Professional Documents
Culture Documents
Association of Smoking in Adolescence With Abdominal Obesity in Adulthood: A Follow-Up Study of 5 Birth Cohorts of Finnish Twins
Association of Smoking in Adolescence With Abdominal Obesity in Adulthood: A Follow-Up Study of 5 Birth Cohorts of Finnish Twins
Association of Smoking in Adolescence With Abdominal Obesity in Adulthood: A Follow-Up Study of 5 Birth Cohorts of Finnish Twins
348 | Research and Practice | Peer Reviewed | Saarni et al. American Journal of Public Health | February 2009, Vol 99, No. 2
RESEARCH AND PRACTICE
Measures T4 were defined as less than 25 kg/m2 for normal Socioeconomic status was classified into 6
Smoking behavior. Adolescent smoking weight, 25.00 to 29.99 kg/m2 for overweight, categories (upper-level employee, lower-level
was categorized as follows: (1) never smokers and 30 kg/m2 or greater for obese. employee, manual worker, self-employed or
(smoked fewer than 50 cigarettes in their other, farmer, and unclassified) according to the
lifetime), (2) former smokers, (3) occasional Confounding Factors criteria of the Finnish Classification of Socio-
smokers (current smokers other than daily We included selected potential confounding economic Groups.30 Educational attainment and
smokers), (4) daily smokers smoking fewer than factors known to be associated with smoking or employment status at wave T3 were used to
10 cigarettes per day, and (5) daily smokers the outcome measures (BMI and abdominal classify the socioeconomic status into 4 cate-
smoking 10 or more cigarettes per day. We obesity) in the analyses. gories (high school/university, vocational school,
primarily used the smoking status at age 18 To control for dietary behavior, we used employed, and unemployed/other).
years (wave T3); if this data point was missing, measures assessed at wave T1: the skipping
we used answers from waves T2 and T1. We of breakfast, type of milk and type of spread Validity Assessment
had several reasons for this: first, we assumed on bread, and cola drinking. Skipping breakfast We assessed the validity of the self-reported
the smoking habits to be most stabilized at has been associated with other risk behav- BMI, waist circumference, and height measures
wave T3 and therefore to most reliably reflect iors23,24 and with an increased risk of weight in a subsample of 566 twins. Those partici-
the smoking behavior during our follow-up. gain.25 Eating breakfast was assessed by using pants had participated in another study on the
Also, at earlier ages, the participants were 3 response categories: having breakfast every consequences of adolescent alcohol use with a
probably more ambivalent about their smoking morning, having breakfast about 3 to 4 mornings median of 650 days after the self-report.
status than at wave T3. This supposition was per week, and having breakfast once per week Height was measured without shoes on a sta-
based on our observation that at wave T1, 80% or less often. Respondents were asked which type diometer, and weight was measured in light
of those reporting to be former smokers had of milk (no milk, skim milk, 1% low-fat milk, clothes on a calibrated beam balance. Waist
smoked fewer than 50 cigarettes in their life- 1.9% low-fat milk, or 3.5% fat whole milk), circumference was measured while the partic-
time. Second, the number of cigarettes smoked and which type of spread (no spread, low-fat, ipants were standing, halfway between the
daily (fewer than 10 or 10 or more) was not margarine, butter-margarine, butter, or other) iliac crest and the lowest rib, at the end of a
asked at wave T1. Third, during data collection, they used. Type of milk and spread on bread light expiration. The intraclass correlations
it became illegal for children and adolescents have been shown to be good indicators of satu- were high. The intraclass correlation for
younger than 18 years to smoke, which might rated fat intake.26 Cola drinking was assessed as measured versus self-reported BMI was 0.89,
have affected how the participants younger than the number of 12-ounce (0.33 L) bottles con- and the mean difference was 0.93 kg/m2
18 years answered questions concerning to- sumed per day. Because cola drinking was quite (95% confidence interval [CI] = 0.79 kg/m2,
bacco use. Also, smoking status remained rea- rare and the distribution was highly skewed, it was 1.07 kg/m2). The intraclass correlation for
sonably stable from waves T1to T3. The j values used as a dichotomized variable in the analyses. measured versus self-reported height was 0.99,
comparing all smoking categories across differ- The use of sugar-sweetened and possibly even and the mean difference was 0.24 cm (95%
ent time points were approximately 0.5, and artificially sweetened27 soft drinks has been CI = 0.14 cm, 0.35 cm). The intraclass cor-
most of the changes were within categories of shown to be associated with weight gain and relation for measured versus self-reported
smokers (occasional and daily smokers). The j obesity.28 waist circumference was 0.75, and the mean
value when comparing never versus ever Physical activity was categorized in 3 classes difference was 2.48 cm (95% CI = 0.96 cm,
smokers at waves T1 and T3 was 0.64. on the basis of questions concerning the fre- 3.00 cm).
Anthropometric measures. Waist circumfer- quency of physical activity at leisure outside
ence was self-reported by the participants by school repeated in identical form in surveys Statistical Methods
using a tape measure supplied by mail in the from wave T1 to T3. Those who reported The odds ratios for abdominal obesity and
wave-T4 survey. We used the World Health exercising 4 to 5 times per week or more in all becoming overweight in adulthood were
Organization20 cutoffs for abdominal obesity of 3 questionnaires composed the exerciser obtained from logistic regression models. We
80 cm for women and 94 cm for men. Height and group; the passive group comprised those chose the binary outcomes for their relevance
weight were self-reported, and body mass index reporting exercising 1 to 2 times a month or in clinical settings and in identifying high-risk
(BMI; weight in kilograms divided by height in fewer in all 3 questionnaires; and the remain- patients. The potential gender interaction was
meters squared) was calculated on the basis of der composed the intermediate group.29 tested by using a likelihood-ratio test between
these values. We categorized the respondents as The age of smoking initiation (experiment- models with and without an interaction term
being normal weight, overweight, or obese at ing) was asked at wave T1. Parents BMI at age (gender smoking). A statistically significant
waves T1 and T2 by using the International 20 years was calculated by using heights and gender interaction was found concerning the
Obesity Task Force reference for adolescent weights recalled in the parental survey. risk of becoming overweight, but this was not
obesity, with the cutoffs created by using specific Fathers socioeconomic status was deter- the case for abdominal obesity. Therefore, risk
percentiles linked to adult cutoffs based on UK mined on the basis of questions concerning of becoming overweight was analyzed for men
data.21,22 The BMI categories for waves T3 and occupation, employment, and education. and women separately, and abdominal obesity
February 2009, Vol 99, No. 2 | American Journal of Public Health Saarni et al. | Peer Reviewed | Research and Practice | 349
RESEARCH AND PRACTICE
350 | Research and Practice | Peer Reviewed | Saarni et al. American Journal of Public Health | February 2009, Vol 99, No. 2
RESEARCH AND PRACTICE
February 2009, Vol 99, No. 2 | American Journal of Public Health Saarni et al. | Peer Reviewed | Research and Practice | 351
RESEARCH AND PRACTICE
Note. Overweight was defined as a body mass index of 25 kg/m2 or greater. Abdominal obesity was defined as a waist circumference of 80 cm or greater among women and 94 cm
or greater among men. Never smokers were the comparison group. Results presented in the figure are from regression models without any adjustment for confounding factors.
*P < .05; **P < .01, tested with logistic regression.
FIGURE 2Prevalence of general overweight (a) and abdominal obesity (b) at age 24 years, by smoking status during adolescence: FinnTwin16
cohort, Finland.
abdominal obesity. Smoking at least 10 ciga- importance because of the well-documented those studies used crude measures of smoking
rettes daily during adolescence was associated detrimental metabolic effects of central fat.3 (i.e., weekly smoking versus nonsmoking at
with an increased risk of abdominal obesity and age 1314 years), which may have reflected
overall overweight among women. The risk of Previous Studies smoking habits not yet stabilized. We were
becoming abdominally obese was not fully Our results differ from those of the previ- able to differentiate between occasional and
explained by overall adiposity and other possi- ous studies,1517,34,35 probably as the result of daily smokers, and could further take into ac-
ble factors affecting central fat accumulation, as some methodologic differences. Neither count the number of cigarettes smoked daily.
shown in the models adjusted for current BMI the Amsterdam Growth and Health Study16,17,34 The results of cross-sectional studies of body
and many other possible confounders. The nor the Northern Finland Cohort Study15,35 weight and smoking behavior have been incon-
extra kilograms on the waistline among the found an association between adolescent sistent,36,37 as have the results of longitudinal
heavy smokers are of clinical and public health smoking and later abdominal obesity. However, studies with no inclusion of indicators of abdom-
inal obesity.9,12,36,38,39
In our data, the prevalence of overweight
rose steeply from adolescence into young
adulthood. The determinants of later obesity
TABLE 2Odds Ratios (ORs) for Abdominal Obesity at Age 24 Years, by Smoking Status in
during this important age period are not well
Adolescence: FinnTwin16 Study, Finland
understood. Our results showed that smoking
Model 1 (n = 4296), Model 2 (n = 4296), Model 3 (n = 4269), during adolescence was associated with future
Smoking Status in Adolescence OR (95% CI) OR (95% CI) OR (95% CI) overweight among young women and with
Never (Ref) 1.00 1.00 1.00 abdominal obesity among both women and
Former 1.25 (0.98, 1.61) 1.17 (0.91, 1.52) 1.21 (0.87, 1.67) men. Smoking is known to be associated with
Occasional 1.21 (0.95, 1.54) 1.16 (0.91, 1.49) 1.12 (0.80, 1.57) low education,4042 dietary behavior,23,24 and
Smoked < 10 cigarettes daily 1.28 (1.00, 1.64) 1.11 (0.85, 1.45) 1.25 (0.87, 1.80) physical inactivity,29,43 all of which are docu-
Smoked 10 cigarettes daily 1.77* (1.39, 2.26) 1.44* (1.11, 1.88) 1.34 (0.95, 1.88) mented risk factors for overweight. However,
these confounders explained only a small
Note. CI = confidence interval. Model 1 adjusted for gender. Model 2 further adjusted for physical activity, dietary factors, amount of the association between smoking and
participants own socioeconomic status, fathers socioeconomic status, and parents body mass index. Model 3 further
adjusted for participants body mass index at age 24 years. overweight and later abdominal obesity. This,
*P < .01. together with the dose-dependent effect of
smoking and our findings from twin pairs
352 | Research and Practice | Peer Reviewed | Saarni et al. American Journal of Public Health | February 2009, Vol 99, No. 2
RESEARCH AND PRACTICE
discordant for abdominal obesity, supports the adolescence in this and other studies,52 it is Research, National Public Health Institute, Helsinki,
Finland.
interpretation that a causal relation may exist unlikely that abdominal obesity is common at
Requests for reprints should be sent to Suoma E. Saarni,
between smoking and the development of this young age or that it could have influenced Department of Public Health, PO Box 41, 00014
obesity. The pathophysiologic mechanisms be- smoking habits in adolescence. University of Helsinki, Helsinki, Finland (e-mail: suoma.
saarni@helsinki.fi).
hind this possibly causal link remain obscure. We used a large population-based sample
This article was accepted June 6, 2008.
However, one possible explanation may be with high response rates. Although twins have
that changes in glucocorticoid metabolism slightly lower BMIs than did singletons in
Contributors
associated with smoking44 and possibly also midadolescence,53 this is unlikely to affect the S. E. Saarni, J. Kaprio, and A. Rissanen were responsible
with psychosocial stress associated with smok- association between smoking and body compo- for the conception and design of this study. All authors
contributed substantially to analysis and interpretation
ing45,46 are responsible for the central fat sition. Further, determination of adult body size
of data. S. E. Saarni, K. Pietilainen, and S. Kantonen wrote
accumulation.47,48 takes place from late adolescence to early adult- drafts of the article, and all authors substantially partic-
hood. Our adolescents were assessed at each ipated in revising it critically for important intellectual
content. All authors gave their final approval of the final
Strengths and Weaknesses survey in adolescence within a very narrow age
version.
The increase in the risk of abdominal obesity range, thus reducing variation caused by age.
or overweight among the women was no Unlike in previous studies, we adjusted for sev-
longer statistically significant in the fully ad- eral confounders affecting abdominal obesity Acknowledgments
This study was supported by grants from the Signe and
justed models. This may have been caused by and smoking. We also used a more detailed Ane Gyllenberg Foundation, the National Institute on
insufficient statistical power. Another possible measure of smoking behavior than did the earlier Alcohol Abuse and Alcoholism (grants AA-08315,
AA-00145, and AA-12502), the European Union
interpretation of our findings is that adolescent studies and were able to consider the level of
Fifth Framework Program (QLRT-1999-00916 and
smoking is a proxy for other factors or is part of a daily cigarette consumption. QLG2-CT-2002-01254), the Academy of Finland
cluster of factors predisposing to later abdominal (grants 44069, 100499, 118555, and 201461), the
Academy of Finland Centre of Excellence in Complex
obesity. There are 2 implications of these 2 Conclusions
Disease Genetics, and Helsinki University Central
explanations: first, adolescent smoking should be Given the greater risk of overweight and Hospital.
seen as a sign of increased metabolic hazards in abdominal obesity among girls who smoked We thank Tellervo Korhonen from the Department of
Public Health, University of Helsinki, for valuable com-
clinical work. Second, counteracting smoking daily and the fact that adolescent smoking is often
ments on the article. We also thank the anonymous
initiation may be a more effective tool against associated with preoccupation with weight,54 referees for their careful help in improving the quality of
later metabolic morbidity than previously emphasizing the deleterious effect of smoking on this article.
Note. Funding sources had no involvement in plan-
thought in both clinical and public health settings. abdominal fat accumulation could be effective in
ning or conducting the study.
In this study, we adjusted for selected indi- smoking prevention among young women.
cators of dietary behavior, physical exercise, Counteracting smoking initiation may be a more
parental BMI, and fathers and participants effective tool against later morbidity than previ- Human Participant Protection
This study was approved by the ethical committees of
own socioeconomic status as potential con- ously thought. These results need to be replicated
Helsinki University and Indiana University.
founders. Our inability to adjust for dietary in other well-conducted epidemiologic studies
habits in more detail (e.g., in a food-frequency with longer follow-ups and possibly more-careful
questionnaire or food diary) can be seen as a measurement of the risk factors and the outcome. References
limitation of our study. Even if dietary mea- Our results show that adolescent smoking 1. World Health Report 2002. Geneva, Switzerland:
sures have several methodologic problems,49 predicts abdominal obesity among young World Health Organization; 2002.
this topic should be addressed in greater detail in adults. Both abdominal obesity and smoking 2. Peeters A, Barendregt JJ, Willekens F, Mackenbach
JP, Al Mamun A, Bonneux L. Obesity in adulthood and its
future research. Our validated measurement of are major risk factors for metabolic dysfunc- consequences for life expectancy: a life-table analysis.
exercise can be seen as reasonably accurate.29 tion55 and cardiovascular disease.56 The pre- Ann Intern Med. 2003;138(1):2432.
Inclusion of both parents BMI in the analysis is a vention of smoking during adolescence could be 3. Bigaard J, Frederiksen K, Tjonneland A, et al.
special strength of our study because BMI has a a very effective tool for preventing later meta- Waist circumference and body composition in
relation to all-cause mortality in middle-aged
strong genetic component.50 bolic morbidity. However, it will be important to men and women. Int J Obes (Lond). 2005;29(7):
We used self-reported data, and our mea- better understand the possible causal pathways 778784.
surement validation showed good association between smoking and later abdominal obesity. j 4. Akbartabartoori M, Lean ME, Hankey CR.
with measured values. Self-reports of smoking Relationships between cigarette smoking, body
size and body shape. Int J Obes (Lond). 2005;29(2):
status among Finns have previously been 236243.
shown to be valid.51 Some underreporting of About the Authors
Suoma E. Saarni, Kirsi Pietilainen, Suvi Kantonen, and 5. Bamia C, Trichopoulou A, Lenas D, Trichopoulos D.
body size may occur, which would lead to an Jaakko Kaprio are with the Department of Public Health, Tobacco smoking in relation to body fat mass and
underestimation of the risk of abdominal obesity. University of Helsinki, Helsinki, Finland. Aila Rissanen distribution in a general population sample. Int J Obes
and Kirsi Pietilainen are with the Obesity Research Unit, Relat Metab Disord. 2004;28(8):10911096.
Unfortunately, we had information on waist
Department of Psychiatry, Helsinki University Central 6. Barrett-Connor E, Khaw KT. Cigarette smoking and
circumference only at young adulthood. Given Hospital, Helsinki. Suoma E. Saarni and Jaakko Kaprio are increased central adiposity. Ann Intern Med. 1989;
the low prevalence of obesity and overweight in also with the Department of Mental Health and Alcohol 111(10):783787.
February 2009, Vol 99, No. 2 | American Journal of Public Health Saarni et al. | Peer Reviewed | Research and Practice | 353
RESEARCH AND PRACTICE
7. Canoy D, Wareham N, Luben R, et al. Cigarette with new functions for egen. Stata Journal. 2004;4(1): adulthood: follow-up of 18 to 20 years in the Oslo
smoking and fat distribution in 21,828 British men and 5055. Youth Study. Arch Pediatr Adolesc Med. 2003;157(12):
women: a population-based study. Obes Res. 2005; 23. Wingard DL, Berkman LF, Brand RJ. A multivariate 12121218.
13(8):14661475. analysis of health-related practices: a nine-year mortality 40. Pierce JP. International comparisons of trends in
8. Marti B, Tuomilehto J, Korhonen HJ, et al. Smoking follow-up of the Alameda County Study. Am J Epidemiol. cigarette smoking prevalence. Am J Public Health.
and leanness: evidence for change in Finland. BMJ. 1982;116(5):765775. 1989;79(2):152157.
1989;298(6683):12871290. 41. Saarni SE, Silventoinen K, Rissanen A, Sarlio-
24. Keski-Rahkonen A, Kaprio J, Rissanen A, Virkkunen
9. Ball K, Brown W, Crawford D. Who does not gain M, Rose RJ. Breakfast skipping and health-compromising Lahteenkorva S, Kaprio J. Intentional weight loss and
weight? Prevalence and predictors of weight maintenance behaviors in adolescents and adults. Eur J Clin Nutr. smoking in young adults. Int J Obes Relat Metab Disord.
in young women. Int J Obes Relat Metab Disord. 2002; 2003;57(7):842853. 2004;28(6):796802.
26(12):15701578. 42. Green MP, McCausland KL, Xiao H, Duke JC,
25. Purslow LR, Sandhu MS, Forouhi N, et al. Energy
10. Molarius A, Seidell JC, Kuulasmaa K, Dobson AJ, intake at breakfast and weight change: prospective study Vallone DM, Healton CG. A closer look at smoking
Sans S. Smoking and relative body weight: an interna- of 6,764 middle-aged men and women. Am J Epidemiol. among young adults: where tobacco control should
tional perspective from the WHO MONICA Project. 2008;167(2):188192. focus its attention. Am J Public Health. 2007;97(8):
J Epidemiol Community Health. 1997;51(3):252260. 14271433.
26. Roos E, Ovaskainen M-L, Pietinen P. Validity and
11. Molarius A, Seidell JC. Differences in the association comparison of three saturated fat indices. Scand J Nutr. 43. Escobedo LG, Marcus SE, Holtzman D, Giovino GA.
between smoking and relative body weight by level of 1995;39:5559. Sports participation, age at smoking initiation, and the risk
education. Int J Obes Relat Metab Disord. 1997;21(3): of smoking among US high school students. JAMA.
27. Swithers SE, Davidson TL. A role for sweet taste:
189196. 1993;269(11):13911395.
calorie predictive relations in energy regulation by rats.
12. Klesges RC, Ward KD, Ray JW, Cutter G, Jacobs DR Behav Neurosci. 2008;122(1):161173. 44. Rohleder N, Kirschbaum C. The hypothalamic-
Jr, Wagenknecht LE. The prospective relationships be- pituitary-adrenal (HPA) axis in habitual smokers. Int J
28. Malik VS, Schulze MB, Hu FB. Intake of sugar-
tween smoking and weight in a young, biracial cohort: the Psychophysiol. 2006;59(3):236243.
sweetened beverages and weight gain: a systematic
Coronary Artery Risk Development in Young Adults 45. Cohen S, Doyle WJ, Baum A. Socioeconomic status
review. Am J Clin Nutr. 2006;84(2):274288.
Study. J Consult Clin Psychol. 1998;66(6):987993. is associated with stress hormones. Psychosom Med.
29. Aarnio M, Winter T, Peltonen J, Kujala UM, Kaprio J. 2006;68(3):414420.
13. Klesges RC, Zbikowski SM, Lando HA, Haddock CK,
Stability of leisure-time physical activity during
Talcott GW, Robinson LA. The relationship between 46. Lahiri K, Rettig-Ewen V, Bohm M, Laufs U. Per-
adolescencea longitudinal study among 16-, 17- and
smoking and body weight in a population of young ceived psychosocial stress and cardiovascular risk factors
18-year-old Finnish youth. Scand J Med Sci Sports.
military personnel. Health Psychol. 1998;17(5):454458. in obese and non-obese patients. Clin Res Cardiol.
2002;12(3):179185.
14. Gordon-Larsen P, Adair LS, Nelson MC, Popkin BM. 2007;96(6):365374.
30. Classification of Socio-economic Groups 1989.
Five-year obesity incidence in the transition period 47. Bjorntorp P, Rosmond R. Obesity and cortisol.
Helsinki: Helsinki Handbooks, Statistics Finland; 1989.
between adolescence and adulthood: the National Nutrition. 2000;16(10):924936.
Longitudinal Study of Adolescent Health. Am J Clin Nutr. 31. STATA Users Guide Release 9.1. 8. College Station,
48. Bjorntorp P. Do stress reactions cause abdominal
2004;80(3):569575. TX: Stata Press; 2005.
obesity and comorbidities? Obes Rev. 2001;2(2):7386.
15. Laitinen J, Pietilainen K, Wadsworth M, Sovio U, 32. Laaksonen M, Rahkonen O, Karvonen S, Lahelma E.
49. Maurer J, Taren DL, Teixeira PJ, et al. The psycho-
Jarvelin MR. Predictors of abdominal obesity among Socioeconomic status and smoking: analysing inequalities
social and behavioral characteristics related to energy
31-y-old men and women born in Northern Finland in with multiple indicators. Eur J Public Health. 2005;15(3):
misreporting. Nutr Rev. 2006;64(2 Pt 1):5366.
1966. Eur J Clin Nutr. 2004;58(1):180190. 262269.
50. Schousboe K, Willemsen G, Kyvik KO, et al. Sex
16. Twisk JW, Kemper HC, van Mechelen W, Post GB, 33. Boomsma D, Busjahn A, Peltonen L. Classical twin
differences in heritability of BMI: a comparative study of
van Lenthe FJ. Body fatness: longitudinal relationship of studies and beyond. Nat Rev Genet. 2002;3(11):872882.
results from twin studies in eight countries. Twin Res.
body mass index and the sum of skinfolds with other risk 34. Bernaards CM, Twisk JW, Snel J, van Mechelen W, 2003;6(5):409421.
factors for coronary heart disease. Int J Obes Relat Metab Kemper HC. In a prospective study in young people,
Disord. 1998;22(9):915922. 51. Vartiainen E, Seppala T, Lillsunde P, Puska P.
associations between changes in smoking behavior and
Validation of self reported smoking by serum cotinine
17. van Lenthe FJ, van Mechelen W, Kemper HC, risk factors for cardiovascular disease were complex.
measurement in a community-based study. J Epidemiol
Post GB. Behavioral variables and development of J Clin Epidemiol. 2005;58(11):11651171.
Community Health. 2002;56(3):167170.
a central pattern of body fat from adolescence into 35. Laitinen J, Nayha S, Kujala V. Body mass index and
adulthood in normal-weight whites: the Amsterdam 52. Rasmussen F, Johansson M, Hansen HO. Trends in
weight change from adolescence into adulthood, waist-to-
Growth and Health Study. Am J Clin Nutr. 1998; overweight and obesity among 18-year-old males in
hip ratio and perceived work ability among young adults.
67(5):846852. Sweden between 1971 and 1995. Acta Paediatr.
Int J Obes (Lond). 2005;29(6):697702.
1999;88(4):431437.
18. Kaprio J, Pulkkinen L, Rose RJ. Genetic and envi- 36. Potter BK, Pederson LL, Chan SS, Aubut JA,
ronmental factors in health-related behaviors: studies on 53. Pietilainen KH, Kaprio J, Rissanen A, et al. Distri-
Koval JJ. Does a relationship exist between body bution and heritability of BMI in Finnish adolescents
Finnish twins and twin families. Twin Res. 2002;5(5): weight, concerns about weight, and smoking among
366371. aged 16y and 17y: a study of 4884 twins and 2509
adolescents? An integration of the literature with singletons. Int J Obes Relat Metab Disord. 1999;23(2):
19. Sarna S, Kaprio J, Sistonen P, Koskenvuo M. Diag- an emphasis on gender. Nicotine Tob Res. 2004;6(3): 107115.
nosis of twin zygosity by mailed questionnaire. Hum 397425.
Hered. 1978;28(4):241254. 54. Fulkerson JA, French SA. Cigarette smoking for
37. Weitzman M, Cook S, Auinger P, et al. Tobacco weight loss or control among adolescents: gender and
20. Han TS, van Leer EM, Seidell JC, Lean ME. smoke exposure is associated with the metabolic syn- racial/ethnic differences. J Adolesc Health. 2003;32(4):
Waist circumference action levels in the identification of drome in adolescents. Circulation. 2005;112(6): 306313.
cardiovascular risk factors: prevalence study in a random 862869.
sample. BMJ. 1995;311(7017):14011405. 55. Manson JE, Ajani UA, Liu S, Nathan DM, Hennekens
38. Cooper TV, Klesges RC, Robinson LA, Zbikowski CH. A prospective study of cigarette smoking and the
21. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. SM. A prospective evaluation of the relationships be- incidence of diabetes mellitus among US male physicians.
Establishing a standard definition for child overweight tween smoking dosage and body mass index in an Am J Med. 2000;109(7):538542.
and obesity worldwide: international survey. BMJ. adolescent, biracial cohort. Addict Behav. 2003;28(3):
56. Mokdad AH, Marks JS, Stroup DF, Gerberding JL.
2000;320(7244):12401243. 501512.
Actual causes of death in the United States, 2000. JAMA.
22. Vidmar A, Carlin J, Hesketh K, Cole T. Standardiz- 39. Kvaavik E, Tell GS, Klepp KI. Predictors and 2004;291(10):12381245.
ing anthropometric measures in children and adolescents tracking of body mass index from adolescence into
354 | Research and Practice | Peer Reviewed | Saarni et al. American Journal of Public Health | February 2009, Vol 99, No. 2