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Gender and weight concerns in adolescent smokers
Addictive Behaviors 31 (2006) 2140 – 2146
Short communication
Gender and weight concerns in adolescent smokers Dana A. Cavallo *, Amy M. Duhig, Sherry McKee, Suchitra Krishnan-Sarin Yale University School of Medicine, Department of Psychiatry, SAC, 34 Park Street, New Haven, CT 06519, United States
Abstract The aim of this study was to examine smoking-specific weight concerns in a well-characterized sample of adolescent daily smokers and the influence of gender, age, and body mass index (BMI). Adolescent smokers (n = 103) were asked two smoking-specific weight concern questions: bHow much do cigarettes help you control your weight?Q and bHow concerned are you about gaining weight as a result of quitting?Q A significant positive relationship was found between average daily cigarette use and belief in smoking as a means to control weight and a significant negative relationship between the years of smoking and belief that smoking controls weight. There was no significant relationship between BMI and smoking to control weight for females, whereas for males, there was a positive relationship, indicating that heavier males were more likely to report smoking to control weight. Additionally, females who smoked more cigarettes reported more concern about gaining weight upon quitting, a pattern not seen in males. Results highlight potentially important gender differences in the relationship between weight concerns and smoking and the influence these concerns may have on quitting smoking. D 2006 Elsevier Ltd. All rights reserved. Keywords: Adolescent smokers; Weight concerns
1. Introduction Adolescence is a critical time when cigarette smoking develops, with approximately 2000 adolescents beginning to smoke each day (Johnston, O’Malley, & Bachman, 2003). Data suggests that 72.9% of adolescent daily smokers tried to quit smoking, but only 13.5% succeeded (CDC, 2001). One reason adolescents may start smoking, return to smoking after quitting, or never attempt to quit may be related to the perceived benefits of smoking on body weight. * Corresponding author. Tel.: +1 203 794 7607; fax: +1 203 974 7606. E-mail address: [email protected] (D.A. Cavallo). 0306-4603/$ - see front matter D 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2006.02.021
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The belief that smoking helps control weight appears to be gender-specific, with female adolescents worrying more about their weight and being more likely to report smoking to control their weight than males (Camp, Klesges, & Relyea, 1993; Charlton, 1984; Coogan et al., 1998). Other variables that influence this relationship include smoking amount and age. Regular smokers (smoking z once per week) are more likely than experimental smokers (smoking less than one cigarette weekly) to believe that smoking is a weight control strategy (Robinson, Klesges, Zbikowski, & Glaser, 1997). Camp and colleagues (see Camp et al., 1993), have shown that the belief that smoking could control weight did not differ between regular smokers (smoking z once per week) and never smokers, but was significantly greater in the regular smokers when compared with experimental smokers (smoked 1–2 cigarettes in lifetime). This suggests that weight control properties of cigarettes may be learned over time and may reinforce continued smoking behavior. Interestingly, among regular smokers, being older and female predicted those who smoked for weight-control reasons. Boles and Johnson (2001) examined the association between age and weight concerns in three cohorts of adolescents (i.e. 12–13, 14–15, and 16–17 year-old smokers) smoking z one cigarette daily and found the youngest male and oldest female groups were most likely to believe smoking controls weight. Concern about gaining weight upon quitting is related to cigarette specific weight control, but there is also some evidence to suggest that these two variables maintain some independent role in smokingspecific weight concern as indicated by the adult literature. Smoking for weight control may explain smoking initiation, while concerns about gaining weight upon quitting may explain smoking maintenance and the difficulty in quitting. In adult smokers, weight gain is often cited as an important reason for relapse to smoking (Borelli & Mermelstein, 1998; Swan, Ward, Carmelli, & Jack, 1993; USDHHS, 2001) and concerns about post-cessation weight gain predict lower intentions to quit smoking (Klesges, Meyers, Klesges, & La Vasque, 1989; Weekley, Klesges, & Relyea, 1992). Although the prevalence of weight-concerned adults who participate in formal smoking cessation programs is low, those who are weight concerned are less likely to quit smoking than those who intend to accept a significant postcessation weight gain (Meyers et al., 1997). There is currently no data to support or refute this relationship in adolescent smokers. There is conflicting evidence on the influence of the adolescent smoker’s actual weight on smokingrelated weight concerns, with some studies showing a correlation between BMI and smoking status (Klesges et al., 1998; Robinson et al., 1997; Townsend, Wilkes, Haines, & Jarvis, 1991) in both genders, and other studies showing no association (Crocker et al., 2001; Killen et al., 1997; Voorhees, Schreiber, Schumann, Biro, & Crawford et al., 2002). Similarly, some studies report a positive relationship between being moderately overweight and increased smoking (Crisp, Sedgwick, Halek, Joughin, & Humphrey et al., 1999; Halek, Kerry, Humphrey, Crisp, & Hughes, 1993) while others find a negative association between weight and smoking, especially among females (Austin & Gortmaker, 2001). Furthermore, the association between BMI and smoking may be altered by smoking intensity (Robinson et al., 1997) and age (Townsend et al., 1991). In summary, the above literature suggests a strong association between weight concerns and smoking in adolescents (see Potter, Pederson, Chan, Aubut, & Koval, 2004 for review). However, most of these studies used a broad range of smoking rates to define a regular smoker and did not differentiate regular daily smokers from other smokers. To date, no studies have examined adolescents with established daily smoking patterns in relation to their belief about how smoking controls their weight and more importantly, how concerned they are about gaining weight upon quitting. These daily smokers may have
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Table 1 Sample characteristics by gender Race (n) Caucasian African-American Hispanic Asian Other Age Average daily cigarette use Urine cotinine (ng/ml)+ Years of daily smoking BMI++ FTND+++
Females (N = 53)
Males (N = 50)
71.7% 15.1% 7.5% 3.8% 1.9% 16.5 (1.3) 12.5 (6.4) 1228.0 (981.2) 2.4 (1.4) 25.0 (6.2) 3.9 (2.4)
82% 10% 6% 0% 2% 16.5 (1.2) 15.3 (10.2) 1474.4 (1222.9) 3.2 (2.3)* 25.5 (6.7) 4.4 (2.2)
Note: With the exception of race, all information is provided in terms of means and standard deviations. BMI = Body Mass Index; FTND = Fagerstrom Test for Nicotine Dependence; +missing urine cotinine data for 17 females and 14 males; ++missing BMI data for 15 females and 11 males; +++missing FTND data for 15 females and 11 males; *p b .05.
a difficult time quitting smoking due to their beliefs about the relationship between smoking and weight. Furthermore, potential gender and age-related differences related to these concerns and beliefs need to be examined. The purpose of the current study was to conduct a preliminary examination of smokingspecific weight concerns in a well-characterized sample of adolescent daily smokers (with biochemical verification of smoking status) and the influence of gender, age, BMI, and smoking intensity on these concerns.
2. Method 2.1. Participants Participants were 103 regular daily smokers (53 girls, 50 boys), ages 14–18 (M = 16.5), participating in a larger inpatient study on tobacco withdrawal who were recruited through southern Connecticut high schools or newspaper advertisements. This study was approved by the Institutional Review Board at Yale School of Medicine; parental consent and adolescent assent were given at an initial interview. Adolescents were excluded for regular drug use, current major psychiatric disorders (e.g., major depression), and significant medical conditions (e.g., neurological, cardiovascular, endocrine pathology, etc.) that would increase risk or interfere with the withdrawal process. Descriptive information is summarized in Table 1. 2.2. Measures 2.2.1. Smoking status Average daily cigarette use was determined using the timeline follow-back method (TLFB) for the 30 days prior to the initial interview (Sobell & Sobell, 1992). Participants were asked about their daily cigarette use going back day by day while referring to a calendar and using individual anchor points (i.e.,
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parties, school events) to aid them in recall of their daily cigarette consumption. Urine cotinine levels were analyzed with an enzyme-linked immunosorbent analysis (ELISA) screening assay, with a sensitivity of 50 ng/ml (Graham Massey Analytical Labs Inc., Shelton, CT). Smoking duration was determined by asking the age at which daily smoking began. Level of nicotine dependence was assessed using the Fagerstrom Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991). 2.2.2. Weight concerns Smoking-specific weight concerns were measured by two questions: bHow much do cigarettes help you control your weight?Q (Boles & Johnson, 2001; Borrelli & Mermelstein, 1998) and bHow concerned are you about gaining weight as a result of quitting?Q (Perkins et al., 2001). Responses were measured using a Likert scale from one (not at all) to five (very much). 2.2.3. Body mass index (BMI) Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared (kg/m2). Height and weight were measured using a balance beam eye-level scale with a height rod. 2.3. Statistical analyses Data was analyzed using hierarchical linear regression models to assess interactions of gender with age, BMI, average daily smoking, and years of daily smoking on predicted belief that smoking controls weight and concern about gaining weight as a result of quitting.
3. Results Overall, females (M = 1.9, SD = 1.1) had significantly higher mean values, compared to males (M = 1.5, SD = 1.0) on the belief that smoking controls their weight [t(101) = 2.22, p b .05]. Females (M = 2.6, SD = 1.5) had higher mean values, compared to males (M = 1.5, SD = 1.1) on concern about gaining weight as a result of quitting [t(101) = 4.30, p b .01]. Cigarette specific weight control and concern about weight gain as a result of quitting were significantly correlated, with r = .50, p b .01. The belief that cigarettes help control weight was positively related to average daily smoking (B = .38, p b .05) and negatively related to number of years smoking (B = .32, p b .05) [r 2 = .09; F(5, 71) = 2.41, p b .05]. There was an interaction of gender and BMI on predicted belief that cigarettes help control weight [r 2 = .15; F(9, 67) = 2.52, p b .05]. The relationship between BMI and the belief that smoking controls weight was positive and showed a statistical trend for males (B = .28, p b .1), and negative, although not statistically significant for females (B = .25, p N .05). Main effects and interactions for age were not statistically significant. When predicting concerns about gaining weight upon quitting, there was an interaction of gender and average daily smoking [r 2 = .21; F(9, 67) = 3.25, p b .05]. For females, there was a significant positive relationship between average daily smoking and concerns about gaining weight upon quitting (B = .43, p b .05), but for males the relationship was negative, but not statistically significant (B = .21, p N .05). Main effects and interactions for number of years smoking, BMI, and age were not statistically significant.
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4. Discussion The results of this preliminary study suggest that among regular daily smokers, females, when compared to males, were more likely to believe smoking controls weight and had more concerns about gaining weight as a result of quitting. This finding is consistent with previous research comparing female and male adolescent smokers (Camp et al., 1993; Charlton, 1984; Coogan et al., 1998). Female smokers are more likely to be weight concerned and smoking is perceived to be a smoking control strategy. Gender differences were expected since it is more common for female adolescents to place emphasis on appearance and take part in the cultural obsession of being thin (Mintz & Betz, 1986). We also found that heavier smokers were more likely than lighter smokers to believe that smoking controls weight, which is consistent with previous research examining smoking rates (Charlton, 1984; Robinson et al., 1997). Differences based on smoking intensity were expected because it is assumed that over time, smokers learn the weight control properties of cigarettes and this reinforces sustained and heavier smoking. Surprisingly, our findings suggested that fewer years of regular daily smoking was predictive of the belief that smoking controls weight. These results that suggest that the belief that smoking helps control weight may be more prevalent in those smoking fewer number of years may be more important for initiation in this age group and should be examined in future research. Males with higher BMIs were more likely to use smoking as a means to control weight, but BMI was not a significant predictor for females. Although previous research suggests that both female and male overweight adolescents smoke more than their normal weight peers (Klesges et al., 1998), our preliminary findings suggest gender differences in this occurrence. It could be postulated that bheavierQ males may be smoking to get thin, but that weight status is not one of the mechanisms moderating the belief that smoking controls weight in females. Perhaps perception of weight plays a bigger factor in smoking behavior of female adolescents. The relationship between weight perceptions and smoking is unclear: some researchers find a positive association (Boles & Johnson, 2001; Pederson, Koval, McGrady, & Tyas, 1998) and others find a negative association in females (Dowdell, 2002). Although we measured height and weight for this study, weight perceptions were not assessed. The indication that weight concerns may be more related to body image or weight perceptions than to actual weight should be assessed in future research. Heavier smoking female adolescents were also more concerned about gaining weight upon quitting, but this relationship did not hold true for male smokers. This suggests that higher rates of smoking among female adolescents may be associated with weight concerns and this group of smokers may have more difficulty quitting, not only because they are more likely to be nicotine dependent, but because of their concerns about weight gain after quitting. Interestingly, our results suggest that intensity of smoking may not be moderating concerns about gaining weight upon quitting in male adolescents. A significant advantage of our study is that to determine smoking status, we used the TLFB, a very reliable retrospective indicator of cigarette smoking. Furthermore, we collected urinary cotinine levels to verify our sample’s regular smoking behavior. Most of the other research in this area has relied on epidemiological self-report data to categorize smoking rates. A limitation to this study, however, is the use of multiple comparisons on a relatively small sample size, which increases the chances of error. Therefore, the data need to be replicated and expanded in future research. Nevertheless, our well-defined sample included only regular smokers who reported daily smoking, with little variability in smoking behavior. This is in contrast to other research (Camp et al., 1993; Robinson et al., 1997) that defined regular smokers as those who smoked at least one cigarette weekly, leading to a lot of variability of
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smoking in the bregular smokers.Q However, although our sample included regular daily smokers, they were non-treatment-seeking smokers participating in a laboratory study and we do not have information on how these beliefs influenced their desire to quit smoking. Future research should examine the relationship between smoking, weight concerns and motivation to quit in treatment-seeking smokers. Additional factors that may account for weight concern should also be addressed, such as race and the presence of eating disorders, as well as other psychiatric problems. In summary, the results of this study point to important gender differences in beliefs about the relationship between weight concerns and smoking behavior in adolescent smokers. These beliefs might serve as significant barriers to the initiation and success of a quit attempt in these smokers, especially among female smokers who endorse increased concerns about gaining weight upon quitting. Therefore, incorporating counseling components aimed at reducing smoking-specific weight concerns or providing behavioral weight control strategies to avoid or reduce weight gain after quitting (Pirie et al., 1992) may improve motivation to quit smoking as well as smoking cessation outcomes in adolescent smokers.
Acknowledgments Preparation of this manuscript was supported by National Institute of Child Health and Human Development Grant, R01HD31688 and National Institute of Drug Abuse Grant, P50 DA13334.
References Austin, S. B., & Gortmaker, S. L. (2001). Dieting and smoking initiation in early adolescent girls and boys: A prospective study. American Journal of Public Health, 91, 446 – 450. Boles, S. M., & Johnson, P. B. (2001). Gender, weight concerns, and adolescent smoking. Journal of Addictive Diseases, 20, 5 – 14. Borrelli, B., & Mermelstein, R. (1998). The role of weight concern and self-efficacy in smoking cessation and weight gain among smokers in a clinic-based cessation program. Addictive Behaviors, 23, 609 – 622. Camp, D. E., Klesges, R. C., & Relyea, G. (1993). The relationship between body weight concerns and adolescent smoking. Health Psychology, 12, 24 – 32. Centers for Disease Control and Prevention. (2001). Youth tobacco surveillance — United States, 2000. Morbidity and Mortality Weekly Report, 50(SS04), 1 – 84. Charlton, A. (1984). Smoking and weight concern in teenagers. Public Health London, 98, 366 – 380. Coogan, P. F., Adams, M., Geller, A. C., Brooks, D., Miller, D. R., & Lew, R. A., et al. (1998). Factors associated with smoking among children and adolescents in Connecticut. American Journal of Preventive Medicine, 15, 17 – 24. Crisp, A. H., Sedgwick, P., Halek, C., Joughin, N., & Humphrey, H. (1999). Why may teenage girls persist in smoking? Journal of Adolescence, 22, 657 – 672. Crocker, P., Kowalski, N., Kowalski, K., Chad, K., Humbert, L., & Forrester, S. (2001). Smoking behaviour and dietary restraint in young adolescent women: The role of physician self-perceptions. Canadian Journal of Public Health, 92, 428 – 432. Dowdell, E. B. (2002). Urban seventh graders and smoking: A health risk behavior assessment. Issues in Comprehensive Pediatric Nursing, 25, 217 – 229. Halek, C., Kerry, S., Humphrey, H., Crisp, A. H., & Hughes, J. M. (1993). Relationship between smoking, weight, and attitudes to weight in adolescent schoolgirls. Postgraduate Medical Journal, 69, 100 – 106. Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., & Fagerstrom, K. O. (1991). The Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction, 86, 1119 – 1127. Johnston, L. D., O’Malley, P. M., & Bachman, J. G. (2003). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2002. (NIH Publication No. 03-5374). Bethesda, MD7 National Institute on Drug Abuse.
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Killen, J. D., Robinson, T. N., Haydel, K. F., Hayward, C., Wilson, D. M., & Hammer, L. D., et al. (1997). Chronic dieting and the belief that smoking controls body weight in a biracial, population-based adolescent sample. Tobacco Control, 6, 89 – 94. Klesges, R. C., Meyers, A. W., Klesges, L. M., & La Vasque, M. E. (1989). Smoking, body weight, and their effects on smoking behavior: A comprehensive review of the literature. Psychological Bulletin, 106, 204 – 230. Klesges, R. C., Ward, K. D., Ray, J. W., Cutter, G., Jacobs, D. R., & Wagenknecht, L. E. (1998). The prospective relationships between smoking and weight in a young, biracial cohort: The coronary artery risk development in young adults study. Journal of Consulting and Clinical Psychology, 66, 987 – 993. Meyers, A. W., Klesges, R. C., Winders, S. E., Ward, K. D., Peterson, B. A., & Eck, L. H. (1997). Are weight concerns predictive of smoking cessation? A prospective analysis. Journal of Consulting and Clinical Psychology, 65, 448 – 452. Mintz, L. B., & Betz, N. B. (1986). Sex differences in the nature, realism, and correlates of body image. Sex Roles, 15, 185 – 195. Pederson, L. L., Koval, J. J., McGrady, G. A., & Tyas, S. L. (1998). The degree and type of relationship between psychosocial variables and smoking status for students in grade 8: Is there a dose–response relationship? Preventive Medicine, 27, 337 – 347. Perkins, K. A., Marcus, M. D., Levine, M. D., D’Amico, D., Miller, A., & Borge, M., et al. (2001). Cognitive-behavioral therapy to reduce weight concerns improves smoking cessation outcome in weight-concerned women. Journal of Consulting and Clinical Psychology, 69, 604 – 613. Pirie, P. L., McBride, C. M., Hellerstedt, W., Jeffery, R. W., Hatsukami, D., & Allen, S., et al. (1992). Smoking cessation in women concerned about weight. American Journal of Public Health, 82, 1238 – 1243. Potter, B. K., Pederson, L. L., Chan, S. H. S., Aubut, J. L., & Koval, J. J. (2004). Does a relationship exist between body weight, concerns about weight, and smoking among adolescents? An integration of the literature with an emphasis on gender. Nicotine and Tobacco Research, 6, 397 – 425. Robinson, L. A., Klesges, R. C., Zbikowski, S. M., & Glaser, R. (1997). Predictors of risk for different stages of adolescent smoking in a biracial sample. Journal of Consulting and Clinical Psychology, 65, 653 – 662. Sobell, L. C., & Sobell, M. C. (1992). Timeline follow-back: a technique for assessing self-reported ethanol consumption. In J. Allen, & R. Z. Litten (Eds.), Measuring alcohol consumption: psychosocial and biological methods. New Jersey7 Humana Press. Swan, G. E., Ward, M. N., Carmelli, D., & Jack, L. M. (1993). Differential rates of relapse in subgroups of male and female smokers. Journal of Clinical Epidemiology, 46, 1041 – 1053. Townsend, J., Wilkes, H., Haines, A., & Jarvis, M. (1991). Adolescent smokers seen in general practice: Health, lifestyle, physical measurements, and response to antismoking advice. British Medical Journal, 303, 947 – 950. USDHHS. (2001). Women and smoking: A report of the surgeon general. Rockville, Maryland7 U.S. Department of Health and Human Services. Voorhees, C. C., Schreiber, G. B., Schumann, B. C., Biro, F., & Crawford, P. B. (2002). Early predictors of daily smoking in young women: The national heart, lung, and blood institute growth and health study. Preventive Medicine, 34, 616 – 624. Weekley, C. K., Klesges, R. C., & Relyea, G. (1992). Smoking as a weight-control strategy and its relationship to smoking status. Addictive Behaviors, 17, 259 – 271.
Short communication
Gender and weight concerns in adolescent smokers Dana A. Cavallo *, Amy M. Duhig, Sherry McKee, Suchitra Krishnan-Sarin Yale University School of Medicine, Department of Psychiatry, SAC, 34 Park Street, New Haven, CT 06519, United States
Abstract The aim of this study was to examine smoking-specific weight concerns in a well-characterized sample of adolescent daily smokers and the influence of gender, age, and body mass index (BMI). Adolescent smokers (n = 103) were asked two smoking-specific weight concern questions: bHow much do cigarettes help you control your weight?Q and bHow concerned are you about gaining weight as a result of quitting?Q A significant positive relationship was found between average daily cigarette use and belief in smoking as a means to control weight and a significant negative relationship between the years of smoking and belief that smoking controls weight. There was no significant relationship between BMI and smoking to control weight for females, whereas for males, there was a positive relationship, indicating that heavier males were more likely to report smoking to control weight. Additionally, females who smoked more cigarettes reported more concern about gaining weight upon quitting, a pattern not seen in males. Results highlight potentially important gender differences in the relationship between weight concerns and smoking and the influence these concerns may have on quitting smoking. D 2006 Elsevier Ltd. All rights reserved. Keywords: Adolescent smokers; Weight concerns
1. Introduction Adolescence is a critical time when cigarette smoking develops, with approximately 2000 adolescents beginning to smoke each day (Johnston, O’Malley, & Bachman, 2003). Data suggests that 72.9% of adolescent daily smokers tried to quit smoking, but only 13.5% succeeded (CDC, 2001). One reason adolescents may start smoking, return to smoking after quitting, or never attempt to quit may be related to the perceived benefits of smoking on body weight. * Corresponding author. Tel.: +1 203 794 7607; fax: +1 203 974 7606. E-mail address: [email protected] (D.A. Cavallo). 0306-4603/$ - see front matter D 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2006.02.021
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The belief that smoking helps control weight appears to be gender-specific, with female adolescents worrying more about their weight and being more likely to report smoking to control their weight than males (Camp, Klesges, & Relyea, 1993; Charlton, 1984; Coogan et al., 1998). Other variables that influence this relationship include smoking amount and age. Regular smokers (smoking z once per week) are more likely than experimental smokers (smoking less than one cigarette weekly) to believe that smoking is a weight control strategy (Robinson, Klesges, Zbikowski, & Glaser, 1997). Camp and colleagues (see Camp et al., 1993), have shown that the belief that smoking could control weight did not differ between regular smokers (smoking z once per week) and never smokers, but was significantly greater in the regular smokers when compared with experimental smokers (smoked 1–2 cigarettes in lifetime). This suggests that weight control properties of cigarettes may be learned over time and may reinforce continued smoking behavior. Interestingly, among regular smokers, being older and female predicted those who smoked for weight-control reasons. Boles and Johnson (2001) examined the association between age and weight concerns in three cohorts of adolescents (i.e. 12–13, 14–15, and 16–17 year-old smokers) smoking z one cigarette daily and found the youngest male and oldest female groups were most likely to believe smoking controls weight. Concern about gaining weight upon quitting is related to cigarette specific weight control, but there is also some evidence to suggest that these two variables maintain some independent role in smokingspecific weight concern as indicated by the adult literature. Smoking for weight control may explain smoking initiation, while concerns about gaining weight upon quitting may explain smoking maintenance and the difficulty in quitting. In adult smokers, weight gain is often cited as an important reason for relapse to smoking (Borelli & Mermelstein, 1998; Swan, Ward, Carmelli, & Jack, 1993; USDHHS, 2001) and concerns about post-cessation weight gain predict lower intentions to quit smoking (Klesges, Meyers, Klesges, & La Vasque, 1989; Weekley, Klesges, & Relyea, 1992). Although the prevalence of weight-concerned adults who participate in formal smoking cessation programs is low, those who are weight concerned are less likely to quit smoking than those who intend to accept a significant postcessation weight gain (Meyers et al., 1997). There is currently no data to support or refute this relationship in adolescent smokers. There is conflicting evidence on the influence of the adolescent smoker’s actual weight on smokingrelated weight concerns, with some studies showing a correlation between BMI and smoking status (Klesges et al., 1998; Robinson et al., 1997; Townsend, Wilkes, Haines, & Jarvis, 1991) in both genders, and other studies showing no association (Crocker et al., 2001; Killen et al., 1997; Voorhees, Schreiber, Schumann, Biro, & Crawford et al., 2002). Similarly, some studies report a positive relationship between being moderately overweight and increased smoking (Crisp, Sedgwick, Halek, Joughin, & Humphrey et al., 1999; Halek, Kerry, Humphrey, Crisp, & Hughes, 1993) while others find a negative association between weight and smoking, especially among females (Austin & Gortmaker, 2001). Furthermore, the association between BMI and smoking may be altered by smoking intensity (Robinson et al., 1997) and age (Townsend et al., 1991). In summary, the above literature suggests a strong association between weight concerns and smoking in adolescents (see Potter, Pederson, Chan, Aubut, & Koval, 2004 for review). However, most of these studies used a broad range of smoking rates to define a regular smoker and did not differentiate regular daily smokers from other smokers. To date, no studies have examined adolescents with established daily smoking patterns in relation to their belief about how smoking controls their weight and more importantly, how concerned they are about gaining weight upon quitting. These daily smokers may have
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Table 1 Sample characteristics by gender Race (n) Caucasian African-American Hispanic Asian Other Age Average daily cigarette use Urine cotinine (ng/ml)+ Years of daily smoking BMI++ FTND+++
Females (N = 53)
Males (N = 50)
71.7% 15.1% 7.5% 3.8% 1.9% 16.5 (1.3) 12.5 (6.4) 1228.0 (981.2) 2.4 (1.4) 25.0 (6.2) 3.9 (2.4)
82% 10% 6% 0% 2% 16.5 (1.2) 15.3 (10.2) 1474.4 (1222.9) 3.2 (2.3)* 25.5 (6.7) 4.4 (2.2)
Note: With the exception of race, all information is provided in terms of means and standard deviations. BMI = Body Mass Index; FTND = Fagerstrom Test for Nicotine Dependence; +missing urine cotinine data for 17 females and 14 males; ++missing BMI data for 15 females and 11 males; +++missing FTND data for 15 females and 11 males; *p b .05.
a difficult time quitting smoking due to their beliefs about the relationship between smoking and weight. Furthermore, potential gender and age-related differences related to these concerns and beliefs need to be examined. The purpose of the current study was to conduct a preliminary examination of smokingspecific weight concerns in a well-characterized sample of adolescent daily smokers (with biochemical verification of smoking status) and the influence of gender, age, BMI, and smoking intensity on these concerns.
2. Method 2.1. Participants Participants were 103 regular daily smokers (53 girls, 50 boys), ages 14–18 (M = 16.5), participating in a larger inpatient study on tobacco withdrawal who were recruited through southern Connecticut high schools or newspaper advertisements. This study was approved by the Institutional Review Board at Yale School of Medicine; parental consent and adolescent assent were given at an initial interview. Adolescents were excluded for regular drug use, current major psychiatric disorders (e.g., major depression), and significant medical conditions (e.g., neurological, cardiovascular, endocrine pathology, etc.) that would increase risk or interfere with the withdrawal process. Descriptive information is summarized in Table 1. 2.2. Measures 2.2.1. Smoking status Average daily cigarette use was determined using the timeline follow-back method (TLFB) for the 30 days prior to the initial interview (Sobell & Sobell, 1992). Participants were asked about their daily cigarette use going back day by day while referring to a calendar and using individual anchor points (i.e.,
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parties, school events) to aid them in recall of their daily cigarette consumption. Urine cotinine levels were analyzed with an enzyme-linked immunosorbent analysis (ELISA) screening assay, with a sensitivity of 50 ng/ml (Graham Massey Analytical Labs Inc., Shelton, CT). Smoking duration was determined by asking the age at which daily smoking began. Level of nicotine dependence was assessed using the Fagerstrom Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991). 2.2.2. Weight concerns Smoking-specific weight concerns were measured by two questions: bHow much do cigarettes help you control your weight?Q (Boles & Johnson, 2001; Borrelli & Mermelstein, 1998) and bHow concerned are you about gaining weight as a result of quitting?Q (Perkins et al., 2001). Responses were measured using a Likert scale from one (not at all) to five (very much). 2.2.3. Body mass index (BMI) Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared (kg/m2). Height and weight were measured using a balance beam eye-level scale with a height rod. 2.3. Statistical analyses Data was analyzed using hierarchical linear regression models to assess interactions of gender with age, BMI, average daily smoking, and years of daily smoking on predicted belief that smoking controls weight and concern about gaining weight as a result of quitting.
3. Results Overall, females (M = 1.9, SD = 1.1) had significantly higher mean values, compared to males (M = 1.5, SD = 1.0) on the belief that smoking controls their weight [t(101) = 2.22, p b .05]. Females (M = 2.6, SD = 1.5) had higher mean values, compared to males (M = 1.5, SD = 1.1) on concern about gaining weight as a result of quitting [t(101) = 4.30, p b .01]. Cigarette specific weight control and concern about weight gain as a result of quitting were significantly correlated, with r = .50, p b .01. The belief that cigarettes help control weight was positively related to average daily smoking (B = .38, p b .05) and negatively related to number of years smoking (B = .32, p b .05) [r 2 = .09; F(5, 71) = 2.41, p b .05]. There was an interaction of gender and BMI on predicted belief that cigarettes help control weight [r 2 = .15; F(9, 67) = 2.52, p b .05]. The relationship between BMI and the belief that smoking controls weight was positive and showed a statistical trend for males (B = .28, p b .1), and negative, although not statistically significant for females (B = .25, p N .05). Main effects and interactions for age were not statistically significant. When predicting concerns about gaining weight upon quitting, there was an interaction of gender and average daily smoking [r 2 = .21; F(9, 67) = 3.25, p b .05]. For females, there was a significant positive relationship between average daily smoking and concerns about gaining weight upon quitting (B = .43, p b .05), but for males the relationship was negative, but not statistically significant (B = .21, p N .05). Main effects and interactions for number of years smoking, BMI, and age were not statistically significant.
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4. Discussion The results of this preliminary study suggest that among regular daily smokers, females, when compared to males, were more likely to believe smoking controls weight and had more concerns about gaining weight as a result of quitting. This finding is consistent with previous research comparing female and male adolescent smokers (Camp et al., 1993; Charlton, 1984; Coogan et al., 1998). Female smokers are more likely to be weight concerned and smoking is perceived to be a smoking control strategy. Gender differences were expected since it is more common for female adolescents to place emphasis on appearance and take part in the cultural obsession of being thin (Mintz & Betz, 1986). We also found that heavier smokers were more likely than lighter smokers to believe that smoking controls weight, which is consistent with previous research examining smoking rates (Charlton, 1984; Robinson et al., 1997). Differences based on smoking intensity were expected because it is assumed that over time, smokers learn the weight control properties of cigarettes and this reinforces sustained and heavier smoking. Surprisingly, our findings suggested that fewer years of regular daily smoking was predictive of the belief that smoking controls weight. These results that suggest that the belief that smoking helps control weight may be more prevalent in those smoking fewer number of years may be more important for initiation in this age group and should be examined in future research. Males with higher BMIs were more likely to use smoking as a means to control weight, but BMI was not a significant predictor for females. Although previous research suggests that both female and male overweight adolescents smoke more than their normal weight peers (Klesges et al., 1998), our preliminary findings suggest gender differences in this occurrence. It could be postulated that bheavierQ males may be smoking to get thin, but that weight status is not one of the mechanisms moderating the belief that smoking controls weight in females. Perhaps perception of weight plays a bigger factor in smoking behavior of female adolescents. The relationship between weight perceptions and smoking is unclear: some researchers find a positive association (Boles & Johnson, 2001; Pederson, Koval, McGrady, & Tyas, 1998) and others find a negative association in females (Dowdell, 2002). Although we measured height and weight for this study, weight perceptions were not assessed. The indication that weight concerns may be more related to body image or weight perceptions than to actual weight should be assessed in future research. Heavier smoking female adolescents were also more concerned about gaining weight upon quitting, but this relationship did not hold true for male smokers. This suggests that higher rates of smoking among female adolescents may be associated with weight concerns and this group of smokers may have more difficulty quitting, not only because they are more likely to be nicotine dependent, but because of their concerns about weight gain after quitting. Interestingly, our results suggest that intensity of smoking may not be moderating concerns about gaining weight upon quitting in male adolescents. A significant advantage of our study is that to determine smoking status, we used the TLFB, a very reliable retrospective indicator of cigarette smoking. Furthermore, we collected urinary cotinine levels to verify our sample’s regular smoking behavior. Most of the other research in this area has relied on epidemiological self-report data to categorize smoking rates. A limitation to this study, however, is the use of multiple comparisons on a relatively small sample size, which increases the chances of error. Therefore, the data need to be replicated and expanded in future research. Nevertheless, our well-defined sample included only regular smokers who reported daily smoking, with little variability in smoking behavior. This is in contrast to other research (Camp et al., 1993; Robinson et al., 1997) that defined regular smokers as those who smoked at least one cigarette weekly, leading to a lot of variability of
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smoking in the bregular smokers.Q However, although our sample included regular daily smokers, they were non-treatment-seeking smokers participating in a laboratory study and we do not have information on how these beliefs influenced their desire to quit smoking. Future research should examine the relationship between smoking, weight concerns and motivation to quit in treatment-seeking smokers. Additional factors that may account for weight concern should also be addressed, such as race and the presence of eating disorders, as well as other psychiatric problems. In summary, the results of this study point to important gender differences in beliefs about the relationship between weight concerns and smoking behavior in adolescent smokers. These beliefs might serve as significant barriers to the initiation and success of a quit attempt in these smokers, especially among female smokers who endorse increased concerns about gaining weight upon quitting. Therefore, incorporating counseling components aimed at reducing smoking-specific weight concerns or providing behavioral weight control strategies to avoid or reduce weight gain after quitting (Pirie et al., 1992) may improve motivation to quit smoking as well as smoking cessation outcomes in adolescent smokers.
Acknowledgments Preparation of this manuscript was supported by National Institute of Child Health and Human Development Grant, R01HD31688 and National Institute of Drug Abuse Grant, P50 DA13334.
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