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Smoking cigarettes was not common among women until intense tobacco marketing specifically addressed to women started in the mid-nineteenth century. In Sweden there was a peak in the number of smoking women around mid seventies. After that, smoking gradually decreased, especially among younger women. Such a trend was not seen among middle aged and elderly women. Smoking cessation among women seems to be less successful than among men. The reason for this is not obvious. Both sexes have shared the same anti-smoking messages. Some authors believe the gender difference is due to the greater use of moist snuff among smoking men. This could be part of the explanation in Sweden but there are probably other explanations as well. It is apparent that women have as strong a nicotine dependence as men. Several studies have also shown that women get the same serious diseases as men after long-term smoking. Both men and women need support to stop smoking. It is apparent that great efforts must be made to stop the "tobacco epidemic" by not forgetting middle aged/elderly women. After many years of smoking, this group is now developing the diseases caused by smoking and quitting rapidly decreases the risks. The impression that middle aged and elderly women have greater difficulty in long-time smoking cessation is important to recognize and merits further discussion. This qualitative study was developed in an attempt to get a deeper understanding of middle aged/elderly women's thoughts and ideas about smoking and smoking cessation. To date, few qualitative studies have been published on this topic.
Six different themes emerged from the analysis. They capture the most striking features from the interviews. Two themes deal with added values from smoking and from quitting, two represent barriers and feelings that made it more difficult to stop smoking, and two deal with expectations and frustrations about the health care system and ideas how to improve its antismoking activities.
Added values from being a smoker: Several of the Participants talked about a special sense of group belonging. When smokers met in the schoolyard or elsewhere there was always a joyful atmosphere. They did not know if there was as much fun among non-smokers, but they believed that smokers had more fun. The non-smokers apparently did not have the same opportunity to "gather around the campfire". The taste and smell of coffee and alcohol was reinforced and problem-solving capacities improved.
Added values from being a quitter: A relieving sense of freedom appeared after the smoking cessation. Positive health aspects were also noted, including less cough, less incontinence, less dental problems and over all greater well-being.
Smoke promoting context, fatalism and shame. The Participants had childhood memories that smoking was permitted at their homes. Later in life, smoking was allowed in the schoolyard as a concession from authorities at school, parents and society as a whole. In adult life it became natural to smoke during work breaks. Fatalistic feelings were described- "Everybody should die, so why not from smoking?" The feeling of shame was strong when grandchildren commented on grandma's smoking.
Cultural and structural barriers. The women in our study mentioned the hazards of weight gain after smoking cessation. The alternative of switching to moist snuff was not attractive. The Participants argued that increased responsibility for the care of elderly or sick relatives, and problems from the fact that many women had "double jobs", both paid and unpaid at home made quitting smoking more difficult.
Expectations versus frustrations on the health care system. The Participants said that the organization of the health service was an obstacle in itself because it was so disease-oriented. They were skeptical of the kind of help they could depend on from the official health care system. Several Participants argued that the most important factor was their own will to stop smoking. Information from health care officials could be important, but everyone knew about the hazardous effects of smoking. Some of the Participants had tried nicotine replacement therapies without success and some of them experienced side effects.
Better ways to do it
Weight gain: This study revealed several different factors that are of importance in the smoking cessation process (Fig1). One is the well-known issue of weight gain which was discussed by all of the Participants. Several studies have shown a moderate weight gain when quitting smoking and a slight weight loss when starting to smoke. There are probably both changes in basal metabolism and energy balance that explains this. A craving for sugar and fat characterizes the period after the smoking cessation process has started. No difference in physical activity has been shown between those gaining weight and those who do not, but there have been differences in energy intake. A study from Kawachi et al showed that a moderate increase in physical activity could minimize weight gain. Good results may come from a cognitive behavior approach that aims to help women handle a slight increase in body weight. The associated increase in body weight has not been shown to increase the risk for cardiovascular disease.
Harm reduction: The use of moist snuff as a "harm reduction strategy" is under debate. The Participants in this study were not interested because it is "unfeminine" to use moist snuff. The concept of femininity elucidates this issue. As described by Harding, perceptions and ideas about appropriate behavior for men and women are embedded in any given culture. These perceptions are integrated into individuals and become a guide for action and behavior. The perceptions are not stable and fixed but are changeable along with time and social context. The middle aged/elderly women in this study have presumably incorporated a certain kind of femininity that does not include the use of snuff. In the next generation of women this might have changed so that snuff becomes a common part of women's life. There could be other circumstances that make it more difficult for women than men to stop smoking. More women than men have low paid jobs and low socio-economic status. Several studies have shown that those women smoke more and have greater difficulties in smoking cessation. The care of the elderly and of sick relatives could be much time-consuming and is probably stressing women still more.
Nicotine replacement therapy: Problems with the use of ordinary nicotine replacements devices were also discussed in the interviews. Perhaps medical staff and pharmacists rely too much on the written information that is enclosed in the package. There is probably more need for discussion and follow up of treatment from the health services. It is also essential to realize that women face different physiological experiences when using administered nicotine replacements such as chewing gum or patches. According to studies of Perkins et al, women have less nicotine adherence than men, behavioral factors are more important. Women are also more dependent on the smell of tobacco smoke, so using nicotine patches or gum may not be as effective as for men.
Health care system: The Participants' view of the role of the health care system was ambiguous. They appreciated the information about different health problems as a counter-weight to the mass media messages. However, much of the information was already well-known; the same as "opening already opened doors". The provided information was almost always about the negative effects of smoking and less focus was on the positive effects of smoking cessation. It is possible that women are more susceptible for these negative messages as depressive states are common among smoking women.
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