A Comparison of the Sexes: Before, During, and After Nicotine Addiction

Jillian Battista
 Introduction

Nicotine use is prevalent throughout society in the United States and in many cultures around the

world. In fact, 15.1% of all U.S. adults smoke regularly, which is about 36.5 million people (Center for

Disease Control and Prevention [CDC], 2017). More specifically, men, women, and even some

adolescents inhale tobacco smoke every day. Continued tobacco use is a problem because smoking

cigarettes remains the single most leading cause of preventable death in 2015 due to its long-term

damaging health effects. Additionally, it remains a significant public health problem (CDC, 2017). An

important step to diminish cigarette use was the Surgeon General Report in 1964 that indicated smoking

as a risk factor for lung cancer for both men and women (NIH, 1993). This report indicated that smokers

had a 70% increase in mortality rate and a 9 to 10-fold increase in risk of lung cancer compared to

non-smokers (NIH, 1993). Since then, smoking rates have decreased, but have not been completely

eliminated. Currently, 16.7% of males and 13.6% of females smoke cigarettes on a daily basis (CDC,

2017). These rates are frequently staggering, especially with current knowledge about the harmful

short-term and long-term consequences.

Not only does smoking cigarettes have damaging effects in an individual’s body, it has a major

impact on U.S. expenses. The tobacco industry uses billions of dollars to advertise and endorse tobacco

companies on a daily basis. Every year, smoking costs the United States more than $300 billion dollars on

medical costs for the effects of cigarette smoking, as well as loss of productivity costs (CDC, 2017). In

addition, according to the Center for Disease Control and Prevention, the costs of illness and loss of life

due to smoking add up to over $300 billion dollars in the United States alone (CDC, 2017). With this, it is

clear that the smoking culture set in place in the United States is not disappearing any time soon,

especially when thousands of people in the U.S. alone start smoking every day (CDC, 2017). These
numbers are just one example of how tobacco and nicotine smoking have made profound effects on

today’s society.

Within this tobacco culture, the men and women of the United States experience varying effects

due to continual smoking. From the role of neurotransmitters to distinct personality traits, there are many

different reasons why men and women start smoking, continue smoking, and quit smoking. Most

importantly, the role of the brain, neurotransmitters, and receptors can create a cascade of distinctive

feelings and emotions that differ between men and women before, during, and after cigarette smoking. In

addition to these factors, however, personality traits, hormones, genetics, and other comorbid conditions

have an important impact on before smoking, during smoking, and after smoking.

Chronologically, the journey to nicotine addiction can have differing effects for men and women

even from adolescence. Before smoking a cigarette for the first time, a conscious decision is made to start

smoking. Men and women may report varying reasons as to why they begin habitually smoking cigarettes

in the first place in adolescence, such as stress, genetic influence, or personality traits (Cosgrove et al.,

2014). Once the point of addiction hits during early to late adulthood, the euphoric sensations that are

experienced during craving and addiction also differ between the sexes (Bierut et al., 2008). In addition,

tolerance and withdrawal that is experienced in later adulthood impacts both men and women differently

as well (Buczkowski et al., 2014).

Part One: Before Nicotine Addiction

Adolescence and Teen Years

Men and women who smoke often reach the same end point of habitually smoking cigarettes

every day, but the journey they take may differ and can have multifactorial elements as to how it is

started. Men had higher rates of smoking in 2015 and according to historical research, this rate may be
due to the “20-year lag” from the start of men smoking to the start of women smoking (Amos, 1996).

Before the First World War, smoking was a taboo subject for women since they were supposed to appear

feminine (Amos and Haglund, 2000). Mostly due to social influences, women did not start smoking until

after the first world war (about 1920s), as a sign of emancipation and a way to challenge old views (Amos

and Haglund, 2000). The tobacco market began aiming their advertisements at women, indicating a shift

in the view of women and smoking. Despite this increase for women, men had been smoking for years

before this newfound freedom. Due to this, men have higher rates of smoking than women today. In order

to fully understand the sex differences in nicotine addiction, the various reasons for starting smoking must

be evaluated. These include body image, self-esteem, peer pressure, stress, personality traits, mental

health prevalence, and genetics.

With the growing rates of adolescents smoking, body image and self-esteem are two topics that

may strongly influence an individual to start smoking. Due to their changing bodies and social influences,

young females have reported having lower self-esteem than males (Bleidorn et al., 2015). In addition,

many studies have shown a relationship between negative body image and increased rates of smoking in

adolescent girls (Abernathy, Massad, and Romano-Dwyer, 1995). In fact, females were 2.5-3.5 more

times as likely to begin smoking later on in life if they indicated low self-esteem during puberty

(Abernathy et al., 1995). As a result of this study, it was shown that self-esteem was an important factor

regarding when and if females began smoking, but this relationship was not shown for males.

Furthermore, young adult females had increased rates of reporting low self-esteem, higher perceived

stress, and lower body satisfaction compared to their male counterparts (Croghan et al., 2006). These

individuals report higher rates of smoking and negative affect (Croghan et al., 2006). Overall, it is evident

how emotions play a role in the beginning of cigarette smoking. Internal factors, such as how they view of
their bodies, may take a toll on young girls. A stressful scenario can have important indicators as to if and

when a female will become a smoker. This impact is more apparent in females and leads to differing

reasons as to why men and women begin smoking.

Certain personality traits drive males and females to try cigarettes at a young age and even

beyond into the young adult years. For males, there is a tendency to be more risk-taking and sensation

seeking as they grow up, leading to an increased likelihood that they will try a cigarette (Johnson, Blum,

and Giedd, 2010). This trait may be traced back to certain brain structures that remain underdeveloped in

young male brains. More specifically, the prefrontal cortex, the area responsible for decision making,

impulse control, high order processing, and executive functioning, is not fully developed in a male brain

until about the age of 25, leaving many years of difficulty controlling impulses and planning (Johnson,

Blum, and Giedd, 2010). These years can be sensitive for growing males and with increased risk-taking

behavior, they may be more willing to experiment with new drugs. However, for females, the prefrontal

cortex is considered to be developed between the ages of 19 and 21 (Johnson, Blum, and Giedd, 2009).

According to a study conducted in 1998 by Patton et al., individuals who reported trying a cigarette at a

younger age (such as adolescence) were 29 times more likely than smokers who began later in life to end

up using cigarettes habitually (Patton et al., 1998). Additionally, within this time of growing and changes,

males and females are often subject to peer pressure, due to the social influence of their peers. Peer

pressure, in combination with risk taking behavior for males, can be a harsh combo on a developing child

and young adult (Lewis and Lewis, 1984). Along with peer pressure, bullying can be a considering factor

for two reasons, regarding when adolescents decide to smoke. Firstly, the child who is being bullied may

undergo severe stress and turn to smoking as an outlet for “destress.” Secondly, the child may also be

bullied into trying a cigarette from forceful peers (Lewis and Lewis, 1984). With this, it is clear that both
young boys and girls are exposed to peer pressure, but in different ways. According to Lewis and Lewis,

young boys reported increased experimentation with drugs due to wanting to “fit in,” whereas young girls

reported increased experimentation with drugs due to increased stress from being rejected from the peer

group (Lewis and Lewis, 1984). The factors of risk taking, peer pressure, bullying, and stress create an

unhealthy environment for adolescent boys and girls and can increase the likelihood of these children

become habitual smokers later on in their lives. The beginning phase of becoming addicted to cigarettes is

a sensitive time for young boys and girls, due to their changing and growing bodies. As they get older,

there are differing reasons as to why they may begin smoking, but this period in their lives may change

the outcome of their health many years later. In addition to puberty being a sensitive period for

adolescents, the risk of mental illness may also be a factor that influences individuals to begin smoking.

The rates of depression and anxiety are extremely high in individuals who are 18 and older and

are more evident in females than males (CDC, 2017). This may be due to females being more likely than

males to report having a mental health disorder, such as Major Depressive Disorder or Generalized

Anxiety Disorder (Bleidorn et al., 2016). These disorders can be stressful and overwhelming, which may

lead to the initiation of smoking to reduce stress and hardship. With this, it has been shown that about

32.6% of adults who have a mental disorder smoke cigarettes compared to 20.7% adults who do not have

a mental disorder (CDC, 2017). More often than not, those with mental health issues tend to turn to

cigarettes as a way to alleviate negative affect associated with their diagnosis. Although nicotine is a

stimulant, many smokers report a calming sensation during smoking as a reason they began using in the

first place (CDC, 2013). Mental illness can be a reason that both men and women start smoking, but it can

also be an outcome of nicotine addiction.

 Lastly, genetics may also increase the likelihood of eventual nicotine use and subsequent

dependence. Genes can influence our behavior and are often affected by our environment, such as the use

of nicotine and alcohol together. In a study conducted in 2008 by Bierut et al., they aimed at showing the

specific genes and nicotinic receptor subtypes that influenced whether an individual who uses alcohol

became a smoker. To test this, they genotyped 219 individuals from European American families and

found that two genetic markers in relation to the α3 and α5 subunits of the nicotinic receptors indicate

increased possibility that an individual may become nicotine dependent later on in their lives (Bierut et

al., 2008). Additionally, the α4 subunit has been indicated in nicotine addiction as well (Hutchison et al.,

2007). These studies show how genetics can influence how an individual follows the path to nicotine

addiction. Although genetics is important by itself, the interplay between genetics and environment is an

essential consideration when determining onset of smoking habits. A recent study conducted in 2012 by

Xie et al. took a deeper look into the interplay between childhood adversity, genetics, and use of nicotine

in later life. For the men, a very specific α5 nicotinic acetylcholine receptor (nAChR) genotype (SNP

rs16969968) in addition to high rates of childhood adversity led to an increased risk of nicotine

dependence compared to controls (Xie et al., 2012). Additionally, for the women, there were 2x

as many reported childhood adversity cases than men, but no genotypic correlation for the

nAChR (Xie et al., 2012). Women exposed to childhood adversity at a young age were still at

increased risk for nicotine dependence in later life compared to their controls (Xie et al., 2012).

Clearly, environmental influences play an important role in later nicotine use for both men and

women, but may impact the women more strongly than the men. In addition, the genetic

predisposition seen in men has a more profound effect than it does for women.
 The start of nicotine use is typically a complex interplay of multifactorial influences. For the men,

high risk-taking behavior, peer influences, and genetics most strongly influence their initiation of nicotine

use, whereas low self-esteem, stress, and childhood adversity more strongly affect the women. Despite the

preceding discussion, these listed factors that indicate possible starting points to nicotine use do not

include every possible reason as to why men and women start smoking cigarettes.

Part Two: During Nicotine Addiction

Early and Late Adulthood

The initial decision to smoke a cigarette can be influenced by many factors, but once nicotine use

reaches the point of addiction, the sensations that are experienced by men and women are unique and

differ. More specifically, the role of the brain becomes increasingly important as both men and women

become dependent on nicotine, crave it, and are addicted to it. The factors that influence nicotine

dependence and tolerance mainly focus on the body. In particular, the role of dopamine and brain

structures, bodily hormones, and metabolism during tolerance are all significant indicators that the body

has become addicted to nicotine (Balfour et al., 2000; Fehr et al., 2008). In addition, mental illness and

other comorbidities may also be an outcome of nicotine addiction. Depression, anxiety, and other

disorders may increase the risk of an individual becoming addicted to nicotine (Patton et al., 1998).

The neurotransmitter, dopamine, is indicative in every drug of abuse and is a major contributor to

addiction as a brain disease. Artificial release of dopamine in response to a drug of abuse contributes to

craving and dependence (Balfour et al., 2000). With nicotine, there is increased dopamine release in the

nucleus accumbens that creates euphoric, pleasurable, and reinforcing sensations (Balfour et al., 2000). In

addition, dopaminergic receptors in the striatum have been shown to be related to nicotine dependence. A

study conducted by Fehr et al. in 2008 examined 17 heavy smoking males who were nicotine dependent.
Using a PET scan, they observed less availability of D2 and D3 receptors in the dorsal striatum in the

nicotine dependent heavy smoking individuals (Fehr et al., 2008). The striatum plays a role in reward

along with the basal ganglia and nucleus accumbens. This decrease in availability may be due to

down-regulation of receptors from over compensation of dopaminergic artificial release by drugs of

abuse, such as nicotine. More interestingly, other studies have shown increased dopamine activity in the

basal ganglia in the brains of heavy smoking men after smoking a cigarette compared to nonsmoking men

(Salokangas et al., 2000). The brain becomes adaptive when a drug is present repeatedly and it adjusts its

release based on how much is already being released in response to the drug of abuse. When this is true

for a repeated exposure to nicotine, the more artificial release of dopamine seen in the brain, the less the

brain will respond with natural dopamine, leading to a decrease in dopaminergic levels at baseline when

the drug is not present. Although there may be an initial smoking-induced release of dopamine, the

baseline levels made by the brain when there is no nicotine present are decreased (Salokangas et al.,

2000). This lack of dopamine may lead to negative affect and depression during withdrawal and smokers

may turn to cigarettes during this time, indicating a cycle of addiction. Although this is true for both

males and females, each study discussed so far used males in their research, even though the response in

the brain from nicotine dependence differs for women. A recent study asked participants (both male and

female) to smoke a cigarette while in a PET scanner. Their goal was to measure dopamine levels in

various areas of the brain. For the females, the dopamine was released quicker in the putamen than for

males and less activation of the right striatum than males (Figure 1a). In addition, females reported taste,

smell, and sensations of holding a cigarette more often than the males did (Cosgrove et al., 2014). This

implies that women may find the environmental sensation (such as feeling the cigarette in her fingers or

the smell) more appealing and arousing rather than the nicotine itself like the men reported. For males,
they had higher activation over all, indicated in Figure 1b. This implies that women may find the

environmental sensation (such as feeling the cigarette in her fingers or the smell) more appealing and

arousing rather than the nicotine itself like the men reported.

Figure 1: (a) A comparison between a male and female brain--specifically in the female brain there
is a diminished response of dopamine in the right striatum compared to males. (b) Males have more
activation compared to females.

Hormone changes in the brain and throughout the body are seen in heavy nicotine smokers

(Tweed et al., 2012) . The endocrine system, in addition to the nervous system, respond to cigarette

inhalation and nicotine circulation by releasing additional hormones or decreasing the overall level.

Prolactin, which is released by the anterior pituitary gland, is regulated by dopamine. Increased dopamine

inhibits prolactin and this effect has been seen in female rats with chronic nicotine use, which could lead

to problems with fertility (Perkins, Donny, and Caggiula, 1999; Tweed et al., 2012). For luteinizing

hormones, the introduction of nicotine increases the release of sex hormones, such as testosterone. In

animal studies, male rats with chronic nicotine use have been shown to have increased luteinizing

hormones (Perkins, Donny, and Caggiula, 1999). However, the increase in luteinizing hormones was not

seen in females to the level it was seen in males (Funabashi et al., 2005). Despite this, females may still

have adverse effects, such as irregular menstruation and issues with ovulation, and men may experience
increased aggression with chronic use (Tweed et al., 2012). In addition, in the endocrine system, changes

in the HPA axis are evident during stress, but also during nicotine use. Higher levels of nicotine in a

cigarette increase the HPA axis hormones, which include ACTH and cortisol (Tweed et al., 2012). This

seems contradicting due to smokers reporting that smoking a cigarette decreases their stress, but it

actually activates the “stress hormone,” cortisol, in the HPA axis. In addition, some researchers suggest

that this activated pathway indicates increased levels of stress and an increased likelihood of relapse,

since this pathway is also activated during cigarette smoking (Tweed et al., 2012).

Substance use disorders are often comorbid with psychiatric disorders (Grant, 1998). This may be

due to psychiatric disorders leading to substance use disorders, or substance use disorders leading to

psychiatric disorders. Either way, many substance users experience deficits in their mental health. In a

study conducted in 2011 by Griesler et al., they observed nicotine dependence and psychiatric disorders in

teens for five years. They found that heavy smokers who were highly dependent on nicotine had higher

rates of anxiety, negative mood, and other substance use disorders (Griesler et al., 2011). Additionally,

anxiety, mood disorder, and obsessive-compulsive disorder (OCD) rates were higher for females than

males, and smoking habits among individuals with OCD were extremely predictive of nicotine

dependence (Griesler et al., 2011). In addition, compared to nonsmokers and nondependent smokers, it

has also been shown that male and female smokers show increased rates of anxiety, depression, and other

substance use disorders (Breslau, 1995). The rate of psychiatric disorders is higher for females than males

and they are more often present in smokers than nonsmokers. Psychiatric disorders appear to be an

influential factor for both men and women, but females are more affected than males. In addition to

psychiatric disorders, male smokers are more likely to report higher rates of other substance use disorders

besides nicotine, such as alcohol or other drugs. A study conducted at the National Institute on Alcohol
Abuse and Alcoholism in 1998 observed the effects of early onset nicotine use and later alcohol abuse in

young boys and girls. Grant found that the earlier an individual smoked cigarettes, the more likely they

were to have a DSM-IV diagnosis of Alcohol Use Disorder (Grant, 1998). This trend held true for both

men and women, but men had much higher rates than the women did (Grant, 1998). The underlying

influence of comorbidity can have an instrumental effect on the development of nicotine use and possible

addiction. The rates of psychiatric disorders as well as other substance use disorders differ between men

and women and could influence the continuing use of nicotine through early and late adulthood.

Smokers undergo many bodily changes when they begin to become addicted to cigarettes.

Dopamine, brain structures, hormones, and comorbid disorders are just a few examples of the many

reasons smokers continue to use nicotine during the development of addiction. Overall, these factors

differ between men and women, and therefore, men and women may experience the aftereffects of

nicotine addiction differently.

Part Three: After Nicotine Addiction

Later Adulthood

During the growing stages of addiction, negative effects may not be totally present, but during

withdrawal and craving, obvious negative symptoms indicate full-blown addiction. The feelings

associated with craving and withdrawal become more evident after nicotine addiction has occurred. After

addiction has occurred, craving and withdrawal are two battles that both men and women face during this

process. In addition, when cessation is attempted, relapse is a possibility. Both men and women deal with

cessation and relapse differently.

Cues surrounding addiction often lead an individual to crave a drug. Cues, such as a lighter, a

pack of cigarettes, a “No Smoking” sign, or their favorite smoking spot, may increase the likelihood of a
smoker wanting a cigarette. Even the time of day can have an impact on an addicted smoker (Perkins et

al., 2009). A study conducted in 2008 observed the brain regions in addicted nicotine smokers (male and

female) in response to smoking cues, such as a lit cigarette. Men reported increased negative affect due to

smoking cues and had higher activation in both the hippocampus and the orbitofrontal cortex compared to

women (McClernon, Kozink, and Rose, 2008). These brain structures are related to memory formation

and appetitive behaviors, respectively, and they may influence a male smoker to crave a cigarette and

eventually initiate smoking. Female smokers were more sensitive to cues and had activation in the

bilateral cuneus, superior temporal gyrus, and putamen (McClernon et al., 2008). These areas are

responsible for visuospatial attention and speech processing, respectively. The putamen is a part of the

striatum and, as indicated earlier, it plays a role in reward and craving. It is possible that different neural

systems are activated in regards to sex differences between men and women in craving.

As indicated earlier, females may be less sensitive to the amount of nicotine in a cigarette and

more sensitive to the environment. This is an important concept when males and females go through

withdrawal. Abstinent women have reported more negative emotions and heavy psychological withdrawal

compared to men (Faulkner et al., 2018). After administration of a cigarette, men reported that their

craving was reduced, they knew how much nicotine was in each cigarette, and increased liking. However,

women responded the same to both a low dose and a high dose cigarette, saying that it decreased their

withdrawal, but the high dose was 28-times higher in nicotine content than the lose dose (Faulkner et al.,

2018). Women seem to place more emphasis on the environmental influence of nicotine, such as the

feeling of it in her hand, whereas men are more focused on the physiological effects, such as the level of

nicotine they are inhaling. Additionally, women report higher rates of psychological effects of nicotine

withdrawal, such as depression or stress, whereas men report higher rates of physiological effects of
nicotine withdrawal, such as shakiness and nausea (McClernon et al. 2008). Clearly, withdrawal impacts

men and women differently and can be reduced by introducing a cigarette at any dose for women.

Quitting smoking can have unwanted effects on an individual’s body, especially when it has been

dependent on nicotine for a long time. Psychologically, men and women fight cravings and withdrawal

symptoms and they experience cessation quite differently. Women are significantly more likely to attempt

to quit smoking than men, but are less likely to be abstinent (Smith et al., 2016). Additionally,

Buczkowski et al. found that women were 16% more likely to quit for 1 day or more (Buczkowski et al.,

2014). Reasoning for quitting may be due to a variety of factors, but for women in particular, having

children may influence a woman’s decision to quit smoking. From trying to become pregnant to being

pregnant to having a child, a woman may quit in order to protect her children (Smith et al., 2016).

Additionally, men may also quit when they have children, but it may not occur until after the child is

born. Men and women may also quit smoking due to health concerns, bad smell, family wishes, or even

the cost of cigarettes (Buczkowski et al., 2014).

After cessation occurs, it is difficult for smokers to remain abstinent in their smoking addiction

over short and long periods of time. Relapse without treatment is very common among smokers who have

become addicted to cigarettes. A study conducted in 1997 wanted to test the ability of men and women to

quit for one full year. Ward et al. found that relapse rates were extremely high for both men and women.

Men and women were equally likely to stop smoking in the short term, but women were three times as

likely to relapse in the long term (Ward et al., 1997). This study suggests that women may become more

susceptible to relapsing with many triggers, such as cues, emotionality and environmental influences.

Men are typically more likely to quit and stay abstinent (Ward et al., 1997). As stated earlier, in response
to stress, men and women are both vulnerable to relapsing, but women are more likely to relapse due to

more difficulty.

Cessation, relapse, and withdrawal, along with many other factors, may impact smokers’ lives on

a daily basis. Cues constantly surround smokers and may lead to cravings and relapse. Withdrawal,

cessation, relapse, and cravings all differ between men and women and contribute to the current smoking

rates in today’s culture.

Conclusion

There has been a plethora of research demonstrating how men and women differ in their approach

to cigarette smoking before, during, and after nicotine addiction. Different factors all interplay to create

contrasting reasons why males and females report various reasons why they begin to smoke, keep

smoking, and quit smoking. However, every individual may report differing reasons for smoking and

broad assumptions about the general population cannot be made.

When smokers begin smoking, various reasons, such as body image, self-esteem, peer pressure,

stress, personality traits, genetics, and environment are possible factors contributing to the start of habitual

smoking. Body image and self-esteem impact young girls more strongly and may cause stress, which can

lead to increased smoking behavior. Peer pressure and bullying can influence a male risk-taker into taking

a risk on a drug of abuse. Personality traits, like anxiousness seen in females and impulsivity and

risk-taking seen in males, may increase the likelihood that young children (both boys and girls) will try a

cigarette in the first place. Mental health issues, like anxiety and depression, each can contribute to and

result from substance abuse. Women more often than men report higher levels of psychiatric disorders.

Additionally, genetics can be the first and foremost indicator of individuals who are at an increased risk

for substance use disorders and this trend was seen to be more influential for males. Environmental
influence, such as childhood adversity, can impact a young girl and increase her likelihood of nicotine use

later in life. All of these reasons may lead to the same end point of addition.

When smokers continue smoking, the focus shifts to the body and the brain. In the brain, the

dopaminergic responses in the nucleus accumbens and the striatum are two key structures when

considering why men and women crave a euphoric sensation. With activations in the hippocampus or

bilateral cuneus for males and females respectively, the brain plays an important role in drug addiction. In

the body, the hormones that regulate systems, such as luteinizing hormones for males and prolactin for

females, are thrown off balance. The consumption of nicotine contributes to the lasting bodily responses.

Even further, comorbidity can be an indicator of early drug use and eventual nicotine addiction. Males

have shown to have higher rates of comorbid substance use disorders, such as alcohol, in addition to

nicotine addiction.

Lastly, when smokers quit or attempt to quit smoking, the contributing factors differ between men

and women. For women, pregnancy is a big factor they take into consideration when determining their

future cigarette use. Additionally, women report higher rates of quitting, but increased likelihood of

relapse, possibly due to strong environmental influences. Responses to cravings differ between the sexes

as well, since both have different responses. Men report higher physiological effects of withdrawal,

whereas women report more psychological effects. All in all, the responses of men and women before,

during, and after addiction to cigarettes remain differing. In the case of nicotine addiction, the destination

may be the same, but the journey to get there varies for men and women.
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