Yep, that’s me, age 18 or so, working hard to become a smoker. (And in case you were wondering: No, that’s not my husband; this photo was taken long before I met him.) I was luckier than the smokers we studied in the Nicotine Research Laboratory in that I never succeeded in learning to inhale. So I never took in enough nicotine to become addicted, and eventually I decided that uncontrollable coughing fits were not exactly the image I was trying to project. As I say, I was very lucky – and believe me, it was sheer luck. I was definitely giving it my best shot! Most smokers start when they’re in their teens. To an adolescent, the hazards seem distant and remote; smoking seems cool or sexy and the tobacco industry is happy to reinforce those notions. And sadly, many girls are seduced by the belief that smoking will help them control their weight. Although smoking does suppress appetite, and although confirmed smokers tend to gain weight when they quit, smoking is really not a very good dieting tool. We have conducted several studies of college women and found no difference in weight between smokers and nonsmokers in this age group. Rather, the weight-suppressing effects of smoking primarily emerge over time, by reducing normal adult weight gain so that eventually adult smokers weigh about ten pounds less, on average, than their nonsmoking counterparts. Conclusion: If you are a young woman and a light or occasional smoker, and you wish to gain as little weight as possible when you quit, now would be an excellent time to stop smoking. It is far easier to quit now than it will be later, when you’re a confirmed smoker, and when you’re more likely to gain weight after quitting. 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. 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. Until his untimely death from kidney failure in 2002, Tomás Chavez was a fixture on the Ann Arbor fitness scene. At various times over the years, I took classes in floor aerobics, step aerobics, and ballroom dancing with Tomás at the local gym. My husband gamely joined me in the ballroom dance classes, despite being, in his own words, “dance-impaired” (hard to explain when he’s an expert skier, but that’s another story!). We weren’t very good at ballroom dancing; we repeated the beginner class, then started intermediate and after the first night dropped back to the beginner class again. But my husband didn’t really mind because Tomás made it so much fun. We joked that we could dance at anyone’s wedding so long as we could bring along Tomás to call out the next move; we agreed that it took three to tango – and the third one had to be Tomás.
Tomás was a true small-d democrat when it came to fitness: Fitness is for everyone. One of his favorite sayings was, “If you can walk, you can dance.” Though my husband might demur, I think Tomás would readily have classified his efforts as “dancing.” It was great if you increased in proficiency over time but it didn’t really matter if you didn’t, so long as you just kept moving. Tomás made aerobics fun by cracking a steady stream of little jokes (often ever-so-slightly risqué), by making up new moves and naming them after the students (he knew everyone’s name), by gradually increasing the complexity of the routine, and by praising even small improvements. He knew that the secret of fitness was to find ways to make it fun. He understood that if it’s fun, you’ll keep doing it. If you can walk, you can dance. If you can do either, you can burn calories. If you can burn calories, you can manage your weight when you stop smoking. The trick is to find something you enjoy doing. Do you prefer to exercise alone, with a friend, or in a class? Indoors or out? In front of the TV or in silence? Experiment till you find a form of physical activity you like well enough to keep doing it. And if you are such a diehard exerphobe that you truly can’t identify any activity you enjoy, then find yourself a Tomás who will make the time fly by so fast your workout will be over before you even realize you’ve been exercising! No one on Facebook could have missed it – a rash of status reports saying “black,” “beige,” “nude,” “white (ho-hum),” and even “green with pink rosebuds.” “Not telling,” said one friend.
What was that about? Well, somebody somewhere had fired off a message to a group of women friends asking them to post the color of their bra in their status box, all in the name of breast cancer awareness and support for medical research, and the whole thing went viral. How this might have raised breast cancer awareness or promoted medical research – who knows? The point is, probably tens or hundreds of thousands of women showed they were ready and willing to stand up and be counted. And many show it on an ongoing basis, in far more tangible ways, by paying a surcharge on pink-ribbon postage stamps and other items to help fund breast cancer research. Not for one second do I begrudge the advocates of breast cancer research their success in gaining support for their cause. Like most, I have seen in my own circle of friends the suffering and devastation that breast cancer can cause in the lives of women. But did you know that lung cancer, not breast cancer, is the leading cause of cancer death in women? Nearly twice as many women die from lung cancer as from breast cancer. We can stop this epidemic – one woman at a time. Lung cancer deaths among women have increased by 600 percent since 1950, closely tracking the increase in smoking among women a few decades earlier. What goes up can come down. But despite improvements in survival rates, don’t look for advances in biomedical research to solve the problem. The real answer lies in prevention – by discouraging girls from starting to smoke and by encouraging women who already smoke to quit and stay quit. For many women, cigarettes are a way of controlling weight and staving off depression. My goal, in writing Life After Cigarettes, was to help you identify better ways to look and feel great, not to try to scare you into quitting. But occasionally it’s salutary to pause and reflect on the health risks the tobacco industry has inflicted on us. The next time you see the ubiquitous pink ribbon promoting breast cancer awareness, imagine it paired with a brown tobacco-awareness ribbon and remember the twin scourges these symbols represent. The holidays are history, the days are short, the nights are long, and in many parts of the country the weather is cold and forbidding. If just the thought of all this makes you want to hibernate until Spring, you may be suffering from Seasonal Affective Disorder (SAD) or the winter blues.
“Hibernate” is the right word. Although the causes of SAD are not fully understood, the condition appears to be associated with disruptions in the daily rhythms of melatonin, a compound secreted by the pineal gland and involved in sleep-induction. In ground squirrels and other hibernating animals, patterns of melatonin release change dramatically during the low-light months, contributing to a state of suspended animation during which the animal conserves energy by reducing body temperature and slowly metabolizing stored body fat. Humans don’t hibernate, but some of us produce enough melatonin, or produce it at the wrong times, to make us sleepy and lethargic during the winter months. Other symptoms of full-blown SAD include depression, anxiety, hopelessness, loss of interest in things that usually give you pleasure, social withdrawal, carbohydrate craving, weight gain, and difficulty concentrating. If you’re a smoker or even an ex-smoker, all this may make you feel like lighting up. As I point out in Chapter 6 of Life After Cigarettes, a better strategy is to add light to your life. If a tropical vacation isn’t in the cards, buy a bright full-spectrum lamp (“light box”) and spend 30-60 minutes under it while you read the morning paper or answer your e-mail. This blocks melatonin secretion and is the standard first-line treatment for SAD. And whenever you’re tempted to smoke to relieve the symptoms of SAD, give yourself an extra dose of bright light therapy. Although I don’t know of any scientific studies to support this recommendation – the smoking-SAD connection has received surprisingly little attention by researchers – it makes a lot of sense to me and is definitely worth a try. SAD is four times as common among women as among men, and many more have mild, subclincal cases of the disorder. No surprises here, since women are more prone to most forms of depression than men. If your winter blues are seriously interfering with your ability to function in your daily work or family life and don’t respond to phototherapy, seek professional help. Treatment options may include cognitive-behavioral therapy, carefully timed administration of melationin to re-regulate circadian rhythms, and antidepressants. “Treating” SAD by smoking a cigarette is definitely a case of the cure being worse than the disease. For more information about light boxes, and about SAD in general, visit http://www.depressioncenter.org/understanding/sad.asp. As always, I invite you to share your experience with SAD and approaches you have used to relieve its symptoms with the readers of this blog. For many, the beginning of a new year (and in this case a new decade!) is an occasion for starting afresh, for launching new projects, for embracing new approaches to healthful living.
If you’re a woman who smokes or has recently quit, and especially if you’re one who cares passionately about looking and feeling your best, I hope it’s your time to become – not just an ex-smoker, someone who has subtracted tobacco from her life, but truly a nonsmoker, someone who has figured out how to use the process of quitting as a springboard to achieving higher levels of comfort, confidence, and awareness. In my new book, Life After Cigarettes: Why Women Smoke and How to Quit, Look Great and Manage your Weight, I call this “the chic of quitting.” Drawing on my twenty-plus years as Director of the Nicotine Research Laboratory at the University of Michigan, I have done my best to translate my own findings and those of others into words that will both teach and inspire you to achieve this goal. My own New Year’s project is this blog. I will use it to communicate the latest research findings and to offer new suggestions for managing your weight, feeling good, and looking great. I hope you will share your journey with me and with others traveling the same path. I look forward to reading about your successes and setbacks, and about your discoveries along the way. |
AuthorCynthia 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. Archives
January 2011
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