Understanding the relations between smoking and body weight and their importance to smoking cessation and relapse

Gestational Weight Gain Among Urban and Rural Pregnant Individuals Who Smoke or Quit Smoking

INTRODUCTION

Approximately 7.2% of individuals in the U.S. smoke during pregnancy, and cessation is associated with excessive gestational weight gain (GWG). Weight gain is a common reason for not quitting smoking or relapsing. The current study aimed to characterize who is at risk for excessive GWG and determine the moderating effect of rurality given the higher smoking rates and lower access to healthcare services in these areas.

METHODS

Data from the Virginia Pregnancy Risk Assessment Monitoring System (PRAMS; years 2009-2020) were used to assess the association between participant characteristics, smoking behaviors, and rurality by excessive GWG status in 2023.

RESULTS

Almost half (44.0%) of participants experienced excessive GWG; 9.8% of participants quit smoking while 6.9% continued smoking. Respondents who quit during pregnancy had higher odds of excessive GWG than non-smoking respondents (OR=1.83, 95% CI: [1.24, 2.71]). Among those who were non-smoking, respondents in rural areas, compared to urban areas, had a higher probability of experiencing excessive GWG (0.46 vs 0.44, p<0.001). For those who quit smoking (0.60 vs 0.41, p<0.001) or continued to smoke during pregnancy (0.46 vs 0.33, p<0.001), urban residence was associated with a higher likelihood of excessive GWG compared to rural residence.

CONCLUSIONS

Smoking cessation and weight management during pregnancy are critical to promoting infant and maternal health. Targeted interventions combining weight management and smoking cessation have been successful among the general population and could be adapted for pregnant individuals who smoke to facilitate cessation and healthy GWG in both urban and rural areas.

A randomized controlled trial to reduce post-cessation weight gain

BACKGROUND/OBJECTIVES

Weight gain is a barrier to smoking cessation. Previous interventions targeting weight gain while quitting smoking have largely been unsuccessful. The current study aimed to assess the efficacy of weight stability and weight loss interventions compared to a low-intensity, self-guided bibliotherapy weight management group.

SUBJECTS/METHODS

A randomized controlled trial with 12-month follow-up from 2018 to 2022 was conducted with participants (N = 305) who reported smoking at least five cigarettes per day for the last year and interest in quitting initially recruited from the Memphis, TN, USA area. Recruitment was expanded nationally with the onset of the COVID-19 pandemic. Subsequently, 276 completed 12-month follow-up.

INTERVENTIONS/METHODS

The Bibliotherapy group was provided a weight management book. Both the Stability and Loss groups met via telephone for eight weeks to learn strategies for maintaining/losing weight, respectively. All three groups then received the same six-week smoking cessation intervention, with six months of varenicline provided.

RESULTS

Individuals in the Loss group lost more weight (-2.01 kg, SE = 1.58) than individuals in the Bibliotherapy group (+1.08 kg, SE = 1.49, p = 0.0004), while the Stability group (-0.30 kg, SE = 1.56) was not significantly different from the Bibliotherapy group (p = 0.17). Those in the Stability group did not gain a significant amount of weight. Participants in the Loss group did not gain back all weight lost after smoking cessation and ended the study approximately 2.01 kg lower than baseline. The Bibliotherapy group did not gain the amount of weight expected after cessation. There were no significant differences between groups related to self-reported smoking cessation at each time point except at eight-month follow-up (p = 0.005).

CONCLUSIONS AND RELEVANCE

Results indicated the Stability and the Loss interventions were effective for preventing post-smoking cessation weight gain, with the Loss group having the benefit of sustained weight loss. These interventions may be helpful to implement to combat weight gain and potentially facilitate smoking cessation.

TRIAL REGISTRATION

The trial is registered on clinicaltrials.gov (NCT03156660).

Interventions for preventing weight gain after smoking cessation

BACKGROUND

Most people who stop smoking gain weight. This can discourage some people from making a quit attempt and risks offsetting some, but not all, of the health advantages of quitting. Interventions to prevent weight gain could improve health outcomes, but there is a concern that they may undermine quitting.

OBJECTIVES

To systematically review the effects of: (1) interventions targeting post-cessation weight gain on weight change and smoking cessation (referred to as 'Part 1') and (2) interventions designed to aid smoking cessation that plausibly affect post-cessation weight gain (referred to as 'Part 2').

SEARCH METHODS

Part 1 - We searched the Cochrane Tobacco Addiction Group's Specialized Register and CENTRAL; latest search 16 October 2020. Part 2 - We searched included studies in the following 'parent' Cochrane reviews: nicotine replacement therapy (NRT), antidepressants, nicotine receptor partial agonists, e-cigarettes, and exercise interventions for smoking cessation published in Issue 10, 2020 of the Cochrane Library. We updated register searches for the review of nicotine receptor partial agonists.

SELECTION CRITERIA

Part 1 - trials of interventions that targeted post-cessation weight gain and had measured weight at any follow-up point or smoking cessation, or both, six or more months after quit day. Part 2 - trials included in the selected parent Cochrane reviews reporting weight change at any time point.

DATA COLLECTION AND ANALYSIS

Screening and data extraction followed standard Cochrane methods. Change in weight was expressed as difference in weight change from baseline to follow-up between trial arms and was reported only in people abstinent from smoking. Abstinence from smoking was expressed as a risk ratio (RR). Where appropriate, we performed meta-analysis using the inverse variance method for weight, and Mantel-Haenszel method for smoking.

MAIN RESULTS

Part 1: We include 37 completed studies; 21 are new to this update. We judged five studies to be at low risk of bias, 17 to be at unclear risk and the remainder at high risk.  An intermittent very low calorie diet (VLCD) comprising full meal replacement provided free of charge and accompanied by intensive dietitian support significantly reduced weight gain at end of treatment compared with education on how to avoid weight gain (mean difference (MD) -3.70 kg, 95% confidence interval (CI) -4.82 to -2.58; 1 study, 121 participants), but there was no evidence of benefit at 12 months (MD -1.30 kg, 95% CI -3.49 to 0.89; 1 study, 62 participants). The VLCD increased the chances of abstinence at 12 months (RR 1.73, 95% CI 1.10 to 2.73; 1 study, 287 participants). However, a second study  found that no-one completed the VLCD intervention or achieved abstinence. Interventions aimed at increasing acceptance of weight gain reported mixed effects at end of treatment, 6 months and 12 months with confidence intervals including both increases and decreases in weight gain compared with no advice or health education. Due to high heterogeneity, we did not combine the data. These interventions increased quit rates at 6 months (RR 1.42, 95% CI 1.03 to 1.96; 4 studies, 619 participants; I² = 21%), but there was no evidence at 12 months (RR 1.25, 95% CI 0.76 to 2.06; 2 studies, 496 participants; I² = 26%). Some pharmacological interventions tested for limiting post-cessation weight gain (PCWG) reduced weight gain at the end of treatment (dexfenfluramine, phenylpropanolamine, naltrexone). The effects of ephedrine and caffeine combined, lorcaserin, and chromium were too imprecise to give useful estimates of treatment effects. There was very low-certainty evidence that personalized weight management support reduced weight gain at end of treatment (MD -1.11 kg, 95% CI -1.93 to -0.29; 3 studies, 121 participants; I² = 0%), but no evidence in the longer-term 12 months (MD -0.44 kg, 95% CI -2.34 to 1.46; 4 studies, 530 participants; I² = 41%). There was low to very low-certainty evidence that detailed weight management education without personalized assessment, planning and feedback did not reduce weight gain and may have reduced smoking cessation rates (12 months: MD -0.21 kg, 95% CI -2.28 to 1.86; 2 studies, 61 participants; I² = 0%; RR for smoking cessation 0.66, 95% CI 0.48 to 0.90; 2 studies, 522 participants; I² = 0%). Part 2: We include 83 completed studies, 27 of which are new to this update. There was low certainty that exercise interventions led to minimal or no weight reduction compared with standard care at end of treatment (MD -0.25 kg, 95% CI -0.78 to 0.29; 4 studies, 404 participants; I² = 0%). However, weight was reduced at 12 months (MD -2.07 kg, 95% CI -3.78 to -0.36; 3 studies, 182 participants; I² = 0%). Both bupropion and fluoxetine limited weight gain at end of treatment (bupropion MD -1.01 kg, 95% CI -1.35 to -0.67; 10 studies, 1098 participants; I² = 3%); (fluoxetine MD -1.01 kg, 95% CI -1.49 to -0.53; 2 studies, 144 participants; I² = 38%; low- and very low-certainty evidence, respectively). There was no evidence of benefit at 12 months for bupropion, but estimates were imprecise (bupropion MD -0.26 kg, 95% CI -1.31 to 0.78; 7 studies, 471 participants; I² = 0%). No studies of fluoxetine provided data at 12 months. There was moderate-certainty that NRT reduced weight at end of treatment (MD -0.52 kg, 95% CI -0.99 to -0.05; 21 studies, 2784 participants; I² = 81%) and moderate-certainty that the effect may be similar at 12 months (MD -0.37 kg, 95% CI -0.86 to 0.11; 17 studies, 1463 participants; I² = 0%), although the estimates are too imprecise to assess long-term benefit. There was mixed evidence of the effect of varenicline on weight, with high-certainty evidence that weight change was very modestly lower at the end of treatment (MD -0.23 kg, 95% CI -0.53 to 0.06; 14 studies, 2566 participants; I² = 32%); a low-certainty estimate gave an imprecise estimate of higher weight at 12 months (MD 1.05 kg, 95% CI -0.58 to 2.69; 3 studies, 237 participants; I² = 0%).

AUTHORS' CONCLUSIONS

Overall, there is no intervention for which there is moderate certainty of a clinically useful effect on long-term weight gain. There is also no moderate- or high-certainty evidence that interventions designed to limit weight gain reduce the chances of people achieving abstinence from smoking.

Use of Tobacco for Weight Control across Products among Young Adults in the U.S. Military

BACKGROUND

Approximately 17% of young adults currently use tobacco, most commonly cigarettes and/or electronic cigarettes (e-cigarettes), followed by other products (i.e., cigarillos, pipe/hookah, smokeless tobacco). Cigarettes have been historically used to control weight. Little is known about use of non-cigarette products for weight control, particularly among non-college young adults. Tobacco use in the military is higher than civilians, and personnel have increased motivation for weight control due to military fitness standards. This population might be vulnerable to use tobacco for this purpose. Purpose: Exploring prevalence, as well as demographic and behavioral correlates, of using tobacco products for weight control, among a large, diverse sample of military young adults. Methods: U.S. Air Force recruits (N = 24,543) completed a questionnaire about tobacco use. Among users of tobacco products, recruits reported if they had ever used that product to maintain their weight. Results: Smokeless tobacco was most commonly used for weight control (12.2%), followed by cigarettes (7.3%), e-cigarettes (5.5%), cigarillos (3.3%), and hookah/pipe (3.2%). Using tobacco for weight control was associated with fewer harm beliefs and more regular use of that product. Among e-cigarette users, having a higher BMI and a lower educational background was associated with ever using this product for weight control. Conclusions: The belief that a tobacco product helps control one's weight might increase the prevalence, and frequency of use, of that product among military young adults. Tobacco cessation programs should assess for this motivation of use and provide education about tobacco harm and alternative strategies for weight maintenance.

Fit & quit: An efficacy trial of two behavioral post-cessation weight gain interventions

While smoking cessation leads to significant improvements in both mortality and morbidity, post-cessation weight gain partially attenuates this benefit. Even though post-cessation weight gain is small (4.7 kg on average), it is a stated reason to delay cessation attempts and is associated with smoking relapse. Fit & Quit is a randomized, controlled efficacy trial that aims to examine the ability of a weight stability intervention and a weight loss intervention to reduce post-cessation weight gain. For this purpose, Fit & Quit will randomize participants to three conditions: (a) Small Changes, a weight gain prevention intervention; (b) Look AHEAD Intensive Lifestyle Intervention; and (c) a lower-intensity bibliotherapy intervention. All conditions will receive a highly efficacious behavioral (i.e., rate reduction skills, motivational interviewing) and pharmacological (i.e., varenicline) smoking cessation program. A total of 400 participants will be recruited and randomized to the three interventions. Participants will be recruited in waves, with 10 waves of approximately 40 participants per wave. The primary outcomes of this study include post-cessation weight gain and cessation status at 12-month follow-up. Fit & Quit will integrate and adapt the strongest evidence-based interventions available for weight management and smoking cessation. Fit & Quit is highly innovative in the areas of the target population, study design, and use of technology. For these reasons, we expect that Fit & Quit will make a significant public health contribution to curtailing the important cessation barrier of post-cessation weight gain.

Association between smoking cessation and weight gain in treatment-seeking African Americans

INTRODUCTION

Research has shown that African Americans gain more than average weight after smoking cessation. However, African Americans have been underrepresented in post-cessation weight gain research. The current study examined 1) the pattern of weight gain and 2) the association between smoking status and weight gain in a sample of African Americans seeking smoking cessation treatment.

METHODS

Data were drawn from a randomized controlled trial testing the efficacy of a 4-week culturally specific smoking cessation cognitive behavioral therapy (CBT) intervention among African American smokers (N = 342). Weight was measured and self-reported smoking status was biochemically verified at baseline, end of counseling, 3-, 6-, and 12-month follow-ups. Random effects multilevel modeling was used to examine weight gain over twelve months post CBT, and a fully unconditional model tested the pattern of weight gain over time. Smoking status was included as a time-varying factor to examine its effect on weight gain, controlling for potential confounding variables.

RESULTS

Weight significantly increased among those who remained abstinent over 12 months post CBT [average gain of seven lbs. (three kg)]. Controlling for covariates, abstinence was predictive of the rate of weight gain for those with high weight concern.

CONCLUSIONS

Weight gain among African American abstainers was comparable to the average post-cessation weight gain observed among the general population. It is possible that exposure to CBT (culturally specific or standard) may have mitigated excessive weight gain. Future research should assess predictors of weight gain in African American smokers to inform future smoking cessation interventions and help elucidate factors that contribute to tobacco- and obesity-related health disparities.

Obesity Might Be a Predictor of Weight Reduction after Smoking Cessation

BACKGROUND AND OBJECTIVES

Approximately one in five ex-smokers reduces or maintains weight after smoking cessation but little is known about who succeeds to avoid weight gain. The purpose of this study was to identify predictors of weight reduction after long-term smoking cessation in a general population.

METHODS

Data was obtained from two Danish population-based cohorts (the Inter99 and the Helbred2006 study). Anthropometric measurements were performed by trained research staff. Out of 3.577 daily smokers at baseline 317 participants had quit smoking at the five-year follow-up for at least one year. Multiple logistic regression analysis was performed to determine predictors of weight reduction.

RESULTS

Thirteen percent reduced weight by at least 1 kg and 4% maintained their weight. Quitters with obesity had more than seven times higher odds than normal weight quitters to lose weight (OR 7.13 (95% CI 2.76-19.71)), and they had the largest median weight loss of 4.45 kg. The only other significant predictor of weight reduction was low tobacco consumption at baseline.

CONCLUSIONS

Predictors of weight reduction after smoking cessation were high body mass index and low tobacco consumption at baseline. This study might motivate smokers with obesity to quit smoking and health professionals to give them support.

The Relationship between Body Mass Index and Post-Cessation Weight Gain in the Year after Quitting Smoking: A Cross-Sectional Study

Introduction

There is wide variability in the amount of weight gained when quitting smoking, but little is known about key predictors of weight gain. We examined the impact of body mass index (BMI) category and sociodemographic variables on post-cessation weight gain.

Materials and Methods

We utilized National Health and Nutrition Examination Survey data from five consecutive cycles of data collection from 2003–2004 to 2011–2012 to estimate post-cessation weight gain by BMI category among recent quitters (n = 654). We analyzed data on their “current weight” and their “past year weight”. We also compared the recent quitters with current smokers, in order to estimate the amount of weight that could be attributed to quitting smoking.

Results

Recent quitters gained 1.4 kg (95% CI: 0.8 to 2.0), while current smokers had a non-significant weight change (-0.01 kg (95% CI: -0.3 to 0.2). Weight gain was significant for those in the normal weight (3.1 kg, 95% CI: 2.3 to 3.9) and overweight BMI categories (2.2 kg, 95% CI: 1.1 to 3.2).

Conclusions

BMI category is a key factor in the extent of post-cessation weight gain, with normal and overweight recent quitters gaining significant amounts of weight.

Comparative Effectiveness of Smoking Cessation Medications to Attenuate Weight Gain Following Cessation

OBJECTIVE

To compare the postcessation weight gain following the use of different FDA-approved smoking cessation medications among obese smokers.

METHODS

A retrospective cohort study was conducted using the General Electric (GE) electronic medical record database (2006-2011). The cohort consisted of obese adult smokers newly initiating use of an FDA-approved smoking cessation medication (i.e., bupropion vs. varenicline). The outcome variable was weight change at 3, 6, or 12 months following the first prescription. Descriptive analyses and t-tests were conducted to assess the frequency distribution of sample characteristics and their association with the postcessation weight change. Multivariate linear regression models were carried out to compare the weight change among the FDA-approved smoking cessation medications and to identify predictors of weight change at 3, 6, and 12 months after assessing the model assumptions.

RESULTS

The mean weight gain was 1.14 pounds (±17.26), 2.06 pounds (±18.46), and 3.06 pounds (±20.78) at 3-, 6-, and 12-month, respectively. Obese smokers who were prescribed varenicline had a mean weight gain of 1.18 pounds (±16.75), 2.14 pounds (±18.14), and 3.12 pounds (±20.89) for each follow up, while those who were prescribed bupropion had a mean weight gain of 0.23 pounds (±25.90), 0.22 pounds (±25.32), and 1.47 pounds (±17.50), respectively. Descriptive analysis showed that obese smokers taking bupropion had less weight gain than those taking varenicline at each follow up; however, this association was not statistically significant after accounting for all covariates.

CONCLUSIONS

While patients using bupropion gained slightly less weight compared to those using varenicline, type of smoking cessation medication was not a significant predictor of weight change in the multivariate linear regression model.

Effects of the combination of wheel running and atomoxetine on cue- and cocaine-primed reinstatement in rats selected for high or low impulsivity

BACKGROUND

Aerobic exercise and the attention-deficit/hyperactivity disorder medication, atomoxetine (ATO), are two monotherapies that have been shown to suppress reinstatement of cocaine-seeking in an animal model of relapse. The present study investigated the effects of combining wheel running and ATO versus each treatment alone on cocaine-seeking precipitated by cocaine and cocaine-paired cues in rats with differing susceptibility to drug abuse (i.e., high vs. low impulsive).

METHODS

Rats were screened for high (HiI) or low impulsivity (LoI) based on their performance on a delay-discounting task and then trained to self-administer cocaine (0.4 mg/kg/inf) for 10 days. Following 14 days of extinction, both groups were tested for reinstatement of cocaine-seeking precipitated by cocaine or cocaine-paired cues in the presence of concurrent running wheel access (W), pretreatment with ATO, or both (W+ATO).

RESULTS

HiI rats acquired cocaine self-administration more quickly than LoI rats. While both individual treatments and W+ATO significantly attenuated cue-induced cocaine seeking in HiI and LoI rats, only W+ATO was effective in reducing cocaine-induced reinstatement compared with vehicle treatment. There were dose-dependent and phenotype-specific effects of ATO with HiI rats responsive to the low but not high ATO dose. Floor effects of ATO and W on cue-induced reinstatement prevented the assessment of combined treatment effects.

CONCLUSIONS

These findings demonstrated greater attenuation of cue- versus cocaine-induced reinstatement by ATO and W alone and recapitulate impulsivity phenotype differences in both acquisition of cocaine self-administration and receptivity to treatment.

Exercise interventions for smoking cessation

BACKGROUND

Taking regular exercise may help people give up smoking by moderating nicotine withdrawal and cravings, and by helping to manage weight gain.

OBJECTIVES

To determine whether exercise-based interventions alone, or combined with a smoking cessation programme, are more effective than a smoking cessation intervention alone.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2014, and searched MEDLINE, EMBASE, PsycINFO, and CINAHL Plus in May 2014.

SELECTION CRITERIA

We included randomized trials which compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme (which we considered the control in this review). Studies were required to recruit smokers or recent quitters and have a follow-up of six months or more. Studies that did not meet the full inclusion criteria because they only assessed the acute effects of exercise on smoking behaviour, or because the outcome was smoking reduction, are summarised but not formally included.

DATA COLLECTION AND ANALYSIS

We extracted data on study characteristics and smoking outcomes. Because of differences between studies in the characteristics of the interventions used we summarized the results narratively, making no attempt at meta-analysis. We assessed risk of selection and attrition bias using standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified 20 trials with a total of 5,870 participants. The largest study was an internet trial with 2,318 participants, and eight trials had fewer than 30 people in each treatment arm. Studies varied in the timing and intensity of the smoking cessation and exercise programmes offered. Only one included study was judged to be at low risk of bias across all domains assessed. Four studies showed significantly higher abstinence rates in a physically active group versus a control group at end of treatment. One of these studies also showed a significant benefit for exercise versus control on abstinence at the three-month follow-up and a benefit for exercise of borderline significance (p = 0.05) at the 12-month follow-up. Another study reported significantly higher abstinence rates at six month follow-up for a combined exercise and smoking cessation programme compared with brief smoking cessation advice. One study showed significantly higher abstinence rates for the exercise group versus a control group at the three-month follow-up but not at the end of treatment or 12-month follow-up. The other studies showed no significant effect for exercise on abstinence.

AUTHORS' CONCLUSIONS

Only two of the 20 trials offered evidence for exercise aiding smoking cessation in the long term. All the other trials were too small to reliably exclude an effect of intervention, or included an exercise intervention which may not have been sufficiently intense to achieve the desired level of exercise. Trials are needed with larger sample sizes, sufficiently intense interventions in terms of both exercise intensity and intensity of support being provided, equal contact control conditions, and measures of exercise adherence and change in physical activity in both exercise and comparison groups.

Expectancies for cigarettes, e-cigarettes, and nicotine replacement therapies among e-cigarette users (aka vapers)

INTRODUCTION

Use of e-cigarettes has been increasing exponentially, with the primary motivation reported as smoking cessation. To understand why smokers choose e-cigarettes as an alternative to cigarettes, as well as to US Food and Drug Administration (FDA)--approved nicotine replacement therapies (NRT), we compared outcome expectancies (beliefs about the results of drug use) for the three nicotine delivery systems among vapers, i.e., e-cigarette users, who were former smokers.

METHODS

Vapers (N = 1,434) completed an online survey assessing 14 expectancy domains as well as perceived cost and convenience. We focused on comparisons between e-cigarettes and cigarettes to determine the attraction of e-cigarettes as a smoking alternative and between e-cigarettes and NRT to determine perceived advantages of e-cigarettes over FDA-approved pharmacotherapy.

RESULTS

Participants believed that e-cigarettes, in comparison to conventional cigarettes, had fewer health risks; caused less craving, withdrawal, addiction, and negative physical feelings; tasted better; and were more satisfying. In contrast, conventional cigarettes were perceived as better than e-cigarettes for reducing negative affect, controlling weight, providing stimulation, and reducing stress. E-cigarettes, compared to NRT, were perceived to be less risky, cost less, cause fewer negative physical feelings, taste better, provide more satisfaction, and be better at reducing craving, negative affect, and stress. Moderator analyses indicated history with ad libitum forms of NRT was associated with less positive NRT expectancies.

CONCLUSIONS

The degree to which expectancies for e-cigarettes differed from expectancies for either tobacco cigarettes or NRT offers insight into the motivation of e-cigarette users and provides guidance for public health and clinical interventions to encourage smoking-related behavior change.

The joint influence of gender and amount of smoking on weight gain one year after smoking cessation

Weight gain is often associated with smoking cessation and may discourage smokers from quitting. This study estimated the weight gained one year after smoking cessation and examined the risk factors associated with weight gain in order to identify socio-demographic groups at higher risk of increased weight after quitting. We analyzed data from 750 adults in two randomized controlled studies that included smokers motivated to quit and found a gradient in weight gain according to the actual duration of abstinence during follow-up. Subjects who were abstinent for at least 40 weeks gained 4.6 kg (SD = 3.8) on average, compared to 1.2 kg (SD = 2.6) for those who were abstinent less than 20 weeks during the 1-year follow-up. Considering the duration of abstinence as an exposure variable, we found an age effect and a significant interaction between sex and the amount of smoking before quitting: younger subjects gained more weight than older subjects; among light smokers, men gained more weight on average than women one year after quitting, while the opposite was observed among heavy smokers. Young women smoking heavily at baseline had the highest risk of weight gain after quitting.

The relationship between obesity and prescription of smoking cessation medications

The objective of this study was to examine the differences in prescription of smoking cessation medications among smokers with different body mass index (BMI) classifications. A retrospective cross-sectional study was conducted using National Ambulatory Medical Care Survey data (2006-2010). Self-reported current smokers aged 18 years and older were included in the study. The outcome of interest was receiving a prescription for a Food and Drug Administration-approved smoking cessation medication. Multivariate logistic regression was performed to assess the association between the outcome variable and the main independent variable (BMI classification), controlling for other covariates. The results showed that overweight, obese, and severely obese smokers were less likely to be prescribed a smoking cessation medication as compared to normal weight smokers. Although 5.11% of normal weight smokers were prescribed a smoking cessation medication, only 3.70% of overweight smokers, 3.41% of obese smokers, and 2.50% of severely obese smokers were prescribed a smoking cessation medication. In addition, older smokers, whites, smokers visiting primary care providers, smokers receiving tobacco counseling, and nondiabetic smokers were more likely to be prescribed a smoking cessation medication. Lower prescription of smoking cessation medications among overweight, obese, and severely obese smokers might be driven by patients' health concerns and behavioral factors or providers' treatment preferences or biases. The disparity in smoking cessation medication prescription among smokers with different BMI classifications raises quality of care and health care concerns for overweight, obese, and severely obese smokers.

Nicotinic regulation of energy homeostasis

INTRODUCTION

The ability of nicotine, the primary psychoactive substance in tobacco smoke, to regulate appetite and body weight is one of the factors cited by smokers that prevents them from quitting and is the primary reason for smoking initiation in teenage girls. The regulation of feeding and metabolism by nicotine is complex, and recent studies have begun to identify nicotinic acetylcholine receptor (nAChR) subtypes and circuits or cell types involved in this regulation.

DISCUSSION

We will briefly describe the primary anatomical and functional features of the input, output, and central integration structures of the neuroendocrine systems that regulate energy homeostasis. Then, we will describe the nAChR subtypes expressed in these structures in mammals to identify the possible molecular targets for nicotine. Finally, we will review the effects of nicotine and its withdrawal on feeding and energy metabolism and attribute them to potential central and peripheral cellular targets.

Interventions for preventing weight gain after smoking cessation

BACKGROUND

Most people who stop smoking gain weight. There are some interventions that have been designed to reduce weight gain when stopping smoking. Some smoking cessation interventions may also limit weight gain although their effect on weight has not been reviewed.

OBJECTIVES

To systematically review the effect of: (1) Interventions targeting post-cessation weight gain on weight change and smoking cessation.(2) Interventions designed to aid smoking cessation that may also plausibly affect weight on post-cessation weight change.

SEARCH METHODS

Part 1 - We searched the Cochrane Tobacco Addiction Group's Specialized Register and CENTRAL in September 2011.Part 2 - In addition we searched the included studies in the following "parent" Cochrane reviews: nicotine replacement therapy (NRT), antidepressants, nicotine receptor partial agonists, cannabinoid type 1 receptor antagonists and exercise interventions for smoking cessation published in Issue 9, 2011 of the Cochrane Library.

SELECTION CRITERIA

Part 1 - We included trials of interventions that were targeted at post-cessation weight gain and had measured weight at any follow up point and/or smoking cessation six or more months after quit day.Part 2 - We included trials that had been included in the selected parent Cochrane reviews if they had reported weight gain at any time point.

DATA COLLECTION AND ANALYSIS

We extracted data on baseline characteristics of the study population, intervention, outcome and study quality. Change in weight was expressed as difference in weight change from baseline to follow up between trial arms and was reported in abstinent smokers only. Abstinence from smoking was expressed as a risk ratio (RR). We used the most rigorous definition of abstinence available in each trial. Where appropriate, we performed meta-analysis using the inverse variance method for weight and Mantel-Haenszel method for smoking using a fixed-effect model.

MAIN RESULTS

Part 1: Some pharmacological interventions tested for limiting post cessation weight gain (PCWG) resulted in a significant reduction in WG at the end of treatment (dexfenfluramine (Mean difference (MD) -2.50 kg, 95% confidence interval (CI) -2.98 to -2.02, 1 study), phenylpropanolamine (MD -0.50 kg, 95% CI -0.80 to -0.20, N=3), naltrexone (MD -0.78 kg, 95% CI -1.52 to -0.05, N=2). There was no evidence that treatment reduced weight at 6 or 12 months (m). No pharmacological intervention significantly affected smoking cessation rates.Weight management education only was associated with no reduction in PCWG at end of treatment (6 or 12m). However these interventions significantly reduced abstinence at 12m (Risk ratio (RR) 0.66, 95% CI 0.48 to 0.90, N=2). Personalised weight management support reduced PCWG at 12m (MD -2.58 kg, 95% CI -5.11 to -0.05, N=2) and was not associated with a significant reduction of abstinence at 12m (RR 0.74, 95% CI 0.39 to 1.43, N=2). A very low calorie diet (VLCD) significantly reduced PCWG at end of treatment (MD -3.70 kg, 95% CI -4.82 to -2.58, N=1), but not significantly so at 12m (MD -1.30 kg, 95% CI -3.49 to 0.89, N=1). The VLCD increased chances of abstinence at 12m (RR 1.73, 95% CI 1.10 to 2.73, N=1). There was no evidence that cognitive behavioural therapy to allay concern about weight gain (CBT) reduced PCWG, but there was some evidence of increased PCWG at 6m (MD 0.74, 95% CI 0.24 to 1.24). It was associated with improved abstinence at 6m (RR 1.83, 95% CI 1.07 to 3.13, N=2) but not at 12m (RR 1.25, 95% CI 0.83 to 1.86, N=2). However, there was significant statistical heterogeneity.Part 2: We found no evidence that exercise interventions significantly reduced PCWG at end of treatment (MD -0.25 kg, 95% CI -0.78 to 0.29, N=4) however a significant reduction was found at 12m (MD -2.07 kg, 95% CI -3.78 to -0.36, N=3).Both bupropion and fluoxetine limited PCWG at the end of treatment (bupropion MD -1.12 kg, 95% CI -1.47 to -0.77, N=7) (fluoxetine MD -0.99 kg, 95% CI -1.36 to -0.61, N=2). There was no evidence that the effect persisted at 6m (bupropion MD -0.58 kg, 95% CI -2.16 to 1.00, N=4), (fluoxetine MD -0.01 kg, 95% CI -1.11 to 1.10, N=2) or 12m (bupropion MD -0.38 kg, 95% CI -2.00 to 1.24, N=4). There were no data on WG at 12m for fluoxetine.Overall, treatment with NRT attenuated PCWG at the end of treatment (MD -0.69 kg, 95% CI -0.88 to -0.51, N=19), with no strong evidence that the effect differed for the different forms of NRT. There was evidence of significant statistical heterogeneity caused by one study which reported a 4.3 kg reduction in PCWG due to NRT. With this study removed, the difference in weight change at end of treatment was -0.45 kg (95% CI -0.66 to -0.27, N=18). There was no evidence of an effect on PCWG at 12m (MD -0.42 kg, 95% CI -0.92 to 0.08, N=15).We found evidence that varenicline significantly reduced PCWG at end of treatment (MD -0.41 kg, 95% CI -0.63 to -0.19, N=11), but this effect was not maintained at 6 or 12m. Three studies compared the effect of bupropion to varenicline. Participants taking bupropion gained significantly less weight at the end of treatment (-0.51 kg (95% CI -0.93 to -0.09 kg), N=3). Direct comparison showed no significant difference in PCWG between varenicline and NRT.

AUTHORS' CONCLUSIONS

Although some pharmacotherapies tested to limit PCWG show evidence of short-term success, other problems with them and the lack of data on long-term efficacy limits their use. Weight management education only, is not effective and may reduce abstinence. Personalised weight management support may be effective and not reduce abstinence, but there are too few data to be sure. One study showed a VLCD increased abstinence but did not prevent WG in the longer term. CBT to accept WG did not limit PCWG and may not promote abstinence in the long term. Exercise interventions significantly reduced weight in the long term, but not the short term. More studies are needed to clarify whether this is an effect of treatment or a chance finding. Bupropion, fluoxetine, NRT and varenicline reduce PCWG while using the medication. Although this effect was not maintained one year after stopping smoking, the evidence is insufficient to exclude a modest long-term effect. The data are not sufficient to make strong clinical recommendations for effective programmes to prevent weight gain after cessation.

Exercise interventions for smoking cessation

BACKGROUND

Taking regular exercise may help people give up smoking by moderating nicotine withdrawal and cravings, and by helping to manage weight gain.

OBJECTIVES

To determine whether exercise-based interventions alone, or combined with a smoking cessation programme, are more effective than a smoking cessation intervention alone.

SEARCH METHODS

In July 2011, we searched the Cochrane Tobacco Addiction Group Specialized Register for studies including the terms 'exercise' or 'physical activity'. We also searched MEDLINE, EMBASE, PsycINFO, Dissertation Abstracts and CINAHL using the terms 'exercise' or 'physical activity' and 'smoking cessation'.

SELECTION CRITERIA

We included randomized trials which compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme, recruiting smokers or recent quitters, and with a follow up of six months or more.

DATA COLLECTION AND ANALYSIS

We extracted data on study characteristics and smoking outcomes. Because of differences in studies we summarized the results narratively, making no attempt at meta-analysis.

MAIN RESULTS

We identified 15 trials, seven of which had fewer than 25 people in each treatment arm. They varied in the timing and intensity of the smoking cessation and exercise programmes. Three studies showed significantly higher abstinence rates in a physically active group versus a control group at end of treatment. One of these studies also showed a significant benefit for exercise versus control on abstinence at the three-month follow up and a benefit for exercise of borderline significance (p = 0.05) at the 12-month follow up. One study showed significantly higher abstinence rates for the exercise group versus a control group at the three-month follow up but not at the end of treatment or 12-month follow up. The other studies showed no significant effect for exercise on abstinence.

AUTHORS' CONCLUSIONS

Only one of the 15 trials offered evidence for exercise aiding smoking cessation at a 12-month follow up. All the other trials were too small to reliably exclude an effect of intervention, or included an exercise intervention which was insufficiently intense to achieve the desired level of exercise. Trials are needed with larger sample sizes, sufficiently intense interventions, equal contact control conditions, and measures of exercise adherence and change in physical activity in both exercise and comparison groups.

Factors associated with higher body mass index, weight concern, and weight gain in a multinational cohort study of smokers intending to quit

The ATTEMPT cohort study is multi-national, longitudinal study of smokers intending to quit recruited in the U.S.A., Canada, U.K. and France. Data on demographics, medical history, body mass index (BMI), weight concerns and smoking status were collected at baseline and after six months. A total of 2,009 subjects provided data at baseline and 1,303 at six months. High baseline BMI was associated with recent quit attempts, high weight concerns and high cigarette consumption. Weight gain was associated with low income, being single and number of cigarette-free days, but not with baseline weight concerns and confidence in preventing weight gain. Quit attempts were more frequent in subjects with a high baseline BMI and low weight concerns.

Interventions for preventing weight gain after smoking cessation

BACKGROUND

Most people who stop smoking gain weight, on average about 7 kg in the long term. There are some interventions that have been specifically designed to tackle smoking cessation whilst also limiting weight gain. Many smoking cessation pharmacotherapies and other interventions may also limit weight gain.

OBJECTIVES

This review is divided into two parts. (1) Interventions designed specifically to aid smoking cessation and limit post-cessation weight gain (2) Interventions designed to aid smoking cessation that may also plausibly have an effect on weight

SEARCH STRATEGY

Part 1: We searched the Cochrane Tobacco Addiction Group's Specialized Register which includes trials indexed in MEDLINE, EMBASE, SciSearch and PsycINFO, and other reviews and conference abstracts. Part 2: We searched the included studies of Cochrane smoking cessation reviews of nicotine replacement therapy, antidepressants, nicotine receptor partial agonists, cannabinoid type 1 receptor antagonists (rimonabant), and exercise interventions, published in Issue 4, 2008 of The Cochrane Library.

SELECTION CRITERIA

Part 1: We included trials of interventions designed specifically to address both smoking cessation and post-cessation weight gain that had measured weight at any follow-up point and/or smoking six months or more after quitting.Part 2: We included trials from the selected Cochrane reviews that could plausibly modify post-cessation weight gain if they had reported weight gain by trial arm at end of treatment or later.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on smoking and weight for part 1 trials, and on weight only for part 2. Abstinence from smoking is expressed as a risk ratio (RR), using the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. The outcome is expressed as the difference in weight change between trial arms from baseline. Where appropriate, we performed meta-analysis using the Mantel-Haenszel method for smoking and inverse variance for weight using a fixed-effect model.

MAIN RESULTS

We found evidence that pharmacological interventions aimed at reducing post-cessation weight gain resulted in a significant reduction in weight gain at the end of treatment (dexfenfluramine (-2.50kg [-2.98kg to -2.02kg], fluoxetine (-0.80kg [-1.27kg to -0.33kg], phenylpropanolamine (PPA) (-0.50kg [-0.80kg to -0.20kg], naltrexone (-0.76kg [-1.51kg to -0.01kg])). No evidence of maintenance of the treatment effect was found at six or 12 months.Among the behavioural interventions, only weight control advice was associated with no reduction in weight gain and with a possible reduction in abstinence. Individualized programmes were associated with reduced weight gain at end of treatment and at 12 months (-2.58kg [-5.11kg to -0.05kg]), and with no effect on abstinence (RR 0.74 [0.39 to 1.43]). Very low calorie diets (-1.30kg (-3.49kg to 0.89kg] at 12 months) and cognitive behavioural therapy (CBT) (-5.20kg (-9.28kg to -1.12kg] at 12 months) were both associated with improved abstinence and reduced weight gain at end of treatment and at long-term follow up.Both bupropion (300mg/day) and fluoxetine (30mg and 60mg/day combined) were found to limit post-cessation weight gain at the end of treatment (-0.76kg [-1.17kg to -0.35kg] I(2)=48%) and -1.30kg [-1.91kg to -0.69kg]) respectively. There was no evidence that the weight reducing effect of bupropion was dose-dependent. The effect of bupropion at one year was smaller and confidence intervals included no effect (-0.38kg [-2.001kg to 1.24kg]).We found no evidence that exercise interventions significantly reduced post-cessation weight gain at end of treatment but evidence for an effect at 12 months (-2.07kg [-3.78kg, -0.36kg]).Treatment with NRT resulted in attenuation of post-cessation weight gain (-0.45kg [-0.70kg, -0.20kg]) at the end of treatment, with no evidence that the effect differed for different forms of NRT. The estimated weight gain reduction was similar at 12 months (-0.42kg [-0.92kg, 0.08kg]) but the confidence intervals included no effect.There were no relevant data on the effect of rimonabant on weight gain.We found no evidence that varenicline significantly reduced post-cessation weight gain at end of treatment and no follow-up data are currently available. One study randomizing successful quitters to 12 more weeks of active treatment showed weight to be reduced by 0.71kg (-1.04kg to -0.38kg). In three studies, participants taking bupropion gained significantly less weight at the end of treatment than those on varenicline (-0.51kg [-0.93kg to -0.09kg]).

AUTHORS' CONCLUSIONS

Behavioural interventions of general advice only are not effective and may reduce abstinence. Individualized interventions, very low calorie diets, and CBT may be effective and not reduce abstinence. Exercise interventions are not associated with reduced weight gain at end of treatment, but may be associated with worthwhile reductions in weight gain in the long term, Bupropion, fluoxetine, nicotine replacement therapy, and probably varenicline all reduced weight gain while being used. Although this effect was not maintained one year after quitting for bupropion, fluoxetine, and nicotine replacement, the evidence is insufficient to exclude a modest long-term effect. The data are not sufficient to make strong clinical recommendations for effective programmes.

The endocannabinoid system: a new molecular target for the treatment of tobacco addiction

Tobacco addiction is one of the leading preventable causes of mortality in the world and nicotine appears to be the main critical psychoactive component in establishing and maintaining tobacco dependence. Several lines of evidence suggest that the rewarding effects of nicotine, which underlie its abuse potential, can be modulated by manipulating the endocannabinoid system. For example, pharmacological blockade or genetic deletion of cannabinoid CB(1) receptors reduces or eliminates many behavioral and neurochemical effects of nicotine that are related to its addictive potential. This review will focus on the recently published literature about the role of the endocannabinoid system in nicotine addiction and on the endocannabinoid system as a novel molecular target for the discovery of medications for tobacco dependence.

Exercise interventions for smoking cessation

BACKGROUND

Taking regular exercise may help people give up smoking by moderating nicotine withdrawal and cravings, and by helping to manage weight gain.

OBJECTIVES

To determine whether exercise-based interventions alone or combined with a smoking cessation programme are more effective than a smoking cessation intervention alone.

SEARCH STRATEGY

In July 2008, we searched the Cochrane Tobacco Addiction Group Specialized Register for studies including the terms 'exercise' or 'physical activity'. We also searched MEDLINE, EMBASE, PsycINFO, Dissertation Abstracts and CINAHL.

SELECTION CRITERIA

We included randomized trials which compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme, recruiting smokers or recent quitters, and with a follow up of six months or more.

DATA COLLECTION AND ANALYSIS

We extracted data on study characteristics and smoking outcomes. Because of differences in studies we summarized the results narratively, making no attempt at meta-analysis.

MAIN RESULTS

We identified 13 trials, six of which had fewer than 25 people in each treatment arm. They varied in the timing and intensity of the smoking cessation and exercise programmes. Three studies showed significantly higher abstinence rates in a physically active group versus a control group at end of treatment. One of these studies also showed a significant benefit for exercise versus control on abstinence at the three-month follow up and a benefit for exercise of borderline significance (P = 0.05) at the 12-month follow up. One study showed significantly higher abstinence rates for the exercise group versus a control group at the three-month follow up but not at the end of treatment or 12-month follow up. The other studies showed no significant effect for exercise on abstinence.

AUTHORS' CONCLUSIONS

Only one of the 13 trials offered evidence for exercise aiding smoking cessation at a 12-month follow up. All the other trials were too small to exclude reliably an effect of intervention, or included an exercise intervention which was insufficiently intense to achieve the desired level of exercise. Trials are needed with larger sample sizes, sufficiently intense interventions, equal contact control conditions, measures of exercise adherence and change in physical activity in both exercise and comparison groups.

Blocking cannabinoid CB1 receptors for the treatment of nicotine dependence: insights from pre-clinical and clinical studies

Tobacco use is one of the leading preventable causes of death in developed countries. Since existing medications are only partially effective in treating tobacco smokers, there is a great need for improved medications for smoking cessation. It has been recently proposed that cannabinoid CB(1) receptor antagonists represent a new class of therapeutic agents for drug dependence, and notably, nicotine dependence. Here, we will review current evidence supporting the use of this class of drugs for smoking cessation treatment. Pre-clinical studies indicate that nicotine exposure produces changes in endocannabinoid content in the brain. In experimental animals, N-piperidinyl-5-(4-chlorophenyl)-1-(2,4-dichlorophenyl)-4-methylpyrazole-3-carboxamide (rimonabant, SR141716) and N-(piperidin-1-yl)-5-(4-iodophenyl)-1-(2,4-dichlorophenyl)-4-methyl-1H-pyrazole-3-carboxamide (AM251), two cannabinoid CB(1) receptor antagonists, block nicotine self-administration behavior, an effect that may be related to the blockade of the dopamine-releasing effects of nicotine in the brain. Rimonabant also seems efficacious in decreasing the influence of nicotine-associated stimuli over behavior, suggesting that it may act on two distinct neuronal pathways, those implicated in drug-taking behavior and those involved in relapse phenomena. The utility of rimonabant has been evaluated in several clinical trials. It seems that rimonabant is an efficacious treatment for smoking cessation, although its efficacy does not exceed that of nicotine-replacement therapy and its use may be limited by emotional side effects (nausea, anxiety and depression, mostly). Rimonabant also appears to decrease relapse rates in smokers. These findings indicate significant, but limited, utility of rimonabant for smoking cessation.

Weight concerns, postexperimental smoking, and perceived difficulty in quitting in Argentinean adolescents

PURPOSE

To assess the relationship among weight concerns, smoking, and perceived difficulty in quitting among Argentinean adolescents.

METHODS

Logistic regression and profile analyses, stratified by sex, were used to estimate the associations among 8th and 11th grade students (n=2524).

RESULTS

Weight concerns were associated with current smoking status and also with perceived quitting difficulty among female, but not male, Argentinean high school students. Profile analyses determined parallel profiles of weight concerns between female smokers and nonsmokers and between male smokers and nonsmokers.

CONCLUSIONS

The presence of weight concerns among adolescent females may require special consideration in smoking prevention and cessation programs.

Energy intake and energy expenditure during the menstrual cycle in short-term smoking cessation

The effect of short-term smoking abstinence on energy intake and expenditure parameters was investigated for women in different phases of the menstrual cycle (follicular or late luteal) in a rigorous inpatient laboratory setting. Twenty-one participants were randomized to a continued smoking (n = 5) or a smoking abstinence (n = 16) group and admitted for 2 7-day inpatient periods during alternate cycle phases. The smoking abstinence group experienced 2 days of baseline smoking and 5 days of smoking abstinence. Measurements included caloric intake (kcal/24 hours), energy expenditure (by indirect calorimetry), and weight. Results of within-subject analyses indicated no smoking abstinence effect on mean daily total kilocalorie intake, sweet kilocalorie intake, or resting metabolic rate. However, a significant cycle phase effect was observed, with increased kilocalorie intake and expenditure-as well as minor weight gain-occurring during the late luteal phase when premenstrual symptoms are highest. In light of this phase effect, women smokers might benefit by attempting to quit smoking during the follicular phase of their cycle.

Smoking cessation, weight gain, and changes in cardiovascular risk factors during menopause: the Healthy Women Study

OBJECTIVES

The relationship between smoking cessation, subsequent weight gain, and cardiovascular disease risk factors from premenopause to postmenopause was studied.

METHODS

Healthy Women Study participants were assessed for changes in coronary heart disease risk factors from a premenopausal baseline assessment to first- and second-year postmenopausal assessments.

RESULTS

Although ex-smokers gained substantially more weight than nonsmokers and smokers, they did not experience a greater increase in cardiovascular risk factors. In fact, the results indicated a trend toward ex-smokers' high-density lipoprotein cholesterol levels increasing slightly more than those of nonsmokers and smokers.

CONCLUSIONS

Smoking cessation in perimenopausal to postmenopausal women is associated with greater weight gain but appears to be modestly associated with certain positive changes in cardiovascular risk factors.

Weight gain associated with prenatal smoking cessation in white, non-Hispanic women

OBJECTIVE

Our purpose was to assess the effect of prenatal smoking cessation on maternal weight gain and infant birth weight in women who smoked at least five cigarettes per week.

STUDY DESIGN

This prospective study followed up a sample of white, non-Hispanic pregnant smokers enrolled in three multispecialty clinics. By use of t tests, women quitting smoking before 28 weeks and continuing smokers were compared on total weight gain, Institute of Medicine weight gain categories, and infant birth weight.

RESULTS

Quitters gained 36.6 pounds (SD 14.5) and smokers 28.9 pounds (SD 11.7) (p < 0.001). The relative risk of quitters gaining less than the Institute of Medicine minimum was 0.47 (95% confidence interval 0.27 to 0.81). Quitters also gained more than Institute of Medicine standards (relative risk 1.74, 95% confidence interval 1.21 to 2.51), and they were 3.1 times as likely to be delivered of infants weighing > 4000 gm (95% confidence interval 1.18 to 7.97). The four low-birth-weight babies were born to smokers with low weight pain.

CONCLUSION

In this population smoking cessation is associated with a lower risk of gaining too little by Institute of Medicine standards and also with higher risk of gaining more than the Institute of Medicine standard and having infants weighing > 4000 gm. The clinical significance of these effects needs to be determined in further studies.

Characteristics associated with excessive weight gain after smoking cessation in men

OBJECTIVES

Data from two surveys of the National Academy of Sciences-National Research Council Twin Registry, conducted 16 years apart, were used to determine characteristics of individuals that were predictive of excessive weight gain after smoking cessation.

METHODS

Over the follow-up, 2179 men quit smoking and averaged a weight gain of 3.5 kg. Quitters were grouped into four categories of weight change: lost weight, no change, gained weight, and excessive weight gain ("super-gainers").

RESULTS

In comparison with quitters reporting no change in weight, super-gainers were younger, were of lower socioeconomic status, and differed on a number of health habits before quitting (all Ps < .05). At follow-up, super-gainers reported changes in health habits that were significantly different from those seen in quitters reporting stable weight (all Ps < .05). Pairwise concordance for weight change in 146 monozygotic and 111 dizygotic twin pairs in which both twins quit smoking was significantly greater in monozygotic than dizygotic pairs (P < .01).

CONCLUSIONS

These results indicate that super-gainers differ in important ways from those who do not gain weight after smoking cessation and that these weight changes may be influenced by underlying genetic factors.

Beliefs about smoking and diabetes care

The purpose of this study was to address the following questions: 1) Do smokers with diabetes believe that cigarettes have favorable outcomes associated with diabetes management? 2) Do smokers with diabetes believe that quitting smoking negatively impacts diabetes management? 3) Do smokers with diabetes perceive significant others as being supportive of attempts to quit smoking? and 4) What is the relationship between these factors and attitude toward quitting smoking? Patients with insulin-dependent diabetes mellitus (IDDM) completed a measure of Attitude Toward Quitting Smoking, which assessed desire and confidence in ability to achieve cessation, and the Diabetes and Smoking Beliefs Questionnaire, which assessed beliefs regarding cigarettes and diabetes management. Smokers whose attitudes reflected less desire to quit and less confidence in doing so reported that cigarettes had utility in diabetes management, that quitting has negative effects on diabetes, and perceived significant others as only moderately supportive of attempts to quit smoking. Implications of these findings for diabetes education are discussed.

The female weight-control smoker: a profile

Hypothesizing the existence of a subgroup of female smokers for whom nicotine masks, and abstinence unmasks, a tendency toward hyperphagia and perhaps even subthreshold disordered eating, we compared female "weight-control smokers" (WC; n = 46) and "non-weight-control smokers" (NWC; n = 52) on smoking- and eating-related variables. We also examined the relationship between weight-control smoking and withdrawal symptomatology during 48-hours of nicotine abstinence (n = 23). Although WC were not more depressed, anxious, or nicotine-dependent than NWC, they were significantly more likely to report weight gain and increased hunger during abstinence; they also scored higher on Cognitive Restraint and Disinhibition (Three-Factor Eating Questionnaire). The expected correlation of cotinine with weight emerged for NWC but not for WC. Weight-control smoking correlated with increased eating during abstinence. Our findings suggest that WC use dietary restraint as well as smoking to manage weight, and that abstinence may precipitate episodes of disinhibited or binge eating. If WC overinclude women vulnerable to excess or unpredictable eating and consequently to substantial weight gain that can be managed by nicotine, highly focused treatment strategies may be helpful.