Abstract:
There are proven health benefits in quitting tobacco use in older adult smokers. Quitting tobacco use can lessen the risk of cognitive decline and brain atrophy, and prevent polypharmacy arising from the management of complex morbidities associated with smoking. Healthcare staff play an important role in helping older adult smokers to abstain from smoking. Multiple approaches can be used to deliver evidence-based tobacco cessation treatments to the geriatric population. With ongoing support from healthcare teams, older adults who smoke can improve their chance of successfully quitting tobacco use, resulting in better quality of life.
Key Words:
tobacco cessation, smoking cessation, older adults
Tobacco use remains the number one cause of preventable disease, disability, and death in the United States, accounting for approximately 480,000 deaths every year, or about one in five (Centers for Disease Control and Prevention [CDC], 2018). In 2018, approximately 49.1 million (19.7 percent) of American adults used tobacco products [cigarettes (13.7 percent), cigars (3.9 percent), e-cigarettes (3.2 percent), smokeless tobacco (2.4 percent), and pipes (1 percent)] (CDC, 2018). Most tobacco users reported using combustible products (cigarettes, cigars, or pipes), and 18.5 percent reported using two or more tobacco products (Creamer et al., 2019).
Examples of smokeless tobacco products include chewing tobacco, snuff, snus, and dissolvable tobacco products, and all can be harmful and addictive (Navas-Acien, 2017). Electronic nicotine delivery systems (ENDS) are battery-powered devices used to smoke or “vape” a flavored solution containing nicotine. Pharmacotherapy can be considered for non-combustible tobacco users; however, the evidence using pharmacotherapy for ENDS cessation is limited.
Between 2000 and 2017, the proportion of smokers older than age 65 increased from 6.8 percent to 11.8 percent, while smoking in younger adults decreased (U.S. Department of Health and Human Services [HHS], 2020). Smoking in older adults increases the risk of complications (such as cardiometabolic, musculoskeletal, and cerebral) of frailty (Wu et al., 2019).
‘Health benefits [of quitting] can be immediate, as early as within the first hour.’
In addition to increased risk for many types of cancer, older adult smokers in comparison to non-smokers are more prone to worse management and outcomes of common age-related diseases such as diabetes, osteoporosis, cardiovascular disease, chronic kidney disease, and respiratory problems (Burns, 2000; and Wu et al., 2019). Smoking also may decrease vaccine efficacy and increase the risk of infections in the older population (Godoy et al., 2018).
During the COVID-19 pandemic, older adults with COVID-19 infection made up 45 percent of hospitalizations, 53 percent of intensive care unit admissions, and 80 percent of deaths (Bialek et al., 2020). The various harmful effects of cigarette smoking in older adults make it imperative to promote and provide effective tobacco cessation treatments in this population.
The Benefits and Challenges of Quitting Tobacco Use
The benefits of quitting tobacco use at any age have been well established (HHS, 2020). Smoking cessation, even in later years of life, can significantly reduce mortality and improve quality of life, including in those older individuals with underlying smoking-related diseases (Burns, 2000; HHS, 2020). Health benefits can be immediate, as early as within the first hour, and continue for days, weeks, months, and years after stopping (U.S. Public Health Service Report, 2008; HHS, 2020).
Older smokers who quit smoking experience many health benefits such as decreased risk of cognitive decline, prevention of polypharmacy, improved health outcomes, and improved quality of life (Kivipelto, Mangialasche, and Ngandu, 2018; HHS, 2020).
Long histories of tobacco use and higher nicotine dependence makes quitting tobacco use challenging in the older population (Henley et al., 2019). Despite abundant evidence of the benefits related to tobacco cessation in older smokers, only about a third of older adults who tried to quit received evidence-based tobacco cessation treatments, and only one in twenty older smokers successfully quit in the past year (Henley et al., 2019). Tobacco cessation in persons older than age 55 often requires multiple quit attempts and repeated interventions to successfully achieve tobacco abstinence (U.S. Public Health Service Report, 2008; HHS, 2020).
Healthcare staff play an essential role in helping older tobacco users recognize the importance of quitting smoking and in providing appropriate resources to improve tobacco cessation outcomes (Toll et al., 2014). With training and knowledge about tobacco cessation management, any healthcare professional—physicians, psychologists, pharmacists, dentists, nurses, and social workers—can effectively deliver evidence-based interventions to help older smokers quit tobacco use (Siu, 2015; and U.S. Public Health Service Report, 2008). Behavioral counseling and Food and Drug Administration (FDA)–approved cessation medications are independently effective in increasing smoking cessation; moreover, these two interventions combined are more effective than either intervention alone and remain the gold standard for treatment (HHS, 2020).
Behavioral counseling can be provided via telephone, face-to-face, in a group, and via telehealth (U.S. Public Health Service Report, 2008; HHS, 2020). Texting for tobacco cessation, tobacco-cessation phone applications, and self-help information can be used adjunctively for tobacco cessation (U.S. Public Health Service Report, 2008; HHS, 2020).
Behavioral Therapy Treatment Approach
Tobacco use disorders are chronic disorders with high risk for relapse and often require multiple quit attempts and interventions (U.S. Public Health Service Report, 2008; HHS, 2020). All healthcare practitioners in clinics and hospitals, therefore, play vital roles in helping individual smokers to quit tobacco use. Healthcare staff must continue to address tobacco use status at every visit and provide ongoing support (Himstreet et al., 2013). Behavioral counseling helps patients with habitual and psychological dependence, especially older smokers who may have a longer duration of use. Using counseling approaches such as the 5A’s (Ask, Advise, Assess, Assist, and Arrange) and motivational interviewing (MI) techniques can increase success in quitting tobacco. Healthcare professionals should perform the 5A’s at each health encounter: ask about tobacco use, advise stopping tobacco use, assess readiness to quit, assist with behavioral counseling and tobacco cessation medications, and arrange for follow-up appointments (U.S. Public Health Service Report, 2008). This intervention helps the healthcare provider to better assess the respondent’s use of tobacco products and cessation behavior (Siu, 2015), and in the development of individualized treatment plans.
Behavioral counseling can teach older smokers coping skills and how to develop strategies while going through the cessation process. Evidence has shown that intervention intensity has a linear effect on the rate of abstinence (U.S. Public Health Service Report, 2008). Cessation counseling lasting four to thirty minutes can double a patient’s chance of abstinence, whereas counseling lasting more than thirty minutes can triple a patient’s chance of success (U.S. Public Health Service Report, 2008). Conducting two to three counseling sessions increases abstinence rates 1.5-fold, while conducting four to eight sessions doubles the chance of abstinence (U.S. Public Health Service Report, 2008). Ultimately, behavioral counseling is dose-dependent—the more intensity, the more sessions, the more long-term follow-up—the better chance of success. Derived from the 5A’s model, the Ask, Advise, Refer (AAR) model offers a shorter alternative (HHS, 2020).
Brief counseling and medications provided as part of an ongoing therapeutic relationship can be especially effective, surpassing prescribing medication alone (U.S. Public Health Service Report, 2008). Behavioral counseling not only supports the older smokers’ attempt to quit smoking, but also helps these individuals to maintain tobacco abstinence.
Ongoing support and positive reinforcement are essential to help prevent relapse in older adults who recently quit using tobacco (U.S. Public Health Service Report, 2008). In older adults, tobacco cessation treatments may be provided face-to-face or over the telephone, as one-on-one sessions or in a group setting. The shared medical visit model uses a collaborative approach where more than one member of a healthcare discipline collaborates to provide comprehensive tobacco cessation treatment to older adults. For example, a prescriber and a behavioral treatment counselor (e.g., clinical pharmacist specialist and psychologist) would work together (Chen et al., 2013).
Varieties of counseling topics can include preparation for quit day; stress and nicotine withdrawal management; coping strategies; use of available family, friends, and healthcare team support; healthy eating; slip and relapse prevention; tobacco use trigger management; self-reward system; and positive reinforcement to continue to live as a non-smoker (U.S. Public Health Service Report, 2008). If staff and resources are available, high intensity and increased number of counseling sessions (more than eight sessions) can increase abstinence rates in older smokers.
Pharmacotherapy Treatment Approach
Pharmacotherapy treatment in conjunction with behavioral treatment can maximize a patient’s success (HHS, 2020). The use of pharmacotherapy is prescribed for approximately three to six months, but can last longer (Benowitz, 2009; Hsia, 2016; U.S. Public Health Service Report, 2008; HHS, 2020). FDA-approved medications for smoking cessation are nicotine replacement therapies (NRTs), including nicotine patches, gum, lozenges, oral inhaler, and nasal spray, and non-nicotine oral medications, including bupropion and varenicline (HHS, 2020).
‘Pharmacotherapy treatment in conjunction with behavioral treatment can maximize a patient’s success.’
Treatment of nicotine dependence with NRT should adhere to the principles of dose to effect based upon the patient’s nicotine dependence (U.S. Public Health Service Report, 2008; Hsia, Myers and Chen, 2016). Nicotine from cigarettes can affect several organ systems in the body. Once absorbed, nicotine induces a variety of central nervous system, cardiovascular, and metabolic effects (Benowitz, 2009).
Within seconds after inhalation from combustible tobacco, nicotine reaches the brain and stimulates the release of various neurotransmitters, including dopamine, which produces nearly immediate feelings of pleasure and relieves nicotine-withdrawal symptoms (Benowitz, 2009). The rapid nicotinic response reinforces the need to repeat nicotine intake, thereby perpetuating smoking behavior (Benowitz, 2009).
NRTs can alleviate the individuals’ nicotine withdrawal symptoms without the harm associated with tobacco. Potential withdrawal symptoms may include irritability, impatience, anxiety, difficulty concentrating, restlessness, hunger, depression, insomnia, and cravings (Benowitz, 2009). Most physical withdrawal symptoms manifest within twenty-four to forty-eight hours after quitting and gradually dissipate over three to four weeks; however, intense cravings for tobacco can persist for months or even years (Himstreet et al., 2013).
To optimize the benefit of NRTs, combining long-acting formulations such as a nicotine patch with a short-acting formulation such as gum, lozenge, nasal spray, or inhaler has shown to increase efficacy as compared to NRT monotherapy (HHS, 2020). NRT does not have a fast onset nor a high peak absorption like tobacco; therefore, it is less prone to induce addiction. NRT reduces withdrawal by allowing patients to be comfortable enough to work on behavioral and habitual changes and slowly reduce the chemical need for nicotine (HHS, 2020). Hence, combination NRT is more effective in reducing withdrawal and has demonstrated better cessation rates (U.S. Public Health Service Report, 2008; HHS, 2020). Choosing the NRT formulation should depend upon the individual’s level of tobacco addiction, product preference, tolerance, concomitant medical conditions, and administration feasibility. Precautions before initiating NRTs in older tobacco users include a recent history of myocardial infarction within the last two weeks, underlying severe arrhythmias or angina pectoris (HHS, 2020).
The use of nicotine gum for intermittent nicotine urges and cravings may not be ideal in some older adult smokers who have poor dentition or wear dentures and should be avoided (HHS, 2020). Instead, nicotine lozenges would be an excellent alternate option. Older adults with chronic nasal disorders or severe reactive airway disease should caution use with nicotine nasal sprays and inhalers, as they may exacerbate these disease states, especially with incorrect use (HHS, 2020).
Two non-nicotine oral medications with FDA-approved indications for tobacco cessation are bupropion and varenicline (HHS, 2020). Bupropion is available as the immediate-release formulation and sustained-release (SR) formulation, and 24-hour extended-release (ER) formulation; however, only the SR formulation is FDA-approved for tobacco cessation. Although all forms of bupropion also can be used as an antidepressant, the anti-smoking effect of bupropion does not seem to be related to the antidepressant effect, as the medication has been observed to be equally effective when used for smoking cessation in smokers with or without depression (Vogeler, McClain, and Evoy, 2015). A combination of bupropion SR and NRT can be used to optimize cessation outcomes (U.S. Public Health Service Report, 2008; HHS, 2020). The use of bupropion is not recommended in older adults with a history of seizure or concomitant therapy or conditions known to lower seizure threshold (HHS, 2020).
Also, bupropion therapy should be avoided in older adults with severe hepatic impairment (HHS, 2020). Although uncommon, monitoring of treatment-emergent neuropsychiatric symptoms is necessary, particularly in those older smokers with high risk for suicidal and homicidal ideations (HHS, 2020). When initiating bupropion, it is essential to recognize that the full benefit of bupropion in decreasing nicotine cravings may be delayed up to six weeks after starting therapy (HHS, 2020); therefore, tobacco users may begin therapy one to two weeks before their quit date (HHS, 2020).
Gradual dose titration during the first week of therapy has been recommended to improve tolerance (HHS, 2020). Bupropion may minimally elevate blood pressure; therefore, self-monitoring of blood pressure after initiating therapy may be beneficial in older adults with underlying hypertension. Duration of tobacco cessation therapy using bupropion is seven to twelve weeks, with maintenance therapy lasting up to six months in selected individuals (HHS, 2020).
Varenicline is the other non-nicotine oral medication approved for tobacco cessation management (HHS, 2020). Because of varenicline’s higher affinity for binding to the nicotinic cholinergic receptor than nicotine, varenicline leads to a reduction of the reinforcement and rewarding effects of nicotine (Vogeler, McClain, and Evoy, 2015). Varenicline use with bupropion or NRT has limited evidence, and further studies are needed to confirm both safety and efficacy (Vogeler, McClain and Evoy, 2015). Hence, varenicline is not currently recommended for use in combination with other tobacco cessation medications (Vogeler, McClain, and Evoy, 2015; HHS, 2020). Varenicline has to be dose adjusted older smokers with renal impairment is recommended (HHS, 2020). Therapy duration of varenicline is typically twelve weeks, although it may be extended to an extra twelve weeks in selected smokers based on tolerance and response (HHS, 2020). Severe nausea has also been associated with varenicline therapy; therefore, gradual dose titration and administration after a meal with a full glass of water can improve tolerance. Varenicline can be safely used in patients with stable mental illness but should be avoided in patients with uncontrolled mental illness as rare neuropsychiatric symptoms can occur. Similar to bupropion SR, monitoring for treatment-emergent changes in neuropsychiatric symptoms is recommended (HHS, 2020). Both bupropion SR and varenicline therapy may be safely discontinued without requiring dose tapering (HHS, 2020).
Smoking cessation provides immediate and long-term health benefits at any age. Therefore, it is never too late for an older adult to quit smoking. The combination of behavioral counseling with FDA-approved tobacco cessation medications can increase the successful quit rate in older smokers. Multiple approaches can be used to provide effective tobacco cessation treatment in older adults. With regular follow-ups and appropriate guidance provided by their healthcare team, these tobacco users will have a higher chance of successfully quitting tobacco use and improve their quality of life.
Lisa U. Nguyen, PharmD, BCGP, CDCES, is a clinical pharmacy specialist–Ambulatory Care at the Department of Veterans Affairs (VA) North Texas Healthcare System in Dallas, Texas. She can be contacted at Lisa.Nguyen2@va.gov. Timothy C. Chen, PharmD, MPH, BCACP, BCGP, directs the Tobacco Cessation Clinical Resource Center in the VA San Diego Healthcare System in San Diego, California.
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