Skip to main content
PMC home page
Nicotine & Tobacco Research logoLink to Nicotine & Tobacco Research
. 2019 May 6;22(6):872–877. doi: 10.1093/ntr/ntz069

Smoking Across the Menopausal Transition in a 10-Year Longitudinal Sample: The Role of Sex Hormones and Depressive Symptoms

MacKenzie R Peltier 1,✉, José M Flores 1, Philip H Smith 1, Walter Roberts 1, Terril L Verplaetse 1, Kelly E Moore 1, Robyn Hacker 1, Lindsay M Oberleitner 1, Sherry A McKee 1
PMCID: PMC7249927  PMID: 31058288

Abstract

Introduction

Current cigarette smoking rates among older women remain problematic, especially given that this population experiences increased smoking-related health consequences. Despite these increased health concerns, little research to date has explored smoking patterns across the menopausal transition (pre-, early-peri-, late-peri-, and postmenopausal) or the effect of unique factors such as sex hormones and depression during this transition.

Methods

This study used 10 yearly waves of data from the Study of Women’s Health Across the Nation, a longitudinal dataset. Data included 1397 women endorsing ever smoking regularly at baseline. Random-effects logistic regression models were used to examine smoking transitions.

Results

Although there were no associations between menopausal transition stage and smoking behavior, increased estradiol was associated with an increased likelihood of quitting regular smoking (eg, transitioning from regular smoking to non-regular or no smoking; odds ratio [OR] = 1.28), whereas increased testosterone was associated with an increased likelihood of relapsing to regular smoking (eg, transitioning from former or nonregular smoking to regular smoking OR = 2.56). Depression was associated with increased likelihood of continued smoking (OR = 0.97) and relapse (OR = 1.03).

Conclusions

The results emphasize the need to develop interventions to target initiated or continued smoking among women across the menopausal transition and specifically highlight the importance of developing treatments that target depressive symptoms in this population. In addition, although singular hormone measures were associated with smoking behavior, there is a need for future study of dynamic changes in hormones, as well as the impact of progesterone on smoking behaviors across the menopausal transition.

Implications

To date, no studies have examined smoking behaviors across the menopausal transition. In this study, although menopausal transition status was not significantly related to transitions in smoking behavior, important relationships between sex hormones and depression were observed. Increased estradiol was associated with an increased likelihood of quitting regular smoking, whereas increased testosterone was associated with an increased likelihood of relapsing to regular smoking behavior. Higher depression scores were related to continued smoking and relapse to regular smoking behavior. These results highlight the need to develop interventions to target smoking cessation among women across the menopausal transition.

Introduction

Current cigarette smoking rates among adults in the United States have recently declined, with rates decreasing from 20.9% in 2005 to 15.5% in 2016.1 However, smoking among older women remains relatively common; among women 45–64 years old, 16.8% report current smoking.1 This is problematic given that cigarette smoking is the leading cause of preventable death and disease in the United States and women experience a greater negative health burden when compared to men, with a greater risk of developing various cancers and cardiovascular diseases.2–5 In addition, women smokers have sex-sensitive and sex-specific health risks, especially associated with menopause, including earlier menopausal transition, increased risk of osteoporosis, impaired respiratory function, and more severe menopausal symptoms.2,6–8 Despite these increased health risks, women overall have poorer rates of smoking cessation, indicating that increased efforts are needed to understand and improve cessation rates,9 specifically among older women.

One potential explanation for the observed differences in cessation rates may be the hormonal milieu. During menopause, endogenous levels of estradiol and progesterone initially fluctuate during the menopausal transition, but gradually decrease to low, stable levels in postmenopause.10 Follicular stimulating hormone (FSH) levels, typically an indicator used in categorizing menopausal stage, increase substantially over the menopausal transition and remain elevated until later in life, whereas testosterone levels remain relatively stable across the transition.11–13 The menopausal transition is typically divided into several stages based upon fluctuating hormone levels and menstrual cycle length. Premenopause is generally a time describing a women’s reproductive years, which is often characterized by regular menses and low levels of FSH; the duration of premenopause is highly variable and may be further broken down into early, peak, and late reproductive stages.10,14 The menopausal transition, often called perimenopause, is divided into early- and late-perimenopause based upon acyclicity. Early-perimenopause stage criteria include variable menstrual cycle length and FSH values; however, the length of this stage is also highly variable based upon the individual. Late-perimenopause is characterized by periods of amenorrhea, lasting at least 60 days, as well as high levels of FSH (greater than 25 IU/L). Late-perimenopause typically lasts 1–3 years. Finally postmenopause follows 1 year of amenorrhea, and may be further broken down into early (variable FSH levels) and late (stabilized FSH levels) stages.10,14 Of note, the duration of such reproductive stages is highly variable based upon a myriad of variables, such as overall health, socioeconomic status, body mass, race, ethnicity, and genetic factors.10

Among premenopausal women, there is evidence that progesterone is generally protective against smoking-related variables (eg, decreased subjective reactivity, fewer puffs of cigarettes in laboratory settings), whereas estradiol is implicated in smoking behavior (eg, relapse, continued smoking; for review, see Wetherill et al.15). However, it is worth noting that there is mixed evidence regarding the hormonal milieu, menstrual cycle, and smoking.15,16 As such, some studies, including one meta-analysis, have reported greater symptoms of withdrawal and craving during the luteal phase, when progesterone levels are highest.17

Regarding testosterone, smoking is associated with higher testosterone levels; however, the specific association among women smokers remains unclear and is understudied.18 Among the few studies that have examined the role of testosterone in female smoking behavior,18 higher concentrations of testosterone have been found in premenopausal smokers relative to former female smokers and nonsmokers.19 This pattern holds true for postmenopausal smokers, with higher levels of testosterone in current versus never smokers, which was associated with the number of cigarettes smoked per day.20 In addition, high levels of testosterone were also observed among the postmenopausal former smokers included in one population-cohort study.20 Given the declining levels of endogenous estradiol and progesterone, as well as the stable levels of testosterone, postmenopause may be an advantageous time to make a cessation attempt. However, to date the majority of the literature has focused on the impact of sex hormones and smoking behavior among premenopausal women.17 In fact, little information is available regarding the impact of these endogenous hormones and their fluctuations on smoking cessation attempts during or after the menopausal transition.7

An additional factor that may explain changes in smoking behavior among older women is negative affect, specifically depressive symptoms. Women are at an increased risk of developing depressive symptoms during the menopausal transition, with a recent study showing that 31% experienced a period of persistent or recurrent depression, and 9% endorsed a single major depressive episode, across a 13-year period during the menopausal transition.21,22 Such associations between the menopausal transition and depressive symptoms, may be associated with the fluctuating hormonal milieu across the transition.7,22 This likely has a meaningful impact on female smokers, as it is well established that negative affect impedes smoking cessation attempts among smokers.23–25 However, little information is known regarding how depressive symptomatology affects smoking behavior across the menopausal transition.

The current scant literature regarding smoking behaviors in older women leaves several important gaps to address in order to improve cessation outcomes in this population. For instance, to the best of our knowledge, there are no studies examining smoking outcomes across the menopausal transition (pre-, early-peri-, late-peri-, and postmenopausal stages) and the impact of endogenous sex hormones and depression on such outcomes. In addition, there is a need to focus on long-term smoking cessation outcomes, as no study has examined treatment outcomes beyond a 1-year follow-up in postmenopausal women.25 This information may provide necessary insights to help develop targeted interventions for cessation among women during and after the menopausal transition.

This study sought to investigate the effect of transitions across menopausal status (pre-, early-peri-, late-peri-, and postmenopausal stages) on the transition from regular smoking to nonregular or no smoking (ie, quitting regular smoking behavior) as well as the reverse transition from nonregular or no smoking, among those endorsing ever smoking to regular smoking (ie, relapse to regular smoking behavior). In addition, we analyzed the impact of sex hormones, specifically, estradiol and testosterone, as well as depressive symptoms on these changes, while accounting for age.

This study used data from the Study of Women’s Health Across the Nation (SWAN). SWAN is a longitudinal, epidemiological study designed to capture the relevant biopsychosocial changes that affect women’ health across the menopausal transition.26 This dataset allowed investigation of the effects of menopausal status and endogenous sex hormones, as well as depression, on smoking. It was hypothesized that late-perimenopausal and postmenopausal status would be associated with an increased likelihood of quitting regular smoking in women followed across the transition and decreased likelihood of women relapsing to regularly smoking. It was hypothesized that increased levels of estradiol and testosterone would be associated with a decreased likelihood of quitting regular smoking and an increased likelihood of relapsing to regular smoking. In addition, it was hypothesized that higher scores of depressive symptoms would be associated with a decreased likelihood of quitting regular smoking, as well as an increased likelihood of relapsing to regular smoking.

Methods

Data Source

The data used in this study are drawn from the publicly available SWAN datasets.26 The study enrolled 3302 participants from seven research centers across the United States between 1996 and 1997. SWAN enrolled women who were between 42–52 years old, reported being pre- or early-perimenopausal (defined as reporting a menstrual period within the past 3 months), did not take hormone medications in past 3 months and denied a total hysterectomy (participants reported an intact uterus and at least one ovary). These participants were then followed annually over 10 years following the baseline visit with in-person examinations, which included biological measures (eg, height, weight, blood draws), as well as and surveys assessing for various physical, biological, psychological, and social changes. Additional information regarding the SWAN data and the specific variables it includes is available elsewhere.26

Data Analysis

Data were analyzed using Stata Statistical Software 16.1 (2016; StataCorp, College Station, TX). Annual datasets were merged, and variables were matched based upon a source-identification variable.

Menopausal status stage was coded each year during annual surveys.26 Women were identified as premenopausal if they reported menses within the past 3 months with no change in menstruation patterns (eg, no changes in regularity or menses occurring further or closer than previous menses). They were classified as early-perimenopausal if they experienced menses within the past 3 months, but identified decreased predictability between menses (eg, changes in menses being further or closer apart; changes in variability or regularity of menses). Late-perimenopausal women were classified as those who had reported no menses within the past 3–11 months. Finally, women reporting no menses for the past year were identified as postmenopausal.

Once categorized, women were not permitted to be categorized “backwards” in future visits.26 In the SWAN dataset, women who reported taking hormonal therapies who had a hysterectomy and/or ovaries removed were classified as “unknown due to [hormonal therapy] use,” or “unknown due to hysterectomy,” respectively.26 Accordingly, these women were not included in analyses for the years their menopausal status was marked “unknown.” In addition, given the scope of this study, women who were currently pregnant or breastfeeding were classified as such26 and were excluded from the present analyses for the years they were pregnant/breastfeeding. It is important to note that the menopausal status definitions used in the SWAN study were based upon menopausal status definitions that were included in the Massachusetts Women’s Health Study27,28; FSH levels were not used to categorize stages of the transitions for participants.

This study included only participants who transitioned to postmenopausal status during the 10-year period. Smokers were identified from baseline data by responding yes to a query about smoking behavior at baseline (Have you ever smoked cigarettes regularly?; response, yes or no). Transitions in smoking behavior were derived from an annual assessment of smoking behavior (Do you smoke regularly since last visit?; response, yes or no), beginning at visit 1. Data were not censored at quitting and/or relapse to regular smoking behavior, in order to best capture subsequent transitions (eg, if a participant relapsed, then, stopped smoking regularly, then relapsed to regular smoking again, both instances were counted in the analyses).

Random-effects logistic regression models with robust standard errors were calculated using the xtlogic command in Stata: the association between menopausal status and transition from regularly smoking to nonregular or no smoking (eg, quitting regular smoking) between any waves of data collection, as well as the association between menopausal status and transition from nonregular or no smoking to regularly smoking between any waves of data collection, among those identified as “ever smokers” (eg, relapse to regular smoking). Baseline age, age of postmenopausal status, and length of transition from early-peri- to postmenopausal status were included in all models. Annual measures of hormonal assays, including estradiol and testosterone, were included in the second and third models. Estradiol and testosterone results did not have normal distributions, and thus natural log-transformed values were used. This strategy has been used in other analyses of SWAN hormonal data (eg, Lasley et al.29 and Luetters et al.30). Of note, FSH was not included in current analyses, due to multicollinearity with the menopausal transition variable. Depression symptoms were also evaluated annually, with the Center for Epidemiological Studies Depression Scale (CES-D),31 and were included in the third model.

Results

Baseline data identified 1397 women as being ever regular smokers. Of the identified baseline, ever regular smokers, the majority were White, non-Hispanic (54.40%; Black and/or African American, 30.60%; Hispanic, 6.70%; Asian and/or Asian American, 8.30%). Mean age at baseline was 45.84 years (SD = 2.67 years).

Transition From Smoking Regularly to Quitting Regular Smoking

There were no significant associations between menopausal status and the transition from smoking regularly to not regularly smoking or not smoking. However, increased estradiol levels were associated with an increased likelihood of quitting regular smoking. Testosterone levels were not significantly related to the transition to quitting regular smoking. In addition, increased depressive symptoms (measured via CES-D) decreased one’s likelihood of quitting regular smoking. See Table 1 for complete results.

Table 1.

Association Between Menstrual Status and Transition From Regular Smoking to Quitting

Model 1 Model 2 Model 3
OR (95% CI) p OR (95% CI) p OR (95% CI) p
Menopausal transition status
 Premenopausal Reference Reference Reference
 Early-perimenopausal 2.29 (0.56 to 9.46) .251 1.70 (0.29 to 9.89) .553 1.92 (0.29 to 12.84) .501
 Late-perimenopausal 1.32 (0.13 to 13.49) .817 0.91 (0.06 to 13.85) .945 1.09 (0.06 to 21.00) .952
 Postmenopausal 2.46 (0.31 to 19.87) .397 1.60 (0.11 to 22.77) .728 1.85 (0.11 to 30.29) .665
Age (years)a 0.95 (0.69 to 1.30) .735 1.06 (0.74 to 1.54) .740 1.06 (0.69 to 1.62) .796
Age of postmenopause (years) 1.14 (0.84 to 1.56) .403 1.07 (0.74 to 1.55) .733 1.08 (0.69 to 1.62) .745
Length of transition (years)b 1.00 (0.76 to 1.31) .994 1.05 (0.76 to 1.44) .786 1.05 (0.74 to 1.48) .778
Estradiol (pg/mL)c 1.28 (1.09 to 1.51) .003 1.28 (1.08 to 1.50) .004
Testosterone (ng/dL)c 0.85 (0.56 to 1.29) .446 0.80 (0.54 to 1.19) .275
Depression (CES-D), total score 0.97 (0.94 to 1.00) .022
Open in a new tab

Bold font indicates significance. CES-D = Center for Epidemiological Studies Depression Scale; CI = confidence interval; OR = odds ratio.

aAt baseline.

bYears from early-peri- to postmenopause.

cNatural log-transformed hormonal assay results.

Transition from Former Smoker or Not Smoking Regularly to Smoking Regularly

Again, no significant association between menopausal status and the transition from nonregular or no smoking, among former “ever smokers,” to regular smoking (eg, relapse) were observed. Similarly, estradiol levels were not significantly related to transition to relapse to regular smoking. However, increased levels of testosterone and depression (measured via CES-D) were associated with an increased likelihood of relapsing. See Table 2 for complete results.

Table 2.

Association Between Menstrual Status and Transition to Relapsing to Regular Smoking

Model 1 Model 2 Model 3
OR (95% CI) p OR (95% CI) p OR (95% CI) p
Menopausal transition status
 Premenopausal Reference Reference Reference
 Early-perimenopausal 0.83 (0.13 to 5.29) .844 0.72 (0.11 to 4.53) .726 0.64 (0.09 to 4.38) .649
 Late-perimenopausal 0.92 (0.19 to 4.50) .921 0.74 (0.16 to 3.36) .693 0.68 (0.16 to 3.12) .622
 Postmenopausal 0.71 (0.11 to 4.38) .712 0.59 (0.08 to 4.29) .601 0.54 (0.07 to 4.33) .563
Age (years)a 0.92 (0.70 to 1.19) .515 0.96 (0.68 to 1.34) .797 0.99 (0.68 to 1.43) .958
Age of postmenopause (years) 0.88 (0.70 to 1.09) .238 0.87 (0.66 to 1.15) .323 0.84 (0.62 to 1.43) .256
Length of transition (years)b 1.16 (0.87 to 1.56) .310 1.21 (0.82 to 1.77) .330 1.25 (0.82 to 1.90) .309
Estradiol (pg/mL)c 1.09 (0.80 to 1.48) .578 1.11 (0.82 to 1.51) .483
Testosterone (ng/dL)c 2.77 (1.48 to 5.17) .001 2.56 (1.02 to 1.04) .007
Depression (CES-D), total score 1.03 (1.02 to 1.04) <.001
Open in a new tab

Bold font indicates significance. CES-D = Center for Epidemiological Studies Depression Scale; CI = confidence interval; OR = odds ratio.

aAt baseline.

bYears from early-peri- to postmenopause.

cNatural log-transformed hormonal assay results.

Discussion

Given the scant literature investigating the menopausal transition and smoking outcomes to date,7 this study sought to explore the effect of menopausal status on smoking behavior. Although our results did not demonstrate an association between the transition through menopause stages and quiting and/or relapsing of regular smoking behavior, the present results did illustrate that it is likely that other unique factors related to the menopausal transition are related to changes in smoking behavior.

One of these unique factors related to smoking outcomes across the menopausal transition is likely the hormonal milieu, given the previous evidence that endogenous sex hormone levels affect smoking cessation in premenopausal women.17 In the current investigation, testosterone was related to an increased likelihood of relapse to regular smoking, with no significant effect on the likelihood of quitting regularly smoking behaviors. This supports previous literature that both male and female smokers, relative to nonsmokers or former smokers, have higher levels of testosterone.18–20 Thus, it is likely that smoking increased testosterone levels among those smoking regularly, although future research should explore potential casual relationships and measure serum testosterone at multiple timepoints to capture potential dynamic changes in relation to smoking behavior.

In this study, increased levels of estradiol increased the likelihood of quitting regular smoking; however, it was unrelated to relapse. This was contrary to the hypothesis that increased estradiol, which is generally associated with increased cravings, would be related to poorer smoking outcomes (ie, less likely to transition to nonregular or no smoking and more likely to relapse to regular smoking). Previous research has asserted that estrogen is related to accelerated nicotine metabolism among premenopausal women; however, “menopausal” or postmenopausal women’ nicotine metabolism does not differ from that of male smokers.32 Thus, women across the menopausal transition may be less susceptible to the proposed effects of estradiol on smoking behavior.

However, additional investigation regarding ovarian hormones and smoking cessation is still warranted in this population, specifically with future studies collecting hormonal assays at multiple timepoints throughout the menopausal transition. There is emerging evidence that endogenous progesterone levels are related to smoking abstinence among premenopausal women.33 It may be that progesterone, which decreases across the menopausal transition, also affects transitions in smoking behaviors during the menopausal transition. Unfortunately, progesterone levels were not included in the publicly available, annual hormonal assays of the SWAN study; thus, the effect of progesterone and its metabolites (eg, allopregnanolone) on smoking transitions were unable to be explored through this dataset.26 Progesterone levels may also be needed to understand estrogen’s effects on smoking behavior, as previous research has shown that the ratio of progesterone to estradiol is a useful predictor of smoking behavior.16

An additional factor related to smoking outcomes among older women is depressive symptoms. Previous literature has established that negative affect and depression negatively affects smoking cessation in postmenopausal women.7,25 This study supported this finding in that depressive symptomatology was significantly related to a decreased likelihood of quitting regular smoking, as well as an increased likelihood of relapsing to smoking regularly. Research has found that postmenopausal women with a history of depression are less likely to quit smoking, compared to those with no history of depression.25 Given the previous research and this study’s results that depressive symptoms are significantly related to the increased likelihood of continued regular smoking, further study of the mechanisms underlying negative affect management and smoking during the menopausal transition are warranted in order to develop cessation interventions that target depressive symptomatology in this population.

Overall, although the present results did not demonstrate that menopausal status is associated to transitions in smoking behavior; they do illustrate that women are making transitions in smoking behavior as they age. Previous research among older smokers has shown that older smokers who are motivated to quit, have at least as high of a chance of quitting as their younger counterparts, especially when using nicotine replacement therapies.34 This highlights the need to develop novel interventions to increase motivation to quit smoking and improve cessation outcomes among this population. Previous research has shown that menopausal symptom severity, including somatic menopausal symptoms (eg sweating, hot flashes, cardiac complaints), was related to increased motivation to quit smoking35; thus, evaluating one’s health and menopausal symptomatology may increase motivation to quit smoking among postmenopausal women.35 In future work, it may be beneficial to incorporate health evaluation into motivational-based interventions with this population. In addition, addressing other potential barriers to cessation, including psychosocial stress may be advantageous. These avenues may offer important insight into the development of novel treatments for tobacco cessation for this population.

Limitations

To the best of our knowledge, this study is the first study to explore transitions in smoking behavior across the menopausal transition and investigate the impact of sex hormones. However, there are limitations that warrant mention. First, although the sample is composed of a racially and ethnically diverse sample, drawn from seven geographic locations across the United States, results may not be generalizable to women in other countries. Second, data analysis was limited to variables collected at annual assessment visits, as well as the study’s inclusion and exclusion criteria (including age restrictions). As such, there is limited information to help us further characterize and understand factors related to smoking transitions. For example, more detailed questions regarding past year smoking behavior and measures of nicotine dependence were not available for the current study. Measures of depressive symptomatology were also only obtained annually, with a measure that surveys such symptoms over the past week. Thus, this may reflect state affect, as opposed to representing affect, as well as fluctuations in mood, across the past year. Furthermore, menopausal status classification did not include a biological confirmation. Inclusion of these variables would improve future research on this topic.

In addition, sex hormone measurements were taken at only one timepoint at each annual visit and thus may not accurately represent the role of fluctuating hormones across the menopausal transition in relation to smoking. Future studies should include more comprehensive hormone assay collection. Finally, smoking behavior was self-reported and no biological measures were collected, thus smoking behavior may be subject to biased reporting. Despite these limitations, given the limited literature available on smoking across the menopausal transition, the present data are a valuable contribution to the literature. Future investigations are needed to replicate and reproduce the current results.

Conclusions

To the best of our knowledge, results from the present investigation are the first to demonstrate unique factors that affect transitions in smoking behavior among women across the menopausal transition. Estradiol levels were associated with an increased likelihood of quitting regular smoking, whereas testosterone levels were related to an increase in likelihood to relapse to regular smoking. Similar to previous research among other populations of smokers, depressive symptoms were related to a decreased likelihood to quit regular smoking, whereas such symptomatology was also related to an increase in likelihood to relapse to regular smoking among this population. These results emphasize the importance of developing interventions potentially targeting depressive symptoms to improve smoking cessation among women across the menopausal transition. Future research is needed to explore additional barriers to cessation among this population. In addition, the examination of the impact of progesterone on cessation outcomes during the menopausal transition is warranted.

Funding

This work was supported by NIH grants P50DA033945 (to SAM) and T32DA007238 (to MRP). This work was supported by the National Institute of Health grants P50DA033945 (SAM), P01AA027473 (SAM), K01AA025670 (TLV), and T32DA007238 (to MRP). The data utilized in this study is from the publicly available Study of Women’s Health Across the Nation (SWAN) databases.

Declaration of Interests

None declared.

References

  • 1. Jamal A, Phillips E, Gentzke AS, et al. . Current cigarette smoking among adults—United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(2):53–59. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2. The United States Department of Health and Human Services (HSS). Women and smoking: a report of the Surgeon General. MMWR Recomm Rep. 2002;51(RR12):1–30. [PubMed] [Google Scholar]
  • 3. Huxley RR, Woodward M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies. Lancet. 2011;378(9799):1297–1305. [DOI] [PubMed] [Google Scholar]
  • 4. Kiyohara C, Ohno Y. Sex differences in lung cancer susceptibility: a review. Gend Med. 2010;7(5):381–401. [DOI] [PubMed] [Google Scholar]
  • 5. Freedman ND, Silverman DT, Hollenbeck AR, Schatzkin A, Abnet CC. Association between smoking and risk of bladder cancer among men and women. JAMA. 2011;306(7):737–745. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. Hayatbakhsh MR, Najman JM, O’Callaghan MJ, Williams GM, Paydar A, Clavarino A. Association between smoking and respiratory function before and after menopause. Lung. 2011;189(1):65–71. [DOI] [PubMed] [Google Scholar]
  • 7. McVay MA, Copeland AL. Smoking cessation in peri- and postmenopausal women: a review. Exp Clin Psychopharmacol. 2011;19(3):192–202. [DOI] [PubMed] [Google Scholar]
  • 8. Bjarnason NH, Nielsen TF, Jørgensen HL, Christiansen C. The influence of smoking on bone loss and response to nasal estradiol. Climacteric. 2009;12(1):59–65. [DOI] [PubMed] [Google Scholar]
  • 9. Smith PH, Bessette AJ, Weinberger AH, Sheffer CE, McKee SA. Sex/gender differences in smoking cessation: a review. Prev Med. 2016;92:135–140. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10. Lobo RA. Menopause and aging. In: Strauss JF, Barbieri RL, eds. Yen and Jaffee’s Reproductive Endocrinology: Physiology, Pathophysiology, and Clinical Management. 6th ed Philadelphia, PA: Saunders Elsevier; 2009:325–356. [Google Scholar]
  • 11. Carmina E, Lobo RA. Evaluation of hormonal status. In: Strauss JF, Barbieri RL, eds. Yen and Jaffe’s Reproductive Endocrinology: Physiology, Pathophysiology, and Clinical Management. 6th ed Philadelphia, PA: Saunders Elsevier; 2009:801–824. [Google Scholar]
  • 12. Yasui T, Matsui S, Tani A, Kunimi K, Yamamoto S, Irahara M. Androgen in postmenopausal women. J Med Invest. 2012;59(1-2):12–27. [DOI] [PubMed] [Google Scholar]
  • 13. Kim C, Harlow SD, Zheng H, McConnell DS, Randolph JF. Changes in androstenedione, dehydroepiandrosterone, testosterone, estradiol, and estrone over the menopausal transition. Womens Midlife Health. 2017;3(9):9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14. Harlow SD, Gass M, Hall JE, et al. ; STRAW 10 Collaborative Group Executive summary of the stages of reproductive aging workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause. 2012;19(4):387–395. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15. Wetherill RR, Franklin TR, Allen SS. Ovarian hormones, menstrual cycle phase, and smoking: a review with recommendations for future studies. Curr Addict Rep. 2016;3(1):1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16. Schiller CE, Saladin ME, Gray KM, Hartwell KJ, Carpenter MJ. Association between ovarian hormones and smoking behavior in women. Exp Clin Psychopharmacol. 2012;20(4):251–257. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17. Weinberger AH, Smith PH, Allen SS, et al. . Systematic and meta-analytic review of research examining the impact of menstrual cycle phase and ovarian hormones on smoking and cessation. Nicotine Tob Res. 2015;17(4):407–421. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18. Zhao J, Leung JY, Lin SL, Schooling CM. Cigarette smoking and testosterone in men and women: a systematic review and meta-analysis of observational studies. Prev Med. 2016;85:1–10. [DOI] [PubMed] [Google Scholar]
  • 19. Sowers MF, Beebe JL, McConnell D, Randolph J, Jannausch M. Testosterone concentrations in women aged 25-50 years: associations with lifestyle, body composition, and ovarian status. Am J Epidemiol. 2001;153(3):256–264. [DOI] [PubMed] [Google Scholar]
  • 20. Manjer J, Johansson R, Lenner P. Smoking as a determinant for plasma levels of testosterone, androstenedione, and DHEAs in postmenopausal women. Eur J Epidemiol. 2005;20(4):331–337. [DOI] [PubMed] [Google Scholar]
  • 21. Soares CN. Depression and menopause: current knowledge and clinical recommendations for a critical window. Psychiatr Clin North Am. 2017;40(2):239–254. [DOI] [PubMed] [Google Scholar]
  • 22. Bromberger JT, Kravitz HM, Youk A, Schott LL, Joffe H. Patterns of depressive disorders across 13 years and their determinants among midlife women: SWAN mental health study. J Affect Disord. 2016;206:31–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23. Weinberger AH, Mazure CM, Morlett A, McKee SA. Two decades of smoking cessation treatment research on smokers with depression: 1990-2010. Nicotine Tob Res. 2013;15(6):1014–1031. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24. Weinberger AH, Pilver CE, Desai RA, Mazure CM, McKee SA. The relationship of dysthymia, minor depression, and gender to changes in smoking for current and former smokers: longitudinal evaluation in the U.S. population. Drug Alcohol Depend. 2013;127(1-3):170–176. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25. Oncken C, Cooney J, Feinn R, Lando H, Kranzler HR. Transdermal nicotine for smoking cessation in postmenopausal women. Addict Behav. 2007;32(2):296–309. [DOI] [PubMed] [Google Scholar]
  • 26.Sutton-Tyrrell K, Selzer F, Sowers M, et al. Study of Women’s Health Across the Nation (SWAN) Series. Ann Arbor, MI: Interuniversity Consortium for Political and Social Research [distributor]. [Google Scholar]
  • 27. Johnston JM, Colvin A, Johnson BD, et al. . Comparison of SWAN and WISE menopausal status classification algorithms. J Womens Health (Larchmt). 2006;15(10):1184–1194. [DOI] [PubMed] [Google Scholar]
  • 28. Brambilla DJ, McKinlay SM, Johannes CB. Defining the perimenopause for application in epidemiologic investigations. Am J Epidemiol. 1994;140(12):1091–1095. [DOI] [PubMed] [Google Scholar]
  • 29. Lasley BL, Chen J, Stanczyk FZ, et al. . Androstenediol complements estrogenic bioactivity during the menopausal transition. Menopause. 2012;19(6):650–657. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30. Luetters C, Huang MH, Seeman T, et al. . Menopause transition stage and endogenous estradiol and follicle-stimulating hormone levels are not related to cognitive performance: cross-sectional results from the Study of Women’s Health Across the Nation (SWAN). J Womens Health (Larchmt). 2007;16(3):331–344. [DOI] [PubMed] [Google Scholar]
  • 31. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401. [Google Scholar]
  • 32. Benowitz NL, Lessov-Schlaggar CN, Swan GE, Jacob P 3rd. Female sex and oral contraceptive use accelerate nicotine metabolism. Clin Pharmacol Ther. 2006;79(5):480–488. [DOI] [PubMed] [Google Scholar]
  • 33. Saladin ME, McClure EA, Baker NL, et al. . Increasing progesterone levels are associated with smoking abstinence among free-cycling women smokers who receive brief pharmacotherapy. Nicotine Tob Res. 2015;17(4):398–406. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34. Scholz J, Santos PC, Buzo CG, et al. . Effects of aging on the effectiveness of smoking cessation medication. Oncotarget. 2016;7(21):30032–30036. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35. Peltier MR, Roys MR, Waters AF, et al. . Motivation and readiness for tobacco cessation among nicotine dependent postmenopausal females: a pilot study. Exp Clin Psychopharmacol. 2018;26(2):125–131. [DOI] [PubMed] [Google Scholar]

Articles from Nicotine & Tobacco Research are provided here courtesy of Oxford University Press

RESOURCES