Generally, men tend to use all tobacco products at higher rates than women.128 In 2015, 16.7 percent of adult males and 13.6 percent of adult females smoked cigarettes.129 Such differences may relate to a combination of physiological (particularly ovarian hormones), cultural, and behavioral factors.130
Results from neuroimaging studies suggest that smoking activates men’s reward pathways more than women's.131 This finding is consistent with the idea that men smoke for the reinforcing effects of nicotine, whereas women smoke to regulate mood or in response to cigarette-related cues. A study of stress responses and craving among male and female smokers who were trying to quit found that during abstinence, lower levels of the stress hormone cortisol predicted relapse in men. However, high cortisol levels were predictive of relapse in women.132 Other work on abstinence found that smoking a cigarette with nicotine, as compared to a de-nicotinized cigarette, alleviated the symptoms of withdrawal and negative mood to a greater extent in men than women. Women obtained equal relief from cigarettes with and without nicotine, suggesting that they found the drug less rewarding than men.133
Cigarette craving is a major reason why smokers find it hard to quit, and this strong urge to smoke can be evoked by sensory cues and stress. Research suggests that women experience stronger craving than men in response to stress,134 but men may be more responsive to environmental cues.135 Additionally, longitudinal data from international surveys conducted in four industrialized countries indicated that men and women did not differ in their desire to quit, plans to quit, or quit attempts. However, women were 31 percent less likely to quit successfully.136 One reason why women may have difficulty quitting is post-cessation weight gain. This concern should be addressed in behavioral counseling and adjunct treatments for all smokers.137
The overall lower cessation rate for women may reflect sex differences in response to particular medications (see "What are treatments for tobacco dependence?"). For example, varenicline has greater short- and immediate-term efficacy (at 3 and 6 months) among women smokers. However, women and men show similar 1-year quit rates when using varenicline.138 In contrast, a combination of varenicline plus bupropion was less effective for cessation among women compared with men.139
Another particular concern related to tobacco use among women is smoking during pregnancy (see "What are the risks of smoking during pregnancy?").