Functional disability and the risk of subsequent smoking initiation: A prospective cohort analysis

Smoking initiation remains a major public health concern, yet little is known about whether functional disability independently increases the risk of becoming a smoker.

We conducted a prospective cohort analysis using data from Waves 10 (2018-2019, baseline) and 14 (2022-2023, follow-up) of the UK Household Longitudinal Study. The analytic sample included 20,529 adults who were non-smokers at baseline and were prospectively followed over four years to assess smoking initiation at Wave 14. Functional disability was assessed across twelve domains; mobility, lifting or carrying objects, manual dexterity, continence, hearing, sight, physical coordination, personal care, memory/concentration/learning/understanding, communication/speech, recognising physical danger, and other health problems or disabilities; and was operationalised based on its presence, number of affected domains, and specific type of limitation reported. Modified Poisson regression with robust standard errors was used to estimate adjusted relative risks (RRs) of smoking initiation, controlling for age, sex, education, ethnicity, and urban/rural residence.

At baseline, 25.1 % of participants (n = 5161) reported at least one functional disability. By follow-up, 379 participants (1.9 %) had initiated smoking. Individuals with functional disabilities had a higher risk of smoking initiation (RR = 1.42, 95 % CI: 1.12-1.80, p = 0.004) after adjustment. A significant trend was observed across increasing numbers of functional disabilities (p-trend < 0.001), with elevated risks among individuals reporting two or more (RR = 1.80, 95 % CI: 1.33-2.42, p < 0.001). Among new smokers, individuals with functional disabilities were also more likely to smoke ≥ 10 cigarettes per day (RR = 1.40, 95 % CI: 1.04-1.64, p = 0.020). Domain-specific analyses showed that mobility limitations (RR = 1.83, 95 % CI: 1.33-2.50, p < 0.001), lifting or carrying impairments (RR = 1.90, 95 % CI: 1.40-2.57, p < 0.001), personal care limitations (RR = 1.95, 95 % CI: 1.19-3.18, p = 0.008), and difficulties recognising physical danger (RR = 2.59, 95 % CI: 1.15-5.81, p = 0.021) were most strongly associated with smoking initiation.

Functional disability is associated with an increased risk of smoking initiation. These findings highlight the need for inclusive tobacco prevention strategies that address the unique vulnerabilities and barriers faced by people with functional impairments.