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Stages of Readiness to Change Theory

Research has recently shown that women may use differing amounts of different change processes than men do to stop smoking successfully, but the effects of these differences are equal. However, basic research is still needed on the general effects of the stages and gender, as well as how they manifest in nicotine cessation.

Nicotine Dependency Treatment for Women

There may be an increased biological sensitivity to nicotine in women who smoke into adulthood. Menstruating women may experience more severe withdrawal symptoms from nicotine during the premenopausal phase of their cycles, suggesting that women may need extra support to be successful during this time. Social support seems to be particularly important for women.

Some circumstances lend themselves to creating a "teachable moment" for women. For example, new mothers may be motivated to make lifestyle change; and physicians can significantly influence older female smokers. Health visits during pregnancy have received particular attention as opportunities for smoking cessation counseling. Interventions delivered at such times, including in the context of programs targeting multi-ethnic populations attending public health clinics, have been found to be effective in improving cessation rates. Even minimal interventions involving generalizable and relatively inexpensive self-help materials tailored to pregnant women in a single brief session have proved successful.

Ways to assist women in remaining abstinent post partum need to be developed. Some assumptions about circumstances that have not been thought conducive to smoking interventions now need to be reconsidered; for example, the belief that those enrolled in alcohol or other substance abuse programs were not good candidates for smoking cessation has been disconfirmed.

The most exciting recent advance in smoking treatment has been the development of pharmacological adjuncts available by prescription. Gender interactions have surfaced with various medications, despite the fact that most research of pharmaceutical agents are completed on young men. The most widely researched nicotine replacement products are nicotine polacrilex (Nicorette), and the transdermal nicotine patch. Both have been proven effective when prescribed and used correctly, in the context of a behavioral change program. A nicotine nasal spray that mimics the fast rise-time of plasma nicotine from smoking is soon to be released, followed by the nicotine inhaler, a cigarette-like nicotine product. Other medications have shown varying degrees of success. They include:

• nicotine cholinergic receptor blocade (mecamylamine), antidepressants
• (buspirone and tricyclics), serotonin agonists or precursors
• (d-fenfluramine, fluoxetine, L-tryptophan), sympathomimetics
• (phenylpropanolamine), and several others ( e.g., depot ACTH).

Although the transdermal patch has had a great impact on the treatment of smoking, medications in these other categories may assume more importance in the successful treatment of special populations such as women who cannot use nicotine replacement therapy due to allergic reaction or other contraindications (e.g., pregnant women, recent heart attack or stroke patients), as supplements to treat specific withdrawal symptoms during time-limited portions of the cessation process, or as treatments for psychiatric conditions that might be uncovered by cessation (e.g.,depression).

Although some forms of nicotine replacement have been found to be helpful in controlling post cessation weight gain, particularly in heavy smokers, serotonergic agents (e.g., fluoxetine, d-fenfluramine) are also similalry effective and have the added benefits of treating depression while delaying weight gain. This allows for more effective strategies to be introduced to cope with more general nicotine withdrawal symptoms. While some of these medications alone have not been shown successful for cessation, they could be used successfully in programs tailored specifically to the needs of women.

It is generally accepted that antidepressants & antipsychotics may have gender-specific effects or side effects. Similarly, these and the nicotine replacement medications may have different effects in women. Nicotine gum was found by one researcher to be more effective in men than in women; another researcher found the opposite for clonidine.

Advantages of Worksite Nicotine Treatment

The introduction of nicotine treatment programs at the worksite offers many advantages. The most obvious is the possibility of reaching fifty percent of America's blue-collar workers who smoke and underutilize existing programs. Worksite programs have the potential of directly reaching many of the seventy-five million Americans who are employed. It is not surprising that some researchers consider worksites to be nearly ideal settings for preventative health programs.

The convenience of worksites is unparalleled. Large numbers of people spend much of their waking day at the workplace, ease of information dissemination through pre-established formal and informal communication channels,structural hierarchies that have the potential to enforce restrictions such as no smoking policies, and the probability that such programs can be considered benefits by employees. In addition, many worksites have facilities that can be modified to accomodate numbers of people interested in educational messages.

Worksites offer other advantages not available in the clinic. Since worksites are daily environments, generalization of intervention benefits is likely to occur. A visible worksite program can provide a multitude of cues for behavior change and maintenance for that change. Worksite programs that are supported by management, union and/or employee groups can help create attitudinal as well as financial support for health promotion programs that may not otherwise be accessible to employees. These groups may even provide incentives for positive, health related behavior change. Chesney and Feuerstein also consider the varied composition of the workforce to be a great advantage. Worksite programs have the potential of being accessible to many different groups simultaneously.

The possibility of maximizing long-term work group relationships to create and maintain behavior change is a major factor yet to be thoroughly examined through research. regular contact with co-workers can provide reinforcement through social support, a primary factor in maintenance of change. Another factor which makes such programs appealing to public health educators and psychologists is the relative ease of long-term research due to fairly stable populations. Work-site health promotion is an important component of a community wide approach.

To make a significant public health impact, it is important to identify those interventions most effective in achieving smoking-related behavior change at the work site. Organizational and environmental change warrant as much attention as those directed at promoting individual change. Workplaces,then, offer unparalleled opportunities to learn about and implement programs for human behavior change.

Reported Success of Worksite Programs

Worksite programs making use of behavioral strategies and/or incentives have shown greater changes than less intensive programs, such as screening and educational interventions. In addition, many arguments are surfacing insupport of multiple risk factor approaches, rather than single risk factors, such as smoking or hypertension. Methodological problems are often associated with much worksite research. Many studies have failed to obtain biochemical validation of self-reported smoking status; and most research has quasi-experimental or case study designs.

Cultural and workplace factors supporting smoking abstinence are likely to be influential in generating gender differences. Cultural specificity of some of these factors is suggested by findings that in some cultures cessation rates are higher among women than men. For example, with workplace restrictions on smoking and more men than women in the workforce, it is likely that the response cost of smoking is increasing relatively more for men than for women.

Continued in Part 3

5/29/98

Marlene M. Maheu, Ph.D. is the founding Director of the Nicotine Recovery Institute. She is the designer of the Nicotine Freedom System, and specializes in the treatment of nicotine-related disorders. Such disorders include underlying depression and anxiety. She has worked extensively with smokers and tobacco chewers in hospital, industrial, and private settings, and is available for individualized consultation and program design. Her program and materials have been developed after completion of her doctoral dissertation in smoking cessation, and following a decade of work with thousands of smokers. Through colorations with SelfhelpMagazine, she offers telephone based services for individuals and groups seeking freedom from nicotine in any form. For more information on this convenient application of her program, email her directly.