85% OF MICHIGAN AGING PROGRAMS 100% SMOKE-FREE

Community Aging Programs Report Smoke-free Policies;
But, Few have Tobacco Education or Cessation Programs

• Smoke-Free Policies Encourage Elders Participation in Programs
• Smoking Cessation & Tobacco Education Programs
• British Playwright Tells Why He Stopped Smoking a Pipe
• Three Million Smoke Pipes: Almost Half are Older Persons
• Smoking & Wrinkled Skin Go Together

SMOKE-FREE POLICIES ENCOURAGE
ELDERS PARTICIPATION IN PROGRAMS

The vast majority of Senior Centers and meals program sites, Area Agencies on Aging, and Councils and Commissions on Aging in Michigan reported that they had smoke-free policies. These policies were well-received by elders and staff using the facilities and appear to have increased attendance at the facilities.

These findings were reported by The Center for Social Gerontology (TCSG) in a recently completed telephone survey of almost 150 facilities serving elders in Michigan. The representative sample of these facilities was the first-ever such survey of smoke-free policies in community-based facilities serving the elderly. The full survey report was published in the Autumn, 1997 issue of Tobacco Control, a journal of the British Medical Society.

TCSG conducted this survey to determine the extent of and impetus for smoke-free policies in community-based facilities serving elders in Michigan. Further, TCSG wanted to determine if these policies appeared to encourage or discourage participation in programs at these facilities.

The importance of smoke-free policies in public facilities has been stressed in a wide variety of studies in recent years. Over 53,000 Americans who never smoked die annually from tobacco-related diseases as a result of Environmental Tobacco Smoke (ETS), also known as second-hand smoke. The overwhelming percentage of these deaths are to older Americans. Further, ETS causes pain and suffering for millions of older persons, especially those who have respiratory or heart problems.

While much media attention has focused recently on laws and policies making hospitals, restaurants, shopping malls, civic and sports centers, and other publicly-used facilities smoke-free, little or nothing was known about smoke-free policies in community-based facilities serving elders. Yet, such policies are of major importance to the health of older Americans.

TCSG found that 99% of the facilities surveyed in Michigan had some form of indoor smoke-free policy. 85% of these facilities were smoke-free, i.e., smoking was not allowed at any time in any area of the facility. The remaining facilities allowed smoking in some areas of the facility, but only a very small number permitted smoking in areas that were not physically separated from smoke-free areas.

Almost half of the facilities stated that they had adopted smoke-free policies because a federal, state or local law required it. Michigan has a statewide Clean Indoor Air Act which largely applies to government-owned facilities and merely prohibits smoking except in designated areas; thus, the law doesn't generally require completely smoke-free facilities. Some cities/towns also have local clean air laws, and some of these laws do require completely smoke-free buildings; some Senior Centers, meals sites, and local Councils and Commissions on Aging are in such sites. Thus, these laws either required smoke-free facilities or may have strongly influenced such policies.

In addition, almost 40% of the facilities said that they had voluntarily adopted smoke-free policies due to concerns about the health of persons using the facility. The remaining survey respondents said they weren't aware of the impetus for the smoke-free policy.

Thus, it appears that having a state or local law requiring smoke-free policies was a major impetus for such policies in many facilities serving elders. However, a high percentage of facilities said they had voluntarily adopted smoke-free policies because they were aware of and concerned about the health dangers of ETS. This result does raise the question of whether states with some form of Clean Indoor Air Law are more likely to have such policies in facilities serving elders, or whether voluntary adoption of such policies has (or will) occurred as more is learned about the dangers of ETS.

Acceptance of smoke-free policies in elderly facilities was generally free of opposition by elders or staff using the facilities, with 62% reporting no opposition to the policies. Of the remaining 38% who reported some opposition to the smoke-free policies, the overwhelming majority stated that the number of elders or staff who objected was minimal -- usually no more than one or two persons, and the persons objecting rarely changed their attendance at the facilities.

Of particular interest to persons operating these facilities, the implementation of smoke-free policies appears to have had a positive effect on attendance by elders at the facilities. Almost three-quarters of facilities stated that no elders stopped using the facility as a result of the smoke-free policy. A very few facilities reported that a minimal number of elders (1 or 2) stopped using the facility due to the smoke-free policy, and almost twice as many facilities reported an increase in new attendees, with many of the latter facilities reporting increases of a lot of elders (5 or more). Thus, on the whole, the survey clearly indicated that smoke-free policies were likely to increase attendance at elderly facilities.

These survey findings concerning smoke-free policies in community-based facilities serving the elderly in Michigan are very positive. The very high percentage of facilities with totally smoke-free policies demonstrates that the vast majority of elders using these facilities can do so without concern about encountering second-hand smoke which would be hazardous to their health.

The survey findings that the smoke-free policies appear to result in increased participation of older persons at the facilities suggests that smoke-free policies are good health policy and good outreach strategy -- a win-win situation.

 

SMOKING CESSATION PROGRAMS &
TOBACCO EDUCATION RARELY FOUND

Smoking cessation programs are rarely found in aging programs in Michigan, nor are they commonly arranged for. Further, less than half of the aging programs surveyed by The Center for Social Gerontology (TCSG) reported that they provided education on the dangers of smoking.

Results from TCSG's telephone survey of a representative sample of community-based facilities serving older Michiganians, described in a separate article in this issue of Notes, showed that, while these facilites overwhelmingly had adopted smoke-free policies, smoking cessation programs and tobacco education were much less common.

Tobacco Education Programs

TCSG's survey showed that 42% of the facilities indicated that they provided some type of education for elders or staff on the effects of tobacco and smoking. There was some variation in the results depending upon the type of facility surveyed, with Councils and Commissions on Aging being most likely to provide this type of health education (almost 60% did so), about 40% of Senior Centers/meals sites provided such education, and less than 20% of Area Agencies on Aging did so (although this may be due to AAAs not generally seeing health education as a part of their specific responsibility).

Of the facilities that did report providing some form of tobacco/smoking education, half reported that they distributed pamphlets or brochures, while slightly less than a third reported inviting speakers to make presentations on the effects of tobacco use. The remainder of facilities reported that they held workshops, seminars or other special programs for elders and staff on the dangers of tobacco use.

The low level of tobacco education reported was also reflected in the comments of some respondents. One program director said: "there is no need for education on the effects of tobacco since, by the time you are a senior citizen, you already know that tobacco is bad for you." A Senior Center director, reflecting the views of other respondents, said, "education on the dangerw of tobacco and smoking is not needed. Everybody knows from TV that it is bad for your health."

Smoking Cessation Programs

Since research on the effects of quitting smoking demonstrates that the health of former smokers of all ages begins to improve almost immediately and continues to improve over time, smoking cessation is valuable for elders as well as younger persons.

Currently, about 12% of persons 65 and over smoke, or over 130,000 older Michiganians; about 26% of Michiganians aged 50 to 64 are smokers, or about 312,000 old or near old persons. Thus, there are almost 450,000 older Michiganians for whom smoking cessation programs could be targeted.

There is also evidence that the adoption of smoke-free policies may serve as a catalyst for smokers to quit, especially if smoking cessation programs are arranged for at the time the smoke-free policies are implemented. With the high percentage of these facilities having smoke-free policies, the potential benefits of arranging for smoking cessation programs for elders and staff seemed particularly high.

TCSG's survey found that just 11% of the facilities provided or arranged for smoking cessaion programs. A few respondents stated that other programs in the community provided smoking cessation, and some of these respondents indicated that they coordinated with these cessation programs.

Several respondents stated that "there is no need for smoking cessation programs for the elderly since there are not that many left smoking, just a few 'die-hards' who are nearly 90 years old and will never quit." A few others said that smoking does not appear to be an issue anymore, and they don't provide a smoking cessation program because there is a lack of interest on the part of seniors. Others indicated that, in a time of shrinking resources and increasing demands, smoking cessation wasn't a high priority.

Those facilities that do arrange for smoking cessation programs for their staff and elders reported mixed success. One Senior Center director said that they "regularly have speakers in to discuss smoking cessation, and attendance is good at these events." Another Senior Center director noted that "the seniors are not intersted in cessation programs so I usually 'blind-side' them with smoking cessation programs as part of the nutrition program or the general health education program."

Yet, a recent article in the Journal of the American Medical Association stated: "Age was also a significant predictor os success -- older persons were more likely than younger persons to quit successfully." And, a paper in the 1994 Cancer Supplement states: "Results from the CLear Horizons trial show that older smokers are interested in quitting and will respond positively to a program tailored to their needs."

TCSG's survey findings show a dearth of tobacco education and smoking cessation programs for older Michiganians and suggest that there is a need for an aggressive campaign to establish such programs for the hundreds of thousands of older Michiganians who are still smokers.

THREE MILLION SMOKE PIPES;
ALMOST HALF ARE OLDER PERSONS

"People who smoke pipes are perceived as being older and retired. It's something the elderly do," stated Norman Sharp, president of the Pipe Tobacco Council, in the Wall Street Journal. He went on to say that nearly half of the estimated three million pipe smokers in the United States are over the age of 46.

Mr. Sharp was not pleased with the above statistics, because the numbers reflected the seven-fold decline in pipe smoking in the past 25 years. For the pipe tobacco industry, it is very troubling that less than 1% of the Americans aged 46 and under smoke pipes, while almost 2% of persons over age 46 smoke pipes.

However, the real cause for sorrow is not the decline in pipe smoking, it is the disease and death that results from pipe smoking. The diseases most associated with pipe smoking are located in the mouth and throat, because less of the smoke is inhaled than in cigarette smoking. However, in spite of less pipe smoke being inhaled, lung cancer death rates among persons who only smoked pipes are still significantly higher than among non-smokers; and the death rate increases for persons who smoked both pipes and cigarettes.

The smoke from pipes, cigars and cigarettes contains similar levels of carcinogens, or cancer-causing agents, and is, thus, equally dangerous. Further, since many pipe smokers also smoke cigarettes, in which the smoke is inhaled into the lungs, these smokers are more likely to also inhale some of the pipe smoke, thereby increasing the dangers to their health.

Pipe tobacco ads such as the one below were common in the 1940's, '50's and '60's when many of today's older smokers started. Note the sexist text of this ad.

BRITISH PLAYWRIGHT TELLS
WHY HE STOPPED SMOKING A PIPE

The British author and playwright Peter Tinniswood rarely used to be seen without his pipe. He had taken up the habit as a 16-year-old because it was considered "manly" and, during most of the following 40 years, he traveled around in a pungent cloud of Amphora tobacco smoke.

Then he developed a toothache. His dentist pulled out the offending tooth and had a good look around his mouth. "At the exact point where the stem of my pipe rested at the back, he saw something he didn't like the look of," Tinniswood recalls. "He said: 'I hope it is not cancer, but prepare yourself - it might be'."

[In the United States in 1996, almost 9,500 deaths were due to smoking-related diseases of the lip, oral cavity, pharynx or larynx. These are the diseases most clearly associated with pipe and cigar smoking, although lung cancer and cardiovascular diseases are also linked to pipe and cigar smoking. Of these almost 9,500 deaths, over 57% were to persons aged 65 and over, or over 5,400 deaths; over 92% of these 9,500 deaths were to persons aged 50 and over, or 8,700+.]

Smoking is recognized as one of the main causes of oral cancer. Early diagnosis is crucial, but you are unlikely to know about it unless you see your dentist regularly, because oral cancer is painless.

"I had no idea there was anything growing in my mouth, or how long it had been there," says Tinniswood. "It was at the back of my tongue, just creeping into my throat, but I couldn't feel it at all."

Tinniswood was referred to a specialist and a biopsy confirmed the dentist's suspicions. Within days, he underwent surgery. "Of course, I was absolutely petrified. I thought: 'This could be it, the beginning of the end for me', and I wasn't sure I would cope. The only way for me to deal with it, as a writer, was to write about it. So I scribbled it all down in a journal. I called it I Blame My Tooth. It was a marvelously therapeutic way of analyzing my feelings. I found it very helpful - even comic."

Tinniswood, 61, is the author of Tales from a Long Room, and several comedy plays, but is best known, perhaps, as the creator of Uncle Mort, the indomitable northerner who contracted cancer in I Didn't Know You Cared. "I made terrible fun of the disease then," Tinniswood remembers. "I had Uncle Mort's mother swearing everyone to secrecy about it, for fear that the house would have to be fumigated by the council. That is the way cancer was often perceived when I was a child - as a disgrace. There is a certain fine irony that, 20 years after writing about it, I should get cancer myself. Even more ironic is that it was my own fault. It was doubtless the pipe that caused it and I can only count myself lucky to have had that toothache. Without it, I would have been a goner. My dentist saved my life."

Dentists are the most likely professionals to detect oral cancer. The average practitioner will see only a few cases during his career, but all are trained to pick up the symptoms - whitish or reddish lesions in the soft tissue of the mouth - during check-ups. Tinniswood's dentist, Robert Hayes, says: "If you have a six monthly check-up, the chances are that any suspicious cells will be found. But 50 per cent of the population don't bother with six-monthly checks and, the longer the cancer goes undetected, the less likely it will be to treat it successfully."

If left undiagnosed, oral cancer can spread into the muscles and bones around the neck, requiring radiotherapy and major surgery to remove sections of the face. If it spreads along the tongue, radiotherapy is usually the only option.

Pipe and cigar smokers are more prone to oral cancer. "Pipe tobacco is unfiltered and the heat generated along the pipe stem doesn't help," says Mr. Hayes. "Pipe smokers tend to rest the pipe in the same place and, over time, the toxins and the heat can cause cell damage."

For Tinniswood, surgery was successful and he has needed no further treatment. He now has three-monthly check-ups. "Every time, the week before I go, I convince myself I can feel pains in my throat and lumps in my neck, but fortunately, my fears have so far proved unfounded."

The fact that he no longer smokes reduces the risk of relapse. He has thrown out his collection of 76 pipes. "Well I kept a couple, but I look at them with revulsion now. It really is a vile habit."

"I stopped dead that day I went to the dentist. I did think I would have one final smoke. I filled the pipe up, tapped the tobacco down to make sure there was a good draw, put it to my mouth and thought: 'I will be sick if I smoke this'. It was only after I stopped that I discovered it never was the smoking I liked; it was the rigmarole of filling the pipe."

Adapted from a 1997 Electronic Telegraph article.

SMOKING AND WRINKLED SKIN GO TOGETHER

"If you were to line up 10 middle-aged smokers on one side of a room and 10 nonsmokers of a similar age on the other, chances are you would notice one striking difference: The smokers would look much older than the nonsmokers. The reason? The skin of middle-aged smokers is substantially more wrinkled. Smokers in their 40s have facial wrinkles similar to those of nonsmokers in their 60s," according to research reported on in Cigarettes: What the Warning Label Doesn't Tell You.

Studies have shown that smoking increases facial wrinkling. The more and longer you smoke, the more wrinkling occurs. Wrinkling in smokers is at least two to three times greater than in nonsmokers.

The effects of smoking on wrinkling begins to show in middle age and is most noticeable in women. And, guess who the skin creme industry targets?

The major signs of wrinkling due to smoking are: leathery-looking skin; tiny wrinkles spreading from the upper and lower lips; "crow's feet" around the eyes; and deep lines and numerous shallow lines on the cheeks and lower jaw. Many smokers also develop hollow cheeks due to the repeated muscular motion of inhaling cigarette smoke, often causing older smokers to look gaunt.

Smokers also have two to three times greater risk than nonsmokers of developing psoriasis, a chronic skin condition characterized by reddish and silvery eruptions that can occur over the entire body.