TABLE 6.--Continued

Hip and/or forearm fractures

Reference

Population

Compartx,n

Estimated rebtive risk          Comments

Paganint-Hill   (`ae4: YI pohtmenopau\al women
elal.(lYXIl    aged 20 with hip fractures
       Controls: I X2 age. race-matched
         postmenopausal women

Krelgcret al.   Car\: OX po.\tmenopausal women aged
t IYX1): Krelger  45-74 yr ho\pitalired with hip fracture
and Htldnch   Trauma Controls: X3 postmenopausd
( IYXh)      women hospitali/.ed for trauma
       Nontrauma Controls: XX4 po\tmenopaussl
        women hospitalixd for medical illness

Williiml\et id.   Cnseh: 344 (3%) white women aged
(19x2):      S(b-74 with hip or forearm fracture
Aldc`rman ct al. Controls Sh7 (562) white women from a
( IYXh)      hou.xhold atrvey

I-lOcig/day vs. none
21 I cig/day Y\. none

I .os
I .Yh

Adjusted for age, age at
menopause. Quelelet'\ Index,
physical activity, alcohol
conxumprion. and exogenous
estrogen use

Ever vs. never smoker\
Trauma controls
Nontram~acornrol\

Among c\tropen nonusers
Hip fractures
Average weight ever smoker vs
  obese never smoker
Thm ever maker v\. obese
  never \moher
Forearm fracture
Thin ever maker v\. obese
  never moher
51 ppd v\. never
> I ppd v\. never

I.27
I.?`)

6.Sh

13.Sh

S.4h


I .o
I.2

Adjusted for ape. Quetelet's
Index, months breast feeding.
ovariectomy, and estrogen use

Smokers and nonsmokers were
not directly compared; the
comparison group for all
analyses was obese nonsmokers
who had used estrogen for
2 I yr; controlled for hex and
race only


TABLE 6.--Continued

Hip and/or fwxrm frnctutw

Kcfcrence        Population

(`ompariwn

E\tlmated relative rl\i\

Smohcr\ v\. nonmoher\

I.3


large samples from the Framingham Heart Study, the Nurses Health Study, and the first
National Health and Nutrition Examination Survey. In the largest study by Hemenway
and colleagues (1988) 96,508 nurses reported 975 hip or forearm fractures during an
average 4 years of observation. The relative risk of fracture was 1 .O in each smoking
category (former smokers, smokers of I-14 cigarettes/day, 15-25 cigarettes/day. and
>25 cigarettes/day) compared with never smokers.

Smoking Cessation and Osteoporosis and Fracture

No studies have evaluated the effect of smoking cessation on osteoporosis and
fracture, nor are there studies of the risk of osteoporosis or fracture in former smokers
compared with continuing smokers.

Summary

There is insufficient evidence to conclude that smoking decreases bone mineral
content and the risk of osteoporotic fractures. Some studies have found lower bone
mineral content in smokers compared with nonsmokers, but others have not. Some.
but not all, case-control studies have found a higher risk of osteoporotic fracture among
smokers. Most negative studies were limited by small sample size, and most positive
studies were not designed to control for potentially strong confounding variables.
Analysis of data in five cohort studies has found no association of smoking with
increased risk of fracture.

Skin Wrinkling

Introduction

Although wrinkling of the facial skin is nearly universal among elderly persons, it is
rarely mentioned in textbooks of dermatology or medicine, and little research has been
published concerning its etiology or risk factors. Skin wrinkling is associated with sun
exposure (Kligman 1969; Allen, Johnson, Diamond 1973; Daniel1 197 1; Knox.
Cockerell, Freeman 1962; Rook, Wilkinson, Ebling 1979). Wrinkling occurs with
increasing age (Daniel1 1971; Knox, Cockerell, Freeman 1962: Rook, Wilkinson.
Ebling 1979), but even among the elderly, wrinkling usually is confined to sun-exposed
areas (Kligman 1969; Allen, Johnson, Diamond 1973; Knox, Cockerell. Freeman
1962). There is limited evidence that dramatic weight loss is associated with skin
wrinkling (Daniel1 1971).

Pathophysiologic Framework

It is not clear how cigarette smoking may promote skin wrinkling. Some investigators
have concluded that a localized finding such as wrinkling of the face and hands could
not be caused by a systemic factor such as the absorbed components of cigarette smoke.


TABLE 7.--Summary of cohort studies of smoking and fractures

Keference


JeflV31
(14X6)

  Populatlon/out~on~~

Population-bawd study of 70-year-old
women in Copenhrigen. Denmarh: 77
smohed daily for 220 yr: 103 never \mohed
0utc0111r: all fractures

Hemenway
et al. (IYXX)

0630X nurwb aged 35-50 31 hahellnc
( IYXO) followed fur 4 yr.
Outcome: self-report of Y7S fracture\ of hip
or fwxrm

Felson et al
(IYXX)

Holbrook.
Barrett-Connor.
Wingard
(IYXX)

Farmer et al.
(19X0)

52OY men and women m the Framingham
Heart Study followed retrr)qxxtively for
about 30 yr.
Outcome. ? I7 documented hip fracture5

Y7S men and women aped S(b7Y at haaeline
followed for I4 yr,
Outcome: 33 documented hip fractures

3,595 white women in NHANES-I aped
4&77 at baseline ( lY71-75) followed fur
an uvernge of IO yr,
Outcome: X4 documcntrd hip fractuw

Comparison

`% smoker\ with fracture vs.
% nonsmokrr~ with fracture:
All po\tmenopauwl fractures
O~troporot~c frscturesh

Age-adjusted fracture rate compared to:
never smoher\
Ex-smokrrx
Smokers
I I4 tip/day
IS-24 c@day
23 cig/d/dny

Bawd on ciglday

Smohrrs vs. nonsmoker\                 I.1

Bawd on number of yr smoked at
huwlinr exam

Relative risk

Comments

All wbject\ were 70.yr-old
women: no control for other
confounders

I .o

  I .o
  I .o
  I .o

No incrrase

No mcreasr

A very large cohort study
producing narrow Cl3 (upper hmn
I .2.5). hut most women were
mlddlr-aged or younger;
controlled for age only

Cox re@re%ion model. adJusted for
age. wx. body ma\\ Index, dietary
calcium. and alwhol conwmptwn

No data given. hut reported no
significant 35wiation: ilnaly~a
adJusted for age. body muss Index.
menopausal Qtuh. citlcium
conwmption. and activity


However. facial skin, and to a lesser extent, the skin of the hands contain an intradermal
elastic tissue mesh that is denser and more complex than in other areas (Shelley and
Wood 1974). Thus. the toxic effect of both sunlight and smoking may be most
damaging in these more susceptible areas. Alternatively. damage from sunlight and
smoking may simply be additive. and the threshold for clinically apparent changes from
smoking may not be reached in sun-protected areas of the skin. Histopathologic
examination of sun-exposed skin commonly shows abnormalities of collagen in the
dermis that decrease the elastic properties of the skin. a condition known as elastosis
(Marks 1976: Shelley and Wood 1974). However. the mechanism by which sunlight
might cause these changes is uncertain, and there is no evidence that smoking is
associated with elastosis. Cigarette smoking has been shown to decrease capillary and
arteriolar blood flow in the skin acutely (Klemp. Staberg. Thomsen 1982: Reus et al.
1984: Richardson 1987). and hence. may cause tissue hypoxia. However. there is no
evidence that this causes changes in skin transparency and turgor or produces wrinkles.

Smoking and Skin Wrinkling

Several studies have reported that smoking is associated with prominent skin wrin-
kling, particularly in the periorbital or "crow's foot" area of the face.

lppen and Ippen (1965) defined "cigarette skin" as appearing pale. grayish. and
wrinkled. especially on the cheeks. with thick skin between the wrinkles. In an
examination of women aged 35 to 84.66 of the 84 .;mokers had cigarette skin compared
with 27 of the 140 nonsmokers (relative risk=4. I. p<O.Ol ). This study did not adjust
for differences in age or sun exposure between the smokers and nonsmokers (lppen and
lppen 1965 ).

Daniel1 ( 197 1) examined facial wrinkles and smoking status among I. 104 subjects.
most of whom were patients or visitors to his medical practice in Redding, CA. Skin
wrinkling was assessed in the crow's foot area and the adjacent areas of the forehead
and cheeks and graded as one of six categories of severity. Potential confounders such
as age, race (98 percent of the subjects were white). sex. sun exposure. and body weight
were also measured. Smokers were more often prominently wrinkled (wrinkle score
4-6) than nonsmokers. Prominent skin wrinkling was also more common in relation
to increasing age and sun exposure. The association between smoking and prominent
wrinkling was found in each age. sex. and sun exposure subgroup and was statistically
significant in most of the subgroups. The most heavily wrinkled class in each age-sex
group was composed entirely of smokers.  Wrinkling increased with duration of
smoking and number of cigarettes smoked daily. Prominent skin wrinkling was more
common among smokers aged 30 to 49 than among nonsmokers aged 60 to 69 years.
This study provided strong evidence that smoking is associated with skin wrinkling
(Daniel1 1971). However. the measurements of wrinkling are not very precise. and
although an attempt was made to blind the wrinkle assessment. the subjects were
patients and friends of the investigator. who may have known their smoking status.

Allen, Johnson. and Diamond (1973). reported on a ctudy that they claimed refuted
the above findings,, but the data presented actually supported an association between
smoking and skin wrinkling in whites (Boston 1973: Daniel1 1973: Weiss 1973). U'cing


Daniell's 6 categories of wrinkling sevserity. Allen. Johnson, and Diamond (1973)
examined 650 persons and obtained information on age, race, sex. smoking status, and
sun exposure. Biopsies of the crow's foot area also were performed on some subjects,
As evidence that there is no association between smoking and skin wrinkling, the
researchers reported that among 137 black subjects, only 2 had prominent wrinkling,
regardless of sun exposure or smoking status. Although only fragmentary data are
presented, wrinkle scores among white smokers who were exposed to the sun less than
2 hours daily were significantly higher than wrinkle scores for white nonsmokers with
limited sun exposure.

In a survey of 122 new patients attending a general medical practice in England. all
but I of whom was white, wrinkling and other skin changes were found to be much
more common among smokers than nonsmokers (Model 1985). "Smoker's face" was
defined as exhibiting one or more of the following: lines or wrinkles on the face.
typically radiating from the corners of the lips or eyes; gaunt facial features: grayish
skin; and a plethoric complexion. Smoker's face was found among 46 percent of
smokers, and none of the nonsmokers were classified as having smoker's face. The
association of smoking and smoker's face was statistically significant (p<O.OOl) and
remained so after controlling for age. social class. sun exposure, and recent weight
change. Although this study shows a striking difference between smokers and non-
smokers. it is not clear that prominent skin wrinkling is the major or most common
criterion for the diagnosis of smoker's face. Thus. the association reported may not be
specific for wrinkling.

Smoking Cessation and Skin Wrinkling

No studies have assessed the effect of smoking cessation on skin wrinkling.  Daniel1
( I97 I ) noted that prominent wrinkling was common in former smokers, but supporting
data were not presented. Model ( 1985) reported that 8 percent of former smokers had
smoker's face compared with 46 percent of smokers.

Summary

There is limited but consistent evidence that smoking is associated with prominent
facial skin wrinkling among whites (Allen. Johnson, Diamond 1973: Daniel1 1971:
Ippen and Ippen 1965: Model 1985) but not among blacks (Allen. Johnson, Diamond
1973). It is not clear whether former smokers are less wrinkled than smokers (Daniel1
1971: Model 1985).

CONCLUSIONS

I. Smokers have an increased risk of development of both duodenal and gastric ulcer,
and this increased risk is reduced by smoking cessation.

2. Ulcer disease is more severe among smokers than among nonsmokers. Smokers are
less likely to experience healing of duodenal ulcers and are more likely to have

456


recurrences of both duodenal and gastric ulcers within specified timeframes. Most
ulcer medications fail to alter these tendencies.

3. Smokers with gastric or duodenal ulcers who stop smoking improve their clinical
course relative to smokers who continue to smoke.

4. The evidence that smoking increases the risk of osteoporotic fractures or decreases
bone mass is inconclusive, with many conflicting findings. Data on smoking
cessation are extremely limited at present.

5. There is evidence that smoking is associated with prominent facial skin wrinkling
in whites, particularly in the periorbital ("crow's foot") and perioral areas of the
face. The effect of cessation on skin wrinkling is unstudied.


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467


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468


          CHAPTER 10
SMOKING CESSATION AND BODY WEIGHT
           CHANGE


CONTENTS

Introduction  ..................................................... ..47 3
Amount of Weight Gain After Smoking Cessation and-Likelihood of Gaining
Weight ....................................................... ..47 3

Causes of Postcessation Weight Gain  ................................... 483
Food Intake ...................................................   4x4
Physical Activity  ..............................................   486
Energy Expenditure  ............................................... 487

Relationship Between Overweight and Adverse Medical and Psychosocial
Outcomes  ....................................................
Change in Weight-Related Health Risks After Smoking Cessation  .........

Strategies to Control Postcessation Weight Gain  .......................
Behavioral Methods for Reducing Postcessation Weight Gain  ..........
Pharmacologic Methods for Reducing Postcessation Weight Gain  .......

Conclusions  ....................................................
                           ...
References ..................... ................................

490

497

-500

500
502

SOS

so7


INTRODUCTION

Cigarette smoking is associated with decreased body weight. and many smokers
report that a major reason they smoke is to reduce body weight (Grunberg 1986: Klespes
et al. 1989; US DHHS 19gXa). However. as documented in this Chapter. the weight
gain associated with smoking cessation is generally small and poses a minimal health
risk.

This Chapter is organized into six sections. Drawing from prospective investigations
meeting specific criteria. the first section of this Chapter determines average weight
gain following smoking cessation compared with continued smoking. assesses the
percentage of continuing smokers and quitters gaining weight. and calculates the risk
of gaining weight after smoking cessation versus continued smoking. The next section
of this Chapter discusses the mechanisms responsible for weight gain after mohing
cessation. The available literature is reviewed on dietary,. activity. and metabolic
changes after smoking cessation The third section reviews the relationship between
body weight and adverse medical and psychosocial outcomes. The fourth section
examines whether weight-related health effects accompany weight gain in ex-smokers.
The fifth section presents potential treatments for reducing postcessation weight gain.
including pharmacologic (e.g.. nicotine polacrilex gum. phenylpropanolamine. and
d-fenfluramine) and nonpharmacologic approaches. The sixth section presents con-
clusions regarding smoking cessation and body weight change.

AMOUNT OF WEIGHT GAIN AFTER SMOKING CESSATION AND
        LIKELIHOOD OF GAINING WEIGHT

To evaluate postcessation weight gain and to determine the likelihood or relativ,e risk
of gaining weight after smoking cessation, longitudinal investigations after 1970 of
postcessation weight gain were examined. Only studies that included a control group
of continuing smokers were evaluated. Requirements for studies in this review included
a minimum followup period of 1 month and at least IO smokers who quit. Studies were
excluded if a weight loss component or severe caloric restriction was part of the
intervention or if an agent known to affect body weight (e.g., nicotine polacrilex gum)
was used; however, placebo conditions within drug trials were considered. A few
studies were excluded for methodologic or interpretive reasons, such as relapsed
subjects included in data analysis along with quit subjects or whenever a weight change
could not be calculated. Table I summarizes the IS studies that fulfilled the\e
inclusionary and exclusionary criteria.

The following information is included for each study listed in Table 1: the study
reference, the followup or period of abstinence. the mean weight gain among in
dividuals whoquit smoking, the mean weight gain of subjects whodid not quit smoking.
the percentage of subjects quitting smoking who gained weight from baseline to the
followup period, the percentage of nonabstinent subjects who gained weight during the
same period, and the relative risk of gaining any weight after smoking cessation versus
continued smoking. Adjusted averages of weight gain are provided to summarize
across all studies. These adjusted averages control for differing sample sizes and assign

173


TAHIX I.--Summary of prospective studies on smoking and body weight

5 yr

! yr

I qr

I Yr

h yr

6.3.5



7.5



5.15



I I.1



3.1X



(1. I



I .h








(1.94



7.7

2.01          -




2.2



0.04          76.9          JO.3         I.66



7.3           x7.0           60.7         I .a3



0.r)                                  -




0.3



0.9                       -



-           7x.0          Sh.0         I ..I9



0.44          -                       -




2.4           X0.6          61.7         1.31


TABLE I.--Continued

Krference

Sample     Number of
\i7c     quitters

Quit
period

     Mean weight               % continuing     Relative ri\h
      gain (lb)         `2 quitter\
                 who gain     \moher\ who     of gaining
Qumer\    Continuing \moher5   weight     gain weight      weight

Puddry et al.
(IYXS)

zx

Kabhin
( lYX4h)

107

Kotlin                42
(lYX7)

Scltfrr
(l'J73)

31X

Tuomilehto et al.
( IYX6)

3Yh

I..( mn



3 mo



I .5 mo



5 yr


s yr

2.Y7



4.4



3.1x



7.`)



6.02

Median l'ollowup
period=7 yr

Avcragc
~elght gain
among
quitter\=l.h:
N=J.h47

0.44

0.7



0.70          5X.3          33.3         I .75



33

I .57

Avcragc
wclght gain
among
continumg
w~oker\=O.X:
N= 15.046

Averq!e       Average      Average
`I$ of quitter\     % ot cclntirlulng   relntive rlah
uho gain        \mcrher\ who    olgaming
wcighk7Y";:    gain \cright=Wk:  weight= I.451
Numhcr ot        Numhcrot      Numher ot
\tudie\ reportlng=5: dud~c\        \tudie\
N=714       reporting=5:    rcpwmg=S:
            N=l,l I3       N= I.77