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Body Dissatisfaction, Weight Concerns and Smoking in U.S. Adolescent Girls: A Systematic Review of the Literature

Body Dissatisfaction, Weight Concerns and Smoking in U.S. Adolescent Girls: A Systematic Review of the Literature. Jennifer Tessmer-Tuck, MD Michelle Berlin, MD, MPH Department of Obstetrics and Gynecology Oregon Health & Science University Portland, Oregon. Objectives.

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Body Dissatisfaction, Weight Concerns and Smoking in U.S. Adolescent Girls: A Systematic Review of the Literature

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  1. Body Dissatisfaction, Weight Concerns and Smoking in U.S. Adolescent Girls: A Systematic Review of the Literature Jennifer Tessmer-Tuck, MD Michelle Berlin, MD, MPH Department of Obstetrics and Gynecology Oregon Health & Science University Portland, Oregon

  2. Objectives • Increase understanding of relationship between body dissatisfaction, weight concerns and smoking in adolescent girls • Encourage prevention and treatment efforts that address these unique perceptions of girls • Emphasize important role of health care providers in smoking prevention and cessation efforts for girls

  3. Overview • Background • What is a systematic review of the literature? • Results of the review • Implications for audience members

  4. Smoking and Weight: What’s the connection?

  5. 1920’s • Established association between smoking and slimness • 300% increase in sales the first year

  6. Obstetrician/Gynecologists interested in smoking? • Each year due to smoking related illnesses • 178,000 women die • 2.1 million years of potential life of U.S. women lost • $12 billion dollars, more than 15% of all Medicaid costs, attributable to women smokers (2001) • SMOKING IS THE LEADING KNOWN CAUSE OF PREVENTABLE DEATH AND DISEASE AMONG U.S. WOMEN • U.S. Surgeon General, 2001

  7. Obstetrician/Gynecologists interested in smoking? • Female specific cancer risks • Increased menstrual abnormalities • Fertility difficulties • Pregnancy complications U.S. Surgeon General, 2001

  8. Public Health • Eliminating maternal smoking • 10% reduction in all infant deaths • 12% reduction in deaths from perinatal conditions • If we reduced smoking rates in women • By 5% $110 million annual savings • By 50% $1.1 billion annual savings • in Medicaid costs alone • U.S. Surgeon General, 2001

  9. What’s up with girls? • Adult smoking rates stabilized in 1990’s • Smoking rates for girls increasing: • 1991: 1 in 8 8th grade girls smoked • 1996: 1 in 5 8th grade girls smoked • Currently 1 in 4 high school girls smokes • 90% first tobacco use occurs before high school graduation • Adolescents who smoke • More likely to be adult smokers • Increased difficulty quitting • Higher rates of smoking mortality

  10. Examine relationships of Body dissatisfaction Weight concerns Dieting To smoking initiation and continuation in U.S. adolescent girls Research Objective

  11. Design • Systematic Review • MEDLINE • Criteria developed by the United States Preventive Services Task Force (USPSTF)

  12. Search • MEDLINE (1990-2004) • Adolescents and Smoking • Adolescence and Smoking • Adolescent Girls and Smoking • Girls and Smoking • Adolescents and Smoking and Gender Differences • Adolescence and Smoking and Gender Differences • Controlled trials, cohort studies, case-control studies and cross-sectional surveys

  13. Exclusions • Non - English • Non - United States • Non - tobacco cigarette smoking • Adolescents with known medical conditions/mental illnesses • Girls not primary focus of study • Girls not analyzed independently from boys in data collection & analysis

  14. Just the facts… • 583 abstracts • 86 full text studies reviewed • 22 studies selected for grading • 19 Good or Fair quality studies included

  15. USPSTF Grading Criteria • Study population • Instruments • Variables and Outcomes • Analysis

  16. Grading Criteria – Study Population • Relevant population? • Representative? • Inclusion/Exclusion criteria? • Recruitment? • Site? • Sample size? • Participation rate?

  17. Grading Criteria – Study Population • Assemble and maintain comparable groups? • Consider potential confounders? • Differential loss to follow-up? • Overall high loss to follow-up?

  18. Grading Criteria • Instruments • Variables and Outcomes • Follow-up • Analysis

  19. Grades • GOOD • met all criteria • Follow up at least 80% • FAIR • Met most criteria • Follow up at least 60% • POOR • Fatal flaws

  20. Results…

  21. Study Quality Score Design Population Outcomes Klesges, 1997 Good Cross-sectional Survey 3515 girls, 7th grade “Smoking can help control weight” All adolescents 39.4% Camp, 1993 Fair Cross-sectional Survey 336 girls, high school “Smoking can help control appetite and weight” All adolescents 40.2% Smokers 67% Non-smokers 36% Boles, 2001 Fair Cross-sectional Survey 588 girls aged 12-17 “Cigarettes help to control weight” Smokers 15% Adolescents believe smoking controls weight

  22. Study Quality Score Design Population Outcomes Klesges, 1997 Good Cross-sectional Survey 3515 girls, 7th grade 12% smokers had smoked to control weight Fulkerson, 2003 Good Cross-sectional Survey 40,150 girls, 6-12th grade Smokers who perceived themselves to be overweight more likely to smoke to lose/control weight Girls =2.10 (1.96-2.25) Boys =2.48 (2.26-2.73) Smokers who had weight concerns more likely to smoke to lose/control weight Girls = 3.18 (2.94-3.44) Boys = 2.11 (1.94-2.31) Adolescents smoke to control weight

  23. Study Quality Score Design Population Smoking for weight control Girls Boys Klesges, 1997 Good Cross-sectional Survey 3515 girls, 7th grade Had smoked to control weight p<0.05 18% 8% Sarigiani, 1999 Good Cross-sectional Survey 3568 girls, 5-12th grade I smoke "because it helps me to be thin" For frequent smokers 8% 13% 1% 2% Fulkerson, 2003 Good Cross-sectional Survey 40,150 girls, 6-12th grade Smoke specifically to lose or control weight 2.50 (2.38-2.63) 49% 28% Camp, 1993 Fair Cross-sectional Survey 336 girls, high school Had used smoking to control their weight 3.46 (1.19-10), p<0.02 39% 12% Boles, 2001 Fair Cross-sectional Survey 588 girls aged 12-17. “Cigarettes help to control weight” p<0.05 For 16-17 year olds, p<0.005 22.2% 29.4% 9.9% 4.7% Girls vs. BoysSmoking for Weight Control

  24. Study Quality Score Design Population Smoking Field, 2002 Good Prospective Cohort 5329 girls, aged 10-15 High concern with weight OR=3.4 (2.4-4.7) Stice E, 2003 Good Prospective Cohort 496 girls, aged 11-15 Elevated body dissatisfaction scores: Non-smokers  experimental smokers OR=7.41 (2.41-21.69) p<.001 Experimental  regular smokers: OR=4.00 (1.22-13.14) p<.05. French, 1994 Fair Prospective Cohort 877 girls, 7-10th grade Feared weight gain OR=2.29 (1.02-5.17) Wished to be thin OR=2.87 (1.43-5.77) Constantly thought about their weight OR=1.96 (1.08-3.53) Honjo, 2003 Fair Prospective Cohort 273 girls, aged 12-15 Valued being thin and regular smoking High, OR=4.46 (1.4-16.68) Medium, OR=3.37 (1.04-10.94) Low, OR=1.0 Body Dissatisfaction and Smoking

  25. Study Quality Score Design Population Smoking Tomeo, 1999 Good Cross-sectional Survey 8299 girls aged 9-14 "Contemplators" vs. "Pre-contemplators" Overly concerned with my weight OR=2.23 (1.80-2.77) Not at all happy with my looks OR=2.05 (1.48-2.84) Fisher, 1991 Fair Cross-sectional Survey 268 girls, high school Belief that they were overweight, p<0.01 Wanting to be thinner, p<0.05 Body Dissatisfaction and Smoking

  26. Study Quality Score Design Population Smoking Initiation Tomeo, 1999 Good Cross-sectional Survey 8299 girls aged 9-14 Dieted daily to lose weight more likely to be "experimenters" vs. "contemplators" OR=1.79 (1.09-2.96) French, 1994 Fair Prospective Cohort 877 girls, 7-10th grade If had tried to lose weight more likely to initiate smoking OR=2.09 (1.15-3.79) Austin, 2001 Fair Prospective Cohort 469 girls, 6-7th grade Dieting once a week or less and smoking initiation OR=1.98 (1.12-3.50) Dieting more than once a week and smoking initiation OR=3.9 (1.46-10.38) Blitstein, 2003 Fair Prospective Cohort 263 girls, 7-10th grade Dieting girls more likely to progress from non-smoking to regular smoking 75% of concern OR=1.90 (1.26-2.86) 90% of concern OR=2.91 (1.47-5.75) Dieting and Smoking Initiation

  27. Study Quality Score Design Population Regular Smoking French, 1995 Good Cross-sectional Survey 17,135 girls, 7-12th grade Daily or weekly tobacco use more common in girls who dieted OR=1.08 (1.04-1.12 95% CI) Tobacco use increased with increasing frequency of dieting 16.4% in never dieters 23.3% in always dieters. Strauss, 2001 Good Cross-sectional Survey 1331 girls and boys, aged 12-18 Girls trying to lose weight were more likely to smoke 23.7% v. 12.6%, p<0.01 OR=2.16 (1.26-3.72) Smokers trying to lose weight smoked more cigarettes per day 14.1 v. 8.6, p<0.001 French, 1994 Fair Prospective Cohort 877 girls, 7-10th grade Girls who had tried to lose weight more likely to be regular smokers OR=2.98 (1.43-6.19, 95% CI) Dieting and Regular Smoking

  28. Study Quality Score Design Population Smoking Stice E, 2003 Good Prospective Cohort 496 girls, Aged 11-15 Girls with elevated eating pathology scores more likely to smoke: Non-smoker to experimental smoker OR=7.41 (2.41-21.69) p<.001 Experimental smoker to regular smoker OR=4.00 (1.22-13.14) p<.05 French, 1994 Fair Prospective Cohort 877 girls, 7-10th grade More likely to initiate smoking w/ higher score on eating disorder symptom scale OR=2.15 (1.16-3.97) Fisher, 1991 Fair Cross-sectional Survey 268 girls, high school High score on eating attitudes survey p<0.05 Eating Attitudes and Smoking

  29. Study Quality Score Design Population Smoking Tomeo, 1999 Good Cross-sectional Survey 8299 girls, aged 9-14 More likely to be smoking "contemplators" vs. "precontemplator" if Changed eating patterns around same sex peers OR=1.69 (1.12-2.56) Changed their eating patterns around opposite sex peers OR=2.87 (2.28-3.62) Binged at least once a month OR=2.52 (1.53-4.14) French, 1995 Good Cross-sectional Survey 17,135 girls, 7-12th grade Smoking more prevalent in girls who purged OR=2.01 (1.89-2.13) Field, 2002 Good Prospective Cohort 5329 girls, aged 10-15 Smoking initiation: History of binge eating OR=3.0 (1.7-5.4) History of purging OR=5.9 (2.8-12.6) History of changing eating around peers OR=4.0 (2.5-6.3) Eating Pathology and Smoking

  30. Summary • Girls believe smoking controls weight • Girls smoke specifically for weight control • Smoking in girls is associated with: • Body dissatisfaction • Dieting • Abnormal eating attitudes • Eating Pathology (without overt eating disorders)

  31. Implications • Smoking prevention efforts must be gender specific • To prevent smoking in girls we must address: • Body Dissatisfaction • Weight Loss Concerns • Dieting

  32. And just one more thing to keep in mind…

  33. Girls want to talk to US… • 18% girls identified doctor or nurse as the first person asked about health issues • 59% wanted to discuss smoking • 57% wanted to discuss good eating behaviors • Only 23% indicated that their doctor addressed these issues • Commonwealth Fund Survey 3575 girls, 5th – 12th grades

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