Nutrition, Weight Gain and

Exercise in the Treatment of

Tobacco Dependence

Amy Cober RDN MPH CTTSFlorida State University College of Medicine AHEC

Session Objectives

At the conclusion of this presentation, the attendee should be able to-• Discuss post smoking cessation weight gain including

patterns of post cessation weight gain, risk factors for post cessation weight gain and mechanisms of post cessation weight gain.

• Identify possible evidence based interventions for preventing weight gain with smoking cessation.

• Discuss the significance of smoking and smoking cessation on nutrition related diseases.

Common Biological Basis of Obesity & Nicotine Addiction

• Brain reward system involved in control of food and tobacco intake

• Absence of nicotine shown to increase reward value of certain foods

• Heavy smokers weigh more than light smokers

• 32 common variants in regulation of appetite for tobacco & food

Thorgeirsson et al., Transl Psychiatry (2013)

Body Weight & Smoking• Association between obesity

and number of cigarettes smoked daily

• Historical practice of smoking to “stay slender”

• Tobacco marketing strategy• Risk factor for smoking

initiation by adolescents• Excuse for not initiating

Tobacco treatment• Decreased confidence in

quitting• Cause of relapse?

Risk Factors for Post Cessation Weight Gain

• Gender• Body weight• Mental Health status• Race• Age• Level of tobacco Use• FTND Score• Socioeconomic status• Initiation age• Physical activity level• Coffee consumption• Genetic factors• Triglyceride levels• Presence of a comorbidity

Taniguchi, et al., Nursing Research (2013); Komiyama et al., PlosOne (2013); Levine et al., Nic & Tob Research (2012); Yoon et al., Atherosclerosis (2010)

Post Cessation Weight Gain

• Average weight gain is 4.7 kg • Standard deviation of 4.7 kg • 16% of quitters lose weight• 25% will gain < 1 kg or lose

weight• 25% will gain more than 8 kg• 13% will gain more than 10 kg• Rapid weight gain in 1st three

months

Aubin et al., BMJ (2012)

Is it better to be a fat ex-smoker than a thin smoker?

Siahpush, M., et al. (2013). "It is better to be a fat ex-smoker than a thin smoker: findings from the 1997-2004 National Health Interview Survey-National Death Index linkage study." Tob Control.

Mechanisms of Post Cessation Weight Gain

• Reduction in nicotine & CO exposure

• Decreased resting metabolic rates

• Altered efficiency of calorie storage

• Increased appetite• Decreased physical activity• Increased lipoprotein lipase

activity• Increased energy intake

Gray et al., J Subst Abuse (1995); Grunberg, Add Behaviors (1982); Hofstetter, NEJM (1982); Wack, Am J Clin Nutr (1982); Filozof et al., Obes Rev (2004)

Weighty Questions

• Do repeated periods of abstinence lead to incremental weight gains?

• Does resumption of smoking lead to weight loss?

• Is the weight gain permanent?

• How much of a weight gain will smokers be willing to tolerate?

Pomerleau et al., J Subst Abuse (1996)

How many pounds would you be willing to gain after quitting smoking?

The Effects of Nicotine and Cigarette Smoking on Food Consumption and Taste Preferences

• Nonsmokers• Smokers allowed to

smoke• Smokers not allowed to

smoke• Test foods-chocolate,

coffee cake, gumdrops, salami, salted peanuts, pretzels, unsalted crackers, cheese & unsalted peanuts

Grunberg, Addictive Behaviors (1982)

Fruit & Vegetable Consumption and Smoking

• Higher F &V Consumption associated with-– Fewer cigarettes smoked/day– Longer time to first cigarette– Lower nicotine dependence

score (NDSS)• Likelihood of making a quit attempt

was higher among persons with the highest vegetable consumption

• F & V Consumption predicted abstinence at follow-up

Prevent or resolve post cessation constipation Dietary improvement as a smoking cessation tool?

Haibach et al., Nicotine & Tobacco Research (2013)

Effects of Food & Beverages on Cigarette Palatability

• Factors that worsen the taste of cigarettes can decrease smoking behavior

• Post prandial cigarette particularly satisfying

McClernon et al., Nicotine & Tobacco Research (2007)

• Biological factors may play a causal role

Clinical implications-• Assess which foods & beverages enhance or

worsen taste • Consider advising patients to increase or

decrease during a quit attempt

Dietary Intake After Smoking Cessation

Energy Intake

Total calories by smoking status over time

Levine, M. D., et al. (2012). "Dietary intake after smoking cessation among weight-concerned women smokers." Psychol Addict Behav 26(4): 969-973.

100 CALORIES

100 calories x 365 days = 36,500 calories/year

36,500 Calories/year divided by 3,500 calories/pound= 10.42 pounds

Evidence Based Weight Management Rx

• Nutritional assessment & treatment

• Dietary interventions• Physical Activity

interventions• Behavioral interventions• FDA approved

medications for weight loss

• Bariatric surgery

During Tobacco Treatment• Lower fat/calorie food

choices while increasing Fruit & Vegetable intake

• Nicotine Replacement Therapy (NRT)

• Increased Physical Activity

Veldheer et al., Intl J Clin Pract (2014)

NRT: Effects on Postcessation Weight Gain

• 50% reduction in cessation related weight gain

• Dose response relation• Follow-up data suggest a

delay rather than prevention of eventual weight gain

Gross et al., J Consult Clin Psych (1989)

Use of nicotine gum may allow time for acceptance of weight gain and/or implementation of new diet & exercise behaviors.

Transdermal Nicotine Therapy & Post Cessation Weight Gain

• Control group– 8 weeks patch therapy

plus 16 weeks placebo– 10.37 lb average weight

gain

• Intervention group– 24 weeks patch therapy– 5.83 lb average weight

gain

Smokers who express a fear of abstinence-induced weight

gain could be encouraged to utilize extended nicotine patch

treatment as a therapeutic option. Schnoll et al., Addictive Behaviors (2012)

Combination Pharmacological Interventions

• Successful combinations– Nicotine inhaler plus

nicotine patch– Nicotine patch plus

bupropion– Naltrexone plus patch (2)– ProBAN plus gum– Naltrexone plus

bupropion– Rimonabant plus patch

Yang et al., Addictive Behaviors (2013)

Offering a Weight Management Program

• Available after treatment for tobacco dependence

• Overweight & obese smokers who expressed moderate concern about weight gain

Love, et al. Am J Addict 2010;20:1-8

Smokers offered a weight management program were five times more likely to attend the first session of tobacco treatment. Smokers offered a weight

management program were three times more likely to be abstinent 6 months after treatment.

Predicting Weight Concerns• Gender• Education level • Income• BMI• Age• Social support• Depressive symptoms• Motivation• Confidence in quitting• Daily number of cigarettes• Gained weight on a prior quit

attempt • Special populations

Veldheer et al., Int J Clin Pract (2014); Collins, B. N., et al., Am J Health Behav (2009)

Smoking Related Weight Concerns

Levine, M. D., et al. (2012). "Smoking-Related Weight Concerns and Obesity: Differences among Normal Weight, Overweight, and Obese Smokers Using a Telephone Tobacco QuitLine." Nicotine Tob Res.

Cognitive Behavioral Therapy

• CBT to reduce weight concerns improves smoking cessation outcomes.

• Does CBT plus Bupropion enhance abstinence for weight concerned women smokers?

• Counseling for Weight Concerns– Therapy Foci

• Restructuring thoughts about food, eating & weight

• Reevaluating beliefs about the importance of a low weight & ideal shape

– Education topics• Cessation related weight gain• Benefits of cessation relative to a modest

weight gain• Disadvantages of trying to diet while quitting• Restrained eating• Moderate consumption of healthy between

meal snacksPerkins et al., J Cons & Clin Psych (2001); Levine et al., Arch Intern Med (2010)

Associations between Exercise and Smoking Behaviors

• Levels of physical activity are inversely related to smoking rates– Gender and mode specific– Adolescents- smoking is

negatively associated with sports participation

• Smokers trying to quit are likely to be more receptive to an active lifestyle than smokers in general– Disease reduction strategy– Associated with less depression

• Positive association between exercise and-

• Initiating a quit attempt• Confidence in staying

abstinent• Quit success

Ussher et al., Cochrane Review (2012)

Exercise- Effect on Post Cessation Weight Gain

• Findings– Excess 2.4 kg weight

gain associated with smoking cessation

This weight gain is minimized if smoking

cessation is accompanied by a

moderate increase in the level of physical activity.

Kawachi et al., Am J of Pub Health (1996)

Exercise- Effect on Post Cessation Weight Gain

• Intervention– Group 1

• Counseling & NRT– Group 2

• Counseling, NRT & Exercise

• Results

Exercise during smoking cessation can successfully prevent weight gain.

Chaney et al., AAOHN Journal (2008)

Adding an exercise program results in a cessation rate higher than that of traditional approaches alone.

Effects of exercise on tobacco withdrawal and cravings

• Reduced psychological withdrawal symptoms

• Reduced desire to smoke

• Alternative reinforcer to smoking

• Influence on cognitive functioning by reducing attentional bias to smoking images

Ussher et al., Cochrane Review (2012)

There is STRONG evidence to recommend exercise as an aid for reducing tobacco withdrawal and cravings.

Smoking and the Risk of Diabetes

• Cigarette smoking is an independent and modifiable risk factor for type 2 diabetes

• No dose response or threshold relationship found in long term studies

• No relationship between pack years of smoking

• Biological mechanismsWannamethee et al., Diabetes Care (2001)

Smoking Cessation and the Risk of Diabetes

• Smoking cessation results in a higher short term risk for diabetes

• Highest risk within first 3 years of quitting

• Decreases to no excess risk by 12 years

• Consistent across numerous studies

• Greatest risk group– Heavy smokers with evidence of

systemic inflammation who gain substantial weight after quitting Yeh et al., Ann Intern Med (2010)

Effects of Smoking on Bone Health

• Key risk factor for bone loss & fractures

• Mechanisms poorly understood

• Dose dependent• May be partially

reversible• Effect of smoking on

falls

Wong et al., Clinical Science (2007)

Dietary Sodium & Smoking Increases Risk for Rheumatoid Arthritis

Sundstrom et al., Rheumatology (2014)

• Purpose of the study was to evaluate the impact of NaCl intake on the risk of developing RA

• Sodium intake more than doubled the risk for RA among smokers

• High sodium intake (taken as the median of the uppermost tertile) was 2.15 grams per day

Practice Implications

• Recommend NRT for withdrawal symptoms, delaying weight gain and decreasing concerns of weight gain.

• Incorporate exercise to prevent or minimize weight gain, reduce withdrawal symptoms and increase cessation success.

• Follow-up to reduce weight gain anxiety and encourage continued abstinence.

• Educate on a healthy diet to prevent or minimize weight gain, prevent chronic diseases and reduce cancer risk.

• Include or offer a weight management program (to weight concerned smokers) for treatment initiation and improved abstinence. (And let smokers know it will be included.)

• Tailor messages to highlight the greater reduction in mortality associated with quitting, compared with potential weight gain.

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Tailored Messages to Negate Fears of Weight Gain

Clinical Practical Guidelines;“Clinician statements” (page 176)