Ignoring our elders: tobacco control’s forgotten health equity issue

Abstract

Over the past decades, demand-side tobacco control efforts in many countries have focused primarily on younger populations, including prevention of initiation in youth and young adults, and encouraging quitting among those in their 20s, 30s and 40s.1 This focus has been explained primarily based on limited resources and long-term efficiency: it is more cost-effective over many decades to prevent initiation or get someone to quit young than it is to get older people who have smoked a long time to quit.2 But there has been almost no examination of this paradigm and its effects from a health equity perspective. In the US private health insurance sector, smoking status is among few factors besides age that health insurers are legally allowed to use to charge a higher premium amount.3 Because premiums for older people are already as much as three times higher than those for younger individuals, the discriminatory effect of this policy is a greater burden for older smokers. Clinicians are also less likely to refer older individuals for cessation support or to prescribe cessation medications.4 Public health agencies likewise expend little effort specifically to motivate and help older tobacco users, compared with outreach and specially designed programmes for younger people who are members of priority populations suffering from health disparities. Yet older smokers as a group have grave intersectional disadvantages: they are poorer, less educated, have higher rates of mental illness, are more likely to be non-White, disabled and have multiple chronic conditions than younger smokers.5 6 The lack of attention has consequences: in the USA, smoking prevalence in those 65 and older did not decrease from 2000 to 2015.7 This lack of progress is likely due to an actual decrease in quit attempts and successes in older smokers, while among those under …

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