The desire to smoke binds people across genders. However, new research shows women may find it harder to quit smoking due to varying needs and anxiety triggers.

The findings, published in the European Society of Cardiology, note women are less dependent on nicotine than male counterparts, but still face more barriers to quitting. Identifying these barriers, such as a higher risk of depression, can help tailor smoking interventions to the concerns of women.

The researchers looked at the abstinence rates of 35,000 males and females between 2001 and 2018 in France. The participants were 18 and older, and carried at least one additional risk factor for cardiovascular disease. “In our study, women who used smoking cessation services had higher rates of overweight or obesity, depression, and anxiety compared to men and kicked the habit less often,” Ingrid Allagbe, one of the authors, noted.

Some facts to put the findings in perspective. Men tend to use tobacco products more than women (due to physiological, cultural, and behavioral factors). Men and women generally do not differ in the desire to quit or plans to quit, according to a 2015 study. The cardiovascular risk due to smoking is also similar.

Yet, the likelihood of quitting is lower for women. This corresponds with longitudinal data collected from four countries in 2015 that found women were 31% less likely to quit.

The trend highlights the gendered impact of smoking and cessation attempts. “Possible contributors could be the higher prevalence of anxiety, depression, and overweight or obesity among women. It has previously been reported that women may face different barriers to smoking cessation related to fear of weight gain, sex hormones, and mood,” Allagbe added.

Post-cessation weight gain is a common consideration. Culturally, the stigma of weight gain is more acutely felt by women and other gender minorities.

A previous study also showed smoking rewards the male brain’s reward pathways differently than female’s. Men were found to smoke for the reinforcing effects of nicotine, whereas women smoked to regulate mood or in social settings. Research also suggests women’s craving for smoking is stronger in response to stress.

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The idea of stress and risk factors like depression is also critical to understanding the challenges in smoking cessation. Research has noted that people with depression are more likely to smoke – a trend concerning when depression affects twice as many women as men. “The relationship between stress and smoking appears to be stronger in women than men, leaving women less able to quit or more likely to restart smoking after stressful events such as a financial setback,” Sherry McKee, director of the Yale Specialized Center of Research (SCOR) who is developing gender-sensitive treatments for tobacco dependence, said.

If the desire for nicotine is regulated by stress, women may find it harder to quit and may even be more vulnerable to depression following cessation attempts. “Depression and other mood disorders need to be addressed in women who smoke, especially those with heart disease and stroke,” Dr. Beth Abramson, an associate professor of medicine at the University of Toronto who co-authored a 2019 study about smoking, noted. “Smoking cessation is the most significant modifiable risk factor to prevent heart disease in women, but there is no one-size-fits-all,” Abramson added.

Women in the present study too were more likely to have symptoms of anxiety or depression than men. The study, moreover, doesn’t factor in smoking data from during the pandemic when the number of people has increased over the last 15-plus months. Research from March noted Covid19 stress and anxiety also made the process of quitting much harder.

There is some dispute among researchers about the gender and sex differences in the ability to quit smoking. Men may replace cigarettes with other tobacco products that may be reflected as “quitting,” or these scientific comparisons are likely to be biased due to skewed ratio of gender in clinical trials.

The exact cause-and-effect at play may thus be hard to pinpoint. However, the gendered idea of quitting smoking is notable here – it aligns with a cultural link to the act of smoking. Smoking has a “strong emotional link” for women, Louise Ross, an expert at the National Centre for Smoking Cessation and Training, who wasn’t involved in the study, told Daily Mail. “It’s often a respite between tasks – looking after small children, or caring for relatives or doing housework. Every time they need a break they go out for a cigarette and it’s a bit of ‘me time.'”

The findings can help shape intervention programs through behavioral counseling and treatment options for all smokers. “The results indicate that comprehensive smoking cessation programs are needed for women that offer a multidisciplinary approach involving a psychologist, dietitian, and physical activity specialist,” Allagbe said.

Expectation setting may help here. Counseling women about changes in food taste and smell, and the likelihood of weight gain, can help.

“Stocking up on healthy foods, particularly fruits and vegetables, and keeping hydrated with plenty of water will help avoid weight gain,” Patricia Folan, director at the Center for Tobacco Control at Northwell Health in the U.S., said.