Smoking Cessation in Women:

1. Smoking Cessation in Women: Michele D. Levine, Ph.D Pittsburgh Mind-Body Center Summer Institute June 6, 2007

2. Overview • Women and smoking • Sex differences in smoking • Women's issues in cessation treatment

3. Women and Smoking • 22% of American women smoke • 30% of young women report smoking within the past month

4. Women and Smoking • The rate of smoking decline has been slower among women than men • Young women are more likely to initiate smoking than young men • Recent evidence suggests that women have greater difficulty quitting smoking than men do

5. Women and Smoking • There are many negative health consequences of smoking • Women suffer additional health consequences that do not affect men, and may be at higher risk for some smoking-related diseases

6. Here’s the Good News

7. Background • 50% of ever smokers have now quit; and many smokers quit each year • Although many smokers quit with minimal intervention, clinic-based smoking cessation treatment accounts for approximately 10% of cessation

8. Sex Differences in Response to Nicotine

9. Women may be less responsive to reinforcing effects of nicotine • Less self-administration of nicotine vs. placebo (Perkins et al. 1996, 1997; West et al. 2001) • Smaller difference in nicotine spray choice following nicotine patch pre-treatment (Perkins et al. 2001) • Smaller difference in rewarding and reinforcing effects due to cigarette nicotine dose (Perkins et al. 2002)

10. Why do women smoke?

11. Women obtain greater reinforcement than men from non-nicotine influences on smoking

12. Women may be more responsive to non-nicotine aspects of smoking • Greater decrease in smoking reinforcement following removal of non-nicotine smoking stimuli (Perkins et al., 1994; 2001) • More responsive to sensorimotor effects of smoking (Carpenter et al. 2005)

13. Clinical Implications • If women’s smoking is less responsive to nicotine, then they should benefit less from nicotine replacement therapy (NRT) when trying to quit • If women’s smoking is more responsive to non-nicotine factors (e.g. cues), then they should benefit more from other approaches

14. Sex Differences in Outcomes from NRT • Men and women (n=504) randomly assigned to one of four active NRT products to use in quit attempt West R, et al., . (2001) Psychopharmacology, 153: 225-230

15. Summary of Sex Differences • Women appear to be less responsive to nicotine than men • Women appear to obtain more reinforcement from the non-nicotine aspects of smoking • Women are less responsive than men to most forms of nicotine replacement therapy • Women may benefit from treatment approaches that address other factors or specific “women’s issues”

16. Women’s Issues in Cessation Treatment • Pregnancy • Postpartum • Weight Concerns

17. Postpartum Smoking

18. Postpartum Smoking • An estimated 65% of women who quit during pregnancy will resume smoking by six months postpartum • 25% of women will relapse in the first month postpartum • There are numerous health consequences of postpartum smoking for both mother and child

19. Postpartum Smoking Relapse and Mood • The experience of depressive symptoms and perceived stress are common during the postpartum period • Concerns about shape and weight are common during the postpartum period • Depressive symptoms, stress and weight concerns have been related to smoking relapse

20. Model of Postpartum Relapse Pregnancy Postpartum Period MOOD CHANGES • Postpartum hormonal changes • Baby blues • Stresses of young motherhood • Changes in role and self perception Increased Vulnerability Smoking Relapse Smoking Cessation INCREASE IN WEIGHT CONCERNS • Retention of pregnancy weight gain • Desire to return to pre-pregnancy weight • Change in perception of body shape Levine MD & Marcus, MD (2004),Archives of Women’s Mental Health, 7, 155-166.

21. Motivation for Postpartum Abstinence • Women who relapse postpartum differ in reasons for quitting during pregnancy from those who remain abstinent • Motivation for the maintenance of smoking abstinence after childbirth may be an important, and potentially modifiable, predictor of women’s relapse to smoking postpartum

22. Method • Pregnant women (N = 119) who had recently quit smoking were recruited from obstetrical clinics • Women completed assessments of motivation, depressive symptoms, perceived stress, and weight concerns in the third trimester of pregnancy

23. Results • 65.6% of pregnant women were highly motivated to remain quit postpartum • 74.0% felt confident in their ability to do so • Self-efficacy for weight management was associated with motivation to maintain abstinence postpartum after controlling for mood and other variables that have been associated with postpartum smoking Levine MD, Marcus MD, et al., (2006). Weight concerns affect motivation to remain abstinent from smoking postpartum. Annals of Behavioral Medicine.

24. Predictors of postpartum relapse • Among women who have completed the three-month postpartum assessments, 45% (36/80) have relapsed • Relapse occurred 28.5 (±29.9) days after delivery

25. Survival Curves by Weight Self-Efficacy 1.0 1.0 Increased (n = 16) Decreased ( n = 27) 0.8 0.8 0.6 0.6 0.4 0.4 0.2 0.2 0.0 0.0 0 0 25 25 50 50 75 75 100 100 125 125 150 150 175 175 Number of days to relapse Number of days to relapse

26. Weight Concerns and Smoking

27. Weight Concerns and Smoking • Concerns about shape and weight are prevalent among women in general • For women smokers, these normative concerns may promote or maintain smoking behaviors

31. Smoking and Weight Concerns • Individuals gain between 8-15 pounds upon quitting smoking • Women are more likely to be concerned about postcessation weight gain than are men • Women gain more weight than do men after quitting

32. Weight-concerned Smokers • Weight-concerned women smokers gain between 10-15 pounds after quitting • There is a considerable discrepancy between the amount of weight women expect to gain and the amount they are willing to tolerate • Expect to gain 17 lbs • Less than 20% would tolerate greater than 5 lbs Levine, M.D., Perkins, K.A., & Marcus, M.D. (2001). Addictive Behaviors, 26, 749-756.

33. Weight-concerned Smokers • Weight-concerned women are likelier than those without concerns to drop out of cessation treatment • Weight-concerned women have significantly poorer outcomes following a cessation attempt than do those without weight concerns

34. Weight Concerns and Smoking • The addition of weight control interventions has not reliably improved smoking cessation outcomes • Concerns about shape and weight are prevalent among women in general • For smokers, maladaptive thoughts and beliefs about shape or weight may promote or maintain smoking • We reasoned that addressing women’s concerns about shape and weight, particularly those relating to the effects of smoking cessation, might improve cessation outcomes

35. The Women’s Smoking Cessation Project Research supported by NIDA DA04174 Ken Perkins, PI

36. Women’s Smoking Cessation Project • The first women’s smoking cessation project was designed to compare two approaches to addressing women’s concern about postcessation weight gain • We compared a cognitive behavioral program designed to reduce postcessation weight concerns and a behavioral weight control program to prevent postcessation weight gain with a standard cessation program Perkins, et al (2001). Cognitive-behavioral therapy to reduce weight concerns improves smoking cessation outcome in weight-concerned women. Journal of Consulting and Clinical Psychology, 69, 604-613.

37. Women’s Smoking Cessation Project • All women received standard smoking cessation treatment plus one of three adjunctive treatments: • SOCIAL SUPPORT • WEIGHT CONTROL • WEIGHT CONCERNS (CBT)

38. SOCIAL SUPPORT ADJUNCT(Standard) • Rationale: Smoking cessation alone requires considerable effort and it may be ineffective to deal with weight gain concerns at the same time • Goal of Treatment: Target smoking cessation only without directly addressing weight concerns

39. WEIGHT CONTROL ADJUNCT • Rationale: Successful prevention of weight gain may help to improve cessation rates among weight concerned smokers • Goal of Treatment: Prevent actual weight gain by reducing calorie intake

40. WEIGHT CONCERNS ADJUNCT(CBT) • Rationale: Average weight gain during smoking cessation is modest. Modifying women’s over-concern about shape and weight during smoking cessation may improve cessation rates • Goal of Treatment: Reduce concern about weight gain and promote acceptance of modest weight gain

41. Weight Concerns Treatment • Adapted from the cognitive behavioral treatment of eating disorders • Treatment Features • Psychoeducation about smoking and weight gain • Cognitive strategies to target irrational thoughts and beliefs about weight gain and smoking • Emphasis on moderation

42. Smoking Cessation by Treatment Group ** % Abstinent * * Compared to standard: ** p<.001 * p<.05 Months postquit

43. Weight Gain by Treatment Group Weight change (lb) * * ** * Compared to Standard: ** p<.001 * p<.05 Months postquit Weight change examined only among abstinent women

44. Study 1 Conclusions • A cognitive-behavioral treatment designed to reduce women’s concern about postcessation weight gain improved long-term smoking cessation outcome • This approach also attenuated postcessation weight gain among women who remained abstinent

45. Study Conclusions • Although the weight concerns treatment helped women who are concerned about postcessation weight gain to quit smoking, the overall cessation rates are low • Rates of abstinence decline sharply at the conclusion of treatment

46. The Women’s Smoking Cessation Project II: “The Zyban Study”

47. Women’s Smoking Cessation Project II • Rationale for bupropion • Nicotine replacement may be a less desirable choice for women • It may attenuate post cessation weight gain • It may relieve negative mood • Thus, the goal of the current investigation was to determine whether the addition of bupropion would enhance the efficacy of our CBT for weight concerns program

48. Weight Concerns and Depression • Depression history may pose a particular problem for weight-concerned women smokers • Weight-concerned individuals may be more likely to gain weight during episodes of depression • Depression history has been associated with postcessation weight gain

49. Hypotheses • The addition of bupropion to CBT for weight concerns (WC) would increase cessation rates (i.e., WC+B vs WC+P) • The addition of CBT for weight concerns to bupropion would increase cessation rates (i.e., WC+B vs SS+B)

50. Participant Characteristics (N = 349)