10 Year Weight Gain in Smokers Who Quit, Smokers Who Continued Smoking And Never Smokers in the United States, NHANES 2003-2012

Abstract

Background/Objectives
Weight gain after quitting smoking is a common concern for smokers and can discourage quit attempts. The purpose of this analysis was to describe the long term weight gain, smoking cessation attributable (SCA) weight gain and describe their relationship to cigarette consumption and body mass index (BMI) 10 years ago in a contemporary, nationally representative sample of smokers who continued to smoke and those who quit.Subjects/Methods12 204 adults ⩾ 36 years old were selected from the 2003-2012 National Health and Nutrition Examination Survey (NHANES). Ten year weight gain for never, continuing and former smokers (who quit 1-10 years ago) was calculated by body mass index (BMI) 10 years ago and cigarettes per day (CPD). SCA weight gain was calculated by taking the difference between the adjusted mean ten year weight gain of former smokers and that of continuing smokers.ResultsMean ten year weight gain among continuing smokers was 3.5 kg versus 8.4 kg among former smokers; 4.9 kg of SCA weight gain. After Bonferroni correction, there was no significant difference in overall weight gain between continuing and former smokers of 1-14 CPD and SCA weight gain was lowest in this group (2.0 kg, CI: 0.3, 3.7). SCA weight gain was highest for former smokers of ⩾25 CPD (10.3 kg, CI: 7.4, 13.2) and for those who were obese (7.1 kg, CI: 2.9, 11.3) mostly due to lower than average weight gain or weight loss among continuing smokers in these groups.Conclusions
In a current, nationally representative sample, baseline BMI and CPD were important factors that contributed to the magnitude of long term weight gain following smoking cessation. Light to moderate smokers (<15 CPD) experienced little SCA weight gain while heavy smokers (⩾25 CPD) and those who were obese prior to quitting experienced the most.International Journal of Obesity accepted article preview online, 09 July 2015. doi:10.1038/ijo.2015.127.

Full text

ORIGINAL ARTICLE
Ten-year weight gain in smokers who quit, smokers who
continued smoking and never smokers in the United States,
NHANES 2003–2012
S Veldheer, J Yingst, J Zhu and J Foulds
BACKGROUND/OBJECTIVES: Weight gain after quitting smoking is a common concern for smokers and can discourage quit
attempts. The purpose of this analysis was to describe the long-term weight gain, smoking cessation attributable (SCA) weight gain
and describe their relationship to cigarette consumption and body mass index (BMI) 10 years ago in a contemporary, nationally
representative sample of smokers who continued to smoke and those who quit.
SUBJECTS/METHODS: In all, 12 204 adults ⩾36 years old were selected from the 2003–2012 National Health and Nutrition
Examination Survey (NHANES). Ten-year weight gain for never, continuing and former smokers (who quit 1–10 years ago) was
calculated by body mass index (BMI) 10 years ago and cigarettes per day (CPD). SCA weight gain was calculated by taking the
difference between the adjusted mean 10-year weight gain of former smokers and that of continuing smokers.
RESULTS: Mean 10-year weight gain among continuing smokers was 3.5 versus 8.4 kg among former smokers; the SCA weight
gain was 4.9 kg. After Bonferroni correction, there was no significant difference in overall weight gain between continuing and
former smokers of 1–14 CPD, and SCA weight gain was lowest in this group (2.0 kg, confidence interval (CI): 0.3, 3.7). SCA weight
gain was highest for former smokers of ⩾25 CPD (10.3 kg, CI: 7.4, 13.2) and for those who were obese (7.1 kg, CI: 2.9, 11.3) mostly
because of lower than average weight gain or weight loss among continuing smokers in these groups.
CONCLUSIONS: In a current, nationally representative sample, baseline BMI and CPD were important factors that contributed to
the magnitude of long-term weight gain following smoking cessation. Light to moderate smokers ( o15 CPD) experienced little
SCA weight gain, whereas heavy smokers (⩾25 CPD) and those who were obese before quitting experienced the most.
International Journal of Obesity advance online publication, 4 August 2015; doi:10.1038/ijo.2015.127
INTRODUCTION
Tobacco smoking and excess body weight are two of the leading
causes of premature death and disability in the United States.
1
It is
known that quitting smoking often leads to an increase in body
weight, although there are differing reports of the magnitude and
duration of weight gain that can be directly attributed to quitting.
For instance, the 1990 Surgeon General’s Report on The Health
Benefits of Smoking Cessation concluded that 'average weight
gain after smoking cessation is only about 5 pounds [2.3 kg]'
(p 505) for smokers who had quit between 1 and 6 years and that
this 'is approximately 4 pounds [1.8 kg] greater than that expected
among continuing smokers' (p 483).
2
More recently, Aubin et al.
3
conducted a meta-analysis of smoking cessation clinical trials
published between 1989 and 2010 and found that the average
weight gain among smokers who quit was 10 pounds (4.5 kg)
1 year after quitting.
People generally gain weight over time as they age, thus a more
accurate estimate of the long-term magnitude of weight gain
because of quitting smoking is one that is able to separate age-
related weight gain from smoking cessation attributable (SCA)
weight gain. Studies with follow-ups beyond 1 year are able to
provide a more comprehensive picture of SCA weight gain by
taking the difference in weight gain between former smokers and
continuing smokers. These studies have established that smokers
who quit gain more overall weight compared with continuing
smokers,
4–9
although the amount of weight attributable to
quitting smoking has been varied with average SCA weight gains
between 3 and 6.6 kg, depending on the population.
5–9
Quitting smoking will have an immediate and positive effect on
a smoker’s health, but many smokers are concerned about gaining
weight after quitting, which can discourage them from making a
quit attempt.
10,11
An important clinical and public health goal is to
remove barriers to quitting, which includes addressing concerns
about weight gain by providing smokers with accurate informa-
tion on what to expect when they quit. However, accurate
information is difficult to provide as long-term studies have
observed substantial variations in weight gain among smokers
who quit,
3,6
suggesting that there are contributing factors to
gaining weight after quitting that are not well understood. Two
possible factors that have emerged as predictors of weight gain
are daily cigarette consumption before quitting and baseline body
mass index (BMI), although reports have not been entirely
consistent.
6,8,9,12–14
Some studies have found that the number of
cigarettes smoked before quitting is positively associated with
weight gain,
5,6,8,13
but the majority of studies reporting on
postcessation weight gain do not discuss this effect. There have
also been significant but inconsistent findings regarding the
relationship between baseline BMI and postcessation weight
gain.
6,9,13,15
Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA. Correspondence: S Veldheer, Department of Public Health Sciences, Penn State College
Of Medicine, 500 University Drive, CH69, Hershey, PA 17033-0850, USA.
E-mail: sveldheer@psu.edu
Received 30 April 2015; revised 25 June 2015; accepted 2 July 2015; accepted article preview online 9 July 2015
International Journal of Obesity (2015), 1–6
© 2015 Macmillan Publishers Limited All rights reserved 0307-0565/15
www.nature.com/ijo

Therefore, the aim of this study was to describe the long-term
weight gain and SCA weight gain in a contemporary, nationally
representative sample of the United States population and to
describe their relationship to baseline cigarettes per day (CPD),
smoking cessation and BMI 10 years ago. This information could
provide public health professionals and clinicians with more
accurate information around which to frame discussions about
cessation-related weight gain with specific groups of smokers.
SUBJECTS AND METHODS
The National Health and Nutrition Examination Survey (NHANES) is a cross-
sectional survey conducted by the National Center for Health Statistics
(NCHS) and includes a nationally representative sample of non-institutio-
nalized, US civilians. Complete details regarding the NHANES methodology
are available elsewhere.
16
This analysis included five survey cycles from
2003 to 2012.
The Weight History Questionnaire is asked of participants ⩾36 years old.
In addition, selected participants had complete information for demo-
graphic, smoking status, height, current weight and weight 10 years ago.
To ensure stability of smoking cessation among former smokers and to
isolate the effect of long-term weight gain, we included only those who
had quit for at least 1 year. We did not include those who had quit 410
years ago (n= 3496), so that we had a sample of former smokers who had
not quit before the time frame for reporting weight (10 years ago). Also
excluded were continuing and former cigarette smokers who used any
other tobacco products (n= 418), women pregnant at the time of the
survey (n= 41) and underweight participants (BMI o18.5 at either time
point, n= 226). There were 2328 potentially eligible participants not
included because of missing height and current weight (n= 93), height
(n= 810), current weight (n= 879) or weight 10 years ago (n= 639).
Current height and weight were self-reported. Weight 10 years ago was
assessed by asking 'How much did you weigh 10 years ago?' BMI was
calculated using the participant’s height and weight with the standard
calculation (weight in kg divided by height in m
2
). BMI class was defined
according to the National Institutes of Health Clinical Guidelines,
17
as
normal weight (BMI 18.5–24.9), overweight (BMI 25.0–29.9) and obese (BMI
30.0+). The participant’s weight 10 years ago was subtracted from their
current weight to create a continuous 10-year weight change variable.
Never smokers were defined as individuals who smoked o100
cigarettes in their lifetime. Former smokers were defined as individuals
who smoked at least 100 cigarettes in their lifetime and who reported not
currently smoking. Continuing smokers were those who smoked at least
100 cigarettes in their lifetime and who reported smoking 'some days' or
'every day' at the time of the survey. CPD were reported by smokers as the
number of cigarettes they currently smoked per day, whereas former
smokers reported the number of cigarettes they usually smoked per day
before quitting. CPD categories were created using 1–14, 15–24 and ⩾25
CPD as cut-points.
Statistical analysis
All data were analyzed using SAS version 9.3 (SAS Institute, Cary, NC, USA)
and were weighted as recommended by NHANES analytical guidelines.
18
These procedures account for the complex sampling structure of NHANES
(i.e. differential weighting, clustering and stratification) when estimating
variances and confidence limits. Bivariate tests of association with smoking
status (never smoker, continuing smoker, former smoker) were conducted
using Rao–Scott modified χ
2
tests for the categorical variables of interest
and weighted analysis of variance models for continuous variables.
Weighted analysis of covariance models were used to estimate means
and 95% confidence intervals (95% CIs) for weight- and smoking-related
outcome variables, controlling for gender, race, age and education level.
Using 10-year weight change as the dependent variable, weighted
analysis of covariance models were set up to accommodate the two-way
interactions between the three main factors under investigation: BMI class,
smoking status and CPD. Gender, race, age and education level were
controlled for in all models. The estimated adjusted least-square means
and the standard errors of the mean (s.e.m.) for 10-year weight change was
obtained and plotted. The 95% CIs for the mean estimates were also
calculated and reported. SCA weight gain was calculated by taking the
difference between the adjusted mean weight gain of former smokers and
that of continuing smokers. Two tailed P-values of o0.05 were considered
significant and Bonferroni adjustments for multiple tests were used when
necessary.
RESULTS
A general description of the overall sample is presented in Table 1.
The proportion of never smokers, continuing smokers and former
smokers was 65.2%, 25.3% and 9.5%, respectively. Former smokers
had a higher proportion of participants who were white and
currently obese compared with never smokers and continuing
smokers. Among continuing and former smokers, there were
similar proportions of obesity 10 years ago and the largest
proportion of participants in both groups smoked 1–14 CPD.
The overall adjusted mean weight gain for the entire population
regardless of smoking status was 4.5 kg (confidence interval (CI):
4.2, 4.8), controlling for race, education level, gender and age.
Former smokers had quit an average of 5.7 years (CI: 5.5, 6.0).
Adjusted cigarette and weight-related characteristics are
Table 1. Weighted study population characteristics of participants aged 36+ in NHANES 2003–2012 by smoking status (n=12 204)
Never smoker (n= 7914) Continuing smoker (n= 3105) Former smoker (n= 1185) P-value
% Female 59.9 45.3 49.7 o0.001
Mean age (s.e.m.) 54.5 (0.27) 50.6 (0.23) 54.2 (0.47) o0.001
% White 71.9 72.3 76.6 0.04
% College educated 35.6 12.0 23.5 o0.001
Mean current BMI (s.e.m.) 28.7 (0.11) 27.8 (0.12) 29.6 (0.22) o0.001
Current BMI class, N(%) o0.001
Normal weight (BMI 18.5–o25) 2155 (28.8) 1062 (36.0) 268 (22.1)
Overweight (BMI 25–o30) 2943 (37.4) 1068 (33.5) 427 (36.5)
Obese (BMI ⩾30) 2816 (33.9) 975 (30.4) 490 (41.3)
Mean BMI 10 years ago (s.e.m.) 27.2 (0.10) 26.3 (0.10) 26.7 (0.18) o0.001
BMI class 10 years ago, N(%) o0.001
Normal weight (BMI 18.5–o25) 2987 (40.2) 1383 (47.0) 474 (42.6)
Overweight (BMI 25–o30) 2896 (35.6) 1092 (33.6) 438 (35.8)
Obese (BMI ⩾30) 2031 (24.2) 630 (19.4) 273 (21.6)
Mean CPD (s.e.m.) —17.6 (0.67) 16.6 (0.39) 0.151
CPD category, N(%) 0.007
1–14 —1550 (43.4) 554 (44.5)
15–24 —1015 (38.0) 368 (32.3)
⩾25 —436 (18.6) 250 (23.2)
Abbreviations: BMI, body mass index; CPD, cigarettes per day, currently or before quitting; s.e.m., standard error of the mean.
Ten-year weight gain in smokers who quit
S Veldheer et al
2
International Journal of Obesity (2015) 1 –6 © 2015 Macmillan Publishers Limited

presented in Table 2. There was no difference in CPD among
continuing and former smokers. Continuing smokers were lighter
and had lower current BMIs compared with both never smokers
and former smokers, whereas former smokers were heavier and
had a higher mean BMI compared with both continuing and never
smokers (Po0.001).
Adjusted mean 10-year weight gains and s.e.m. by smoking
status are presented in Figure 1. The overall mean SCA weight
gain was 4.9 kg (CI: 3.4, 6.4). Former smokers gained significantly
more weight compared with continuing smokers (Po0.001) and
this difference remained significant after Bonferroni adjustment.
Ten-year weight gains by BMI class are presented in Figure 2.
The SCA weight gain for normal weight, overweight and obese
participants was 4.4 (CI: 2.9, 5.9), 5.0 (CI: 3.3, 6.8) and 7.1 (CI: 2.9,
11.3) kg, respectively. Regardless of the smoking status, those who
were obese 10 years ago experienced less long-term weight gain
compared with those who were normal weight and overweight 10
years ago. The general pattern of the data shows that normal
weight and overweight former smokers gained about the same
amount of weight, whereas those who were obese gained the
least. However, the SCA weight gain was the highest for those
who were obese because of weight loss in obese continuing
smokers. All differences in weight gains between continuing and
former smokers were statistically significant (Po0.002) and
remained significant after Bonferroni adjustment.
Weight gain by CPD group among continuing and
former smokers is presented in Figure 3. The SCA weight
gain for those who smoked 1–14, 15–24 and ⩾25 CPD was 2.0
(CI: 0.3, 3.7), 6.0 (CI: 4.0, 7.9) and 10.3 (CI: 7.4, 13.2) kg, respectively.
There was a stepwise, positive relationship between CPD and
weight gain among former smokers, a pattern that is also
reflected in SCA weight gain partly because continuing
smokers in each CPD category gained significantly less
weight over time compared with former smokers. The difference
in weight gain between continuing and former smokers
of 1–14 CPD (P= 0.02) did not remain significant after Bonferroni
adjustment. Differences in weight gain between continuing
and former smokers of 15–24 and ⩾25 CPD were
significant (Po0.001) and remained significant after Bonferroni
adjustment.
There was a similar overall pattern of results in both genders,
except that women gained more weight compared with men in
most groups, with the exception of obese female continuing
smokers who lost more weight compared with men (data not
shown). We have not focused on gender effects as there is some
evidence from a previous study that women are more likely to
underestimate historical weight.
19
This pattern was also found
when looking at continuing and former smokers within each CPD
group by BMI (Supplementary information is available at IJO's
website).
DISCUSSION
An important finding from the analysis of this contemporary,
nationally representative sample is that there is a positive, dose–
response relationship between CPD and both overall weight gain
and SCA weight gain in smokers who quit. While the average
smoker reported 4.9 kg of weight gain that could be directly
attributed to smoking, light to moderate smokers (1–14 CPD)
gained much less than this (2.0 kg). In addition, the amount of
Table 2. Mean (95% CI) values for cigarette and weight-related characteristics, controlling for race, education level, gender and age
Never smoker (n= 7914) Continuing smoker (n= 3105) Former smoker (n= 1185) P-value
CPD —12.5 (11.9, 13.1) 13.6 (12.4, 14.8) 0.07
Years smoked —34.9 (34.6, 35.2) 29.8 (29.2, 30.5) o0.001
Current weight (kg)
a,b,d
81.7 (81.1, 82.3) 77.7 (76.7, 78.7) 84.2 (82.7, 85.7) o0.001
Weight 10 years ago (kg)
a,c,e
77.4 (76.7, 78.0) 74.2 (73.4, 75.1) 75.9 (74.7, 77.1) o0.001
Current BMI
a,b,d
29.1 (28.9, 29.3) 27.5 (27.2, 27.9) 29.8 (29.3, 30.2) o0.001
BMI 10 years ago
a,c,d
27.5 (27.3, 27.7) 26.3 (26.0, 26.5) 26.8 (26.4, 27.2) o0.001
Abbreviations: BMI, body mass index; CI, confidence interval; CPD, cigarettes per day, currently or before quitting.
a
Difference between never smoker and
continuing smoker Po0.001.
b
Difference between continuing smoker and former smoker Po0.001.
c
Difference between continuing smoker and former
smoker Po0.02.
d
Difference between never smoker and former smoker Po0.004.
e
Difference between never smoker and former smoker Po0.02.
Figure 1. Adjusted mean differences (and s.e.m.
a
) in weight
compared with 10 years ago by smoking status, controlling for
race, gender, education level and age.
a
s.e.m., standard error of the
mean;
b
P=0.03;
c
Did not remain significant after Bonferroni
adjustment;
d
Po0.001;
e
Remained significant after Bonferroni
adjustment.
Figure 2. Adjusted differences (and s.e.m.
a
) in weight compared
with 10 years ago by smoking status and BMI class 10 years ago,
controlling for age, gender, race and education level.
a
s.e.m.,
standard error of the mean;
b
Po0.001;
c
Po0.002;
d
Remained
significant after Bonferroni adjustment.
Ten-year weight gain in smokers who quit
S Veldheer et al
3
© 2015 Macmillan Publishers Limited International Journal of Obesity (2015) 1 –6

10-year weight gain reported by light to moderate smokers who
quit was not significantly different (after Bonferroni adjustment)
compared with the amount of weight gain reported by those who
continued to smoke this amount.
On the other hand, heavy smokers (⩾25 CPD) had much more
SCA weight gain (10.3 kg) compared with lighter smokers, which
was mostly because of the combined effects of lower weight gain
in continuing, heavier smokers and higher weight gain in heavier
smokers who quit (versus lighter smokers who quit). Our findings
on heavy smokers are consistent with other studies
5,8,13
that have
identified CPD as a predictor of extreme amounts of weight gain
(413 kg) and they suggest that the average smoker of ⩾25 CPD
will experience a 15.7% increase in body weight after they quit
smoking, 12.2% being directly attributable to quitting smoking.
When considering weight gain by BMI, we found that
participants who were obese 10 years ago gained less weight
compared with their normal or overweight counterparts regard-
less of their smoking status. While it may be counterintuitive that
those with higher BMIs gain less weight over time, this has been
observed before in both prospective studies and clinical trials.
9,20
For instance, the Prospective Studies Collaboration
20
used
measured weight for 95% of their data and found weight
change over 5–9 years among those who were obese at baseline
(BMI 30–50) was lower compared with that of those who were
normal weight (change in BMI of 0.12 for obese versus change in
BMI of 0.62 for normal weight participants). In addition, within the
obesity category, those with higher BMIs lost weight over that
time (those with a BMI 30–35 had a BMI change of 0.24 compared
with those with a BMI 40–50 who had a BMI change of −0.69). This
pattern of findings is consistent with the present report, which
found that obese former smokers experienced 2.5 kg of long-term
weight gain, which was significantly less than that of normal
weight (10.1 kg) and overweight (9.9 kg) former smokers. How-
ever, tempering this finding is the observation that obese
continuing smokers lost weight over time, making the magnitude
of SCA weight gain higher for obese former smokers (7.1 kg)
compared with for those who were normal weight (4.4 kg) or
overweight (5.0 kg).
An important observation to note is that our overall weight gain
estimate for former smokers is higher than the 1990 Surgeon
General’s Report on The Health Benefits of Smoking Cessation
2
and higher than the Clinical Practice Guideline for Treating
Tobacco Use and Dependence: 2008 Update, which stated that
'Most [quitters] will gain fewer than 10 pounds (4.5 kg)' (p 173).
21
A
possible reason for these differences is that a number of the
studies in the above reports were clinical trials, which are known
to have different sample characteristics that make them difficult to
generalize to population surveys.
22
Our average long-term weight gain among former smokers is
also higher than previously reported from older NHANES data sets
(6.9 kg (1988–1991)
5
absolute mean weight gain in those quitting
for o10 years). This difference may be because of the overall
increase in the prevalence of obesity across all US sub-populations
since this data was published,
23
which is supported by the
observation that even never smokers in the present study
experienced a higher 10-year weight gain (4.4 kg) compared with
data previously reported (2.6 kg in 1988–1991).
5
From 1960 to 2012, the prevalence of obesity in the United
States jumped from o14% to 35%.
24
At the same time, a number
of public health initiatives (e.g., health education campaigns, clean
indoor air laws and increases in cigarette taxes) converged to
successfully decrease the prevalence of smoking from a high of
42% in 1964 to its current rate of 18%.
25
Although it is not thought
that the decrease in smoking prevalence with its associated
weight gain has significantly contributed to the overall US
prevalence of obesity,
5
our data suggest that this overall societal
weight increase may have impacted body weights among
contemporary continuing and former smokers as well.
With regard to overall SCA weight gain, although our estimate of
4.9 kg is higher than the 3.3 kg reported in the 1971–1984 NHANES
survey,
8
it is similar to the SCA weight gain estimate of 4.7 kg
reported for the 1988–1991 NHANES surveys by Flegal et al.
5
This
suggests that even though overall weight gain in smokers and
former smokers may have increased because of the general societal
increase in obesity, weight gain that can be directly attributable to
smoking cessation has remained fairly constant.
This study’sfindings highlight the complex relationship
between smoking and weight control
26–28
and raise questions
for how to present the issue to different groups of smokers. For
smokers of 1–14 CPD who want to quit, the message can be fairly
simple since the weight they gain may not be much more than if
they continued to smoke. In addition, they should be reminded
that weight gain occurs naturally as people age, and that if they
quit, relatively little of the weight they will gain over the long term
may be directly attributable to quitting smoking.
However, the question remains as to what messages should be
provided to obese and heavy smokers. Fernandez and Chapman
29
have suggested that because weight gain can be barrier to
smoking cessation, 'It may be unwise to incorporate this message
into clinical or public health practice'. However, the majority of
heavy smokers have experienced weight gain on a previous quit
attempt,
30
and it is clear that they already know that significant
weight gain after quitting is likely. In addition, obese smokers have
been shown to be the most concerned about weight gain after
quitting,
31
thus avoiding this discussion may be counterproduc-
tive. The issue may be addressed by acknowledging potential
weight gain and putting into perspective the substantially
lowered health risks for smokers who quit regardless of their
postcessation weight. For instance, Clair et al.
32
analyzed data
from the Framingham Offspring cohort and found that smoking
cessation was associated with a lower risk of cardiovascular events
regardless of the associated weight gain. In addition, for smokers
who are already obese, Freedman et al.
33
have demonstrated that
the compounded mortality risk for those who both smoke and are
obese is much greater than the mortality risk of excess weight
alone. Therefore, although former smokers gain more weight
compared with continuing smokers, the clinical significance of
quitting outweighs the potential risks of weight gain. Heavy and
obese smokers should be encouraged to use evidence-based
tobacco dependence treatment and they should be assured that
cessation is a health priority regardless of the weight they may
gain. These patients may also benefit most from weight manage-
ment interventions to help attenuate future weight gain. While
formal clinical research may be needed to identify the most
Figure 3. Adjusted differences (and s.e.m.
a
) in weight compared
with 10 years ago for continuing and former smokers by current
CPD or CPD before quitting, controlling for race, gender, education
level and age.
a
s.e.m., standard error of the mean;
b
P=0.02;
c
Did not
remain significant after Bonferroni adjustment;
d
Po0.001 and
e
Remained significant after Bonferroni adjustment.
Ten-year weight gain in smokers who quit
S Veldheer et al
4
International Journal of Obesity (2015) 1 –6 © 2015 Macmillan Publishers Limited

efficacious interventions for these specific groups, Farley et al.
34
reviewed the topic of concurrent smoking cessation and weight
management and found modest evidence that personalized
weight management support may be effective and does not
appear to reduce abstinence.
There are some limitations to our findings. First, smoking status
was based on self-report and was not biochemically validated.
Several studies have compared self-reported smoking status with
biochemically validated smoking status in population surveys such
as NHANES and found that underreporting of smoking is minimal
(o2% misclassification).
35,36
A second limitation was that our
weight-related variables were self-reported but as NHANES
includes measured current weight for some participants, we were
able to calculate Bland–Altman limits of agreement. Based on the
log-transformed self-reported weight and actual weight measures,
the Bland–Altman plots
37
showed good agreement with a bias of
nearly zero and limits of agreement between −0.10 and 0.096. In
addition, the correlation between current self-reported weight
and measured weight was +0.98 overall. No group (never smokers,
continuing smokers, or former smokers and normal weight,
overweight or obese) had a mean difference in self-reported
and measured weight 4± 1.0 kg. Previous analyses of the
NHANES data compared measured weight 10 years ago with
self-reported estimates of weight 10 years ago and found these to
be more variable but still broadly accurate (correlation +0.74, with
a mean under estimation of reported body weight 10 years ago of
o0.9 kg).
19
Regardless of possible variation in the self-reported
data, our findings provide robust evidence of a pattern of weight
gain that is unlikely to be due to minor underestimations of
historical weight.
CONCLUSION
Baseline BMI and CPD are important factors that contribute to the
magnitude of long-term weight gain following smoking cessation.
Light to moderate smokers (o15 CPD) experienced relatively little
weight gain that could be directly related to smoking cessation.
Heavy smokers (⩾25 CPD) and those who were obese before quitting
experienced significant SCA weight gain, partly because of lower
than average weight gain or weight loss among continuing smokers
in these groups. For smokers of more than 24 cigarettes per day,
quitting smoking resulted in a weight increase averaging 12.2% of
their body weight. Obese and heavy smokers may particularly
benefit from both tobacco dependence treatment and early weight
management intervention during a quit attempt.
CONFLICT OF INTEREST
JF has done paid consulting for pharmaceutical companies involved in producing
smoking cessation medications including GSK, Pfizer, Novartis, J&J and Cypress
Bioscience. The other authors have no conflict of interest to declare.
ACKNOWLEDGEMENTS
This research was supported by funds from the Penn State Cancer Institute to JF.
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Supplementary Information accompanies this paper on International Journal of Obesity website (http://www.nature.com/ijo)
Ten-year weight gain in smokers who quit
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International Journal of Obesity (2015) 1 –6 © 2015 Macmillan Publishers Limited