Barry Goldlist, MD, FRCPC, FACP
Cigarette smoking remains the leading cause of preventable morbidity and premature death in North America, despite the recent decline in the prevalence of smoking. Data from the United States reveals that in those over age 60, smoking is a major factor in 6 of the 14 leading causes of death, and a complicating factor in three others. The current cohort of elderly includes large numbers of women who never smoked so the overall prevalence of smoking in the elderly is lower than for the population as a whole. However, this gender difference in smoking is shrinking (or even disappearing in some age groups) and the middle-aged cohort of smokers (45 to 64 years of age), has the same proportion of smokers as the population as a whole. This suggests that over the next two decades, we will continue to see large amounts of smoking-associated morbidity among the elderly.
There is now compelling evidence that stopping smoking is a worthwhile endeavor even in old age. It was reported in the British Medical Journal as long ago as 1977, that stopping smoking in old age could slow the progression of chronic airflow obstruction. Loss of physiological reserve is one of the major causes of the common geriatric syndromes that result in functional impairment. It is therefore apparent that maintaining such reserves is frequently the difference between dependence and independence in old age. As well, duration of smoking is a key factor in the development of lung cancer, so it can be expected that stopping smoking, even among the elderly, will also reduce the incidence of lung cancer. There is now data that also shows similar beneficial effects of stopping smoking on complications of vascular disease.
Unfortunately, the perception remains that it is not worthwhile for the elderly to stop smoking, and even if it were, it could not be done. This is incorrect. Not only do the elderly benefit from stopping; the current evidence is that they are just as likely to stop as younger individuals (although specific data is limited).
What does this mean to the practicing physician? First, it is important to determine whether your elderly patients smoke or not. For all those who actively smoke, a formal smoking cessation program should be offered. Although these are successful in the elderly, most patients will prefer to try quitting smoking on their own, at least initially. Their doctor must be available to provide the appropriate counseling and support. It is a misconception that nicotine replacement therapy is unsafe in the elderly. As recently documented in the Ontario Medical Review, smoking is almost always riskier than nicotine replacement therapy.
In summary, there are relatively few interventions physicians can provide their elderly patients with that are as beneficial as helping them stop smoking. It is important that we offer our help in stopping smoking to all our patients, including the elderly.
For more information on smoking and the elderly, read "Nicotine Substitution Aids Smoking Cessation" in the March/April 1999 edition of Geriatrics & Aging, or on our Web site at www.geriatricsandaging.com. You can also read about the smoking behaviour of Canadians on the Health Canada Web site at: http://www.hc-sc.gc.ca/ main/lcdc/web/bc/nphs/.