Abstract and Introduction
Abstract
Purpose of the Study: Though older adults smoke at a lower rate than younger adults, cessation can be difficult, especially after years of smoking. This paper examined the influence of a diagnosis of chronic illness, social isolation, and depression on smoking cessation among the most recent cohort of older smokers who were representative of U.S. Medicare beneficiaries.
Design and Methods: We used data from the 2011 (T1) and 2012 (T2) interview waves of the U.S. National Health and Aging Trends Study. Multivariate regression models examined correlates of T1 smoking status (never smoker, former smoker, and current smoker; n = 6,680) and predictors of T2 smoking status among T1 smokers (quit smoking vs. continued smoking; n = 412).
Results: At T1, 8.8%, 44.7%, and 46.5% of the sample, respectively, were current, former, and never smokers. Current smokers had lower socioeconomic status, were more socially isolated, and had higher depressive symptoms than never smokers. At T2, 88.9% of T1 smokers continued smoking and 11.1% no longer smoked. The odds of smoking cessation increased with a new diagnosis of chronic illness since T1 and decreased with a higher number of cigarettes smoked at T1. Social isolation at T1 increased the odds of smoking cessation, but depressive symptoms at T1 were not a significant factor.
Implications: Heavy-smoking older adults may require extended pharmachotherapy and counseling. As newly diagnosed health problems can be a trigger for smoking cessation, health care providers can motivate and help older adults quit (or reduce) smoking as an integral part of their practices.
Introduction
In 2011, 9.1% of U.S. adults aged 65 and older smoked compared with 15.0% of those aged 18–44 and 18.3% of those aged 45–64 (Centers for Disease Control and Prevention, 2013). However, the rate of decline (from 13.3% in 1995) has been slower in older adults than in younger adults, and smoking in late life continues to be marked by disparities in socioeconomic status, low quit rate, and short duration of intervention effects (Reid, Hammond, & Driezen, 2010; Zbikowski, Magnusson, Pockey, Tindle, & Weaver, 2012). Smoking remains the most significant health hazard for all age groups, and its pernicious effects on older adults' morbidity and mortality have been extensively documented (Gellert, Schöttker, & Brenner, 2012; Jha et al., 2013; Thun et al., 2013). These studies also reported dramatic beneficial effects of smoking cessation at any age on reducing death rates.
Research based on the Health and Retirement Study, 1992–2000, found that older adults recently diagnosed with stroke, cancer, lung disease, heart disease, or diabetes mellitus were 3.2 times more likely to quit smoking than those with no new diagnosis (Keenan, 2009). In general, adverse health events (e.g., a hospitalization for cardiovascular disease) and reduced number of cigarettes smoked (which was in turn associated with older age and previous quit attempts) are associated with smoking cessation (Doolan & Froelicher, 2008; Falba, Jofre-Bonet, Busch, Duchovny, & Sindelar, 2004; Yong, Borland, Thrasher, & Thompson, 2012). However, a study based on the Canadian National Population Health Survey, 1994/1995–2006/2007, found that even after a chronic illness diagnosis, 75% of smokers aged 50+ continued to smoke, although the number of cigarettes smoked daily fell significantly (Newsom et al., 2012). Older adults who continue to smoke are more likely to be of lower socioeconomic status, nonwhite, and female and to have major depressive disorder or high levels of depressive symptoms (Agrawal, Sartor, Pergadia, Huizink, & Lynskey, 2008; Kenney et al., 2009; Weinberger, Pilver, Desai, Mazure, & McKee, 2012). The relationship between late-life depression and smoking appears to be bidirectional, with depressed people more likely to smoke and smoking increasing the risk of depression, although one study of veterans found no association between depressive symptoms and decreased smoking cessation (Anstey, von Sanden, Sargent-Cox, & Luszcz, 2007; Byers et al., 2012; Kinnunen et al., 2006; Husten et al., 1997).
Studies of middle-aged and older adults in Australia, Denmark, the United States, and England also found that smokers tend to have less social support and interactions than their peers who never smoked or were former smokers and that social support is a significant factor in smoking cessation and relapse (Chiew, Weber, Egger, & Sitas, 2012; Holahan et al., 2012; Ross et al., 2013; Shankar, McMunn, Banks, & Steptoe, 2011). Holahan and colleagues (2012) found that middle-aged and older U.S. women who had higher social support were more likely to have stopped smoking 1 year later, whereas those with lower social support were more likely to have had a smoking relapse. Ross and colleagues (2013) study of Danish middle-aged and older men and women (and younger women) found that social relationship quality was associated with smoking abstinence: close relationships (e.g., having a confidant) contributed to abstinence, and demanding or conflict-ridden relationships contributed to a lower probability of abstinence. Shankar and colleagues (2011) study, based on the English Longitudinal Study of Ageing, shows that smoking, inactivity, and other health-risk behaviors were associated with social isolation and loneliness. Loneliness and social isolation may affect health independently through their effects on health behaviors and through biological processes associated with developing cardiovascular disease (Shankar et al., 2011).
A Robert Wood Johnson Foundation (2011) report shows that during the past few decades, multipronged, active antismoking campaigns in the United States contributed to significant shifts in social norms and attitudes about and overall decrease in smoking, especially among youth. Slower rates of decline among older adults suggest that these campaigns have been less effective in changing older adults' behaviors despite cessation's benefits. Despite many previous epidemiologic studies of older adults' smoking and smoking cessation, little research has examined smoking and individual-level predictors of smoking cessation among the most recent cohort of U.S. older adults. Given the importance of cessation for this age group, the purposes of the present study were to (1) cross-sectionally compare the socioeconomic, health, and mental health status of current, former, and never smokers and (2) examine the influence of a new diagnosis of chronic illness, social isolation, depressive symptoms, and smoking quantity on smoking cessation over 1-year period among a nationally representative sample of U.S. older adults. The 1-year follow-up period provides an optimum window of opportunity to examine the potential influence of a newly diagnosed chronic illness on smoking cessation.