Smoking and the Older Person
Since the first Surgeon General report on smoking was issued in 1964, the smoking rate in the United States has been progressively declining.1 Yet today, cigarette smoking remains the leading cause of preventable death in the United States, and it is associated with significant health and economic burdens to society.2 A vast array of resources have been assigned to address smoking cessation or abstinence programs, almost exclusively aimed at the adult and adolescent populations. Little to no attention has been paid to older smokers. Obstacles to smoking intervention in the elderly include the beliefs that little or nothing can be done to change the habits of older individuals,3 there is little health benefit from smoking cessation, and it is one of the few pleasures in life left to older persons. This article reviews current literature about the harmful effects of smoking in the elderly and the benefits of smoking cessation among this growing population.
EPIDEMIOLOGY OF AGING AND SMOKING
Older adults 65 years of age and older are the fastest growing segment of the population in the United States, totaling almost 40 million and making up more than 12% of the population.4 It is projected that their number will grow to more than 71 million and will account for close to 20% of the total population by the year 2030.5 Although smoking rates continue to decline for the adult population at large, and for the elderly population in particular, approximately 440,000 people continue to die yearly in the United States from illnesses attributable to cigarette smoking.2 Only 9.3% of adults 65 years of age and older smoke, but it is more worrisome that 21.8% of adults 45-64 years of age are current smokers. It is this large smoking population that will be of major concern to the health care system in the near future.6 Programs geared toward the elderly will be necessary to reduce the number of smokers in the present elderly age group and the soon-to-be elderly age group.
TOBACCO CHEMICALS AND CARCINOGENS
At least 4000 chemicals and 60 carcinogens have been identified in tobacco smoke.7,8 These carcinogens include aromatic amines, phenols, nitrogen dioxide compounds, aldehydes, polycyclic aromatic hydrocarbons, nitrosamines, volatile hydrocarbons, inorganic compounds, and other organic compounds. These chemicals have been shown to be carcinogenic in human and animal models. The list does not exclude the presence of other carcinogens that have yet to be identified or evaluated. The mechanism by which smoking carcinogens cause cancer is believed to be via the production of DNA adducts.9
DNA adducts are formed by covalent bonds between the carcinogen and the DNA and can disturb the architecture of the DNA. DNA adducts are implicated in many types of human cancers, and they can block antitumor genes and activate oncogenes. Another mechanism proposed for the damage induced by smoking is via the production of free radicals. Products of free radical–induced lipid peroxidation were shown to be significantly elevated in smokers as compared to nonsmokers.10,11 Evidence of free radical damage is not only limited to lipid peroxidation, because smoking has also been shown to induce oxidative damage of proteins and DNA.12,13 Interestingly, there is evidence suggesting that smoking causes significantly greater free radical–induced damage in older smokers than in young adult smokers, implying that the elderly are more susceptible to the hazards of smoking (E. E. Tuppo, DO, unpublished data, July 2005).
HEALTH CONSEQUENCES OF SMOKING IN THE OLDER PERSON
It is well known that smoking is associated with increased risk of cancers (lung, gastric, genitourinary, lymphatic, and head and neck), pulmonary diseases (asthma, chronic obstructive pulmonary disease, pulmonary fibrosis, pulmonary thromboembolism, and pulmonary hypertension), vascular diseases (stroke, coronary artery disease, and peripheral vascular disease), gastrointestinal diseases (peptic ulcer disease and gastroesophageal reflux disease), and osteoporosis.3,14-16 The absolute risk of dying prematurely due to smoking increases with the age of the smoker. Excess mortality from all causes of death increases with the age of the smoker and the years he or she has smoked.17
It is known that older smokers have a higher rate of cardiovascular and cancer mortality than their nonsmoking counterparts.18 Interestingly, elderly female smokers may be more susceptible to tobacco carcinogens, which result in higher levels of diagnosed cancers for women when compared to male smokers.19 Smoking aggravates existing diseases such as cardiovascular disease, diabetes mellitus, and hypertension, which occur disproportionately frequently in the elderly population in general. Smoking can also interact with, and adversely affect, the efficacy of many medications, further increasing the medical burden for the elderly (who are among the largest users of medications).20 A decline in the quality of life has been shown to occur in older smokers.21 This includes increased risk for impairment in mobility and high life stress among elderly male smokers, along with low happiness and dissatisfaction with social relationships among elderly female smokers, when compared to nonsmokers.21
RISK FACTORS AND REASONS FOR SMOKING
There are multiple risk factors associated with smoking in the elderly. These include living with another smoker or sharing living quarters and common areas with other smokers, socially interacting with other smokers (which may reinforce smoking behavior), being employed or seeking work (possibly using smoking as a stress reducer), and participating less frequently in organized religion.22 In men, smoking addiction and educational level were not associated with long-term smoking; however, heavy smoking was related to long-term smoking.23 The reasons that older persons continue to smoke may differ from reasons why younger adults smoke. The elderly are more likely to smoke than younger smokers because it has become an automatic habit and can act as a tension reducer. However, older smokers are less likely to actually obtain pleasure from smoking than younger smokers.24
BENEFITS TO SMOKING CESSATION IN THE OLDER PERSON
Contrary to the old belief that there is little benefit to smoking cessation in the elderly, research has provided evidence for benefits. In the elderly, the mortality risk for former smokers has been shown to be decreased, when compared to continuing smokers.25 The magnitude of the decline increased with increasing duration of smoking cessation. Smoking cessation was found to reduce the risk of lung cancer mortality at any age, even older age.26 Older individuals who stop smoking for five years can reduce their cardiovascular mortality to that of nonsmokers.18 Hermanson et al27 looked into the six-year mortality rate from myocardial infarction in men and women with coronary artery disease who are 55 years of age or older. They found that the risk of myocardial infarction was decreased with smoking cessation, with no reduction in benefit with increasing age.27
A population-based study showed that quitting smoking increased the expected time spent in good health and reduced the time spent in poor health.28 Similarly, smoking cessation was found not only to extend life and increase time spent without disability but also to reduce disability to a shorter time period in the younger (30 years of age) and older adult (70 years of age).29 Health care providers and the health care system continue to do poorly in helping their patients quit smoking. A survey on the use of office-based smoking cessation activities in family practice revealed that while all of the physicians believed that smoking is a significant health risk and smoking cessation counseling is important, only 51% of practices documented the smoking status of their patients, 52% had smoking cessation material accessible to the patient, and only a few practices involved support staff to assist with assessment or counseling.30
A survey of primary care physicians’ smoking cessation practices with middle-aged adults who smoked revealed that while a majority of physicians (67%) asked about smoking habits and advised their patients about smoking cessation (74%), 35% assisted their patients in stopping smoking, and only 8% arranged follow-up visits for their patients.31 When smokers were surveyed, 51% reported being spoken to about their habit by their physician, 45.5% were advised to quit, 14.9% were offered help to quit smoking, 8.5% had medications prescribed for them, and only 3% had follow-up appointments arranged.32
One of the reasons given for the inadequacy of smoking cessation counseling offered by health care providers is the competing demands placed on the physician during the visit. Whereas it was noted that three-fourths of clinical visits by smokers require counseling interventions by the physician,33 only one-third of the visits involved smoking cessation counseling. Another study showed that only 70% of smokers reported that they were advised to quit smoking by their physicians.34 Even with older smokers who have been hospitalized for acute myocardial infarction, a population that would certainly benefit from not smoking, only 40% received counseling on smoking cessation.35
In the 1996-1997 Community Tracking Study Household Survey, less than 50% of those surveyed reported receiving smoking cessation advice from their physicians.36 There is some evidence that patient characteristics impact on the physician’s willingness to counsel against smoking. The age of the patient was shown to be a factor in smoking cessation counseling, with those over the age of 65 being less likely than younger patients to receive counseling from hospital-based physicians.37 Although the reasons were not clear, it is possible that those physicians believed that by living to old age with the habit of smoking, those elderly persons were less susceptible to the hazards of smoking.
PROMOTING SMOKING CESSATION
Smoking cessation programs can be effective with the elderly. Dale et al38 showed that almost 25% of elderly smokers treated for nicotine dependence were able to remain abstinent from smoking at six-month follow-up.38 Also, abstinence was more likely to occur if the smoker was hospitalized, was married to a nonsmoking spouse, or was motivated to stop smoking. Health practitioners can have an impact on smoking rates in the older patient. One study reported that regular contact between elderly patients and physicians or dentists was associated with a decreased rate of smoking, when compared to not having regular contact.39
An interventional study using physician-delivered, quit-smoking advice and counseling for midlife and older smokers in an outpatient medical practice significantly increased smoking abstinence rates, as compared to the usual care provided.40 Interestingly enough, the training of physicians and office staff took only 45-60 minutes, indicating that it is possible to train many, if not most, health care providers to be more effective in helping their patients quit smoking. It is possible that different intervention techniques aimed specifically at the older smoker would be more effective for them. Evidence has shown that tailoring smoking cessation programs toward the older adult, such as the Clear Horizons program (a smoking cessation self-help guide for smokers 50 years of age and older), may help increase the rate of quitting.41,42 In one study, 20% of those using the tailored Clear Horizons program reported quitting smoking, as compared to 15% using a generic guide.42 Nicotine replacement therapy, widely used to help smokers quit, is likely to benefit elderly smokers. The transdermal nicotine may be better than other forms of nicotine replacement for the elderly43 because it can be applied once per day and has good tolerability.
It is time to put to rest the belief that there is no benefit to smoking cessation in the older person. Although society has placed much emphasis and resources on programs to help adults and teens to quit or not start, it is also important to focus on smoking cessation in the elderly population. The health care system itself—from government to hospitals to health care providers—has not adequately met the challenge of helping older individuals quit smoking. Given that the elderly come with a greater medical burden, such as chronic disease and medication use, that is aggravated by smoking, smoking cessation may not only improve their health but also may reduce the financial burden placed on society and the health care system. In addition, there is evidence that smoking cessation in older persons can be successful, and there are health benefits to be gained.