I’m often asked how I came to write Life After Cigarettes. “Aren’t there already a lot of how-to-stop-smoking books already?” “Does the world really need another how-to-quit book, even one with a special focus on women and weight concerns?”
Indeed there are a lot of how-to-stop-smoking books. Many of them are of dubious value – written either by charlatans or more often by people who found a method that worked for them after all else failed and are sincerely convinced it will also help others, despite the lack of randomized clinical trials that would really establish superiority and control for placebo effects. But there are are several written by recognized authorities and based on approved, well-tested methods. There are also a number of excellent books targeting not the end user but clinicians who want to learn how to help smokers quit. (To do this successfully, you really need to understand the unique pharmacological and behavioral rhythms of smoking and nicotine dependence; knowing how to treat alcohol dependence or other forms of drug dependence isn’t enough.)
Back when I was looking for an agent to help me identify a publisher for Life After Cigarettes, one of them asked me about the genre of the book. I told him it was in some ways sui generis – in a class by itself – and he frowned. (Well, to be exact, he e-frowned.) Publishers don’t know what to do with a book they don’t know what to do with. It’s much easier to market a book when it fits neatly into a well-established pigeon-hole.
Although amazon.com does in fact classify the book under smoking, I have never thought of Life After Cigarettes as either a how-to book in general or a stop-smoking book in particular. It’s not a how-to book because it doesn’t include step-by-step instructions, each one building logically and systematically on the previous milestone. It doesn’t include lots of self-tests to help you identify what type of smoker you are or how dependent you are or any of the other things that might serve as the basis for choosing one quitting strategy over another. And it’s not a stop-smoking book because the central message has more to do with the weight increase and depression that can follow quitting than with quitting itself. Competent and accurate instruction on how to quit smoking is a good thing, but as noted, it’s already been done, and in at least a few instances, done well.
But wait, isn’t there a whole chapter in Life After Cigarettes on how to stop smoking? Yes, and here’s a little secret about that chapter – it was the very last one to be written. The material in that chapter, in a much sketchier form, was originally relegated to an appendix. Why? Because I felt strongly not only that my little book was not about how to quit smoking but also that to frame it as such would exclude an important part of the book’s potential readership – that is, former smokers who were dissatisfied with where they’d landed after quitting and wanted to go back and get it right. But the Powers that Be at Hunter House, my publisher, were very insistent that the words “how to quit” be included in the subtitle. My editors were refreshingly hands-off about the text of the book but much more directive about the title and indeed anything that appeared on the cover. Since my contract stated that in case of disagreement, Hunter House had the final say, and since I was committed to truth-in-advertising, I decided that if the cover was going to promise information on how to quit, I was honor-bound to provide it. Thus Chapter 7, Quitting for Good, was born. I placed it just before the final chapter, in order to emphasize that it was not part of the book’s main thrust but rather included as a courtesy to readers who had not yet found the help they needed on the “mechanics” of quitting. Like the rest of the book, it is not prescriptive; rather, it reviews available options and the scientific rationale for each, leaving the reader to match the method to her own preference.
In retrospect, I think adding this chapter was a good decision. I see it as a lagniappe, as the Cajuns say – something a little extra, a bonus – and I’m grateful to Hunter House for pushing me to include it. But as I say, it wasn’t part of my original plan.
But enough about what Life After Cigarettes is NOT. Although I didn’t believe I had a unique contribution to make to the smoking cessation literature, I saw a crying need for a book that dealt sympathetically but honestly with the topic of smoking and weight, a book that translated scientific findings into a motivational message that women could apply directly to their own needs, a book written from a woman’s point of view. The gap in the available literature was twofold: 1) Most such books are written by health professionals, mostly men, who with all the good intentions in the world just don’t get it. Deep down they don’t understand how someone can take a serious health risk just to avoid gaining weight—even though both men and women take all sorts of risks for reasons that are equally hard to defend if your sole aim is to maximize short- and long-term health. They exceed the posted speed limit to compensate for a late start, they go hurtling down steep hills on skis because it gives them a brief thrill, they drive home after an evening of drinking; the list goes on and on. 2) Virtually all such books claim to tell you how to quit without gaining any weight. Yet most women know, from watching their friends or their sisters or their mothers quit or from their own experience, that this isn’t a realistic expectation or likely outcome. And anyone starting with the attitude of “three pounds and I’m gone” is on a fast track to early relapse.
What I really wanted was to create a space in which women smokers and ex-smokers would feel safe in confronting their profoundest fears about gaining weight. I believe that when they learn the scientific facts about the effects of smoking on appearance and about weight gain after quitting, they will understand that a few pounds are an excellent trade-off not just in terms of health but also in terms of appearance. The operative word here is “few.” I am convinced that the real, deep-down, bedrock fear of most women is not of gaining a few pounds but of weight spinning out of control – a fear compounded by the fact that quitters often gain a couple of pounds or more in the first week after their last cigarette. Women need to know that this the weight gain curve quickly tapers off. They need to know that managing weight gain so that it stays in the 5-10 pound zone, within a unit of BMI and within a dress size, is a realistic goal. They need the tools for doing so. That’s Life After Cigarettes’ niche, and I know of no other book that fills it.
The link between smoking and depression is well-documented. Smoking can relieve depression, and depressed mood can emerge as a withdrawal symptom after quitting, particularly in people with a tendency towards depression to begin with. Severe depression is relatively uncommon and may require medical intervention; for the more mundane blues and blahs that may plague quitters, here’s something you can try on your own – something that doesn’t take any special equipment or medication and requires no planning or preparation.
Although we generally think of a smile as something that results from rather than causes good feelings, it has actually been shown in the Laboratory that moving your facial muscles to form a smile produces self-reported mood elevation. (This experiment is not so easy as it sounds, since your results will be hard to interpret if you generate amusement by your instructions rather than by the smile itself; but scientists have succeeded in conducting a convincing demonstration of the phenomenon.) Smiling has the additional benefits of making you look younger and more attractive. It may even boost your immune system!
Improving your mood by acting the way you want to feel is not restricted to smiling; apparently the rest of your body can also be recruited for this purpose. I recently saw a fascinating presentation by Dr. Tal Shafir, a postdoctoral fellow in my Department, who along with her colleagues has conducted a study in which participants were taught to carry out short sequences of happy, sad, and neutral whole body movements. These researchers found, as predicted, that the happy movements increased positive feelings and decreased negative feelings. The happy movements also produced different patterns of brain activation from the sad and neutral movements. Looking at Dr. Shafir’s happy-movement photos, one of which resembled a cheerleader’s leap, I wryly asked if she could recommend something a little easier on the knees, and she responded that the critical element was probably “opening the chest.”
So next time you’re feeling glum and thinking about smoking, try squaring your shoulders and pasting on a happy face. You have nothing to lose but the blues.
I recently blogged about the Rule of Thirds – the myth that only a third of smokers gain weight after quitting (with a third remaining the same and a third actually losing weight). This would be nice if it were true but it simply is not. The large majority of quitters gain weight. Only a handful actually lose weight, and as I have suggested elsewhere, some of those who do may be suffering from loss of appetite associated with depression.
Another dubious claim floating around out there is that weight gain after quitting smoking is temporary, and that after an initial increase in weight, quitters will return to their pre-cessation weight with no special effort. This optimistic view – basically just a twist on misleading promises that anyone can quit without gaining weight – is propagated in a government pamphlet entitled Forever Free. Even then, the pamphlet waffles, asserting that “most [quitters] lose weight over time with no special action” but repeatedly suggesting otherwise in the text.
So far as I can tell, the idea that weight gained after quitting magically melts away originated with an MIT economist named Jonathan Gruber, who flatly stated, “There’s no evidence in the medical literature that quitting smoking will affect your weight over a long period of time.” In fact, there is considerable evidence in both cross-sectional studies, including one from my own laboratory, and longitudinal studies showing that exsmokers weigh about the same as people who never smoked, even several years after quitting, and that both of these groups weigh more than current smokers. These findings are consistent with the common-sensical inference that quitters on average revert to the weight they would have been had they never smoked.
What IS true is that the period of gaining weight is temporary. When you stop smoking, your weight generally goes up by a few pounds, mostly within the first six months. Although Americans typically put on weight as they age, little of the weight you gain beyond your six-month anniversary is likely to be attributable to the fact that you stopped smoking.
This is also not to say that you cannot avoid weight gain or even lose weight after quitting by aggressively modifying your dietary and exercise patterns. Alternatively, you can accept a few extra pounds as your badge of success, knowing that those pounds are likely to land in all the right places as your body, no longer exposed to the anti-estrogenic effects of smoking, assumes a more “feminine” shape. And you can manage that weight gain so that you remain in the 5-10 pound category that will minimize the impact on your Body Mass Index and your wardrobe – a very achievable goal.
But why not tell a little white lie if it might encourage people to quit by making them more hopeful? Is it really any worse than responding “Fine” when people casually ask how you are, even if you had a fight with your husband, the dog threw up on the rug, and you feel a cold coming on?
Anyone following this blog has heard my mantra that realistic expectations are the best path to life as a contented nonsmoker who is not plagued by craving for cigarettes or dissatisfaction with her body. I would rather see smokers directly addressing the task of managing weight gain after quitting than facing disappointment, a sense of personal failure, and relapse because they hoped that if they ignored it, it would just go away.
Take a naturally-occurring mildly addictive substance (there are many), then refine and redesign it so it’s more addictive – maybe much more addictive. There are lots of ways to do this. You can combine it with other substances that enhance its addictive properties, you can modify the vehicle so that it’s easier to ingest or can be ingested via a route that reaches the brain more rapidly (faster “rise time”), you can increase its availability so that users can dose themselves readily, and you can standardize the concentration of the substance so that users can dose themselves reliably. You can advertize and display it prominently on shelves so that it is salient in the environment. You can make it available to young people so that dependence can be established in the susceptible developing brain.
Tobacco’s like that. The tobacco that native Americans put in their peace pipes was probably somewhat addictive, but the tobacco in cigarettes is exponentially more so. Why? It’s combined with flavorants that make it more palatable. It’s flue-cured and modified in other ways to make it easier to inhale, so that nicotine, the main psychoactive ingredient in tobacco, reaches the brain in just a few seconds. The nicotine content is manipulated to produce a consistent, fairly strong product. The invention of the Bonsack cigarette-rolling machine in the 19thcentury allowed the tobacco industry to start making its product much more widely available and affordable.
Cocaine is like that, too. Cocaine as absorbed from chewing or drinking tea brewed from coca leaves acts as a mild stimulant but is only questionably addictive. Purify that cocaine and cook it up as crack, and you have a substance that produces highly euphoric and psychoactive effects, a product that poses serious threats to the individual user and to society.
And a lot of the food we eat is like that.
Yes, food manufacturers have taken a page from the tobacco industry’s playbook and devoted considerable research to developing combinations of salt, sugar, and fat that maximize palatability. “Once a preference is acquired, most people do not change it, but simply obey it,” wrote a top Frito-Lay scientist in a 1979 internal memorandum. For a more extended account of these practices, read David Kessler’s excellent description in his book entitled The End of Overeating, which I reviewed in an earlier post. These products have never been seen in nature, nor do you have to forage for them; accessibility is as easy as tearing open a bag or replying “yes” to the question, “Supersize those fries?”
Recent calls to reduce the salt content of processed foods have produced an outcry from the manufacturers of salt and of products made with salt. They claim it’s needed as a preservative and for a variety of other culinary reasons. They acknowledge that low-salt foods require more expensive (read better quality!) ingredients to taste good. They fear that consumers will abandon them if they tamper with tried and true formulas.
All these things are true. But in emphasizing the forces to which they must passively submit, the food manufacturers soft-pedal their own active efforts to create products that many people will be unable to resist. And here, the food manufactures have taken another page from Big Tobacco’s playbook. It’s called blame the victim. Point to their customers’ strong appetites for their products. Stress the need for personal responsibility and restraint to curb consumption.
Although some people are clearly more susceptible to addiction than others, remember that for most of human history we lived in an environment where food was scarce and required work to obtain, an environment in which most of the products on supermarket shelves didn’t even exist. (If you doubt this, read the list of ingredients on virtually any package you pick up. What would your grandmother make of a recipe that called for lactose, soy lecithin, partially hydrogenated soybean oil, and artificial flavor – all listed among the ingredients in Snickers, the most popular candy bar of all time?) Remember, food tastes good for a reason. We are meant to eat, and to eat heartily. But what happens when we are confronted with food engineered to interact with our brain chemistry in such a way as to be irresistible to a large portion of the population?
Now let’s talk about the “obesity epidemic.” Why are we suddenly living in a culture where, like the children in Lake Wobegon, “all the people are above average?” No one answer can fully explain this phenomenon. Although it’s sometimes said that our genes haven’t changed, in fact they have, at least collectively, in the ethnic composition of our population. The decline in smoking, with quitters tending to gain weight, has probably made a modest contribution. People are living longer, leading to an older population, and weight gain with age is typical if not normal.
All these factors undoubtedly play a role. But I can’t help wondering if changes in the food we buy in grocery stores or eat in restaurants aren’t the most important factor. I don’t know the answer to this question, but perhaps it’s time to start a national conversation about the addictiveness of food similar to the one that finally led to the recognition that tobacco use was not simply a “pleasant adult custom” that could be taken up and put down at will.
One difference between food and tobacco: We don’t need the latter to live but we do need the former. So quitting eating is not an option. We can, however, avoid highly processed products designed to create intense craving without ever fully satisfying it.
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.