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Southern Online Journal of
Nursing Research
www.snrs.org
Issue
4, Vol. 3
October
2002
Smoking
Patterns Among Rural Elderly
R.
Craig Stotts RN, DrPH;1 Constance K. Smith, RN, BSN2
1Professor, College of Nursing, University
of Tennessee Health Science Center, Memphis
2Research Assistant, University of
Arkansas for Medical Sciences, Little Rock
Interactive
comments section
ABSTRACT
Health
promotion among the elderly has been shown to produce positive outcomes
despite widespread belief that the elderly will not benefit. Helping
the elderly to quit smoking has immediate and significant health and
economic benefits. This epidemiological study examined the tobacco
use status of elderly living in rural areas primarily because of their
reduced accessibility to group cessation programs and their relative
isolation. The authors found that although a large proportion of rural
elderly visited their primary care provider at least once during the
previous year and had received advice to quit smoking, only about
half of those receiving this advice had actually made a serious attempt
to quit for at least one day. Persons living in this rural mid-south
state also have higher point prevalence rates of smoking for both
men and women as compared to national data. Use of spit tobacco, cigars
and pipes is also practiced on an occasional basis by some of the
men in the sample. Future research should be focused on improving
the cessation counseling methods used with the rural elderly tobacco
user and on assisting them in their maintenance efforts.
Keywords: smoking, aged, rural, tobacco, health promotion, cessation
Introduction
The
elderly constitute about 12.4% of the U.S. population, a proportion
that has changed little since 1990, although the absolute number of
elderly has grown by 12%. This decade was the first time in U.S. history
that the proportion of elderly did not increase, a reflection of the
lower birth rate of the 1920s and 1930s. This trend will reverse when
the baby boom generation begins turning 65 in 2011.1
Although the proportion of elderly has not increased since 1965, the
total number of elderly who smoke has gone up and will increase even
more when the baby boomers hit retirement age.2,3
As some researchers have said, smoking is a geriatric health issue.3
Unfortunately,
many elderly continue to smoke, even into their 70s and 80s, despite
knowledge that it is damaging their health. Some elderly believe that
quitting smoking will not improve their health which contravenes many
research findings.4
Quitting smoking after the age 65 improves cardiovascular functioning,
reduces pulmonary infections, and reduces the risk of lung and oropharyngeal
cancers,4-8
hip fractures,9
osteoporosis,10,11
and eye disease.12-14
Of
the top 16 causes of death among the elderly, eight are caused by
smoking.15
Smoking in the elderly has also been associated with functional decline
among those living in the community, thus serving as a risk factor
for institutionalization.16
Persons who continue smoking past 65 aretwice as likely to die at every year of life than their
non-smoking counterparts17
and have increased risks of coronary heart disease, other cardiovascular
disease, cancer,18,
19 and emphysema.20
Depression is also more frequent among elderly smokers than their
non-smoking counterparts,21
as is cognitive impairment.22
The World Health Organization has declared tobacco use to be the single
most important modifiable factor for the prevention of non-communicable
diseases among the elderly.23
The elderly typically take
several medications daily. Smoking can interfere with some of these
drugs, causing lower serum levels than desired which in turn impairs
the effectiveness of the drugs,24
Drugs commonly taken by the elderly in which smoking is known to reduce
serum levels include propanolol, antidepressants, phenothiazines,
theophylline, and aminophylline.25,
26 Emergency use of lidocaine is also not as effective
in smokers.27
The
benefits of quitting smoking in the elderly are many. Risks of stroke
and coronary heart disease begin dropping almost immediately.28-32
Pulmonary function also improves, albeit slower.33-35
Patients who are classified “moderately ill” have improved survival
rates after quitting smoking. The mechanism for these improvements
appears to be improved pulmonary perfusion and increased blood circulation.
Overall, quality of life improves significantly for elderly who quit
smoking.36
Life expectancy also increases; for men who quit smoking at age 65,
their life expectancy increases 2.0 years and for women, 3.7 years.37
Seniors who live in rural
areas are at a disadvantage to their urban or suburban counterparts
regarding smoking cessation. Group therapy, as offered by the volunteer
health associations, or intensive behavioral therapy, is often only
available in cities and often at night. The elderly have difficulty
traveling long distances over country roads and into cities they may
not be familiar with; nighttime travel is even more problematic due
to visual difficulties. Of all rural residents the elderly are the
most isolated because of their difficulty with driving, especially
in unfamiliar areas, reduced reaction times, and reduced vision.38,39
Despite difficulties in travel, however, elderly persons seek medical
care to treat symptoms. Yet, the medical office remains a relatively
untapped potential for smoking cessation programs.
Due to the rate and frequency
of morbidity increasing with age, the elderly in general have more
office visits to their primary care providers (PCP). Among smokers,
older smokers are more likely to visit their PCP’s office than younger
smokers (84% vs. 69% in 1992).40
These visits are “teachable moments” that are often not fully utilized.41
Among Medicare patients, it has been found that 25,000 smokers per
year could be encouraged to quit if 90% of them were advised to quit
by their PCP.42
Many health care providers
believe that they should not counsel their patients about quitting
smoking because they do not have the large amount of time it takes
to counsel, the patient does not want to hear about quitting smoking,
and the provider does not feel qualified to do the counseling. All
of these concerns have been found to be baseless, according to the
most recent Clinical Practice Guideline, “Treating Tobacco Use and
Dependence.”43
According to this Guideline, minimal interventions, in the range of
3-5 minutes, have been found to be effective. Another finding was
that the majority of smoking patients state that they would like to
hear from their PCP about their need to quit and how to quit. Finally,
the 5 As program is a very simple program that any PCP can use easily
and effectively. The national panel that developed the Guideline conducted
meta-analyses and found that it is clear that all PCPs should advise
their patients to quit smoking, with an “A” level strength of evidence.
This meta-analysis found that physicians can achieve an abstinence
rate of 19.9% while other clinicians (including nurses) can achieve
abstinence rates of 15.8%, with only the use of minimal interventions.
More intensive interventions can yield even higher abstinence rates.
Helping the elderly to quit
smoking is a responsibility for health care professionals and it is
a service that elderly patients desire.44
There are not many cessation programs or materials designed with the
elderly in mind. Most health care professionals have not received
any significant training in smoking cessation counseling in general,
much less geared toward the elderly.
No recent studies have focused
on the problem of smoking among rural elderly. The conceptual basis
for this study is based on the meta-analysis performed by the Clinical
Practice Guideline Task Force on Treating Tobacco Use and Dependence.
This document establishes the need to conduct more research on finding
effective methods to motivate older smokers to make a quit attempt.43
This meta-analysis presented the previous studies that helped determine
the questions used in the present survey.
The purpose of this study
was to examine the smoking patterns of rural elderly with a particular
emphasis on their quit attempts. The frequency and type of tobacco
use will also be described.
Methods
This
study used a population-based, stratified random sample of all rural
areas of Arkansas. This state is near the median in total population
(33rd)45
and is fairly typical of many other states in its percentage of elderly
(14% vs. 12.4% nationally),1
but its smoking rate among adults is among the highest (11th).46
Of 75 counties, nine are part of a Standard Metropolitan Statistical
Area, leaving 66 counties designated rural. In order to obtain a sample
size sufficient to be representative of the rural areas of the state
and analyze the data by the most important variables, we sampled a
proportionate number of elderly from each of these 66 rural counties
to provide an overall sample of 311. Each subject represents 695.6
elderly residents; this figure was used in the weighting of all analyses.
Names
in each county were randomly selected from the phone exchanges assigned
to that county. From a list of telephone subscribers in that county,
each nth name was chosen based on the total number of subjects
to be obtained in that county divided by the total number of phone
subscribers. Approximately 88% of Arkansans have telephone service;
no further data by age is available.
When
a person answered the phone, they were asked whether an individual
aged 65 or older lived in the home. If they responded affirmatively,
the surveyor asked to speak to that person. If more than one elderly
person resided there, the surveyor asked to speak to the one who was
available for an interview. The surveyor then explained to that individual
the intent of the phone call, following a script approved by the Investigational
Review Board.
Subjects were asked about
their demographic data and about various behaviors and attitudes toward
smoking cessation. The following figure lists the questions pertinent
to smoking behavior and their interaction with health care professionals
(skip patterns were used but are not shown here). These questions
were taken from the National Health Interview Survey.47
- Have you smoked at least 100
cigarettes in your entire
life?
- Do you now smoke cigarettes?
- During the past 12 months, have
you quit smoking for one
day or longer?
- In the past 12 months, have
you seen a doctor, nurse,
or other health professional
to get any kind of care
for yourself?
- In the past 12 months, has a
doctor, nurse, or other
health professional advised
you to quit smoking?
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Results
Of the 329 households contacted
in which at least one elderly person lived, 18 refused to participate
in the survey, yielding a final sample of 311 and a response rate
of 94.5%. The age range of the sample was 65-93 with a mean of 72.9.
Females outnumbered males in most of the age cohorts. The following
table shows the sample broken down by age cohort and percentage female.
Table
1. Age and gender distribution
of sample
|
Age
Cohort
|
N
|
% of total
|
% Female
|
|
65-69
|
125
|
40.2
|
52.0
|
|
70-79
|
112
|
36.0
|
50.0
|
|
80-89
|
67
|
21.5
|
67.2
|
|
90-93
|
7
|
2.3
|
85.7
|
|
Total
|
311
|
100.0
|
55.3
|
The
ethnic distribution was skewed towards white respondents with 92.6%
white, 6.1% African American, 1.0% Asian American, and 0.3% Native
American. No Hispanics were surveyed. The small sample sizes in the
non-white groups prevented data analysis by ethnicity. Statewide data
of the elderly population indicate the state’s elderly population
is 88.3% white, 9.8% African American, 0.3% Asian American, 0.3% Native
American, and 0.6% Hispanic, which approximates our study sample.
Among
the current smokers (daily or some days), the data are shown for age
cohorts (Table 2. The majority of the study sample are younger, with
almost half under the age of 70.
Table
2. Age distribution of smokers
in study (n=43, Weighted
n =216,322)
Group
|
Smokers
|
|
65-69
|
46.5
|
|
70-79
|
34.9
|
|
80-89
|
18.6
|
|
90-93
|
0
|
|
Total
|
100.0
|
The
prevalence of smoking among rural elderly in this study is comparable
to national figures. Table 3 indicates smoking history of this sample.
Except for women aged 65-74, rural elderly have higher rates of smoking
than their counterparts in other parts of the state and nation.
Table
3. Point Prevalence of Current
Smoking Among Elderly in Study
Sample Compared to Total State
Data and National Data
(95% Confidence Interval)
|
|
Men
|
Women
|
Total
|
|
Area
|
65-74
yrs
|
75+
yrs
|
65-74
yrs
|
75+
yrs
|
65-74
yrs
|
75+
yrs
|
|
Arkansas Rural Elderly§
|
23.2
(±0.7)
|
14.0
(±1.1)
|
8.5
(±0.7)
|
9.2
(±0.9)
|
15.4
(±0.5)
|
11.1
(±0.7)
|
|
Arkansas£
|
15.6
(±4.8)
|
N/A¥
|
14.7
(±3.4)
|
7.7
(±3.0)
|
15.1
(±2.8)
|
7.8
(±2.6)
|
|
National (medians)£
|
13.9
|
8.0
|
12.9
|
6.3
|
13.3
|
6.8
|
§Weighted
data.
£Compiled
from the BRFSS 1995-97. 95% Confidence Intervals not provided for
the national medians.48
¥Sampling
error was excessive.
Table
4 illustrates the current smoking status of the participants in this
study. Elderly men are more than twice as likely to be daily smokers
as women. Men are also twice as likely to be former smokers, while
women are more than twice as likely to have never smoked regularly.
Table 4. Smoking Status of Rural
Elderly (Point Prevalence (95%
Confidence Interval)
|
Smoking Status
|
Men |
Women
|
Total
|
|
Daily
|
19.5
(±0.6)
|
7.6
(±0.5)
|
12.9
(±0.4)
|
|
Some days
|
0.7
(±0.6) |
1.2
(±3.4)
|
1.0
(±0.4)
|
|
Former
|
54.3
(±0.4) |
25.0
(±0.5)
|
37.9
(±0.3)
|
|
Never
|
25.4
(±0.5) |
66.3
(±0.3)
|
48.2
(±0.3)
|
Only
35.7% (±1.6) of women and 28.6%
(±1.2) of men reported having
tried to quit for at least one day during the previous year, although
69.2% (±1.1) of
women and 62.5% (±0.8) of
men reported that their PCP had advised them to do so. Of all current
smokers, 66.7% (±1.1) of
women and 53.6% (±0.7) of
men report having seen their PCP during the previous 12 months.
For other forms of tobacco,
spit tobacco use was somewhat prevalent among males. Approximately
7.2% reported daily use while 6.5% reported occasional use. Among
women, only 0.6% reported daily use and 2.3% reported occasional use.
Occasional pipe tobacco use was claimed by 18.1% of males but none
claimed daily use; no females reported any use of pipes. No respondents
reported smoking cigars daily and no females reported any cigar use;
23.2% of males reported smoking a cigar occasionally.
Limitations of this study
include a lack of data from rural elderly who do not own phones. However,
most elderly who live alone are more likely to have phones due to
their need to communicate with family and friends for assistance.
Another limitation was the non-inclusion of Hispanic elderly. This
was due to the very small proportion of Hispanic residents in Arkansas
(<1%); those Hispanics who do live in the state tend to be young
adults who have recently migrated to the state to seek employment.
Conclusions
Smoking
among rural elderly, especially in this mid-south state, is higher
than expected from the national data of all elderly. Even among the
very old (75+) smoking rates continue to be high, despite the prevalence
of multiple chronic health problems in this population.
Although
the literature shows that rural elderly are relatively isolated, they
do visit their physician and nurse practitioner’s offices. In other
studies, approximately 84% of older smokers report that they visited
their MD/NP office within the previous year, but this rate was somewhat
lower in the present study. The primary care office visit is a prime
opportunity for the elderly smoker to receive counseling about smoking
cessation, although this study showed that less than half of those
receiving advice to quit had actually attempted to quit for at least
a day. Although the temporal relationships between counseling and
attempts to quit have not been established by these data, the strong
statistical correlation between these two variables would tend to
indicate that such a relationship might exist.
Other
channels of education have been attempted with some success in the
elderly. Rimer and Orleans tested the use of a smoking cessation brochure
designed specifically for the elderly. In the three arms of the study,
the control group received a brochure not specifically designed for
the elderly, while the other two groups received the senior-focused
brochure and either one or two follow-up phone counselings. The groups
receiving the senior-focused brochure had higher quit rates than the
control group but even that figure was only 20% at 12 months, compared
to 15% for the generic brochure.49
This study showed the effectiveness of a low-cost intervention and
one that could be used among rural elderly; however, the quit rates
are still very low.
Regardless
of the fact that primary prevention of smoking among youth will yield
the most substantial returns in the future, more immediate cost savings
will be found among older adults who quit smoking.31
Notwithstanding the age of the patient, nurses and other health care
professionals should inquire about tobacco use status (including other
forms of tobacco) and, if the patient is a user, follow the clinical
practice guidelines43
for helping the tobacco user to quit.50
More research needs to be
done on optimizing the effectiveness of office-based tobacco counseling
of the elderly user and on maintenance strategies. How to improve
the effectiveness of follow-up phone counselings and mailed educational
and motivational materials should be carefully evaluated in this high-risk
population.
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Acknowledgement:
This study was partially funded by
the UAMS College of Nursing Intramural
Grants Program.
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