- Email: [email protected]
Do weight concerns hinder smoking cessation efforts?
.-lddictirv Behaviors. L’ol. 17. pp. 2 19-226, 1992 Printed in the USA. All rights reserved.
0306~3603192 Sj.00 i .OO Copyright 5 1992 Pergamon Press Ltd.
DO WEIGHT CONCERNS HINDER SMOKING CESSATION EFFORTS? SIMONE A. FRENCH, ROBERT W. JEFFERY, PHYLLIS L. PIRIE. and COLLEEN M. MCBRIDE University of Minnesota Abstract - This study examined the hypothesis that weight concerns interfere with smoking cessation efforts. Four hundred fifty-nine women screened for participation in a smoking cessation treatment program completed Stunkard’s Three Factor Eating Questionnaire (1981). measures of smoking-specific weight gain concern. and smoking history measures. Success in current cessation efforts was assessed 6 months following treatment. The restraint subscale of the TFEQ was associated with lower baseline level of nicotine dependence, a history ofsmoking feuer cigarettes. and longer prior periods of successful smoking abstinence. Baseline level of nicotine dependence and treatment group were significant predictors ofsmoking cessation at 6 months posttreatment. Restraint score was marginally predictive of higher rates of abstinence from smoking at 6 months when baseline level of nicotine dependence and treatment group were controlled. These results do not support the hypothesis that weight concerns interfere with smoking cessation attempts.
Cigarette smoking is associated with lower body weight and smoking cessation is usually accompanied by weight gain (Blitzer, Rimm, & Giefer, 1977; Grunberg, 1986; Wack & Rodin, 1982). It has been suggested that concerns about weight gain may interfere with smoking cessation efforts, especially among women (Charlton, 1984; Feldman, Hodgson, & Corber, 1985; Klesges & Klesges, 1988; Wack & Rodin, 1982). Cultural preferences for thin female figures in the United States have been well documented (Garner & Garfinkel, 1980; Rozin & Fallon, 1988). Women are more concerned about their weight than men (Fallon & Rozin, 1985; Dwyer. Feldman, & Mayer, 1970), and this is true among smokers as well as nonsmokers (Charlton, 1984; Feldman et al., 1985; Klesges & Klesges, 1988). In a survey of 16,000 school children, girls were more likely than boys to agree that smoking controls weight (Charlton, 1984). Another survey of 1,000 adolescents aged 12-20 found that smokers did not differ from nonsmokers overall in the extent to which they worried about their weight, but among women aged 18 years or older, 52% of smokers vs. only 3 1% of nonsmokers reported worrying about their weight (Feldman et al., 1985). Women are more likely than men to believe that smoking maintains body weight (Page, 1982), and overweight women report that they are more likely to start smoking for weight-related reasons than are normal weight women (Klesges & Klesges, 1988). Thus, it seems plausible that concerns about weight gain may impede cessation attempts and promote relapse among women (Klesges & Klesges, 1988; Feldman et al., 1985; Sorensen & Pechacek, 1987). An important limitation of the studies described above is that they have measured weight concerns and smoking status concurrently and therefore yield little information about the direction of causation. There is some evidence, however, that weight-related concerns prospectively predict smoking cessation. Maheu ( 1985) conducted a worksite intervention study which examined the relationship between weight concerns and This research was supported by grant (CA41647) to Phyllis L. Pirie from the National Cancer Institute. Requests for reprints should be sent to Simone A. French, Division of Epidemiology, School of Public Health. University of Minnesota, Suite 300. 1300 South Second Street, Minneapolis, MN 554541015. 219
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.A. FRENCH
et al.
smoking cessation. The best predictor of smoking cessation at 3 month follow-up was a negative answer to the question “Do you think that smoking helps control your weight?” In another worksite intemention study, Klesges, Brown, Pascale. Murphy, Williams. and Cigrang (1988) found that the best predictors ofcessation at posttest were lower pretest nicotine levels and less anticipated weight gain as a result of smoking cessation. The best predictors ofcessation at 6 month follow-up were self-reported number of coworkers who smoked at the pretest and less anticipated cessation-related weight gain. There is also evidence to suggest that weight gain concerns may prevent cessation efforts. In a community survey of 6 11 nonsmokers, exsmokers. and smokers, Klesges et al. ( 1988) found that smokers who had never attempted to quit could be distinguished from smokers who had attempted to quit by their greater concern regarding weight control. The results of all of these studies suggest that weight concerns are related to fewer smoking cessation efforts and greater relapse among smokers. The present study examined the relationship between baseline measures of weight concern, baseline level of nicotine dependence, previous smoking cessation efforts, and prospective success in smoking cessation. Assuming that those who express weight concerns may use cigarette smoking as a weight control strategy. it was hypothesized that weight concerns would be associated with greater baseline levels of nicotine dependence, a history of smoking more cigarettes. fewer and less successful previous cessation efforts, and less success in current quitting efforts. hl E T H 0
D
Data for this article were collected as part of a randomized trial comparing treatment methods for helping women quit smoking. A complete description of this trial is being prepared in a separate report. Participarm
A total of 459 women completed baseline assessments in the study and 4 17 were randomly assigned to different treatment groups.’ Participants were recruited from a variety ofsources, including women smokers who had been screened for cardiovascular risk factors through the iMinnesota Heart Health Program (Murray, Luepker, Pirie, Grimm, Bloom, Davis, & Blackbum, 1986), newspaper advertisements, and brochures distributed at worksites with primarily female employees. To be eligible participants had to be aged 20-64, express a desire to quit smoking, express concerns about weight gain, and a desire to maintain weight while quitting. Women who wanted to gain weight, were pregnant, nursing, planning to become pregnant, or who had serious medical conditions, including cardiovascular disease, cancer, TMJ syndrome, gastric ulcer, and a history ofsubstance abuse in the past 6 months were excluded from participation. Sixtyfive out of 2,367 (2.7%) age-eligible women smokers were excluded because they expressed a desire to gain weight. The average age of participants was 45 years (SD = 9), average weight was 142 lbs. (SD = 22), average body mass index (weight in pounds/height in inches’-5) was .06 (SD = .O1), average number of cigarettes smoked per day was 26 (SD = 13) and average age at which participants began smoking was 17 years (SD = 3). ‘Forty-two
women
were excluded
for medical
reasons
or as a result of scheduling
problems
Weight concerns
and smoking
221
Treatment groups All participants received the American Lung Association Freedom From Smoking (FFS) treatment. In addition to the FFS treatment, participants were randomly assigned to one of the following supplementary treatments: (a) FFS alone, control group (n = 103): (b) Nicorette” gum (n = 108); (c) behavioral weight control treatment (n = 108); and (d) behavioral weight control treatment plus Nicorette@ gum (n = 98). Initial treatment consisted of seven group counseling sessions scheduled approximately 1 week apart. Data were collected in person at baseline, at each treatment session, and at 6 months posttreatment. Measures of weight concerns Baseline measures of weight concerns included questions about both chronic and smoking-specific weight concerns. Stunkard’s Three Factor Eating Questionnaire (TFEQ; Stunkard, 1981; Stunkard & Messick, 1985) was the principal measure of chronic weight concern. This questionnaire consists of a total of 5 1 items and is broken down into three subscales. A cognitive restraint subscale consists of 2 1 items and measures the extent to which a person engages in conscious attempts to restrict eating. A disinhibition subscale consists of 16 items and measures the propensity to overeat in times of stress, A hunger subscale consists of 14 items and measures desire for food and food cravings. Smoking-specific weight concern was measured with the question “I fyou were to quit smoking, how concerned would you be about the possibility of gaining weight?’ ( 1 = not at all concerned; 5 = extremely concerned). Additional measures of weight concern collected at baseline included whether participants thought that they weighed too much, whether they were currently on a diet to lose weight, exercising to lose weight, or attending Weight Watchers,@ a reducing salon, exercise gym, or health spa to lose weight. Measures of smoking Severity of smoking history was measured using the largest number of cigarettes per day ever smoked. Previous cessation efforts were measured using responses to three questions: number of cessation efforts in the past year, number of cessation efforts in one’s life, and longest previous period of successful abstinence. Severity of nicotine dependence was measured using the Fagerstrom Tolerance Questionnaire (Fagerstrom, 1978). This scale consists of eight items that assess typical smoking behaviors assumed to be indicative of one’s level of nicotine dependence (e.g., “How soon after you wake up do you smoke your first cigarette?” and “Do you find it difficult to refrain from smoking in places where it is forbidden?“). Smoking outcome measures Self-reported smoking at 6 months and expired air carbon monoxide levels (CO) were used as smoking outcome measures and were collected in person at the clinic. Nonsmokers were defined as those who responded “no” to the question “Are you currently smoking one or more cigarettes a day?” and (a) had been smoking at the last contact, but reported smoking no cigarettes since the last contact or (b) had not been smoking at the last contact, and reported no smoking since the last contact. Smokers were defined as those who responded “yes” to the question “Are you currently smoking one or more cigarettes a day?“, or those who responded “no” to this question, but who reported any smoking at all since the last contact. Self-reports and CO measurements were in general but not perfect agreement. Three of 128 self-reported nonsmokers had
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SIMONE A. FRENCH et al
CO measures L 9 ppm, and 41 of 282 self-reported smokers had CO measures I 8 ppm. For the present analyses, only self-reports were used to classify subjects as nonsmokers or smokers. The decision to use self-reported smoking status and not CO measurements to classify subjects as smokers or nonsmokers was made in light of the fact that an extremely conservative method was used to classify subjects as nonsmokers and thus resulted in a large number of smokers with CO values I 8 ppm. Analyses conducted using only subjects whose self-reported smoking status and CO measurements were in agreement, or classifying subjects as nonsmokers only if their selfreported smoking status and CO measurements were in agreement, and all other subjects as smokers yielded results that were essentially identical to those reported below and are, thus, not presented. RESULTS
The first analysis included a total of 459 subjects and was conducted in order to examine the relationship between level of nicotine dependence, previous smoking cessation efforts, and weight concerns measured at baseline. It was hypothesized that those who expressed weight concerns would be more addicted to nicotine and would have a history of fewer and less successful cessation efforts. A multiple regression analysis2 was conducted using the following independent variables: (a) restraint,(b) disinhibition, and(c) hunger subscales ofthe TFEQ; (d) smokingspecific weight gain concern; (e) the perception of weighing too much (scored dichotomously: 0 for “no” and 1 for “yes”); (f) whether the participant was currently dieting (scored dichotomously); (g) whether the participant was exercising to lose weight (scored dichotomously); (h) whether the participant was going to Weight Watchers, a gym, or reducing salon to lose weight (scored dichotomously); (i) body mass index (BMI); (j) age; (k) educational attainment; and (1) marital status. This model was used to predict level of nicotine dependence, history of smoking, and previous smoking cessation efforts. Level of nicotine dependence Three variables were significantly related to Fagerstrom’s nicotine dependence score. Restraint scores on the TFEQ were negatively related (F( 1,3523.4) = 4.65 p -=c.03), hunger scores were positively related (F( 1,352) = 5.53, p < .Ol), and educational attainment was negatively related (F(5,352) = 2.40, p < .03). Disinhibition score, age, BMI, marital status, and other,measures of dieting and exercise behavior were unrelated to baseline level of nicotine dependence. History of smoking The largest number of cigarettes per day ever smoked was negatively related to restraint score (F( 1,43 1) F 3.68, p < .05). That is, higher levels ofweight concern were associated with lower smoking rates. No other variables were significantly related to the largest number of cigarettes per day ever smoked. 2Multiple regression analysis was selected over univariate correlational analysis in order to examine the unique contribution of each independent variable when the other independent variables are also included in the model. ‘Numbers vary due to missing data. 4Baseline regression analyses were conducted using the SAS General Linear Model program. All F values reported are Type III sums ofsquares (partial sums of squares), which reflect the marginal contribution ofthe indpendent variable, givjen that the other independent variables are included in the model.
Weight concerns and smoking
223
Previous cessation efforts Contrary to expectation, number of cessation efforts in the past year and number of cessation efforts in one’s life were unrelated to any of the independent variables in the regression model. Longest previous period of successful prior abstinence was positively associated with age (F( 1,428) = 6.66, p < .Ol), restraint score (F( 1,428) = 8.98, p < .002), and hunger score (F( 1,428) = 3.85, p < .05). BMI, marital status, educational attainment, disinhibition score, smoking-specific weight gain concern, history of dieting, and exercising to lose weight were unrelated to prior successful abstinence. Current smoking cessation Six-month smoking outcome data were examined to determine the extent to which success in smoking cessation was predictable from weight concerns. It was hypothesized that those who expressed weight concerns would be less successful. This analysis included 4 10 women with complete data on all variables (128 self-reported nonsmokers and 282 self-reported smokers). Logistic regression was conducted with smoking status as the outcome measure. Baseline level of nicotine dependence, treatment group, and the variables described above in the baseline model were entered as independent variables. Baseline level of nicotine dependence was negatively related to success in smoking cessation (X’ (1, N = 339) = 4.63, p < .03). Treatment group was also a significant predictor (X2 (3, N = 339) = 12.85, p < .005). Independent of these two effects, restraint score was marginally significant in predicting success in smoking cessation (X’ (1, N = 339) = 3.34, p < .06). Thirty-four percent of subjects high in dietary restraint were abstinent at 6 months posttreatment in comparison with a 28% abstinence rate among subjects low in dietary restraint. Exercising to lose weight was also associated with abstinence at 6 months (X2 (1, N = 339) = 5.92, p < .OI). The abstinence rate among those exercising to lose weight was 25% in comparison to 33% among those not doing so. Smoking-specific weight concern, disinhibition score, hunger score, dieting behaviors, and demographic variables did not predict smoking cessation. A second analysis strategy was pursued in an attempt to assess the independence of restraint, nicotine dependence, and treatment group as predictors of smoking cessation. Nicorettee and non-Nicorette treatment groups were analyzed separately using the model described above. Among non-Nicorette treatment groups, Fagerstrom score (X’(1, N = 166) = 11.27, p < .OOOS),treatment group (X2 (1, N = 166) = 6.04, p < .Ol), and disinhibition score (X2 (1, N = 166) = 4.13, p < .04) were significant predictors of smoking cessation, but restraint score was not. High disinhibition scores were predictive of abstinence. Among Nicorette@ treatment groups, restraint score was a significant predictor of smoking cessation (X2 (1, N = 173) = 4.20, p < .04), but Fagerstrom score and treatment group were not. Exercising to lose weight was also significantly negatively predictive of abstinence at 6 months posttreatment among Nicorette@ treatment groups only (X2 (1, N = 173) = 5.57, p < .Ol). The analyses described above focus on smoking cessation at 6 months and include all subjects entering treatment. To assess whether weight concerns might play a more important role in short-term than in long-term cessation efforts, a main effects logistic regression analysis was conducted identical to that described above predicting quitting at the end of the treatment group sessions, 4 weeks after the quit date. Subjects were classified as quitters ifthey reported smoking no cigarettes since the treatment quit date and if their CO measurements were I 9 ppm. All other subjects were classified as smokers. Restraint score and smoking-specific weight gain concern did not predict short-
22-l
term cessation. Treatment the end of treatment.
SIblONE .A. FRENCH er al.
group was the only significant predictor of smoking status at
DISCUSSIOS
In this research, we examined the hypothesis that weight concerns interfere with smoking cessation efforts. Although the study sample was large relative to previous studies, and diverse measures of weight concern were employed, the overall findings were that weight concern measures were not predictive of either past smoking behavior or future success in quitting. Moreover, the few associations that were found were opposite to the hypothesized direction. Weight concerns measured by the TFEQ restraint subscale were related to lower rather than higher baseline level of nicotine dependence, longer rather than shorter prior periods of successful abstinence. and a history of smoking fewer rather than more cigarettes. No measure of weight concern predicted number of prior smoking cessation attempts or successful short-term cessation. Weight concerns were also positively predictive of long-term success in smoking cessation, again contrary to our hypothesis. The ability of restraint to predict cessation, however. was weak and appeared to be present only in treatment groups receiving nicotine replacement therapy. The hunger subscale findings are interesting in light of previous research which suggests that one possible mechanism ofsmoking cessation-related weight gain is increased feelings of hunger and eating (Hughes & Hatsukami, 1986). Hunger scores in the present study were related to higher baseline levels of nicotine dependence and longer prior periods of successful smoking abstinence. Laboratory studies of food intake among abstinent smokers have also found a positive relationship between smoking abstinence and hunger scale scores (Duffy & Hall, 1988). These findings suggest that the hunger subscale of the TFEQ might be usefully evaluated in future research investigating the relationship between hunger, smoking abstinence, and cessation-related weight gain. The consistent negative relationship between exercising to lose weight and successful smoking cessation was unexpected and is not readily interpretable. One possible interpretation is that participants vvho are actively exercising to lose weight vvhile simultaneously attempting to stop smoking are attempting too many changes at once and, therefore, are less successful at either. This interpretation is admittedly tenuous, given that success in exercising to lose weight was not measured. Researchers should continue to examine the relationship between dietary restraint, actual postcessation weight gain, and long-term smoking cessation. The dietary intakes and, therefore, postcessation weight gain of chronic dieters may differ from that of nondieters (Hall, Ginsberg, & Jones. 1986; Klesges, Meyers, Winders, & French, 1989). Restrained eaters may also differ from unrestrained eaters in their response to small amounts of weight gained as a result of cessation (Gritz, Klesges. & Meyers. 1989). They may attach greater significance to it and therefore be more likely to relapse as a result of small weight gains than those less concerned about their weight. Alternatively, restrained eaters may exert even greater control over their dietary intake and gain less weight following cessation. In the present study, restrained eaters may have gained less weight following cessation because they were initially less nicotine dependent (Klesges, Meyers, KIesges & LaVasque, 1989). Both weight gain and dietary restraint may have independent and interactive effects on smoking cessation and relapse and need to be examined simultaneously. Unfortunately, smoking cessation and weight gain are confounded with each other, as well as with initial level of nicotine dependence. Nonethe-
Weight concerns and smoking
225
less, future studies should measure each of these variables in order to determine their relative importance for smoking cessation and the role that they play in determining relapse. Related to the issue of weight gain is the influence of Nicorette gum on weight gain and smoking cessation. If Nicorette gum use prevents weight gain following smoking cessation, it is possible that people with weight concerns will be more successful in smoking cessation efforts if they use Nicorette gum. Nicorette gum may not only help alleviate physiological withdrawal symptoms among those more addicted initially, but also may help alleviate weight gain and thereby prevent relapse among restrained eaters. The negative findings from the present study may be explained in different ways. First, it is perhaps the case that there is in fact no causal relationship between weight concerns and smoking cessation efforts. Women may report weight concerns as an excuse not only for failure to quit smoking, but also for many other behaviors. This explanation may not correspond with reality, as self-reported reasons for behavior frequently do not (Nisbett & Wilson, 1977). Second, the measures of weight concern used in the present study may not have assessed weight concerns specifically enough. Although both a smoking-specific weight gain concern and a general measure of weight concern were included in the study, perhaps a different measure would have detected the relationship of interest. Finally, the range restriction due to sample selection may have attenuated the relationship between weight concerns and smoking cessation. It could be argued that those extremely fearful of weight gain would not attempt to quit smoking in the first place, and those unconcerned about weight gain, or desiring to gain weight, were excluded from the study. The proportion of smokers in the first group is not known, but the second category comprised only 3% of age-eligible women. Overall, weight concerns do not appear to hinder smoking cessation efforts. Other variables appear to be stronger determinants of successful smoking cessation. The effects of weight concern, actual postcessation weight gain, level of nicotine dependence, and the interaction of these variables on long- and short-term smoking cessation merits additional study.
REFERENCES Blitzer, P. H.. Rimm, A. A., & Giefer. E. E. (1977). The effect of cessation of smoking on hod! weight in 57,032 women:cross-sectional and longitudinal analyses. Journal q/Chronic Diseases. 30.4 15-429. Charlton, A. ( 1984). Smoking and weight control in teenagers. Public Health. 98,277-28 I. Duffy, J., & Hall, S. M. (1988). Smoking abstinence, eating style, and food intake. Jo~rmal o/Corwhingand Clinical Psycholog!,. 56(3), 4 17-12 I. Dwyer, J., Feldman, J.. & Mayer, J. (1970). The social psychology of dieting. JOIU& oj‘Heuhh and Social Behavior, 11, 269-287. Fanerstrom. K. (1978). Measuring degree of physical dependence on tobacco smoking with reference to individualization of treatment. kddicrive Bihhaviors. 3, 235-24 1. Fallon, A.. & Rozin, P. (1985). Sex differences in perceptions of desirable bodyshaps. Journal q/‘.ihnormnl Ps1’c/1010g)‘. 94( I). 102-105. Feldman, W., Hodgson. C., & Corber. S. (1985). Relationship between higher prevalence of smoking and weight concern amongst adolescent girls. Canadian Jownal o/Public Health. 76. 205-206. Garner,b., & Garfinkel. p. (1980). So&-cultural factors in the development of anorexia nenosa. Psychological Medicine. 10,647-656. Gritz, E. R.. Kiesges, R. C., & Meyers. A. W. (1989). The smoking and body weight relationship:implications for intervention and postcessation weight control. Annuls o/BehaviorulMedicine. 11(4), 144-152. Grunberg. N. E. (1986). Behavioral and biologic factors in the relationship between tobacco use and body weight. In E. S. Katkin, & S. B. Manuck (Eds.), Advances in behaviorul medicine, vol. 2. (pp. 97- 120). Greenwich, CT: JAI Press. Hall, S. M.. Ginsberg, D., & Jones, R. T. (1986).Smoking cessation and weight gain. Journal q/Consulfing and ClinicalPsychology, 54(3), 332-346.
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Hughes. J. R.. & Hatsukami. D. (1986). Signs and symptoms of tobacco withdrawal. Archives oj’Grr~t~rul Psychiarr~~,43.289-294. Klesges. R. C.. & Klesges, L. hl. (1988). Cigarette smoking as a dieting strategy in a university population. Inlernarional Journal oj‘Eating Disorders. 7( 3). 4 13-3 19. Klesges. R. C.. Brown. K., Pascale. R. W.. hiurphy, M.. Williams, E., & Cigrang. J. A. ( 1988). Factors associated with participation. attrition, and outcome in a smoking cessation program at the workplace. Health Psj,chology. 7(6), 575-589. Klesges. R. C.. Meyers. A. W.. Klesges, L. bl., & LaVasque, M. D. (1989). Smoking, body weight, and their effects on smoking behavior: A comprehensive review of the literature. Psychological Bulletin. 106(2). 204-230. Klesges. R. C.. Meyers, A. W., Winders, S. E., & French, S. N. (1989). Determining the reasons for weight gain following smoking cessation: Current findings. methodological issues. and future directions for research. .-lnnals ofBehavioral Medicine. 1 l(4). I34- 143. Xiaheu. M. ( 1985). The efficcls of comperition/cuoperalion on wurksitesmoking cessation. Unpublished doctoral dissertation. California School of Professional Psychology, San Diego. (University Microfilms International No. 85- 17.936). Xlurray. D. hl.. Luepker, R. V., Pirie. P. L.. Grimm, R. H., Bloom. E., Davis. M. A., & Blackburn. H. (1986). Systematic risk factor screening and education: A community-wide approach to prevention ofcoronary heart disease. Preventive .\iedicine. 15.66 I-672. Nisbett, R. E., & Wilson, T. D. (1977). Telling more than we can know: Verbal reports on mental processes. Psychological Review. 84,23 l-259. Page, R. ( 1982). Assessinggender d@rences in collegecigarettesmoking intenders and nonintenders. Unpublished doctoral dissertation, Southern Illinois University, Carbondale. (University Microfilms International No.82-2 1953). 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. Journa~o~Abnormal Psychology. 97(3). 342-345. Sorensen. G., & Pechacek, T. F. (1987). Attitudes toward smoking cessation among men and women. Journal oj‘Behavioral.\fedicine. 10(Z), 129-I 37. Stunkard. A. (198 I). ‘*Restrained eating”: \h’hat it is and a new scale to measure it. In L. Cioffi (Ed.). The body weight regulatory system: Normal and disturbed mechanisms. (pp. 243-25 I). New York: Raven Press. Stunkard, A., & Messick, S. (1985). The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. Journal o/Psychosomaric Research, 29(l), 7 l-83. Wack, J. T., & Rodin, J. (I 982). Smoking and its effects on body weight and the systems of caloric regulation. .4merican Journal ofClinical Nutrition. 35(2), 366-380.
0306~3603192 Sj.00 i .OO Copyright 5 1992 Pergamon Press Ltd.
DO WEIGHT CONCERNS HINDER SMOKING CESSATION EFFORTS? SIMONE A. FRENCH, ROBERT W. JEFFERY, PHYLLIS L. PIRIE. and COLLEEN M. MCBRIDE University of Minnesota Abstract - This study examined the hypothesis that weight concerns interfere with smoking cessation efforts. Four hundred fifty-nine women screened for participation in a smoking cessation treatment program completed Stunkard’s Three Factor Eating Questionnaire (1981). measures of smoking-specific weight gain concern. and smoking history measures. Success in current cessation efforts was assessed 6 months following treatment. The restraint subscale of the TFEQ was associated with lower baseline level of nicotine dependence, a history ofsmoking feuer cigarettes. and longer prior periods of successful smoking abstinence. Baseline level of nicotine dependence and treatment group were significant predictors ofsmoking cessation at 6 months posttreatment. Restraint score was marginally predictive of higher rates of abstinence from smoking at 6 months when baseline level of nicotine dependence and treatment group were controlled. These results do not support the hypothesis that weight concerns interfere with smoking cessation attempts.
Cigarette smoking is associated with lower body weight and smoking cessation is usually accompanied by weight gain (Blitzer, Rimm, & Giefer, 1977; Grunberg, 1986; Wack & Rodin, 1982). It has been suggested that concerns about weight gain may interfere with smoking cessation efforts, especially among women (Charlton, 1984; Feldman, Hodgson, & Corber, 1985; Klesges & Klesges, 1988; Wack & Rodin, 1982). Cultural preferences for thin female figures in the United States have been well documented (Garner & Garfinkel, 1980; Rozin & Fallon, 1988). Women are more concerned about their weight than men (Fallon & Rozin, 1985; Dwyer. Feldman, & Mayer, 1970), and this is true among smokers as well as nonsmokers (Charlton, 1984; Feldman et al., 1985; Klesges & Klesges, 1988). In a survey of 16,000 school children, girls were more likely than boys to agree that smoking controls weight (Charlton, 1984). Another survey of 1,000 adolescents aged 12-20 found that smokers did not differ from nonsmokers overall in the extent to which they worried about their weight, but among women aged 18 years or older, 52% of smokers vs. only 3 1% of nonsmokers reported worrying about their weight (Feldman et al., 1985). Women are more likely than men to believe that smoking maintains body weight (Page, 1982), and overweight women report that they are more likely to start smoking for weight-related reasons than are normal weight women (Klesges & Klesges, 1988). Thus, it seems plausible that concerns about weight gain may impede cessation attempts and promote relapse among women (Klesges & Klesges, 1988; Feldman et al., 1985; Sorensen & Pechacek, 1987). An important limitation of the studies described above is that they have measured weight concerns and smoking status concurrently and therefore yield little information about the direction of causation. There is some evidence, however, that weight-related concerns prospectively predict smoking cessation. Maheu ( 1985) conducted a worksite intervention study which examined the relationship between weight concerns and This research was supported by grant (CA41647) to Phyllis L. Pirie from the National Cancer Institute. Requests for reprints should be sent to Simone A. French, Division of Epidemiology, School of Public Health. University of Minnesota, Suite 300. 1300 South Second Street, Minneapolis, MN 554541015. 219
‘20
SIMOSE
.A. FRENCH
et al.
smoking cessation. The best predictor of smoking cessation at 3 month follow-up was a negative answer to the question “Do you think that smoking helps control your weight?” In another worksite intemention study, Klesges, Brown, Pascale. Murphy, Williams. and Cigrang (1988) found that the best predictors ofcessation at posttest were lower pretest nicotine levels and less anticipated weight gain as a result of smoking cessation. The best predictors ofcessation at 6 month follow-up were self-reported number of coworkers who smoked at the pretest and less anticipated cessation-related weight gain. There is also evidence to suggest that weight gain concerns may prevent cessation efforts. In a community survey of 6 11 nonsmokers, exsmokers. and smokers, Klesges et al. ( 1988) found that smokers who had never attempted to quit could be distinguished from smokers who had attempted to quit by their greater concern regarding weight control. The results of all of these studies suggest that weight concerns are related to fewer smoking cessation efforts and greater relapse among smokers. The present study examined the relationship between baseline measures of weight concern, baseline level of nicotine dependence, previous smoking cessation efforts, and prospective success in smoking cessation. Assuming that those who express weight concerns may use cigarette smoking as a weight control strategy. it was hypothesized that weight concerns would be associated with greater baseline levels of nicotine dependence, a history of smoking more cigarettes. fewer and less successful previous cessation efforts, and less success in current quitting efforts. hl E T H 0
D
Data for this article were collected as part of a randomized trial comparing treatment methods for helping women quit smoking. A complete description of this trial is being prepared in a separate report. Participarm
A total of 459 women completed baseline assessments in the study and 4 17 were randomly assigned to different treatment groups.’ Participants were recruited from a variety ofsources, including women smokers who had been screened for cardiovascular risk factors through the iMinnesota Heart Health Program (Murray, Luepker, Pirie, Grimm, Bloom, Davis, & Blackbum, 1986), newspaper advertisements, and brochures distributed at worksites with primarily female employees. To be eligible participants had to be aged 20-64, express a desire to quit smoking, express concerns about weight gain, and a desire to maintain weight while quitting. Women who wanted to gain weight, were pregnant, nursing, planning to become pregnant, or who had serious medical conditions, including cardiovascular disease, cancer, TMJ syndrome, gastric ulcer, and a history ofsubstance abuse in the past 6 months were excluded from participation. Sixtyfive out of 2,367 (2.7%) age-eligible women smokers were excluded because they expressed a desire to gain weight. The average age of participants was 45 years (SD = 9), average weight was 142 lbs. (SD = 22), average body mass index (weight in pounds/height in inches’-5) was .06 (SD = .O1), average number of cigarettes smoked per day was 26 (SD = 13) and average age at which participants began smoking was 17 years (SD = 3). ‘Forty-two
women
were excluded
for medical
reasons
or as a result of scheduling
problems
Weight concerns
and smoking
221
Treatment groups All participants received the American Lung Association Freedom From Smoking (FFS) treatment. In addition to the FFS treatment, participants were randomly assigned to one of the following supplementary treatments: (a) FFS alone, control group (n = 103): (b) Nicorette” gum (n = 108); (c) behavioral weight control treatment (n = 108); and (d) behavioral weight control treatment plus Nicorette@ gum (n = 98). Initial treatment consisted of seven group counseling sessions scheduled approximately 1 week apart. Data were collected in person at baseline, at each treatment session, and at 6 months posttreatment. Measures of weight concerns Baseline measures of weight concerns included questions about both chronic and smoking-specific weight concerns. Stunkard’s Three Factor Eating Questionnaire (TFEQ; Stunkard, 1981; Stunkard & Messick, 1985) was the principal measure of chronic weight concern. This questionnaire consists of a total of 5 1 items and is broken down into three subscales. A cognitive restraint subscale consists of 2 1 items and measures the extent to which a person engages in conscious attempts to restrict eating. A disinhibition subscale consists of 16 items and measures the propensity to overeat in times of stress, A hunger subscale consists of 14 items and measures desire for food and food cravings. Smoking-specific weight concern was measured with the question “I fyou were to quit smoking, how concerned would you be about the possibility of gaining weight?’ ( 1 = not at all concerned; 5 = extremely concerned). Additional measures of weight concern collected at baseline included whether participants thought that they weighed too much, whether they were currently on a diet to lose weight, exercising to lose weight, or attending Weight Watchers,@ a reducing salon, exercise gym, or health spa to lose weight. Measures of smoking Severity of smoking history was measured using the largest number of cigarettes per day ever smoked. Previous cessation efforts were measured using responses to three questions: number of cessation efforts in the past year, number of cessation efforts in one’s life, and longest previous period of successful abstinence. Severity of nicotine dependence was measured using the Fagerstrom Tolerance Questionnaire (Fagerstrom, 1978). This scale consists of eight items that assess typical smoking behaviors assumed to be indicative of one’s level of nicotine dependence (e.g., “How soon after you wake up do you smoke your first cigarette?” and “Do you find it difficult to refrain from smoking in places where it is forbidden?“). Smoking outcome measures Self-reported smoking at 6 months and expired air carbon monoxide levels (CO) were used as smoking outcome measures and were collected in person at the clinic. Nonsmokers were defined as those who responded “no” to the question “Are you currently smoking one or more cigarettes a day?” and (a) had been smoking at the last contact, but reported smoking no cigarettes since the last contact or (b) had not been smoking at the last contact, and reported no smoking since the last contact. Smokers were defined as those who responded “yes” to the question “Are you currently smoking one or more cigarettes a day?“, or those who responded “no” to this question, but who reported any smoking at all since the last contact. Self-reports and CO measurements were in general but not perfect agreement. Three of 128 self-reported nonsmokers had
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CO measures L 9 ppm, and 41 of 282 self-reported smokers had CO measures I 8 ppm. For the present analyses, only self-reports were used to classify subjects as nonsmokers or smokers. The decision to use self-reported smoking status and not CO measurements to classify subjects as smokers or nonsmokers was made in light of the fact that an extremely conservative method was used to classify subjects as nonsmokers and thus resulted in a large number of smokers with CO values I 8 ppm. Analyses conducted using only subjects whose self-reported smoking status and CO measurements were in agreement, or classifying subjects as nonsmokers only if their selfreported smoking status and CO measurements were in agreement, and all other subjects as smokers yielded results that were essentially identical to those reported below and are, thus, not presented. RESULTS
The first analysis included a total of 459 subjects and was conducted in order to examine the relationship between level of nicotine dependence, previous smoking cessation efforts, and weight concerns measured at baseline. It was hypothesized that those who expressed weight concerns would be more addicted to nicotine and would have a history of fewer and less successful cessation efforts. A multiple regression analysis2 was conducted using the following independent variables: (a) restraint,(b) disinhibition, and(c) hunger subscales ofthe TFEQ; (d) smokingspecific weight gain concern; (e) the perception of weighing too much (scored dichotomously: 0 for “no” and 1 for “yes”); (f) whether the participant was currently dieting (scored dichotomously); (g) whether the participant was exercising to lose weight (scored dichotomously); (h) whether the participant was going to Weight Watchers, a gym, or reducing salon to lose weight (scored dichotomously); (i) body mass index (BMI); (j) age; (k) educational attainment; and (1) marital status. This model was used to predict level of nicotine dependence, history of smoking, and previous smoking cessation efforts. Level of nicotine dependence Three variables were significantly related to Fagerstrom’s nicotine dependence score. Restraint scores on the TFEQ were negatively related (F( 1,3523.4) = 4.65 p -=c.03), hunger scores were positively related (F( 1,352) = 5.53, p < .Ol), and educational attainment was negatively related (F(5,352) = 2.40, p < .03). Disinhibition score, age, BMI, marital status, and other,measures of dieting and exercise behavior were unrelated to baseline level of nicotine dependence. History of smoking The largest number of cigarettes per day ever smoked was negatively related to restraint score (F( 1,43 1) F 3.68, p < .05). That is, higher levels ofweight concern were associated with lower smoking rates. No other variables were significantly related to the largest number of cigarettes per day ever smoked. 2Multiple regression analysis was selected over univariate correlational analysis in order to examine the unique contribution of each independent variable when the other independent variables are also included in the model. ‘Numbers vary due to missing data. 4Baseline regression analyses were conducted using the SAS General Linear Model program. All F values reported are Type III sums ofsquares (partial sums of squares), which reflect the marginal contribution ofthe indpendent variable, givjen that the other independent variables are included in the model.
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Previous cessation efforts Contrary to expectation, number of cessation efforts in the past year and number of cessation efforts in one’s life were unrelated to any of the independent variables in the regression model. Longest previous period of successful prior abstinence was positively associated with age (F( 1,428) = 6.66, p < .Ol), restraint score (F( 1,428) = 8.98, p < .002), and hunger score (F( 1,428) = 3.85, p < .05). BMI, marital status, educational attainment, disinhibition score, smoking-specific weight gain concern, history of dieting, and exercising to lose weight were unrelated to prior successful abstinence. Current smoking cessation Six-month smoking outcome data were examined to determine the extent to which success in smoking cessation was predictable from weight concerns. It was hypothesized that those who expressed weight concerns would be less successful. This analysis included 4 10 women with complete data on all variables (128 self-reported nonsmokers and 282 self-reported smokers). Logistic regression was conducted with smoking status as the outcome measure. Baseline level of nicotine dependence, treatment group, and the variables described above in the baseline model were entered as independent variables. Baseline level of nicotine dependence was negatively related to success in smoking cessation (X’ (1, N = 339) = 4.63, p < .03). Treatment group was also a significant predictor (X2 (3, N = 339) = 12.85, p < .005). Independent of these two effects, restraint score was marginally significant in predicting success in smoking cessation (X’ (1, N = 339) = 3.34, p < .06). Thirty-four percent of subjects high in dietary restraint were abstinent at 6 months posttreatment in comparison with a 28% abstinence rate among subjects low in dietary restraint. Exercising to lose weight was also associated with abstinence at 6 months (X2 (1, N = 339) = 5.92, p < .OI). The abstinence rate among those exercising to lose weight was 25% in comparison to 33% among those not doing so. Smoking-specific weight concern, disinhibition score, hunger score, dieting behaviors, and demographic variables did not predict smoking cessation. A second analysis strategy was pursued in an attempt to assess the independence of restraint, nicotine dependence, and treatment group as predictors of smoking cessation. Nicorettee and non-Nicorette treatment groups were analyzed separately using the model described above. Among non-Nicorette treatment groups, Fagerstrom score (X’(1, N = 166) = 11.27, p < .OOOS),treatment group (X2 (1, N = 166) = 6.04, p < .Ol), and disinhibition score (X2 (1, N = 166) = 4.13, p < .04) were significant predictors of smoking cessation, but restraint score was not. High disinhibition scores were predictive of abstinence. Among Nicorette@ treatment groups, restraint score was a significant predictor of smoking cessation (X2 (1, N = 173) = 4.20, p < .04), but Fagerstrom score and treatment group were not. Exercising to lose weight was also significantly negatively predictive of abstinence at 6 months posttreatment among Nicorette@ treatment groups only (X2 (1, N = 173) = 5.57, p < .Ol). The analyses described above focus on smoking cessation at 6 months and include all subjects entering treatment. To assess whether weight concerns might play a more important role in short-term than in long-term cessation efforts, a main effects logistic regression analysis was conducted identical to that described above predicting quitting at the end of the treatment group sessions, 4 weeks after the quit date. Subjects were classified as quitters ifthey reported smoking no cigarettes since the treatment quit date and if their CO measurements were I 9 ppm. All other subjects were classified as smokers. Restraint score and smoking-specific weight gain concern did not predict short-
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group was the only significant predictor of smoking status at
DISCUSSIOS
In this research, we examined the hypothesis that weight concerns interfere with smoking cessation efforts. Although the study sample was large relative to previous studies, and diverse measures of weight concern were employed, the overall findings were that weight concern measures were not predictive of either past smoking behavior or future success in quitting. Moreover, the few associations that were found were opposite to the hypothesized direction. Weight concerns measured by the TFEQ restraint subscale were related to lower rather than higher baseline level of nicotine dependence, longer rather than shorter prior periods of successful abstinence. and a history of smoking fewer rather than more cigarettes. No measure of weight concern predicted number of prior smoking cessation attempts or successful short-term cessation. Weight concerns were also positively predictive of long-term success in smoking cessation, again contrary to our hypothesis. The ability of restraint to predict cessation, however. was weak and appeared to be present only in treatment groups receiving nicotine replacement therapy. The hunger subscale findings are interesting in light of previous research which suggests that one possible mechanism ofsmoking cessation-related weight gain is increased feelings of hunger and eating (Hughes & Hatsukami, 1986). Hunger scores in the present study were related to higher baseline levels of nicotine dependence and longer prior periods of successful smoking abstinence. Laboratory studies of food intake among abstinent smokers have also found a positive relationship between smoking abstinence and hunger scale scores (Duffy & Hall, 1988). These findings suggest that the hunger subscale of the TFEQ might be usefully evaluated in future research investigating the relationship between hunger, smoking abstinence, and cessation-related weight gain. The consistent negative relationship between exercising to lose weight and successful smoking cessation was unexpected and is not readily interpretable. One possible interpretation is that participants vvho are actively exercising to lose weight vvhile simultaneously attempting to stop smoking are attempting too many changes at once and, therefore, are less successful at either. This interpretation is admittedly tenuous, given that success in exercising to lose weight was not measured. Researchers should continue to examine the relationship between dietary restraint, actual postcessation weight gain, and long-term smoking cessation. The dietary intakes and, therefore, postcessation weight gain of chronic dieters may differ from that of nondieters (Hall, Ginsberg, & Jones. 1986; Klesges, Meyers, Winders, & French, 1989). Restrained eaters may also differ from unrestrained eaters in their response to small amounts of weight gained as a result of cessation (Gritz, Klesges. & Meyers. 1989). They may attach greater significance to it and therefore be more likely to relapse as a result of small weight gains than those less concerned about their weight. Alternatively, restrained eaters may exert even greater control over their dietary intake and gain less weight following cessation. In the present study, restrained eaters may have gained less weight following cessation because they were initially less nicotine dependent (Klesges, Meyers, KIesges & LaVasque, 1989). Both weight gain and dietary restraint may have independent and interactive effects on smoking cessation and relapse and need to be examined simultaneously. Unfortunately, smoking cessation and weight gain are confounded with each other, as well as with initial level of nicotine dependence. Nonethe-
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less, future studies should measure each of these variables in order to determine their relative importance for smoking cessation and the role that they play in determining relapse. Related to the issue of weight gain is the influence of Nicorette gum on weight gain and smoking cessation. If Nicorette gum use prevents weight gain following smoking cessation, it is possible that people with weight concerns will be more successful in smoking cessation efforts if they use Nicorette gum. Nicorette gum may not only help alleviate physiological withdrawal symptoms among those more addicted initially, but also may help alleviate weight gain and thereby prevent relapse among restrained eaters. The negative findings from the present study may be explained in different ways. First, it is perhaps the case that there is in fact no causal relationship between weight concerns and smoking cessation efforts. Women may report weight concerns as an excuse not only for failure to quit smoking, but also for many other behaviors. This explanation may not correspond with reality, as self-reported reasons for behavior frequently do not (Nisbett & Wilson, 1977). Second, the measures of weight concern used in the present study may not have assessed weight concerns specifically enough. Although both a smoking-specific weight gain concern and a general measure of weight concern were included in the study, perhaps a different measure would have detected the relationship of interest. Finally, the range restriction due to sample selection may have attenuated the relationship between weight concerns and smoking cessation. It could be argued that those extremely fearful of weight gain would not attempt to quit smoking in the first place, and those unconcerned about weight gain, or desiring to gain weight, were excluded from the study. The proportion of smokers in the first group is not known, but the second category comprised only 3% of age-eligible women. Overall, weight concerns do not appear to hinder smoking cessation efforts. Other variables appear to be stronger determinants of successful smoking cessation. The effects of weight concern, actual postcessation weight gain, level of nicotine dependence, and the interaction of these variables on long- and short-term smoking cessation merits additional study.
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