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Former smokers still face higher disease and premature death risks, but they were able to cut down on that mortality risk by sticking with a healthy lifestyle, according to a prospective cohort study.

Among people who used to smoke, higher total adherence scores to healthy lifestyle recommendations (e.g., healthy weight, balanced diet) were linked with lower all-cause mortality (HR per unit increase 0.95, 95% CI 0.94-0.95), reported Maki Inoue-Choi, PhD, of the National Cancer Institute in Bethesda, Maryland, and colleagues.

They explained in that total adherence was summed up to a value of 8. When compared against the lowest score category (0-2), increased adherence was associated with reduced risk of all-cause mortality:

• Score of 3-4: HR 0.88 (95% CI 0.86-0.90)
• Score of 5-6: HR 0.80 (95% CI 0.79-0.82)
• Score of 7-8: HR 0.73 (95% CI 0.71-0.75)

Inoue-Choi's group said these associations were seen regardless of health status, comorbid conditions, the number of cigarettes participants used to smoke per day, years of cessation, and age at smoking initiation.

When examined individually, the component measurement of the total summed adherence score also had significant ties to all-cause morbidity. Comparing the highest versus lowest adherence for each recommendation:

• Body weight: HR 0.86 (95% CI 0.84-0.88)
• Diet: HR 0.91 (95% CI 0.90-0.93)
• Physical activity: HR 0.83 (95% CI 0.81-0.85)
• Alcohol intake: HR 0.96 (95% CI 0.94-0.97)

Participants with a higher total adherence score also had reduced risks of mortality from cancer, cardiovascular disease, and respiratory disease, according to the authors, which is good news for former smokers and possibly inspiring for current smokers (52.1 million and 34.2 million, respectively, according to federal data).

In an accompanying , Kolawole Okuyemi, MD, of the University of Utah in Salt Lake City, and colleagues, said that it was "time to engage in strategic dialogue that outlines a range of practical, ethical, and impactful interventions that incorporate non-tobacco-related metrics (e.g., body mass index, physical activity, and alcohol use) for former smokers and particularly those who are often left behind, including in collection of and analyses of data that would help direct promising interventions."

They suggested that these types of interventions could be done in clinical and community settings. They also called for "policy changes that are aligned with a multilevel chronic disease prevention model aimed at addressing co-occurring social determinants of health at multiple levels of influence (individual, interpersonal, community, and societal) and domains (biological, behavioral, physical, and built environment, sociocultural environment, and health care system)."

Okuyemi's group stressed that an "equitable tobacco endgame must view harm reduction from a broader lens -- one that includes multiple non-tobacco metrics and targets the underlying social determinants, such as educational level, income, and neighborhood context, the types of interventions that ultimately reduce harm to former smokers."

The study was done with data from 159,937 participants from the . Responses were collected via questionnaires that were mailed from 1995 to 1996 to 3.5 million AARP members with a mean age of 62.6 years (two-thirds men, 93.6% white). Most reported their health status as ranging from good to very good/excellent. The majority reported quitting smoking at least a decade ago.

Those who completed the baseline and risk factor questionnaires and self-identified as former smokers were included in the study. The baseline questionnaire assessed demographic, anthropometric, medical, smoking, and other lifestyle factors.

Adherence to evidence-based lifestyle recommendations were scored by body weight, diet, physical activity, and alcohol intake, with higher scores indicating better adherence.

Primary outcomes were all-cause and cause-specific mortality through December 2019, for a mean follow-up of 18.9 years.

Study limitations included its observations nature, the use of self-reported information, the predominantly white population, and the fact that changes in lifestyle also could have occurred during follow-up, including restarting smoking.

Okuyemi and colleagues pointed out that getting former smokers on track with a healthy lifestyle was particularly important "at a time when COVID-19 is markedly reducing overall lifespan among groups with comorbid conditions."

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