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Relationship Between Smoking and Weight Control Efforts Among Adults in the United States
Christina C. Wee, MD, MPH;
Nancy A. Rigotti, MD;
Roger B. Davis, ScD;
Russell S. Phillips, MD
Arch Intern Med. 2001;161:546-550.
ABSTRACT
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Background The effect of weight control concerns on smoking among adults is unclear.
We examined the association between smoking behavior and weight control efforts
among US adults.
Methods A total of 17 317 adults responded to the Year 2000 Supplement
of the 1995 National Health Interview Survey (83% combined response rate).
Respondents provided sociodemographic and health information, including their
smoking history and whether they were trying to lose weight, maintain weight,
or gain weight.
Results Rates of smoking were lower among adults who were trying to lose or
maintain weight than among those not trying to control weight (25% vs 31%; P<.001). After adjustment for sex, race, education,
income, marital status, region of the country, and body mass index, the relationship
between trying to lose weight and current smoking varied according to age.
Among adults younger than 30 years, those trying to lose weight were more
likely to smoke currently (odds ratio, 1.36 [95% confidence interval, 1.09-1.70]),
whereas older adults trying to lose weight were as likely or less likely to
smoke compared with adults not trying to control weight. After adjustment,
smokers of all ages who were trying to lose weight were more likely to express
a desire to quit smoking. Results were similar after stratification by sex
and body mass index.
Conclusions Adults younger than 30 years are more likely to smoke if they are trying
to lose weight. However, smokers of all ages who are trying to lose weight
are more likely to want to stop smoking. Patients' weight control efforts
should not discourage clinicians from counseling about smoking cessation.
Education about smoking and healthy weight control methods should target young
adults.
INTRODUCTION
THE DECLINE in cigarette smoking prevalence during the past 35 years
has been much greater among men than women.1, 2, 3
Consequently, the sex difference in smoking prevalence has narrowed substantially.2, 3 Concern about weight control, which
is stronger among women than men, has been suggested as one reason for the
smaller decline in women's smoking rates. The hypothesis is that women are
more likely to use tobacco as a means of weight control.4, 5, 6, 7
Over the long term, smoking appears to have a weight suppressant effect, and
weight gain is a common consequence of smoking cessation.8, 9, 10
Several recent studies, however, suggest that this weight suppressant effect
may be minimal in the short term.11, 12, 13
Nevertheless, children and adolescents frequently smoke to control their weight.14, 15, 16 Furthermore, women
smokers are more likely to cite weight gain as a major concern when discussing
smoking cessation.4, 5, 7
Whether weight concerns affect smoking behavior among adults generally
is not established. As public health efforts to address the obesity epidemic
heighten awareness of the adverse effects of overweight and obesity, these
efforts may lead to a greater use of smoking as a means of weight control
and discourage smokers from quitting because of concerns about weight gain.
In this context, we studied the relationship between weight control efforts
and smoking and smoking cessation behavior among adults in the United States.
METHODS
The National Health Interview Survey is an in-person household survey
conducted by the Census Bureau for the National Center for Health Statistics.17 The survey uses a multistage probability design to
permit continuous sampling of the civilian noninstitutionalized US population.
In 1995, approximately 102 000 persons (including children) from approximately
39 000 households responded to the core survey (94% response rate), which
elicited information on sociodemographic factors, basic health status, health
care utilization, height, and weight.
In addition, a supplemental survey (Year 2000 Supplement) was administered
to 1 randomly selected adult, aged 18 years or older, from one half of the
responding households (n = 17 317 respondents; 88% response rate). The
overall response rate to both the core survey and the supplemental survey
was 83%. Respondents were asked whether they were trying to "lose weight,
gain weight, stay the same, or not do anything" in the preceding year. They
were also asked whether they "smoked at least 100 cigarettes (5 packs) in
[their] entire life"; if they "now smoke[d] cigarettes every day, some days,
or not at all"; and for those who smoked everyday, how old they were "when
[they] started smoking every day." Current smokers were asked if they "would
like to quit smoking cigarettes" and, for those who smoked daily, whether
they "stopped smoking for 1 day or longer" during the past 12 months. In addition,
questions elicited information about 6 common chronic medical conditions,
including cardiac disease, pulmonary disease, and cancer. Respondents were
also asked about their participation in an extensive list of leisure or sport
activities in the 2 weeks before the interview and the frequency of participation.
We hypothesized that respondents trying to lose or maintain weight would
be more likely to smoke, less interested in smoking cessation, and less likely
to have made a "quit attempt" in the previous year. Respondents were categorized
as (1) trying to lose weight, (2) trying to maintain weight ("stay the same"),
or (3) not trying to control weight (which included trying to gain weight).
We defined smoking behavior as current (smoking cigarettes at least on some
days), former (smoked at least 100 cigarettes in their entire life but not
currently), or never. Among current everyday smokers, respondents who intentionally
stopped smoking for at least 1 day in the previous year were classified as
having made a "quit attempt."
We performed bivariable analyses to compare unadjusted rates of smoking
behavior across categories of weight control effort and several clinical and
demographic factors. We built logistic regression models by means of backward
elimination for the various smoking behavior outcomes. For the outcome of
current smoking behavior, we considered age (in decades), sex, race or ethnicity,
marital status, education, income, region of the country, and body mass index
(BMI; calculated as weight in kilograms divided by the square of height in
meters) in addition to weight control efforts. We categorized BMI on the basis
of standard definitions.18 We did not include
comorbid illnesses in our primary model because most smokers initiate tobacco
use at a young age19 before developing many
of the comorbid illnesses elicited by the survey. Moreover, many of these
diseases are part of the causal pathway of smoking (ie, complications of smoking);
hence, adjustment for these diseases may inappropriately mask important relationships
between smoking and other factors of interest. In any case, adjustment for
comorbid illness and health status did not alter our results substantially
and is not presented. We repeated our primary analyses excluding former smokers,
since former smokers are more likely to gain weight after smoking cessation7, 10 and as a result may develop concerns
about their body weight after, rather than before, smoking cessation. To explore
the possibility that any association between weight control efforts and smoking
was a result of health-seeking behavior, we adjusted our primary model for
the interaction between physical activity and weight control efforts. Respondents
were categorized into low, moderate, or high physical activity using a validated
method described previously.20, 21
We performed additional analyses to examine factors associated with
the desire to stop smoking among current smokers. In addition to weight control
efforts and sociodemographic factors, we considered comorbid illnesses (diabetes,
cardiac disease, chronic pulmonary disease, and cancer), BMI, self-reported
health status, years smoked, and packs smoked per day. Significant factors
were used for adjustment in another model that examined the importance of
weight control efforts on quit attempts in the preceding year among current
smokers who smoked daily.
To examine whether the relationship between weight control efforts and
smoking behavior (current smoking, desire to stop smoking, and having made
a quit attempt in the preceding year) was influenced by a person's sex, BMI,
or age, we introduced interaction terms between weight control efforts and
these 3 separate factors to our main models. For significant interactions,
we then stratified analyses by the factor.
We considered P<.05 to be statistically
significant for all analyses. We used sampling weights to correct for nonresponse
and to reflect the US population. We used SUDAAN statistical software (Research
Triangle Institute, Research Triangle Park, NC) to obtain Taylor series linearization
variance estimates.22, 23
RESULTS
Of 17 213 respondents to the Year 2000 supplemental survey who
provided information on smoking status, 25% (weighted) of the sample were
current smokers and 23% were former smokers. Table 1 provides the characteristics of these respondents. Respondents
trying to lose or maintain weight were less likely to smoke currently than
those not trying to control their weight. Current smokers had lower BMIs than
never or former smokers but were more sedentary than nonsmokers. Men were
more likely to smoke than women. Rates of smoking were lowest among respondents
older than 70 years. Hispanic and other ethnic groups had lower rates than
whites or blacks. Smoking rates also were lower among respondents with higher
socioeconomic status. Of the eligible sample, 1673 participants did not provide
information about weight control efforts. Of these, only 1% smoked currently;
compared with all other respondents, nonrespondents were younger (44 vs 47
years) and had lower BMIs (26.0 vs 26.3) but were similar in sex, race, and
socioeconomic status.
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Table 1. Sample Characteristics and Prevalence of Current Smoking (n
= 17 213*)
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After adjustment for sociodemographic factors and BMI, respondents'
weight control efforts were still significantly associated with current smoking.
Moreover, there was a statistically significant interaction between age group
and weight control efforts (P<.001). Table 2 shows the results of our adjusted
model stratified by age group. Among adults trying to lose weight, those younger
than 30 years were more likely to smoke currently, whereas older adults were
as likely or less likely to smoke than respondents not trying to control weight
(Table 2). We did not find significant
interactions between efforts to control weight and respondent sex or BMI.
Our results were not altered substantially after adjustment for the interaction
between physical activity level and weight control efforts. When we excluded
former smokers from our primary analysis, the results were consistent with
our primary results; the interaction between age group and weight control
efforts remained statistically significant, showing similar relationships.
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Table 2. Likelihood of Current Smoking Among Adults Who Were Trying
to Lose or Maintain Weight Compared With Adults Not Trying to Control Weight
Across Different Age Groups* (n = 12 988)
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Among respondents who smoked currently and who provided information
about weight control efforts (n = 3904), 74% (weighted) of the sample reported
a desire to quit smoking. The weighted percentages of respondents who would
like to quit smoking among those trying to lose weight, trying to maintain
weight, or not trying to control weight were 81%, 73%, and 70%, respectively
(P<.001). After adjustment for BMI, age, and marital
status, respondents trying to lose weight were most likely to express a desire
to quit compared with those not controlling weight (odds ratio [OR], 1.72;
95% confidence interval [CI], 1.42-2.07) (Table 3). For those trying to maintain weight, the OR was 1.15 (95%
CI, 0.91-1.46). Factors such as sex, socioeconomic status, years smoked, number
of cigarettes smoked per day, and chronic illness did not confound this relationship.
Results did not change substantially when we added interaction terms for weight
control efforts and sex, BMI, age, or physical activity.
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Table 3. Factors Associated With Desire to Quit Smoking Among Current
Smokers* (n = 3834)
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Among smokers who smoked daily (n = 3354), 46% (weighted) of the sample
made at least 1 attempt to quit smoking in the preceding year. The weighted
percentages of respondents who reported a quit attempt among those trying
to lose weight, trying to maintain weight, or not trying to control weight
were 54%, 46%, and 41%, respectively (P<.001).
After adjustment for BMI, age, and marital status, smokers who were trying
to lose or maintain weight were more likely to have made a quit attempt, with
respective ORs of 1.66 (95% CI, 1.40-1.96) and 1.35 (95% CI, 1.10-1.66). Interactions
between weight control efforts and sex, BMI, and age did not substantially
alter our adjusted results.
COMMENT
We found a significant relationship between smoking status and weight
control efforts in this representative sample of US adults. After adjustment
for sociodemographic factors and BMI, adults younger than 30 years were more
likely to smoke cigarettes if they were trying to lose weight. However, adults
aged 30 years and older who were actively trying to lose or maintain their
body weight were no more likely to smoke cigarettes than those not trying
to control their weight. In several age categories, these individuals were
actually less likely to smoke currently. Regardless of age, adult smokers
trying to lose weight were more likely to express a desire to quit smoking
and were more likely to have made an attempt to quit smoking in the preceding
year. These relationships did not vary substantially by sex or BMI.
Numerous studies have suggested an association between concern about
body weight and higher smoking rates among children and adolescents.7, 14, 15, 16, 19, 24, 25, 26
Our results suggest that this relationship persists into young adulthood in
both sexes. Cross-sectional and prospective studies suggest that children
who have misperceptions of their own body weight and dissatisfaction with
their appearance are more likely to contemplate smoking,16
that children are much more likely to experiment with smoking if they are
dieting and trying to lose weight,15, 16
and that they are more likely to smoke explicitly to control weight and appetite.25
Concerns about body weight, however, appear to have less influence on
smoking behavior among older adults. Previous studies suggest that current
smokers are no more concerned about weight than are those who have never smoked.7, 27, 28, 29 Although
smokers, particularly women, do report that weight gain is a major barrier
to smoking cessation,4, 5, 29
several studies show that concerns about weight gain are only weakly or not
at all correlated with smoking behavior.7, 27, 28
Our study is the first, to our knowledge, to support these findings in a nationally
representative population, but it clearly suggests a divergence in smoking
behavior and weight control efforts between adults younger than 30 years and
those 30 years or older. Our study also suggests that adults of all ages who
are actively trying to lose weight are more likely to contemplate quitting
if they do smoke.
Our findings can be interpreted in several ways. Younger adults may
use smoking as a means of weight control, as is consistent with studies in
adolescents.7, 14, 15, 16, 24, 25, 26
Alternatively, both smoking and dieting may be related to a broader tendency
to engage in unhealthy behaviors. Negative behaviors have been shown to cluster
during adolescence and young adulthood.7, 26
Unhealthy behaviors may be an expression of rebelliousness and independence.26, 30 Of greater concern, however, is the
possibility that this relationship may represent a cohort effect, so that
as the young adult population ages, they may continue to use smoking as a
means to control weight. On the other hand, adults aged 30 years and older
who are trying to lose weight may represent individuals who are generally
concerned about health and trying to lose weight to improve overall health.
Only a minority of US adults cite improving physical appearance as a reason
for losing weight31, 32; the majority
appear to be motivated by health and fitness reasons.31, 32
Our study has several limitations. Although we used data from a nationally
representative sample, this generalizability is limited by our exclusion of
respondents with missing data; nonrespondents to questions pertaining to weight
control efforts had a substantially lower rate of smoking, although the nonresponse
rate was reasonably low. Second, information was obtained entirely from self-report
and may reflect reporting bias. Our primary outcomes of interest—smoking
behavior, desire to stop smoking, and efforts to control weight—however,
are unlikely to be affected to a large degree by reporting bias. The cross-sectional
nature of the study also precludes us from detecting causal relationships
or from concluding that smokers who were not interested in weight control
did not at some earlier point initiate smoking to lose weight. Because the
weight suppressant effect of smoking may be negligible in the short term,11, 12, 13 young adults who
may have only recently initiated smoking are less likely to have derived much
weight-reducing benefit and are more likely to continue to try to lose weight.
Over time, however, smoking leads to modest weight reduction and weight gain
prevention8, 9; long-term smokers,
who tend to be older adults, are more likely to achieve sufficient weight
reduction over time and are less likely to need further weight control. In
our study, these adults would have been classified as not trying to control
weight. We also did not actually measure the degree to which the subjects'
weight or potential weight gain was a concern to them. Respondents who may
have been concerned about weight but were not actively trying to lose or maintain
weight may have described themselves as "not doing anything" about their weight.
It is possible that we may not have detected a relationship between these
latter respondents and higher tobacco use.
The limitations of this study do not diminish the clinical implications
of our findings, however. Our study suggests that young adults may regard
smoking as a weight control method. As public health efforts heighten awareness
of the adverse consequences of overweight and obesity, our results raise concern
that these efforts may lead to a rise in smoking initiation among young adults.
Clinicians and public health officials need to target young adults for education
about not only the adverse effects of smoking but also healthier methods of
weight control.
Furthermore, our findings suggest that smokers who are trying to lose
weight may be particularly receptive to advice about smoking and smoking cessation.
Contrary to the conventional clinical wisdom of targeting one behavior change
at a time, our findings identify adult smokers who are trying to lose weight
as potential candidates for discussions about smoking cessation. It remains
unclear, however, whether concern about weight affects the effectiveness of
smoking cessation efforts. Studies on the subject have been conflicting.7, 27, 33, 34, 35, 36, 37, 38, 39
Some suggest that smokers who have gained weight during quit attempts may
be more likely to relapse and less likely to make subsequent attempts,27, 33, 34 and others find that
efforts to control weight and smoking simultaneously may produce lower cessation
rates.7, 34, 35 However,
some investigators report that the amount of weight gain after smoking cessation
does not increase the likelihood of relapse to smoking.7, 34, 35
Finally, recent evidence suggests that weight gain after smoking cessation
may be transient.40 In this context, clinicians
should help patients understand the greater health benefits of smoking cessation
compared with those of weight loss.29, 41, 42
In summary, our study suggests that adults younger than 30 years who
are trying to lose weight are more likely to smoke and may be smoking to control
their weight. However, older adults who are trying to lose or maintain weight
are less likely to smoke when compared with those who are not trying to control
their weight. Furthermore, adult smokers of all ages who report trying to
lose weight are more likely to want to quit smoking. Hence, patients' concern
about body weight should not discourage clinicians from discussing smoking
and smoking cessation with these patients. Moreover, public health efforts
should target young adults for education about smoking and healthy weight
control habits. Further studies are needed to examine the impact of heightened
concerns about weight and its impact on smoking initiation, smoking cessation
efforts, and the efficacy of combined weight loss and smoking cessation efforts.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
Dr Wee was supported in part by a grant from the Medical Foundation,
Inc, Boston, Mass, and National Research Service Award 1 F32 HS00137-01 from
the Agency for Health Care Research and Quality, Bethesda, Md.
We thank the National Center for Health Statistics for providing the
initial data. The analyses, interpretations, and conclusions in this article,
however, are those of the authors and do not reflect those of the National
Center for Health Statistics.
From the Division of General Medicine and Primary Care, Beth Israel
Deaconess Medical Center (Drs Wee, Davis, and Phillips), and Tobacco Research
and Treatment Center, Massachusetts General Hospital (Dr Rigotti), Harvard
Medical School, Boston, Mass.
Corresponding author and reprints: Christina C. Wee, MD, MPH, Division
of General Medicine and Primary Care, Beth Israel Deaconess Medical Center,
330 Brookline Ave, Libby 330, Boston, MA 02215 (e-mail: cweekuo{at}caregroup.harvard.edu).
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