Abstract

Introduction

Despite the results of epidemiological and psychometric studies reporting comparable levels of tobacco dependence among males and females, some clinical studies have detected disparities. Some smoking cessation studies based on clinical setting programs reported poorer outcomes among women than men.

Methods

This retrospective cohort study aimed to compare treatment success and retention between men and women on a smoking cessation program (n = 1,014) delivered at a CAPS-AD unit in Brazil. The psychological intervention lasted 6 weeks for each group of 15 patients. Each patient had to participate in weekly group cognitive-behavioral therapy (CBT) sessions and individual medical appointments during this period. These appointments were focused on the possibility of prescribing pharmacological treatment (i.e., nicotine replacement therapy, bupropion, or nortriptyline) as adjuvants to group therapy.

Results

The women had lower smoking severity at baseline, more clinical symptoms, and lower prevalence of alcohol and drug use disorders and were older than the men. Females had significantly higher levels of success (36.6% vs. 29.7%) and retention (51.6% vs. 41.4%) than males. Sensitivity analysis showed that female gender was significantly associated with both retention and success, among those without drug use disorders only.

Conclusion

Depending on the smoking cessation setting (i.e., low and middle-income countries and mental health and addiction care units), females can achieve similar and even higher quit rates than males. Previous drug use disorder was an important confounding variable in the gender outcomes analyses. Future studies should try to replicate these positive smoking cessation effects of CBT-based group therapy plus pharmacotherapy in women.

Tobacco use cessation; female; tobacco use disorder

Introduction

Worldwide, approximately 175 million women are daily smokers, with half of female smokers living in low and middle-income countries.¹1. Drope J, Schluger N, Cahn Z, Drope J, Hamill S, Islami F, et al. The tobacco Atlas. Atlanta: American Cancer Society and Vital Strategies; 2018. Due to stigma, females may experience particular difficulties on smoking cessation programs, especially during pregnancy and motherhood.²2. Greaves L. The meanings of smoking to women and their implications for cessation. Int J Enviro Res Public Health. 2015;12:1449-65. A large number of factors may affect the outcome, such as caregiving demands, insufficient social backing, hormonal effects, a spouse who smokes, neurobiological variables determining dependence levels, and psychiatric comorbidities.²2. Greaves L. The meanings of smoking to women and their implications for cessation. Int J Enviro Res Public Health. 2015;12:1449-65.,³3. Evans-Polce RJ, Castaldelli-Maia JM, Schomerus G, Evans-Lacko SE. The downside of tobacco control? Smoking and self-stigma: a systematic review. Soc Sci Med. 2015;145:26-34.

In Brazil, according to the Vigitel/2019 survey (Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico), 9.8% of adults are smokers, being 12.3% of males and 7.7% of females.⁴4. Brasil, Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis. Vigitel Brasil 2019: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2019 [recurso eletrônico]. Brasília: Ministé́rio da Saú́de; 2020. Since 2002, the Brazilian Ministry of Health, in conjunction with state and municipal health departments, has organized a network within SUS (Sistema Único de Saúde) healthcare units, aiming to promote and offer smoking treatment. Health professionals administer treatment in individual consultations and support group sessions. Patients who smoke should be helped to understand the role of cigarettes in their lives and be given guidance on how to quit smoking, how to resist the urge to smoke, and, especially, how to live without cigarettes. During the first four group meetings (or individual consultations), support manuals are provided with information on each of the sessions. Pharmacological treatment may also be provided to reduce the symptoms of nicotine withdrawal syndrome.

Despite results of epidemiological and psychometric studies reporting comparable levels of tobacco dependence among males and females,⁵5. Castaldelli-Maia JM, Andrade LH, Storr CL, Viana MC, Andrade AG, Martins SS. The latent trait of ICD-11 nicotine dependence criteria: dimensional and categorical phenotypes. Psychiatry Res. 2018;266:275-83.,⁶6. Castaldelli-Maia JM, Martins SS, Storr CL, Viana MC, Andrade LH, Andrade AG. Investigating the dimensional diagnosis of ICD-11 nicotine dependence. Psychol Addict Behav. 2018;32:415-25. some disparities have been detected in clinical studies.⁷7. Castaldelli-Maia JM, Loreto AR, Guimarães-Pereira BBS, Carvalho CFC, Gil F, Frallonardo FP, et al. Smoking cessation treatment outcomes among people with and without mental and substance use disorders: an observational real-world study. Eur Psychiatry. 2018;52:22-8.,⁸8. Castaldelli-Maia JM, Harutyunyan A, Herbec A, Kessel T, Odukoya O, Kemper KE, et al. Tobacco dependence treatment for special populations: challenges and opportunities. Braz J Psychiatry. 2021;43:75-82. Females more frequently seek treatment than males,⁹9. Huang Y, Britton J, Hubbard R, Lewis S. Who receives prescriptions for smoking cessation medications? An association rule mining analysis using a large primary care database. Tob Control. 2013;22:274-9. but employ anti-smoking medications less often.¹⁰10. Steinberg MB, Akincigil A, Delnevo CD, Crystal S, Carson JL. Gender and age disparities for smoking-cessation treatment. Am J Prev Med. 2006;30:405-12. In addition, there are more reports of side effects associated with smoking cessation medication and craving in females.¹¹11. Perkins KA, Karelitz JL, Giedgowd GE, Conklin CA. Negative mood effects on craving to smoke in women versus men. Addic Behav. 2013;38:1527-31.

12. Halperin AC, McAfee TA, Jack LM, Catz SL, McClure JB, Deprey TM, et al. Impact of symptoms experienced by varenicline users on tobacco treatment in a real world setting. J Subst Abuse Treat. 2009;36:428-34.-¹³13. Jarvis MJ, Cohen JE, Delnevo CD, Giovino GA. Dispelling myths about gender differences in smoking cessation: population data from the USA, Canada and Britain. Tob Control. 2013;22:356-60. Moreover, females report more concerns about weight gain related to smoking cessation.¹⁴14. Lombardi EMS, Prado GF, Santos UDP, Fernandes FLA. Women and smoking: risks, impacts, and challenges. J Bras Pneumol. 2011;37:118-28. According to Cepeda-Benito et al.,¹⁵15. Cepeda-Benito A, Reynoso JT, Erath S. Meta-analysis of the efficacy of nicotine replacement therapy for smoking cessation: differences between men and women. J Consult Clin Psychol. 2004;72:712-22. nicotine replacement therapy (NRT), which is a treatment for tobacco dependence that is widely available as worldwide, seems to be less effective in females than in males. Moreover, smoking cessation studies based on programs in clinical settings reported poorer outcomes among women than men.

The literature on this topic presents mixed findings. It was therefore necessary to conduct this study to compare success and retention between males and females participating in a smoking cessation program offered by a Psychosocial Care Center (Centro de Atenção Psicossocial - Álcool e Drogas – CAPS-AD) that treats alcohol and drug problems in the state of São Paulo, Brazil. In the present study, we hypothesized that males would have higher abstinence rates than females at the end of the treatment, as in previous studies with the general population.

This retrospective cohort study aimed to compare treatment success and retention between men and women on a smoking cessation program offered at a CAPS-AD unit in Brazil.

Methods

Treatment protocol

Our sample was recruited from people enrolled on a Smoking Cessation Protocol delivered at a CAPS-AD treatment unit located in the city of São Caetano do Sul, in the state of São Paulo, Brazil. São Caetano do Sul has the highest Human Development Index (HDI) in Brazil, according to the Brazilian Institute of Geography and Statistics (IBGE).¹⁶16. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de domicílios: síntese de indicadores 2014. Rio de Janeiro: IBGE; 2015.

The CAPS-AD units are well-known among health professionals and patients seeking addiction treatment (especially alcohol and marijuana) or needing smoking cessation treatment.

As part of the protocol, the unit offers weekly group therapy, including motivational approaches for smoking cessation. Individuals interested in quitting smoking are then evaluated for further inclusion in the smoking cessation treatment.

Patients may join the treatment protocol for smoking cessation in three different ways: 1) being referred by a Primary Care Unit (Unidade Básica de Saúde – UBS); 2) on-demand in a CAPS-AD; and 3) after treatment failure (patients who decide to repeat treatment). People in this category were only included in the present study at the time of their first contact with the smoking cessation treatment.

Patients whose previous treatment has failed (after attending all six treatment appointments with no substance abuse cessation) are invited to join the initial motivational lecture again.

The intervention lasted 6 weeks for each group of 15 patients. During this period, each patient had to participate in weekly group therapy sessions and attend individual appointments with a physician (t1 = 0, t2 = 1 week, t3 = 3 weeks, t4 = 6 weeks).

The topics discussed in the group therapy sessions included risks of smoking, difficulties and benefits of quitting smoking, and relapse prevention. The group-conduction technique is based on the principles of cognitive-behavioral therapy (CBT).

Medical appointments were focused on the possibility of including pharmacological treatment (i.e., nicotine replacement therapy, bupropion, or nortriptyline) as an adjuvant to group therapy. These appointments also evaluated side effects and dose adjustments. The physician could also refer the patient to another specialist or psychiatrist, if necessary, during or after the 6 weeks of treatment. Most of the investigators were psychiatry residents supervised by a qualified preceptor.

Sample

The participants were interviewed by health professionals (i.e., physicians, psychiatrists, and psychologists) at the service (who were trained by the director of the unit, who is a certified psychiatrist) at four times: t0, t1 (1 week), t2 (3 weeks), and t3 (6 weeks). During this period, weekly group sessions were held. The study sample comprised 1014 patients who completed the smoking cessation program from 2007 to 2016. Patients’ data were collected using a structured questionnaire containing questions on their sociodemographic conditions and smoking habits. The following inclusion and exclusion criteria were applied:

Inclusion criteria:

1. Patients referred by a member of the smoking cessation team at the São Caetano do Sul CAPS-AD unit.

2. Patients who openly agreed to participate in the smoking cessation program.

3. Patients who completed the initial questionnaire.

Exclusion criteria:

1. Patients who did not live in São Caetano do Sul.

2. Patients younger than 18 years and older than 65 years.

3. Patients who did not complete the initial questionnaire.

4. Pregnant women.

Baseline variables and outcome measures

A preliminary questionnaire was administered and explored 27 variables related to smoking, divided into five groups: sociodemographic, medical, smoking, psychiatric, and environmental profiles.

Patient data were collected with a structured questionnaire, which contained sociodemographic, medical, and smoking profile questions, and then later tabulated. Sociodemographic data collected included: gender, age, education, and income. Medical screening was focused on hypertension, coughing, throat clearing, difficulty breathing, bad physical conditions, paresthesia, palpitation, heartburn, any other symptoms, any other diseases, and being currently on any medical treatment. Smoking information included years of smoking, the number of cigarettes per day, time from waking up until smoking the first cigarette of the day, difficulty avoiding smoking in prohibited places, tendency to smoke even when ill, previous attempts to quit smoking, and the number of other smokers in the patient’s house. The Heaviness of Smoking Index (HSI) was also assessed. This combines the information about time to first cigarette and number of cigarettes per day and measures predictors of cigarette dependence severity.¹⁶16. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de domicílios: síntese de indicadores 2014. Rio de Janeiro: IBGE; 2015. Surveyed comorbidities included concomitant psychiatric treatment, alcohol-related issues, and problems with any drug. Daily physical activity was also assessed, as well as patients’ supporters in the smoking cessation attempt. The type of pharmacological treatment employed during the treatment, if any, was recorded (i.e., nicotine patch, nicotine gum, bupropion, nortriptyline).

Treatment success was defined as when the patient (i) achieved abstinence of at least 28 days at the end of the treatment period and (ii) completed the 6 weeks of treatment. Both criteria were based on the self-report measures.¹⁷17. Christofferson DE, Dennis PA, Hertzberg JS, Beckham JC, Knoeppel J, Hamlett-Berry K. Real-world utilization and outcomes of the Veterans Health Administration’s smoking cessation text message program. Nicotine Tob Res. 2021;23:931-8. In the present study, all patients who did not meet both criteria were considered treatment failures. In addition to treatment success, we also measured treatment retention as a secondary outcome of the present study.

Statistical analysis

Data were initially organized in a database and later analyzed using STATA version 11 software. The chi-square test was employed for descriptive analysis. All of the 33 variables were then analyzed separately when gender-related. We analyzed the linear correlations of variables with significant differences between genders to include them in the multivariate logistic regression model. Variables with significant correlations were excluded from the logistic regression model based on clinical relevance. Logistic regression models were estimated for successful treatment. Cox survival regression models were estimated for treatment retention. Initially, we employed multivariate survival variable models, including gender and all co-variables. We employed logistic and survival bivariate models including gender and co-variables to investigate possible confounding factors of this co-variable.

Ethics approval

This study was approved by the Institutional Review Board at the FMABC University Center, with CAAE number 50004314.0.0000.0082.

Results

Figure 1 presents the patient flowchart, showing that 1,014 patients started the intervention, 486 attended all 4 medical appointments, and 528 failed to attend all the medical appointments. None of the patients who started the treatment (n = 1,014) were excluded from the analysis in the present study. Sociodemographic data are shown in Table 1. More males had attended undergraduate level education than females (p = 0.022). The most prevalent salary category was from 2 to 3 times the minimum wage for both sexes, but this characteristic was not significantly different. Regarding their medical profile, women reported significantly less phlegm than men (p = 0.022), while men reported significantly fewer symptoms of palpitation (p = 0.004) and significantly less concomitant medical treatment (p = 0.021) than the opposite sex. The other variables did not differ between the sexes (i.e., hypertension, other diseases, coughing, difficulty breathing, decreased physical performance, paresthesia, heartburn, any symptoms).

Regarding their smoking profile, women reported greater difficulty not smoking in prohibited areas (p = 0.044) or not smoking when ill (p = 0.002) than men. Men had higher prevalence of alcohol use (p > 0.001) and drug use (p > 0.001) disorders than women. Being on treatment for other mental and substance use disorders was not statistically significant between sexes.

Investigation of the environment and lifestyle of the individuals in the sample revealed that more than 85% of both sexes had encouragement from family members to quit. In contrast, minorities reported regular physical activity and medical advice to quit smoking. However, none of the variables analyzed in this category were relevant to the aim of this study. Differences in years of smoking, previous attempts to quit, and presence of other smokers in the house were not statistically significant between sexes. However, the differences in age (p = 0.032) and smoking heaviness index (HSI) (p = 0.0003) were both significantly different between men and women.

Table 2 shows the prevalence rates of types of adjuvant treatment employed: men used more pharmacological aids, nicotine patches (p = 0.086), nicotine gums (p = 0.636), bupropion (p = 0.879), and nortriptyline (p = 0.144) than women. We did not find any significant association between the type of treatment and success rates in either sex (p > 0.05). Females had significantly higher levels of success (36.6% vs. 29.7%, p = 0.027) and retention (51.6% vs. 41.4%, p = 0.002) than males.

In Table 3, we report the results of linear correlation among nine variables. The strongest correlations were as follows: educational level and being on medical treatment (-0.10); educational level and age (-0.21); palpitation and throat clearing (0.11); palpitation and being on medical treatment (0.12); being on medical treatment and age (0.22); difficulty in not smoking in prohibited areas and difficulty in not smoking while sick (0.32); difficulty in not smoking in prohibited areas and age (-0.13); and difficulty in not smoking while sick and age (-0.20).

Regarding crude cessation rates, 36.60% of the females and 29.72% of the males achieved cessation. In the univariate regression model, female sex was associated with successful treatment (odds ratio [OR] = 0.73, 95% confidence interval [95%CI] = 0.55-0.96, p = 0.027) although this was not confirmed in the multivariate logistic regression model (OR = 0.76; 95%CI = 0.56-1.02; p = 0.072). Table 4 presents the model with adjustment for several possible confounding variables. The sex-adjusted variables for throat clearing (p = 0.022), palpitation (p = 0.020), concomitant medical treatment (p = 0.020), difficulty not smoking while sick (p = 0.029), difficulty not smoking in prohibited areas (p = 0.030), Heaviness of Smoking Index (p = 0.030), and educational level (p = 0.028) were statistically significant. However, problems with any drug were a confounding factor in this analysis (p = 0.099).

The survival analysis using multivariate Cox regression (Table 5) showed that female gender (aHR =1.24; 95%CI = 1.02-1.50; p = 0.024) was significantly associated with retention. We performed sensitivity analysis for logistic and survival regression models (Tables S1 and S2, available as online-only supplementary material), splitting the sample into those with and without other drug use disorders. Female gender was significantly associated with both retention (HR = 1.28; 95%CI = 1.02-1.59; p = 0.026) and success (OR = 0.70; 95%CI = 0.50-0.98; p = 0.040), only among those without drug use disorders.

Discussion

In the present study, women presented lower smoking severity at baseline, more clinical symptoms, and lower prevalence of alcohol and drug use disorders, and were older than men. Before adjusting for variables, women were more successful than men at completing the treatment and at quitting smoking. This finding contradicted our initial hypothesis. In the multivariate regression, however, the association between female gender and treatment success was statistically non-significant. After adjusting for each variable, having previous issues with use of alcohol and other drugs was identified as a confounding factor in the analysis.

According to the literature, women having one or more children increases their odds of cessation compared to similarly aged women with no children.¹⁸18. Smith PH, Bessette AJ, Weinberger AH, Sheffer CE, McKee SA. Sex/gender differences in smoking cessation: a review. Prev Med. 2016;92:135-40. Moreover, the prevalence of smoking decreases substantially in the last three months of pregnancy.¹⁹19. Tong V, Dietz P, Morrow B, D’Angelo DV, Farr SL, Rockhill KM, et al. Trends in smoking before, during, and after pregnancy--pregnancy risk assessment monitoring system, United States, 40 sites, 2000-2010. MMWR Surveill Summ. 2013;62:1-19. Other potentially important factors may include hormone variation and menstrual cycle, sex/gender differences in use and effectiveness of smoking cessation medication, and sex/gender differences in use of other tobacco products both prior to and subsequent to quitting smoking.²⁰20. Smith PH, Rose JS, Mazure CM, Giovino GA, McKee SA. What is the evidence for hardening in the cigarette smoking population? Trends in nicotine dependence in the US, 2002–2012. Drug Alcohol Depend. 2014;142:333-40. The results of prospective observational and cross-sectional studies are mixed and demonstrate that bio-psycho-social variation in samples across place and time might determine whether or not women or men are less likely to quit smoking.

Having issues with use of other substances is a relevant indicator of vulnerability to smoke, and it has been associated with greater difficulty with quitting smoking.²¹21. Campbell BK, Le T, Andrews KB, Pramod S, Guydish J. Smoking among patients in substance use disorders treatment: Associations with tobacco advertising, anti-tobacco messages and perceived health risk. Am J Drug Alcohol Abuse. 2016;42:649-56. Regarding sex differences, literature shows that women with a substance use disorder diagnosis are more likely to be regular smokers when compared to men with the same diagnosis.²²22. Husky MM, Paliwal P, Mazure CM, McKee SA. Gender differences in association with substance use diagnoses and smoking. J Addict Med. 2007;1:161-4.

According to our experience, women may benefit more than men from a smoking cessation program even though several smoking cessation studies based on programs in clinical settings have described poorer outcomes for women when compared to men.²³23. Lima DR, Carvalho CFC, Guimarães-Pereira BBS, Loreto AR, Frallonardo FP, Ismael F, Andrade AG, Castaldelli-Maia JM. Abstinence and retention outcomes in a smoking cessation program among individuals with co-morbid substance use and mental disorders. J Psychiatr Res. 2020;125:121-8.,²⁴24. Torchalla I, Okoli CT, Hemsing N, Greaves L. Gender differences in smoking behaviour and cessation. J Smok Cessat. 2011;6:9-16. However, surveys in the general population have also suggested that this finding is not generalized to all women, since age could be an influencing variable, as demonstrated by Jarvis et al.²⁵25. Jarvis MJ, Cohen JE, Delnevo CD, Giovino GA. Dispelling myths about gender differences in smoking cessation: population data from the USA, Canada and Britain. Tob Control. 2013;22:356-60. They used data from three major national surveys and showed that women under the age of 50 were more likely to have completely given up smoking than men, while among older age groups, men were more likely to have quit smoking than women. In our study, the mean age of both sexes was over 50 years, but women were nevertheless more successful.

Further studies are needed to understand the maintenance of gender-specific smoking patterns better and to develop more specific smoking cessation efforts for vulnerable smoker subgroups. Nonetheless, individuals with a history of substance use disorder are expected to report more difficulty in remaining abstinent after quitting smoking.²⁶26. Quisenberry AJ, Pittman J, Goodwin RD, Bickel WK, D’Urso G, Sheffer CE. Smoking relapse risk is increased among individuals in recovery. Drug Alcohol Depend. 2019;202:93-103. Even after a successful treatment, former smokers with a history of other substance use should receive special follow-up attention regarding risk of relapse related to tobacco and other substances.

For females, early implementation of evidence-based smoking cessation treatment, including NRT (such as transdermal patches, chewing gum, etc.), bupropion, varenicline, and individual or group psychotherapies, is suggested.²⁷27. Stead LF, Carroll AJ, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev. 2017;3:CD001007.

28. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016;3:CD008286.-²⁹29. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2017;3:CD001292. Lack of medication and/or psychotherapy decreases the chance of successfully quitting smoking.²⁷27. Stead LF, Carroll AJ, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev. 2017;3:CD001007.

28. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016;3:CD008286.-²⁹29. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2017;3:CD001292. Despite seeking treatment more often,³⁰30. Huang Y, Britton J, Hubbard R, Lewis S. Who receives prescriptions for smoking cessation medications? An association rule mining analysis using a large primary care database. Tob Control. 2013;22:274-9. females are more likely to receive less pharmacological treatments when compared to men.¹⁰10. Steinberg MB, Akincigil A, Delnevo CD, Crystal S, Carson JL. Gender and age disparities for smoking-cessation treatment. Am J Prev Med. 2006;30:405-12.

Employing longitudinal data from the International Tobacco Control Four Country Surveys, conducted in Australia, Canada, the UK, and the US (ITC-4), Smith et al.³¹31. Smith PH, Kasza KA, Hyland A, Fong GT, Borland R, Brady K, et al. Gender differences in medication use and cigarette smoking cessation: results from the International Tobacco Control Four Country Survey. Nicotine Tob Res. 2015;17:463-72. examined differences between genders in quitting attempts, reasons for quitting, use of smoking cessation medication, reasons for discontinuing smoking cessation medications, and rates of smoking cessation. There were no sex differences in plans to quit, desire to quit, or quitting attempts. However, quitting success was lower among females who did not use any smoking cessation medication.

Mainly in females, there are promising findings on the use of bupropion, varenicline, contingency management, cognitive-behavioral therapy (CBT), and CBT plus pharmacotherapy (especially bupropion). Castellani et al.³²32. Castellani V, Gonçalves PD, Castaldelli-Maia JM, Malbergier A. Investigating gender differences for effectiveness and side effects of varenicline during smoking cessation treatment. Rev Assoc Med Bras. 2020;66:146-52. investigated short and long-term gender differences in smoking cessation using varenicline, finding similar treatment success rates between males and females, with females presenting more side effects due to medication than males. Waters et al.³³33. Waters AF, Businelle MS, Frank SG, Hébert ET, Kendzor DE. Understanding the link between contingency management and smoking cessation: The roles of sex and self-efficacy. Addict Behav. 2018;84:99-105. reported that contingency management during the smoking cessation might produce higher self-efficacy in females when compared to males. Loreto et al.³⁴34. Loreto AR, Carvalho C, Frallonardo FP, Ismael F, Andrade AG, Castaldelli-Maia JM. Smoking Cessation Treatment for Patients With Mental Disorders Using CBT and Combined Pharmacotherapy. J Dual Diagn. 2017;13:238-46. evaluated a short-duration smoking cessation protocol using CBT plus pharmacotherapy, showing that females achieve more success than males, as reported in our study. Collins et al.³⁵35. Collins BN, Wileyto EP, Patterson F, Rukstalis M, Audrain-McGovern J, Kaufmann V, et al. Gender differences in smoking cessation in a placebo-controlled trial of bupropion with behavioral counseling. Nicotine Tob Res. 2004;6:27-37. and Chatkin et al.³⁶36. Chatkin JM, Abreu CM, Blanco DC, Tonietto R, Scaglia N, Wagner MB, et al. No gender difference in effectiveness of smoking cessation treatment in a Brazilian real-life setting. Int J Tuberc Lung Dis. 2006;10:499-503. employed CBT plus bupropion and found similar success rates for both sexes. Corroborating these results, a meta-analysis investigating brief tobacco interventions in primary care found no significant gender differences.³⁷37. Wray JM, Funderburk JS, Acker JD, Wray LO, Maisto SA. A meta-analysis of brief tobacco interventions for use in integrated primary care. Nicotine Tob Res. 2018;20:1418-26. Finally, since weight gain is a major concern in this subgroup, any intervention addressing this issue might be promising.³⁸38. Pegington M, French DP, Harvie MN. Why young women gain weight: a narrative review of influencing factors and possible solutions. Obes Rev. 2020;21:e13002.

Unfortunately, different authors report that a significant number of smokers receiving smoking cessation treatment relapse in the subsequent weeks and months.³⁹39. Martínez-Vispo C, López-Durán A, Senra C, Becoña E. Specific relapse predictors: could cognitive-behavioral treatment for smoking cessation be improved? Int J Environ Res Public Health. 2020;17:4317.,⁴⁰40. Bold KW, Rasheed AS, McCarthy DE, Jackson TC, Fiore MC, Baker TB. Rates and predictors of renewed quitting after relapse during a one-year follow-up among primary care patients. Ann Behav Med. 2015;49:128-40. According to these authors’ data, around half of the successful quitters in the present study should have relapsed. Generally, relapse rates range from 30 to 80%³⁹39. Martínez-Vispo C, López-Durán A, Senra C, Becoña E. Specific relapse predictors: could cognitive-behavioral treatment for smoking cessation be improved? Int J Environ Res Public Health. 2020;17:4317.,⁴⁰40. Bold KW, Rasheed AS, McCarthy DE, Jackson TC, Fiore MC, Baker TB. Rates and predictors of renewed quitting after relapse during a one-year follow-up among primary care patients. Ann Behav Med. 2015;49:128-40. during the following year. Smith et al.⁴¹41. Smith SS, McCarthy DE, Japuntich SJ, Christiansen B, Piper ME, Jorenby DE, et al. Comparative effectiveness of 5 smoking cessation pharmacotherapies in primary care clinics. Arch Intern Med. 2009;169:2148-55. described 6-month abstinence rates as follows: bupropion = 16.8%; nicotine lozenge = 19.9%; patch = 17.7%; patch plus lozenge = 26.9%; and bupropion plus lozenge = 29.9%.

Limitations of this study may include that we did not perform a population-based study (selection-bias). Almost 15% of the women involved in the study reported any drug use disorder, which may not represent all women who seek treatment for smoking cessation in general services. Also, we did not consider the effect of the menstrual cycle on success rates, with premenstrual symptoms associated with higher relapse rates in the literature among women attempting smoking cessation.⁴²42. Allen SS, Allen AM, Pomerleau CS. Influence of phase-related variability in premenstrual symptomatology, mood, smoking withdrawal, and smoking behavior during ad libitum smoking, on smoking cessation outcome. Addict Behav. 2009;34:107-111.

Conclusion

Our study may contribute more information to the current literature on the topic regarding those factors influencing the success rates of smoking cessation treatment programs in women. Depending on the smoking cessation setting (i.e., low and middle-income countries, mental health, and addiction care units), females could achieve similar and even higher quit rates than males. Previous drug use disorder was an important confounding variable in the gender outcomes analyses. Future studies should try to replicate these positive smoking cessation effects of CBT-based group therapy plus pharmacotherapy in women.

References

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History