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Weight concerns among male smokers
Addictive Behaviors 29 (2004) 1637 – 1641
Short communication
Weight concerns among male smokers Matthew M. Clark*, Paul A. Decker, Kenneth P. Offord, Christi A. Patten, Kristin S. Vickers, Ivana T. Croghan, J. Taylor Hays, Richard D. Hurt, Lowell C. Dale Department of Psychiatry and Psychology and Nicotine Research Center, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
Abstract Many smokers perceive that smoking controls their body weight and that stopping smoking leads to weight gain. This study examined characteristics associated with weight concerns in 72 male smokers enrolled in a controlled trial for smoking cessation. Motivation to quit smoking was found to be significantly lower in those with weight concerns ( P < .001). Further investigation is needed to enable the tailoring of interventions for weight-concerned male smokers. D 2004 Elsevier Ltd. All rights reserved. Keywords: Weight concerns; Nicotine dependence; Male smoker
1. Introduction Concern about weight gain subsequent to stopping smoking is a frequently identified barrier, and smokers with weight concerns are more likely to relapse (Meyers et al., 1997). Smoking for weight control reasons has been associated with being female (Klesges & Klesges, 1988), smoking more cigarettes per day (Sorensen et al., 1992), lower motivation to quit smoking (Chapman, Wong, & Smith, 1993), body image dissatisfaction (King, Matacin, Marcus, Bock, & Tripolone, 2000), and higher Fagerstro¨m scores (Pinto et al., 1999). Tailored interventions designed specifically for weightconcerned female smokers have shown that assignment to an on-site exercise program
* Corresponding author. Tel.: +1-507-284-3789; fax: +1-507-284-4345. E-mail address: [email protected] (M.M. Clark). 0306-4603/$ – see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2004.02.034
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M.M. Clark et al. / Addictive Behaviors 29 (2004) 1637–1641
improved smoking abstinence rates and delayed weight gain (Marcus et al., 1999), and cognitive –behavioral therapy to reduce weight concerns (Perkins et al., 2001) both improved smoking cessation outcome and reduced weight gain. In contrast, the factors associated with weight concerns in men have received limited empirical attention. Thus, the purpose of this study was to examine the association of weight concerns in male smokers to motivational level to stop smoking, weight, level of nicotine dependence, and smoking history variables.
2. Method 2.1. Participants and measurements A total of 600 participants enrolled in a randomized, pharmacological, and behavioral clinical trial. The basis of this report is the 286 male participants, of whom 72 were classified as ‘‘weight concerned.’’ Participants were current cigarette smokers with a mean age of 45.0 years. The ethnic composition was 86% Caucasian, 6% African-American, 3% Asian, and 5% of other ethnicity. Participants smoked an average of 26.2 cigarettes per day. Their average body mass index (BMI) was 27.2. Participants were recruited for a multisite, randomized double-blind, placebo-controlled study designed to examine the effectiveness of a new oral medication for smoking cessation. The study was approved by the Institutional Review Board at each site. To be eligible for study inclusion, they needed to be motivated to stop smoking (level of motivation to quit z 7 on a 10-point scale ranging from 1–10; Table 1). 2.1.1. The weight concerns scales The weight concerns scale (Meyers et al., 1997) is a series of 11 questions where participants self-report that if they gained an increment of weight after quitting smoking, would they start smoking again. Participants are first asked if they would return to smoking after a gain of less than 2 lb. This questioning is repeated, adding 2-lb increments with each successive question. The last question in the series is ‘‘If after quitting smoking, you gained 20 pounds or more, would you start smoking?’’ Participants who responded affirmatively, indicating intent to return to smoking for any weight gain classified as weight concerned. 2.1.2. Motivation to stop smoking The participants were asked on an 10-point scale (1–10) to rate how motivated the were to stop smoking. The anchors for the scale were ‘‘1’’ being not at all motivated and ‘‘10’’ being highly motivated. 2.1.3. Nicotine dependence The Fagerstro¨m Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstro¨m, 1991) is a six-item reliable measure of nicotine dependence.
M.M. Clark et al. / Addictive Behaviors 29 (2004) 1637–1641
1639
Table 1 Baseline demographic and psychosocial characteristics of subjects with weight concerns versus those without weight concerns Characteristic Age, years 21 – 35 36 – 50 > 50 Race Caucasian Black Asian Other Weight (kg) Body mass index* < 18.5 (Underweight) 18.5 – 24.9 (Normal) 25 – 29.9 (Overweight) 30 – 39.9 (Obese) z 40 (Extreme obesity) Cigarettes per day 15 – 20 21 – 39 z 40 Missing Fagerstrom Test for Nicotine Dependence <6 6+ Missing Smoking duration (years) Previous stop attempts 0 1 2–5 6 – 10 11 + Beck Depression Inventory <9 10 – 18 19 – 29 Missing a
With weight concerns (n = 72) a
Mean F S.D.
Median
44.4 F 10.2
43.5 17 (24) 37 (51) 18 (25)
5.5 F 2.1
60 (83) 3 (4) 2 (3) 7 (10) 87.0 27.9 0 (0) 17 (24) 34 (47) 20 (28) 1 (1) 20 42 (59) 18 (25) 11 (15) 1 5
24.6 F 10.9
36 (52) 33 (48) 3 25
87.7 F 15.2 27.8 F 3.9
25.7 F 9.8
3.3 F 3.1
3.3 F 2.8
2 9 (13) 14 (19) 36 (50) 10 (14) 3 (4) 3
No weight concerns (n = 214)
Range 25 – 72
Mean F S.D. 45.1 F 11.3
Mediana 46 52 (24) 90 (42) 72 (34)
5.5 F 2.1
187 (87) 14 (7) 6 (3) 7 (3) 82.4 26.1 1 (0) 79 (37) 82 (38) 50 (23) 2 (1) 20 97 (52) 60 (32) 29 (16) 28 6
2 – 50
26.4 F 12.2
100 (47) 113 (53) 1 27
0 – 12
4.3 F 4.9
0 – 10
3.3 F 4.0
56.4 – 138.0 19.5 – 42.6
85.2 F 15.2 27.0 F 4.6
15 – 50
26.3 F 10.7
1 – 10
68 (99) 1 (1) 0 (0) 3
Categorical variables are represented as n (%). *P=.041 from two-sample rank sum test analyzing BMI as a continuos variable.
3 14 (7) 42 (20) 113 (53) 28 (13) 17 (8) 2 194 (93) 12 (6) 3 (1) 5
Range 23 – 73
58.2 – 126.4 18.4 – 41.0
15 – 80
0 – 10
1 – 60 0 – 30
0 – 22
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M.M. Clark et al. / Addictive Behaviors 29 (2004) 1637–1641
2.1.4. Statistical methods Logistic regression was used to identify variables predictive of weight concerns. For this analysis, the participants were classified into two groups, those having weight concerns versus those without weight concerns. Possible predictors included age, race, weight, BMI, average cigarettes per day, FTND, smoking duration, previous stop attempts, and motivation level to quit. Study site was included as a covariate for each model. In all cases, P values =.05 were used to denote statistical significance.
3. Results Of the 286 males, 25% (72) were weight concerned. Univariately, BMI, FTND scores, or average number of cigarettes smoked per day were not significantly associated with weight concerns. Motivation to quit smoking was found to be significantly associated with weight concerns. As motivation increased, the participants were less likely to be weight concerned (odds ratio 0.54; 95% confidence internal [0.40 – 0.73]; P < .001). The percentage of participants who were weight concerned for motivational levels 7, 8, 9, and 10 was 29%, 39%, 21%, and 11%, respectively. A subsequent multivariate analysis, including all possible predictors using backward elimination of nonsignificant variables, found no multivariate set of predictors.
4. Discussion In this study, we found that 25% of men enrolled in a clinical trial were weight concerned. This frequency is very similar with the frequency (22.1%) reported by previous investigators (Meyers et al., 1997). We also found that motivational level for quitting decreased as weight concerns increased. This finding is striking, given that the study inclusion criteria of a rating of 7 or higher on a motivational level scale of 1–10 restricted the range of responses. Motivation level has been shown to be predictive of outcome from smoking interventions (Colby et al., 1998). It is plausible that one means of enhancing the level of motivation to stop smoking will be to reduce weight concerns in this subpopulation. Some have proposed that weight concerns are more related to body image issues rather than to the individual’s weight status (King et al., 2000). Our finding that BMI was not associated with weight concerns supports this premise. Neither cigarettes smoked per day nor the FTND was associated with weight concerns. That weight concerns were not related to smoking rate was not surprising because while previous investigators have found a relationship between the level of cigarette smoking and weight in females, the number of cigarettes smoked per day has not been related to weight in males (Klesges et al., 1991). The limitations of the present investigation include a sample that was 86% Caucasian, the use of a motivational scale with unknown psychometric properties, and that neither body image satisfaction nor mood was assessed. Future investigations should further explore the prevalence and characteristics of weight-concerned male smokers and investigate how to tailor interventions for weight-concerned male smokers.
M.M. Clark et al. / Addictive Behaviors 29 (2004) 1637–1641
1641
Acknowledgements This study was supported by Sanofi-Synthelabo Researche.
References Chapman, S., Wong, W., & Smith, W. (1993). Self-exempting beliefs about smoking and health: Differences between smokers and ex-smokers. American Journal of Preventive Medicine, 83, 215 – 219. Colby, S., Monti, P., Barnett, N., Rohsenow, D., Weissman, K., Spirito, A., Woolard, R., & Lewander, W. (1998). Brief motivational interviewing in a hospital setting for adolescent smoking: A preliminary study. Journal of Consulting and Clinical Psychology, 66(3), 574 – 578. Heatherton, T., Kozlowski, L., Frecker, R., & Fagerstro¨m, K. (1991). The Fagerstro¨m test for nicotine dependence: A revision of the Fagerstro¨m tolerance questionnaire. British Journal of Addiction, 86, 1119 – 1127. King, T., Matacin, M., Marcus, B., Bock, B., & Tripolone, J. (2000). Body image evaluations in women smokers. Addictive Behaviors, 25(4), 613 – 618. Klesges, R., & Klesges, L. (1988). Cigarette smoking as a dieting strategy in a university population. International Journal of Eating Disorders, 7(3), 413 – 419. Klesges, R.C., Klesges, L.M., & Meyers, A.W. (1991). Relatioship of smoking status, energy balance, and Body wieght: Analysis of the second national health and nutrition examination survey. Journal of Consulting and Clinical Psychology, 59 (6), 899 – 905. Marcus, B., Albrecht, A., King, T., Parisi, A., Pinto, B., Roberts, M., Niaura, R., & Abrams, D. (1999). The efficacy of exercise as an aid for smoking cessation in women. Archives of Internal Medicine, 159, 1229 – 1234. Meyers, A., Klesges, R., Winders, S., Ward, K., Peterson, B., & Eck, L. (1997). Are weight concerns predictive of smoking cessation? A prospective analysis. Journal of Consulting and Clinical Psychology, 65(3), 448 – 452. Perkins, K., Marcus, M., Levine, M., D’Amico, D., Miller, A., Broge, M., Ashcom, J., & Shiffman, S. (2001). Cognitive-behavioral therapy to reduce weight concerns improves smoking cessation outcome in weightconcerned women. Journal of Consulting and Clinical Psychology, 69(4), 604 – 613. Pinto, B., Borrelli, B., King, T., Bock, B., Clark, M., Roberts, M., & Marcus, B. (1999). Weight control smoking among sedentary women. Addictive Behaviors, 24(1), 75 – 86. Sorensen, G., Goldberg, R., Ockene, J., Klar, J., Tannenbaum, T., & Lemeshow, S. (1992). Heavy smoking among a sample of employed women. American Journal of Preventive Medicine, 8, 208 – 214.
Short communication
Weight concerns among male smokers Matthew M. Clark*, Paul A. Decker, Kenneth P. Offord, Christi A. Patten, Kristin S. Vickers, Ivana T. Croghan, J. Taylor Hays, Richard D. Hurt, Lowell C. Dale Department of Psychiatry and Psychology and Nicotine Research Center, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
Abstract Many smokers perceive that smoking controls their body weight and that stopping smoking leads to weight gain. This study examined characteristics associated with weight concerns in 72 male smokers enrolled in a controlled trial for smoking cessation. Motivation to quit smoking was found to be significantly lower in those with weight concerns ( P < .001). Further investigation is needed to enable the tailoring of interventions for weight-concerned male smokers. D 2004 Elsevier Ltd. All rights reserved. Keywords: Weight concerns; Nicotine dependence; Male smoker
1. Introduction Concern about weight gain subsequent to stopping smoking is a frequently identified barrier, and smokers with weight concerns are more likely to relapse (Meyers et al., 1997). Smoking for weight control reasons has been associated with being female (Klesges & Klesges, 1988), smoking more cigarettes per day (Sorensen et al., 1992), lower motivation to quit smoking (Chapman, Wong, & Smith, 1993), body image dissatisfaction (King, Matacin, Marcus, Bock, & Tripolone, 2000), and higher Fagerstro¨m scores (Pinto et al., 1999). Tailored interventions designed specifically for weightconcerned female smokers have shown that assignment to an on-site exercise program
* Corresponding author. Tel.: +1-507-284-3789; fax: +1-507-284-4345. E-mail address: [email protected] (M.M. Clark). 0306-4603/$ – see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2004.02.034
1638
M.M. Clark et al. / Addictive Behaviors 29 (2004) 1637–1641
improved smoking abstinence rates and delayed weight gain (Marcus et al., 1999), and cognitive –behavioral therapy to reduce weight concerns (Perkins et al., 2001) both improved smoking cessation outcome and reduced weight gain. In contrast, the factors associated with weight concerns in men have received limited empirical attention. Thus, the purpose of this study was to examine the association of weight concerns in male smokers to motivational level to stop smoking, weight, level of nicotine dependence, and smoking history variables.
2. Method 2.1. Participants and measurements A total of 600 participants enrolled in a randomized, pharmacological, and behavioral clinical trial. The basis of this report is the 286 male participants, of whom 72 were classified as ‘‘weight concerned.’’ Participants were current cigarette smokers with a mean age of 45.0 years. The ethnic composition was 86% Caucasian, 6% African-American, 3% Asian, and 5% of other ethnicity. Participants smoked an average of 26.2 cigarettes per day. Their average body mass index (BMI) was 27.2. Participants were recruited for a multisite, randomized double-blind, placebo-controlled study designed to examine the effectiveness of a new oral medication for smoking cessation. The study was approved by the Institutional Review Board at each site. To be eligible for study inclusion, they needed to be motivated to stop smoking (level of motivation to quit z 7 on a 10-point scale ranging from 1–10; Table 1). 2.1.1. The weight concerns scales The weight concerns scale (Meyers et al., 1997) is a series of 11 questions where participants self-report that if they gained an increment of weight after quitting smoking, would they start smoking again. Participants are first asked if they would return to smoking after a gain of less than 2 lb. This questioning is repeated, adding 2-lb increments with each successive question. The last question in the series is ‘‘If after quitting smoking, you gained 20 pounds or more, would you start smoking?’’ Participants who responded affirmatively, indicating intent to return to smoking for any weight gain classified as weight concerned. 2.1.2. Motivation to stop smoking The participants were asked on an 10-point scale (1–10) to rate how motivated the were to stop smoking. The anchors for the scale were ‘‘1’’ being not at all motivated and ‘‘10’’ being highly motivated. 2.1.3. Nicotine dependence The Fagerstro¨m Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstro¨m, 1991) is a six-item reliable measure of nicotine dependence.
M.M. Clark et al. / Addictive Behaviors 29 (2004) 1637–1641
1639
Table 1 Baseline demographic and psychosocial characteristics of subjects with weight concerns versus those without weight concerns Characteristic Age, years 21 – 35 36 – 50 > 50 Race Caucasian Black Asian Other Weight (kg) Body mass index* < 18.5 (Underweight) 18.5 – 24.9 (Normal) 25 – 29.9 (Overweight) 30 – 39.9 (Obese) z 40 (Extreme obesity) Cigarettes per day 15 – 20 21 – 39 z 40 Missing Fagerstrom Test for Nicotine Dependence <6 6+ Missing Smoking duration (years) Previous stop attempts 0 1 2–5 6 – 10 11 + Beck Depression Inventory <9 10 – 18 19 – 29 Missing a
With weight concerns (n = 72) a
Mean F S.D.
Median
44.4 F 10.2
43.5 17 (24) 37 (51) 18 (25)
5.5 F 2.1
60 (83) 3 (4) 2 (3) 7 (10) 87.0 27.9 0 (0) 17 (24) 34 (47) 20 (28) 1 (1) 20 42 (59) 18 (25) 11 (15) 1 5
24.6 F 10.9
36 (52) 33 (48) 3 25
87.7 F 15.2 27.8 F 3.9
25.7 F 9.8
3.3 F 3.1
3.3 F 2.8
2 9 (13) 14 (19) 36 (50) 10 (14) 3 (4) 3
No weight concerns (n = 214)
Range 25 – 72
Mean F S.D. 45.1 F 11.3
Mediana 46 52 (24) 90 (42) 72 (34)
5.5 F 2.1
187 (87) 14 (7) 6 (3) 7 (3) 82.4 26.1 1 (0) 79 (37) 82 (38) 50 (23) 2 (1) 20 97 (52) 60 (32) 29 (16) 28 6
2 – 50
26.4 F 12.2
100 (47) 113 (53) 1 27
0 – 12
4.3 F 4.9
0 – 10
3.3 F 4.0
56.4 – 138.0 19.5 – 42.6
85.2 F 15.2 27.0 F 4.6
15 – 50
26.3 F 10.7
1 – 10
68 (99) 1 (1) 0 (0) 3
Categorical variables are represented as n (%). *P=.041 from two-sample rank sum test analyzing BMI as a continuos variable.
3 14 (7) 42 (20) 113 (53) 28 (13) 17 (8) 2 194 (93) 12 (6) 3 (1) 5
Range 23 – 73
58.2 – 126.4 18.4 – 41.0
15 – 80
0 – 10
1 – 60 0 – 30
0 – 22
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M.M. Clark et al. / Addictive Behaviors 29 (2004) 1637–1641
2.1.4. Statistical methods Logistic regression was used to identify variables predictive of weight concerns. For this analysis, the participants were classified into two groups, those having weight concerns versus those without weight concerns. Possible predictors included age, race, weight, BMI, average cigarettes per day, FTND, smoking duration, previous stop attempts, and motivation level to quit. Study site was included as a covariate for each model. In all cases, P values =.05 were used to denote statistical significance.
3. Results Of the 286 males, 25% (72) were weight concerned. Univariately, BMI, FTND scores, or average number of cigarettes smoked per day were not significantly associated with weight concerns. Motivation to quit smoking was found to be significantly associated with weight concerns. As motivation increased, the participants were less likely to be weight concerned (odds ratio 0.54; 95% confidence internal [0.40 – 0.73]; P < .001). The percentage of participants who were weight concerned for motivational levels 7, 8, 9, and 10 was 29%, 39%, 21%, and 11%, respectively. A subsequent multivariate analysis, including all possible predictors using backward elimination of nonsignificant variables, found no multivariate set of predictors.
4. Discussion In this study, we found that 25% of men enrolled in a clinical trial were weight concerned. This frequency is very similar with the frequency (22.1%) reported by previous investigators (Meyers et al., 1997). We also found that motivational level for quitting decreased as weight concerns increased. This finding is striking, given that the study inclusion criteria of a rating of 7 or higher on a motivational level scale of 1–10 restricted the range of responses. Motivation level has been shown to be predictive of outcome from smoking interventions (Colby et al., 1998). It is plausible that one means of enhancing the level of motivation to stop smoking will be to reduce weight concerns in this subpopulation. Some have proposed that weight concerns are more related to body image issues rather than to the individual’s weight status (King et al., 2000). Our finding that BMI was not associated with weight concerns supports this premise. Neither cigarettes smoked per day nor the FTND was associated with weight concerns. That weight concerns were not related to smoking rate was not surprising because while previous investigators have found a relationship between the level of cigarette smoking and weight in females, the number of cigarettes smoked per day has not been related to weight in males (Klesges et al., 1991). The limitations of the present investigation include a sample that was 86% Caucasian, the use of a motivational scale with unknown psychometric properties, and that neither body image satisfaction nor mood was assessed. Future investigations should further explore the prevalence and characteristics of weight-concerned male smokers and investigate how to tailor interventions for weight-concerned male smokers.
M.M. Clark et al. / Addictive Behaviors 29 (2004) 1637–1641
1641
Acknowledgements This study was supported by Sanofi-Synthelabo Researche.
References Chapman, S., Wong, W., & Smith, W. (1993). Self-exempting beliefs about smoking and health: Differences between smokers and ex-smokers. American Journal of Preventive Medicine, 83, 215 – 219. Colby, S., Monti, P., Barnett, N., Rohsenow, D., Weissman, K., Spirito, A., Woolard, R., & Lewander, W. (1998). Brief motivational interviewing in a hospital setting for adolescent smoking: A preliminary study. Journal of Consulting and Clinical Psychology, 66(3), 574 – 578. Heatherton, T., Kozlowski, L., Frecker, R., & Fagerstro¨m, K. (1991). The Fagerstro¨m test for nicotine dependence: A revision of the Fagerstro¨m tolerance questionnaire. British Journal of Addiction, 86, 1119 – 1127. King, T., Matacin, M., Marcus, B., Bock, B., & Tripolone, J. (2000). Body image evaluations in women smokers. Addictive Behaviors, 25(4), 613 – 618. Klesges, R., & Klesges, L. (1988). Cigarette smoking as a dieting strategy in a university population. International Journal of Eating Disorders, 7(3), 413 – 419. Klesges, R.C., Klesges, L.M., & Meyers, A.W. (1991). Relatioship of smoking status, energy balance, and Body wieght: Analysis of the second national health and nutrition examination survey. Journal of Consulting and Clinical Psychology, 59 (6), 899 – 905. Marcus, B., Albrecht, A., King, T., Parisi, A., Pinto, B., Roberts, M., Niaura, R., & Abrams, D. (1999). The efficacy of exercise as an aid for smoking cessation in women. Archives of Internal Medicine, 159, 1229 – 1234. Meyers, A., Klesges, R., Winders, S., Ward, K., Peterson, B., & Eck, L. (1997). Are weight concerns predictive of smoking cessation? A prospective analysis. Journal of Consulting and Clinical Psychology, 65(3), 448 – 452. Perkins, K., Marcus, M., Levine, M., D’Amico, D., Miller, A., Broge, M., Ashcom, J., & Shiffman, S. (2001). Cognitive-behavioral therapy to reduce weight concerns improves smoking cessation outcome in weightconcerned women. Journal of Consulting and Clinical Psychology, 69(4), 604 – 613. Pinto, B., Borrelli, B., King, T., Bock, B., Clark, M., Roberts, M., & Marcus, B. (1999). Weight control smoking among sedentary women. Addictive Behaviors, 24(1), 75 – 86. Sorensen, G., Goldberg, R., Ockene, J., Klar, J., Tannenbaum, T., & Lemeshow, S. (1992). Heavy smoking among a sample of employed women. American Journal of Preventive Medicine, 8, 208 – 214.