Socioeconomic status across the life course and smoking cessation among older adult smokers in the U.S
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.
Section snippets
Study population
The Health and Retirement Study (HRS) is a nationally representative longitudinal, biennial survey of individuals 50 and older in the U.S. and their spouses. The first HRS cohort has been followed every-two years since 1992, and new study cohorts are added every-six years. Our study included 10 HRS waves, from 1998 to 2018, including four study cohorts: War Babies and earlier cohorts in 1998, born in 1947 or earlier; the Early Baby Boomers in 2004, born 1942–1947; the Mid-Baby Boomers in 2010,
Results
Study participants were followed for an average of 6 years (range: 2–11 years). The majority of older smokers had persistent high life course SES (61.0 %), followed by downward mobility (18.6 %), persistent low SES (14.9 %) and upward mobility (5.5 %). Those with persistent high SES were more likely to be 49–59 years old than those with persistent low SES and upward mobility (57.7 % vs 42.8 %, 39.2 %, p < 0.001). However, those with persistent high SES were less likely to be 60–79 than those
Discussion
Our study investigating whether SES across the life course impacted smoking cessation among older adults showed that at the age of 65, those with persistent low SES, upward and downward SES mobility were less likely to quit than those with persistent high SES. However, the interaction with age showed that this association was only significant over time for those with persistent low SES or downward mobility compared to those with persistent high SES. The longitudinal effect of upward mobility on
Research ethics approval
This study uses data from a publicly available study and is exempt from IRB review. The Health and Retirement Study was approved by the IRB at the University of Michigan.
CRediT authorship contribution statement
Jaqueline C. Avila: Conceptualization, Methodology, Formal analysis, Data curation, Writing – original draft, Writing – review & editing, Visualization. Sangah Lee: Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Ezinwa Osuoha: Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Dale Dagar Maglalang: Conceptualization, Methodology, Writing – review &
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
The HRS (Health and Retirement Study) is sponsored by the National Institute on Aging (grant number NIA U01AG009740) and is conducted by the University of Michigan.
The authors Avila, Maglalang, Sokolovsky and Ahluwalia are partially or fully funded by an NIH-funded Center of Biomedical Research Excellence (COBRE) (P20GM130414). The author Sokolovsky is also funded by NIDA (K08DA048137).
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