Women & Smoking

The impact of smoking on health has been researched for many years. In numerous publications, it has been cited that cigarette smoking is the most important preventable cause of premature death in the United States.1

Over the last couple of decades, the health hazards of smoking and women’s health has become a global issue. This has created a need for innovative smoking cessation strategies aimed at women to help decrease health issues and improve quality of life (QoL).

In 2011, the American Heart Association estimated that more than 16 million women were smokers.3 An examination of recent epidemiological trends in lung cancer among men and women from 2005-2009 show a rapid decline in lung cancer incidence among men compared to women ages 35 to 44.4

In recent years data has shown an increase in disabilities and mortality from various diseases among women, especially lung cancer and chronic obstructive pulmonary disease (COPD) exacerbated by smoking.3 This supports the need for gender-based tobacco reduction and cessation strategies.

Pilot Study

The aim of this quality improvement pilot study was to reduce smoking, encourage smoking cessation and improve QoL as participants engaged in an outpatient smoking cessation education program using informed lung age.

Lung age was calculated using a spirometric device that measured the forced expiratory lung volume after one second and refers to the average age of a nonsmoker’s lung compared to an individual that smokes.

Smoking cessation programs and motivational tools can play a vital role in smoking cessation programs targeted toward women’s health. One tactic, informed lung age combined with cessation programs, is becoming a popular tool and incentive to help people decrease smoking.5,6 Lung age can provide a visual indication of the damage of smoking on lung health, using methods similar to spirometry, and may help improve smokers’ progress in a cessation program.

Study Methods

The interdisciplinary team consisted of a bilingual certified public health educator, an acute care nurse practitioner, who worked in internal medicine, clinic administrators, clinic Spanish translators and office staff.

Three outpatient community-oriented primary care clinics that held smoking cessation programs and were affiliated with a large county teaching hospital were used to conduct the study. Targeted participants for the project were female smokers 18 years and older. Eligibility for their participation was determined by the following:  non-pregnant adult female smokers who were voluntary participants in a smoking cessation program.

Female patients at this chosen facility were smokers, reported decrease QoL and were oblivious to the detrimental effects smoking imposed on their health.

A total of 11 participants were informed of the study and agreed to participate. Three participants were from the first clinical site, three participants were from the second site and five participants were from the third site.

Spanish speaking participants were informed of the study purpose, their role and information by the public health educator who was authorized to teach classes in both English and Spanish.

Individual smoking and tobacco use was defined using the National Survey on Drug Use and Health (NSDUH) which included a series of questions about the use of tobacco products, including cigarettes, chewing tobacco, snuff, cigars and pipe tobacco. Cigarette use was defined as smoking “all or part of a cigarette”.7

An assessment of quality of life, defined by the World Health Organization was an analysis of subjective evaluations of both positive and negative aspects of life due to smoking using the Smoking Cessation Quality of Life Questionnaire (SCQoL),8,9was done to determine how efforts at smoking cessation can affect one’s QoL. The lung age intervention was designed to provide volunteers a visual index of how smoking has affected their lungs.

Study Phases

The project implementation was composed of two phases. Phase one for each site consisted of recruiting volunteers, use of informed lung age and completion of the SCQoL questionnaire by participants.

Once the SCQoL questionnaires were completed and questions answered, participants were selected to receive the lung age intervention. Those who didn’t receive the lung age intervention were told in English or Spanish that they would receive this information at the last class of the cessation program for each clinical site.

Phase two took place during the last cessation class for each of the three sites and consisted of completion of the SCQoL again and informing those, who did not receive lung age at the first education session, of their lung age.

Volunteers at the last cessation class were informed that they would receive a follow-up phone call 2 weeks and 1 month post-cessation program. On average, two attempts were made to contact participants for a post-program follow-up phone call. Phone calls were made to both home and cell numbers to increase chances that participants would be reached to assess their post-cessation class smoking status.

Study Results

The effectiveness of the intervention was measured based on the reported smoking status 2 weeks and 1 month post intervention. The proportion of participants who had reduced smoking at 2 weeks post program and quit after 1 month (85.7%) was larger than the proportion of participants who had reduced smoking at 2weeks post program and were still reduced at 1month post program (14.3%). All participants who reported quitting after 2 weeks also reported that they quit smoking at 1 month (100%).

Descriptive statistics were used for determining any variances and similarities of demographic data. Demographic information of the 11 volunteers was collected from a survey sheet done during the initial cessation education program class. Information collected included age, years smoking and ethnicity.

Participants’ ages ranged from 47 to 64, with a mean age of 56 years between the three groups. The majority of the women were Hispanic (45.4%). The remaining participants were white (36.4%) and black (18.1%).

The average number of years smoking between the groups was 35 years, with a range between 20 and 45 years. Lung age among participants ranged from 60 to 115 years, with an average of 92.2 years. Scores regarding the social interaction component of the SCQoL questionnaire revealed that prior to beginning the program, participants scored relatively high (average 63.8 on a scale of 0 to 100 in 25-point increments), indicating a possible need for support and socialization. Areas of self-control, sleep and cognitive functioning were relatively low pre-intervention, particularly in responses pertaining to willpower, falling asleep and getting enough sleep.

Scores for these cessation targeted items had a mean average score of 33.3 on a scale from zero to 100, with higher scores indicating better functioning. Cessation targeted questions relating to anxiety had a median score of 55.5, indicating a fairly neutral response to anxiety relating to smoking cessation efforts.  After the cessation program ended, SCQoL scores were reassessed and revealed a higher level of social interaction score (69.4), indicating some improvement in this aspect of quality of life. Scores for cognitive functioning and self-control also saw increases (56.8 and 45.5 respectively).

This re-evaluation showed that QoL can improve with cessation efforts. It also confirms what authors of the SCQoL postulated; QoL can improve over time with cessation efforts.8 It also helps provide strong evidence for the reliability and validity of the SCQoL when evaluating smoking efforts and its effect on health and QoL over time.

Practice, Policy & Education

Reducing the prevalence of smoking among women is an important public health goal. Nurse practitioners are in unique positions to contribute to health outcomes of patients and families.

Outpatient primary care clinics are often the initial point that healthcare providers are able to make an impact on an individual’s healthcare behaviors. This is particularly important when caring for patients in a population group where access to healthcare is challenging and often limited.

In 2006, a non-randomized observational study of more than 4,400 smokers from Poland used spirometry to promote cessation.10 The authors found that patients who were informed that they had obstruction were more likely to quit (12%), compared to normal routine physician advice to stop smoking.10 Although they didn’t specifically use informed lung age, spirometry demonstrated that higher quit rates were attributed to being informed about decreased lung function.

Smoking is preventable and smoking cessation programs are effective tools. Data from this project showed that informed lung age interventions can help improve the health and quality of life of female smokers and can be used to support current clinical practices.

However, policies toward gender control are often lacking. Integrating lung age interventions in larger sample populations and more outpatient smoking cessation programs can provide more in-depth analysis of the need for smoking cessation among women.

Tonya Sawyer-McGee is an acute care nurse practitioner, who has worked at Parkland Health and Hospital System in Dallas, Texas, in internal medicine at one of Parkland’s Community-Oriented Primary Care Clinics. She is the program director for the doctor of nursing practice program in development at Abilene Christian University-Dallas.


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  3. Go, AS, et al. Heart disease and stroke statistics-2013 update: a report from the American Heart Association. Circulation. 2013;127:6-245.
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  6. Parkes G, et al. Effect on smoking quit rate of telling patients their lung age:
    the Step2quit randomized controlled trial. BMJ. 2008;336:598-600.
  7.  Substance Abuse and Mental Health Services Administration.
    Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings.
  8. The WHOQOL Group. The World Health Organization Quality of Life Assessment (WHOQOL): development and psychometric properties.
    Soc Sci Med. 1998;46:1569-1585.
  9. AO Olufade, et al.  Development of the smoking cessation quality of life questionnaire. Clinical Therapeutics. 1999;21(12):2113-2130.
  10. Bednarek M, et al. Smokers with airway obstruction are more likely to quit smoking. Thorax.2006;61(10):869-73.

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