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Effect of Smoking and Smoking Cessation on Morbidity and Mortality Among the Elderly in a Longitudinal Study

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Effect of Smoking and Smoking Cessation on Morbidity and Mortality Among the Elderly in a Longitudinal Study View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector H.C. Hsu and R.F. Pwu TOO LATE TO QUIT? EFFECT OF SMOKING AND SMOKING CESSATION ON MORBIDITY AND MORTALITY AMONG THE ELDERLY IN A LONGITUDINAL STUDY Hui-Chuan Hsu and Raoh-Fang Pwu1 Department of Health Care Administration, Taichung Healthcare and Management University, Taichung, and 1Research Director, iStat Healthcare Consulting Co Ltd, Taipei, Taiwan. This prospective study of the elderly population estimated the risks of smoking for morbidity and mortality and identified whether cessation of smoking reduced the risk of disease. Data came from face-to-face interviews that used a population-based probability sample of those aged 60 years or over in Taiwan, provided by the Population and Health Research Center, Bureau of Health Promotion. In total, 4,049 subjects were included at the baseline year of 1989 and followed up in 1993 and 1996. Smoking-related variables included current smoking status, smoking history, daily consumption, and years since the cessation of smoking. Cox regression models were used to analyze the relative risks for morbidity and mortality, controlling for demographics, physical function, and comorbidities. The sample was made up of 50.2% nonsmokers, 15.2% ex-smokers, and 34.6% current smokers in the baseline year. Current smokers were more likely to have lower respiratory tract diseases throughout the study. Current smokers had a higher risk of stroke from 1989 to 1993. No dose-response relationship for smoking exposure or impact of years since smoking cessation was found. Whether cessation of smoking is protective should be investigated for middle-aged adults followed to old age. An effective strategy for smoking cessation in the elderly is suggested, and people should be encouraged to quit smoking at any time. Key Words: smoking, smoking cessation, longitudinal studies, elderly, relative risk, successful aging (Kaohsiung J Med Sci 2004;20:484–91) Smoking is an important health hazard in mortality. It is There is evidence that a reduction in risk occurs on estimated that about 3 million people die each year from quitting smoking. The reduction in risk for heart disease is smoking-related diseases, and this will increase to over 10 linked to the duration of cessation [14]. Smoking cessation million worldwide by 2025 [1]. Many prospective studies can reduce the risk of mortality, and smoking cessation af- have identified cigarette smoking as an important risk ter acute myocardial infarction can reduce the relative risk factor for cardiovascular disease, chronic bronchitis, several (RR) of death by between 15% and 61% [15]. Smoking types of cancer, and other diseases [2–13]. cessation may increase lung function and lower mortality for male smokers [16]; even an interrupted cessation of smoking is helpful and can improve lung function. Only a few studies of the impact of smoking on health in Received: May 17, 2004 Accepted: August 27, 2004 Taiwan have been reported. A prospective cohort study Address correspondence and reprint requests to: Dr. Hui-Chuan explored the attributable risk of cigarette smoking to death Hsu, Department of Health Care Administration, Taichung Health- from various diseases in township residents aged 40 or over care and Management University, 500 Lioufeng Road, Wufeng Shiang, Taichung 413, Taiwan. [17]. The RR of mortality for male smokers was 1.3, and 1.5 E-mail: [email protected] in all cancers. The RRs for stomach disease, ischemic and 484 Kaohsiung J Med Sci October 2004 • Vol 20 • No 10 © 2004 Elsevier. All rights reserved. Effect of smoking on morbidity & mortality among the elderly other heart diseases, and chronic obstructive pulmonary for 1989, 1993 and 1996 were 91.8%, 91.0%, and 88.9%. There disease (COPD) ranged from 1.4 to 1.9, with higher RRs for were no differences in age, sex, and smoking status among females. The attributable risks for mortality associated with the completed cases and those missing through loss or smoking were 21.3% and 2.9% for males and females, re- death from the initial sample when examined for goodness- spectively. In another case-control study, the risk of lung of-fit. cancer was significantly higher in smokers than in non- smokers [18]. Even for those who had stopped smoking, the Variables RRs were higher at 6.39 and 4.00. The risk for every pack of Dependent variables were self-reported chronic diseases cigarettes smoked was 1.04. The risk of a smoking history and mortality. Diseases included heart disease, stroke, lower over 25 years for nasopharyngeal cancer in Taiwan was 1.7 respiratory tract diseases (asthma, bronchitis, tuberculosis), compared to nonsmokers [19]. In Taiwan, smoking cessation diabetes, digestive system diseases (ulcer, gastrointestinal projects and intervention programs have been developed problems, liver/gallbladder diseases), kidney diseases, and [20–23]. However, evidence that cessation of smoking re- cancer (only surveyed in 1993 and 1996). duces the risk of disease and mortality is limited [24]. The major independent variables related to smoking The question of whether smoking cessation reduces were current smoking status (nonsmokers, who had never health hazard risks for the elderly is important for the smoked; ex-smokers, who quit smoking; and current attractive strategy of health promotion as a way of achieving smokers), smoking history (starting age of smoking, years successful aging [25]. However, few studies have shown of quitting), and smoking exposure (cumulative smoking that smoking cessation has an impact on morbidity and years, amount smoked every day). The cumulative smoking mortality in old age. Also, there have been no prospective years were defined from the age of starting smoking to the follow-up studies targeting the elderly population to esti- survey year. If the subject had quit smoking, their smoking mate the risks of smoking and the effect of smoking cessation history was also counted. The cumulative smoking years on morbidity and mortality. Therefore, to explore the effects for those who never smoked was defined as zero. of smoking cessation on the risk of disease will be useful as Controlled risk factors included age (60–74, ≥ 75 years), a basis for the development of a health promotion strategy gender, education (low = illiterate, no formal education, for the elderly and to attain the goal of successful aging. elementary school; medium = junior high school; high = The purpose of this study was to use prospective elderly senior high school or over), ethnic group (Ming-Nan, others samples with 7-year follow-up to assess the impact of including Hakka, mainland provinces, etc), disability in smoking status on morbidity and mortality, and examine physical function in 1989 (any difficulties caused by health whether cessation of smoking reduced the risks of diseases problems in shopping for personal items, management of in old age. money, making phone calls, and taking a bath alone). Analysis METHODS The incidence of each disease was estimated. The RRs and population-attributable risk (PAR) of smoking status on Data and samples morbidity and mortality were estimated using Cox Data came from a face-to-face interview, the “Study of proportional hazards regression models. Three kinds of Health and Living Status of the Elderly” a national repre- smoking effects were analyzed. First, the risk of smoking sentative elderly sample from a survey conducted by the status (nonsmokers, ex-smokers, and current smokers) in Population and Health Research Center, Bureau of Health all samples. Second, for current smokers, the risks of smok- Promotion. Samples were of people aged 60 years or over ing exposure (daily cigarette consumption, age at starting and drawn randomly from the entire elderly population in smoking, cumulative smoking years) were analyzed. Final- Taiwan with 1989 as the baseline, and then followed up in ly, for ex-smokers, the risk of smoking history (cumulative 1993 and 1996. Sampling was made up of a three-stage smoking years, years after quitting) on morbidity and probability sample. All interviews were conducted by senior mortality were analyzed. We did not estimate the 7-year interviewers under high quality control. In this study, we morbidity from cancer because of the absence of cancer used the 1989 sample as the baseline (n = 4,049), together data for the baseline year. Multiple Cox regression analysis with follow-up data for 1993 (n = 3,155) and 1996 (n = 2,669, of smoking status relative to morbidity and mortality, aged 67 years or over). Completion rate (excluding deaths) controlling for related factors, was also done. Kaohsiung J Med Sci October 2004 • Vol 20 • No 10 485 H.C. Hsu and R.F. Pwu RESULTS at starting smoking, and cumulative smoking years on the 7-year incidence of disease and mortality (Table 2). How- In 1989, 36.6% of the initial sample were aged 60–64 ever, no dose-response relationship was found. We also years, 28.5% were aged 65–69 years, 17.9% were aged 70– analyzed the risk of cumulative smoking years and the 74 years, and 17.0% were aged 75 years or above. There years since quitting on the 7-year incidence of disease and were more men (57.1%, n = 2,311) than women (42.9%, mortality for ex-smokers (Table 3). Smoking history did n = 1,738). Half (50.3%) of the elderly were illiterate or not have a significant impact on the relative risks of mor- without formal education, 30.7% had attended elementary bidity or mortality. school, and 18.9% were educated to junior high school or Table 4 shows the multiple Cox regression models for above. Of the sample, 60.9% were Ming-Nan, 15.0% were smoking status relative to morbidity and mortality, Hakka, 22.4% came from mainland provinces, and 1.7% controlling for demographic and related health factors.
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