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. Author manuscript; available in PMC: 2020 Dec 1.
Published in final edited form as: Qual Health Res. 2019 Jul 16;29(14):2096–2107. doi: 10.1177/1049732319857536

Lifetime Smoking Patterns and Preferences for Smoking Cessation among Women Veterans Receiving Veterans Health Administration Care

Sarah M Wilson 1,2,3, Alyssa M Medenblik 3, Julia M Neal 2,4, Jennifer L Strauss 3,5, J Murray McNiel 2,3, Warren E Christian 6, Jean C Beckham 2,3,4, Patrick S Calhoun 1,2,3,4
PMCID: PMC6848747  NIHMSID: NIHMS1030160  PMID: 31307290

Abstract

The objective of this study was to identify common themes among women veterans who smoke or recently quit and had used smoking cessation treatment within the Veterans Health Administration (VHA). The study built upon previous research by utilizing in-depth interviews to encourage disclosure of potentially stigmatized topics. Twenty women veterans enrolled in VHA care engaged in a quality improvement project focused on improving smoking cessation services. Qualitative analysis of de-identified interviews used a combination of content analysis and thematic analysis within the sociopharmacological model of tobacco addiction. Findings revealed that participants’ smoking was influenced by woman veteran identity and by several gender-related contextual factors, including military sexual trauma and gender discrimination. Findings also highlighted other contextual factors, such as personal autonomy, emotional smoking triggers, and chronic mental health concerns. Findings are interpreted within the context of cultural power imbalances, and recommendations are provided for VHA smoking cessation for women veterans.

Introduction

Tobacco smoking in the United States (U.S.) remains a significant source of mortality and morbidity (U.S. Department of Health and Human Services, 2014). Although women within the U.S. are generally less likely than men to smoke (Jamal et al., 2018), across studies, female smokers are up to half as likely as men to quit smoking (Smith et al., 2016). For women smokers, there are a multitude of health risks, including cancer, early menopause, and pulmonary/cardiovascular disease (Einarson & Riordan, 2009; Mackay & Amos, 2003). Women veterans are significantly more likely to smoke (19%) than civilian women (15%; Lehavot, Hoerster, Nelson, Jakupcak, & Simpson, 2012). Additionally, among Veterans Health Administration (VHA) patients, women are more likely than men to smoke (29% vs. 23%; Farmer, Rose, Riopelle, Lanto, & Yano, 2011). Although women veterans are one of the fastest-growing groups of VHA users (Department of Veterans Affairs, 2017), there are relatively few smoking cessation resources specifically designed for women veterans. Few studies address women veterans’ experiences of smoking and needs for smoking cessation treatment.

There are a number of reasons why women veterans have heightened risk for smoking. Women veterans may be affected by underlying cultural norms in the military. Compared to civilians, those who join the military are more likely to believe in traditional gender roles (Yastrzemsky, 2016). Within military careers, stereotypically masculine traits, such as stoicism and dominance, are promoted and rewarded (Boyce & Herd, 2003). This emphasis on traditional gender and preference for masculine traits may lead to gender bias or discrimination, which is associated with higher rates of smoking (Purnell et al., 2012). Additionally, around 1 in 3 women veterans has experienced military sexual trauma (MST; sexual harassment or assault during military service) (Wilson, 2018), which is consistently linked to posttraumatic stress disorder (PTSD) and negative outcomes, including tobacco use (Bean-Mayberry et al., 2011).

In general, women veterans are provided with the same cessation resources that are available to veteran men within VHA, which are overseen by the Smoking and Tobacco Use Cessation Program at the national level (Department of Veterans Affairs, 2014). VHA offers free telehealth and mobile health interventions for veterans, has eliminated copayments for smoking cessation counseling, and has taken steps to ensure that advice to quit is given and nicotine replacement therapy (NRT) is offered annually for all veteran smokers (McFall, 2006; Hamlett-Berry et al., 2009).

There are two known tailored smoking cessation interventions specifically for women veterans within VHA. The VA Women & Smoking Cessation Handbook promotes smoking cessation among women veterans (San Diego Tobacco Cessation Clinical Resource Center, 2014). This provider handbook outlines evidence-based strategies for brief (3–5 minutes) or intensive (> 10 minutes) interventions. Additionally, the Woman-to-Woman Veterans Stop Smoking Program was developed based upon expert advice and qualitative patient focus groups (Katzburg et al., 2009). VA researchers held a series of concept-development focus groups to inform tailored smoking cessation for women veterans (Katzburg, Farmer, Poza, & Sherman, 2008; Katzburg et al., 2009). In these focus groups, the need for support (educational and emotional) was consistent. Opinions on whether groups should be women-only or mixed-gender varied. The program features a toolkit to aid decision-making for women veterans, with five treatment options ranging in format.

There are some gaps in past qualitative research on smoking among women veterans. First, previous qualitative findings related to smoking among women veterans were gleaned from a sample of women veterans living in California (Katzburg et al., 2008), and current best practice models of smoking cessation care for women veterans were exclusively developed in California (Katzburg et al., 2009; San Diego Tobacco Cessation Clinical Resource Center, 2014). Since California is a state that has a particularly low smoking rate among women (7.8%; Kaiser Family Foundation, 2017), it is essential to gather further qualitative data on preferences for smoking cessation among women veterans living in states with higher rates of smoking, since barriers and preferences may differ culturally or geographically.

Additionally, previous qualitative research on smoking among women veterans exclusively used a focus group format (Katzburg et al., 2008; Katzburg et al., 2009). Results of focus group interviews can be affected by group processes and may not always reflect the diversity of experiences and opinions of participants (Stokes & Bergin, 2006). Many veterans express concern regarding mental health stigma and labelling (Vogt, 2011), and thus a focus group format could discourage women veterans from disclosing psychiatric concerns and discussing how mental health relates to smoking.

The current study aimed to fill these gaps by gathering data from women veterans with smoking history who lived in North Carolina, which has a high smoking rate among women (15.4%; Kaiser Family Foundation, 2017). Data were gathered using in-depth interviews rather than focus group discussions, which may help generate new themes in smoking cessation among women veterans.

Theoretical Model

To provide a theoretical underpinning to our analytic strategy, we applied the sociopharmacological model of tobacco addiction (Leventhal, 2016). This model was chosen because of its specific relevance to sociocultural disparities in tobacco uptake and maintenance (Leventhal, 2016). The model highlights how contextual factors and disparity group membership affect psychopharmacological stimuli, the acute psychopharmacological effects of nicotine, and tobacco use. For women veterans, disparity group membership (i.e., female gender and veteran status) may increase risk for sex discrimination and “othering,” which may in turn affect psychological symptoms, smoking cues, and risk for smoking relapse. Women veterans may also hold other disparity group memberships, including racial/ethnic minority status, sexual/gender minority status, stigmatized health conditions, and/or low socioeconomic status. Other models of gender and smoking behavior (Triandafilidis, Ussher, Perz, & Huppatz, 2017a, 2017b) and power/oppression (Prilleltensky, 2008) were used in interpretation of qualitative findings, but not in qualitative analysis.

Study Objective

The objective of the current study was to identify themes among women veterans who smoke or recently quit in terms of their experiences of smoking, experiences of smoking cessation, and needs for VA smoking cessation treatment.

Method

Researchers’ Positionality

The team was comprised of researchers who identified as cisgender men and cisgender women, and were from different racial/ethnic backgrounds (White and Black/African American). The research team would like to acknowledge that they are not veterans and consider themselves advocates for the health and well-being of veterans. The research team are non-smokers and advocates of smoking cessation.

Participants

Purposive sampling was used. Inclusion criteria were: 1) received smoking cessation services within VHA, and 2) had a documented quit attempt in the past 12 months. Women veterans were recruited in order to reflect diversity in age and current smoking status. Study participants included 20 women veterans enrolled in medical care at a large VA medical center in the Southeastern U.S who had participated in a quality improvement project focused on improving smoking cessation services for women veterans. This sample size was selected a priori due to its high likelihood of reaching saturation, based on the previous finding that after 12 interviews, there are diminishing returns on new themes, and that at 18 interviews, 96% of salient themes are coded (Guest, Bunce, & Johnson, 2006). All twenty women veterans who were approached agreed to participate.

Most participants were Black/African American (n = 14; 70%), with five White participants (25%) and one Native Hawaiian/Pacific Islander participant. The high proportion of Black/African American participants in this sample was due to a high proportion of Black/African American patients who participated in smoking cessation treatments at the medical center.

Procedures

Women veterans were asked to attend a 60-minute in-person interview. At the beginning of the visit, each veteran completed a consent for audio recording and was provided with information regarding the VA clinical quality improvement project as well as limits to confidentiality. After being told the project goals, women veterans were asked for written consent to audio record the interview.

Interviews followed a semi-structured format that included open-ended questions and follow-up probes for each topic. The interview guide was developed a priori by members of the project team. Interview questions were not designed based upon the Leventhal et al. (2016) model. Rather, interview questions were designed to be as open as possible, gathering general information about five key areas: 1) general smoking history, 2) experiences of smoking/quitting during pregnancy, 3) perceptions of health risks of smoking, 4) barriers to treatment/abstinence, and 5) perceptions of and preferences for VA smoking cessation. These areas were selected based upon VA programmatic areas of emphasis as well as key chronological time points during lifetime tobacco use. All interviews were subsequently transcribed and de-identified. Participants were compensated $100 for time and travel expenses.

Following project completion, rapid analysis, and a report to VHA, a secondary qualitative research analysis of de-identified interviews (redacted dates, locations, names, and other HIPAA identifiers) was approved by the Durham Veterans Affairs Health Care System Institutional Review Board.

Qualitative Analysis

Qualitative analysis of de-identified, transcribed interviews was completed using a combination of content analysis and a priori thematic analysis (Braun & Clarke, 2006; Hsieh & Shannon, 2005). The coding guide was drafted iteratively during and after data collection. The final coding guide was based upon the following content areas: experiences of smoking (initiation, during military service, prenatal smoking), smoking knowledge, cessation experiences (advice to quit, treatments received, relapse), mental health influences, internal and external barriers, facilitators, influence of family and friends, and treatment preferences (format, medications, provider). The two coders trained together on the coding guide and then coded one interview collaboratively. Next, the two coders independently coded an interview, from which inter-rater reliability was calculated at 97.6% agreement.

Following content coding, qualitative analysis utilized memoing, narrative analysis, and thematic analysis, within the context of the sociopharmacological model of tobacco addiction (Leventhal, 2016). The study team identified both common themes (i.e., patterns across a large proportion of interviews) as well as outliers (i.e., cases that did not fit overarching patterns). Additionally, narrative descriptions were created for each participant characterizing lifetime smoking trajectories.

Given that a sample size was determined a priori, data saturation was verified post hoc based on the Saunders’ et al. (2018) definition of data saturation. We split the data into the first 12 interviews (which we hypothesized would yield saturation; Guest et al., 2006) and contrasted this with the last 8 interviews. With the exception of one new theme (i.e., later initiation of smoking), all identified themes reflected repetition between the first 12 interviews and last 8 interviews (i.e., no new data patterns emerged).

Findings

See Table 1 for participant characteristics. The mean age of participants was 48.5 years (SD = 10.0), and ranged from 31 to 64. This average age is consistent with the average age of women veterans using VHA care, which is 48 (Department of Veterans Affairs, 2013). See Figure 1 for emergent themes, presented within the sociopharmacological model of tobacco addiction (Leventhal, 2016). Conceptual areas correspond to: psychopharmacological stimuli, acute psychopharmacological effects, tobacco use, contextual factors, and disparity group membership. The themes presented also appear in Figure 1 in italicized text under corresponding conceptual areas. One additional theme outside of the conceptual model emerged: how to break the cycle (i.e., tobacco abstinence).

Table 1.

Sample Characteristics, N = 20

Variable Mean N (SD) (%)
Age 48.5 (9.7)
Smoking Initiation Age 17.1 (4.5)
Reported Military Smoking History 17 (85.0%)
Current Smoking Status
 Smoking 15 (75.0%)
 Quit 5 (25.0%)
 Months Quit (of n = 5 currently quit) 12.6 (7.7)
Reported Prenatal Smoking History (of n = 18 who reported having given birth) 8 (44.4%)
Smoking Cessation Experiencesa
 Discussed Experiences in Clinic 11 (55.0%)
  Positive Clinic Experience (of n = 11) 7 (63.6%)
  Negative Clinic Experience (of n = 11) 4 (36.4%)
 Discussed Experiences in Study 11 (55.0%)
  Positive Study Experience (of n = 11) 8 (72.7%)
  Negative Study Experience (of n = 11) 3 (27.3%)
 Discussed Experiences of Self-Quit 15 (75.0%)
  Positive Self-Quit Experience (of n = 15) 13 (86.7%)
  Negative Self-Quit Experience (of n = 15) 2 (13.3%)
Pharmacotherapy Experiencesb
 Discussed Medication 4 (20.0%)
  Positive Medication Experience (of n = 4) 3 (75.0%)
  Negative Medication Experience (of n = 4) 1 (25.0%)
 Discussed NRT Patches 17 (85.0%)
  Positive Patch Experience (of n = 17) 7 (41.2%)
  Negative Patch Experience (of n = 17) 10 (58.8%)
 Discussed NRT Rescue 14 (70.0%)
  Positive NRT Rescue Experience (of n = 14) 7 (50.0%)
  Negative NRT Rescue Experience (of n = 14) 7 (50.0%)
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a

“Clinic” refers to VA stop smoking clinic, “study” refers to VA stop smoking clinical trial, and “self-quit” refers to self-initiated quit attempt.

b

“Medication” refers to either bupropion or varenicline, “NRT patches” refers to transdermal nicotine patch, and “NRT rescue” refers to oral nicotine replacement therapy (inhaler, gum, or lozenge).

Figure 1.

Figure 1.

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Study thematic findings presented in the context of the sociopharmacological model of tobacco addiction (Leventhal, 2016). The themes appear in italicized text under corresponding conceptual areas from the model.

Psychopharmacological Stimuli: Conditioned Smoking Cues

According to the theoretical model (Leventhal, 2016), over time chronic tobacco use can cause an automatic conditioned response (i.e., craving) to environmental cues, such as seeing a cigarette. Nearly all participants (n = 19/20; 95%) described smoking as a conditioned response to certain stimuli, such as places (e.g., car), activities (e.g., drinking coffee), or emotional states (e.g., anger). In general, the women veterans had good insight into how specific conditioned cues led to cravings and smoking behavior. Participants evenly endorsed both emotional triggers (stress, anger, anxiety, happiness, boredom, sadness) as well as place/activity triggers (driving, time of day, eating/drinking, smelling/seeing cigarettes).

Acute Psychopharmacological Effects: Positive and Negative Reinforcement

Acute psychopharmacological effects of tobacco use included positive reinforcement (appetitive stimulus) and negative reinforcement (relief of aversive stimulus). The most highly reported psychopharmacological effect of smoking was positive reinforcement (n = 12/20; 60%). Women veterans had insight into the positive reinforcing properties of tobacco use (i.e., mood enhancement, feeling of relaxation). One participant noted that smoking “soothes something inside of me which is not soothing, but it is dangerous.” Another participant echoed this sentiment by stating that “cigarettes numb the pain just as much as alcohol or drugs.” Some participants (n = 5/20; 25%) described relief of withdrawal, cravings, or urges as a reason to smoke. For example, one veteran described how during a quit attempt, her NRT did not adequately treat her nicotine withdrawal symptoms and cigarette cravings, so she went back to smoking.

Tobacco Use: Numerous Lifetime Quit Attempts

Among the 20 participants, 15 (75%) currently smoked, and 5 (25%) had quit. Duration of smoking abstinence ranged from 3 months to 2 years. The majority of participants (n = 15/20; 75%) reported that at some point they had attempted to quit smoking cold turkey (i.e., self-initiated with no pharmacotherapy). Given that most participants had made numerous quit attempts over their lifetimes, the study team used narrative analysis to generate lifetime trajectories of smoking for each participant based on their interview data. Results from narrative analysis highlighted the areas of commonality and heterogeneity in participants’ lifetime smoking trajectories. Seventeen participants (85%) started smoking during their teens or early 20’s. Outliers included two participants who started smoking in childhood (age 5 and age 12) and one participant who started smoking in her late 20’s. After smoking initiation, the norm among the sample was relapsing and remitting tobacco use. Only one participant had a smoking narrative that involved quitting once without difficulty.

Contextual Factors

Military tobacco exposure.

The majority of the veterans (n = 17/20; 85%) interviewed noted that smoking was a significant part of their lives while in the military. These participants either initiated smoking, increased from occasional to daily smoking, or relapsed to smoking during their military careers. Many participants described smoking and smoking breaks during military service as a stress reliever and social occasion, noting that smoke breaks were often the only type of break that was provided. One participant described her first experience with smoking, stating, “I started smoking in the service. Basically because those who didn’t smoke didn’t get as long as a break [sic]. And the captain hit me one day and said, ‘I never see you take a drag off it.’ And so I did, and I was hooked.”

Mental health.

A majority of participants (n = 13/20; 65%) spontaneously discussed a lifetime history of PTSD or depression. Eight of these participants specifically noted that mental health concerns – particularly symptoms related to traumatic experiences – had been a barrier to stopping smoking. Each of these 8 women veterans had been unable to quit at the time of the interview despite multiple quit attempts. One participant summarized how her PTSD had contributed to her struggle to stop smoking:

Even though mentally I want to quit – in my heart I really want to quit – I’ve got all of these other sideline issues. But when you’re sitting at home and you’re not having a good PTSD day, smoking is probably the only thing that I can actually physically do on a day like that.

Participants also noted how combining treatment for smoking cessation and other mental health concerns would be helpful. Smoking related to stress, negative mood (anger, anxiety, and sadness), and psychiatric symptoms. For example, one veteran related her PTSD symptoms to her difficulty quitting smoking, yet related her ability to quit to resilience:

For me, I have PTSD, so I get anxiety. […] On the way up I just smoked – I probably smoked 5–6 cigarettes in an hour. […] There’s never a good day to stop smoking. There’s always stress, there’s always going to be ‘life happens.’ So it’s just a matter of realizing I am strong enough. I’ve come through a lot of things, and I can do it.

Military sexual trauma and civilian gender-based violence.

Six of the twenty participants (30%) discussed personal experiences of gender-based violence in and out of the military and noted how those experiences affected their smoking behavior. The proportion of women who discussed MST and gender-based violence is similar to rates of MST in general among women veterans (38%; Wilson, 2018). This is notable, given that we did not specifically query about MST in the interview. All of these participants linked the experience of gender-based violence with distress and increased smoking. One participant described how her smoking began due to a military recruitment sexual assault experience: “I started smoking around when I was 17, right after I was assaulted by a [military] recruiter. […] I had tried it [smoking] when I was in high school, […] but I didn’t like it. But the trauma from the MST, well they call it MST but I wasn’t even really in the military yet.” In addition to the six participants who discussed personal experiences of gender-based violence, two participants (10%) noted that they felt military sexual trauma was important to consider when addressing treatment for women veterans.

Social influences: relationships and stigma.

Women veterans emphasized social relationships (n = 15/20; 75%), which were either motivators of or barriers to abstinence. Concern for the health or wellbeing of a fetus, child, or grandchild was a key motivator for abstinence and decreased smoking (n = 12/20; 60%). Additionally, seeing family suffer from smoking-related disease was also a motivator (n = 2/20; 10%). When participants had stressful relationships with family or close friends, they reported difficulty quitting or being less likely to want to quit (n = 12/20; 60%). These stressful relationships were often associated with pressure to quit, rather than support to quit. One woman described her encounters with family members about smoking thusly, “I can even say family members – family members who I’m not close with – would frequently judge my smoking. In my mind, I’m like whatever. Go to hell.” For one quarter of participants (n = 5/20; 25%), there was an emotional attachment or relationship to smoking itself. For example:

A cigarette is like my friend, it’s something constant. My life has been faced with so many uncertainties, so many disappointments, so many failed marriages, so many ailments, that the cigarette is like my only constant over that forty-seven years. Excuse me. [Participant becomes tearful.] That’s okay, I’m fine. It’s just like, it’s like a part of me.

Social stigma was another social influence that was spontaneously discussed by nearly half of participants (n = 9/20; 45%). Due to their smoking, women stated that they were treated like a “horrible person,” a “social pariah,” and like their tobacco addiction was a personal failing. However, stigma consistently did not make smoking abstinence easier to attain or more appealing.

Autonomy and prenatal smoking.

In participant responses regarding prenatal smoking, we can see the intersection between disparity group membership, contextual factors, and tobacco use. A majority of participants (n = 18/20; 90%) had given birth, and of those, nearly half (n = 8/18; 44%) had smoked during at least one pregnancy. Participants ranged from describing the process of quitting smoking during pregnancy as “easy,” to others acknowledging continued smoking throughout multiple pregnancies. Facilitators of prenatal smoking cessation included concern for fetal health and family social support. For veterans with a history of prenatal smoking, barriers to prenatal smoking abstinence included disbelief in or unawareness of the risks of prenatal smoking, lack of resources to facilitate quitting, and stress.

Autonomy was spontaneously discussed by a majority of participants regarding both reasons to smoke and reasons to be abstinent during pregnancy (n = 11/20; 55%). Some women stated that, when pregnant, others had told them to or “made them” quit. For example, one veteran explained that she felt forced to stop smoking during pregnancy despite her belief that it was not harmful:

It’s bulls***, it’s bulls***. Honestly it is. […] That’s why I changed doctors. Anytime they – when they said, ‘You smoking and it’s going to cause low birthweight,’ I said, ‘I don’t have time for this. If every time I come in here you’re going to tell me quit smoking or your baby’s going to be little, going to have breathing problems.’ I said, ‘I already told you, I had one already. I know that you went to school and you have your doctorate degree, but that doesn’t mean that you know everything.’

The autonomy theme was also observed in participants’ descriptions of prenatal smoking cessation to protect their unborn child. One veteran explained how her mother’s smoking inspired her to limit her daughter’s exposure to tobacco: “I mean you think about […] how it affected you; and how it really wasn’t your decision. It came off of somebody else, and it’s because of somebody else that you’re smoking; and it’s making it difficult for you to quit.”

Access to information and treatment.

Lack of access to information was notable in this sample. When asked about smoking health risks, half of the sample (n = 10/20; 50%) either stated misinformation or noted a lack of information about smoking risks, particularly about the effects of nicotine. One participant summarized the general lack of information reported by many participants by saying, “Apparently nicotine is bad for you. I mean that is what I was told. […] I’m not real clear on it. I don’t know the whole thing about the cigarette, you know? I know it’s tobacco, I know how they process. I used to crop tobacco.” This example is particularly remarkable given the participant’s direct experience with tobacco farming, contrasted with her lack of access to information about smoking risks.

Participants largely had high access to smoking cessation treatment (Table 1). Only 3 participants (15%) reported a single quit attempt with no relapse. All other participants (n = 17/20; 85%) had a history of multiple quit attempts, including cold turkey, behavioral treatment, NRT, and other medications. All pharmacotherapy discussed during interviews had been prescribed through a VA provider. Regarding experiences in smoking cessation treatment, Table 1 also shows the quality of each experience of smoking cessation for each participant. Negative experiences were most often characterized by ineffective pharmacotherapy, pharmacotherapy side effects, a lack of sufficient support, or a lack of respect for the participant’s autonomy. In positive treatment experiences, participants generally underscored the importance of support and accountability from a group therapy modality, an individual counselor, or from a friend or family member.

Disparity Group Membership: Salience of female identity and veteran status

In the sociopharmacological model of tobacco addiction (Leventhal, 2016), disparity group membership can affect contextual factors, psychopharmacological stimuli, psychopharmacological effects of nicotine, and overall tobacco use. A majority of participants (n = 17/20; 85%) described the salience of woman veteran identity and female gender identity. Women veterans noted that they have to be “superwomen,” meaning that they need to fill multiple roles (e.g., spouse, mother, grandmother, working professional). One veteran stated, “As far as women, shoot, women, we have the weight of the world on our shoulders. We’re mothers, wives, we work. Then the menstrual hormonal thing. There’s so much going on that needs to be taken into consideration.” Over half of participants (n = 11/20; 55%) specifically discussed woman veteran identity. Woman veteran identity related to minority status in the military, discomfort around men due to MST, and lack of resources for women veterans. One participant described her military experience: “They sent me on recruitment duty for two years. […] I started back smoking every single day. I was the only female on the unit. I smoked every single day. Every single day. Every single day.” The repetition in this quotation is notable since the veteran places strong emphasis directly on the connection between gender minority status and smoking behavior. Other themes that emerged related to societal expectations for around smoking (e.g., it’s not “cute for a woman to smoke”) and heightened emotional connections to smoking for women.

Although female gender was a salient minority group for most participants, four participants (20%) noted that men and women veterans largely did not differ. These participants noted that “everyone has their struggles, everyone has their issues,” and that being a veteran was more salient than being a man or woman. Although the majority of participants in the sample were Black or African American; race, racism, and racial discrimination did not arise as experiences that were related to smoking maintenance or cessation.

Breaking the Cycle: Preferences for Smoking Cessation Treatment

Participants were asked about their preferences for VA smoking cessation, yielding responses that can be classified as relating to contextual factors and disparity group membership. Preferences for pharmacotherapy were not very salient (n = 5; 25%; NRT [n = 4] and varenicline [n = 1]).

Contextual factors of treatment preferences.

Most participants (n = 15; 75%) preferred an intensive (i.e., more frequent than status quo) or long-duration (i.e., longer follow-up than status quo) approach to smoking cessation. Specific strategies included residential treatment, telehealth/texting follow-up, and individualized treatment plans. Participants were evenly split between preferring face-to-face appointments versus telehealth (or a combination). Reasons for preferring telehealth centered around convenience. Reasons for face-to-face appointments related to comfort with the clinician. Participants were also evenly split in preferring individual or group treatment. Six participants (30%) specifically highlighted the importance of peer support, especially among fellow women veterans, to facilitate exchange of ideas and social support.

With regard to the qualities of an ideal clinician, participants emphasized respect and empathy (n = 9/20; 45%). Participants wanted a friendly, kind provider who would not make them feel guilty or ashamed. As one participants stated, “It’s just about the tone of how you present things.” Many participants (n = 8; 40%) also noted that they preferred a provider who had been a former smoker because the person would have a more personal understanding of smoking. Other criteria offered by participants included wanting a mental health provider (n = 3) and wanting a female provider (n = 3).

Disparity group membership factors of treatment preferences.

Most participants (n = 17; 85%) supported women-specific smoking cessation services. Reasons for their support included reducing psychological trauma-related triggers arising from a larger mixed-gender group and feeling more open to sharing in a group where women were not a minority. One participant said, “I always find when I’m in the midst of a group of women, I find that during the time in the group it’s almost like we draw energy from one another, and almost like by the end of the group it’s almost like a little sisterhood that we have, just that support.”

Among participants, a minority (n = 3/20; 15%) expressed that they did not find women’s smoking cessation services necessary. One participant stated, “I don’t understand the whole concept of tailoring things to the female veteran as opposed to the male veteran, because we didn’t have a distinction when we were in the military.” Among participants who did not support women’s cessation services, participants felt that tailoring treatment to the individual (rather than by gender) would be beneficial.

Discussion

The current study qualitatively examined women veterans’ experiences of smoking across the lifespan and preferences for VA smoking cessation. This study built upon previous research by sampling women veterans who had previously utilized VA smoking cessation services, and by utilizing in-depth interviews to encourage disclosure of potentially stigmatized topics (e.g., prenatal smoking and mental health concerns).

Regarding the sociopharmacological model of tobacco addiction (Leventhal, 2016), findings highly aligned with the model. Thematic areas overlaid constructs presented in the Leventhal et al. paper. Moreover, connections between thematic areas mapped onto associations presented in the Leventhal paper. For example, disparity group membership (being a woman veteran) was explicitly linked to contextual factors (e.g., military sexual assault and harassment), and then to tobacco use.

Results from the current study also expand upon findings from the Katzburg et al. (2008) study, in which many participants endorsed a history of military smoking related to increased tobacco exposure. Similar to the Katzburg study, current findings also suggest that smoking behavior is related to military service. However, unlike the Katzburg study, the current study found themes related to important contextual factors and disparity group membership. Military service affected tobacco use through three key mechanisms: tobacco exposure, social incentives for tobacco use (e.g., smoke breaks), and coping with psychological stressors (e.g., discrimination and military sexual trauma). There is quantitative evidence that military service increases risk for smoking initiation and maintenance across the lifespan (London, Herd, Miech, & Wilmoth, 2017), as well as qualitative work that suggests smoking norms during military service influence smoking initiation and maintenance (Gierisch et al., 2012). The current study, however, provides new information regarding how gender-related assault, harassment, and discrimination in the military may affect women veterans’ smoking behavior.

Findings from the Katzburg study (2008) focused on smoking cessation treatment preferences, with emergent themes including support and choice. Similar to the Katzburg study, support (peer support and provider empathy/respect) was an emergent theme in the current study. This is also similar to qualitative findings regarding treatment preferences among civilian women who smoke (Minian, Penner, Voci, & Selby, 2016). Another similarity to the Katzburg study was the desire among participants for a smoking cessation provider who was a former smoker. However, unlike the Katzburg study, a large proportion of participants in the current study specifically advocated for intensive or long-duration format treatment and for telehealth or texting. This difference may be due to the increased amount of time spent in the current study discussing barriers to smoking cessation, which included considerable stress and mental health concerns. Findings related to the emphasis on telehealth and texting treatment modalities may be due to advancing technology.

In a departure from previous studies (Katzburg, 2008; Minian, 2017; Gierisch, 2012), participants in the current study emphasized the effects of comorbid mental health concerns on smoking. A large proportion of participants in this study discussed the inextricable association between smoking and mental health, and several further noted how mental health concerns must be addressed in order to successfully stop smoking. This difference is likely due to the data collection method. Whereas the Katzburg, Minian, and Gierisch studies all used focus group discussion, the current study used individual interviews. In a focus group, mental health stigma may have prevented or diminished discussion of the ways in which mental health relates to smoking behavior and cessation. In our one-on-one interviews, participants may have felt more comfortable discussing mental health concerns.

When considering study results overall, findings from the current study can be interpreted in light of Triandafilidis et al.’s work on perceptions of smoking stigma and risk among young women who smoke (Triandafilidis, Ussher, Perz, & Huppatz, 2017a, 2017b). Similar to their findings, themes associated with smoking stigma, a gender double standard, and smoking and pregnancy/motherhood/grandmotherhood emerged in the current study. Participants in the current study expressed conflict relating to smoking discussions, in which providers and/or family members would tell them to stop smoking or try to make them stop smoking. Regarding perceptions of smoking risks, two of Triandafilidis et al.’s interpretive risk repertoires emerged in the findings: ‘the risks of smoking are self-evident’ and ‘smoking to cope with stress and emotion.’ However, unlike Triandafilidis et al.’s work, findings did not suggest that women in this study smoked to avoid “unfeminine” emotions. Rather, participants in the sample often smoked as an expression of their autonomy and self-determination.

In this sense, overall findings may be best interpreted using Prilleltensky’s model of power, which distinguishes between three types of power: the power to strive for wellness, to oppress, and to resist oppression, each of these three relating to the self, others, and the collective (Prilleltensky, 2008). Findings suggest that disparity group membership (veteran status, female identity, and woman veteran identity) affect smoking behavior and maintenance. Additionally, it is possible that because a majority of the sample identified as Black or African American, racial minority status may have interacted with other disparity group memberships (i.e., multiple minority status; (Barile, 2000). Through Prilleltensky’s lens of power we can see how entreaties or commands to stop smoking (if delivered in a way that does not honor autonomy) can constitute an oppressive force on the self. Thus, continued smoking may in fact function as a way to resist oppression, especially in the context of other current and lifetime oppressive forces (e.g., gender bias and discrimination, military sexual trauma, racism, social pressures, mental health stigma, smoking stigma, etc.). The use of personal power to resist oppression through smoking, however, may impede the ability to use personal power to strive for wellness. Additionally, the observed gaps in access to information (especially with regard to NRT) could further reduce power to strive for wellness.

With regard to clinical care of women veterans who smoke, these findings highlight the ways in which current models of women’s health care within VA may be already addressing, or easily adapted to address, smoking cessation needs. Regarding pharmacotherapy, study findings suggested two important needs: a) increased access to information regarding NRT, and b) increased access to medications. In a recent observational study, only 8% of women veterans referred to VHA tobacco cessation services were abstinent at 6 months post-referral; however, for each additional medication prescribed by the tobacco cessation service, there was a two-fold increase in the likelihood of making a quit attempt (Berg, Smith, Cook, Fiore, & Jorenby, 2016).

Regarding behavioral treatment, current study findings suggest that an intensive and/or long-duration smoking cessation behavioral treatment may be appropriate. There are two published models for women’s smoking cessation within VA (Katzburg et al., 2009; San Diego Tobacco Cessation Clinical Resource Center, 2014). Thematic areas in these treatment models generally map well onto the findings from the current study. However, these treatment models do not include guidelines for intensive or long-duration treatments. It may be particularly useful to further explore implementation strategies for increasing resources for smoking cessation in mental health settings. This type of approach might be similar to the intervention tested in a multi-site clinical trial (McFall et al., 2010) and a recently piloted smoking cessation intervention that paired psychotherapy for PTSD with concurrent smoking cessation treatment (Dedert et al., 2016). Additionally, there have been efforts in VA to develop and implement an integrated approach to smoking cessation treatment in mental health care (Ebert et al., 2014). However, in order to fully implement integrated smoking cessation, more resources may be required to train clinicians. Additionally, provider time would need to be allocated to smoking cessation services on an ongoing basis. Although each VA medical center is mandated to have a Tobacco Cessation Specialist (Department of Veterans Affairs, 2014), this is rarely a full-time position. Thus, more detailed and resourced implementation strategies may be required to ensure the uptake and sustainability of integrated smoking cessation programs.

VA is well-positioned to address the needs and preferences that arose in the current study for several reasons. First, VA typically provides care across physical and mental health domains and across the lifespan, allowing for recurring opportunities to offer and initiate cessation services. Second, given that all patients are veterans, there is a “built-in” element of peer support that is unique to veteran culture and may facilitate smoking cessation (Strom et al., 2012). Third, VA provides gender-specific care in its facilities’ women’s health clinics; thus, delivering integrated care for smoking cessation in these clinics may be a logical pathway to help more women veterans quit smoking. However, in smaller facilities (e.g., rural VA community-based outpatient clinics), delivery of gender-tailored smoking cessation may require more flexible approaches, such as primary care integration or telehealth.

It is also important to consider the limitations of this study. Each of these participants received smoking cessation treatment at the VA in the past year. Thus, these data do not reflect the experiences of women veterans who do not receive VA care, or who receive VA care but have not sought smoking cessation treatment. Given these considerations, the study sample likely emphasized intensive smoking cessation more strongly than women veterans who do not seek smoking cessation treatment. Additionally, the current study did not specifically probe for elements of the Leventhal model (2016). Thus, the lack of findings of the ways in which tobacco use is related to other disparity group memberships, such as racial minority status or sexual minority status, may reflect the interview guide’s content. Rates of MST endorsement (30%) are similar to previously published rates among women veterans (Wilson, 2018). Thus, we believe that the interview environment promoted a safe space where participants felt comfortable endorsing MST.

In conclusion, this study used individual in-depth interviews with women veterans to examine their lifetime experiences of smoking and preferences for VA smoking cessation. Results highlight the importance of sociocultural context as well as disparity group membership when considering women veteran’s smoking behavior and smoking cessation. Findings also highlight key elements for smoking cessation treatments for women veterans, including access to information and medication, intensive format, integration with mental health services, involvement/training of social support contacts, and longer follow-up duration. It will be important to continue to investigate methods to improve smoking cessation strategies for veterans, including women veterans.

Funding Acknowledgements

The quality improvement project for which this data was originally collected was funded by the Department of Veterans Affairs Women’s Health Services Program Office. Research analysis and manuscript preparation were supported by the VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, a VA Career Development Award from VA Health Services Research and Development (IK2HX002398) (Dr. Wilson), NIH grant R25MH083620 from the National Institute of Mental Health (Dr. Wilson), and a VA Research Scientist Award from the VA Office of Research and Development (ORD) Clinical Sciences Research and Development Service (11S-RCS-009) (Dr. Beckham). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the United States government, or any of the institutions with which the authors are affiliated.

Footnotes

Declaration of Conflicting Interests

The authors declare that there are no conflicts of interest.

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