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Guidelines on Overweight and Obesity: Electronic Textbook
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Smoking Cessation in the Overweight or Obese Patient

Cigarette smoking is a major risk factor for cardiopulmonary disease. Because of its attendant high risk, smoking cessation is a major goal of risk-factor management. This aim is especially important in the overweight or obese patient, who usually carries excess risk from obesity-associated risk factors. Thus, smoking cessation in such patients becomes a high priority for risk reduction.

Evidence Statement: Smoking and obesity together increase cardiovascular risk, but fear of weight gain upon smoking cessation is an obstacle for many patients who smoke. Evidence Category C.

Rationale: Both smoking and obesity are accompanied by increased risks for cardiovascular disease. Many well-documented health benefits are associated with smoking cessation, but a major obstacle to successful smoking cessation has been the attendant weight gain observed in about 80 percent of quitters. This weight gain averages 4.5 to 7 lb, but in 13 percent of women and 10 percent of men, weight gains in excess of 28 lb have been noted among quitters (613-615).  Weight gain is an important barrier to smoking cessation, particularly in women (616, 617).  Weight gain that accompanies smoking cessation so far has been relatively resistant to most dietary, behavioral, or physical activity interventions (618, 619).  Postcessation weight gain has been associated with a reduction in energy expenditure of up to 100 kcal/day, accounting for approximately one-third of the weight gain after smoking cessation (620, 621).  The reduction in energy expenditure appears to be the result of a decrease in the resting metabolic rate (614).

In general, no differences in the level of physical activity have been observed after smoking cessation. About two-thirds of the weight gain after smoking cessation appears to result from increased caloric intake (621-623).  However, dietary counseling programs combined with smoking cessation programs have not been very successful. There are several products that reduce postcessation weight gain during drug administration, including nicotine replacement therapy (624),  phenylpropanolamine (625), and bupropion (626).  No matter what the drug, however, it appears that these drugs merely delay rather than prevent postcessation weight gain. That is, while providing weight gain suppression during drug administration, subjects on these drugs experience a rebound of weight gain once they go off the products and long-term weight gain is equal to that in those not receiving these drugs (624, 626). 

The weight gained with smoking cessation is less likely to produce negative health consequences than would continued smoking. For this reason, smoking cessation should be strongly reinforced in persons regardless of their baseline weight. Smoking is not an acceptable weight control therapy, although it seems to be used for this purpose by a great many people. Overweight patients, as well as all others, should be counseled to quit smoking. For practical reasons, it may be prudent to avoid initiating smoking cessation and weight loss therapy simultaneously. Prevention of weight gain through diet and physical activity should be stressed. If weight gain ensues after smoking cessation, it should be managed vigorously according to the guidelines outlined in this report. Although short-term weight gain is a common side effect of smoking cessation, this gain does not rule out the possibility of long-term weight control. There are no clinical trials to test whether ex-smokers are less likely to successfully achieve long-term weight reduction than those who never smoked.

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