KHARTOUM COLLEGE OF MEDICAL SCIENCES DEPARTMENT OF COMMUNITY MEDICINEKHARTOUM COLLEGE OF MEDICAL SCIENCES

DEPARTMENT OF COMMUNITY MEDICINE

EFFECT OF TOBACCO SMOKING ON BODY MASS INDEX (BMI)determinants of BODY MASS INDEX (BMI) among medical students at Khartoum collage of medical sciences- 2013determinants of BODY MASS INDEX (BMI) among medical students at Khartoum collage of medical sciences- 2013 SAMBO SAADA ABDULRAHMANSAMBO SAADA ABDULRAHMAN
5/1/20135/1/2013

SUPERVISOR:
Dr Mona Muna Hassan, mbbsMBBS, MD

Department of community medicine Khartoum College of medical sciences Email: mhmhs67@hotmail.com

Abstract

Comment [a1]: The summery shoud include t folloeing

DEDICATION

Brief introduction plus the objectives (1 paragrap A paragraph describing the methodology A paragraph of the main results Paragraph about the conclusion and recommendations

Smoking generally has negative effect on the human body. This research focuses on the effect of smoking on BMI, if any association exists or otherwise. After adjusting for socio-economic status, the odds ratio for having an abnormal BMI among smokers is 1. Thus, abnormal BMI is independent of smoking Thus, abnormal BMI is independent of smokingSmoking generally has negative effect on the human body. This research focuses on the effect of smoking on BMI, if any association exists or otherwise. After adjusting for socio-economic status, the odds ratio for having an abnormal BMI among smokers is 1.

CONTENTS
1. Introduction Background information Problem statement and justification 2. Literature review 3. Objectives General objective Specific objectives 4. Methodology Study design, area and population Sampling: type, frame, sample size Data collection method 5. Ethical concerns 6. Time plan 7. Budget outlines

8. Result 9. Discussion 10. Conclusion 11. Recommendation 12. Annex: questionnaire 13. References

INTRODUCTION
BACKGROUND
Tobacco is an agricultural product derived from plant of genus Nicotiana2. It has been recreational smoked world-wide for centuries and also a major environmental hazard. Despite its negative effect and no acknowledged medical importance, its use is not particularly illegal. However, it is strictly prohibited in certain places such as in-flight, petrol station and some public places.

Comment [a2]: You start by reference numbe

PROBLEM STATEMENT & JUSTIFICATION

Epidemiological studies have generally shown an inverse relationship between smoking and body weight or nutritional status measured as Body Mass Index (BMI) 1. Negative effects of smoking on food intake, such as anorexia and reduced olfactory and gustatory receptor sensitivity, may contribute to this inverse association1. Studies have also shown smoking to be a major risk factor in diseases such as coronary heart diseases, chronic obstructive pulmonary diseases, and a 10 fold increased risk in lung cancers 3. In the WHO Monica project, carried out in 42 populations in the mid-1980s, smoking was observed to be variably associated with lower relative body

weight in individuals as well as in populations as a whole 1. The magnitude of this association was found to be affected by the proportion of smokers and exsmokers. However, the association has weakened or even reversed over time in western countries1. At a population level, the metabolic effects of smoking seem to be increasingly overridden by several other unfavourable health behaviors of smokers such as unhealthy diet, low physical activity and alcohol intake. Given the high prevalence of smoking habit in Sudan with gross gender differences (male predominance), and the fact a nutritional transition is occurring with both undernutrition and overweight or obesity becoming increasingly common, the magnitude and direction of the association between smoking and nutritional status needs to be studied in Sudan as both are major public health issues.

LITERATURE REVIEW
HISTORY OF TOBACCO SMOKING
Tobacco was first used by the peoples of the pre-Columbian Americas. Native Americans apparently cultivated the plant and smoked it in pipes for medicinal and ceremonial purposes. Christopher Columbus brought a few tobacco leaves and seeds with him back to Europe, but most Europeans didn't get their first taste of tobacco until the mid16th century, when adventurers and diplomats like France's Jean Nicot -- for whom nicotine is named -- began to popularize its use. Tobacco was introduced to France in 1556, Portugal in 1558, and Spain in 1559, and England in 1565. The first successful commercial crop was cultivated in Virginia in 1612 by Englishman John Rolfe. Within seven years, it was the colony's largest export. Over the next two centuries, the growth of tobacco as a cash crop fuelled the demand in North America for slave labour. Smoking is the most common method of consuming tobacco, and tobacco is the most common substance smoked. The agricultural product is often mixed with additives and then combusted. The resulting smoke is then inhaled and the active substances absorbed through the alveoli in the lungs. As of 2000,

Comment [a3]: Always write the rfernce num

smoking is practiced by approximately 1.22 billion people. In most communities men are more likely to smoke than women, although the gender gap tends to be less pronounced in lower age groups.

EFFECTS OF TOBACCO SMOKING

The active substances in tobacco trigger chemical reactions in nerve endings, which heighten heart rate, alertness, and reaction time. Dopamine and endorphins are released, which are often associated with pleasure. Users report feelings of relaxation, sharpness, calmness, and alertness. Those new to smoking may experience nausea, dizziness, and rapid heartbeat. Generally, the unpleasant symptoms will eventually vanish over time, with repeated use, as the body builds a tolerance to the chemicals in the cigarettes, such as nicotine. The negative health effects of tobacco were not initially known; in fact, most early European physicians subscribed to the Native American belief that tobacco can be an effective medicine. By the early 20th century, with the growth in cigarette smoking, articles addressing the health effects of smoking began to appear in scientific and medical journals. In 1930, researchers in Cologne, Germany, made a statistical correlation between cancer and smoking. Eight years later, Dr. Raymond Pearl of Johns Hopkins University reported that smokers do not live as long as nonsmokers. By 1944, the American Cancer Society began to warn about possible ill effects of smoking, although it admitted that "no definite evidence exists" linking smoking and lung cancer. The negative effects of tobacco smoking include: Pulmonary: COPD, carcinoma Cardiovascular: Smoking also increases the chance of heart disease, stroke, atherosclerosis, and peripheral vascular disease Renal: increased risk of chronic kidney disease, carcinoma and diabetic nephropathy Oral: staining teeth, halitosis, gingival recession, increased risk of oropharyngeal cancers. Infections Impotence and female sterility Dependence Others: stress, smoking in pregnancy results in IUGR and other complications, increased risk of crohns disease, etc.

BODY MASS INDEX

The body mass index (BMI), or Quetelet index, is a measure for human body shape based on an individual's weight and height. It was devised between 1830 and 1850 by the Belgian polymath Adolphe Quetelet during the course of developing "social physics". Body mass index is defined as the individual's body mass divided by the square of their height. The formulae universally used in medicine produce a unit of measure of kg/m2. BMI can also be determined using a BMI chart, which displays BMI as a function of weight (horizontal axis) and height (vertical axis) using contour lines for different values of BMI or colors for different BMI categories.

Category Very severely underweight Severely underweight Underweight Normal (healthy weight) Overweight Obese Class I (Moderately obese) Obese Class II (Severely obese) Obese Class III (Very severely obese)

BMI range kg/m2 less than 15 from 15.0 to 16.0 from 16.0 to 18.5 from 18.5 to 25 from 25 to 30 from 30 to 35 from 35 to 40 over 40

BMI Prime less than 0.60 from 0.60 to 0.64 from 0.64 to 0.74 from 0.74 to 1.0 from 1.0 to 1.2 from 1.2 to 1.4 from 1.4 to 1.6 over 1.6

Applications Statistical device

The BMI is generally used as a means of correlation between groups related by general mass and can serve as a vague means of estimating adiposity. The duality of the BMI is that, whilst easy-to-use as a general calculation, it is limited in how accurate and pertinent the data obtained from it can be. Generally, the index is suitable for recognizing trends within sedentary or overweight individuals because there is a smaller margin for errors. This general correlation is particularly useful for consensus data regarding obesity or various other conditions because it can be used to build a semiaccurate representation from which a solution can be stipulated, or the RDA for a group can be calculated. Similarly, this is becoming more and more pertinent to the growth of children, due to the majority of their exercise habits. The growth of children is usually documented against a BMI-measured growth chart. Obesity trends can be calculated from the difference between the child's BMI and the BMI on the chart.

Clinical practice
BMI has been used by the WHO as the standard for recording obesity statistics since the early 1980s. In the United States, BMI is also used as a measure of underweight, owing to advocacy on behalf of those suffering with eating disorders, such as anorexia nervosa and bulimia nervosa.

BMI can be calculated quickly and without expensive equipment. However, BMI categories do not take into account many factors such as frame size and muscularity. The categories also fail to account for varying proportions of fat, bone, cartilage, water weight, and more. Despite this, BMI categories are regularly regarded as a satisfactory tool for measuring whether sedentary individuals are underweight, overweight or obese with various exemptions, such as: athletes, children, the elderly, and the infirm. One basic problem, especially in athletes, is that muscle weight contributes to BMI. Some professional athletes would be overweight or obese according to their BMI, despite carrying little fat, unless the number at which they are considered overweight or obese is adjusted upward in some modified version of the calculation. In children and the elderly, differences in bone density and, thus, in the proportion of bone to total weight can mean the number at which these people are considered underweight should be adjusted downward.

1) A study in India EFFECT OF SMOKING ON BODY MASS INDEX: A COMMUNITY-BASED STUDY

Pragti Chhabra1, Sunil K Chhabra2 1Professor, Department of Community Medicine, University College of Medical Sciences, Delhi 2Professor Department of Cardiorespiratory Physiology, Vallabhbhai Patel Chest Institute, Delhi Correspondence: Dr Pragti Chhabra, MD Department of Community Medicine, University College of Medical Sciences, Delhi-110095 Email: pragschhabra@yahoo.co.in ABSTRACT

Comment [a4]: Rather than reporting the who study you summarize the results under the subheading (effect of smoking on BMI)

Smoking has a negative effect on Body Mass Index (BMI). This association may be confounded by demographic factors. Secondary analysis of data of 3446 non-smokers and 948 current smokers from a previously published community study on respiratory morbidity in Delhi was carried out to examine the association between smoking and BMI, and the confounding effects of gender and economic status. The BMI values were higher among nonsmokers while smokers had a higher proportion of underweights. After adjusting for gender and economic status, the odds ratio for being underweight was 1.34 (95% CI 1.13-1.6) among smokers whereas non-smokers had an adjusted odds ratio for overweight/obesity of 2.16 (95% CI 1.24-3.78). The study shows that smoking is independently associated with reduced BMI after adjusting for gender and economic status in an Indian population. Key words: Body mass index, Smoking, Community-based study, Gender, Economic status

METHODS
Data on height and weight, gender, smoking and economic status obtained during a community-based study 12 was analysed. The study had been approved by the Ministry of Environment and Forests, Government of India and financially supported by the World Health Organization. Sample selection and Methodology: The details of sampling have been described earlier18. Briefly, nine urban and four rural areas of Delhi were surveyed. A stratified random sample was taken from each area allowing inclusion of population across a wide economic spectrum. In each selected house, all the available members above 18 years of age were included and administered a standardized symptoms questionnaire, and examined by physicians. Standing height to the nearest cm without shoes, and weight rounded off to the nearest kilogram were recorded using standard techniques. For the present analysis, data of healthy adults (current smokers and non-smokers) were included. Ex-smokers and those found to have symptoms of respiratory or any other disease were excluded. This was done to avoid the confounding effect of diseases on nutritional status. Smoking status was classified as follows: Current smokers: smoked regularly within 1 month prior to the examination; Non-smokers: never smoked; subjects occasionally having a smoke; Exsmokers: stopped more than 1 month prior to the examination. Depending upon the monthly family income, the population was classified into three convenient categories of economic status (equivalent to US$): Low: income below US$ 100; Middle: income between $100 to 350; High: income above $350. BMI was calculated by dividing the weight of an individual in kg by the square of his/her height measured in meters. The subjects were classified into one of

the four categories as follows: (1) underweight - BMI < 18.5 kg/m2; (2) normal BMI 18.5 to 24.9 kg/m2; (3) overweight BMI 25 to 29.9 kg/m2; (4) obese BMI >= 30 kg/m2. As the 5th, 85th and 95th percentiles have also been used to define underweight, obesity and overweight subjects, these were also calculated.

STATISTICS
Data was analysed using SPSS 11.0 and Graph Pad Prism 4.01. Descriptive exploration of data on BMI was carried out to determine the 5th, 15th, 50th, 85th and 95th percentiles among smokers and non-smokers. The homogeneity of distribution was checked to decide the tests to be applied. Comparison of mean BMI sd among categories of smoking, gender and economic status was done using students unpaired t test or analysis of variance (ANOVA) as applicable. Chi square test was applied to study the difference in proportions of underweight, normal, overweight and obese subjects among smokers and nonsmokers, and obtain unadjusted odds ratios. A General Linear Model (GLM) analysis of variance was carried out to study the main effects of the three independent variables (smoking status, sex, and economic status) as well to explore any interactions between these. Multiple logistic regression analysis was carried out to calculate the adjusted odds ratio. Factors associated with occurrence of underweight status, and for overweight and obesity were obtained with normal BMI category serving as the reference.

RESULTS
There were 948 smokers and 3446 non-smokers. The demographic and anthropometric characteristics of the study population are shown in Table 1. Data are presented as mean sd.

Table 1: Demographic and anthropometric characteristics of the study population

Smokers n=948 36.87 12.58 1.65 0.08 56.06 11.33 20.42 3.64 830 (87.6%) 118 (12.4%) 310 (32.7%) 467 (49.3%) 171 (18%) Non-smokers n=3446 35.03 14.08 1.58 0.09*** 55.57 12.78ns 22.14 4.61*** 1368 (39.7%) 2078 (60.3%) 846 (24.6%) 1543 (44.8%) 1057 (30.7%)

Age, years Height, m Weight, Kg BMI, Kg/m2 Gender ratio (M:F) Male Female Economic status ns Low Middle High

Ns: not significant, p>0.05, ***: p<0.001

The histogram showing frequency distribution of BMI in smokers and nonsmokers is given in Fig.1.The BMI ranged from 13.34 to 36.17 in smokers and from 9.13 to 40.04 in non-smokers. There was a leftward shift in the frequency distribution of BMI in smokers with the 5th, 15th, 50th, 85th and 95th percentiles being 15.69, 16.96, 19.72, 24.16 and 27.41 for smokers and 16.02, 17.47, 21.53, 26.99, and 30.47 for the non-smokers, respectively.

Table 2: Distribution of subjects across categories of BMI

BMI Category Underweight (less than 18.5) Normal (18.5 to 24.99) Overweight (25 to 29.99) Obese (30 or more) Smokers 342 (36.1%) 496 (52.3%) 95 (10.0%) 15 (1.6%) Non-smokers 847 (24.8%) 1701 (49.7%) 663 (19.4%) 210 (6.1%)

Chi square 103.33, p<0.001

The proportions of subjects in the four categories of BMI (underweight, normal, overweight and obesity) among smokers and non-smokers are shown in Table 2. There were more underweight subjects among smokers, and more overweight and obese subjects among non-smokers (p<0.001). On comparison among categories by smoking status, gender and economic status, it was observed that Non-smokers, females, and those with a high economic status had a significantly higher BMI as compared to smokers, males, and those with a low economic status (Table 3). Table 3: Comparison of BMI among categories
Smoking status Gender Economic status+ **: Categories Smokers Non-smokers Males Females Low Middle High BMI mean sd 20.42 3.64 ** 22.14 4.61 21.15 3.95 ** 22.38 4.87 19.75 3.44 *** 21.49 4.32 *** 24.12 4.53

p<0.01; +: p<0.001 ANOVA (for economic status) followed by Bonferroni test, *** p<0.001 for each paired comparison: middle vs low, high vs low, high vs middle

GLM analysis of variance revealed that the main effects were significant: Gender (F = 9.15, p<0.01); Economic status: (F = 50.08, p<0.001); Smoking status: (F = 11.13, p<0.01). The interactions (gender economic status, gender smoking status, economic status smoking status and gender economic status smoking status) were not significant (p>0.05).

Fig2. General Linear Model Analysis of variance results showing estimated marginal means for BMI among smokers and non-smokers across categories of gender, and lack of interactions between smoking and gender;( _______ Females, _ _ _ _ _ Males) The lack of interactions is illustrated by the near parallel and non-intersecting lines in Figs. 2 and 3 showing the estimated marginal means for BMI among smokers and non-smokers across categories of gender and economic status. The descriptive data of BMI in smokers and Non-smokers across the three levels of economic status for males and female subjects are shown in Table 4.

Fig3. General Linear Model Analysis of variance results showing estimated marginal means for BMI among smokers and non-smokers across categories of economic status, and lack of interactions between smoking and economic status; ( _______ High, _ _ _ _ _ Middle, ..Low)

Table 4: Multiple logistic regression models for underweight and overweight/obesity

Factor

Odds for being underweight (95% CI) Smokers 1.34 (1.13 1.6) Male 2.44 (1.78 3.35) 1.25 (1.08 1.47) Low economic status 5.5 (4.44 6.81) High economic status 8.10 (4.77 13.78)

Factor

Odds for overweight/ obesity (95% CI) (1.24 3.78) 2.44 (1.78 3.35) 3.03 (2.47 3.71) 3.09 (1.80 5.31)

non-smokers Females Middle economic status Middle economic status

For the risk of being underweight, the reference categories were non-smokers, females and high economic status; for the risk of being Overweight / obese, the reference categories were smokers, males and low economic status.

DISCUSSION
The present community-based study shows that in the population in Delhi, smoking is negatively associated with BMI. The median BMI was higher in nonsmokers as compared to smokers. The proportion of overweight and obese subjects was greater among non-smokers as compared to smokers while underweight subjects were in higher proportions among smokers as compared to non-smokers. Although gender and economic status had significant associations with BMI, the effect of smoking was independent of these. The results of our study are consistent with those of other studies1-4 that have shown a negative association between smoking and nutritional status. The strength of the association has however been found to vary among populations. In the WHO MONICA project it was observed that regular smokers had a significantly lower BMI in 20 populations for men and 30 populations among women out of the 42 populations studied.5Among men, the association between leanness and smoking was less apparent in populations with relatively low proportions of regular smokers and high proportions of ex-smokers. Similarly, in the US NHANES II data, 4 a lower BMI was observed in the current smokers as compared to non-smokers. The only other study in an Indian population that examined the association between smoking and nutritional status was carried out in Mumbai. 11 All forms of tobacco use were associated with low BMI, being highest for bidi smokers. However, the study did not include overweight and obese subjects. The present study thus adds new information to the existing knowledge about this major public health issue in India.

In our study, after adjusting for gender and economic status, the odds for smokers being underweight were about 30% greater than among non-smokers. In the study reported from Mumbai, the adjusted OR for low BMI was 1.8 for men and 1.6 for women.11 The prevalence of overweight subjects was significantly lower among current smokers after adjusting for other socioeconomic and dietary factors in a Chinese population. 13 In the Inter 99 study, daily smoking men had 3% lower BMI than never smoking men and daily smoking women had 5% lower BMI than never-smoking women after adjusting for age and socio-economic status.14 In contrast, in the FINRISK studies, male smokers were more likely to be obese as compared to never-smokers.7 Similarly, in the Swiss health survey, the odds for obesity adjusted for age, nationality and physical activity were higher among ex-smokers and heavy smokers and lower among non-smokers and light smokers.6 Thus, the direction and the magnitude of association between smoking and nutritional status is not consistent, possibly confounded by other demographic and behavioural factors in the population 3,7,15 as well as the proportion of smokers and non-smokers in the population as shown in the WHO Monica project. 5 In a Finnish study where educational status was used as an indicator of socioeconomic status, current smokers weighed less at the lowest level and more at the highest level than never smokers.16 However we observed an inverse relation after adjusting for socioeconomic status. This is consistent with and explained by the observations in several studies that high socioeconomic status is negatively associated with obesity in developed countries but positively correlated with it in developing countries.16 Similar to our results, in the WHO Monica project too, adjustment for socioeconomic status did not affect the relationship between smoking and leanness.5 Our study has a few limitations. It is a retrospective secondary analysis of data of an earlier study. Although only subjects who were apparently healthy were included, other factors that could contribute to abnormalities of nutritional status such as diet, genetics, exercise habits and other life style factors were not taken into account. These could yet confound the association between smoking and nutritional status. However, identification of determinants of the nutritional status was not the objective of the present study. Hence, only two well-known and major determinants, gender and economic status, were included as confounding factors. To conclude, smoking is associated with reduced BMI in a population sample in Delhi. Its effect is independent of gender and economic status of the subject, both of which also influence the nutritional status.

2) A study in united kingdom

SMOKING STATUS AND BODY MASS INDEX: A LONGITUDINAL STUDY Abstract

Introduction: The general consensus is that smoking cessation leads to some degree of weight gain, although considerable disagreement remains regarding the magnitude and duration of this gain. Methods: We investigated the relationship between smoking status and change in body mass index (BMI) over time in a cohort of male participants recruited for a study of cardiovascular risk factors and assessed at multiple time points. We further investigated whether calorie consumption, recorded using food frequency questionnaires, mediated any effect of smoking cessation on change in BMI. Results: Our results indicate that never-smokers and ex-smokers differ in BMI from current smokers by an average of 1.6 kg/m 2 based on a comparison at baseline. Moreover, smoking cessation between time points is associated with a corresponding average increase in BMI of 1.6 kg/m 2. Discussion: These results suggest that when cigarette smokers achieve longterm abstinence, they revert to a mean BMI roughly equivalent to that of neversmokers. Perhaps surprisingly, this difference in BMI was not substantially attenuated following adjustment for calorie and alcohol consumption, suggesting that the effects of smoking cessation on BMI are not mediated entirely by changes in dietary or alcohol consumption behaviour.

INTRODUCTION
Cigarette smoking is the leading preventable cause of death in developed countries, and it is a major risk factor for a variety of cancers, cardiovascular disease, respiratory disease, and other illnesses (Doll, Peto, Boreham, & Sutherland, 2004). Although the majority of smokers report a willingness to stop smoking, only a relatively small proportion attempt to do so in any given modest, but absolute cessation rates could be improved if a larger proportion of smokers engaged in smoking cessation attempts. One reason commonly cited for smokers unwillingness to stop smoking is concern about weight gain following smoking (Pomerleau, Zucker, & Stewart, 2001). Weight gain

following smoking cessation has been associated with an increased risk of relapse to smoking (Borrelli, spring, Niaura, Hitsman, & Papandonatos, 2001). The general consensus is that smoking cessation leads to some degree of weight gain, and the recent increase in overweight and obesity in developed countries has been suggested to be attributable, in part, to increased smoking cessation (Filozof, Fernandez Pinilla, & Fernandez-Cruz, 2004 ). It also has been suggested that the health benefits of smoking cessation may be negated at least in part by the detrimental effects on health of associated weight gain (Chinn et al., 2005). Continued cigarette smoking likely confers a protective effect with respect to long-term trends in body mass index (BMI), so that an increase in BMI over time is prevented by continued smoking. Substantial evidence from experimental studies indicates that cigarette smoking exerts an appetite-suppressant effect ( Jo, Talmage, & Role, 2002 ), and it has long been recognized that cigarette smoking is used as a means of weight control, in particular by women ( Li, Kane, & Konu, 2003 ), possibly mediated via a lowering of the body weight set point following chronic nicotine use ( Cabanac & Frankham, 2002 ). It is likely that cigarette smokers experience a short-term rebound effect, whereby a marked initial weight gain follows smoking cessation as a result of the removal of this lowering of the set point ( Cabanac & Frankham, 2002 ), in addition to reduced sympathovagal ratio and resensitization of nicotinic receptors ( Yun, Bazar, Lee, Gerber, & Daniel,2005). However, few studies have investigated directly whether weight gain following smoking cessation is mediated by changes in dietary behaviour. Considerable disagreement remains regarding the magnitude and duration of weight gain following smoking cessation (John, Hanke, Rumpf, & Thyrian, 2005). In particular, few studies have investigated the long-term consequences of smoking status on weight and BMI. A recent report from a representative sample of treatment-seeking smokers found an increase in BMI over time following smoking cessation; the increase persisted beyond any acute effect up to 8 years after smoking cessation (Munaf, Murphy, & Johnstone, 2006). This increase may be due in part to the continued use of food by ex-smokers as a substitute for cigarette smoking (Borrelli et al., 2001), beyond the short-term effects of smoking cessation on weight gain. The study lacked a comparison group of never-smokers, however, and another study indicated that the proportions of ex-smokers and never-smokers that are overweight or obese do not differ significantly (John et al., 2005), although these data were collected in a cross-sectional survey, which means that any conclusions regarding causation are necessarily limited. Munaf et al. (2006) also had several limitations, including a lack of data at intermediate time points between the 1-year follow-up and the 8-year follow-up,

during which time smokers may have relapsed to smoking and then quit once again. In addition, these data were from treatment-seeking smokers participating in a clinical trial of the nicotine transdermal patch, and they may not be comparable with data from smokers who attempt spontaneous, unaided cessation, which is the case for the majority of smokers (Hughes, 2003). Also, given the lack of a comparison group of non-smokers assessed over a similar period of time, the authors were able to draw only indirect conclusions from normative data regarding whether continued smoking protects against weight gain over time. Therefore, remarkably few studies have investigated the longterm effects of smoking cessation on weight gain in the general population, and those that have (Williamson et al., 1991) typically have not included a comparison group of never-smokers. The inclusion of a comparison group is particularly important to assess whether smoking and subsequently stopping smoking results in a net increase in weight relative to having never smoked. We therefore investigated the relationship between smoking status and change in BMI over time in a cohort of male participants recruited for a study of cardiovascular risk factors and assessed at multiple time points. We hypothesized that smoking cessation would be associated with a long-term increase in BMI. In addition, these data allowed a comparison with participants who were non-smokers at all time points, to assess more directly whether continued smoking protects against weight gain over time. Finally, we assessed whether changes in dietary behaviour could account for any increase in BMI following smoking cessation

METHODS
Participants The Caerphilly Prospective Study is a longitudinal study of men. The initial design attempted to contact all men aged 45 59 years from the town of Caerphilly and adjoining villages in the United Kingdom. A total of 2,512 subjects (response rate = 89%) identified from the electoral register and general practice lists were examined between July 1979 and September 1983 (Phase I). Men were initially seen at an evening clinic, where they completed a questionnaire about their smoking behaviour, and anthropometric measures were taken. Further details about other measures are described elsewhere (Caerphilly and Speedwell Collaborative Group, 1984). Phase II was undertaken between July 1984 and June 1988, when an additional 447 men were included who had moved into the study areas. Phases III and IV were undertaken between November 1989 and September 1993 and October 1993 to February 1997, respectively. No additional participants were included at Phases

III and IV. At each of these phases, the same methods were used for consistency. Materials and measures At all phases, the following measures were taken: height and weight (from which BMI was calculated), smoking history, and occurrence of serious illness. Dietary behavior was assessed at all phases except Phase IV. In addition, demographic data were collected on age and socioeconomic status, based on the Registrar Generals 1980 classifi- cation (I, II, III nonmanual, III manual, IV, and V, where I represents professional and V unskilled manual; Szreter, 1984). Height in bare feet was measured in millimetres using the Holtain stadiometer, and weight in light clothes was measured in kilograms using scales. Smoking history was assessed using interviewer-administered questionnaires as smoking status (never-smoker, ex-smoker, current smoker), among ex-smokers, as years since stopping smoking (>10, 5 9, 1 4, <1), and among current smokers, as daily cigarette consumption (1 14, 15 24, 25+). Dietary data were collected in Phases I III using a self-administered semi quantitative food frequency questionnaire, which, after initial instruction, the men took home and completed with the help of their spouses. This questionnaire assessed weekly consumption of alcohol and of sugar, starch, cereal fiber, vegetable fiber, protein, and fat. Alcohol consumption was converted to weekly ethanol consumption (grams). These data were validated against dietary diaries in a subset of the cohort (Yarnell, Fehily, Milbank, Sweetnam, & Walker, 1983). Other dietary data, including alcohol consumption, were converted to total weekly energy consumption (kilocalories). Serious illness was assessed in Phases I IV using interviewer administered questionnaires and subsequently coded as the presence or absence of any serious illness (heart attack, high blood pressure, diabetes, kidney disease, and blood clots) since the preceding visit. Data analyses Only participants reporting cigarette smoking at the first visit and non-smokers were included in all main analyses. The sample was limited further to those providing data on BMI and smoking status from at least two visits and to those with consecutive visits only. The final analyses presented here compared those who stopped smoking with never-smokers. Linear regression models were used to relate BMI to smoking status, with robust SE s and clustering to allow for dependence of measures within the same participant across visits. These models were then extended to adjust first for age and socioeconomic status, second for age, socioeconomic status, alcohol consumption, and calorie consumption, and third for all these factors plus episodes of serious illness since the previous visit. We conceptualized age, socioeconomic status, and serious illness as potential confounders and alcohol and calorie consumption as potential intermediaries.

Time-dependent confounding was investigated in three stages. First, linear, and logistic regression models were used to model the relationship between BMI at one visit (here as an explanatory variable) and confounders and smoking status at the next visit. Second, a logistic regression model was used to model the relationships between smoking at one visit (here as the outcome variable) and confounders at the previous visit. Third, linear and logistic regression models were used to model the relationship between the confounders at one visit (here as outcome variables) and smoking status at the previous visit. Marginal structural models (Robins, Hernan, & Brumback, 2000) were then used to take into account time-varying confounding. However, since we found little evidence of time varying confounding (except a small effect of previous BMI), the marginal structural models differed little from the nave approach and so are not presented here (results available on request). To examine the longer term effect of smoking cessation on BMI, we compared two subsamples of those who smoked at Visit 1. The first subsample consisted of all those who stopped smoking between Visits 1 and 2, remained abstinent for the rest of the study, and had BMI data at Visits 2, 3, and 4. The second subsample consisted of those who smoked throughout the study and had BMI data at Visits 2, 3, and 4. We compared these two groups with those who were never-smokers throughout the study. We used linear regression to compare BMI at each visit among these three groups. These models were then extended to adjust first for age and socioeconomic status and second for age, socioeconomic status, alcohol consumption, and calorie consumption. We repeated these analyses with calorie consumption as the outcome variable, to test whether smoking cessation was associated with a corresponding change in calorie consumption. All p values are two tailed.

RESULTS
Characteristics of participants Participants (N = 2,638) were on average 53 years old ( SD = 5, range = 45 67). Table 1 shows the characteristics of the entire sample at baseline. Current smokers, ex-smokers, and never smokers did not differ in age. Alcohol consumption and calorie consumption increased from never-smokers to current smokers, with ex-smokers occupying an intermediate position. In addition, we found a shift in the distribution of socioeconomic status toward higher positions among never-smokers compared with current smokers; again, ex-smokers occupied an intermediate position.

BMI was higher among ex-smokers (mean difference = 1.59, 95% CI = 1.28 1.90, p < .001) and never-smokers (mean difference = 1.58, 95% CI = 1.20 1.96, p < .001), compared with current smokers. Adjustment for age, socioeconomic position, alcohol consumption, and calorie consumption did not alter these results substantially. The analyses below were limited to those who smoked at baseline (n = 1,271). The sample was limited further to those providing data on BMI and smoking status from at least two visits and to those with consecutive visits only ( n = 852). The characteristics of those included and excluded from the analyses are compared in Table 2. Compared with excluded participants, included participants were older (p = .022) but did not differ significantly on alcohol consumption, calorie consumption, or socioeconomic position (p values > .07 for all comparisons). Over the four visits, the proportion of participants who smoked fell from 100% at baseline to 59% at Visit 4. Over this period, BMI increased, while alcohol consumption and calorie consumption decreased. The values of these variables over the four visits are presented in Table 3. Smoking cessation and BMI In the unadjusted model, linear regression indicated an increase in BMI of 2.02 kg/m 2 (95% CI = 1.58 2.47) following smoking cessation. This difference, which reflects primarily the acute effects of stopping smoking on BMI, was not altered substantially when adjusted for age and socioeconomic status but was reduced somewhat when further adjusted for alcohol consumption and calorie consumption and for illness. When these analyses were adjusted for baseline BMI, the mean difference in BMI following smoking cessation was reduced, but this estimate was not altered substantially in the fully adjusted model, which indicated a BMI increase of 1.56 kg/m 2 (95% CI = 1.29 1.82). These results are summarized in Table 4. We also compared BMI at Visits 2, 3, and 4 among smokers those who stopped smoking between Visits 1 and 2 and then remained ex-smokers (n = 137), those who were never-smokers throughout (n = 396), and those who were continuing smokers throughout ( n = 506). These results, which reflect primarily the longterm effects of stopping smoking on BMI over approximately 10 years, indicated a mean difference of 2.73 kg/m 2 (95% CI = 1.39 3.35) in the unadjusted model and 1.66 kg/m 2 (95% CI = 1.11 2.21) in the fully adjusted model, both of which are of comparable in magnitude to the acute differences described above. Table 5 presents the mean BMI and calorie consumption for these groups at each visit. Using regression models, we found that, by Visit 2, smokers had a significantly lower BMI than ex-smokers (mean difference = 1.90 kg/m 2,

95% CI = 2.60 to 1.20, p < .001), whereas ex-smokers and never-smokers did not differ significantly (mean difference = +0.05 kg/m 2 , 95% CI = 0.67 to 0.77, p = .90). This pattern persisted through Visit 4 (mean differences = 2.35 kg/m 2 and 0.64 kg/m 2, respectively) and were not altered substantially in the fully adjusted model. We repeated this analysis using weekly calorie consumption as the outcome measure. This analysis indicated that, at Visit 1, calorie consumption was higher among smokers than among those who subsequently stopped smoking and also higher among those who subsequently stopped smoking than among neversmokers. By Visit 2, calorie consumption was higher among smokers than exsmokers (mean difference = 120 kcal, 95% CI = 20 223, p = .019) and higher among ex-smokers than among never-smokers (mean difference = 100 kcal, 95% CI = 4 to 204, p = .059). By Visit 3, however, although calorie consumption remained higher among smokers than ex-smokers (mean difference = 208 kcal, 95% CI = 91 325, p = .001), there was no difference between ex-smokers and never-smokers (mean difference = 66 kcal, 95% CI = 52 to 185, p = .27). These results were not altered substantially in the fully adjusted model. Calorie consumption data were not available at Visit 4. Table 1: characteristics of participants
Characteristic BMI, kg/m 2 ; M ( SD ) Age, years; M ( SD ) Alcohol consumption, g/week; M ( SD ) Calorie consumption; kcal/week; M ( SD ) SES; n (%) I II III NM III M IV V Current smokers ( n = Ex-smokers ( n = 891) 1,271) 25.36 (3.65) 26.95 (3.54) 53 (5) 53 (5) 56 (4) 48 (5) 2,384 (618) 2,181 (572) Never-smokers ( n = 476) 26.94 (3.57) 52 (5) 31 (7) 2,140 (561)

21 (2) 139 (11) 112 (9) 734 (59) 174 (14) 68 (5)

43 (5) 185 (21) 111 (13) 414 (47) 95 (11) 34 (4)

37 (8) 117 (25) 56 (12) 197 (42) 51 (11) 14 (3)

Note. SES, socioeconomic status; I, professional; II, managerial; III NM, skilled non manual; III M, skilled manual; IV, semiskilled; V, unskilled; BMI

Table 2: characteristics of included and excluded current smokers at baseline

Characteristic BMI, kg/m 2 ; M ( SD Age, years; M ( SD ) Alcohol consumption, g/week; M ( SD Calorie consumption, kcal/week; M (S ) SES; n (%) I II III NM III M IV V Included ( n = 852) 25.37 (3.59) 52 (5) 195 (209) 2,362 (568) Excluded ( n = 419) 25.34 (3.78) 53 (5) 201 (228) 2,433 (713)

16 (2) 105 (12) 77 (9) 493 (58) 112 (13) 47 (6)

5 (1) 34 (8) 35 (9) 241 (61) 62 (16) 21 (5)

Note. SES, socioeconomic status: I, professional; II, managerial; III NM, skilled non manual; III M, skilled manual; IV, semiskilled; V, unskilled; BMI, body mass index. Excluded participants were those for whom data on BMI and smoking status were not available from at least two visits.

Table 3: smoking status, BMI, alcohol consumption, and calorie consumption overtime Visit 1 Visit 2 Current smoker; 852 (100) 691 (81) n (%) BMI (kg/m 2 ); 25.37 (3.59) 25.75 (3.86) M ( SD ) Alcohol 195 (209) 161 (210) consumption (g/week); M ( SD ) Calorie 2,362 (568) 2,178 (540) consumption (kcal/week); M ( SD ) Note. BMI, body mass index; na, not applicable. Visit 3 434 (66) 26.08 (4.12) 156 (206) Visit 4 265 (59) 26.23 (4.13) 152 (207)

2,151 (554)

na

Table 4: mean difference in BMI between those stopping smoking at any visit and those remaining smokers at each visit
Mean difference (95% CI ) at next visit

Unadjusted

Adjusted for age and socioeconomic position only

Adjusted for age, socioeconomic position, alcohol consumption, and calorie consumption 1.78 (1.31 2.25) 1.55 (1.29 1.82)

Adjusted for age and socioeconomic position alcohol consumption, calorie consumption, and illness 1.55 (1.07 2.03) 1.56 (1.29 1.82)

No adjustment for baseline BMI Adjusted for baseline BMI

2.02 (1.58 2.47) 1.53 (1.26 1.79)

2.01 (1.56 2.46) 1.53 (1.27 1.79)

DISCUSSION
Never-smokers and ex-smokers differed in BMI from current smokers by an average of 1.6 kg/m2, based on a comparison at baseline. Moreover, smoking cessation between time points was associated with a corresponding average increase in BMI of 1.6 kg/m 2. Our comparisons of BMI over time suggest that when cigarette smokers achieve long-term abstinence from tobacco they revert to a mean BMI roughly equivalent to that of never smokers. The difference in BMI between current and ex-smokers does not appear to be mediated entirely by changes in dietary or alcohol consumption behavior. This finding is supported by our analysis of calorie consumption among individuals who stopped smoking between Visits 1 and 2, which indicated that at subsequent visits, although they demonstrated greater calorie consumption than neversmokers until Visit 3, they consumed fewer calories than continuing smokers. Moreover, the change appears to be relatively rapid. Among those who stopped smoking between Visits 1 and 2, BMI was comparable with that of neversmokers from Visit 2 and beyond. An increase in 1.6 kg/m 2 is considerable. For example, it has been suggested that a population reduction of one BMI unit would result in a reduced incidence of Type 2 diabetes of more than 10% ( Burke et al., 2003 ), and every unit

increase in BMI is disease of 8% 10% ( Stevens et al., 1998 ). This further supports recent suggestions that the health benefits of smoking cessation may be negated at least in part by the detrimental effects on health of associated weight gain (Chinn et al., 2005). Weight gain is a known risk of smoking cessation, and concern about weight gain has been described as a deterrent to quitting, in particular among women ( Klesges et al., 1988 ), who may gain more weight following cessation than do men ( Pisinger & Jorgensen, 2007 ). Smoking has been shown to impair glucose tolerance and insulin sensitivity, and cross-sectional studies suggest that smokers are insulin resistant and hyperinsulinemic, compared with non-smokers (Filozof et al., 2004). Smoking cessation is followed by changes in food preferences and increased caloric intake (Filozof et al., 2004), possibly mediated by dopaminergic mechanisms (Reinholz et al., 2008). This might contribute to weight gain, although insulin sensitivity is improved in spite of the weight gain. Although changes in dietary behaviour and calorie consumption have been suggested widely as the principal determinants of weight gain following smoking cessation (Filozof et al., 2004), our data indicate that these factors may account for only a small proportion of the total observed change in BMI. The self-report nature of these data suggests caution, given the potential for systematic biases in the reporting of calorie intake. Other possible mechanisms include a decrease in resting metabolic rate (Moffatt & Owens, 1991), reduced fat oxidation (Jensen, Fusch, Jaeger, Peheim, & Horber, 1995), and increased adipose tissue metabolism (via increased activity in lipoprotein lipase; Ferrara, Kumar, Nicklas, McCrone, & Goldberg, 2001 ). Strong evidence indicates that nicotine modifies metabolic rate and energy expenditure (Perkins, Epstein, Marks, Stiller, & Jacob, 1989; Perkins, Sexton, & DiMarco, 1996; Perkins et al., 1990). Given the importance of understanding the mechanisms by which smoking cessation results in weight gain, further research is required to explore these possibilities so that accurate public health messages may be formulated. The longitudinal nature of our data and the comprehensive dietary behavior and alcohol consumption data are considerable strengths of the present study. Nevertheless, a number of limitations should be considered when interpreting these results. First, our sample consisted entirely of males, so that it is not possible to draw conclusions regarding women. This limitation is particularly important given evidence that the impact of post-cessation weight gain on longterm smoking cessation outcomes may differ between men and women. Future studies should attempt to replicate our findings in men and women. Second, our data reflect relatively short- and medium-term post-cessation weight gain. Some evidence indicates that weight et al., 2005), although our comparison of neversmokers, ex-smokers, and current smokers at baseline indicates that this effect

may be modest or negligible. Third, dietary behavior and alcohol consumption data were collected by means of a self-completed food frequency questionnaire, without full independent validation, and systematic differential reporting biases may have been present between those who did and did not stop smoking. Unfortunately, our data do not allow us to test this possibility directly, and it is a potentially serious confound, although such instruments continue to represent the dominant method in nutritional epidemiology (Drewnowski, 2001; Prentice, 2003). Even so, our results were largely unchanged following adjustment for calorie consumption, suggesting that this is not a major concern. In addition, the reduction in calorie consumption in all groups between Visits 1 and 2 is difficult to explain and suggests some caution in the interpretation of these data. Even a small difference in calorie consumption, potentially below the level of sensitivity of the measure we used, may be sufficient to result in a net change in BMI over time. Clearly, measurement of biomarkers of nutrient consumption would be valuable in more accurately assessing dietary behavior. Fourth, and a related point, smoking behaviour was assessed by self-report and lacked biochemical verification. However, if we assume that continuing smokers are more likely to report being abstinent than vice versa, this would presumably serve to attenuate any effect of smoking cessation on change in BMI, given that BMI was not assessed by self-report and therefore can be regarded as reliable. In conclusion, a substantial proportion of the weight gain and corresponding increase in BMI attributable to smoking cessation cannot be accounted for by alterations in dietary behaviour or alcohol consumption. These findings, if true, are of considerable clinical importance with respect to advising individuals attempting to stop smoking how they might limit any post-cessation weight gain. Future studies should investigate the mechanisms associated with weight gain following smoking cessation, in particular those related to metabolism as opposed to dietary intake alone. More detailed analysis of differences in weight gain following smoking cessation among light and heavy smokers also may be valuable, given evidence from cross-sectional studies that the relationship between cigarette consumption and BMI follows a J- or U-shaped pattern (Sneve & Jorde, 2008). This may offer insight into specific novel interventions that target weight gain, which may offer the additional advantage of improving long-term smoking cessation outcomes, given the increased risk of relapse associated with post-cessation weight gain. Research into the genetic factors associated with weight gain also may provide insight into likely mechanisms and clarify the nature of individual differences in weight gain.

Hypothesis:
Null hypothesis1: There is no effect of tobacco smoking on body mass index Null hypothesis 2: There is no effect of exercise on smoking on body mass index Null hypothesis 3: There is no effect of nutritional habits on body mass index
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OBJECTIVES
GENERAL OBJECTIVE
The general objective of this study is to explicate the effect of tobacco smokingdeterminants of on Body Mass Index among??? .

SPECIFIC OBJECTIVES
To measure the BMI of the study population. To measure the frequency of smoking in the study population. To determine the effect of tobacco smoking and on the body mass index of????? To determine the effect of nutritional habits on the body mass index of????? To determine the effect of exercise on the body mass index of????? demographic characteristics on BMI. To obtain the odds ratio of smoking on BMI. To point out if differences in age and gender affects BMI, through variations in smoking status, exercise and nutritional habits.

Formatted: Underline

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METHODOLOGY
STUDY DESIGN

Type of study used is Analytical case-control (retrospective). This is most suitable for this research as it is the first approach to testing hypothesis. The study proceeds backwards from effect (abnormal BMI) to cause (smoking). Case: abnormal BMI Control: normal BMI Risk factordeterminants: tobacco smoking nutritional habits exercise Confounding factors: age and gender Risk factor (smoking, ) present absent Cases (abnormal BMI) a c Control (normal BMI) b d

STUDY SETTING
Khartoum College of medical sciences. Departments of medicine and medical laboratory sciences.

STUDY POPULATION
Under-graduate students, of all age groups and both sexes at alla academic levels in the two departments these include students with: controls:Normal BMI of 18.5-25 kg/m2 Cases :Abnormal BMI, either underweight <18.5 kg/m2 or overweight >25 kg/m2 (This is based on the WHO BMI values)

SAMPLING
Type of sampling: stratified simple random sampling The study population was stratified based on gender (males, females), and subjects selected from each stratum by simple random sampling. Sample size: With Confidence level of 95%, Z = 1.960

Population value = 1,000 Expected frequency of the factor under study = 95% Worst acceptable frequency = 85% D = 95%-85% = 10% Sample size = n/ [1+ (n/population)] n = Z2 [P (1-P) / (D2)] = 18.24 Sample size = 18.24 / 1.01824 = 17.9 ~ 18 By this method the most practical sample size is 40, which gives a margin of error at 15%. Therefore, 40 cases (20 males, 20 females): 20 underweight subjects (10 males, 10 females) and 20 overweight subjects (10 males, 10 females) 40 controls (20 males, 20 females)

DATA COLLECTION METHODS AND TOOLS

Data was collected by the use of self-administered questionnaires. including background data, history and habits of smoking- nutritional habits exercise

DATA MANAGEMENT AND ANALYSIS

Data was analysed using SPSS. Estimation of risk / strength of association between risk factor (smoking) and outcome (abnormal BMI) was obtained via odds ratio. Dependent variable: body mass index Independent variables : tobacco smoking - nutritional habits exercise

ETHICAL CONCERN
This research is not directed to contradict the ethical values of the study population. Notwithstanding, the consent of persons involved was verbally obtained and also the approval of the National Ethical Clearance Committee

TIME PLAN
1 2 3 Proposal writing and submission Data collection, management and analysis Final report writing and submission

BUDGET OUTLINE
Printing of questionnaires Weighing scale and measuring tape Transportation Instalment of SPSS Printing out and binding of Report

RESULT
CONTROL Table (1) background characteristics of the study population
Comment [a5]: Insert a table here

Table (2)SMOKING STATUS AMONG CONTROL

Frequency Per cent Valid Per cent Cumulative Per cent

smoker non-smoker Total

6 34 40

15.0 85.0 100.0

15.0 85.0 100.0

15.0 100.0

age * smoking status

Smoking status

Mean 20.8333 21.5294 21.4250

N 6 34 40

Std. Deviation 1.47196 2.28613 2.18254

smoker non-smoker Total

gender * smoking status

Smoking status smoker gender Total male female 5 1 6 non-smoker 15 19 34

Total 20 20 40

Formatted: Space After: 10 pt, Line spacin Multiple 1.15 li, Adjust space between Latin and Asian text, Adjust space between Asian text and numbers

Duration of Number of cigarettes per day smoking in months N Mean Std. Deviation Valid Missing 6 34 27.500 22.642 6 34 4.167 1.471

Comment [a6]: Add this to table 1

gender

Duration of smoking in months Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation 23.400 22.689 48.000 . 27.500 22.642

Number of cigarettes per day 4.600 1.140 2.000 . 4.166 1.471

male female Total

AGE VS. GENDER

age gender male female Total Mean 22.050 20.800 21.425 N 20 20 40 Std. Deviation 2.282 1.935 2.182

EXERCISE HABIT AMONG CONTROL

Comment [a7]: Add this to table 1

exercise Frequency always sometimes never 7 26 7 Per cent 17.5 65.0 17.5 Valid Per cent Cumulative Per cent 17.5 65.0 17.5 17.5 82.5 100.0

Total

40

100.0

100.0

Comment [a8]: You use either a table or a diagram not both

gender * exercise exercise always gender Total male female 5 2 7 sometimes 13 13 26 never 2 5 7 20 20 40 Total

Comment [a9]: Delete this

NUTRITIONAL STATUS OF CONTROL

Comment [a10]: Add to table 1

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Mean

Number of meals per day * Gender Std. Deviation Std. Error 95% Confidence Interval for Minimum Maximum Mean Lower Bound Upper Bound 1.399 .587 1.095 .312 .131 .173 2.545 2.375 2.574 3.854 2.924 3.275 2.00 2.00 2.00 8.00 4.00 8.00

male female Total

20 20 40

3.200 2.650 2.925

Smoking status

Number of meals * Smoking status Mean N

Std. Deviation

smoker non-smoker Total

3.000 2.911 2.925

6 34 40

.894 1.137 1.095

Comment [a11]: Add to table one

Comment [a12]: ??????

Genetic factor Frequency yes no Total 22 18 40 Per cent 55.0 45.0 100.0 Valid Per cent 55.0 45.0 100.0 Cumulative Per cent 55.0 100.0

Comment [a13]: ??????

diabetes Frequency Per cent Valid Per cent Cumulative Per cent 100.0

no

40

100.0

100.0

CASES

SMOKING STATUS AMONG CASES

Frequency Per cent Valid Per cent Cumulative Per cent 15.0 100.0

Comment [a14]: Add it to the contol table

smoker non-smoker Total

6 34 40

15.0 85.0 100.0

15.0 85.0 100.0

age * smoking status Smoking status smoker non-smoker Total Mean 19.833 19.852 19.850 N 6 34 40 Std. Deviation 1.602 1.956 1.888

gender * smoking status

Smoking status smoker gender Total male female 6 0 6 non-smoker 14 20 34

Total

20 20 40

BMI * smoking status

Smoking status smoker BMI Total overweight underweight 3 3 6 non-smoker 17 17 34

Total 20 20 40

Duration of smoking Number of cigarettes per in months day N Mean Std. Deviation Valid Missing 6 34 28.500 21.011 6 34 4.666 3.076

BMI Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation

duration 13.667 3.214 43.333 20.816 28.500 21.011

Number of cigarettes 3.333 1.527 6.000 4.000 4.667 3.076

overweight underweight Total

AGE VS. GENDER

age gender male female Total Mean 19.800 19.900 19.850 N 20 20 40 Std. Deviation 1.704 2.100 1.888

EXERCISE HABIT AMONG CASES

Comment [a15]: Add it to table one of the controls

exercise Frequency always sometimes never Total 4 23 13 40 Per cent 10.0 57.5 32.5 100.0 Valid Per cent 10.0 57.5 32.5 100.0 Cumulative Per cent 10.0 67.5 100.0

Exercise * BMI

exercise always BMI Total overweight underweight 1 3 4 sometimes 10 13 23 never 9 4 13

Total 20 20 40

Exercise *smoking status

exercise always Smoking status Total smoker non-smoker 0 4 4 sometimes 2 21 23 never 4 9 13

Total 6 34 40

gender * exercise exercise always gender Total male female 2 2 4 sometimes 12 11 23 never 6 7 13 20 20 40 Total

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NUTRITIONAL STATUS OF CASES

Comment [a16]: Add it to table 1 of the contr

gender

Number of meals * gender Mean N

Std. Deviation

male female Total

3.250 3.500 3.375

20 20 40

1.292 1.357 1.314

BMI overweight underweight Total

Mean

Number of meals * BMI Std. Deviation Minimum 1.348 .680 1.314 2.00 1.00 1.00

Maximum 7.00 4.00 7.00

4.150 2.600 3.375

Smoking status smoker non-smoker Total

Number of meals * smoking status Mean N 3.500 3.350 3.375 6 34 40

Std. Deviation 1.378 1.323 1.314

Main content Frequency Per cent 22 11 6 1 40 55.0 27.5 15.0 2.5 100.0

Comment [a17]: Add it to table 1 of the contr

Valid Per cent Cumulative Per cent 55.0 27.5 15.0 2.5 100.0 55.0 82.5 97.5 100.0

carbohydrates proteins fat vitamins Total

Main content * BMI BMI overweight Carbohydrates Main content Proteins Fat vitamins Total 9 7 3 1 20 underweight 13 4 3 0 20 22 11 6 1 40 Total

Genetic factor * BMI BMI overweight Genetic factor Total yes no 8 12 20 underweight 12 8 20 20 20 40 Total

Comment [a18]: ????

Frequency yes no Total 1 39 40

diabetes Per cent Valid Per cent 2.5 97.5 100.0 2.5 97.5 100.0

Comment [a19]: Add it to table 1 of the contr

Cumulative Per cent 2.5 100.0

BMI * diabetes Count diabetes yes BMI Total overweight underweight 1 0 1 no 19 20 39 20 20 40 Total

gender * diabetes Count diabetes yes gender Total male female 1 0 1 no 19 20 39 20 20 40 Total

age * diabetes Count diabetes yes 16.00 17.00 18.00 age 19.00 20.00 21.00 22.00 23.00 26.00 Total 0 0 0 0 0 1 0 0 0 1 no 1 2 7 7 10 5 5 1 1 39 1 2 7 7 10 6 5 1 1 40 Total

Smoking status * diabetes Count diabetes yes Smoking status Total smoker non-smoker 1 0 1 no 5 34 39 6 34 40 Total

diabetes Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation

Duration in months 15.000 1 . 31.200 5 22.297 28.500 6 21.011

Number of cigarettes per day 5.000 1 . 4.600 5 3.435 4.667 6 3.076

yes

no

Total

exercise * diabetes Count diabetes yes always exercise Total sometimes never 0 1 0 1 no 4 22 13 39 4 23 13 40 Total

Number of meals * diabetes Count diabetes yes 1.00 2.00 3.00 Number of meals 4.00 5.00 6.00 7.00 Total 0 0 0 0 1 0 0 1 no 1 8 18 6 2 3 1 39 1 8 18 6 3 3 1 40 Total

Main content * diabetes Count diabetes yes carbohydrates Main content proteins fat vitamins Total 0 1 0 0 1 no 22 10 6 1 39 22 11 6 1 40 Total

Risk factor (smoking) present absent

Cases (abnormal Overweight BMI)underweight 6 34

Control (normal BMI) 6 34

Formatted Table

There were 12 smokers and 68 non-smokers Odds ratio: (634)/ (634) Odds ratio = 1 This shows that smokers and non-smokers have equal risk of having abnormal BMI

DISCUSSION
This case-control study showed no association between smoking and abnormal BMI. Smokers were at equal risk of having an abnormal BMI as non-smokers. Previous research has shown negative association between smoking and BMI. However, this may vary among different populations. The proportion of underweight subjects among smokers and overweight subjects among smokers were equal. Differences arose in the duration of smoking and number of packs among cases and control, on average Overweight subjects smoke: 3.3 cigarettes per day for a duration of 13.6 months (pack years = 0.19) underweight subjects smoke: 6 cigarettes per day for a duration of 43.3 months (pack years = 1.08) Normal subjects smoke: 4 cigarettes per day for 27.5 months (pack years = 0.46) Thus, underweight subjects have the most pack years Gender consideration: Amongst the 12 smokers, only 1 female smoke, and she has a normal BMI, smokes 2 cigarettes per day for duration of 48 months. (Pack years = 0.4) While male smokers with normal BMI smoke, 4.6 cigarettes per day for duration of 23.4months (pack years = 0.45) (Using 20 as the number of cigarettes in a pack)
Comment [a20]: Over or under weight?

Exercise habit Control: 7 (17.5%) always, 26 (65%) sometimes, 7 (17.5%) never exercise

Cases: 4 (10%) always, 23(57.5%) sometimes, 13 (32.5%) never exercise Overweight: 1 (5%) always, 10 ( 50%) sometimes, 9 (45%) never exercise Underweight: 3 (15%) always, 13 (65%) sometimes, 4 (20%) never exercise. Among smoker Underweight subjects: 2 never (66%), 1 sometimes (33%) Overweight subjects: 2 never (66%), 1 sometimes (33%) Normal subjects: 3 always (50%), 3 sometimes (50%) Among non-smokers Underweight subjects: 12 sometimes (70.5%), 4 always (23.5%), 1 never (6%) Overweight subjects: 9 sometimes (52.9%), 1 always (6%), 7 never (41.1%) Normal subjects: 23 sometimes (67.6%), 4 always (11.7%), 7 never (20.7%) These values show an association between exercise and BMI as, overweight subjects most likely never exercise, while underweight and normal subjects most likely exercise sometimes. The highest value of exercising always was found in normal subjects. Exercise vs. gender: Male: 7 always, 25 sometimes, 8 never exercise Female: 4 always, 24 sometimes, 12 never exercise Thus, as with previous research, male exercise more than female, as the most frequency of never exercising was found in female.

Comment [a21]: Move this to result section

Nutritional status Average number of meals per day Control: 2.9

 Cases: overweight 4.15 ; underweight 2.60 The main content is of little value to this research as both cases and control mostly consume carbohydrates. Smoking vs. number of meals per day (both cases and control) Smokers: 3.25 meals per day Non-smokers: 3.13 meals per day Although, this study shows smokers to eat more meals daily, the difference is not of significance.

Comment [a22]: Move this to results section

Only one subject was found to be diabetic: an overweight 21 year old male smoker, 5 cigarettes per day for 15 months (pack years = 0.31). He is on a protein diet, eats 5 times daily and exercises sometimes. Genetic factors Cases overweight subjects: 40% yes, 60% no Underweight: 60% yes. 40% no Control: 55% yes, 45% no In general 52.5% yes, 47.5% no, this may depict BMI to be a subject of genetic inheritance.
Comment [a23]: What do u mean by genetic factors? Move this to result section

CONCLUSION
Body mass index is independent of smoking status and dependent of exercise habits, nutritional status and genetic predispositions. However, heavy smokers incline to a lower BMI. Age and gender may also affect BMI as variation arose in exercise habits, as less exercise results in a higher BMI and vice versa and this was proved in females and older people who tend to exercise less. Males in control group eat more meals per day, while females eat more meals per day in cases. Also, smoking trend has declined immensely. This decrease may apply only to this socio-economic class and/or educational background or it could be a result of a general decrease in smoking habit amongst youth in Sudan.

Comment [a24]: Just answer your objectives

Likelihood Ratio Tests Effect Model Fitting Criteria -2 Log Likelihood of Reduced Model 21.201a of 42.282

Likelihood Ratio Tests

ChiSquare

df

Sig.

Intercept .000 0 . Number 21.080 1 .000 meals exercise 27.888 6.686 1 .010 Genetic factor 22.414 1.212 1 .271 Smoking 23.100 1.899 1 .168 status The chi-square statistic is the difference in -2 log-likelihoods between the final model and a reduced model. The reduced model is formed by omitting an effect from the final model. The null hypothesis is that all parameters of that effect are 0. a. This reduced model is equivalent to the final model because omitting the effect does not increase the degrees of freedom.

RECOMMENDATION
People should quit smoking as it has a lot of harmful effects on the body and environment. The BMI of individuals should be kept at the optimum level (18.5-25 kg/m2) as this increases the quality of life Regular exercise and healthy eating are essential in maintaining a healthy BMI and thus healthier lives.

Comment [a25]: Should come from your resu

KHARTOUM COLLEGE OF MEDICAL SCIENCES DEPARTMENT OF COMMUNITY MEDICINE QUESTIONNAIRE FOR EFFECT OF SMOKING ON BODY MASS INDEX (BMI)

1. Age ( ) 2. Gender Male ( ) female ( ) 3. Smoking status Smoker ( ) non-smoker ( ) Questions 4 and 5 for smokers only 4. Duration of smoking in months ( ) 5. Number of cigarettes smoked per day ( ) 6. Do you exercise? Always ( ) sometimes ( ) never ( ) 7. How many meals do you eat daily ( ) 8. What is your meal mainly consisting: Carbohydrates ( ) protein ( ) Fat ( ) vitamins ( ) 9. Do you have diabetes? Yes ( ) no ( ) 10. Do you consider your body mass to be genetic? Yes ( ) no ( )

REFERENCES
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4. http://marcus-

munafo.psy.bris.ac.uk/Publications/2009%20Nicotine%20Tob%20Res%20d.pdf

Comment [a26]: Revise numbering