Abstracts

INTRODUCTION

In the early 20^th century, cigarette use was a habit restricted to the male urban elite, in a small number of countries at the beginning of industrialization. Currently, cigarettes are consumed on a global scale and are considered the most utilized and disseminated drug in the contemporary society. Its use is the main cause of preventable death among men and women, totalizing approximately six million deaths in the world.^aa World Health Organization. WHO report on the global tobacco epidemic - warning about the dangers of tobacco 2011. Geneva; 2011. Although tobacco use among men is higher, it is declining among this group in several countries, while the rate of female smokers is in constant growth.^bb World Health Organization. 10 facts on gender and tobacco 2011. Geneva; 2011. From 1950 to 2000, about 10 million women died due to tobacco use,²⁰20 Mackay J, Amos A. Invited review series: Tobacco and lung health - Women and tobacco. Respirology. 2003;8(2):123-30. DOI:10.1046/j.1440-1843.2003.00464.x and it is estimated that from 2002 to 2030 this number will exceed 40 million.²²22 Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442. DOI:10.1371/journal.pmed.0030442

Smoking-related diseases in men and women should be interpreted as a multifaceted phenomenon, considering the complexity of the influences of gender related to tobacco, and the changing social norms that shaped the diversity and the pattern of use.¹²12 Curry LE, Vallone DM, Cartwright J, Healton CG. Tobacco: an equal-opportunity killer? Tobacco Control. 2011;20(4):251-2. DOI:10.1136/tc.2011.044479 Evidences indicate specific factors related to gender. For example, studies²⁷27 Najman JM, Toloo G, Siskind V. Socioeconomic disadvantage and changes in health risk behaviours in Australia: 1989-90 to 2001. Bull World Health Organ. 2006;84(12):976-83. DOI:10.2471/BLT.05.028928^,3434 Teles CCGD, Costa Viegas Muniz M, Ferrari R. Tabagismo associado às lesões precursoras para o câncer de colo uterino. Rev Enferm UFPE.2013;7(9):5427-34.^,3535 Turner LR, Morera OF, Johnson TP, Crittenden KS, Freels S, Parsons J, et al. Examining the effectiveness of a community-based self-help program to increase women’s readiness for smoking cessation. Am J Community Psychol. 2001;29(3):465-91. DOI:10.1023/A:1010375931040 point the high risk of several types of cancers in female smokers, particularly bladder and uterus cancer, in addition to increasing the risk of infertility in women.

Concerning smoking habit cessation, men and women present slight differences, however significant, in relation to the characteristics of nicotine dependence. Although controversial, studies⁵5 Bohadana A, Nilsson F, Rasmussen T, Martinet Y. Gender differences in quit rates following smoking cessation with combination nicotine therapy: influence of baseline smoking behavior. Nicotine Tob Res.2003;5(1):111-6. DOI:10.1080/1462220021000060482^,1515 Ferguson JA, Patten CA, Schroeder DR, Offord KP, Eberman KM, Hurt RD. Predictors of 6-month tobacco abstinence among 1224 cigarette smokers treated for nicotine dependence. Addict Behav. 2003;28(7):1203-18. DOI:10.1016/S0306-4603(02)00260-5^,2424 McKee SA, Maciejewski PK, Falba T, Mazure CM. Sex differences in the effects of stressful life events on changes in smoking status.Addiction. 2003;98(6):847-55. DOI:10.1046/j.1360-0443.2003.00408.x^,2626 Monso E, Campbell J, Tonnesen P, Gustavsson G, Morera J. Sociodemographic predictors of success in smoking intervention. Tob Control. 2001;10(2):165-9. DOI:10.1136/tc.10.2.165^,2929 Osler M, Prescott E, Godtfredsen N, Hein HO, Schnohr P. Gender and determinants of smoking cessation: a longitudinal study. Prev Med.1999;29(1):57-62. DOI:10.1006/pmed.1999.0510 suggest that women have greater difficulty in quitting smoking than men because smoking women’s behavior is more influenced by mood and negative affection, while men are more conditioned by pharmacological response regulated by nicotine intake.³3 Benowitz NL. Clinical pharmacology of nicotine: implications for understanding, preventing, and treating tobacco addiction. Clin Pharmacol Ther. 2008;83(4):531-41. DOI:10.1038/clpt.2008.3Women also have faster nicotine metabolism²2 Benowitz NL, Lessov-Schlaggar CN, Swan GE, Jacob P 3rd. Female sex and oral contraceptive use accelerate nicotine metabolism. Clin Pharmacol Ther. 2006;79(5):480-8. DOI:10.1016/j.clpt.2006.01.008 and higher prevalence of depression than men. Additionally, there is evidences that nicotine may interact differently in the body during menstrual cycle, causing reactions during the abstinence period.²2 Benowitz NL, Lessov-Schlaggar CN, Swan GE, Jacob P 3rd. Female sex and oral contraceptive use accelerate nicotine metabolism. Clin Pharmacol Ther. 2006;79(5):480-8. DOI:10.1016/j.clpt.2006.01.008

3 Benowitz NL. Clinical pharmacology of nicotine: implications for understanding, preventing, and treating tobacco addiction. Clin Pharmacol Ther. 2008;83(4):531-41. DOI:10.1038/clpt.2008.3^-44 Benowitz NL. Nicotine addiction. N Engl J Med. 2010;362(24):2295-303. DOI:10.1056/NEJMra0809890^,1010 Chellini E, Gorini G, Carreras G, Giordano L, Anghinoni E, Iossa A, et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health. 2011;11:906. DOI:10.1186/1471-2458-11-906 On the other hand, the higher demand for health services by women, compared to men,¹1 Araújo AJ, Menezes AMB, Dórea AJPS, Torres BS, Viegas CAA, Silva CARd, et al. Diretrizes para Cessação do Tabagismo. J B Pneumol.2004;30 Suppl 2:1-76. DOI:10.1590/S1806-37132004000800002 suggests more easiness to recognize problems related to health and to seek assistance.

Due to social, economic and cultural changes that affected women – as the massive insertion in the job market and, consequently, more purchasing and decision power within the society –, smoking industry started considering women customers as a promising market. By millionaire advertisement campaigns, it heavily invested in satisfying women’s desires, as well as their social demands.³⁰30 Otero M. Tabaquismo en la mujer: consideraciones especiales.Trast Adict. 2004;6(2):113-24. DOI:10.1016/S1575-0973(04)70152-X Advertisements are used to explore concepts such as freedom, independence, self-assertion, social ascension and beauty. This last concept is responsible for imposing and reinforcing body aesthetic standards that influence the initiation and permanence in tobacco consumption among women.⁶6 Borges MTT, Barbosa RHS. As marcas de gênero no fumar feminino: uma aproximação sociológica do tabagismo em mulheres. Cienc Saude Coletiva.2009;14(4):1129-39. DOI:10.1590/S1413-81232009000400019 Currently, smoking is understood as a complex and multicausal health problem involving biological, psychological and social factors.⁶6 Borges MTT, Barbosa RHS. As marcas de gênero no fumar feminino: uma aproximação sociológica do tabagismo em mulheres. Cienc Saude Coletiva.2009;14(4):1129-39. DOI:10.1590/S1413-81232009000400019

In Brazil, most of the population seeking treatment in health services to cease smoking is female;¹1 Araújo AJ, Menezes AMB, Dórea AJPS, Torres BS, Viegas CAA, Silva CARd, et al. Diretrizes para Cessação do Tabagismo. J B Pneumol.2004;30 Suppl 2:1-76. DOI:10.1590/S1806-37132004000800002^,aa World Health Organization. WHO report on the global tobacco epidemic - warning about the dangers of tobacco 2011. Geneva; 2011. however, published studies about this subject are scarce. Because of these facts, the aim of this study was to analyze the profile of women, in health services, who carry out treatment for smoking cessation.

METHODS

We performed a systematic review according to the Joanna Briggs Institute (JBI) review manual.^cc Joanna Briggs Institute. Reviewers’ Manual: 2014 edition. South Australia; 2014 [cited 2014 Jun 25]. Available from: http://joannabriggs.org/assets/docs/sumari/ReviewersManual-2014.pdf

We consulted the following sources for information during the period from April 7, 2014 to April 22, 2014: Biblioteca Virtual em Saúde (BVS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline (via PubMed), Scopus and Web of Science. Keywords were grouped as follows: “smoking cessation” and “women’s health” and “health services”, in the BVS; “women’s health” and “health services” and “smoking cessation” in PubMed; “women’s health” and “health services” and “smoking cessation”, in CINAHL; “smoking cessation” and “health services” and “women’s health”, in Scopus; and TS = (“smoking cessation” and “women’s health” and “health services”), in the Web of Science.

We used the following eligibility criteria: (1) articles about smoking women who sought care in general health services and who participated in smoking cessation programs offered at these places; (2) articles in English, Spanish or Portuguese that addressed the profile of smoking women who sought specialized health services for smoking cessation; (3) articles that reported quantitative surveys and that were available in full on the sources of information researched.

For the selection of the articles, the first author of this study (Pereira CF) made an initial tracking by reading the summaries of the works and identifying those that met the inclusion criteria. In case of doubt about the relevance of the article for inclusion in the analysis, both authors (Pereira CF, Vargas D) examined it independently. Uncertainties regarding the quality of the studies were resolved by discussion among them. Periodicals in which each article was published were considered relevant if their impact factor were higher than or equal to 1.0.

In the five sources of information researched, we found 156 studies; 15 were duplicate, remaining 141 studies for selection; out of these, 129 were excluded because they were out of the eligibility criteria. The final sample of the review was composed of 12 studies. A summary of the literature identified in each stage of the research process can be found in the Figure, PRISMA flow diagram.²⁵25 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.Ann Int Med. 2009;151(4):264-9. DOI:10.7326/0003-4819-151-4-200908180-00135

The first author extracted the following information from each article included in the analysis: location (country) and study outline, year of publication, population/sample, interventions (type of treatment), outcomes and main results. Independently, the second author checked the extracted data and made changes as needed. Both authors led the quality assessment of the studies and reached an agreement using the MAStARI, a statistical evaluation instrument of meta-analysis and review from Joanna Briggs Institute.^cc Joanna Briggs Institute. Reviewers’ Manual: 2014 edition. South Australia; 2014 [cited 2014 Jun 25]. Available from: http://joannabriggs.org/assets/docs/sumari/ReviewersManual-2014.pdf According to the studies found, all of the three assessment tools that comprise the MAStARI were used: 1) critical evaluation of comparable cohort/case-control, 2) critical evaluation of randomized control/pseudo-randomization and 3) critical evaluation of descriptive/case-series. To evaluate the methodological quality of the articles, cut-off scores between one and 10 were established. Articles that scored between one and four were classified as low methodological quality; articles with scores between five and seven, as moderate quality; and those with scores > 7, as high quality.

RESULTS

Out of the 12 studies found, six evaluated smoking women who were at general health services and have accepted to participate in the smoking cessation program offered by the services. The other six studies evaluated smoking women who were at specialized services for smoking cessation. The Table indicates, respectively, the studies described above.

The studies that formed the final sample were performed in the United States (10) and in Italy (two). The interview was made in person or by telephone using a questionnaire. It was the main data collection strategy and was used in 12 studies.

Smoking women who were at general health services

Out of the total studies conducted in general health services, three were developed in cervical cancer prevention services,¹⁰10 Chellini E, Gorini G, Carreras G, Giordano L, Anghinoni E, Iossa A, et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health. 2011;11:906. DOI:10.1186/1471-2458-11-906^,1111 Chellini E, Gorini G, Gasparrini A, Grazzini G, lossa A, Martellucci PM, et al. Cervical cancer screening visit as an occasion for counseling female smokers to quit. Tumori. 2012;98(1):27-32. DOI:10.1700/1053.11496^,2323 McClure JB, Westbrook E, Curry SJ, Wetter DW. Proactive, motivationally enhanced smoking cessation counseling among women with elevated cervical cancer risk. Nicotine Tob Res. 2005;7(6):881-9. DOI:10.1080/14622200500266080 two in specialized health services in women’s health,¹⁸18 Glasgow RE, Whitlock EP, Eakin EG, Lichtenstein E. A brief smoking cessation intervention for women in low-income planned parenthood clinics.Am J Public Health. 2000;90(5):786-9.^,2121 Manfredi C, Crittenden KS, Warnecke R, Engler J, Cho YI, Shaligram C. Evaluation of a motivational smoking cessation intervention for women in public health clinics. Prev Med. 1999;28(1):51-60. and one in services that aim to decrease the risk of cardiovascular diseases.⁸8 Buchanan L, Likness S. Evidence-based practice to assist women in hospital settings to quit smoking and reduce cardiovascular disease risk.J Cardiovasc Nurs. 2008;23(5):397-406. DOI:10.1097/01.JCN.0000317449.87649.8e In cervical cancer prevention services, most women were young average-aged, were highly level educated, were married, and were employed; two of the three studies were performed in Italy.¹⁰10 Chellini E, Gorini G, Carreras G, Giordano L, Anghinoni E, Iossa A, et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health. 2011;11:906. DOI:10.1186/1471-2458-11-906^,1111 Chellini E, Gorini G, Gasparrini A, Grazzini G, lossa A, Martellucci PM, et al. Cervical cancer screening visit as an occasion for counseling female smokers to quit. Tumori. 2012;98(1):27-32. DOI:10.1700/1053.11496 In the specialized health services in women’s health, women were young-aged and highly level educated; however, in the services aimed at decreasing the risk of cardiovascular diseases, most women were middle-aged, were highly level educated and were employed.

Smoking women who were in specialized services for smoking cessation

Out of the six studies carried out in specialized services for smoking cessation, four occurred in research centers⁹9 Carpenter MJ, Saladin ME, Leinbach AS, Larowe SD, Upadhyaya HP. Menstrual phase effects on smoking cessation: a pilot feasibility study.J Womens Health (Larchmt). 2008;17(2):293-301. DOI:10.1089/jwh.2007.0415^,1616 Franklin TR, Ehrman R, Lynch KG, Harper D, Sciortino N, O’Brien CP, et al. Menstrual cycle phase at quit date predicts smoking status in an NRT treatment trial: a retrospective analysis. J Womens Health(Larchmt). 2008;17(2):287-92. DOI:10.1089/jwh.2007.0423^,2828 O’Hara P, Portser SA. A comparison of younger-aged and older-aged women in a behavioral self-control smoking program. Patient Educ Couns.1994;23(2):91-6. DOI:10.1016/0738-3991(94)90046-9^,3535 Turner LR, Morera OF, Johnson TP, Crittenden KS, Freels S, Parsons J, et al. Examining the effectiveness of a community-based self-help program to increase women’s readiness for smoking cessation. Am J Community Psychol. 2001;29(3):465-91. DOI:10.1023/A:1010375931040 and two in health care centers (one at the Veterans Health Administration,³³33 Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Womens Health Issues. 2005;15(3):126-33. DOI:10.1016/j.whi.2005.01.001 a wide system of health care in the world in which most of the units have a smoking cessation program, and the other in a health care program of Minnesota administered by the Minnesota Department of Human Services).⁷7 Burgess DJ, Fu SS, Noorbaloochi S, Clothier BA, Ricards J, Widome R, et al. Employment, gender, and smoking cessation outcomes in low-income smokers using nicotine replacement therapy. Nicotine Tob Res.2009;11(12):1439-47. DOI:10.1093/ntr/ntp158 The population of the studies carried out in health services were females. They were white, were married, had a higher average age ranging from 50 to 60 years old, and had already tried to quit smoking more than once. A study³³33 Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Womens Health Issues. 2005;15(3):126-33. DOI:10.1016/j.whi.2005.01.001 also reported depression in those women. The studies conducted in research centers were composed mostly of young and white women;⁹9 Carpenter MJ, Saladin ME, Leinbach AS, Larowe SD, Upadhyaya HP. Menstrual phase effects on smoking cessation: a pilot feasibility study.J Womens Health (Larchmt). 2008;17(2):293-301. DOI:10.1089/jwh.2007.0415^,1616 Franklin TR, Ehrman R, Lynch KG, Harper D, Sciortino N, O’Brien CP, et al. Menstrual cycle phase at quit date predicts smoking status in an NRT treatment trial: a retrospective analysis. J Womens Health(Larchmt). 2008;17(2):287-92. DOI:10.1089/jwh.2007.0423^,2828 O’Hara P, Portser SA. A comparison of younger-aged and older-aged women in a behavioral self-control smoking program. Patient Educ Couns.1994;23(2):91-6. DOI:10.1016/0738-3991(94)90046-9^,3535 Turner LR, Morera OF, Johnson TP, Crittenden KS, Freels S, Parsons J, et al. Examining the effectiveness of a community-based self-help program to increase women’s readiness for smoking cessation. Am J Community Psychol. 2001;29(3):465-91. DOI:10.1023/A:1010375931040 out of these studies, one⁹9 Carpenter MJ, Saladin ME, Leinbach AS, Larowe SD, Upadhyaya HP. Menstrual phase effects on smoking cessation: a pilot feasibility study.J Womens Health (Larchmt). 2008;17(2):293-301. DOI:10.1089/jwh.2007.0415 showed a significant percentage of highly level educated and depressed women.

In general, we observed that the predominant profile of women who carried out treatment for smoking cessation in health services was composed of white, married, employed, and highly level educated women.

Regarding the methodological quality, in most studies we identified randomized clinical trials (six),⁹9 Carpenter MJ, Saladin ME, Leinbach AS, Larowe SD, Upadhyaya HP. Menstrual phase effects on smoking cessation: a pilot feasibility study.J Womens Health (Larchmt). 2008;17(2):293-301. DOI:10.1089/jwh.2007.0415^,1010 Chellini E, Gorini G, Carreras G, Giordano L, Anghinoni E, Iossa A, et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health. 2011;11:906. DOI:10.1186/1471-2458-11-906^,1616 Franklin TR, Ehrman R, Lynch KG, Harper D, Sciortino N, O’Brien CP, et al. Menstrual cycle phase at quit date predicts smoking status in an NRT treatment trial: a retrospective analysis. J Womens Health(Larchmt). 2008;17(2):287-92. DOI:10.1089/jwh.2007.0423^,2121 Manfredi C, Crittenden KS, Warnecke R, Engler J, Cho YI, Shaligram C. Evaluation of a motivational smoking cessation intervention for women in public health clinics. Prev Med. 1999;28(1):51-60.^,2323 McClure JB, Westbrook E, Curry SJ, Wetter DW. Proactive, motivationally enhanced smoking cessation counseling among women with elevated cervical cancer risk. Nicotine Tob Res. 2005;7(6):881-9. DOI:10.1080/14622200500266080^,2828 O’Hara P, Portser SA. A comparison of younger-aged and older-aged women in a behavioral self-control smoking program. Patient Educ Couns.1994;23(2):91-6. DOI:10.1016/0738-3991(94)90046-9 cohort studies (five)⁷7 Burgess DJ, Fu SS, Noorbaloochi S, Clothier BA, Ricards J, Widome R, et al. Employment, gender, and smoking cessation outcomes in low-income smokers using nicotine replacement therapy. Nicotine Tob Res.2009;11(12):1439-47. DOI:10.1093/ntr/ntp158^,1111 Chellini E, Gorini G, Gasparrini A, Grazzini G, lossa A, Martellucci PM, et al. Cervical cancer screening visit as an occasion for counseling female smokers to quit. Tumori. 2012;98(1):27-32. DOI:10.1700/1053.11496^,1818 Glasgow RE, Whitlock EP, Eakin EG, Lichtenstein E. A brief smoking cessation intervention for women in low-income planned parenthood clinics.Am J Public Health. 2000;90(5):786-9.^,3333 Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Womens Health Issues. 2005;15(3):126-33. DOI:10.1016/j.whi.2005.01.001^,3535 Turner LR, Morera OF, Johnson TP, Crittenden KS, Freels S, Parsons J, et al. Examining the effectiveness of a community-based self-help program to increase women’s readiness for smoking cessation. Am J Community Psychol. 2001;29(3):465-91. DOI:10.1023/A:1010375931040 and a descriptive exploratory study⁸8 Buchanan L, Likness S. Evidence-based practice to assist women in hospital settings to quit smoking and reduce cardiovascular disease risk.J Cardiovasc Nurs. 2008;23(5):397-406. DOI:10.1097/01.JCN.0000317449.87649.8e (one). In some studies,⁷7 Burgess DJ, Fu SS, Noorbaloochi S, Clothier BA, Ricards J, Widome R, et al. Employment, gender, and smoking cessation outcomes in low-income smokers using nicotine replacement therapy. Nicotine Tob Res.2009;11(12):1439-47. DOI:10.1093/ntr/ntp158^,1818 Glasgow RE, Whitlock EP, Eakin EG, Lichtenstein E. A brief smoking cessation intervention for women in low-income planned parenthood clinics.Am J Public Health. 2000;90(5):786-9.^,3333 Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Womens Health Issues. 2005;15(3):126-33. DOI:10.1016/j.whi.2005.01.001 the method was unclear and resulted in some difficulty in comprehending the inclusion criteria of the survey final sample. Most randomized clinical trials⁹9 Carpenter MJ, Saladin ME, Leinbach AS, Larowe SD, Upadhyaya HP. Menstrual phase effects on smoking cessation: a pilot feasibility study.J Womens Health (Larchmt). 2008;17(2):293-301. DOI:10.1089/jwh.2007.0415^,1010 Chellini E, Gorini G, Carreras G, Giordano L, Anghinoni E, Iossa A, et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health. 2011;11:906. DOI:10.1186/1471-2458-11-906^,1616 Franklin TR, Ehrman R, Lynch KG, Harper D, Sciortino N, O’Brien CP, et al. Menstrual cycle phase at quit date predicts smoking status in an NRT treatment trial: a retrospective analysis. J Womens Health(Larchmt). 2008;17(2):287-92. DOI:10.1089/jwh.2007.0423^,2121 Manfredi C, Crittenden KS, Warnecke R, Engler J, Cho YI, Shaligram C. Evaluation of a motivational smoking cessation intervention for women in public health clinics. Prev Med. 1999;28(1):51-60.^,2323 McClure JB, Westbrook E, Curry SJ, Wetter DW. Proactive, motivationally enhanced smoking cessation counseling among women with elevated cervical cancer risk. Nicotine Tob Res. 2005;7(6):881-9. DOI:10.1080/14622200500266080^,2828 O’Hara P, Portser SA. A comparison of younger-aged and older-aged women in a behavioral self-control smoking program. Patient Educ Couns.1994;23(2):91-6. DOI:10.1016/0738-3991(94)90046-9 lacked the description of the randomization process¹⁶16 Franklin TR, Ehrman R, Lynch KG, Harper D, Sciortino N, O’Brien CP, et al. Menstrual cycle phase at quit date predicts smoking status in an NRT treatment trial: a retrospective analysis. J Womens Health(Larchmt). 2008;17(2):287-92. DOI:10.1089/jwh.2007.0423^,2121 Manfredi C, Crittenden KS, Warnecke R, Engler J, Cho YI, Shaligram C. Evaluation of a motivational smoking cessation intervention for women in public health clinics. Prev Med. 1999;28(1):51-60.^,2828 O’Hara P, Portser SA. A comparison of younger-aged and older-aged women in a behavioral self-control smoking program. Patient Educ Couns.1994;23(2):91-6. DOI:10.1016/0738-3991(94)90046-9 and the individuals who were removed from the studied group.⁹9 Carpenter MJ, Saladin ME, Leinbach AS, Larowe SD, Upadhyaya HP. Menstrual phase effects on smoking cessation: a pilot feasibility study.J Womens Health (Larchmt). 2008;17(2):293-301. DOI:10.1089/jwh.2007.0415^,1010 Chellini E, Gorini G, Carreras G, Giordano L, Anghinoni E, Iossa A, et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health. 2011;11:906. DOI:10.1186/1471-2458-11-906^,1616 Franklin TR, Ehrman R, Lynch KG, Harper D, Sciortino N, O’Brien CP, et al. Menstrual cycle phase at quit date predicts smoking status in an NRT treatment trial: a retrospective analysis. J Womens Health(Larchmt). 2008;17(2):287-92. DOI:10.1089/jwh.2007.0423^,2121 Manfredi C, Crittenden KS, Warnecke R, Engler J, Cho YI, Shaligram C. Evaluation of a motivational smoking cessation intervention for women in public health clinics. Prev Med. 1999;28(1):51-60.^,2828 O’Hara P, Portser SA. A comparison of younger-aged and older-aged women in a behavioral self-control smoking program. Patient Educ Couns.1994;23(2):91-6. DOI:10.1016/0738-3991(94)90046-9 Most cohort studies⁷7 Burgess DJ, Fu SS, Noorbaloochi S, Clothier BA, Ricards J, Widome R, et al. Employment, gender, and smoking cessation outcomes in low-income smokers using nicotine replacement therapy. Nicotine Tob Res.2009;11(12):1439-47. DOI:10.1093/ntr/ntp158^,1111 Chellini E, Gorini G, Gasparrini A, Grazzini G, lossa A, Martellucci PM, et al. Cervical cancer screening visit as an occasion for counseling female smokers to quit. Tumori. 2012;98(1):27-32. DOI:10.1700/1053.11496^,1818 Glasgow RE, Whitlock EP, Eakin EG, Lichtenstein E. A brief smoking cessation intervention for women in low-income planned parenthood clinics.Am J Public Health. 2000;90(5):786-9.^,3333 Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Womens Health Issues. 2005;15(3):126-33. DOI:10.1016/j.whi.2005.01.001^,3535 Turner LR, Morera OF, Johnson TP, Crittenden KS, Freels S, Parsons J, et al. Examining the effectiveness of a community-based self-help program to increase women’s readiness for smoking cessation. Am J Community Psychol. 2001;29(3):465-91. DOI:10.1023/A:1010375931040 lacked the description of the participants removed from the studied group,⁷7 Burgess DJ, Fu SS, Noorbaloochi S, Clothier BA, Ricards J, Widome R, et al. Employment, gender, and smoking cessation outcomes in low-income smokers using nicotine replacement therapy. Nicotine Tob Res.2009;11(12):1439-47. DOI:10.1093/ntr/ntp158^,1111 Chellini E, Gorini G, Gasparrini A, Grazzini G, lossa A, Martellucci PM, et al. Cervical cancer screening visit as an occasion for counseling female smokers to quit. Tumori. 2012;98(1):27-32. DOI:10.1700/1053.11496^,1818 Glasgow RE, Whitlock EP, Eakin EG, Lichtenstein E. A brief smoking cessation intervention for women in low-income planned parenthood clinics.Am J Public Health. 2000;90(5):786-9.^,3333 Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Womens Health Issues. 2005;15(3):126-33. DOI:10.1016/j.whi.2005.01.001 and the descriptive exploratory study⁸8 Buchanan L, Likness S. Evidence-based practice to assist women in hospital settings to quit smoking and reduce cardiovascular disease risk.J Cardiovasc Nurs. 2008;23(5):397-406. DOI:10.1097/01.JCN.0000317449.87649.8e showed no enough follow-up for inferences. Another studies⁹9 Carpenter MJ, Saladin ME, Leinbach AS, Larowe SD, Upadhyaya HP. Menstrual phase effects on smoking cessation: a pilot feasibility study.J Womens Health (Larchmt). 2008;17(2):293-301. DOI:10.1089/jwh.2007.0415^,2121 Manfredi C, Crittenden KS, Warnecke R, Engler J, Cho YI, Shaligram C. Evaluation of a motivational smoking cessation intervention for women in public health clinics. Prev Med. 1999;28(1):51-60.^,2828 O’Hara P, Portser SA. A comparison of younger-aged and older-aged women in a behavioral self-control smoking program. Patient Educ Couns.1994;23(2):91-6. DOI:10.1016/0738-3991(94)90046-9 insufficiently analysed the profile of women who sought the health service. It emphasized the interventions applied during treatment in the results and discussion.

DISCUSSION

We found two types of health services: the general, which offered smoking cessation programs, and the specialized in smoking cessation. In the general services, the profile was composed of younger, highly level educated, and employed women.

Most participants who sought the service for smoking cessation had a high educational level and were employed, a fact that may reflect a favored social class. In fact, the prevalence of smoking habit presents significant differences between the different socioeconomic groups: individuals with a higher purchasing power have a higher chance of quitting smoking because the social environment in which they live exerts great pressure against tobacco use due to reports by anti-tobacco campaigns, and the damage it causes to health.³¹31 Paul CL, Ross S, Bryant J, Hill W, Bonevski B, Keevy N. The social context of smoking: a qualitative study comparing smokers of high versus low socioeconomic position. BMC Public Health. 2010;10(1):211. DOI:10.1186/1471-2458-10-211 On the other hand, the most impoverished segments of the world population show a increase in smoking use¹⁷17 Giatti L, Barreto SM. Tabagismo, situação no mercado de trabalho e gênero: análise da PNAD 2008. Cad Saude Publica. 2011;27(6):1132-42. DOI:10.1590/S0102-311X2011000600010^,dd Eriksen M, Mackay J, Ross H, Shafey O. The Tobacco Atlas. Mexico: World Lung Foundation; 2009 [cited 2014 Jul 4]. Available from: http://www.worldlungfoundation.org/ht/a/GetDocumentAction/i/10792^,ee Jha P, Chaloupka F. A epidemia do tabagismo: os governos e os aspectos econômicos do controle do tabaco. Rio de Janeiro (RJ): Instituto Nacional de Câncer; 2000. due to less access to information, education and health care.^ff Instituto Nacional de Câncer. Abordagem e tratamento do fumante - consenso 2001. Rio de Janeiro (RJ); 2001.

To be employed was reported in most studies, and this has been characterized by some studies⁷7 Burgess DJ, Fu SS, Noorbaloochi S, Clothier BA, Ricards J, Widome R, et al. Employment, gender, and smoking cessation outcomes in low-income smokers using nicotine replacement therapy. Nicotine Tob Res.2009;11(12):1439-47. DOI:10.1093/ntr/ntp158^,1313 Fagan P, Shavers V, Lawrence D, Gibson JT, Ponder P. Cigarette smoking and quitting behaviors among unemployed adults in the United States.Nicotine Tob Res. 2007;9(2):241-8. as a barrier to smoking cessation among women. Long journey work may encourage the adoption of behaviors that momentarily reduce tensions, such as smoking.⁶6 Borges MTT, Barbosa RHS. As marcas de gênero no fumar feminino: uma aproximação sociológica do tabagismo em mulheres. Cienc Saude Coletiva.2009;14(4):1129-39. DOI:10.1590/S1413-81232009000400019 In addition, adverse psychosocial conditions in the work environment, such as high level of stress and anxiety, have also been associated with smoking among women¹⁶16 Franklin TR, Ehrman R, Lynch KG, Harper D, Sciortino N, O’Brien CP, et al. Menstrual cycle phase at quit date predicts smoking status in an NRT treatment trial: a retrospective analysis. J Womens Health(Larchmt). 2008;17(2):287-92. DOI:10.1089/jwh.2007.0423^,1919 Lallukka T, Lahelma E, Rahkonen O, Roos E, Laaksonen E, Martikainen P, et al. Associations of job strain and working overtime with adverse health behaviors and obesity: evidence from the Whitehall II Study, Helsinki Health Study, and the Japanese Civil Servants Study. Soc Sci Med.2008;66(8):1681-98. DOI:10.1016/j.socscimed.2007.12.027^,3232 Radi S, Ostry A, Lamontagne AD. Job stress and other working conditions: Relationships with smoking behaviors in a representative sample of working Australians. Am J Ind Med. 2007;50(8):584-96. DOI:10.1002/ajim.20492 and are considered additional barriers to the treatment.⁷7 Burgess DJ, Fu SS, Noorbaloochi S, Clothier BA, Ricards J, Widome R, et al. Employment, gender, and smoking cessation outcomes in low-income smokers using nicotine replacement therapy. Nicotine Tob Res.2009;11(12):1439-47. DOI:10.1093/ntr/ntp158^,88 Buchanan L, Likness S. Evidence-based practice to assist women in hospital settings to quit smoking and reduce cardiovascular disease risk.J Cardiovasc Nurs. 2008;23(5):397-406. DOI:10.1097/01.JCN.0000317449.87649.8e

In relation to smoking history, two studies showed the same age at which smoking began: between 18 and 19 years old.¹⁰10 Chellini E, Gorini G, Carreras G, Giordano L, Anghinoni E, Iossa A, et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health. 2011;11:906. DOI:10.1186/1471-2458-11-906^,2828 O’Hara P, Portser SA. A comparison of younger-aged and older-aged women in a behavioral self-control smoking program. Patient Educ Couns.1994;23(2):91-6. DOI:10.1016/0738-3991(94)90046-9 One of these studies¹⁰10 Chellini E, Gorini G, Carreras G, Giordano L, Anghinoni E, Iossa A, et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health. 2011;11:906. DOI:10.1186/1471-2458-11-906 identified the association between older ages and more difficulty in quitting smoking as a result of the time of exposure to the psychoactive substance. On the other hand, younger women smoke more cigarettesper day, when compared to older women.¹⁰10 Chellini E, Gorini G, Carreras G, Giordano L, Anghinoni E, Iossa A, et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health. 2011;11:906. DOI:10.1186/1471-2458-11-906 That interferes in the successful tobacco cessation, because women who smoke from 11 to 20 cigarettes a day are less likely to quit smoking than those who smoke between one to five cigarettes.¹⁰10 Chellini E, Gorini G, Carreras G, Giordano L, Anghinoni E, Iossa A, et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health. 2011;11:906. DOI:10.1186/1471-2458-11-906 The age also influences the seeking for treatment: while younger women seek the smoking cessation service due to bad breath, stains caused by the substance, and the desire to stop the smoking habit by someone close; older women seek treatment because they have already experienced some health problems related to smoking, because of concerns about lung cancer, and because of the benefits of a more active lifestyle, hampered by smoking.²⁸28 O’Hara P, Portser SA. A comparison of younger-aged and older-aged women in a behavioral self-control smoking program. Patient Educ Couns.1994;23(2):91-6. DOI:10.1016/0738-3991(94)90046-9 However, for both age groups, the concern about health is the main reason for smoking cessation.²⁸28 O’Hara P, Portser SA. A comparison of younger-aged and older-aged women in a behavioral self-control smoking program. Patient Educ Couns.1994;23(2):91-6. DOI:10.1016/0738-3991(94)90046-9

Regarding the effort to stop smoking, three studies¹⁴14 Farmer MM, Rose DE, Riopelle D, Lanto AB, Yano EM. Gender Differences in Smoking and Smoking Cessation Treatment: An Examination of the Organizational Features Related to Care. Womens Health Issues.2011;21(4 Suppl):182-9. DOI:10.1016/j.whi.2011.04.018^,2323 McClure JB, Westbrook E, Curry SJ, Wetter DW. Proactive, motivationally enhanced smoking cessation counseling among women with elevated cervical cancer risk. Nicotine Tob Res. 2005;7(6):881-9. DOI:10.1080/14622200500266080^,3333 Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Womens Health Issues. 2005;15(3):126-33. DOI:10.1016/j.whi.2005.01.001 showed that almost all studied women had already tried at least once in their lives. In four studies,⁷7 Burgess DJ, Fu SS, Noorbaloochi S, Clothier BA, Ricards J, Widome R, et al. Employment, gender, and smoking cessation outcomes in low-income smokers using nicotine replacement therapy. Nicotine Tob Res.2009;11(12):1439-47. DOI:10.1093/ntr/ntp158

8 Buchanan L, Likness S. Evidence-based practice to assist women in hospital settings to quit smoking and reduce cardiovascular disease risk.J Cardiovasc Nurs. 2008;23(5):397-406. DOI:10.1097/01.JCN.0000317449.87649.8e^-99 Carpenter MJ, Saladin ME, Leinbach AS, Larowe SD, Upadhyaya HP. Menstrual phase effects on smoking cessation: a pilot feasibility study.J Womens Health (Larchmt). 2008;17(2):293-301. DOI:10.1089/jwh.2007.0415^,3333 Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Womens Health Issues. 2005;15(3):126-33. DOI:10.1016/j.whi.2005.01.001 we identified that depression is one of the factors that interfere the treatment. Another reason that may contribute to the failure of this effort is the lack of assistance to cease smoking,²³23 McClure JB, Westbrook E, Curry SJ, Wetter DW. Proactive, motivationally enhanced smoking cessation counseling among women with elevated cervical cancer risk. Nicotine Tob Res. 2005;7(6):881-9. DOI:10.1080/14622200500266080 which increase the difficulties faced by them.

The findings of this review contribute to the formulation of actions directed to the female smoking. To offer full assistance to women who seek general health services and specialized services in smoking cessation, it is necessary to know their profile.

This review included different health services that kept smoking cessation programs, which allowed the assessment of smoking women with varied profiles. The delimitation of a specific period of publication of the studies is inexistent. Because of the lack of previous systematic reviews on the subject, the search strategy did not restrict the papers by year of publication. The small number of studies that analyze the profile of women who carried out smoking cessation treatment limits the power of empirical evidence and conclusions from these results.

Although most studies found present a longitudinal characteristic, many of them lack groups of comparison between profile of women who carried out treatment for smoking cessation and women who did not, making it impossible to verify whether exist differences in the profile observed in this review. Additionally, the review was conducted only by two appraisers. This may contribute to the presence of publication bias.

To conclude, publications on smoking women are scarce and a Brazilian or Latin American study is inexistent. Studies will be needed to address the characterization of the profile of women who start the treatment for smoking cessation in Brazil, as well as review studies that include qualitative research and in languages uncovered by this review, which may increase the reach of evidences.

REFERENCES

Publication Dates

History