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Many studies have reported that adolescent girls and young women smoke to control their weight. The majority of these studies are cross-sectional and report on ...
MIMI NICHTER Department of Anthropology, University of Arizona MARK NICHTER Department of Anthropology, University of Arizona NANCY VUCKOVIC Kaiser Permanente, Center for Health Research LAURA TESLER Department of Anthropology, University of Arizona SHELLY ADRIAN Department of Anthropology, University of Arizona CHERYL RITENBAUGH Kaiser Permanente, Center for Health Research

Smoking as a Weight-Control Strategy among Adolescent Girls and Young Women: A Reconsideration Many studies have reported that adolescent girls and young women smoke to control their weight. The majority of these studies are cross-sectional and report on correlational data from quantitative surveys. This article presents data from ethnographic interviews with 60 smokers, interviewed in high school and in follow-up interviews at age 21. Contrary to previous research, this study found little evidence for the sustained use of smoking as a weight-control strategy. In high school, smokers were no more likely than nonsmokers to be trying to lose weight. In the follow-up study, 85 percent of informants replied that they had never smoked as a way to control their weight. One-half of informants at age 21 believed that smoking as a weight-control strategy would be ineffective, while the other one-half had no idea whether it would work or not. Researchers need to exert caution in propagating the idea that smoking is commonly used as a conscious and sustained weight-control strategy among adolescent females and young women. [adolescent females, smoking, dieting]

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espite extensive public health efforts in tobacco prevention, more than 3,000 youths in the United States begin smoking each day (CDC 1998). It is estimated that more than five million of today’s young smokers will

Medical Anthropology Quarterly, Vol. 18, Issue 3, pp. 305–324, ISSN 0745-5194, online ISSN 1548C 2004 by the American Anthropological Association. All rights reserved. Send requests for 1387.  permission to reprint to: Rights and Permissions, University of California Press, Journals Division, 2000 Center Street, Suite 303, Berkeley, CA 94704-1223.

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die of tobacco-related illnesses (CDC 1996). Although for many years smoking among youth was more prevalent among adolescent males than females, recent data indicate that smoking is now equal or slightly more prevalent among adolescent females than males. Findings from the Youth Risk Behavior Survey reveal that 28 percent of female high school students report smoking on one or more days in the previous month (CDC 2002). Although these statistics include experimentation and occasional smoking, it is important to note that 30 percent of all adolescents who experiment with tobacco will progress to daily smoking (Choi et al. 1997). Both in the popular press and in academic journals, it is not uncommon to read that tobacco use among adolescent girls is on the rise in part because of the industry’s portrayal of smoking as a way to be slim, fashionable, and feminine. Indeed, slenderness and smoking have been intentionally linked in the minds of the American public for decades (French and Perry 1996; Kaufman and Nichter 2001). Since the 1920s, cigarette ads have exploited consumer desires by presenting subtle and overt portrayals of the slimming properties of cigarettes. The first ad campaign, which pictured an attractive woman’s face with her silhouette behind her with a sizable double-chin, was captioned “First a shadow, then a sorrow; Reach for a Lucky instead of a Sweet.” Reportedly, this was one of the most successful advertising campaigns in history (USDHHS 1994). The vast majority of ads promoting smoking for weight loss have been directed at women. Women’s brands—comprised mostly of long and slim cigarettes—are often advertised with the word “slim” in their tag line (e.g., Capri—“the slimmest slim in town”; Misty— “slim and sassy”; More—“slim and elegant”; etc.) and use slender young women as models in the ads. A close reading of the literature reveals a range of findings on smoking as a weight-control strategy among adolescent girls. Several studies have found that girls who diet or who express more concern with their weight initiate smoking at higher rates than nondieters (Camp et al. 1993; Charlton 1984; French and Perry 1996; French et al. 1994; Gritz and Crane 1991). Other researchers conclude that even contemplation of smoking is more pronounced among those girls who express weight concerns (Tomeo et al. 1999). Smoking has been reported to be more common among girls who are overweight, and several studies find that adolescent females agree with the statement that smoking helps keep body weight down (Crisp et al. 1999). Researchers have found that girls who engage in unhealthy weight-loss methods (e.g., vomiting, laxatives, diet pills, etc.) are more likely to be smokers than girls who do not engage in these behaviors (Krowchuk et al. 1998; NeumarkSztainer et al. 1996). These adolescents are reported to be more deviance prone and therefore more likely to engage in other health-compromising behaviors, including smoking (French et al. 1994; Gritz and Crane 1991). One study concluded that the adolescent who is most likely to be smoking for weight-control reasons is white, female, and a chronic dieter (Camp et al. 1993). Of note, at least one study has concluded that weight concerns were not predictors of smoking initiation among adolescent females (Killen et al. 1997). Rather than weight concerns or body fat being a predictor of smoking in this longitudinal study, the likelihood of smoking was highest among girls with high sociability scores and those who had more friends who smoked. Results of several studies confirm that youth who have friends who smoke are more likely to be smokers themselves (Conrad et al. 1992; Flay et al. 1998; Kobus 2003) and that

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many youth engage in social smoking, particularly when drinking (Michel and Amos 1997; Nichter et al. 1997). Concern about body weight is reported to be a strong predictor of smokers with no history of cessation attempts (Klesges, Zbikowski et al. 1998) and with no intention to quit in the future (Weekley et al. 1992). In addition, studies report that weight concern may be a cause for the higher relapse rates of women when compared to men (Gritz et al. 1996; Jarry et al. 1998; Klesges, Meyers et al. 1989). Relatively little is known about cessation and weight concerns among adolescents. While results of several studies suggest a correlation between smoking and weight management, two points are worth noting. First, the results of two longitudinal studies among young adults show little evidence that regular smoking or smoking initiation actually leads to weight loss, nor are smokers thinner than their nonsmoking counterparts (Klesges 1998; Klesges, Zbikowski et al. 1998). Second, the majority of adult smokers do not report that they use smoking to control weight (Killen et al. 1997; Perkins 1994). These points led us to critically examine existing data on smoking as a weightcontrol strategy among adolescents and young adults. A first observation is that the data have largely been generated by cross-sectional surveys, with several notable exceptions (Austin and Gortmaker 2001; Honjo and Siegel 2003; Killen et al. 1997; Klesges, Ward et al. 1998; Voorhees et al. 2002). In the majority of cross-sectional studies, dieting and smoking attitudes and behaviors are assessed separately and responses to these distinct sets of questions are then correlated. Positive correlations reveal that girls who smoke are more often those who diet or who are dissatisfied with their body. Adolescents may be asked to agree or disagree with the statement, “Smoking keeps your weight down.” Responses typically reveal greater endorsement of this statement among adolescent girls than boys of similar ages (Camp et al. 1993; Charlton 1984; Klesges, Elliott, and Robinson 1997). Surprisingly, relatively few studies ask girls directly whether they have smoked in the past or smoke presently to control their weight, or whether they think that smoking is or might be an effective weight-management strategy for them. Even fewer studies follow the progression of girls’ dieting and smoking behavior over time, and no studies to date have investigated the specific strategies by which girls smoke to control their weight (e.g., timing, location, amount, etc.). This article addresses a lacuna in the literature. Although the results of many cross-sectional studies suggest an association between dieting and smoking, researchers might benefit from a more detailed understanding of the ways in which girls use smoking to control their weight. Drawing on qualitative and quantitative data from a three-year longitudinal study and a five-year follow-up, this article addresses several questions that have not previously been discussed in the literature. For example, given that smoking is prohibited on school campuses and in many homes, how do teenage girls manage to smoke to control their weight? Among girls who smoke, is weight control the main reason for their smoking, or are there other factors more closely associated with smoking initiation and continuation? Does smoking constitute a primary means of weight control, or is it combined with other weight-loss practices (e.g., exercising, reduced food consumption, etc.)? Do young women who adopt this practice feel it is a successful strategy? Data are drawn from an initial three-year longitudinal study of adolescent girls that examined the relationship between body image, dieting, and smoking over time. Five

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years after the completion of the initial study, a follow-up of the same cohort was undertaken. At the onset of the longitudinal study, one of our main areas of interest was the extent to which adolescent girls initiated and continued smoking as a way to control their weight. However, during the first round of ethnographic interviews with 8th and 9th graders, it became evident that while many girls expressed concern about their weight and talked about dieting, few made an association between dieting and smoking. In fact, so few girls had even heard of smoking being used as a weight-control strategy that we were concerned that we might inadvertently give them this idea. This concern arose from responses to interview questions about the use of smoking as a weight-control strategy. Several girls responded, “No, I haven’t heard of that—does it work?” This raised ethical issues about our research and we decided it was best not to directly ask about the subject until the girls were older or reported this association themselves in open-ended interviews. Had we not done the ethnographic component, we might have just asked questions on the survey, assuming the association as the literature suggested. In this article, we examine how the association between dieting and smoking changed over time. Sample The original longitudinal study, known as the Teen Lifestyle Project, was conducted over a three-year period by a team of researchers. The genesis of the project was a year of discussion and exploratory research on the relationship between girls’ body image, dieting, smoking, and advertising (Nichter and Nichter 1991; Nichter and Vuckovic 1994). The longitudinal study, which used both qualitative and quantitative methods, began with a cohort of 240 girls (130 8th graders and 110 9th graders) recruited from two middle- and two high schools in Tucson, Arizona. One middle school and one high school were located in urban, lower-to-middle-income neighborhoods, while the others were located in suburban Tucson, with a student population from middle-to-upper-middle-income families. This sampling permitted us to recruit students from a range of economic backgrounds. Participants were followed for three years, until they were in 10th and 11th grades, respectively. In terms of ethnicity, 68 percent of the sample was white, 13 percent were Mexican American, 3 percent were Asian American, and 3 percent were Native American. The remaining 13 percent of informants did not categorize themselves into any ethnic group. The project was introduced in physical education classes and was described to the students as an opportunity for them to express their opinions about issues important to teenagers. Approximately 80 percent of the girls chose to participate and returned consent forms signed by themselves and a parent or guardian. Of the original study participants (n = 240), 205 girls remained in the study during year three (85 percent retention rate). The mean age for the girls in year three was 16.02 + 0.44 (mean + SD) for the 10th graders, and 16.99 + 0.49 (mean + SD) for 11th graders. There were no significant differences between the ethnic backgrounds of the girls who joined the study in year one and those who remained at year three. The data from the high school sample reported in this article use year-three data, when the girls were in the 10th and 11th grades. By that time, the

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topic of smoking and dieting was more easily and openly discussed in interview settings. At the end of the third year, we asked girls whether they would be willing to be recontacted in the future, and almost 90 percent agreed. In 1998–99—five years after the initial longitudinal study had been completed—we conducted a follow-up study and were able to contact 178 of the original study participants by telephone. The mean age of participants in the follow-up interview was 21.67 years. Methods Qualitative and Quantitative Data Collection In each of the three years of the original longitudinal study, each girl participated in one in-depth, semi-structured, ethnographic interview that took place at the school and lasted approximately one hour. Eight field researchers trained in ethnographic interviewing conducted the interviews. An interview script was devised to ensure a level of standardization in data collection. Because the ethnographic method is hermeneutic in approach, new questions were added to the script when our knowledge of a topic increased as a result of the interview experience. Each girl completed an annual 110-item survey questionnaire that contained multiple questions on attitudes and behaviors regarding dieting and smoking (Nichter, Nichter et al. 1997; Nichter, Ritenbaugh et al. 1995). Interviews and survey completion took place at the schools. After the girls completed the survey, height and weight measurements were taken in the privacy of a separate room. These measurements allowed us to calculate body mass index (BMI). Girls also received two telephone call interviews each year to ascertain dieting and smoking behaviors in the previous two weeks. All interviews were tape recorded and transcribed verbatim. The text of these transcripts were coded and analyzed with the Ethnograph program.This software program permits classification and retrieval of transcripts on the basis of themes, which facilitates comparison of discourse across participants. Themes were established by the research team on the basis of questions in the interview script and themes that emerged as the cycle of interviews progressed. Results from the surveys were entered into a database for analysis using SPSS (Statistical Package for Social Sciences 1998). Ethnographic research was conducted to enable the researchers to gather data on the way in which girls discussed smoking and dieting. Through ongoing ethnography and analysis of girls’ discourse about dieting and smoking, the researchers were able to identify new variables for study and inclusion in the subsequent interviews and surveys over the three years. Interviews also provided an opportunity to clarify the meaning of survey responses. Qualitative and Quantitative Data Collection: Follow-Up Study (1998–1999) In the follow-up study, telephone interviews were conducted with 178 of the original study participants. Informants were located across the country, although the majority had remained in Arizona. After rapport had been reestablished with participants, a semi-structured questionnaire, composed of both open- and closeended questions was administered. Interviews ranged in length from 45 minutes to

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two hours. During interviews, recent weight management and smoking histories of women were obtained as well as narrative accounts of quitting attempts and relapses for those who were smokers or quitters. Telephone interviews were tape recorded and later transcribed and coded for analysis. Once all telephone interviews were completed, a survey questionnaire was mailed to those young women who had identified themselves as smokers. Out of 53 current smokers, only 32 mail-in responses were received. Results among High School Girls Classifying Teen Smoking Status: An Ethnographic Perspective Researchers typically classify teens who smoke at the level of one or more cigarettes per month as “smokers.” In discussions with girls, however, it became clear that terms such as smoker and nonsmoker, which are typically used as descriptors of teen behavior in the expert literature, did not capture the adolescent experience of smoking. During in-depth interviews, we asked girls: “Have you smoked cigarettes since we last talked to you?” followed by “Would you call yourself a smoker now?” Of those girls in our sample who reported smoking in the past few months, many commented, “Well, I’ve smoked, but I wouldn’t call myself a smoker.” In fact, many of these occasional smokers appeared disturbed by the characterization of their behavior as a smoker. Notably, the largest group of smokers in the high school sample (as defined by national surveys) considered themselves to be nonsmokers. In an effort to capture teens’ perceptions of their smoking behavior on our survey, we developed question and response categories that used girls’ categorization of smoking that emerged from interviews (Nichter et al. 1997). This permitted a more refined categorization of smoking defined by teens themselves (e.g., “I’m not really a smoker but I’ll have a cigarette every once in a while”; “I just smoke when I’m partying”). Table 1 shows the survey question and response choices that were used to determine a qualitative classification of girls’ smoking. In addition to the qualitative description of their smoking, more standard survey questions were also asked to assess smoking status. Of the 205 girls who responded to the survey, 30 percent (n = 61) were current smokers and 20 percent (n = 41) were experimenters, meaning that they had tried smoking once or twice Table 1 Responses to “Which statement best describes your smoking? (n = 205). Response Categories I don’t smoke I’m not a smoker but I’ll have a cigarette every once in a while I just smoke when I’m partying I smoke on a fairly regular basis but I don’t need to I’ve got to have my cigarettes I’m an ex-smoker

n

%

129 31 8 10 12 15

63 15 4 5 6 7

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in the past but were not currently smoking. Forty-three percent (n = 88) had never smoked, and 7 percent (n = 15) were ex-smokers. Based on their qualitative responses and the number of cigarettes smoked per week, girls were grouped in the following broad categories: regular smokers (n = 22), occasional smokers (n = 39), and nonsmokers (n = 129). Regular smokers were those girls who reported, “I smoke on a fairly regular basis but I don’t need to,” and “I’ve got to have my cigarettes.” Occasional smokers were those who classified themselves as “I’m not a smoker but I’ll have a cigarette every once in a while” and “I just smoke when I’m partying.” Using these descriptors, of the girls who currently smoked (n = 61), 36 percent were regular smokers and 64 percent were occasional smokers (Nichter et al. 1997). The median number of cigarettes smoked by occasional smokers was one per week (mean = 4) as compared with a median of 40 cigarettes per week (mean = 60) for girls described as regular smokers. The mean age of initiation for the occasional smokers was 13.7 years old, as compared with a mean age of initiation for regular smokers of 11.5 years old. This is consistent with national data that suggest that smoking levels escalate over time and that early initiation results in higher sustained levels of smoking (Lloyd-Richardson et al. 2002).

Smoking and Weight Control: Survey Responses In response to the survey question in year three, “Did you start smoking as a way to control your weight?” six girls out of 61 smokers (11 percent) reported that they had started smoking for this reason. Of these six girls, three were significantly overweight as determined by analysis of their BMI. The other three girls were of average weight (by BMI) but expressed concern with their weight and engaged in frequent and severe episodes of dieting. In addition, all but one of these girls was involved in other high-risk behaviors, including regular drinking and drug consumption. The remaining girl, who was an excellent student and a nondrinker, described herself as a “type A” personality. Smoking, she noted, helped her cope with the stress of school. If most girls did not initiate smoking as a way to control their weight, what reasons did they give for starting? On the survey, response choices were given based on data collected during face-to-face interviews. We asked girls to respond to the question “I started smoking because . . .” (multiple responses allowed). Almost half (49 percent) of the girls who smoked reported that they started smoking because they had a lot of stress in their lives, while 47 percent reported that they began smoking because they thought it was relaxing. Many of these girls explained that after they started inhaling, “It started to calm my nerves and make me relax.” Importantly, even girls who smoked rather infrequently articulated this benefit of smoking (Nichter et al. 1997). This substantiates findings of previous studies that report on smoking as a coping mechanism for stress among teens (Covey and Tam 1990; Quintero and Davis 2002; Revell et al. 1985; Wills 1986). Forty percent of girls who smoked reported that they started smoking because their friends did. Narrative data revealed that smoking often went with drinking at parties. Smoking for social facilitation has been widely cited in the literature (Kobus 2003; Michel and Amos 1997).

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Responses to the question “Are you trying to change your weight now?” were analyzed to ascertain whether girls who smoked were more likely to be trying to lose weight compared to nonsmokers. There were no significant differences in dieting attempts between these groups. We also assessed whether girls who smoked but who had not initiated smoking to control their weight (n = 55) had ever used smoking as a means of weight control. Accordingly, smokers were asked to complete the statement “When I’m trying to lose weight . . .” to ascertain whether they changed their smoking level while dieting. Thirty-eight percent of smokers (n = 21) reported that they did not try to lose weight. Twenty-one percent (n = 7) reported “I stop smoking so I can exercise” during weight-loss attempts. This finding verified information gathered during ethnographic interviews, in which some smokers said that they preferred to increase their exercise when they wanted to lose weight. Since smoking interfered with their ability to exercise vigorously, these girls curtailed their smoking during weight-loss attempts. Further analyses by level of smoking revealed that among regular smokers who dieted, almost half replied that they smoked the same number of cigarettes as usual during weight-loss attempts, compared to 20 percent of occasional smokers who gave this response. Occasional smokers were more likely to report that they stopped smoking when trying to lose weight so they could exercise (25 percent), as compared to regular smokers (8 percent). In response to the statement “I sometimes smoke so I’ll be less hungry,” approximately three-fourths of both occasional and regular smokers disagreed. Girls’ narratives substantiated this response. As one occasional smoker who was trying to quit noted: “Smoking doesn’t make me any less hungry or any more hungry, which is why I found it kind of a useless thing to do. I always heard, ‘Oh yeah, it makes you not eat. It makes you not hungry.’ Wrong! It doesn’t do anything like that for me.” In response to the statement “I smoke cigarettes instead of snacking,” regular smokers reported doing this “a lot of the time” (21 percent) and “sometimes” (33 percent). In contrast, over three-fourths of occasional smokers (80 percent) reported that they “hardly ever” smoked instead of snacking. Thus, smoking instead of snacking was a far more common behavior among those who smoked regularly when compared to those who smoked only occasionally.

Perceptions of the Body Weight of Smokers Although it is commonly believed that girls learn to make an association between smoking and weight control from viewing ultra-thin models who smoke in magazine advertisements and in the movies, findings from our ethnographic study led us to reconsider this notion. In year-three interviews when we asked girls about smoking as a weight-loss strategy, some informants who smoked remarked that they knew women and girls who were smokers and were overweight, so smoking as a weight-control strategy clearly did not work for everyone. As one girl noted: “Some of my friends smoke because they think they’re gonna lose weight or it’ll control their appetite. But I don’t think it works. Like a friend of my mom smokes, and she’s fat, really fat and she’s smoking all the time.”

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Interestingly, observations noted by these teenage girls corroborate findings of several large-scale studies that have concluded that smoking has no relationship to body weight in women nor is it associated with sustained weight loss (Klesges, Ward et al.1998; Klesges, Zbikowski et al. 1998). Even among girls in our sample, those who were regular smokers were heavier (mean BMI 22.93) when compared to occasional smokers (mean BMI 21.37). Girls’ statements about the media and their observations of others made it clear that they were active agents in an information-gathering process. Rather than simply incorporating media messages passively, girls interpret the contradictory information they glean from the media and environments in which they live. It seems simplistic to assume that because girls see slim women in cigarette ads, they therefore believe that smoking makes you thin or that smoking is an effective dieting aid. Approximately 80 percent of nonsmokers, occasional smokers, and regular smokers disagreed with the statement “In general, I think people who smoke cigarettes are thinner than people who don’t smoke.” Smoking and Weight Control: Ethnographic Findings As noted earlier, during ethnographic interviews in year one, we found that very few girls made an association between smoking and weight control. Given the structure of their school day, 8th and 9th grade girls had multiple constraints on both time and spaces where they would be able to smoke. For example, none of these girls were allowed off campus for lunch, and smoking was prohibited and closely monitored on school grounds. Few girls were allowed to smoke at home, so lighting up a cigarette instead of eating or at the end of a meal was not a viable option for most of the day. By the time these girls had reached 11th grade, many of them experienced increased freedom (via access to automobiles) and increased income from part-time jobs. These factors were described in some girls’ narratives as contributing to their increased smoking frequency. As smoking frequency and duration increased, so did the recognition of smoking as a weight-control strategy. Narrative data provide insights into the mechanisms by which some girls who smoked at higher levels (a half pack to a pack per day) used smoking to control their weight. As one 11th grader remarked, “When I had food cravings, I would try to smoke instead of being hungry. I’d grab a cigarette and go hide in a far corner of the school and then I’d get satisfied . . . and it passed time—when I smoked I ended up missing my lunch period.” Similarly, another 11th grader who had managed to lose about ten pounds while smoking explained: “Some people say if you smoke you’ll lose weight so I decided, OK, and I tried it. It worked a little . . . it did help me lose weight because every time I got hungry I figured OK, I can have a cigarette. . . . I’m fine, I can do without dinner.” Both of these girls smoked almost a pack a day, and were able to smoke in the presence of their families. Another girl, a half-pack-a-day smoker who continually expressed concern with her weight, felt that smoking would be helpful for her diet as it would serve as a distraction from food. She noted, “Instead of eating I’ll have a cigarette. When I smoke I eat less.” Importantly, even though her mother disapproved of her daughter’s smoking, she was allowed to smoke outside of her house. In fact, she stated, “My mom is the person who told me about smoking instead of eating!”

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Another informant, who smoked about nine cigarettes a day, similarly explained, “I smoke a lot now especially because of my diet. It doesn’t kill my appetite but it gives me something to do.” Questioning the Strategy Clearly, not all girls who smoked were aware of or “believed in” smoking for weight control. One girl, a high school junior who occasionally smoked, noted that she had heard her friend talking about smoking for weight control. She recalled, “I remember my friend Megan saying ‘If I start smoking more, I’ll probably lose weight.’ But I don’t think it really works like that. I think when somebody says that it’s because they’re trying to start a diet, so instead of eating they smoke.” In other words, she believed that some girls talked about increasing their smoking as a means of “jumpstarting” a diet. However, as she observed, this talk did not always translate into action, at least as far as her friend was concerned. Another girl described what she and her friends referred to as the “Diet Coke and cigarette diet.” She explained, “That’s what you do when you have a party to go to that’s kind of important in like a week. The whole week you smoke cigarettes and you drink diet sodas and if you eat, it’s like a cracker.” She realized that it wouldn’t work as a long-term strategy but it was something she could manage for a few days. Another high school smoker, when asked if she had friends who smoked to control their weight, expressed concern about the effectiveness of the strategy: Well, I do know some people that smoke instead of eat, and I don’t know, I guess I can see how that would kind of fill you up, just because after you eat, smoking makes you feel a little more complete. But it doesn’t really fill you up completely. It actually hurts my stomach if I smoke on an empty stomach. If I’m really hungry and I have a cigarette, I’ll drink something with it, like juice or a hot chocolate. If I don’t, it hurts my stomach, and it makes me feel sick for a while.

For this girl and three others, smoking was not a viable alternative to eating, as lighting up on an empty stomach made them feel queasy. Another girl explained, “When I’m hungry and I smoke, it’s like I’ve taken something into my body but really there’s nothing going into my stomach. It’s like a big myth that it will fill you up.” Among some girls who smoked, there was an overt concern about increasing their smoking that made it unattractive as a weight-control strategy. Several 11th graders noted that they wouldn’t try it because they were well aware that smoking was bad for their health and to increase it seemed stupid. As one girl explained, “I don’t want to die that quick!” Quit Attempts As girls began to engage in quit attempts, several described their experiences of weight gain. One 11th grader who smoked a pack a day (including at home with her mother) had tried to quit many times. As she noted: “It’s really difficult because last time I tried to quit smoking I gained ten pounds and I didn’t want to gain more so I said, ‘I’ll smoke.’ ”Although her weight gain was an important

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reason for her relapse, it was not the only reason. In her extended narrative, she described her loneliness and how she needed to smoke when she was alone, as her cigarette served as a substitute for someone else being there. Another girl, whose cigarette consumption had risen from five cigarettes a day to a pack a day over a three-month period, had been trying to quit but finally gave up. Although the weight gain she had experienced following quitting had frustrated her, the main reason she had resumed smoking was because of her stressful relationship with her mother. She explained, “I’ve been fighting a lot with my mom lately so I really need to smoke. I’m back up to smoking a pack a day, which is bad, but I’m just so stressed out and angry about what’s going on at home. Smoking helps calm me down.” Thus, among those smokers who attempted to quit, several relapsed to smoking. Beyond weight control, there were multiple reasons for their relapse, including to combat loneliness and to provide relief from a stressful family life. Results of the Follow-Up Telephone Call Interviews Overview Results of the original three-year study led us to conclude that while some girls did smoke to lose or manage their weight at some points in their smoking trajectories, for others, smoking served several purposes, including—but not restricted to—weight control. Smoking as a weight-control strategy became important to some young women as they progressed to regular smoking, while for others it became an issue following a quit attempt. More importantly, the narratives of those high school girls who were regular smokers reveal themes of stress, anger, and loneliness and the use of smoking for self-medication (Nichter et al. 1997). In the follow-up study, we continued to investigate the relationship between smoking as a weight-control strategy and the extent to which this changed as these girls became young women and had increased freedom to smoke associated largely with living on their own. Of the 178 young women who were recontacted, 30 percent were current smokers (n = 53). Thirty-three percent had experimented with smoking (n = 58), and 5 percent were ex-smokers (n = 9). Fifty-eight young women (33 percent) had never smoked. Smoking histories revealed that ten women had tried smoking in their final year of high school, and 13 had tried smoking after graduation from high school. Thus, a large number of study participants had experimented with tobacco after high school. This supports a growing literature that reports that smoking uptake is not confined to early and mid-adolescence, but may continue to early adulthood (Wechsler 1998). Smoking and Weight Control In telephone interviews, we asked current and ex-smokers (n = 62) a series of questions on dieting and smoking to assess whether this was a strategy that they had utilized, either initially or as part of their present behavior. In response to the question, “Thinking back to when you first started smoking, would you say that you started smoking as a way to control your weight?” 92 percent (n = 57) responded that they had not. All but one of the six young women who had reported

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that they initiated smoking to control their weight in the original study reconfirmed that response in the follow-up interviews. In response to the question, “Did you ever smoke as a way to control your weight, 85 percent of informants (n = 53) replied “no” and 15 percent (n = 9) replied “yes.” We next asked, “Do you think smoking is an effective weight loss strategy?” Of the nine women who had utilized smoking for weight control, six said it was an effective strategy. Of the remaining women, almost half (n = 26) believed that it would not be an effective strategy, and the other half (n = 27) responded that they did not know. We also tried to assess behavior on a follow-up survey. In response to the survey question, “When I’m trying to lose weight . . .” (n = 32), three young women did report that they increased their smoking while trying to lose weight. However, further discussion revealed that these increases were not a part of a dieting strategy. Rather, as one woman explained, “When I was trying to lose weight, I used Metabolife and it makes you feel real jittery. I needed to do something with my hands so I smoked. But I didn’t smoke more so I could control my appetite.” The other two women explained that they had increased their smoking while trying to lose weight because they were stressed out because their diets were not going as well as they had hoped. Smoking helped these unsuccessful dieters deal with the frustration of not being able to lose weight. Approximately 20 percent of the current smokers at follow-up said that when they dieted, they tried to stop or reduce their smoking so they could exercise. As a one-pack-a-day smoker explained: “I’m gonna stop smoking so I can exercise. Then hopefully it’ll make me not want to smoke again, cause I won’t be able to breathe when I’m trying to exercise.” One obese informant explained that she had initially smoked because it provided her with something to do besides eat. However, she later realized “that it limits your physical exercise because you’re out of breath and not in good physical health. I’d just be better off if I exercised.” But exercising rather than smoking was not a strategy that all young women could adopt. As one informant who had a long history of dissatisfaction with her body size remarked: I dropped a lot of sizes when I was not eating and smoking two packs a day. I lost weight and that’s when I was like “Oh I like this,” because for me exercise is like a chore, it’s just not something that I can do. And I’ve been that way since I was little—I remember being in elementary school and saying, “Do I have to do this?” You know, I’d rather walk the mile than run the mile, so smoking really helped me get it all under control.

In this case, smoking comes into play as a strategy for a young woman who is slightly overweight and for whom other methods of weight loss have proved unsuccessful and unappealing. Smoking as a Substitute for Eating In interviews, some informants described how smoking a cigarette served as a substitute for snacking. As one smoker (four cigarettes per day) who was concerned with her weight explained: “Instead of picking up a potato chip, you

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pick up a cigarette. It’s so bad, but it totally works. I think I still feel a little bit hungry, I mean, nicotine is a kind of stimulant, I mean it’s not like this suppressant at all, so I do feel hungry, but I just don’t think about it if I’m smoking.” Several informants who believed that smoking was not an effective strategy for weight control provided insightful comments. One smoker (seven cigarettes a day) who expressed concern with her weight explained: Smoking was never like a way to control my weight, it was like, well, you could smoke and you weren’t really hungry anymore . . . cigarettes are sort of like food. . . . At the beginning, I probably thought that smoking might have a nice little side effect, you know, like an added bonus, but that’s not how it is. . . . If I really thought instead of not eating I could have a cigarette, I would be like smoking a pack a day or something!

Another pack-a-day smoker who was extremely overweight found the idea of smoking for weight-control purposes quite humorous. As she noted, “If it worked I’d be skinny! It doesn’t work!” In response to the question, “Do/did you ever smoke at the end of a meal so you wouldn’t continue eating?” 97 percent (n = 60) replied “no.” One young woman, who smoked three-and-a-half packs per week and expressed concern with her weight, described how she smoked when she finished eating. Although this might appear to be a weight-control strategy, she quickly explained “Actually I smoke at the end of a meal because it feels good. It’s like a cherry on top but it’s not so I’ll stop eating!” In response to the question, “Do you smoke at times so you’ll be less hungry?” 80 percent (n = 42) of current smokers responded “no.” Three of the women who answered “yes” explained how their use of cigarettes to curb hunger went beyond issues of weight. As one informant, a pack a day smoker, noted, “I do smoke sometimes so I’ll be less hungry . . . it’s usually that I’ve run out of money because I have to buy cigarettes. I guess it’s very much of a choice, I could go buy food to eat, but instead I buy cigarettes.” Another young woman, who smoked about ten cigarettes per day, provided a similar explanation of her behavior: “I’ve used smoking as a substitute for food, not to lose weight though, I mean it’s usually when I don’t have money, or I don’t have the time to eat, and it’s like well, I’m really hungry but I’ve got to go in five minutes . . . so I’ll just go and have a cigarette and that’ll make me feel better.” Cultural Knowledge about Smoking for Weight Control Although relatively few smokers in the study had utilized smoking as a weightcontrol strategy, by the time these women reached early adulthood, cultural knowledge of the practice was commonplace. In response to the follow-up telephone call question, “Have you ever heard that smoking helps a person control their weight?” 87 percent (n = 54) of smokers and ex-smokers responded that they had. Some, however, were quick to note that although they had heard this, they had not experienced it themselves. When asked where they had heard this, young women explained that they had heard about smoking and weight control from a range of sources, including friends, school, their mothers, and the media. As one college student noted, “It’s been mostly word of mouth. Even in a nutrition class

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that I took in college, I remember the teacher saying that smoking numbs your hunger . . . that all that nicotine and stuff is numbing to your body.” Another young woman replied, “Oh God, I’ve heard it all over the place. I mean you hear it more when people quit—that they eat like monsters . . . because when you’re a smoker instead of putting food in your mouth, you’re having a cigarette.” Notably, five young women reported that they had learned about smoking as a weight-control strategy from their mothers who also smoked. In these households, the daughters described how “fat talk”—that is, talking about body dissatisfaction—was a common discourse pattern that they and their mothers engaged in frequently (Nichter 2000). Quitting and Weight Concerns It has often been noted in the literature that fear of weight gain after cessation is a major deterrent to quitting among women (Klesges, Zbikowski et al. 1998; Weekley et al. 1992). In our follow-up interview questions, we were interested in assessing the extent to which this was true among this sample of young adults. In response to the question “Are you concerned that you might gain weight if you quit smoking?” half of the current smokers (n = 27) reported that they were “not at all concerned,” while the other 50 percent (n = 26) were “somewhat concerned.” However, several young women explained that this concern would not be a deterrent to quitting. In fact, seven women reported that they had previously gained weight when they quit, but only one woman associated her relapse to smoking with weight gain. Rather than be a primary concern, weight seems to be a part of a complex of issues that women face when they give up smoking. For some of these women, quitting was particularly difficult because of addiction, because of other coexisting stressors in their lives (including finances), because their close friends or romantic partners still smoked, and because they missed the comfort that cigarettes provided them. For women who were regular smokers, cigarettes were “something you can always count on . . . you know what you’re getting, and it calms your nerves.” For those who relapsed to smoking, it was stress-related factors and needing to smoke that emerged as more salient than issues of weight gain. In discussions of their struggles with quitting, three women described how they were tempted to smoke by cues in their environment from other people smoking. Narrative accounts of attempts to quit led us to recognize that cues to smoke do not arise solely from looking at one’s body in the mirror or one’s weight on a scale but from observations of other smokers as well. Four informants recognized that gaining some weight after quitting was inevitable, since “whether you realize it or not, smoking speeds up your metabolism.” However, there were also benefits associated with quitting that counterbalanced the initial weight gain. As one young woman who had been on and off diets for years and smoked about four packs a week explained: “I’ve tried to quit before and I’ve gained weight. But this time it doesn’t concern me like it did then. I mean, if I make the commitment to quit smoking and be healthy it would be more important to me than gaining weight.” Another young woman similarly explained that stopping smoking was part of a lifestyle change, which she described as a shift in identity from “her smoking frame of mind to her nonsmoking frame.” Now that she had a full-time job, she

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was able to avoid smoking all day at work and as soon as she came home she would quickly change clothes and go out to exercise. After exercising, she immediately showered and feeling clean again made lighting up a cigarette unappealing. Though it was a struggle, she hoped that her focus on exercise and an identity shift to being a healthier person would result in a more successful quit attempt than previous ones. She also hoped that this strategy would help her avoid any weight gain. In narratives, it was evident that young women were aware of the possibility of weight gain following quitting. However, this was viewed as a short-term result that was overshadowed by the health benefits of quitting. Discussion Although previous research has concluded that many adolescent girls and young women smoke to control their weight—or make a clear association between these two behaviors—we found only a few women in our study population who did so as a conscious sustained strategy, either in high school or in young adulthood. The results of this three-year longitudinal study, with a five-year follow-up, suggest that the relationship between dieting and smoking may be less robust and more complex than previously noted. Similarly, in previous publications from this project, we have critiqued the psychology and public health literatures on girls’ dieting, noting that the behavior is far more complex than presented through most quantitative analyses (Nichter 2000; Nichter et al. 1995). Although many girls are concerned with their weight and appearance, this does not typically result in actual and sustained dieting behaviors (Nichter 2000; Nichter and Nichter 1991; Nichter and Vuckovic 1994; Nichter et al. 1995). Social desirability and the cultural imperative to be “in control” of one’s body may cause females to over-report their dieting behaviors. Reports of dieting may reflect intention or token gestures, such as skipping a meal or dieting from breakfast until lunch. We have argued that the term dieting as a unitary construct is problematic, and often has a range of meanings depending on the person and the social context (Nichter 2000; Nichter et al. 1995). Given the complexity of terms such as dieting, the limitations of correlational data on dieting and smoking should be recognized. Just as dieting among this cohort was found to be a short-lived, sporadic practice among a small group of girls (Nichter 2000), smoking as a method of weight control was also practiced by a few girls occasionally, not as a long-term, sustained practice. In the high school sample, smokers were no more likely than nonsmokers to be trying to lose weight. Rather than using smoking as a dieting strategy, over 20 percent of high school smokers stopped smoking when they dieted so they could increase their exercise. To our knowledge, this has not been reported elsewhere. There is clearly a need for additional ethnographic research that explores and situates the multiple meanings of dieting and smoking behaviors in the contexts of girls’ and young women’s lives. There are notable limitations of the present study. The sample of smokers is small and the response rate to the survey questionnaire mailed in the followup study is low. Findings of this study may not be generalizable to other regions of the United States or to girls of different age cohorts. The strengths of the present study are its longitudinal span, the use of ethnography to explore

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the complex relationship between dieting and smoking, and the rapport that was developed with informants over a period of years. Insights from this study of the relationship between smoking and weight management need to be incorporated into future studies of why women take up, continue, and relapse into smoking. It has often been suggested that because females are exposed to thin models in the media who smoke, they will make an association between thinness and smoking and will adopt this behavior. Listening to girls and young women speak about their observations of their social worlds, it was evident that they are exposed to many types of smokers in their environments. Not only are they exposed to thin models who smoke, but they also observe girls and women at a range of weights (including very overweight) who smoke and are not thin. Rather than simply accepting media messages, adolescent girls and young women are critical observers and active interpreters of their everyday worlds. In the follow-up study—when informants were aged 21—85 percent reported that they had never smoked as a way to control their weight. Of those women who had never engaged in this behavior, half believed that this would be an ineffective strategy while the other half had no idea whether it would work or not. Of those who had used the strategy, several had tried smoking for weight-control purposes and had found it to be ineffective after a short period of time. This finding is consistent with results of much larger longitudinal studies that found little evidence of sustained weight-control benefits of smoking (Klesges, Ward et al.1998; Klesges, Zbikowski et al. 1998). Although some women did report smoking to reduce hunger, it was evident in interviews that this was not always a dieting strategy. It could also be a substitution of cigarettes for food because of budgetary concerns or the inconvenience of having nothing readily available to eat. The findings of this study on fear of weight gain following quitting raises questions about previous research that has concluded that this fear is the primary deterrent to women’s quitting or a major factor in relapse. Though young women in this sample recognized that they might gain weight if they quit, they emphasized that their quitting attempts were part of more far-reaching lifestyle shifts. Weight concerns were often not the primary issue, considering that one was moving toward establishing a “healthier or different self,” a goal that eclipsed weight gain. Women who relapsed to smoking did so for a multitude of reasons, including cravings to smoke, stress of family problems, economic difficulties in trying to manage on their own, and constantly being around friends or partners who smoked. Several young women directly challenged the idea that the primary reason women relapse to smoking is due to weight gain, noting that they found this idea demeaning. Simplistic reasoning about fear of weight gain may be open to feminist critique, as women’s lives are far more complex than weight issues alone. From initiation in high school to young adulthood, the primary reasons for smoking among females in this sample was not to control weight but rather to manage the stress and difficulties of their everyday lives, for social facilitation among friends, and nicotine dependence. Both researchers and the popular media have been complicit in propagating the idea that smoking is a commonly used weight-control strategy among young women in the United States. This ethnographic study challenges this impression

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and the simplistic notion that issues of weight are what drive smoking among young women. Rather than focusing attention on what might be a small minority of girls and young women who do practice this behavior, it might be far more productive for those involved in tobacco control to emphasize teens’ own observations that many women who smoke are overweight and research findings that document that smoking is not an effective weight-loss strategy. Public health practitioners need to exert caution in presenting risk data to the public. Inadvertently, risk data—such as the widespread myth of smoking as a weight-control strategy—may actually put a population at risk. NOTES Acknowledgments. The initial research was supported by the National Institute of Child Health and Human Development. The follow-up study was supported by a grant from the Robert Wood Johnson Foundation and from the Robert Wood Johnson Tobacco Etiology Research Network (TERN). We greatly appreciate the assistance from these sources.

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