Smoking Risks Higher in Women: The Dental Hygienist’s Role

It isn’t news that smoking is bad for your health. Cigarette smoking is responsible for more than 480,000 deaths each year and is the leading cause of preventable death. That equates to one in five deaths.^1-3 More deaths are caused by smoking than human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle accidents, and fire-arm related incidents.⁴

Historically speaking, smoking was much more accepted, and men cornered the market. In the 1920s and 1930s, things changed for women. Some say it was a “liberation.” I remember my parents having dinner parties in the 1960s and 1970s where virtually everyone smoked. My Mom also had a bridge club that rotated between different houses. Every table in every house had an ashtray. Crazy to remember this, but my Dad smoked Parliaments, and my Mom’s brand was More cigarettes.

Targeting Women Smokers

There were three key moments in the history of marketing tobacco to women beginning in the 1920s. Lucky Strike had tried to push the agenda in 1925 when they said, “Reach for a Lucky instead of a sweet,” implying that smoking would make you thin. In the New York City’s Easter parade of 1929, the American Tobacco Company organized a group of women to march down Fifth Avenue holding “torches of freedom” – cigarettes – to squash the public’s perception that smoking was taboo for women. The mastermind behind the propaganda was Edward Bernays whose double uncle happened to be Sigmund Freud.⁵

In 1968, “You’ve Come a Long Way Baby” was born. Women’s liberation was tapped, and there was an underlying message related to freedom, emancipation, and empowerment. In the 1960s, one in three women smoked.

The push toward women doesn’t stop there. In 2007, R.J. Reynolds introduced a new cigarette called Camel No. 9 with stylish packaging featuring black, pink, and teal colors. The packages even said, “light and luscious.” A study found that this campaign encouraged young girls to start smoking, and teenage girls cited it as a favorite cigarette campaign.

Health risks of smoking for women became clearer – low-birth-weight babies, early menopause, osteoporosis, and cervical cancer, to name a few. A class gap in female smoking emerged. Women with more education and higher incomes reduced their smoking. In the past four decades, the tobacco business started marketing to poor and working-class women, who are more likely to smoke and less likely to quit. Rooted in many inequalities, low-income communities have the least information about health hazards, fewest resources and social support, and the least access to services to help them quit. For 60 years, Big Tobacco has targeted low-income consumers by giving free cigarettes to kids in housing projects, issuing tobacco coupons with food stamps, and even exploring giving away financial products like prepaid debit cards. Low-income communities have more concentrations of tobacco retailers and are more likely to have more retailers near schools.^6-8

Gender Differences for Health

There are clear differences in smoking and its effects between men and women. Overall, men smoke to “reinforce the effects” of nicotine. On the other hand, women smoke to relieve stress and, unfortunately, out of habit.⁹

You read that right. Smoking activates different parts of the brain, depending on gender. In men, it stimulates the striatum, a part of the brain that reinforces the cigarette’s drug effect. In women, it activates a rapid response in an area that is associated with habit formation. For decades, men have had better luck quitting by using medications and patches. Science tells us that women are more stressed than men and that creates more difficulties when quitting. High cortisol levels were predictive of relapse in women.¹⁰

Other work on abstinence found that smoking a cigarette with nicotine, compared to a denicotinized cigarette, alleviated the symptoms of withdrawal and negative mood to a greater extent in men than women. Women obtained equal relief from cigarettes with and without nicotine, suggesting that they found the drug less rewarding than men.¹¹

Risks from Smoking

Women have different risks for smoking when dealing with our brains, hormones, and ovaries. The toxins in tobacco reduce estrogen levels and then speeds up the biological clock. What that means is menopause and the onslaught of issues related to it is triggered earlier. The Women’s Health Initiative, a long-term national health study, had 93,000 female participants between 1993 and 1998. It found that women who smoked 100 cigarettes or more had a 14% greater risk of infertility and a 26% greater risk of going through menopause before turning 50. The study stated, “Tobacco toxins also seem to lower the age of natural menopause by reducing circulation estrogen.”¹²

In the Study of Women’s Health Across the Nation, female smokers had 60% more hot flashes than nonsmokers, and they persisted for over six years. Smoking can also block the effect of interventions to reduce hot flashes. The frequent occurrence of hot flashes may be related to an increased experience of heart attack and stroke or other serious cardiovascular problems.

Suggestions are made specifically for women to reduce hot flashes. If you are a smoker or past smoker (even in high school), focus on increasing your antioxidants, engage in regular moderate-intensity exercise, reduce stress, and minimize pollutants in your environment.

Women’s health risks are higher:

• Colon cancer risk for smoking women increases by 19% (only 8% for smoking men).
• Breast cancer rates are higher for smokers; 9% increase for former smokers and 16% increased risk for current smokers.
• There are suggestions that smoking may increase the progression from HPV to cervical intraepithelial neoplasia.
• More women die from lung cancer than any other cancer. There are now more new cases of lung cancer in women (ages 30-49) than men.
• Women who smoke have a 25% greater increased risk of coronary heart disease than their male-smoker counterparts.¹³

Fast Facts for Women

• Smoking is directly responsible for 80% of lung cancer deaths in women each year.¹⁴
• In 1987, lung cancer surpassed breast cancer as the leading cause of cancer deaths among women in the United States.¹⁵
• From 1959 to 2010, the risk of developing lung cancer increased tenfold for women.¹
• Women who smoke also have an increased risk for developing cancers of the oral cavity, pharynx, larynx (voice box), esophagus, pancreas, kidney, bladder, and uterine cervix. They also double their risk for developing coronary heart disease.¹⁶
• Postmenopausal women who smoke have lower bone density than women who never smoked.
• Women who smoke have an increased risk for hip fracture compared to someone who never smoked.¹⁶
• Female smokers are nearly 22 times more likely to die from chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis, compared to women who never smoked.¹

Focus on Dentistry

The detriment of smoking to oral health isn’t news to the dental community. Smoking weakens the immune system. Gingival infections are more difficult to treat, and tissue repair is more difficult. Wound healing is suppressed, which moves into post-extraction and implant issues.

There are many oral mucosal changes for smokers that dental providers must look out for. During a thorough oral cancer exam, you may find:

• Erythroplakia
• Leukoplakia
• Nicotinic stomatitis
• Smoker’s melanosis
• Oral candidiasis
• Periodontal disease
• Xerostomia, halitosis, and caries
• Wound-healing problems
• Implant rejection
• Aesthetic issues
• Recurrent aphthous stomatitis

Our Role as Dental Hygienists

An internationally accepted approach to brief intervention for nicotine users in a primary care setting has been shown to increase smoking cessation by 1-3%.¹⁷ “Brief advice” has been shown to increase cessation by 2%. In 2018, 13.7% of American adults smoked, and that equals over 34 million adults.

If just primary care intervention could help 2% of those people, that totals more than 650,000 people. We are health-care providers, and I believe part of primary care. Successful cessation increases to 15% if referred to a stop smoking service.

Time is often the perceived problem in dental practices as to why there are limited discussions with patients. There is a technique called the 5 A’s protocol. The guidelines are: Ask, Advise, Assess, Assist, and Arrange:

• Ask about and record smoking status.
• Advise smokers of the benefit of stopping in a personalized and appropriate way.
• Assess motivation to quit (using stages of change model).¹⁷
• Assist smokers in their quit attempt.
• Arrange to follow up with stop smoking services.

For practitioners who genuinely do not have time, a modified version is called the 3 A’s protocol: Ask, Advise, and Act.

• Ask about and record smoking status.
• Advise patient of personal health benefit
• Act on the patient’s response.

While the 5 A’s is not gender-specific, women need more social support during their journey to quitting.¹⁸ Being positive, uplifting, and perhaps setting up your own follow-up may make a big difference for your female patients. Keep in mind that, for women, they have higher stress-related factors and anxiety while trying to stop.

Studies show that using an additional program of yoga and meditation can help with social support, stress, depression, and even the weight gain that is often a concern for women who are trying to quit.^19-21

There are many tips and tricks to help support all our patients to stop smoking. The health risks, however, for women appear to be greater, and our encouragement is vital. Whether helping your patient build a plan, assist in prescription medications, finding an app, or a referral to a stop-smoking program or even a texting program, our options as health-care providers are abundant.

For a detailed look into worldwide cancer incidence and mortality divided between sexes, please read Ferlay, J., Soerjomataram, I., Dikshit, R., Eser, S., Mathers, C., Rebelo, M., Parkin, D.M., Forman, D. and Bray, F. (2015). Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int. J. Cancer, 136: E359-E386. doi:10.1002/ijc.29210 https://onlinelibrary.wiley.com/doi/epdf/10.1002/ijc.29210

Now Listen to the Today’s RDH Dental Hygiene Podcast Below:

References

1. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. 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. 2014. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK179276/
2. How Tobacco Smoke Causes Disease: What It Means to You. Atlanta: U.S. 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. 2010. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK53017/
3. QuickStats: Number of Deaths from 10 Leading Causes—National Vital Statistics System, United States, 2010. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. 2013; 62(08): 155. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6208a8.htm
4. Mokdad, A.H., Marks, J.S., Stroup, D.F., Gerberding, J.L. Actual Causes of Death in the United States. JAMA: Journal of the American Medical Association. 2004; 291(10): 1238–45. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2678018
5. Edward Bernays. Wikipedia. Retrieved from https://en.wikipedia.org/wiki/Edward_Bernays
6. Evans v. Lorillard: A Bittersweet Victory Against the Tobacco Industry. Tobacco Control Legal Consortium. Retrieved from https://publichealthlawcenter.org/sites/default/files/resources/tclc-Evans-v-Lorillard-case-study-2016.pdf
7. Brown-Johnson, C.G., England, L.J., Glantz, S.A., et al. Tobacco industry marketing to low socioeconomic status women in the USA. Tobacco Control. 2014; 23: e139-e146. Retrieved from https://tobaccocontrol.bmj.com/content/23/e2/e139
8. Tobacco is a social justice issue – Low-income communities. Truth Initiative. 2017. Retrieved from https://truthinitiative.org/research-resources/targeted-communities/tobacco-social-justice-issue-low-income-communities
9. Cosgrove, K.P., Wang, S., Kim, S.J., et al. Sex Differences in the Brain’s Dopamine Signature of Cigarette Smoking. Journal of Neuroscience. 10 December 2014; 34(50): 16851-16855. doi:10.1523/JNEUROSCI.3661-14.2014. Retrieved from https://www.jneurosci.org/content/34/50/16851.
10. 10.^. al’Absi, M., Nakajima, M., Allen, S., Lemieux, A., Hatsukami, D. Sex differences in hormonal responses to stress and smoking relapse: a prospective examination. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2015; 17(4): 382-389. doi:10.1093/ntr/ntu340. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4481709/
11. Perkins, K.A., Karelitz, J.L. Sex differences in acute relief of abstinence-induced withdrawal and negative affect due to nicotine content in cigarettes. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2015; 17(4): 443-448. doi:10.1093/ntr/ntu150. http://europepmc.org/article/PMC/5183546 Retrieved from https://www.cdc.gov/tobacco/data_statistics/sgr/2001/index.htm
12. Hyland, A., Piazza, K., Hovey, K.M., et al. Associations between lifetime tobacco exposure with infertility and age at natural menopause: The Women’s Health Initiative Observational Study Tobacco Control. 2016; 25: 706-714. Retrieved from https://tobaccocontrol.bmj.com/content/25/6/706
13. Huxley, R.R., Woodward, M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies. Lancet. 2011; 378(9799): 1297–305. Retrieved from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60781-2/fulltext
14. Health Consequences of Smoking: A Report of the Surgeon General, 2004. U.S. Department of Health and Human Services. Retrieved from https://pubmed.ncbi.nlm.nih.gov/20669512/
15. Itri, L. Women and lung cancer. Public Health Rep. 1987; 102(4 Suppl): 92-96. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1478035/
16. Women and Smoking: A Report of the Surgeon General, 2001. U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/tobacco/data_statistics/sgr/2001/index.htm
17. The Five Stages of Change Model. Smoking Cessation Advice. Retrieved from http://smokingcessationtraining.com/contents/five-stages-change-model/
18. Chaney, S., Sheriff, S., Merritt, L. Gender differences in smoking behavior and cessation. Clinical Nursing Studies. 2015. Retrieved from https://www.researchgate.net/publication/273901098_Gender_differences_in_smoking_behavior_and_cessation
19. Thind, H., Jennings, E., Fava, J.L., et al. Differences between Men and Women Enrolling in Smoking Cessation Programs Using Yoga as a Complementary Therapy. J Yoga Phys Ther. 2016; 6(3): 245. doi:10.4172/2157-7595.1000245. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036391/
20. Rosen, R.K., Thind, H., Jennings, E., Guthrie, K.M., Williams, D.M., Bock, B.C. “Smoking Does Not Go With Yoga:” A Qualitative Study of Women’s Phenomenological Perceptions During Yoga and Smoking Cessation. Int J Yoga Therap. 2016; 26(1): 33-41. doi:10.17761/1531-2054-26.1.33. Retrieved from https://meridian.allenpress.com/ijyt/article/26/1/33/137893/Smoking-Does-Not-Go-With-Yoga-A-Qualitative-Study
21. Bock, B.C., Fava, J.L., Gaskins, R., et al. Yoga as a complementary treatment for smoking cessation in women. J Womens Health (Larchmt). 2012; 21(2): 240-248. doi:10.1089/jwh.2011.2963. Retrieved from https://www.liebertpub.com/doi/10.1089/jwh.2011.2963