Tobacco dependency is a growing problem among older adults. Given the addictive nature of tobacco use, smokers need a multifactorial
treatment program to help stop smoking. Health care professionals can play a pivotal role in the promotion of a smoking cessation
treatment program to people of all ages, including the elderly. This paper presents important evidence that smoking cessation
services for the elderly are effective, and describes how primary care physicians can support elderly people quit smoking.
Abdullah ASM, Simon JL. Health promotion in older adults: Evidence based smoking cessation programs for use in primary care
settings. Geriatrics 2006; 61(Mar):30-5.
Key words: tobacco • nicotine addiction • smoking cessation elderly
Drugs discussed: Nicotine replacement therapy
Cigarette smoking is the leading cause of premature mortality among older persons.1 The World Bank has estimated that 500 million people alive today will eventually be killed by tobacco.2 It has also predicted that worldwide trends in mortality attributable to smoking will increase in both older men and women.3 Many common morbidities among older people are caused by tobacco use.4,5 Promotion of smoking cessation could affect such trends.6
Studies have shown that older adults can successfully quit smoking and do benefit from abstinence.6 Smoking cessation can reduce an older patient's susceptibility to smoking-related illnesses and promote more rapid recovery
from illnesses exacerbated by smoking.7 Even moderately ill patients benefit from stopping smoking.8 For example, in the study by Hermanson et al,8 the six-year mortality rate was greater among continuing smokers than among those who quit smoking during the year before
enrollment in the study and abstained throughout the study (RR, 1.7; 95% CI, 1.4, 2.0).
Quitting smoking also improves quality of life9 and may improve the quitter's relationships with family members.10 Because older smokers tend to be chronic smokers who do not want to quit, or who want to quit but cannot, or believe that
they are already so irreversibly damaged by smoking that quitting would bring no benefit,11 promotion of smoking cessation to this group presents a challenge. This paper describes the importance of, and evidence
for, smoking cessation among the elderly, and a primary care approach that physicians can follow to help elderly patients
quit smoking.
Prevalence of smoking
Approximately 4 million older Americans smoke tobacco products. Although the prevalence of cigarette smoking among older Americans
(age >64) is lower compared with adults age 18 to 64 (9.6% vs 25.9%),12 it is comparable with Chinese smokers in Hong Kong.13 The proportion of individuals age ≥60 who smoked daily in Hong Kong in 2002 was 14.3% (25% of males; 3.6% of females); the
corresponding figure among the general population age ≥15 was 26.1% and 3.6% respectively.13 This similarity in the smoking prevalence indicates that the elderly and the general population in the United States are
at similar risks from smoking-related hazards.
Approximately one-half of all smokers will die from diseases related to cigarette smoking.3 Given this fact, health professionals have a responsibility to inform older smokers, indeed ALL smokers, about the options
available to reduce risk. Because quitting smoking improves health, it would be unethical not to help smokers who wish to
quit. Moreover, many elderly smokers want to quit smoking: In one U.S. study, 44% of smokers age ≥50 wanted to quit smoking14 and in another, smokers who were age≥65 were more likely to be successful in quitting attempts than smokers age 35-64.15 Thus, there is a compelling case for the promotion of smoking cessation throughout the life cycle.
Effective smoking cessation interventions among elderly Several studies, including randomized controlled trials and population-based surveys, demonstrate the effectiveness of various
smoking cessation interventions for older adults.16-20
Randomized controlled trials: Three randomized controlled trials (RCT) on smoking cessation carried out among middle-aged and older (age ≥50) smokers16-18 used only behavioral therapy (advice, counseling) as an aid to smoking cessation. A statistically significant percentage
of subjects quit smoking over the course of these studies.
In the study by Vetter and Ford, 471 English smokers age ≥65 were randomized to an intervention group (involving a single
visit to a physician to receive brief advice on quitting smoking, followed by lifestyle modification counseling by a nurse
counselor at 6 months or a control group.16 At the 6-month follow-up, the expired air carbon monoxide validated quit rate was significantly higher in the intervention
group (14%) compared with the control group (9%). The number needed to treat was 20. Although this study demonstrated the
impact of medical advice, the intervention was not delivered in the context of a regular health care visit; rather, it was
provided in a single general practitioner's visit and backed up by a practice nurse.
In a second RCT of 659 smokers age 50 to74, the intervention group received brief advice from a physician on quitting smoking,
one week's supply of nicotine replacement therapy as appropriate, a manual on smoking cessation, and a follow-up by clinic
staff within 2-4 weeks of intervention, while the control group received the usual care.17 At the 6-month follow-up, the self-reported quit rate was significantly higher in the intervention group (15.41%) compared
with the control group (8.16%). The number needed to treat was 14.
In an RCT on preventive health care among Medicare beneficiaries age ≥50,18 subjects were assigned either to an intervention group that offered yearly preventive visits for 2 years and optional counseling
visits to their primary care provider, or to a control group that received the usual care. The intervention group received
preventive advice on three different types of health threats (smoking, excessive alcohol drinking, and lack of exercise).
At the 2-year follow-up, the smoking quit rate was higher in the intervention group (24.2%) compared with the control group
(17.9%), but the difference was not statistically significant (P = 0.09). The smoking cessation intervention might have been less effective in this study because other intervention components
were included at the same time.
Population-based studies: In a community-based longitudinal study of 1,259 American elderly smokers (age ≥65), the cessation rate at the 3-year follow-up
was 35%.19 In this study, the quit rate was higher among individuals age ≥85 (52%) compared with those age 65 to 69 (23%). This suggests
that smoking cessation intervention might be particularly beneficial for this oldest old group. However, because those age
≥85 are the eldest in the population, there may be confounding factors in the quit rate, including, the desire to set an example
for younger family members, the presence of other chronic conditions, encouragement from other family members, less accessibility
to cigarettes, and financial hardship.19
Another population-based study assessed the smoking outcomes of 1,070 smokers age 65 to 74 who were prescribed nicotine replacement
therapy (NRT) by their physicians or pharmacists.20 No follow-up arrangements were made. The self-reported quit rate at six months was 29%, suggesting that significant benefits
could be achieved even with brief interventions by physicians or pharmacists.
Nicotine replacement therapy (NRT): Whereas no randomized controlled trials on NRT have focused exclusively on smokers age >65, data on elderly smokers are available
from studies that included adults of all ages.21,22 This data is relevant to this discussion because the pharmacokinetics of nicotine do not change substantially with age23 and the plasma concentrations of nicotine and cotinine are similar across the age range of 18 to 69 years when individuals
use the same dose nicotine patch.24
Two placebo-controlled trials of transdermal nicotine on patients with coronary artery disease (limited to patients age ≥70)
showed a short-term effectiveness of NRT on quitting smoking and found no evidence for an increased risk of cardiac complications,21,22 indicating that NRT is safe and efficacious for older smokers. The current clinical practice guidelines for treating tobacco
use and dependence recommend the use of NRT for elderly smokers.6
Gourlay's prospective study23 examined transdermal nicotine use among 1481 adults (mean age 41.1; range 18-70) who smoked at least 15 cigarettes per day.
Older smokers (age ≥40) reported a higher quit rate (25%) compared with younger smokers (age <40; 17%). The lack of sub-group
analysis makes the quit rate for true elderly smokers (age ≥65) unclear.
Smoking cessation supports
Nicotine replacement therapy: NRT is the most widely investigated pharmacological treatment option used to aid smoking cessation. Addicted smokers experience
unpleasant nicotine withdrawal symptoms on stopping smoking, which undermine their efforts to quit. NRT provides temporary
nicotine substitution through a less hazardous means of delivery (ie, dermal or oral) and a more manageable form of drug (ie,
patch or pill). This spares smokers the craving that typically accompanies smoking cessation, and enables them to gradually
adjust to life as a non-smoker. NRT is available OTC in patch and gum systems; prescriptions are required for inhaler, nasal
spray, and lozenges.
All types of NRT are equally effective and safe in helping smokers to quit.6 Older smokers with the following chronic conditions would also benefit from using NRT to support their quitting initiative:
Cardiovascular disease: NRT has fewer cardiovascular effects than tobacco smoke, and there is no contraindication for active heart disease patients.
NRT can therefore be given to individuals of all ages with cardiovascular diseases.6 However, the primary care physician should be involved in the decision-making process for NRT use in those patients who
have experienced a serious cardiovascular event, or been hospitalized for a cardiovascular complaint in the previous 4 weeks
(eg, stroke, MI, unstable angina, cardiac arrhythmia, coronary artery bypass graft, angioplasty) or where they suffer with
uncontrolled hypertension.25
Psychiatric illness: This group of smokers would benefit from NRT, but requires careful monitoring and counseling while quitting. Withdrawal symptoms
do have the potential to modify psychiatric symptoms and can interfere with the diagnosis and treatment of psychiatric disorders.26 The guidelines recommend that smokers with psychiatric illnesses be referred to a psychiatrist who can initiate treatment
for smoking cessation and also for the psychiatric condition after appropriate evaluation.6
Other treatment options: The antidepressants bupropion and nortriptyline have been shown to be effective in increasing the quit rate.6 Certain other prescription drugs (clonidine, mecamylamine, and lobeline) initially appeared to show promise, but long-term
trials demonstrated that they were not. There is no evidence that either acupuncture27 or hypnosis28 are effective.
What physicians can do
Although not specifically validated in older adults, the 5As approach (Ask, Advise, Assess, Assist and Arrange) can assist
physicians in providing a smoking cessation service to their patients.6
Ask about smoking and quitting history at every contact. Keep a note so that the issue can be raised again.
Table 1 Fagerstrom test for nicotine dependence
|
Assess smokers' readiness to quit and degree of nicotine dependency. The Fagerstrom Test for Nicotine Dependency is widely used
to measure nicotine dependency (table 1).29
Table 2 Stage-matched counseling approach
|
Advise ALL smokers to quit by personalising the risks of smoking (eg, if symptoms are related to smoking, discuss the relationship
between smoking and the specific symptoms) and the benefits from quitting smoking. A stage-matched counseling approach is
useful (table 2).6 Set a quit date within one to two weeks of the contact, and prepare the smoker for the process of quitting smoking starting
from that date. If the patient does not wish to quit, note this fact and discuss the issue again in a later interview.
Assist smokers who want to quit by giving appropriate counseling and/or pharmacological treatment. If available, also provide self-help
materials to each smoker.
Arrange a follow-up, so that improvements or difficulties may be discussed.
To improve success rate
The following aspects need special attention to maximize the opportunity for a successful outcome.:
Weight gain: Some individuals will gain weight as they attempt to quit smoking. The weight gain following cessation, assuming there is
no change in physical activity, appears to be due to a transient increase in eating coupled with the removal of the acute
metabolic effects of each cigarette (ie, decreased metabolic rate).30 The weight gain is usually less if the smoker continues to ingest nicotine in some form.30 Suggest that smokers NOT focus on weight control (diet and exercise) before overcoming the early withdrawal symptoms of
nicotine cessation.
Withdrawal symptoms: Withdrawal symptoms are the product of an individual's physical or psychological adaptation to long-term drug use; the body
requires a period of readjustment when the drug is no longer ingested. The common withdrawal symptoms when a nicotine-dependent
individual abruptly ceases tobacco use without treatment support include depression, insomnia, irritability, frustration,
anger, anxiety, difficulty in concentrating, restlessness, decreased heart rate, gastrointestinal disturbances, and an increased
appetite.31 These symptoms are most often temporary, peak within the first few days (1-2 days) of cessation, and then subside within
a few weeks. Successful quitters typically have a plan of action to address symptoms before they even begin the cessation
process.
Dealing with failure: Quitting smoking is a chronic, often recurrent process. Many people find it difficult to quit smoking: Approximately 70%
of smokers having made at least one unsuccessful attempt to quit smoking. While such initial failures are disappointing,
they are also a sign that the individuals concerned could succeed later with the help of appropriate counseling and treatment
modalities.
Adherence to recommendations and treatment: Smokers should be advised clearly that success in quitting smoking depends primarily on themselves. However, counseling and
pharmacological treatment are supportive, and smokers should follow the protocol as suggested. There is no reason to believe
that the use of NRT or other pharmacological products will automatically help smokers to quit—a common misconception among
many smokers in the United States and in Asian countries.32 Successful quitting depends ultimately on the motivation of the individual concerned and his/her adherence to treatment
guidelines.
Conclusion
Smoking tobacco kills. Quitting smoking at any age can produce significant health benefits. Despite often chronic smoking,
elderly smokers quit smoking at rates comparable to those of younger smokers. Health care professionals should prepare themselves
(using the Internet and continuing medical education opportunities) to provide smoking cessation service to each elderly smoker
they encounter. This can be done by identifying elderly smokers, encouraging them to quit smoking, providing them with appropriate
support and pharmacological therapy to relieve their withdrawal symptoms, and providing regular and continuing follow-up.
Acknowledgements: The author would like to acknowledge the assistance of Dr David Wilmshurst (Research Services Section) of the University
of Hong Kong, who commented on an early draft of this paper.
Dr. Abdullah is associate professor, Department of International Health, Boston University School of Public Health, Boston, Massachusetts,
and Department of Community Medicine, Faculty of Medicine, The University of Hong Kong.
Dr. Simon is chair and associate professor, Department of International Health, Boston University, School of Public Health, Boston,
Massachusetts.
Disclosures: The authors report no relevant disclosures.
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