Fear and Loathing: Nicotine, Tobacco, and Obesity

Dialing up emotions about health can be very unhelpful. Especially if the goal is to make good decisions and good policy. But today, we have many examples of strong emotions getting in the way of clear thinking about public health. Face masks and vaccination come to mind. Nicotine, tobacco, and obesity are also subjects that arouse strong feelings. These three subjects came together in a recent paper on the relationship between smoking, vaping, and BMI.

Mohammed Alqahtani and colleagues found that e-cigarette use correlates with a lower BMI, just as cigarette smoking does. This raises issues. Weight gain is a concern for many people who want to quit smoking. Some people use e-cigarettes because of concern about gaining weight if they quit using nicotine. Is this good or bad? The authors sidestep the issue:

“Results from this study should not be interpreted as warranting the use of e‐cigarettes for its potential effects on weight.”

The Relationship Between Nicotine and Body Mass

The findings by Alqahtani et al are not especially surprising. They looked at health records for 965 patients and confirmed what nicotine and tobacco researchers already knew. Smoking correlates with a lower BMI. But the reason for this study was to test the hypothesis that vaping would show a similar association. And the analysis confirmed this hypothesis:

“Both e‐cigarette and conventional tobacco use were inversely and significantly associated with BMI, after controlling for age, sex, race/ethnicity, and educational attainment.”

A Significant Concern for Nicotine Users

Fear of gaining weight discourages some persons from quitting cigarette smoking. However, the rise of e-cigarette use has corresponded with historic lows in rates of smoking. In fact, a recent study in the NEJM showed that e-cigarettes are more effective than nicotine replacement therapy (patches, gum, etc.)  for helping people quit smoking – almost twice as effective.

There’s a catch, though. When people quit smoking with e-cigarettes, they’re more likely to keep using them. After a year, 80 percent of the subjects who successfully quit smoking in the e-cigarette group were still using the e-cigarettes. In the nicotine replacement group, only nine percent of successful quitters were still using patches, gum, or lozenges a year later.

Pragmatic Decisions

There’s a pretty clear consensus that e-cigarettes are safer than smoking. Yet people still argue about recommending e-cigarettes to help people quit smoking. Questions about long-term safety are some of the more prominent reasons cited in the controversy. But strong feelings about nicotine are quite clearly part of the picture. Nicotine bad, abstinence good. It’s a simple moral equation.

Add in a third factor – obesity – and the conversation gets even harder. About 13 percent of e-cigarette users cite concerns about body weight as a reason for vaping. Of course, there’s a cultural bias that people ought to control their weight by eating less and moving more. But the biological reality of obesity is that it’s not as simple as that.

So it’s not surprising that people are vaping to avoid gaining weight when they quit smoking. Equally unsurprising is the moralistic clucking about the dangers of vaping. Thus, regular people have a pragmatic dilemma. What should I fear most – cigarettes, vaping, or weight gain?

Nicotine, tobacco, and obesity inspire strong emotions, but that does not bring good decisions or good public health policies. A bit more objectivity would help.

Click here for the Alqahtani paper. For more perspective on the debates about vaping, click here and here. For background on tobacco, nicotine, and body weight, click here.

Tobacco Pipes and a Brazier, painting by Pieter Claesz / WikiArt

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May 2, 2021