Although the percentage of women who smoke is declining, the United States still has more than 20 million women and girls who currently smoke cigarettes, according to the U.S. Centers for Disease Control and Prevention.
Smoking puts these women at increased risk for heart attacks, strokes, lung cancer and other chronic illnesses such as emphysema and diabetes. In fact, more than 170,000 American women die of smoking-related illnesses each year, with lung cancer accounting for more deaths than breast cancer.
Despite decades of government-sponsored anti-smoking campaigns and the development of medications to aid quitting, as Dr. Philip Smith points out, smoking remains the leading cause of preventable death and illness in the United States.
Tobacco dependence, Smith explains, is a particularly serious health challenge for women for another important reason: women have more difficulty quitting smoking than men.
A BIRCWH Scholar (see box on page 7) and Associate Research Scientist in Yale’s Department of Psychiatry, Smith is examining differences between women and men in smoking behavior and smoking cessation in order to provide the necessary data for implementing more effective gender-based therapies. In particular, as part of his training as a junior faculty BIRCWH Scholar, he is investigating smoking cessation approaches using medications such as the nicotine patch and varenicline (Chantix), to determine which methods may help women improve their chances of quitting.
“The overall goal is to help smokers, both women and men, make informed decisions about which medications work best, and to communicate the findings to health care providers as well so that, when they are recommending treatment, they are aware of important gender differences,” Smith said.
Smith was selected — from a highly competitive national field — to fill one of two junior faculty research training slots under a federally-funded research training grant awarded to Dr. Carolyn M. Mazure, as Principal Investigator.
This $2.5 million grant — the Building Interdisciplinary Research Careers in Women’s Health, or BIRCWH — provided the funding for our Yale program to train exceptional junior faculty interested in a research career focused on women’s health and addictive behaviors. The training program is available only to top-tier candidates who have earned an M.D., Ph.D., or equivalent and have already completed post-doctoral training.
Smith grew up in Buffalo, N.Y., and early on developed keen interests in math and statistics, coupled with a desire to help people with health challenges. While pursuing a master’s degree in Epidemiology and a Ph.D. in Community Health and Health Behavior from the School of Public Health and Health Professions at the University of Buffalo, he worked at the Roswell Park Cancer Institute, the nation’s oldest cancer center. His work included educating smokers about the dangers of their smoking, and his epidemiology courses allowed him to put his knack for statistical analysis to use for determining the risk factors and health outcomes of smoking.
He considered attending medical school, “but the classes I was taking showed me how much I enjoyed doing science, and my experiences led me to pursue a career in health research,” Smith said.
While pursuing his doctoral degree, Smith also completed an internship at a center for victims of partner violence, conducting intake interviews of people seeking help — mostly women.
“That’s when I really started to get interested in research on women’s health, including the underrepresentation of women in clinical research, and the lack of attention to sex differences in research across various health conditions,” Smith said.
He began investigating the interplay between addictive behaviors and violence between partners — a key health challenge for women. For his dissertation, Smith was part of a team of investigators that found a significantly lower incidence of partner violence among married couples who smoke marijuana. This was a controversial and surprising result given that the use of other substances, such as alcohol, is known to increase partner violence.
The study, published in 2014 in the journal Psychology of Addictive Behaviors, was partly funded by the National Institute on Drug Abuse. The institute, part of the National Institutes of Health, has a particular interest in understanding the health effects of marijuana, and the social, behavioral and public health impacts of policy changes related to marijuana, as many states ease restrictions for medical and/or recreational use.
The problem with previous studies which showed inconsistent results, according to Smith and his colleagues, was that prior reports used data from one point in time. Their more thorough study examined 634 couples during the first nine years of marriage, gathering information on marijuana and alcohol consumption habits, antisocial behavior, tendencies toward partner violence and past incidents.
Smith was quick to add that these findings certainly do not endorse the use of marijuana. Rather, they identify those substance use behaviors which are more or less likely to contribute to partner violence.
Smith began his training as a Yale BIRCWH Scholar in July 2014 and will be in the program for two years — until June 2016, with a possibility of a third year. His mentor, Dr. Sherry McKee, is a Professor of Psychiatry and Research Director for the BIRCWH Scholar program. She is the Director of the Yale Translational Center to Develop Gender-Sensitive Treatment for Tobacco Dependence, funded by
a federal grant that stemmed in part from her work on a WHRY-funded study investigating gender differences in smoking and cessation.
With grant support from The Grace J. Fippinger Foundation, Smith’s primary BIRCWH project is to determine which medications work best for women trying to quit smoking.
Nicotine replacement therapies, such as the nicotine patch and gum, are the most commonly used interventions to aid in quitting smoking. But they do not appear to work as well for women compared to men. This is likely because men dependent on tobacco tend to light their next cigarette to satisfy their biological craving for nicotine, while women tend to smoke to alleviate negative mood or reduce stress — symptoms not addressed by nicotine replacement therapies.
Specifically, Smith is comparing the efficacy in clinical trials of women vs. men using the nicotine patch, and evaluating the difference between the patch and varenicline for women and men.
His project represents a massive undertaking, a comprehensive review of more than 30 studies published since 1990, sifting the data for information on sex differences.
“One of our major findings so far is that varenicline is more effective for women trying to quit than the nicotine patch,” Smith said.
“Varenicline provides an advantage compared to the patch for both women and men, but the advantage with varenicline is much greater for women than for men,” he said. “For women, varenicline may do a better job of curtailing smoking related to stress. There is also evidence that varenicline reduces craving for cigarettes, particularly in reaction to environmental cues. This ‘cue-induced’ craving has been shown to be stronger in women than men who smoke.”
Smith said the next step is to study gender differences in how well these medications work for smokers trying to quit in real-world contexts as opposed to controlled clinical trials. “So far, the available data have mostly come from clinical trials which tend to recruit otherwise healthy smokers. We know that smokers trying to quit in real world contexts often have other physical and mental health concerns, and tend to have less interaction with health care providers than research participants,” he said.
Smith will also work with mentor Dr. Rani Hoff, Professor of Psychiatry and Epidemiology, and Director of the WHRY interdisciplinary Research Core on Women and Trauma, to determine the prevalence of tobacco use among homeless military veterans. Importantly, the study will determine the frequency with which these male and female veterans are referred for therapy for nicotine dependence, and whether these factors differ by gender.
“Around 80% of homeless people smoke cigarettes. This obviously presents a large health burden for those who already have very limited resources. Homeless veterans tend to have at least some contact with the VA healthcare system, so we want to look at whether they are being referred to treatment for smoking cessation,” Smith said.
Looking forward, Smith expects his BIRCWH experience to help him flourish among a growing number of researchers improving the health of both men and women by studying gender and addictions. “The BIRCWH program is a phenomenal launching pad for someone who wants to learn how to study gender and health,” Smith said.
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