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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 70-77

Smoking and tobacco use cessation in the elderly

Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Submission08-Jun-2020
Date of Decision04-Jul-2020
Date of Acceptance22-Jul-2020
Date of Web Publication21-Jan-2021

Correspondence Address:
Dr. Siddharth Sarkar
Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgmh.jgmh_23_20

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Smoking and tobacco use are the most used psychoactive substances globally, with an estimated population of more than one billion users across the world. It is a significant public health problem and is associated with a multitude of adverse health consequences, particularly in the elderly population, such as various types of neoplasms, cardiovascular and respiratory illnesses, delayed wound healing, and cognitive deficits. It has been seen that the adverse consequences are reduced in past smokers/tobacco users who have eventually become abstinent as compared to active smokers/users. Effective treatment strategies are available to assist individuals in quitting smoking or tobacco use. It is especially important in the elderly as their mobility is reduced, and so is their motivation to quit, mainly due to the longer duration of tobacco use and insufficient knowledge about its adverse effects than the younger population. It is worthwhile to understand the impact and the measures of assessment and treatment to improve the health outcomes in the elderly. This review intends to present clinically relevant aspects of smoking and tobacco use in the elderly, including epidemiology, predictors and risk factors, adverse impact on physical health, and assessment and management of tobacco use and smoking.

Keywords: Counseling, cultural, geriatric, NRT, substance use

How to cite this article:
Sarkar S, Chawla N, Dayal P. Smoking and tobacco use cessation in the elderly. J Geriatr Ment Health 2020;7:70-7

How to cite this URL:
Sarkar S, Chawla N, Dayal P. Smoking and tobacco use cessation in the elderly. J Geriatr Ment Health [serial online] 2020 [cited 2021 Sep 21];7:70-7. Available from:

  Introduction Top

Smoking and tobacco use are among the most common psychoactive substance use worldwide. Although the prevalence rates of smoking and tobacco use are gradually reducing in recent decades, it is estimated that globally, there are 1.3 billion tobacco users.[1] High rates of tobacco use have been reported from all the continents. Tobacco use and smoking are quite prevalent in the older population as well. Evidence from large-scale population studies suggest that about one in eight elderly may be using tobacco products.[2],[3]

Smoking and tobacco use in the elderly has been associated with considerable adverse health consequences. It is associated with increased rates of chronic obstructive pulmonary disease, myocardial infarctions, and many types of neoplasms. It is also associated with poorer wound healing and accentuated cognitive decline. Effective treatment approaches have been developed for tobacco use disorders. The use of psychological and pharmacological interventions can reduce the use of tobacco products and the consequent harms related to tobacco.

Although there are reviews on smoking and tobacco cessation in the elderly, many of them have looked at specific aspects like epidemiology and treatment effectiveness. An integrated review can present the various clinically relevant aspects of smoking and tobacco cessation in the elderly population. Thus, this review aimed to assess the prevalence, predictors and risk factors, health impact, assessment, and treatment of elderly with smoking or tobacco use.

  Methods of the Review Top

This narrative review used Medline and Google Scholar databases for searching literature on smoking and tobacco use in the elderly. The keyword combination used was (smoking OR tobacco) AND (elderly OR geriatric) AND (prevalence OR incidence OR predictors OR “risk factors” OR “Health impact” OR morbidity OR “medical illness” OR assessment OR treatment). Additional searches were made for certain aspects such as hookah use in the elderly. The review included varied types of studies, including systematic reviews and meta-analysis and observational and interventional studies. Nonempirical studies were used for formulating the assessment section. Hand searches and contacting experts were not done as a part of the review. The searches were carried out in May 2020. Relevant literature from the included studies was extracted. The findings were summarized and synthesized qualitatively and presented in different sections of the review. Wherever applicable, recent reviews were referred to for the presentation of the literature. Quantitative synthesis or quality appraisal of the literature was not done as a part of the review.

  Prevalence of Smoking and Tobacco Use in the Elderly Top

Tobacco use among the elderly in various forms is widely prevalent all over the world. A systematic review by Marinho et al.[3] assessed tobacco use among elderly. They included 48 studies of either community-dwelling elderly or adult populations, which included the elderly. The definition of tobacco users varied across the studies, e.g., smoking daily, or who sometimes smoked at the time of examination, smoking more than one cigarette weekly for the last few months before the study. The sample sizes ranged from 52 to 40,146 subjects with a median sample size of 1,233 participants. The overall prevalence of tobacco use was found to be 13.5' (95' confidence intervals of 12.0' to 15.1'). The prevalence rate of tobacco use among men was 22.5', which was much higher than the prevalence figure of 8.7' among women. The highest prevalence rates of tobacco use were found in North America, followed by Europe, Asia, and then Latin America.

Several large-scale studies that have reported on the prevalence of tobacco use have been published since the review published by Marinho et al.[3] A representative survey was conducted among 3,071 elderly across 17 European countries in 2010.[2] The authors found that 11.5' of the surveyed population were current smokers, and 23.5' were past smokers. The smoking prevalence was higher in men as compared to women. The prevalence of current smokers varied considerably across the countries, from 6.6' in Austria to 30.3' in Albania. The data from the China Health and Retirement Longitudinal Study[4] reported findings of 19,841 elderly individuals from a nationally representative sample. In this study, 31.0' of the population were reported to be current smokers, and 10.1' of the population were reported to be former smokers. In a study from the USA, which used data from the Health Information National Trends Survey 2015 cycle (HINTS-FDA),[5] 3738 Americans were surveyed. It was seen that the prevalence of current smoking in the elderly population (aged 65 and above) was 10.5', which was less as compared to 50–65 years age group. In a study in a nationally representative sample of 8397 participants in Brazil, the prevalence rate of current smokers was 17.1' and that of former smokers was 37.5'. Religion has been explored as one of the determinants of tobacco use in the elderly, and it has been suggested that those individuals who have greater religious disposition are less likely to use tobacco products.[6]

Studies are available from India as well, which have presented the rates of smoking and tobacco use in the elderly population. In the India Human Development Survey (IHDS; 2011–12) conducted among 39,493 elderly individuals in a nationally representative survey,[7] it was seen that 40.2' of the population was daily smokers, and 52.0' of the population were daily users of chewed tobacco. The Global Adult Tobacco Survey (GATS) in India suggested that the prevalence of exclusive smoked tobacco in elderly aged 65 years and above was 22.1', exclusive smokeless tobacco use was 24.7', and dual (smoked and smokeless tobacco) use 8.9'.[8] This translated to a prevalence rate of 55.7' of tobacco use in any form. Several community-based surveys are also available that have looked into the prevalence rates of tobacco use in the elderly in India. A study from slums from the North Eastern region of India reported 80.8' of those aged 55–64 years, and 72.7' of those aged 65 years and above were current consumers of tobacco.[9] In another study from Chennai among 1425 aged 55 years and above, the prevalence rate of any tobacco use was 29.8', with a prevalence rate of smoked tobacco being 17.4' and the prevalence of smokeless tobacco being 12.4'.[10] In a study from Faridabad among 1117 elderly, the prevalence of smoking was 71.8' in men and 41.4' in women.[11] A recent study from Ujjain among elderly population found that 55.4' of the elderly were tobacco users with 31.1' of the participants being smoked tobacco users, 47' being smokeless tobacco users, and 22' were dual users.[12] The rate of tobacco users was higher in women in this study. Another study from Palwal, Haryana, found that the prevalence of hookah smoking was 36.4' among elderly women.[13]

Thus, the literature suggests that tobacco use may be common in the elderly population. The prevalence rates of tobacco use seem to be higher in men than in women. There are geographic variations in the prevalence rates of tobacco usage. Smokeless tobacco use seems to be common in India, which is in frequently reported in Western literature. In fact, studies suggest that smokeless tobacco users may outnumber smokers in some regions.

  Predictors and Risk Factors Of Smoking and Tobacco Use in the Elderly Top

Several predictors of smoking and tobacco use in the elderly have been studied. One of the consistent findings has been prevalence of tobacco use being lower among elderly women as compared to men.[3],[11] This reflects the general gender distribution among adults,[14] and reasons for smoking, individual reactions to nicotine, cultural influences, and expected roles may be an important reason for this difference. Waterpipe or hookah use in the elderly has been found culturally ingrained in Indian subcontinent and the Middle East.[11],[15] Age has also been remarked as a predictor of smoking and tobacco use. There has been some suggestion that among the elderly, as the age increases, the prevalence rates of tobacco use may go down.[11],[16],[17],[18] This may be related to mobility and cognitive issues, or greater rates of medical morbidity leading to quit attempts. Positive association with education, and negative association with poor health perception, and not being married have also been discussed by some authors.[19]

Smoking has been linked to alcohol use in the elderly population. A study from Brazil among elderly individuals found that current smoking status was associated with alcohol abuse.[20] Results from the National Survey on Drug Use and Health also found that in the elderly population, smoking had an association with binge drinking, both in men and women.[21] Literature from India also suggests that alcohol use occurs more commonly with smoking, than otherwise, and increasing frequency of tobacco use was associated with an increasing use of alcohol use.[11],[22]

  Sociocultural Influences on Smoking and Tobacco Use Among Elderly Top

Social and cultural factors have been seen to affect the use of tobacco in smokeless as well as smoking form. Sociocultural factors may be determined by many factors such as the place of residence, education, occupation, and type of family. For example, tobacco is commonly consumed as bidi in India, in the form of hand-rolled cigars in Cuba, and mixed with clove in Indonesia.[23] Conventionally, it was observed in the Indian subcontinent that younger generations smoking with their elders is not acceptable. In joint families of India, smoking was considered a taboo. With the concept of nuclear families taking over the joint family structure, the prevalence of tobacco use rose. Women in India are not expected to smoke and hence the reported prevalence in women is lower than in men. Overall, smokeless/chewable tobacco is less stigmatized in India than smoking, explaining higher prevalence of smokeless tobacco as compared to smoking.[24],[25],[26]

Various authors have pointed out that lower socioeconomic status or disadvantaged group have higher prevalence of tobacco use and tobacco-related harms. Their chances of quitting tobacco successfully are also lower due to poor motivation, poor community support, more severe dependence, less likelihood of completing pharmacotherapy or nonpharmacological treatment, poor self-efficacy, or involvement in marketing of tobacco.[24] Even the type of tobacco product smoked may vary based on the socioeconomic status. For example, individuals with lower socioeconomic status are seen to smoke “bidi,” while those with higher socioeconomic status are more likely to smoke cigarettes.[26]

In a cohort study done on 81837 males in India, it was seen that the risk of smoking tobacco was higher in illiterate participants than college-educated students. After controlling for age and education, the type of occupation showed significant differences; professionals were less likely to smoke than unskilled workers, male service workers, and unemployed individuals. Overall, smokeless tobacco use was more prevalent than smoking across all occupational groups. The prevalence of 'bidi' smoking was higher in men with lower educational attainment, while cigarette was smoked by those with the highest educational attainment.[26] Even on secondary analysis of GATS 2009–2010 (69,030 respondents), in most states of India, decreasing odds of tobacco consumption was seen with increasing wealth.[25]

A qualitative study from Australia on 12 male and eight female smokers aged 50 years or more used semi-structured face-to-face interviews. Some of the important groups embedded in participants' social network that encouraged smoking or abstinence included family, friends, and physicians. Smokers' family members (e.g., brothers) and friends were considered as facilitators of smoking, while nonsmokers' family members and friends were considered barriers to smoking.[27] Another qualitative study done among the south Asians (21 focused groups discussions, comprising four to eight members per group) residing in the US about the culture-specific tobacco use observed high use rate of a considerable number of culturally-specific products among this population, e.g., “gutka,” “paan,” “paan masala,” “niswar,” “zarda,” and “bidi.” Many such culture-specific products were perceived to have beneficial effects and were used to preserve cultural traditions and specific ethnic identity in a new dominant culture.[28]

Since there are socioeconomic and cultural disparities in the prevalence and the type of tobacco product used, the intervention also varies according to the target population. It is, hence, important for the tobacco control policies and public health interventions to consider this widespread disparity.

  Impact of Smoking and Tobacco Use on Medical Comorbidity and Elderly Patient Outcomes Top

Smoking has been associated with increased rates of mortality.[29],[30] Almost 70' of deaths due to smoking occurs over the age of 60 years.[31] In a meta-analysis that included 489,056 participants in 22 population-based cohort studies aged 60 years and above, current smokers had 2-fold, and former smokers had 1.3-fold increased all-cause mortality compared with never smokers.[30] This translated into 6.4 and 2.4 years of premature deaths (quantified as risk enhancement period), respectively. The investigators found a dose–response relationship between smoking and deaths. As compared to younger smokers, where the most common cause of mortality is cardiovascular events, in smokers more than 60 years of age, lung cancer is the most common cause of mortality. At even older age groups, mortality due to chronic obstructive lung disease equals cardiovascular events.[31]

Smoking has been associated with the impairment of several organ systems. Smoking results in multiple cardiovascular adverse outcomes. It has been seen that smoking leads to more than a two-fold increased risk of myocardial infarction, stroke, and cardiovascular mortality and deaths due to cardiovascular causes.[32] Mons et al.[33] conducted a systematic review and meta-analysis of the cardiovascular outcomes of elderly smokers among 25 population cohorts with a pooled sample of more than half a million individuals. It was seen that smoking status was associated with two-fold increased rates of cardiovascular mortality and acute coronary events and about one and half fold increased risk of stroke. The risk was lower in former smokers, but still higher than nonsmoker population.

The relationship of smoking with cancer risk and mortality has also been looked at by Consortium on Health and Aging: Network of Cohorts in Europe and the United States (CHANCES).[34] During an average follow-up of 12 years in this meta-analysis of cohort studies, 140,205 subjects had a first incident cancer, and 53,164 died from cancer. Current smoking advanced the overall risk of developing and dying from cancer by 7.9 and 9.9 years, respectively, compared with never smokers. Current smokers had 1.4 and 2.2 times risk of developing cancer and dying of cancer, respectively. Lung cancer had the greatest increase in cancer risk and mortality, while breast cancer had the least increase in risk. Smoking cessation predicted deferment of risk of cancer occurrence and mortality compared with sustained smoking.

Smoking has been related to the occurrence of respiratory problems as well. It has been seen in cohort studies that smoking resulted in greater rates of occurrence of chronic obstructive pulmonary disease.[35],[36] Smoking status has been linked to frailty in the geriatric population. In a systematic review, four out of five studies found baseline smoking to be associated with developing frailty or worsening frailty status at follow-up.[37] Pooled analysis of cohort studies has also suggested that smoking was associated with about 25' increased rates of fractures in the elderly.[38]

The relationship of smoking with cognitive decline and dementia has been evaluated by Peters et al.[39] The authors found that five studies demonstrated a significant link between current smoking and risk of incident dementia, seven demonstrated a significant link between current smoking and cognitive decline, and six did not find a link between current smoking and dementia or cognitive decline. Current smokers (but not former smokers) had 1.6 times increased risk of developing Alzheimer's dementia. Similar results were reported by subsequent cohort studies from Japan and China as well.[40],[41] It has been seen that an incident diagnosis of dementia may not result in smoking cessation or reduction of tobacco use,[42] though tobacco use may decrease in the overall population of dementia patients, signifying the possible role of cognitive decline in procurement and use of tobacco products.[43]

Smoking has been associated with adverse outcomes in elderly patients who undergo surgery. Zhang et al.[44] reported that after adjusting for confounding factors, smoking history was associated with about 1.8 times the risk of postoperative pulmonary complications such as respiratory infections, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, and aspiration pneumonia. Apart from this, tobacco use in the elderly women in the form of hookah has been associated with anemia.[13]

Thus, smoking and tobacco use is associated with several adverse health outcomes in the elderly population. Premature deaths can be attributed to smoking, and the risks reduce after quitting. There are financial costs as well to smoking and tobacco use, which is less frequently discussed in the literature.

  Tobacco Use and Psychiatric Comorbidity and its Impact on Tobacco Cessation Top

Inferences can be drawn from the existing literature on adults for many types of psychiatric comorbidities. The use of tobacco is associated with various psychiatric comorbidities, both substance related and nonsubstance related. The prevalence of smoking is seen to be higher among those with psychiatric disorders. More than three-fourths of individuals with affective or nonaffective psychosis smoke.[45] The data from 2008 to 2009 US National Surveys on Drug Use and Health (n = 10,891) showed that the odds of binge drinking and other drugs use were higher in adults aged 65 years or more who were smoking in the past 1 year.[21] A cross-sectional survey on 100 patients attending the dental outpatient department with a history of tobacco use was compared with 100 patients with no history of tobacco use (comparable mean age of 40 years). On applying General Health Questionnaire-28, it was seen that 61' of tobacco users as compared to only 17' of nonusers scored above 24 in the questionnaire, indicating that users had more than seven times risk of developing psychiatric comorbidity than nonusers.[46] A study done on elderly attending psychiatric emergency settings in a tertiary care hospital (n = 300) in North India showed that almost one-third of such individuals had comorbid tobacco dependence.[47]

Although it is known that patients with psychiatric morbidity are more likely to be smokers and suffer from severe dependence, they are not less likely to be willing to quit smoking than controls. More than 50' of individuals suffering from psychiatric illness or on psychotropics are likely to attempt quitting. The interventions in such patients can be in the form of brief intervention during routine follow-ups. It is even observed that individuals with psychiatric illness are more likely to receive abstinence advice than individuals without any psychiatric illness using tobacco. However, the prescription of nicotine replacement therapy appears to be low.[45] Interestingly, one study suggested that depressed women, but not men, are more likely to be able to be successful in smoking cessation.[48] A study from Korea, however, found that depressed individuals were less likely to quit smoking than those who were not depressed.[49]

  Benefits of Smoking Cessation in the Elderly Top

Smoking cessation has been associated with better outcomes in individuals who have quit smoking. As compared to younger individuals, the benefits are seen to be somewhat slower in the elderly, but still, the most effective way to reduce smoking-related health risks.[31] Gellert et al.[32] studied a population-based cohort of elderly individuals and looked at the cardiovascular outcomes. The cohort had 17.2' of current smokers and 31.7' of former smokers (the rest 51.1' being never smokers). Compared to never smokers, adjusted hazard ratios of current smokers were 2.25, 2.12, and 2.45 for myocardial infarction, stroke, and cardiovascular death, respectively. The investigators found a strong dose–response relationship between these outcomes with current and life-time amounts of smoking. The excess risk of worse outcomes waned within 5 years after smoking cessation. This provides credence to the beneficial effects of smoking cessation in the elderly. Similarly, the literature suggests that smoking cessation has been associated with a reduction in the all-cause mortality rates, cancer occurrence rates, cancer mortality rates, incidences of stroke, and acute coronary events in individuals.[33],[34] Smoking cessation has also been reported to be associated with a reduction in the rates of dementia.[40]

Smoking cessation has been found to be associated with better outcomes in patients who undergo surgery. Zhang et al.[44] reported lower rates of postoperative pulmonary complications among former smokers as compared to former smokers. Zhao et al.[50] found that compared with nonsmokers, male patients with a high degree of nicotine dependence experienced more severe pain and required treatment with more sufentanil after thoracoscopic radical lung cancer surgery when deprived of cigarettes. The authors also found that smoking cessation done at least three weeks before surgery had better postoperative pain outcomes than cessation done within three weeks of surgery.

Factors that predict the cessation of smoking in the elderly have been studied by various authors. For example, Cohen-Mansfield observed in a longitudinal prospective study carried out on 619 older individuals aged 75–94 years, that loneliness predicted continuation of smoking, and higher medication use for physical problems and cognitive deficit predicted greater quit rates.[51] Another prospective cohort on 573 elderly individuals showed that women smokers, and those who showed a trend toward a greater likelihood of cancer diagnosis recently, had higher chances of quitting.[52] Some more factors predicting cessation in the elderly, which have been highlighted in the literature, include good motivation, being married to a nonsmoking spouse, hospitalization at the time of consultation, or having significant abstinence attempts in the past.[53]

  Assessment Considerations for Elderly Patients who Use Tobacco Top

Assessment of an elderly individual for tobacco cessation consultation may be called for in two situations. In the first situation, the individual encounters a health problem and is suggested to quit smoking. In the second situation, the individual seeks help to cease the use of tobacco anticipating future adverse consequences. Tobacco cessation follows some of the elements of management of other substance use disorders.[54],[55] Screening, brief intervention, and referral to treatment is one of the important approaches for smoking/tobacco cessation. This comprises screening, which can be done in the medical setting during the clinical encounter, brief intervention to counsel for tobacco cessation, and then referral for further treatment where required.[56] The aim of the evaluation is to ascertain whether the tobacco use in a pathological pattern and warrants and diagnosis and formulating a management plan (and in some circumstances using principles of motivational interviewing to nudge the patient toward reduction or cessation of tobacco). A scheme for evaluation of an elderly patient with tobacco use is presented in [Box 1].

Some elements of evaluation have salience for an elderly individual with tobacco use. As compared to the younger population, the elderly population have a longer duration of use and are less aware of the potential harms of tobacco use or smoking and the possible benefits of quitting. Moreover, they may have also experienced failed attempts at quitting in the past. Thus, their motivation may be poor.[3],[57] However, it has also been emphasized that although the elderly are less likely to attempt to quit smoking than younger individuals, their attempts are more likely to be successful.[31] Hence, motivational interviewing techniques using a nonconfrontational approach, expressing empathy, and giving hope might help the individual to consider quitting more favorably. Another perceived hindrance pertains to ageism, wherein the treatment providers may not feel too inclined to make efforts to change the tobacco consumption pattern. However, it has been seen that quitting tobacco has benefits even in the elderly age groups and thus efforts for tobacco cessation are required. Many a time, family members may facilitate tobacco use and may give a normative explanation to overlook or justify tobacco use. Educating the family members and involving them in the treatment process may help to get better outcomes.[58]

A consideration for the clinician is whether to diagnose a substance use disorder. Diagnoses that are generally entertained include tobacco harmful use and dependence according to the International Classification of Diseases and Health-Related Conditions,[59] or tobacco use disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.[60] Either of the diagnostic systems is useful, but requires time for application and practice to make a reliable diagnosis. Sometimes, information may not be forthcoming due to recollection problems or willful concealment. A provisional diagnostic impression may then be relied on in such circumstances to provide treatment interventions. Furthermore, in brief encounters, intervention like brief intervention can be provided without due process of diagnostic ascertainment being completed. Assessment instruments are available and have been used in the elderly population. Alcohol Smoking and Substance Involvement Test is one such instrument that can be used to ascertain the problematic use of tobacco.[61] Similarly, the Fagerström Test for Nicotine Dependence can be used to assess the severity of tobacco use.[61]

  Treatment Approaches for Smoking and Tobacco Cessation in the Elderly Top

Several treatment approaches for tobacco cessation have been used in the elderly. These can be categorized into pharmacological and nonpharmacological approaches for the simplicity of classification. However, before that, certain considerations for tobacco use cessation in the elderly are depicted in [Box 2].

  Pharmacological Approaches Top

The pharmacological approaches that have been well studied and found to be effective in the adult population are nicotine replacement therapy, bupropion, and varenicline.[62],[63] Nicotine replacement therapy is available in the form of chewing gum, nicotine patches, sprays, inhalers, and lozenges. Nicotine replacement therapy can be used in the elderly population using similar principles as in adults.[64] It acts not only by reducing the withdrawal symptoms, but also reduces the reinforcing effects of nicotine released from tobacco products, and maintains the desired mood and attention state to keep the person away from tobacco products.[65] Studies have shown that nicotine replacement therapy can be used in the elderly safely, and is helpful in increasing quit rates.[66],[67]

Bupropion and varenicline are antidepressant and nicotine receptor partial agonist respectively, which have been shown to be effective in a reduction in smoking but reducing craving. Bupropion has been reported to be useful for smoking cessation in the elderly population. A 52-week randomized controlled study in which patients were randomized to either placebo, bupropion 100 mg/day, bupropion 150 mg/day, and bupropion 300 mg/day (bupropion given for seven weeks) reported outcomes separately for elderly population as well.[68] It was seen that the outcomes for bupropion were better in the elderly groups than the younger study population. Combination treatment of older adults using nicotine replacement treatment and bupropion has been used and has been found to be beneficial.[69]

Similarly, a 52-week randomized trial of varenicline with the mean age of the participants around 57 years gave varenicline for 12 weeks.[70] It was seen that the varenicline was associated with greater rates of carbon monoxide-confirmed abstinence rates. The most common adverse events in the varenicline group were nausea, abnormal dreams, upper respiratory tract infection, and insomnia.

The majority of the medications and regimen mentioned above have approved for smoking. While no drug is approved for smokeless/chewable tobacco, the same therapy is often extrapolated. One of the earliest trials for employing NRT in smokeless tobacco was done almost 6 years after it was approved for smoking. NRT (2 mg nicotine gums) versus placebo was compared in 100 patients using chewable tobacco in a randomized, double-blinded, placebo-controlled trial. No significant differences were found after 6 weeks.[71] Similarly, no significant differences were found with 1, 2, and 4 mg nicotine gums in 60 patients over 5 days.[72] The results for other forms of NRT (lozenges, patches) are also equivocal. The evidence for the use of bupropion for smokeless tobacco is also low. These agents may enhance short-term tobacco abstinence and abstinence associated weight gain, respectively. The only agent found to have positive effects on long-term abstinence, i.e., six or more months, is varenicline.[65],[73] Other nontobacco substitutes have been emphasized, such as sunflower seeds, chewing gum, hard candy, beef jerky, herbal chews, toothpicks, cinnamon sticks, and coconut/mint snuff substitute.[65]

  Nonpharmacological Approaches Top

The World Health Organization has described the five As and five Rs model to be employed by a primary care provider to help someone quit smoking or tobacco use. Five As model is used to help someone who is ready to quit, while five Rs is used for increasing someone's motivation who is not ready to quit.[66] Five As include Ask, Advise, Assess, Assist, and Arrange. This means asking the patient in every visit routinely about tobacco use, advising, and persuading them to quit. The advice should be clear, strong, and personalized. Next step is an assessment of their readiness to quit. If the person is ready to quit, the clinician has to assist (acronym STAR: Set a quit date, Tell a family/friend to help the patient quit, Anticipate challenges, Remove tobacco products from patient's environment) and arrange schedule for follow-up and referral wherever needed. Five Rs include Relevance, Risks, Rewards, Roadblocks, and Repetitions. Relevance is important in helping a person quit, as someone may want to quit because of physical harm caused by tobacco, while someone else may quit as tobacco is causing interpersonal difficulties with the spouse. The individuals should be appraised of, and made to identify for himself, the risk of smoking/tobacco use, and the rewards or benefits one may achieve on quitting. The individual should also be made to identify the barrier (roadblocks) to quitting. Eventually, the approach mentions the need for repetition of assessment of motivation and repeating the model at a later date.[74] Specific challenges of counseling in older patients may include slowed cognitive processing, leading to the need to repeat the message, and keeping the message simple.

Counseling approaches for the elderly population has been found to be helpful in reducing tobacco usage.[66],[75],[76] Counseling approaches emphasize on enhancing the motivation to quit. In a randomized controlled study (n = 402 smokers using more than 10 cigarettes, 50 years of age or beyond), all individuals completed 12 weeks of nicotine replacement therapy, group counseling and bupropion. They were then randomly assigned to one of the four groups (i) standard treatment (i.e., no further treatment); (ii) extended cognitive behavior therapy (11 sessions over a 40 week period); (iii) extended nicotine replacement treatment (40 weeks of nicotine gum availability); and (iv) combination of extended cognitive behavior therapy and extended nicotine replacement.[69] It was seen that extended cognitive behavior therapy alone had an additional beneficial effect on the outcomes in terms of abstinence rates, as compared to standard treatment/nicotine replacement alone/combination. In another study, behavioral training coupled with nicotine replacement had the best abstinence rates compared to behavior training, behavioral training, and physical exercise, and physical exercise only.[77] Many of the studies use a combination of nonpharmacological approaches and pharmacological approaches. Outcomes are seemingly better when both approaches are combined.[61],[69] This echoes the findings of studies in adults wherein best outcomes are found when pharmacological and nonpharmacological approaches of treatment are combined.[78] Since mobility has been an issue for the elderly, mobile services have also been tried to make treatment access easier.[66]

  Conclusion Top

Tobacco use and smoking are common in the elderly. While smokers outnumber chewable tobacco in western countries, the situation is reversed in the Indian sub-continent. The use of tobacco products is associated with premature deaths due to various factors, the risks of which reduce with quitting. Screening, brief intervention, and referral to treatment is one of the important approaches for smoking cessation. Elderly users differ from younger smokers and tobacco users in terms of longer duration of use, poor awareness of the adverse effects, and poor motivation. Hence, motivational interviewing plays an even more important role. Combinations of pharmacological (nicotine replacement/bupropion/varenicline) and nonpharmacological approaches have revealed the best results. Clinicians need to focus on helping elderly tobacco users quit to improve their overall health condition.

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Journal of Substance Use. 2021; : 1
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