Smoking Cessation: Don’t Give Up on Older Adults
Mr. J, a 65-year-old married man, visits his primary care physician following completion of a course of radiation therapy. Mr. J was diagnosed with squamous cell carcinoma of the oral mucosa and underwent surgical excision of the lesion 6 months ago. He has a smoking history of 2 packs per day since the age of 15, and quit on his own “cold turkey” when his cancer was diagnosed. He was compliant with all radiation therapy sessions and was fortunate that the cancer was localized. Dr. Z has been his primary care physician for the past 5 years. He had advised the patient many times to quit smoking when Mr. J presented with sinusitis, chronic coughing, sore throats, and bronchitis. Dr. Z congratulates Mr. J on completing his radiation therapy and becoming a non-smoker. Mr. J appears embarrassed and reluctantly admits that his friends took him out to celebrate last week, and he resumed smoking 1 pack per day after having a cigarette with them in a bar. He reports that he only quit initially out of fear, and felt weak and tired while receiving radiation treatment. He often wanted to smoke, had cravings for a cigarette, but slept a lot. Mr. J states that he feels better when he smokes. He reports that his wife and daughter are angry with him, but he feels that he is “hooked” and cannot quit. Dr. Z speaks with Mr. J again about the risks of smoking but feels somewhat defeated. He wants to help Mr. J, but is unsure of which approach will be most effective.
Everyone knows that smoking is bad for your health. Using this information in a personalized way to help a patient quit is the challenge that physicians must undertake. Smoking cessation at any age is challenging, and older adults who have been chronic smokers for decades can feel unable to stop. Older adults often began smoking at a time when it was fashionable, widely accepted, and little was known of the health hazards. Among those 65 years and older, 10.5% are chronic smokers.1 In 2001, there were 46.2 million smokers in the United States. Of these, 15.3 million tried to quit in the past year. Relapse rates are high among those who try to stop smoking, approaching 70% at 3 months and greater than 90% at 1 year for each attempt.2 For the older adult who has made multiple failed attempts at smoking cessation, feelings of futility are common. In addition, although most Americans who smoke are now aware of the specific health risks of smoking, few actually view themselves as being at risk.2,3
Many physicians neglect to counsel older adults about the specific benefits of smoking cessation, and they often do not offer education and interventions.1 This is unfortunate, as the benefits of smoking cessation, such as reduction in smoking-related disease and disability, apply to older as well as younger adults.1-3 Habitual cigarette smoking is a chronic condition, which is characterized by DSM-IV psychiatric criteria as nicotine dependence.2 Nicotine has been identified as the substance in tobacco that causes habituation, tolerance, and withdrawal on cessation, along with the sensation of craving that often results in relapse. Nicotine acts as both a stimulant and a short-term anxiolytic, properties that are part of the highly addictive nature of smoking. Fortunately, there are a variety of pharmacologic methods available to treat symptoms of nicotine withdrawal and craving (Table I).4,5 However, there are also strong psychosocial and behavioral components of chronic smoking. Smoking is a repetitive behavior that is often performed as part of social routines and rituals.2,3 When education, medications, counseling, and behavioral interventions are used in combination, the success rate for smoking cessation improves dramatically.1-3
Education, counseling, and behavioral interventions can easily be provided by clinicians (Table II).1-3 It is vital to advise, assist, and engage patients in a smoking cessation program that will meet their specific needs and coping skills.2 Identification of tobacco use by taking a smoking history is an important initial intervention. This should include amount, duration of smoking, history of quit attempts, and any current health problems that are directly related to tobacco use. Advice and education from the physician are essential to engaging a patient in the process of smoking cessation.1-3 Elderly patients value the advice of their physicians. When counseled in a clear, supportive, and personalized manner an older adult may gain the motivation needed to begin a smoking cessation program.
Many types of support groups and programs are available in the community for smokers who want assistance. Good resources include local chapters of the American Cancer Society and the American Lung Association. Many communities offer Nicotine Anonymous meetings, which can be accessed through the website www.nicotine- anonymous.org. A valuable Web resource for physicians is www.surgeongeneral.gov/tobacco, a site that includes the most recent report from the Surgeon General on smoking cessation treatment, policy, and recommendations. Patient support literature can be downloaded from the websites www.quitsmokingsupport.com, www. quitnet.org, and www.americanheart.org.
As nicotine withdrawal symptoms and craving are associated with early relapse, nicotine replacement strategies should be offered to all patients.1-3 In addition, the antidepressant agent buproprion has been useful both individually and combined with nicotine replacement agents. Some studies have found that combining several types of nicotine replacement, such as gum and patches, to be more effective than relying on a single product.3,4 In the elderly, it is important to monitor for signs of nicotine excess, such as nausea, tachycardia, or dizziness, and to lower the dose if necessary. The FDA has approved the use of nicotine replacement agents for up to 6 months of therapy, although many patients have continued to use these agents for extended periods of time with no apparent adverse effects.
It is generally accepted that the risk of relapse and return to smoking is of greater harm than continuing the use of nicotine replacement agents. The majority of patients who attempt to quit smoking do not make it through the first 24 hours on their initial attempts.6,7 This means that support from the physician or office staff on the designated quit day is vital to the patient. Seeing the patient for a brief visit, calling later in the day, or encouraging the patient to seek support through a local community program may make the difference. In addition, brief calls and letters of encouragement from the physician to the patient on a regular basis in the early weeks of cessation improve the success rate.3 It is important to remember that relapse is common.6 This should be treated as a temporary setback, not a failure. Patients should be advised to contact the physician as soon as possible after a relapse. It is an opportunity for the patient and physician to re-evaluate the interventions and make adjustments in the smoking cessation plan. A change in type of nicotine replacement, the addition of an educational program, or joining a support group may be important at this point to ensure success after a relapse.2,3
Outcome of the Case
Patient Mr. J initially stopped smoking on his own, without the use of any nicotine replacement therapies or behavioral strategies to assist him. Dr. Z has a variety of options to offer Mr. J to help him quit again following this relapse. It is important to assess the patient’s readiness to quit and to enlist available family members in a supportive way. Dr. Z arranged to meet with Mr. J and his wife. Mr. J clearly understood the greatly increased risk of recurrence of his cancer if he continued to smoke. When his wife spoke of how she could not bear to see him die before their first grandchild was born, he became tearful and asked for help. Dr. Z offered medications to help with the patient’s cravings, including bupropion 150 mg daily and a nicotine patch or lozenge. He also referred Mr. J to a local community center that offered a smoking cessation group sponsored by the American Lung Association.
Dr. Z remained very involved, and arranged to start the bupropion 2 weeks prior to the patient’s planned quit date. Dr. Z recommended that Mr. J use a 14-mg-per-day nicotine patch based on his current smoking of 20 cigarettes per day. Dr. Z called Mr. J on the morning of his quit day and was pleased to hear that he and his wife were attending a program with his smoking cessation group. Mr. J stopped smoking on his quit day, but one month later called Dr. Z in a panic, complaining of feeling anxious with strong cravings to smoke. Dr. Z advised Mr. J to reduce the bupropion dose to 75 mg and recommended use of a nicotine lozenge for his cravings. He saw Mr. J the next day, and found that he had smoked one cigarette. Dr. Z reassured him that he can remain a nonsmoker and advised him to return to his smoking cessation group. Mr. J remains smoke-free after 6 months, and periodically uses nicotine lozenges when he has cravings.