Better late than never: smoking cessation

The National Institute for Health and Clinical Excellence (NICE) published its first piece of public health guidance on smoking cessation earlier this year¹. The guidance puts forward a set of recommendations aimed at all smokers and identifies a range of professionals who have a role to play in supporting smokers to give up. This paper outlines the main features of this guidance and highlights how it should be operationalised within the older smoking population

Effects of smoking on health

Smoking remains the leading cause of preventable morbidity and premature mortality in Great Britain. It is a major risk factor for four of the five leading causes of death. They include heart disease, stroke, cancer and coronary obstructive pulmonary disease (COPD). Of 118,900 deaths in 1995 caused by smoking nearly eight out of 10 (78 per cent) were among men and women aged 65 years and older². Among men aged 65 or older, smokers are twice as likely as non-smokers to die from stroke. The odds are nearly as high for older female smokers. The risk of dying from a heart attack is 60 per cent higher for smokers aged 65 years or older compared with their non-smoking counterparts³. According to the US Surgeon General’s report⁴ smoking lessens normal life expectancy by an average of 13 to 15 years, thereby eliminating retirement years for most smokers. In addition, older smokers can experience a reduction in the quality of their life. For example, smoking can aggravate existing health problems and increase the time needed to recover from many illnesses and major surgery^5,6. Smoking in later life has also be been associated with higher rates of physical disability, higher levels of depressive symptoms and lower levels of physical function⁷.

Prevalence of smoking

In 2004, 25 per cent of adults in Great Britain reported smoking. This varied with gender and age. Smoking prevalence among men was 26 per cent and among women 23 per cent. The lowest level reported was for those aged 60 and over (15 per cent for men and 14 per cent for women) and highest for those aged 20€“24 (36 per cent men and 29 per cent women). Among those aged 50€“59 around one out of four smoked (26 per cent men and 24 per cent women)⁸. Combining the figures for the two oldest groups suggests that around one in five adults aged 50 and over smoke cigarettes. Based on the mid-year population estimates for 2005 this amounts to around 4,068,960 smokers in Great Britain⁹.

Consumption of cigarettes was higher for men than women and also varied with age. The average daily consumption for men was 15 and 13 for women. Heaviest consumption was among those aged 50€“59; male smokers smoked on average 18 cigarettes a day and women smoked 15 a day⁸. Heavy smokers €“ defined as smoking 20 or more cigarettes a day €“ were much more likely than other smokers or ex-smokers to have started smoking at an early age. Of those who smoke 20 or more cigarettes a day 55 per cent of men and 48 per cent of women started smoking before the age of 16 compared with 28 per cent of men and 30 per cent of women who smoke less than 10 cigarettes a day⁸. A study by Jarvis et al¹⁰ defined ‘hardcore’ smokers’ as those who have not gone without a cigarette in the last five years, had made no attempt to quit in the last year and had no desire or intention to quit. These characteristics were most strongly associated with age, rising from five per cent among young adults aged 16€“24 to 30 per cent of smokers aged 65 and over classified as hard core smokers.

Benefits of smoking cessation

Although older smokers are likely to have smoked for longer, tend to be heavier smokers and are more likely to suffer from smoking related illnesses, quitting smoking can radically reduce their risks and the benefits will continue for years to come. There is evidence that even smokers who give up at the age of 65 gain an average of more than two years of additional life expectancy¹¹. Older smokers who quit have a reduced risk of coronary events and of cardiac deaths within one year of quitting. For those who have already had a heart attack, quitting smoking reduces their chances of another attack and in some cases ex-smokers can cut their risk of another heart attack by half or more¹². Other benefits include reductions in post-operative complications¹³.

Quitting smoking in later life

There is good evidence among the general population that a substantial number of smokers want to quit. For example in 2004, 67 per cent of male smokers and 69 per cent of female smokers said they would like to stop altogether and there has been little change since the question was first asked in 1992⁸. However, there is some evidence that this may diminish in later life. The reasons for the downward trend include lack of knowledge about the harms of smoking¹⁴ and beliefs that the damage has already been done and there are no health benefits¹⁵. An additional barrier to quitting smoking in later life is the attitude of health professionals. Kerr¹⁶ found that primary care professionals were less likely to refer older smokers for specialist smoking cessation support than younger people, in part because they feel that few older smokers will be able to stop successfully.

Older smokers can quit successfully

It is also clear that smokers can be successful in quitting smoking. In 2004, 28 per cent of men and 20 per cent of women claimed to be ex-smokers and the figures are substantially higher among older smokers. Among those aged 50€“59 the figure rises to 34 per cent for men and to 27 per cent for women. Among those aged 60 and over the figure rises to 50 per cent for men and 28 per cent for women⁸.

However, it is evident that smokers need help to quit smoking as more than half of smokers (52 per cent male; 57 per cent female) report they would find it difficult to go without smoking for a day and one out of six smokers (17 per cent male; 16 per cent female) claim to have their first cigarette within five minutes of waking. In older smokers, this help needs to take account of their knowledge and attitudes to quitting, their heavy nicotine dependence and the social context of their smoking. Attitude change within health professionals is also important as there is evidence older smokers are less likely to be offered smoking cessation advice and support¹⁷.

Smoking cessation interventions that have been effective in the general population have also been effective with older smokers⁴. Research has demonstrated the efficacy of range of treatments including brief advice; pharmacotherapy, intensive one to one counselling and group therapy^18,19,20. The next section outlines a specific strategy for practitioners (or clinicians) to support smokers to quit. It is important to bear in mind that smokers are likely to require repeated intervention as many attempts to stop smoking end in failure.

According to guidance recently issued by NICE, all smokers should be advised to quit. Smokers who are not ready to quit should be asked to consider the possibility and encouraged to seek help in the future. If the smoker presents with a smoking related disease the advice may be linked to their medical condition. NICE guidance also recommends that the most effective treatments be offered first. In practice, this means offering the more intensive treatments initially as there is a strong relationship between the intensity of a treatment and its effectiveness. The more intensive treatments include one-to-one counselling or group therapy, both of which can, but not necessarily, include pharmacotherapy, and are offered by the NHS stop smoking services.

For smokers unwilling or unable to take up the referral for more intensive support, NICE guidance recommends that pharmacotherapy be offered in line with the NICE technology appraisal guidance no 39. For smokers unwilling to use intensive treatment or pharmacotherapy NICE recommends they be given brief advice on how to quit and a helpline number. The brief advice that was found to be effective typically takes between five to 10 minutes and includes one or more of the following:

• simple opportunistic advice to stop;
• an assessment of the patient’s commitment to quit;
• an offer of pharmacotherapy and/or behavioural support;
• provision of self-help material and referral to more intensive support such as the NHS stop smoking services.

The particular package that is provided will depend on a number of factors, including the individual’s willingness to quit, how acceptable they fi nd the intervention on offer and the previous ways they have tried to quit.

Conclusion

Practitioners (or clinicians) area ideally placed to intervene with their patients who smoke. By asking patients routinely about their smoking, assessing their commitment to quit and providing effective support to quit, practitioners can contribute to a reduction in the level of smoking and its health consequences.

Key points

• It is never too late to benefit from giving up smoking; there is evidence that even smokers who quit at the age of 65 gain an average of more than two years of additional life expectancy.
• Until now, older smokers have largely been ignored by health professionals and there is evidence that older smokers are less likely to be offered smoking cessation advice and support.
• Older smokers can quit successfully if they receive support that takes account of knowledge and attitudes to quitting, their heavy nicotine dependence and the social context of their smoking.

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Drs Lesley Owen and Antony Morgan

Conflict of interest: Drs Lesley Owen and Antony Morgan were part of the team that led the development of the NICE public health intervention guidance no 1 described in the article.

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References

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