7.19Interventions tailored for age and/or gender

Last updated: June 2022

Suggested citation: Greenhalgh, EM, & Scollo, MM. 7.19 Interventions tailored for age and/or gender. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022. Available from: https://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-19-interventions-tailored-for-age-and-or-gender

  

7.19.1 Younger smokers

Although adults experience the major burden of disease from tobacco use, interventions that influence children’s and adolescents’ smoking behaviours are an integral part of ending the tobacco epidemic. Almost all smokers start smoking when they are teenagers, and those who start earlier appear to have more difficulty quitting and be more susceptible to tobacco-related disease.1 Young people with mental health or behavioural problems are also far more likely to smoke than their peers, with emerging evidence showing that smoking appears to play a causal role in some mental disorders.2, 3 In a 2014 survey of Australian school students aged 12–17 years, about 14% of those who had smoked more than 100 cigarettes in their lifetime (who comprised about 3% of students) identified as ex-smokers. Just over half (55%) of students who had smoked in the past twelve months intended not to smoke in the next year.4

7.19.1.1 Factors influencing smoking and quitting

A complex range of factors influence adolescent smoking and quitting. Some findings suggest that while many younger smokers intend to quit, they have negative attitudes towards most formal cessation approaches and their quit attempts are more likely to be unaided compared to adults.5, 6 Quitting may be a much more stressful, uncomfortable, and socially isolating experience for youth than research typically acknowledges.7, 8 Young smokers may receive little active support from family and friends in their quit attempts.8 They may rationalise continuing to smoke by downplaying the health risks of smoking, emphasising the perceived health benefits such as stress relief, and thinking of smoking as a temporary activity that they can easily stop once they enter adulthood.9

In terms of individual differences, lower nicotine dependence, being older at smoking initiation, perceived peer and parental tolerance of smoking, self-efficacy, resisting peer pressure to smoke, negative beliefs about the consequences of smoking, not having intentions to smoke in the future, and less smoking among social networks are associated with quitting among young people.10-14 Maintenance of regular physical activity among young smokers also appears to help to facilitate smoking cessation,15 as does adding physical activity to an adolescent cessation program, particularly among boys.16   Factors that can predict relapse include socialising with friends, cravings, social pressure, desire for a cigarette, abstinence–violation cognitions (it’s okay to smoke occasionally, wanted to see what it was like) and negative emotions.17 Although withdrawal symptoms may be uncomfortable for adolescent smokers trying to quit, they do not appear to be the most important factors causing relapse.18

7.19.1.2 Cessation interventions

Unlike the extensive body of literature studying smoking cessation among adults, there is a paucity of good quality studies focusing on smoking cessation intervention and cessation programs for young people. Prevention and cessation are intertwined, but most of the effort with young people to date has focused on preventing uptake rather than promoting cessation.19 A 2013 Cochrane review of cessation interventions for young people concluded that complex approaches show promise, with some promoting maintained abstinence, especially those incorporating elements sensitive to stage of change and using motivational enhancement and cognitive-behavioural therapy.  A small number of studies investigated the use of pharmacological interventions for adolescent smokers (nicotine replacement and bupropion), but none demonstrated effectiveness. The authors call for well-designed and robust trials of interventions for young smokers.20

Despite limited evidence of its efficacy, nicotine replacement therapy is recommended for use with teenagers who exhibit symptoms of dependence.19 If used, it should be individualised and combined with psychosocial and behavioural interventions.21 Counselling is a vital component of interventions for young people.22  

There is some evidence that specialist youth settings can be effective venues for the delivery of tailored cessation programs for young people.23 A systematic review and meta-analysis published in 2015 found that the mostly moderate quality evidence suggested targeted behavioural interventions can assist with cessation in school-aged children and adolescents.24 Earlier research found that programs that are delivered in a context that is structured for youth, such as a school, and that extend for at least five sessions seem to be more effective than community-based and single session interventions;25, 26 however, there are many barriers to delivering such programs within schools.26 Further, a seven-year follow up study found no evidence that previously positive effects of a high school-based cessation intervention for teens were sustained long-term.27 One of the single most inexpensive actions a school can take to reduce smoking is to introduce and enforce a no-smoking policy for students, teachers and visitors.28, 29 Similarly, community youth services should develop policy that addresses smoking by clients and staff, and encourages and supports smoking cessation. A national evaluation of community-based youth cessation programs in the US concluded that providing evidence-based treatment to youth in community-based settings results in successful cessation.30

Proactive, personalised telephone counselling is effective for adolescent smoking cessation.31 About 4% of callers to the Victorian Quitline are under 18 years of age, and protocols for young callers have been developed as part of the set of national minimum standards.32 These recommend that services focus on the immediate harmful effects of smoking and issues of appearance and youth-specific reasons for smoking, such as rebellion or aspiring to be more grown up. Recognising differences in patterns of smoking between adolescents and adults, for example infrequent and situation-dependent smoking, is important in appropriately tailoring interventions, as is referring young people to youth-specific resources, especially internet sites.33 Internet- and mobile phone-based interventions offer enormous potential for reaching young people, and these are discussed in detail in Section 7.14.

7.19.1.3 Social marketing and public education campaigns

Population-wide approaches can also effectively shape young people’s smoking-related attitudes and behaviours. Despite primarily targeting young to middle-aged adults, the impact of Australia’s national campaigns to promote smoking cessation also reach younger people. For example, evaluation of the early National Tobacco Campaign showed that adolescents learnt as much, if not more, than the 18–40 years target group from the television advertisements, and the campaigns prompted changes in smoking behaviour.34, 35 A systematic review that assessed the equity impact of interventions/policies on youth smoking found that price/tax increases had the most consistent positive equity impact (i.e., reduced smoking inequity between high- and low-SES young people).36

For a detailed discussion of the effects of social marketing campaigns, see Chapter 14.

7.19.1.4 The role of health professionals

As with adult smokers, health professionals play an important role in encouraging and assisting younger smokers to quit, and paediatric-based interventions are feasible and effective.37 Paediatric healthcare professionals can provide opportunistic evidence-based brief interventions to adolescents and their carers, and/or can provide referrals to specialist services and resources. However, many health professionals have not received appropriate smoking cessation training.19 Practitioners’ low levels of confidence in helping young smokers to quit, their lack of clarity about what strategies and pharmacotherapies should be used, their concern for maintaining rapport with their adolescent patients, and the health problem of the patient can hinder the delivery of interventions in this setting.25, 38, 39 Nonetheless, health professionals’ training should emphasise the importance of smoking cessation as a part of their everyday practice.19  

7.19.2 Older smokers

The greatest proportion of burden of disease due to smoking affects those aged 55–75 years. (See Chapter 1, Section 1.5). A comprehensive study on the impact of smoking and smoking cessation on cardiovascular events and mortality among adults aged 65 years and over found that smoking cessation in these age groups is still beneficial in reducing the excess risk, thus should be supported and encouraged.40 A large Australian study similarly found that smoking cessation, even at older ages, reduces the risk of preventable hospitalisation for chronic conditions.41

7.19.2.1 Factors influencing smoking and quitting

Results from surveys in the UK, US, Canada, and Australia suggest that older smokers tend to perceive themselves as being less vulnerable to the health effects of smoking, are less convinced or concerned about these health effects, believe that smoking has not affected their own health so far, are less confident about being able to quit, do not see any health benefit of quitting, and are overall less willing to quit.42 Depression43 and loneliness44 also appear to act as important barriers to quitting in older smokers. Factors that appear to encourage older smokers to quit include increasing the price of cigarettes, advice from a health professional, and cheaper stop-smoking medications.42 As in the general population, developing health problems can also trigger cessation attempts.45 A large German survey found that high-risk older patients with comorbidities are highly motivated to quit and would benefit from effective assistance.46 One study found that continuing older smokers who quit tended to be those who took more medications and had greater cognitive dysfunction.44

There is evidence that transition into retirement represents a time when smokers are more likely to quit, suggesting that interventions could be developed to take greater advantage of this lifestyle change.47 Older people’s continued smoking, quitting, and relapse appear to be significantly influenced by friends and family members, especially a spouse, and their attempts to quit are often unplanned.48 When provided with an appropriate intervention, older smokers can and do quit successfully.49 Indeed, Danish research found that, following a “gold standard” intensive six-week smoking cessation program, participants over the age of 60 years had significantly higher continuous abstinence rates than participants under 60 years.50

7.19.2.2 Cessation interventions

A number of recent studies have reviewed the evidence on smoking cessation interventions for middle-aged and older adults. Although the research is limited, a systematic review and meta-analysis study found support for pharmacological, non-pharmacological, and multimodal interventions in adults over fifty years,51 while another suggested that the use of NRT may be an effective strategy for smokers aged 65 and over.52 Research in the US demonstrated that adding extended cognitive behavioural therapy to standard cessation treatment (i.e., 12 weeks of NRT) was cost-effective.53 Among community-dwelling elderly smokers, one study found that behavioural group therapy achieved higher short-and long-term abstinence rates than education alone.54 Interventions may need to address the underestimation by older smokers of the risks of smoking and their misperceptions that there are no benefits of quitting.42 Findings from focus groups in the US revealed that anti-tobacco messages with a positive frame that outline immediate and long-term benefits of cessation would be an effective approach for older long-term smokers.55

7.19.2.3 The role of health professionals

Health professionals have an important role to play in educating older people about the health benefits of quitting and a range of opportunities exist in which to advise and assist older patients to stop smoking.42 (See Section 7.10.) Older adults tend to visit their health professionals more frequently, creating many opportunities for intervention. They are able to quit at high rates when given effective advice and support by health professionals, including behavioural therapy and pharmacotherapy.42, 49, 56   Studies have found however, that health professionals may be less likely to promote smoking cessation to older patients.49 Interviews with older ex-smokers revealed that they may need additional education on tobacco risks and cessation benefits provided by health care providers during routine office visits.57 Health professionals cite a number of misperceptions and perceived barriers to providing interventions, including that older smokers are unwilling and unable to quit, that they would not respond positively to advice, that they understand the risks of continuing to smoke, that quitting would not have any great benefit, that it is wrong to take away something pleasurable in their life, and that quitting might actually harm the patient’s health. They also report lack of organisational support and concerns about harming the health professional–patient relationship. There is some evidence that nurses who do not smoke are more likely to provide advice to quit.49, 58

Cigarette smoking may contribute to worse health outcomes for peri- and postmenopausal women and cessation may be particularly challenging for this group. (See Chapter 3, Section 3.6.1.) Further research is warranted in this area.59

7.19.3 Women

Cessation interventions for pregnant women are covered in detail in Section 7.11 .

While the prevalence of smoking has typically been higher among men than women, this gap has narrowed over time (See Chapter 1, Section 1.3). This has largely been attributed to aggressive tobacco industry marketing targeting women, as well as the production of specially formulated products for women, such as ‘light’, ‘slim’, ‘super-slim’, low-tar, light-coloured packaging, and menthol cigarettes.60 Although women and men who smoke share excess risks for diseases such as cancer, heart disease, and emphysema, women also experience unique smoking-related disease risks related to pregnancy, oral contraceptive use, menstrual function, and cervical cancer.61 Women and men tend to have different reasons for initiating and continuing tobacco use and may experience different barriers to quitting smoking, some of which are gendered.62 Barriers to quitting that are unique to or experienced to a greater degree among women include fear of weight gain, certain social factors, withdrawal and craving in response to environmental cues, the point in the menstrual cycle in which an attempt is made to quit, and depression.63 For example, while depression consistently predicts lower rates of abstinence, the effects are stronger among women.64 Women taking oral contraceptives also appear to experience different patterns of smoking-related symptomatology during short-term smoking abstinence.65 Further, during the follicular phase (the first half) of the menstrual cycle, cognitive control appears to be lower and cue reactivity higher, which could potentially hinder quit attempts.66 Gendered roles and experiences can limit women’s ability to access treatment and support due to heightened stigma surrounding substance use among women, particularly pregnant women and mothers.67

Compared with men, women may be less successful at quitting,68, 69 and have worse health outcomes.61, 69 Results from the International Tobacco Control Four Country Survey showed that although women were equally as likely as men to want, plan, and try to quit,  among quit attempters, women had 31% lower odds of success.70 Women also tend to relapse faster, and experience more difficulties with maintaining abstinence.60 While bupropion and varenicline appear to be equally effective among men and women,71, 72 results regarding NRT are mixed. A number of studies have suggested that NRT may be less effective in women,73, 74 and that women experience less quitting success when using nicotine patches.75 Others have found no gender differences.76 Another study found that abstinence rates were lower in women who used gum, patches and spray compared with men; however, women experienced greater success than men after using an inhaler.77 Regardless, due to its safety and efficacy, NRT is also recommended for women trying to quit.63 A meta-analysis of sex differences in the comparative efficacy of transdermal nicotine, varenicline, and sustained release bupropion for smoking cessation concluded that the advantage of varenicline over bupropion and nicotine patches is greater for women than men, and the authors suggest that clinicians should strongly consider varenicline as the first-line treatment for women. Among men, the relative advantages were less clear.78

Together, these issues have led to calls for the importance of attending to gender to be recognised in health promotion interventions.62 One of the recommendations of a 2007 policy brief by the WHO was to “Increase availability and access to treatment services for tobacco dependence and train health professionals in these services to take into account sex and gender specificities when treating tobacco dependence.”79 The preamble to the FCTC likewise highlights “the need for gender-specific tobacco control strategies.”80 However, a recent review found that tobacco use interventions designed with an understanding of the effect of gender roles, norms, and behaviours on women’s health are limited, and primarily focused on pregnant and postpartum women. The authors conclude that much work remains to encourage practitioners to use a gender-sensitive approach when designing interventions.62 Others have called for policy and program developers to apply gender theory in designing their initiatives, with the goal of changing negative gender and social norms and improving social, economic, health and social indicators along with tobacco reduction.81 A recent study examining cessation outcomes following an intervention that included gender-tailored components found no short- or long-term gender differences in the effectiveness of the intervention.82 A small qualitative study from Canada suggests that smoking cessation programs for women should ideally include: a women's centred approach with sufficient variety and choice; free pharmacotherapy; non-judgmental support; accessible services; and clear communication of program options and changes.83

Gender-sensitive approaches to medication development for smoking cessation may also be a critical next step for addressing low quit rates and exacerbated health risks among women. Smoking appears to activate different brain systems modulated by noradrenergic activity in women compared with men, and noradrenergic compounds may preferentially target these gender-sensitive systems.84 Researchers have also suggested that investigation of any nicotine addiction protective effect of progesterone in women may be worthwhile.85, 86 A recent cessation medication trial found that increases in progesterone level in women smokers were associated with a 23% increase in the odds for being abstinent within each week of treatment.87

 

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated June 2022)

 

1. US Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/2012/

2. Gurillo P, Jauhar S, Murray RM, and MacCabe JH. Does tobacco use cause psychosis? Systematic review and meta-analysis. The Lancet Psychiatry, 2015; 2(8):718–25. Available from: http://dx.doi.org/10.1016/S2215-0366(15)00152-2

3. Boden JM, Fergusson DM, and Horwood LJ. Cigarette smoking and depression: tests of causal linkages using a longitudinal birth cohort. British Journal of Psychiatry, 2010; 196(6):440–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20513853

4. White V and Williams T, Australian secondary school students’ use of tobacco in 2014. Centre for Behavioural Research in Cancer, Cancer Council Victoria; 2015. Available from: http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/content/school11.

5. Leatherdale S and McDonald P. Youth smokers' beliefs about different cessation approaches: Are we providing cessation interventions they never intend to use? Cancer Causes and Control, 2007; 18(7):783–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17549592

6. Solberg L, Boyle R, McCarty M, Asche S, and Thoele M. Young adult smokers: are they different? The American Journal of Managed Care, 2007; 13(11):626–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17988188

7. Falkin G, Fryer C, and Mahadeo M. Smoking cessation and stress among teenagers. Qualitative Health Research, 2007; 17(6):812–23. Available from: http://qhr.sagepub.com/cgi/reprint/17/6/812

8. McVea K, Miller D, Creswell J, McEntarrfer R, and Coleman M. How adolescents experience smoking cessation. Qualitative Health Research, 2009; 19(5):580–92. Available from: http://qhr.sagepub.com/cgi/reprint/19/5/580

9. Gough B, Fry G, Grogan S, and Conner M. Why do young adult smokers continue to smoke despite the health risks? A focus group study. Psychol Health, 2009; 24(2):203–20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20186652

10. Henningfield J, Michaelides T, and Sussman S. Developing treatment for tobacco addicted youth–Issues and challenges, in Nicotine Addiction among Adolescents.  Wagner E, Editor New York, NY: The Haworth Press; 2000.

11. Zhu SH, Sun J, Billings SC, Choi WS, and Malarcher A. Predictors of smoking cessation in U.S. adolescents. American Journal of Preventive Medicine, 1999; 16(3):202–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10198659

12. Chen PH, White HR, and Pandina RJ. Predictors of smoking cessation from adolescence into young adulthood. Addictive Behaviors, 2001; 26(4):517–29. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11456075

13. Costello D, Dierker L, Jones B, and Rose J. Trajectories of smoking from adolescence to early adulthood and their psychosocial risk factors. Health Psychology, 2008; 27(6):811–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19025277

14. Cengelli S, O'Loughlin J, Lauzon B, and Cornuz J. A systematic review of longitudinal population-based studies on the predictors of smoking cessation in adolescent and young adult smokers. Tobacco Control, 2012; 21(3):355–62. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21846777

15. Loprinzi PD and Walker JF. Association of Longitudinal Changes of Physical Activity on Smoking Cessation Among Young Daily Smokers. Journal of Physical Activity and Health, 2016; 13(1):1–5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25966498

16. Horn K, Dino G, Branstetter SA, Zhang J, Noerachmanto N, et al. Effects of physical activity on teen smoking cessation. Pediatrics, 2011; 128(4):e801–11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21930544

17. Myers MG, Gwaltney CJ, Strong DR, Ramsey SE, Brown RA, et al. Adolescent first lapse following smoking cessation: situation characteristics, precipitants and proximal influences. Addictive Behaviors, 2011; 36(12):1253–60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21903332

18. Smith AE, Cavallo DA, McFetridge A, Liss T, and Krishnan-Sarin S. Preliminary examination of tobacco withdrawal in adolescent smokers during smoking cessation treatment. Nicotine and Tobacco Research, 2008; 10(7):1253–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18629736

19. Towns S, DiFranza JR, Jayasuriya G, Marshall T, and Shah S. Smoking Cessation in Adolescents: targeted approaches that work. Paediatric Respiratory Reviews, 2017; 22:11–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26187717

20. Stanton A and Grimshaw G. Tobacco cessation interventions for young people. Cochrane Database of Systematic Reviews, 2013; 8(8):CD003289. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23975659

21. Karpinski JP, Timpe EM, and Lubsch L. Smoking cessation treatment for adolescents. J Pediatr Pharmacol Ther, 2010; 15(4):249–63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22477813

22. Fiore MC, Jaén M, Carlos Roberto, Baker TB, Bailey WC, Benowitz NL, et al. Treating tobacco use and dependence. Clinical Practice Guidelines. Rockville, MD: US Department of Health and Human Services, 2008. Available from: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/index.html

23. Bowles H, Maher A, and Sage R. Helping teenagers stop smoking: Comparative observations across youth settings in Cardiff. Health Education Journal, 2009; 68(2):111–8. Available from: http://hej.sagepub.com/cgi/reprint/68/2/111

24. Peirson L, Ali MU, Kenny M, Raina P, and Sherifali D. Interventions for prevention and treatment of tobacco smoking in school-aged children and adolescents: A systematic review and meta-analysis. Preventive Medicine, 2016; 85:20–31. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26743631

25. Eureka Strategic Research for the Australian Government Department of Health and Ageing. Youth Tobacco Prevention Literature Review. 2005. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-pub-tobacco-literature-cnt.htm

26. Sussman S and Sun P. Youth tobacco use cessation: 2008 update. Tobacco Induced Diseases 2009; 5:3. Available from: http://www.tobaccoinduceddiseases.com/content/5/1/3

27. Peterson AV, Jr., Marek PM, Kealey KA, Bricker JB, Ludman EJ, et al. Does Effectiveness of Adolescent Smoking-Cessation Intervention Endure Into Young Adulthood? 7-Year Follow-Up Results from a Group-Randomized Trial. PLoS ONE, 2016; 11(2):e0146459. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26829013

28. Bellhouse B, Johnston G, Deed C, and Taylor N, Smoke-free schools: tobacco prevention and management guidelines for Victorian schools. Melbourne, Vic: The State of Victoria, Department of Education & Training, Australian Government, Department of Education, Science and Training; 2003. Available from: http://www.sofweb.vic.edu.au/edulibrary/public/stratman/Policy/schoolgov/druged/SmokeFreeSchools.pdf.

29. Barylak M, Smith B, Oliver L, Davis B, Duigan P, et al., Intervention matters: a policy statement and procedural framework for the management of suspected drug-related incidents in schools. Adelaide, SA: Australian Government, Department of Education, Science and Training, Government of South Australia, Department of Education and Children's Services, Drug Strategy with our eyes open; 2005.

30. Curry SJ, Mermelstein RJ, Emery SL, Sporer AK, Berbaum ML, et al. A national evaluation of community-based youth cessation programs: end of program and twelve-month outcomes. American Journal of Community Psychology, 2013; 51(1-2):15–29. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22395364

31. Peterson AV, Jr., Kealey KA, Mann SL, Marek PM, Ludman EJ, et al. Group-randomized trial of a proactive, personalized telephone counseling intervention for adolescent smoking cessation. Journal of the National Cancer Institute, 2009; 101(20):1378–92. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19822836

32. Ferretter I. Victorian Quitline data 2003–2007, 2008, The Cancer Council Victoria: Melbourne, Vic.

33. Quit Victoria. Youth Protocol, Minimum Standards for Australian Quitlines 2007, 2007, The Cancer Council Victoria: Melbourne, Vic.

34. Tan N, Montague M, and Freeman J. Impact of the National Tobacco Campaign: comparison between teenage and adult surveys, in Australia's National Tobacco Campaign. Evaluation Report  Volume Two. Canberra: Commonwealth Department of Health and Aged care; 2000. p 78–103 Available from: http://catalogue.nla.gov.au/Record/1402074.

35. White V, Tan N, Wakefield M, and Hill D. Do adult focused anti-smoking campaigns have an impact on adolescents? The case of the Australian National Tobacco Campaign. Tobacco Control, 2003; 12(Suppl 2):ii23–ii9. Available from: http://tobaccocontrol.bmj.com/content/12/suppl_2/ii23.short

36. Brown T, Platt S, and Amos A. Equity impact of interventions and policies to reduce smoking in youth: systematic review. Tobacco Control, 2014; 23(e2):e98–105. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24842855

37. Pbert L, Flint AJ, Fletcher KE, Young MH, Druker S, et al. Effect of a pediatric practice-based smoking prevention and cessation intervention for adolescents: a randomized, controlled trial Pediatrics, 2008; 121(4):738–47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18381502

38. Price J, Jordan T, and Dake J. Pediatricians' use of the 5A's and nicotine replacement therapy with adolescent smokers. Journal of Community Health, 2007; 32(2):85–101. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17571523

39. Stevens SL, Pailler ME, Diamond GS, Levy SA, Latif S, et al. Providers' experiences caring for adolescents who smoke cigarettes. Health Psychology, 2009; 28(1):66–72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19210019

40. Mons U, Muezzinler A, Gellert C, Schottker B, Abnet CC, et al. Impact of smoking and smoking cessation on cardiovascular events and mortality among older adults: meta-analysis of individual participant data from prospective cohort studies of the CHANCES consortium. BMJ, 2015; 350:h1551. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25896935

41. Tran B, Falster MO, Douglas K, Blyth F, and Jorm LR. Smoking and potentially preventable hospitalisation: the benefit of smoking cessation in older ages. Drug and Alcohol Dependence, 2015; 150:85–91. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25769393

42. Yong HH, Borland R, and Siahpush M. Quitting-related beliefs, intentions, and motivations of older smokers in four countries: findings from the International Tobacco Control Policy Evaluation Survey. Addictive Behaviors, 2005; 30(4):777–88. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15833581

43. Shahab L, Gilchrist G, Hagger-Johnson G, Shankar A, West E, et al. Reciprocal associations between smoking cessation and depression in older smokers: findings from the English Longitudinal Study of Ageing. British Journal of Psychiatry, 2015; 207(3):243–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25999339

44. Cohen-Mansfield J. Predictors of Smoking Cessation in Old-Old Age. Nicotine and Tobacco Research, 2016; 18(7):1675–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26783294

45. Choi NG and DiNitto DM. Role of New Diagnosis, Social Isolation, and Depression in Older Adults' Smoking Cessation. Gerontologist, 2015; 55(5):793–801. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24904055

46. Breitling L, Rothenbacher D, Stegmaier C, Raum E, and Brenner H. Older smokers' motivation and attempts to quit smoking: Epidemiological insight into the question of lifestyle versus addiction. Deutsches Ärzteblatt International, 2009; 106(27):451–5. Available from: http://www.aerzteblatt.de/int/article.asp?id=65282

47. Lang I, Rice N, Wallace R, Guralnik J, and Melzer D. Smoking cessation and transition into retirement: analyses from the English Longitudinal Study of Ageing. Age and Ageing, 2007; 36(6):638-43(6):638–43. Available from: http://ageing.oxfordjournals.org/cgi/content/full/36/6/638

48. Medbo A, Melbye H, and Rudebeck CE. "I did not intend to stop. I just could not stand cigarettes any more." A qualitative interview study of smoking cessation among the elderly. BMC Fam Pract, 2011; 12(1):42. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21627833

49. Doolan DM and Froelicher ES. Smoking cessation interventions and older adults. Progress in Cardiovascular Nursing, 2008; 23(3):119–27. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19039892

50. Kehlet M, Schroeder TV, and Tonnesen H. The Gold Standard Program for smoking cessation is effective for participants over 60 years of age. International Journal of Environmental Research and Public Health, 2015; 12(3):2574–87. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25734789

51. Chen D and Wu LT. Smoking cessation interventions for adults aged 50 or older: A systematic review and meta-analysis. Drug and Alcohol Dependence, 2015; 154:14–24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26094185

52. Cawkwell PB, Blaum C, and Sherman SE. Pharmacological Smoking Cessation Therapies in Older Adults: A Review of the Evidence. Drugs and Aging, 2015; 32(6):443–51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26025119

53. Barnett PG, Wong W, Jeffers A, Munoz R, Humfleet G, et al. Cost-effectiveness of extended cessation treatment for older smokers. Addiction, 2014; 109(2):314–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24329972

54. Pothirat C, Phetsuk N, Liwsrisakun C, and Deesomchok A. Real-world comparative study of behavioral group therapy program vs education program implemented for smoking cessation in community-dwelling elderly smokers. Clinical Interventions in Aging, 2015; 10:725–30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25926726

55. Cataldo JK, Hunter M, Petersen AB, and Sheon N. Positive and instructive anti-smoking messages speak to older smokers: a focus group study. Tob Induc Dis, 2015; 13(1):2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25653578

56. Eisenberg MJ, Blum LM, Filion KB, Rinfret S, Pilote L, et al. The efficacy of smoking cessation therapies in cardiac patients: a meta-analysis of randomized controlled trials. Canadian Journal of Cardiology, 2010; 26(2):73–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20151052

57. Brown LM. Tobacco myths: the older adult perspective. Journal of Gerontological Nursing, 2015; 41(5):9–13. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25642695

58. Rowa-Dewar N and Ritchie D. Smoking cessation for older people: neither too little nor too late. British Journal of Community Nursing, 2010; 15(12):578–82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21240081

59. McVay MA and Copeland AL. Smoking cessation in peri- and postmenopausal women: a review. Experimental and Clinical Psychopharmacology, 2011; 19(3):192–202. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21480728

60. Sieminska A and Jassem E. The many faces of tobacco use among women. Med Sci Monit, 2014; 20:153–62. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24487778

61. US Department of Health and Human Services. Women and smoking. A report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2001. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/index.htm

62. Fang ML, Gerbrandt J, Liwander A, and Pederson A. Exploring promising gender-sensitive tobacco and alcohol use interventions: results of a scoping review. Substance Use and Misuse, 2014; 49(11):1400–16. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24827863

63. Allen SS. Cigarette smoking among women: how can we help? Minnesota Medicine, 2014; 97(3):41–3. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24720068

64. Cooper J, Borland R, McKee SA, Yong HH, and Dugue PA. Depression motivates quit attempts but predicts relapse: differential findings for gender from the International Tobacco Control Study. Addiction, 2016; 111(8):1438–47. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26888199

65. Hinderaker K, Allen AM, Tosun N, al'Absi M, Hatsukami D, et al. The effect of combination oral contraceptives on smoking-related symptomatology during short-term smoking abstinence. Addictive Behaviors, 2015; 41:148–51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25452059

66. Wetherill RR, Jagannathan K, Hager N, Maron M, and Franklin TR. Influence of menstrual cycle phase on resting-state functional connectivity in naturally cycling, cigarette-dependent women. Biol Sex Differ, 2016; 7:24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27168932

67. Greaves L, Johnson J, Bottorff J, Kirkland S, Jategaonkar N, et al. What are the effects of tobacco policies on vulnerable populations? A better practices review. Canadian Journal of Public Health, 2006; 97(4):310–5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16967752

68. Scharf D and Shiffman S. Are there gender differences in smoking cessation, with and without bupropion? Pooled- and meta-analyses of clinical trials of Bupropion SR. Addiction, 2004; 99(11):1462–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15500599

69. Perkins KA. Smoking cessation in women. Special considerations. CNS Drugs, 2001; 15(5):391–411. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11475944

70. Smith PH, Kasza KA, Hyland A, Fong GT, Borland R, et al. Gender differences in medication use and cigarette smoking cessation: results from the International Tobacco Control Four Country Survey. Nicotine and Tobacco Research, 2015; 17(4):463–72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25762757

71. Jorenby DE, Hays JT, Rigotti NA, Azoulay S, Watsky EJ, et al. Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. JAMA, 2006; 296(1):56–63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16820547

72. Hurt R, Sachs E, Glover K, Offord K, Johnston J, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. New England Journal of Medicine, 1997; 337(17):1195–202. Available from: http://content.nejm.org/cgi/content/abstract/337/17/1195

73. Hatsukami D, Skoog K, Allen S, and Bliss R. Gender and the effects of different doses of nicotine gum on tobacco withdrawal symptoms. Experimental and Clinical Psychopharmacology, 1995; 3(2):163. Available from: http://psycnet.apa.org/journals/pha/3/2/163/

74. Wetter DW, Fiore MC, Young TB, McClure JB, de Moor CA, et al. Gender differences in response to nicotine replacement therapy: objective and subjective indexes of tobacco withdrawal. Experimental and Clinical Psychopharmacology, 1999; 7(2):135–44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10340153

75. Swan GE, Jack LM, and Ward MM. Subgroups of smokers with different success rates after use of transdermal nicotine. Addiction, 1997; 92(2):207–17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/9158232

76. Shiffman S, Sweeney CT, and Dresler CM. Nicotine patch and lozenge are effective for women. Nicotine and Tobacco Research, 2005; 7(1):119–27. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15804684

77. West R, Hajek P, Nilsson F, Foulds J, May S, et al. Individual differences in preferences for and responses to four nicotine replacement products. Psychopharmacology, 2001; 153(2):225–30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11205423

78. Smith PH, Weinberger AH, Zhang J, Emme E, Mazure CM, et al. Sex Differences in Smoking Cessation Pharmacotherapy Comparative Efficacy: A Network Meta-analysis. Nicotine and Tobacco Research, 2017; 19(3):273–81. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27613893

79. World Health Organization, Gender and tobacco control: a policy brief. Geneva 2007. Available from: http://www.who.int/tobacco/resources/publications/general/policy_brief.pdf.

80. World Health Organization. Framework Convention on Tobacco Control. New York: United Nations, 2003. Available from: http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf.

81. Greaves L. Can tobacco control be transformative? Reducing gender inequity and tobacco use among vulnerable populations. International Journal of Environmental Research and Public Health, 2014; 11(1):792–803. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24402065

82. Marqueta A, Nerin I, Gargallo P, and Beamonte A. Gender differences in success at quitting smoking: Short- and long-term outcomes. Adicciones, 2016; 29(1):13–21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27391847

83. Minian N, Penner J, Voci S, and Selby P. Woman focused smoking cessation programming: a qualitative study. BMC Womens Health, 2016; 16(1):17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26971306

84. Verplaetse TL, Weinberger AH, Smith PH, Cosgrove KP, Mineur YS, et al. Targeting the noradrenergic system for gender-sensitive medication development for tobacco dependence. Nicotine and Tobacco Research, 2015; 17(4):486–95. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25762760

85. Lynch WJ and Sofuoglu M. Role of progesterone in nicotine addiction: evidence from initiation to relapse. Experimental and Clinical Psychopharmacology, 2010; 18(6):451–61. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21186920

86. Wetherill RR, Franklin TR, and Allen SS. Ovarian hormones, menstrual cycle phase, and smoking: a review with recommendations for future studies. Curr Addict Rep, 2016; 3(1):1–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27134810

87. Saladin ME, McClure EA, Baker NL, Carpenter MJ, Ramakrishnan V, et al. Increasing progesterone levels are associated with smoking abstinence among free-cycling women smokers who receive brief pharmacotherapy. Nicotine and Tobacco Research, 2015; 17(4):398–406. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25762749