For the last 50 years, men have consistently had an easier time quitting smoking than women. More men go cold turkey. More men stop on nicotine blockers like gum and patches. More men succeed on medications. Sherry McKee, an associate professor of psychiatry at the Yale School of Medicine, thinks she may know why.
McKee, who directs the Yale Tobacco Treatment Clinic, says quitting strategies have been geared to male biology. Most target the nicotine receptors in the brain, the ones that send feel-good signals when the person smokes.
McKee says women are more likely to smoke to cope with stress, not to get those feel-good signals. She’s now testing drugs that help women to relax, hoping that these will also help them quit. Dozens of women smokers regularly visit her New Haven lab to test her hypothesis.
“Our preliminary results are encouraging,” McKee said, adding that it will take a few more years to reach a conclusion.
The Limits of Success
The anti-smoking movement is considered the greatest public health success story of all time. Smoking rates have been cut by more than half. It’s now illegal to smoke in restaurants, at work, and near schools and hospitals.
Still, nearly one in five Americans are smokers, and cigarettes cause 440,000 premature deaths a year in the United States alone, according to the U.S. Centers for Disease Control and Prevention.
Helping more people quit could save hundreds of thousands of lives, and spare even more from cancer, breathing problems, heart disease, preterm labor, diabetes and other ailments, according to the CDC.
Female smokers are more likely to develop lung cancer than male smokers, McKee said, and are at 25 percent higher risk for heart disease. Women smokers also have more smoking-related health problems related to lowered estrogen, irregular menstrual cycles, and pregnancy-related complications. They enter menopause sooner.
Worries about weight gain can also make it harder for women to quit. Many women turn to food when they are stressed, particularly if they can’t smoke.
“Even a few gained pounds, which men wouldn’t notice, can discourage a woman from quitting,” said Diahann Wilcox, a nurse practitioner in pulmonary medicine at UConn Health in Farmington.
Historically, men in nearly every culture start smoking first, and women follow, McKee said. In this country, brands like Virginia Slims – “You’ve come a long way, baby” – started turning massive numbers of women into smokers in the late 1960s, though rates of female smokers never caught up, she said.
In China now, 65 percent of men smoke, compared to just 2 percent of women. Tobacco companies are starting to see this as a marketing opportunity, McKee said.
“Tobacco companies are very good at marketing smoking to women,” she said, “as a source of empowerment and emancipation from men.”
One Woman’s Struggle
Sheila Hoffman tried 30 to 40 times to quit smoking. She’d decide it was time, use up all her Camels, and then forbid herself to buy any more. Sometimes the strategy worked, for a while.
“Inevitably, I would get up in the middle of the night and drive to the all-night drug store,” the Meriden resident admitted. “I’d smoke one in the car, and another on the porch, and then I’d go back to bed.” By her 70th birthday, she was suffering the consequences of a habit that took hold in middle school.
Hoffman had COPD, chronic obstructive pulmonary disease, a lung disease that leaves people struggling to breathe. She couldn’t walk more than a few steps without getting winded. She coughed constantly. She was convinced she was going to die, even as she succumbed to the cravings for another puff.
In September 2012, Hoffman, who is not part of the Yale study, started attending a support group in Meriden and wearing a nicotine patch. She’d made it three weeks smoke-free when a granddaughter committed suicide. Hoffman turned back to her smokes to cope.
By New Year’s, she was resolute again. On January 9, Hoffman spent the day with a smoker friend, puffing like a chimney. That night, she went back to her smoking support group. She hasn’t lit up since. “I just walked out of there on the ninth of January,” she said, “and I was a non-smoker.”
Searching for Better Treatments
Though men have an advantage when it comes to quitting, the problem hasn’t been solved for them, either. “Even with our most effective medications, tested under the most optimal conditions, 70 percent [of those who quit] will have relapsed by one year,” McKee said. “So we still have a ways to go for both men and women.”
Current nicotine replacement treatments – like patches, gums, sprays and the drug Chantix – target a part of the brain that has been shown to respond to nicotine.
McKee reviewed previous studies of those drugs to see if women had responded differently than men. Few studies even looked at gender, she said, and those that did “either showed no difference or when there was a difference, women did worse than men.”
The ineffectiveness of these current medications and the smoking-stress connection in women suggests the need for a different treatment approach, McKee said.
She is now testing medications that reduce levels of norepinephrine, a neurochemical in the brain that is increased by stress. Such drugs are known to reduce stress levels in animals. She’s looking to see if they also reduce stress in women smokers, and whether such lower stress can help them quit smoking. It will take several more years to reach a conclusion.
Wilcox, the UConn nurse, said smokers need to understand why they smoke - what are their emotions as they reach for a cigarette and what the triggers or times of day that are most vulnerable for them?
“Is it a cigarette because you’re bored?” she asked. “Is it out of stress, anger, [need for a] reward?”
To break those behavioral triggers, smokers need to strategize different responses that don’t involve cigarettes, Wilcox said. If the trigger is stress, for instance, think about other ways to manage it besides smoking, she suggests, like talking with a friend. “It’s replacing the smoking behavior with another healthy behavior that’s not going to sabotage them.”
As irrational as it seems to keep smoking, Wilcox said that even a cancer diagnosis, “still isn’t enough” to convince some people to quit. Heart attacks, which are sudden and dramatic, are usually more motivating, she said.
More than 9 percent of smokers still light up even after a cancer diagnosis, according to an August 6 study in the journal Cancer Epidemiology, Biomarkers & Prevention. The vast majority of those who still smoke light up every day, smoking an average of 14 cigarettes a day, the study found.
For most people, quitting requires a multi-pronged approach, Wilcox said. Medications can help reduce some of the withdrawal symptoms that people have; groups can provide support and encouragement; electronic cigarettes may offer people a substitute to help them break the smoking habit.
People need to plan out how they’re going to quit, Wilcox said, rather than thinking they can just will themselves out of every craving.
“You don’t just wake up one day and say you’re going to climb Mount Everest,” she said. “You have to live your life differently. You do need to plan.”
Some selected sources to help kick the smoking habit:
Yale Tobacco Treatment Clinic: (855) 737-9882
Connecticut Quit Line: (800) QUIT NOW