British Journal of Addiction (1991) 86, 577-581
Smoking cessation and weight gain SCOTT J. LEISCHOWi & MAXINE L. STITZER^ Alto Center for Pulmonary Disease Prevention, ^Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Abstract Significant progress has been made in the research on smoking cessation and weight gain since the 1988 Surgeon General's Report, particularly on mechanisms and treatment methods. Smoking cessation results in weight gain in most quitters, primarily due to changes in caloric intake and to a lesser extent from changes in energy expenditure. Thus far, pharmacologic treatments appear more efficacious at preventing the weight gain than behavioral methods. And regarding who should receive treatment, preliminary research suggests that females are more concerned about postcessation weight gain than males, and it is the concern about weight gain—more than the weight gain itself^that appears to play an important role in relapse to smoking. Given the progress that has been made along the spectrum from mechanisms to treatment, those concerned about postcessation weight now have treatment options for preventing weight gain in the critical period immediately after smoking cessation. However, continued research into mechanisms, treatment methods, and individual differences will surely result in new and more effectively tailored treatment options.
Introduction As the 1988 Surgeon General's Report on The Health Consequences of Smoking' made clear, nicotine is an addicting drug. However, the same Report recognized the complexity and unique characteristics of nicotine addiction, and substantial portions of the Report were devoted to describing nicotine effects that may promote smoking. According to the Report, among the effects of nicotine that may promote smoking, or make smoking cessation more difficult, is the finding that most smokers gain weight when they quit. The Report thus recommended continued research into mechanisms and treatment issues pertaining to the relationship between smoking and weight. Since the Report's publication, several interesting and clinically important studies have been completed, though critical questions regarding mechanisms and treatment have
Correspondence address: Scott J. Leischow, 750 Welch Road, Suite 200, Palo Alto, CA 94304-1509, U.S.A.
yet to be answered. This report will summarize research findings and suggest future research directions.
Mechanisms of Postcessation Weight Gain Smokers gain, on average, 6.4 pounds after quitting smoking.^ However, when nicotine use is discontinued, and weight gain occurs, what are the contributing factors for that weight gain? Three mechanisms have been considered to account for the weight gain that occurs after smoking cessation: changes in (1) physical activity, (2) metabolic factors, and (3) dietary in
Physical activity There is little evidence that postcessation weight gain is a result of decreased physical activity,'"' though one study' did find increased physical activity after cessation. Thus, it is likely that
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physical activity plays a negligible role in postcessation weight gain.
Energy expenditure and metabolism The evidence implicating decreased energy expenditure in post-cessation weight gain is mixed. Some studies have found small decreases in energy expenditure,'-'" while others have found no significant change.*'"-'^ Acute effects of nicotine increase energy expenditure 5-10% (or approximately 200 kcal/day),"-''* and this effect is enhanced during light physical exercise.'^ Removal of the small but repeated nicotine-induced boosts in energy expenditure following smoking cessation could contribute to postcessation weight gain, although the relative magnitude of the contribution is not currently known. One mechanism that may influence changes in fat distribution is the impact of nicotine on lipoprotein lipase (LPL), an enzyme which acts to regulate the uptake and storage of free fatty acid. Carney & Goldberg" evaluated changes in the adipose tissue LPL in relation to smoking and found that there was a significant positive correlation between the prequit level of LPL and amount of weight gained postcessation. However, a follow-up study'* found a significant positive correlation between changes in caloric intake and LPL in both smokers and abstainers, so that the relationship between LPL and weight change in both smokers and abstainers may be mediated more by caloric intake than by nicotine. Thus, it is not clear whether the changes in caloric intake drive changes in LPL or the reverse—or whether some other factor (e.g. insulin) plays a mediating role."
Energy balance summary Although the data are not altogether consistent, it appears that increased caloric intake and the elimination of a calorie burning substance (nicotine) most likely combine to produce postcessation weight gain. The number of excess calories resulting from smoking cessation can be estimated by combining the observed increase in caloric consumption through food (approximately 300 kcal/day) and the excess calories due to reduced energy expenditure (approximately 200 kcal/day), which together add approximately 500 calories per day (or 3500 per week) to an ex-smoker's daily caloric availability. Since 3500 calories is equivalent to one pound of fat,^' the average abstainer should gain approximately one pound per week—and in fact two investigations have found that ex-smokers did gain an average of one pound per week.^^-^' Thus, to prevent weight gain after smoking cessation, the average smoker must not only refrain from eating extra calories, but must also decrease their daily caloric intake by approximately 200 calories per day after smoking cessation.
Areas offuture investigation: mechanisms Carefully controlled studies are needed to assess behavioral and metabolic differences between smokers and non-smokers, and to assess postcessation changes in abstinent smokers of both genders over an extended period of time—with attention given to potential differences between nicotine alone and nicotine via smoking. In particular, changes in caloric intake, Oj and CO2 exchange, LPL, lipoproteins, insulin, glucose, catecholamines, thyroid hormones, sex hormones, and anthropometry need to be included.
Prevention of weight gain after smoking cessation Caloric intake Like the data on energy expenditure and metabolism, the evidence implicating increased caloric intake in postcessation weight gain is mixed. Studies have found that caloric intake increases after smoking cessation, with per day increases of approximately 300 kilocalories.*'''"'" Although overall increases in caloric intake have not been universally observed,''' studies with both animals^" and humans' have shown a specific increased intake of sweets after cessation, which may account in part for the increased caloric intake.
Behavioral methods Three studies^**"^' have systematically evaluated behavioral interventions for preventing postcessation weight gain in a healthy population; studies assessing the prevention of weight gain in high-risk or diseased groups will not be discussed. None of the studies were successful at preventing weight gain after cessation, although both weight control information^'*'^' and specific dietary recommendations^' appeared to moderate the postcessation weight gain somewhat. Of particular note is the study by Duffy et aP^, which showed that subjects
Smoking cessation and weight gain who received a specific diet were more successful at reducing caloric intake during the first 6 weeks after cessation than those who received general dietary education, who were in turn more successful than a control group. Unfortunately, those assigned to the dietary treatments were also more likely than those in dietary control group to relapse. The association between dietary intervention and increased rates of smoking relapse suggested by the Duffy study is intriguing and of potential clinical significance, particularly given the evidence found in animal research that increased use of reinforcing drugs occurs when food (another reinforcer) is deprived.^'' Carroll & Meisch^' hypothesized that this phenomenon is an example of a process whereby decreased availability of one reinforcer results in the increased valence of another reinforcer. Human trials investigating this phenomenon are needed.
Pharmacologic methods Nicotine replacement. A number of studies have shown that nicotine replacement (via Nicorette®) suppresses postcessation weight gain.^'-^''^^ Of the three, the study by Gross & Stitzer^^ was published after the 1988 Surgeon General's Report and is the most rigorous regarding the impact of nicotine replacement on weight gain. The study found that subjects who were high users of nicotine polacrilex (mean=9.2 pieces per day) gained 1.5 pounds, while low users (mean=5.4 pieces per day) gained 5 pounds—thus suggesting a nicotine dose effect on postcessation weight gain. However, after nicotine polacrilex was discontinued, the 23 week follow-up showed that there was no difference in body weight between the nicotine replacement and placebo groups, indicating that nicotine replacement only delays weight gain. Further research is needed to determine more rigorously whether there is a nicotine dose effect on weight gain, as well as the impact of immediate versus delayed weight gain on rates of relapse.
Other pharmacologic treatments. Two recent studies indicate that pharmacologic treatments other than nicotine replacement may prove effective at preventing weight gain—at least during the first few months after smoking cessation when relapse is most likely. Klesges et al.^^ assessed the efficacy of phenylpropanolomine (PPA), a common over-thecounter anorectic, as a means of preventing postces-
579
sation weight gain. During the 2 week trial, PPA users decreased caloric intake by an average of 630 kcal/day and did not gain weight. Subjects receiving PPA were also less likely to relapse to smoking than those who received placebo. Spring et a/." assessed the efficacy of d-fenfiuramine, a prescription anorectic, for preventing postcessation weight gain and, like the nicotine replacement and PPA studies, found that d-fenfiuramine prevented weight gain. After 4 weeks of treatment, subjects on placebo gained an average of 3.5 pounds, while those on d-fenfiuramine lost an average of 1.8 pounds. The amount of weight gain that occurred after d-fenfiuramine was discontinued was not reported. In sum, the data on preventing postsmoking cessation weight gain suggests that efficacy may depend on the type of intervention used, with strictly behavioral methods mostly ineffective, and three different pharmacologic methods showing high efficacy. Thus, smokers who are concerned about weight gain immediately after smoking cessation have a number of pharmacologic options; however, it is possible that weight gain will occur after the drug is discontinued.
Treatment intervention issues The above review of treatment studies suggests that weight gain can be prevented, particularly with certain pharmacological interventions. However, the side-effects and long-term outcomes must be considered. In the short term, treatment of postcessation weight gain may be highly beneficial, especially with pharmacological treatments that can also improve abstinence success rates. The long-term efficacy of weight control treatment requires more study. If subjects gain weight and relapse upon discontinuation of pharmacological intervention, then the benefits of such treatment might be questioned. However, additional cognitive, dietary, and/or exercise interventions might be developed that could be implemented during early treatment phases to prevent long-term relapses associated with weight gain.
Areas of future investigation: treatment methods. Large and carefully controlled treatment trials assessing the efficacy of dietary restriction/management, exercise, and pharmacologic treatments are needed. In particular, human research assessing the impact of dietary restriction on smoking relapse is
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needed, as is research evaluating the impact of discontinued use of effective pharmacologic agents (and hence weight gain) on relapse.
Target population issues Studies that have examined the relationship between postcessation weight gain and relapse suggest that precessation fear of weight gain may be an imporant predictor of likelihood to relapse,'"'" while abstinence success rates may be better for those who allow weight gain to occur.'^'^' Thus, it may be that treatment efforts should focus on those who express concern about postcessation weight gain prior to cessation. This group appears to be predominantly female. Research indicates that there is more concern about postcessation weight gain in women than men.-''*-'' In one study, for example, 82% of the women reported gaining weight after quitting smoking, compared with 18% of the men'*—although there was no objective evidence that more women than men did gain weight.
gain—more than the weight gain itself—that appears to play an important role in relapse to smoking. Given the progress that has been made along the spectrum from mechanisms to treatment, those concerned about postcessation weight now have treatment options for preventing weight gain in the critical period immediately after smoking cessation. However, continued research into mechanisms, treatment methods, and individual differences will surely result in new and more effectively tailored treatment options.
References 1. DEPARTMENT OF HEALTH AND HUMAN SERVICES
(1988) The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General. DHHS Pub. No. (CDC) 88-8406. 2.
3.
Areas offuture investigation: treatment specificity Prospective research stratifying on gender, concern about weight gain, and dieting history (e.g. yo-yo dieting) is needed to clarify who is most likely to relapse as a result of postcessation weight gain and who would thus benefit the most from treatments to prevent the weight gain. Such research is needed because it appears that strategies for preventing postcessation weight gain will need to be individually tailored and implemented, where some abstainers may benefit from pharmacologic methods, others from behavioral methods, and still others may neither need nor desire any treatment.
Conclusions Significant progress has been made in the research on smoking cessation and weight gain since the 1988 Surgeon General's Report, particularly on mechanisms and treatment methods. Smoking cessation results in weight gain in most quitters, primarily due to changes in caloric intake and to a lesser extent from changes in energy expenditure. Thus far, pharmacologic treatments appear more efficacious at preventing the weight gain than behavioral methods. And regarding who should receive treatment, preliminary research suggests that females are more concerned about postcessation weight gain than males, and it is the concern about weight
KLESGES, R. C , MEYERS, A., KLESGES, L . M . & LA
VASQUE, M . E . (1989) Smoking, body weight, and their effects on smoking behavior: A comprehensive review of the literature, Psychological Bulletin, 106(2), pp. 204-230. KLESGES, R. C , MEYERS, A., WINDERS, S. & FRENCH,
S. (1989) Determining the reasons for weight gain following smoking cessation: Current findings, methodological issues, and future directions. Annals of Behavioral Medicine, 11(4), pp. 134-143. 4. WACK, J. T . & RODIN, J. (1982) Smoking and its
effects on body weight and the systems of caloric consumption. The American Journal of Clinical Nutrition, 35, pp. 366-380. 5. DALLOSSO, H . M . & JAMES, W . P. T. (1984) The role
of smoking in the regulation of energy balance. International Journal of Obesity, 8, pp. 363-375. 6.
HATSUKAMI, D . K . , HUGHES, J. R., PICKENS, R. W . &
SviKis, D. (1984) Tobacco withdrawal symptoms: An experimental analysis, Psychopharmacology, 84, pp. 231-236. 7. LEISCHOW, S. & STITZER, M . (unpublished) Smoking
cessation and weight gain in an inpatient setting. 8.
STAMFORD, B . A., MATTER, S., FELL, R. D . &
PAPANEK, P . (1986) Effects of smoking cessation on weight gain, metabolic rate, caloric consumption, and blood lipids. The American Journal of Clinical Nutrition, 43, pp. 486-494. 9. RODIN, J. (1987) Weight change following smoking cessation: The role of food intake and exercise. Addictive Behaviors, 12, pp. 303-317. 10.
GLAUSER, S. C,
GLAUSER, E . M . , REIDENBERG,
M. M., RUSY, B. F. & TALLARIDA, R. J. (1970) Metabolic changes associated with the cessation of cigarette smoking. Archives of Environmental Health, 20, pp. 377-381. 11. BURSE, R. L . , BYNUM, G . D . , PANDOLF, K . B., GOLDMAN, R. F . , SIMS, E . A. H. & DANFORTH, K . B .
(1975) Increased appetite and unchanged metabolism upon cessation of smoking with diet held constant. The Physiologist, 18, pp. 157. 12.
PERKINS, K . A., EPSTEIN, . H. & PASTOR, S. (1989a,
March/April) Changes in energy balance following
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brief smoking cessation and return to normal smoking 25. GRINSTEAD, O . A. (1981) Preventing weight gain in women. Presented at the 10th Annual Meeting of following smoking cessation: A comparison of behathe Society of Behavioral Medicine, San Francisco, vioral treatment approaches. (Doctoral dissertation, CA. UCLA). (University Microfilms International No. 82-06024, 1-174). 13. PERKINS, K . A., EPSTEIN, L . H . , MARKS, B . L . , STILLER, R . L . & JACOB, R. G . (1989) The effect of
nicotine on energy expenditure during light physical activity. The New England Journal of Medicine, 320(14), pp. 898-903. 14. HOFSTETTBR, A., SCHUTZ, Y., JEQUIER, E . & WAHREN, J. (1986) Increased 24-hour energy expenditure in cigarette smokers. The New England Journal of Medicine, 314(2), pp. 79-82. 15. CARNEY, R. M . & GOLDBERG, A. P. (1984) Weight
26.
DUFFY, J., TUNSTALL, C , VILA, K . , DUNCAN, C . &
HALL, S. (1990) Weight control and maintaining nonsmoking: Two incompatible health goals.' Paper presented at the annual meeting of the American Psychological Association, Boston, MA, August 13, 1990. 27. CARROLL, M . E . & MEISCH, R. A. (1984) Increased
drug-reinforced behavior due to food deprivation, in: T. THOMPSON, P. B., DEWS & J. E. BARRETT (Eds),
Advances in Behavioral Pharmacology, Vol. 4, p. gain after cessation of cigarette smoking: A possible 47-88 (New York, Academic Press). role for adipose-tissue lipoprotein lipase. New England Journal of Medicine, 310, pp. 614-616. 28. EMONT, S. L . & CuMMiNGS, K. M. (1987) Weight gain following smoking cessation: A possible role for 16. LEISCHOW, S. J. & STrrzER, M. L. (1990) Postcessanicotine replacement in weight management. Addiction weight gain: Contributions of diet and lipoprotein tive Behaviors, 12, pp. 151-155. lipase. Paper presented at the annual meeting of the American Psychological Association, Boston, MA, 29. FAGERSTROM, K. O . (1987) Reducing the weight gain August 13, 1990. after stopping smoking. Addictive Behaviors, 12, pp. 91-93. 17. GRUNBERG, N . E. (1989) Cigarette smoking and body weight: Current perspective and future directions. 30. KLESGES, R. C, BROWN, K . , PASCALE, R . W . , MURPHY, M . , WILLIAMS, E . & CIGRANG, J. (1988) Annals of Behavioral Medicine, 11(4), pp. 154-157. Factors associated with participation, attrition, and 18. HALL, S. M . , MCGEE, R., TUNSTALL, C , DUFFY, J. & outcome in a smoking cessation program as the BENOWrrz, N. (1989) Changes in food intake and workplace. Health Psychology, 7, pp. 575-589. activity after quitting smoking. Journal of Consulting and Clinical Psychology, 57(1), pp. 81-86. 31. MAHEU, M . (1985) The effects of competition/cooperation on worksite smoking cesssation. Unpublished 19. SPRING, B., WURTMAN, J., GLEASON, R . , WURTMAN, doctoral dissertation. California School of ProfesR. & KESSLER, K. (1990) Food intake and weight gain sional Psychology, San Diego, CA. University Microafter smoking cessation: Preventive intervention with films International No. 85-17936, 1-337. d-fenfluramine. Paper presented at the annual meeting of the American Psychological Association, Bos32. SWAN, G . E. & DENK, C. E. (1987) Dynamic models ton, MA, August 13, 1990. for the maintenance of smoking cessation: Event history analysis of late relapse, Jowma/ of Behavioral 20. GRtTNBERG, N. E., BOWEN, D. J., MAYCOCK, V. A. & Medicine, 10, pp. 527-554. NESPOR, S. M . (1985) The importance of sweet taste and caloric content in the effects of nicotine on 33. HALL, S. M . , GINSBERG, D . & JONES, R. T . (1986) specific food consumption, Psychopharmacology, 87, Smoking cessation and weight gain. Journal of pp. 198-203. Consulting and Clinical Psychology, 54(3), pp. 342-346. 21. WHrrNEY, CATALDO & ROLFES (1987) Understanding Normal and Clinical Nutrition, 2nd Ed (St. Paul, 34. KLESGES, R. C . & KLESGES, L . M . (1988) Cigarette West Publishing). smoking as a weight loss strategy in a university population. International Journal of Eating Disorders, 22. GROSS, J., STrrzER, M. L. & MALDONADO, J. (1989) 7, pp. 413-419. Nicotine replacement: Effects on post-cessation 35. SORENSEN, G. & PECHACEK, T . F . (1987) Attitudes weight gain. Journal of Consulting and Clinical toward smoking cessation among men and women. Psychology, 57(1), pp. 87-92. Journal of Behavioral Medicine, 10, pp. 129-137. 23. KLESGES, R . C , KLESGES, L . M . , MEYERS, A. W., 36. BLACK, P. M., GIOVANO, G . A., OSSIP-KLEIN, D . J., KLEM, M . L . & ISBELL, T. (1990) The effects of MEGAHEAD, N . , REYNOLDS, W . , LENT, L . , DEBOLE, phenylpropanolomine on dietary intake, physical N., VALENZUELA, L . , LEONE, M . A. & STIGGINS, J. activity, and body weight after smoking cessation. (1989) Weight gain following smoking cessation in a Clinical Pharmacology and Therapeutics, 47, pp. self-help population: An exploratory analysis. Paper 747-754. presented at the 10th Annual Meeting of the Society 24. MERMELSTEIN, R . (1987) Preventing weight gain of Behavioral Medicine, San Francisco, CA. following smoking cessation. Poster presented at the Society of Behavioral Medicine 8th Annual Scientific Session, Washington, DC.
Smoking cessation and weight gain SCOTT J. LEISCHOWi & MAXINE L. STITZER^ Alto Center for Pulmonary Disease Prevention, ^Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Abstract Significant progress has been made in the research on smoking cessation and weight gain since the 1988 Surgeon General's Report, particularly on mechanisms and treatment methods. Smoking cessation results in weight gain in most quitters, primarily due to changes in caloric intake and to a lesser extent from changes in energy expenditure. Thus far, pharmacologic treatments appear more efficacious at preventing the weight gain than behavioral methods. And regarding who should receive treatment, preliminary research suggests that females are more concerned about postcessation weight gain than males, and it is the concern about weight gain—more than the weight gain itself^that appears to play an important role in relapse to smoking. Given the progress that has been made along the spectrum from mechanisms to treatment, those concerned about postcessation weight now have treatment options for preventing weight gain in the critical period immediately after smoking cessation. However, continued research into mechanisms, treatment methods, and individual differences will surely result in new and more effectively tailored treatment options.
Introduction As the 1988 Surgeon General's Report on The Health Consequences of Smoking' made clear, nicotine is an addicting drug. However, the same Report recognized the complexity and unique characteristics of nicotine addiction, and substantial portions of the Report were devoted to describing nicotine effects that may promote smoking. According to the Report, among the effects of nicotine that may promote smoking, or make smoking cessation more difficult, is the finding that most smokers gain weight when they quit. The Report thus recommended continued research into mechanisms and treatment issues pertaining to the relationship between smoking and weight. Since the Report's publication, several interesting and clinically important studies have been completed, though critical questions regarding mechanisms and treatment have
Correspondence address: Scott J. Leischow, 750 Welch Road, Suite 200, Palo Alto, CA 94304-1509, U.S.A.
yet to be answered. This report will summarize research findings and suggest future research directions.
Mechanisms of Postcessation Weight Gain Smokers gain, on average, 6.4 pounds after quitting smoking.^ However, when nicotine use is discontinued, and weight gain occurs, what are the contributing factors for that weight gain? Three mechanisms have been considered to account for the weight gain that occurs after smoking cessation: changes in (1) physical activity, (2) metabolic factors, and (3) dietary in
Physical activity There is little evidence that postcessation weight gain is a result of decreased physical activity,'"' though one study' did find increased physical activity after cessation. Thus, it is likely that
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Scott J. Leischow & Maxine L. Stitzer
physical activity plays a negligible role in postcessation weight gain.
Energy expenditure and metabolism The evidence implicating decreased energy expenditure in post-cessation weight gain is mixed. Some studies have found small decreases in energy expenditure,'-'" while others have found no significant change.*'"-'^ Acute effects of nicotine increase energy expenditure 5-10% (or approximately 200 kcal/day),"-''* and this effect is enhanced during light physical exercise.'^ Removal of the small but repeated nicotine-induced boosts in energy expenditure following smoking cessation could contribute to postcessation weight gain, although the relative magnitude of the contribution is not currently known. One mechanism that may influence changes in fat distribution is the impact of nicotine on lipoprotein lipase (LPL), an enzyme which acts to regulate the uptake and storage of free fatty acid. Carney & Goldberg" evaluated changes in the adipose tissue LPL in relation to smoking and found that there was a significant positive correlation between the prequit level of LPL and amount of weight gained postcessation. However, a follow-up study'* found a significant positive correlation between changes in caloric intake and LPL in both smokers and abstainers, so that the relationship between LPL and weight change in both smokers and abstainers may be mediated more by caloric intake than by nicotine. Thus, it is not clear whether the changes in caloric intake drive changes in LPL or the reverse—or whether some other factor (e.g. insulin) plays a mediating role."
Energy balance summary Although the data are not altogether consistent, it appears that increased caloric intake and the elimination of a calorie burning substance (nicotine) most likely combine to produce postcessation weight gain. The number of excess calories resulting from smoking cessation can be estimated by combining the observed increase in caloric consumption through food (approximately 300 kcal/day) and the excess calories due to reduced energy expenditure (approximately 200 kcal/day), which together add approximately 500 calories per day (or 3500 per week) to an ex-smoker's daily caloric availability. Since 3500 calories is equivalent to one pound of fat,^' the average abstainer should gain approximately one pound per week—and in fact two investigations have found that ex-smokers did gain an average of one pound per week.^^-^' Thus, to prevent weight gain after smoking cessation, the average smoker must not only refrain from eating extra calories, but must also decrease their daily caloric intake by approximately 200 calories per day after smoking cessation.
Areas offuture investigation: mechanisms Carefully controlled studies are needed to assess behavioral and metabolic differences between smokers and non-smokers, and to assess postcessation changes in abstinent smokers of both genders over an extended period of time—with attention given to potential differences between nicotine alone and nicotine via smoking. In particular, changes in caloric intake, Oj and CO2 exchange, LPL, lipoproteins, insulin, glucose, catecholamines, thyroid hormones, sex hormones, and anthropometry need to be included.
Prevention of weight gain after smoking cessation Caloric intake Like the data on energy expenditure and metabolism, the evidence implicating increased caloric intake in postcessation weight gain is mixed. Studies have found that caloric intake increases after smoking cessation, with per day increases of approximately 300 kilocalories.*'''"'" Although overall increases in caloric intake have not been universally observed,''' studies with both animals^" and humans' have shown a specific increased intake of sweets after cessation, which may account in part for the increased caloric intake.
Behavioral methods Three studies^**"^' have systematically evaluated behavioral interventions for preventing postcessation weight gain in a healthy population; studies assessing the prevention of weight gain in high-risk or diseased groups will not be discussed. None of the studies were successful at preventing weight gain after cessation, although both weight control information^'*'^' and specific dietary recommendations^' appeared to moderate the postcessation weight gain somewhat. Of particular note is the study by Duffy et aP^, which showed that subjects
Smoking cessation and weight gain who received a specific diet were more successful at reducing caloric intake during the first 6 weeks after cessation than those who received general dietary education, who were in turn more successful than a control group. Unfortunately, those assigned to the dietary treatments were also more likely than those in dietary control group to relapse. The association between dietary intervention and increased rates of smoking relapse suggested by the Duffy study is intriguing and of potential clinical significance, particularly given the evidence found in animal research that increased use of reinforcing drugs occurs when food (another reinforcer) is deprived.^'' Carroll & Meisch^' hypothesized that this phenomenon is an example of a process whereby decreased availability of one reinforcer results in the increased valence of another reinforcer. Human trials investigating this phenomenon are needed.
Pharmacologic methods Nicotine replacement. A number of studies have shown that nicotine replacement (via Nicorette®) suppresses postcessation weight gain.^'-^''^^ Of the three, the study by Gross & Stitzer^^ was published after the 1988 Surgeon General's Report and is the most rigorous regarding the impact of nicotine replacement on weight gain. The study found that subjects who were high users of nicotine polacrilex (mean=9.2 pieces per day) gained 1.5 pounds, while low users (mean=5.4 pieces per day) gained 5 pounds—thus suggesting a nicotine dose effect on postcessation weight gain. However, after nicotine polacrilex was discontinued, the 23 week follow-up showed that there was no difference in body weight between the nicotine replacement and placebo groups, indicating that nicotine replacement only delays weight gain. Further research is needed to determine more rigorously whether there is a nicotine dose effect on weight gain, as well as the impact of immediate versus delayed weight gain on rates of relapse.
Other pharmacologic treatments. Two recent studies indicate that pharmacologic treatments other than nicotine replacement may prove effective at preventing weight gain—at least during the first few months after smoking cessation when relapse is most likely. Klesges et al.^^ assessed the efficacy of phenylpropanolomine (PPA), a common over-thecounter anorectic, as a means of preventing postces-
579
sation weight gain. During the 2 week trial, PPA users decreased caloric intake by an average of 630 kcal/day and did not gain weight. Subjects receiving PPA were also less likely to relapse to smoking than those who received placebo. Spring et a/." assessed the efficacy of d-fenfiuramine, a prescription anorectic, for preventing postcessation weight gain and, like the nicotine replacement and PPA studies, found that d-fenfiuramine prevented weight gain. After 4 weeks of treatment, subjects on placebo gained an average of 3.5 pounds, while those on d-fenfiuramine lost an average of 1.8 pounds. The amount of weight gain that occurred after d-fenfiuramine was discontinued was not reported. In sum, the data on preventing postsmoking cessation weight gain suggests that efficacy may depend on the type of intervention used, with strictly behavioral methods mostly ineffective, and three different pharmacologic methods showing high efficacy. Thus, smokers who are concerned about weight gain immediately after smoking cessation have a number of pharmacologic options; however, it is possible that weight gain will occur after the drug is discontinued.
Treatment intervention issues The above review of treatment studies suggests that weight gain can be prevented, particularly with certain pharmacological interventions. However, the side-effects and long-term outcomes must be considered. In the short term, treatment of postcessation weight gain may be highly beneficial, especially with pharmacological treatments that can also improve abstinence success rates. The long-term efficacy of weight control treatment requires more study. If subjects gain weight and relapse upon discontinuation of pharmacological intervention, then the benefits of such treatment might be questioned. However, additional cognitive, dietary, and/or exercise interventions might be developed that could be implemented during early treatment phases to prevent long-term relapses associated with weight gain.
Areas of future investigation: treatment methods. Large and carefully controlled treatment trials assessing the efficacy of dietary restriction/management, exercise, and pharmacologic treatments are needed. In particular, human research assessing the impact of dietary restriction on smoking relapse is
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needed, as is research evaluating the impact of discontinued use of effective pharmacologic agents (and hence weight gain) on relapse.
Target population issues Studies that have examined the relationship between postcessation weight gain and relapse suggest that precessation fear of weight gain may be an imporant predictor of likelihood to relapse,'"'" while abstinence success rates may be better for those who allow weight gain to occur.'^'^' Thus, it may be that treatment efforts should focus on those who express concern about postcessation weight gain prior to cessation. This group appears to be predominantly female. Research indicates that there is more concern about postcessation weight gain in women than men.-''*-'' In one study, for example, 82% of the women reported gaining weight after quitting smoking, compared with 18% of the men'*—although there was no objective evidence that more women than men did gain weight.
gain—more than the weight gain itself—that appears to play an important role in relapse to smoking. Given the progress that has been made along the spectrum from mechanisms to treatment, those concerned about postcessation weight now have treatment options for preventing weight gain in the critical period immediately after smoking cessation. However, continued research into mechanisms, treatment methods, and individual differences will surely result in new and more effectively tailored treatment options.
References 1. DEPARTMENT OF HEALTH AND HUMAN SERVICES
(1988) The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General. DHHS Pub. No. (CDC) 88-8406. 2.
3.
Areas offuture investigation: treatment specificity Prospective research stratifying on gender, concern about weight gain, and dieting history (e.g. yo-yo dieting) is needed to clarify who is most likely to relapse as a result of postcessation weight gain and who would thus benefit the most from treatments to prevent the weight gain. Such research is needed because it appears that strategies for preventing postcessation weight gain will need to be individually tailored and implemented, where some abstainers may benefit from pharmacologic methods, others from behavioral methods, and still others may neither need nor desire any treatment.
Conclusions Significant progress has been made in the research on smoking cessation and weight gain since the 1988 Surgeon General's Report, particularly on mechanisms and treatment methods. Smoking cessation results in weight gain in most quitters, primarily due to changes in caloric intake and to a lesser extent from changes in energy expenditure. Thus far, pharmacologic treatments appear more efficacious at preventing the weight gain than behavioral methods. And regarding who should receive treatment, preliminary research suggests that females are more concerned about postcessation weight gain than males, and it is the concern about weight
KLESGES, R. C , MEYERS, A., KLESGES, L . M . & LA
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