Wrong question #1: Which is a more serious threat to your health, smoking or obesity? It’s a question that epidemiologists bat around periodically. A few years back, a group of respected scientists announced that obesity was rapidly overtaking smoking as a cause of disease and death, then found themselves in the embarrassing position of having to retract their claim because of a data analytic error. A more recent study tried to estimate the relative overall burden of smoking and obesity over time and after heavily factoring in quality of life issues, concluded that obesity was even more of a bad actor than smoking. Yet bottom line: smoking remains the number one cause of preventable disease and death in the U.S.
The question, of course, is rendered more provocative by the fact that smoking and weight are in a seesaw relationship with one another. On average, smokers weigh a few pounds less than nonsmokers of the same age and sex, and smokers tend to gain a few pounds after quitting. Although the causes of our current obesity epidemic are multifactorial, the success of public health campaigns to discourage smoking has made at least a small contribution to these statistics.
So to be fair, the question of which is a greater health risk is not necessarily a wrong question for policy wonks who need to decide on the allocation of limited resources. But on the individual level, it has always struck me as being about as productive as “Which is worse, death by fire or death by ice?”
Wrong question #2: How much weight would I have to gain to equal the risk of smoking? This is a question raised by experts in the past with the hope of coming up with a number so high (30 pounds? 50 pounds? more?) that the smoker would be convinced it was preposterous either to worry about it or to offer it as an excuse not to quit. Unfortunately, however well-intended, the question may have backfired by unnecessarily raising the specter of out-of-control weight gain. In actual fact, the answer can’t be calculated for any given person without factoring in how much she weighs, how much she smokes, how old she is, how long she’s smoked, etc. Moreover, whatever the answer, you definitely don’t want to go there – nor do you need to.
Wrong question #3: How can I keep from gaining any weight at all when I quit? This is the Holy Grail of smoking cessation for women. When asked about how many pounds they’d be willing to gain if they quit smoking, nearly half of all women say “zero.” The fear of weight gain keeps many women from even trying to quit, and causes others to relapse as soon as they gain a pound or two.
This is sad because I’m convinced the real, deep-down fear of most women is less that they’ll gain a little weight and more that they’ll gain a lot of weight. Face it, when the needle on the scale starts to creep up – and this can happen quite soon after quitting – you have no idea where all this will end up. Like the wheel of fortune, “where she stops, nobody knows.”
Although there are certainly ways to modify your eating behavior to reduce food intake comfortably, most women probably cannot achieve the goal of zero weight gain without being on a permanent diet or being plagued by nagging twinges of hunger. That’s because nicotine has a number of effects, such as increased metabolism and decreased fluid volume, that go away when nicotine is removed, making your body “want” to revert to the weight you would be had you never smoked.
That’s why any program or book or website that promises to teach you “how to quit smoking without gaining weight” will almost certainly disappoint most of its adherents. For every woman who succeeds in the quest to gain no weight at all, many more will not. Anyone who’s had experience treating smokers knows this, so why do they persist in holding out false hopes? Because it sells books? Because they’re afraid knowing the truth will be too discouraging?
Personally I prefer to tell the truth – not just because my mother told me honesty was the best policy (although indeed she did), not just because I respect your intelligence (although indeed I do), but because if you keep asking the wrong question, the all or nothing question, you’ll never learn what you need to learn to get beyond it.
And now for the right question: How much can I gain without putting my health at risk, forcing me to buy a new wardrobe, and making me feel miserable about my body? This question may at first strike you as defeatist, like giving up on the Holy Grail before you’ve even mounted your steed. But it’s the right question because it actually has a practical, positive answer that is within the grasp of most women – and (drumroll, please) here it is: Depending on your height, a unit of Body Mass Index (which is exactly what the experts use to measure weight-related health risk; basically it’s a measure of weight corrected for differences in height) is 5-7 pounds. The difference between one dress size and the next is around 8 pounds. Are you starting to get the picture here? If you can keep weight gain after quitting in the range of 5-10 pounds, you will not increase your health risk, no matter how overweight you are to begin with, and your clothes will still fit. And with a little positive self-talk, you should also be able to negotiate a truce between your mind and your new weight.
Some women will have more trouble than others in staying within the magic window. Women who “use” nicotine to manage a tendency toward binge-eating or to quell depression-induced munchies may need some additional help in regulating behavior and managing mood. For most women, however, this is a realistic goal, one that is near the peak of the bell curve for weight gain and one that can be nudged along by modest lifestyle changes like exercising a little more and eating a little less – changes most women find they can carry out. So even though weight gain can begin quite soon after quitting, don’t worry that it is on a linear upward trajectory. For most women it will level off shortly, leaving you at a weight you can make your peace with.
A joke I’ve made about self-help quit-smoking books that claim high rates of success is that they in effect state, “This book is guaranteed to work if you follow the instructions to the letter,“ then add, “Instruction #1: Stop smoking now.”
The Easy Way for Women to Stop Smoking: A Revolutionary Approach Using Allen Carr’s Easyway Method was published almost simultaneously with Life After Cigarettes. Because Life After Cigarettes is not prescriptive but rather encourages women to find stop-smoking and weight-management strategies that fill their own needs and preferences, I was hopeful that this book could serve as a useful companion piece to Life After Cigarettes.
And possibly it can. Certainly the personal testimonials and celebrity endorsements the program has garnered suggest that many have happily succeeded using this method. That said, it must be added that the easyway approach does not play well with others. Indeed, an alternative phrase it adopts is “The Only Way.” Unsuccessful quitters are dismissed as having failed to understand or correctly apply easyway principles. (“Instruction #1: Stop smoking now.”) Medications like nicotine replacement products, Zyban, and Chantix, which have repeatedly been shown to double quit rates in highly dependent smokers, are off limits to easyway quitters.
A little background: This book is a reissue of a book originally published in 1985, updated by an easyway therapist (Francesca Cesati) and purporting to focus on issues of particular concern to women, especially weight. (I say “purporting” because it actually includes surprisingly little specific information on managing weight, instead simply rejecting the weight-suppressing effects of smoking as “myth.”) It is what might be called a guru-based (rather than research-based) program, representing the vision of Allen Carr, who was able to quit using a method he developed on his own after years as a 100-cigarettes/day smoker. Like most stop-smoking gurus, he became an enthusiastic proponent of his own method. Unlike most, he was also an astute businessman who devoted the remainder of his career to developing clinics and books for treating smoking (and subsequently other addictions, weight loss, and even worrying) widely marketed for use by individuals and in corporate settings around the world. Sadly, he died of lung cancer in 2006, but his clinics and books continue to propagate his message and his program.
I don’t for an instant doubt the sincerity of the easyway people. I also don’t doubt that the easyway approach has helped many smokers who might otherwise have been unable to quit, and that is all to the good. It is full of testimonials that will ring true for many, many smokers and includes bon mots that some will find comforting (e.g., “Remember: you’ve only stopped smoking, not living!”). I do, however, have two serious reservations:
1) The success claims do not meet established scientific standards for evaluating smoking intervention outcomes. As is typical of self-help books, The Easy Way has received five-star reviews on amazon.com from smokers who succeeded in quitting using its principles (and as noted above, there are many) and one or two stars from those who didn’t. Although these reviews, especially those that provide enough detail to allow determination of how relevant they are to the reader’s own situation, can be very helpful, they are no substitute for trials with well-defined outcome measures in which would-be quitters are randomly assigned to either the easyway method or a control condition, abstinence is biologically verified (by measures of a nicotine metabolite or expired carbon monoxide), and findings are peer-reviewed prior to publication. These studies have not been done, but less rigorous attempts by independent observers to evaluate easyway outcomes do not support the superiority of the method over alternative approaches.
2) A number of the premises on which it rests are factually just plain wrong. The title alone includes two – first, that it is easy for most smokers to quit, and second, that it is easy to avoid any weight gain. There is no evidence from data in the scientific literature on patients in clinical trials, self-quitting in population-based samples, or any other type of study that stopping smoking and avoiding subsequent weight gain are easy. So unless you are willing to accept the claim that there is only one easy way, Allen Carr’s, and that if it wasn’t easy for you, you just didn’t “get it,” then the title doesn’t live up to its promise. To add just one more example, the book states that nicotine is not addictive, despite overwhelming scientific evidence to the contrary.
Despite these concerns, let me emphasize that The Easy Way works for those for whom it works, and if you’re one of them, I’ll never knock it – any more than I would knock other approaches that have not (or not yet) been fully tested. If, after reading the reviews of the book on the major bookseller sites, you find you resonate with the experiences described by successful quitters, then by all means invest in the book. But please don’t buy into the implicit easyway dictum that if this doesn’t work for you then all is lost – and that you yourself are to blame. There are many paths to quitting and to controlling weight; as Life After Cigarettes makes clear, you need to find the one that works for you, whether it be the easyway or someotherway.
Eat, Pray . . . Whoa!
I may be the last woman on the planet to read Eat, Pray, Love, but after seeing the author interviewed on the PBS special “This Emotional Life”, I finally broke down and took it out of the library. I’m not sure I qualify as having read the book, having only digested Eat and skimmed Love, but I thought I’d share my reactions from the perspective of someone who wants to help women smokers manage their weight and stave off depression when they quit.
Of course, I knew from the buzz I’d heard that the first third of the book was about an orgy of eating in Italy. What I didn’t realize till I actually started reading was that what it’s really about is eating as self-medication for depression. Over the course of her four-month stay in Rome, Elizabeth Gilbert gained 23 pounds. Fifteen of those pounds, she adds, “I actually needed to gain because I had become so skeletal during the last hard years of divorce and depression.”
Even though Gilbert’s own eating-depression mix doesn’t happen to include smoking, her experiences will hit home for women trying to quit. For example, for many women, pasta and gelato can elevate mood and take the edge of craving, at least temporarily. If you’re a smoker trying to quit, however, the tendency to gain a little weight due to increased fluid volume and metabolic changes can be magnified by excessive eating. And though many women eat to comfort themselves when they feel depressed, a few actually lose their appetite. For those women, not gaining any weight after quitting smoking can be a mixed blessing since it may reflect a depression-induced loss of interest in eating.
That said, the goal is not to be a sad, hungry ex-smoker but a joyous nonsmoker who relishes food and manages her weight. For some, this may mean repairing your relationship with food. It may mean forgiving yourself for the occasional lapse and getting back on track rather than using it as an excuse to say “the heck with it” and giving up altogether. For all, it means finding a balance you can and will sustain not for just a day or a week but over the long haul. It means finding your own best path to life after cigarettes.
Elizabeth Gilbert writes well. Like all gifted writers, she seduces you into her mind set. So by all means enjoy EPL as a fantasy, or as a metaphorical journey of self-discovery. But unless you can find a publisher who will give you a six-figure advance so that you can take a year off to document your travels, and unless you can spend the next four months in an ashram shedding the pounds you gained after tying on the feedbag for the last four months, please don’t take her itinerary as a literal roadmap.
When I visit the Life After Cigarettes Facebook fan page, I sometimes see ads for electronic cigarettes. Please be aware that I am not in any way endorsing these products.
If you’re a Facebook user, you probably know from the ads that appear on your own wall that Facebook uses demographics and the contents of your messages to pair ads with posts. If you mention your cat in an e-mail, you’ll get ads for pet products. If you’re a woman of a certain age, you’ll get ads for wrinkle crèmes. I heard of a woman who briefly changed the sex listing under her “info” tab from female to male, just to see what would heppen, and found that the ads displayed on her wall were quite different from the ones she was used to seeing. (Hint: They weren’t about face crèmes.)
So what about e-cigarettes? Although they are undoubtedly safer than cigarettes (hardly anything isn’t!), it remains to be seen whether they are enough safer to justify risking primary addiction by children and adolescents and relinquishing the hope of persuading addicted smokers to give up nicotine altogether. These products have not been approved by the FDA and require further testing before the risk-benefit ratio to the individual and society can be determined.
Electronic cigarettes, and other alternative nicotine delivery systems, are discussed in Chapter 7 of Life After Cigarettes. Bottom line: These products, especially the ones that don’t involve combustion, merit further study as a smoking cessation aid or even as a long-term substitute for cigarettes. But is this really where you want to go? And is that really how you want to spend your money? For the moment, my recommendation is to envision yourself as someone who is truly, not just technically, a nonsmoker. Leave smoking behind, if you can (and I’m confident you can!), and move on with your life.
Cynthia S. Pomerleau, Ph.D., is currently research professor emerita in the University of Michigan Department of Psychiatry. From 1985 to 2009 she served as director of the Nicotine Research Laboratory, where much of her research focused on the impact of smoking on women. She is the author of more than a hundred articles and book chapters on smoking and a contributor to the 2001 Surgeon General’s Report on Women and Smoking.