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State Variations of Chronic Disease Risk Factors in Older Americans

December 28, 2012

State Variations of Chronic Disease Risk Factors in Older Americans

Source: Preventing Chronic Disease


The objective of this study was to examine and compare 3 key health behaviors associated with chronic disease (ie, risky drinking, smoking, and sedentary lifestyle). We used data from the National Health Interview Survey from 1997 through 2010 to calculate the prevalence of these behaviors among older Americans and rank each state, and we analyzed overall trends in prevalence for each behavior over the 14 years. Older adults residing in Arkansas and Montana had the worst chronic disease risk profile compared with other states. These findings indicate the need for improved or increased targeted interventions in these states.


Risky drinking, smoking, and sedentary lifestyle are key health behaviors associated with chronic disease and increased illness and death in older adults (1). Excessive drinking is associated with cancers of the liver, head and neck, colorectum, pancreas, and breast, as well as cardiovascular disease and diabetes (2). Smoking is associated with cancer and poor cardiovascular outcomes (1). Cardiovascular disease and cancer risk are increased by sedentary behavior (1). The objective of this study was to examine the prevalence and trends of these 3 health behaviors among older Americans and rank them at the state level to determine the best allocation of public health resources.


Data were obtained from the National Health Interview Survey (NHIS), an annual, cross-sectional, multistage probability household survey of the noninstitutionalized civilian US population, from 1997 through 2010. Eligibility criteria were adults aged 65 or older (N = 79,973; representing 34,632,575 people). NHIS questions regarding the 3 variables are available online (3). Smoker was defined as “current smoker” (4). Risky drinking was defined as current drinkers having 10 or more drinks per week in men and 7 or more drinks per week in women, or having 5 or more drinks on 1 occasion, 1 or more times per year for men and women (4). Physical activity level was defined as compliance with the Healthy People 2010 goal of moderate physical activity for at least 30 minutes per day on 5 or more days per week or vigorous physical activity for at least 20 minutes per day on 3 or more days per week (5).

NHIS data were pooled and analyses were conducted using SAS version 9.2 (SAS Institute Inc, Cary, North Carolina), adjusting for sample weights and design effects (3). We calculated prevalence, standard errors (SEs), and 95% confidence intervals (CIs) and ranked states according to the prevalence of each risk factor indicator. We analyzed trends by using weighted linear regression of prevalence on year. Weight was generated with the inverse of the variance of prevalence. Some states were missing values because they did not meet the criteria for stable estimate analysis in all study years (6).

Because state-level data are not released to the public, all analyses were performed remotely at the National Center for Health Statistics Research Data Center. The study was approved by the University of Miami’s institutional review board.


The prevalence of smoking among US adults aged 65 years or older was 9.6% (Table 1). States with the highest smoking prevalence were Nevada (17.9%) and Kentucky (15.0%). States with the lowest rates of smoking were Utah (5.4%) and South Dakota (6.2%). Overall, 22% of older Americans reported risky drinking patterns; Arizona and New Hampshire had the highest prevalence, both at 29.0%, and the lowest prevalences were found in Kansas (14.4%) and Oklahoma (16.4%) (Table 2). Twenty-two percent of older Americans reported meeting physical activity recommendations; the highest prevalence was reported in Colorado (30.8%), Hawaii (34.8%), and Maine (40.1%), and the lowest prevalence was reported in Louisiana (13.4%), Mississippi (13.4%), and South Dakota (14.6%) (Table 3). Older Americans residing in Arkansas and Montana were in the top 10 worst rankings for all 3 behaviors.

A downward trend in smoking was observed during the 14 years for California (slope, −0.32; SE, 0.09; P = .004) and South Carolina (slope, −0.54; SE, 0.21; P = .046), and an increased trend for risky drinking was observed in Massachusetts (slope, 1.07; SE, 0.39; P = .026). In North Carolina (slope, 0.82; SE, 0.25; P = .007) and Texas (slope, 0.57; SE, 0.16; P = .004), an upward trend in exercise compliance was observed. Trend analysis was not conducted for 7 states and the District of Columbia due to insufficient sample sizes.


The average age of Americans is expected to increase substantially in the coming years (7). Modifying key health behaviors and creating cost-effective interventions may contribute to decreasing illness and death in this growing population demographic (8).

Lifestyle changes that occur with aging can affect chronic disease risk. Older adults who exercise regularly have a reduced mortality risk (9), but those who drink alcohol excessively are more prone to oxidative stress, which further increases the incidence of chronic disease (10). A twofold higher mortality rate was shown for older male smokers than nonsmokers (11). Risky drinking with aging has been positively associated with vigorous physical activity and negatively associated with current smoking, possibly reflecting better health among adults who engage in risky drinking as they age (12). Nevertheless, excessive alcohol consumption is associated with risk of falls (1) and adverse medication interactions in older Americans (10).

Limitations of this study included an inability to use estimates from all states due to small sample sizes or unstable estimates in some states (ie, a relative SE of ≥30%). We were unable to conduct complete trend analyses for all states given sample size limitations. The strength of this study was the access to a large set of sample data at the state level for prevalence comparisons in older Americans.

Public health resources should focus on specific interventions to affect behaviors in states with residents at high risk for developing chronic disease. These resources can include a purposeful combination of the following: 1) increasing tobacco excise taxes, proven to be the most effective means to decrease smoking (1), 2) using online and telephone substance abuse treatment facility locators and media campaigns to disseminate information on alcohol abuse (1), and 3) enhancing access to recreational and physical activity facilities in communities specific to older Americans, pursuant to the Healthy People 2010 guidelines (5). Emphasis on geographic aggregation of risk factors should be considered so that integrated and tailored prevention activities can be developed and customized to each state’s profile and funds be made appropriately available. States with the highest prevalence of 2 or 3 risky behaviors should review resource allocation to promote health more effectively.

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