Low Self-Esteem for Physical Appearance Mediates the Effect of Body Mass Index on Smoking Initiation Among Adolescents.

Objective: Adolescence is a period during which youth may begin experimenting with substances. Youth with overweight or obesity may be at increased risk for substance use, including cigarette smoking. Understanding the associations between smoking and excess weight and the pathways associated with increased likelihood for smoking initiation is of particular importance given the increased risk for negative health outcomes associated with each. Methods: Using longitudinal panel data from 1,023 middle school youth (baseline age M = 12.5, 52% female), we tested whether smoking initiation was concurrently and prospectively predicted by self-reported body mass index (BMI) and whether self-esteem for physical appearance (SEPA) mediated the effect of BMI on risk of early initiation. Results: BMI predicted smoking initiation concurrently and prospectively in unadjusted models. In adjusted models, SEPA mediated the effects of BMI on smoking initiation. Bootstrapped mediation results indicated that the positive relationship between BMI and subsequent smoking initiation was significantly mediated by lower SEPA (B =.10, 95% confidence interval [0.01, 0.22]). Conclusions: Adolescents who have overweight or obesity are more likely to feel negatively about their appearance and bodies, and this negative perception may result in experimentation with cigarettes. Cigarettes may be used by youth with overweight or obesity in an effort to manage weight, to cope with low self-esteem or for other reasons. Future research should explore the motives and psychosocial context of smoking initiation among adolescents with overweight/obesity further (e.g., with whom they first try smoking, perceived benefits of smoking).