Socioeconomic status across the life course and smoking cessation among older adult smokers in the U.S

Highlights

• The majority of older adult smokers in the U.S. have persistent high SES.

• Those with SES mobility are less likely to quit than those with persistent high SES.

• Low child SES impacts smoking cessation independently of adult SES.

Abstract

Introduction

Socioeconomic status (SES) at different stages of the life course impacts late-life health. However, whether SES across the life course impacts smoking cessation in late-life is not known. Purpose: Assess how life course SES impacts smoking cessation among older smokers.

Methods

We identified 5,124 smokers, 50 years and older, from the 1998 to 2018 waves of the Health and Retirement Study. The outcome was self-reported smoking cessation. The main exposure was life course SES, defined as: low child and low adult SES (persistent low); low child, high adult SES (upward mobility); high child, low adult SES (downward mobility); and high child, high adult SES (persistent high). A multilevel mixed-effect logistic model was used to examine how life course SES predicts smoking cessation at age 65 and over time, adjusted for covariates.

Results

Compared to those with persistent high SES, those with persistent low SES, upward and downward SES were more likely to be Hispanic or non-Hispanic Black. The adjusted results showed that at age 65, compared to those with persistent high SES, those with persistent low SES (OR= 0.69, 95 % CI = [0.51–0.92]), upward SES (OR= 0.49, [0.32–0.75]), and downward SES (OR= 0.55, [0.40–0.76]) were less likely to quit. However, as age increased, only those with downward or persistent low SES were significantly less likely to quit compared to those with persistent high SES.

Discussion

Social mobility of SES from childhood to adulthood significantly impacts smoking cessation. Both stages of the life course should be considered to understand smoking behaviors.

Introduction

Cigarette smoking remains the leading cause of preventable disease, disability, and death in the United States (U.S.) (National Center for Chronic Disease Prevention & Health Promotion, 2014). In 2020, 12.5 % of U.S. adults or approximately 30.8 million adults were current cigarette smokers (Cornelius et al., 2022). The health consequences of smoking have long been established, and today, more than 16 million U.S. adults live with a disease caused by smoking, including but not limited to cancer, stroke, lung diseases, and chronic obstructive pulmonary disease (COPD) (National Center for Chronic Disease Prevention & Health Promotion, 2014).

Trends in smoking prevalence between 2005 and 2015 showed that while there was a 22–46 % decline in current smoking among those age 18–64 years old, smoking rates in adults 65 years and older have been steady (declined by only 2.1 %) (Jamal et al., 2016). Further evidence showed that the smoking prevalence and smoking cessation rates among older adults 65 and older enrolled in Medicare did not change significantly between 2005 and 2015 (Isenberg et al., 2016). Older adult smokers have greater all-cause mortality and lung cancer rates than never smokers, older former smokers, and younger smokers (Gellert et al., 2012, National Center for Chronic Disease Prevention & Health Promotion, 2014).

In addition to the burden of tobacco use among older adults, smoking is a leading contributor to socioeconomic inequalities in health (Petrovic et al., 2018). Tobacco use is most prevalent among those with an annual household income <$35,000; uninsured adults and those receiving Medicaid; and those whose highest level of educational attainment was a General Educational Development (GED) certificate (Cornelius et al., 2020). On the other hand, smokers with higher education and income have greater intentions to quit and are more likely to achieve smoking abstinence for 1 to 6 months (Reid et al., 2010); (Assari, 2021). For example, the proportion of those who quit for at least 1 month among those who attempted to quit before was 23.3 % for those with less than high school education, 22.9 % for those with some college education and 28.3 % for those with a college degree or more (Reid et al., 2010).

There is also robust evidence that socioeconomic status (SES) over one’s life course impacts late-life health (Kuh, Ben-Shlomo, & Ezra, 2004, Mishra et al., 2009, Palloni et al., 2009, Pollitt et al., 2005). A study on financial strain over the life course found that long-term financial hardship affects health outcomes at late-life, even when current financial circumstances are considered (Kahn and Pearlin, 2006). Studies have also found that lower childhood SES was associated with worse health outcomes in later life, but that the negative impact of low childhood SES could be partially ameliorated if people with low SES shifted to higher SES in adulthood (Luo and Waite, 2005).

This evidence is anchored in the life course epidemiology framework. This framework proposes that biological, structural, behavioral and psychosocial exposures impact health throughout the developmental stages of life (Ben-Shlomo et al., 2014, Kuh, Ben-Shlomo, & Ezra, 2004). Life course theory proposes several models by which these life course exposures impact health. The simple distinction of these models is that exposures impact late life health either within a critical period or through an accumulation of risks (Ben-Shlomo et al., 2014, Cable, 2014). These two models are divided into other pathways. The critical period model proposes that there is a specific time period where an exposure can have an impact on later life health, independent of the exposures in other life periods. On the other hand, the accumulation of risks model proposes that life course exposures are not limited to a critical period in life. Instead, it is the gradual accumulation of these exposures throughout one’s life that impacts health (Ben-Shlomo et al., 2014). Independent of the pathway, it is important to consider an individual’s SES over the life course when evaluating the impact of SES on health outcomes, including smoking cessation.

The impact of SES over the life course on adult and older adult smoking behavior has been examined by several authors (Parnia and Siddiqi, 2020, Paavola, 2004, Puolakka et al., 2018, Gilman, 2003, Tian et al., 2019). Among adults, greater childhood SES predicted lower initiation of cigarette use (Gilman, 2003). Further, both child and adult SES were independently associated with lower progression to regular smoking after initiation. However, only greater adult SES was associated with greater probability to quit smoking (Gilman, 2003). Among older adults, Parnia and colleagues combined childhood SES measures with adulthood SES measures to create a cumulative life course SES measure (Parnia and Siddiqi, 2020). Their results showed that compared to those in the top SES quartile, those in the bottom quartile of SES combining both child and adult measures were more than four times as likely to be current smokers (Parnia and Siddiqi, 2020). While this study assessed current smoking status, it did not assess how SES at different stages of the life course predicted quitting behavior or how social mobility between child and adulthood impact smoking cessation.

Considering the growing proportion of older adults in the U.S., older smokers are an increasingly important group that benefit from tobacco-related harm reduction, including smoking cessation, smoking reduction and switching to less harmful products. Although this age group has been recognized as a priority population for smoking cessation interventions and tobacco-related research, there continues to be a paucity of research focused on older smokers (Kleykamp and Heishman, 2011). Health care professionals and public health agencies continue to focus on younger smokers while believing older adult smokers are less likely to be interested in quitting, contributing to the overall institutionalized ageism seeing in tobacco control (McAfee et al., 2021). The objective of this study was to assess how SES over the life course impacts smoking cessation among older adult smokers in the U.S. This study examined the relationship between both childhood and adulthood SES factors and smoking cessation among older adult smokers in the Health Retirement Study. Given previous findings on the association between low SES and difficulty in quitting, we hypothesized that older smokers with persistent low SES, upward and downward SES mobility would be less likely to quit smoking over time compared to older smokers with persistent high SES.