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2002 Selected Articles

The Young Female Smoker: What Can the Physician Do?

Lorraine Greaves, PhD

Physicians concerned about smoking prevention and cessation in girls and young women should begin by listening nonjudgmentally to their feelings about tobacco use. Once the physician elicits what smoking "means" to the patient, then together the patient and physician can design a plan that will promote a positive and perhaps permanent behavioral change. A persistent physician can be the key to sustaining the patient’s motivation and interest in quitting smoking.

Early in 2001, the US Surgeon General’s Report on Women and Smoking was released amid growing anxiety about the epidemic of smoking-related illnesses in American girls and women. ¹ This alarming pattern is emerging in several other industrialized countries as well. The World Health Organization is equally concerned about women and girls in less developed countries who are being targeted as a major growth market by the tobacco industry—a process that will likely result in similar patterns of disease and death across the globe. ²

The toll of smoking-related illnesses in women is increasing, with women now experiencing 39% of all diseases associated with tobacco use in the United States. ¹ In addition, the historically wide gender gap between female and male rates of smoking is closing, particularly among teens. The future effect of this trend will be a higher proportion of smoking-related illnesses occurring among adult women.

The US Department of Health and Human Services reports that approximately 6,000 children and adolescents try their first cigarette every day, with 3,000 eventually becoming daily smokers. ³ Traditionally, the focus in tobacco control with respect to children and adolescents has been on preventing the initiation and maintenance of smoking. However, the majority of adolescent smokers wish they had never started, and many try to quit during their teen years. ³ Therefore, it is also important to consider cessation planning and treatment for children and teens—a process in which physicians and other health care practitioners can play a key role. Like adult smokers, many teens want to quit smoking, but need regular reinforcement to try again after relapse. ⁴

While there is little definitive knowledge about the best approaches to young women and smoking, reviewing what is known about the subject can assist in understanding their special needs. In addition to conducting a thorough biomedical assessment, it is critically important for the physician to consider the psychosocial influences on girls and young women in contemporary society and how they affect adolescent smoking patterns and dictate the mode of physician intervention.

HEALTH RISKS

The general health risks of smoking are well known to the public. In addition to the frightening and undeniable risks of heart disease, cancer, and chronic lung diseases, other risks are emerging for women of all ages as specific sex and gender differences in the effects of smoking are becoming apparent. For example, there is an association between smoking and cervical and vulvar cancers, and a suggested link between environmental tobacco smoke (ETS) and breast cancer. ¹ Few adolescent girls realize that their rate of lung growth can be reduced by smoking, or that exposure to ETS can cause lung cancer in nonsmokers. Many are not aware that lung cancer—not breast cancer—is the leading cause of cancer death in women. Similarly, the co-existence of smoking with other substance abuse, disordered eating, lack of physical activity, depression, or sexual abuse are other notable indicators for the involved physician to mark.

TRENDS AND PATTERNS

Overall smoking prevalence has dropped in the United States in the past few decades, but the rate of decline among women has been much slower than that among men, leading to the closing of an historic gender gap in tobacco use. Further, the rates of both male and female teen smoking have either plateaued or increased slightly in the past 6 to 10 years. ¹ Currently, approximately 33% of young women are smoking. ¹ In the United States, white girls and teens are 2 to 3 times more likely to smoke than black or Hispanic girls. ¹ Early onset of smoking is much less prevalent in black teens due to the presence of fewer risk factors. ⁵ However, Native American girls and women smoke more than white girls. ¹ Smoking is also higher among gay, lesbian, and bisexual girls. ¹ Finally, smoking among pregnant girls and women has declined over the past few decades, but still hovers at an unacceptable 22%. ¹

PREDICTORS

There are several situational predictors of adolescent smoking, both positive and negative. Adolescents who live and work in smoke-free environments tend to be nonsmokers, and those whose parents have quit smoking are more likely to quit themselves. ⁶ On the other hand, having disposable income is positively associated with cigarette consumption, and adolescents who work often begin to establish a smoking habit at this juncture. ⁶

Major life changes, such as entering college, frequently mark a time of experimentation with a wide range of tobacco products. According to a national college survey, more than 60% of college students have tried a tobacco product of some kind. ⁷ The physician can gauge these kinds of risks by questioning the patient about her environment and the behaviors of her family, friends, and co-workers. Does the patient live with smokers, especially parents or relatives? Do they work amid cigarette smoke? Do their friends smoke?

Wider factors can have an impact as well. Targeted advertising campaigns correlate positively with historic trends of smoking among US girls. ⁸ However, increases in cigarette taxes provide a general deterrent to teen smoking and assist in lowering prevalence rates.

PSYCHOSOCIAL INFLUENCES

The developmental and psychosocial factors that influence young women to begin smoking and to use tobacco as much or more than young men in contemporary North America are less clear. However, recent trends show that girls and young women remain at risk for smoking, and that they could form a growing cohort of persistent adult women smokers who will experience serious health consequences over the next few decades. It is therefore crucial to intervene through clinical measures, improved community and media programs, and innovative research.

PHYSICIAN INTERVENTION

Although only 20% of people who quit smoking use any form of assistance, the physician can be very important in the quitting process. ⁹ Among those who quit, women are more likely than men to use assistance (particularly counseling), and use of assistance increases with age. Nonetheless, physician intervention can be very effective in raising the issue of smoking, even though the process of quitting is often lengthy and staged, and the physician must stay engaged by raising the issue at each visit.

At least two sets of guidelines are important to consider. The American College of Obstetricians and Gynecologists (ACOG) published guidelines on smoking for women, and the US Department of Health and Human Services published guidelines for adolescents and children. ^3,10 In addition to following these directives, developing a dialogue on smoking with the young female patient could have a major effect on her future smoking behavior. This process raises the consciousness of both patient and physician about the complex and sometimes deep-rooted issues attached to tobacco use in girls and young women.

Further, routinely discussing smoking during every patient visit sends the message that the physician considers this a vital health issue. Clinicians may benefit from education; brief training of physicians in intervention protocols has been shown to result in a 15% quit rate after 1 year. ¹⁰ In addition, patients who are reminded regularly about health risks by trained physicians are six times more likely to stop smoking than those who are not. ¹⁰

SCREENING, COUNSELING, PRESCRIBING, AND FOLLOW-UP

The guidelines for treating tobacco use published by the US Department of Health and Human Services recommend several approaches to dealing with smoking among children and adolescents. ³ The first step is to screen all children, adolescents, and parents. A recent study that screened children aged 14 to 18 for smoking in a pediatric practice revealed that a simple questionnaire produced valid data regarding cigarette consumption levels when checked against a biomarker. ¹¹ More importantly, this approach identified children and adolescents at early stages of experimentation, allowing intervention before nicotine addiction occurred.

Secondly, counseling and behavioral interventions are also recommended as early as age 10 (when crucial experimentation begins), particularly in children who have access to cigarettes. ^11,12 Appropriate assistance can then be offered to motivated patients. Thirdly, prescription of cessation aids is suggested when appropriate. Finally, the guidelines recommend encouraging cessation for parents who smoke with the aim of reducing ETS exposure in children and adolescents.

These guidelines can be extremely helpful, especially when used in conjunction with the ACOG materials. ACOG recommends using the "five A" approach developed by the US National Cancer Institute for physicians: anticipate, ask, advise, assist, and arrange. However, this concept must be adjusted to the wider context of a gender analysis of smoking and tobacco use. Sensitivity to stress, weight issues, and pregnancy are critical intervention points with female patients.

UNDERSTANDING AND UTILIZING PATIENT PERCEPTIONS

A complementary and equally important approach is listening to the patient’s feelings about smoking. While seeing the patient alone, asking her to reflect on her smoking behavior can be a tremendously enlightening step for both the practitioner and the patient. This can also form the basis for motivational interviewing that can serve as a platform for cessation planning in future patient visits. Such interviewing must be pursued patiently, recognizing that there may be several attempts to quit before the patient succeeds, and that the process of deciding to quit is staged and often protracted. During this process, the physician can use the patient’s "smoking story" to identify her personal strengths, the external factors that may threaten her commitment, and the emotional and physical rewards that can encourage persistence. ¹³

This author’s research with adult women smokers on the meaning of smoking to them highlighted some key questions that can be adapted to the clinical situation or the patient visit. ¹⁴ For example, asking the patient to recall her first cigarette and the feelings surrounding that event, or asking her what conditions would have to change so she could visualize herself as a nonsmoker, are two questions that can elicit critical information.

Interesting themes emerge from analyzing these data, offering clues to a better understanding of female smokers in general. Adult women typically report that smoking facilitates social relationships, assists in creating an "image," helps to calm their emotions, affords predictability and control, and becomes incorporated with their identity. ¹⁴

Smoking assists in developing social relationships in a variety of ways, from "breaking the ice," to building bonds to dealing with differential power issues. Images of risk-taking and independence are often absorbed through potent cultural messages in advertising and movies about young women who smoke. These images often resonated with adult smokers when they began using tobacco as adolescents.

Women describe the ability to calm their emotions through smoking, particularly the suppression of negative emotions. Identity becomes intertwined with smoking, but the tension between controlling life through smoking and feeling controlled by smoking can cause frustration, and serves as a useful starting point for discussion and reflection. Even so, smoking becomes an important source of predictability and solace for women, like a "dependable partner" or "best friend." ¹⁴

These themes are echoed in similar social research on adolescent female smokers. Young girls use smoking as a bonding agent or a badge of belonging, a way to defy parents, acquire independence, and deal with negative emotions. The ability to adopt an image and to take risks are critical issues for adolescents. ¹⁵ In these ways, smoking is functional or adaptive for teen girls. However, by late adolescence, these initial meanings of independence and risk are replaced by negative and powerless images (negative health effects, odor, cost, or the feeling that smoking is a "stupid habit"). ¹⁵ These shifts parallel the drift into nicotine addiction, and illustrate how this important transformation from control to being controlled can occur within a short time of initiating smoking.

Weight control is another issue for teen-aged and adult women smokers, in that smoking can be used to suppress appetite and control weight. However, in qualitative research with both adolescent and older women smokers, this is not usually identified as an issue. Nevertheless, marketing campaigns have pushed the association between weight control and smoking for women for almost two decades, resulting in large sales of certain female-oriented brands. Surveys report girls using smoking to control weight and their concomitant concern about weight gain upon cessation. ⁴ This link offers another important platform for discussion with the female patient about the interplay between smoking and controlled or disordered eating.

CONCLUSION

There is strong evidence that a multipronged, comprehensive, population-based approach to tobacco control among young people sets the broad stage for prevention and cessation. This involves prevention programs, media campaigns, and cigarette taxation, plus regulation of advertising, sales, and cigarette content. ¹⁶ Taken together, these measures can protect a large group of girls and young women by changing the social environment and "denormalizing" tobacco use. Even so, current prevention programs do not seem to meet the needs of young women, who are often more socially sophisticated and self-confident than boys. ¹⁷

The physician visit can be a "golden opportunity" for change on an individual level. To effectively assist with smoking prevention and cessation for the young female patient, the biomedical/clinical assessment must be supplemented by assessment of the psychosocial aspects of smoking. The physician can play a key role by listening to the patient’s perceptions in an open and respectful manner. The patient and physician can mutually identify the individual meanings and functions of smoking, which can be used to create ambivalence about smoking and instigate motivation. ¹⁸

Together, they can begin the process of counteracting the perceived benefits of smoking with a cessation plan. The female adolescent smoker will need more emphasis on offsetting the social and functional aspects of tobacco use. ¹⁹ For example, what strategies can be employed to deal with changes in social relationships if the girl quits? What can serve as sources of identity formation to replace smoking?

Physician intervention can be key in identifying the young female smoker, offering clinical support, assistance, prescriptions, and follow-up, and practicing motivational interviewing to promote cessation. When dealing with a young woman in the office, there is scope for powerful intervention and a caring connection, that, if pursued sensitively and patiently, can offer a chance for permanent behavioral change and a lifetime of improved health.

Lorraine Greaves, PhD, is executive director, British Columbia Centre of Excellence for Women’s Health, Children’s and Women’s Health Centre of British Columbia.

REFERENCES

1. US Department of Health and Human Services, Public Health Services Office of the Surgeon General. Women and Smoking: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services; 2001.
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