# Do Determinants of Smoking Cessation and Relapse Differ between Men and Women? Data from a French National Study

Aurélia Manns, Hugo Torregrossa, Sarah Mahdjoub, Ramchandar Gomjee,
Maria Melchior, Fabienne El-Khoury Lesueur

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Aurélia Manns, Hugo Torregrossa, Sarah Mahdjoub, Ramchandar Gomjee, Maria Melchior, et al. Do Determinants of Smoking Cessation and Relapse Differ between Men and Women? Data from a French National Study. Substance Use and Misuse, 2023, 59 (2), pp.167-176. 10.1080/10826084.2023.2267106. inserm-05528771

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# Do Determinants of Smoking Cessation and Relapse Differ between Men and Women? Data from a French National Study

Aurélia Manns, Hugo Torregrossa, Sarah Mahdjoub, Ramchandar Gomajee,
Maria Melchior, Fabienne El-Khoury Lesueur

► To cite this version:

Aurélia Manns, Hugo Torregrossa, Sarah Mahdjoub, Ramchandar Gomajee, Maria Melchior, et al. Do Determinants of Smoking Cessation and Relapse Differ between Men and Women? Data from a French National Study. Substance Use and Misuse, 2023, 59 (2), pp.167-176. 10.1080/10826084.2023.2267106. inserm-05528771

HAL Id: inserm-05528771

https://inserm.hal.science/view/index/docid/5528771

Submitted on 26 Feb 2026

HAL is a multi-disciplinary open access
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entific research documents, whether they are pub-
lished or not. The documents may come from
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L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
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# Do Determinants of Smoking Cessation and Relapse Differ between Men and Women? Data from a French National Study

Aurélia Manns¹, Hugo Torregrossa¹, Sarah Mahdjoub¹, Ramchandar Gomajee¹, Maria Melchior¹, Fabienne El-Khoury Lesueur¹

* ¹Department of Social Epidemiology, Sorbonne Université, Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, IPLESP, Paris, France.
# Do determinants of smoking cessation and relapse differ between men and women? Data from a French national study.

There is limited understanding of different predictors of smoking cessation success (SCS) among women and men, despite well-documented differences in smoking behavior. Using data from DePICT (Description des Perceptions, Images, et Comportements liés au Tabagisme), a national survey of French adults which recruited 2377 regular and former smokers we investigated whether major determinants of SCS differed by sex. Factors associated with unsuccessful vs. No successful quit attempt; vs. SCS were studied using multivariate multinomial logistic regression analyses stratified by sex.

Women and men share some determinants of SCS including no cannabis use, living in a non-smoker household and importance giving to being a non-smoker. However, no e-cigarette use, low-to-moderate alcohol consumption, early smoking initiation, and higher education were associated with SCS only among women. No use of nicotine replacement, having family members who smoke, family opinion on smoking and current employment, were associated with SCS only among men. Neutral or negative friends' opinion on smoking or living with a smoker were associated with unsuccessful smoking attempts among men. Our results show differences between determinants of SCS according to sex, which highlights the importance of developing tailored interventions that account for sex/gender differences in smoking cessation.

Keywords: Smoking cessation, Sex differences, sex/gender, smoking

## Introduction

Smoking continues to be one of the major risk factors for global disease burden, leading to more than eight million deaths annually (Global Burden of Disease Study 2019 (GBD 2019) Data Resources | GHDx, s. d.), despite increasing tobacco control which contributed to the reduction of smoking prevalence worldwide (Flor et al., 2021). Tobacco-control science has also highlighted the need for medical support for smoking cessation success (SCS): combining behavioral support and pharmacotherapy is the most efficient strategy (Zwar, 2020).
## Nicotine dependence and smoking cessation

For the past decade, the role of gender and sex in nicotine dependence and smoking cessation has been discussed. Women experience unique barriers to smoking cessation and have more difficulty quitting compared to men (Schnoll et al., 2007; Smith et al., 2016). Biological sex has been reported to influence vulnerability to addiction, smoking behavior and smoking cessation (Bobzean et al., 2014; Reid et al., 2009; Riley et al., 2018). Estradiol is implicated in regulation of dopamine in the reward system associated with substance use disorders (Quigley et al., 2021) and there are reports that the menstrual cycle phase and ovarian hormones could affect smoking and cessation (A. H. Weinberger et al., 2015). Sex differences in smoking cue reactivity have been shown, in which males exhibit higher reactivity to smoking cues in reward-related regions of the brain compared to females (Dumais et al., 2017). Female smokers have been reported to have greater craving in response to stressful cues (Tomko et al., 2020), while men have higher scores on physical dependence scales (Bohadana et al., 2003; Grant et al., 2020).

## Substance use

Sex differences have been reported in the neurobiology of drug addiction (Bobzean et al., 2014). Alcohol drinking and cannabis use are highly prevalent among tobacco smokers (Agrawal et al., 2012; Han & Palamar, 2020). Both are obstacles to quitting tobacco (Driezen et al., 2022; Khati et al., 2015). Alcohol use disorder makes smoking cessation less successful, and alcohol consumption is associated with a higher risk of relapse among smokers trying to quit (van Amsterdam & van den Brink, 2023). In a previous paper from our team we have also shown that cannabis use is associated with a lower likelihood of SCS as well as relapse to smoking after quitting (because users are less likely to quit smoking) (El-Khoury Lesueur et al.,
2018). Sex differences have been shown in short-term effects of cannabis, with women reporting greater subjective effects than men at low doses (Matheson et al., 2020).

Women have been also reported to experience more withdrawal symptoms then men during quit attempts (Schlienz et al., 2017).

## Barriers and social pressure

Concerns about weight gain have been reported as gender-specific barriers to smoking cessation (Clark et al., 2006; Martin et al., 2016). Women are also reported to experience less effective social support while attempting to stop smoking (Torchalla et al., 2011). In El-Khoury Lesueur et al., 2018, we studied the effects of smoking perceptions on smoking cessation. Negative perceptions were more prevalent among participants who successfully quit, but friends' opinion was not significantly different between current and former smokers. Perception of non-smoking norms seem to be more linked to motivation to stop smoking in women compared to men (Jackson et al., 2020). Moreover, women experience additional pressure to quit smoking during pregnancy but are facing more barriers than facilitators (Bauld et al., 2017).

## Sex/Gender Inequalities

Multiple studies have reported inequalities between men and women in terms of smoking cessation (Henley et al., 2019; Jackson et al., 2019; Legleye et al., 2011), since women tend to maintain abstinence for a shorter time than men (Smith et al., 2016).

Some interventions have developed programs targeting female only participants like an intervention tested using a randomized controlled trial design in Brazil (Scarinci et al., 2022) which shows that it can successfully promote smoking cessation. Focus groups were set up prior to the trial to identify the motivating factors and the barriers to smoking cessation that are specific to women. The intervention, which consisted of a
home visit by a female community health worker, was built around these specific
features to feed into the motivational interviews. But the factors predicting success,
relapse, or failure of smoking cessation and their differences among women and men
are not yet well identified, when these differences could help optimize the design of
smoking cessation interventions. Thus, further research on these differences could lead
to more adequate support depending on the patient's sex/gender and potentially, a more
efficient one. In fact, Chaney et al., 2015 has highlighted the need for smoking cessation
programs which include gender specific interventions, and some novel smoking
cessation interventions are trying to take into consideration sex-specific differences to
improve effectiveness (Zawertailo et al., 2023).

In this secondary analysis of the Depict data, whose main objective was to study
tobacco related perceptions and behaviors among the French population, we investigate
whether there are sex differences in factors associated with SCS.

Methods

***DePICT: study design and recruitment***

DePICT (Description des Perceptions, Images, et Comportements liés au Tabagisme) is
a nationwide telephone survey of adults (18–64 years old) residing in Metropolitan
France. Participants were recruited via a computer assisted telephone interview (CATI)
system and interviewed via landline or mobile telephone between August 15 and
November 15, both in 2016 and 2017. Telephone lists were randomly generated and
cross-checked to remove wrong or professional numbers. This method has the
advantage of including both listed and unlisted phone numbers and therefore provides
maximum population representativeness. All phone numbers were dialed up to 30 times
at different periods of the day and week. In households reached by landline, one
participant was randomly selected by the CATI system (Kish method (de Rada, 2021)).

## Study Interview

Telephone interviews (average duration: 25 min) were conducted by 30 trained interviewers who administered the questionnaire from a call center equipped with computerized telephone stations. After a brief description of the study aims and participants' verbal consent, data were collected on: demographics, smoking status, smoking-related behaviors, and perceptions. Overall, 4456 people participated in the study in 2016 and 4114 in 2017, with respectively 56.7% and 54.0% current or former smokers (regular or occasional). The participation rate among adults was 63% for the first wave and 50% for the second wave

DePICT received approval from the ethical review committee of the French National Institute of Health and Medical Research (INSERM, CEEI-IRB00003888).

## Outcome variable and covariates

### Study outcome: smoking cessation and relapse

We chose to define as “Current smokers” participants who smoke at least one cigarette a day. Current smokers were asked whether they had ever attempted to quit smoking for at least one week, and if so, the duration of their longest quit attempt. Based on this information, the following study outcomes has been defined: 1. Current smokers who never quit or quit for less than 6 months (no successful quit attempt); 2. Current smokers who previously quit for at least 6 months (smoking relapse); 3. Former smokers who quit for at least 6 months (successful quit attempt). Six months of abstinence has been suggested and is commonly used as a standard period to define smoking cessation (Piper et al., 2020; West et al., 2005). Current smokers were asked
about the daily number of cigarettes smoked, while former smokers were asked whether they had smoked “less than 10 cigarettes”, or “at least 10 cigarettes” a day when their smoking was at its highest. Phone operators classified participants as men or women according to their voice, and in case of uncertainty, they asked participants to confirm whether they were a man or a woman.

## Risk factors

We examined potential risk factors which are associated with tobacco use in the literature and could have different distributions according to sex/gender of the participant. These risk factors were split into three categories: substance use, social support, and smoking perceptions.

## Substance use

All participants were asked about cannabis use in the preceding 12 months (yes/no), lifetime use of an e-cigarette (yes/no), and alcohol use (At least 2 drinks per week / at most 4 per month). Cannabis and alcohol were examined because they are associated with smoking use and present differences between sex or gender, as described earlier. E-cigarette use has shown heterogeneous results on smoking cessation but according to randomized controlled trial evidence, it can help to quit successfully (Villanti et al., 2018).

Different aspects of tobacco use have been considered, including: the number of cigarettes smoked daily (≥ 10/0–9), lifetime use of nicotine replacement products (yes/no), age of regular smoking initiation (≤17, >17 years old), because their roles are essential in smoking cessation (Choi & Stommel, 2017).

## Social support
Social support has been evaluated by the household tobacco exposure (living with a smoker: yes, no, living with a smoking partner, living alone), proportion of smokers among friends and among family (most vs. some or none), opinion of family and of friends on smoking (acceptable/neutral/unacceptable). Moreover, it seems relevant to dissociate family and friends because of their different approaches and the way their views would be received by the participant.

Smoking perception

We also measured the importance given to not smoking (yes/no). As mentioned in the
introduction, this enables us to assess the participant's perception of smoking, as well as
his or her motivation to quit.

Other covariates

Several factors potentially associated with tobacco use were also studied.

Sociodemographic characteristics were defined by: age (grouped into categories to
examine nonlinear relationship with study outcomes: 18–24, 35–44, 45-54, 55–64 years
old), educational attainment (< high school degree, 2 years post-secondary, 3 years
post-secondary), current employment (yes/no) and year of investigation (study wave:
2016, 2017), to take social inequalities into account (Levy et al., 2005).

Statistical analyses

The probability of being solicited through a landline or mobile phone was calculated for
each participant, taking into account the Kish method (number of eligible
individuals/telephone lines in the household/owned by the person). Data were then
weighted based on the inverse probability of being solicited. Additionally, weights were
used to make participants representative of the French population in terms of sex, age,
educational attainment, region of residence and population density, based on data from
the French National Institute of Statistics and Economic Studies (2016) (Activité, emploi
et chômage en 2016 - Insee Résultats, s. d.).

In this analysis, only current and former smokers who attempted to quit tobacco
after 2010, the year in which e-cigarettes were introduced in France (Andler et al.,
2016) were included (n = 2377).

Multivariable logistic regression models were implemented to test whether
potential determinants of smoking cessation are associated with our study outcome,
stratified by sex. The reference category for the outcome variable was “no successful
quit attempt”.

All analyses were conducted using SAS 9.4, and all tests were two tailed with
statistical significance set at the 5% level.

## Results

### Participants characteristics

Tables 1 and 2 show characteristics of participants included in the statistical analyses
according to their smoking cessation patterns and sex.

Among all women included in our study (n = 1040): 52.4% never successfully
quit smoking, 31.8% quit for at least 6 months but later relapsed, and 15.8% achieved
long-term smoking cessation. Among men (n = 1337), 64.3% never successfully quit,
20.3% relapsed, and 15.4% succeeded.

### Multivariate multinomial analysis

Tables 3 and 4 show associations between all covariates and smoking cessation
patterns tested by a multivariate logistic regression model, respectively among women
and men.
Among women, participants who used cannabis in the year were less likely to successfully quit smoking compared to those who did not (OR = 0.09[0.02-0.46]). Lifetime e-cigarette use (OR = 0.24[0.16-0.37]), drinking alcohol more than twice a week (OR = 0.50[0.28-0.88]) and starting to smoke after 17 years of age (OR = 0.51[0.33-0.79]) were significantly linked with lower rates of successful smoking cessation but also lower rates of relapse (respectively, OR = 0.63[0.45-0.87]; OR = 0.48[0.32-0.72]; OR = 0.71[0.51-0.98]). Living in a non-smoker household compared with living alone was associated with higher levels of smoking cessation (OR = 3.20[1.97-5.21]) but also a higher risk of relapse (OR = 1.80[1.22-2.65]). The same pattern was found for post-secondary degree compared to less than high-school (OR 2 years post = 2.27[1.25-4.14] and 1.64[1.08-2.49]; OR 3 years post = 5.02[2.57-9.77] and 2.13[1.32-.45]). Women living with a smoking partner were more likely to relapse (OR = 1.85[1.25-2.74]), as well as women having no or few smoking friends (OR = 1.54[1.04-2.30]). On the contrary, lifetime use of nicotine replacement products, the proportion of smokers in the family, opinion of friends or family about smoking, and currently working were not significantly associated with smoking cessation patterns.

Conversely, among men, alcohol use, lifetime e-cigarette use, age of smoking initiation, the proportion of smokers among friends, and level of education were not associated with smoking cessation patterns. But men who were currently working were more likely to successfully quit smoking (OR= 1.86[1.20-2.89]). Men who used cannabis in the preceding year were less likely to successfully quit smoking compared to those who did not (OR = 0.37[0.21-0.67]) and they were also less likely to relapse (OR = 0.48[0.31-0.72]). Lifetime use of nicotine replacement products was associated with lower rates of SCS (OR = 0.61[0.41-0.90]). Having some or none smoking family members (OR = 1.55[1.04-2.31]), and reporting a neutral opinion of the family on
smoking (OR = 2.26[1.27-4.00]) were associated with better rates of successful cessation while neutral or disapproval opinions from friends (OR = 0.53[0.33-0.86] and OR = 0.49[0.28-0.86]) were associated with fewer rates of success. Men living in a smoking household compared to men living alone were less likely to succeed in smoking cessation (OR = 0.22[0.09-0.53]), but living with a smoking partner was not associated with smoking cessation (OR = 0.54[0.29-1.01]). Living in a non-smoking household was associated with better success in smoking cessation (OR = 2.49[1.65-3.77]) and a lower likelihood of relapse (OR = 0.65[0.45-0.94]).

Both men and women who reported that not smoking is important for them were more likely to successfully quit smoking compared to those who did not give much importance to being a non-smoker (OR = 9.37[5.61-15.64] and OR = 4.57[2.68-7.77]). For both sexes, smoking more than ten cigarettes a day prior to smoking cessation was also significantly associated with a lower rate of relapse (OR = 0.57[0.39-0.82] and OR = 0.60[0.42-0.84]).

## Discussion

In this representative study of smokers and former smokers in France, the majority of the factors associated with smoking cessation patterns differed in women and in men. Among women, there was a negative relationship between alcohol consumption and e-cigarette use, and the ability to quit smoking. However, this association was not observed among men. The opinion of friends and family members was associated with smoking cessation among men but not in women. Women were more likely to succeed in quitting smoking if they had a higher level of education, while men had higher rates of success if they were working.
## Interpretation

Studies have shown an association between psychiatric disorders, heavy alcohol use, and greater difficulty with nicotine withdrawal among women than among men (A. Weinberger et al., 2009). Thus, a lower rate of SCS and relapse among women who consume alcohol more than twice a week can be partly explained by stronger nicotine withdrawal symptoms. Moreover, overall alcohol consumption is generally greater in men compared to women, but this difference is narrowing; and White, 2020 suggests that women are more susceptible than men to health risks induced by alcohol consumption. Thus, alcohol consumption among women could be seen as a more severe additional comorbidity preventing them to quit smoking than it is for men.

Multiple studies report that tobacco and cannabis consumption are linked with lower chances of smoking cessation (Driezen et al., 2022; Rabin et al., 2016). Previous investigations led by our team (El-Khoury Lesueur et al., 2018) also found evidence that cannabis use deters individuals from attempting to quit smoking. People using cannabis could therefore probably make less attempt to quit in the first place, and cannabis could be an additional cue which triggers tobacco cravings. There is some evidence that women experience more intense subjective effects of cannabis than men when they use it daily (Cooper & Haney, 2014), which might explain a stronger association between cannabis use and unsuccessful smoking cessation among women. Moreover, the levels of addictive behaviors among women are overall lower and more associated with psychological problems and traumatic experiences than among men (Embersin-Kyprianou et al., 2020), which could explain greater difficulties to quit.

Wang et al., 2021 show that e-cigarette use is not associated with smoking cessation when it is used as a consumer product, in comparison to when it is used as a therapeutic device. In our study, e-cigarette use is in fact associated with lower rates of
SCS among women while it is not associated with smoking cessation among men.

According to Piñeiro et al., 2016, men were more likely to use e-cigarettes to quit smoking while women used it on social recommendation or for weight control and reported higher negative reinforcement attributions. These results can be explained by our population because the majority of participants were not trying to quit smoking. E-cigarette ineffectiveness, as well as the fact that nicotine replacement products seem to be less effective for women than for men, can also be explained by the lack of medical guidance or follow-up when such products are bought over the counter.

Although it has been proven that an early initiation of smoking leads to higher nicotine dependence (Keady et al., 2022), a lower rate of success has been found among women who started smoking after 17 years of age compared to before 17 in our sample. A lower rate of relapse is also observed, which can lead to the hypothesis that female participants with a late tobacco initiation were making fewer attempts to quit. It can also be explained by factors affecting smoking initiation: impulsiveness and sensation seeking are linked with smoking initiation among boys whose smoking is more socially accepted, while adolescent girls seem to start smoking due to stressful experiences and comorbid internalizing disorders which may make quitting more difficult. (Hammerslag & Gulley, 2016). However, since the group of participants who had never succeeded in quitting smoking had a slightly lower average age, this association may also be explained by a smaller time widow to successfully quit.

Living with non-smokers was more strongly associated with the success of smoking cessation compared to living alone, possibly because of the feeling of exclusion. This could also be explained by the overall poorer health of people who live alone (Hawkley & Cacioppo, 2010). But in terms of relapse, very different results have been observed among women and men: women seem to relapse more while men
relapsed significantly less. It could be explained by women being less sensitive to social support (Murray et al., 1995) and this is reinforced by the higher rates of relapse among women living with a smoking partner and the lower rates of success among men living with a smoker. Moreover, no difference has been observed in smoking cessation patterns among women depending on the proportion of friends who smoke, or family's and friends' opinions on tobacco, only a higher risk of relapse when they didn't have smoking family members. On the contrary, men had higher chances of success if their friends were not smokers, but also higher risk of relapse, and lower chances of success if their friends had a neutral or poor opinion on smoking, which might demonstrate their need of 'non-judgmental' support from friends. Men had higher chances of success if their family members were not smokers, and if their family had a neutral opinion on smoking, which contrasts with the results about friends' opinions. This can be explained by the fact that opinion from family can be more welcomed such as positive pressure which is leading to motivation, while opinion from friends could be more stigmatizing concerning tobacco use. A qualitative study which took place in the Netherlands (Dieleman et al., 2021) supports this hypothesis, showing that when it comes to counselling smokers, women are more sensitive to internal problems while men tend to focus on external obstacles. So according to this hypothesis, men are more likely to depend on family's and friend's opinions. These results support the need to adapt motivational instruments according to the patient's sex/gender.

Women and men face different social inequalities in smoking cessation. According to our results, women are more likely to successfully quit if they have higher education, but this group also has a higher risk of relapse. However, higher education was not associated with smoking cessation among men in our study. This may be explained by the fact that women are more aware and concerned by health risks of
smoking when they have a higher level of education, which can lead to a better
 treatment compliance and a better knowledge on how to get help. Indeed, Hiscock et al.,
 2011 showed that treatment compliance is one of the major factors producing social
 inequalities in smoking cessation. Men had a higher likelihood to succeed in smoking
cessation when they were currently working, which wasn't the case among women. It
can be explained by the distance from a smoking household while at work (as shown by
the association with environmental tobacco exposure), household smokers being
another major factor cited by Hiscock et al., 2011, or by the need to have a better
physical condition for a more physically demanding job (seen as an external obstacle).

Limitations

The first limitation is that being cross-sectional, DePICT study includes two
groups of distinct participants, the first wave took place before the introduction of a
plain cigarette packaging in France, the second one took place one year later. This law
change, with a rise of tobacco price, could have influenced participants in the second
wave to quit smoking more than those from the first wave. However, the adjustment on
the study wave have reduced the risk of a bias. Second, some variables could be
influenced by recall bias, but our data were consistent with other nationally
representative studies.

Finally, selection bias cannot be ruled out, since only two third of eligible adults
agreed to participate in our study. Therefore, such bias has been minimized by
weighting our analysis to have a representative sample of the French population.

Further, the sex/gender of the participants was determined by voice recognition
except in cases of uncertainty where participants were asked to confirm whether they
were a man or a woman (the number of times this might have happened was not
measured). As a result, some participants may have been misgendered. Moreover,
sex/gender was coded as a binary variable, thus overlooking gender minorities who
might have distinct smoking-related behaviors.

Conclusions

Based on a representative sample of the French population, our study highlights
important differences between sex/gender when it comes to factors influencing smoking
cessation. Social norms, socio-demographic characteristics (education level) and the use
of other substances (alcohol, cannabis) were not similarly associated with quitting
tobacco in men and women. However, these variables could be used to adapt gender/sex
specific smoking cessation interventions. Our results therefore highlight the need to
design and test such targeted interventions.

Acknowledgments

We thank members of the DePICT scientific committee: François Beck (OFDT), Renaud Crespin (CNRS), Karine Gallopel-Morvan (EHESP), Gwenn Menvielle (INSERM), Brigitte Metadieu (Association Charonne), Viet Nguyen-Than (ANSP), and Peretti-Watel (INSERM) for their help in discussing the study protocol, questionnaire, and planned analyses. We also want to acknowledge Carla Estaquio and Antoine Deutsch from the French National Cancer Institute (INCa). We also like to acknowledge "MV2" polling institute, as well as "CDA" for monitoring and auditing the study's execution.

Conflict of Interest

The authors have no competing interests to report.

Role of funding source

This research was funded by the French National Cancer Institute (INCa) under grant N°2016-097. INCa had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Contributors
MM is the PI and FEKL the co-PI of the DePICT study. All authors were implicated in designing the study, analyzing the data and in the manuscript preparation. AM wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.

Data availability

The data are available upon request from corresponding author.

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