3.22 Poorer quality of life and loss of function

Last updated: June 2020
Suggested citation: Purcell, K, Bellew, B, Greenhalgh, EM & Winstanley, MH. 3.22 Poorer quality of life and loss of function. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors].  Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2020. Available from  http://www.tobaccoinaustralia.org.au/chapter-3-health-effects/3-22-poorer-quality-of-life


This section is about impacts on health-related quality of life (HRQOL), activities of daily living (ADL) and general health caused by smoking. The discussion here goes beyond the burden of morbidity and mortality from specific diseases that are comprehensively described in other sections. The evidence presented here confirms that exposure to tobacco smoke should be considered an important contributing factor to wide-ranging non-specific morbidity and a diminished quality of life.

3.22.1 Poorer health-related quality of life

The concept of health-related quality of life (HRQOL) and its determinants have evolved since the 1980s to encompass those aspects of overall quality of life that can be clearly shown to affect health—either physical or mental. Several instruments have been used to assess HRQOL and related concepts of functional status. Among them are the Medical Outcomes Study Short Forms (SF-12 and SF-36), the Sickness Impact Profile, the Quality of Well-Being Scale and the European Quality of Life-5 dimensions scale (EQ-5D) The SF-36 and the EQ-5D are the measures commonly used in the HRQOL studies cited in this Section.

There is compelling evidence linking active smoking and poor HRQOL; this has been demonstrated in large longitudinal studies conducted in North America,1 2 Spain3 and Finland4; in cross-sectional studies conducted in Croatia,5 Finland6 and North America;7 in a large study of Medicare beneficiaries in North America8 and in a British study conducted among female patients with atherosclerosis.9

A 2014 systematic review of 54 studies concluded that smoking is negatively associated with quality of life with a dose–dependent relationship between differences in QOL scores and the number of cigarettes smoked.10 A 2019 study in Brazil of older adults found that current smokers had lower scores than never smokers for social participation and intimacy. Smokers with high or very high dependence reported higher levels of fear and concern about death and pain before death than those with low or very low dependence.11 A 2019 cross-sectional study from Iran with 2197 participants found significant differences in the HRQOL (as measured by the SF-36) between males who smoked and those who did not. Male smokers had a lower physical functioning, lower mental health, and a lower overall health related quality of life score compared with non-smokers.12 A 2019 cross-sectional study from the US found that among lower-income African Americans, smokers attempting to quit had a lower HRQOL than current smokers.13 A 2017 study from Spain found that smoking had an independent negative effect on HRQOL, although smoking related diseases, such as lung cancer, were associated with a reduction in HRQOL about 5 times greater than the difference between current smokers and never smokers.14 Among young adults, smokers also had a lower HRQOL than never smokers.15

Smoking cessation is associated with improved HRQOL,11, 10 and longer abstinence is associated with higher scores for psychological health.11, 15 A 2015 longitudinal population cohort study of young adults found that smokers who quit and remained abstinent for 5 years had higher physical measures of HRQOL compared with current smokers.15

A 2016 study analysing data from the US National Health and Nutrition Examination Survey found a dose-response effect of smoking status on quality-adjusted life years (QALY) for adults aged 65 years and over. Never, former and current smokers had a mean QALY of 16.1, 12.7 and 7.3 years, respectively. Current smokers who commenced smoking as a child (before age 18) had fewer QALYs than those who started later, and heavier smokers had fewer QALYs than those smoking <20 cigarettes per day. The potential health gain associated with cessation in this older age group is 5.4 QALYs, and the gains would increase with a longer abstinence and quitting at a younger age.16

Smokers who quit and then relapse appear to be particularly vulnerable to lower HRQOL.15, 17 Among young adults, smokers who relapsed after a quit attempt had poorer HRQOL scores than current smokers and were 39 % more likely to have a clinically significant reduction of physical HRQOL than those who remained abstinent. Smokers who maintained their cessation were 43% more likely than continuing smokers to have a clinically significant improvement in physical HRQOL and no worsening of mental HRQOL.15 A 2018 UK study17 and a Spanish study18 found that among smokers who quit, those who relapse have poorer HRQOL and that this deterioration is associated with increased symptoms of anxiety and depression. Higher nicotine dependence and longer duration of smoking were related to worse HRQOL.18

Engaging in regular physical activity while trying to quit smoking may have benefits for quitters. Smokers who successfully quit smoking and are physically active have an improved HRQOL approaching that of non-smokers.19

Secondhand smoke also appears to be negatively associated with quality of life.10 20 A cross-sectional study of 2,500 never smokers in Switzerland found that exposure to secondhand smoke was associated with reduced HRQOL, more significantly so in women. Exposure to secondhand smoke at home and high levels of exposure were associated with lower SF-36 scores, suggesting a dose–response relationship.20

3.22.2 Impaired activities of daily living (ADL) and instrumental ADL

‘Activities of daily living’ (ADL) are those skills needed in typical daily self-care, while ‘Instrumental activities of daily living’ (IADL) refer to skills beyond basic self-care that evaluate how individuals function within their homes, workplaces and social environments. IADL may include typical domestic tasks such as driving, cleaning, cooking and shopping, as well as other less physically demanding tasks such as operating electronic appliances and handling budgets.21 Researchers use various tools to measure these capacities, such as the Katz or Barthel scales for ADL22 and the Lawton IADL scale.23

A longitudinal study conducted in Japan examined the relationship between smoking in middle age and long-term risk of impaired activities of daily living (ADL) in more than 2000 men and women. The researchers reported more than double the odds of impaired ADL among current smokers compared with non-smokers. The odds of impaired ADL was higher as the number of cigarettes increased. The study concluded that smoking in middle age increases future risks of impaired ADL and that smoking cessation may be important to prevent future impairment of ADL.24 Another, similar longitudinal study was conducted in North America involving more than 10,000 middle-aged people; the study found that smoking was significantly associated with deterioration in ADL status.25 Impairment in instrumental activities of daily living (IADL) was associated with smoking in a Japanese longitudinal study involving more than 1200 elderly people26 and a North American cross-sectional study involving more than 9500 subjects.27 There is also evidence that women with COPD are more than twice as likely to have impaired ADL, and more than four times as likely to have impaired IADL.28

A 2018 meta-analysis of 18 prospective cohort studies found smokers had a greater risk of physical impairment compared with never smokers. Men had a higher risk of physical impairment than women although this may be associated with higher smoking prevalence among men.29 A 2016 Swedish study of older adults found that heavy smokers had greater mobility impairment as they aged compared with non-smokers.30 A 2018 study of 9,704 women aged 64 years and over at baseline found that current smokers had worse walking speed, poorer self-reported health, more difficulty with IADLs, and increased depression at 10 years compared with never smokers. Smokers also had higher death rates at 10 and 20 years of follow-up compared with never smokers.31

A 2017 English longitudinal study of 2,542 community-dwelling older people aged 60 years and over found that current smokers were significantly more likely to develop frailty over four years compared with non-smokers.32 Frailty is a geriatric condition associated with a decline of physical and cognitive reserves that leads to increased vulnerability to poor health outcomes with exposure to a stressor. These poorer outcomes include falls, fractures, disability, hospitalisation and institutionalisation.32

3.22.3 Smoking, low bone density and hip fracture

A causal relationship exists between smoking, low bone density and hip fractures.33 The causal relationship with low bone density was previously established for older women only; however there is now systematic review evidence that smoking is a risk factor for low bone mineral density/bone loss among men over 50 years of age as well.34 These findings linking smoking to the risk of low bone density and hip fracture are important; it is well established that there is a pronounced and long-term reduction in HRQOL as a result of hip fracture35, 36 and independence in many of the normal activities of daily living is compromised37 (see Chapter 3, Section 3.13 for more detailed discussion of musculoskeletal disease).

3.22.4 Diminished general health and accelerated ageing

There is established scientific evidence of a causal relationship between smoking and diminished health status, and this evidence is consistent across studies and indicators. Smokers of different ages, genders, and locations experience poorer physical and mental health compared with people who have never smoked. Manifestations of this diminished overall health include smokers’ increased absenteeism at work, self-reported poorer health, and higher health care costs and utilisation, and these relationships remain after controlling for a broad range of potential confounders.38 This more general decrement in health may be the result of altered inflammatory/immune processes, oxidative stress and sub-clinical organ injury. However, there are many direct and indirect mechanisms that link smoking to poorer health.33

There is evidence that tobacco smoking is a contributing factor in a wide range of skin diseases.39, 40 Smoking is also a cause of premature skin ageing41, 42 with estimates of almost four times the amount of facial wrinkling in 'heavy' smokers (>40 packs per year) compared with non-smokers.43 (This issue is discussed in more detail in Chapter 3, Section 3.14.1.)

A range of studies support the contention that smoking is associated with accelerated biological ageing.44-48 A 2018 systematic review and meta-analysis of 28 longitudinal studies on healthy ageing found that smoking is negatively associated with healthy ageing.49 Higher cigarette consumption was associated with accelerated biological aging, with strong effects present even at low levels of exposure.50

Smoking modifies leukocyte telomeres, the structures at the end of a chromosome that protect the DNA from damage. These modifications are thought to accelerate biological ageing as well as development of smoking-induced chronic diseases.51 A 2017 systematic review of 84 studies and a meta-analysis of 30 studies found that telomere length was shorter among ever smokers compared to never smokers. Current smokers had shorter telomere length compared with former smokers. There was a dose–response inverse relationship between pack-years of smoking and telomere length.52

A large cross-sectional study conducted in North America found that both smoking and exposure to second-hand smoke were associated with increased odds of earlier age at menopause.53

3.22.5 Smoking and disturbed sleep

Smoking is associated with sleep disorders in the general population; smokers are also more likely to experience sleep disturbances, including taking longer to fall asleep, being less likely to stay asleep, and having less total sleep time than non-smokers.54-56

A 2019 population study from Indonesia found that current smokers were almost one-and-one-half times more likely to report sleep disturbance compared with non-smokers, while heavy smokers were almost twice as likely to report sleep disturbance.57 A 2017 study found that poorer sleep duration was associated with a higher tobacco consumption, higher nicotine dependence and increased risk of finding it difficult to abstain from smoking for one day.58 A 2019 population study of 27,300 participants from China found that poor sleep was inversely associated with number of cigarettes per day and positively associated with the number of years smoking, the number of quit attempts, and intensity of smoking cravings.59 Sleep recording data suggests reduced sleep continuity (increased wake time after sleep onset) is higher among smokers compared with non-smokers.60

A 2016 US study of 85,138 college students found that daily tobacco use was associated with more sleep problems than other behaviours including binge drinking, illegal drug use, obesity, gender, and working more than 20 hours/week.61 Tobacco use and depression/anxiety disorders are both independently associated with greater sleep problems in college students. Students with depression and/or anxiety who also smoked had the highest reports of sleep disturbance.61

Evidence from a very large cross-sectional study conducted in North America indicates an association between smokeless tobacco use, second-hand smoke exposure and insufficient rest/sleep. Current users of smokeless tobacco were 70% more likely to report insufficient rest/sleep compared to those who have never used smokeless tobacco. For dual users of cigarettes and smokeless tobacco there was more than a doubling of these odds. Those with second hand smoke exposure had an estimated 29% increased odds for insufficient rest/sleep than those without this exposure.62 A 2017 cross-sectional study found that active smoking and exposure to high levels of second- hand smoke are associated with sleep disturbance.63

Regular physical activity may be beneficial for smokers with sleep problems. Smokers who reported increasing their daily physical activity every day, also reported improved sleep quality over 12 weeks.64

Smoking is also associated with a higher risk of insomnia.65, 66 A 2014 longitudinal study examined the association between smoking and insomnia from adolescence to adulthood. The study found an increased odds of insomnia for those who commenced smoking cigarettes around 15 years of age and continued smoking into adulthood.65 A large population survey from Taiwan in 2017 found that inactive adults and ever smokers had an increased risk of developing insomnia. The highest risk of insomnia was found among ever-smokers who were inactive.66 A 2018 US study found that increasing use of alcohol, cigarette, and marijuana was associated with an increased likelihood of having insomnia as compared to the no or low use of all three substances group.67

As multiple dimensions of sleep appear to be affected by smoking, it is likely that several sleep pathways may be impacted by smoking.59 There may also be a genetic component linking smoking and sleep behaviours (e.g. sleep duration, chronotype (preferring mornings or evenings) and insomnia). Heavier smoking may influence circadian rhythm (decreasing the odds of being a morning person).68

The relationships between smoking and sleep-disordered breathing (SDB) and smoking and chronic obstructive sleep apnoea (OSA) are complex. A 2019 cross—sectional cohort study of US Hispanic/Latino subjects found no statistically significant association between smoking and sleep disordered breathing (SDB).69 However, further analysis by age and sex found there was a statistically significant association between smoking and SDB in younger (35–54 years old) female smokers who had an increased odds of SDB almost 83% higher than young female never smokers. There was a dose response relationship in this group and younger female smokers who smoked 10 or more cigarettes a day had almost three times the odds of developing SDB compared with never smokers.69

Evidence regarding the association between cigarette smoking and obstructive sleep apnoea (OSA) disease is mixed. A 2015 study of 964 patients with OSA found that smokers with OSA were diagnosed at a younger age and had more severe disease than former and never smokers. Desaturation time during sleep was also higher among former smokers compared with never smokers.70 A 2019 retrospective analysis of 5,353 patients suspected of having OSA found smoking was associated with greater severity of OSA and a higher daytime sleepiness.71 However, a meta-analysis of 14 studies in 2018 found there was insufficient evidence to identify whether there was an association between OSA and with tobacco.72 A 2019 retrospective review of patient records did not find any significant association between cigarette smoking and OSA after adjusting for age, sex, and BMI.73 

3.22.6 Other impairments

In the elderly, smoking is associated with accelerated declines in physical function, and increased levels of clinical illness and physical and cognitive impairment.33, 74 (See Chapter 3, Section 3.23).

A small cross-sectional study of chronic pancreatitis patients found that smoking is independently associated with worse quality of life and higher rates of opioid addiction and depression for patients.75

Recent research into the association between back pain and other types of chronic pain and smoking has indicated the possibility of a causal link; this finding is supported by recent studies.76 Smokers are more likely to report pain during health examinations.77 A large cross-sectional study from the US in 2016 found that current smokers had an increased risk of headaches compared with never smokers, with increased odds of headache associated with higher daily consumption and duration of smoking in pack-years.78 A 2017 retrospective study of 239 surgical patients treated by a Transitional Pain Service found that smoking is associated with greater pain intensity one month after surgery and a slower reduction in opioid use three months after surgery.79 A 2019 US study of 363 Latino patients found current pain intensity was significantly related to greater cigarette dependence, perceived barriers for quitting, and negative experiences of past quit attempts.80 A small cross-sectional study in 2018 also reported that greater pain was significantly associated with greater cigarette dependence, greater perceived barriers to cessation, and greater cessation-related problems among female, but not male, smokers.81 A 2018 prospective cohort study in the UK found that smokers had a higher risk of chronic widespread pain in later life.82

A meta-analysis of 13 studies found that nicotine obtained through smoking or via other delivery systems (e.g., patch, nasal spray) delivered small to medium acute analgesic effects that could make smoking more rewarding for people with chronic pain and make it more difficult for them to quit successfully.83 A small 2018 study of 137 daily smokers found people deprived of nicotine (12–24 hour abstinence) were 3.5 times more likely to report pain at follow up after manipulation than continuing smokers. This suggests that smokers may experience greater pain in the early quitting phase (12-24 hours after quitting).84

Smoking is associated with hearing impairment.85-90 Studies from Japan91 and Turkey92 found smoking is associated with increased risk of hearing loss, especially at the high frequency, in a dose–response manner. Smoking cessation reduces the excess risk of hearing loss.91 Female smokers may demonstrate hearing loss at lower levels of exposure.92 (also see Chapter 3, Section 3.25)

Smoking is also associated with a poorer sense of taste93-96 and smell.97, 98 A small experimental design study of 131 participants found smokers demonstrated significantly lower taste sensitivity than non-smokers. Higher nicotine dependence was associated with lower taste sensitivity.99 Cessation is beneficial and results in a rapid recovery of taste sensitivity among smokers. Recovery time varies based on the location on the tongue, with some recovery on the tip of the tongue occurring after 2 weeks of abstinence while other locations around the tongue improved after 8 weeks or more.99 Use of chewing tobacco is also associated with reduced perception of salty tastes compared with non-tobacco chewers.100

Smoking increases the risk of both cataract and age-related macular degeneration (AMD), responsible for a large burden of vision impairment and blindness (also see Chapter 3, Section 3.10), which impose substantial costs on the Australian community.

Many other impacts associated with exposure to tobacco smoke have clear implications for HRQOL. For example, dental diseases are described in Chapter 3, Section 3.11, Gastro-intestinal diseases in Section 3.12, and the impact of smoking on treatment of disease101, 102 in Section 3.15.

3.22.7 Smoking and absence from work due to illness

Smoking is associated with the amount and duration of sick leave and degree of productivity loss at work.103-105 Smokers are more likely to miss work due to ill-health, have longer duration of absence from work, and access all levels of medical care more frequently.33, 106 Level of consumption also plays a role, with heavier smokers having more absences than lighter smokers.38 Work absences are reportedly higher in smokers resulting from a broad range of symptoms, including problems with the digestive tract, neck, back and upper limbs.106 These effects are evident in younger smokers, before the effects of major tobacco-caused disease become apparent during middle age and later years.33 There is also evidence that smokers are more likely to suffer injury in the workplace than non-smokers.33

A 2019 study on the social costs of smoking in Australia put the cost of absenteeism due to smoking at just over $4.2b107 (see Section 17.2.5).

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated January 2021)


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