E   TABLE 3.-Continued


   Study             Design and sample             Major results               Moderator variables            Limitations

Haworth et al. t1990) 536 women (2.74 nonsmokers, 302
            smokers) interviewed last
          prenatal visit (18%) or within
           day after delivery (82%1

No smoker/nonsmoker pregnancy
weight gain difference

Hickey and       150 men 1124 smokers); Bmonth.
Mulcahy        2.year followups after myocardial
(1973)           infarction

Quitter, reducer, continuing
smoker differences not signilicant

Smoking self-report:
pregnancy weight gain
data only

Smoking self-report;
postmyocardial
infarction may
motivate heahhy
behavior

Iiolme et al.
(1985)

16,202 Oslo men, aged 4049,
screening program; 1,232
(elevated cholesterol or upper
quartile coronary risk score)
randomly assigned diet/smoking
intervention or control: &year
fOlLOWID

17% controls, 24% intervention
quit; l- to 2.yearquitter weight
increased more than controls,
then decreased to below prequit
level

Smoking self-report;
confounded by high
cardiovascular disease
risk health
intervention; weights
not reported

Howell
(1971)

Retrospective, 1,121 men, aged
40-54; 15 to 20year weight gain
examinations

Light smokers (~20
cigarettes/day) gained 1.9 lb less
than heavy smokers, 3.1 lb less
than ex-smokers, 3.6 lb less than
never smokers

Smoking rate: lower rate related
to less weight gain

Retrospective report

Hughes and
Hutchinson
(1963)

37 smokers and 19 ex-smokers
with pulmonary emphysema
followed 23 years

Smokers lost 0.32 lb/yr, ex-
smokers gained 1.17 lb/yr;
significant difference

Smoking self-report;
pulmonary emphysema
population


TABLE 3.-Continued

Study            Design and sample

Major results

Moderator variables

Limitations

Jenkins et al.
( 1973)

2,318 men (546 never smokers,
359 previous quitters, 547 light
smokers, 666 heavy smokers),
aged 39-49, 11 California
corporations in Western
Collaborative Group Study;
changes asses& since age 25;
1960-1969 studv

Weight loss more likely for light
and heavy smokers than never
smokers and quitters

Smoking self-report;
weights not presented

Kramer
( 1982)

175 subjects, commercial
cessation prcgram (41
nonparticipants or nonlocated, 59
quitters. 75 continuing smokers)
2 l-year followup

76% nonsmokers, 56% smokers
gained weight: these smokers
mean gain 1.7 lb, these
nonsmokers mean gain 3.0 lb

All date self-report;
high attrition. data
loss; presentation
incomplete

Lund-Larsen and
Tretli
(1992,

12,329 men and women, aged
2049. cardiovascular disease
project; 2 screenings 3 years
apart

Stpokers mean and relative
weight less than nonsmokers;
female quitters gained 5.95 lb,
male quitters 7.64 lb; smoking-
starter men lost 1.96 lb, women
5.5 lb; smokers and nonsmokers
little/no change

Sex: men. women weight
change/smoking cessation and
initiation similar

Self-report

Manley and
Roland
(1963)

39 male, 55 female smokers,
cessation program; randomly
assigned, 1 of 3 4-week
treatments or attention placebo
control; Bmonth followup; CC
verification

31% abstinent at followup:
abstainers averaged 10.93 lb gain,
relapsers 6.92 lb

Relapser definition
unclear


TABLE 3.-Continued

Study             Design and sample

M.?+ar zwults

Moderator variables

Limitations

Noppa and
Rengtsmn
(1980)

1,362 Swedish women, aged 38-W

Current smokers leaner than
nonsmokers; At 6 years, quitters
gained 7.72 lb; smoking-starters
lost 1.54 lb, nonchangers gained
3.09 lb

Smoking self-report

Pincherle
(19711

222 upper-class male quitters;
followup 2 1 year after first visit

28% gained weight; 22% last

Smoking self-report;
limited population;
incomplete report; no
weights presented

Powell and
McCann
(1981)

29 women, 22 men, 5day
cessation project; 2- and 6month
followup

At 2 months, 54% gained weight,
range 3-20 lb. mean 8.96 lb; all
subjects mean 4.69 lb

Smoking self-report; no
separate abstainer,
smoker data; small
sample sire

Puddey et al.
(1985)

66 cessation program volunteers,
pair-matched by age, sex, body
mass index; randomly assigned
experimental, control groups; 2-
week baseline, &weak treatment,
6week followup; thiocyanate, Co
verification

14 quitters gained 3.97 lb;
controls 0.44 lb

Small sample sire

Rabkin
(1964)

40 male, 67 female smokers,
assigned to 3 cessation groups;
followup 3 weeks w&completion;

67.3% gained weight, average
1.76 lb; skinfold increase 6.6 mm

bicchet&l verification

No age. age at smoking start,
rate. relative weight, anxiety
correlation to male or female
weight change

Small sample size;
weight self-report


TABLE 3.-Continued


Study            Design and sample             Major results               Moderator variables            Limitations



Rantakallio and    12.068 pregnant women. n.        No smoking/nonsmoking                           Pregnant women only;
Hartikainen-Sorrin   Finland, 1966, 15% smokers       pregnancy weight gain difference                        smoking self-report;
(1981)         (smoked after 2 months                                               pregnancy weight gain
         pregnant); nonsmoking controls                                            data only
          matched for age. parity, place of
           residence, marital status

Rush         162 low-income urban pregnant      Mean pregnancy weight gain       Smoking rate: higher rate        Pregnant women only;
(1974)         women, no known medical         lower for smokers (0.73 lb/wk)      related to lower pregnancy       smoking self-report;
          problems, < 140 lb preconception     than nonsmokers (0.90 lb/wk)       weight gain              pregnancy weight gain
          weight; had borne low                                                 data only
          birthweight infant; randomized
            controlled nutritional
          supplementation trial
Schoenenberger    4,421 male MRFIT volunteers,       With MRFIT intervention,                            Smoking self-report;
(1982)        aged 35-57, good health but       significant body weight decrease                        confounded by risk
          upper lO-15% coronary risk       in smokers (mean 4.6 lb).                                  factor reduction
          factor score; randomly assigned      nonsmokers (mean 5.6 lb),                           program participation;
          to intervention or control groups;     reducers (mean 3.75 lb); quitters                        restricted population
          followup 3 annual visits        average weight change minimal
                                (mean 0.55 lb)

Seltzer         794 adult white male veterans,      At admission, ex-smokem 5.9 lb                           White veterans;
(1974)        average age 45, Normative Aging     heavier than nonsmokers, 8.1 lb                         smoking self-report
          Study; screened for "high" health     heavier than currant smokers; at
         level, geographic stability; 214      5 years, quitters gained 8.0 lb,
           screened at 5 years           continuing smokers 3.5 lb


TABLE 3.-Continued

Study            Design and sample

Major results

Moderator variables

Limitations

Stamford et al.
(1966)

13 sedentary women, 48day
su-ful quitters; l-year
follow"p

At 48 days, weight increased 4.85
lb; at 1 year, quitters increased
18.07 lb; 3 relapsers reduced
weight to baseline levels; per
hydrostatic weighing, gain was
96% fat

Small female sample;
smoking self-report

Tuomilehto et al.
(198.5)

10,940 cardiovascular disease
prevention program participants.
aged 25-59, random sample. e.
Finland; selectees with high blood
pressure or hypertensive medicine
asses& 5 years apart; smoking
data from 2,264

Quitters body nmss increased 2.31
lb/m*; starting smokers decreased
1.46 lb/m'

Smoking self-report;
hypertensives

Vandenbroucke
et al.
(1984)

3,091 Netherlands civil servants,
spouses (1,583 men. 1,508
women), aged 40-65, general
health exam: 25year followup

76.6% lean, 65.1% obese men
smoked; 22.1% lean, 11.3% obese
women smoked

Smoking self-report;
restricted population


Gottenborg 1981; Khosla and Lowe 1971) documented increasing
weight differences between smokers and nonsmokers with advancing
age. Typically, aging smokers failed to gain as much weight as aging
nonsmokers.

Three evaluations systematically compared males with females
(Bjelke 1971; Kopczynski 1972; Sutherland et al. 1980). Two of the
three (Bjelke 1971; Sutherland et al. 1980) reported the differences in
body weight between smokers and nonsmokers to be greater in
females than in males.

Longitudinal Evaluations of Smoking and Body Weight

Table 3 presents the results of 43 longitudinal evaluations of the
effects of smoking on body weight. Consistent with the cross-section-
al evaluations, the overwhelming majority (86 percent, 37 of 43)
present evidence that smokers who quit smoking gain weight, that
people who quit smoking gain more weight than nonsmokers, and
that people who initiate smoking lose weight relative to nonsmokers.
Of the six studies that did not find these relationships, three limited
their examination to smoking and weight changes in pregnant
women (Gormican, Valentine, Satter 1980; Haworth et al. 1980;
Rantakallio and Hartikainen-Sorri 1981). two relied on participants
making broad cardiovascular risk factor reduction efforts in subjects
at high risk for cardiovascular disease (Hickey and Mulcahy 1973;
Holme et al. 19851, and the remaining study supplied incomplete
reports of the data (Kramer 1982). Of those studies on the effects of
smoking cessation on weight, the length of followup ranged from 4
days to 7 years. According to these investigations, those who quit
smoking gained an average of 6.16 lb (range: 1.76 to 18.07) during the
year after cessation.

Daily cigarette consumption was the only moderator variable that
received sufficient attention in this group of studies reaching specific
conclusions. Seven of nine studies (78 percent) (Blitzer, Rimm, Giefer
1977; Bosse, Garvey, Costa 1980; Comstock and Stone 1972; Fried-
man and Siegelaub 1980; Hall, Ginsberg, Jones 1986; Howell 1971;
Rush 1974) reported a positive relationship between cigarette
consumption and weight change; that is, as pretest cigarette
consumption increased, postcessation weight gains also increased.
Two studies (Carney and Goldberg 1984; Rabkin 1984) did not find a
relationship between cigarette consumption and postcessation
weight gain.

In summary, there is substantial evidence of an inverse relation-
ship between cigarette smoking and body weight. Of 71 studies
reported since 1970, 62 (87 percent) collectively indicate that
smokers weigh less than nonsmokers and that people who quit
smoking gain weight. Older smokers, females, and those smoking
approximately one pack of cigarettes/day may experience the

431


largest weight control effects of cigarette smoking. Smokers who
smoke heavily tend to gain the most weight following smoking
cessation. These generalizations are consistent with reviews based on
other studies reported since 1880 (Grunberg 1986a). Not all smokers
who quit smoking gain weight. Further, for ex-smokers who do gain
weight, the amount of weight infrequently poses a serious health
risk.

The Role of Nicotine

Animal studies indicate that nicotine administration results in
weight loss or decreased weight gains and that cessation of nicotine
results in body weight gains greater than those of controls (Bowen,
Eury, Grunberg 1986; Grunberg 1982, 1985, 198613; Grunberg,
Bowen, Morse 1984; Grunberg, Bowen, Winders 1986; Grunberg,
Winders, Popp 1987; McNair and Bryson 1983; Morgan and Ellison
1987; Schechter and Cook 1976; Wager-Srdar et al. 1984; Wellman et
al. 1986). Most of these studies report inverse dose-response relation-
ships between nicotine and body weight.

Becent research on nicotine polacrilex gum with humans corrobo-
rates the role of nicotine in body weight effects. Fagerstriim (1987)
reported that subjects who quit smoking were much less likely to
gain weight when they consistently used nicotine polacrilex gum.
Abstinent subjects who regularly used the gum gained less than 2 lb
at a 6month followup. In contrast, the infrequent gum users gained
almost 7 lb (p< 0.05). Emont and Cummings (1987) reported a
significant negative relationship (r=-O.37) between the number of
pieces of nicotine polacrilex gum chewed per day and weight gain for
heavy smokers ( > 26 cigarettes/day). No such relationship between
gum use and weight gain was observed for lighter smokers (< 26
cigarettes/day).

Mechanisms Underlying The Relationship Between
Smoking and Rody Weight

The inverse relationship between smoking and body weight may
result from changes in energy intake, changes in energy expendi-
ture, or both. Energy intake involves dietary intake. Energy
expenditure is affected by behavioral factors (physical activity1 and
biological factors (e.g., metabolism). These potential mechanisms are
examined below.

Dietary Intake

Several prospective investigations have evaluated dietary intake
changes following smoking cessation in humans. Hatsukami and
coworkers (1984) hospitalized 27 smokers for a 7day period. After a
3day baseline, 20 of the subjects were deprived of smoking for 4 days

432


while the remaining 7 served as a control group. During this I-day
period of abstinence, caloric intake increased significantly (from
1,397 to 1,651 kcal), which corresponded with a significant 1.76lb
increase in weight. In the most comprehensive study to date,
Stamford and coworkers (1986) evaluated changes in dietary intake,
physical activity, and resting metabolic rate in 13 sedentary females
who quit smoking for a 48day period. Following smoking cessation,
mean daily caloric consumption increased by 227 kcal, which
accounted for 69 percent of the variance in postcessation weight gain
(4.85 lb). Robinson and York (1986) followed 11 smokers who quit for
7 days. Mean dietary intake significantly increased, but changes in
resting metabolic rate were not observed. Dallosso and James (1984)
followed 10 subjects for 6 weeks after they participated in a stop
smoking clinic. There was a 4percent drop in resting metabolic rate
in smokers who quit, a drop which was reliable when the data were
expressed per kilogram of body weight. The average dietary intake
increased by 6.5 percent, but this difference did not reach statistical
significance.

Preliminary results of a recent investigation indicate gender
differences in the effects of short-term smoking cessation on body
weight and food intake (Klesges, Meyers et al. 1987). Female smokers
who quit for 1 week increased their body weight and dietary intake
significantly more than male smokers who quit. This sex difference
is consistent with animal studies (Grunberg, Bowen, Winders 1986;
Grunberg, Winders, Popp 1987). Given females' marked concerns
regarding postcessation weight gain (Klesges and Klesges, in press),
future studies will need to investigate possible gender differences in
response to smoking cessation.

Several studies indicate that smokers may differ from nonsmokers
in their intake of sweet-tasting simple carbohydrates (sugar) in
particular. In a human laboratory study, Grunberg (1982) observed
that smokers who were allowed to smoke ate less sweet food than
smokers who were not allowed to smoke or nonsmokers. Smokers not
allowed to smoke also reported the greatest preference for sweet
foods. There were no differences among the three subject groups in
consumption of other types of foods. Rodin (1987) conducted a
prospective study in which food intake after smoking cessation was
carefully evaluated. Smokers who gained weight after quitting
smoking increased their sugar consumption in particular. Further,
smokers increase consumption of sweet snack foods when they are
deprived of cigarette smoking (Duffy and Hall, in press; Perlick
1977). On the other hand, two early investigations (Bennett, Doll,
Howell 1970; Richardson 1972) found higher sugar consumption in
smokers relative to nonsmokers. However, Richardson (1972) found
that this difference was because of low-sugar intake in ex-smokers,
while Bennett, Doll, and Howell (1970) argued that the differences

433


were largely due to increased added sugar intake because of hot
beverage consumption. These two studies, which are inconsistent
with the more recent studies, did not carefully measure all food
intake and did not assess intentional changes in food intake to
control body weight.

Several animal experiments have documented that food intake
decreases during nicotine administration and increases after admin-
istration has ceased and that these changes in food intake corre-
spond with changes in body weight (Bowen, Eury, Grunberg 1986;
Grunberg 1982; Grunberg, Bowen, Winders 1986; Levin et al. 1987;
McNair and Bryson 1983; Wager-Srdar et al. 1984). Consumption of
sweet foods by male rats is particulary affected by nicotine (Grun-
berg 1982; Grunberg et al. 1985). However, nicotine also reduces
bland food intake in female rats and has a greater effect on body
weight of female rats than of male rats (Grunberg, Winders, Popp
1987; Grunberg, Bowen, Winders 1986; Levin et al. 1987).
Several investigations have reported that changes in body weight
in animals also occur without observing decreases in food intake as
the result of nicotine administration (Grunberg, Bowen, Morse 1984;
Schechter and Cook 1976; Wellman et al. 1986). In one investigation,
chronic exposure to cigarette smoke reduced body weight and food
intake in rata; however, hamsters exposed to cigarette smoke
decreased body weight without reducing food intake (Wager-&&r et
al. 1984). Several methodological factors complicate these results,
including the use of different strains of animals, different routes of
administration and dosages of nicotine, and whether acute versus
chronic effects of nicotine were reported. However, these results
indicate that more than the mechanism of food intake was involved
in producing nicotine- and smoking-related weight changes.

Data from short-term human studies and several animal experi-
ments indicate that dietary intake is involved with smoking-related
energy imbalance. Based on self-reported cross-sectional surveys, it
has been reported that smokers' dietary intake is the same as
(Albanes et al. 1987; Fehily, Phillips, Yarnell 1984; Fisher and
Gordon 1985; Matsuya 1982) or significantly higher than (Picone et
al. 1982; Stamford et al. 1984a,b) that of nonsmokers while the
smokers simultaneously maintained a lower body weight. Assuming
that smokers are not consistently biased in their reports of dietary
intake, it appears that either differences in physical activity or
metabolic rate are maintaining the body weight differences between
smokers and nonsmokers.

Physical Activity

The data available from cross-sectional investigations, short-term
prospective studies, and animal investigations seem to indicate that
changes in physical activity do not play a role in either differences in

434


body weight between smokers and nonsmokers or the weight gain
associated with smoking cessation. Some cross-sectional investiga-
tions have found that smokers have lower levels of physical activity
compared with nonsmokers (Karmas 1981). Others have not found
differences in physical activity and physical fitness between smokers
and nonsmokers (Gyntelberg and Meyer 1974; Stamford et al. 1984b;
Stephens and Pederson 1983). A recent review (Blair, Jacobs, Powell
1985) that addressed the relationships among exercise, physical
activity, and smoking concluded that smoking and physical activity
are negatively associated; however, the relationship was extremely
weak and variable.

Animal studies on the relationship between nicotine and physical
activity have generally found that physical activity plays a small
role or fails to correspond to decreases in weight during nicotine
administration (Bowen, Eury, Grunberg 1986; Cronan, Conrad,
Bryson 1985; Grunberg and Bowen 1985b). One study found that
decreases in physical activity after cessation of nicotine appeared to
contribute to postdrug body weight increases (Grunberg and Bowen
1985b), but this effect was quite small and occurred only in males.
A few prospective human investigations have evaluated physical
activity changes following smoking cessation (Hatsukami et al. 1984;
Hofstetter et al. 1986; Klesges, Brown et al. 1987; Rodin 1987;
Stamford et al. 1986). These investigations found no changes in
physical activity as a result of smoking cessation.

Metabolic Rate

Metabolic rate is an important consideration in energy imbalances
associated with smoking cessation because approximately 75 percent
of total energy expenditure is in the form of metabolism (Bernstein
et al. 1983; Ravussin et al. 1982). Metabolism increases as the result
of acute nicotine administration and immediate effects of smoking
(Ghanem 1973; Ilebekk, Miller, Mjos 1975; Robinson and York 1986;
Schievelbein et al. 1978; Wennmalm 1982). The major question,
however, is whether these effects persist long enough to have a direct
impact on body weight. Given that (1) smokers do not have higher
levels of physical activity compared with nonsmokers (Blair, Jacobs,
Powell 1985). (2) some studies report smokers' dietary intakes are the
same as or higher than those of nonsmokers (Picone et al. 1982;
Stamford et al. 1984a,b), and (3) smokers maintain lower body
weights than nonsmokers, it is reasonable to postulate that changes
in metabolism contribute to the relationship between smoking and
body weight. Additionally, there are several reports in the literature
on animals that have documented nicotine-induced reductions in
body weight without a concomitant reduction in food intake (Grun-
berg, Bowen, Morse 1984; Schechter and Cook 1976; Wellman et al.
1986).

435


Direct evidence supporting a chronic metabolic mechanism that
modulates the smoking/body weight relationship is beginning to
emerge. Metabolic rate was chronically measured in a study of rat
and hamster exposure to cigarette smoke (Wager-Srdar et al. 1984).
Higher resting metabolic rates were observed on only one of the test
days compared with the pretest in the rat investigation, while no
significant differences were observed in the hamster study. Another
recent investigation (Wellman et. al. 1986) evaluated brown adipose
tissue (BAT) thermogenesis at different levels of nicotine and
caffeine injections. No differences in BAT thermogenesis were
observed in response to either nicotine or caffeine. The group that
received a combination of caffeine and nicotine showed a 63 percent
increase in BAT thermogenesis.

The few studies that have evaluated metabolic rate changes in
response to smoking cessation in humans have produced inconclu-
sive results. Three investigations found metabolic changes after
cessation in human smokers. An early report (Glauser et al. 1970)
found decreases in oxygen consumption for seven male subjects who
quit smoking for 1 month (neither food intake nor physical activity
was monitored). A more recent investigation found a 4-percent drop
in metabolic rate (reliable when data were expressed per kilogram of
body weight) and no significant increase in dietary intake for 10
subjects who quit smoking for 6 weeks (Dallosso and James 1984). In
the only study that used a respiration chamber, Hofstetter and
others (1986) reported that total energy expenditure was 10 percent
higher during a 24-hr period of smoking versus a 24-hr period of
abstinence in eight smokers. No changes were observed in physical
activity or mean basal (sleeping) metabolic rate (dietary intake was
held constant). However, this difference in energy expenditure
disappeared after 24 hr.
Three investigations did not find a change in metabolic rate as the
result of smoking cessation. Burse and associates (1982, 1975) did not
observe changes in resting metabolism in a sample of four smokers
who quit for 3 weeks. This investigation did find reliable increases in
desire for food, however. In another study, 11 smokers were studied
after a `I-day period of smoking abstinence (Robinson and York 1986).
Total energy expenditure following a meal did not change during the
cessation period. Stamford and colleagues (1986) failed to fmd
changes in oxygen consumption in 13 subjects who quit smoking for
48 days. This investigation did find marked dietary intake changes
that accounted for 69 percent of the variance of postcessation weight
gain.

There are several possible explanations for the inconsistency
observed in the literature on metabolic rate. Different investigators
have used different criteria (e.g., resting oxygen consumption, BAT
thermogenesis) for operationalizing metabolism. It is possible that

436


previous dieting history (Brownell et al. 1986) and the use of nicotine
polacrilex gum (Fagerstrom 1987) may directly impact the metabolic
response to smoking cessation. It is not clear what the metabolic
response to nicotine with added agents is likely to be. For example,
one study found that while neither nicotine nor caffeine alone
produced a change in BAT thermogenesis, the two combined
increased thermogenesis by 63 percent (Wellman et al. 1986). This
finding is particularly interesting given that smokers may be more
likely to drink caffeinated beverages than nonsmokers (Blair et al.
1980). Finally, the available literature on human studies used very
small subject groups, making it impossible to detect subtle but
potentially meaningful changes in resting metabolic rate. The small
sample sizes do not allow for an evaluation of variables that may
potentially moderate the metabolic response to smoking cessation.

Summary of Mechanisms Literature

Changes in dietary intake appear to be involved in weight gains
after cessation of smoking or cessation of nicotine administration.
Physical activity plays little or no role in the relationship between
smoking and body weight. The data on metabolic contributions to
postcessation weight gain are suggestive, but further research is
needed. Unfortunately, much of the relevant human research
literature is characterized by small sample sizes, short followup
evaluations, and inadequate evaluations of energy balance following
smoking cessation. To date, only one investigation has comprehen-
sively evaluated (i.e., simultaneous assessment of dietary intake,
physical activity, and metabolic rate) energy balance changes as the
result of smoking cessation. This was a sample of 13 sedentary
females followed for 48 days (Stamford et al. 1986). Comprehensive,
prospective evaluations of energy balance changes in response to
smoking cessation are needed. Additionally, no study has evaluated
possible long-term changes in dietary intake, physical activity, and
metabolic rate as a result of smoking cessation. The longest followup
period reported in the literature to date is 2 months (Dallosso and
James 1984). Finally, evaluation of potential moderator variables of
dietary intake, physical activity, and metabolic rate as the result of
cessation is needed. Gender (Grunberg, Winders, Popp 1987; Klesges,
Meyers et al. 1987), previous dieting history (Brownell et al. 1986;
Hall, Ginsberg, Jones 1986). pretest levels of lipoprotein lipase
(Carney and Goldberg 1984), and the use of nicotine polacrilex gum
(Fagerstrom 1987) appear to be important variables influencing
weight gain and need further investigation.


Does the Relationship Between Smoking and Weight
Promote Either the Initiation or Maintenance of Smoking
Behavior?

Some research attention has been given to body weight as a
potential moderator of smoking initiation, maintenance, and cessa-
tion. Unfortunately, many investigations do not report weight-
related issues (Borkon, Baird, Siff 1983; Eiser et al. 1985; Pederson
and Lefcoe 1976; Perri, Richards, Schultheis 1977). The investiga-
tions that have evaluated these issues consistently report relation-
ships between body weight and smoking initiation (Charlton 1984a)
and maintenance (Klesges and Klesges, in press).

A survey of 16,000 school children (Charlton 1984a) in England
found that the heaviest regular smokers were the most likely to
agree that smoking controls weight (42.2 percent) compared with
those students who never smoked (16.6 percent). Agreement in-
creased with increased levels of smoking. More girls than boys
agreed with this statement, and girls were also more likely to be
regular smokers. Charlton (1984b) also reported that among the
perceived effects of smoking, smokers viewed "calming the nerves"
as the most popular reason (72 percent) followed by "smoking keeps
your weight down" (39 percent).

Other investigations are consistent with the Charlton (1984a,b)
report. In a recent study of 1,000 adolescents in Canada (Feldman,
Hodgson, Corber 1985), significantly more girls than boys were
concerned about becoming overweight (36 vs. 14 percent, p<O.OOl).
In girls 18 years or older, 52.6 percent of smokers reported worrying
about their weight, whereas only 31 percent of nonsmokers reported
weight-related concerns (p < 0.05). In a study of smoking intentions
among 406 U.S. high school males, Tucker (1983) reported that
overweight boys scored much higher on smoking intent than either
normal weight or underweight boys (p<O.O05). Another survey
evaluated gender differences in a sample of 221 college cigarette-
smoking intenders and nonintenders (Page 1983). Results indicated
that females were much more likely to intend to smoke than males.
Females were also more likely to believe that smoking maintains
body weight, and smoking intenders were also more likely to believe
that smoking controls weight. Finally, in a retrospective survey of
more than 1,090 young adults (Klesges and Klesges, in press),
overweight females reported that they were much more likely (20
percent) to start smoking for weight-related reasons compared with
normal-weight females (2 percent). No differences between over-
weight versus normal-weight males (8 vs. 6 percent) were observed.

Several surveys on smoking maintenance have shown that individ-
uals report that weight control is a powerful motivator to continue to
smoke. Physicians who smoked were much more likely than those
who had quit (46 vs. 22 percent) to believe that smoking cessation

438


increases appetite and weight (Fletcher and Doll 1969). Nurses who
failed to quit smoking listed (in order) loss of determination, stress,
and weight gain as the major reasons for failure (Knobf and Morra
1983). Beliefs regarding the weight-control effects of smoking and
quitting differentiate smokers and nonsmokers (Hill and Gray 1984;
Loken 1982; Shor et al. 1981). Females are particularly worried
about postcessation weight gains (Klesges and Klesges, in press;
Sorensen and Pechacek 1987). They are more likely to endorse
smoking as an active weight-loss strategy (39 vs. 25 percent) and are
more likely to report relapse for weight-related reasons (20 VS. 7
percent) (Klesges and Klesges, in press).

The research cited above is based on self-reports of the weight-
control effects of smoking and, as such, could be viewed as an excuse
for smoking. Two recent worksite-based investigations evaluated
whether pretest concerns regarding smoking and weight-related
issues prospectively predicted cessation. Maheu (1985) evaluated 49
subjects who either received a competition-based (n=32) or a no-
competition condition (n = 17). In the competition-based condition,
participants were told that they would be rewarded if those at their
worksite lost more weight than those at a neighboring worksite. At a
3-month followup, 78 percent of the subjects in the competition and
76 percent of the subjects in the no-competition condition were
reportedly abstinent. Regression analysis at followup indicated that
the best pretest predictors of smoking cessation (in order) were
negative responses to the questions: (1) "Do you think smoking helps
control your weight?"; (2) "Did one of your parents smoke when you
were young?"; and (3) "If you have tried to quit before, did you suffer
any withdrawal symptoms ?" Klesges, Brown, and associates (1987)
found that the best predictors of cessation at posttest were pretest
cotinine levels and anticipated weight gain as the result of smoking
cessation. The best predictors of cessation at followup were the
number of coworkers who smoked followed by anticipated cessation-
related weight gain.

A recent community survey evaluated predictors of current and
former smoking status in a sample of 611 nonsmokers, ex-smokers,
smokers who had tried to quit smoking, and smokers who had not
attempted cessation (Klesges, Somes et al. 19871. The best predictors
of smokers who had never attempted cessation versus those with a
history of cessation efforts were a greater concern related to weight
control, followed by knowledge of the health consequences of
smoking. Smokers who had not attempted cessation were significant-
ly more likely to cite weight-control issues compared with smokers
who had made active attempts at smoking cessation. Collectively,
these investigations indicate that weight-related concerns may not
only predict successful smoking cessation, but also attempted
smoking cessation.

439


Weight gain following smoking cessation as a predictor of smoking
relapse has been evaluated in two recent investigations. Hall,
Ginsberg, and Jones (1986) found a relationship between smoking
status at a l-year followup and weight gain at 6 months; greater
weight gain during the first 6 months predicted continued absti-
nence. This finding was contrary to expectations. In another
investigation, Gritz, Carr, and Marcus (in press) found that continu-
ous abstainers had gained an average of 6.1 lb, relapsers had gained
2.7 lb and subsequently lost half the gain (1.3 lb), and never quitters
had gained only 0.3 lb. While it was expected that postcessation
weight gain would be predictive of relapse, one would expect that
those who have been abstinent from cigarettes would have gained
more weight than those whc either failed to quit or those who
relapsed, because these latter groups have regained the weight
reducing effects of smoking. Additional research will need to
evaluate the impact of weight gain on relapsers at the point of
relapse compared with the impact on abstainers at a comparable
point in time. Further, it is clear that actual weight may have little
relationship with subjects' perceptions of their weight status. For
example, overweight males consistently view themselves as normal
weight, while underweight and normal-weight females consistently
view themselves as overweight (Klesges 1983). Very small weight
gains in some subjects (e.g., normal-weight females) may be much
more predictive of relapse than very large weight fluctuations in
others (e.g., overweight males) (Klesges 1983). Future research
should evaluate potential variables (e.g., gender, obesity) that may
moderate the relationship between weight gain and smoking relapse.

In summary, weight-related issues may be important in the
maintenance and cessation of smoking. Weight-reducing effects of
smoking may encourage smoking initiation by some people, but the
data on this point are currently unconvincing. Future research
should focus on who (e.g., males versus females, those with a history
of chronic dieting) is most at risk to smoke because of weight-related
concerns. In particular, prospective studies on weight-related issues
as they predict smoking initiation, cessation, and relapse are needed.

Implications for Tobacco Use

Cigarette smokers weigh less than comparably aged nonsmokers,
and many smokers who quit smoking gain weight. This inverse
relationship between smoking and body weight is well established,
and the role of food intake and energy expenditure as mechanisms
for this relationship is currently receiving research attention. The
post-smoking weight gains are frequently undesired by the ex-smok-
er. People are quite aware of the relationship between smoking and
body weight, and this relationship may encourage some people to
initiate smoking and to keep smoking. However, other people may

440


modify food intake and avoid weight gains after cessation of
smoking.

Summary and Conclusions

1. After smoking cigarettes or receiving nicotine, smokers per-
form better on some cognitive tasks (including sustained
attention and selective attention) than they do when deprived
of cigarettes or nicotine. However, smoking and nicotine do not
improve general learning.

2. Stress increases cigarette consumption among smokers. Fur-
ther, stress has been identified as a risk factor for initiation of
smoking in adolescence.

3. In general, cigarette smokers weigh less (approximately 7 lb
less on average) than nonsmokers. Many smokers who quit
smoking gain weight.

4. Food intake and probably metabolic factors are involved in the
inverse relationship between smoking and body weight. There
is evidence that nicotine plays an important role in the
relationship between smoking and body weight.

441


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