1. Varda Shoham, Ph.D. Senior Advisor for Translational Research NIMH May 15, 2013 Women, Smoking, and Mental Health

2. Women and Smoking

3. 17.3% of adult women smoke Prevalence is higher among: young women (18-24) less educated women (< high school) women living below poverty level CDC, 2012

4. Although men smoke at slightly higher rates than women… woman suffer more severe health consequences of smoking women have a much harder time quitting and staying quit (Bjornson et al., 1995; Fiore et al., 1996; Perkins et al., 2001; Schroeder, 2013; Wetter et al., 1998)

5. Over 170,000 US women die each year from smoking- related diseases (CDC, 2008; Jha et al., 2013)

6. Compared to men, women smokers are at increased risks for –Heart disease –COPD –Diabetes –Rheumatoid arthritis –Bone fractures (due to lower density) –Cataracts –Macular degeneration… and more… (Al-Delaimy et al., 2001; CDC, 2008; Prescott et al., 1998; Rimm et al., 1993; US Surgeon General, 2001)

7. More US women die of lung cancer than of breast, uterine and ovarian cancers combined.

8. Lung vs. Breast Cancer Simard et al., 2013

9. Menstrual dysfunction – pain, irregularities Earlier menopause, more severe symptoms Delayed conception, infertility Ectopic pregnancy, spontaneous abortion Pregnancy complications – preterm birth, low birth weight, still birth, premature rupture of membranes Surgeon General, 2001 Effects of smoking on reproductive health

10. Compared to men, women smokers… show greater physical and emotional dependence on cigarettes have poorer cessation outcomes gain more weight after quitting more often relapse after quitting (Jha et al., 2013; Perkins et al., 2001)

11. Women and Mental Health

12. Women are at least twice as likely as men to experience the most prevalent mental disorders (depression and anxiety) A cross-cultural phenomenon Gender differences emerge during adolescence and continue throughout life Cyranowski et al, 2000; NIMH Statistics, http://www.nimh.nih.gov/statistics/1mdd_adult.shtml

13. Risk of First Major Depressive Episode Bby Age and Sex 0.0000 0.0020 0.0040 0.0600 0.0800 0.0100 0.0120 0.0140 0-45-910-1415-1935-3940-4420-2425-2930-34 Female Male Age Category Hazard Rate Kessler et al, 1993

14. Smoking and Mental Health

15. People with all mental illnesses (AMI) and substance abuse (SUD) account for 40% of all cigarettes smoked (SAMHSA, 2013)

16. Smokers with mental illness have… lower cessation rates higher morbidity earlier mortality. (CDC, 2013; Lasser, 2000; National Health and Nutrition Examination Surveys 2005-2008) Adults with mental illness are twice as likely to smoke as people without mental illness.

17. Compared to men, women… more often smoke to reduce negative affect. show a stronger association between – smoking and depression – depression and cessation rates (Perkins et al., 2001 )

18. A Missing Piece? Women are relational creatures In response to stress we “tend and befriend” (rather than “fight or flight”) (Taylor et al., 2000)

19. Women are more sensitive to social stress than men Social isolationRelationship problems Cyranowski et al., 2011; Taylor, 2006

20. Compared to men, women smokers are… more responsive to their social environment. (Keicolt-Glaser & Newton, 2001 ) more reinforced (rewarded) by social cues than by nicotine. (Perkins et al., 2001) less likely (or able) to quit when a spouse or partner also smokes. (Homish & Leonard, 2005).

21. So... In addition to evidenced-based behavioral and pharmacological interventions, efforts to help women with smoking and mental health problems may benefit from taking into account important relationships (Shoham et al., 2006). For women, close relationships have double- edged significance. They can... -help to maintain smoking and some mental health problems. (Shoham et al., 2007) -provide a valuable resource for change. (Lyons et al., 2008; Rohrbaugh et al., 2008)

22. www.nimh.nih.gov Paving the Way for Prevention, Recovery, and Cure