Behavioral intervention to promote smoking cessation and prevent weight gain: a systematic review and meta-analysis

"Healthier health in more ways than one": Perspectives on a program for changing both smoking and obesity-related health behaviors

INTRODUCTION

Individuals with obesity who smoke cigarettes have increased risk of morbidity and mortality. The goal of the current study was to inform the development of a multiple health behavior change intervention designed to facilitate smoking cessation while also targeting weight gain.

METHODS

Four qualitative focus groups were conducted with individuals who smoked cigarettes and had overweight or obesity (n = 16) to explore the combined effects of smoking and obesity, past attempts to quit smoking or lose weight, and preferences for a combined health intervention.

RESULTS

Focus groups converged on five themes including: the interactive effects of weight and smoking; lack of experience with evidence-based weight loss approaches; a desire and expectation to lose weight quickly; rapid weight gain during past attempts at smoking cessation; and interest in a multiple health behavior change intervention with weight management preceding smoking cessation and an emphasis on planning for the future and receiving encouragement and support.

CONCLUSIONS

Groups provided insight into key topics to highlight in a combined intervention and key issues that have interfered with success in both domains.

A smoking cessation intervention for rural veterans tailored to individual risk factors: A multicenter randomized clinical trial

INTRODUCTION

Rates of cigarette use remain elevated among those living in rural areas. Depressive symptoms, risky alcohol use, and weight concerns frequently accompany cigarette smoking and may adversely affect quitting. Whether treatment for tobacco use that simultaneously addresses these issues affects cessation outcomes is uncertain.

METHODS

The study was a multicenter, two-group, randomized controlled trial involving mostly rural veterans who smoke (N = 358) receiving treatment at one of five Veterans Affairs Medical Centers. The study randomly assigned participants to a tailored telephone counseling intervention or referral to their state tobacco quitline. Both groups received guideline-recommended smoking cessation pharmacotherapy, selected using a shared decision-making approach. The primary outcome was self-reported seven-day point prevalence abstinence (PPA) at three and six months. The study used salivary cotinine to verify self-reported quitting at six months.

RESULTS

Self-reported PPA was significantly greater in participants assigned to Tailored Counseling at three (OR = 1.66; 95 % CI: 1.07-2.58) but not six (OR = 1.35; 95 % CI: 0.85-2.15) months. Post hoc subgroup analyses examining treatment group differences based on whether participants had a positive screen for elevated depressive symptoms, risky alcohol use, and/or concerns about weight gain indicated that the cessation benefit of Tailored Counseling at three months was limited to those with ≥1 accompanying concern (OR = 2.02, 95 % CI: 1.20-3.42). Biochemical verification suggested low rates of misreporting.

CONCLUSIONS

A tailored smoking cessation intervention addressing concomitant risk factors enhanced short-term abstinence but did not significantly improve long-term quitting. Extending the duration of treatment may be necessary to sustain treatment effects.

Non-pharmacological interventions for smoking cessation: analysis of systematic reviews and meta-analyses

BACKGROUND

Although non-pharmacological smoking cessation measures have been widely used among smokers, current research evidence on the effects of smoking cessation is inconsistent and of mixed quality. Moreover, there is a lack of comprehensive evidence synthesis. This study seeks to systematically identify, describe, and evaluate the available evidence for non-pharmacological interventions in smoking populations through evidence mapping (EM), and to search for best-practice smoking cessation programs.

METHODS

A comprehensive search for relevant studies published from the establishment of the library to January 8, 2023, was conducted in PubMed, Web of Science, Embase, the Cochrane Library, CNKI, CBM, Wan Fang, and VIP. Two authors independently assessed eligibility and extracted data. The PRISMA statement and AMSTAR 2 tool were used to evaluate the report quality and methodology quality of systematic reviews/meta-analyses (SRs/MAs), respectively. Bubble plots were utilized to display information, such as the study population, intervention type, evidence quality, and original study sample size.

RESULTS

A total of 145 SRs/MAs regarding non-pharmacological interventions for smoking cessation were investigated, with 20 types of interventions identified. The most commonly used interventions were cognitive behaviour education (n = 32, 22.07%), professional counselling (n = 20, 13.79%), and non-nicotine electronic cigarettes (e-cigarettes) (n = 13, 8.97%). Among them, counselling and behavioural support can improve smoking cessation rates, but the effect varies depending on the characteristics of the support provided. These findings are consistent with previous SRs/MAs. The general population (n = 108, 74.48%) was the main cohort included in the SRs/MAs. The total score of PRISMA for the quality of the reports ranged from 8 to 27, and 13 studies (8.97%) were rated as high confidence, and nine studies (6.21%) as moderate confidence, in the AMSTAR 2 confidence rating.

CONCLUSIONS

The abstinence effect of cognitive behaviour education and money incentive intervention has advantages, and non-nicotine e-cigarettes appear to help some smokers transition to less harmful replacement tools. However, the methodological shortcomings of SRs/MAs should be considered. Therefore, to better guide future practice in the field of non-pharmacological smoking cessation, it is essential to improve the methodological quality of SRs and carry out high-quality randomized controlled trials (RCTs).

A randomized controlled trial to reduce post-cessation weight gain

BACKGROUND/OBJECTIVES

Weight gain is a barrier to smoking cessation. Previous interventions targeting weight gain while quitting smoking have largely been unsuccessful. The current study aimed to assess the efficacy of weight stability and weight loss interventions compared to a low-intensity, self-guided bibliotherapy weight management group.

SUBJECTS/METHODS

A randomized controlled trial with 12-month follow-up from 2018 to 2022 was conducted with participants (N = 305) who reported smoking at least five cigarettes per day for the last year and interest in quitting initially recruited from the Memphis, TN, USA area. Recruitment was expanded nationally with the onset of the COVID-19 pandemic. Subsequently, 276 completed 12-month follow-up.

INTERVENTIONS/METHODS

The Bibliotherapy group was provided a weight management book. Both the Stability and Loss groups met via telephone for eight weeks to learn strategies for maintaining/losing weight, respectively. All three groups then received the same six-week smoking cessation intervention, with six months of varenicline provided.

RESULTS

Individuals in the Loss group lost more weight (-2.01 kg, SE = 1.58) than individuals in the Bibliotherapy group (+1.08 kg, SE = 1.49, p = 0.0004), while the Stability group (-0.30 kg, SE = 1.56) was not significantly different from the Bibliotherapy group (p = 0.17). Those in the Stability group did not gain a significant amount of weight. Participants in the Loss group did not gain back all weight lost after smoking cessation and ended the study approximately 2.01 kg lower than baseline. The Bibliotherapy group did not gain the amount of weight expected after cessation. There were no significant differences between groups related to self-reported smoking cessation at each time point except at eight-month follow-up (p = 0.005).

CONCLUSIONS AND RELEVANCE

Results indicated the Stability and the Loss interventions were effective for preventing post-smoking cessation weight gain, with the Loss group having the benefit of sustained weight loss. These interventions may be helpful to implement to combat weight gain and potentially facilitate smoking cessation.

TRIAL REGISTRATION

The trial is registered on clinicaltrials.gov (NCT03156660).

Addressing nutrition and physical activity in substance use disorder treatment: Client reports from a wellness-oriented, tobacco-free policy intervention

Introduction

Interest in wellness interventions in substance use disorder (SUD) treatment is growing although evidence remains limited. This study evaluated nutrition, physical activity, nutrition and physical activity counseling, and relationships of counseling with wellness behavior before and after a wellness-oriented, tobacco-free policy intervention in 17 residential SUD programs.

Methods

Clients completed cross-sectional surveys reporting sugar-sweetened beverage consumption, physical activity, and receipt of nutrition and physical activity counseling before (n= 434) and after (n = 422) an 18-month intervention. Multivariable regression models assessed pre-post-intervention differences in these variables and examined associations of nutrition counseling with sugar-sweetened beverage consumption and physical activity counseling with physical activity.

Results

Post-intervention clients were 83% more likely than pre-intervention clients to report nutrition counseling (p = 0.024). There were no pre-post- differences for other variables. Past week sugar-sweetened beverage consumption was 22% lower among clients reporting nutrition counseling than for those who did not (p = 0.008) and this association did not vary by time (pre/post). There was a significant interaction of physical activity counseling receipt by time on past week physical activity (p = 0.008). Pre-intervention clients reporting physical activity counseling had 22% higher physical activity than those who did not; post-intervention clients reporting physical activity counseling had 47% higher physical activity.

Conclusion

A wellness policy intervention was associated with increased nutrition counseling. Nutrition counseling predicted lower sugar-sweetened beverage consumption. Physical activity counseling predicted higher physical activity, an association that was greater post-intervention. Adding wellness components to tobacco-related interventions may promote health among SUD clients.

Effectiveness of including weight management in smoking cessation treatments: A meta-analysis of behavioral interventions

INTRODUCTION

The potential of weight gain after smoking cessation reduces the incentive to quit. This meta-analysis examines the efficacy of behavioral interventions for smoking cessation that also address post-cessation weight gain.

METHODS

Medline, Web of Science, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials on behavioral treatments targeting both health outcomes. Six separate meta-analyses were undertaken to assess treatment efficacy on smoking abstinence and weight outcomes at end of treatment (EOT), short-term, and long-term follow-up. Individual and treatment moderators were examined as well as methodological quality and publication bias of studies.

RESULTS

A total of 28 studies were included in the meta-analysis. There was a statistically significant positive impact of treatments addressing both targets on smoking outcomes at EOT (RR = 1.279, 95% CI: 1.096, 1.492, p = .002), but not at follow-ups. Age impacted on EOT abstinence rates Q (1) = 4.960, p = .026) while increasing the number of sessions significantly improved EOT abstinence rates (p = .020). There was no statistically significant impact of these treatments on weight at EOT (Hedges' g = -0.015, 95% CI: -.164, 0.135, p = .849) or follow-ups (short term: Hedges' g = 0.055, 95% CI: -0.060, 0.170, p = .347; long term: Hedges' g = -0.320, 95% CI: -.965, 0.325, p = .331). There were minimal impacts of publication bias, mostly related to sample size, meaning studies including small sample sizes revealed larger effect sizes on abstinence at EOT.

DISCUSSION

Addressing post-cessation weight management in treatments for smoking cessation significantly enhances tobacco abstinence at EOT though it was not found to have a lasting impact after treatment.

Post-Cessation Weight Gain among Smokers with Depression Predicts Smoking Relapse

Objective: Weight gain (WG) is one of the most widespread consequences of smoking cessation, although there is a great variability of post-cessation weight changes among smokers. Its approach is critical because it depicts an important barrier to trying to quit smoking and because it has been considered as a long-term predictor of relapse. Notwithstanding, little is known about post-cessation WG specifically among depressed smokers. The current study sought to: (1) describe the WG at posttreatment and follow-ups in smokers with depression, (2) examine the predictors of posttreatment WG, and (3) analyze whether post-cessation WG predicts smoking relapse at 6-month follow-up. Methods: The sample was comprised of 125 smokers with depression who achieved tobacco abstinence at posttreatment following a psychological smoking cessation intervention. Smoking abstinence was biochemically verified through carbon monoxide and urine cotinine. Multiple linear and hierarchical logistic regressions were conducted to examine predictors of WG at posttreatment and tobacco relapse at 6-month follow-up, respectively. Results: Abstinent participants gained an average of 3.55 kg at 6-month follow-up compared to 1.49 kg among participants who relapsed. Greater nicotine dependence (β = .372, p = .001) and diastolic pressure at baseline (β = .252, p = .021) predicted higher WG at end of treatment. WG at posttreatment increased the likelihood of relapse 6 months later (B = .303, OR = 1.354; 95% CI [1.006, 1.822]). Limitations: Weight concerns, disordered eating, and BMI were not recorded, and they could be related to the present findings. Conclusions: These results suggest that individuals with depression during treatment for smoking cessation should be regularly screened and offered treatment to prevent WG.

Nicotine addiction and overweight affect intrinsic neural activity and neurotransmitter activity: A fMRI study of interaction effects

BACKGROUND

Nicotine addiction and overweight often co-exist, but the neurobiological mechanism of their co-morbidity remains to be clarified. In this study, we explore how nicotine addiction and overweight affect intrinsic neural activity and neurotransmitter activity.

METHODS

This study included 54 overweight people and 54 age-, sex-, and handedness-matched normal-weight individuals, who were further divided into four groups based on nicotine addiction. We used a two-way factorial design to compare intrinsic neural activity (calculated by the fALFF method) in four groups based on resting-state functional magnetic resonance images (rs-fMRI). Furthermore, the correlation between fALFF values and PET- and SPECT-derived maps to examine specific neurotransmitter system changes underlying nicotine addiction and overweight.

RESULTS

Nicotine addiction and overweight affect intrinsic neural activity by themselves. In combination, they showed antagonistic effects in the interactive brain regions (left insula and right precuneus). Cross-modal correlations displayed that intrinsic neural activity changes in the interactive brain regions were related to the noradrenaline system (NAT).

CONCLUSION

Due to the existence of interaction, nicotine partially restored the changes of spontaneous activity in the interactive brain regions of overweight people. Therefore, when studying one factor alone, the other should be used as a control variable. Besides, this work links the noradrenaline system with intrinsic neural activity in overweight nicotine addicts. By examining the interactions between nicotine addiction and overweight from neuroimaging and molecular perspectives, this study provides some ideas for the treatment of both co-morbidities.

Behavioral activation for smoking cessation and the prevention of smoking cessation-related weight gain: A randomized trial

BACKGROUND

Post-cessation weight gain (PCWG) is an obstacle to smoking cessation. This trial evaluated a behavioral intervention targeting alternative rewards to smoking and high calorie snacking to promote smoking cessation while mitigating PCWG.

METHODS

Adult smokers (n = 288; 119 females, 169 males) received eight weeks of transdermal nicotine and were randomized to eight sessions of behavioral activation for smoking cessation and the mitigation of PCWG (BAS+) or standard smoking cessation counseling (SC). Primary outcomes were 7-day point prevalence abstinence and PCWG 26 weeks after the target quit date. Change in caloric intake from pre-treatment through the 26-week follow-up was a secondary outcome. Data were collected from September 2016 to February 2021, and analyses were completed in July 2022.

RESULTS

BAS+ and SC did not differ in smoking abstinence rates at the 26-week follow-up (OR=0.80, 95%CI 0.50-1.27, p = 0.34; 18% versus 23%). There were no significant differences in PCWG between BAS+ and SC who were 7-day point prevalence abstinent (β = -0.29, 95%CI -2.13 to 1.65, p = 0.77; 2.60 versus 2.20 pounds, respectively) or among those continuously abstinent (5.78 versus 5.34 pounds, respectively). There were no significant differences in caloric intake between BAS+ and SC from baseline to the 26-week follow-up (β = 110.65, 95%CI -96.72 to 318.02, p = 0.30; -19.1 versus -116.9 kcals/day, respectively).

CONCLUSIONS

The results do not support the efficacy of BAS+ for smoking cessation and the prevention of PCWG. These findings join a growing body of research highlighting the challenge of minimizing PCWG and promoting smoking abstinence.

Reward and inhibition in obesity and cigarette smoking: Neurobiological overlaps and clinical implications

Cigarette smoking and obesity are the leading causes of premature morbidity and mortality and increase the risk of all-cause mortality four-fold when comorbid. Individuals with these conditions demonstrate neurobiological and behavioral differences regarding how they respond to rewarding stimuli or engage in inhibitory control. This narrative review examines the role of reward and inhibition in cigarette smoking and obesity independently, as well as recent research demonstrating an effect of increased body mass index (BMI) on neurocognitive function in individuals who smoke. It is possible that chronic smoking and overeating of highly palatable food, contributing to obesity, dysregulates reward neurocircuitry, subsequently leading to hypofunction of brain networks associated with inhibitory control. These brain changes do not appear to be specific to food or nicotine and, as a result, can potentiate continued cross-use. Changes to reward and inhibitory function due to increased BMI may also make cessation more difficult for those comorbid for obesity and smoking.

Explore the effects of overweight and smoking on spontaneous brain activity: Independent and reverse

Accumulating evidence suggested that overweight and smoking often co-exist. However, current neuroimaging researches have almost always studied smoking or overweight status separately. Here we sought to investigate the neurobiological mechanisms of this comorbid association, by detecting spontaneous brain activity changes associated with smoking and weight status separately and collectively. We used 2 × 2 factorial design and included the following four groups: overweight/normal-weight smokers (n = 34/n = 30) and overweight/normal-weight non-smokers (n = 22/n = 24). The spontaneous brain activity among the four groups was comparable using an amplitude of low-frequency fluctuation (ALFF) method based on resting-state fMRI (rs-fMRI). Furthermore, correlation analyses between brain activity changes, smoking severity and BMI values were performed. A main effect of smoking was discovered in the default mode network (DMN) and visual network related brain regions. Moreover, overweight people had high ALFF value in the brain regions associated with reward and executive control. More importantly, smoking and overweight both affected brain activity of the middle temporal gyrus (MTG), but the effect was opposite. And the brain activity of MTG was negatively correlated with smoking years, pack year and BMI value. These results suggest that smoking and overweight not only affect spontaneous brain activity alone, but also paradoxically affect spontaneous brain activity in the MTG. This suggests that we need to control for weight as a variable when studying spontaneous brain activity in smokers. Besides, this interaction may provide a neurological explanation for the comorbidity of overweight and smoking and a target for the treatment of comorbid populations.

Obesity Prevention is the Key to a Nation’s Health

The overweight and obesity is increasing problem for the health care system and for the health of the general population. The number of overweight people with varying degrees of obesity is growing in most countries around the world each year, a third of the world’s population suffers from this condition. According to scientists, lack of sleep, stress, use of certain pharmacological drugs can lead to obesity. The causes and factors of weight gain are varied, not only in personal life, such as eating habits and physical activity, but also include factors that can not be controlled, such as environmental factors, socio-economic factors, genetic factors and more. Obesity is a major risk factor for many diseases such as diabetes, cardiovascular disease, stroke and some cancers. Obesity prevention should be one of the top priorities for the health care system. Preventive measures aimed to prevent the development of overweight and obesity have three levels of intervention: primary, secondary and tertiary. The purpose of the primary prevention is to minimize weight gain and prevent the development of overweight or obesity. Secondary prevention aimes to reduce the impact of the existing disease. Tertiary prevention concentraits on reduction of the complications that have developed as a result of the disease. To prevent overweight and obesity, doctors advise to limit the caloric content of diet by reducing the consumption of fats and sugars; increase the consumption of fruits and vegetables, as well as whole grains and nuts; perform regular exercise. Regular weighing by health professionals can help identify patterns and factors that contribute to weight gain. The success of obesity therapy depends on the patient’s trust to his doctor and the knowledge of the clinician in this area.

Effects of Abstinence Self-Efficacy and Outcome Expectancies of Tobacco Smoking on the Desire to Quit Among Saudi Women: A Cross-Sectional Mediation Analysis

Background

Smoking is one of the major preventable causes of morbidity and mortality and has been associated with numerous illnesses. While smoking is increasing among Saudi women, the characteristics of smoking behavior related to abstinence self-efficacy, which is a belief regarding one’s ability to successfully resist performing a behavior, and outcome expectancies, meaning the anticipated consequences of performing a behavior, are unknown. Therefore, this study aimed to test whether abstinence self-efficacy mediated the relationship between tobacco smoking outcome expectancies and the desire to quit tobacco among Saudi women who smoke.

Methods

This cross-sectional study collected a sample of 211 Saudi women who smoked tobacco, including cigarettes and shisha. A self-administered questionnaire was used to examine several variables, including abstinence self-efficacy, outcome expectancies, and desire to quit tobacco smoking. Mediational path analysis was used to answer the research question. Indirect effects were estimated through a bootstrapping of 10,000.

Results

All 4 constructs of outcome expectancies (negative consequences, positive reinforcement, negative reinforcement, and appetite/weight control) were associated with lower abstinence self-efficacy and desire to quit tobacco smoking. In the mediation analysis, the indirect effect of negative consequences (standardized beta = −.013, SE = .008, 95% CI [−.030, −.001]), negative reinforcement (standardized beta = −.012, SE = .006, 95% CI [−.025, −.001]), and appetite/weight control (standardized beta = −.008, SE = .006, 95% CI [−.022, −.001]) through abstinence self-efficacy were significant, suggesting mediation in the relationship between outcome expectancies and desire to quit tobacco smoking.

Conclusion

Cognitive mechanisms that may explain the desire to quit tobacco smoking among Saudi women were identified. Although future longitudinal studies are required to determine relationships prospectively, targeted interventions that correct tobacco smoking outcome expectancies and boost abstinence self-efficacy skills may reduce tobacco smoking among Saudi women.

Exploration of the influence of body mass index on intra-network resting-state connectivity in chronic cigarette smokers

BACKGROUND

Obesity and cigarette smoking are two leading preventable causes of death. Previous research suggests that comorbid smoking and obesity likely share neurobehavioral underpinnings; however, the influence of body mass index (BMI) on resting-state functional connectivity (rsFC) in smokers remains unknown. In this study, we explore how BMI affects rsFC and associations between rsFC and smoking-related behavior.

METHODS

Treatment-seeking cigarette smokers (N = 87; 54 % men) completed a BOLD resting-state fMRI scan session. We grouped smokers into BMI groups (N = 23 with obesity, N = 33 with overweight, N = 31 lean) and used independent components analysis (ICA) to identify the resting state networks commonly associated with cigarette smoking: salience network (SN), right and left executive control networks (ECN) and default mode network (DMN). Average rsFC values were extracted (p < 0.001, k = 100) to determine group differences in rsFC and relationship to self-reported smoking and dependence.

RESULTS

Analyses revealed a significant relationship between BMI and connectivity in the SN and a significant quadratic effect of BMI on DMN connectivity. Heavier smoking was related to greater rsFC in the SN among lean and obese groups but reduced rsFC in the overweight group.

CONCLUSIONS

Findings build on research suggesting an influence of BMI on the neurobiology of smokers. In particular, dysfunction of SN-DMN-ECN circuitry in smokers with overweight may lead to a failure to modulate attention and behavior and subsequent difficulty quitting smoking. Future research is needed to elucidate the mechanism underlying the interaction of BMI and smoking and its impact on treatment.

Brain-derived neurotrophic factor gene variants and obesity in former smokers

OBJECTIVE

From genome-wide association studies, brain-derived neurotrophic factor (BDNF) locus on chromosome 11 was the only SNP associated with both smoking and body mass index (BMI) in European, African and Asian population. This study aims to explore the unique genetic predisposition to obesity in former smokers by examining the effects of BDNF on BMI and waist circumference (WC).

METHODS

The study design is case-control study with a cohort validation in supplementary. We included 15,072 ethnic Chinese participants in the Guangzhou Biobank Cohort Study (GBCS) with data of four BDNF SNPs related to both BMI and smoking behavior. We used baseline smoke exposure data in 2003-2007 and follow-up outcomes of general obesity (by BMI) and central obesity (WC) in 2008-2012. Odds ratios (ORs) and 95% confidence intervals (CIs) for general obesity and central obesity associated with these SNPs were derived from logistic regression.

RESULTS

Of 15,072 participants (3169 men and 11,903 women), 1664 (11.0%) had general and 7868 (52.2%) had central obesity. In 1233 former smokers, the rs6265 GG, versus AA, genotype was associated with higher risks of general obesity (OR = 1.79, 95% CI = 1.06-3.01) and central obesity (OR = 2.08, 95% CI = 1.47-2.92) after adjustment. These associations were not significant in never or current smokers. In former heavy (≥20 cigarettes/day) smokers, the rs6265 GG genotype showed a higher odds for general obesity (OR = 2.15, 95% CI = 1.05-4.40), while no association was found in former light (1-9 cigarettes/day) smokers. Similar results were found for the association of rs6265 with central obesity and for the associations of other two BDNF SNPs (rs4923457 and rs11030104) with both general and central obesity.

CONCLUSIONS

We firstly identified the genetic predisposition (BDNF SNPs) to general and central obesity in former smokers, particularly in former heavy smokers. The different associations of the SNPs for general/central obesity in different smoke exposure groups may be related to the competitive performance of the sites and epigenetic modification, which needs further study.

Weight Gain After Smoking Cessation and Lifestyle Strategies to Reduce it

BACKGROUND

Weight gain following smoking cessation reduces the incentive to quit, especially among women. Exercise and diet interventions may reduce postcessation weight gain, but their long-term effect has not been estimated in randomized trials.

METHODS

We estimated the long-term reduction in postcessation weight gain among women under smoking cessation alone or combined with (1) moderate-to-vigorous exercise (15, 30, 45, 60 minutes/day), and (2) exercise and diet modification (≤2 servings/week of unprocessed red meat; ≥5 servings/day of fruits and vegetables; minimal sugar-sweetened beverages, sweets and desserts, potato chips or fried potatoes, and processed red meat).

RESULTS

Among 10,087 eligible smokers in the Nurses' Health Study and 9,271 in the Nurses' Health Study II, the estimated 10-year mean weights under smoking cessation were 75.0 (95% CI = 74.7, 75.5) kg and 79.0 (78.2, 79.6) kg, respectively. Pooling both cohorts, the estimated postcessation mean weight gain was 4.9 (7.3, 2.6) kg lower under a hypothetical strategy of exercising at least 30 minutes/day and diet modification, and 5.9 (8.0, 3.8) kg lower under exercising at least 60 minutes/day and diet modification, compared with smoking cessation without exercising.

CONCLUSIONS

In this study, substantial weight gain occurred in women after smoking cessation, but we estimate that exercise and dietary modifications could have averted most of it.

A Feasibility Study of Smoking Cessation Utilizing an Exercise Intervention among Black Women: 'Quit and Fit'

BACKGROUND

Women who engage in higher levels of exercise while trying to quit smoking have been shown to be less likely to relapse and to sustain their smoking abstinence longer. This study sought to examine the benefits of exercise for improving smoking cessation among Black women.

METHODS

We evaluated the feasibility of a 12-week smoking and exercise intervention, Quit and Fit, tailored for Black women. All participants (intervention and control) received 12 weeks of smoking cessation counseling via telephone and 9 weeks of nicotine lozenges. Participants who were randomly assigned to the intervention condition were also assigned to a 12-week exercise group.

RESULTS

Thirty-eight women were enrolled and 27 completed a 12-week follow-up assessment. Women from the intervention group were more likely to complete the 12-week follow-up assessment compared to participants in the control group (80% vs. 61%). Overall, 7 of the 38 participants (18%) were abstinent at 12 weeks (biochemically verified by expired carbon monoxide). Among the 25 women who completed the 12-week follow-up, abstinence was reported in 33% of the intervention group and 20% of the control group. Using an intent-to-treat approach, 25% of women in the intervention group were abstinent at 12 weeks (n = 5), compared to 11.1% for the control group (n = 2). These differences were not statistically significant.

CONCLUSIONS

The overall retention rate was 71% (27/38) at 12 weeks with higher among the intervention group (16/20; 80%) compared to the control group (11/18; 61%). The study demonstrates that it is feasible to retain African-American women in a short-term study of smoking cessation and exercise.

Race differences in predictors of weight gain among a community sample of smokers enrolled in a randomized controlled trial of a multiple behavior change intervention

African Americans have disproportionate rates of post-cessation weight gain compared to non-Hispanic whites, but few studies have examined this weight gain in a multiracial sample of smokers receiving evidence-based treatment in a community setting. We examined race differences in short-term weight gain during an intervention to foster smoking cessation plus weight management.

Data were drawn from the Best Quit Study, a randomized controlled trial conducted via telephone quitlines across the U.S. from 2013 to 2017. The trial tested the effects on cessation and weight gain prevention of adding a weight control intervention either simultaneously with or sequentially after smoking cessation treatment. African Americans (n = 665) and whites (n = 1723) self-reported smoking status and weight during ten intervention calls. Random effects longitudinal modeling was used to examine predictors of weight change over the intervention period (average 16 weeks).

There was a significant race × treatment effect; in the simultaneous group, weight increased for African Americans at a faster rate compared to whites (b = 0.302, SE = 0.129, p < 0.05), independent of smoking status, age, baseline obesity, and education. After stratifying the sample, the effect of treatment group differed by race. Education level attenuated the rate of weight gain for African Americans in the simultaneous group, but not for whites.

African Americans receiving smoking and weight content simultaneously gained weight faster than whites in the same group; however, the weight gain was slower for African Americans with higher educational attainment. Future studies are needed to understand social factors associated with treatment receptivity that may influence weight among African American smokers.

Pilot feasibility trial of dual contingency management for cigarette smoking cessation and weight maintenance among weight-concerned female smokers

Many women who smoke cigarettes report that concern about weight gain is a barrier to quitting. Indeed, most quitters gain weight and some attribute relapses to weight gain concern. Contingency management (CM), which refers to reinforcing a target behavior with financial incentives, has been demonstrated effective for promoting smoking abstinence and weight management independently. We conducted a pilot trial to establish the feasibility of dual CM, in which both smoking cessation and weight maintenance were incentivized, as a smoking cessation intervention for female weight-concerned smokers. Participants (N = 10) received a 12-week intervention during which they earned financial incentives for smoking abstinence, verified by breath carbon monoxide (CO) testing, and for maintaining their weight (larger incentives for gaining less than five pounds, smaller incentives for 5-10 pound gain) while abstaining from smoking. They attended an end of intervention visit at week 13 and a follow-up visit at week 26. Total compensation was up to $550 ($255 for participation independent of smoking and weight, $145 for smoking abstinence incentives, and $150 for weight maintenance incentives). Results indicated that five of the 10 participants (50%) were continuously abstinent for at least 4 weeks and received at least 2 weight maintenance incentives. Three participants (33%) were abstinent at every visit they attended from quit date through week 26; 2 of these 3 had gained more than 10 pounds by week 26. Additional formative research to test alternative incentive schedules and modalities should be conducted before CM-W is evaluated in a larger trial. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A Pilot Randomized Controlled Trial of Distress Tolerance Treatment for Weight Concern in Smoking Cessation Among Women

INTRODUCTION

The majority of women who smoke cigarettes report that concern about weight gain is a barrier to quitting. We developed an intervention incorporating distress tolerance, appetite awareness, and mindful eating skills to target concerns about post-cessation weight gain and emotional eating (DT-W). In the current study, we conducted a pilot randomized controlled trial of DT-W versus a smoking health education (HE) intervention.

METHODS

Participants (N = 69 adult female, weight-concerned smokers) were recruited in cohorts of 4-11. Cohorts were randomized to DT-W or HE. DT-W and HE were matched on format (single individual session followed by eight group sessions), inclusion of cognitive behavioral therapy for smoking cessation (CBT) content, and pharmacotherapy (nicotine patches). Follow-up assessments occurred at 1-, 3-, and 6-months post-treatment.

RESULTS

The recruitment goal was met; 61 of the 69 participants attended at least one group session. There were no significant differences between DT-W and HE in the number of group sessions attended (DT-W adjusted M = 5.09, HE adjusted M = 5.03, p = .92), ratings of treatment effectiveness or usefulness of skills, or retention at 6-month follow-up (79% in DT-W vs. 78% in HE) (ps > .05), but comprehension ratings were lower in DT-W than in HE (p = .02).

CONCLUSIONS

Overall, these results suggest that the study procedures and interventions were feasible and acceptable, but changes to the DT-W intervention content to improve comprehension should be considered prior to conducting a fully powered trial.

IMPLICATIONS

A distress tolerance-based treatment targeting fear of weight gain after smoking cessation and post-cessation emotional eating was feasible and acceptable relative to a smoking HE comparison condition, but changes should be considered before conducting a larger trial. Continued innovation in treatment development for weight-concerned smokers is needed.

Nicotine Effects, Body Weight Concerns and Smoking: A Literature Review

How people become addicted to cigarette smoking and remain addicted despite repeated attempts to quit requires piecing together a rather complex puzzle. The present review contextualizes the role of nicotine and smoking sensory stimulation on maintaining smoking, describes nicotine's effects on feeding behavior and body weight, and explores the impact of smoking outcome expectancies, including the belief that nicotine suppresses appetite and body weight, on the decision to smoke or vape (use of e-cigarettes). The analysis concludes with a review of rat models of human nicotine intake that attempt to isolate the effects of nicotine on appetite and weight gain. Animal research replicates with relative closeness phenomena observed in smokers, but the rat model falls short of replicating the long-term weight gain observed post-smoking cessation.

Effect of Tobacco Cessation on Weight in a Veteran Population

Introduction/Objectives:

Weight gain concerns remain a barrier to tobacco cessation. Literature suggests that weight gain can occur after stopping tobacco, but continuing tobacco can have far worse outcomes. Limited information is available regarding weight gain in military personnel. The objective of this study was to evaluate weight change in veterans that stopped tobacco for a minimum of 12 months enrolled in a pharmacist managed telephone tobacco cessation clinic (PMTTCC).

Methods:

A retrospective analysis of veterans who had been tobacco-free for 12 months enrolled in a PMTTCC were included in this analysis. Primary outcomes were change in weight (kg) and body mass index (BMI) from baseline. Descriptive data were utilized where appropriate and paired t-tests were utilized for the primary outcomes.

Results:

Seventy-seven patients were screened and 10 were excluded. Sixty-seven veterans met inclusion criteria and were mostly male (91%, n = 61) and Caucasian (74.6%, n = 50). At 12 months post cessation, the mean weight gain was (1.81 kg ± 6.83, P = .03) and BMI (0.51 ± 2.23 kg/m², P = .06).

Conclusions:

Veterans appeared to have minimal weight gain despite statistical significance and no statistical change with BMI after 12 months of being tobacco-free. Results suggest that the long-term weight gain is minimal, and a comprehensive tobacco cessation program can be helpful to improve weight outcomes.

The Effect of Brief Mindfulness Training on Brain Reactivity to Food Cues During Nicotine Withdrawal: A Pilot Functional Imaging Study

Objectives

Many individuals who smoke relapse due to weight gain. Mindfulness training has been shown to help smokers quit smoking, and, in other populations, has been used to help people lose weight. This study was designed to assess the effect of one week of mindfulness practice on food cravings in smokers during 12-hour smoking abstinence.

Methods

We assessed daily smokers with a history of smoking lapse after weight gain. Participants were provided with brief training in mindfulness meditation and mindful eating and were asked to practice each skill daily for one week. Before and after this week of mindfulness practice, participants completed surveys to rate their nicotine dependence and food cravings and underwent testing via functional magnetic resonance imaging.

Results

Study results included pre-post intervention reduction in brain activity in dorsomedial prefrontal cortex, visual areas, and pre-motor areas, regions potentially associated with response to food images.

Conclusions

The study was small; however, it suggests the possibility that mindfulness training might be used to decrease food cravings after smoking cessation.

Exercise interventions for smoking cessation

BACKGROUND

Taking regular exercise, whether cardiovascular-type exercise or resistance exercise, may help people to give up smoking, particularly by reducing cigarette withdrawal symptoms and cravings, and by helping to manage weight gain.

OBJECTIVES

To determine the effectiveness of exercise-based interventions alone, or combined with a smoking cessation programme, for achieving long-term smoking cessation, compared with a smoking cessation intervention alone or other non-exercise intervention.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies, using the term 'exercise' or 'physical activity' in the title, abstract or keywords. The date of the most recent search was May 2019.

SELECTION CRITERIA

We included randomised controlled trials that compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme alone or another non-exercise control group. Trials were required to recruit smokers wishing to quit or recent quitters, to assess abstinence as an outcome and have follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison, as either smoking cessation or relapse prevention. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models.

MAIN RESULTS

We identified 24 eligible trials with a total of 7279 adult participants randomised. Two studies focused on relapse prevention among smokers who had recently stopped smoking, and the remaining 22 studies were concerned with smoking cessation for smokers who wished to quit. Eleven studies were with women only and one with men only. Most studies recruited fairly inactive people. Most of the trials employed supervised, group-based cardiovascular-type exercise supplemented by a home-based exercise programme and combined with a multi-session cognitive behavioural smoking cessation programme. The comparator in most cases was a multi-session cognitive behavioural smoking cessation programme alone. Overall, we judged two studies to be at low risk of bias, 11 at high risk of bias, and 11 at unclear risk of bias. Among the 21 studies analysed, we found low-certainty evidence, limited by potential publication bias and by imprecision, comparing the effect of exercise plus smoking cessation support with smoking cessation support alone on smoking cessation outcomes (RR 1.08, 95% CI 0.96 to 1.22; I² = 0%; 6607 participants). We excluded one study from this analysis as smoking abstinence rates for the study groups were not reported. There was no evidence of subgroup differences according to the type of exercise promoted; the subgroups considered were: cardiovascular-type exercise alone (17 studies), resistance training alone (one study), combined cardiovascular-type and resistance exercise (one study) and type of exercise not specified (two studies). The results were not significantly altered when we excluded trials with high risk of bias, or those with special populations, or those where smoking cessation intervention support was not matched between the intervention and control arms. Among the two relapse prevention studies, we found very low-certainty evidence, limited by risk of bias and imprecision, that adding exercise to relapse prevention did not improve long-term abstinence compared with relapse prevention alone (RR 0.98, 95% CI 0.65 to 1.47; I² = 0%; 453 participants).

AUTHORS' CONCLUSIONS

There is no evidence that adding exercise to smoking cessation support improves abstinence compared with support alone, but the evidence is insufficient to assess whether there is a modest benefit. Estimates of treatment effect were of low or very low certainty, because of concerns about bias in the trials, imprecision and publication bias. Consequently, future trials may change these conclusions.

Tobacco Smoking, Eating Behaviors, and Body Weight: A Review

Purpose of review

This narrative review provides an overview of the relationships among tobacco smoking, eating behaviors, and body weight. The aims are to (1) examine the concurrent and longitudinal associations between tobacco smoking and body weight, (2) describe potential mechanisms underlying the relationships between smoking and body weight, with a focus on mechanisms related to eating behaviors and appetite, and (3) discuss management of concomitant tobacco smoking and obesity.

Recent findings

Adolescents who smoke tobacco tend to have body mass indexes (BMI) the same as or higher than nonsmokers. However, adult tobacco smokers tend to have lower BMIs and unhealthier diets relative to nonsmokers. Smoking cessation is associated with a mean body weight gain of 4.67 kg after 12 months of abstinence, though there is substantial variability. An emerging literature suggests that metabolic factors known to regulate food intake (e.g., ghrelin, leptin) may also play an important role in smoking-related behaviors. While the neural mechanisms underlying tobacco smoking-induced weight gain remain unclear, brain imaging studies indicate that smoking and eating cues overlap in several brain regions associated with learning, memory, motivation and reward. Behavioral and pharmacological treatments have shown short-term effects in limiting post-cessation weight gain; however, their longer-term efficacy is limited.

Summary

Further studies are needed to identify the exact mechanisms underlying smoking, eating behaviors, and body weight. Moreover, effective treatment options are needed to prevent long-term weight gain during smoking abstinence.

Fit & quit: An efficacy trial of two behavioral post-cessation weight gain interventions

While smoking cessation leads to significant improvements in both mortality and morbidity, post-cessation weight gain partially attenuates this benefit. Even though post-cessation weight gain is small (4.7 kg on average), it is a stated reason to delay cessation attempts and is associated with smoking relapse. Fit & Quit is a randomized, controlled efficacy trial that aims to examine the ability of a weight stability intervention and a weight loss intervention to reduce post-cessation weight gain. For this purpose, Fit & Quit will randomize participants to three conditions: (a) Small Changes, a weight gain prevention intervention; (b) Look AHEAD Intensive Lifestyle Intervention; and (c) a lower-intensity bibliotherapy intervention. All conditions will receive a highly efficacious behavioral (i.e., rate reduction skills, motivational interviewing) and pharmacological (i.e., varenicline) smoking cessation program. A total of 400 participants will be recruited and randomized to the three interventions. Participants will be recruited in waves, with 10 waves of approximately 40 participants per wave. The primary outcomes of this study include post-cessation weight gain and cessation status at 12-month follow-up. Fit & Quit will integrate and adapt the strongest evidence-based interventions available for weight management and smoking cessation. Fit & Quit is highly innovative in the areas of the target population, study design, and use of technology. For these reasons, we expect that Fit & Quit will make a significant public health contribution to curtailing the important cessation barrier of post-cessation weight gain.

Sex differences in affect-triggered lapses during smoking cessation: A daily diary study

INTRODUCTION

Smoking lapses during a cessation attempt are common and are thought to be a key predictor of full relapse. Positive and negative affective states have been hypothesized as important precipitants of lapses during quit attempts, although findings have been mixed. Accumulating evidence suggests that women may smoke more when experiencing negative affective states, while men may smoke more when experiencing positive affective states. The possibility that these sex differences may play a role in predicting lapses during a smoking cessation attempt, however, has not been well-investigated. In this study, we hypothesized that, during a quit attempt, negative affect would be more strongly associated with lapses among women, and positive affect would be more strongly associated with lapses among men.

METHOD

We conducted a prospective study in which male and female nicotine-dependent smokers (n = 60) made an unaided, 'cold-turkey' quit attempt. For fourteen days following the initiation of the quit attempt, participants completed daily diaries in which they recorded the degree to which states of 'good mood' and 'bad mood' preceded smoking lapses.

RESULTS

Consistent with the study hypothesis, findings indicated that men reported higher good-mood-induced smoking lapses than women across the 14-day study interval. Conversely, while levels of bad-mood-induced smoking subsided over the 14-day interval among men, levels persisted among women.

DISCUSSION

Results further underscore the need to address sex-specific affective triggers when developing smoking cessation strategies.

Weight concerns as a predictor of smoking cessation according to nicotine dependence: A population-based study

Background:

Nicotine-dependent smokers find it difficult to quit smoking. Additionally, smoking-specific weight concerns may affect smoking cessation although the evidence is controversial. We investigated whether smoking-specific weight concerns predict the probability of cessation and, if so, whether the effect varies according to the level of nicotine dependence.

Methods:

The study was conducted with a population-based sample of 355 adult daily smokers who participated in the baseline examination in 2007 and in the 2014 follow-up. Baseline nicotine dependence was classified as low or high (Fagerström Test for Nicotine Dependence; 0–3 vs. 4–10 points). Within these groups, we examined whether baseline weight concerns predict smoking status (daily, occasional, ex-smoker) at follow-up by using multinomial logistic regression with adjustment for multiple covariates.

Results:

Among low-dependent participants at baseline, 28.5% had quit smoking, while among highly dependent participants 26.1% had quit smoking. The interaction between weight concerns and nicotine dependence on follow-up smoking status was significant. Among participants with low nicotine dependence per the fully adjusted model, greater weight concerns predicted a lower likelihood of both smoking cessation (relative risk ratio 0.93 [95% CI 0.87–1.00]) and smoking reduction to occasional occurrence (0.89 [95% CI 0.81–0.98]). Weight concerns were not associated with follow-up smoking status among participants with high nicotine dependence.

Conclusions:

Weight concerns are associated with a smaller likelihood of quitting among smokers with low nicotine dependence. Weight concerns should be addressed in smoking cessation interventions, especially with smokers who have low nicotine dependence.

Physical activity and weight gain after smoking cessation in postmenopausal women

OBJECTIVE

Weight gain frequently occurs after smoking cessation. The objective of this study was to examine whether weight gain after smoking cessation was attenuated by physical activity (PA) in postmenopausal women.

METHODS

A total of 4,717 baseline smokers from the Women's Health Initiative were followed for 3 years. One thousand two hundred eighty-two women quit smoking, and 3,435 continued smoking. Weight was measured at baseline and at the year 3 visit. PA was assessed at both times by self-report, summarized as metabolic equivalent task-hours per week. Multiple linear regression models were used to assess the association between PA and postcessation weight gain, adjusting for potential confounding factors.

RESULTS

Compared with continuing smokers, quitters gained an average of 3.5 kg (SD = 5.6) between the baseline and year 3 visit. Quitters with decreased PA had the highest amount of weight gain (3.88 kg, 95% CI: 3.22-4.54); quitters with increased PA (≥15 metabolic equivalent task-hours /week) had the lowest weight gain (2.55 kg, 95% CI: 1.59-3.52). Increased PA had a stronger beneficial association for postcessation weight gain for women with obesity compared to normal weight women. Quitters who had low PA at baseline and high PA at year 3 and were also enrolled in a dietary modification intervention had nonsignificant weight gain (1.88 kg, 95% CI: -0.21-3.96) compared with continuing smokers.

CONCLUSIONS

Our data demonstrate that even a modest increase in PA (equivalent to current recommendations) can attenuate weight gain after quitting smoking among postmenopausal women, especially in combination with improved diet.

Association between smoking cessation and weight gain in treatment-seeking African Americans

INTRODUCTION

Research has shown that African Americans gain more than average weight after smoking cessation. However, African Americans have been underrepresented in post-cessation weight gain research. The current study examined 1) the pattern of weight gain and 2) the association between smoking status and weight gain in a sample of African Americans seeking smoking cessation treatment.

METHODS

Data were drawn from a randomized controlled trial testing the efficacy of a 4-week culturally specific smoking cessation cognitive behavioral therapy (CBT) intervention among African American smokers (N = 342). Weight was measured and self-reported smoking status was biochemically verified at baseline, end of counseling, 3-, 6-, and 12-month follow-ups. Random effects multilevel modeling was used to examine weight gain over twelve months post CBT, and a fully unconditional model tested the pattern of weight gain over time. Smoking status was included as a time-varying factor to examine its effect on weight gain, controlling for potential confounding variables.

RESULTS

Weight significantly increased among those who remained abstinent over 12 months post CBT [average gain of seven lbs. (three kg)]. Controlling for covariates, abstinence was predictive of the rate of weight gain for those with high weight concern.

CONCLUSIONS

Weight gain among African American abstainers was comparable to the average post-cessation weight gain observed among the general population. It is possible that exposure to CBT (culturally specific or standard) may have mitigated excessive weight gain. Future research should assess predictors of weight gain in African American smokers to inform future smoking cessation interventions and help elucidate factors that contribute to tobacco- and obesity-related health disparities.

Behavioral and mental health risk factor profiles among diverse primary care patients

Behavioral and mental health risk factors are prevalent among primary care patients and contribute substantially to premature morbidity and mortality and increased health care utilization and costs. Although prior studies have found most adults screen positive for multiple risk factors, limited research has attempted to identify factors that most commonly co-occur, which may guide future interventions. The purpose of this study was to identify subgroups of primary care patients with co-occurring risk factors and to examine sociodemographic characteristics associated with these subgroups. We assessed 12 behavioral health risk factors in a sample of adults (n=1628) receiving care from nine primary care practices across six U.S. states in 2013. Using latent class analysis, we identified four distinct patient subgroups: a 'Mental Health Risk' class (prevalence=14%; low physical activity, high stress, depressive symptoms, anxiety, and sleepiness), a 'Substance Use Risk' class (29%; highest tobacco, drug, alcohol use), a 'Dietary Risk' class (29%; high BMI, poor diet), and a 'Lower Risk' class (27%). Compared to the Lower Risk class, patients in the Mental Health Risk class were younger and less likely to be Latino/Hispanic, married, college educated, or employed. Patients in the Substance Use class tended to be younger, male, African American, unmarried, and less educated. African Americans were over 7 times more likely to be in the Dietary Risk versus Lower Risk class (OR 7.7, 95% CI 4.0-14.8). Given the heavy burden of behavioral health issues in primary care, efficiently addressing co-occurring risk factors in this setting is critical.

The Impact of Weight and Weight-Related Perceptions on Smoking Status Among Young Adults in a Text-Messaging Cessation Program

Introduction

Weight gain and concerns about weight can influence a smoker's ability to successfully quit, and young adults are a subgroup of smokers who are particularly concerned about the impact of quitting on their body weight. This study explored the associations between body mass index, weight perceptions, and smoking status among young adults.

Methods

The sample consisted of 4027 young adults between the ages of 18 and 29 who participated in a randomized control trial of the National Cancer Institute's SmokefreeTXT program. Multivariable logistic regression models were used to examine the associations between weight related variables and smoking status.

Results

Obese participants had a 0.72 lower odds (95% CI: 0.62, 0.85) of reporting smoking at the end of the program than participants of normal weight, and this difference persisted over time. Weight perceptions were also associated with smoking status. Those who perceived themselves to be slightly underweight/underweight were more likely to report smoking than those who reported being just about the right weight (OR: 1.53, 95% CI: 1.20, 1.95), and those who strongly disagreed that smoking cigarettes helps people keep their weight down were less likely to report smoking at the end of treatment than those who neither agreed nor disagreed with this statement (OR: 0.69, 95% CI: 0.54, 0.87).

Conclusions

Weight related factors assessed at baseline predicted smoking status at the end of treatment and through long term follow-up. Smoking cessation programs that tailor content to addresses the specific needs of weight concerned smokers may enhance effectiveness.

Implications

This study explores the association between weight related factors and smoking status among young adults, a priority population for smoking cessation efforts. This study demonstrates that both actual weight and weight perceptions (eg, perception of body weight, perception of associations between smoking and weight) are associated with smoking outcomes, and thus need to be a considered in the development of smoking cessation programs.

Action and inaction in multi-behaviour recommendations: a meta-analysis of lifestyle interventions

This meta-analysis examined theoretical predictions about the effects of different combinations of action (e.g., start an exercise regime) and of inaction (e.g., reduce screen time, rest in between weight lifting series) recommendations in smoking, diet, and physical activity multiple-domain interventions. The synthesis included 150 research reports of interventions promoting multiple behaviour domain change and measuring change at the most immediate follow-up. The main outcome measure was an indicator of overall change that combined behavioural and clinical effects. There were two main findings. First, as predicted, interventions produced the highest level of change when they included a predominance of recommendations along one behavioural dimension (i.e., predominantly inaction or predominantly action). Unexpectedly, within interventions with predominant action or inaction recommendations, those including predominantly inaction recommendations had greater efficacy than those including predominantly action recommendations. This effect, however, was limited to interventions in the diet and exercise domains, but reversed (greater efficacy for interventions with predominant action vs. inaction recommendations) in the smoking domain. These findings provide important insights on how to best combine recommendations when interventions target clusters of health behaviours.

Reducing alcohol consumption to minimize weight gain and facilitate smoking cessation among military beneficiaries

INTRODUCTION

Smoking cessation-related weight gain can have significant negative health and career consequences for military personnel. Alcohol reduction combined with smoking cessation may decrease weight gain and relapse.

METHOD

A randomized clinical trial of military beneficiaries compared a standard smoking cessation (i.e., brief informational) intervention (N=159), with a brief motivational smoking cessation intervention that emphasized reduced drinking to lessen caloric intake and minimize weight gain (N=158).

RESULTS

Participants who received the motivational intervention were significantly more likely to quit smoking at the 3-month follow-up (p=0.02), but the differences were not maintained at 6 (p=0.18) or 12months (p=0.16). Neither weight change nor alcohol reduction distinguished the 2 groups. Smoking cessation rates at 12months (motivational group=32.91%, informational group=25.79%) were comparable to previous studies, but successful cessation was not mediated by reduced drinking.

CONCLUSIONS

Alcohol reduction combined with smoking cessation did not result in decreased weight gain or improved outcomes.

Worsening Dietary and Physical Activity Behaviors Do Not Readily Explain Why Smokers Gain Weight After Cessation: A Cohort Study in Young Adults

Introduction

The relationship between smoking cessation and weight gain is well established but the underlying mechanisms remain poorly understood. We aimed to determine whether postcessation weight gain was mediated by changing health behaviors.

Methods

A total of 281 smokers self-reported their demographic, smoking, and lifestyle characteristics in 2004-2006 (aged 26-36) and 2009-2011 (aged 31-41). Behaviors considered as potential mediators of weight gain were changes in consumption of breakfast, discretionary foods (servings/d), fruit and vegetables (servings/d), alcohol (g/d), takeaway food (times/wk), Diet Guideline Index score, leisure time physical activity (PA, min/wk), total PA (min/wk), time spent sitting (min/d), and TV viewing (h/d).

Results

In total, 124 smokers quit smoking during 5 years follow-up. After adjustment for age, sex, baseline body mass index, education, and follow-up length, smoking cessation was associated with average excess weight gain of 2.09kg (95% CI = 0.35-3.83). Compared with continuing smokers, quitters reported a higher Diet Guideline Index score and less consumption of alcohol at baseline and follow-up (all p < .05). In addition, there was a tendency towards healthier dietary and PA behaviors over 5 years among quitters than continuing smokers except for time spent sitting, although these differences did not reach statistical significance. Adjustment for changes in these behaviors made little difference to the magnitude of postcessation weight gain (β: 2.32kg, 95% CI = 0.54-4.10).

Conclusions

The weight gain associated with smoking cessation was not explained by worsening dietary and PA behaviors. Future research is needed to elucidate the complex mechanisms and particularly ways it may be prevented.

Implications

Fear of weight gain often discourages smokers from trying to quit but guidance on ways to most effectively avoid weight gain is lacking. It is important to identify what causes postcessation weight gain and the ways it may be prevented. The current study explored the effects of several changing dietary and PA behaviors on the relationship between smoking cessation and weight gain in 281 young Australian smokers. We found that quitters tended to adopt healthier dietary and PA behaviors than continuing smokers, so these behaviors did not readily explain the postcessation weight gain. Further investigations of other potential mechanisms are needed.

Evaluation of a web-based cognitive behavioral smoking cessation treatment for overweight/obese smokers

This pilot study tested the efficacy of an Internet-administered smoking cessation treatment for overweight/obese smokers. Participants were 54 community volunteers with overweight/obesity who were regular smokers. Treatment consisted of 12 weeks of nicotine replacement therapy and randomization to Internet-administered cognitive behavioral treatment or health education. In-person assessments of key outcomes occurred at baseline, post-treatment, and at 24-week follow-up. Cessation rates did not differ across the two treatments (25.9% vs 18.5%). Participants receiving cognitive behavioral treatment gained less weight when abstinent than those receiving the standard treatment. Larger studies are needed to replicate these findings.

Distress Tolerance Treatment for Weight Concern in Smoking Cessation Among Women: The WE QUIT Pilot Study

Fear of gaining weight after quitting cigarette smoking is a major barrier to smoking cessation among women. Distress tolerance, which refers to one's ability and willingness to tolerate physical and emotional discomfort, predicts successful behavior change. Novel interventions rooted in Acceptance and Commitment Therapy (ACT) have emerged that aim to increase distress tolerance and engagement in values-oriented behavior. In this study, we developed a 9-week, group-based distress tolerance intervention for weight concern in smoking cessation among women (DT-W). Using an iterative process, we piloted DT-W with two small groups ( n = 4 and n = 7) of female weight-concerned smokers. Results indicated that we successfully established the feasibility and acceptability of DT-W, which was well-attended and well-received. Biochemically verified 7-day point-prevalence abstinence rates at post-intervention, 1, 3, and 6 months were 64%, 36%, 27%, and 27%, respectively. We are now evaluating DT-W in a randomized controlled trial.

IMPLEMENTATION, RECRUITMENT AND BASELINE CHARACTERISTICS: A RANDOMIZED TRIAL OF COMBINED TREATMENTS FOR SMOKING CESSATION AND WEIGHT CONTROL

Background

Two-thirds of treatment-seeking smokers are obese or overweight. Most smokers are concerned about gaining weight after quitting. The average smoker experiences modest post-quit weight gain which discourages many smokers from quitting. Although evidence suggests that combined interventions to help smokers quit smoking and prevent weight gain can be helpful, studies have not been replicated in real world settings.

Methods

This paper describes recruitment and participant characteristics of the Best Quit Study, a 3-arm randomized controlled trial testing tobacco cessation treatment alone or combined with simultaneous or sequential weight management. Study participants were recruited via tobacco quitlines from August 5, 2013 to December 15, 2014.

Results

Statistical analysis on baseline data was conducted in 2015/2016. Among 5082 potentially eligible callers to a tobacco quitline, 2540 were randomized (50% of eligible). Compared with individuals eligible but not randomized, those randomized were significantly more likely to be female (65.7% vs 54.5%, p < 0.01), overweight or obese (76.3% vs 62.5%, p < 0.01), more confident in quitting (p < 0.01), more addicted (first cigarette within 5 min: 50.0% vs 44.4%, p < 0.01), and have a chronic disease (28.6% vs. 24.4%, p < 0.01). Randomized groups were not statistically significantly different on demographics, tobacco or weight variables. Two-thirds of participants were female and white with a mean age of 43.

Conclusions

Adding weight management interventions to tobacco cessation quitlines was feasible and acceptable to smokers. If successful for cessation and weight outcomes, a combined intervention may provide a treatment approach for addressing weight gain with smoking cessation through tobacco quitlines.

Trial registration

Clinicaltrials.gov NCT01867983.

Development and evaluation of the See Me Smoke-Free multi-behavioral mHealth app for women smokers

Women face particular challenges when quitting smoking, especially those with weight concerns. A multi-behavioral smoking cessation intervention addressing these concerns and incorporating guided imagery may assist women to engage in healthy lifestyle behaviors. An mHealth app can easily disseminate such an intervention. The goals of this pilot study were to develop and test the feasibility and potential of the See Me Smoke-Free™ mHealth app to address smoking, diet, and physical activity among women smokers. We used pragmatic, direct-to-consumer methods to develop and test program content, functionality, and the user interface and conduct a pre-/post-test, 90-day pilot study. We enrolled 151 participants. Attrition was 52%, leaving 73 participants. At 90 days, 47% of participants reported 7-day abstinence and significant increases in physical activity and fruit consumption. Recruitment methods worked well, but similar to other mHealth studies, we experienced high attrition. This study suggests that a guided imagery mHealth app has the potential to address multiple behaviors. Future research should consider different methods to improve retention and assess efficacy.

Development of a Multi-Behavioral mHealth App for Women Smokers

This article describes the development of the See Me Smoke-Free™ (SMSF) mobile health application, which uses guided imagery to support women in smoking cessation, eating a healthy diet, and increasing physical activity. Focus group discussions, with member checks, were conducted to refine the intervention content and app user interface. Data related to the context of app deployment were collected via user testing sessions and internal quality control testing, which identified and addressed functionality issues, content problems, and bugs. Interactive app features include playback of guided imagery audio files, notification pop-ups, award-sharing on social media, a tracking calendar, content resources, and direct call to the local tobacco quitline. Focus groups helped design the user interface and identified several themes for incorporation into app content, including positivity, the rewards of smoking cessation, and the integrated benefits of maintaining a healthy lifestyle. User testing improved app functionality and usability on many Android phone models. Changes to the app content and function were made iteratively by the development team as a result of focus group and user testing. Despite extensive internal and user testing, unanticipated data collection and reporting issues emerged during deployment due not only to the variety of Android software and hardware but also to individual phone settings and use.

Obesity and Smoking: can we Kill Two Birds with one Tax?

The debate on tobacco and fat taxes often treats smoking and eating as independent behaviors. However, the available evidence shows that they are interdependent, which implies that policies against smoking or obesity may have larger scope than expected. To address this issue, we propose a dynamic rational model where eating, smoking, and physical exercise are simultaneous choices that jointly affect body weight and addiction to smoking. Focusing on direct and cross-price effects, we study the impact of tobacco and food taxes, and we show that in both cases a single policy tool can reduce both smoking and body weight. Copyright © 2015 John Wiley & Sons, Ltd.

[Psychotherapy and pharmacotherapy for harmful tobacco use and tobacco dependency]

Tobacco consumption is one of the major preventable health risk factors. In Germany approximately 110,000 people prematurely die from tobacco-related diseases and approximately 50% of regular smokers are considered to be tobacco dependent. Nevertheless, motivation to quit smoking is low and the long-term abstinence rates after attempts to stop smoking without professional support are far below 10%. As part of the S3 treatment guidelines 78 recommendations for motivation and early interventions for smokers unwilling to quit as well as psychotherapeutic and pharmacological support for smokers willing to quit were formulated after an systematic search of the current literature. More than 50 professional associations adopted the recommendations and background information in a complex certification process. In this article the scientific evidence base regarding the psychotherapeutic and pharmacological treatment options as well as recommendations and further information about indications and treatment implementation are presented. By following these guidelines for treatment of heavy smokers who are willing to quit combined with individual and group therapies on the basis of behavioral treatment strategies and pharmacological support, long-term success rates of almost 30% can be achieved.

The effect of tobacco cessation on weight gain, obesity, and diabetes risk

OBJECTIVE

Most smokers gain weight after quitting, and some develop new onset obesity and type 2 diabetes. The purpose of this paper is to synthesize the current science investigating the consequences of tobacco cessation on body weight and diabetes, as well as intervention strategies that minimize or prevent weight gain while still allowing for successful tobacco cessation.

METHODS

Systematic reviews and relevant studies that were published since prior reviews were selected.

RESULTS

Smoking cessation can cause excessive weight gain in some individuals and can be associated with clinically significant outcomes such as diabetes or obesity onset. Interventions that combine smoking cessation and weight control can be effective for improving cessation and minimizing weight gain but need to be tested in specific populations.

CONCLUSIONS

Despite the health benefits of quitting tobacco, post-cessation weight gain and new onset obesity and diabetes are a significant concern. Promising interventions may need to be more widely applied to reduce the consequences of both obesity and tobacco use.

Comparative effectiveness of adding weight control simultaneously or sequentially to smoking cessation quitlines: study protocol of a randomized controlled trial

Background

Prevalence of multiple health risk behaviors is growing, and obesity and smoking are costly. Weight gain associated with quitting smoking is common and can interfere with quit success. Efficacy of adding weight management to tobacco cessation treatment has been tested with women in group sessions over an extended period of time, but has never been tested in real-world settings with men and women seeking help to quit. This paper describes the Best Quit study which tests the effectiveness of delivering tobacco and weight control interventions via existing quitline infrastructures.

Methods

Eligible and consenting smokers (n = 2550) who call a telephone quitline will be randomized to one of three groups; the standard quitline or standard quitline plus a weight management program added either simultaneously or sequentially to the tobacco program. The study aims to test: 1) the effectiveness of the combined intervention on smoking cessation and weight, 2) the cost-effectiveness of the combined intervention on cessation and weight and 3) theoretically pre-specified mediators of treatment effects on cessation: reduced weight concerns, increased outcome expectancies about quitting and improved self-efficacy about quitting without weight gain.

Baseline, 6 month and 12 month data will be analyzed using multivariate statistical analyses and groups will be compared on treatment adherence, quit rates and change in weight among abstinent participants. To determine if the association between group assignment and primary outcomes (30-day abstinence and change in weight at 6 months) is moderated by pre-determined baseline and process measures, interaction terms will be included in the regression models and their significance assessed.

Discussion

This study will generate information to inform whether adding weight management to a tobacco cessation intervention delivered by phone, mail and web for smokers seeking help to quit will help or harm quit rates and whether a simultaneous or sequential approach is better at increasing abstinence and reducing weight gain post quit. If proven effective, the combined intervention could be disseminated across the U.S. through quitlines and could encourage additional smokers who have not sought cessation treatment for fear of gaining weight to make quit attempts.

Trial registration

Clinicaltrials.gov NCT01867983. Registered: May 30, 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3231-6) contains supplementary material, which is available to authorized users.

Protocol for a systematic review of evaluation research for adults who have participated in the 'SMART recovery' mutual support programme

INTRODUCTION

Self-Management and Recovery Training (SMART Recovery) offers an alternative to predominant 12-step approaches to mutual aid (eg, alcoholics anonymous). Although the principles (eg, self-efficacy) and therapeutic approaches (eg, motivational interviewing and cognitive behavioural therapy) of SMART Recovery are evidence based, further clarity regarding the direct evidence of its effectiveness as a mutual aid package is needed. Relative to methodologically rigorous reviews supporting the efficacy of 12-step approaches, to date, reviews of SMART Recovery have been descriptive. We aim to address this gap by providing a comprehensive overview of the evidence for SMART Recovery in adults with problematic alcohol, substance and/or behavioural addiction, including a commentary on outcomes assessed, potential mediators, feasibility (including economic outcomes) and a critical evaluation of the methods used.

METHODS AND ANALYSIS

Methods are informed by the Cochrane Guidelines for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. 6 electronic peer-reviewed and 4 grey literature databases have been identified. Preliminary searches have been conducted for SMART Recovery literature (liberal inclusion criteria, not restricted to randomised controlled trials (RCTs), qualitative-only designs excluded). Eligible 'evaluation' articles will be assessed against standardised criteria and checked by an independent assessor. The searches will be re-run just before final analyses and further studies retrieved for inclusion. A narrative synthesis of the findings will be reported, structured around intervention type and content, population characteristics, and outcomes. Where possible, 'summary of findings' tables will be generated for each comparison. When data are available, we will calculate a risk ratio and its 95% CI (dichotomous outcomes) and/or effect size according to Cohen's formula (continuous outcomes) for the primary outcome of each trial.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. Findings will be disseminated widely to clinicians and researchers via journal publication and conference presentation(s).

PROSPERO REGISTRATION NUMBER

CRD42015025574.

See Me Smoke-Free: Protocol for a Research Study to Develop and Test the Feasibility of an mHealth App for Women to Address Smoking, Diet, and Physical Activity

BACKGROUND

This paper presents the protocol for an ongoing research study to develop and test the feasibility of a multi-behavioral mHealth app. Approximately 27 million women smoke in the US, and more than 180,000 women die of illnesses linked to smoking annually. Women report greater difficulties quitting smoking. Concerns about weight gain, negative body image, and low self-efficacy may be key factors affecting smoking cessation among women. Recent studies suggest that a multi-behavioral approach, including diet and physical activity, may be more effective at helping women quit. Guided imagery has been successfully used to address body image concerns and self-efficacy in our 3 target behaviors-exercise, diet and smoking cessation. However, it has not been used simultaneously for smoking, diet, and exercise behavior in a single intervention. While imagery is an effective therapeutic tool for behavior change, the mode of delivery has generally been in person, which limits reach. mHealth apps delivered via smart phones offer a unique channel through which to distribute imagery-based interventions.

OBJECTIVE

The objective of our study is to evaluate the feasibility of an mHealth app for women designed to simultaneously address smoking, diet, and physical activity behaviors. The objectives are supported by three specific aims: (1) develop guided imagery content, user interface, and resources to reduce weight concern, and increase body image and self-efficacy for behavior change among women smokers, (2) program a prototype of the app that contains all the necessary elements of text, graphics, multimedia and interactive features, and (3) evaluate the feasibility, acceptability, and preliminary efficacy of the app with women smokers.

METHODS

We created the program content and designed the prototype application for use on the Android platform in collaboration with 9 participants in multiple focus groups and in-depth interviews. We programmed and tested the application's usability with 6 participants in preparation for an open, pre- and posttest trial. Currently, we are testing the feasibility and acceptability of the application, evaluating the relationship of program use to tobacco cessation, dietary behaviors, and physical activity, and assessing consumer satisfaction with approximately 70 women smokers with Android-based smart phones.

RESULTS

The study was started January 1, 2014. The app was launched and feasibility testing began in April 1, 2015. Participants were enrolled from April 1-June 30, 2015. During that time, the app was downloaded over 350 times using no paid advertising. Participants were required to use the app "most days" for 30 days or they would be dropped from the study. We enrolled 151 participants. Of those, 78 were dropped or withdrew from the study, leaving 73 participants. We have completed the 30-day assessment, with a 92% response rate. The 90-day assessment is ongoing. During the final phase of the study, we will be conducting data analyses and disseminating study findings via presentations and publications. Feasibility will be demonstrated by successful participant retention and a high level of app use. We will examine individual metrics (eg, duration of use, number of screens viewed, change in usage patterns over time) and engagement with interactive activities (eg, activity tracking).

CONCLUSIONS

We will aggregate these data into composite exposure scores that combine number of visits and overall duration to calculate correlations between outcome and measures of program exposure and engagement. Finally, we will compare app use between participants and non-participants using Google Analytics.