Is a fear of getting fatter partly to blame for the fact that nearly one in five American women still smokes, and many don't try to quit?
Although there are many possible reasons for the stubborn persistence of smoking, fear of weight gain is high on the list for many women, says a University of Michigan Health System researcher who has devoted much of her career to studying this issue.
Several years ago, she and her team reported that 75 percent of all women smokers say they would be unwilling to gain more than five pounds if they were to quit smoking, and nearly half said they would not tolerate any weight gain. In fact, many women started smoking in the first place because they thought it might help them stay slim.
Now, new U-M research findings published in the October issue of Addictive Behaviors show that women who smoke tend to be further from their ideal body image, and more prone to dieting and bingeing, than those who don't smoke.
Cigarettes are well known to suppress appetite and weight, says Cindy Pomerleau, Ph.D., director of the U-M Nicotine Research Laboratory. "So it's hardly surprising that women who have trouble managing their weight or are dissatisfied with their bodies are drawn to smoking," she says.
In another recent study, published in August, the U-M team found that overweight women smokers who were overweight as children were far more likely to have started smoking in their early teens than women whose weight problems started later in life. They also had worse withdrawal symptoms when they tried to quit.
Once they make a serious attempt to quit, evidence suggests that most weight-concerned smokers can be just as successful in kicking the habit as others.
"The problem here is getting women who are concerned about their weight to be willing to try to make a quit attempt," says Pomerleau, "and then helping them gain a sense of control over their weight."
Women who are highly concerned about weight tend to be concerned about other aspects of their appearance as well, she notes. What they need to understand, she says, is that smoking has an impact on many aspects of appearance and attractiveness. Among other things, it causes wrinkled skin, thinning hair, cracked fingernails, yellowed teeth and terrible breath.
Pomerleau, a research professor of psychiatry, is working on a book about women, smoking and weight loss that will draw together research findings, helpful tips and real-life examples of women who quit tobacco while also containing their weight.
Some beliefs about smoking and weight are true, she says. For instance, nicotine suppresses the appetite and increases resting metabolic rate. Smokers on average weigh less than people who have never smoked, and that smokers who quit tend to gain weight. Adding to these perceptions are tobacco advertisements that portray female smokers as slim and successful.
Even so, the effect of quitting on weight is often less dramatic than many women fear, Pomerleau says. A rough rule of thumb is that one in four women who quit smoking will gain less than five pounds, and another two out of four will gain five to 15 pounds. Only one in four women who quit will gain 15 pounds or more.
But Pomerleau's own research suggests that many women smokers start out with an unrealistic image of how they would like their bodies to look. This may make their dread of gaining weight even worse.
In her paper in Addictive Behaviors, she reports the results of a study of 587 women between the ages of 18 and 55, including 420 smokers and 167 women who had never smoked. An equal proportion of both groups was overweight or obese, with a body mass index of 25 or more.
In the study, the smokers and non-smokers were asked to look at silhouette pictures of ten different body types, ranging from thinnest to fattest, and to choose which one their current body type was closest to, and which one they wanted to look most like. They were also asked questions about their self-image and their eating habits, about how concerned they were about gaining weight if they quit smoking, and about how sure they were that they could stay off cigarettes even if they gained weight.
The smokers chose an ideal body shape that was slimmer than the non-smokers chose, and further from how they perceived themselves as looking. They also had more problems with limiting their eating. Smokers who were overweight were especially doubtful about their ability to stay off tobacco if they started to gain weight.
This study, Pomerleau says, suggests that if women smokers are to succeed in quitting, they may need extra help in achieving a more realistic body image and paying attention to unhealthful eating patterns, particularly if they are already overweight.
At the same time, Pomerleau and her team have found that the earlier in life a weight problem starts, the more likely a woman is to start smoking.
In a study of 89 overweight women smokers, those who remembered being overweight before they reached junior high school reported that they had started experimenting with smoking at around age 13 -- compared with women whose weight problems didn't start until junior high or after, who hadn't tried smoking till they reached age 15.
The women who were overweight as children also reported more nicotine-withdrawal symptoms when they tried to quit smoking, especially symptoms like anger, irritability and trouble concentrating. The study was published in the August issue of Eating Behaviors.
These studies, and others that the U-M team have done, all point to the importance of finding new strategies to help women quit smoking without losing control of their weight. Although severe dieting during a smoking cessation attempt has not been shown to be helpful in either quitting smoking or controlling weight, it may be unrealistic to expect women with strong weight concerns to put these concerns on hold for several weeks or months while they try to quit tobacco.
"What we would like to work for is a kind of compromise strategy, where the focus is on the smoking cessation, but women can also take some passive and active measures to control their weight," Pomerleau says.
Passive measures include things like nicotine patches and gum, and medicines like bupropion, which can help in controlling weight gain while keeping nicotine withdrawal symptoms at bay.
Another option for women is to launch their stop-smoking effort early in their menstrual cycle, so that the bloating that can happen soon after they snuff out their last cigarette won't be compounded by the bloating that comes along right before their period begins.
Finally, although strenuous dieting is not recommended, Pomerleau says, women can start immediately to rebalance the energy-in/energy-out equation by not substituting eating for smoking, and by increasing their physical activity. Even brief bouts of exercise, such as stretching or walking, can be effective in distracting a woman when the urge to smoke strikes, she says, and they burn a few calories too.
Study references: Addictive Behaviors, Volume 32, Issue 10, October 2007, pp. 2329-2334 and Eating Behaviors, Volume 8, Issue 3, August 2007, pp. 418-422
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