The Journal of Nutrition Vol. 128 No. 9 September 1998, pp. 1450-1457

Cigarette Smoking Is Associated with Unhealthy Patterns of Nutrient Intake: a Meta-analysis^1,2

Jean Dallongeville^{*, , 3}, Nadine Marécaux, Jean-Charles Fruchart^{*, **}, and Philippe Amouyel

^* Département d'athérosclérose,  INSERM CJF 95-05, ^** INSERM U-325, Institut Pasteur de Lille, 59019 Lille cedex, France

	ABSTRACT

Abstract Introduction Methods Results Discussion References

The aim of this investigation was to assess the relationship between smoking status and nutrient intakes using a meta-analysis. Publications in English were sought through a Medline search using the following key words: food habits, eating, feeding behavior, diet, food, nutrition, nutritional status or assessment, tobacco use disorder, tobacco, nicotine and smoking. Scanning relevant reference lists of articles and hand searching completed the data collection. No attempt was made to search for unpublished results. Paper selection was based on nutritional surveys including comparisons of smokers with nonsmokers. Fifty-one published nutritional surveys from 15 different countries with 47,250 nonsmokers and 35,870 smokers were used in the analysis. The estimates of size effects were calculated with the mean and variance values of each nutrient intake and the size of the sample. Smokers declared significantly (all P < 10⁵) higher intakes of energy (+4.9%), total fat (+3.5%), saturated fat (+8.9%), cholesterol (+10.8%) and alcohol (+77.5%) and lower intakes of polyunsaturated fat (6.5%), fiber (12.4%), vitamin C (16.5%), vitamin E (10.8%) and -carotene (11.8%) than nonsmokers. Protein and carbohydrate intakes did not differ between smokers and nonsmokers. There was no evidence of heterogeneity among studies. In conclusion, the nutrient intakes of smokers differ substantially from those of nonsmokers. Some of these differences may exacerbate the deleterious effects of smoke components on cancer and coronary heart disease risk.

	INTRODUCTION

Abstract Introduction Methods Results Discussion References

In industrialized countries, cigarette smoking is a major cause of preventable disease and premature death (Department of Health and Human Services 1989, Lakier 1992, Phillips et al. 1996, Thun et al. 1995). Several studies have shown anthropometric and biological heterogeneity between smokers and nonsmokers (Blair et al. 1980, Craig et al. 1989, Goldbourt and Medalie 1975, Klesges et al. 1989). These differences may be the consequence of the effects of smoke components on various metabolic reactions (Craig 1993, Jensen et al. 1995, Morrow et al. 1995) or may depend on different behaviors or lifestyles in smokers and nonsmokers (Blair et al. 1980, Goldbourt and Medalie 1975, Revicki et al. 1991, Woodward et al. 1994). The assessment of nutritional habits in population studies has demonstrated that smokers and nonsmokers differ in the way they select their food (Midgette et al. 1993, Preston 1991, Subar and Harlan 1993). These studies were conducted in countries with different cultures and lifestyles, thus adding to the already important variability of the nutrient intakes in the population. The aim of this analysis is to assess the relationship between smoking status and nutrient intake using the powerful tool of the meta-analysis. This technique absorbs part of the background variability and therefore, in our view, appears to be suitable for the transcultural comparisons of nutrient intakes.

	MATERIALS AND METHODS

Abstract Introduction Methods Results Discussion References

Studies.  The publications included in this analysis were those that examined the association between energy and nutrient intakes and smoking status. The inclusion criteria were as follows: nutritional surveys including comparisons of smokers to nonsmokers. Nutrients had to be presented as quantitative variables in weight units. Only published articles written in English were recorded. Publications were sought through a Medline search, scanning relevant reference lists of articles and hand searching in published papers that were surveyed (list available on request). No attempt was made to search for unpublished results. Only the most recently published study with the largest number of subjects from the same survey was included in the analysis. When the values of heavy smokers were available for statistical calculations, they were used instead of those of unspecified groups of smoker. Similarly, the data from nonsmokers or never-smokers were selected as a control. Nutritional surveys were made with 3- to 7-d food records, 24-h recalls or records, food-frequency questionnaires or dietary histories. In certain studies, special questionnaires were used to assess alcohol consumption. Total energy intake was used where expressed in calories or Joules. The nutritional variables (protein, carbohydrate, lipid, alcohol, saturated fat, polyunsaturated fat, cholesterol, fiber, vitamin C, -carotene, vitamin E, iron and calcium) were analyzed only when available in mass per unit time. Intakes of protein, lipids, carbohydrates and alcohol expressed as a percentage of total energy were not selected for statistical analysis. Mean values were adjusted for covariates in five studies. When necessary, the standard deviation was calculated from the standard error or 95% confidence interval of the mean for the purpose of the study.

The exclusion criteria included the following: unpublished papers, articles written in any language other than English, old data (updated in more recent selected publications) and repeated studies with a smaller number of subjects. Other publications were rejected because of missing information (variance or number of subjects) for the statistical analysis, or where data were presented in percentage of total energy or nonconventional units (drinks or frequency of intake). The list of the rejected papers is presented in the Appendix. In addition, in a subsample analysis, we excluded a total of 15 studies based on the following criteria: selected populations (pregnant women or adolescents) and dietary assessment based on a 24-h recall.

Data collected.  A total of 51 studies (67 samples) was included and analyzed in the present meta-analysis. The following information was collected from each paper: population characteristics (gender, origin of the sample, age), sampling methodology, type of dietary investigation, statistical analysis, size of the sample, means and standard deviations of energy and nutrients, and smoking status (smokers, heavy smokers, never-smokers and nonsmokers).

Statistical method.  Differences between nutrient intakes of smokers and non-smokers were expressed as the proportion of pooled SD: where M_smoi and M_non-smoi represent the mean value of a given nutrient in smoker and nonsmoker groups of the same study. SD_i, the pooled standard deviation of each nutrient was calculated for each study as follows: where n_smoi and n_non-smoi represent the number of smokers and nonsmokers in each study for a given nutrient; SD_smoi and SD_non-smoi are the standard deviations of the mean value of the given nutrient. The mean Z-score difference, 95% confidence interval and homogeneity of the data were assessed as previously described (Hedges and Olkin 1985). To this end, each study was weighted by W_i: and the mean Z-score was calculated by the following: This strategy permits normalization of the data and statistical evaluation of the differences between smokers and nonsmokers.

To quantitatively assess the differences in nutrient intakes between smokers and nonsmokers, the mean percentage difference for a given nutrient was calculated after weighting each percentage difference by the number of subjects of the sample as follows: where N_smo and N_non-smo are the sum of n_i for a given nutrient.

	RESULTS

Abstract Introduction Methods Results Discussion References

The total number of subjects varied according to the nutrient that was analyzed (Table 1). Samples originated from 15 countries. In a few instances, samples were taken from selected groups of subjects: pregnant women (n = 6), adolescents (n = 3), manual and non-manual workers (n = 1).

The relationships between smoking status and total energy, fat, protein, carbohydrate, alcohol and fiber intakes are presented as Z-score differences for each individual study (Fig. 1). Smokers reported higher intakes of total energy, fat and alcohol than nonsmokers in 69.2% (36/52), 68.6% (24/35) and 100% (29/29) of the studies, respectively. This difference was particularly clear for alcohol. In all studies reporting alcohol intake, it was higher in smokers than in nonsmokers. In contrast, protein and carbohydrate consumption were evenly distributed around a Z-score of 0. Fiber intake was lower in smokers than in nonsmokers in 93.7% (30/32) of the studies. Saturated fat and cholesterol intakes were higher in smokers than in non-smokers in 87.5% (21/24) and 89.5% (17/19), respectively, and polyunsaturated fat intake was lower in smokers in 62.5% (10/16) of the studies, suggesting an association between fatty acid composition of the diet, cholesterol consumption and smoking status (Fig. 2). The intakes of vitamins C, E and -carotene were lower in smokers than in nonsmokers in 88.9% (24/27), 61.5% (8/13) and 100% (15/15) of the studies, respectively (Fig. 2).

View larger version (18K): [in this window] [in a new window]   Fig 1. Standardized difference (Z-score) of energy, fat (Fat), protein (Pro), carbohydrate (Carb), alcohol (Alc) and fiber (Fib) intakes between smokers and nonsmokers. Each circle represents the Z-score of an individual study. Positive Z-score differences indicate higher and negative differences indicate lower reported intakes in smokers than in nonsmokers.

View larger version (16K): [in this window] [in a new window]   Fig 2. Standardized difference (Z-score) of saturated (SFA) and polyunsaturated (PUFA) fatty acids, cholesterol (Chol), vitamin C (Vit C), vitamin E (Vit E) and -carotene (-car) intakes between smokers and non-smokers. Each circle represents the Z-score of an individual study. Positive Z-score differences indicate higher and negative differences indicate lower reported intakes in smokers than in nonsmokers.

The mean Z-score difference was significant and positive (P < 10⁵) for total energy, fat, saturated fat, cholesterol and alcohol, suggesting that smokers declared significantly greater intakes of these nutrients than nonsmokers (Table 2). In contrast, the mean Z-score differences of polyunsaturated fat, fiber, vitamin C, vitamin E, -carotene, iron (P < 10⁵) and calcium (P = 0.0002) intakes were significant and negative, indicating lower intakes of these nutrients in smokers compared with nonsmokers. Finally, the mean Z-score differences of total protein and carbohydrate were not significantly different from 0, suggesting that smokers reported an intake of these macronutrients similar to that of nonsmokers.

The weighted percentage difference in total energy equaled 4.9% between smokers and nonsmokers. This increase was accounted for by a 3.5 and 77.5% difference in total fat and alcohol intake, respectively, in smokers compared with nonsmokers. The consumption of fiber and antioxidant vitamins was on average between 10 and 20% lower in smokers than in nonsmokers (Table 2).

There was no evidence of heterogeneity among studies for each variable. In addition, to avoid the potential bias related to selected samples or to nutritional assessment methods, the analysis was repeated on a subsample (excluding pregnant women and adolescents) and intakes measured by the 24-h recall method. This analysis yielded qualitatively the same results as for the entire group for each nutrient. Finally, analyses were performed separately in men and women (excluding pregnant women) for energy, fat, protein, carbohydrate, alcohol, fiber and vitamin C. The mean Z-score differences in both genders were consistent with those of the whole group.

	DISCUSSION

Abstract Introduction Methods Results Discussion References

This study shows that smokers have unhealthy patterns of nutrient intake compared with nonsmokers and that these habits are homogeneous among studies despite extreme variability in food intake habits in different countries. On average, smokers declared consuming more fat (+3.5%) and more alcohol (+77.5%) than nonsmokers, resulting in a greater energy intake (+4.9%). Smokers also reported greater intakes of saturated fat (+8.9%) and cholesterol (+10.8%) and lesser intakes of polyunsaturated fat (6.5%) and fiber (12.4%). Moreover, the reported consumption of antioxidants, vitamin C (16.5%), vitamin E (10.8%) and -carotene (11.8%), was lower among smokers than nonsmokers. These associations were not different among studies. Such nutritional habits are compatible with a greater risk of cancer (Byers and Guerrero 1995, Shils and Young 1988) and coronary heart disease (Buring and Hennekens 1997, Kohlmeier and Hastings 1995, NCEP 1993, Willet 1990). Thus, smokers reported specific food intake patterns that may aggravate their smoking-related risk of cancer and coronary heart disease.

Several epidemiologic studies have shown anthropometric and biological differences between smokers and nonsmokers (Blair et al. 1980, Craig et al. 1989, Goldbourt and Medalie 1975, Klesges et al. 1989). These differences may result in part from behavioral differences such as peculiar food choices in smokers that have been described in a number of studies (Table 1). The present meta-analysis permits the overall estimation of the relationship between smoking status and nutritional intakes. Accordingly, the consistency of the difference in intake of a number of nutrients among population samples with different cultural environments suggests, although does not prove, a causal association between smoking and specific food choices. Alternatively, the associations reported in this study may be the consequence of publisher policy bias toward positive results (Chalmers and Altman 1995), although we believe that this effect is small in this study because many variables were assessed in the each survey.

Cigarette smoking is closely associated with the development and progression of cancer and coronary heart disease and increased mortality (Department of Health and Human Services 1989, Lakier 1992, Phillips et al. 1996, Thun et al. 1995). Such association is dependent on the effects of smoke components on cancer induction (Duthie et al. 1995), lipoprotein metabolism (Craig et al. 1989, Craig 1993) and lipid peroxidation (Morrow et al. 1995). This meta-analysis demonstrates that smokers also differ from nonsmokers in nutrient intake. Epidemiological evidence demonstrates a positive relationship between elevated alcohol, fat, saturated fat and cholesterol intakes and risk of cancer and/or coronary heart disease (NCEP 1993, Shils and Young 1988, Willet 1990). Inverse associations between antioxidant vitamin or fiber intakes and these diseases have also been shown (Buring and Hennekens 1997, Byers and Guerrero 1995, Kohlmeier and Hastings 1995, Shils and Young 1988). Thus, the observed differences between smokers and nonsmokers may exacerbate the effect of smoke components on the genesis and progression of cancer and coronary heart disease. Moreover, smoking by itself increases the requirements for various antioxidant vitamins such as vitamin C (Preston 1991), further compounding these risks.

The connection between smoking and dietary intake is extremely complex. Nicotine, the most characteristic of tobacco components, is a highly toxic alkaloid that is both a ganglionic stimulant and a depressant (Benowitz 1988). Many of its complex effects are mediated by the release of catecholamines. Recent studies have demonstrated that tobacco smoke exposure is associated with a marked reduction in monoamine oxidase, an enzyme that is associated with mood function (Fowler et al. 1996). It is conceivable that such effects result in dysregulation of appetite or attitudes toward food (Grunberg 1986). Others have suggested that modifications of taste related to smoking may lead smokers to prefer certain foods (Grunberg 1982). Particular food choices might also correspond to a generally unhealthy lifestyle a socio-economic status associated with smoking or a lack of nutrition knowledge (Goldbourt and Medalie 1975, Woodward et al. 1994). Finally, although it is possible that smokers and nonsmokers differ in the way in which they answer a food-frequency questionnaire, food record or dietary history, we believe that this hypothesis is unlikely.

In conclusion, the dietary habits of smokers are characterized by higher intakes of energy, total fat, saturated fat, cholesterol and alcohol and by lower intakes of antioxidant vitamins and fiber, compared with nonsmokers. Such a nutrient profile may exacerbate the risk of coronary heart disease and cancer associated with smoking. The results of this study indicate that any public health preventive action toward smokers should aim not only at suppressing tobacco use, but also at promoting better nutritional habits.

	APPENDIX: NONSELECTED PAPERS AND REASONS FOR EXCLUSION

Duplicate studies

Bolton-Smith, C. (1993) Antioxidant vitamin intakes in Scottish smokers and nonsmokers. Dose effects and biochemical correlates. Ann. N.Y. Acad. Sci. 686: 347-360. Duplicate of Bolton-Smith et al. (1993) Br. J. Nutr. 69: 315-332.

Cade, J. & Margetts, B. (1989) Cigarette smoking and serum lipid and lipoprotein concentrations. Br. Med. J. 298: 1312. Duplicate of Cade et al. (1991) J. Epidemiol. Community Health 45: 270-272.

Haste, F. M., Brooke, O. G., Anderson, H. R. & Bland, J. M. (1991) The effect of nutritional intake on outcome of pregnancy in smokers and non-smokers. Br. J. Nutr. 65: 347-354. Duplicate of Haste et al. (1990) Am. J. Clin. Nutr. 51: 29-36.

Klesges, R. C., Stein, R. J., Hultquist, C. M. & Eck, L. H. (1992) Relationships among smoking status, body composition, energy intake, and physical activity in adult males: a longitudinal analysis. J. Subst. Abuse 4: 47-56. Duplicate of Klesges et al. (1990) Am. J. Clin. Nutr. 51: 784-789.

Aberrant value of alcohol in the sample of women

Beser, E., Baytan, S. H., Akkoyunlu, D. & Gul, M. (1995) Cigarette smoking, eating behaviour, blood haematocrit level and body mass index. Ethiop. Med. J. 33: 155-162.

Sample size missing

Kee, F., Weston, J., McCrum, E. E., McMaster, D., Yarnell, J., Fruchart, J. C., Bard, J. M., Cambien, F. & Evans, A. E. (1995) The effect of diet on lipid, apoprotein and lipoparticle variation in the ECTIM study in Belfast. Rev. Epidemiol. Sante Publique 43: 18-25.

Subar, A. F., Harlan, L. C. & Mattson, M. E. (1990) Food and nutrient intake differences between smokers and non-smokers in the US. Am. J. Public Health 80: 1323-1329.

Standard deviation missing

Bennet, A. E., Doll, R. & Howell, R. W. (1970) Sugar consumption and cigarette smoking. Lancet 16: 1011-1014.

Carruth, B. R. (1981) Smoking and pregnancy outcome of adolescents. J. Adolesc. Health Care 2: 115-120.

Clearman, D. R. & Jacobs, D.R.J. (1991) Relationships between weight and caloric intake of men who stop smoking: the Multiple Risk Factor Intervention. Addict. Behav. 16: 401-410.

Fisher, M. & Gordon, T. (1985) The relation of drinking and smoking habits to diet: the Lipid Research Clinics Prevalence Study. Am. J. Clin. Nutr. 41: 623-630.

Flegal, K. M., Troiano, R. P., Pamuk, E. R., Kuczmarski, R. J. & Campbell, S. M. (1995) The influence of smoking cessation on the prevalence of overweight in the United States. N. Engl. J. Med. 333: 1165-1170.

Gordon, T., Kannel, W. B., Dawber, T. R. & McGee, D. (1975) Changes associated with quitting cigarette smoking: the Framingham Study. Am. Heart J. 90: 322-328.

Gridley, G., McLaughlin, J. K. & Blot, W. J. (1990) Dietary vitamin C intake and cigarette smoking. Am. J. Public Health 80: 1526.

Hebert, J. R. & Kabat, G. C. (1990) Differences in dietary intake associated with smoking status. Eur. J. Clin. Nutr. 44: 185-193.

Kaprio, J. & Koskenvuo, M. (1988) A prospective study of psychological and socioeconomic characteristics, health behavior and morbidity in cigarette smokers prior to quitting compared to persistent smokers and non-smokers. J. Clin. Epidemiol. 41: 139-150.

La Vecchia, C., Negri, E., Franceschi, S., Parazzini, F. & Decarli, A. (1992) Differences in dietary intake with smoking, alcohol, and education. Nutr. Cancer 17: 297-304.

Le Marchand, L., Ntilivamunda, A., Kolonel, L. N., Vanderford, M. K. & Lee, J. (1988) Relationship of smoking to other life-style factors among several ethnic groups in Hawaii. Asia Pac. J. Public Health 2: 120-126.

Lee, D. J. & Markides, K. S. (1991) Health behaviors, risk factors, and health indicators associated with cigarette use in Mexican Americans: results from the Hispanic HANES. Am. J. Public Health 81: 859-864.

Matsuya, T. (1982) Alcohol intake and smoking habits of Japanese telephone employees and their effects on the dietary patterns. Taiwan I-Hsueh-Hui Tsa-Chih. 81: 857-867.

Mellstrom, D., Rundgren, A., Jagenburg, R., Steen, B. & Svanborg, A. (1982) Tobacco smoking, ageing and health among the elderly: a longitudinal population study of 70-year-old men and an age cohort comparison. Age Ageing 11: 45-58.

Olsson, A. G. & Mölgaard, J. (1990) Relations between smoking, food intake and plasma lipoproteins. In: Tobacco Smoking and Atherosclerosis (Diana, J. N., ed.), pp. 237-243. Plenum Press, New York, NY.

Smithells, R. W., Ankers, C., Carver, M. E., Lennon, D., Schorah, C. J. & Sheppard, S. (1977) Maternal nutrition in early pregnancy. Br. J. Nutr. 38: 497-506.

Stamier, J., Rains-Clearman, D., Lenz-Litzow, K., Tillotson, J. L. & Grandits, G. A. (1997) Relation of smoking at baseline and during trial years 1-6 to food and nutrient intakes and weight in the special intervention and usual care groups in the Multiple Risk Factor Intervention Trial. Am. J. Clin. Nutr. 65: 374S-402S.

Strickland, D., Graves, K. & Lando, H. (1992) Smoking status and dietary fats. Prev. Med. 21: 228-236.

Stryker, W. S., Kaplan, L. A., Stein, E. A., Stampfer, M. J., Sober, A. & Willett, W. C. (1988) The relation of diet, cigarette smoking, and alcohol consumption to plasma beta-carotene and alpha-tocopherol levels. Am. J. Epidemiol. 127: 283-296.

Subar, A. F. & Harlan, L. C. (1993) Nutrient and food group intake by tobacco use status: the 1987 National Health Interview Survey. Ann. N.Y. Acad. Sci. 686: 310-322.

Tillotson, J. L., Bartsch, G. E., Gorder, D., Grandits, G. A. & Stamler, J. (1997) Food group and nutrient intakes at baseline in the Multiple Risk Factor Intervention Trial. Am. J. Clin. Nutr. 65: 228S-257S.

Van Poppel, G., Schrijver, J., Meulmeester, J. F. & Kempen-Voogd, N. (1989) Biochemical and anthropometric evaluation of the nutritional status of 35-year-old Dutch men with reference to smoking and drinking habits. Int. J. Vitam. Nutr. Res. 59: 381-387.

Wood, D. A., Riemersma, R. A., Butler, S., Thomson, M., Macintyre, C., Elton, R. A. & Oliver, M. F. (1987) Linoleic and eicosapentaenoic acids in adipose tissue and platelets and risk of coronary heart disease. Lancet 24: 177-182.

Logistic regression analysis

Haste, F. M., Brooke, O. G., Anderson, H. R., Bland, J. M. & Peacock, J. L. (1990) Social determinants of nutrient intake in smokers and non-smokers during pregnancy. J. Epidemiol. Community Health 44: 205-209.

Swan, G. E., Carmelli, D., Rosenman, R. H., Fabsitz, R. R. & Christian, J. C. (1990) Smoking and alcohol consumption in adult male twins: genetic heritability and shared environmental influences. J. Subst. Abuse 2: 39-50.

Correlation analysis

Philipps, C. & Johnson, N. E. (1977) The impact of quality of diet and other factors on birth weight of infants. Am. J. Clin. Nutr. 30: 215-225.

Categorial data presented

Blair, A., Blair, S. N., Howe, H. G., Pate, R. R., Rosenberg, M., Parker, G. M. & Pickle, L. W. (1980) Physical, psychological, and sociodemographic differences among smokers, exsmokers, and nonsmokers in a working population. Prev. Med. 9: 747-749.

Craig, T. J. & Van Natta, P. A. (1977) The association of smoking and drinking habits in a community sample. J. Stud. Alcohol 38: 1434-1439.

Green, M. S., Jucha, E. & Luz, Y. (1986) Blood pressure in smokers and nonsmokers: epidemiologic findings. Am. Heart J. 111: 932-940.

Hebert, J. R. & Kabat, G. C. (1990) Differences in dietary intake associated with smoking status. Eur. J. Clin. Nutr. 44: 185-193.

Revicki, D., Sobal, J. & DeForge, B. (1991) Smoking status and the practice of other unhealthy behaviors. Fam. Med. 23: 361-364.

Schectman, G., Byrd, J. C. & Hoffmann, R. (1991) Ascorbic acid requirements for smokers: analysis of a population survey. Am. J. Clin. Nutr. 53: 1466-1470.

Thornton, A., Lee, P. & Fry, J. (1994) Differences between smokers, ex-smokers, passive smokers and non-smokers. J. Clin. Epidemiol. 47: 1143-1162.

Whitehead, T. P., Robinson, D. & Allaway, S. L. (1996) The effects of cigarette smoking and alcohol consumption on blood lipids: a dose-related study on men. Ann. Clin. Biochem. 33: 99-106.

Intake data expressed as foods

Aoki, K., Ito, Y., Sasaki, R., Ohtani, M., Hamajima, N. & Asano, A. (1987) Smoking, alcohol drinking and serum carotenoids levels. Jpn. J. Cancer Res. 78: 1049-1056.

Charlton, A. (1984) The Brigantia smoking survey. Smoking-related habits and preferences of 9 to 19-year-olds in northern England. Hygiene 3: 36-41.

Grunberg, N. E. (1982) The effects of nicotine and cigarette smoking on food consumption and taste preferences. Addict. Behav. 7: 317-331.

Holly, E. A., Cress, R. D., Ahn, D. K., Aston, D. A., Kristiansen, J. J. & Felton, J. S. (1992) Characteristics of women by smoking status in the San Francisco Bay Area. Cancer Epidemiol. Biomarkers Prev. 1: 491-497.

Kato, I., Tominaga, S. & Suzuki, T. (1989) Characteristics of past smokers. Int. J. Epidemiol. 18: 345-354.

Morabia, A. & Wynder, E. L. (1990) Dietary habits of smokers, people who never smoked, and exsmokers. Am. J. Clin. Nutr. 52: 933-937.

Suyama, Y. & Itoh, R. (1992) Multivariate analysis of dietary habits in 931 elderly Japanese males: smoking, food frequency and food preference. J. Nutr. Elder. 12: 1-12.

Whichelow, M. J., Erzinclioglu, S. W. & Cox, B. D. (1991) A comparison of the diets of non-smokers and smokers. Br. J. Addict. 86: 71-81.

Whichelow, M. J., Golding, J. F. & Treasure, F. P. (1988) Comparison of some dietary habits of smokers and non-smokers. Br. J. Addict. 83: 295-304.

Zavela, K. J., Barnett, J. E., Smedi, K. J., Istvan, J. A. & Matarazzo, J. D. (1990) Concurrent use of cigarettes, alcohol, and coffee. J. Appl. Soc. Psychol. 20: 835-845.

Missing data

Istvan, J. & Matarazzo, J. D. (1984) Tobacco, alcohol, and caffeine use: a review of their interrelationships. Psychol. Bull. 95: 301-326.

Oliver, M. F. (1989) Cigarette smoking, polyunsaturated fats, linoleic acid, and coronary heart disease. Lancet 1: 1241-1243.

Preston, A. M. (1991) Cigarette smokingnutritional implications. Prog. Food Nutr. Sci. 15: 183-217.

Reviews

Diana, J. N. (1993) Tobacco smoking and nutrition. Ann. N.Y. Acad. Sci. 686:1-11.

Perkins, K. A. (1992) Effects of tobacco smoking on caloric intake. Br. J. Addict. 87: 193-205.

No cross-analysis between smoking status and nutritional variables

Aho, W. R. (1979) Smoking, dieting, and exercise: age differences in attitudes and behavior relevant to selected health belief model variables. The perceived seriousness is an important factor in influencing behavior. R. I. Med. J. 62: 85-92.

Anonymous (1992) From the Centers for Disease Control. Selected tobacco-use behaviors, dietary patterns among high school studentsUnited States, 1991. J. Am. Med. Assoc. 268: 448-451.

Allen, C. D. & Ries, C. P. (1985) Smoking, alcohol, and dietary practices during pregnancy: comparison before and after prenatal education. J. Am. Diet. Assoc. 85: 605-606.

Audrain, J. E., Klesges, R. C., DePue, K. & Klesges, L. M. (1991) The individual and combined effects of cigarette smoking and food on resting energy expenditure. Int. J. Obes. 15: 813-821.

Beckwith, J. B. (1986) Eating, drinking, and smoking and their relationship in adult women. Psychol. Rep. 59: 1075-1089.

Berrino, F., Merletti, F., Zubiri, A., Del Moral, A., Raymond, L., Esteve, J. & Tuyns, A. J. (1988) A comparative study of smoking, drinking and dietary habits in population samples in France, Italy, Spain and Switzerland. II. Tobacco smoking. Rev. Epidemiol. Sante Publique 36: 166-176.

Brooten, D., Peters, M. A., Glatts, M., Gaffney, S. E., Knapp, M., Cohen, S. & Jordan, C. (1987) A survey of nutrition, caffeine, cigarette and alcohol intake in early pregnancy in an urban clinic population. J. Nurse Midwifery 32: 85-90.

Chularojanamontri, V., Kewsiri, D., Chuapasert, S., Chanrit, S. & Viseshakul, D. (1985) Effects of cigarette smoking and alcohol consumption on blood lipid variables. J. Med. Assoc. Thai. 68: 503-507.

Chyou, P. H., Nomura, A. M. & Stemmermann, G. N. (1995) Diet, alcohol, smoking and cancer of the upper aerodigestive tract: a prospective study among Hawaii Japanese men. Int. J. Cancer 60: 616-621.

Cummins, R. O., Shaper, A. G., Walker, M. & Wale, C. J. (1981) Smoking and drinking by middle-aged British men: effects of social class and town of residence. Br. Med. J. (Clin. Res. Ed.) 283: 1497-1502.

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	FOOTNOTES

Manuscript received 5 January 1998. Initial reviews completed 5 March 1998. Revision accepted 19 May 1998.

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