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VOLUME 8 NUMBER 3 • SEPTEMBER 2011
PREVENTION IN PRACTICE
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Table 1. Effective behavioural techniques for weight
management during smoking cessation
Keeping a diary to monitor lifestyle behaviour changes
•
Monitoring progress and giving self-rewards for achieving short- and long-
•
term goals to reinforce changes
Effectively dealing with triggers to eat and with high-risk situations
•
Coping with relapse
•
Seeking support and encouragement
•
Learning to cope with stress and problem-solving in ways other than
•
eating or smoking
Changing eating behaviour – sitting down to eat at a table, slowing rate of
•
eating
Adopting a non-smoking activity to signal the end of a meal, such as
•
taking a walk, brushing teeth, washing dishes or sucking a mint
the end of a meal. Rather than taking a second helping or having dessert,
smokers may be more likely to stop eating and have a cigarette.
After quitting, the urge to smoke can be frequent and uncomfortable,
so food is often used as a replacement. Recent research suggests that
the pleasurable and rewarding value of food may increase in certain sus-
ceptible individuals following smoking cessation.
Food intake studies show that average energy intake increases by
250–300 kcal per day after smoking cessation. However, there is disa-
greement in the literature as to whether additional food intake is suf-
ficient to account for the observed weight gain and it is widely believed
that other factors are important.
Nicotine appears to increase the resting metabolic rate and so in-
creases energy expenditure. Metabolic studies have shown that smoking
24 cigarettes a day increases energy expenditure by around 200 kcals.
Similar studies have shown reductions in resting metabolic rate of around
16% in females after 30 days of smoking cessation. However, it is im-
portant to note that not all studies have found such marked effects on
metabolism and the importance is under debate.
Other proposals for explaining weight gain following smoking cessa-
tion include changes in fat oxidation and adipose tissue enzyme activity
and reductions in the production of chemicals associated with appetite
control in individuals with underlying genetic susceptibility. For a compre-
hensive review of the subject area see the further information section at
the end of this article.
WHAT CAN EX-SMOKERS DO TO LIMIT WEIGHT GAIN?
Use of nicotine replacement therapy (NRT) and other
pharmacotherapies
NRT is a way of partially and temporarily replacing some of the nicotine
provided by cigarettes, so it can ease the withdrawal symptoms and help
during the transition to complete abstinence. Nicotine gums, transdermal
patches, inhalers, sublingual microtablets or lozenges, and nasal sprays
can be bought over the counter and are also available on prescription.
A recently updated
Cochrane Review
including more than 130 trials
concluded that all forms of NRT were able to increase the rate of quitting
smoking by around 50–70% compared to placebo. The likelihood of stay-
ing stopped for more than six months is also increased when a smoker
uses NRT according to the directions.
It is useful to dispel some of the myths and misunderstandings about
the use of NRT. This might include educating patients about who can use
these therapies, the correct way to use them, the recommended dura-
tion for use, their relative safety and side effects, and fear of addiction,
which sometimes prevent effective use (
MythsaboutNRTFactSheet.pdf). Individuals also benefit from personal ad-
vice on which type or combinations of NRT are best suited to their level
and style of smoking.
Effective non-nicotine pharmacological treatments for smoking cessa-
tion include bupropion SR, which modulates levels of neurotransmitters
in the brain, and varenicline, which is a nicotine receptor partial agonist.
Not only do these agents increase the chances of effective smoking ces-
sation, they seem to have at least short-term effects in limiting associated
weight gain. They seem to be particularly effective in people who have
been shown to increase food intake after stopping smoking.
The effects have been shown to be modest over the long term once
treatment has stopped. Nevertheless, they may be worthwhile if weight
gain is at least delayed until the ex-smoker feels better able to consider
additional lifestyle changes to address weight gain.
Behavioural solutions
Individually tailored behavioural interventions, including some of the tech-
niques of cognitive behavioural therapy (CBT), are effective in improving
smoking abstinence and reducing associated weight gain (see Table 1).
Benefits of these approaches have been shown both at end of treatment
programmes and in longer-term follow up. Behavioural techniques are
also effective in weight management. Many self-help resources are avail-
able for health professionals and patients (see
wise.com/going.html).
DIETARY INTERVENTIONS
Unsurprisingly, generalised and non-tailored dietary advice on its own
is not very effective for achieving weight control in ex-smokers or in the
general population. In contrast, individualised dietary advice tailored to
food preferences, particularly when used in conjunction with other inter-
ventions, may be effective.
Surveys of the dietary habits of people who are successful in losing
weight – whether ex-smokers or non-smokers – show that effective
strategies include eating regular meals, taking smaller portions, avoiding
extreme diets, eating a diet low in fat and high in fruit, vegetables and
whole grains, and restricting alcohol (see Table 2). These recommenda-
