Discussion

Previous studies have shown that smokers’ concerns about weight gain after smoking cessation are associated with being less likely to want to quit smoking (Aubin et al., Reference Aubin, Berlin, Smadja and West2009; Jeffery et al., Reference Jeffery, Hennrikus, Lando, Murray and Liu2000). Moreover, racial differences in perceptions about ideal body weight and its relationship with health may influence the impact of weight on readiness to quit smoking amongst African-Americans. Our study showed that regardless of actual weight, the perception of being above one's ideal weight is associated with increased readiness to quit smoking amongst whites. However, this effect was not observed amongst African-Americans. These results suggest that weight awareness may be used to motivate white smokers to engage in cessation efforts but that different strategies may be more effective for African-American smokers.

Prior research has suggested that some smokers may be reluctant to quit smoking because they are concerned about subsequent weight gain (Levine, Bush, Magnusson, Cheng, & Chen, Reference Levine, Bush, Magnusson, Cheng and Chen2013; Pisinger & Jorgensen, Reference Pisinger and Jorgensen2007; Twardella et al., Reference Twardella, Loew, Rothenbacher, Stegmaier, Ziegler and Brenner2006; Weekley, Klesges, & Reylea, Reference Weekley, Klesges and Reylea1992). Those who already perceive themselves to be overweight may be even more reluctant to quit smoking due to fears of post-cessation weight gain. In particular, women are less likely to accept the possibility of weight gain after quitting smoking and are more concerned than men about post-cessation weight gain (Baha & Le Faou, Reference Baha and Le Faou2013; Levine et al., Reference Levine, Bush, Magnusson, Cheng and Chen2013; Pomerleau & Kurth, Reference Pomerleau and Kurth1996). Consequently, women smokers who perceive themselves as being above their ideal weight may be less likely to want to quit smoking. Our study contradicts these findings by suggesting that weight concerns, at least amongst white smokers, may be a motivation to discontinue smoking. Moreover, we did not find a relationship between gender and readiness to quit, nor did we observe an interaction between gender and weight perception with regards to readiness to quit. Potential reasons for our findings may be related to differences in the study populations and/or random sampling variability. Whilst we did not explore the factors mediating the relationship between weight and attitudes towards smoking cessation, it is possible that smokers who perceive themselves to be above their ideal weight are more health conscious overall and may recognise the combined detrimental effects of obesity and smoking on their health.

Consistent with prior studies, we also found that African-Americans were more likely to be ready to quit (Daza et al., Reference Daza, Cofta-Woerpel, Mazas, Fouladi, Cinciripini and Gritz2006; Rayens, Hahn, Fernander, & Okoli, Reference Rayens, Hahn, Fernander and Okoli2013). African-American smokers have also been found to be more confident they can successfully quit smoking, but despite this, they are less likely to be successful maintaining long-term smoking cessation (Cokkinides et al., Reference Cokkinides, Halpern, Barbeau, Ward and Thun2008; Fu et al., Reference Fu, Kodl, Joseph, Hatsukami, Johnson and Breslau2008; Houston, Scarinci, Person, & Greene, Reference Houston, Scarinci, Person and Greene2005; Trinidad et al., Reference Trinidad, Perez-Stable, White, Emery and Messer2011). African-Americans are less likely to use nicotine replacement therapy, possibly because they may not believe it to be effective (Hendricks et al., Reference Hendricks, Westmaas, Ta Park, Thorne, Wood and Baker2014; Ryan, Garrett-Mayer, Alberg, Cartmell, & Carpenter, Reference Ryan, Garrett-Mayer, Alberg, Cartmell and Carpenter2011). However, a recent Veterans Affairs smoking cessation trial found that quit rates for African-Americans can be higher than whites in a system with equivalent access to care and medications (Burgess et al., Reference Burgess, van Ryn, Noorbaloochi, Clothier, Taylor and Sherman2014). Thus, if smoking cessation services are targeted to reach minorities, African-Americans may be more successful at quitting, especially given their baseline greater motivation to quit.

We also showed that the influence of weight perception on readiness to quit is different for white vs. African-American smokers. Prior literature has found that compared to whites, African-Americans are less likely to perceive themselves as overweight, regardless of actual BMI, and are more likely to report higher ideal weights (Dorsey et al., Reference Dorsey, Eberhardt and Ogden2009; Langellier et al., Reference Langellier, Glik, Orega and Prelip2015; Maynard, Serdula, Galuska, Gillespie, & Mokdad, Reference Maynard, Serdula, Galuska, Gillespie and Mokdad2006; Squiers et al., Reference Squiers, Renaud, McCormack, Tzeng, Bann and Williams2014). Furthermore, in one study, African-American smokers who perceived themselves to be overweight were more likely to have depressive symptoms and greater stress whilst trying to lose weight (Lee et al., Reference Lee, Harris, Catley, Shostrom, Choi and Mayo2005). Consequently, African-American smokers who perceive being above their ideal weight may be more concerned about weight gain after smoking cessation and may be less ready to quit. These data suggest that perception of being overweight may be a less effective motivator to quit smoking amongst African-Americans.

This study was conducted with a cohort of workers taking part in a health evaluation programme. Workplace smoking cessation interventions have shown success in helping quit smoking (Cahill & Lancaster, Reference Cahill and Lancaster2014). Programmes that use individual counselling, pharmacotherapy or group therapy appear to be the most effective. King et al. found that African-American smokers demonstrate greater desire to quit and appear more interested in enrolling in a smoking cessation trial, yet actual enrolment was three times lower for African-Americans (King, Cao, Southard, & Matthews, Reference King, Cao, Southard and Matthews2011). African-Americans may experience more logistic barriers (such as transportation or childcare issues), have greater mistrust about formal smoking cessation programmes or using pharmacological therapy, or may be less knowledgeable about the risks of smoking (Fu et al., Reference Fu, Burgess, van Ryn, Hatsukami, Solomon and Joseph2007; Reimer, Gerrard, & Gibbons, Reference Reimer, Gerrard and Gibbons2010; Warren & Catona, Reference Warren and Catona2013). Thus, workplace interventions may be more effective at targeting minorities since these programmes often minimise some of the logistic barriers that can prevent smokers from enrolling in a cessation programme.

There are some limitations of our study. Our cohort consisted of individuals undergoing a voluntary health maintenance examination as part of a corporate wellness programme. Thus, our results may not be generalisable to the general population or to older individuals and may reflect workers who are more engaged in their health. In addition, a number of variables, such as nicotine dependence level, past smoking abstinence, educational attainment, type of occupation or employment level, that may affect smokers’ readiness to quit were not captured in the health examination survey so we were not able to include these factors in our analyses. Our dichotomisation of the outcome variable, readiness to quit, was somewhat arbitrary; however, analyses considering the outcome as a 3-level measure showed similar findings and suggest that the operationalisation of the outcome did not bias the results. Moreover, this outcome was based on a single item question that has not been validated as an assessment of readiness; due to the nature of the secondary data analysis, we were not able to use an existing tool to assess readiness. Future work should develop robust validated instruments to accurately assess smokers’ readiness to quit. Due to the cross-sectional nature of this study, we are unable to assess a causal relationship between weight perception and desire to quit smoking. Moreover, we did not have access to information about actual quit rates, nor about the types of smoking cessation services provided by the workplaces or about smokers’ reasons for not enrolling in smoking cessation programmes. Strengths of this study include a large, consecutive sample of current smokers, measured (rather than reported) weight and height, and data on participants’ weight perception.

In conclusion, we found that white smokers who perceive themselves to be above their ideal weight are more likely to be ready to quit smoking, a factor that may be used as motivator to engage them in cessation programmes. However, our findings suggest a different relationship between weight perception and smoking cessation readiness in African-Americans. Smoking cessation programmes should be aware of racial differences in the effects of weight perception on readiness to quit smoking to culturally tailor their interventions.