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Body image evaluations in women smokers
Addictive Behaviors, Vol. 25, No. 4, pp. 613–618, 2000 Copyright © 2000 Elsevier Science Ltd. Printed in the USA. All rights reserved 0306-4603/00/$–see front matter
Pergamon
PII S0306-4603(99)00039-8
BRIEF REPORT BODY IMAGE EVALUATIONS IN WOMEN SMOKERS TERESA K. KING, MALA MATACIN, BESS H. MARCUS, BETH C. BOCK, and JANICE TRIPOLONE Brown University School of Medicine
Abstract — While body image has been found to be an important predictor for several health behaviors (abnormal dieting, weight regain, exercise), only one study to date has examined body image attitudes in women smokers (Australian sample) with results suggesting that women smokers feel less attractive than nonsmokers. The purpose of the present study was to compare body image in women smokers to normative samples of women. Subjects were 136 women (89.0% White, M age ⫽ 39.85, 74% employed, 52% married, body mass index [BMI] ⫽ 25.54) entering a randomized clinical smoking cessation trial. Subjects completed the Appearance Evaluation and Fitness Orientation subscales of the Multidimensional Body-Self Relations Questionnaire and the Silhouette Choosing Task. Pooled t-tests showed that subjects scored significantly lower on Appearance Evaluation (t ⫽ ⫺6.58, p ⬍ .01) and Fitness Orientation (t ⫽ ⫺5.55, p ⬍ .01) than the normative sample. For the silhouette choosing task, the present sample reported a significantly higher current silhouette (t ⫽ 2.29, p ⬍ .05) and dissatisfaction score (t ⫽ 4.04, p ⬍ .01) than the comparative sample. There were no significant differences on the ideal or attraction scores. Results suggest that women smokers may be more dissatisfied with their bodies than women in general. Possible implications include that smoking may adversely affect body image and/or body image concerns may negatively impact cessation attempts. © 2000 Elsevier Science Ltd.
Key Words. Body image, Smoking, Weight concerns, Women’s health.
Despite the serious health risks associated with cigarette smoking, 23.1% of women smoke (Centers for Disease Control, 1996). Thus, understanding the mechanisms which promote smoking behavior in women is extremely important. One mechanism which has been examined is weight concerns. There is substantial evidence that cigarette smoking is associated with lower body weight, on average, and that smoking cessation is associated with weight gain (Klesges, Meyers, Klesges, & LaVasque, 1989). Concern about weight appears to be an important motivator for smoking among women (Klesges & Klesges, 1988; Pirie, Murray, & Luepker, 1991); however, no consistent relationship between weight concerns and smoking behavior has been established (French & Jeffery, 1995; Jeffery, Boles, Strycker, & Glasgow, 1997). Related to weight concerns is body image, a construct which encompasses perceptual, subjective (cognitive, affective), and behavioral components (Thompson, 1996).
Commit to Quit is an ongoing study conducted at the Division of Behavioral and Preventive Medicine, The Miriam Hospital. The study is supported by grants from the National Cancer Institute (KO7CA0157 and R29CA59660) and by a supplemental grant to R29CA59660 from the Office of Research on Womens’ Health. Part of this study was presented at the 31st Annual AABT Convention. We acknowledge and thank David Abrams, Ph.D., Anna Albrecht, R.N., M.S., and Alfred Parisi, M.D. for their contributions to this trial. We thank Mary Roberts and Regina Traficante for their contributions to this study. Mala Matacin is now at the University of Hartford, Department of Psychology. Requests for reprints should be sent to Teresa K. King, PhD, Division of Behavioral and Preventive Medicine, Brown University School of Medicine, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906; E-mail: [email protected] 613
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T. K. KING et al.
Individuals may experience disturbances in one or more of these areas. The perceptual component involves the accuracy of size estimation, the subjective aspect entails thoughts and feelings about the body in general or specific body parts, and the behavioral component represents the specific behaviors that are engaged in or avoided (e.g., excessive mirror checking, avoiding swimming). Only one study to date has examined body image among women smokers. Ben-Tovim and Walker (1991a) measured body attitudes in 504 Australian women categorized as current smokers and non-smokers (ex-smokers and never-smokers). Participants were asked to complete the Body Attitudes Questionnaire (Ben-Tovim & Walker, 1991b) which assessed a wide range of body-related attitudes such as the subjective feeling of fatness, attractiveness, strength and fitness, and the importance of weight and shape. Current smokers reported feeling less attractive than never-smokers, but interestingly, did not differ on feelings of physical fitness, fatness, or the importance of weight. Thus, one study suggests that smokers feel less attractive than nonsmokers. It is possible that body image evaluations play an important role in smoking behavior. For example, women who negatively evaluate the size or shape of their body may be more likely to initiate smoking to lose weight, or to maintain their smoking habit to prevent weight gain. Conversely, smoking could influence body image through its numerous effects on the body (e.g., smell, health). The purpose of this study was to compare women smokers’ body image evaluations to normative samples. It was hypothesized that women smokers would report more negative attitudes towards their body than women in general. M E T H O D
The present investigation represents a substudy of a clinical trial designed to compare the efficacy of a professionally led cognitive-behavioral smoking cessation treatment plus supervised vigorous exercise with the same cessation treatment plus contact control on cessation rates in women (Marcus, King, Albrecht, Parisi, & Abrams, 1997). Participants Participants were 141 women who completed pretreatment measures assessing body image perceptions and attitudes in addition to the full battery of questionnaires described elsewhere (Marcus, King, Albrecht, Parisi, & Abrams, 1997). The study population consisted predominantly of White (89.4%) middle-aged (M ⫽ 39.52) women. Racial and ethnic backgrounds for the remainder of the respondents were 6.4% African American, .7% Hispanic, 2.1% Asian, and 1.4% American Indian/Alaskan Native. The majority of the subjects were married (51.8%) and employed (73.8%) in professional occupations (41.4%) or clerical positions (37.4%). The median household income level was in the $30,000 to $39,999 range. Subjects weighed an average of 149.74 pounds (SD ⫽ 31.02), average BMI was 25.52 (SD ⫽ 5.18), average percent body fat was 27.57 (SD ⫽ 6.34), and the average waist-to-hip ratio was .80 (SD ⫽ .07). At baseline subjects reported smoking on average 21.42 (SD ⫽ 9.95) cigarettes per day. Procedure Healthy sedentary women (18–65 years) who had regularly smoked 10 or more cigarettes a day for at least 3 years were recruited through newspaper advertisements. Exclusionary criteria included medical problems and/or medications which would make
Body image and women smokers
615
compliance with the study protocol difficult or dangerous, or limit the subject’s ability to perform the exercise test. Women with a current psychiatric illness, eating disorder, alcoholism or alcohol abuse, or other substance abuse were also excluded. Subjects agreed to be assigned randomly to either of the two investigational conditions and provided written consent to participate in the research procedures.
Measures Participants completed subscales of the Multidimensional Body-Self Relations Questionnaire (MBSRQ; Brown, Cash, & Mikulka, 1990; Cash, 1994) and the Silhouette Choosing Task (SCT; Fallon & Rozin, 1985; Stunkard, Sorenson, & Schulsinger, 1983). The MBSRQ provides a standardized, attitudinal assessment of body image, normed from a national body-image survey (Cash, Winstead, & Janda, 1986). The normative sample (N ⫽ 2,000) was randomly sampled from a pool of 30,000 respondents to a national survey stratified on the sex and age distribution of the U.S. population. The scales that comprise the MBSRQ assess attitudes toward health and illness, and fitness and appearance on two dimensions: Orientation (which includes both importance and behavioral components), and Evaluation (the subject’s evaluation of his/ her own abilities on a given dimension). Subjects completed the Appearance Evaluation and Fitness Orientation factor subscales. The Appearance Evaluation subscale was chosen for its assessment of global appearance concerns (Thompson, 1996). This subscale measures feelings of physical attractiveness and satisfaction or dissatisfaction with one’s appearance. High scorers feel mostly positive and satisfied with their appearance, while low scorers are more unhappy with their appearance. The Appearance Evaluation subscale (7 items) has an internal consistency of .88 (Cash et al., 1986). The Appearance Evaluation subscale correlates significantly with measures of overall psychological adjustment and measures of eating disorders, particularly binge eating (Keeton, Cash, & Brown, 1990). The Fitness Orientation subscale was chosen in order to examine fitness attitudes in women smokers, and represents the extent of investment in being physically fit or athletically competent. High scorers value fitness and engage in activities which promote fitness. Low scorers do not value physical fitness and are not particularly interested in exercise. The Fitness Orientation subscale (13 items) has an internal consistency of .89 (Cash et al., 1986). The SCT consists of nine female figures approximately 1 1/4 inches tall evenly spaced horizontally on an 8 1/2 ⫻ 11 inch sheet of paper (designed by and illustrated in Stunkard et al., 1983). The figures range from very thin to morbidly obese with corresponding numbers printed underneath each one (10 to 90). Participants were asked to indicate the figure that best represented their actual figure (actual score), the figure that best represented what they would like to look like (ideal score), and the figure they thought was most attractive to the opposite sex (attractive score). A body dissatisfaction score was calculated by subtracting the ideal score from the actual score. Silhouette choosing tasks are one of the most widely used methods of assessing body image (Thompson, Penner, & Altabe, 1990). Specifically, they measure subjective components of body image, namely perceived body image, ideal body image, and body satisfaction. Thompson and Altabe (1991) reported test-retest reliabilities ranging from .55 to .71 for six different ratings in females over a 2-week period. In order to compare scores on the SCT obtained from the women smokers in our sample to women in general, a sample of women for which scores on the SCT were available was chosen based on its similarity to our sample. The sample was composed
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of 97 American women with an average age of 46.5 years (Rozin & Fallon, 1988), which approximates the average age of the women in our study. R E S U L T S
Pooled t-tests were conducted to compare the present sample to normative samples. Table 1 shows the pooled mean estimates of normal samples for the factor scores of the MBSRQ and the silhouette choosing task. Compared with normative samples, subjects scored significantly lower on the Appearance Evaluation (t ⫽ ⫺6.58, p ⬍ .01) and Fitness Orientation (t ⫽ 5.55, p ⬍ .01) scales. For the Silhouette Choosing Task, subjects reported a significantly higher actual silhouette (t ⫽ 2.29, p ⫽ .02) and dissatisfaction score (t ⫽ 4.04, p ⬍ .01) than the comparative sample. There were no significant differences on the ideal or attraction scores. D I S C U S S I O N
Similar to the results obtained by Ben-Tovim and Walker (1991a), this sample of women smokers reported feeling less attractive than women in the comparison sample. We also found that this sample of women smokers perceived themselves as heavier than the comparison sample. This is interesting given that smokers typically weigh less than nonsmokers (Klesges et al., 1989). Unfortunately, weights for the women in the comparison sample were not reported, so actual weights can not be directly compared. However, the average BMI of our sample appears to be somewhat less than recent national averages for women. Data collected from 1988 through 1991 for the National Health and Nutrition Examination Survey indicated that the average BMI for women at least 20 years old is 26.3 (Kuczmarski, Flegal, Campbell, & Johnson, 1994) versus 25.5 for our sample. The women smokers also reported a greater discrepancy between their actual and ideal figure than the comparative sample. Given the similar ratings for the ideal and attraction scores, it does not appear that these women smokers considered smaller figures as more desirable, but rather that they perceived themselves as heavier and disliked their bodies to a greater extent. These findings may suggest some perceptual distortions for body size in women smokers. In contrast to Ben-Tovim and Walker’s (1991a) finding of no differences between smokers and nonsmokers in perception of fitness, women smokers in our sample re-
Table 1. Normative comparisons for body image measures Current sample Variable MBSRQ: Appearance evaluationa MBSRQ: Fitness orientation SCT: Actualb SCT: Ideal SCT: Dissatisfaction SCT: Attractive
Normative sample
N
Mean
SD
N
Mean
SD
T
p value
139 139 141 141 141 141
2.85 2.79 43.16 29.22 14.72 27.14
0.77 0.52 15.21 6.50 11.46 8.32
1070 1070 97 97 97 97
3.36 3.20 39.10 29.80 9.40 28.30
0.87 0.85 10.26 6.00 7.27 5.45
⫺6.58 ⫺5.55 2.29 ⫺0.70 4.04 ⫺1.21
⬍ .001 ⬍ .001 .02 .49 ⬍ .001 .23
Note. Values for the normative comparison for the MBSRQ are from aCash, Winstead, and Janda (1986) and bFallon and Rozin, (1985) for the Figure Rating Scale. MBSRQ ⫽ Multidimensional Body-Self Relations Questionnaire; SCT ⫽ Silhouette Choosing Task.
Body image and women smokers
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ported less investment in physical fitness than the normative sample. One reason for this finding may be the nature of our sample. We recruited for sedentary women which may have resulted in lower scores on fitness orientation. However, advertisements for the study did mention that treatment may include exercise, therefore women who were not interested in exercise probably would not have been interested in participating. Thus, sample bias may not be the best explanation for the conflicting findings, but rather that women smokers actually value fitness less than women in general. Other studies have documented an association between poor health practices (Abood & Conway, 1994; Blair, Jacobs, & Powell, 1985; Emmons, Marcus, Linnan, Rossi, & Abrams, 1994; Troisi, Heinold, Vokonas, & Weiss, 1991) including a negative relationship between smoking and motivation to exercise (King, Marcus, Pinto, Emmons, & Abrams, 1996). Limitations of this study include the use of a volunteer sample and the sedentary status of the sample. While the sample used in this investigation may not be representative of the larger population of women smokers, it is likely representative of women smokers who would attend a smoking cessation program. Therefore, it appears appropriate to draw generalizations from this study to guide smoking cessation treatment efforts for women smokers. Another limitation includes the lack of some descriptive information for the comparison samples (e.g., socioeconomic status, ethnicity, weight) which makes it difficult to fully interpret the differences in body image evaluations and to attribute differences solely to smoking status. Replication of the present findings is needed before any conclusions can be made regarding body image attitudes in women smokers. Recently, it has been suggested that weight concerns is at best, a weak predictor of smoking cessation (Jeffery et al., 1997). Body image encompasses weight concerns but includes other concepts as well, such as perceptual distortions. Given that a negative body image relates to poor treatment outcome in other areas (e.g., Rosen, 1990), it may well be one of the critical understudied factors in research on women smokers. It is hoped that body image will be more regularly assessed in future investigations, and that individual and group-based treatment will address issues regarding body image distortion and body dissatisfaction. Since body image is unlikely to improve in women who quit smoking but gain weight, cognitive treatment to directly alter body image attitudes may be an important component for smoking cessation programs for women. R E F E R E N C E S Abood, D. A., & Conway, T. L. (1994). Smoking status, body composition, exercise, and diet among Navy men. Health Values, 18, 51–62. Ben-Tovim, D. I., & Walker, M. K. (1991a). Some body-related attitudes in women smokers and non-smokers. British Journal of Addictions, 86, 1129–1131. Ben-Tovim, D. I., & Walker, M. K. (1991b). The development of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ), a new measure of womens’ attitudes towards their own bodies. Psychological Medicine, 21, 775–784. Blair, S. N., Jacobs, D. R., & Powell, K. E. (1985). Relationships between exercise or physical activity and other health behaviors. Public Health Reports, 100, 172–180. Brown, T. A., Cash, T. F., & Mikulka, P. J. (1990). Attitudinal body-image assessment: Factor analysis of the Body-Self Relations Questionnaire. Journal of Personality Assessment, 55, 135–144. Cash, T. F. (1994). The Multidimensional Body-Self-Relations Questionnaire user’s manual. Norfolk, VA: Old Dominion University. Cash, T. F., Winstead, B. W., & Janda, L. H. (1986). The great American shape-up: Body image survey report. Psychology Today, 20, 30–37. Centers for Disease Control. (1996). Cigarette smoking among adults—United States, 1994. Morbidity and Mortality Weekly Report, 45, 588–590.
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Emmons, K. M., Marcus, B. H., Linnan, L., Rossi J. S., & Abrams, D. B. (1994). Mechanisms in multiple risk factor interventions: Smoking, physical activity, and dietary fat intake among manufacturing workers. Preventive Medicine, 23, 481–489. Fallon, A., & Rozin, P. (1985). Sex differences in perceptions of desirable body shape. Journal of Abnormal Psychology, 94, 102–105. French, S. A., & Jeffery, R. W. (1995). Weight concerns and smoking: A literature review. Annals of Behavioral Medicine, 17, 234–244. Jeffery, R. W., Boles, S. M., Strycker, L. A., & Glasgow, R. E. (1997). Smoking-specific weight gain concerns and smoking cessation in a working population. Health Psychology, 16, 487–489. Keeton, W. P., Cash, T. F., & Brown, T. A. (1990). Body image of body images? Comparative multidimensional assessment among college students. Journal of Personality Assessment, 54, 213–230. King, T. K., Marcus, B. H., Pinto, B. M., Emmons, K. M., & Abrams, D. B. (1996). Cognitive-behavioral mediators of changing multiple behaviors: Smoking and a sedentary lifestyle. Preventive Medicine, 25, 684–691. Klesges, R. C., & Klesges, L. M. (1988). Cigarette smoking as a dieting strategy in a university population. International Journal of Eating Disorders, 7, 413–419. Klesges, R. C., Meyers, A. W., Klesges, L. M., & LaVasque, M. E. (1989). Smoking, body weight, and their effects on smoking behavior: A comprehensive review of the literature. Psychological Bulletin, 106, 204–230. Kuczmarski, R. J., Flegal, K. M., Campbell, S. M., & Johnson, C. L. (1994). Increasing prevalence of overweight among US adults: The national health and nutrition examination surveys, 1960–1991. Journal of the American Medical Association, 272, 205–211. Marcus, B. H., King, T. K., Albrecht, A. E., Parisi, A. F., & Abrams, D. B. (1997). Rationale, design, and baseline data for Commit to Quit: An exercise efficacy trial for smoking cessation among women. Preventive Medicine, 26, 586–597. Pirie, P. L., Murray, D. M., & Luepker, R. V. (1991). Gender differences in cigarette smoking and quitting in a cohort of young adults. American Journal of Public Health, 81, 324–327. Rosen, J. C. (1990). Body image disturbance in eating disorders. In T. F. Cash & T. Pruzinsky (Eds.), Body image: Development, deviance, and change (pp. 190–216). New York: Guilford Press. Rozin, P., & Fallon, A. (1988). Body image, attitudes to weight, and misperceptions of figure preferences of the opposite sex: A comparison of men and women in two generations. Journal of Abnormal Psychology, 97, 342–345. Stunkard, A. J., Sorenson, T., & Schulsinger, F. (1983). Use of the Danish Adoption Register for the study of obesity and thinness. In S. S. Kety, L. P. Rowland, R. L. Sidman, & S. W. Matthysse (Eds.), Genetics of neurologic and psychiatric disorders (pp. 115–120). New York: Raven Press. Thompson, J. K. (1996). Assessing body image disturbance: Measures, methodology, and implementation. In J. K. Thompson (Ed.), Body image, eating disorders and obesity: An integrative guide for assessment and treatment (pp. 49–81). Washington, DC: American Psychological Association. Thompson, J. K., & Altabe, M. N. (1991). Psychometric qualities of the Figure Rating Scale. International Journal of Eating Disorders, 10, 615–619. Thompson, J. K., Penner, L. A., & Altabe, M. N. (1990). Procedures, problems, and progress in the assessment of body images. In T. F. Cash & T. Pruzinsky (Eds.), Body images: Development, deviance, and change (pp. 21–46). New York: Guilford Press. Troisi, R. J., Heinold, J. W., Vokonas, P. S., & Weiss, S. T. (1991). Cigarette smoking, dietary intake, and physical activity: Effects on body fat distribution—the Normative Aging Study. American Journal of Clinical Nutrition, 53, 1104–1111.
Pergamon
PII S0306-4603(99)00039-8
BRIEF REPORT BODY IMAGE EVALUATIONS IN WOMEN SMOKERS TERESA K. KING, MALA MATACIN, BESS H. MARCUS, BETH C. BOCK, and JANICE TRIPOLONE Brown University School of Medicine
Abstract — While body image has been found to be an important predictor for several health behaviors (abnormal dieting, weight regain, exercise), only one study to date has examined body image attitudes in women smokers (Australian sample) with results suggesting that women smokers feel less attractive than nonsmokers. The purpose of the present study was to compare body image in women smokers to normative samples of women. Subjects were 136 women (89.0% White, M age ⫽ 39.85, 74% employed, 52% married, body mass index [BMI] ⫽ 25.54) entering a randomized clinical smoking cessation trial. Subjects completed the Appearance Evaluation and Fitness Orientation subscales of the Multidimensional Body-Self Relations Questionnaire and the Silhouette Choosing Task. Pooled t-tests showed that subjects scored significantly lower on Appearance Evaluation (t ⫽ ⫺6.58, p ⬍ .01) and Fitness Orientation (t ⫽ ⫺5.55, p ⬍ .01) than the normative sample. For the silhouette choosing task, the present sample reported a significantly higher current silhouette (t ⫽ 2.29, p ⬍ .05) and dissatisfaction score (t ⫽ 4.04, p ⬍ .01) than the comparative sample. There were no significant differences on the ideal or attraction scores. Results suggest that women smokers may be more dissatisfied with their bodies than women in general. Possible implications include that smoking may adversely affect body image and/or body image concerns may negatively impact cessation attempts. © 2000 Elsevier Science Ltd.
Key Words. Body image, Smoking, Weight concerns, Women’s health.
Despite the serious health risks associated with cigarette smoking, 23.1% of women smoke (Centers for Disease Control, 1996). Thus, understanding the mechanisms which promote smoking behavior in women is extremely important. One mechanism which has been examined is weight concerns. There is substantial evidence that cigarette smoking is associated with lower body weight, on average, and that smoking cessation is associated with weight gain (Klesges, Meyers, Klesges, & LaVasque, 1989). Concern about weight appears to be an important motivator for smoking among women (Klesges & Klesges, 1988; Pirie, Murray, & Luepker, 1991); however, no consistent relationship between weight concerns and smoking behavior has been established (French & Jeffery, 1995; Jeffery, Boles, Strycker, & Glasgow, 1997). Related to weight concerns is body image, a construct which encompasses perceptual, subjective (cognitive, affective), and behavioral components (Thompson, 1996).
Commit to Quit is an ongoing study conducted at the Division of Behavioral and Preventive Medicine, The Miriam Hospital. The study is supported by grants from the National Cancer Institute (KO7CA0157 and R29CA59660) and by a supplemental grant to R29CA59660 from the Office of Research on Womens’ Health. Part of this study was presented at the 31st Annual AABT Convention. We acknowledge and thank David Abrams, Ph.D., Anna Albrecht, R.N., M.S., and Alfred Parisi, M.D. for their contributions to this trial. We thank Mary Roberts and Regina Traficante for their contributions to this study. Mala Matacin is now at the University of Hartford, Department of Psychology. Requests for reprints should be sent to Teresa K. King, PhD, Division of Behavioral and Preventive Medicine, Brown University School of Medicine, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906; E-mail: [email protected] 613
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T. K. KING et al.
Individuals may experience disturbances in one or more of these areas. The perceptual component involves the accuracy of size estimation, the subjective aspect entails thoughts and feelings about the body in general or specific body parts, and the behavioral component represents the specific behaviors that are engaged in or avoided (e.g., excessive mirror checking, avoiding swimming). Only one study to date has examined body image among women smokers. Ben-Tovim and Walker (1991a) measured body attitudes in 504 Australian women categorized as current smokers and non-smokers (ex-smokers and never-smokers). Participants were asked to complete the Body Attitudes Questionnaire (Ben-Tovim & Walker, 1991b) which assessed a wide range of body-related attitudes such as the subjective feeling of fatness, attractiveness, strength and fitness, and the importance of weight and shape. Current smokers reported feeling less attractive than never-smokers, but interestingly, did not differ on feelings of physical fitness, fatness, or the importance of weight. Thus, one study suggests that smokers feel less attractive than nonsmokers. It is possible that body image evaluations play an important role in smoking behavior. For example, women who negatively evaluate the size or shape of their body may be more likely to initiate smoking to lose weight, or to maintain their smoking habit to prevent weight gain. Conversely, smoking could influence body image through its numerous effects on the body (e.g., smell, health). The purpose of this study was to compare women smokers’ body image evaluations to normative samples. It was hypothesized that women smokers would report more negative attitudes towards their body than women in general. M E T H O D
The present investigation represents a substudy of a clinical trial designed to compare the efficacy of a professionally led cognitive-behavioral smoking cessation treatment plus supervised vigorous exercise with the same cessation treatment plus contact control on cessation rates in women (Marcus, King, Albrecht, Parisi, & Abrams, 1997). Participants Participants were 141 women who completed pretreatment measures assessing body image perceptions and attitudes in addition to the full battery of questionnaires described elsewhere (Marcus, King, Albrecht, Parisi, & Abrams, 1997). The study population consisted predominantly of White (89.4%) middle-aged (M ⫽ 39.52) women. Racial and ethnic backgrounds for the remainder of the respondents were 6.4% African American, .7% Hispanic, 2.1% Asian, and 1.4% American Indian/Alaskan Native. The majority of the subjects were married (51.8%) and employed (73.8%) in professional occupations (41.4%) or clerical positions (37.4%). The median household income level was in the $30,000 to $39,999 range. Subjects weighed an average of 149.74 pounds (SD ⫽ 31.02), average BMI was 25.52 (SD ⫽ 5.18), average percent body fat was 27.57 (SD ⫽ 6.34), and the average waist-to-hip ratio was .80 (SD ⫽ .07). At baseline subjects reported smoking on average 21.42 (SD ⫽ 9.95) cigarettes per day. Procedure Healthy sedentary women (18–65 years) who had regularly smoked 10 or more cigarettes a day for at least 3 years were recruited through newspaper advertisements. Exclusionary criteria included medical problems and/or medications which would make
Body image and women smokers
615
compliance with the study protocol difficult or dangerous, or limit the subject’s ability to perform the exercise test. Women with a current psychiatric illness, eating disorder, alcoholism or alcohol abuse, or other substance abuse were also excluded. Subjects agreed to be assigned randomly to either of the two investigational conditions and provided written consent to participate in the research procedures.
Measures Participants completed subscales of the Multidimensional Body-Self Relations Questionnaire (MBSRQ; Brown, Cash, & Mikulka, 1990; Cash, 1994) and the Silhouette Choosing Task (SCT; Fallon & Rozin, 1985; Stunkard, Sorenson, & Schulsinger, 1983). The MBSRQ provides a standardized, attitudinal assessment of body image, normed from a national body-image survey (Cash, Winstead, & Janda, 1986). The normative sample (N ⫽ 2,000) was randomly sampled from a pool of 30,000 respondents to a national survey stratified on the sex and age distribution of the U.S. population. The scales that comprise the MBSRQ assess attitudes toward health and illness, and fitness and appearance on two dimensions: Orientation (which includes both importance and behavioral components), and Evaluation (the subject’s evaluation of his/ her own abilities on a given dimension). Subjects completed the Appearance Evaluation and Fitness Orientation factor subscales. The Appearance Evaluation subscale was chosen for its assessment of global appearance concerns (Thompson, 1996). This subscale measures feelings of physical attractiveness and satisfaction or dissatisfaction with one’s appearance. High scorers feel mostly positive and satisfied with their appearance, while low scorers are more unhappy with their appearance. The Appearance Evaluation subscale (7 items) has an internal consistency of .88 (Cash et al., 1986). The Appearance Evaluation subscale correlates significantly with measures of overall psychological adjustment and measures of eating disorders, particularly binge eating (Keeton, Cash, & Brown, 1990). The Fitness Orientation subscale was chosen in order to examine fitness attitudes in women smokers, and represents the extent of investment in being physically fit or athletically competent. High scorers value fitness and engage in activities which promote fitness. Low scorers do not value physical fitness and are not particularly interested in exercise. The Fitness Orientation subscale (13 items) has an internal consistency of .89 (Cash et al., 1986). The SCT consists of nine female figures approximately 1 1/4 inches tall evenly spaced horizontally on an 8 1/2 ⫻ 11 inch sheet of paper (designed by and illustrated in Stunkard et al., 1983). The figures range from very thin to morbidly obese with corresponding numbers printed underneath each one (10 to 90). Participants were asked to indicate the figure that best represented their actual figure (actual score), the figure that best represented what they would like to look like (ideal score), and the figure they thought was most attractive to the opposite sex (attractive score). A body dissatisfaction score was calculated by subtracting the ideal score from the actual score. Silhouette choosing tasks are one of the most widely used methods of assessing body image (Thompson, Penner, & Altabe, 1990). Specifically, they measure subjective components of body image, namely perceived body image, ideal body image, and body satisfaction. Thompson and Altabe (1991) reported test-retest reliabilities ranging from .55 to .71 for six different ratings in females over a 2-week period. In order to compare scores on the SCT obtained from the women smokers in our sample to women in general, a sample of women for which scores on the SCT were available was chosen based on its similarity to our sample. The sample was composed
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of 97 American women with an average age of 46.5 years (Rozin & Fallon, 1988), which approximates the average age of the women in our study. R E S U L T S
Pooled t-tests were conducted to compare the present sample to normative samples. Table 1 shows the pooled mean estimates of normal samples for the factor scores of the MBSRQ and the silhouette choosing task. Compared with normative samples, subjects scored significantly lower on the Appearance Evaluation (t ⫽ ⫺6.58, p ⬍ .01) and Fitness Orientation (t ⫽ 5.55, p ⬍ .01) scales. For the Silhouette Choosing Task, subjects reported a significantly higher actual silhouette (t ⫽ 2.29, p ⫽ .02) and dissatisfaction score (t ⫽ 4.04, p ⬍ .01) than the comparative sample. There were no significant differences on the ideal or attraction scores. D I S C U S S I O N
Similar to the results obtained by Ben-Tovim and Walker (1991a), this sample of women smokers reported feeling less attractive than women in the comparison sample. We also found that this sample of women smokers perceived themselves as heavier than the comparison sample. This is interesting given that smokers typically weigh less than nonsmokers (Klesges et al., 1989). Unfortunately, weights for the women in the comparison sample were not reported, so actual weights can not be directly compared. However, the average BMI of our sample appears to be somewhat less than recent national averages for women. Data collected from 1988 through 1991 for the National Health and Nutrition Examination Survey indicated that the average BMI for women at least 20 years old is 26.3 (Kuczmarski, Flegal, Campbell, & Johnson, 1994) versus 25.5 for our sample. The women smokers also reported a greater discrepancy between their actual and ideal figure than the comparative sample. Given the similar ratings for the ideal and attraction scores, it does not appear that these women smokers considered smaller figures as more desirable, but rather that they perceived themselves as heavier and disliked their bodies to a greater extent. These findings may suggest some perceptual distortions for body size in women smokers. In contrast to Ben-Tovim and Walker’s (1991a) finding of no differences between smokers and nonsmokers in perception of fitness, women smokers in our sample re-
Table 1. Normative comparisons for body image measures Current sample Variable MBSRQ: Appearance evaluationa MBSRQ: Fitness orientation SCT: Actualb SCT: Ideal SCT: Dissatisfaction SCT: Attractive
Normative sample
N
Mean
SD
N
Mean
SD
T
p value
139 139 141 141 141 141
2.85 2.79 43.16 29.22 14.72 27.14
0.77 0.52 15.21 6.50 11.46 8.32
1070 1070 97 97 97 97
3.36 3.20 39.10 29.80 9.40 28.30
0.87 0.85 10.26 6.00 7.27 5.45
⫺6.58 ⫺5.55 2.29 ⫺0.70 4.04 ⫺1.21
⬍ .001 ⬍ .001 .02 .49 ⬍ .001 .23
Note. Values for the normative comparison for the MBSRQ are from aCash, Winstead, and Janda (1986) and bFallon and Rozin, (1985) for the Figure Rating Scale. MBSRQ ⫽ Multidimensional Body-Self Relations Questionnaire; SCT ⫽ Silhouette Choosing Task.
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ported less investment in physical fitness than the normative sample. One reason for this finding may be the nature of our sample. We recruited for sedentary women which may have resulted in lower scores on fitness orientation. However, advertisements for the study did mention that treatment may include exercise, therefore women who were not interested in exercise probably would not have been interested in participating. Thus, sample bias may not be the best explanation for the conflicting findings, but rather that women smokers actually value fitness less than women in general. Other studies have documented an association between poor health practices (Abood & Conway, 1994; Blair, Jacobs, & Powell, 1985; Emmons, Marcus, Linnan, Rossi, & Abrams, 1994; Troisi, Heinold, Vokonas, & Weiss, 1991) including a negative relationship between smoking and motivation to exercise (King, Marcus, Pinto, Emmons, & Abrams, 1996). Limitations of this study include the use of a volunteer sample and the sedentary status of the sample. While the sample used in this investigation may not be representative of the larger population of women smokers, it is likely representative of women smokers who would attend a smoking cessation program. Therefore, it appears appropriate to draw generalizations from this study to guide smoking cessation treatment efforts for women smokers. Another limitation includes the lack of some descriptive information for the comparison samples (e.g., socioeconomic status, ethnicity, weight) which makes it difficult to fully interpret the differences in body image evaluations and to attribute differences solely to smoking status. Replication of the present findings is needed before any conclusions can be made regarding body image attitudes in women smokers. Recently, it has been suggested that weight concerns is at best, a weak predictor of smoking cessation (Jeffery et al., 1997). Body image encompasses weight concerns but includes other concepts as well, such as perceptual distortions. Given that a negative body image relates to poor treatment outcome in other areas (e.g., Rosen, 1990), it may well be one of the critical understudied factors in research on women smokers. It is hoped that body image will be more regularly assessed in future investigations, and that individual and group-based treatment will address issues regarding body image distortion and body dissatisfaction. Since body image is unlikely to improve in women who quit smoking but gain weight, cognitive treatment to directly alter body image attitudes may be an important component for smoking cessation programs for women. R E F E R E N C E S Abood, D. A., & Conway, T. L. (1994). Smoking status, body composition, exercise, and diet among Navy men. Health Values, 18, 51–62. Ben-Tovim, D. I., & Walker, M. K. (1991a). Some body-related attitudes in women smokers and non-smokers. British Journal of Addictions, 86, 1129–1131. Ben-Tovim, D. I., & Walker, M. K. (1991b). The development of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ), a new measure of womens’ attitudes towards their own bodies. Psychological Medicine, 21, 775–784. Blair, S. N., Jacobs, D. R., & Powell, K. E. (1985). Relationships between exercise or physical activity and other health behaviors. Public Health Reports, 100, 172–180. Brown, T. A., Cash, T. F., & Mikulka, P. J. (1990). Attitudinal body-image assessment: Factor analysis of the Body-Self Relations Questionnaire. Journal of Personality Assessment, 55, 135–144. Cash, T. F. (1994). The Multidimensional Body-Self-Relations Questionnaire user’s manual. Norfolk, VA: Old Dominion University. Cash, T. F., Winstead, B. W., & Janda, L. H. (1986). The great American shape-up: Body image survey report. Psychology Today, 20, 30–37. Centers for Disease Control. (1996). Cigarette smoking among adults—United States, 1994. Morbidity and Mortality Weekly Report, 45, 588–590.
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