The American College of Obstetricians and Gynecologists

Womens Health Care Physicians

Committee Opinion
Number 503 September 2011
Committee on Health Care for Underserved Women
Reaffirmed 2013

This information should not be construed as dictating an exclusive course of treatment or

procedure to be followed.

Tobacco Use and Womens Health

ABSTRACT. Tobacco use negatively affects every organ system and is the most prevalent cause of premature death for adults within the United States. Compared with women who are nonsmokers, women who smoke
cigarettes have greater risks of reproductive health problems, many forms of gynecologic cancer and other types
of cancer, coronary and vascular disease, chronic obstructive lung disease, and osteoporosis. Brief behavioral
counseling and the use of evidence-based smoking cessation aids are effective strategies for achieving smoking
cessation even for very heavy smokers. The trained obstetriciangynecologist is well positioned to screen and
counsel all patients on tobacco use and to advocate for smoke-free environments. Smoking cessation counseling
is often reimbursed by health insurers. Tobacco use has deleterious effects on women through all stages of life.
Tools are available for obstetriciangynecologists to screen for and treat tobacco abuse and give the appropriate
coding for smoking cessation counseling.

Epidemiology
Despite the evidence of the negative effects of tobacco use,
the Centers for Disease Control and Prevention reports
18% of women older than 18 years smoked cigarettes in
2009 (1). This rate of smoking has remained essentially
unchanged over the past 5 years, thus falling short of the
Healthy People 2010 goal of a smoking rate of 12% or
less (2). More than 80% of current smokers began their
addiction to tobacco before age 18 years (3). Tobacco use
by women is most prevalent among women who have
attained lower levels of education, are poor, and are white
or of mixed race (1).
From 2000 to 2004, the United States spent $193
billion on annual tobacco use health-related economic
losses with one half dedicated to direct medical costs and
the other half to lost productivity (4). The money spent
by U.S. private and public entities on the adverse effects
of tobacco use is twice the amount of tobacco sales (4).

Forms of Tobacco
In recent years, tobacco products have changed and others have been developed or gained popularity. There are
many flavors of cigarettes, cigars, and other forms of
tobacco that are available for sale and marketed primarily
to young and minority users. In fact, menthol cigarettes
increase the likelihood and degree of nicotine addiction
in new smokers and makes smoking cessation more diffi-

cult, particularly for some African Americans who believe

health benefits are associated with smoking menthol
cigarettes (5). Smokeless tobacco products are mistakenly believed to be a safer and may be a more convenient
alternative to cigarettes when smoking is prohibited. One
form of smokeless tobacco popular with young women
is snus, a flavored self-contained tobacco pouch that is
placed between the cheek and gum and does not require
spitting. Other smoking alternatives include a gel strip
impregnated with nicotine that melts on the tongue and
an electronic or e-cigarette, a battery powered device that
heats cartridges of liquid containing nicotine to create
a mist, which users inhale. Hookahs, or tobacco water
pipes, have become popular among youth and young
adults. Inhalation when using a hookah is deeper and
smoking sessions are longer than with a typical cigarette,
resulting in higher concentration of toxins after hookah
smoking compared with cigarette smoking (6). Evidence
indicates that changing tobacco delivery devices and
cigarette designs, including low-tar and light variations,
have not reduced overall disease risk among smokers (7).
Although the U.S. Food and Drug Administration is moving toward requiring disclosure and regulation, currently
tobacco companies are not required to divulge the additive content of tobacco products. It is widely known that
alkaloids are added to tobacco to increase the absorption
of nicotine and, therefore, add to the addictive nature of
the product (8).

Health Effects of Tobacco Use on

Women
Because of the negative effects of tobacco use on fertility
and fetal development, there is a focus on smoking cessation in consideration of womens reproductive health.
However, the sequelae of tobacco use have negative
health effects on a woman through all stages of her life.
Approximately 90% of cases of lung cancer are caused by
smoking or exposure to tobacco smoke. Lung cancer has
surpassed breast cancer as the leading cause of cancer
death in women (9). Colon cancer is the third leading
cause of cancer deaths in women, and there is a doserelated increased risk of colon cancer in smokers (10).
Women who smoke are also at an increased risk of gynecologic cancer. Cigarette smoking has been identified as
a risk factor in the development of mucinous epithelial
ovarian cancer (11). There is a linear relationship between
premenopausal tobacco use and breast cancer, particularly if smoking is initiated before the birth of the first
child (12). Smoking also contributes to the progression
of cervical intraepithelial neoplasia, and both active and
passive smoking have been linked to squamous cell carcinoma of the cervix in women seropositive for HPV-16
or HPV-18 (13, 14). Smoking also has been linked to
cancer of the bladder, kidney, and pancreas (15).
Tobacco is the single greatest modifiable risk factor
for cardiovascular disease and the leading cause of death
in women in the United States (9). Women who smoke
have a sixfold increased risk of myocardial infarction
when compared with nonsmoking women (16). Tobacco
use causes endothelial damage and platelet aggregation,
contributing to thrombosis in smokers (17). The antiestrogen effect of tobacco use accelerates menopause. This
premature menopause increases the risk of cardiovascular disease and increases the risk of osteoporotic fracture
independent of bone mineral density score (1719).
Furthermore, the risk of stroke is almost doubled in individuals who smoke (17).

Role of the ObstetricianGynecologist

Screening and Intervention
Tobacco use screening and cessation counseling is rated
among the three most effective and efficacious preventive
health actions that can be undertaken in a clinical setting, receiving a Grade A rating from the U.S. Preventive
Services Task Force (20, 21). Each visit to the obstetriciangynecologist is an opportunity for intervention.
The clinician can make a difference with minimal (less
than 3 minutes) intervention. Even when patients are not
willing to make a quit attempt, clinician-delivered brief
interventions enhance motivation and increase the likelihood of future attempts (22). In addition, tobacco users
are being primed to consider quitting by a wide range of
societal and environmental factors as well as through the
availability of effective tobacco cessation aids.

The nicotine in tobacco products is highly addictive.

Symptoms of physical dependence can result after less
than 1 week of smoking initiation, especially in youth
(23). When smoked or ingested through oral mucosa,
nicotine rapidly increases blood levels of dopamine,
thereby affecting the channels controlling reward and
pleasure. Tobacco cessation for those dependent on nicotine is often uncomfortable causing one to experience
vasomotor, gastrointestinal, and mood altering symptoms. It takes an average of seven quit attempts for the
average smoker to quit smoking and stay abstinent for 1
year. However, patient adherence to physician smoking
cessation advice is better than that for diet change and
increasing physical activity (24).
The 5 As intervention model is an evidence-based
model successfully used by the busy clinician to address
patient smoking. The 5 As are: Ask, Advise, Assess,
Assist, and Arrange.
1. ASK about tobacco use in any form or amount and
document this in the patient record. This can be accomplished through questions on the patient visit intake
form with a question such as: Circle the tobacco products (cigarettes, cigars, smokeless tobacco, hookah, or
electronic cigarettes) used during the past year. Any
use would require a further question on amount and
frequency of use.
2. ADVISE patients who smoke to quit in a clear, strong,
and personalized manner. It is best to incorporate in the
advice any clinical findings that may be influenced by
the patients tobacco use. All of the elements of the 5As
need not be delivered by one individual or during a single
office visit; however, it is important that the primary clinician give the personalized advice to quit smoking. For
example:
I see that you are smoking two or three cigarettes a day. As your obstetriciangynecologist,
I want you to know that your smoking, even in
small amounts, increases your risk of cervical
and breast cancer, and may be contributing to
your menstrual irregularities. You dont have to
stop on your own. If you are willing, I can help
you stop smoking. What do you think about
that?
3. ASSESS the patients willingness to make a quit
attempt. Ask if she is willing at this time to set a date to
stop using tobacco. Reducing smoking or switching to
another form of tobacco should not be considered a goal.
4. ASSIST in the quit attempt for those who are willing.
As a health care provider, you may offer medication and
provide or refer a patient for counseling or additional
treatment. The woman who is willing to try to quit smoking needs to develop a quit plan. A direct referral to the
Smokers Quitline (1-800-QUIT NOW) is a great place
to start. In addition, there are excellent materials avail-

Committee Opinion No. 503

able from the American College of Obstetricians and

Gynecologists as well as the American Cancer Society
(www.acs.org) that will help her set a quit date, encourage her to tell her friends and family about her quit intent
to garner support, counsel her to anticipate challenges to
her quit attempt, and encourage her to remove tobacco
products from her environment.
For those who are unwilling or not ready to quit
at this time provide motivational messages to increase
future attempts to quit and explore their possible fears
and concerns with smoking cessation or demoralization
caused by a past relapse (25). Continue to ask and advise
about smoking status at every encounter and assess their
willingness to make an attempt to quit.
5. ARRANGE follow-up. If the patient is willing to
attempt to stop smoking, have someone from the office
staff call her within a week of the date she chooses to quit

to support and encourage her in her attempt. Flag her

record and make sure to verbally ask her about smoking at subsequent visits. If she has been successful with
smoking cessation, praise her progress. If she slips back to
tobacco use, encourage her to quit immediately, reviewing her personalized rationale for staying smoke-free and
offering additional smoking cessation aids.
Medications and Other Evidence-Based
Smoking Cessation Aids
In addition to counseling, all smokers making a quit
attempt should be offered medication to improve quit success and reduce withdrawal symptoms (Table 1) (22).
Those who should not routinely use medication for
smoking cessation are pregnant women, adolescents,
smokeless tobacco users, and light smokers. The medications can be used individually or combined, and they can

Table 1. Smoking Cessation Aids

6-Month
Abstinence
Method
Rate (%)
Patient desire
Physician advice

Cost*/Duration

Where Available

8
10.2

Group or individual counseling

1417
Low to very high cost

depending on provider

Telephone counseling
16
Free
(Smokers Quitline)

Health centers
Public health programs
Private counselor
1-800-QUIT NOW

Nicotine gum, patch, or lozenge

1926

$150$300
614 weeks

Over-the-counter

Nicotine inhaler or nasal spray

25 27

$150$300
Up to 6 months

Requires prescription

Combined nicotine replacement

2436
therapies

$150$400
Up to 6 months

Over-the-counter
Requires prescription

Bupropion
24

$150$300
Up to 14 weeks

Requires prescription

Varenicline
33

$250$400
Up to 14 weeks

Requires prescription

Clonidine
25

Less than $150

Up to 12 weeks

Requires prescription

Nortriptyline
22.5

Less than $150

Up to 12 weeks

Requires prescription

Combined counseling and medication

$150 and up

Hypnosis
Acupuncture

2832
Insufficient evidence

Greater than $300

Not covered by insurance

Greater than $300

Not covered by insurance

*Cost of a course of treatment. This may be covered by insurance unless otherwise indicated in the patients health insurance policy.
Data from Fiore MC, Jean CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline, Rockville
(MD); U.S. Department of Health and Human Services. Public Health Service; 2008.

Committee Opinion No. 503

be used as an addition to cognitive behavioral counseling. Medications include nicotine replacement therapy
products such as gum, patches, lozenges, inhalers, and
nasal sprays. Some of the nicotine replacement therapy
products are sold over-the-counter, whereas the inhaler
and nasal spray require a prescription. Other effective
prescription medications include the antidepressant,
bupropion, and varenicline, which block the pleasant
effects of smoking from the brain. A combination of nicotine replacement therapy products or nicotine replacement therapy plus bupropion may be used to prevent
physical withdrawal from nicotine and to quell sudden
urges to smoke. The prescribing obstetriciangynecologist
needs to be aware of the black box label warning on
bupropion and varenicline in regard to suicide ideation.
Patients should be counseled and monitored for abrupt
mood changes. The U.S. Food and Drug Administration
has issued a warning concerning an increase in cardiovascular events for those individuals with cardiovascular
disease who use varenicline. Nortriptyline and clonidine
are used as second-line smoking cessation aids. Both
have adverse effects that often prove to be undesirable.
A downloadable, comprehensive, and patient-centered
chart of evidence-based smoking cessation interventions with effectiveness ratings can be found at http://
whatworkstoquit.tobacco-cessation.org/NTCCguide.pdf.
Hypnotherapy, acupuncture, and the use of herbal remedies have not proved to be effective for achieving smoking cessation (22).
Addressing Roadblocks to Smoking Cessation
As with other behavioral health issues, there are roadblocks to smoking cessation. Many are particularly relevant to women, including fear of weight gain, inability
to deal with negative mood and anxiety, the influence
of other tobacco users, difficulty in concentration, and
other withdrawal symptoms. Smoking cessation medications greatly decrease withdrawal symptoms and reduce
anxiety and mood swings. Approximately one half of
those who stop smoking gain weight and most will gain
fewer than 10 pounds (22). Those who use bupropion
tend to not gain weight rapidly following cessation. For
others who do gain weight, the health care provider must
stress the benefits of cessation and offer advice on physical activity and a modified eating plan. To reduce the
urge of smoking, temporary changes in routine such as
brushing teeth directly after eating, taking a walk instead
of a smoke, wearing mittens, or buffing fingernails when
talking on the phone, are simple effective strategies. In
addition, the Smokers Quitline offers free supportive
counseling at timed intervals during a quit attempt.
Developing Systems for Addressing
Tobacco Use
Training for smoking cessation and other behavioral
counseling greatly enhances clinician confidence, efficiency, and the effectiveness of the intervention. Active

training is particularly helpful in working with patients

on denial, ambivalence, and relapse. Adding tobacco use
questions and a brief intervention screen to the electronic
medical record enhances the performance of screening
and counseling across a practice. Offices instituting or
revising their electronic medical records should include a
template on tobacco use.
An important office improvement in addressing
tobacco use is requiring a smoke-free office environment. This smoke-free zone should extend around the
building to discourage staff and patients from smoking at
the entrance. In addition, the obstetriciangynecologist
can advocate at the state and community level for the
institution of ordinances that reduce smoking and smoke
exposure such as imposing clean air acts and increasing
tobacco taxes; the cost of tobacco products is inversely
proportional to the uptake of use by adolescents.

Coding and Reimbursement

As of October 2010, the Affordable Care Act requires
all new health plans to cover smoking cessation counseling as a U.S. Preventive Services Task Force Grade
A preventive service. In January 2011, all Medicare
patients became covered and it is expected that all persons will be covered in 2014. Also in January 2011, the
International Classification of Diseases, 9th Revision, and
Current Procedural Terminology codes for reimbursement
for smoking cessation counseling went into effect. Under
the new codes, counseling can be provided for all patients
who smoke. Reimbursement is based on the amount of
time spent counseling patients. Counseling that takes
310 minutes is considered intermediate and counseling
lasting longer than 10 minutes is considered intensive.

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Committee Opinion No. 503

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