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Sir,We read with interest the recent report of Crispet al 1 in the pages of this journal, concerning the association between smoking and pursuit of thinness among schoolgirls. In particular, they found smoking was related to over-concern with body shape and weight, being ‘overweight’, and regular self-induced vomiting. We examined smoking and related behaviour among 542 women referred to the St George's Hospital Eating Disorder Unit for the treatment of bulimia nervosa between 1984 and 1994. All subjects fulfilled DSM-III-R criteria for bulimia nervosa2 at the time of referral. Subjects with a clear history of anorexia nervosa were also identified, which has previously been named ‘Type II’ bulimia.3 In total, 60.9% of the sample were smokers, with a mean intake of 19.2 cigarettes per day; 43.7% of smokers and 33.5% of non-smokers had a previous history of anorexia nervosa, which difference was statistically significant (p=0.018; χ2(1)=5.55). Unsurprisingly, there were significant differences in mean minimum postpubertal weight between smoking and non-smoking bulimics (48.8vs 51.5 kg; p=0.015; t=2.45). Likewise, bulimic smokers were more likely to abuse amphetamines (p=0.007; χ2(1)=7.31), cannabis (p=0.006; χ2(1)=7.50) and cocaine (p=0.003; χ2(1)=8.57). However, there were no significant differences in mean current body-mass index (22.2vs 24.8 kg/m2; p=0.33; t=0.98), mean weight at menarche (53.2 vs 53.1 kg; p=0.95; t=0.06) or mean maximum post-pubertal weight (68.4vs 70.2 kg; p=0.36; t=0.93). There were no significant differences in means of monthly frequency of bingeing (31.7vs 28.8; p=0.44; t=-0.77) or vomiting (43.5vs 55.9; p=0.36; t=0.93), and frequency of laxative abuse did not significantly differ between the two groups (p=0.67; χ2(1)=0.18).
Our findings lend support to Crisp's notion that cigarette smoking may be related to the goal of achieving weight loss, in this case to the extent of fully-fledged anorexia nervosa. However, in contrast with the findings of Crisp et al,1 this was not associated with either current body-mass index, or previous pubertal and maximum weights. This difference might be explained by differences between our samples, with the general population sample of Crisp et alresponding behaviourally to objective weight, and the bulimic sample of our study responding behaviourally to subjective distortions in perception of weight and shape.
Our study also strongly suggests that bulimic girls and women are more prone to smoking than the general population as a whole, on the basis of recent figures from the Office of Population Censuses and Surveys,4 but without accurate matching of cases and controls this must remain conjecture. Nonetheless, the authors would support the theory of Crisp5 that smoking may represent a displacement of oral activity normally associated with food ingestion in the eating-disordered population. In conclusion, smoking is associated with the pursuit of thinness in women with bulimia nervosa, and preventative measures must address both behaviours in synchrony.