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The Relevance of Stress and

Eating to the Study of

Gender and Drug Use

Neil E. Grunberg, Ph.D., and Laura Cousino Klein, M.S.

INTRODUCTION

Cigarette smoking is the single most preventable cause of death

and illness in our country; it exacts a staggering toll on health services

and runs up high health costs (Grunberg et al. 1997; U.S. Department

of Health and Human Services 1989). Cigarette smoking involves the

self-administration of an addictive drug, nicotine (U.S. Department of

Health and Human Services 1988). Cigarette smoking incidence in

the United States differed between men and women for decades, but

recently became similar (Grunberg et al. 1997; Centers for Disease

Control 1991). Now it is plausible that gender differences in smoking

behavior could reverse as more girls than boys begin to smoke.

Understanding why people smoke and how to help prevent smoking

by women and men, and by girls and boys, deserves our attention.

Eating behavior is central to survival, but the U.S. population,

particularly women, appears to be obsessed with reducing body weight

(Brownell 1991; Rodin 1993). Diet pills, diet programs, and images

of low ideal body weights and shape are pervasive in U.S. society and

account for a remarkable amount of income. Yet obesity is on the rise

in the United States (Brownell and Rodin 1994). Because eating

behavior and body weight have been related to drug use and abuse

(Grunberg and Baum 1985, pp. 25-62), the study of these topics is

important in the consideration of gender and drug use.

Stress-induced illnesses, chronic fatigue syndrome, and the role

of stress in causing marital and family strife all seem to be on the rise.

Stress also affects cigarette smoking, other drug use, and eating (Greeno

and Wing 1994; Grunberg and Baum 1985, pp. 25-62; Kosten et al.

1986; O’Doherty 1991; Shaham et al. 1992, 1993; Shiffman and Wills

1985). Therefore, how stress affects substance use by women and men

is worth considering (Baum and Grunberg 1991).
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This chapter addresses cigarette smoking, other drug use, and eating

as these topics relate to gender, stress, and each other and uses examples

from research to highlight the value of studying cigarette smoking,

other drug use, and eating behavior along with the important variables

of gender and stress. This chapter is not meant to be exhaustive. It is

meant to illustrate the importance of these variables and to focus

interest and future work on them.

CIGARETTE SMOKING

Smoking and Gender

Roughly one out of four women and one out of four men smoke

cigarettes in the United States today (Grunberg et al. 1997; U.S.

Department of Health and Human Services 1989). These statistics are

remarkable in light of the changes since 40 years ago, when roughly the

same proportion of women but more than 50 percent of men smoked

(Centers for Disease Control 1991; U.S. Department of Health and

Human Services 1989). Because as many or more adolescent girls now

smoke as do adolescent boys (U.S. Department of Health and Human

Services 1994), U.S. society could soon have more female than male

smokers. Outside the United States, the statistics and gender differences

are more pronounced. In Japan, for example, 15 percent of women and

roughly 70 percent of men smoke. In Indonesia 5 percent of women and

75 percent of men smoke (Crofton 1990; Grunberg et al. 1991). As the

tobacco industry continues to penetrate Asian markets, there is the

disturbing likelihood that the lives and health of Asian women will

suffer. It is, therefore, important to determine the causes of these gender

differences in tobacco use and how to prevent increased use. Cigarette

use is a result of the availability of products, perceptions of health risks,

perceptions of benefits, attitudes toward this behavior, and psychopharmacologic effects of the product (Grunberg et al. 1991, 1997;

U.S. Department of Health and Human Services 1989). With regard

to smoking and gender, it is important to determine which variables

contribute to use by females compared with males, including

psychological, behavioral, pharmacological, and biological factors.

An unfortunate example regarding smoking and gender illustrates

how well-intentioned programs can go awry because of a lack of

understanding of gender differences and smoking. In an attempt to

protect the public from the dangers of smoking, public health advocates
175

long have encouraged a decrease in the nicotine and tar content of

cigarettes. Logically, less nicotine and tar content should expose

individuals to fewer toxic effects of a given cigarette. However, two

important matters were not taken into account. First, most smokers are

addicted, and they smoke to self-administer nicotine (U.S. Department

of Health and Human Services 1988). Therefore, reduced nicotine

content often results in smokers adjusting their smoking topography

by either increasing the number of cigarettes smoked or increasing the

number of puffs or depth of inhalation per cigarette (Kozlowski et al.

1980; U.S. Department of Health and Human Services 1988). This

“compensatory smoking” can actually increase the health risks of

smoking. Second, with regard to gender differences and smoking,

women may be more sensitive to nicotine than are men (Bättig et al.

1982; Silverstein et al. 1980), a finding consistent with studies with

female laboratory animals (Bättig 1981; Grunberg et al. 1986, 1987;

Levin et al. 1987; Rosecrans 1971, 1972). Therefore, women may

smoke less when nicotine yields from tobacco products are high and

smoke more when nicotine yields are low.

Smoking, Eating, Body Weight, and Gender

It is now well established that smoking is inversely related to

body weight and decreases consumption of certain foods (e.g., sweettasting, high-carbohydrate foods) (Grunberg 1990, pp. 273-316, 1992;

U.S. Department of Health and Human Services 1988). These clinically

significant relationships have suggested investigations that have revealed

the actions of nicotine, the primary pharmacological agent of addiction

in tobacco. For these effects, nicotine has greater actions on females

(women and animals) than on males (Grunberg et al. 1986, 1987, 1991;

Levin et al. 1987; Winders and Grunberg 1989). These studies have

revealed that women gain relatively more weight after smoking cessation

than do men and that the most effective behavioral and pharmacological

treatment strategies for smoking cessation and prevention should have

somewhat different emphases for women and men.

Smoking, Stress, and Gender

Stress increases smoking (Shiffman and Wills 1985; U.S. Department

of Health and Human Services 1988). Some investigators argue that

smoking is calming or anxiolytic, but there is little support for this
176

interpretation (U.S. Department of Health and Human Services 1988).

Other investigators argue that smoking is not anxiolytic but that

smoking cessation results in an abstinence phenomenon that includes

increased anxiety or stress (Schachter 1978). Therefore, the argument

goes, smokers who continue smoking are less anxious than smokers who

are abstinent, but smoking per se is not anxiolytic (Schachter 1978).

Alternatively, smoking increases during stress because stress alters the

effects of smoking (Grunberg and Kozlowski 1986; Grunberg et al. 1983;

U.S. Department of Health and Human Services 1988). It would be

valuable to determine whether there are gender differences in the effects

of stress on smoking, smoking on stress, smoking abstinence as a stress

response, smoking abstinence on stress responses, and stress on smoking

relapse and the role of nicotine or relative potency of nicotine on stresssmoking interactions.

Smoking, Drug Use, and Gender

Smoking is highly correlated with the use of licit and illicit drugs

(Henningfield et al. 1990). Smoking is commonly associated with

alcohol consumption (DiFranza and Guerrera 1988; Kozlowski et al.

1986, 1993) and increases during drinking (Griffiths et al. 1976;

Henningfield et al. 1984; Keenan et al. 1990; Mintz et al. 1985).

Cigarette smoking and alcohol consumption are considered to lead to

the subsequent use and abuse of illicit drugs, including marijuana and

cocaine (Kandel et al. 1992). Given the facts that nearly 90 percent

of all smokers begin smoking during adolescence and that adolescents

are particularly vulnerable to illicit drug use (U.S. Department of Health

and Human Services 1994), the relationships and mechanisms by which

smoking translates into the use of other addictive drugs are important

but unresolved. In this context, gender has never been addressed as a

variable in terms of its relationship to multiple drug use or the “gateway”

hypothesis. Because gender differences exist in sensitivity to nicotine

(Grunberg et al. 1991) and because recent animal research suggests

gender differences in response to the effects of opiates (Brown et al.

1995; Klein et al. 1997), it is logical to postulate that gender differences

exist in the relationship between cigarette smoking and other drug use.

Furthermore, the study of these relationships might reveal biobehavioral

and neuropharmacological mechanisms of action with clinical and
177

treatment applications. For now, however, little is known about these

relationships.

DRUG USE

Drug Use and Gender

Gender differences exist in the use of licit and illicit drugs (Lex

1991). For example, more men than women drink and abuse alcohol,

use cocaine, and use marijuana (Lex 1991). The epidemiology is a

first critical step, but researchers must move on to address causality

and mechanisms. There are clear data that gender differences exist

with specific drugs, which presents opportunities to access populations

to study psychological, social, behavioral, and biological mechanisms

that may contribute to these important differences.

Animal studies allow for careful evaluation of behavior and biology

with regard to drug use. Recent studies indicate that female rats selfadminister more opiates than do male rats (Brown et al. 1995; Klein et

al. 1997), but male rats exhibit more withdrawal behaviors (Klein et al.

1997). In addition, animal studies provide a useful tool to manipulate

drug history and environmental conditions that may play a role in

gender differences related to drug use and abuse. Recent studies have

manipulated environmental stress in male and female rats, have allowed

subjects to self-administer opiates, and have reported that there are

gender differences in responses to environmental stressors and in opiate

self-administration (Brown and Grunberg 1995; Brown et al. 1995).

Drug Use, Stress, and Gender

A recent series of laboratory studies examined the effects of

stressors on opiate self-administration by male and female rats (Brown

et al. 1995; Klein et al. 1997; Shaham 1993; Shaham et al. 1992,

1993). Physical stressors (e.g., immobilization, mild electric foot shock)

increased opiate self-administration by male rats during the initiation,

maintenance, and relapse phases of the studies compared with no-stress

conditions (Shaham 1993; Shaham et al. 1992, 1993). A different

stressor (predictable foot shock) also increased opiate self-administration

by male rats compared with unpredictable foot shock (Klein et al. 1997).
178

For female rats, predictable foot shock increased opiate self-administration

compared with unpredictable foot shock, but unpredictable foot shock

increased opiate self-administration over no-stress control conditions

for only half the females (Klein et al. 1993, 1997). This latter finding

indicates that individual differences in responses among females are

important (Klein et al. 1993). Furthermore, environmental stressors

(e.g., housing conditions) decreased opiate self-administration by female

rats but had no effect on opiate consumption by male rats (Brown et al.

1995). This study also revealed sex differences in drug sensitivity under

stress (e.g., drug-induced deaths among females despite lower amounts

of drug consumption) (Brown et al. 1995). This finding would not have

been uncovered by a study that lacked the inclusion of stress and gender

as independent variables. Much work is still needed to determine the

role stress plays for females and males in drug self-administration.

Drug Use, Eating, and Gender

The relationship between nicotine and eating (as discussed above

under “Smoking, Eating, Body Weight, and Gender”) reveals that there

are gender differences consistent with the widely reported concerns of

women about weight gain after smoking cessation. As a result of reports

that female laboratory animals, as well as human females, are more

sensitive to the effects of nicotine and nicotine cessation on behavioral

and biological variables related to body weight and eating behavior,

clinical studies have followed up on these issues (U.S. Department of

Health and Human Services 1988). These studies led to new research

studies of diet, mood, and stress (Greeno and Wing 1994; Grunberg and

Klein 1995; Grunberg and Straub 1992; Klein et al. 1996). In a similar

vein, drug use (other than nicotine) and eating by females and males is

an important but understudied area that also may reveal mechanisms and

treatment strategies that are not obvious from studies that avoid multiple

variables. For example, various drugs (e.g., opiates, cocaine, amphetamines) are known to affect eating behavior (e.g., Levine and Morley

1983), but are there gender differences in these effects? Food deprivation

affects drug self-administration (Carroll and Meisch 1984, pp. 47-88),

but what about the effects of gender? Specific food consumption (e.g.,

craving for carbohydrates, specific nutrient selection) is related to specific

neurochemicals (e.g., serotonin) that are altered by specific drugs (e.g.,

nicotine, opiates) (Grunberg 1986; Kanarek and Marks-Kaufman 1988,
179

pp. 1-25; Marks-Kaufman 1982; Marks-Kaufman and Lipeles 1982).

On a clinical level, it is known that depression is associated with

changes in eating behavior (American Psychiatric Association 1994),

but little is known about how best to deal with this problem in men

compared with women. The interactions among drug use, eating, and

gender are indeed complicated, but they are worth exploring.

EATING

Eating and Gender

Within a chapter on drugs, it is a judgment call whether to include

information about eating. We certainly are not suggesting that eating

is synonymous with drug use and abuse, but many of the biological and

psychosocial variables and mechanisms involved in drug use also are

involved in eating behavior. It also has been suggested that the same

biological processes that underlie eating regulation are involved in

drug addiction and craving (Grunberg and Baum 1985, pp. 25-62).

Whether or not this is true, this conceptual framework is a tool to design

investigations, categorize and critique available literature, delineate

important avenues, and develop specific hypotheses that are yet to

be explored.

There are gender differences in eating that are obvious and others

that are less obvious. In general, men consume more food, of all types,

than do women. In U.S. society, women tend to be more concerned

about body weight and more self-conscious about what they eat and

in front of whom (Brownell 1991; Rodin 1993). Women are markedly

more likely to suffer from anorexia nervosa and bulimia nervosa (Hsu

1989). Women and men both have a high prevalence of obesity, with

women in lower socioeconomic groups showing the highest prevalence

rates (Centers for Disease Control and Prevention 1993). It is relevant

to consider the research and clinical literature on eating and eating

disorders in men and women to search for major, reliable findings that

may be applicable to drug use.

Eating, Stress, and Gender

Recently, there has been a growing interest in the relationships

among eating, stress, and gender. Greeno and Wing (1994) published

a substantial review of the stress and eating literature and noted that
180

several studies have considered gender. A few studies have addressed

eating, stress, and gender using experimental paradigms and controlled

environments. These studies have revealed that stress and eating

are related but in different ways for men and women. Moderate stress

seems to increase the eating of specific foods by women, whereas stress

generally decreases eating by men (Grunberg and Klein 1995; Grunberg

and Straub 1992; Klein et al. 1996). In this context, it is relevant to

consider animal studies on eating and stress (e.g., Morley and Levine

1980; Morley et al. 1983) to draw from already established paradigms.

These studies, however, did not consider gender. As discussed above

under “Eating and Gender,” we advocate the consideration of the eating

literature in the present context because there are important parallels

within appetitive behaviors between eating and drug use and because

there is a substantial, available literature on eating behavior that avoids

the difficulties of working with illicit drugs.

CONCLUSION

Although a fair amount is known about nicotine, other addictive

drugs, stress, and gender differences, investigations rarely have examined

two or more of these variables at a given time. The study of several

of these variables reveals interactions and may uncover effects to infer

mechanisms of action or moderating variables (Baron and Kenny 1986).

Studies of gender and substance abuse are beginning to receive attention

as evidenced, for example, by the contributions to this volume. However, even these well-intentioned and thoughtful investigations tend

to be limited in scope to the study of drug “X” in women or in men.

Although this is certainly valuable, there is much more that can and

should be done.

Studies of substance use and abuse should include licit and illicit

drugs. Eating behavior also should be included in the consideration of

substance use and gender, because eating behavior by women and men

involves many biological and psychological processes that are relevant to

drug use. In addition, eating disorders, and their relative prevalence in

women and men, provide valuable information in the present context.

Stress is another important construct to consider in the examination

of gender differences in drug use. This construct is useful as a tool to

determine how drug-taking, drug effects, and eating behaviors change

in females and males, with and without stress. Stress is a commonly
181

reported contributor to drug use and relapse to drug use. Because stress

affects the organism on psychological, behavioral, physiological, and

biochemical levels, it is a relevant and useful tool to study responses

regarding drug use by females and males.

Finally, we advocate the inclusion of studies of gender, stress, and

drug use in which drug use includes cigarette smoking and alcohol use.

Moreover, we advocate the consideration and study of eating behavior as

a comparison behavior with drug use in the context of stress and gender.

This chapter provides some examples to highlight our position and to

reveal the value of this approach.

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ACKNOWLEDGMENTS

The views contained herein are the private ones of the authors and

do not reflect those of the Uniformed Services University of the Health

Sciences or the Department of Defense. Dr. Tracy Sbrocco, Kelly J.

Brown, and E. Jon Popke provided helpful comments during preparation

of this chapter.
186

AUTHORS

Neil E. Grunberg, Ph.D.

Professor

Department of Medical and Clinical Psychology

Uniformed Services University of the Health Sciences

4301 Jones Bridge Road

Bethesda, MD 20814-4799

(301) 295-9673 (Tel)

(301) 295-3034 (Fax)

grunberg@usuhsb.usuhs.mil (E-mail)

Laura Cousino Klein, M.S.

Assistant Researcher

Department of Psychology and Social Behavior

School of Social Ecology

University of California, Irvine

3340 Social Ecology II

Irvine, CA 92697-7085

714-824-1450 (Tel)

714-824-3002 (Fax)

lklein@uci.edu (E-mail)