Getting Smoke-free: An Information Kit For Community Organizations Working With Women

Materials for Providers

• About This Kit - Who it's intended for, what it contains, and how it might be used
• Women and Tobacco in Canada: Some Facts and Figures - Selected statistics on women and smoking, including rates, recent trends and other important facts
• The Health Risks of Smoking - Major health risks -- for both men and women, for women only, and from second-hand smoke; a few notes about how to get your message across
• Why Women Smoke - An overview of the factors that contribute to women's smoking behaviour; suggested topics for group discussion
• Cessation Programs that Work - Food for thought on the characteristics of successful cessation programs for women; what role women's organizations can play
• Tailoring Your Efforts - Some food for thought on how to meet the special needs of selected groups
• Understanding and Using the Stages of Change - The five stages for getting smokefree, highlighting program strategies for each one; suggested topics for discussion

Materials for Participants

• Useful Facts About Smoking - Some commonly asked questions (and answers) about women and smoking
• The Healing Process - What to expect when you quit; the good news about quitting
• Managing Your Stress - Some positive approaches to stress reduction
• Look Good, Feel Good: Maintaining a Healthy Weight - Practical tips for managing your weight
• Getting Active - A few easy stretches to get your body moving
• Canada's Food Guide to Healthy Eating - An easy-to-use reference to help you practise balanced, healthy eating

About This Kit

What it is

Getting Smoke-Free: An Information Kit for Community Organizations Working With Women is a resource on smoking reduction and cessation designed with women in mind. It provides facts, figures and program suggestions on a range of topics related to women's smoking behaviour -- from why women smoke and the health risks they face, to what makes a successful reduction/cessation program and where to get more information. It includes resource material both for providers and the women who are their clients.

Much of the information presented in the kit is based on research sponsored by Health Canada under its Tobacco Demand Reduction Strategy, including:

• research and fieldwork conducted by academics, tobacco control agencies and program providers
• in-depth consultations with priority women (including those living on low incomes, women who have been abused, new immigrants and women from minority racial and ethnic groups)
• consultations with non-traditional service providers (community-based women's groups and centres)

What it isn't

The kit is not meant to be a comprehensive review of the literature or a stand-alone, smoking reduction/cessation program. Rather, it offers an overview of information in key areas, some "food for thought" about women and smoking, and ideas about where to go for more information.

Who it's for

This kit is designed to be useful to a range of program providers who work with women -- including providers in traditional tobacco control agencies, and those working with community groups and women's centres currently offering women's programming in such areas as self-esteem and self-care. Public health nurses and physicians may also find the materials useful.

Why it's needed

Up to now tobacco control issues have often taken a back seat to other pressing concerns -- violence, poverty and equality issues, for example. But taking action on women and tobacco issues can have broad-reaching effects for social change and personal empowerment. By learning new coping skills and finding out more about themselves, women can use this knowledge in other areas of their lives. If women's groups and organizations at the community level decide to champion the cause of smoking cessation among women, much can be accomplished.

How to use it

This kit is designed as an easy-to-use reference about women and smoking. Depending on your own and your clients' needs and areas of interest, you can use the information in a number of ways:

• by building it in to programs already under way in related areas (for example, in discussions about women's coping strategies or in prenatal programs)
• to respond to clients' questions and concerns about smoking
• to help refer women to other providers or to full-scale cessation programs
• by making the information materials available to your clients (e.g., post them on bulletin boards, insert articles or facts into newsletters or information flyers)
• as a resource to find out where and how to get more information about women and smoking

The kit includes nine leaders' modules as well as supporting materials that can be distributed to clients. Photocopy and use these materials to help increase your clients' awareness and knowledge about smoking. You can also assist in getting the smoking cessation message out by passing the information along to your colleagues.

Women and Tobacco in Canada

Some Facts and Figures

Up until now, men of all ages have smoked more than women. But things are starting to change. Over the last decade and a half, the smoking rate for men in Canada has dropped significantly. At the same time, the percentage of women who smoke declined only slightly. If these trends continue, Canadian women will soon be smoking more than men.

For your information ...

• 25% of Canadian women smoke -- (21% on a daily basis, 4% non-daily), compared to 29% of men
• women aged 15-19 have higher rates of smoking than men in the same age group (26% vs. 25%)
• more women aged 20-24 smoke (37%) than in any other age group
• for both men and women, smoking is inversely related to income -- the lower the income, the higher the smoking rate
• women smoke fewer cigarettes than men (an average of 15.6 cigarettes per day vs. 19.6 per day)
• of the reasons women give for smoking, "liking it" is the most frequent (38%), followed by "habit" (36%), "to relax" (19%) and "addiction" (14%)
• the reasons women most often give for quitting smoking are "concerns about their future health" (32%) and "present health" (26%)
• teen smokers aged 15-19 are the age group most open to quitting, while the next oldest age group (20-24) is the most resistant
• more than half (58%) of women smokers continued to smoke during their last pregnancy; almost three-quarters (74%) were regularly exposed to their own or their partner's smoke while pregnant
• women are more likely than men to know about the health risks associated with smoking
• the vast majority of men and women (almost 90%) quit smoking "cold turkey" and without the help of a stop smoking program
• 59% of current women smokers are not even thinking about quitting smoking, while 41% are considering quitting soon or sometime in the future

A practical note ...

If you're a program provider, having a range of general smoking information at your fingertips can help you plan appropriate programs and respond to your clients' questions and concerns about smoking. This section provides a quick overview of women's smoking behaviours and attitudes -- including some key facts, figures and trends to keep in mind.

References

Health Canada. (1994). Survey on Smoking in Canada, (Cycles 3, 4). Ottawa: Government of Canada.

The Health Risks of Smoking

As women's smoking rates increase, they are more and more likely to experience a whole range of smoking-related diseases. Although some of the health risks of smoking are widely known, women may not be aware of all the risks -- to themselves and their unborn babies -- and the risks of breathing second-hand smoke.

The great equalizer ...

An "equal opportunity" health risk, smoking is the leading killer of women in Canada. In many provinces, lung cancer is overtaking breast cancer as the leading cause of death for women.

Women -- like men -- who smoke are at increased risk of:

• coronary heart disease
• lung cancer
• breathing problems, such as emphysema and chronic bronchitis
• cancer of the throat, mouth, larynx, esophagus, pancreas, kidney, bladder

For women only ...

Women who smoke have many health risks that men who smoke don't have. They tend to have disorders related to their reproductive system, including menstrual problems and an earlier menopause. Early menopause means a woman is more likely to develop osteoporosis, a weakening of the bones that can result in long-term pain, disability and even permanent disfigurement. Smoking during pregnancy can also affect the health of the fetus and the pregnant woman.

Smoking among women is linked to:

• lower fertility
• stroke (especially when women smoke and take birth control pills)
• cancer of the cervix (the opening to the womb)
• osteoporosis (weakening of the bones)
• menstrual and menopausal problems
• miscarriage, premature births and stillbirths
• low birthweight babies
• reduced breast milk
• Sudden Infant Death Syndrome (SIDS), breathing difficulties and slowed growth in infants

Where there's smoke ...

Second-hand smoke is a combination of the smoke released from the burning end of a cigarette (or cigar, etc.) together with the smoke a person exhales into the air. Also known as environmental tobacco smoke (ETS), second-hand smoke contains more than 4,000 chemicals -- at least 40 of these are known to cause cancer, and others either help cancer to get started or make it grow faster. Infants, children and people with breathing and heart problems are most vulnerable to the effects of second-hand smoke.

if a pregnant women regularly breathes second-hand smoke, it can have almost the same effects on the fetus as if the mother smoked, including:

• low-birth weight baby
• premature birth
• spontaneous abortion
• lung damage
• birth defects

because infants and children are still growing, breathing second-hand smoke can have both immediate and long-term effects, including:

• breathing illnesses, such as bronchitis, asthma and pneumonia
• reduced lung capacity
• more coughs, wheezing and phlegm
• Sudden Infant Death Syndrome (SIDS)
• middle ear disease (including ear infections)

Did you know that second-hand smoke ...

• increases the risk of heart disease and lung cancer in otherwise healthy non-smokers?
• contributes to clogging, hardening and obstruction of the arteries?
• can affect a non-smoker's lung capacity the same as if she smoked 1 to 10 cigarettes a day?
• can aggravate the heart, lung or allergic conditions experienced by up to 1/4 of Canada's population?
• increases the risk of death from heart disease by 20 to 30% for non-smokers married to smokers?
• irritates the eyes, nose, throat and respiratory system, and causes headaches, nausea and dizziness?

A practical note ...

Although it's important for women to be aware of the health risks associated with smoking, it may be difficult for them to talk about it. If you start a discussion on this issue, be prepared for your clients to be a little defensive or even to deny that there is a health risk at all.

Now that the dangers of second-hand smoke are more widely known, there is a lot of pressure on women to stop smoking during pregnancy, and around infants and children. Many women and men feel guilty and angry about being labelled a "bad parent" if they smoke. Program providers need to offer information, support and encouragement to their clients, without passing judgment.

"I can't even make it up to Winchester Street, that's pretty sad ... yeah. My legs throb and everything." (Centre for Health Promotion, 1995)

"Yeah I do (feel bad about smoking), because I do a lot of things to damage my body and I feel bad about it. Like I say, you can't do anything unless you pay for it." (Centre for Health Promotion, 1995)

About Fear Tactics

Sometimes it's tempting to try and get the "stop smoking" message out to women by using "fear tactics" -- pictures or statistics that drive home the negative health effects of smoking. Keep in mind that most women can't be scared into quitting -- and if they are, the effects rarely last. In fact, fear tactics can have the opposite effect and leave your clients feeling more out of control and helpless than before.

References

Canadian Council on Smoking and Health. (1993). A New Start in Life: About Pregnancy and Smoking. Ottawa.

Centre for Health Promotion, University of Toronto. (1995). Consultation with Priority Women. Prepared for Health Canada.

Greaves, L. (1990). Background Paper on Women and Tobacco (1987) and Update (1990). Ottawa: Health Promotion Directorate, Health Canada.

Health Canada. (1995). Smoking and Pregnancy: A Woman's Dilemma. (Booklet 1 of The Tobacco Free Booklets for Prenatal and Postpartum Providers). Ottawa. Government of Canada.

Health Canada. (1995). The Effects of Tobacco Smoke and Second-Hand Smoke in the Prenatal & Postpartum Periods: A Summary of the Literature. (Booklet 3 of The Tobacco Free Booklets for Prenatal and Postpartum Providers.) Ottawa. Government of Canada.

Health Canada. (1995). Tobacco Control: A Blueprint to Protect the Health of Canadians. Ottawa. Government of Canada.

Health Canada. (1995). Women and Tobacco: A Framework for Action. Ottawa. Government of Canada.

Heart and Stroke Foundation. Fact Sheet: Environmental Tobacco Smoke: Behind the Smoke Screen. Cat. 34099512.

Heart and Stroke Foundation. Second-Hand Smoke and Your Heart (Brochure). Cat. 34059522.

Heart and Stroke Foundation. Smoking and Cardiovascular Disease: The Heart of the Problem (Fact Sheet).

Heart and Stroke Foundation. Tobacco and Your Heart (Brochure). Cat. 34095222.

Heart and Stroke Foundation. Women and Tobacco: Of Smoke and Mirrors (Fact Sheet). Cat. 34079212.

Hotz, Stephen. (1995). Understanding and Using the Stages of Change (Info Pack). Program Training and Consultation Centre. Prepared for the Ontario Ministry of Health and Health Canada.

Kinnon, Diane. and L. Hanvey. (1995). Delivering Gender-sensitive Tobacco Reduction Programs: Issues and Approaches. Prepared for Health Canada.

Why Women Smoke

When we know so much about what smoking does to our bodies, when there are fewer and fewer places where it's acceptable to smoke, why do women continue to smoke? Many of the reasons women smoke are tied to what they've experienced in their lives, and to their place in the larger society. A range of factors come into play -- including women's self-esteem, sexuality, body image, the influence of family and friends, financial pressures and daily workload. Social and environmental influences play a key role in women's smoking behaviour

Why do women smoke? Quotes are from: Centre for Health Promotion (1995)

To deal with stress and depression ... I think cigarettes are a medicine. I really truly believe ... I don't know. I find other people tell me that too, they think that cigarettes are a medicine for you, it keeps you calm. )

Smoking gives women some relief from dealing with money pressures, the responsibilities of work and family, or volatile relationships. If they don't have other options for coping with stress, women turn to cigarettes in times of anxiety or crisis.

For enjoyment ... I think it's the only pleasure to be perfectly honest. I enjoy it.

For many women, smoking is enjoyable -- the only small luxury that they have over the course of a busy day. It's the friend who is always there, never makes demands and delivers just what's expected.

Because tobacco is addictive ... In a way, smoking is something like alcoholism. You get tied up in that too.

Tobacco is an extremely addictive drug that is as hard to "kick" as alcohol or heroin. The withdrawal symptoms from nicotine include irritability, nervousness, depression and a sense of great loss.

As a sign of control over their lives ... It's the one thing I can do that I've got control over. I can control what I smoke. And personally, at the moment that's about the only thing I can control in my life ...

For some, smoking can be an act of independence and control when other areas of their lives seem out of control. For example, women who balance the demands of work, caregiving and household responsibilities may see smoking as the one thing they do that's manageable; women in abusive relationships sometimes smoke to show defiance, or to gain a small measure of freedom.

To relax ... A relaxing time ... here at coffee time, I'm enjoying my tea or my cigarette, or a glass of water and a cigarette -- anything with a cigarette is a good thing.

In the middle of the turmoil and activity of the day, a cigarette break can be a welcome reward. The "cigarette and coffee break" is something to look forward to -- one way of dropping out for a moment and taking stock.

To pass the time ... I think we do it out of boredom too, though. Because there's not really a lot to offer around.

For at-home mothers and women who are unemployed, smoking is one way of filling in time, of coping with boredom.

To control their weight ... He says not to smoke around the baby and all that ... he jumps down my throat because I won't quit ... but I would rather stay smoking than gain weight.

One of the reasons women most often give for smoking is to help them control their weight. Women learn early on about cultural ideals for body weight. Television, magazines and movies, and tobacco advertising promote unrealistic images of women, that equate being thin with being physically attractive.

To deal with "negative" emotions ... I have a hard time expressing anger constructively. I use cigarettes to suppress this anger.

Most women grow up believing that only men are allowed to get angry, and that showing their anger is unacceptable. Believing this doesn't keep women from getting angry -- it just keeps them from being open about their feelings. Smoking is one of the ways women have of keeping their anger hidden.

In social situations... It's kind of like you had to have a cigarette so you could say, "Can I get a light off you?" or just ... there's something social about it.

Smoking is a social act that links people together in a shared activity. It helps break the ice between two strangers or brings friends closer together. Cigarettes can also work as a social "crutch" -- something to focus on in awkward situations. Now that many buildings are "non-smoking," smokers must often go outside or away from non-smokers. This helps to create a sense of belonging to a group, of being part of a clique.

Because their family and friends do ... I'm a bad influence. I find she can take it or leave it ... but when I light up, so does she.

Women's smoking behaviours -- whether they start or try to stop, and how much they smoke -- are influenced by what their close friends and family members do and say. Women who quit smoking may even find their friendships get strained when they're not sharing the habit any more. Living with a partner who smokes can make cutting back or quitting especially difficult.

The big picture

Understanding the influences on women's smoking behaviour means looking at their place in society. Much of the stress that women deal with is directly related to inequalities they experience because they are women -- many are in low-paying jobs, have few employment opportunities and have little power at home or at work.

For many women, smoking is a practical tool that helps them cope with the stress in their lives. Being "female" may even train women for addiction by discouraging them from learning healthy ways of managing their stress, and allowing them less control than men. For example, women may have difficulty expressing anger or confronting people. Dieting and smoking are two of the ways women cope and maintain control over their lives.

Poverty:

Women are much more likely to be poor than men, especially women who are single parents or have been divorced or separated
Being poor increases the likelihood that a woman will smoke (35% of women living on low incomes are smokers versus 22% with higher incomes)

Employment:

As a group, women earn less than men, more often work part-time and in low-status, poorly paid jobs
Women in low-status jobs are much more likely to be smokers; many don't have the money or social support to cope with stress in other ways

Roles:

More and more women are working outside the home, yet they still take care of most of the home and family responsibilities -- including housework and caregiving

Violence:

Many women live with violence or face the fear of violence; one in three Canadian women who is, or has been, married or lived common-law, has experienced physical or sexual violence at the hands of her partner (see Kinnon and Hanvey, 1995)

Get the Ball Rolling

Try opening up a group discussion about why women smoke by asking your clients to share some of their thoughts and personal experiences about smoking. For example:

• Briefly describe what you remember about your first cigarette -- when, why, who else was there, how it felt, etc.
• Share a little about your smoking history -- including any attempts to quit or cut down.
• Identify the barriers to quitting or reducing smoking, and some possible ways of overcoming these barriers.

References

Centre for Health Promotion, University of Toronto. (1995). Consultation with Priority Women. Prepared for Health Canada.

Frederick, J. (1995). Cigarette Smoking and Young Women's Presentation of Self. Department of Sociology and Anthropology, Carleton University. Prepared for Health Canada.

Greaves, L. (1990). Background Paper on Women and Tobacco (1987) and Update (1990). Ottawa: Health Promotion Directorate, Health Canada.

Greaves, L. (1995). Mixed Images: Women, Tobacco and the Media, Canada, 1989-1994. Prepared for the Health Promotion Branch, Health Canada.

Health Canada. (1995). Act Now: Women and Tobacco.

Health Canada (1995). Smoking Interventions in the Prenatal and Postpartum Periods. (Booklet 5 of The Tobacco Free Booklets for Prenatal and Postpartum Providers.) Ottawa. Government of Canada.

Health Canada. (1995). Tobacco Control: A Blueprint to Protect the Health of Canadians. Ottawa. Government of Canada.

Health Canada. (1995). Women and Tobacco: A Framework for Action. Ottawa. Government of Canada.

Heart and Stroke Foundation. Women and Tobacco (Brochure). Cat. 34035922.

Heart and Stroke Foundation. Women and Tobacco: Of Smoke and Mirrors (Fact Sheet). Cat. 34079212.

Hobbs, F. et al. (1996). Women and Cessation. Prepared for the Ontario Tobacco Research Unit.

Kinnon, D. and L. Hanvey. (1995). Delivering Gender-sensitive Tobacco Reduction Programs: Issues and Approaches. Prepared for Health Canada.

Women's Health Clinic (in cooperation with Canadian Women's Health Network Ensemble! Pan-Canadian Women's Centres Network). (1995). Breathing Space: A Needs Assessment and Feasibility Study for a National Program on Women and Tobacco. Prepared for Health Canada.

Women's Health Clinic. (1990). Catching Our Breath: A Journal About Change for Women Who Smoke. Winnipeg.

Cessation Programs that Work

Smoking cessation programs come in a variety of shapes and sizes - from intensive individual counselling and group programs to self-help initiatives, worksite programs, telephone support, community cessation contests and media programs. Regardless of what format they use, programs that meet women's needs effectively share a number of important characteristics. Cessation programs that work for women ...

• are women centered: grounded in an understanding of women's needs and recognize smoking as a response to women's social, economic, cultural and personal experiences
• are holistic: position smoking reduction/ cessation as one element of a comprehensive approach to women's health and well-being
• are flexible: encourage leaders and their clients to "mix and match" program components according to the particular needs and interest areas of different client groups
• are designed by women: involve women -- including program providers and clients -- in their initial planning, set up and evaluation
• are accessible: available to women free or at a low cost, provide child care services/facilities, are held in convenient locations at convenient times, and take into account a range of literacy levels
• are non-judgmental: offer women information and support in their efforts to reduce or quit smoking in an atmosphere of mutual respect and empathy, without shame or blame
• are not "all or nothing": acknowledge smoking reduction as an appropriate goal and recognize that most women who smoke will try to quit at least several times before they are successful
• take into account the stages of change: recognize that women will need different kinds of support as they move through each change stage (see also Section 7)
• offer positive lifestyle alternatives: provide tools for healthy living, including stress management, active living, healthy eating, and other self-care techniques
• include family/partner/group support: acknowledge the importance of social support to women, and aim to increase understanding and support for their smoking cessation efforts among family and friends
• include relapse support: offers guidance on how to anticipate, resist and manage smoking relapses on a long-term basis

A practical note ...

If you're a program provider working with women, this section is designed to give you some food for thought about the characteristics of a successful smoking reduction program. So whether you're designing your own programs, trying to choose from among the various programs that are already out there, or looking into referral programs that best suit your clients' needs, keep this checklist close at hand.

Women's Organizations: Perfectly Placed to get the Word Out

Community-based women's groups have a long history of being involved in issues of self-esteem and equality - issues that are not at the root of many of women's health concerns, including smoking. Many use a holistic approach that stresses self-help and social action, and mirrors what we know about effective health promotion - that it is community-based, client-centered and empowers people to take responsability for themselves.

Although most local women's groups have not traditionally been involved in tobacco control programs, they are in a good position to promote smoking cessation/reduction among the women who are most at risk from smoking - including women who live on low incomes, women from ethnic and racial minorities, Aboriginal women, and women who are abused. By organizing locally, developing partnerships among groups, and sharing their knowledge, experience and information resources, community-based women's groups can be a strong force in tobacco reduction initiatives for women.

References

AWARE et al. (1995). Support for Women Smokers: Final Report and Evaluation Results of the Pilot Project. Kingston. AWARE Press Inc.

Greaves, L. (1990). Background Paper on Women and Tobacco (1987) and Update (1990). Ottawa: Health Promotion Directorate, Health Canada.

Health Canada. (1995). Women and Tobacco: A Framework for Action. Ottawa. Government of Canada.

Heart and Stroke Foundation. Women and Tobacco: Of Smoke and Mirrors (Fact Sheet). Cat. 34079212. Consultation Centre. Prepared for the Ontario Ministry of Health and Health Canada. er-Sensitive Tobacco Reduction Programs: Issues and Approaches. Prepared for Health Canada.

Physicians for a Smoke-Free Canada. (1995). Development of a Bilingual Resource on Gender Specific Issues for Women Smokers (Final Report). Ottawa.

The Centre for Health Promotion, University of Toronto and Atlantic Centre for Health Promotion Research, Dalhousie University. (1995). Assessment of Existing Smoking Cessation Programs for Priority Women (Priority Women and Tobacco Project). Health Canada.

Women's Health Clinic (in cooperation with Canadian Women's Health Network Ensemble! Pan-Canadian Women's Centres Network). (1995). Breathing Space: A Needs Assessment and Feasibility Study for a National Program on Women and Tobacco. Prepared for Health Canada.

Women's Health Clinic. (1990). Catching Our Breath: A Journal About Change for Women Who Smoke. Winnipeg.

Tailoring Your Efforts

Women are a diverse group of people, based on ages and life stages, racial, cultural and linguistic background, nationhood (as in the case of Aboriginal women), and disadvantage. (Kinnon and Hanvey (1995), pg. 7)

It's impossible to design smoking messages and programs that will work for everyone. That's why it's important to tailor your approach to the particular needs of the women you serve. Following are a few general points to keep in mind when developing, selecting or adapting smoking reduction/cessation initiatives for specific groups. The ideas presented below aren't meant as a step-by-step program or a detailed blueprint for action. Rather, they are designed to give you some "food for thought."

Francophone women

Smoking rates for women in Quebec are higher than in any other province. Part of the reason is that the francophone culture has never really questioned people's smoking behaviour. Also, given the high proportion of Quebec residents who smoke, children and adolescents may simply be following the majority's lead. Adults wanting to quit may find little support in the wider environment (e.g., non-smoking policies in the workplace and public areas).

Although a growing number of programs are now available in French, most smoking cessation programs and resources have traditionally been developed for English-speaking audiences. If program resources are to meet the needs of Francophone audiences, they must:

• be adapted in culturally sensitive ways (e.g., to reflect the French cultural emphasis on freedom of lifestyle choice) or developed specifically for Francophone women
• be as visual as possible
• stress an oral/interactive approach (rather than written)
• recruit women by using positive messages (not guilt inducing)
• propose ways of replacing cigarettes with other pleasurable activities
• incorporate varied and multiple approaches (e.g., telephone lines, discussion groups, buddy systems and personalized programs)
• include strategies to support maintenance and follow-up after quitting
• raise their awareness and involve physicians, nurses and social workers in interventions

Aboriginal women

Aboriginal women and men have the highest smoking rates of any group in Canada. Well over half (57%) of Canada's Aboriginal adults are smokers --46% on a daily basis. Program providers working with Aboriginal women to reduce their smoking should bear the following in mind:

• Tobacco has important spiritual and ceremonial uses in Canadian Aboriginal cultures. Historically, medicine men and women mixed tobacco with other plants to use during their rituals and ceremonies.
• Because of cultural preferences for involving the entire community in problem-solving, some Aboriginal women may prefer programs that include both women and men.
• Approaches, materials, messages and services for Aboriginal women should reflect their language and culture. That means involving Aboriginal women in developing prevention and cessation programs.
• A community-based approach, rather than general media campaigns, are more effective in reaching Aboriginal women.
• In addition to cultural issues, socioeconomic disadvantages (e.g., poverty, few educational opportunities) and discrimination issues need to be considered in addressing Aboriginal women's health issues such as smoking.

An ancient healer

"What is important to remember about the use of tobacco in ancient cultures is that it was not used as a crutch for individuals to make it through the day. The people doing the growing and blending were respected healers. They recognized the powerful effects on both mind and body when smoked. Most importantly, the blend was smoked in a group of people for specific religious and spiritual purposes." (Catching Our Breath (1990), pg. 36)

Women from minority racial or ethnic groups

Women from minority racial or ethnic groups are often more susceptible to stress and mental health problems than men in these groups. Because they may lack social support networks, be dependent on their husbands and face restrictions on what they are allowed to do, some women turn to smoking as a means of coping. Even in cultures where women have not traditionally smoked, the influence of Canadian values and practices increase the likelihood that they will take up smoking.

It's important that information materials and programs be sensitive to the special needs of these women. Program providers should try and determine the cultural practices for each group that influences smoking behaviour. For example, it is common practice in some cultural groups to offer tobacco as a sign of hospitality -- even if members of the group don't smoke themselves. Tobacco reduction initiatives intended for women from racial and ethnic minorities must also take into account the realities of racism and ethnic discrimination faced by women from minority racial or ethnic groups.

Pregnant/postpartum women

Most expectant mothers know that smoking during pregnancy can harm the fetus, and that is one of the main reasons pregnant women want to quit. Even so, more than 60% of pregnant smokers continue smoking throughout their pregnancy and after the birth of their child. Many expectant mothers who do quit smoking, relapse during the first six months of the postpartum period.

Providing information on the risks of smoking and second-hand smoke is a start, but on going support is needed for women who want to quit during or after pregnancy. The research has identified some important characteristics of smoking cessation strategies designed for pregnant women:

• avoid guilt tactics -- women don't need the added stress at an already stressful time
• include support for staying or becoming smokefree in the postpartum as well as the prenatal period
• help women improve communication with their partners and increase their partners' support in smoking cessation efforts
• start early, ideally before pregnancy or at the first possible opportunity during the pregnancy
• tailor programs to pregnant women who are most at risk, including women with low education levels and living on low incomes, teenagers, Aboriginal women, and Francophone women
• include information from a variety of sources, such as the media, family, friends, health professionals, etc.
• treat quitting as a process with a number of different stages --each stage requiring a specialized approach --and recognize smoking reduction as an appropriate goal

References

Canadian Cancer Society (Ontario Division) et al. (1995). How to Talk About Smoking with High Risk Pregnant Smokers --A Guide For Support Providers. Prepared for the Ontario Ministry of Health.

Canadian Council on Smoking and Health. (1993). A New Start in Life: About Pregnancy and Smoking. Ottawa.

Canadian Public Health Association. (1995). Smoking Cessation Training Resource for Prenatal and Postpartum Providers: Needs Assessment Final Report. Prepared for Health Canada.

Greaves, L. (1990). Background Paper on Women and Tobacco (1987) and Update (1990). Ottawa: Health Promotion Directorate, Health Canada.

Health Canada. (1996). Identifying Characteristics of Hard to Reach Pregnant Women Who Smoke and Cessation Recruitment Interventions (draft).

Health Canada. (1995). Smoking and Pregnancy: A Woman's Dilemma. (Booklet 1 of The Tobacco Free Booklets for Prenatal and Postpartum Providers.) Ottawa. Government of Canada.

Health Canada. (1995). Smoking Interventions in the Prenatal and Postpartum Periods. (Booklet 5 of The Tobacco Free Booklets for Prenatal and Postpartum Providers.) Ottawa. Government of Canada.

Health Canada. (1995). Study on Tobacco Use Among Francophone Women and on the Tobacco Reduction Programs and Resources Developed for This Group.

Health Canada. (1995). The Effects of Tobacco Smoke and Second-Hand Smoke in the Prenatal & Postpartum Periods: A Summary of the Literature. (Booklet 3 of The Tobacco Free Booklets for Prenatal and Postpartum Providers.) Ottawa. Government of Canada.

Health Canada. (1995). Tobacco Reduction in Prenatal and Postpartum Programs for High-Priority Families: Results of a Cross-Canada Survey. (Booklet 4 of The Tobacco Free Booklets for Prenatal and Postpartum Providers.) Ottawa. Government of Canada.

Health Canada. (1995). Tobacco Resource Material for Prenatal and Postpartum Providers: A Selected Inventory. (Booklet 2 of The Tobacco Free Booklets for Prenatal and Postpartum Providers.) Ottawa. Government of Canada.

Health Canada. (1994). Women and Tobacco: A Framework for Action. Ottawa. Government of Canada.

Kinnon, D. and L. Hanvey. (1995). Delivering Gender-sensitive Tobacco Reduction Programs: Issues and Approaches. Prepared for Health Canada.

Native Women's Association of Canada (South Region). (1995). Tobacco Reduction Strategy. Prepared for Health Canada.
Stephens, T. (1994). Smoking Among Aboriginal People in Canada. Ottawa. Health Canada.

Women's Health Clinic. (1990). Catching Our Breath: A Journal About Change for Women Who Smoke. Winnipeg.

Understanding and Using the Stages of Change

Everyone, regardless of who she is, goes through five successive stages in the process of quitting smoking. The issues and challenges a woman faces will depend on what stage she is in.

What does this mean for program providers? Helping women move successfully from one stage to the next (and eventually stop smoking for good) means identifying "where they're at" and tailoring approaches to meet their particular needs for motivation and support at each stage.

Following are the five stages of change, together with a "mini-profile" of smokers at each stage. Also included are suggested intervention goals for program providers, and some ideas on how they can help clients attain them.

1. Precontemplation (= not thinking about quitting)

Women who are at the first stage are not really thinking about quitting, and if you challenge them, will probably defend their smoking behaviour. They may be discouraged about previous attempts to quit or believe they're too addicted to ever stop smoking. Whatever the reason, at this stage the "pros" of smoking outweigh the "cons."

Help clients to:
-see more of the "pros" for changing their behaviour
-think and talk about smoking

By:
-talking about their smoking behaviour (e.g., why they smoke, personal risks of smoking)
-helping them understand the quitting process and that most women do not quit on the first try
-building confidence in their ability to change

2. Contemplation (= thinking about quitting but not ready to quit)

At this stage, women are considering quitting sometime in the near future (probably six months or less). Although they are more aware of the personal consequences of their smoking and spend time thinking about smoking as a problem, women at this stage still doubt that the long-term benefits of quitting are greater than the short-term costs. On the plus side, they're more open to receiving information about smoking and identifying the barriers that prevent them from quitting.

Help clients to:
-feel more committed and comfortable about taking the next step

By:
-offering basic skill development and information on how to manage the quitting process and referring clients to helpful resources
-discussing their concerns about not being able to quit
-addressing their competing attitudes towards quitting
-encouraging clients to focus on reasons for quitting that are personally relevant

3. Preparation (= getting ready to quit)

Women in the preparation stage have made the decision to quit and are getting ready to stop smoking. They see the "cons" of smoking as outweighing the "pros" and are taking small steps towards quitting. For example, they may be delaying their first cigarette of the day, or smoking fewer cigarettes. They make statements such as "I've got to do something about this --this is serious." or "Something has to change."

Help clients to:
-not to be intimidated by "fear of failure" and to see relapse as a normal part of the process of change

By:
-identifying what has and has not worked for them in the past
-discussing what behaviour changes are needed
-encouraging clients to focus on reasons for quitting that are personally relevant
-discussing reasons for past relapses and how to overcome them

4. Action (= quitting)

In this stage, women are actively trying to stop smoking, perhaps using short-term rewards to keep themselves motivated and often turning to family, friends and others for support. They mentally review their commitment to themselves and develop plans to deal with both personal and external pressures that may lead to slips. This stage usually lasts about six months and sees smokers at the greatest risk of relapse.

Help clients to:
-maintain "quit" behaviour
-deal with relapse in a positive way (if necessary)

By:
-providing ongoing peer, professional and family support
-identifying coping strategies (e.g., positive self-talk, stress management)
-encouraging self-confidence
providing information about relapse

5. Maintenance (= remaining a non-smoker)

Women in the maintenance stage have learned to anticipate and handle temptations to smoke and are able to use new ways of coping. Although they may slip and have a cigarette from time to time, they try to learn from the slip so it doesn't happen again. This helps to give them a stronger sense of control and the ability to stay on track.

Help clients to:
-maintain "quit" behaviour
-prevent relapse, or deal with it in a positive way (if necessary)

By:
-helping them identify and deal with high- risk situations
-encouraging the use of rewards

Dealing with Relapse

Along the way to quitting permanently, most women will go through at least one relapse. Although relapse can be discouraging, women who successfully quit don't usually follow a straight path from one stage to the next --they cycle through the five stages several times before finally stopping smoking.

Relapses can be important opportunities for learning and becoming stronger, or they can be an excuse to give up. The key to recovering from a relapse is to look back over the quit attempt, identify personal strengths and weaknesses, and develop a game plan for the next time. People who relapse may need to learn how to anticipate high-risk situations more effectively (like being around good friends who smoke), and

A practical note ...

Most existing programs focus on the last few stages of change, and not many are tailored specifically to high-risk women. According to providers, the most successful programs for this group focus on issues in the precontemplation and contemplation stages, with no expectation that participants will quit smoking.

Up For Discussion

Following are some ideas for group discussion focusing on change. These topic suggestions are designed to raise participants' awareness about the process of change in general, and as it relates to smoking. You may want to try and build a discussion about change and smoking behaviour into a more general discussion about the nature of change. Topic areas might include, for example:

Quitting, just like smoking, is tightly bound to other issues in women's lives. What other areas of your life are changing?
Do you manage the changes in your life, or are the changes just "happening" to you and are outside of your control?
What helps you to handle change in positive ways? How have you handled change in the past?
Identify some realistic goals you can set to reduce or quit smoking (e.g., cutting down on coffee or other activities that you associate with smoking, making one room in the house the smoking area and other rooms "off limits").

References

AWARE et al. (1995). Support for Women Smokers: Final Report and Evaluation Results of the Pilot Project. Kingston. AWARE Press Inc.

Health Canada. (1995). Smoking Interventions in the Prenatal and Postpartum Periods. (Booklet 5 of The Tobacco Free Booklets for Prenatal and Postpartum Providers.) Ottawa. Government of Canada.

Hotz, Stephen. (1995). Understanding and Using the Stages of Change (Info Pack). Program Training and Consultantion Centre. Prepared for the Ontario Ministry of Health and Health Canada.

Kinnon, D. and L. Hanvey. (1995). Delivering Gender-sensitive Tobacco Reduction Programs: Issues and Approaches. Prepared for Health Canada.

The Centre for Health Promotion, University of Toronto and Atlantic Centre for Health Promotion Research, Dalhousie University. (1995). Assessment of Existing Smoking Cessation Programs for Priority Women (Priority Women and Tobacco Project). Prepared for Health Canada.

Useful Facts About Smoking

"Short snappers" on smoking
Here are a few of the questions women commonly ask about smoking. Try them out and test your smoking "IQ."

Q. Will I automatically gain weight when I quit or cut down my smoking?
A. Not everyone who quits smoking will gain weight, although the majority of people usually gain from five to 10 pounds

Q. If I quit smoking and gain weight, have I traded one health problem for another?
A. No. You would need to gain 125-pounds to equal the health hazard of smoking.

Q. Does smoking help to reduce people's stress level? How else can I have for deal with the stress in my life?
A. Smoking actually increases your stress by "upping" the body's heart rate and blood pressure. You can help reduce stress by being more physically active (this will reduce your heart rate when you are "at rest") --or by doing breathing or visualization exercises.

Q. If I try to quit and fail, does that mean I won't be successful the next time I try?
A. No. Quitting is a process. The more often you try to quit, the more likely you are to succeed.

Did you know?

• Stress is a natural part of living ... it only becomes a problem if you don't get a break from it.
• Adults breathe an average of 16,000 quarts of air each day.
• Spicy or very rich foods can make you crave nicotine.
• The physical symptoms of quitting usually last a week at most.
• Most women are non-smokers.
• What we think about ourselves has a big influence on what we're able to do.
• Aerobic activity (such as running, dancing, etc.) stimulates your heart and lungs and speeds up the healing process.
• You can help your body heal faster and more easily by doing simple deep breathing exercises.
• When you stop smoking, the risk of having a stroke or heart attack decreases almost immediately.
• Many American women's magazines rely on the money they get from tobacco advertising.

(From: Kort, Marjorie and Sherryl Smith. (1993). Stop Smoking: A Program for Women. Canadian Public Health Association. Ottawa.)

The Healing Process

What quitting feels like...
Nicotine is a very powerful drug. When you quit smoking your body will begin to recover from the effects of the nicotine and other chemicals found in cigarettes. The signs that your body is recovering start about one to two hours after your last cigarette and are most intense for the next three days. Here are some of the things you might experience when you first quit smoking:

Coughing:

Smoking deadens the feeling in the tiny hairs (cilia) in your lungs. Coughing is a sign that the cilia are recovering and starting to clear the tar out of your throat and lungs.

Slightly sore throat:

As the "numbness" goes out of your mouth and throat, you may get a sore throat for a couple of days. Try throat lozenges, cough syrup, or a lemon and honey drink.

Headache or dizziness:

You may feel dizzy as you get used to having oxygen going to your head. If you don't decrease the amount of coffee you drink, there's also a chance you'll suffer from headaches, dizziness or nervousness from the caffeine. Less caffeine, extra sleep, fresh air and massage can help.

Tiredness:

Because nicotine acts as a stimulant, you might find that you're more tired than usual.

Lack of Concentration:

After learning to associate smoking with certain tasks, it may be difficult to maintain your concentration. Try taking frequent activity and/or deep breathing breaks.

Nervousness:

You might seem on edge for a while -- drink lots of water and juice, swim, walk and bathe to flush the nicotine out of your body.

Constipation or Diarrhea:

After quitting, your digestive system may be a little disturbed. Take prunes, dried fruit or bran to get rid of constipation. Avoid caffeine to prevent diarrhea.

Sleep Disturbance:

It's very common to dream that you've been smoking or to have more vivid dreams in general after you quit. You might also wake up earlier than usual. Try deep breathing and doing relaxation exercises.

Sugar Craving:

Many ex-smokers get strong cravings for sweets. Whatever the reason for it, it's a good idea to keep lots of healthy food around, drink lots of fluids and exercise.

(From: Women's Health Clinic. (1990). Catching Our Breath: A Journal About Change for Women Who Smoke. Winnipeg.)

The good news is ...
On the bright side, your body will start to heal itself as soon as you put out your last cigarette. Here are some of the health benefits you can look forward to. For example:

After not smoking for:

20 minutes:

blood pressure and pulse rate are back to normal, body temperature increases to normal

8 minutes:

carbon monoxide levels in blood drop and oxygen levels increase to normal

24 hours:

chance of a heart attack decreases

48 hours:

food tastes and smells better

72 hours:

lung capacity is increasing

6 months:

coughing, sinus congestion, tiredness and shortness of breath are reduced

1 year:

the risk of smoking-related heart disease is reduced by half

10 years:

the risk of dying from lung cancer is about half that of continuing smokers

(From: Women's Health Clinic. (1990). Catching Our Breath: A Journal About Change for Women Who Smoke. Winnipeg.)

Managing Your Stress

Stress is one of the major problems facing women today, and one of the main reasons women give for why they smoke. The next time you feel stressed, try one (or more) of these approaches to help deal with it:

1. Change the situation your in

• ask for help
• talk to a friend
• go for a walk
• ask a friend to mind your children so you can have a break

2. Change your self talk from negative to positive

• I can change"
• "I am capable"
• "I deserve better"
• "Everybody makes mistakes"

3. Change your body's reaction to stress

• take a deep breath (or more than one)
• go for a walk
• lie down and relax (talk yourself into relaxing)
• do something that makes you work physically --like fast walking

4. Change your resistance to stress

• eat well and avoid foods that include a lot of fat, salt and sugar
• get regular exercise
• get plenty of sleep
• avoid drugs such as caffeine and alcohol
• practise a regular stress management technique (e.g., deep breathing,relaxation, meditation)

(Adapted from: Kort, Marjorie and Sherryl Smith. (1993). Stop Smoking: A Program for Women. Canadian Public Health Association. Ottawa.)

Look Good, Feel Good: Maintaining a Healthy Weight

1. Be aware of appetite stimulants (food that makes you want to eat more).
Alcohol and coffee both increase the appetite, and both are often used with cigarettes and snack food. Alcohol is also a source of calories, as is coffee with milk, cream or sugar. Cut down on these until you're confidently smoke-free and satisfied with your weight.

2. Pay attention to fluids.
It's a healthy practice to drink six to eight glasses of fluid a day(water, vegetable or fruit juice, low-fat milk, clear soup, etc.). Water is the best choice, because it has no calories. One glass of water before a meal, at mid-morning, at mid-afternoon, and before going to bed helps curb the appetite.

3. Eat a "stress relief" diet.
This means a) eating less salt, sugar and fat; b) eating three regular meals or five smaller ones; and c) following Canada's Food Guide to Healthy Eating.

4. Increase fibre.
Fibre helps fill the stomach and satisfy the appetite. Foods containing fibre are grains, legumes (peas, beans, lentils), fruits, vegetables, nuts, and seeds. (Nuts and seeds are higher in fat than other choices.)

5. Be aware of fat.
Fat has twice the calories of protein or carbohydrates. Use low-fat cooking methods, such as baking, broiling or boiling, instead of frying; look for low-fat substitutes, including skim milk and low-fat cheese and yogurt; have fruit or vegetables on hand for snacking.

6. Plan meals.
Plan what you will eat each day, either the night before or in the morning. It will help you make better quality food choices. Try to eat meals and snacks at the same time each day. This will help your body learn to expect food at regular times, and will stop the "binge --then starve" cycle.

7. Make meals attractive.
Put food on the plate in as attractive a way as possible. Use a smaller plate rather than a large one so that portions seem larger.

(Adapted from: Kort, Marjorie and Sherryl Smith. (1993). Stop Smoking: A Program for Women. Canadian Public Health Association. Ottawa.)

Getting Active

Regular physical activity can work wonders if you're trying to quit smoking. It helps to relieve stress, speeds up the healing process and generally makes you feel good. Here are some easy stretches you can do to increase your flexibility and overall vitality. You can also burn calories and increase your energy level by making your daily activities more "physical" --for example, try taking the stairs instead of the elevator, walk to work, spend some of your visiting time with friends doing something active, such as walking, skating or cycling. Or try riding your bike, gardening, bowling or curling.

1. Shoulder Stretch

• Sit on floor, legs extended.
• Bend legs, clasping arms under knees. Hug knees to chest.
• Gently pull torso away from knees, while continuing to clasp arms.
• Hold a few seconds and repeat.

2. Shoulder and Back "Massage"

• Stand firmly grounded; feet shoulder-width apart.
• Raise arms over head, elbows slightly bent.
• Bend forward from waist, slowly.
• Relax upper body; let everything "dangle": head, neck, arms.
• Slowly straighten up, vertebra by vertebra, starting from bottom of spine.

3. Child's Pose

• Sit back on heels.
• Slowly bend until torso rests on knees.
• "Nestle" yourself into comfortable position.
• Rest arms by your sides.
• Release neck, shoulders, and back.
• Hold as long as you wish.

4. Waist Stretch

• Stand firmly grounded, legs about three feet apart.
• Bend right knee; rest right arm on thigh.
• Raise other arm, shifting weight to the right.
• Reach over head until you feel a gentle stretch along waist.
• Hold a few seconds and repeat on other side.

(From: Women's Health Clinic. (1990). Catching Our Breath: A Journal About Change for Women Who Smoke. Winnipeg.)

Canada's Food Guide to Healthy Eating