Smoking Cessation, Weight Gain, and. Changes in Cardiovascular Risk Factors during Menopause: The Healthy Women. Study. M. Michele Burnette, PhD, MPH ...
Public Health Briefs 18. Ewing JA, Rouse BA. Identifying the hidden alcoholic. Presented at the 29th International Congress on Alcoholism and Drug Dependence, February 1970, Sydney, Australia. 19. Institute of Medicine, Division of Mental Health
and Behavioral Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press; 1990. 20. Saunders JB, Aasland OG, Babor TF, de la Fuenta JR, Grant M. Development of the
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Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption-I1. Addiction. 1993;88:791-804.
Smoking Cessation, Weight Gain, and Changes in Cardiovascular Risk Factors during Menopause: The Healthy Women Study
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M. Michele Burnette, PhD, MPH, Elaine Meilahn, DrPH, Rena R. Wing, PhD, and Lewis H. Kuller, MD, DrPH
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Introduction
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From perimenopause to postmenopause, weight and other cardiovascular risk factors increase, resulting in an increased prevalence of atherosclerosis and subsequent clinical cardiovascular disease.' Thus, potential benefits of reducing coronary heart disease risks might make smoking cessation most important during this time. Altematively, the effects of cessation of~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~fon weight may contribute to alreadyincreasing weight from perimenopause to t*j jj-_t postmenopause. The present study examined the relationship between smoking cessation and weight gain from premenopause to the first and second years postmenopause in particii. ., ,?. ,T,*,,eR! . . j;*,,*, . X:;.: . . . . s:.:i pants of the Healthy Women Study, the first prospective study to track individual women through menopause measuring n~c. i ,,,, .w.h , , .., coronary heart disease risk factor changes. j~~it~r *.~~cig~A gaii~ but with It was expected that women who maintained cessation for 2 years postmenopause would experience substantially more weight gain than either continuing smokers or non........ .~~~~ ~~~~~~~~~ ~~~~ b smokers but that their coronary heart disease risk factors would not increase substantially more than either smokers' or _ei........
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Methods Participants
Subjects were participants in the Healthy Women Study. Five hundred fortyone women were initially entered into the Healthy Women Study between 1983 and 1984. Recruitment procedures and inclu-
sion/exclusion criteria have been reported elsewhere.' Nonsmokers reported that they did not smoke at either the premenopausal baseline clinic visit or at 1- and 2-year postmenopausal visits. Nonsmokers at baseline for whom no follow-up data were available were assumed to be continuing nonsmokers and were included in the baseline analyses. Continuing smokers reported smoking at all three assessments. Baseline smokers for whom data were unavailable at postmenopausal visits were assumed to be continuing smokers and were included in the baseline analyses. Baseline smokers who reported quitting at only one follow-up assessment were considered continuing smokers. Ex-smokers included only those participants who reported smoking at baseline and reported not smoking at years 1 and 2 postmenopause. Groups did not differ by age or race. However, nonsmokers were more likely to be married and to have a college degree or higher, and a greater percentage of nonsmokers and ex-smokers than continuing smokers had household incomes of $50 000 or greater. M. Michele Burnette, Elaine Meilahn, and Lewis H. Kuller are with the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pa. Rena R. Wing is with the Department of Psychiatry, Western Psychiatric Institute and Clinic, University of
Pittsburgh. Requests for reprints should be sent to Lewis H. Kuller, MD, DrPH, University of Pittsburgh, Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA 15261. This paper was accepted May 6, 1997.
American Journal of Public Health 93
Public Health Briefs
Baseline analyses included 375 nonsmokers, 133 continuous smokers, and 33 ex-smokers who reported that they quit smoking at some point before the first-year postmenopausal visit and were not smoking at the second-year postmenopausal visit. Thirty-one percent of the sample smoked at baseline, and only 20% of all smokers reported that they quit smoking at the first and second postmenopausal assessments. Subsequent analyses of follow-up risk factors excluded participants who were premenopausal or perimenopausal (0.4% at both the first and second follow ups), and those who died (.4% at first and .6% at second follow up) or dropped out (6% at first and 7% at second follow up). Some participants, whose data were included, provided paper-and-pencil information only (13% at first and 20% at second follow up). Repeated prompts by phone and mail were employed to encourage full participation in the follow-up assessments. Procedures Participants were assessed for smoking status after eligibility for the study had been established and again at 1 and 2 years postmenopause. Monthly menses were tracked via postcards completed by the participants. Follow-up assessment was scheduled with a participant when she reported one of the following regarding menstruation: (1) cessation for 12 months, (2) cessation followed by hormone replacement therapy for a combined total of 12 months, or (3) no cessation
of hormone replacement therapy for 12 months. The present study used data on weight, height, fasting glucose, insulin, systolic blood pressure, diastolic blood pressure, cigarettes per day, total cholesterol, highdensity lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol, triglycerides, calorie expenditure, and alcohol intake. A previously published investigation used Healthy Women Study data to assess the relationship of smoking status at entry and year 3 to nutrient intake, alcohol consumption, and energy expenditure.2 and
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Results Baseline Comparisons
Comparisons of nonsmokers with all smokers (smokers and future ex-smokers combined) for each dependent variable at baseline are summarized in Table 1. The groups did not differ statistically on weight, height, fasting glucose, insulin, systolic blood pressure, or diastolic blood pressure. However, nonsmokers had significantly higher HDL cholesterol (n = 372, mean = 60.99) and calorie expenditure (n = 375, mean= 1522.07) levels than smokers (HDL: n = 165, mean= 55.49; calories: n = 165, mean = 1199.56). Furthermore, nonsmokers had significantly lower total cholesterol (n= 372, mean = 182.11), LDL cholesterol (n = 372, mean = 105.21), and triglyceride (n = 372, mean = 79.56) levels than smokers
(total cholesterol: n = 165, mean= 189.81; LDL cholesterol: n= 165, mean= 115.68; triglycerides: n = 165, mean = 93.20). Finally, nonsmokers consumed significantly less alcohol (n = 375, mean = 7.48) than smokers (n= 166, mean= 10.79). The baseline data for nonsmokers, continuing smokers, and those who quit after baseline are also summarized in Table 1. There were no statistically significant group differences for weight, fasting glucose, 2hour glucose, insulin, or systolic blood pressure. Diastolic blood pressure differences approached significance (P =.054). Group differences were found for total cholesterol; Newman-Keuls analyses indicated that continuing smokers' cholesterol levels (n = 132, mean= 189.59 mg/dL) were statistically higher than nonsmokers' levels (n = 372, mean = 182.11 mg/dL). In addition, HDL cholesterol levels of continuing smokers (n= 132, mean= 55.55 mg/dL) and those who quit after baseline (n = 33, mean = 55.25 mg/dL) were significantly lower than nonsmokers' levels (n = 372, mean = 60.99 mg/dL), and LDL cholesterol and triglyceride levels of continuing smokers (LDL:n = 132, mean= 115.53 mg/dL; triglycerides: n= 132, mean = 92.57 mg/dL) were significantly higher than nonsmokers' levels (LDL: n = 372, mean= 105.21 mg/dL; triglycerides: n=372, mean= 79.56 mg/dL). Calorie expenditure was significantly lower for continuing smokers (n= 133, mean= 1106.26) than for nonsmokers (n = 375, mean = 1522.07). Finally, nonsmokers consumed significantly less alcohol (n = 375, mean = 7.48 g) than either continuing smokers (n = 133,
TABLE 1-Analyses of Variance Results Comparing Baseline Means on Biological Measures: Healthy Women Study, 1983184
Weight, lb Height, in Fasting glucose, mg/dL Insulin, pg/dL Systolic blood pressure, mm Hg Diastolic blood pressure, mm Hg Cigarettes per day Total cholesterol, mg/dL HDL cholesterol, mg/dL LDL cholesterol, mg/dL Triglycerides, mg/dL Calorie expenditure Alcohol intake, g
NS, Mean ± SD (n)
AS,
CS,
XS,
Mean ± SD (n)
Mean ± SD (n)
Mean ± SD (n)
147.08 ± 27.72 (374) 64.40 ± 2.40 (374) 87.71 ± 19.82 (371) 8.45 ± 5.86 (370) 109.70 ± 12.20 (375) 73.03 ± 8.06 (375) 0.0 ± 0(375) 182.11 ± 30.90 (372) 60.99 ± 13.62 (372) 105.21 ± 28.34 (372) 79.56 ± 45.87 (372) 1522.07 ± 1807.19 (375) 7.48 ± 9.48 (375)
143.67 ± 30.51 (166) 64.21 ± 2.30 (166) 87.26 ±11.46 (165) 8.53 ± 6.26 (165) 109.05 ± 13.47 (166) 71.98 ±8.83 (166) 18.63 ± 11.99 (166)'***** 189.81 ± 32.75 (165)a** 55.49 ± 12.78 (165)a***** 115.68 ± 31.71 (1 65)a*** 93.2 ± 49.79 (165)a*** 1199.56 ± 1148.45 (165)a*
10.79 ± 11.82 (166)a***
143.09 ± 31.18 (33) 143.81 ± 30.46 (133) 63.74 ± 2.48 (33) 64.32 ± 2.25 (133) 89.33 ±1.75 (33) 86.74 ± 11.76 (132) 10.18 ± 9.76 (33) 8.12 ± 4.99 (132) 105.91 ± 12.88 (33) 109.83 ± 13.55 (133) 69.39 ± 9.41 (33) 72.62 ± 8.60 (133) 15.52 ± 12.56 (33)t**** 19.41 ±11.78 (133) 190.70 ±38.13 (33)b* 189.59 ± 31.42 (132) 55.25 ± 12.60 (33)b**** 55.55 ±12.87 (132) 116.30 ± 37.54 (33)b*** 115.53 ± 30.24 (132) 95.73 ± 63.88 (33)b*** 92.57 ± 45.88 (132) 1106.26 ± 1121.33 (133) 1587.33 ± 1196.29 (32)b* 11.87 ± 9.90 (33)b*** 10.52 ± 12.27 (133)
Note. NS = nonsmokers; AS = all smokers; CS = smokers who continued through second year postmenopause; XS = baseline smokers who reported quitting at years 1 and 2 postmenopause. aNS vs AS. bNS vs CS vs XS. *P
