Table 2.3Studies assessing use of smoking to control body weight (school and population surveys)

508-Compliant Version

StudyDesign/populationMeasuresPercentage endorsingFindingsComments
Klesges et al. 1987204 undergraduates
Mean 19.9 years of age (SD = 3.4; range 17–40 years)
Cross-sectional
Self-reported questionnaires
Participants selected from among 21 weight-loss strategies they had used in past 6 months including “smoke cigarettes/use caffeine”Females = 21%
Males = 4%
  • Overweight participants (22%) more likely than those of normal weight (13%) or underweight (2%) to endorse smoking/caffeine use for weight loss
NR
Klesges and Klesges 19881,076 university students, faculty, and staff
Mean 21.7 years of age (SD = 6.5; range 16–72 years)
Cross-sectional
Self-reported questionnaires
Participants selected which of 6 dieting strategies (including smoking) they had used in past 6 months to lose weight
Smokers indicated whether they initially started smoking to lose or maintain weight
Reasons for relapse (including weight gain and increased appetite) also assessed
Use of smoking:
Total smokers = 32.5%
Female smokers = 39%
Male smokers = 25%
Nonsmokers = 0.5%

Female smokers = 5%
Male smokers = 10%
  • Use of smoking to control weight did not differ between normal-weight and overweight smokers
  • Younger smokers (<25 years) more likely (38%) to endorse smoking as a weight-control strategy than were older smokers (23.4%)
  • Among females, overweight smokers more likely (20%) than normal-weight smokers (2%) to report starting to smoke to lose weight
Weaknesses: self-reported data
Worsley et al. 1990809 adolescents
Mean 15 years of age
Cross-sectional study, part of the Dunedin Multidisciplinary Health and Development Study cohort
New Zealand
Participants identified which weight-loss strategies they had used in past year, including cigarette smokingGirls = 5%
Boys = 2%
  • Girls more likely than boys to report using smoking to control weight
NR
Frank et al. 1991364 female college freshmen
Mean 18 years of age
Cross-sectional
Self-reported questionnaire
Participants selected from among healthy and unhealthy strategies they had used for losing or maintaining their weight37% of smokers reported
1 of the reasons they smoked was to control their weight
  • Women currently endorsing methods of purging (self-induced vomiting, laxative, or diuretics use) more likely to smoke (44.4%) than were nonpurgers (10.7%)
Strengths: sample was not biased toward people in physical activity class

Weaknesses: self-report; questions did not specify if diet pills were prescribed by a doctor or were over-the-counter
Camp et al. 1993659 high school students
Mean 16.3 years of age
Cross-sectional questionnaire
Item asked smokers whether they had used smoking to control their weightAll female smokers = 39%
Black females = 0%
White females = 61%
All male smokers = 12%
Black males = 0%
White males = 12%
  • Among daily smokers, 100% of White females and 37.5% of White males reported smoking to control weight
  • Significant predictors of smoking for weight control included female gender, increasing age, and higher restrained eating scores
Strengths: addresses several gaps in literature; racially diverse sample; use of variables supported by research; uses conservative statistical tests

Weaknesses: cannot infer causality; results may not generalize to other areas or to nonparochial subjects; did not use bogus pipeline or biochemical methods
Klesges et al. 1997a6,961 7th-grade students enrolled in the Memphis Health Project
Mean 13 years of age
Cross-sectional questionnaire as part of Memphis Health Project
Tennessee
Item asked smokers whether they had ever used smoking to control their weightTotal smokers = 12%
All female smokers = 18%
All male smokers = 8%
All Black smokers = 9%
Black girls = 11%
Black boys = 7%
All White smokers = 15%
White girls = 27%
White boys = 8%
  • Female smokers more likely than male smokers to endorse smoking for weight control
  • Weight-control smoking did not differ between Black and White smokers
Strengths: large sample size; high participation rate; ethnic and gender composition representative of Memphis schools; majority Black children in sample can add to literature re: the behaviors and concerns of this population

Weaknesses: limited generalizability outside of Memphis public schools; did not use bogus pipeline or biochemical procedures; possible response bias due to substance users missing school; lack of temporality
Robinson et al. 19976,967 7th-grade students enrolled in the Memphis Health Project
Mean 13 years of age
Cross-sectional questionnaire as part of Memphis Health Project
Tennessee
Item asked smokers whether they had ever used smoking to control their weightNR
  • Students who endorsed smoking for weight control 3.34 times as likely to be regular (vs. experimental) smokers as those who did not smoke for weight control (Same sample as Klesges et al. 1997a)
Strengths: examined predictors of experimental and regular smokers

Weaknesses: only two ethnic groups examined; did not measure some variables thought to be associated with cigarette smoking; cross-sectional
Jarry et al. 1998220 female undergraduate college students
Mean 27.0 years of age
Cross-sectional retrospective questionnaire
Canada
Never smokers were asked if they ever considered starting to smoke to avoid gaining or to lose weight
7-point scale: “never considered” to “seriously considered”
Current and former smokers indicated agreement with the statements “I started smoking to avoid gaining weight or to lose weight” and “I smoke(d) to avoid gaining weight or to lose weight”
7-point scale: “totally disagree” to “totally agree”
NR
  • Nonsmokers who were dieters marginally more likely than nondieters to report considering starting to smoke for weight control
  • Among current and former smokers, dieters agreed more than nondieters that they started smoking for weight control and continued smoking for this purpose
  • Current smokers more likely than former smokers to endorse starting and continuing to smoke to control weight
Strengths: focus on female population; direct measurement of subjects’ self-perceived motivation to smoke as this relates to weight; assessment of self-reported postcessation weight gain among dieters and nondieters

Weaknesses: retrospective nature of the design; subjects participated on a voluntary basis
Ryan et al. 1998420 students
Mean 15 years of age (range 14–17 years)
Cross-sectional questionnaire
Dublin, Ireland
Questionnaire assessing perceived body weight, weight concerns, and slimming practices including “beginning or continuing smoking”Total sample: 13%
  • Among those attempting to lose weight in the past, 19% reported beginning or continuing smoking as a weight-control strategy
NR
Crisp et al. 19992,768 female students from London (n = 1,936) and Ottawa (n = 832)
Age NR (range 10–19 years)
Cross-sectional questionnaire
United Kingdom and Canada
Smokers identified reasons for smoking, including “instead of eating” and “makes you less hungry”
Smokers indicated expected consequences of quitting smoking, including “eat more” and “put on weight”
Reasons for smoking:
Instead of eating: London = 21%*
Ottawa = 33%*
Makes less hungry: London = 19%*
Ottawa = 36%*
Expected consequences of quitting smoking: Eat more: London = 30%*
Ottawa = 34%*
Put on weight: London = 31%*
Ottawa = 33%*
*Responded “yes, definitely”
  • Smokers more likely than nonsmokers to report “proneness to overeating” and self-induced vomiting
Weaknesses: low response rate in Ottawa schools
Crocker et al. 2001702 female 9th-grade students
Age NR (range 14–15 years)
Cross-sectional questionnaire
Canada
Smoking Situations Questionnaire (SSQ)
6 items to measure use of smoking for weight control (sample items: “I continue to smoke so that I don’t gain weight,” “I smoke at the end of a meal so I won’t eat so much”)
19.4% of female smokers classified as smoking for weight control (defined based on scores of ≥2 on SSQ)
  • Weight-control smokers reported higher levels of dietary restraint, lower levels of global self-esteem, and lower scores on measures reflecting self-perceived body attractiveness and physical condition
Strengths: incorporated a validated physical self-perception model and instrument; used a large regionalized sample of 9th- grade girls from various socioeconomic levels; included a measure of using smoking as a means to control weight

Weaknesses: cross-sectional design; low prevalence of smoking and dietary restraint behavior; not assessing other weight control strategies; used self-reported data
George and Johnson 20011,852 college students
Age NR (>90%, range 17–24 years)
Cross-sectional self-administered questionnaire
Participants identified their primary reason for smoking4% of female and 1% of male smokers cited weight control as primary reason for smoking
  • Respondents allowed to identify only one primary reason for smoking
Strengths: unique population of ethnically diverse university students

Weaknesses: sample demographics and size; possible bias in self-reported weight and smoking status, question design, study design
Granner et al. 2001206 Black and White college students
Mean 20.6 years of age (SD = 2.17)
Cross-sectional ex post facto design
Weight Control Smoking Scale (WCSS)
Eating Disorders
Inventory-2
Sample item: “I smoke to keep from gaining weight”
58% endorsed at least one item regarding smoking for weight control
11.1% of Black smokers and 20.0% of White smokers scored above the cutoff (≥6) for being classified as a weight-control smoker
  • Smokers scored higher on several subscales of the Eating Disorders Inventory-2
  • Students at elevated risk for eating disorders more likely to smoke and scored significantly higher on the WCSS
Weaknesses: cross-sectional design and convenience sampling; some relatively small cell sizes may have limited the ability to fully test associations
Plummer et al. 20012,808 9th-grade students enrolled in a study of smoking, sun protection habits, and reduction in dietary fat
Mean 15.2 years of age (SD = 0.6)
Cross-sectional data from first intervention session
Part of a larger study (n = 4,983)
2 items from the Temptation to Smoke measure for adolescents (Ding et al. 1994) that addressed temptations associated with weight control: “when I am afraid I might gain weight” and “when I want to get thinner”NR
  • Current smokers: temptations to smoke for weight control greater among those in the precontemplation (PC) stage than in the preparation (PR), action (AC), and maintenance (MN) stages; smokers in the contemplation (CN), PR, and AC stages reported stronger temptations related to weight control than those in MN stage
  • Nonsmokers: those in acquisition-PR stage had higher temptations to smoke related to weight control than those in acquisition-CN and acquisition-PC
  • Nonsmokers in acquisition-CN also reported higher temptations than those in acquisition-PC
Strengths: largest sample in which these theoretical constructs have been evaluated; provides basis for interventions based on the Transtheoretical Model (TTM), improved measurement model previously developed by Pallonen et al. (1998) (by including a Habit Strength factor and by using both smokers and nonsmokers in the development of the Weight Control subscale)

Weaknesses: cross-sectional; sample not nationally representative
Zucker et al. 2001188 female undergraduates
Mean 19.0 years of age (SD = 0.9; range 14–17 years)
Cross-sectional-correlational
Self-reported questionnaire
WCSSNR
  • Acceptance of societal appearance standards toward thinness and belief that smoking helps control weight positively associated with smoking for weight control in a multivariate logistic regression model, while feminist consciousness was negatively related
Weaknesses: generalizability limited because of highly selective sample; could not include ethnicity as a variable predicting smoking status
Croll et al. 2002; Fulkerson and French 2003Population-based sample of 81,247 9th- and 12th-grade public school students
Age NR
Cross-sectional from Minnesota Student Survey
“During the last 12 months, have you done any of the following to lose or control your weight? (mark all that apply)”
Response choices included “smoking cigarettes”
Female smokers (in past 30 days):
Total = 48.8%
White = 48.6%
Black = 32.6%
Hispanic = 43.2%
Asian American = 50.0%
Native American = 49.4%
Other/mixed = 55.0%

Male smokers (in past 30 days): Total = 27.6%
White = 26.5%
Black = 27.8%
Hispanic = 32.0%
Asian American = 35.0%
Native American = 38.2%
Other/mixed = 31.3%
  • Female smokers 2.5 (95% CI, 2.38–2.63) times as likely as male smokers to smoke for weight control
  • Among female smokers, Whites were more likely to smoke for weight control than were Black and less likely than those identifying themselves as multiracial
  • Among male smokers, Native Americans and Asian Americans were more likely than Whites to smoke to control their weight
  • In general, heavier smoking, perceiving oneself as overweight, and weight concerns correlated with weight-control smoking in both boys and girls
Strengths: examined ethnic-specific risk and protective factors for disordered eating across a large, statewide, population-based sample utilizing a range of socioenvironmental, personal, and behavioral measures (Croll et al. 2002)

Weaknesses: caution needed when making inferences outside of Minnesota youth; socioeconomic status (SES) not directly assessed; nonspecific nature of the survey questions regarding disordered eating behaviors; not able to distinguish between youth with more severe, frequent disordered eating behaviors and those engaging in disordered eating behaviors less frequently (Croll et al. 2002)

Weaknesses: staff-measured height and weight not feasible—unable to examine relationships among body mass index and perceptions of overweight, worrying about weight, and smoking to lose or control weight; SES data not collected; data do not include adolescents who are not enrolled in public school; cross-sectional (Fulkerson and French 2003)
Neumark-Sztainer et al. 2002Population-based sample of 4,746 adolescents from urban public schools participating in Project EAT
Mean 14.9 years of age (SD = 1.7)
Cross-sectional questionnaire including height and weight measurements by staff; Project EAT surveys
Participants identified healthy, unhealthy, and extreme weight-control behaviors they had engaged in over the past year including “smoked more cigarettes”Girls:
Total = 9.2%
White = 10.5%
African American = 6.1%
Hispanic = 9.3%
Asian American = 7.1%
Native American = 23.3%
Other/mixed = 7.4%

Boys:
Total = 4.7%
White = 4.1%
African American = 2.8%
Hispanic = 6.7%
Asian American = 6.5%
Native American = 8.7%
Other/mixed = 6.7%
  • Rates of smoking for weight control differed across race and ethnicity for both boys and girls
Strengths: large size and diverse nature of the study population; collection of actual height and weight measurements; assessment of a variety of weight-related concerns and behaviors

Weaknesses: self-reported behaviors; generalizations to other populations need to be made cautiously
Forman and Morello 20032,524 8th- and 11th- grade students
Age NR (range ≤13 to ≥18 years)
Cross-sectional self-administered anonymous survey
Argentina
Item and response indicative of weight control smoking:
  • Participants endorsing smoking to avoid eating 2.84 (95% CI, 2.02–3.98) times as likely as those not endorsing this behavior to perceive difficulty in quitting (64.2% vs. 38.7%)
  • Participants reporting smoking to keep weight down 1.96 (95% CI, 1.32–2.90) times as likely as those not smoking to maintain weight to perceive difficulty in quitting (57.8% vs. 41.1%)
Strengths: use of profile analysis using generalized estimating equations to compare clustered groups of adolescents; large sample size; inclusion of specific survey questions regarding different types of weight concerns and perceived difficulty in quitting

Weaknesses: inability to make causal inferences due to cross-sectional nature of the data; use of a single self- report questionnaire to assess the relationships among smoking, perceived difficulty in quitting, and weight concerns
“Why did you first try cigarettes?” (“to avoid getting fat”)Female smokers = 11.3%
Male smokers = 4.0%
“In what situations do you smoke?” (“to avoid eating when I am hungry”)Female smokers = 22.3%
Male smokers = 12.9%
“Why do you smoke?” (“to maintain my weight”)Female smokers = 16.0%
Male smokers = 7.0%
Park et al. 2003297 high school students who were current or former smokers
Age NR
Cross-sectional study; used TTM and structured self-report questionnaire
Korea
Temptation to Smoke measure for adolescents (Ding et al. 1994)NR
  • Temptations to smoke for weight control differed significantly across students’ stage of change; although weight-related temptations to smoke tended to decrease as readiness to change increased, none of the individual group comparisons was significant
NR
Dowdell and Santucci 200454 urban 7th-grade students
Mean 11.9 years of age (range 11–13 years)
Descriptive correlational study using a convenience sample; used Youth Risk Behavior Surveillance System (YRBSS) questionnaire
NR62% of students who smoked indicated that controlling their weight was the reason they smoked
  • Girls more likely than boys to endorse using smoking as their primary method of weight control (percentages not reported)
Strengths: YRBSS has a kappa statistic reliability of 61–80% or higher; alpha reliability of 0.79 determined for this sample of 54 students

Weaknesses: small sample size; absence of information about parental health-related lifestyle behaviors and attitudes; absence of information about the subjects’ access to health care providers and nurses; sample predominantly White children
Nichter et al. 2004205 female 10th- and 11th-grade students interviewed during year 3 of a longitudinal study
10th grade (Mean 16.02 years of age; SD = 0.44)
11th grade (Mean 16.99 years of age; SD = 0.49)
178 surveyed again
5 years later
Longitudinal study known as the Teen Lifestyle Project
Qualitative and quantitative data collection
Various study-specific items assessing smoking for reasons related to weight controlYear 3 (current smokers):
“Did you start smoking as a way to control your weight”? = 11%
“I sometimes smoke so I’ll be less hungry” = 25% of occasional and regular smokers

5-year follow-up (current and former smokers): “Thinking back to when you first started smoking, would you say that you started smoking as a way to control your weight?” = 8%
“Did you ever smoke as a way to control your weight?” = 15%
“Do/did you ever smoke at the end of a meal so you wouldn’t continue eating?” = 3%
“Do you smoke at times so you’ll be less hungry?” = 20%
  • 20% of students endorsed the statement: “In general, I think people who smoke cigarettes are thinner than people who don’t smoke”
  • Smokers and nonsmokers did not differ in the likelihood of trying to lose weight
Strengths: longitudinal span; use of ethnography to explore complex relationship between dieting and smoking; the rapport that was developed with informants over a period of years

Weaknesses: sample of smokers is small and the response rate to the survey questionnaire mailed follow-up is low; findings may not be generalizable to other regions or girls of different ages
Facchini et al. 2005144 female students
Mean 20.0 years of age (SD = 1.74; range 18–27 years)
Cross-sectional design, convenience sample, using a self-reported questionnaire
Argentina
Participants selected from among various reasons for starting to smoke, currently smoking, anticipated consequences of quitting, and reasons for not quitting, several of which were related to eating and body weightReasons for starting to smoke:
To avoid eating = 9%
Because it makes them less hungry = 7%
To control weight = 4%

Reasons for currently smoking:
Because it makes them less hungry = 27%
Instead of snacking when bored = 24%
At the end of a meal so they will not eat so much = 19%
To avoid eating = 16%

Reasons for not quitting:
Eating more = 37%
Putting on weight = 34%
  • Restrained eaters who smoked scored higher on a measure of dietary restraint than did restrained eaters who were nonsmokers
  • Those endorsing at least one behavior indicating smoking for weight control scored higher on a measure of dietary restraint
Strengths: first study of its kind in Argentina and with females older than 18; high level of participation

Weaknesses: cross-sectional design; greater psychometric data on psychosocial items; convenience sample; self-reported weight and height
Malinauskas et al. 2006185 female undergraduate college students
Mean 19.7 years of age (SD = 1.4; range 18–24 years)
Quasi-experimental design; convenience sample; surveys and body composition assessment
Participants completed a dieting practices questionnaire (Calderon et al. 2004) that assessed the use of 15 different weight-loss behaviorsTotal = 9%
Normal weight = 8%
Overweight = 14%
Obese = 5%
NRWeaknesses: cross-sectional study design—cannot determine if a causal relationship exists between dieting and weight control; only involved female students from 1 university
Jenks and Higgs 200730 female undergraduates
Current dieters (n = 15)
Nondieters (n = 15)
Mean 20.5 years of age (SD = 1.6; range 18–24 years)
Randomized intervention with participants randomized to session ordering by food cues
Dieting status was used as an effect modifier
WCSS
Participants also rated agreement with: “I started smoking to control my weight” and “I am concerned about weight gain upon smoking cessation”
100-mm visual analog scale: “totally disagree” to “totally agree”
NR
  • Dieters scored higher than nondieters on measures of weight-control smoking and items assessing having started smoking to control weight and fear of weight gain upon cessation
Strengths: examined for the first time the relationship between weight-control smoking and smoking-related variables in young women and examined the effect of presentation of food cues on these responses

Weaknesses: measurement of expired air carbon monoxide may not be sensitive enough to pick up small differences in the number of cigarettes smoked at low levels of daily smoking; self-report bias

Note: CI = confidence interval; mm = millimeter; NR = not reported; SD = standard deviation.

From: 2, The Health Consequences of Tobacco Use Among Young People

Cover of Preventing Tobacco Use Among Youth and Young Adults
Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General.
National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health.

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