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Monaldi Arch Chest Dis
2009; 71: 2, 81-87 TOBACCO POUCH
Weight Gain after Smoking Cessation
F. Pistelli1,2, F. Aquilini1, L. Carrozzi1,2
Introduction
Both overweight or obesity and cigarette smok-
ing are relevant risk factors for public health, being
associated with an increased risk of death [1, 2].
Epidemiological data indicates that the prevalence
of overweight and obesity has doubled or tripled in
the past few decades in the US, in Europe, and even
in many developing countries [3]. According to es-
timates from the National Health and Nutrition Ex-
amination Survey (NHANES), a nationally repre-
sentative sample of the US population, in 2003-
2004 the prevalence of overweight or obesity
(Body Mass Index (BMI) ≥25 kg/m2) in adults
aged 20 years or older was 66.3% [4].
Cigarette smoking is associated with lower
body weight while smoking cessation is associated
with weight gain [5-8]. Weight gain may be a bar-
rier against quitting smoking, a reason to restart
smoking or a risk for health problems. This review
briefly addresses some issues on the relationship
between smoking cessation and weight gain, with
regard to the size of the problem, mechanisms,
health risks and control strategies.
The size of the problem
Amount of weight gain and likelihood of gaining
weight after smoking cessation
In 1990, the US Surgeon General published a
landmark report on The Health Benefits of Smok-
ing Cessation, which included a chapter on smok-
ing cessation and body weight change [6]. Based
on 15 longitudinal studies conducted between
1970-1990, with a median follow-up of 2 years
and an average sample size of 1348 subjects, the
average weight gain after smoking cessation was
about 2.3 kg, ranging between 0.74 and 5.15 kg.
Overall, in five reviewed studies, the risk of
weight gain after cessation was 45% (mean l.45,
range 1.31-1.75) greater for quitter than for con-
tinuing smokers. The report concluded that ap-
proximately 80% of smokers who quit gain weight
after cessation, but only about 3.5% of those who
quit smoking gain more than 9 kg [6].
Data from the third NHANES study [7], con-
ducted from 1988 through 1991, has shown that
the weight gain among smokers who quit that was
in excess of the gain among continuing smokers
was 4.4 kg for men and 5.0 kg for women over a
10-year period. 16% of the men and 21% of the
women who had quit smoking within the past 10
years gained 15 kg or more. Quitters were signifi-
cantly more likely to become overweight than
those who had never smoked (OR 2.42, 95% C.I.
1.02–5.775 for men, and OR 2.02, 95% C.I. 1.04-
3.94 for women).
Among participants in the Lung Health Study
[8], a randomised clinical trial of smoking cessa-
tion on middle-aged volunteers with asymptomatic
airway obstruction, men who achieved sustained
quitting for 5 years gained a mean of 4.9 kg in the
first year and a mean of 2.6 kg over the 5-year fol-
Key words: Smoking cessation, Weight gain, Body mass index, Nicotine withdrawal symptoms, Gender-related differences.
1UO Pneumologia e Fisiopatologia Respiratoria 1 Universitaria, Dipartimento Cardiotoracico, Azienda Ospedaliero-
Universitaria Pisana, Pisa,
2Unità di Epidemiologia Ambientale Polmonare, Istituto di Fisiologia Clinica CNR, Pisa, Italy.
Correspondence: Francesco Pistelli, Unità di Epidemiologia Ambientale Polmonare, Istituto di Fisiologia Clinica CNR, Via
Trieste 41, 56126 Pisa, Italy; e-mail francesco.pistelli@ifc.cnr.it
ABSTRACT: Weight Gain after Smoking Cessation. F. Pistelli,
F. Aquilini, L. Carrozzi.
Both overweight or obesity and cigarette smoking are
relevant risk factors for public health. Cigarette smoking is
associated with lower body weight while smoking cessation
is associated with weight gain. Most smokers who quit ex-
perience a weight gain, particularly within one year, and it
may persist up to 8 years after smoking cessation. Howev-
er, only a minority of quitters gain excessive weight. Some
individual characteristics have been found to be associated
with excessive weight gain after smoking cessation while
methodological problems may affect estimates of weight
gain observed in different studies. Main mechanisms to ex-
plain weight gain after smoking cessation include increased
energy intake, decreased resting metabolic rate, and de-
creased physical activity. The health benefits of smoking
cessation far exceed any health risks that may result from
smoking cessation-induced body weight gain. As weight
gain may be a barrier against quitting smoking or a reason
to restart smoking, behavioural and pharmacological
methods have been evaluated to control weight gain after
smoking cessation. Physicians should apply efficient strate-
gies to promote smoking cessation on their weight-con-
cerned smoking patient. This review briefly addresses
some issues on the relationship between smoking cessation
and weight gain, with regard to the size of the problem,
mechanisms, health risks and control strategies.
Monaldi Arch Chest Dis 2009; 71: 2, 81-87.
82
F. PISTELLI ET AL.
low-up, while corresponding figures for women
were 5.2 kg and 3.4 kg, respectively. Also, among
sustained quitters, 7.6% of men and 19.1% of
women gained ≥20% of baseline weight; 60% of
the gain occurred in year 1, although significant
weight gains continued through year 5. Over one
third of those who sustained smoking cessation for
5 years gained > 10 kg.
In a sample of 7124 residents of Germany aged
18-79 years from a national health examination
survey [5], adjusted OR of the risk for former
(> 12 months) smokers of 20 cigarettes per day to
become overweight (BMI ≥25 kg/m2) or obese
(BMI ≥30 kg/m2) was 1.7 and 2.3 in males, and
1.4 and 1.1 in females, respectively, as compared
to never smokers. The proportions of overweight
or obesity ranged from 78.7 to 91.1% and from
51.9 to 64.3% among male and female former
smokers, respectively, depending on the number of
cigarettes smoked per day.
The mean increase in waist circumference after
smoking cessation has been reported in a popula-
tion-based study in Copenhagen: an increase ≥5 cm
was observed in 42% of the quitters, and it was 3.88
cm (± 5.4 cm) higher in females than in males [9].
With regard to the trend over time, evidence
suggests that weight gain is greater within one year
[8] and even in the 1-2 months following cessation
[10]. In the long term, population-based data from
the third NHANES study showed that quitters
within the past 10 years prior the examination
were significantly more likely than never smokers
to remain overweight (OR 1.50, 95% C.I. 0.47-
4.85 for men, and OR 1.45, 95% C.I. 0.54-3.92 for
women) [7]. In a cohort (n = 1532) of treatment-
seeking heavy smokers (≥15 cigarettes per day)
participating in a double-blind randomised place-
bo-controlled trial with nicotine transdermal patch,
an increase in BMI (2.5 kg/m2more on average vs.
baseline) persisted up to 8 years after smoking ces-
sation [11]. In a cross-sectional study, it was ob-
served that heavy smokers (≥25 cigarettes per
day), after experiencing large weight gain in the
few years after smoking cessation, thereafter lose
weight to the never smoker level, while light and
moderate smokers gain weight up to the never-
smoker level without any excess after smoking
cessation [12].
Methodological issues
We selected relevant references on weight gain
after smoking cessation by using the PubMed
searching engine of the United States National Li-
brary of Medicine and the National Institutes of
Health (URL: www.pubmed.org). A manual
search starting from selected references was also
performed. No systematic selection procedure was
applied. Those large, population-based, longitudi-
nal studies or large clinical trials from United
States and Europe were preferably selected.
In order to correctly interpret data on weight
gain after smoking cessation, some general
methodological issues should be taken into ac-
count. The magnitude of the weight gain varies ac-
cording to the study population, while it could al-
so be related to the increase of weight observed in
the general population. There are few studies de-
signed specifically to assess the effect of smoking
cessation on weight gain prospectively. Existing
studies may have methodological problems, in-
cluding limited follow-up periods, the use of self-
reported height and weight, failure to biochemical-
ly validate smoking status, and a tendency to re-
port point prevalence instead of continuous absti-
nence.
Characteristics associated with excessive weight
gain after smoking cessation
Smokers gaining excessive weight after smok-
ing cessation may differ from those who do not
gain weight. Several individual characteristics
should be considered, including gender, age, race,
number of cigarettes smoked per day before cessa-
tion, weight history, comorbidity, life styles such
as eating patterns and physical activity, or con-
cerns about post-cessation weight gain.
Subjects younger than 55 years old, smokers of
≥25 cigarettes per day, and those with low socio-
economic status has been associated to higher
weight gain [10, 13, 14]. Most studies report that
women tend to gain more weight than men [7-9,
14], but in other studies an opposite figure has
been found [5, 15]. Longitudinal data from the Na-
tional Academy of Sciences-National Research
Council Twin Registry [14] has shown that weight
change was significantly greater in monozygotic
than dizygotic pairs in which both twins quit
smoking, suggesting that underlying genetic fac-
tors may influence weight changes. In this study,
super-gainers were significantly younger, with a
lower socio-economic status, and differed on a
number of health habits before quitting, including
physical activity, alcohol consumption and other
diet habit.
Mechanisms
Although there is convincing evidence for the
association between smoking and lower body
weight, underlying mechanisms are not clear.
Nicotine may be involved in feeding behaviour by
influencing the levels and expression of many pep-
tide hormones and neurotransmitters, including
leptin (negative regulator of food intake and a pos-
itive regulator of energy expenditure), neuropep-
tide Y (stimulator of feeding), orexins (positive
regulators of food intake), noradrenaline (stimula-
tor of food ingestion), dopamine and serotonin (in-
hibitors of food ingestion) [16].
Effects of cigarette smoking on adipose tissue
metabolism have also been evaluated. It has been
observed that fat oxidation increases with increas-
ing nicotine uptake [17] and smoking cessation is
associated with increases in lipoprotein lipase ac-
tivity in adipose tissue, which contribute to weight
gain after smoking cessation [18]. On the other
hand, it has been shown that cigarette smoking
stimulates lipolysis without increasing oxidation
83
WEIGHT GAIN AFTER SMOKING
of fat and that smoking cessation does not result in
a rebound tendency to synthesis or storage of fat,
both under controlled eucaloric dietary conditions
[19] and even in the presence of positive short-
term energy balance [20].
Main mechanisms that have been evaluated to
explain weight gain after smoking cessation in-
clude increased energy intake, decreased resting
metabolic rate, and decreased physical activity.
However, it has been also observed that lower
BMI of smokers compared to non-smokers re-
flects the personality characteristics of those who
choose to smoke and that the tendency to gain
weight after smoking cessation may have behav-
ioural rather than tobacco-related pharmacologi-
cal explanations [21]. Further research is needed
in this field.
Increases in food intake and decreases in rest-
ing energy expenditure are largely responsible for
weight gain after smoking cessation, while change
in physical activity does not play a role in either
differences in body weight between smokers and
nonsmokers or the weight gain associated with
smoking cessation [6]. Among studies reviewed in
the 1990 Surgeon General report, large individual
differences in subjects’ dietary and metabolic
changes after smoking cessation were demonstrat-
ed. Most short-term evaluations (e.g. 3 days or
less) found that food intake, particularly the con-
sumption of sweet foods and simple carbohy-
drates, increases after smoking cessation. Prospec-
tive investigations found that both self-reported
and quantified food intake changes over time in-
creased among subjects after quitting. In a quoted
comprehensive evaluation of change in energy bal-
ance, analysing changes in food intake, physical
activity, and resting metabolic rate in 13 sedentary
females who quit smoking for 48 days, mean daily
food intake increased by 177 kcal and explained
69% of the variance in changes in weight (1.84
kg), while no changes in physical activity or rest-
ing metabolic rate were observed [22].
Even in subsequently published studies, con-
trasting results have been reported on decreased
resting metabolic rate as mechanisms partly ex-
plaining weight gain after smoking cessation, with
the mean resting metabolic rate reduction ranging
between 4% and 16% and accounting for less than
40% of the weight gain [16]. In a clinical trial that
monitored dietary intake and had biochemically
validated smoking status over 5 years (Multiple
Risk Factor Intervention Trial), weight gain con-
tinued after quitting smoking despite decreases in
caloric intake [23].
Changes in weight-related health risks
after smoking cessation
The health benefits of smoking cessation far
exceed any health risks that may result from smok-
ing cessation-induced body weight gain. This af-
firmation has been initially supported by studies
demonstrating that individuals who quit smoking
and gain weight experienced relatively small
changes in health-related risk factors such as blood
pressure, serum cholesterol and blood glucose [6].
Indeed, some of the potentially adverse effects of
weight gain on health risks are mitigated by the re-
duction of the risk of cardiovascular problems. For
example, according to reviewed evidence [16], in
spite of the weight gain, smoking cessation seems
to improve insulin sensitivity and is associated
with an increase in high density lipoprotein cho-
lesterol, while it is associated with a gradual nor-
malisation of blood and plasma viscocities,
haematocrit, blood cell filter ability, plasma fib-
rinogen levels as well as total white cell count.
Only those smokers who have large weight gain
after smoking cessation would experience impor-
tant changes in weight related risk factors, and the
proportion of ex-smokers who gain large amounts
of weight (e.g. more than 10 kg) is small [6]. It
should be noted that these figures might be revisit-
ed over time, if it is taken into account that mean
BMI tends to increase in the general population.
Consistently with other longitudinal studies, in
an Italian general population sample, we showed
that weight gain over time affects lung function in-
dependently of age, occupational exposure and al-
so smoking habit reported at baseline [24, 25].
Those longitudinal studies that have assessed the
relation of change in lung function to smoking ces-
sation and change in BMI have shown that the
beneficial effect of smoking cessation outweighs
the adverse effect of weight gain [26-28]. For ex-
ample, according to estimates based on data from
the Lung Health Study, a person who quit smoking
would have to gain about 60 kg or 38 kg of weight
to have the same effect of 5 years changes in
forced expiratory volume in one second (FEV1) or
in forced vital capacity, respectively, as continuing
to smoke.
The net effect of both smoking cessation and
weight gain on lung function in a population-based
study has been evaluated among participants in the
European Community Respiratory Health Study
[29]. The authors found a similar net effect of
smoking cessation in men and women, but a
greater decline in lung function due to weight gain
in men: the FEV1changed by -11.5 mL (-13.3 to -
9.6) per kg of weight gained in men, and by -3.7
mL per kg (-5.0 to -2.5) in women, which dimin-
ished the benefit of quitting by 38% in men, and by
17% in women.
Control strategies
Smoking may be used as a means of weight
control, especially by younger adults [30], and
weight gain after smoking cessation is of concern
to many cigarette smokers, particularly women
[31, 32]. Even in the context of poor health and
limited physical functioning, smokers have been
found to be concerned about weight gain after
quitting [33]. There are several weight-related
smoking variables that characterise weight-con-
cerned smokers, including: importance of weight
as a factor in smoking initiation; smoking as a
weight control strategy; increased appetite and
weight gain as withdrawal symptoms; willingness
84
F. PISTELLI ET AL.
to quit to gain weight; self-efficacy about relapse
in the face of weight gain; readiness to quit smok-
ing; preoccupation with body image - rather than
weight gain [32, 34]. Also pregnant women who
are more concerned about post-cessation weight
gain may be less likely to quit smoking during
pregnancy or remain abstinent in the postpartum
period [35]. It has been also hypothesised that
weight gain and weight concerns are independent
factors, as daily smokers were found to be signif-
icantly less concerned about their weight than
never-smokers, and neither weight concerns nor
eating patterns were predictive of point abstinence
at 1-year follow-up, in a Danish general popula-
tion sample of more than 6000 adults aged 30-60
years [36].
Strategies that successfully moderate weight
gain after smoking cessation may encourage
weight-conscious smokers to attempt cessation
and may facilitate the efforts of successful quitters
to remain abstinent. Behavioural and pharmaco-
logical methods have been evaluated to reduce
weight gain after smoking cessation.
There is no convincing evidence that coun-
selling interventions specifically designed to miti-
gate weight gain during a quit attempt result in re-
duced weight gain [37, 38], and smoking cessation
programmes that include a weight control compo-
nent have not successfully increased smoking ces-
sation [6]. Also, simultaneously dieting and quit-
ting has been observed to undermine attempts to
quit smoking [39, 40]. A different approach, i.e. to
combat the weight concerns themselves rather than
the weight gain, has been shown to be efficient. In
a group of weight-concerned women, cognitive-be-
havioural therapy to reduce weight concern while
discouraging dieting improved smoking cessation
outcome compared to a behavioural weight control
programme to prevent weight gain [41]. In obser-
vational studies [42] and randomised trials [43] it
has been observed that physical activity at the time
of smoking cessation can lessen the weight gain as-
sociated with quitting. Evidence suggests that rela-
tively small doses of exercise should be recom-
mended also as an aid to managing cigarette crav-
ings and withdrawal symptoms [44].
With regard to the pharmacological methods,
according to 2008 update of US Guidelines on
Treating Tobacco Use and Dependence, for smok-
ers who are greatly concerned about weight gain, it
may be most appropriate to prescribe or recom-
mend bupropion SR or nicotine replacement ther-
apy (NRT) (in particular, nicotine gum 4 mg and
nicotine lozenge 4 mg), which have been shown to
delay weight gain after quitting (strength of evi-
dence B) [45].
A number of other pharmacological approach-
es have been evaluated. In three studies satisfying
criteria for a Cochrane systematic review was
found that Rimonabant 20 mg, a selective type 1
cannabinoid receptor antagonist, may increase the
odds of quitting approximately 1(1/2)-fold and
moderate weight gain in the long term [46]. Pre-
liminary results suggest that combining naltrexone
and bupropion may help minimise post-cessation
weight gain [47]. Some evidence has shown that
weight gain can be minimised to some degree by
serotoninergic drugs such as fluoxetine [48, 49].
From a clinical viewpoint, the physician
should neither deny the likelihood of weight gain
nor minimise its significance to the patient. Rather,
the physician should inform the patient about the
likelihood of weight gain and prepare the patient
for its occurrence. Clinician statements to help a
patient prepare for and cope with weight gain after
quitting recommended in the 2008 update Guide-
lines on Treating Tobacco Use and Dependence
are reported in table 1 [45].
The experience of the Smoking Cessation
Clinic of the University Hospital of Pisa (Italy)
As an example of what can be observed in the
real life of a clinical routine, we present some da-
ta on weight gain observed in smokers following a
physician-assisted smoking cessation programme
within the Smoking Cessation Centre of the Uni-
versity Hospital of Pisa (Italy). This is a clinic op-
Table 1. - Clinician statements to help a patient prepare for and cope with weight gain after smoking cessation.
From 2008 update Guidelines on Treating Tobacco Use and Dependence [45]
The great majority of smokers gain weight once they quit smoking. However, even without special attempts at dieting or
exercise, weight gain is usually 4.5 kg or less.
Some medications, including bupropion SR and nicotine replacement medicines, may delay weight gain.
There is evidence that smokers often gain weight once they quit smoking, even if they do not eat more. However, there are
medications that will help you quit smoking and limit or delay weight gain. I can recommend one for you.
The amount of weight you will likely gain from quitting will be a minor health risk compared with the risks of continued
smoking.
I know that you don’t want to gain a lot of weight. However, let’s focus on strategies to get you healthy rather than on weight.
Think about eating plenty of fruits and vegetables, getting regular exercise, getting enough sleep, and avoiding high-calorie
foods and beverages. Right now, this is probably the best thing you can do for both your weight and your health.
Although you may gain some weight after quitting smoking, compare the importance of this with the added years of healthy
living you will gain, your better appearance (less wrinkled skin, whiter teeth, fresher breath), and good feelings about quitting.
85
WEIGHT GAIN AFTER SMOKING
erating in a Respiratory Unit since 1994, where
controlled clinical trials, interventions on specific
groups of smokers (e.g. participants in a lung can-
cer screening project, pregnant women, etc.), and
routine interventions are carried out [50-57].
Briefly, pneumologists conduct a programme
based on individual counselling and prescription
of pharmacotherapy (NRT - in the form transder-
mal patches, lozenges, inhalers or gums - Vareni-
cline or Bupropion, separately or in various asso-
ciations). Five visits are scheduled in the first three
months after a baseline evaluation, and follow-up
visits are planned at 6 and 12 months.
We analysed data provided by 1765 smokers
(1025 males and 740 females) who underwent to a
smoking cessation programme between January
2001 and May 2007. Figure 1 shows the percent-
age change of BMI from baseline observed at var-
ious follow-up visits over 12 months in smokers
continuously abstinent from their target quit day.
Both in males and females a higher change in BMI
was observed starting from one-month follow-up
visit and continued up to 12 months. The distinc-
tion between males and female were not statisti-
cally different. Even those smokers who had been
abstinent for a certain period showed a change in
BMI significantly higher than those who had been
never abstinent. For example, at the fourth control
visit (70-140 days from baseline), the percentage
change in BMI was 2.93% in those male smokers
who had been continuously abstinent up to the
control visit while it was 1.55% in those who had
been continuously abstinent less than 70 days; the
corresponding figures for female smokers were
3.73 and 1.58%. Gaining weight after smoking
cessation was significantly related to the duration
of continuous abstinence (about 90 gr per each
week of abstinence, p< 0.001) and the number of
cigarettes smoked per day at baseline (about 37 gr
per each cigarette smoked per day, p= 0.002) but
not to the age of the smoker. The mean absolute
gain in weight observed in this study population of
smokers was 0.42, 1.43, 3.66, and 4.08 kg at 1
week, 1 month, 6 month and 12 months control
visit, respectively, ranging from to a minimum of
–6.20 to a maximum of 17.0 kg. Only 6% of smok-
ers continuously abstinent over 12 months gained
more than 10 kg.
Conclusions
Weight gain after smoking cessation is expect-
ed, but only a minority of quitters experience ex-
cessive weight gain. In our experience, the mean
absolute weight gain was 4 kg after 12 months of
continuous abstinence from smoking. Altogether,
the health benefits of smoking cessation far exceed
any health risk that may result from weight gain.
Physicians should intervene on their weight-con-
cerned smoking patients to promote smoking ces-
sation by offering both behavioural and pharmaco-
logical support. Thus, avoiding weight gain would
not only remove a barrier to cessation, but also al-
low for greater health benefits.
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Pavia - Almo Collegio Borromeo
