Public Health Briefs
Weight Concerns, Dieting Behavior,
and Smoking Initiation among
Adolescents: A Prospective Study
SimoneA. French, PhD, Cheryl L. Peny, PhD, Gloria R. Leon, PhD,
and JayneA. Fulkerson, MA
Introduction
Women's concern about their weight
has been hypothesized to be a factor in
preventing smoking cessation efforts, in-
creasing smoking relapse rates among
quitters, and encouraging smoking initia-
tion.lA Women are more likely than men
to believe that smoking helps control body
weight' and are more likely to report
actually using cigarettes as a means to
control their weight.5'6
The extent to which weight concems
are used as reasons for continued smoking
or are a cause of initiation or relapse is
unclear. Results of prospective studies of
smoking cessation interventions with
adults have been inconsistent.3'7'8 Two of
these studies found that weight concerns
about quitting smoking predicted less
success in smoking cessation at follow-
up,7'8 while the third found that a more
general measure of chronic dieting and
weight concern predicted greater success
in smoking cessation at follow-up.3
No published studies have prospec-
tively examined weight concerns, dieting
behaviors, and smoking initiation. Adoles-
cents constitute the ideal population in
which to examine the relationship be-
tween weight concerns and smoking, since
most smokers have already initiated smok-
ing by late adolescence.9 Given the clear
health-compromising consequences of
smoking and its persistence as a habit,
examining why adolescents might be moti-
vated to initiate or maintain such a
deleterious habit is important.
In the present study we examined the
relationship between weight concerns and
dieting behaviors and smoking behavior
over a 1-year period in a cohort of
adolescents. We hypothesized that weight
concerns and dieting behaviors would be
cross-sectionally related to current smok-
ing and prospectively related to smoking
initiation. These relationships were hypoth-
esized to be stronger in girls than in boys.
Methods
Study Participants
The subjects were 1999 7th- through
10th-grade students (n = 1030 girls and
969 boys) who were participating in a
4-year longitudinal study on the develop-
ment of eating disorders in adolescents. A
complete description of the study meth-
ods and procedures is reported else-
where.'0 At baseline, data were collected
on 1010 girls and 950 boys. Five students
refused to participate and 34 students
were absent on testing and make-up days.
Data from 877 girls and 828 boys who
were measured both at baseline and at
1-year follow-up (87% response rate) are
presented here.
Dieting behaviors were assessed with
three measures. A 21-item eating disorder
survey developed by the investigators to as-
sess past and current eating disorder
symptoms was administered.10 Items
were scored dichotomously (1 = pre-
sent, 0 = absent), yielding potential
scores from 0 to 21. Chronic dieting
behavior and concern with weight were
measured on the 10-item Restrained
Eating Scale.' 112 Recent attempts to lose
weight were measured by a single ques-
The authors are with the Division of Epidemiol-
ogy, School of Public Health, University of
Minnesota, Minneapolis.
Requests for reprints should be sent to
Simone A. French, PhD, Division of Epidemi-
ology, School of Public Health, University of
Minnesota, 1300 S Second St, Suite 300,
Minneapolis, MN 55454-1015.
This paper was accepted March 2, 1994.
November 1994, Vol. 84, No. 11
 Public Health Briefs

tion, "Have you tried to lose weight in

the past year?" Responses were coded TABLE 1-Odds Ratios for TABLE 2-Odds Ratios for
yes or no. Baseline Smoking Smoking Initiation
Weight concerns were measured by among Adolescent among Adolescent Girls
three questions: (1) "Do you constantly Girls and Boys, by and Boys (Baseline
think about your weight and shape?" (2) Weight Concerns and Nonsmokers), by
Dieting Behaviors Weight Concerns and
"Are you afraid of gaining weight?" and Dieting Behavior
(3) "Do you have a strong wish to be as OR 95% Cl
thin as possible?" Response options were OR 95% Cl
yes and no. Girls (n = 877)
Smoking status was measured by the High eating 2.04 0.95, 4.39 Girls (n = 799)
question, "Have you ever smoked even restraint High eating 1.57 0.84, 2.94
part of a cigarette?" Responses were (1) High eating dis- 2.36 1.15, 4.85 restraint
"Yes, I now smoke cigarettes," (2) "Yes, I order symptom High eating dis- 2.15 1.16, 3.97
used to smoke at least once a week, but I score order symptom
Tried to lose 2.98 1.43, 6.19 score
quit," (3) "Yes, but I've only smoked a weight Tried to lose 2.09 1.15, 3.79
few times," (4) "Yes, but I've only smoked Constant 1.70 0.87, 3.32 weight
part of a cigarette," and (5) "No, I've thoughts about Constant 1.96 1.08, 3.53
never smoked even part of a cigarette." weight thoughts about
Fearof weight 2.29 1.02, 5.17 weight
Current smokers were defined as those gain Fear of weight 1.44 0.77, 2.66
who marked response 1. Nonsmokers Wish to be thin 2.87 1.43, 5.77 gain
were defined as those who marked re- Wish to be thin 1.51 0.84, 2.71
sponse 2, 3, 4, or 5. This self-report Boys (n = 828)
measure has acceptable reliability and High eating 0.78 0.39,1.55 Boys (n = 758)
validity and was chosen for consistency restraint High eating 0.69 0.37,1.28
with previous adolescent smoking re- High eating dis- 1.34 0.66, 2.69 restraint
order symptom High eating dis- 1.67 0.91, 3.07
search.'3",4 score order symptom
Body mass index was calculated as Tried to lose 1.16 0.48, 2.77 score
weight in kilograms divided by height in weight Tried to lose 0.86 0.38,1.92
meters squared (kg/M2); height and weight Constant 0.99 0.44, 2.24 weight
were measured. Socioeconomic status was thoughts about Constant 0.90 0.42,1.93
weight thoughts about
determined by responses to a question Fearof weight 1.93 0.89, 4.21 weight
regarding father's occupation.15 gain Fear of weight 1.15 0.53, 2.48
Wish to be thin 2.39 1.08, 5.27 gain
Wish to be thin 0.72 0.28,1.90
StatisticalAnalysis Note. Odds ratios (ORs) were estimated by
Both cross-sectional and longitudinal logistic regression and adjusted for Note. Odds ratios (ORs) were estimated by
grade, body mass index, and father's logistic regression and adjusted for
analyses were conducted with simulta- occupation. Cl = confidence interval. grade, body mass index, and father's
neous logistic regression models to assess occupation. Cl confidence interval.
=

relationships between weight concerns

and dieting behaviors and smoking behav-
ior. Separate analyses were conducted on Results
each weight concern or dieting behavior The sample was mostly White (87%) from 0.36 to 0.49 in girls (mean r .43, =

as a predictor of smoking status. Grade and of upper middle socioeconomic SD .04).

=

and father's occupation were included as
covariates in the analyses because of their
positive and inverse correlations, respec-
tively, with the smoking outcome variable.
Body mass index was included as a
covariate because of its positive relation-
ship in girls with both the weight concern
and dieting behavior predictors and the
smoking outcome variable.
Eating disorder symptom scores (me-
dian split), dietary restraint scores (me-
dian split), grade (7th and 8th vs 9th and
10th), and father's occupation (profes-
sional vs other) were dichotomized for the
purpose of analysis. Body mass index was
divided into tertiles for the purpose of
analysis. Prospective analyses of smoking
initiation included only those who were
not smokers at baseline.
status; approximately half of the stu-
dents reported their fathers' occupation
as executive, administrative, or profes-
sional. Body mass indexes were in the
normal range for age and sex (for
girls, mean = 20.7, SD = 3.7; for boys,
mean = 20.3, SD = 3.7).116 Thirty-nine
boys and 42 girls reported current smok-
ing at baseline. Of those not smoking at
baseline, 54 girls and 49 boys initiated
smoking during the study. About twice as
many girls as boys responded yes to the
weight concern questions. Eating disorder
symptom scores were low; on average,
boys reported one symptom and girls
reported two symptoms. Intercorrelations
between the weight concern and dieting
behavior measures ranged from 0.16 to
0.47 in boys (mean r = .26, SD = .08) and
Girls who reported two or more
eating disorder symptoms, who had tried
to lose weight during the past year, who
reported fear of weight gain, or who
reported a strong wish to be thin were
about twice as likely as girls who did not
report these behaviors or concerns to be
current smokers (Table 1). The propor-
tions of current smokers in these groups
were 8% vs 3%,9% vs 2%,7% vs 2%, and
9% vs 3% respectively. Eating restraint
scores and constant thoughts about weight
and shape were not significantly related to
current smoking. Among boys, dieting
behaviors and weight concerns were largely
unrelated to current smoking. However,
boys who reported a strong wish to be as
thin as possible were significantly more
likely to be current smokers than those

November 1994, Vol. 84, No. I I American Journal of Public Health 1819
Public Health Briefs
who did not report this wish (9% vs 4%,
respectively, were current smokers).
Girls who reported at baseline that
they had tried to lose weight during the
previous year, who reported two or more
eating disorder symptoms, or who re-
ported constantly thinking about weight
were about twice as likely as those not
reporting these behaviors or concerns to
initiate smoking (Table 2). The propor-
tions of smoking initiators in these groups
were 11% vs 5%, 11% vs 4%, and 11% vs
5%, respectively. Eating restraint scores,
fear of weight gain, and a strong wish to be
as thin as possible were not significantly
related to smoking initiation. Among boys,
none of the weight concern measures
significantly predicted smoking initiation.
Discussion
This study is the first to demonstrate
prospectively that adolescent girls who
diet or who are concerned about their
weight initiate smoking at higher rates
than nondieters or those with fewer
weight concerns. These results support
the hypothesis that girls who are con-
cerned about their weight or who are
dieting are likely to use multiple methods
for weight control, one of which may be
cigarette smoking. A broader interpreta-
tion is that girls who engage in unhealthy
dieting behaviors, such as binging and
purging, fasting, or diet pill use, are more
deviance prone and thereby more likely to
engage in other unhealthy behaviors such
as smoking and drug use.17-20 Weight
concerns and dieting behaviors were not
significantly related to smoking initiation
among boys.
Strengths of the present study in-
clude its prospective design, large sample
size, and specific questions about weight
concerns and dieting behaviors. Limita-
tions include the use of a single, self-
report measure of smoking behavior and
the lack of questions specifically related to
the use of smoking to control weight,
smoking-specific weight concern mea-
sures, and reasons for smoking other than
weight concerns.
These data suggest that the issues of
weight concern and the use of smoking as
1820 American Journal of Public Health
a weight control strategy need to be
addressed in smoking prevention pro-
grams targeted toward adolescent girls,
particularly as these two behaviors are
linked by cigarette advertising. Unless
these issues are addressed, the current
trend of greater weight concern and
dieting21-23 and the possible use of smok-
ing for weight control may continue, with
significant implications for the future
health of young women. O
Acknowledgments
This research was supported by a grant to Dr
Gloria R. Leon from the National Institutes of
Health (NIH 1RO1-HD24700-0251 NICHD).
The authors would like to thank Robert
W. Jeffery for his valuable comments on an
earlier version of this manuscript.
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