Bridget K. Gorman, PhD, Assistant Professor, Department of Sociology, Rice University, Houston, TX, USA.
Jen’nan Ghazal Read, PhD, Assistant Professor, Department of Sociology and Center for Health Policy Research, University of California, Irvine, CA, USA.

Men have shorter life expectancies than women in most nations around the world. The gender gap in mortality is particularly striking in high-income industrialized nations such as the United States, where women were expected to live 5.3 years longer than men in 2003 (80.1 years compared to 74.8 years). However, in recent decades this gap has been steadily shrinking in many nations. This review examines the mortality gap, primarily in the U.S. context, by providing an overview of the gender pattern in mortality, an explanation of its existence, and an assessment of how and why it has changed over time.
Key words: mortality, life expectancy, gender, smoking, cigarettes.

D'Arcy Little, MD, CCFP, Lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; Director of Medical Education, York Community Services; 2002 Royal Canadian Legion Fellow in Care of Elderly at Baycrest Centre, Toronto, ON.

Prevalence of Smoking in the Elderly
Smoking is one of the major causes of morbidity and mortality in Canada. In fact, it has been called the leading preventable cause of death in North America.¹ This is because smoking is a known risk factor for four of the leading causes of death in the industrialized world--coronary heart disease, cancer, lung disease and stroke--and because it contributes to many other causes of morbidity.² While the current prevalence of smoking in Canadians aged 15 years and older declined by 10.3% between 1985 and 1999, the numbers remain high for both men and women (26.8% and 22.9%, respectively, in 1999).³ In those aged 65 and older, current smoking prevalence decreased by 8.9% over the same time period. However, it is estimated that 11.6% of seniors continue to smoke. The prevalence of smoking is highest in the Atlantic provinces and Quebec, and lowest in Saskatchewan and Ontario.⁴

Impact of Smoking on Health of the Elderly

Mortality
The health-related impact of smoking in the elderly is manifold. The increase in mortality has already been mentioned.

In the past year, the head of Cancer Care Ontario died, tragically of cigarette-induced lung cancer. I learned last week that a gifted and brilliant surgeon has been diagnosed with unresectable cigarette-induced lung cancer. He is a thoracic surgeon with an international reputation in the surgical management of lung cancer. When one knows the people involved, the lunacy of cigarette addiction becomes even more disturbing. A report this week that early cigarette smoking among teenage girls (the current growth market) doubles their risk of breast cancer reinforces my long-standing desire to grab cigarettes from children and destroy them (I have controlled these desires, and thus I am still free to walk the streets).

Older people also suffer from the pernicious effects of tobacco. They are part of a cohort that started smoking when society considered cigarettes an acceptable part of life, and their longer period of smoking means more complications. Many of the articles in this issue focus on the pulmonary effects of tobacco, but it must be remembered that the number of premature cardiac deaths attributed to tobacco is even greater than the number of pulmonary deaths.

Dr. D'Arcy Little, Medical Director of CME for Geriatrics & Aging, sets the stage for this issue with his article on tobacco use in the elderly. Drs. Michael Johnston and Yaron Shargall discuss current practices in the screening and treatment of lung cancer, while Dr. Robert Hyland reviews chronic obstructive lung disease and its management. Drs. John Granton and Moiz Zafar cover the issue of pulmonary hypertension, an entity for which new information and new treatments seem to hit the general medical journals every month. Smoking is, of course, an important factor in the pathogenesis of secondary pulmonary hypertension via its contribution to chronic lung disease. The article on the aging respiratory system by Drs. Don Sin and Benjamin Chiam helps us put the various diseases discussed in this month's issue into the proper context. We have even included a patient information section detailing The BreathWorks Program, courtesy of the Ontario Lung Association. We are grateful for their participation.

As well as our focus on lung diseases in the elderly, we have our usual collection of interesting topics. Dr. Gladstone continues his superb series on the neurological examination in aging, dementia and cerebrovascular disease with an article on cerebellar testing. This is particularly relevant as instability and falls are considered "geriatric giants". Dr. Fodor discusses hypertension in the elderly, and Dr. D'Arcy Little explores an unusual aspect of dementia, that of personhood and spirituality.

Enjoy this edition, and remember, don't smoke!

Barry Goldlist, MD, FRCPC, FACP

Cigarette smoking remains the leading cause of preventable morbidity and premature death in North America, despite the recent decline in the prevalence of smoking. Data from the United States reveals that in those over age 60, smoking is a major factor in 6 of the 14 leading causes of death, and a complicating factor in three others. The current cohort of elderly includes large numbers of women who never smoked so the overall prevalence of smoking in the elderly is lower than for the population as a whole. However, this gender difference in smoking is shrinking (or even disappearing in some age groups) and the middle-aged cohort of smokers (45 to 64 years of age), has the same proportion of smokers as the population as a whole. This suggests that over the next two decades, we will continue to see large amounts of smoking-associated morbidity among the elderly.

There is now compelling evidence that stopping smoking is a worthwhile endeavor even in old age. It was reported in the British Medical Journal as long ago as 1977, that stopping smoking in old age could slow the progression of chronic airflow obstruction. Loss of physiological reserve is one of the major causes of the common geriatric syndromes that result in functional impairment. It is therefore apparent that maintaining such reserves is frequently the difference between dependence and independence in old age. As well, duration of smoking is a key factor in the development of lung cancer, so it can be expected that stopping smoking, even among the elderly, will also reduce the incidence of lung cancer. There is now data that also shows similar beneficial effects of stopping smoking on complications of vascular disease.

Unfortunately, the perception remains that it is not worthwhile for the elderly to stop smoking, and even if it were, it could not be done. This is incorrect. Not only do the elderly benefit from stopping; the current evidence is that they are just as likely to stop as younger individuals (although specific data is limited).

What does this mean to the practicing physician? First, it is important to determine whether your elderly patients smoke or not. For all those who actively smoke, a formal smoking cessation program should be offered. Although these are successful in the elderly, most patients will prefer to try quitting smoking on their own, at least initially. Their doctor must be available to provide the appropriate counseling and support. It is a misconception that nicotine replacement therapy is unsafe in the elderly. As recently documented in the Ontario Medical Review, smoking is almost always riskier than nicotine replacement therapy.

In summary, there are relatively few interventions physicians can provide their elderly patients with that are as beneficial as helping them stop smoking. It is important that we offer our help in stopping smoking to all our patients, including the elderly.

For more information on smoking and the elderly, read "Nicotine Substitution Aids Smoking Cessation" in the March/April 1999 edition of Geriatrics & Aging, or on our Web site at www.geriatricsandaging.com. You can also read about the smoking behaviour of Canadians on the Health Canada Web site at: http://www.hc-sc.gc.ca/ main/lcdc/web/bc/nphs/.

Shechar Dworski, BSc

Lung cancer is the most common cause of cancer-related deaths in both men and women, accounting for 34% of cancer-related deaths in men, and 22% in women. Lung cancer survival rates are dismal: the five-year survival rate is 14% for all cases of lung cancer, and the median survival is less than half a year for untreated patients. The lung cancer mortality rate in the United States is approximately 50 in 100,000, 68% of which occur in people over 65 years of age. Lung cancer mortality in the elderly is rising, which may be due to the aging of the population. Between 1968 and 1983, there was an 8.2% annual growth in mortality in white women 54 to 74 years old. The mortality rates in males seemed to reach a plateau in the 1980's, or may even be declining, possibly due to a decrease in the cigarette smoking by men from 67% in the 1950's, to 28% presently in the United States.

Over one half of all cases of lung cancer are reported in people aged 65 and over. Men aged 65 years and over have an incidence of lung cancer three times higher than men age 45 to 64. This trend is thought to be related to increased lifetime exposure to tobacco smoke and other carcinogens. The rate of lung cancer has risen dramatically in the last 70 years, accounting for 18% of all cancer cases in men, and 12% in women.

Michelle Durkin, BSc

According to the Addiction Research Foundation tobacco use is still considered Canada's greatest public health concern even though the percentage of cigarette smokers is declining. Approximately 35,000 Canadians die prematurely each year due to smoking.¹ Despite the increased risk of heart disease, lung cancer, emphysema and other health problems, patients are reluctant to stop smoking and attempts to stop often fail. This is because of nicotine, a naturally occurring alkaloid. It can cause both a physical and psychological dependence that can be compared closely with addiction to substances such as heroin and cocaine.¹

Nicotine in the Body

Nicotine is rapidly absorbed into the body through the respiratory tree, buccal membranes, as well as percutaneously. Once in the body, it will mimic the effects of acetylcholine at nicotinic receptors (see Figure 1). These receptors are found at autonomic ganglionic synapses of the sympathetic and parasympathetic branches of the nervous system as well as neuromuscular junctions. Due to the wide distribution of these receptors in the body, nicotine can illicit a wide variety of effects and can act as a stimulant or a depressant.

Nicotine Substitution Therapy

Although the majority of smokers want to reduce or stop smoking, attempts to do so often fail.¹ It is the powerful addiction to nicotine that can make quitting so difficult.