Addictive Behaviors 41 (2015) 29–33
Contents lists available at ScienceDirect
Addictive Behaviors
Short Communication
General and smoking cessation weight concern in a Hispanic sample of light and intermittent smokers Erica Landrau-Cribbs, José Alonso Cabriales, Theodore V. Cooper ⁎ Department of Psychology, The University of Texas at El Paso, USA
H I G H L I G H T S • Light and intermittent smokers demonstrated high levels of weight concern. • General weight concern was associated with higher odds of abstinence. • Females and weight were associated with greater general weight concern.
a r t i c l e
i n f o
Available online 28 September 2014 Keywords: Smoking Smoking cessation Weight concern Hispanics Light and intermittent smoking LITS
a b s t r a c t This study assessed general and cessation related weight concerns in a Hispanic sample of light (≤10 cigarettes per day) and intermittent (non-daily smoking) smokers (LITS) participating in a brief smoking cessation intervention. Three hundred and fifty-four Hispanic LITS (Mage = 34.2, SD = 14; 51.1% male; 57.9% Mexican American; 59.0% daily light, 41.0% intermittent) completed baseline measures assessing demographics, tobacco use/history, stage of change (SOC), general weight concern, and cessation related weight concern. Three multiple logistic regression models examined potential predictors (i.e., age, gender, SOC, cigarettes per month, smoking status [daily vs non-daily], weight, cessation related weight concern, general weight concern) of general weight concern, cessation related weight concern, and past 30 day abstinence (controlling for the intervention). Study results indicated that a majority of participants reported general weight concern (59.6%), and slightly more than a third (35.6%) reported post cessation weight gain concern (mean and median weight tolerated before relapse were within the 10–12 lb range). Lower weight and endorsing general weight concern were associated with cessation related weight concern. Female gender, higher weight, and endorsing cessation related weight concern were associated with general weight concern. Monthly cigarette use was associated with smoking cessation at the three-month follow-up. The results indicate a substantial prevalence of general weight concern and non-trivial rates of cessation related weight concern in Hispanic LITS attempting to quit, and greater success in quitting among those who reported lower rates of cigarettes smoked per month. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Smoking cessation related weight concerns can hinder efforts (or be perceived as a barrier) to quit smoking (Rosenthal et al., 2013) and increase the risk for relapse in those who have quit (Donny, Caggiula, Weaver, Levin, & Sved, 2011). For example, smokers with cessation related weight concerns report less successful quit attempts compared to those without such concerns (Schauer et al., 2013). On the other hand, previous studies have indicated that cessation related weight
⁎ Corresponding author at: Department of Psychology, The University of Texas at El Paso, 500 W. University Avenue, El Paso, TX 79968, USA. Tel.: + 1 915 747 6270; fax: + 1 915 747 6553. E-mail address: [email protected] (T.V. Cooper).
http://dx.doi.org/10.1016/j.addbeh.2014.09.018 0306-4603/© 2014 Elsevier Ltd. All rights reserved.
concerns were not associated with cessation outcomes, both in a population-based study (Jeffrey, Boles, Strycker, & Glasgow, 1997) and in a Hispanic sample (Ortiz et al., 2003). Similarly, studies assessing the association between general weight concern and smoking cessation have reported inconsistent results. For example, previous research indicated that general weight concern was not associated with cessation (Pisinger & Jorgensen, 2007); however, Cooper, Dundon, Hoffman, and Stoever (2006) found that general weight concern was associated with increased odds of quitting smoking. Currently, there are no known studies assessing cessation related weight concern in Hispanic and/or LITS samples. Since weight related concerns may be perceived as a significant barrier to smoking cessation among regular smokers, this study sought to assess potential predictors of general and cessation related weight concerns in a Hispanic light (≤10 cigarettes per day) and intermittent (non-daily) smoking sample.
30
E. Landrau-Cribbs et al. / Addictive Behaviors 41 (2015) 29–33
Study hypotheses were that gender, daily light smoking, cigarettes smoked per month, baseline weight, and general weight concern would be positively associated with cessation related weight concern. Additionally, it was hypothesized that gender and baseline weight would be positively associated with both general weight concern and smoking cessation at the three-month follow-up. 2. Material and methods
the informed consent process, the survey, and were then randomly assigned to receive either the immediate or delayed intervention. Participants in the immediate condition received the intervention after completing the baseline survey; those in the delayed condition were paid and debriefed after completing the baseline survey. The intervention included motivational enhancement, trigger management, and health education components. All participants completed a threemonth follow-up survey.
2.1. Participants
2.3. Measures
Data from 354 Hispanic LITS who participated in a randomized trial of a brief smoking cessation intervention were analyzed in this study. The majority of participants were male (51.1%; Mage = 34.2, SD = 14), and Mexican American (57.9%). The mean baseline self-reported weight was 174.8 lb (SD = 40.3), and the mean number of cigarettes smoked per day (among daily smokers) was 4.6 (SD = 3.6). See Table 1 for additional demographic characteristics.
2.3.1. Tobacco use behavior and attitudes questionnaire Categorical smoking status, smoking frequency, and cigarettes per day were self-reported through a tobacco use history and attitudes survey used in past studies (e.g., Cooper, Rodríguez de Ybarra, Charter, & Blow, 2011). Smoking cessation was established by endorsing not having smoked any cigarettes during the past thirty days at the threemonth follow-up.
2.2. Procedure
2.3.2. The Smoking: Stage of Change Short Form The Smoking: Stage of Change Short Form (McConnaughy, Prochaska, & Velicer, 1983) is a three-question algorithm designed to assess an individual's motivation to quit smoking by placing him/her into one of the five stages of change depending on his/her willingness to quit in the next month or six months.
LITS were recruited to participate in a brief smoking cessation intervention at either one family health clinic, one hospital, or at a University on the U.S./México border. Eligibility criteria were to be at least 18 years of age and to have smoked at least one cigarette during the past month and up to 10 cigarettes per day (CPD). Eligible participants completed
2.3.3. General weight concern Participants were asked: “Are you in general concerned about your weight?” Participants who responded “yes” to this question were considered to have general weight concerns.
Table 1 Characteristics of light and intermittent smokers.
Gender Male Female Ethnicity-Hispanic Mexican national Mexican American Other Hispanic Stage of change Precontemplation Contemplation Preparation Baseline weight related characteristics General weight concern Yes No Cessation related weight concern Yes No
Light daily (59%)
Intermittent (41%)
Total
%
%
%
54.1 45.9
46.9 53.1
51.1 48.9
25.8 56 18.2
24.1 60.7 15.2
25.1 57.9 16.9
53.4 26.7 19.9
41.4 25 31.4
24.6 26 48.6
61.2 38.8
57.2 42.8
59.6 40.4
41.3 58.7
36.2 63.8
35.6 55.4
56.1 43.9
28.8 24.6
26.6 74.4
13.3 38.4
11.7 88.3
8.2 91.8
Follow-up weight related/tobacco use characteristics General weight concern Yes 52.3 No 47.7 Cessation related weight concern Yes 25.7 No 74.3 Past 30 day abstinence Yes 5.7 No 94.3 Continuous baseline characteristics
M (SD)
M (SD)
M (SD)
Age (years) Weight in pounds Weight gain prompting relapse (lbs) Days smoked in last 30 days Cigarettes smoked per day (0–20) Past year intentional quit attempts
36.6 (14.5) 174.8 (40.2) 11.4 (17.7) 26.3 (6.5) 6.2 (3.2) 2.5 (1.5)
30.8 (12.6) 174.8 (40.6) 9.9 (15.8) 10.1 (7.8) 1.6 (1.7) 2.6 (1.7)
34.2 (14.0) 174.8 (40.3) 10.7 (16.9) 19.7 (10.7) 4.6 (3.6) 2.6 (1.6)
2.3.4. Cessation related weight concern Participants were asked a series of ten questions concerning the weight gain they would tolerate before relapsing to smoking in two pound increments, starting from 0–2 lb up to 18–20 lb. Participants who responded “yes” to intending to relapse at any amount of weight gain were considered to have cessation related weight concerns. Additionally, participants self-reported their current weight in pounds. 2.4. Approach to analyses Descriptive statistics were computed for demographics, tobacco use, and weight related variables. Three multiple hierarchical logistic regressions examined potential correlates of cessation related weight concern (at baseline), general weight concern (at baseline), and smoking cessation at follow-up. Variables were included in each model based on their significant association with the outcome variable or due to past research. First, age (r = −.13), weight (r = −.26), and general weight concern (r = .18) were associated with cessation related weight concern (all ps b .05). Second, gender (r = .31), weight (r = .24), and cessation related weight concern (r = .18) were associated with general weight concern (all ps b .01). Third, cigarettes per month (r = −.12), and smoking status (r = −.11) were associated with smoking cessation (all ps b .01). Given the primary aims of this study, weight, and weight/ cessation related concerns were included in all three models. The first logistic regression assessed the following predictors of cessation related weight concern (yes/no): age, gender (coded 0 = male, 1 = female; block 1), cigarettes per month, smoking status (daily vs. non-daily) (block 2), weight, and general weight concern (block 3). The second logistic regression assessed the following potential predictors of general weight concern (yes/no): age, gender (block 1), SOC (block 2), cigarettes per month, smoking status (daily vs. non-daily) (block 3), weight, and cessation related weight concern (block 4). The third model included the following predictors of past 30 day abstinence: intervention condition, age, gender (block 1), SOC (block 2), cigarettes
E. Landrau-Cribbs et al. / Addictive Behaviors 41 (2015) 29–33 Table 2 Logistic regressions predicting weight related and smoking cessation outcomes. Hierarchical logistic regression predicting cessation related weight concern B
SE
OR
95% CI Lower Upper
Age −.03 .02 .97 .93 1.01 Gender −.66 .49 .52 .20 1.35 Cigarettes per month .00 .00 1.00 .99 1.01 Daily vs. intermittent smoking .40 .53 1.50 .53 4.23 Weight (in pounds) −.02 .01 .98 .97 .99 General weight concern .97 .49 2.65 1.01 6.94 Constant 2.57 1.10 5.42 Note: block 1, χ2 (2) = 8.33, p = .016, Nagelkerke R2 = 0.09; block 2, χ2 2 (2) = 1.28, p = .53, Nagelkerke R = 0.10; block 3, χ2 (2) = 9.45, p b .01, Nagelkerke R2 = 0.19. Model: χ2 (6) = 19.07, p = .004, Nagelkerke R2 = 0.19. Hierarchical logistic regression predicting general weight concern B
SE
OR
95% CI Lower Upper
Age .012 .02 1.01 .98 1.05 Gender 2.09 .51 8.12 2.99 22.04 Stage of change (ref. is precontemplation) Contemplation .71 .58 2.02 .65 6.30 Preparation .65 .59 1.92 .60 6.10 Cigarettes per month −.01 .00 .996 .991 1.002 Daily vs. intermittent smoking .38 .58 1.47 .47 4.56 Weight (in pounds) .02 .01 1.02 1.01 1.04 Cessation related weight concern 1.13 .53 3.09 1.10 8.71 Constant −5.25 1.41 .005 Note: Bold indicates p b .05. block 1, χ2 (2) = 17.73, p b .001, Nagelkerke R2 = 0.18; block 2, χ2 (2) = .35, p = .84, Nagelkerke R2 = 0.18; block 3, χ2 (2) = 1.52, p = .47, Nagelkerke R2 = 0.19; block 4, χ2 (2) = 15.67, p b .001, Nagelkerke R2 = 0.33. Model: χ2 (8) = 35.27, p b .001, Nagelkerke R2 = 0.33. Hierarchical logistic regression predicting smoking cessation at three-month follow-up B
SE
OR
95% CI Lower Upper
Intervention Age Gender Stage of change (ref. is precontemplation) Contemplation Preparation Cigarettes per month Daily vs. intermittent smoking Weight (in pounds) General weight concern Cessation related weight concern Constant
.24 .03 .25
.65 1.27 .03 1.03 .70 1.29
.36 .97 .32
4.48 1.08 5.12
−.66 .99 .52 .83 .96 2.29 −.02 .01 .98 .06 .79 1.07 −.001 .01 .99 1.91 1.15 6.78 1.12 .87 3.06 −3.04 1.94 .05
.07 .35 .97 .23 .98 .71 .56
3.57 15.02 .99 5.05 1.02 64.51 16.65
Note: bold indicates p b .05. For each model only last block is shown. Block 1, χ2 (3) = 3.14, p = .37, Nagelkerke R2 = 0.05; block 2, χ2 (2) = .97, p = .62, Nagelkerke R2 = 0.06; block 3, χ2 (2) = 10.08, p b .01, Nagelkerke R2 = 0.21; block 4, χ2 (3) = 6.12, p = .11, Nagelkerke R2 = 0.29. Model: χ2 (10) = 20.31, p b .05, Nagelkerke R2 = 0.29. Intervention: 1 = immediate, 2 = delayed; gender: 0 = male, 1 = female; smoking status: 0 = intermittent, 1 = daily light.
per month, smoking status (daily vs. non-daily) (block 3), weight, general weight concern, and cessation related weight concern (block 4). 3. Results The following descriptive results pertain to the baseline assessment only. The majority of participants (60%) reported general weight concern, and slightly more than a third (35.6%) reported cessation related weight concern. The mean range of weight at which participants indicated that a relapse to smoking would occur was 10 to 12 lb. During their longest quit attempt, 34% of participants reported having ever
31
gained any weight. Among those who gained any weight during their longest quit attempt, gaining an average of 11.9 lb (SD = 9.86) was reported. The first logistic regression model assessed cessation related weight concern at baseline (see Table 2). The results indicated that higher weight (OR = .98, 95% CI [.97, .99]) was associated with lower odds of cessation related weight concern, and endorsing general weight concern was associated with higher odds of cessation related weight concern (OR = 2.65, 95% CI [1.01, 6.94]). The second logistic regression model assessed general weight concern (see Table 2). Female gender (OR = 8.12, 95% CI [2.99, 22.04]), higher weight (OR = 1.02, 95% CI [1.01, 1.04]), and endorsing cessation related weight concern (OR = 3.09, 95% CI [1.10, 8.71]) were associated with higher odds of reporting general weight concern. The third logistic regression assessed past 30 day abstinence at the three-month follow-up (see Table 2). Lower number of cigarettes per month (OR = .98, 95% CI [.97, .99]) at baseline was significantly associated with lower odds of smoking cessation at the three-month follow-up. 4. Discussion Consistent with a past study in the U.S./Mexico region which compared Hispanic smokers (light and heavier smokers were included) and non-smokers (Rodriguez-Esquivel, Cooper, Blow, & Resor, 2009) a non-trivial rate of cessation related weight concern was found in this study. Moreover, the rates of cessation weight concern observed in this study are also consistent with those previously observed in a sample of heavier smokers (Cooper et al., 2006). Overall, cessation related weight concern may be explained by the greater degree of body dissatisfaction and motivation to control weight observed in smokers relative to non-smokers (King, Matacin, Marcus, Brock, & Tripolone, 2000). For example, consistent with Cooper et al. (2006), individuals who reported cessation related weight concern indicated that a post cessation weight gain of 10–12 lb would prompt them to relapse to smoking. Similarly, consistent with this weight threshold, study participants reported having gained an average of 11.9 lb during their longest quit attempt (yet as they were participating, clearly they had relapsed to smoking). However, a more recent study (Veldheer et al., 2014) with heavier daily smokers indicated that participants reported having gained on average 20.4 to 22.7 lb during their longest quit attempt. This may suggest that heavier smoking is associated with great weight gain relative to light and intermittent smoking. A comparison of concern between our sample and the heavier smoking sample (Veldheer et al., 2014) is not feasible as cessation related weight concern was measured quite differently. Taken together, educating weight concerned LITS particularly to the possibility of dose dependent cessation related weight gain prior to the possibility of increasing smoking frequency may be a beneficial abstinence and weight control intervention. The finding that higher weight was associated with lower odds of reporting cessation related weight concern is consistent with a previous study (Clark et al., 2006). Studies have suggested that cessation related weight concern may be more likely affected by body image dissatisfaction than by being overweight or obese, especially in females (Clark et al., 2005; King et al., 2000). Regarding this finding, it may be that decreases in weight are associated with cessation weight concern given that individuals who already engage in dieting/weight control practices (or those showing greater general weight concern) are reinforced by their belief (i.e., weight related smoking expectancies) that smoking is a helpful weight control strategy. Despite the high levels of cessation related weight concern reported by female smokers in the literature (e.g., Pirie, Murray, & Luepker, 1991), in this study female gender was not associated with cessation related weight concern. To date, no studies have systematically assessed gender differences with respect to cessation weight concern, so it may be that this dynamic is different among LITS, compared to heavier smokers. General weight concern was associated with cessation related weight concern; indeed at the bivariate level
32
E. Landrau-Cribbs et al. / Addictive Behaviors 41 (2015) 29–33
these variables were correlated (r = .18, p b .001). This suggests that individuals who regularly “worry” about their weight are also more likely to endorse cessation related weight concern. Consistent with previous studies (French & Jeffery, 1995; Pisinger & Jorgensen, 2007), female gender was associated with general weight concern. This finding may be partially explained by an overall low body satisfaction (Grogan, Hartley, Conner, Fry, & Gough, 2010) and greater body image concerns observed in females (Clark et al., 2005) and overweight/obese individuals (Pomerleau & Saules, 2007) which is not necessarily specific to smoking. Consistent with past research (French & Jeffery, 1995), higher weight was associated with greater odds of reporting general weight concern. Higher weight may contribute to the perception that individuals need to engage in dieting or in weight control attempts, and thus be more likely to experience general weight concern (Malinauskas, Raedeke, Aeby, Smith, & Dallas, 2006). Not surprisingly, endorsing cessation related weight concern was associated with general weight concern (as noted in the previous model). Consistent with past studies assessing smoking rate (Diemert, Bondy, Brown, & Manske, 2013; Hymowitz et al., 1997), results indicated that smoking a greater number of cigarettes smoked per month was associated with lower odds of cessation. This finding suggests that individuals who smoke a higher number of cigarettes per month may be more likely to experience greater levels of nicotine addiction (if any) than those who smoke more lightly, which in turn may reduce their chances of quitting. The finding that cessation related weight concern was not associated with decreased smoking cessation warrants further examination. Although few studies have suggested (e.g., Cavallo et al., 2010; Copeland & Carney, 2003) that the level of cessation related weight concern is directly associated with level of smoking (heavy, daily, non-daily), no study has assessed this relationship among a Hispanic LITS sample only, as in the present study. The substantial reported levels of general and smoking cessation related weight concern suggest the need to focus more intensely on weight concern and body image among Hispanic LITS. 4.1. Study limitations and strengths Study limitations include the use of a self-report measure for weight status, not assessing weight gain during the current quit attempt, and a great amount of missing data on the height variable at baseline such that body mass index could not be calculated. Study strengths included the use of a continuous abstinence measure (i.e., past 30 days), a large sample, and the focus on a group of understudied smokers (i.e., Hispanics LITS). 5. Conclusions Lower weight and endorsing general weight concern were significantly associated with cessation related weight concern. Female gender and higher weight were associated with general weight concern. Lastly, the number of cigarettes smoked per month was significantly associated with smoking abstinence. The results indicated that despite lower smoking frequency and rates, the salience of general weight concern and cessation related weight concern among Hispanic LITS may be similar to that observed in heavier smokers (e.g., Cooper et al., 2006). Future studies may benefit from the inclusion of body image measures throughout the cessation process (including an assessment of body satisfaction). Finally, a strong focus on general and cessation related weight concern among Hispanic LITS in future smoking cessation intervention studies may be warranted. Role of funding source Funding for this study was provided by A Smoke Free Paso Del Norte: An Initiative of the Paso Del Norte Health Foundation Grant Nos. 26-8113-48 and 26-8113-61. Paso Del Norte Health Foundation had no role in the study design, collection, analysis or
interpretation of the data, writing of the manuscript, or the decision to submit the paper for publication. Contributors Author Cooper designed the study, was awarded the funding, and assisted in the analyses and manuscript review and revision. Author Landrau-Cribbs was responsible for writing initial and revised versions of the manuscript. Author Cabriales performed the analyses and reviewed versions of the manuscript. Conflict of interest The authors declare that they have no conflicts of interest. Acknowledgments The authors wish to thank the students of the Prevention and Treatment in Clinical Health Lab, as well as the staff at the Centro San Vicente Health Center and the University Medical Center.
References Cavallo, C. A., Smith, A. E., Schepis, T. S., Desai, R., Potenza, M. N., & Krishnan-Sarin, S. (2010). Smoking expectancies, weight concerns, and dietary behaviors in adolescence. Pediatrics, 126, e66–e72. http://dx.doi.org/10.1542/peds.2009-2381. Clark, M. M., Croghan, I. T., Reading, S., Schroeder, D. R., Stoner, S. M., Patten, C. A., et al. (2005). The relationship of body dissatisfaction to cigarette smoking in college students. Body Image, 2, 263–270. http://dx.doi.org/10.1016/j.bodyim.2005.05.002. Clark, M. M., Hurt, R. D., Croghan, I. T., Patten, C. A., Novotny, P., Sloan, J. A., et al. (2006). The prevalence of weight concerns in a smoking abstinence clinical trial. Addictive Behaviors, 31, 1144–1152. http://dx.doi.org/10.1016/j.addbeh.2005.08.011. Cooper, T. V., Dundon, M., Hoffman, B.M., & Stoever, C. J. (2006). General and smoking cessation related weight concerns in veterans. Addictive Behaviors, 31, 722–725. http:// dx.doi.org/10.1016/j.addbeh.2005.05.045. Cooper, T. V., Rodríguez de Ybarra, D., Charter, J. E., & Blow, J. (2011). Characteristics associated with smoking in a Hispanic college sample. Addictive Behaviors, 36, 1329–1332. http://dx.doi.org/10.1016/j.addbeh.2011.07.021. Copeland, A. L., & Carney, C. E. (2003). Smoking expectancies as mediators between dietary restraint and disinhibition and smoking in college women. Experimental and Clinical Psychopharmacology, 11, 247–251. http://dx.doi.org/10.1037/1064-1297.11. 3.247. Diemert, L. M., Bondy, S. J., Brown, S., & Manske, S. (2013). Young adult smoking cessation: Predictors of quit attempts and abstinence. American Journal of Public Health, 103, 449–453. http://dx.doi.org/10.2105/AJPJ.2012.300878. Donny, E. C., Caggiula, A.R., Weaver, M. T., Levin, M. E., & Sved, A. F. (2011). The reinforcement-enhancing effects of nicotine: Implications for the relationship between smoking eating and weight. Physiology & Behavior, 104, 143–148. http:// dx.doi.org/10.1016/j.physbeh.2011.04.043. French, S. A., & Jeffery, R. W. (1995). Weight concerns and smoking: A literature review. Annals of Behavioral Medicine, 17, 234–244. http://dx.doi.org/10.1007/BF02903918. Grogan, S., Hartley, L., Conner, M., Fry, G., & Gough, B. (2010). Appearance concerns and smoking in young men and women: Going beyond weight control. Drugs: Education, Prevention, and Policy, 17, 261–269. http://dx.doi.org/10.3109/ 09687630802422019. Hymowitz, N., Cummings, K. M., Hyland, A., Lynn, W. R., Pechacek, T. F., & Hartwell, T. D. (1997). Predictors of smoking cessation in a cohort of adult smokers followed for five years. Tobacco Control, 6, S57–S62. http://dx.doi.org/10.1136/tc.6.suppl_2.S57. Jeffrey, R. W., Boles, S. M., Strycker, L. A., & Glasgow, R. E. (1997). Smoking-specific weight gain concerns and smoking cessation in a working population. Health Psychology, 16, 487–489. http://dx.doi.org/10.1037/0278-6133.16.5.487. King, T., Matacin, M., Marcus, B., Brock, B., & Tripolone, J. (2000). Body image evaluations in women smokers. Addictive Behaviors, 25, 613–618. http://dx.doi.org/10.1016/ S0306-4603(99)00039-8. Malinauskas, B.M., Raedeke, T. D., Aeby, V. G., Smith, J. L., & Dallas, M. B. (2006). Dieting practices, weight perceptions, and body composition: A comparison of normal weight, overweight, and obese college females. Nutrition Journal, 5, 11. http://dx. doi.org/10.1186/1475-2891-5-11. McConnaughy, E., Prochaska, J., & Velicer, W. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368–375. http://dx.doi.org/10.1037/h0090198. Ortiz, A., Martínez, M., Torres, A., Casal, J., Rodríguez, W., & Nazario, S. (2003). Predictors of smoking cessation success. Puerto Rico Health Sciences Journal, 22, 173–177 (Retrieved from http://prhsj.rcm.upr.edu/index.php/prhsj/article/view/697/500). Pirie, P. L., Murray, D.M., & Luepker, R. V. (1991). Gender differences in smoking and quitting in a cohort of young adults. American Journal of Public Health, 81, 324–327. http://dx.doi.org/10.2105/AJPH.81.3.324. Pisinger, C., & Jorgensen, T. (2007). Weight concerns and smoking in a general population: The Inter99 study. Preventive Medicine, 44, 283–289. http://dx.doi.org/ 10.1016/j.ypmed.2006.11.014. Pomerleau, C. S., & Saules, K. (2007). Body image, body satisfaction, and eating patterns in normal-weight and overweight/obese women current smokers and never-smokers. Addictive Behaviors, 32, 2329–2334. http://dx.doi.org/10.1016/j.addbeh.2007.01.027. Rodriguez-Esquivel, D., Cooper, T. V., Blow, J., & Resor, M. R. (2009). Characteristics associated with smoking in a Hispanic sample. Addictive Behaviors, 34, 593–598. http://dx.doi.org/10.1016/j.addbeh.2009.03.030.
E. Landrau-Cribbs et al. / Addictive Behaviors 41 (2015) 29–33 Rosenthal, L., Carroll-Scott, A., Earnshaw, V. A., Sackey, N., O'Malley, S. S., Santilli, A., et al. (2013). Targeting cessation: Understanding barriers and motivations to quitting among urban adult daily tobacco smokers. Addictive Behaviors, 38, 1639–1642. http://dx.doi.org/10.1016/j.addbeh.2012.09.016. Schauer, G. L., Bush, T., Cerutti, B., Mahoney, L., Thompson, J. R., & Zbikowski, S. M. (2013). Use and effectiveness of quitlines for smokers with diabetes: Cessation and weight
33
outcomes, Washington State Tobacco Quit Line, 2008. Preventing Chronic Disease, 10, 120324. http://dx.doi.org/10.5888/pcd10.120324. Veldheer, S., Yingst, J., Foulds, G., Hrabovsky, S., Berg, A., Sciamanna, C., et al. (2014). Once bitten, twice shy: Concern about gaining weight after smoking cessation and its association with seeking treatment. International Journal of Clinical Practice, 68, 388–395. http://dx.doi.org/10.1111/ijcp.12332.
Contents lists available at ScienceDirect
Addictive Behaviors
Short Communication
General and smoking cessation weight concern in a Hispanic sample of light and intermittent smokers Erica Landrau-Cribbs, José Alonso Cabriales, Theodore V. Cooper ⁎ Department of Psychology, The University of Texas at El Paso, USA
H I G H L I G H T S • Light and intermittent smokers demonstrated high levels of weight concern. • General weight concern was associated with higher odds of abstinence. • Females and weight were associated with greater general weight concern.
a r t i c l e
i n f o
Available online 28 September 2014 Keywords: Smoking Smoking cessation Weight concern Hispanics Light and intermittent smoking LITS
a b s t r a c t This study assessed general and cessation related weight concerns in a Hispanic sample of light (≤10 cigarettes per day) and intermittent (non-daily smoking) smokers (LITS) participating in a brief smoking cessation intervention. Three hundred and fifty-four Hispanic LITS (Mage = 34.2, SD = 14; 51.1% male; 57.9% Mexican American; 59.0% daily light, 41.0% intermittent) completed baseline measures assessing demographics, tobacco use/history, stage of change (SOC), general weight concern, and cessation related weight concern. Three multiple logistic regression models examined potential predictors (i.e., age, gender, SOC, cigarettes per month, smoking status [daily vs non-daily], weight, cessation related weight concern, general weight concern) of general weight concern, cessation related weight concern, and past 30 day abstinence (controlling for the intervention). Study results indicated that a majority of participants reported general weight concern (59.6%), and slightly more than a third (35.6%) reported post cessation weight gain concern (mean and median weight tolerated before relapse were within the 10–12 lb range). Lower weight and endorsing general weight concern were associated with cessation related weight concern. Female gender, higher weight, and endorsing cessation related weight concern were associated with general weight concern. Monthly cigarette use was associated with smoking cessation at the three-month follow-up. The results indicate a substantial prevalence of general weight concern and non-trivial rates of cessation related weight concern in Hispanic LITS attempting to quit, and greater success in quitting among those who reported lower rates of cigarettes smoked per month. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Smoking cessation related weight concerns can hinder efforts (or be perceived as a barrier) to quit smoking (Rosenthal et al., 2013) and increase the risk for relapse in those who have quit (Donny, Caggiula, Weaver, Levin, & Sved, 2011). For example, smokers with cessation related weight concerns report less successful quit attempts compared to those without such concerns (Schauer et al., 2013). On the other hand, previous studies have indicated that cessation related weight
⁎ Corresponding author at: Department of Psychology, The University of Texas at El Paso, 500 W. University Avenue, El Paso, TX 79968, USA. Tel.: + 1 915 747 6270; fax: + 1 915 747 6553. E-mail address: [email protected] (T.V. Cooper).
http://dx.doi.org/10.1016/j.addbeh.2014.09.018 0306-4603/© 2014 Elsevier Ltd. All rights reserved.
concerns were not associated with cessation outcomes, both in a population-based study (Jeffrey, Boles, Strycker, & Glasgow, 1997) and in a Hispanic sample (Ortiz et al., 2003). Similarly, studies assessing the association between general weight concern and smoking cessation have reported inconsistent results. For example, previous research indicated that general weight concern was not associated with cessation (Pisinger & Jorgensen, 2007); however, Cooper, Dundon, Hoffman, and Stoever (2006) found that general weight concern was associated with increased odds of quitting smoking. Currently, there are no known studies assessing cessation related weight concern in Hispanic and/or LITS samples. Since weight related concerns may be perceived as a significant barrier to smoking cessation among regular smokers, this study sought to assess potential predictors of general and cessation related weight concerns in a Hispanic light (≤10 cigarettes per day) and intermittent (non-daily) smoking sample.
30
E. Landrau-Cribbs et al. / Addictive Behaviors 41 (2015) 29–33
Study hypotheses were that gender, daily light smoking, cigarettes smoked per month, baseline weight, and general weight concern would be positively associated with cessation related weight concern. Additionally, it was hypothesized that gender and baseline weight would be positively associated with both general weight concern and smoking cessation at the three-month follow-up. 2. Material and methods
the informed consent process, the survey, and were then randomly assigned to receive either the immediate or delayed intervention. Participants in the immediate condition received the intervention after completing the baseline survey; those in the delayed condition were paid and debriefed after completing the baseline survey. The intervention included motivational enhancement, trigger management, and health education components. All participants completed a threemonth follow-up survey.
2.1. Participants
2.3. Measures
Data from 354 Hispanic LITS who participated in a randomized trial of a brief smoking cessation intervention were analyzed in this study. The majority of participants were male (51.1%; Mage = 34.2, SD = 14), and Mexican American (57.9%). The mean baseline self-reported weight was 174.8 lb (SD = 40.3), and the mean number of cigarettes smoked per day (among daily smokers) was 4.6 (SD = 3.6). See Table 1 for additional demographic characteristics.
2.3.1. Tobacco use behavior and attitudes questionnaire Categorical smoking status, smoking frequency, and cigarettes per day were self-reported through a tobacco use history and attitudes survey used in past studies (e.g., Cooper, Rodríguez de Ybarra, Charter, & Blow, 2011). Smoking cessation was established by endorsing not having smoked any cigarettes during the past thirty days at the threemonth follow-up.
2.2. Procedure
2.3.2. The Smoking: Stage of Change Short Form The Smoking: Stage of Change Short Form (McConnaughy, Prochaska, & Velicer, 1983) is a three-question algorithm designed to assess an individual's motivation to quit smoking by placing him/her into one of the five stages of change depending on his/her willingness to quit in the next month or six months.
LITS were recruited to participate in a brief smoking cessation intervention at either one family health clinic, one hospital, or at a University on the U.S./México border. Eligibility criteria were to be at least 18 years of age and to have smoked at least one cigarette during the past month and up to 10 cigarettes per day (CPD). Eligible participants completed
2.3.3. General weight concern Participants were asked: “Are you in general concerned about your weight?” Participants who responded “yes” to this question were considered to have general weight concerns.
Table 1 Characteristics of light and intermittent smokers.
Gender Male Female Ethnicity-Hispanic Mexican national Mexican American Other Hispanic Stage of change Precontemplation Contemplation Preparation Baseline weight related characteristics General weight concern Yes No Cessation related weight concern Yes No
Light daily (59%)
Intermittent (41%)
Total
%
%
%
54.1 45.9
46.9 53.1
51.1 48.9
25.8 56 18.2
24.1 60.7 15.2
25.1 57.9 16.9
53.4 26.7 19.9
41.4 25 31.4
24.6 26 48.6
61.2 38.8
57.2 42.8
59.6 40.4
41.3 58.7
36.2 63.8
35.6 55.4
56.1 43.9
28.8 24.6
26.6 74.4
13.3 38.4
11.7 88.3
8.2 91.8
Follow-up weight related/tobacco use characteristics General weight concern Yes 52.3 No 47.7 Cessation related weight concern Yes 25.7 No 74.3 Past 30 day abstinence Yes 5.7 No 94.3 Continuous baseline characteristics
M (SD)
M (SD)
M (SD)
Age (years) Weight in pounds Weight gain prompting relapse (lbs) Days smoked in last 30 days Cigarettes smoked per day (0–20) Past year intentional quit attempts
36.6 (14.5) 174.8 (40.2) 11.4 (17.7) 26.3 (6.5) 6.2 (3.2) 2.5 (1.5)
30.8 (12.6) 174.8 (40.6) 9.9 (15.8) 10.1 (7.8) 1.6 (1.7) 2.6 (1.7)
34.2 (14.0) 174.8 (40.3) 10.7 (16.9) 19.7 (10.7) 4.6 (3.6) 2.6 (1.6)
2.3.4. Cessation related weight concern Participants were asked a series of ten questions concerning the weight gain they would tolerate before relapsing to smoking in two pound increments, starting from 0–2 lb up to 18–20 lb. Participants who responded “yes” to intending to relapse at any amount of weight gain were considered to have cessation related weight concerns. Additionally, participants self-reported their current weight in pounds. 2.4. Approach to analyses Descriptive statistics were computed for demographics, tobacco use, and weight related variables. Three multiple hierarchical logistic regressions examined potential correlates of cessation related weight concern (at baseline), general weight concern (at baseline), and smoking cessation at follow-up. Variables were included in each model based on their significant association with the outcome variable or due to past research. First, age (r = −.13), weight (r = −.26), and general weight concern (r = .18) were associated with cessation related weight concern (all ps b .05). Second, gender (r = .31), weight (r = .24), and cessation related weight concern (r = .18) were associated with general weight concern (all ps b .01). Third, cigarettes per month (r = −.12), and smoking status (r = −.11) were associated with smoking cessation (all ps b .01). Given the primary aims of this study, weight, and weight/ cessation related concerns were included in all three models. The first logistic regression assessed the following predictors of cessation related weight concern (yes/no): age, gender (coded 0 = male, 1 = female; block 1), cigarettes per month, smoking status (daily vs. non-daily) (block 2), weight, and general weight concern (block 3). The second logistic regression assessed the following potential predictors of general weight concern (yes/no): age, gender (block 1), SOC (block 2), cigarettes per month, smoking status (daily vs. non-daily) (block 3), weight, and cessation related weight concern (block 4). The third model included the following predictors of past 30 day abstinence: intervention condition, age, gender (block 1), SOC (block 2), cigarettes
E. Landrau-Cribbs et al. / Addictive Behaviors 41 (2015) 29–33 Table 2 Logistic regressions predicting weight related and smoking cessation outcomes. Hierarchical logistic regression predicting cessation related weight concern B
SE
OR
95% CI Lower Upper
Age −.03 .02 .97 .93 1.01 Gender −.66 .49 .52 .20 1.35 Cigarettes per month .00 .00 1.00 .99 1.01 Daily vs. intermittent smoking .40 .53 1.50 .53 4.23 Weight (in pounds) −.02 .01 .98 .97 .99 General weight concern .97 .49 2.65 1.01 6.94 Constant 2.57 1.10 5.42 Note: block 1, χ2 (2) = 8.33, p = .016, Nagelkerke R2 = 0.09; block 2, χ2 2 (2) = 1.28, p = .53, Nagelkerke R = 0.10; block 3, χ2 (2) = 9.45, p b .01, Nagelkerke R2 = 0.19. Model: χ2 (6) = 19.07, p = .004, Nagelkerke R2 = 0.19. Hierarchical logistic regression predicting general weight concern B
SE
OR
95% CI Lower Upper
Age .012 .02 1.01 .98 1.05 Gender 2.09 .51 8.12 2.99 22.04 Stage of change (ref. is precontemplation) Contemplation .71 .58 2.02 .65 6.30 Preparation .65 .59 1.92 .60 6.10 Cigarettes per month −.01 .00 .996 .991 1.002 Daily vs. intermittent smoking .38 .58 1.47 .47 4.56 Weight (in pounds) .02 .01 1.02 1.01 1.04 Cessation related weight concern 1.13 .53 3.09 1.10 8.71 Constant −5.25 1.41 .005 Note: Bold indicates p b .05. block 1, χ2 (2) = 17.73, p b .001, Nagelkerke R2 = 0.18; block 2, χ2 (2) = .35, p = .84, Nagelkerke R2 = 0.18; block 3, χ2 (2) = 1.52, p = .47, Nagelkerke R2 = 0.19; block 4, χ2 (2) = 15.67, p b .001, Nagelkerke R2 = 0.33. Model: χ2 (8) = 35.27, p b .001, Nagelkerke R2 = 0.33. Hierarchical logistic regression predicting smoking cessation at three-month follow-up B
SE
OR
95% CI Lower Upper
Intervention Age Gender Stage of change (ref. is precontemplation) Contemplation Preparation Cigarettes per month Daily vs. intermittent smoking Weight (in pounds) General weight concern Cessation related weight concern Constant
.24 .03 .25
.65 1.27 .03 1.03 .70 1.29
.36 .97 .32
4.48 1.08 5.12
−.66 .99 .52 .83 .96 2.29 −.02 .01 .98 .06 .79 1.07 −.001 .01 .99 1.91 1.15 6.78 1.12 .87 3.06 −3.04 1.94 .05
.07 .35 .97 .23 .98 .71 .56
3.57 15.02 .99 5.05 1.02 64.51 16.65
Note: bold indicates p b .05. For each model only last block is shown. Block 1, χ2 (3) = 3.14, p = .37, Nagelkerke R2 = 0.05; block 2, χ2 (2) = .97, p = .62, Nagelkerke R2 = 0.06; block 3, χ2 (2) = 10.08, p b .01, Nagelkerke R2 = 0.21; block 4, χ2 (3) = 6.12, p = .11, Nagelkerke R2 = 0.29. Model: χ2 (10) = 20.31, p b .05, Nagelkerke R2 = 0.29. Intervention: 1 = immediate, 2 = delayed; gender: 0 = male, 1 = female; smoking status: 0 = intermittent, 1 = daily light.
per month, smoking status (daily vs. non-daily) (block 3), weight, general weight concern, and cessation related weight concern (block 4). 3. Results The following descriptive results pertain to the baseline assessment only. The majority of participants (60%) reported general weight concern, and slightly more than a third (35.6%) reported cessation related weight concern. The mean range of weight at which participants indicated that a relapse to smoking would occur was 10 to 12 lb. During their longest quit attempt, 34% of participants reported having ever
31
gained any weight. Among those who gained any weight during their longest quit attempt, gaining an average of 11.9 lb (SD = 9.86) was reported. The first logistic regression model assessed cessation related weight concern at baseline (see Table 2). The results indicated that higher weight (OR = .98, 95% CI [.97, .99]) was associated with lower odds of cessation related weight concern, and endorsing general weight concern was associated with higher odds of cessation related weight concern (OR = 2.65, 95% CI [1.01, 6.94]). The second logistic regression model assessed general weight concern (see Table 2). Female gender (OR = 8.12, 95% CI [2.99, 22.04]), higher weight (OR = 1.02, 95% CI [1.01, 1.04]), and endorsing cessation related weight concern (OR = 3.09, 95% CI [1.10, 8.71]) were associated with higher odds of reporting general weight concern. The third logistic regression assessed past 30 day abstinence at the three-month follow-up (see Table 2). Lower number of cigarettes per month (OR = .98, 95% CI [.97, .99]) at baseline was significantly associated with lower odds of smoking cessation at the three-month follow-up. 4. Discussion Consistent with a past study in the U.S./Mexico region which compared Hispanic smokers (light and heavier smokers were included) and non-smokers (Rodriguez-Esquivel, Cooper, Blow, & Resor, 2009) a non-trivial rate of cessation related weight concern was found in this study. Moreover, the rates of cessation weight concern observed in this study are also consistent with those previously observed in a sample of heavier smokers (Cooper et al., 2006). Overall, cessation related weight concern may be explained by the greater degree of body dissatisfaction and motivation to control weight observed in smokers relative to non-smokers (King, Matacin, Marcus, Brock, & Tripolone, 2000). For example, consistent with Cooper et al. (2006), individuals who reported cessation related weight concern indicated that a post cessation weight gain of 10–12 lb would prompt them to relapse to smoking. Similarly, consistent with this weight threshold, study participants reported having gained an average of 11.9 lb during their longest quit attempt (yet as they were participating, clearly they had relapsed to smoking). However, a more recent study (Veldheer et al., 2014) with heavier daily smokers indicated that participants reported having gained on average 20.4 to 22.7 lb during their longest quit attempt. This may suggest that heavier smoking is associated with great weight gain relative to light and intermittent smoking. A comparison of concern between our sample and the heavier smoking sample (Veldheer et al., 2014) is not feasible as cessation related weight concern was measured quite differently. Taken together, educating weight concerned LITS particularly to the possibility of dose dependent cessation related weight gain prior to the possibility of increasing smoking frequency may be a beneficial abstinence and weight control intervention. The finding that higher weight was associated with lower odds of reporting cessation related weight concern is consistent with a previous study (Clark et al., 2006). Studies have suggested that cessation related weight concern may be more likely affected by body image dissatisfaction than by being overweight or obese, especially in females (Clark et al., 2005; King et al., 2000). Regarding this finding, it may be that decreases in weight are associated with cessation weight concern given that individuals who already engage in dieting/weight control practices (or those showing greater general weight concern) are reinforced by their belief (i.e., weight related smoking expectancies) that smoking is a helpful weight control strategy. Despite the high levels of cessation related weight concern reported by female smokers in the literature (e.g., Pirie, Murray, & Luepker, 1991), in this study female gender was not associated with cessation related weight concern. To date, no studies have systematically assessed gender differences with respect to cessation weight concern, so it may be that this dynamic is different among LITS, compared to heavier smokers. General weight concern was associated with cessation related weight concern; indeed at the bivariate level
32
E. Landrau-Cribbs et al. / Addictive Behaviors 41 (2015) 29–33
these variables were correlated (r = .18, p b .001). This suggests that individuals who regularly “worry” about their weight are also more likely to endorse cessation related weight concern. Consistent with previous studies (French & Jeffery, 1995; Pisinger & Jorgensen, 2007), female gender was associated with general weight concern. This finding may be partially explained by an overall low body satisfaction (Grogan, Hartley, Conner, Fry, & Gough, 2010) and greater body image concerns observed in females (Clark et al., 2005) and overweight/obese individuals (Pomerleau & Saules, 2007) which is not necessarily specific to smoking. Consistent with past research (French & Jeffery, 1995), higher weight was associated with greater odds of reporting general weight concern. Higher weight may contribute to the perception that individuals need to engage in dieting or in weight control attempts, and thus be more likely to experience general weight concern (Malinauskas, Raedeke, Aeby, Smith, & Dallas, 2006). Not surprisingly, endorsing cessation related weight concern was associated with general weight concern (as noted in the previous model). Consistent with past studies assessing smoking rate (Diemert, Bondy, Brown, & Manske, 2013; Hymowitz et al., 1997), results indicated that smoking a greater number of cigarettes smoked per month was associated with lower odds of cessation. This finding suggests that individuals who smoke a higher number of cigarettes per month may be more likely to experience greater levels of nicotine addiction (if any) than those who smoke more lightly, which in turn may reduce their chances of quitting. The finding that cessation related weight concern was not associated with decreased smoking cessation warrants further examination. Although few studies have suggested (e.g., Cavallo et al., 2010; Copeland & Carney, 2003) that the level of cessation related weight concern is directly associated with level of smoking (heavy, daily, non-daily), no study has assessed this relationship among a Hispanic LITS sample only, as in the present study. The substantial reported levels of general and smoking cessation related weight concern suggest the need to focus more intensely on weight concern and body image among Hispanic LITS. 4.1. Study limitations and strengths Study limitations include the use of a self-report measure for weight status, not assessing weight gain during the current quit attempt, and a great amount of missing data on the height variable at baseline such that body mass index could not be calculated. Study strengths included the use of a continuous abstinence measure (i.e., past 30 days), a large sample, and the focus on a group of understudied smokers (i.e., Hispanics LITS). 5. Conclusions Lower weight and endorsing general weight concern were significantly associated with cessation related weight concern. Female gender and higher weight were associated with general weight concern. Lastly, the number of cigarettes smoked per month was significantly associated with smoking abstinence. The results indicated that despite lower smoking frequency and rates, the salience of general weight concern and cessation related weight concern among Hispanic LITS may be similar to that observed in heavier smokers (e.g., Cooper et al., 2006). Future studies may benefit from the inclusion of body image measures throughout the cessation process (including an assessment of body satisfaction). Finally, a strong focus on general and cessation related weight concern among Hispanic LITS in future smoking cessation intervention studies may be warranted. Role of funding source Funding for this study was provided by A Smoke Free Paso Del Norte: An Initiative of the Paso Del Norte Health Foundation Grant Nos. 26-8113-48 and 26-8113-61. Paso Del Norte Health Foundation had no role in the study design, collection, analysis or
interpretation of the data, writing of the manuscript, or the decision to submit the paper for publication. Contributors Author Cooper designed the study, was awarded the funding, and assisted in the analyses and manuscript review and revision. Author Landrau-Cribbs was responsible for writing initial and revised versions of the manuscript. Author Cabriales performed the analyses and reviewed versions of the manuscript. Conflict of interest The authors declare that they have no conflicts of interest. Acknowledgments The authors wish to thank the students of the Prevention and Treatment in Clinical Health Lab, as well as the staff at the Centro San Vicente Health Center and the University Medical Center.
References Cavallo, C. A., Smith, A. E., Schepis, T. S., Desai, R., Potenza, M. N., & Krishnan-Sarin, S. (2010). Smoking expectancies, weight concerns, and dietary behaviors in adolescence. Pediatrics, 126, e66–e72. http://dx.doi.org/10.1542/peds.2009-2381. Clark, M. M., Croghan, I. T., Reading, S., Schroeder, D. R., Stoner, S. M., Patten, C. A., et al. (2005). The relationship of body dissatisfaction to cigarette smoking in college students. Body Image, 2, 263–270. http://dx.doi.org/10.1016/j.bodyim.2005.05.002. Clark, M. M., Hurt, R. D., Croghan, I. T., Patten, C. A., Novotny, P., Sloan, J. A., et al. (2006). The prevalence of weight concerns in a smoking abstinence clinical trial. Addictive Behaviors, 31, 1144–1152. http://dx.doi.org/10.1016/j.addbeh.2005.08.011. Cooper, T. V., Dundon, M., Hoffman, B.M., & Stoever, C. J. (2006). General and smoking cessation related weight concerns in veterans. Addictive Behaviors, 31, 722–725. http:// dx.doi.org/10.1016/j.addbeh.2005.05.045. Cooper, T. V., Rodríguez de Ybarra, D., Charter, J. E., & Blow, J. (2011). Characteristics associated with smoking in a Hispanic college sample. Addictive Behaviors, 36, 1329–1332. http://dx.doi.org/10.1016/j.addbeh.2011.07.021. Copeland, A. L., & Carney, C. E. (2003). Smoking expectancies as mediators between dietary restraint and disinhibition and smoking in college women. Experimental and Clinical Psychopharmacology, 11, 247–251. http://dx.doi.org/10.1037/1064-1297.11. 3.247. Diemert, L. M., Bondy, S. J., Brown, S., & Manske, S. (2013). Young adult smoking cessation: Predictors of quit attempts and abstinence. American Journal of Public Health, 103, 449–453. http://dx.doi.org/10.2105/AJPJ.2012.300878. Donny, E. C., Caggiula, A.R., Weaver, M. T., Levin, M. E., & Sved, A. F. (2011). The reinforcement-enhancing effects of nicotine: Implications for the relationship between smoking eating and weight. Physiology & Behavior, 104, 143–148. http:// dx.doi.org/10.1016/j.physbeh.2011.04.043. French, S. A., & Jeffery, R. W. (1995). Weight concerns and smoking: A literature review. Annals of Behavioral Medicine, 17, 234–244. http://dx.doi.org/10.1007/BF02903918. Grogan, S., Hartley, L., Conner, M., Fry, G., & Gough, B. (2010). Appearance concerns and smoking in young men and women: Going beyond weight control. Drugs: Education, Prevention, and Policy, 17, 261–269. http://dx.doi.org/10.3109/ 09687630802422019. Hymowitz, N., Cummings, K. M., Hyland, A., Lynn, W. R., Pechacek, T. F., & Hartwell, T. D. (1997). Predictors of smoking cessation in a cohort of adult smokers followed for five years. Tobacco Control, 6, S57–S62. http://dx.doi.org/10.1136/tc.6.suppl_2.S57. Jeffrey, R. W., Boles, S. M., Strycker, L. A., & Glasgow, R. E. (1997). Smoking-specific weight gain concerns and smoking cessation in a working population. Health Psychology, 16, 487–489. http://dx.doi.org/10.1037/0278-6133.16.5.487. King, T., Matacin, M., Marcus, B., Brock, B., & Tripolone, J. (2000). Body image evaluations in women smokers. Addictive Behaviors, 25, 613–618. http://dx.doi.org/10.1016/ S0306-4603(99)00039-8. Malinauskas, B.M., Raedeke, T. D., Aeby, V. G., Smith, J. L., & Dallas, M. B. (2006). Dieting practices, weight perceptions, and body composition: A comparison of normal weight, overweight, and obese college females. Nutrition Journal, 5, 11. http://dx. doi.org/10.1186/1475-2891-5-11. McConnaughy, E., Prochaska, J., & Velicer, W. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368–375. http://dx.doi.org/10.1037/h0090198. Ortiz, A., Martínez, M., Torres, A., Casal, J., Rodríguez, W., & Nazario, S. (2003). Predictors of smoking cessation success. Puerto Rico Health Sciences Journal, 22, 173–177 (Retrieved from http://prhsj.rcm.upr.edu/index.php/prhsj/article/view/697/500). Pirie, P. L., Murray, D.M., & Luepker, R. V. (1991). Gender differences in smoking and quitting in a cohort of young adults. American Journal of Public Health, 81, 324–327. http://dx.doi.org/10.2105/AJPH.81.3.324. Pisinger, C., & Jorgensen, T. (2007). Weight concerns and smoking in a general population: The Inter99 study. Preventive Medicine, 44, 283–289. http://dx.doi.org/ 10.1016/j.ypmed.2006.11.014. Pomerleau, C. S., & Saules, K. (2007). Body image, body satisfaction, and eating patterns in normal-weight and overweight/obese women current smokers and never-smokers. Addictive Behaviors, 32, 2329–2334. http://dx.doi.org/10.1016/j.addbeh.2007.01.027. Rodriguez-Esquivel, D., Cooper, T. V., Blow, J., & Resor, M. R. (2009). Characteristics associated with smoking in a Hispanic sample. Addictive Behaviors, 34, 593–598. http://dx.doi.org/10.1016/j.addbeh.2009.03.030.
E. Landrau-Cribbs et al. / Addictive Behaviors 41 (2015) 29–33 Rosenthal, L., Carroll-Scott, A., Earnshaw, V. A., Sackey, N., O'Malley, S. S., Santilli, A., et al. (2013). Targeting cessation: Understanding barriers and motivations to quitting among urban adult daily tobacco smokers. Addictive Behaviors, 38, 1639–1642. http://dx.doi.org/10.1016/j.addbeh.2012.09.016. Schauer, G. L., Bush, T., Cerutti, B., Mahoney, L., Thompson, J. R., & Zbikowski, S. M. (2013). Use and effectiveness of quitlines for smokers with diabetes: Cessation and weight
33
outcomes, Washington State Tobacco Quit Line, 2008. Preventing Chronic Disease, 10, 120324. http://dx.doi.org/10.5888/pcd10.120324. Veldheer, S., Yingst, J., Foulds, G., Hrabovsky, S., Berg, A., Sciamanna, C., et al. (2014). Once bitten, twice shy: Concern about gaining weight after smoking cessation and its association with seeking treatment. International Journal of Clinical Practice, 68, 388–395. http://dx.doi.org/10.1111/ijcp.12332.
