Photograph by Emilie Richardson
Photograph by Emilie Richardson
"I tried to quit smoking. I found it to be one of the most profoundly depressing experiences of my life. It knocked my socks off. I wasn't functioning," said Jane, a 65-year-old smoker who asked to remain anonymous. "Smoking is such a shameful thing. I don't feel shameful about anything in my life, except this," she confessed.

Her one attempt to quit happened about 12 years ago and lasted 10 days. "I was thinking about cigarettes all the time, and I was so sad. I wondered if I could even quit, what it was going to take for me to do it. I was almost paralyzed in the anxiety. I didn't feel like myself. I almost didn't want to get off the couch. I can't explain how disappointed I felt in myself that I couldn't do it," she admitted. "I never tried to analyze the experience," she said, "because I just didn't want to stay in that place."

While Jane can readily recall why she started smoking-she was in college and it was the "thing" to do-she can't remember what it was that propelled her to try to quit. Certainly, she said, there are people in her life who would love to see her give up the habit, but truthfully, she doesn't think about quitting anymore. To keep the peace at home, however, she never smokes in the house, never around family and rarely in the car. She did cut down on cigarettes. She used to smoke about a pack a day, but since her quitting attempt, she only allows herself five or six instead. "I tell myself, 'You're not going to have that many cigarettes, but the ones you do have you can enjoy.' It seems to work for me."

Hard to quit
Jane's attempt to give up cigarettes isn't so different from what many women smokers face. "Women experience more difficulties quitting smoking, and are more likely than men to relapse completely," said Sharon Allen, M.D., Ph.D., a professor in the University of Minnesota's Department of Family Practice and researcher in the field of smoking cessation among women. "Most women can't quit cold turkey or even on the first try," she said.

The Center for Disease Control (CDC) reported that in 2005, 18 percent of American women were smokers. According to Allen, about 75 percent of these female smokers would like to quit. Roughly 47 percent of them, Allen said, tried to quit in the past year.

Obstacles to quitting
As a researcher, Allen has tried to identify obstacles women face when quitting. Yet there is not one reason why women relapse more often than men. "Lots of studies have been done and several barriers have been identified as to why it might be more difficult for women to quit smoking," Allen said. "It might be that women have less confidence in their ability to quit. More women fear the weight gain associated with quitting than men. Mood symptoms play a significant role in undermining quit attempts. Women have higher rates of depression and that factors in when it comes to the effects of withdrawal."

Allen suspects the monthly hormone shifts women's bodies undergo as part of the menstrual cycle play a role in the difficulty they face in quitting smoking. Smokers, she said, experience the most severe nicotine withdrawal symptoms three to five days after quitting. Does this mean that trying to quit while you're experiencing PMS could lead to even stronger withdrawal symptoms? Allen cautioned that while this appears to make logical sense, it's not that easy. "We think there is a moderate correlation between the two, but the role of PMS isn't totally clear," Allen said. "It's really hard to tease out which one, withdrawal or the effects of PMS, plays a greater role in the sadness and ineffability women experience when quitting smoking."

Allen and her research partner, Dorothy Hatsukami, recently completed a trial at the University to investigate the intersection of a woman's quit plan with her menstrual cycle. The results have not yet been published , but their findings did surprise them. "We found that women who quit early in their cycle relapsed sooner than women who quit near the end of their cycle. Intuitively, this didn't make sense to us, but it does fit with some of the animal literature and the cocaine literature," Allen explained.

It will take more studies, Allen said, to help scientists determine which hormones interfere with a woman's attempt to quit smoking. She hopes her soon-to-be-published research will help point other scientists to which weeks of the menstrual cycle they should target in future research about the hormonal role in smoking cessation.

It feels good
Hormones aside, another difficulty women face is their addiction to the overall sensory experience of smoking, Allen said. While nicotine gum, for example, combats the physical nicotine addiction, many women miss the feel of a cigarette in their hands, or the feel of the smoke. Some miss smoking a cigarette while talking on the phone; some miss the social interaction that takes place with co-workers over a smoking break. Other women have a hard time resisting stress points in their lives that had regularly triggered their urge to smoke in the past, such as an argument. "The sensory cues never go away," Allen said. "Women can only learn to cope, and it varies how well they can cope, with these cues. It will get better with time, but for many women, this is where slipping starts to happen. Many say, oh I'll just have one or two puffs with a friend, but it's a slippery slope."

Rx remedies
One drug, varenicline, approved by the FDA in May 2006, was created specifically to treat tobacco addiction and has proven effective in helping smokers. Varenicline, which is sold under the brand name Chantix, works in two ways. First, it blocks the nicotine receptor in the brain, which in turn makes smoking less pleasurable. Next, it releases a low level of dopamine, which reduces both cravings for cigarettes and feelings of withdrawal. Smokers take varenicline twice a day for 12 weeks. A second 12-week cycle can be prescribed.

In January of this year, The Cochrane Library, a nonprofit, Oxford-based organization that independently reviews healthcare findings, released its conclusion that varenicline increases a smoker's ability to successfully quit by three fold. Although The Cochrane Library found the most promise in Varenicline, it reported that some antidepressants can also play a role in smoking cessation. They found that bupropion (sold under the brand names Wellbutrin and Zyban) and nortriptyline can double a smoker's ability to successfully quit. The thought behind prescribing antidepressants to a smoker is that quitting can set off an episode of depression, especially if the smoker has experienced depression in the past or has a family history of depression. Since women are twice as likely as men to experience depression at some point throughout their lives, antidepressants stand to help many women smokers quit.

Inclusivity is important
Pharmaceutical companies will likely keep investing in new drugs to help smokers kick the habit; however, Allen would like to see more smoking cessation studies focus on women living in poverty and women of color. According to the Centers for Disease Control (CDC), 29 percent of women with less than a high school diploma are smokers; 39 percent of women with a GED degree are smokers; 10 percent of women with a college degree are smokers; and 7 percent of women with graduate level degrees are smokers. These numbers translate into the CDC's figures on the number of women smokers living in poverty: 27 percent of women living below the poverty level smoke.

"We just can't take the tools we do have to help smokers quit and apply them in the same way to different cultural groups. We need our tools to be culturally sensitive," Allen said, pointing out that women living in poverty can't afford a 12-week supply of varenicline. And traveling to a counseling session outside your comfort zone can be stressful, she added, and probably trigger the urge to smoke. Allen said she would like to see smoking cessation counseling be brought into neighborhood community centers, and believes that many women in this population would find it helpful to have a quit-smoking mentor-someone local who has already successfully quit-to shepherd them through the process.

Allen has advised many women on how to quit smoking. Since most smokers have tried to quit at least once, Allen said women need to examine their previous quit attempts and their current realities. "You really need to know what you're up against," she said. "Go over the barriers you faced in the past and think about how you're going to cope differently this time."

Call on a pro
She also suggests women who want to quit should schedule a doctor's appointment. "A doctor can really help tailor the tools we do have for each patient," she said. Beyond the nicotine gum, patches and lozenges available over the counter, nicotine inhalers and nasal sprays are available with a prescription. Plus, a doctor can prescribe varenicline or antidepressants. Additionally, Allen said, "Behavioral counseling is key, either in a group or one on one." Smoking, while a physical addiction, is also a habit. Many smokers need help changing their daily routines and mental processes. A woman who is trying to break the habit can find support by talking through the sensory triggers she is feeling. If health insurance or money is scarce to pay for counseling, Allen suggested a woman call a help line for a one on one conversation with a counselor.

"Quitting is a really hard thing to do," emphasized Allen. "It may take two or three tries, but eventually, women can become smoke free."

FFI: National Women's Health Information Center: www.4woman.gov/quitsmoking/

Free help for Minnesotans who want to quit: www.quitplan.com

U.S. Surgeon General's report about women and smoking: www.cdc.gov/tobacco/sgr_forwomen/ataglance.htm