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. Author manuscript; available in PMC: 2021 Feb 22.
Published in final edited form as: Health Psychol. 2019 Mar;38(3):248–258. doi: 10.1037/hea0000702

Predictive Utility of Subtyping Women Smokers on Depression, Eating, and Weight-Related Symptoms

Rachel H Salk 1, Lisa J Germeroth 1, Rebecca L Emery 1, Rachel P Kolko Conlon 1, Zheng Wang 2, Yu Cheng 2, Marsha D Marcus 1, Kenneth P Perkins 1, Michele D Levine 1
PMCID: PMC7899085  NIHMSID: NIHMS1614206  PMID: 30762404

Abstract

Objective

Smoking and overweight/obesity are preventable causes of disease and death. Women are reluctant to quit smoking because of concerns about postcessation weight gain, underscoring the need to elucidate patterns of weight concerns and associated psychosocial factors that may affect smoking cessation outcomes. The present study aimed to subtype women smokers based on psychosocial and behavioral factors associated with smoking and weight, and examine the utility of these subtypes to predict abstinence and postcessation weight gain.

Methods

Weight-concerned women (N=343) were randomized to one of two smoking cessation counseling adjuncts and one of two cessation medication conditions. At baseline, women were weighed and completed measures of depression, weight/appearance concerns, and eating behaviors. At 3-, 6-, and 12-months following the target quit date, women were weighed and completed self-report and biochemical smoking assessments.

Results

Latent profile (LP) analyses supported a three-profile model. The groups had typical (53%, LP1), minimal (33%, LP2), and high (14%, LP3) levels of depressive symptoms and weight concerns. At 12-months post target quit date, women in LP3 were more likely to relapse than women in LP1 (OR = 2.93). Among abstinent women, those in LP2 and LP3 gained more postcessation weight than those in LP1.

Conclusions

Heterogeneity in symptoms of depression, weight/appearance concerns, and eating behaviors was captured by three groups of women smokers, with unique risks for relapse and postcessation weight gain. The distinct profiles identified may help personalize the delivery of care for smoking cessation and, ultimately, reduce disease risk.

Keywords: Smoking Cessation, Weight Gain, Depression, Feeding Behavior, Patient-Specific Modeling

Cigarette smoking is the leading cause of preventable disease and death in the United States (U.S. Department of Health and Human Services, 2014). Although average rates of smoking have declined over the past fifty years, the high prevalence of smoking-related diseases among women smokers remains a serious public health concern (U.S. Department of Health and Human Services, 2014). Smoking cessation interventions to address the unique needs of women smokers have specifically targeted women’s concerns about postcessation weight gain and depressive symptoms (Torchalla et al., 2012). Although interventions that address these factors demonstrate promising results in the short-term (i.e., 3 to 6 months), abstinence rates decrease significantly over longer-term (i.e., 12 month) follow-up (Torchalla et al., 2012). Further tailoring of smoking cessation programs that accounts for individual differences in factors like weight concerns and mood that are common in women may enhance long-term cessation outcomes. Specifically, characterizing patterns of depressive symptoms, weight concerns, and associated psychosocial factors among women smokers may reveal subgroups of women who are at greater risk for relapse or postcessation weight gain.

Substantial prior research on women smokers has focused on mood and weight concerns as precipitants and maintaining factors for smoking (Pomerleau & Snedecor, 2008; Weinberger et al., 2017) and as targets of smoking cessation intervention (Levine et al., 2010; MacPherson et al., 2010). At least half of women smokers express concerns about potential weight gain after quitting (Pirie, Murray, & Luepker, 1991; Pomerleau, Zucker, & Stewart, 2001), compared to one quarter of men smokers who endorse weight concerns (Clark et al., 2006). Moreover, many women report that these concerns are a barrier to quitting smoking (Pomerleau et al., 2001). In a national survey of women smokers in the United States, 39% of women reported that they would be “very concerned” about gaining weight if they stopped smoking cigarettes that day (Pomerleau et al., 2001). Thus, postcessation weight concerns are common among women smokers and may hinder cessation efforts.

Smoking-related weight concerns are especially common among women smokers who engage in eating behaviors that may be maladaptive (Copeland & Carney, 2003). Relatedly, maladaptive eating behaviors are common in women smokers (Kendzor, Adams, Stewart, Baillie, & Copeland, 2009) and the report of maladaptive eating behaviors affects smoking cessation outcomes. For example, women smokers with restrained eating patterns, who consciously control food intake, report gaining more weight and having shorter quit attempts compared with women smokers without restrained eating patterns (Jarry, Coambs, Polivy, & Herman, 1998). Additionally, women smokers characterized as disinhibited eaters, who tend to consume food in response to emotional or environmental cues rather than physical cues (e.g., hunger), are also more likely to report greater postcessation weight gain (Hudmon, Gritz, Clayton, & Nisenbaum, 1999). Thus, patterns of restrained or disinhibited eating may influence women’s cessation and postcessation weight gain.

Maladaptive eating behaviors are frequently correlated with depressive symptoms (Spoor et al., 2006), another important psychosocial factor related to women’s cessation outcomes. Being a current smoker (Goodwin et al., 2017) and a woman (Salk, Hyde, & Abramson, 2017) are both associated with increased odds of depression. Depressive symptoms are also a risk factor for poor cessation intervention outcomes. Women report heightened levels of depressed mood after quitting (Xu et al., 2008), which has been shown to increase risk for relapse following cessation (Levine, Marcus, & Perkins, 2003; Weinberger et al., 2017). Depressive symptoms have not been rigorously examined as a risk factor for postcessation weight gain, probably because few women with depression maintain abstinence. However, depression is associated with higher weight more generally (Luppino et al., 2010) and may influence postcessation weight gain. Thus, depression is common among women smokers, associated with weight, and a barrier to maintaining abstinence.

Weight concerns, maladaptive eating behaviors, and depression are interrelated and each has been associated with women’s smoking; however, extant research has not simultaneously examined the utility of these behavioral and psychosocial factors in predicting smoking cessation outcomes. Consistent with personalized medicine approaches, we must better understand patterns of co-occurring symptoms to further tailor smoking cessation interventions for women and, ultimately, reduce disease risk. Therefore, we aimed to understand heterogeneity among women smokers by identifying subtypes of women characterized by different levels of depressive symptoms, weight and appearance concerns, and eating behaviors. We hypothesized that if unique subtypes were found, they would relate to abstinence and postcessation weight gain in the context of a smoking cessation randomized clinical trial.

Methods

Participants

Participants were weight-concerned women enrolled in a randomized, double-blind, placebo-controlled quit smoking trial investigating the efficacy of combining a cognitive behavioral therapy for smoking-related weight concerns and bupropion (Levine et al., 2010). Treatment-seeking women were recruited from the general population via posters, advertisements, and mailings. Of the 349 women enrolled in the parent trial, 6 were missing data on all 5 measures used to identify the subtypes of interest and, thus, were excluded from the current study. The 343 women included in the present analysis were between the ages of 18 and 65 years, smoked a minimum of 10 cigarettes per day, and endorsed concern about postcessation weight gain as assessed by the following 2 questions: (1) “How concerned are you about gaining weight after quitting?” and (2) “How concerned would you be if quitting smoking caused you to permanently gain 10 to 15 pounds, the amount typically gained by weight-concerned women after quitting?” (Perkins et al., 2001). To be eligible, women were required to score ≥ 50 on a 1 (not at all) to 100 (extremely) scale on one of these questions. Only two women were excluded for not meeting the weight-concern criteria (Levine et al., 2010).

Procedure

Interested women completed a telephone screening and eligible women were randomly assigned to receive either cognitive behavioral therapy for smoking-related weight concerns or standard cessation treatment without a focus on weight. Women were further randomized to receive bupropion or placebo, resulting in a total of four intervention conditions: (1) weight concerns + bupropion, (2) weight concerns + placebo, (3) standard cessation counseling + bupropion, and (4) standard cessation counseling + placebo. There were no baseline differences in participant characteristics (e.g., age, body mass index [BMI], cigarettes per day) across the four intervention conditions (Levine et al., 2010). All women were offered 12, 90-minute group cessation counseling sessions focused on preparing to quit, the benefits of cessation, coping with smoking urges, and relapse prevention. The cognitive behavioral therapy for weight concerns intervention included additional content related to weight concerns, such as education about cessation-related weight gain and instruction of cognitive strategies to identify and restructure maladaptive thoughts and beliefs. Study medication (bupropion or placebo) was initiated at the second treatment session and a target quit date 10–14 days later was set. Women completed assessments prior to the first treatment session (baseline), and 1-, 3-, and 6- months following their target quit date. The trial was approved by the University of Pittsburgh Institutional Review Board, and women provided written informed consent. The study was conducted between September 1999 and October 2005. Details on the methods and results of the main trial have been previously reported (see Levine et al., 2010).

Assessments

Demographic information

Women reported their age, education, and race/ethnicity at baseline. Women separately reported on their ethnicity (if they identified as Hispanic/Latina) and then described their race from the following categories: White, Black or African American, Asian, American Indian/Alaska Native, and Native Hawaiian or other Pacific Islander.

Depressive symptoms and lifetime Major Depressive Disorder

At baseline, women completed the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a reliable and valid 21-item self-report questionnaire of depressive symptoms (Beck, Steer, & Carbin, 1988). A meta-analysis estimated Cronbach’s alpha to be 0.81 for non-psychiatric patients (Beck et al., 1988). Cronbach’s alpha was 0.89 in this sample. At baseline women also completed a diagnostic interview using the Structured Clinical Interview for DSM-IV Axis I Disorders Non-patient Edition (SCID-I/NP; First et al., 1998). The interview provides Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnoses of lifetime Major Depressive Disorder (MDD). MDD is characterized by one or more Major Depressive Episodes (i.e., at least 2 weeks of depressed mood or loss of interest along with four additional symptoms of depression that cause clinically significant distress or impairment) without a history of Manic, Mixed, or Hypomanic episodes.

Weight and appearance concerns

Given that the sample was recruited to include women with postcessation weight gain concerns, we further characterized women’s general weight and appearance concerns using the reliable and valid Body Esteem Scale for Adolescents and Adults (BESAA; Mendelson, Mendelson, & White, 2001), administered at baseline. The Weight (weight satisfaction; 8 items) and Appearance (general feelings about appearance; 10 items) subscales were used in the current analyses. The authors reported Cronbach’s alphas of 0.93 and 0.95 for Weight and Appearance, respectively (Mendelson et al., 2001). Cronbach’s alphas were 0.91 and 0.89 in this sample. In the current study items were reverse-scored so that higher scores reflect greater weight and appearance concerns.

Eating behaviors

At baseline women completed the Three Factor Eating Questionnaire (TFEQ; Stunkard & Messick, 1985), a reliable and valid self-report scale of eating behaviors. The Restraint and Disinhibition subscales were used in the current analyses due to their assessment of eating behavior. The Restraint subscale (21 items) measures conscious thoughts and behaviors related to restricting calorie intake. The Disinhibition subscale (16 items) reflects a general tendency to consume food in response to emotional or environmental cues rather than physical cues (e.g., hunger). The authors reported Cronbach’s alphas of 0.93 and 0.91 for Restraint and Disinhibition, respectively (Stunkard & Messick, 1985). In the current sample, Cronbach’s alphas were 0.87 and 0.82, respectively.

Smoking history and behavior

Nicotine dependence was assessed at baseline using the Fagerström Test of Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991). Continuous and dichotomous (high dependence ≥ 6) FTND scores were used to describe the subgroups of women. Women also self-reported the current number of cigarettes per day (CPD) and the number of previous quit attempts at baseline.

Smoking-specific weight concerns

Smoking-specific weight concerns were used to test for concurrent validity of the identified subgroups. We would expect that a group with high levels of weight and appearance concerns would also endorse high smoking-specific weight concerns. Women completed the Weight Concerns Scale and the Weight Efficacy After Quitting Scale (Borrelli & Mermelstein, 1998; Perkins et al., 2001) at baseline to assess smoking-specific weight concerns (6 items) and self-efficacy to manage weight after quitting (6 items). The authors reported Cronbach’s alphas of 0.87 and 0.88, respectively (Borelli & Mermelstein, 1998). In this sample, alphas were 0.85 and 0.89, respectively. Women also completed the Weight-Control Smoking Scale at baseline to assess the extent to which individuals perceive smoking as a weight-control tool (Pomerleau et al., 1993). Cronbach’s alpha was 0.86 in both the original sample (Pomerleau et al., 1993) and the current sample.

Additionally, women answered three specific questions about postcessation weight gain at baseline: 1) “How concerned are you that quitting smoking will likely cause a total permanent weight gain of 10–15 pounds or more?”; 2) “How much would a 15-pound weight gain affect your motivation to quit smoking/stay free from smoking?”; and 3) “How much weight would you be willing to gain permanently if you quit smoking?” Women responded to the first two items on a 0 (not at all) to 100 (extremely) Likert rating scale.

Smoking point-prevalence

At 3-, 6-, and 12-months after the target quit date, women were interviewed about smoking using a timeline follow-back format (TLFB; Brown et al., 1998) and expired-air carbon monoxide (CO) was collected. Point-prevalence abstinence was defined as the self-report of no smoking during the 7 days prior to the assessment and a CO reading ≤ 8 ppm (Hughes et al., 2003; Society for Research on Nicotine and Tobacco Subcommittee on Biochemical Verification, 2002). In all cases where self-report or CO indicated smoking, women were coded as relapsed. Women who dropped-out of treatment were considered to have relapsed as of the day following the last visit on which abstinence was verified.

Weight outcome

Women were weighed in personal clothing without shoes prior to each assessment using a Seca 882 digital scale. Precessation weight was computed as the mean of weights at the 3 treatment sessions prior to the target quit date. Postcessation weight change was calculated as the difference between the precessation weight and weight at each assessment (3-, 6-, and 12-months) following the target quit date. Women were categorized as overweight (BMI 25.0–29.9 kg/m2) or obese (BMI ≥ 30 kg/m2) at baseline.

Data-Analytic Plan

Analyses first examined whether a group-based analysis could meaningfully capture individual differences on baseline measures of depressive symptoms, weight and appearance concerns, restrained eating, and disinhibited eating. Latent profile analysis (LPA; Gibson, 1959; Lazarsfeld & Henry, 1968; Masyn, 2013), a probabilistic technique that assumes that overall heterogeneity on continuous indicators results from the existence of two or more distinct latent classes of individuals, was used for this purpose. LPA was used in an exploratory manner because this was the first study to examine latent profiles of these constructs among weight-concerned women smokers. As such, no a priori hypotheses about the number of classes or homogenous subgroups were made.

The number of latent classes was examined iteratively, starting with the null hypothesis of only one latent class and specifying an increasing number of classes. Evaluation of the output for subsequent iterations included interpretability of the results, meaningfulness of the classes, relevant model fit statistics, and parsimony (Masyn, 2013). Model fit was compared using the Bayesian Information Criterion (BIC), entropy (Celeux & Soromenho, 1996), the adjusted Lo-Mendell-Rubin likelihood ratio test of model fit (adjusted LMR-LRT; Lo, Mendell, & Rubin, 2001), and the bootstrapped likelihood ratio test (BLRT; McLachlan & Peel, 2000). Models were estimated in Mplus using full information maximum likelihood for missing data (n = 322 completed the BDI; n = 343 completed all other measures) and maximum likelihood with robust standard errors.

Chi-square and ANOVA were used to characterize the latent profiles further. Chi-square analyses were conducted with latent profile membership and the following dichotomous variables: education, race/ethnicity, and lifetime MDD diagnosis. ANOVAs were run with latent profile membership as the fixed factor and the following dependent variables: age, precessation weight, BMI, CPD, FTND, number of previous quit attempts, smoking cessation-specific weight concerns, self-efficacy to manage weight after quitting, weight control smoking, and the three questions about postcessation weight gain (see Methods section). Post-hoc testing with Bonferroni-adjustments was used to follow-up any significant effects. Analyses were run in SPSS/PASW.

Last, generalized mixed effect models were used to explore whether latent profile membership predicted relapse and postcessation weight gain at 3-, 6- and 12-months after the target quit date, beyond the effects of treatment condition. Based on the results of the latent profile analyses, n-1 theoretically meaningful contrasts were created to be included as predictors in the models. Time and interactions between time and each contrast variable were included as covariates. Treatment condition was represented as a covariate in all models by three variables: therapy group (cognitive behavioral therapy for weight concerns versus standard cessation treatment), medication group (bupropion versus placebo), and the interaction of therapy group and medication group. Women receiving the combination of cognitive behavioral therapy for smoking-related weight concerns and bupropion were the most likely to sustain abstinence at 6-months following the target quit date. There were no differences among abstinent women in postcessation weight gain across intervention conditions (see Levine et al., 2010 for more details).

Relapse analyses were evaluated on an intent-to-treat basis, regardless of medication adherence, treatment received, or nonattendance at follow-up visits. Analyses with postcessation weight gain were only conducted among those maintaining point-prevalent abstinence, given that the resumption of smoking confounds analyses of weight change. Mixed effect models were used to compare the LPA groups in postcessation weight gain, with fixed terms of the aforementioned group contrasts, time, the interaction of the contrasts and time, as well as precessation weight, and participant was included as a random term. Type 1 tests of fixed effects are reported for overall effects and contrasts were set to test profile differences at 3-, 6-, and 12-months following the target quit date. Both generalized mixed models and linear mixed models were run in SAS 9.4.

Results

See Table 1 for demographic information and smoking characteristics for the sample included in the current study (N = 343). On average, the sample consisted of middle-aged, overweight, White Non-Hispanic women who completed some college or technical school, smoked roughly one pack of cigarettes a day, and had three previous quit attempts.

Table 1:

Baseline Characteristics of Overall Sample

Overall Sample (N = 343)
% n
College or more education 33% 116
White Non-Hispanic 86% 295
High nicotine dependence 48% 163
BMI Category
 Overweight 33% 114
 Obese 26% 90
Mean SD
Age, years 41.97 10.20
Weight, pounds 161.04 32.96
BMI 27.34 5.49
Cigarettes per day 20.66 8.46
FTND score 5.18 2.19
Previous auit attempts 3.13 2.59
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Note. SD = standard deviation. High nicotine dependence reflects FTND (Fagerström Test for Nicotine Dependence) ≥ 6. BMI = body mass index. Participants were categorized as overweight when BMI was between 25.0 and 29.9 kg/m2 and were categorized as obese when BMI was ≥ 30 kg/m2. Weight = mean pre-quit weight average.

Latent profile analyses

Evaluation of the model statistics indicated that a three-class model provided the best fit to the data (see Table 2). The four-class model had the lowest BIC; however, the LMR-LRT comparison of the three- and four-class models was not significant, indicating that the four-class model did not fit the data better than the three-class model. The LMR-LRT comparison of the two- and three- class models was significant, indicating that the three-class model fit the data better than the two-class model. For the three-class model, average latent class probabilities for most likely class membership ranged from 88% to 92% and entropy was 0.77.

Table 2:

Latent Profile Analysis Model Fit Indices

Profiles Parameters LL BIC aBIC AIC Adjusted LMR-LRT BLRT Entropy Posterior Probabilities
1 10 −3436.10 6930.58 6898.86 6892.20 .
2 16 −3295.99 6685.39 6634.64 6624.00 p <.001 p <.001 .73 .92–.93
3 22 −3240.30 6609.03 6539.24 6524.60 p = .01 p <.001 .77 .88–.92
4 28 −3208.73 6580.92 6492.09 6473.46 p = .30 p <.001 .81 .86–.90
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Note. LL = Log-likelihood; BIC = Bayesian Information Criterion; aBIC = Sample-size adjusted Bayesian Information Criterion; AIC = Akaike Information Criterion; LMR-LRT = Lo-Mendell-Rubin likelihood ratio test of model fit; BLRT = bootstrapped likelihood ratio test. Smaller values of BIC, aBIC, and AIC indicate better data-model fit. The adjusted LMR-LRT compares the estimated model with a model with one fewer class, and yields a p-value that reflects whether the current model fits the data significantly better than a model with one less class. Higher posterior probabilities and entropy suggest better prediction of latent profile membership and clearer delineation of latent profiles, respectively. The final model is indicated in boldface.

Latent Profile 1 (LP1; n = 180; “Typically Concerned”) endorsed average levels of depressive symptoms, weight and appearance concerns, disinhibition, and restraint for this sample of women. Latent Profile 2 (LP2; n = 114; “Minimally Concerned”) had low depressive symptoms, low weight and appearance concerns, and high disinhibition, relative to the other profiles. Latent Profile 3 (LP3; n = 49; “Highly Concerned”) had elevated depressive symptoms, high weight and appearance concerns, high restraint, and low disinhibition, relative to the other profiles (see Figure 1).

Figure 1.

Figure 1.

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Group differences among three-profile solution using latent profile analysis. LP = latent profile. Error bars indicate +/− 1 standard error of the mean. Rating scale ranges: Depressive symptoms (0–66), Appearance concerns (1–5), Weight concerns (1–5), Restraint (0–21), and Disinhibition (0–19).

Characterization of latent profiles

Demographic, weight, and smoking variables

The profiles did not differ on education, age, FTND score, or previous quit attempts (see Table 3). There was a significant relationship between latent profile membership and race/ethnicity, with the lowest proportion of racial-ethnic minority women in the Highly Concerned group (2%) compared to the Typically Concerned (13%) and Minimally Concerned (21%) groups. African American Non-Hispanic women represented most women in the racial/ethnic minority group. There were main effects of latent profile membership on BMI and CPD. Follow-up testing indicated that Minimally Concerned women had a significantly lower BMI than Typically Concerned women. Highly Concerned women had a higher BMI (most women had obesity) and smoked more CPD compared to Typically Concerned women.

Table 3:

Latent Profile Differences on Baseline Characteristics

LP1, Typically Concerned (n = 180) LP2, Minimally Concerned (n = 114) LP3, Highly Concerned (n = 49)
Demographic, Weight, and Smoking Variables
% n % n % n χ2 p
College or more education 32% 57 37% 42 35% 17 0.86 .652
White Non-Hispanic 87% a 157 79% a 90 98% c 48 9.81 .007
High nicotine dependence* 44% 79 46% 53 63% 31
BMI Cate gory*
 Overweight 38% 68 28% 32 29% 14
 Obese 31% 55 9% 10 51% 25
Mean SD Mean SD Mean SD F p
Age, years 41.52 10.65 42.13 10.01 43.22 8.95 0.56 .571
Weight, pounds 166.17 a 34.07 146.02 b 23.61 177.17 a 34.60 22.38 .001
BMI 28.26 a 5.49 24.65 b 3.94 30.26 c 6.02 26.63 .001
Cigarettes per day 20.24 a 8.02 19.82 a 7.92 24.18 c 9.73 5.28 .006
FTND score 5.09 2.23 5.10 2.01 5.67 2.41 1.47 .233
Previous quit attempts 3.37 2.97 2.90 2.15 2.83 1.83 1.32 .268
Major Depressive Disorder (MDD)
% n % n % n χ2 p
Lifetime MDD diagnosis 25% a 45 14% b 16 31% a 15 7.24 .027
Smoking-Specific Weight Concerns
Mean SD Mean SD Mean SD F p
Weight concerns, 1–10 6.08 a 1.72 6.00 a 2.00 6.56 a 1.92 5.15 .006
Weight self-efficacy, 1–10 5.83 a 1.67 6.22 a 1.72 5.28 a 1.75 5.45 .005
Weight control, 0–10 4.04 a 2.67 3.35 a 2.88 4.57 a 3.01 3.84 .022
“How concerned are you that quitting smoking will likely cause a total permanent weight gain of 10–15 pounds or more?” 0–100 scale 68.23 a 23.92 59.26 b 28.63 73.16 a 23.95 6.55 .002
“How much would a 15-pound weight gain affect your motivation to quit smoking/stay free from smoking?” 0–100 scale 60.02 a 26.53 50.36 b 29.32 60.47 a 30.38 4.54 .011
“How much weight would you be willing to gain permanently if you quit smoking?” 0–20 pounds 5.72 a 3.98 7.25 b 4.05 6.33 a 5.46 4.52 .012
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Note. LP = latent profile; SD = standard deviation. High nicotine dependence reflects FTND (Fagerström Test for Nicotine Dependence) ≥ 6. Weight = pre-quit weight average. BMI = body mass index. Participants were categorized as overweight when BMI was between 25.0 and 29.9 kg/m2 and were categorized as obese when BMI was ≥ 30 kg/m2.

*

Group differences were not examined to decrease family-wise error. Group differences were examined on the continuous measures of FTND and BMI.

a

Indicates that LP2 and/or LP3 are not statistically different from LP1.

b

Indicates that LP2 is statistically different from LP1.

c

Indicates that LP3 is statistically different from LP1.

Lifetime MDD diagnosis

There was a significant relationship between latent profile membership and lifetime MDD. There were significantly fewer Minimally Concerned women with lifetime MDD (14%) compared to Typically Concerned women (25%). Highly Concerned women (31%) did not differ significantly from Typically Concerned women on lifetime MDD.

Smoking-specific weight concerns

There were main effects of latent profile membership on the three measures and three individual items assessing smoking-specific weight concerns (see Table 3). Follow-up tests indicated that, compared to Typically Concerned women, Minimally Concerned women were less concerned that smoking would cause a permanent weight gain of 10–15 pounds or more, reported their motivation to stay quit would be affected less by a 15-pound weight gain after quitting smoking, and reported they would be willing to gain more weight permanently if they quit smoking. Highly Concerned women did not differ significantly from Typically Concerned women on any of the smoking-specific weight concerns measures.

Latent profile membership predicting relapse and postcessation weight gain

See Table 4 for abstinence rates and postcessation weight gain descriptive statistics for each latent profile as well as results from the mixed effects models. We created planned orthogonal contrasts with Typically Concerned women as the reference group. Results from mixed effects models indicated that Minimally Concerned women did not differ from Typically Concerned women in overall relapse rates. As compared to Typically Concerned women, Highly Concerned women were likely to relapse. More specifically, contrasts indicated that Highly Concerned women were more likely to relapse at 12-months following the target quit date, OR = 2.93, 95% confidence interval [1.07, 8.05], p = 0.037, but did not differ at 3- or 6-months following the target quit date.

Table 4:

Point Prevalent Abstinence and Postcessation Weight Gain for the Three Latent Profiles

LP1, Typically Concerned (n = 180) LP2, Minimally Concerned (n = 114) LP3, Highly Concerned (n = 49)
Point prevalent abstinence % n % n % n
3-months 32% 63 31% 35 25% 12
6-months 23% 41 28% 32 16% 8
12-months 24% 43 24% 27 10% 5
LP2 v. LP1 F or t p OR
Overall 0.10 0.753
 3-months 1.06 0.291 1.33
 6-months −0.76 0.445 0.81
 12-months 0.30 0.762 1.09
LP3 v. LP1 F or t p OR
Overall 7.23 0.008
 3-months 1.46 0.145 1.74
 6-months 1.04 0.300 1.57
 12-months 2.09 0.037 2.93
LP1, Typically Concerned (n = 180) LP2, Minimally Concerned (n = 114) LP3, Highly Concerned (n = 49)
Postcessation weight gain* Mean SD n Mean SD n Mean SD n
3-months 4.67 6.11 49 5.39 4.41 28 6.61 8.00 8
6-months 7.08 7.99 38 6.88 8.33 29 13.09 7.93 5
12-months 6.60 10.68 41 10.75 10.85 25 15.44 16.16 5
LP2 v. LP1 F or t p Estimate
Overall 0.52 0.473
 3-months 0.13 0.898 0.26
 6-months 0.30 0.762 0.63
 12-months 1.92 0.058 3.98
LP3 v. LP1 F or t p Estimate
Overall 3.10 0.081
 3-months 1.11 0.268 3.46
 6-months 1.71 0.090 6.18
 12-months 1.94 0.055 7.15
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Note. LP = latent profile; SD = standard deviation. OR = odds ratio.

*

Only examined among women who were abstinent, of whom some did not provide weight information. Weight is presented in pounds. Treatment condition was included as a covariate in all models. Precessation weight was included as a covariate in postcessation weight gain models.

Overall, Minimally Concerned and Highly Concerned women did not differ from Typically Concerned women in postcessation weight gain. However, contrasts revealed that Minimally Concerned women had more postcessation weight gain at 12-months following the target quit date than Typically Concerned women, at a marginal level of significance. This effect was not statistically significant at 3- or 6-months following the target quit date. Contrasts also indicated that Highly Concerned women had more postcessation weight gain than Typically Concerned women specifically at 12-months following the target quit date, at a marginal level of significance; this effect was not significant at 3- or 6-months following the target quit date.

Discussion

The present study was the first to characterize subtypes of weight-concerned women smokers, who comprise more than half of all women who smoke. Most women (53%; Typically Concerned; LP1) endorsed depression, eating, and weight-related symptoms that have been typically reported in previous samples of community women and weight-concerned women smokers (Beck et al., 1988; Levine, Perkins, & Marcus, 2001). In contrast, one third of women (33%; Minimally Concerned; LP2) were distinguished by minimal mood, weight, and appearance concerns. A smaller subset (14%; Highly Concerned; LP3) was characterized by moderate depressive symptoms and high levels of weight and appearance concerns. The three groups also differed on BMI, race/ethnicity, cigarettes per day, lifetime MDD diagnosis, and smoking-specific weight concerns, as discussed further below. Moreover, group membership predicted relapse and postcessation weight gain, with women in the two less common groups (Minimally Concerned and Highly Concerned) demonstrating worse cessation-related outcomes at 12 months after the target quit date.

Highly Concerned Women Smokers, Latent Profile 3

The small group of women classified as Highly Concerned were, on average, women who had mild to moderate depressive symptoms (Beck et al., 1988) and levels of weight and appearance concerns similar to those reported by women with eating disorders (Keating, Tasca, & Hill, 2013). Consistent with extant research on women smokers with high levels of weight concerns (Levine, Bush, Magnusson, Cheng, & Chen, 2013; Pomerleau et al., 2001), Highly Concerned women were mostly White Non-Hispanic, a large percentage had obesity, and most smoked more than one pack of cigarettes per day. Highly Concerned women also endorsed the highest level of restrained eating in this study; however, this level was comparable to restrained eating in other non-clinical samples of women (Hays & Roberts, 2008; Kruger, De Bray, Beck, Conlon, & Stonehouse, 2016; Provencher, Drapeau, Tremblay, Despres, & Lemieux, 2003).

The profile of moderate depressive symptoms and high weight concerns in the context of obesity and high numbers of cigarettes smoked per day suggests that this relatively small group of Highly Concerned women may be especially vulnerable to poor smoking cessation outcomes. Indeed, Highly Concerned women were almost three times more likely to relapse at 12-months following the target quit date compared to Typically Concerned women, with only 10% of Highly Concerned women maintaining abstinence at 12-months. Although the specific mechanisms contributing to these women’s higher risk of relapse are unknown, their moderate depressive symptoms and elevated concern about postcessation weight gain may decrease their chances of successful smoking cessation.

Moreover, at 12-months following the target quit date, the few Highly Concerned women who maintained abstinence gained an average of 15 pounds, more than two times the amount of postcessation weight gained by Typically Concerned women. This finding is consistent with research documenting that heavy smokers and smokers with obesity are at risk for greater than average postcessation weight gain (Veldheer, Yingst, Zhu, & Foulds, 2015). Postcessation weight gain places Highly Concerned women at greater prospective risk for developing cardiometabolic diseases, such as type 2 diabetes (Yeh, Duncan, Schmidt, Wang, & Brancati, 2010); however, maintaining abstinence can mitigate some of these health risks. Unfortunately, experiencing high rates of weight gain may be another reason for Highly Concerned women to resume smoking.

Notably, Highly Concerned women did not differ from Typically Concerned women on smoking-specific weight concerns or lifetime MDD, highlighting the utility of considering individual differences in current depressive symptoms and general weight concerns to elucidate subgroups of weight-concerned women smokers who are at greater than average risk for relapse and postcessation weight gain. Thus, women smokers with obesity, moderate depressive symptoms, and high levels of weight concerns are on a trajectory towards poor cessation outcomes and continued disease risk. Future research is needed to determine the optimal cessation intervention for a Highly Concerned woman. For example, more intensive treatment and possibly medication management could be advantageous in addressing the multiple co-occurring symptoms.

Minimally Concerned Women Smokers, Latent Profile 2

One out of three weight-concerned women smokers was characterized as Minimally Concerned. On average, Minimally Concerned women had normal weight, endorsed minimal depressive symptoms (Beck et al., 1988), and the prevalence of lifetime MDD was lower than that expected among national samples of women (Kessler et al., 2010). These women also had minimal levels of weight and appearance concerns, levels that were lower than those reported by community samples of women (Therrien et al., 2008). Minimally Concerned women also reported the lowest levels of smoking-specific weight concerns among the overall group of weight-concerned women smokers. Surprisingly, Minimally Concerned women endorsed the highest levels of disinhibited eating compared to women in the other two groups, though disinhibited eating was not endorsed at clinically significant levels (Marcus, Wing, & Lamparski, 1985; Wadden, Foster, Letizia, & Wilk, 1993). The implications of this finding are unclear. Disinhibited eating is usually positively related to weight, particularly in clinical samples (Bryant, King, & Blundell, 2008). Some authors have suggested that disinhibition can be considered to reflect opportunistic eating or uncontrolled eating among women (Bryant, King, & Blundell, 2008; Yeomans, Leitch, & Mobini). Thus, the disinhibited eating patterns endorsed by Minimally Concerned women may reflect that these women are simply less weight-concerned and engage in uncontrolled eating, which may have implications for postcessation weight gain.

Among women who maintained abstinence, Minimally Concerned women gained an average of 11 pounds at 12-months following the target quit date, more than 1.5 times the amount of postcessation weight gained by Typically Concerned women. Minimally Concerned women may have been susceptible to overeating after they quit smoking given their tendency toward disinhibited eating and their relatively low postcessation weight concerns. Thus, women smokers with normal weight and minimal depressive symptoms who are less weight-concerned are vulnerable to greater than average postcessation weight gain. It should be noted, however, that these Minimally Concerned women were not at greater risk for relapse compared to Typically Concerned women.

Future research is needed to determine the optimal cessation intervention for a Minimally Concerned woman. Most smoking interventions that target women focus on postcessation weight gain concerns and depressive symptoms, and women in the Minimally Concerned subgroup reported very few depressive symptoms despite being recruited for weight concerns. Therefore, Minimally Concerned women may benefit from a more standard behavioral smoking intervention that provides additional psychoeducation on postcessation weight gain and the associated health consequences.

Limitations and Future Directions

There are several limitations to the present study worth noting. First, the specificity of the sample limits the generalizability of the results. Although most women smokers are weight-concerned (Pomerleau et al., 2001), one limitation of these findings is that they are specifically applicable to women who express postcessation weight concerns. Thus, the findings cannot be generalized to men smokers who have weight concerns. Future research is warranted to characterize men smokers based on unique psychosocial, behavioral, and/or other factors associated with smoking and weight gain for men. It also is important to conduct future studies that include a more representative sample with regard to race/ethnicity and take racial/ethnic differences in postcessation weight gain concerns into account (Pomerleau, Zucker, Namenek Brouwer, Pomerleau, & Stewart, 2001). Although the Highly Concerned women were more likely to be White Non-Hispanic, the current sample consisted predominantly of White Non-Hispanic women, limiting our understanding of the relationship between race/ethnicity and subtypes of women smokers. Research examining women who have attempted to quit more recently is also needed as the data for the current study were collected between 1999 and 2005 and data on changes in the amount, types, and characteristics of smokers have changed over time (Ng et al., 2014). Last, information on weight gain was only available for women with point-prevalence abstinence. As such, the findings on weight gain may not be fully representative of the larger sample. To more comprehensively describe patterns of weight change in relation to smoking, future research should examine weight change among women who return to smoking and among women who maintain prolonged abstinence.

The current findings highlight the utility of using brief, self-report measures to elucidate patterns of depression, weight and appearance concerns, and eating behaviors among women smokers that are associated with cessation outcomes. In future investigations, it will be important to consider that the identified subtypes are unique to each sample. The number of subtypes and patterns of depressive symptoms, eating-, and weight-related concerns in each subtype may differ from those found in the current study and could therefore further inform distinct approaches to tailoring smoking cessation interventions for women.

Moreover, additional investigations with larger sample sizes are needed to examine the optimal smoking cessation treatment for a woman based on her profile of depressive symptoms, weight and appearance concerns, and eating behaviors. The current study was not powered to examine the relationship between subtype and treatment condition. For instance, we could not examine if, among the Highly Concerned women, those who received bupropion had better cessation outcomes than those who received the placebo. These studies are important to guide tailoring of smoking cessation interventions to fit the unique symptom profiles of women smokers.

Conclusions

Smoking and overweight/obesity are associated with significant disease risks. Women have great difficulty quitting smoking and gain postcessation weight that may impact their quit success. The current study identified subgroups of weight-concerned women smokers who were at greater than average risk for relapse and/or postcessation weight gain. The three distinct groups identified may help personalize the delivery of care for weight-concerned women smokers based on responses to short self-report questionnaires of depressive symptoms, weight and appearance concerns, and eating behaviors. In particular, these results highlight the significant disease risks for women smokers with obesity, high weight and appearance concerns, and moderate depressive symptoms, and call for focus on developing personalized adjunct interventions for this vulnerable group of women.

Acknowledgments

This material is based upon work supported by the following: R01 DA 04174 from the National Institute on Drug Abuse (Marcus), T32MH018269, T32HL007560, and T32HL82610.

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