Eating Issues, Smoking and Public Health

“I am often asked whether I would have done anything differently. Yes-I would have focused far more attention on the relation between smoking and weight and the importance American women attach to being thin”, said Joseph Califano Jr, former secretary of Health, Education and Welfare (USA). “Had public health efforts dealt with this fear in the fight against smoking, it might have made a difference”. (Cited in Chamberlain, 1998. p.1).

Research indicates that increasing numbers of women believe that smoking controls weight (Bowles & Johnson, 2001) and are engaging in smoking behaviour as a weight loss strategy (Berg, 1996). Young people associate weight control with smoking at increasingly earlier ages, and are using cigarettes as part of their weight control/loss attempts (Klesages, Elliot & Robinson, 1997). Dieting and weight concerns have been found to be predictive of smoking initiation in girls (Austin & Gortmaker, 2001; Torneo, Field, Berkey, Colditz & Frazier, 1999). Furthermore, fear of weight gain inhibits quitting attempts, and can contribute to relapse (Bowen, McTiernan, Powers, & Feng, 2001).

The weight concerns of smokers seem well grounded with some studies indicating that almost 80% of people who stop smoking can expect to gain weight. This is particularly true for women. While most women gain an average of 3-4kgs, 21% gain 15kgs or more (Flegal & Troiano, 1995). In the same study it was suggested that “weight gain is a physiologic process reflecting nicotine withdrawal” (pg 1168). In addition it has been shown that dieters reported more weight gain than non dieters and had shorter quit attempts (Jarry, Coambs, Polivy & Herman, 1998).

Public health initiatives around smoking have tended to minimise rather than engage with the weight concerns of smokers. Interventions often state that the chances of weight gain following smoking cessation are minimal. This is problematic because as discussed weight gain is common and if this isn’t normalised then the possibility for relapse due to ‘failure’ (i.e. weight gain) is increased. In addition to this tendency to minimise the weight concerns of smokers, there is quitting advice which reproduces common messages within dieting and eating disordered cultures, including food restriction, drinking water to reduce hunger and exercising to keep weight down. Such weight management advice may be counter productive in supporting smoking cessation attempts. Spring (Berg, 1996) cited a study that found more relapse in groups which tried to prevent weight gain following smoking cessation than in the control group.

The focus on weight management is particularly problematic where it reproduces healthy weight myths, encourages vigilance about any weight gain and pathologises weight gain. In 1990 in the US, the Surgeon General concluded that the health benefits of smoking cessation far exceeded the ‘risks’ associated with weight gain (Flegal & Troiano, 1995). The life affirming choice to become smokefree is buried beneath warnings about weight gain and advice about weight control.

EDEN recommends consideration of the following points:

• Reducing concern about weight gain after the cessation of smoking is preferable to trying to prevent weight gain.
• Concern about weight clearly informs the smoking activity of individuals and must be recognised and addressed in a sensitive and open manner within smoking cessation literature.
• Within Public Health the links between smoking and weight concerns must be recognised and seen as legitimate. Strategies need to be developed to address these concerns and to challenge the healthy weight myths that inform them.
• Collaborative relationships between agencies working in the areas of smoking cessation, eating issues and healthy weight would greatly enhance the efficacy of smokechange interventions.
• In line with our final recommendation EDEN would like to extend an invitation to agencies working in this field to consult with us, particularly where issues of smoking and weight overlap.
  

References

Austin, S. B. & Gortmaker, (2001). Dieting and smoking initiation in early adolescent girls and boys: A prospective study. American Journal of Public Health, 91, 446-450.

Berg, F. (1996). Smoking cessation impacts weight. Healthy Weight Journal, March/April, 27-28.

Bowen, D., McTiernan, A., Powers, D., & Feng, Z. (2001). Recruiting women into a smoking cessation program: Who might quit? Women and Health, 31, (4). 41-66.

Bowles, S., & Johnson, P. (2001). Gender, weight concerns, and adolescent smoking. Journal of Addictive Diseases. 20 (2), 5-14.Califano, J (1995). The Wrong Way to Stay Slim (Editorial). New England Journal of Medicine, 333, 1214-1216.

Flegal, N. & Troiano, R. (1995). The Influence of Smoking Cessation on the Prevalence of Overweight in the United States. New England Journal of Medicine, 333, (18). 1165-1170

Jarry, J., Coambes, R., Polivy, J., & Herman, C.(1998). Weight gain after smoking cessation in women: The impact of dieting status. International Journal of Eating Disorders, 24, 53-64.

Klesages, R., Elliot, V., & Robinson, L. (1997). Chronic dieting and the belief that smoking controls body weight in a bi-racial population-based adolescent sample. Tobacco Control, 6, 89-94.

Torneo, C., Field, A., Berkey, D. Colditz, G., & Frazier, A. (1999). Weight concerns, weight control behaviours, and smoking inititiation. Pediatrics, 104, 918-924.