|Vol. 7, Nos. 3 & 4||
On Delivery of Legal Assistance to Older Persons
For years health professionals have said that "tobacco is a children's issue," and it is, since almost 90% of current adult smokers1 started by the time they were 18 -- the legal age for retailers to sell cigarettes to youth. But, tobacco is also an older persons' issue, because that is when most of the pain and suffering occurs, due to the late on-set of many tobacco-related diseases.
When one thinks of the people who have died of tobacco-related diseases, generally one thinks of older relatives and friends, or of older celebrities, such as Sammy Davis, Jr., Pat Nixon, Bette Davis, Audrey Meadows, Edward R. Murrow, and Wayne McLaren -- one of the original Marlboro man models.
Nationally, over 434,000 people2 die annually from tobacco-related diseases, such as cancer, heart disease, and lung disease, and an additional 53,000 or more persons die from the effects of second-hand smoke.3 The estimated medical care costs annually in the United States due to the treatment of persons with tobacco-related diseases is $50 billion.4
In a time when Congress is attempting to slash the Medicare budget, it is astounding that, of $87 billion spent in 1994 by Medicare on in-patient hospital care, about $16 billion was for treatment of smoking-attributable diseases, according to a study released by former Secretary of Health, Education & Welfare (now Health & Human Services) Joseph Califano.5 All these costs are for persons who are elderly or disabled and on Medicare. Tobacco is an elderly issue! And, tobacco is an issue for organizations, including legal programs, serving the elderly.
As Congress continues to debate Medicare and Medicaid cost issues, the public policy implications of tobacco on the elderly and on these programs should not be ignored by the Aging Network. Joseph Califano stated the issue succinctly: "If the problems of substance abuse [particularly tobacco] did not exist, we would not now be concerned about the solvency of the [Medicare] Hospital Trust Fund....[T]he proposed solutions involve raising taxes or cutting benefits....[H]owever, little time is spent thinking about how we can keep elderly people healthy and avert hospitalizations. The worst example of this is our failure to move aggressively on the pervasive impact of substance abuse, including tobacco, alcohol and drugs, on both Medicare and overall health costs."6 Tobacco is a public policy issue of direct concern to the elderly.
10 Million Older Smokers and Growing
Nationally, approximately 13% of the over-65 population are smokers,7 equaling over 4 million older Americans.8 Of the over 31 million persons aged 65 and over,9 almost 15% of men and almost 12% of women are smokers.10 Of the approximately 22 million Americans aged 55 to 64,11 about 28% are smokers,12 equaling about 6.2 million smokers. Thus, over 10 million older Americans today are smokers, or about 19.2% of the 55 and over population.
By contrast, the Surgeon General's report in 1994 on tobacco use among youth estimated that "at least 3.1 million U.S. adolescents are current smokers."13
As America moves into the 21st century, the elderly population will increase much more dramatically than younger age groups. Between 1989 and 2030, the 65 and over population is expected to more than double,14 and this population will move from 12.6% to almost 22% of the total population by 2030.15 The 55 to 64 year old population will grow from the current 8.5% of the total population to 11.6%.16 Thus, if the current percentages of older smokers remain constant, there will be about 18 million older smokers out of a projected 96 million people aged 55 and over.17 The human and health care cost implications of the tobacco-related diseases these elders will endure is staggering. Tobacco is an elderly issue!
Addiction & the Benefits of Cessation
The experience of older smokers is instructive as an example of the addictiveness of tobacco. Most older persons who smoke have been doing so for over 40 or 50 years, at least. And, among adult smokers, older Americans are the least likely to want to quit -- undoubtedly due to the intensely addictive qualities of tobacco.
A U.S. National Health Survey found that about 70% of current adult smokers would like to quit, and about 34% try to quit each year, but only about 2.5% are successful.18 But, older persons were the least likely to want to quit, with 50-60% saying they wanted to do so.19
Yet, the health benefits of quitting smoking are almost immediate for older persons, as well as younger adults and youth. Recent studies have shown that, within days of quitting, the health of the former smoker improves, and it continues to improve as the weeks, months and years go by.20 The likelihood of former smokers having tobacco-related diseases also decreases the longer a person refrains from smoking, particularly heart and lung diseases, as well as risks of stroke and cancer.21
Aging Network organizations, particularly Senior Centers and casework agencies, have the potential to very effectively address these issues. Smoking cessation programs can generally be arranged, or referrals made to such programs, by working with a variety of organizations which operate such programs. Aging Network agencies can contact local American Lung Association (ALA), American Cancer Society (ACS), American Heart Association (AHA) agencies or state Health Departments for information on smoking cessation programs that are available. If enough older persons are interested in attending a smoking cessation program, many of these agencies would consider running the sessions at locations that are most convenient for attendees, such as Senior Centers.
In addition, State and Area Agencies on Aging, Senior Centers and other Aging Network agencies can take a leading role in disseminating information about the health effects of tobacco use, the health benefits of smoking cessation and the health hazards of second-hand smoke. Aging Network agencies can work with ALA, ACS, AHA groups to arrange for speakers at Senior Citizens group meetings to discuss these issues, as well as making written materials available.
Second-hand Smoke and the Elderly
Fortunately, over 80% of the elderly do not smoke. However, environmental tobacco smoke (ETS) is a serious health concern for all elders, as it is for other age groups. The 1992 E.P.A. report classified ETS as a carcinogen known to cause cancer and stated that "passive smoking has subtle but significant effects on the respiratory health of nonsmoking adults, including coughing, phlegm production, chest discomfort, and reduced lung function."22
ETS is a concern for all older persons, but it is particularly dangerous for elders with respiratory illnesses, such as emphysema or asthma, which can be exacerbated by inhalation of second-hand smoke. Further, second-hand smoke poses a clear danger to older persons with heart disease, allergies or other lung diseases.23
The most effective way to prevent harm from ETS is the implementation of smokefree public places policies. Today, most health facilities are smokefree, increasing numbers of businesses are smokefree, and many shopping malls, restaurants and other public places are smokefree. Aging Network programs appear to have a wide variety of policies on smokefree facilities. In the clear interest of protecting the health of elders and staff members, Aging Network agencies should take a leading role in adopting smokefree policies in their own facilities. Further, Aging Network agencies should join other ALA, ACS, AHA and health groups in their localities and states who are actively advocating for smokefree policies in public facilities of all types.
Tobacco Is an Intergenerational Issue
For older persons, tobacco is also an intergenerational issue. Very few elders want their children or grandchildren to smoke or chew tobacco, even if they are themselves smokers. For older persons, these feelings are compounded by the fear of seeing their children or grandchildren suffer and die from cancer, lung or heart diseases before they have had the opportunity to live full lives.
Because elders and youth face the same dangers from second-hand smoke, and because elders do not want children purchasing tobacco products and becoming addicted to tobacco, the opportunity is great for building intergenerational coalitions of youth and elders. Such intergenerational efforts can be focused on various public policy issues concerning tobacco, such as smokefree public places laws, stopping tobacco sales to minors, and tobacco excise tax increases. Such intergenerational coalitions can be especially effective since few segments of the population are as well thought of by policymakers as youth and elders.
Aging Network agencies can play a leading role in facilitating the creation of such intergenerational coalitions, as well as in encouraging elders to become active and involved with tobacco-control groups locally and statewide. Again, ALA, ACS, AHA and state Health Departments can be contacted to learn more about who is doing what on these issues. Today, almost all states have active statewide advocacy coalitions working on tobacco and health issues, and many localities have similar coalitions. Representatives of the Aging Network have only rarely been involved in such coalitions. Yet, tobacco is an elderly issue.
TCSG Initiates Tobacco & the Elderly Project
While much attention in recent years has, rightfully, been focused on preventing children and youth from becoming addicted to tobacco, until now there has been very little done concerning tobacco and the elderly. As indicated above, that lack of involvement needs to change -- for the health of all generations.
With support from the Michigan Department of Community Health and the national ASSIST program, The Center for Social Gerontology (TCSG) has begun a special tobacco and the elderly project. We are developing a statewide network of elder rights advocates -- both elders and persons working with them -- to work on reducing tobacco use and exposure to ETS among older and younger persons. TCSG is also working with local organizations to increase their knowledge about tobacco and the elderly issues, as well as about tobacco issues affecting all ages.
We are developing materials on tobacco and the elderly issues, including health issues, tobacco cessation, tobacco advertising, ETS and related topics. A quarterly Tobacco & the Elderly Notes newsletter is disseminated to Aging Network and tobacco-control organizations. Further, we are preparing a special resource guide, with slides, on Tobacco and the Elderly, which will be available early in 1997.
Tobacco is an elderly issue! And, the time has come for more attention to be focused on this issue. Persons interested in TCSG's project on tobacco and the elderly may write, call, fax or e-mail us for more information.
James A. Bergman, J.D., is former Executive Director of STAT (Stop Teenage Addiction to Tobacco). He is now Co-Director of The Center for Social Gerontology, where he is also directing the new project on tobacco and the elderly described here.
1David E. Nelson et al., Trends in Cigarette Smoking Among US Adolescents, 1974 Through 1991, 85 Am. J. Pub. Health 34 (1995).
2U.S. Dep't of Health and Human Servs., Preventing Tobacco Use Among Young People a Report of the Surgeon General (1994) (introductory letter from Secretary of Health and Human Services Donna Shalala) [hereinafter Surgeon General's Report].
3Stanton A. Glantz & William W. Parmley, Passive Smoking and Heart Disease: Epidemiology, Physiology, and Biochemistry, 83 Circulation 1 (1991). See also, James L. Repace & Alfred H. Lowrey, An Enforceable Indoor Air Quality Standard for Environmental Tobacco Smoke in the Workplace, 13 Risk Analysis 463, 463-4 (1993).
4Office on Smoking and Health, Centers for Disease Control and Prevention, State Tobacco Control Highlights--1996 112 (1996).
5Adam Clymer, Addiction Center Says Tobacco's Hospital Costs Will Imperil Medicare, N. Y. Times, May 17, 1994; and Medicare's Big Cigarette Burn, N. Y. Times, May 18, 1994.
6Center on Addiction and Substance Abuse at Columbia University, The Cost of Substance Abuse to America's Health Care System -- Report 2: Medicare Hospital Costs 1 (1994).
7Centers for Disease Control and Prevention, Surveillance for Selected Tobacco-Use Behaviors -- United States, 1900-1994, 43 Morbidity & Mortality Wkly. Rep. 5, 9 (November 18, 1994).
8Id. at 13.
9U.S. Dep't of Health and Human Servs., Aging America: Trends and Projections 3 (1991) [hereinafter Aging America].
10Centers for Disease Control and Prevention, Cigarette Smoking Among Adults -- United States, 1993, 43 Morbidity & Mortality Wkly. Rep. 926 (December 23, 1994) (averages of 1992 and 1993 smoking rates for 65 and over population).
11Aging America, supra note 9, at 3.
12Barbara K Rimer & C. Tracy Orleans, Older Smokers, in Nicotine Addiction: Principles and Management 385 (C. Tracy Orleans & John Slade, eds., 1993).
13Surgeon General's Report, supra note 2, at 58.
14Aging America, supra note 9, at 6.
15Id. at 7.
18Centers for Disease Control and Prevention, supra note 10, at 928-929.
19Id. at 927-928. See also, Rimer and Orleans, supra note 12.
20See, e.g., U.S. Dep't of Health and Human Serv's, The Health Benefits of Smoking Cessation (1990); Cindy L. Jajich et al., Smoking and Heart Disease Mortality in the Elderly, 252 JAMA 2831 (1984); R. L. Rogers et al., Abstention from Cigarette Smoking Improves Cerebral Perfusion Among Elderly Chronic Smokers, 253 JAMA 2970 (1985); Smoking Cessation Offers Significant Benefits for Older Adults, Geriatrics, May 1992, at 91; and C. Tracy Orleans et al., Long-Term Psychological and Behavioral Consequences and Correlates of Smoking Cessation, in The Consequences of Smoking: A Report of the Surgeon General (1990).
21Annlia Paganini-Hill & Grace Hsu, Smoking and Mortality Among Residents of a California Retirement Community, 84 Am. J. Pub. Health 992-995 (1994). See also, Millicent W. Higgins, et al., Smoking and Lung Function in Elderly Men and Women, 269 JAMA 2741-2748 (1993).
22Environmental Protection Agency, Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders, 1-6 (1992).
23Massachusetts Dep't of Public Health, Indoor Tobacco Smoke and Ventilation, Public Health Fact Sheet (November 1989).
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