Bethea (Annie) Kleykamp
Assistant Professor, University of Maryland School of Medicine, Psychiatry 
Director, Research and Evaluation, Maryland Addiction Consultation Service 

Biography

The question was simple: Do people still smoke cigarettes?

They asked because none of their friends or family smoked, they didn’t see people do it in public, and they hadn’t seen a cigarette butt since the 90s.

They also asked because they had heard alarming news stories about nicotine vaping alongside warnings from public health agencies, including a congressional testimonial from FDA leadership on the youth vaping “epidemic” and a 295-page Surgeon General’s report on e-cigarette use among young people (my thoughts on the low quality of the latter are published in Nicotine and Tobacco Research). 

Vaping was the new smoking, and youth were its victims, right? 

The epidemics and crises related to youth addiction don’t stop at tobacco. Just out in the New England Journal of Medicine is an article highlighting the “The Overdose Crisis among U.S. Adolescents.” Other headline stories on the state and national level add to growing concerns about opioid use among youth. 

The sense of responsibility to protect young people impacted by the harms of tobacco, fentanyl, and other drugs is compelling. But isn’t that what we have been doing and, by many measures, succeeding? 

Youth Progress and an Anecdote from the 90s 

Substance use, including opioid, alcohol, and tobacco use, has dropped significantly since peaking in the 1990s. Reductions in smoking prevalence have been most profound over the last ten years, with smoking at the lowest level ever recorded for youth in the United States. And despite early concerns regarding vaping, numbers have been declining among youth.

The statistics are much more sobering when we broaden the lens to include all age groups. More than one million people have died since 1999 from a drug overdose, and the age-adjusted rate of overdose deaths increased by 14% from 2020 to 2021. 

This mix of statistics has made me wonder how much of the emotional urgency to protect youth from drugs is missing the totality of people impacted by substance use – and how these people are often forgotten because of race, ethnicity, income, and older age. My own experience growing up in a small, economically depressed town in Eastern Kentucky sheds light on these overdose patterns.

The county where I call home later took center stage as opioid overdoses took over America. But when I was there as a high schooler in the mid-90s, tobacco dominated, as it still does throughout Kentucky and across the river in West Virginia, where more people smoke than any other state.

I started smoking as a teenager. I shared packs of Marlboro ultralights with my friends as we drove along the edge of the Ohio River with windows down and Beastie Boys up. We also did other risky things like drink alcohol, ride bikes without helmets, and pile in the back of pickup trucks to get around town. And those are just the options I feel comfortable sharing in an ASAM weekly. We were young and made risky, sometimes really bad, decisions like many people do as they figure out their place in the world. 

When I left Kentucky in 1997 for college on the East Coast, I spent my long drives to and from my hometown with cigarettes and cheap gas station coffee as my trusted companions. But eventually, smoking lost its luster. But that was not true for many of my friends and family, including my father. I wrote my Dad's obituary nearly 10 years ago after his unexpected death at age 63 – a daily smoker and a family medicine doctor in recovery from his own opioid and alcohol addictions.

Maybe it was my Dad’s persistent struggle with addiction from the day I was born until his death, or my lack of that struggle as a young person, that has pushed me to address age-related disparities in addiction care. 

The Unseen 

Smoking is very much still happening in America and across the world. At least 1 out of every 10 US adults currently smokes tobacco, or nearly 30 million people (close to the population of Texas). The majority of people who smoke in the US are middle-aged or older and have a low income and education level. While vaping has taken over headlines as an epidemic, smoking, the most harmful form of tobacco use, has remained the predominant form of nicotine delivery. Unlike younger cohorts, smoking prevalence has not changed for people 65 and over (for 20 years), disproportionately impacting racial and ethnic minorities. Extrapolating smoking prevalence to US Census numbers reveals that there are now an estimated 3 million more adults 65 and over who smoke cigarettes compared to adults 18-24. These disparities will likely grow as the older adult population nearly doubles in the next 30 years.

Opioid overdose trends and the headlines that highlight them also miss large groups of people. Yes, it is true that opioid overdose is a leading cause of death among young people. However, overdose is still much more common among middle-aged and older adults. Increases in opioid overdose have been steep in recent years for adults 55 and over (CDC data by age found here), especially for older Black adults. In some regions, like Washington, DC and Maryland, adults 55 and over are dying from opioid overdoses at significantly higher numbers than all other age groups. In December, the US Senate took the hint that crises and epidemics get attention when they released a report detailing these deaths, “The Silent Epidemic: Fentanyl and Older Americans.”

Compounding the harms of tobacco and opioids is the reality that they are often used concurrently. Similar to fentanyl, cigarettes kill with confidence. But unlike fentanyl, the deaths are not quick or sudden. An older adult who smokes cigarettes and survives an opioid overdose still faces the long-drawn-out torture of tobacco use that accumulates into the later decades of life (especially among particular racial and socioeconomic groups). In America, if you are white, have a higher education, and are economically okay, you might never see or know older people who smoke tobacco or experience an opioid overdose because you are not around them.

Widening our Focus

As noted above, aging and addiction intersect with social determinants of health, including race, education, and income, in tragic ways. I am not the first to address this intersectionality or the reality that older adults are underrepresented in medical research. A review of the literature found that <1% of articles in leading substance use and aging journals address older adults. Efforts are underway to increase awareness of “age-friendly care” that incorporates the principles of geriatric medicine and harm reduction into addiction treatment. 

While I am unsure of a simple solution to the age-related disparities I have presented here, I am very clear about the lives in the balance. Over 1000 people die each day from tobacco use and opioid-related overdoses- most of whom are not young adults and are from historically marginalized groups. These numbers don’t take into account the increasing use of other substances among older adults, including cannabis and alcohol.

Certainly, there is a way to continue our focus on protecting young people from substance use while also accepting that many people will and do use addictive substances later in life. And they deserve our attention in addiction research, policy, and treatment.