INTERVIEW WITH DIRK HANSON
Dirk Hanson, MA, is a freelance science writer whose books include The Chemical Carousel: What Science Tells Us About Beating Addiction and The New Alchemists: Silicon Valley and the Microelectronics Revolution. He has worked as a business and science reporter for numerous magazines and trade publications including Wired, Scientific American, The Dana Foundation and more. He currently edits the Addiction Inbox blog.
Dirk Hanson: You mention that a certain “dopamine receptor gene” may make some people gain more weight after quitting than others. Would this be the D2 allele, or something different?
Cynthia S. Pomerleau: Yes, that is my understanding. In a laboratory study of food reward in smokers attempting to quit, Caryn Lerman and colleagues found that carriers of the DRD2 A1 minor allele exhibited significant increases in the rewarding value of food following abstinence from smoking, and that higher levels of food reward after quitting predicted a significant increase in weight by 6-month follow-up in participants receiving placebo. Both effects were attenuated in participants receiving bupropion, leading them to conclude that bupropion’s s efficacy in attenuating abstinence-induced weight gain may be attributable, in part, to decreasing food reward. How well these findings will hold up to further scrutiny in larger samples remains to be seen.
DH: The concept of “weight‑control smoking” and the image of the “smoking ballerina” are striking ideas. How widespread, in your opinion, is the practice of using tobacco as a weight loss medicine?
CSP: Although some girls may take up smoking in hopes of losing weight, it is probably more accurate to call it a weight management (as opposed to weight loss) tool. We have looked repeatedly at groups of nonsmoking college women and their (generally light-) smoking counterparts and found no differences in body weight. (That’s why, for women who don’t want to experience postcessation weight gain, this is an excellent time to quit!) Weight differences tend to emerge in heavier, more experienced smokers such that smokers on average weigh about 10 pounds less than neversmokers – partly because of metabolic changes, but mostly because of the appetite-suppressing effects of nicotine.
Since we’re dealing with an addictive drug, it’s difficult to attribute resistance to quitting, even in women who are seriously concerned about postcessation weight gain, solely to the weight-suppressing effects of smoking. But using a variety of different measures, it’s probably safe to say that around 40% of women qualify as serious weight-control smokers. (The proportion is much lower in men.) By the way, though findings are mixed, these women don’t necessarily fare worse than other women when they quit, even if they do gain weight; the real challenge is bringing them to the point of even considering quitting.
DH: You note that people with eating disorders are more likely to smoke than regular eaters. I find this fascinating, and quite in line with other avenues of addiction research, such as the link between smoking and depression. Do we know why this is so, at the biochemical level? Are we primarily talking about bulimia?
CSP: Yes, we are primarily talking about bulimia and binge-eating. Perhaps surprisingly, smoking does not appear to be over-represented in anorectics. As I’m sure you’re aware, the question of “self-medication” is a complicated one, but it seems likely that some women “use” nicotine to hold the symptoms of bulimia in check; when they quit, the underlying predisposition re-emerges – which helps to explain why these women may be more prone to large weight gain than other quitting smokers.
DH: Ninety per cent of quitters gain weight, ten pounds on average. But everyone gains weight as they age. Do you think these metabolic facts are sufficiently explained to patients by their primary care physicians, or is there still a knowledge gap in this area?
CSP: My husband doesn’t weigh an ounce more than he did the day we married 45 years ago, so it’s a bit of an exaggeration to say that everyone gains weight. But you’re right, most of us don’t modulate our food intake enough to compensate for metabolic changes and, all too often, reductions in exercise as we age, typically resulting in a pattern of weight gain over the years. Your point that not all postcessation weight gain can be attributed quitting and that comparisons need to adjust for “normal” weight gain is well taken. Weight gain following smoking cessation, however, begins immediately after quitting (in some instances as much as two or three pounds in the first week, due to increases in fluid volume and appetite as well as metabolic changes) and is largely complete after six months of abstinence; for most individuals this is easy enough to distinguish from the background weight gain we’ve been discussing.
Though it’s fine for primary care physicians to address this “knowledge gap,” I’m far more concerned about possible attempts to downplay the amount of weight quitters can expect to gain or to overstate the ease with which it can be avoided – which can backfire and lead to relapse when the needle on the scale begins to creep up. I personally think it’s better to be realistic about the likelihood of weight gain after quitting and to concentrate on keeping it in the 5-10 pound range (approximately one unit of BMI and less than a dress size) – something that is in fact an achievable goal for most women.
DH: Is your official title still Director of the Nicotine Research Laboratory at the University of Michigan Department of Psychiatry?
CSP: My husband and I retired a year ago but maintain active emeritus status, which means we continue to participate selectively in various research projects. My official title is Research Professor Emerita in the University of Michigan Department of Psychiatry.
Dirk Hanson: You mention that a certain “dopamine receptor gene” may make some people gain more weight after quitting than others. Would this be the D2 allele, or something different?
Cynthia S. Pomerleau: Yes, that is my understanding. In a laboratory study of food reward in smokers attempting to quit, Caryn Lerman and colleagues found that carriers of the DRD2 A1 minor allele exhibited significant increases in the rewarding value of food following abstinence from smoking, and that higher levels of food reward after quitting predicted a significant increase in weight by 6-month follow-up in participants receiving placebo. Both effects were attenuated in participants receiving bupropion, leading them to conclude that bupropion’s s efficacy in attenuating abstinence-induced weight gain may be attributable, in part, to decreasing food reward. How well these findings will hold up to further scrutiny in larger samples remains to be seen.
DH: The concept of “weight‑control smoking” and the image of the “smoking ballerina” are striking ideas. How widespread, in your opinion, is the practice of using tobacco as a weight loss medicine?
CSP: Although some girls may take up smoking in hopes of losing weight, it is probably more accurate to call it a weight management (as opposed to weight loss) tool. We have looked repeatedly at groups of nonsmoking college women and their (generally light-) smoking counterparts and found no differences in body weight. (That’s why, for women who don’t want to experience postcessation weight gain, this is an excellent time to quit!) Weight differences tend to emerge in heavier, more experienced smokers such that smokers on average weigh about 10 pounds less than neversmokers – partly because of metabolic changes, but mostly because of the appetite-suppressing effects of nicotine.
Since we’re dealing with an addictive drug, it’s difficult to attribute resistance to quitting, even in women who are seriously concerned about postcessation weight gain, solely to the weight-suppressing effects of smoking. But using a variety of different measures, it’s probably safe to say that around 40% of women qualify as serious weight-control smokers. (The proportion is much lower in men.) By the way, though findings are mixed, these women don’t necessarily fare worse than other women when they quit, even if they do gain weight; the real challenge is bringing them to the point of even considering quitting.
DH: You note that people with eating disorders are more likely to smoke than regular eaters. I find this fascinating, and quite in line with other avenues of addiction research, such as the link between smoking and depression. Do we know why this is so, at the biochemical level? Are we primarily talking about bulimia?
CSP: Yes, we are primarily talking about bulimia and binge-eating. Perhaps surprisingly, smoking does not appear to be over-represented in anorectics. As I’m sure you’re aware, the question of “self-medication” is a complicated one, but it seems likely that some women “use” nicotine to hold the symptoms of bulimia in check; when they quit, the underlying predisposition re-emerges – which helps to explain why these women may be more prone to large weight gain than other quitting smokers.
DH: Ninety per cent of quitters gain weight, ten pounds on average. But everyone gains weight as they age. Do you think these metabolic facts are sufficiently explained to patients by their primary care physicians, or is there still a knowledge gap in this area?
CSP: My husband doesn’t weigh an ounce more than he did the day we married 45 years ago, so it’s a bit of an exaggeration to say that everyone gains weight. But you’re right, most of us don’t modulate our food intake enough to compensate for metabolic changes and, all too often, reductions in exercise as we age, typically resulting in a pattern of weight gain over the years. Your point that not all postcessation weight gain can be attributed quitting and that comparisons need to adjust for “normal” weight gain is well taken. Weight gain following smoking cessation, however, begins immediately after quitting (in some instances as much as two or three pounds in the first week, due to increases in fluid volume and appetite as well as metabolic changes) and is largely complete after six months of abstinence; for most individuals this is easy enough to distinguish from the background weight gain we’ve been discussing.
Though it’s fine for primary care physicians to address this “knowledge gap,” I’m far more concerned about possible attempts to downplay the amount of weight quitters can expect to gain or to overstate the ease with which it can be avoided – which can backfire and lead to relapse when the needle on the scale begins to creep up. I personally think it’s better to be realistic about the likelihood of weight gain after quitting and to concentrate on keeping it in the 5-10 pound range (approximately one unit of BMI and less than a dress size) – something that is in fact an achievable goal for most women.
DH: Is your official title still Director of the Nicotine Research Laboratory at the University of Michigan Department of Psychiatry?
CSP: My husband and I retired a year ago but maintain active emeritus status, which means we continue to participate selectively in various research projects. My official title is Research Professor Emerita in the University of Michigan Department of Psychiatry.