3.22 Poorer quality of life and loss of function

Last updated: April 2015
Suggested citation: Bellew, B, Greenhalgh, EM & Winstanley, MH. 3.22 Poorer quality of life and loss of function. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2015. 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, and the Quality of Well-Being Scale.1 The SF-36 is the measure most commonly used in the HRQOL studies cited in this chapter.

There is compelling evidence linking active smokingi and poor HRQOL; this has been demonstrated in large longitudinal studies conducted in North America,3,4 Spain5 and Finland6; in cross-sectional studies conducted in Croatia,7 Finland8 and North America9; in a large study of Medicare beneficiaries in North America10 and in a British study conducted among female patients with atherosclerosis.11

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.12 Researchers use various tools to measure these capacities, such as the Katz or Barthel scales for ADL13 and the Lawton IADL scale.14

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 risk of impaired ADL among current smokers compared with non-smokers (OR 2.11; 95% CI, 1.09–4.06). Risk 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.15 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.16 Impairment in instrumental activities of daily living (IADL) was associated with smoking in a Japanese longitudinal study involving more than 1200 elderly people 17 and a North American cross-sectional study involving more than 9500 subjects.18 There is also evidence that women with COPD are more than twice as likely to have impaired ADL (OR 2.63; 95% CI, 1.15–5.99), and more than four times as likely to have impaired IADL (OR 4.23; 95% CI, 1.92–9.29).19

3.22.3 Smoking, low bone density and hip fracture

A causal relationship exists between smoking, low bone density and hip fractures.20 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.21 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 fracture22, 23 and independence in many of the normal activities of daily living is compromised.24 (See Chapter 3, Section 3.13 for more detailed discussion of musculoskeletal disease.)

3.22.4 Diminished general health, accelerated ageing, disturbed sleep

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 confounders25 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.20

Smoking modifies leukocyte telomere length (TL – or DNA sequencing), which is thought to accelerate biological ageing as well as development of smoking-induced chronic diseases.26 A range of recent studies support the contention that smoking is associated with accelerated biological ageing.27-31 There is evidence that tobacco smoking is a contributing factor in a wide range of skin diseases,32, 33 and that it is a cause of premature skin ageing34, 35 with estimates of almost four times the amount of facial wrinkling in 'heavy' smokers (>40 packs per year) compared with non-smokers.36 (This issue is discussed in more detail in Chapter 3, Section 3.14.1.)

A large cross-sectional study conducted in North America found that tobacco use and exposure to secondhand smoke were associated with increased odds of earlier age at menopause.37

Cigarette 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.38-40 There is also emerging evidence of an association with obstructive sleep apnoea.41 Recent evidence from a very large cross-sectional study conducted in North America indicates an association between smokeless tobacco use, secondhand smoke exposure and insufficient rest/sleep. Current users of smokeless tobacco were more than 70% (OR 1.74; 95% CI, 1.37–2.22) more likely to report insufficient rest/sleep compared to never smokeless tobacco users. For those who were both current smokers and current smokeless tobacco users there was more than a doubling of this risk (OR 2.21; 95% CI, 1.66–2.94). Those with secondhand smoke exposure had an estimated 29% increased risk for insufficient rest/sleep than those without (OR 1.29; 95% CI, 1.02–1.63).42

3.22.5 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.20, 43 (See Chapter 3, Section 3.23).

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 prospective studies.44 Smokers are also more likely to report pain during health examinations.45


Other studies show that smoking is associated with hearing impairment,46-51 (also see Chapter 3, Section 3.25) and poorer sense of taste52-55 and smell.56, 57 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.58

Many other impacts associated with exposure to tobacco smoke have clear implications for HRQOL even if specific confirmatory research to quantify the impairment with precision may not yet be available. For example, dental diseases59 are described in Chapter 3, Section 3.11, Gastro-intestinal diseases in Section 3.12, and the impact of smoking on treatment of disease60, 61 in Section 3.15.

3.22.6 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.62-64 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.65, 20 Level of consumption also plays a role, with heavier smokers having more absences than lighter smokers.25 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.65 These effects are evident in younger smokers, before the effects of major tobacco-caused disease become apparent during middle age and later years.20 There is also evidence that smokers are more likely to suffer injury in the workplace than non-smokers.20

Australian data show that men who smoke are 66% more likely to be absent from work than male never smokers, and that female smokers are 23% more likely to miss work than female never smokers.66 This in turn has a major quantifiable economic impact on the nation's productivity.67 (Also see Chapter 17, Section

Relevant news and research

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A recent cross-sectional study of 2500 never smokers in Switzerland found that exposure to secondhand smoke was also 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.


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