Comprehensive assessment of lifetime cigarette smoking and its association with health-related quality of life among older US adults

Cigarette smoking has a modest association with health-related quality of life (QOL), largely due to its causal role in cancer, cardiovascular disease, and chronic lung disease. However, prior studies have often underestimated exposure by using limited measures of smoking, by including young adults, and by adjusting for smoking related diseases—which mediate the association. We aimed to examine the association between a comprehensive index of lifetime cigarette smoke exposure (LCSEI) and QOL among older adults in the USA. We analyzed data for 7,001 U.S. adults ≥ 40y from an available US sample (wave 5 of the Population Assessment of Tobacco and Health Study). The 11-point LCSEI included heaviness of smoking, pack-years, childhood smoking, and second-hand smoke exposure. QOL measures included PROMIS global physical and mental health (GPH, GMH) scores. We estimated the multivariable association between LCSEI scores and mean GPH or GMH, adjusting for sociodemographics, BMI, and weekly exercise but not smoking-related diseases. Regarding lifetime smoking, 6.7% smoked during childhood, and 16.9% currently smoked. In the multivariable analysis, high vs. low LCSEI was associated with significant reductions in mean GPH (−14.5%) and GMH (−15.2%), significantly more than reductions for extremes of education (−3.0% and −5.3% respectively) and comparable to extremes of income (−10.9% and −11.4% respectively). Sensitivity analysis found that associations were greatly attenuated but remained significant even after further adjustment for smoking-related diseases. Among older adults, reducing lifetime cigarette smoking could yield gains in QOL similar in magnitude to those associated with narrowing socioeconomic inequalities, highlighting importance of eliminating cigarettes to promote healthy aging. For the poor, disadvantage delivers a double blow to QOL: directly, through the material hardships of poverty, and indirectly, through greater lifetime exposure to cigarette smoke.Author summary: Most people know that cigarette smoking is bad for health, but prior research has likely underestimated just how much it affects quality of life — particularly in older adults who have experienced decades of exposure. In this study, we developed a comprehensive measure of lifetime cigarette smoke exposure that captured not just current smoking, but also how heavily people smoked, how many years they smoked, whether they started as children, and how much secondhand smoke they were exposed to. We found that the quality-of-life burden associated with high lifetime smoking exposure was far larger than prior studies suggested — exceeding the burden associated with differences in education and rivaling the burden of poverty itself — highlighting the importance of eliminating cigarettes to promote healthy aging. Perhaps most striking is what this means for who bears the greatest burden of poor health. Lower-income adults already suffer from a reduced quality of life due to material hardship. Because they also smoke at higher rates, they bear a double burden: lower quality of life from socioeconomic disadvantage and lower quality of life from their greater lifetime smoking. Our findings suggest that tobacco control not only improves public health generally but also narrows the socioeconomic health outcomes gap, delivering greatest benefit to older adults most in need.