their smoking during pregnancy and the postpartum period.

DATA SYNTHESIS

An analysis of the interaction of the process of smoking cessation with pregnancy was conducted to gain insight into the unique problems faced by the pregnant smoker and discover directions for intervention.

CONCLUSIONS

Pregnancy and the postpartum period provide a window of opportunity to promote smoking cessation and smoke free families. Understanding obstacles and pathways for pregnancy and postpartum smoking cessation can guide implementation of effective existing programs and development of new ones. Recommendations include promoting cessation before and at the beginning of pregnancy, increasing delivery of treatment early in pregnancy, helping spontaneous and intervention assisted quitters to remain tobacco free postpartum, aiding late pregnancy smokers, and involving the partner of the woman smoker.

Gender and smoking behavior in a worksite smoking cessation program

Gender-specific patterns in smoking behavior among 844 men and women who participated in a worksite smoking cessation program were explored. Although gender did not predict outcome, men and women did differ on a number of smoking behaviors and smoking history variables. Male participants smoked cigarettes with a higher nicotine content and smoked a greater number of cigarettes per day. Females reported having made more previous attempts to quit, less confidence about quitting, greater effort to quit, greater worry about smoking-related illness, and that they would be less likely to quit on their own if this program were not offered. Females did tend to report receiving higher levels of general social support, as well as partner support for quitting smoking; however, greater support did not lead to higher quit rates. At the 2-year assessment, 14.3% of female participants (n = 532) reported abstinence, while 13.5% of male participants (n = 312) reported abstinence, when missing data were recoded as smoking.

A review of women and tobacco: have we come such a long way?

The trends in smoking by women over the past century parallel social and economic changes. The crumbling of the double standard spurred the tobacco industry to launch advertising campaigns that target women, juxtaposing images of liberation and feminism with glamour and slimness. As a result, in the 1990s, smoking initiation and prevalence is higher among teenage females than males. Tobacco-related mortality and morbidity among women and their children continue to rise. Women's health care providers must be integral players in a multitiered, broad-based approach to decreasing tobacco use among women. Research is needed on socially isolated women and on the efficacy of nursing interventions related to tobacco use.

Changes in food consumption and body weight associated with smoking cessation across menstrual cycle phase

Forty women smokers were randomly assigned to smoking cessation for a 10-day period of time, either during the follicular or the luteal phase of their menstrual cycle. Measurements of dietary intake and body weight were collected during the same phase the previous (smoking as usual) month and during the cessation phase. Physical activity was controlled across the 2 months. Comparisons between the smoking and cessation months indicated that both groups increased their dietary intake during the cessation month, but no interaction occurred between phase and month. That is, women in both groups increased dietary intake to the same degree. All energy nutrients tested (fat, complex carbohydrates, and sugar) increased significantly from baseline to cessation. Conversely, body weight increased by 1.8 kg (4 lb) in the Luteal group, while weight remained stable (0.1 kg change) in the Follicular group.

A smoking cessation plan for pregnant women

Women continue to smoke during pregnancy for many reasons. Successful smoking cessation requires a comprehensive treatment approach. The proposed plan described in this article incorporates training for care providers; life skills support for clients; and ongoing, brief interventions. Prenatal visits provide the opportunity for these interventions. A smoking flow chart is used to facilitate continuity of message and consistent charting. Support for life skills, such as stress management, assertiveness, self-esteem, and role clarification, is integral to disrupting the cycle of addiction. Motivation of staff and smokers may be the nurse's most significant challenge. Further research into physiologic support, such as nicotine replacement, is recommended.

Carotid endarterectomy in women versus men: patient characteristics and outcomes

PURPOSE

To examine and compare the results of carotid endarterectomy in women and men in a single-group experience.

METHODS

A review of a consecutive series of 426 carotid endarterectomy procedures performed over an 11-year period.

RESULTS

Women and men who underwent carotid endarterectomy were remarkably similar in nearly all characteristics except that women were less likely to have clinically overt coronary artery disease. Women were more likely than men to undergo patch closure of the carotid artery, but details of surgery and hospital stay were otherwise similar. A trend toward higher perioperative stroke risk in women was not significant, and late ipsilateral stroke risk was comparable in women and men. Women enjoyed a better late survival rate, presumably related to their lower prevalence of coronary artery disease.

CONCLUSIONS

Women enjoyed similarly low risks of perioperative and late stroke and a better long-term survival rate when compared with men who underwent carotid endarterectomy. Further experience and longer follow-up in prospective randomized trials may provide more definitive information regarding the comparative efficacy of carotid endarterectomy in women and men, but our results suggest that absolute results are similar and excellent in both women and men.

Using mass media to prevent cigarette smoking among adolescent girls

This article describes the development of a mass media smoking prevention intervention targeted primarily toward adolescent girls at increased risk for smoking and assesses its outcomes. A cohort of 5,458 students was surveyed at baseline in Grades 4-6 and annually for 4 years. Through diagnostic and formative research, media messages were created to appeal especially to girls. Students beginning in Grades 5-7 received the 4-year media intervention and a school program in two communities, while students in two matched communities received the school program alone. Media targeting techniques resulted in high levels of message appeal and exposure consistent with effects on mediating variables and 40% lower weekly smoking at Grades 8-10 for girls receiving the media and school interventions compared to school alone. Smoking behavior effects were maintained at Grades 10-12. These results indicate that mass media interventions targeting specific audience segments can reduce substance use behavior for those segments.

The effects of interview mode on smoking attitudes and behavior: self-report among female Latino adolescents

Although a substantial literature compares data on health-related behaviors collected by face-to-face and telephone interview formats, little attention has been paid to the comparability of responses regarding cigarette-smoking-related behavior, particularly among Latino youth. This study compares telephone and face-to-face interview methods for assessing smoking behaviors, attitudes, and beliefs among Latina adolescents. Data indicated no significant differences in demographic characteristics or smoking-related behaviors between the face-to-face and telephone groups. However, respondents interviewed face-to-face were significantly more likely to express dislike of smokers and state that quitting smoking was easy.

Smoking characteristics of female veterans

Recent studies suggest that the prevalence of smoking among active duty military women is higher than that of active duty military men or civilians of either gender. No data have been published on cessation rates among female veterans. We wanted to report such rates in a group of female veterans at Pettis VAMC Preventive Medicine Clinic and to study predictive factors for smoking cessation and prevention. We identified female patients at Pettis VAMC Preventive Medicine Women's Clinic who had received services in the past 3 years or who enrolled as new patients during the study period; 529 received questionnaires by mail or at the clinic; 409 returned completed surveys. A high proportion (32.5%) of our sample of female veterans were current smokers, and 67% of female veteran smokers reported smoking at least one pack daily. More than one-third of ever-smokers began smoking during military service. Thirty-nine percent of the female veteran sample had CES-D scores of 16 or greater, and current smokers had significantly greater mean CES-D scores than former smokers. Twenty-three percent of current smokers had high nicotine dependence scores (> 7). The highest proportion of CES-D scores compatible with depressive symptoms (55%) was seen among current smokers who consumed a pack or more of cigarettes per day. Ever-smokers who screened as depressed were significantly less likely to have quit than those with lower CES-D scores; however, in multivariate models, CES-D scores were not significantly related to cessation. The prevalence of current, ever, and heavy smoking was high among this sample of female veterans attending a VAMC Preventive Medicine clinic. An unexpectedly high prevalence of screening scores compatible with depression was found among this sample, particularly among smokers. This warrants further investigation, particularly in light of the reported relationship between depression and smoking.

Maternal smoking among blacks and whites

Data from a random sample of mothers and children participating in a study on the sequelae of low birth weight were used to examine potential risk factors of maternal smoking. It was hypothesized that maternal smoking will vary by race, age, education, psychiatric status, employment status, single mother status and indicators of the burden of child care. Low education, young age, current psychiatric disorder and having a child with a psychiatric disorder or a physical illness predicted maternal smoking. The association of maternal smoking with other factors, specifically maternal employment and indicators of the burden of child care, varied between blacks and whites. Single mother status and having pre-school children in the home was associated with a higher odds ratio for smoking in whites, but not in blacks. On the other hand, maternal employment was associated with a lower odds ratio for smoking in blacks only. This study identified common and race-specific predictors of smoking in white and black mothers. It emphasizes the need for a greater understanding of the social context of maternal smoking in different ethnic populations, and highlights the importance of the burden of child care as a factor in maternal smoking.

Performance by gender in a stop-smoking program combining hypnosis and aversion

Increased rates of smoking initiation and smoking-related illness among women have narrowed the gender gap in smoking behavior. Past studies of performance by gender in prevention and treatment programs have reported reduced success with women and have suggested a need for stronger interventions having greater effects on both genders' smoking cessation. A field study of 93 male and 93 female CMHC outpatients examined the facilitation of smoking cessation by combining hypnosis and aversion treatments. After the 2-wk. program, 92% or 86 of the men and 90% or 84 of the women reported abstinence, and at 3-mo. follow-up, 86% or 80 of the men and 87% or 81 of the women reported continued abstinence. Although this field study in a clinical setting lacked rigorous measurement and experimental controls, the program suggested greater efficacy of smoking cessation by both sexes for combined hypnosis and aversion techniques.