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Short-term weight gain in abstaining women smokers
Journal of Substance Abuse Treatment 18 (2000) 339–342
Article
Short-term weight gain in abstaining women smokers Cynthia S. Pomerleau, Ph.D.*, Ovide F. Pomerleau, Ph.D., Rebecca J. Namenek, M.S., Ann M. Mehringer, B.A. Nicotine Research Laboratory, Behavioral Medicine Program, Department of Psychiatry, University of Michigan, Suite L, 475 Market Place, Ann Arbor, MI 48108, USA Received 6 July 1998; received in revised form 9 August 1999; accepted 9 August 1999
Abstract Although most studies of weight gain following smoking cessation assess long-term change, weight gain during the critical period immediately following cessation may be more salient to the smoker for whom fear of weight gain constitutes a serious barrier to cessation. The current study examined weight change in 20 highly dependent women smokers provided with monetary incentives to abstain for 1 week, along with concomitant changes in cotinine. Abstaining smokers (n ⫽ 7) gained 3.1 pounds, compared with 0.3 pounds in women who continued to smoke (n ⫽ 13). Across all subjects, change was significantly negatively correlated with final plasma cotinine concentration and marginally negatively correlated with percent cotinine reduction. Weight gain in women abstainers in the luteal phase of the menstrual cycle exceeded that in women abstainers in the follicular phase; a significant interaction such that continuing smokers showed no phase-related differences in weight suggests that the effect was not an artifact of perimenstrual increases in eating or fluid retention. Although long-term weight gain has been shown to be positively associated with success in quitting, little is known about the effects of short-term weight gain. Since many weight-concerned individuals either do not attempt to quit or terminate their quit attempts very early, it may be that if weight gain can be postponed beyond the first few fragile days of cessation, women with strong weight concerns may actually be good candidates for success. © 2000 Elsevier Science Inc. All rights reserved. Keywords: Weight gain; Cigarette smoking; Cotinine; Women; Menstrual phase
1. Introduction Most studies of weight gain following smoking cessation assess change over months or even years. While such studies allow an evaluation of the full impact of cessation of nicotine use upon weight, they do not capture the pattern of weight change over time. Since most relapse occurs early (Hunt et al., 1971), short-term weight change during the critical period immediately following cessation may be more salient to the smoker—especially the smoker for whom fear of weight gain constitutes a serious barrier to cessation—and hence an important consideration in successfully treating such individuals. Studies reporting weight gain over periods of 2 weeks or less have produced widely varying results. A number of studies reporting on short-term (4–10 days) weight change have shown nonsignificant differences (Hatsukami et al., 1993; Hellerstein et al., 1994; Perkins et al., 1990; Robinson & York, 1986). Other studies have shown somewhat larger * Corresponding author. Tel.: 734-998-6430. E-mail address: [email protected] (C.S. Pomerleau).
weight increments; Klesges et al. (1990), for example, showed a significant weight gain (a mean of 1.9 pounds) after 2 weeks of abstinence in 14 women in the no-drug group of a cessation trial. Leischow and Stitzer (1991), studying weight change in 9 male smokers deprived of cigarettes for 10 days on an inpatient unit, reported a mean gain of 2.23 kg (4.9 pounds), compared with a gain of .82 kg (1.8 pounds) in 8 male smokers who continued to smoke ad libitum. Eck et al. (1997), looking at women smokers randomly assigned to smoking cessation for a 10-day interval in either the luteal or follicular phase, observed a weight gain of 4 pounds in the luteal group, as opposed to less than a pound in the follicular group. In an attempt to investigate further the amount of shortterm weight change and to identify factors that might be associated with individual differences in this phenomenon, we studied highly dependent women smokers not planning to quit smoking who were provided with monetary incentives to remain abstinent from smoking for 1 week on an outpatient basis. Both weight and plasma cotinine were assessed at baseline and following 1 week of abstinence, allowing assessment of the relationship between weight change and
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biochemically verified changes in nicotine intake. Onset of menses was queried in women for purposes of inferring menstrual phase; the availability of data on abstainers and continuing smokers permitted assessment of the effects of menstrual phase per se upon weight.
2. Methods 2.1. Subjects Subjects were 20 premenopausal women smokers, in otherwise good health, recruited from the local community to participate in a test of their ability to remain abstinent. To be eligible to participate, candidates were required to be between the ages of 21 and 45 and to have a Fagerstrom Tolerance Questionnaire (FTQ; Fagerstrom, 1978) of at least 6, characterizing them as moderately to highly dependent smokers. 2.2. Procedure Subjects participated in a screening session in which eligibility was determined, informed consent obtained, height and weight measured, and demographic data and smoking history collected. After taking part in two sessions testing response to a laboratory stressor (unpublished data), separated by approximately 1 week, they participated in a 1-week test of their ability to remain abstinent when motivated by competition for a monetary bonus ($250 for the “winner[s]” in each cohort of 10, based on final cotinine concentration). No prior notice of this opportunity was given, nor were any suggestions offered about how to accomplish this goal; no advice or information on diet or exercise was provided. Onset of menses was tracked in women over the course of their participation in the study. On the final day of the abstinence week, subjects reported to the Laboratory for withdrawal of a blood sample for cotinine analysis and measurement of weight.
3. Results Subjects whose plasma cotinine concentration after a week of abstinence was less than 30 ng/mL (the maximum level deemed consistent with passive smoking as a source of possible exposure; Jarvis et al., 1992) were classified as abstainers (n ⫽ 7); the remaining subjects (n ⫽ 13) served as a control for continued smoking. Study results (M ⫾ SD) are shown in Table 1. Abstainers had significantly lower plasma cotinine concentration and significantly higher Body Mass Index (BMI) at baseline than continuing smokers. No significant differences were detected between groups in the amount of time that elapsed between the baseline weigh-in and the start of the 1-week abstinence trial (mean number of days ⫾ SD: abstainers, 22.7 ⫾ 5.1; continuing smokers, 23.0 ⫾ 7.2). Weight change was not significantly correlated with length of time between weigh-ins. Change in weight after 1 week differed significantly between groups (see Table 1). Weight change for the abstainers differed significantly from zero, t(6) ⫽ 2.87, p ⬍ .05; no significant difference was found for continuing smokers. Across all subjects, weight change was significantly predicted by cotinine concentration at abstinence (r ⫽ ⫺.50, p ⬍ .05) and marginally by change in cotinine (r ⫽ ⫺.42, p ⬍ .10). Women who began their abstinence week no more than 7 days after onset of last menses were defined as being in the follicular phase of their menstrual cycle; those who began their abstinence week at least 13 days after onset of last menses were considered to be in the luteal phase. (Oral contraceptive users [n ⫽ 6] were included in the analysis.) Follicular abstainers (n ⫽ 4) gained 1.5 ⫾ 2.0 pounds, as opposed to 5.3 ⫾ 2.5 pounds for luteal abstainers (n ⫽ 3). By contrast, weight remained stable for nonabstainers (reducers and maintainers combined) regardless of menstrual phase, with follicular nonabstainers (n ⫽ 6) gaining 0.5 ⫾ 1.8 pounds and luteal nonabstainers (n ⫽ 7) gaining 0.0 ⫾ 2.1 pounds. Despite the small sample size, a trend toward a sig-
Table 1 Subject characteristics, smoking patterns, cotinine concentrations, and weight change Abstainers (n ⫽ 7) Subject characteristics Age (years) Education (years) Body Mass Index (kg/M2) Self-reported smoking patterns Smoking rate (cigarettes/day) Nicotine dependence (FTQ score) Cotinine concentration Baseline cotinine (ng/mL) Cotinine at abstinence (ng/mL) Change in cotinine (percent of baseline) Weight change Weight change (lbs.)
Continuing smokers (n ⫽ 13)
Significance
31.7 ⫾ 7.2 13.9 ⫾ 1.3 27.2 ⫾ 5.2
29.2 ⫾ 6.5 13.8 ⫾ 1.2 21.3 ⫾ 2.2
NS NS t (7.16) ⫽ 2.89, p ⬍ .05
21.7 ⫾ 6.0 7.0 ⫾ 1.0
23.3 ⫾ 4.8 7.8 ⫾ 1.5
NS NS
132.7 ⫾ 95.7 7.0 ⫾ 9.7 ⫺92% ⫾ 13
237.7 ⫾ 47.2 190.4 ⫾ 60.4 ⫺16% ⫾ 33
⫹ 3.1 ⫾ 2.9
⫹ 0.3 ⫾ 1.9
NS ⫽ not significant; FTQ ⫽ Fagerstrom Tolerance Questionnaire.
t (18) ⫽ ⫺3.32, p ⬍ .005 — t (18) ⫽ 5.79, p ⬍ .001 t (18) ⫽ 2.69, p ⬍ .05
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nificant main effect was found for menstrual phase, F(1, 19) ⫽ 3.1, p ⬍ .10, with a significant status by phase interaction, F(1, 19) ⫽ 4.8, p ⬍ .05.
4. Discussion Weight gain in a group of women heavy smokers after 1 week’s abstinence was more than 3 pounds, as compared with the very minimal change (less than half a pound) seen in continuing smokers. Across all subjects, the amount of change was significantly related in a linear fashion to final plasma cotinine concentration and marginally to the percent reduction in plasma cotinine concentration. Consistent with the findings of Eck et al. (1997), weight gain in women abstainers in the luteal phase of the menstrual cycle substantially exceeded that in women abstainers in the follicular phase. The emergence of a significant interaction such that continuing smokers showed no phase-related differences in weight suggests that the effect was not an artifact of perimenstrual increases in eating or fluid retention. Although lower baseline cotinine concentrations may have facilitated abstaining under laboratory conditions, it is unlikely that they caused the significant between-group differences in weight gain. Rather, these baseline differences constitute a bias against showing greater postcessation weight gain in these subjects, since lower baseline cotinine should indicate less chronic exposure to the weight-suppressing effects of nicotine. The higher BMI in the abstaining group is also unlikely to account for our findings, since overweight individuals have been reported to gain less weight postcessation than normal-weight individuals (Williamson et al., 1991). It must also be noted that since baseline weight was measured at screening, not on the day on which the abstinence trial began, we cannot be sure that the change in weight represents exactly 1 week’s change. The negligible weight change in those whose smoking rates (as indicated by plasma cotinine concentrations) remained relatively stable, however, suggests that the observed increment in those who successfully abstained primarily reflects the effects of stopping smoking for 1 week, with only minimal contributions by random fluctuation during ad libitum smoking. Our findings indicate that even after only 1 week of abstinence, many smokers are already approaching, and some are exceeding, the 5-pound cutoff for acceptable weight gain specified by 75% of women (as opposed to 35% of men; Pomerleau & Kurth, 1996). Although long-term weight gain has been shown in some studies (Gritz et al., 1990; Hall et al., 1986; Norregaard et al., 1993) to be positively associated with success in quitting, little is known about the effects of short-term weight gain. Evidence that many weight-concerned individuals terminate their quit attempts early (Jarry et al., 1998), without ever seeking treatment (Klesges & Klesges, 1988; Klesges et al., 1988; Meyers et al., 1997; Weekley et al., 1992), raises the possibility that if weight
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gain can be delayed until after the fragile first few days of cessation and intensive support is delivered early in the quit attempt, women with strong weight concerns may actually be good candidates for success. The exacerbation of early postcessation weight gain associated with abstention from smoking during the luteal phase may also contribute to the difficulty of quitting and supports the recommendation to avoid scheduling quit attempts at that time if possible (Gritz et al., 1996). For women whose quit attempt must be scheduled during the luteal phase, administration of a diuretic for the first few days might be considered, especially for women with a history of failed cessation due to early weight gain, in consultation with a physician. Although our sample was small, our findings are in line with those of other investigators (Eck et al., 1997; Leischow & Stitzer, 1991). In view of the widespread aversion of women to the prospect of postcessation weight gain (Pomerleau & Kurth, 1996), these preliminary results strongly point to the need for a closer examination of early weight change as a potential precipitator of relapse—perhaps even before the smoker is willing to acknowledge publicly her intention to quit—as well as upon mood and withdrawal symptomatology. It is becoming increasingly evident that the first few days of a quit attempt are of crucial importance, with smoking during early abstinence predicting poor longterm outcome (Yudkin et al., 1996). Further study is needed to determine the extent to which early weight gain may contribute to difficulty in remaining abstinent, and to investigate the possibility that pharmacological aids to smoking cessation that attenuate weight gain, such as nicotine gum, nicotine patch, and sustained release bupropion (Dale et al., 1998; Gross et al., 1989; Hurt et al., 1997), may be differentially effective in women with strong concerns about postcessation weight gain. Exploration of the influence of such factors as age, race, dieting status, and activity level upon patterns of early weight gain in abstainers may also be helpful in specifying individual differences that contribute to vulnerability during this critical time in the quitting process. Acknowledgment Preparation of this manuscript was supported by grants HL52981 to Cynthia S. Pomerleau from the National Heart, Lung, and Blood Institute and CA42730 to Ovide F. Pomerleau from the National Cancer Institute. References Dale, L. C., Schroeder, D. R., Wolter, T. D., Croghan, I. T., Hurt, R. D., & Offord, K. P. (1998). Weight change after smoking cessation using variable doses of transdermal nicotine replacement. Journal of General Internal Medicine 13, 9–15. Eck, L. H., Klesges, R. C., Meyers, A. W., Slawson, D. L., & Winders, S. A. (1997). Changes in food consumption and body weight associated with smoking cessation across menstrual cycle phase. Addictive Behaviors 22, 775–782. Fagerstrom, K. O. (1978). Measuring degree of physical dependence to to-
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bacco smoking with reference to individualization of treatment. Addictive Behaviors 3, 235–241. Gritz, E. R., Berman, B. A., Read, L. L., Marcus, A. C., & Siau, J. (1990). Weight change among registered nurses in a self-help smoking cessation program. American Journal of Health Promotion 5, 115–121. Gritz, E. R., Nielsen, I. R., & Brooks, L. A. (1996). Smoking cessation and gender: the influence of physiological, psychological, and behavioral factors. Journal of the American Medical Women’s Association 51, 35–42. Gross, J., Stitzer, M. L., & Maldonado, J. (1989). Nicotine replacement: Effects on postcessation weight gain. Journal of Consulting and Clinical Psychology 57, 87–92. Hall, S. M., Ginsberg, D., & Jones, R. T. (1986). Smoking cessation and weight gain. Journal of Consulting and Clinical Psychology 54, 342– 346. Hatsukami, D., Labounty, L., Hughes, J., & Laine, D. (1993). Effects of tobacco abstinence on food intake among cigarette smokers. Health Psychology 12, 499–502. Hellerstein, M. K., Benowitz, N. L., Neese, R. A., Schwartz, J. M., Hoh, R., Jacob, P., III, Hseih, J., & Faix, D. (1994). Effects of cigarette smoking and its cessation on lipid metabolism and energy expenditure in heavy smokers. Journal of Clinical Investigation 93, 265–272. Hunt, W. A., Barnett, L. W., & Branch, L. G. (1971). Relapse rates in addiction programs. Journal of Clinical Psychology 27, 455–456. Hurt, R. D., Sachs, D. P., Glover, E. D., Offord, K. P., Johnston, J. A., Dale, L. C., Khayrallah, M. A., Schroeder, D. R., Glover, P. N., Sullivan, C. R., Croghan, I. T., & Sullivan, P. M. (1997). A comparison of sustained-release bupropion and placebo for smoking cessation. New England Journal of Medicine 337, 1195–1202. Jarry, J. L., Coambs, R. B., Polivy, J., & Herman, C. P. (1998). Weight gain after smoking cessation in women: The impact of dieting status. International Journal of Eating Disorders 24, 53–64. Jarvis, M. J., Foulds, J. & Feyerabend, C. (1992). Exposure to passive smoking among bar staff. British Journal of Addiction 87, 111–113. Klesges, R. C., & Klesges, L. M. (1988). Cigarette smoking as a dieting strategy in a university population. International Journal of Eating Disorders 7, 413–419.
Klesges, R. C., Klesges, L. M., Meyers, A. W., Klem, M. L., & Isball, T. (1990). The effects of phenylpropanolamine on dietary intake, physical activity, and body weight after smoking cessation. Clinical Pharmacology and Therapeutics 47, 747–754. Klesges, R. C., Somes, G., Pascale, R. W., Klesges, L. M., Murphy, M., Brown, K., & Williams, E. (1988). Knowledge and beliefs regarding the consequences of cigarette smoking and their relationships to smoking status in a biracial sample. Health Psychology 7, 387–401. Leischow, S. J., & Stitzer, M. L. (1991). Effects of smoking cessation on caloric intake and weight gain in an inpatient unit. Psychopharmacology 104, 522–526. 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. Norregaard, J., Tonnesen, P., & Petersen, L. (1993). Predictors and reasons for relapse in smoking cessation with nicotine and placebo patches. Preventive Medicine 22, 261–271. Perkins, K. A., Epstein, L. H., & Pastor, S. (1990). Changes in energy balance following smoking cessation and resumption of smoking in women. Journal of Consulting and Clinical Psychology 58, 121–125. Pomerleau, C. S., & Kurth, C. L. (1996). Willingness of female smokers to tolerate postcessation weight gain. Journal of Substance Abuse 8, 371– 378. Robinson, S., & York, D. A. (1986). The effect of cigarette smoking on the thermic response to feeding. International Journal of Obesity 10, 407– 417. Weekley, C. K., Klesges, R. C., & Relyea, G. (1992). Smoking as a weightcontrol strategy and its relationship to smoking status. Addictive Behaviors 17, 259–271. Williamson, D. F., Madans, J., Anda, R. F., Kleinman, J. C., Giovino, G. A., & Byers, T. (1991). Smoking cessation and severity of weight gain in a national cohort. New England Journal of Medicine 324, 739–745. Yudkin, P. L., Jones, L., Lancaster, T., & Fowler, G. H. (1996). Which smokers are helped to give up smoking using transdermal nicotine patches? Results from a randomized, double-blind, placebo-controlled trial. British Journal of General Practice 46, 145–148.
Article
Short-term weight gain in abstaining women smokers Cynthia S. Pomerleau, Ph.D.*, Ovide F. Pomerleau, Ph.D., Rebecca J. Namenek, M.S., Ann M. Mehringer, B.A. Nicotine Research Laboratory, Behavioral Medicine Program, Department of Psychiatry, University of Michigan, Suite L, 475 Market Place, Ann Arbor, MI 48108, USA Received 6 July 1998; received in revised form 9 August 1999; accepted 9 August 1999
Abstract Although most studies of weight gain following smoking cessation assess long-term change, weight gain during the critical period immediately following cessation may be more salient to the smoker for whom fear of weight gain constitutes a serious barrier to cessation. The current study examined weight change in 20 highly dependent women smokers provided with monetary incentives to abstain for 1 week, along with concomitant changes in cotinine. Abstaining smokers (n ⫽ 7) gained 3.1 pounds, compared with 0.3 pounds in women who continued to smoke (n ⫽ 13). Across all subjects, change was significantly negatively correlated with final plasma cotinine concentration and marginally negatively correlated with percent cotinine reduction. Weight gain in women abstainers in the luteal phase of the menstrual cycle exceeded that in women abstainers in the follicular phase; a significant interaction such that continuing smokers showed no phase-related differences in weight suggests that the effect was not an artifact of perimenstrual increases in eating or fluid retention. Although long-term weight gain has been shown to be positively associated with success in quitting, little is known about the effects of short-term weight gain. Since many weight-concerned individuals either do not attempt to quit or terminate their quit attempts very early, it may be that if weight gain can be postponed beyond the first few fragile days of cessation, women with strong weight concerns may actually be good candidates for success. © 2000 Elsevier Science Inc. All rights reserved. Keywords: Weight gain; Cigarette smoking; Cotinine; Women; Menstrual phase
1. Introduction Most studies of weight gain following smoking cessation assess change over months or even years. While such studies allow an evaluation of the full impact of cessation of nicotine use upon weight, they do not capture the pattern of weight change over time. Since most relapse occurs early (Hunt et al., 1971), short-term weight change during the critical period immediately following cessation may be more salient to the smoker—especially the smoker for whom fear of weight gain constitutes a serious barrier to cessation—and hence an important consideration in successfully treating such individuals. Studies reporting weight gain over periods of 2 weeks or less have produced widely varying results. A number of studies reporting on short-term (4–10 days) weight change have shown nonsignificant differences (Hatsukami et al., 1993; Hellerstein et al., 1994; Perkins et al., 1990; Robinson & York, 1986). Other studies have shown somewhat larger * Corresponding author. Tel.: 734-998-6430. E-mail address: [email protected] (C.S. Pomerleau).
weight increments; Klesges et al. (1990), for example, showed a significant weight gain (a mean of 1.9 pounds) after 2 weeks of abstinence in 14 women in the no-drug group of a cessation trial. Leischow and Stitzer (1991), studying weight change in 9 male smokers deprived of cigarettes for 10 days on an inpatient unit, reported a mean gain of 2.23 kg (4.9 pounds), compared with a gain of .82 kg (1.8 pounds) in 8 male smokers who continued to smoke ad libitum. Eck et al. (1997), looking at women smokers randomly assigned to smoking cessation for a 10-day interval in either the luteal or follicular phase, observed a weight gain of 4 pounds in the luteal group, as opposed to less than a pound in the follicular group. In an attempt to investigate further the amount of shortterm weight change and to identify factors that might be associated with individual differences in this phenomenon, we studied highly dependent women smokers not planning to quit smoking who were provided with monetary incentives to remain abstinent from smoking for 1 week on an outpatient basis. Both weight and plasma cotinine were assessed at baseline and following 1 week of abstinence, allowing assessment of the relationship between weight change and
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biochemically verified changes in nicotine intake. Onset of menses was queried in women for purposes of inferring menstrual phase; the availability of data on abstainers and continuing smokers permitted assessment of the effects of menstrual phase per se upon weight.
2. Methods 2.1. Subjects Subjects were 20 premenopausal women smokers, in otherwise good health, recruited from the local community to participate in a test of their ability to remain abstinent. To be eligible to participate, candidates were required to be between the ages of 21 and 45 and to have a Fagerstrom Tolerance Questionnaire (FTQ; Fagerstrom, 1978) of at least 6, characterizing them as moderately to highly dependent smokers. 2.2. Procedure Subjects participated in a screening session in which eligibility was determined, informed consent obtained, height and weight measured, and demographic data and smoking history collected. After taking part in two sessions testing response to a laboratory stressor (unpublished data), separated by approximately 1 week, they participated in a 1-week test of their ability to remain abstinent when motivated by competition for a monetary bonus ($250 for the “winner[s]” in each cohort of 10, based on final cotinine concentration). No prior notice of this opportunity was given, nor were any suggestions offered about how to accomplish this goal; no advice or information on diet or exercise was provided. Onset of menses was tracked in women over the course of their participation in the study. On the final day of the abstinence week, subjects reported to the Laboratory for withdrawal of a blood sample for cotinine analysis and measurement of weight.
3. Results Subjects whose plasma cotinine concentration after a week of abstinence was less than 30 ng/mL (the maximum level deemed consistent with passive smoking as a source of possible exposure; Jarvis et al., 1992) were classified as abstainers (n ⫽ 7); the remaining subjects (n ⫽ 13) served as a control for continued smoking. Study results (M ⫾ SD) are shown in Table 1. Abstainers had significantly lower plasma cotinine concentration and significantly higher Body Mass Index (BMI) at baseline than continuing smokers. No significant differences were detected between groups in the amount of time that elapsed between the baseline weigh-in and the start of the 1-week abstinence trial (mean number of days ⫾ SD: abstainers, 22.7 ⫾ 5.1; continuing smokers, 23.0 ⫾ 7.2). Weight change was not significantly correlated with length of time between weigh-ins. Change in weight after 1 week differed significantly between groups (see Table 1). Weight change for the abstainers differed significantly from zero, t(6) ⫽ 2.87, p ⬍ .05; no significant difference was found for continuing smokers. Across all subjects, weight change was significantly predicted by cotinine concentration at abstinence (r ⫽ ⫺.50, p ⬍ .05) and marginally by change in cotinine (r ⫽ ⫺.42, p ⬍ .10). Women who began their abstinence week no more than 7 days after onset of last menses were defined as being in the follicular phase of their menstrual cycle; those who began their abstinence week at least 13 days after onset of last menses were considered to be in the luteal phase. (Oral contraceptive users [n ⫽ 6] were included in the analysis.) Follicular abstainers (n ⫽ 4) gained 1.5 ⫾ 2.0 pounds, as opposed to 5.3 ⫾ 2.5 pounds for luteal abstainers (n ⫽ 3). By contrast, weight remained stable for nonabstainers (reducers and maintainers combined) regardless of menstrual phase, with follicular nonabstainers (n ⫽ 6) gaining 0.5 ⫾ 1.8 pounds and luteal nonabstainers (n ⫽ 7) gaining 0.0 ⫾ 2.1 pounds. Despite the small sample size, a trend toward a sig-
Table 1 Subject characteristics, smoking patterns, cotinine concentrations, and weight change Abstainers (n ⫽ 7) Subject characteristics Age (years) Education (years) Body Mass Index (kg/M2) Self-reported smoking patterns Smoking rate (cigarettes/day) Nicotine dependence (FTQ score) Cotinine concentration Baseline cotinine (ng/mL) Cotinine at abstinence (ng/mL) Change in cotinine (percent of baseline) Weight change Weight change (lbs.)
Continuing smokers (n ⫽ 13)
Significance
31.7 ⫾ 7.2 13.9 ⫾ 1.3 27.2 ⫾ 5.2
29.2 ⫾ 6.5 13.8 ⫾ 1.2 21.3 ⫾ 2.2
NS NS t (7.16) ⫽ 2.89, p ⬍ .05
21.7 ⫾ 6.0 7.0 ⫾ 1.0
23.3 ⫾ 4.8 7.8 ⫾ 1.5
NS NS
132.7 ⫾ 95.7 7.0 ⫾ 9.7 ⫺92% ⫾ 13
237.7 ⫾ 47.2 190.4 ⫾ 60.4 ⫺16% ⫾ 33
⫹ 3.1 ⫾ 2.9
⫹ 0.3 ⫾ 1.9
NS ⫽ not significant; FTQ ⫽ Fagerstrom Tolerance Questionnaire.
t (18) ⫽ ⫺3.32, p ⬍ .005 — t (18) ⫽ 5.79, p ⬍ .001 t (18) ⫽ 2.69, p ⬍ .05
C.S. Pomerleau et al. / Journal of Substance Abuse Treatment 18 (2000) 339–342
nificant main effect was found for menstrual phase, F(1, 19) ⫽ 3.1, p ⬍ .10, with a significant status by phase interaction, F(1, 19) ⫽ 4.8, p ⬍ .05.
4. Discussion Weight gain in a group of women heavy smokers after 1 week’s abstinence was more than 3 pounds, as compared with the very minimal change (less than half a pound) seen in continuing smokers. Across all subjects, the amount of change was significantly related in a linear fashion to final plasma cotinine concentration and marginally to the percent reduction in plasma cotinine concentration. Consistent with the findings of Eck et al. (1997), weight gain in women abstainers in the luteal phase of the menstrual cycle substantially exceeded that in women abstainers in the follicular phase. The emergence of a significant interaction such that continuing smokers showed no phase-related differences in weight suggests that the effect was not an artifact of perimenstrual increases in eating or fluid retention. Although lower baseline cotinine concentrations may have facilitated abstaining under laboratory conditions, it is unlikely that they caused the significant between-group differences in weight gain. Rather, these baseline differences constitute a bias against showing greater postcessation weight gain in these subjects, since lower baseline cotinine should indicate less chronic exposure to the weight-suppressing effects of nicotine. The higher BMI in the abstaining group is also unlikely to account for our findings, since overweight individuals have been reported to gain less weight postcessation than normal-weight individuals (Williamson et al., 1991). It must also be noted that since baseline weight was measured at screening, not on the day on which the abstinence trial began, we cannot be sure that the change in weight represents exactly 1 week’s change. The negligible weight change in those whose smoking rates (as indicated by plasma cotinine concentrations) remained relatively stable, however, suggests that the observed increment in those who successfully abstained primarily reflects the effects of stopping smoking for 1 week, with only minimal contributions by random fluctuation during ad libitum smoking. Our findings indicate that even after only 1 week of abstinence, many smokers are already approaching, and some are exceeding, the 5-pound cutoff for acceptable weight gain specified by 75% of women (as opposed to 35% of men; Pomerleau & Kurth, 1996). Although long-term weight gain has been shown in some studies (Gritz et al., 1990; Hall et al., 1986; Norregaard et al., 1993) to be positively associated with success in quitting, little is known about the effects of short-term weight gain. Evidence that many weight-concerned individuals terminate their quit attempts early (Jarry et al., 1998), without ever seeking treatment (Klesges & Klesges, 1988; Klesges et al., 1988; Meyers et al., 1997; Weekley et al., 1992), raises the possibility that if weight
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gain can be delayed until after the fragile first few days of cessation and intensive support is delivered early in the quit attempt, women with strong weight concerns may actually be good candidates for success. The exacerbation of early postcessation weight gain associated with abstention from smoking during the luteal phase may also contribute to the difficulty of quitting and supports the recommendation to avoid scheduling quit attempts at that time if possible (Gritz et al., 1996). For women whose quit attempt must be scheduled during the luteal phase, administration of a diuretic for the first few days might be considered, especially for women with a history of failed cessation due to early weight gain, in consultation with a physician. Although our sample was small, our findings are in line with those of other investigators (Eck et al., 1997; Leischow & Stitzer, 1991). In view of the widespread aversion of women to the prospect of postcessation weight gain (Pomerleau & Kurth, 1996), these preliminary results strongly point to the need for a closer examination of early weight change as a potential precipitator of relapse—perhaps even before the smoker is willing to acknowledge publicly her intention to quit—as well as upon mood and withdrawal symptomatology. It is becoming increasingly evident that the first few days of a quit attempt are of crucial importance, with smoking during early abstinence predicting poor longterm outcome (Yudkin et al., 1996). Further study is needed to determine the extent to which early weight gain may contribute to difficulty in remaining abstinent, and to investigate the possibility that pharmacological aids to smoking cessation that attenuate weight gain, such as nicotine gum, nicotine patch, and sustained release bupropion (Dale et al., 1998; Gross et al., 1989; Hurt et al., 1997), may be differentially effective in women with strong concerns about postcessation weight gain. Exploration of the influence of such factors as age, race, dieting status, and activity level upon patterns of early weight gain in abstainers may also be helpful in specifying individual differences that contribute to vulnerability during this critical time in the quitting process. Acknowledgment Preparation of this manuscript was supported by grants HL52981 to Cynthia S. Pomerleau from the National Heart, Lung, and Blood Institute and CA42730 to Ovide F. Pomerleau from the National Cancer Institute. References Dale, L. C., Schroeder, D. R., Wolter, T. D., Croghan, I. T., Hurt, R. D., & Offord, K. P. (1998). Weight change after smoking cessation using variable doses of transdermal nicotine replacement. Journal of General Internal Medicine 13, 9–15. Eck, L. H., Klesges, R. C., Meyers, A. W., Slawson, D. L., & Winders, S. A. (1997). Changes in food consumption and body weight associated with smoking cessation across menstrual cycle phase. Addictive Behaviors 22, 775–782. Fagerstrom, K. O. (1978). Measuring degree of physical dependence to to-
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