Tobacco and smoking have been commonplace throughout much of American history. In ¿he middle part of this century, when most of the current older adults were adolescents or young adults, smoking was an acceptable habit. In movies in the 1940s and 1950s, smoking came to symbolize the best in American Ufe - success, sensuality, independence, adulthood. Smoking was "the thing to do."
Since then, public perceptions about smoking have changed drastically (Viscusi, 1992; Warner, 1986). Smoking is currently regarded as a nasty habit with severe health consequences and, more important, as dangerous for both smoker and nonsmoker alike. The overall prevalence of cigarette smoking among older adults (those age 65 and older) is not greatly different from that of younger individuals, but smoking prevalence among older individuals does vary with increasing age. Public health goals, outlined in Healthy People 2010, are for smoking rates for the population age 20 or older, including older adults, to drop to 20% by 2010 (U.S. Department of Health and Human Services [USDHHS], 2000).
Have the beliefs and practices of elderly individuals about smoking kept pace with these changes in public perception? Is the public health goal of a 15% smoking rate for older adults achievable? What are the beliefs of elderly individuals about the health consequences of smoking, especially elderly individuals very vulnerable to the consequences of smoking - those in longterm care facilities?
Less is known about smoking at older ages than at younger ages. Currently, approximately 25% of all adults in the United States smoke (Centers for Disease Control and Prevention, 1996; National Center for Health Statistics [NCHS], 1989; USDHHS, 2000). In 1987, 2.1 million (32%) of men and 2.4 million (25%) of women age 65 or older were current smokers (LaCroix & Omenn, 1992). Of individuals age 75 or older, the proportion of current smokers decreased to approximately 9% for both sexes - a decrease largely due to the heightened mortality and morbidity associated with prolonged smoking (Institute of Medicine [IOM], 1990).
By 1995, current tobacco use by elderly individuals had declined to 15% of all men and 12% of all women age 65 or older (NCHS1 1999). The proportion of older adults who never smoked, who formerly smoked, and who currently smoke varies widely by education, marital status, socioeconomic status, ethnicity, and location (whether rural or urban), as well as by age and sex. In general, compared to women, men started smoking earlier in life, smoked more heavily, and are more addicted to smoking, yet are more likely to quit (Colsher et al., 1990; LaCroix & Omenn, 1992).
The cohort of men most exposed to cigarettes was born in the decade from 1919 to 1920 (i.e., men who are currently 75 years old and older) (Harris, 1983; Warner, 1986). The cohort of women maximally exposed to cigarette smoking is that currently age 50 to 75 (i.e., women born between 1 920 and 1940). Because of these demographic factors, the issue of access to smoking for residents in nursing homes will endure for some time.
Recent studies have shown that older adults can achieve improved health status if they quit smoking, with some measurable changes in less than a year (Connoly, 2000; IOM, 1990; LaCroix et al., 1991; Salive et al., 1992). At the same time, fiscal and regulatory constraints can make it difficult to offer smoking cessation programs to residents in long-term care.
The median age of nursing home residents is currently approximately 80 years, and most residents are frail, with between three and four limitations in daily activity. Approximately two thirds of older adults have mental health problems (Barker & Lewis, 1998), mainly with memory or cognition. These deficits make control of smoking in nursing homes imperative. Mobility and other functional impairments, sensory losses, respiratory conditions, and medication use make older adults very vulnerable to fire and more susceptible to its consequences than younger people. Not only do individuals age 65 and older have fire fatality rates twice as high as younger people but smoking and smoking materials are the leading causes of fatal fires for this age group (Petraglia, 1991).
Smoking in nursing homes is so much a part of everyday life that it has remained invisible, generally unnoticed, receiving only a passing reference in the ethnographic literature on life in nursing homes. There is an absence of epidemiological studies of smoking prevalence in long-term care. In the only published survey, smoking rates among the predominantly male residents in 106 Veterans' Affairs nursing home care units varied from 5% to 80%, with a median of 22% (Kochersberger & Clipp, 1996). These figures demonstrate the extent to which smoking and its management is a common, central, and continuing concern in long-term care. Smoking has to be managed to ensure the safety, rights, and health of residents and staff, both smokers and nonsmokers (Barker & Lewis, 1998; Barker, Mitteness, & Wolf sen, 1994; Kochersberger & Clipp, 1996).
The study reported in this article investigated the prevalence and location of smoking by elderly residents in a long-term care facility, and the beliefs residents held regarding the relationship of smoking to health. Implications for nursing practice are also discussed.
This study was conducted between 1990 and 1992 in a longterm care facility with more than 500 beds in a major metropolitan city. At least 75% of residents were older than age 65, and approximately two thirds of residents were women. All residents had two or more cognitive or functional impairments severe enough to preclude community living.
At the time of the study administrative personnel were increasingly concerned about smoking within the institution, but consensus about how to manage smoking was difficult to achieve. Some believed smoking was a health hazard for smokers and nonsmokers alike. Others believed smoking was a "last pleasure," not to be taken away by a faceless institution (Kochersberger & Clipp, 1996). A moderately restrictive smoking policy had been established by a committee, composed of institutional administrators, physicians, and a director of nurses. This smoking policy affirmed the right of a resident to smoke while providing a smoke-free environment for those who do not wish to be exposed to smoke and to ensure the safety of everyone. Rules related to smoking were:
* Residents must be allowed to smoke if they so wished.
* All smoking must occur in designated areas only.
* All smoking must be supervised, with the level of supervision dependent on the safety risk posed by the resident.
* Staff and visitors could smoke only if outside the buildings.
Smoking materials were readily available to residents. Cigarettes and lighters could be purchased in the gift shop run by volunteers. Cigarettes were given away as prizes in Bingo games, giving them a cachet that other social events did not have.
Two research protocols were employed. First, systematic observation and documentation was undertaken of smoking in public areas of the facility. Second, face-toface interviews were conducted with elderly residents about smoking and its relation to health.
Because observations of smoking were undertaken only in public space, this could have biased the study through overlooking important happenings in private. Ultimately, this was not a major issue. All designated smoking areas were in public spaces. A few smokers were unable to leave their bed or the private space of the ward because of the nature or severity of their physical or cognitive limitations. For these individuals, smoking was limited to a few occasions per day and was strictly supervised. Thus, the majority (more than 90%) of elderly residents who smoked did so voluntarily, and did so in some type of public space.
Two types of observation were made: unstructured and structured. Unstructured observations were performed at random times of day, including weekends, in specific "high profile" public locations in the facility (e.g., next to candy and soda vending machines, in the front hall). During a 6-month interval, 250 such observations were made. Structured observations were performed during 10 consecutive weekdays (excluding weekends). A parallel set of structured observations was performed every hour from 7 a.m. to 6 p.m. in approximately 20 different public locations throughout the institution.
Both styles of observation recorded the number of persons and of smokers present, the place and time of day, and the type and quality of interaction occurring. In addition, structured observations mapped the mix of residents and nonresidents, smokers and nonsmokers, and their clustering at specific times or places.
All newly admitted residents older than age 65 who were cognitively and functionally capable of giving consent and who spoke English, were asked to participate. The authors intended to interview only newly admitted current smokers to understand how they learned about and adjusted to the institution's smoking policy. Because of prior acute hospitalizations, however, only four newly admitted residents (9%) were current smokers. Four others were not currently smoking but still identified themselves as smokers. For this study, all eight were categorized as smokers. Because of the small number of smokers among the newly admitted residents, an additional convenience sample of 16 other elderly residents still on the intake ward was also interviewed. These people had been in the facility for 1 to 6 months. Of these additional residents, 11 (69%) were smokers.
Not all residents answered every question, so the number of responses to each question varied slightly, between 40 and 43. Interviews lasted approximately 45 minutes and were conducted at the resident's bedside or at another location of the resident's choosing.
The interview included the following:
* The resident's demographic and smoking history.
* Self-reported health problems and functional status.
* Self-reported current social interactions.
* Personal beliefs relating health to smoking.
* General commentary on smoking and related behavior in the nursing home, including, when appropriate, their own smoking. In particular, residents were asked if they agreed that there was a relationship between smoking and health, if the health consequences of smoking were mild or severe, and if smoking was related to any of seven specific health conditions. Responses to the structured interviews were either fit into precoded categories or were noted verbatim directly onto the protocol sheets.
Observational data were coded for the following:
* Number of persons present, apparent age and sex of individuals, whether they were residents or staff members, and whether or not they were smoking.
* Location in institution, day of week, and time of day.
* Number and style of interactions (e.g., greetings, request for or sharing of cigarettes, conversation) and their emotional quality (e.g., affirming of the resident). Coded data were then subject to numerical analysis, using simple descriptive statistics, such as frequency and proportion, or where appropriate, means or Fisher's exact test for significance.
Pre-coded answers to interview questions were analyzed using statistical techniques appropriate for categorical data, such as frequency and proportion. Verbatim notes recorded during the interviews were categorized thematically.
Prevalence of Smoking by Residents
Overall, 1 in 6 (15%) of all elderly residents were identified by staff as smoking on a regular basis. Smoking was common in the facility, being a documented activity in 41% of the structured 10-minute observations. Smoking was largely a solitary activity, however, as almost half the time (46%) smokers were observed to be alone. Less than half (42%) of all observed smokers were elderly residents.
When only those interactions involving elderly residents are considered, the proportion of interactions involving smoking rises sharply, to more than 75%. More than two thirds (74%) of interactions involving smoking were rated as positive or supportive toward the smoker. This suggests that smoking and interactions around smoking are key elements in the lives of many elderly nursing home residents who smoke.
Disregarding policy, residents smoked everywhere in the facility, including hallways and public rooms. Observations indicated that 84% of smoking occurred outside designated smoking areas. Indeed, an institutional joke among the staff was that the preferred place for elderly residents to smoke was sitting directly under a "no smoking" sign. On one third of occasions (30%) in which smoking was documented, caregiving or administrative staff greeted residents who were smoking, including those in "no smoking" zones. Rarely, however, was the issue of smoking in an inappropriate place addressed, even when safety hazards existed, such as when another resident sitting next to the smoker was using oxygen. Occasionally, housekeeping and other staff smoked while sitting or chatting with the residents. Because staff were subject to disciplinary action if found breaking the rules by smoking indoors, such smoking groups were only occasional and tended to occur in the more secluded locations or at times of day when there was less "traffic" in the public areas.
ELDERLY RESIDENTS' BELIEFS ABOUT SMOKING AND ITS DELETERIOUS EFFECT ON HEALTH
Elderly Residents' Beliefs Related to Smoking and Health
The majority (75%, n = 45) of eligible residents in the intake ward agreed to be interviewed. The interview sample comprised 19 smokers and 38 nonsmokers, with an average age of 75.8 years (SD = 9.4, range 65 to 104 years). Almost half this sample (46%) were women.
In general, most of these older residents (74%) agreed that smoking was related to health outcomes. There was a nonsignificant tendency for nonsmokers more than smokers to agree that a relationship exists between smoking and poor health (78% vs. 62%; ? < .06). Compared to nonsmokers, too, smokers tended to express their beliefs very mildly, and fewer smokers than nonsmokers linked smoking to severe health consequences. Overall, residents had mUd attitudes toward smoking, a limited sense of vulnerability to the health consequences of smoking, and a limited understanding of the range of organ systems affected by smoking.
Even when respondents said they believed smoking harmed health, their explanatory comments revealed attitudes that were mild, even equivocal. In general, these elderly nursing home residents did not strongly believe that smoking posed a substantial risk to health. Many respondents prefaced their agreement by saying, "I think so," or, **I guess so." A typical response, for example, was given by one resident who said, "Yes, I think people who smoke have a higher incidence of coughing and so forth."
Ten people (26%), all nonsmokers, had views that represented the mildest, most benign connection between smoking and health. Two people believed that smoke caused damage only if a smoker inhaled. Three people believed that smoking was harmful only if one smoked "too much." Four people indicated that smoking had only very minor, localized health affects. Two people believed that smoking could not cause health problems but could only make existing problems a little worse. Comments ranged from "smoke irritates the throat" to "smoke down there [lungs] isn't going to do any good."
In contrast, 11 individuals (26%) used strong, definite language and affective tone, connecting smoking to poor health outcomes. For example, one elderly woman replied, "Absolutely, no doubt about it. Smoking helped kill my husband."
Some had a limited sense of vulnerability to the health consequences of smoking. Just 10% of individuals described smoking as having severe health consequences, of being a "killer," or causing death. Only six people volunteered any mention of cancer, but of these people, two indicated they did not believe smoking caused cancer. No one mentioned secondary smoke as a concern.
Some elderly residents (29%) offered very specific individual experiences that were claimed to counter effectively the negative health effects associated with smoking. One resident said, "My Dad smoked and he lived a long time." Another explained, "You're breathing something that isn't natural to breathe. It's a killer, of course, but that doesn't apply to me because I'm different, somewhat above the norm." Significantly more smokers than nonsmokers (60% vs. 19%, Fisher's exact,/» < .02) interpreted and limited the consequences of smoking in terms of personal experience.
Thirty respondents further described the relationship of health to smoking. More than one third (38%) mentioned only a single body part or organ system as being affected by smoking, almost always the lung or respiratory system. For example, "Smoking dirties your lungs - that's conclusive. Smokers* lungs are different from nonsmokers," or, "Smoking is very bad for the lungs and throat."
Elderly residents were specifically asked if they believed smoking was linked to seven particular body systems or diseases known to be affected by smoking (Table). Approximately three fourths of people indicated they believed smoking to be related to breathing problems and heart disease. Significantly fewer smokers (64%) than nonsmokers (92%), however, linked smoking with breathing problems (Fisher's exact, p < .04). Smokers more than nonsmokers tended to indicate that smoking harms multiple body parts or body systems, but this difference was not significant. These results are consistent with other studies of older adults* beliefs related to the impact of smoking on health (Clark, Hogan, Kviz, & Prohaska, 1999). For example, current smokers age 50 to 70 years more strongly associated deleterious health consequences from smoking with the respiratory and cardiovascular systems than with any other organ system (Barker & Kramer, 1998).
Respondents' beliefs seem to mirror the amount of attention the popular press has paid to the effects of smoking. Media presentations tend to place greater emphasis on smoking 's impact on heart and lungs than on diabetes and its sequelae or on bone disease, such as osteoporosis.
Smoking by residents in longterm care is an issue that has not been examined much. However, estimates suggesting that as many as 25% of elderly residents in nursing homes continue to smoke make attention to the management of smoking an important topic. Smoking is a health issue as well as a safety (fire) hazard. In particular, efforts to reduce current smoking through effective cessation programs are needed.
While most elderly residents of nursing homes believed that smoking could and did affect health, this study indicates that many did not believe the link was very strong, that the harm was severe, or that the damage (if and when it occurred) was extensive. Even when smokers associated smoking with health, over half limited their vulnerability to only those consequences they had observed or experienced in their lives. Elderly nursing home residents, smokers and nonsmokers alike, minimized the risks associated with smoking.
These elderly residents were raised in an era when smoking was a strong symbol of adulthood. In many cases, residents viewed smoking as the singular remaining vestige of their former life as competent independent adults. The individual right to choose was an important issue for both smokers and nonsmokers. Indeed, a majority of nonsmokers (53%) said smoking should not be prohibited in nursing homes. Nonsmokers and smokers alike recognized that for residents who smoke, being able to smoke when and where they liked was an important way to maintain and assert autonomy.
Nursing home staff also recognized smoking as a right for residents and as a factor contributing to quality of life. Staff and residents often referred to smoking as "the last remaining pleasure." Smoking was discussed as a mechanism for coping with stress, for combating boredom, and for facilitating social interaction and social activities (Barker, Mitteness & Wolf sen, 1994; Kochersberger & CIipp, 1996). Obtaining a supply of cigarettes often occupied a substantial portion of a smoker's day, providing a much-valued sense of purpose. Getting a pack of cigarettes as a prize in games such as bingo was an incentive to participation and interaction for smokers and nonsmokers alike - smokers because they then smoked the cigarettes, nonsmokers because they could trade the pack of cigarettes for candy or other items or for services, such as help with letter writing or making telephone calls. Smokers could not imagine any other activity that could substitute for smoking.
Thus, smoking in long-term care cannot be banned without serious, potentially negative, consequences. Smoking or the exchange of smoking paraphernalia is central to social interaction for both smokers and nonsmokers alike.
HEALTH BELIEFS AND SMOKING BEHAVIOR
Various health belief models exist. Among the most influential are the Health Belief Model (Becker, 1974), the Transtheoretic Model (Prochaska & DiClemente, 1983), and the Theory of Reasoned Action (Ajzen & Fishbein, 1980). All are frameworks for explaining and predicting why individuals do or do not engage in specific health behaviors. These models define perceptual dimensions central to changing behavior, such as perceived severity of the health problem, perceived susceptibility to the consequences of the problem, and perceived benefits and barriers to changing behavior.
Although the anti-smoking movement has successfully raised the consciousness of the general public about the health hazards of smoking, this study indicates that elderly residents of nursing homes do not yet hold strong anti-smoking views. Elderly residents in longterm care hold views similar to community-dwelling older smokers. They do not perceive smoking to be a serious threat to health and do not link smoking to many known health consequences (Barker & Kramer, 1998; Connolly, 2000).
Smoking is addictive, and perceived severity and perceived susceptibility contribute to whether or not a person is able to quit smoking. Though the relationship is not causal, greater perception of risk is associated with lower smoking rates (Viscusi, 1992). In part, perceptions are based on knowledge. The proportion of "don't know" responses in this study suggests that an educational intervention for both elderly smokers and nonsmokers might positively influence perceptions of smoking's harm and lead to reductions in smoking prevalence. It is important, too, to recognize that smoking by residents poses a health risk not just to the individual who smokes but also to other residents and caregiving staff.
Regardless of how much or how long one has smoked, and regardless of age, evidence indicates that stopping smoking benefits health in both the short- and long-term (Connolly, 2000; IOM, 1990). Quitting has an immediate benefit on pulmonary and cardiovascular functioning, with the ex-smoker's risk of coronary heart disease being approximately the same as a nonsmoker at 12 months after cessation. Among long-term benefits are a slowed progression of chronic obstructive pulmonary disease, an increase in life span, and a decreased risk of cancer. Smokers associate adverse effects with quitting (e.g., weight gain, irritability, self-perceived decrease in ability to concentrate). The benefits of quitting outweigh these drawbacks.
Individuals entering a long-term care institution should be assessed for smoking status, and an appropriate care plan should be devised. Smokers who have recently become abstinent, because of a prior stay in a nonsmoking acute care hospital, for example, should be assisted in remaining abstinent. Smokers expressing a desire to quit should be assisted to achieve this goal. On-síte supportive behavioral therapies along with supervised use of nicotine patches or gum should be available. Those who wish to remain smoking should be permitted to do so and their autonomy respected. However, they should also be given information that allows them to make an educated assessment of risk and benefit. At regular intervals, approximately every 6 or 12 months and after every significant change in health status, smokers' decisions about continuing to smoke should again be discussed with them in a nonharassing fashion (Clark, Rakowski, Kviz & Hogan, 1997; Connolly, 2000).
Several major recommendations emerge from these data. A most important recommendation is for long-term care institutions to devise and implement effective smoking cessation programs for elderly residents. Moreover, these programs must take into account the full range of desires and wishes of smoking residents, and balance the desire of residents to improve health with maintaining and enhancing their autonomy and quality of life. They must also find substitute means acceptable to elderly residents for stimulating and sustaining social interaction. Smoking cessation interventions for elderly nursing home residents should also:
* Emphasize the full range and extent of health hazards associated with cigarette smoke.
* Emphasize the health benefits of smoking cessation.
* Devise and provide creative alternative strategies and activities for addressing the residents' needs for management of stress, maintenance of autonomy, alleviation of boredom, and enhancement of social interaction.
* Heighten awareness of the dangers associated with secondary smoke, for both residents and staff.
* Improve compliance with institutional rules about smoking in a nonpunitive fashion.
Gerontological nurses are exceptionally well placed to understand patients' decisions about smoking and to implement appropriate smoking cessation programs. Not only do nurses have a broad sensitivity to the entire range of psychosocial issues facing older adults who are deciding to continue or to quit smoking, but they possess relevant biomedical knowledge that can help individuals make informed decisions.
With respect to older patients who smoke, nurses must be inquisitive, informative, inclusive, and responsive. Gerontological nurses are skilled at inquiring into the meaning and importance of smoking to an older adult in terms of autonomy, independence, pleasure, and continuity with the past. Nurses are adept at educating patients about both short- and longterm deleterious impacts of smoking, and of the benefits of quitting.
Nurses should readily incorporate family, friends, other residents, and staff into supporting an elderly individual's quitting attempts. Nurses should help older adults engage in acceptable alternate activities. Most important, nurses may develop long and comfortable relationships with patients based on mutual trust and rapport. In this context of wellestablished relationships, nurses not only monitor changes in the elder's health status, but also respond by revisiting the patient's decision to continue smoking in view of new circumstances. Ultimately, nurses advocate for their patients and their patients' decisions.
When evaluating and setting smoking policy, long-term care administrators need to be wary of producing rules so restrictive that they abrogate smokers' civil rights and undermine their moral status as adults (Barker & Lewis, 1998; Barker, Mitteness & Wolf sen, 1994; Kochersberger & Clipp, 1996). Allowing smoking in designated areas is a minimally coercive policy that effectively restricts the smoke exposure of nonsmokers while respecting and preserving the autonomy of the smoker who does not choose to quit.
Health promotion activities are often underrated in long-term care settings. When undertaken, sickness prevention efforts are often geared to more dramatic or visible issues, such as preventing falls or reducing injury. Smoking cessation, however, also offers benefits and should become a focus for health promotion in the nursing home setting. Managing addiction to nicotine, educating about health consequences, and providing effective substitutes for stress management, could all provide short- and longterm cost-effective benefits for residents and staff alike.
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ELDERLY RESIDENTS' BELIEFS ABOUT SMOKING AND ITS DELETERIOUS EFFECT ON HEALTH