Introduction

In industrial countries, 300,000 women die every year due to tobacco-related diseases. The World Health Organisation estimates that in the year 2020 this number will approximate one million women. Of these, approximately 20% die of lung cancer, nearly 20% of chronic obstructive lung disease, and 40% of cardiovascular diseases (especially coronary heart disease and stroke).¹

According to estimates, two thirds of the difference in mortality rates between men and women is attributable to male smokers. However, projected calculations indicate that the difference in life expectation between men and women will be reduced in the future by the changing smoking habits of women. Smoking exposes women to additional risks of disease, associated with specific conditions such as pregnancy, the use of oral contraceptives, osteoporosis, and post-menopause.²

Our own studies show that about one quarter of all women who smoke are moderately or strongly nicotine dependent. Seventy percent report withdrawal symptoms when they try to give up smoking.² It is evident that women are eager to receive support in their efforts to quit smoking. There is an obvious requirement for therapeutic alternatives tailored to the needs and problems of women.

Smoking cessation for women

Male and female smokers have been treated at the Institute for Social Medicine, University of Vienna, for over 20 years. Smoking cessation programmes for women were initiated over 6 years ago as part of a WHO model project. Socio-epidemiological trends and the special risks for women emphasise the need for specific therapeutic alternatives.

The treatment of female smokers is based on a combination of behaviour modification and nicotine replacement therapy, adjusted to the degree of nicotine dependence and the indication for treatment. Factors considered relevant for maintaining smoking behaviour were a) psychological factors such as habit and positive consequences (e.g. cigarettes as a reward), and b) nicotine dependence. These influences were of varying importance in different women.³

The treatment program utilises individualised group counselling - if necessary, single counselling sessions are also provided. A one-hour session each week is carried out for 6 to 10 weeks, depending on the progress of the participants.³ Spouses or partners are invited to participate in the groups - a particularly positive aspect for pregnant women. However, spouses or partners rarely avail themselves of this opportunity.

The treatment is preceded by a detailed history and an exact diagnosis. Both are documented with the help of the "Vienna Standard Smoker's Inventory" (German abbreviation, WSR).⁴ When recording the history, special attention is paid to items like current pregnancy, planned pregnancy, use of oral contraceptives, menopause, hormone replacement therapy (HRT) existence of tobacco-related diseases, specific women's diseases etc.

Nicotine dependence is diagnosed using the Fagerström test.⁵ Carbon monoxide in exhaled air is measured at every therapy session. The extent of tar exposure, calculated by a formula based on the patient's smoking history,⁴ permits an assessment of the risk of lung cancer. The diagnosis also includes the presence or absence of nocturnal sleep-disturbing nicotine craving (NSDNC) which may be present in strongly nicotine-dependent women, as well as the presence of a so-called carbohydrate craving. The main items of the patient's history are former cessation attempts, former experience in regard of nicotine replacement therapy, specific tobacco-related conditions (e.g. stressful situations, reward effect of cigarettes, etc.), a documentation of smoking behaviour, and the existence of a pre-abstinence syndrome (PAS).⁶

Our experience so far has shown that counselling offices for smokers are mainly visited by women in or after menopause, as well as (but to a much lesser extent) by pregnant women. Many women already have tobacco-related diseases or diseases whose course is substantially influenced by the consumption of tobacco (osteoporosis, cardiovascular diseases, chronic respiratory diseases, diabetes, asthma, hypertension, thrombosis, hypercholesterolemia, obesity, general symptoms of ill-health, menopausal symptoms, etc.). These diseases (and pregnancy) are the most frequent motives to quit smoking. The majority of women have tried to quit smoking on several occasions, except for those who are very strongly nicotine-dependent. The latter group are primarily interested in becoming totally abstinent or at least trying to reduce their cigarette consumption. Only a small percentage of women want to abstain from smoking; a larger percentage want to reduce their consumption of cigarettes, as a first step.

Weight gain

The program also includes counselling in regard to general health and nutrition. An increase in body weight, or the fear of such an increase, is a particularly common obstacle to quitting smoking, especially for women. Therefore it is necessary to devote part of the treatment to nutrition counselling and, if necessary, to offer weight reduction measures after smoking cessation. The aim of weight reduction should be to achieve a sustained change in eating behaviour, based on behaviour modification. An increase in weight is not an obligatory outcome of smoking cessation, but a gain of 2 to 4 kg (4 to 8 lbs) is quite possible, even if calorie intake is not increased (the basal metabolism of smokers is about 5% higher than that of non-smokers, irrespective of the number of cigarettes smoked). This marginal increase in weight can be quickly controlled after the individual has quit smoking - any weight gain is caused by higher calorie intake and usually occurs in the first 6 months following smoking cessation.³ Controlled calorie and fat intake, together with more exercise (without expressly mentioning sports) help prevent weight increase or keep weight increase at a minimum. Nicotine replacement therapy also reduces this problem.

Relapse

Prevention of relapse is recognized as one of the most difficult aspects of smoking therapy. Both the literature and our experience in this field show that the situations precipitating a relapse differ between men and women. Men tend to relapse in positive situations, such as social events, whereas women are especially prone to relapse in stressful and conflicting situations. Basically, women display a greater reliance on cigarettes to help them cope with stress and anxiety. Therefore, emotional conflicts are liable to serve as typical relapse situations. Women are especially prone to relapse after pregnancy and breast-feeding. Only a third of women who stop smoking during pregnancy continue to abstain afterwards.³

Lifestyle medicine

Smoking cessation is a typical example of lifestyle medicine. Lifestyle medicine should be regarded as a focal point in preventive medicine and includes all risk factors that lead to lifestyle-associated diseases (fatty food, smoking behaviour, lack of exercise etc.). Lifestyle medicine is a meaningful combination of pharmaceutical treatment and behaviour modification. It requires close co-operation between therapist and the patient, who together constitute a "lifestyle team".

In lifestyle medicine, it is impossible to demarcate between prevention and therapy, since both are addressed by the same measures. The treatment of nicotine dependence (by using nicotine replacement therapy in combination with behaviour modification) is a therapeutic measure in this sense. However, successful treatment (i.e. achieving lasting abstinence) is also preventive in terms of averting cardiovascular disease, cancer, chronic respiratory diseases, osteoporosis etc. It is clearly meaningful to apply the concept of lifestyle medicine in the field of female smoking cessation and to create additional anti-smoking facilities that will help reduce the frequency of tobacco-related diseases.

Summary

In industrial countries, 300,000 women die every year from tobacco-related diseases. The World Health Organisation estimates that this number will rise to approximately one million women by the year 2020.

Women have specific additional health risks from smoking, which are related to conditions such as pregnancy, the use of oral contraceptives, osteoporosis, and post-menopause. There is therefore an obvious need for therapeutic interventions tailored to the needs and problems of women who smoke. Male and female smokers have been treated at the Institute for Social Medicine, University of Vienna, for over 20 years. Smoking cessation programmes for women were initiated over 6 years ago as part of a WHO model project.

The treatment program designed for women takes physiological and psychological factors into account and includes behaviour modification as well as the diagnosis and treatment of nicotine dependence. The program is thereby adjusted to the needs of individual smokers, and is a typical example of lifestyle medicine.