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Gender Differences Within the Barriers to Smoking Cessation and The Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-042623 on 29 January 2021. Downloaded from Gender differences within the barriers to smoking cessation and the preferences for interventions in primary care a qualitative study using focus groups in The Hague, The Netherlands Lieke Agathe Dieleman, Petra G van Peet, Hedwig M M Vos To cite: Dieleman LA, van ABSTRACT Strengths and limitations of this study Peet PG, Vos HMM. Gender Objectives This research aimed to provide a deeper differences within the insight into the gender- specific barriers to smoking ► This study helps to develop a better understanding barriers to smoking cessation cessation and gender- specific preferences for and the preferences for of gender differences in smoking cessation by com- interventions in primary care, in order to contribute to interventions in primary care paring focus groups with women and men. better aligned cessation care for women. a qualitative study using ► This study used the intervention ladder to classify Design Qualitative study using focus groups. focus groups in The Hague, gender- specific preferences for interventions by Setting Regularly smoking female and male adults were The Netherlands. BMJ Open their degree of pressure. 2021;11:e042623. doi:10.1136/ recruited from four different general practices in The ► This study provides more insight into severely ad- bmjopen-2020-042623 Hague (The Netherlands). dicted smokers, and gives recommendations for Participants A total of 11 women and nine men ► Prepublication history and adjusting treatment in clinical setting. participated. Participants included were regular smokers additional material for this ► Additional individual interviews were conducted, as with a minimum age of 18 and sufficient command of the paper are available online. To not enough male participants were simultaneously Dutch language, who were willing to talk about smoking view these files, please visit available to participate in focus groups. A mixed- cessation. Inclusion ended when saturation was reached the journal online (http:// dx. doi. gender group was not included as a control, what org/ 10. 1136/ bmjopen- 2020- for both women and men. Participants were selected by could have promoted the reliability of this study. 042623). means of purposeful sampling, whereby looking at age, ► The study group was not fully representative for http://bmjopen.bmj.com/ educational level and experience with quitting. smokers in the Dutch population, as the average Received 17 July 2020 Results The main barriers to smoking cessation in Revised 21 December 2020 age in both groups was high and the level of educa- women were psychological factors, such as emotion Accepted 13 January 2021 tion among female participants was relatively high. and stress, compared with environmental factors in The number of quit attempts turned out to be non- men. Women indicated they were in need of support and quantifiable in both women and men, impairing us to positivity, and both women and men expressed the desire match participants to addiction severity. for assistance without judgement. Contrary to men, women were not drawn to restrictions and (dis)incentives. Conclusion When counselling smokers, in women on September 25, 2021 by guest. Protected copyright. the focus should be on perceived internal problems, as Although women and men attempt to quit opposed to more external obstacles in men. Contrary smoking just as often, women appear to be 2 to men, female smokers seem to prefer non- coercive 31% less successful. Yet, smoking cessation interventions, such as a group intervention offering support seems particularly important for women, as and positivity. Future research should focus on these their health risks exceed those of men. Both gender differences, and how they could improve treatment the tobacco- attributed mortality and lung in primary care. cancer incidence have been increasing in © Author(s) (or their women, opposed to decreasing in men.3–5 employer(s)) 2021. Re- use The increase in lung cancer among women permitted under CC BY-NC. No BACKGROUND can be explained by their higher sensitivity commercial re- use. See rights 6 7 and permissions. Published by Cigarette smoking is the leading cause of to carcinogens, as well as the results of BMJ. premature death and an important risk strategic actions by the tobacco industry by 8–10 Department of Public Health and factor for chronic diseases, such as cancer targeting women. Compared with non- Primary Care, LUMC, Leiden, and cardiovascular disease.1 Although the smokers, the relative risk of cardiovascular The Netherlands total number of smokers in the Netherlands disease is 25% higher in female smokers than 11 Correspondence to has been decreasing over the past decades, in male smokers. Also, smoking women have 12 13 Hedwig M M Vos; the number of female smokers has declined an increased risk of breast cancer, cervical h. m. m. vos@ lumc. nl slower than the number of male smokers. cancer,14 infertility,15 16 poor pregnancy Dieleman LA, et al. BMJ Open 2021;11:e042623. doi:10.1136/bmjopen-2020-042623 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-042623 on 29 January 2021. Downloaded from outcomes,17 18 early menopause19 and osteoporosis.20 21 behavioural interventions.39 Women- specific programmes Although relatively few women are aware of these risks,22 are limited and show inconsistent outcomes, but might these risks highlight the importance of improving cessa- help to reduce barriers to treatment entry.44 This study tion success rates in female smokers in particular. aimed to provide a deeper insight into the gender- specific Different explanations can be found for the lower barriers to smoking cessation and gender- specific prefer- success rates of smoking cessation in female smokers. ences for interventions, in order to contribute to better First of all, the physical nicotine dependency is lower aligned cessation care for women. in women than men.23 This may seem contradictory, but women seem to experience higher mental and behavioural dependency, which might persist longer after METHODS cessation than physical nicotine dependency. Women Population 24 metabolise nicotine faster than men, especially when Qualitative research was conducted, using focus groups 25 using oral contraception. This might also explain why with smoking women and men recruited in primary care. nicotine replacement therapy is less effective in women The total number of participants was depending on when 26 27 than in men in the same dosage. Research has indi- saturation was reached, while pursuing diversity. Partici- cated that craving and nicotine reward might be positively pants that met the inclusion criteria were regular smokers 28 29 associated with oestrogen levels. with a minimum age of 18 and sufficient command of the Another explanation can be found in the sociophar- Dutch language, who were willing to talk about smoking macological model for tobacco addiction proposed by cessation. Willingness to actually quit smoking was not 30 Leventhal, wherein the interaction between psycho- a requirement, since the barriers participants perceived pharmacological and contextual factors is studied. This towards actually wanting to quit smoking were subject of theory argues that social and environmental factors form investigation. greater barriers to women.31 For example, women are more often victims of sexual violence,32 which is related to Procedure substance use.33 Also, on average, women appear to have Participants were recruited from four general practices a lower income,34 and might, therefore, be less able to located in the Dutch city of The Hague during October afford adequate care. 2019 and November 2019. General practices and partic- Moreover, gender differences seem to exist within the ipants were selected by means of purposeful sampling. barriers smokers perceive towards cessation, and these Criteria for diversity were age, educational level as a might contribute to the varying success rates. Regarding proxy for socioeconomic status and experience with quit- smoking behaviour, men seem to smoke more often ting assessed by the number of attempts. Suitable partic- because of the stimulating effects of nicotine, while ipants were approached by their GP or practice nurse on average, women smoke more often out of habit or during consultation, or by telephone based on informa- http://bmjopen.bmj.com/ to regulate their mood.35 In addition, smoking in men tion about smoking in electronic medical records. Data seems to be more related to food, alcohol and smokers in analysis started immediately following each focus group. the vicinity, compared with stress and craving in women.36 When the earlier mentioned criteria for diversity were Although barriers related to stress and mood regulation guaranteed and no new information was obtained from and social factors seem to be common in both women and the focus groups, it was concluded that saturation was be men, women on average seem to be affected by a greater reached. An additional interview was conducted for final number of barriers and distinct stress- related barriers.37 confirmation. For further details on the recruitment of Other barriers that seem to be more prominent in women participants, see figure 1. on September 25, 2021 by guest. Protected copyright. are sensory aspects, the lack of social support,37 and the All focus groups and interviews were audiorecorded. fear of weight gain.38 Besides the previously
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