Previous research with the general population has shown that lower levels of psychological distress are associated with individuals who are more likely to quit smoking. Previous research has suggested that among older adults, the characteristics of those who quit smoking may differ from those of younger adults. Building on the work of Salive and Blazer (1993)
and Whitson, Heflin, and Burchett (2006)
, in the present study, we explored smoking behavior among older adults by gender and race.
CES-D symptoms of distress at baseline were generally higher for females than males, higher for Blacks than Whites, and higher for smokers than nonsmokers. In cross-sectional analyses, Time 1 CES-D symptoms of distress were correlated with several indices of poor health functioning at baseline. In prospective analyses, older adults who experienced greater levels of psychological distress at Time 1 were more likely to have quit smoking 3 years later compared with those smokers with lower levels of such problems. Further, the number of health problems occurring between Time 1 and Time 2 fully mediated the association between distress and smoking cessation. Thus, although Time 1 psychological distress predicted smoking cessation at Time 2, health problems occurring between Time 1 and Time 2 explained the association between Time 1 distress and smoking cessation.
How do health problems occurring between Time 1 and Time 2 mediate the association between symptoms of distress measured at Time 1 and smoking cessation at Time 2? First, distress at Time 1 was highly associated with Time 1 health problems. Still, distress predicted the association even after controlling for Time 1 health problems. Although we were able to measure the presence or absence of health problems, we could not measure the severity of the health problems. The severity of the Time 1 health problems may be associated with the level of Time 1 distress. Moreover, symptoms of distress assessed at Time 1 may be associated with unmeasured Time 1 health problems. As suggested by Black, Markides, and Ray (2003)
, depression among older adults may be a marker for underlying disease severity. The severity of health problems at Time 1, in turn, is a risk factor for subsequent health problems. A second, but not mutually exclusive, possibility is that Time 1 distress itself contributed to increased health problems occurring between Time 1 and Time 2 (Black et al., 2003
). Time 1 depressive symptoms were associated with each of the Time 2 health measures. We also tested for this alternative explanation, specifically that psychological distress mediated the association between change in health problems and smoking cessation; this model was not significant.
We identified racial and gender differences in the prediction of smoking cessation. Psychological distress predicted smoking cessation for the sample as a whole but not for White males. Among White males, those with lower levels of distress were more likely to quit smoking. These results should be viewed in light of our findings of selective attrition. For White male smokers, those with higher levels of Time 1 distress and health functioning problems were more likely to have died (or refused to be interviewed again) by Time 2. Due to selective attrition, we may have been unable to identify the smoking cessation patterns of White males who have higher levels of distress and health problems. Nonetheless, it appears that White male smokers who were interviewed at Time 2 had relatively high rates of Time 2 health problems as well as Time 2 symptoms of distress. We can only speculate that the present results suggest for White male smokers that the experience of increased health problems between Time 1 and Time 2 explains, in great part, their smoking cessation behavior. Indeed, among older smokers who have relatively low levels of distress and health problems, the occurrence of a significant health problem may be pivotal in an individual's decision to quit smoking. Interventions that directly address the motivation to quit smoking may be essential in addressing the needs of older smokers who have yet to experience the negative effects of smoking. Furthermore, in contrast to younger populations, we found women to be more likely than men to quit smoking. This gender difference appears to be related to increased health problems among women compared with men. After we controlled for the specific health problems, female gender no longer predicted smoking cessation. Indeed, after controlling for Time 2 health problems, we found no gender or racial differences in smoking cessation.
The present study's results support the development of two very different approaches to treating older adults who are smokers. First, older adults who will attempt to quit smoking are likely to have relatively high rates of health problems and psychological distress. Such problems have implications for developing treatment cessation programs for this segment of the population. Health problems and psychological distress should be addressed directly within the context of the smoking cessation programs for older adults. Indeed, negative affect is a leading cause for relapse among quitters (Shiffman, 1982
); therefore, smoking cessation programs need to address coping with such negative affect. In contrast, older adults who have lower levels of health problems and distress appear to be less likely to quit smoking. This segment of the population may need a different, more motivational approach to smoking cessation interventions. Smoking cessation programs are being developed to target smokers who have low motivation to quit (Soria, Legido, Escolano, Lopez Yeste, & Montoya, 2006
Considerable attention has been given to offering smoking cessation programs to young and middle-aged adults, whereas older adults have not been a focus of most interventions (Cox, 1993
). Further, women and Blacks may be less likely to receive smoking cessation counseling (Brown et al., 2004
), although our results show that among older adults, female smokers were more likely than male smokers to quit smoking and Black smokers were just as likely as White smokers to quit smoking. Moreover, Black males had the highest rate of smoking at baseline compared with all other groups. Even though these data were collected more than 20 years ago, recent data have shown that Black men aged 65 years and older have higher rates of smoking than other groups (National Center for Health Statistics, 2007
), and this may be the case particularly among southern populations (CDC, 1999
). This finding points out the need for a focus on Black males in developing smoking cessation programs. Barbeau et al. (2004)
have noted that more attention should be given to developing programmatic efforts focusing on socioeconomic disparities in smoking behavior, within and across diverse racial, ethnic, and gender groups.
The limited focus on smoking cessation programs for older adults may be due to several misperceptions regarding smoking behavior among older adults. Many researchers may assume that it is too late to attempt to modify risk factors in elders because smoking behavior is so difficult to change (Riegel & Bennett, 2000
). Additionally, older smokers may be less apt to quit because they are unaware of the many benefits of smoking cessation even at an advanced age (Donze, Ruffieux, & Cornuz, 2007
). However, the benefits of smoking cessation even among older adults are quite substantial. For example, risk of recurrent infarction in smokers may decline by as much as 50% within 1 year of smoking cessation and may normalize to that of nonsmokers within 2 years (Wilhelmsson, Vedin, Elmfeldt, Tibblin, & Wilhelmsen, 1975
). Indeed, in the present study, participants who had a heart attack between Time 1 and Time 2 were nearly twice as likely to quit smoking as those who did not have a heart attack. Others have found that smoking cessation strategies for older adults that address psychological distress and beliefs about smoking and health harms would aid in successful cessation (Honda, 2005
). In particular, when offered the tools they need, older smokers quit smoking at rates comparable to those of younger smokers (Donze et al., 2007
Research in the general population has found that smoking cessation programs developed to directly address symptoms of anxiety and depression, in addition to providing standard smoking cessation interventions, are more effective than programs that provide the standard smoking cessation intervention alone (Honda, 2005
). Our results demonstrate that older individuals who are most likely to quit smoking generally have high levels of distress; thus, adding a component that addresses psychological distress and coping strategies to deal with compromised health functioning in delivering smoking cessation programs may be vital to best help such older adults quit (Honda, 2005
). Significant strides in helping older smokers to quit smoking ultimately will require the development of specialized treatments that target the particular needs of subgroups of smokers (Brown, 2003
; Shiffman, 1993
The present study identified a subgroup of older adult smokers who are less likely than others to quit smoking. These individuals have lower levels of distress and fewer health problems. Although data strongly suggest that it is just a matter of time before smoking-related health problems will affect these smokers, this population may need a different, more motivational approach to even engage them in smoking cessation programs (Schmitt, Tsoh, Dowling, & Hall, 2005
). Research is needed to identify public health strategies, including educational and motivational procedures, that will encourage such individuals to consider smoking cessation even though they have yet to feel significant negative effects of smoking. Schmitt et al. (2005)
suggest that smoking cessation programs also may target individuals who are not ready to quit and that education about the benefits of quitting smoking in older adults is needed for health professionals as well as older smokers.
As with any study, a number of limitations of the present work point to directions for future studies. In the present study, we relied on participants’ self-report of medical problems identified by a physician. Although self-reports of health problems among older adults have been found to be reliable (Mossey & Shapiro, 1982
), some participants may have been unaware of their health problems or may have forgotten about the occurrence of some medical problems assessed in the study. This may have attenuated the observed association between health problems and smoking cessation. Further, a number of medical problems were not assessed; a more comprehensive assessment might have strengthened the association between health and smoking cessation.
Further, results may have been influenced by selective attrition. The attrition rate was high among White male smokers who were depressed and who had higher levels of health problems than smokers who were interviewed at follow-up. Thus, we were unable to identify clear patterns of smoking cessation among White male smokers with high levels of distress and health problems. Additionally, a number of smokers who were interviewed at Time 2 were excluded from analyses because we did not have data on their smoking status at Time 2. Analyses of these participants’ data at Time 1 suggested that these participants also had high levels of depressive symptoms and poor health functioning. If participants with missing data would have quit smoking, the results of the study would be consistent with that reported here. However, at some point, an individual may theoretically be too ill or distressed to quit smoking. Thus, we may have failed to capture a potential curvilinear relationship between distress, health problems, and smoking cessation. Future research is needed to determine if the pattern of smoking cessation identified in the present study also applies to older smokers with more advanced health problems.
Data were collected in the late 1980s. Subsequent cohorts of older adults are more likely to have been exposed to educational materials regarding the negative health effects of smoking before they started smoking. As the current population ages, the differences between the characteristics of older adults and those of the present sample may increase (Morabia, Costanza, Bernstein, & Rielle, 2002
). Indeed, given increased knowledge of the profound negative effects of smoking, subsequent cohorts of older adults who continue to smoke into older age may consist of individuals who have had the most difficulties in quitting.
As Husten et al. (1997)
have pointed out that, given the rapid growth of the elderly population, the medical, social, and economic consequences of smoking will become a greater burden over the next several decades. Thus, focusing greater attention on providing smoking cessation programs for the elderly should be a priority among public health professionals. Our findings underscore the significant role psychological distress and health problems may play among older adults who may be most likely to quit smoking.