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Smoking Nicotine in Eating Disorders

smoking and eating disordersWe all know by now that smoking is bad for you. It is bad in almost every conceivable way insofar as your health is concerned. Yet, we also know by now that we should keep an eye on our weight, that being overweight or obese is just as bad for you as smoking. Unfortunately, some have decided that the best way to watch their weight is through a haze of smoke. Smoking is known to be an appetite suppressant and, in some people, can be an effective, if highly undesirable, means of weight control. And it gets worse. Many of those people who have adopted smoking as a means of weight control are not innocently keeping excessive weight off. Many – most of them young women – are adding smoking to an already existing eating disorder, such as anorexia nervosa. In such a case, the subject has co-occurring disorders: eating disorder and a nicotine habit. The National Centre on Addiction and Substance Abuse in Canada has declared that young women using cigarette smoking to suppress their appetites are among the largest group of new nicotine addicts.

Smoking for Weight Control

A study in 2006 sponsored by the University of North Carolina Department of Psychiatry looked into this problem. Led by Doris Anzengruber of UNC, the researchers published their findings in “Smoking in eating disorders,” an article in the November 2006 issue of the journal Eating Behaviors. The researchers began with the assumption that smoking had been reported to be used for weight control in eating disorders in general but that insufficient research had been done on smoking across the various types of eating disorders. Their goal, therefore, was to investigate the smoking behavior of a large, well-defined sample of women. They sought to find the relationship between smoking, the various subtypes of eating disorder, and distinct personality traits. Their main assumptions at the outset were the following:

  • Subjects with eating disorders would be found to smoke more than those in the control group.
  • Subjects with the bulimic subtypes would smoke more than those with the restricting subtypes.
  • Those subjects with eating disorders would be primarily motivated by weight control, and therefore would exhibit less dependence on nicotine than the controls.
  • Subjects with eating disorders who smoke would grade higher on the impulsivity scale than those who do not smoke.
  • Subjects who smoked, in particular current smokers, would have lower body mass indexes than the non-smokers.

A total of 1,524 women were studied, including some diagnosed with various types of eating disorders, plus a control group without eating disorders:

  • 306 with anorexia nervosa of the food-restricting type
  • 186 with anorexia nervosa of the purging type
  • 180 with both anorexia nervosa and bulimia nervosa
  • 107 with bingeing disorder
  • 71 with purging disorder (non-bingeing)
  • 674 without an eating disorder

Recent Studies

Results of the Study

Those subjects with eating disorders of any type had higher rates of smoking as well as greater nicotine dependence than the controls.

Subjects with the bingeing and purging subtypes had the highest rates of smoking of all. Smoking in eating disorders was found to be related to impulsivity. As the researchers had hypothesized, those subjects in the bingeing and purging subgroups did in fact smoke more than either the controls or the restriction subgroup. All the subjects, those with eating disorders and those without, tended to have begun smoking around the same age (16 to 17), and those with eating disorders most commonly began smoking after the first onset of the disorder. The researchers’ hypothesis that smokers in the control group would have greater nicotine dependence than those in the eating disorder group was not confirmed. The eating disorder group exhibited greater nicotine dependence; they smoked more cigarettes, smoked in the morning, and had more difficulty not smoking and in foregoing the first cigarette of the day. Except for subjects with the restricting subtype of anorexia, subjects with eating disorders of all the subtypes, including the bingers and purgers, graded out higher on the nicotine dependence scale than the controls. The researchers offer as a tentative explanation for this surprising discovery that perhaps these results indicate a tendency for bulimic women to be at greater risk for all substance abuse disorders and problems with impulse control. They offer as substantiation the high scores on impulsivity among the smokers.

Although most of the eating disorder group of all subtypes smoked more than the controls, an important exception was the restrictive anorexics, whose scores were not significantly different from the controls’.

The researchers point out that other studies have uncovered similar results regarding the comparatively lower levels of impulsivity among subjects in that eating disorder subgroup. The researchers’ hypothesis about body mass index was somewhat confirmed. They had reasoned that subjects with eating disorders who smoked, in particular current smokers, would have lower body mass indexes than those who did not smoke. As it turned out, both the current smokers and the non-smokers had lower BMI than the former smokers, perhaps confirming the long-held supposition that smoking cessation results in weight gain. In attempting to quit smoking, both the subjects with eating disorders and the controls tended to quit at similar rates. Interestingly, those who had attempts of seven days or longer, rated high on the self-directedness scale (meaning they tend to accept responsibility for their choices and were resourceful and self-accepting). A high degree of self-directedness, the researchers state, is predictive of success in treatment of bulimia as well as depression.

The researchers conclude that therapeutic methods designed to enhance self-directedness might be useful both in quitting smoking and in recovering from an eating disorder. They summarize by stating that smoking is a significant health problem, especially for women with eating disorders, and that it might require novel prevention and treatment techniques.

Health care providers should monitor patients with eating disorders for signs that they are beginning a smoking habit.  The study authors point out that their finding of higher nicotine dependence in patients with eating disorders, contrary to their assumption, may indicate a need for follow-up studies to look at the effect that nicotine dependence might have on treatment.

Canadian-British Study

A joint Canadian-British study in the late 1990s, headed by Dr. Arthur Crisp, was written up in the British Postgraduate Medical Journal, in an article titled “Smoking and Pursuit of Thinness in Schoolgirls in London and Ottawa.” This study surveyed evaluated 1,936 girls in London and 832 girls in Ottawa. The girls’ ages ranged from 11 to 18.

The study examined the relationship between BMI and the subjects’ responses to a questionnaire regarding such topics as:

  • Smoking
  • Consumption of alcohol
  • Moods
  • Weight changes
  • Their attitudes to body weight
  • Eating habits
  • Menstruation

Most of the subjects surveyed, regardless of their weight, wanted to be thinner than what they were. After overeating, they were twice as likely to vomit frequently. Around 20 percent of all the girls surveyed smoked; those who smoked the most were the 15-year-old and 16-year-old girls. This was true in both the London and Ottawa groups. Most of the girls had taken up smoking after starting menstruation, a period when changes in body shape often lead to concerns about weight. Nearly a third of all the girls assumed that if they quit smoking they would eat more and gain weight. The subjects who smoke reported having lost at least 14 pounds since puberty, to which they gave credit to their smoking. The researchers stated that many girls have concluded that smoking can help keep them thin. Unfortunately, they say, the girls are right. However, according to one of the study’s authors, the girls were “trading pounds for years off their life.” Professor Gordon McVie, the director general of the Cancer Research Campaign, which sponsored the study, was quoted as saying, “This study portrays a desperately sad picture of teenage girls’ self-image and their unsuccessful attempts to attain an idealized, lower weight. But smoking is not the way to do it.” Perhaps the most significant finding of this study is that so many young girls, in Ottawa, London, and no doubt elsewhere in much of the world, have such poor self-image that they are willing, in the face of unassailable scientific and medical evidence, to take up a dangerous habit for the sake of losing a few pounds. As a matter of fact, they are adopting two very risky habits, for the sake of appearance: smoking and the eating disorder behaviors. Either can be potentially lethal. Together, they are disastrous.

Food for Thought

Finally, we mention a 2003 report published by the National Center on Addiction and Substance Abuse at Columbia University, entitled “Food for Thought: Substance Abuse and Eating Disorders.” This report was the first comprehensive look at the connection between eating disorders and the consumption of a whole range of substances: not just tobacco, but caffeine, alcohol, emetics, diuretics, laxatives, amphetamines, heroin and cocaine, all of which have been used by women to suppress their appetites and lose weight.

The report emphasizes that the mental health community, policymakers, and parents need to do more to educate children, particularly girls but also boys as well, about the importance of a positive self-image.

The report’s authors conclude that more treatment options need to be provided for patients with co-occurring substance abuse and eating disorders.

Effective Treatment for Multiple Disorders

Often when eating disorders are an issue, there are other co-occurring disorders that must be addressed during treatment in order for there to be any real progress in recovery. For example, researchers are finding more and more that use of harmful substances – including but not limited to tobacco – all too often goes hand in hand with eating disorders. Drug and alcohol abuse can quickly turn into addiction and can bring with it a host of problems of its own. Additionally, mental health disorders are exceedingly common among those who struggle with eating disorders.

It’s not uncommon to find symptoms of any one or more of the following issues:

  • Depression
  • Anxiety
  • Trauma

All of these can exacerbate or may even be the cause of the eating disorder; additionally, smoking is often connected to these disorders as well. No matter what combination of symptoms or disorders is in evidence in a patient, it is important that the treatment program addresses all of them at the same time and not attempt to focus first on one then another. If you or someone you love is affected by any of the disorders described above, please contact our trained staff here at Futures at the number provided. We’re here to assist you.