Age and Ageing Advance Access originally published online on July 29, 2008
Age and Ageing 2008 37(5):490-491; doi:10.1093/ageing/afn137
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What determines the ability to stop smoking in old age?
There was a time, not so long ago, when there was thought to be no clinical reason for an elderly smoker to quit the habit. We now have a substantial body of evidence that such an assumption is incorrect, and that there are meaningful benefits in terms of physical and mental function, general health status and survival for the older person who is able to stop smoking. For example, subjects who continued to smoke were found to have reduced mobility, earlier loss of mobility, a higher prevalence of chronic ill health and lower quality-of-life scores when compared to matched ex-smoker contemporaries [1]. Further, in another large study, elderly ex-smokers had lower risks of death from lung cancer, several other cancers, stroke and cardiovascular disease compared with current smokers [2]. The adverse effect of current smoking on physical performance in elderly women has been shown to be particularly clear, leading to a lower mean walking speed and reduced grip strength, probably mediated through the effect of smoking on vitamin D metabolism, and possibly by a direct effect on skeletal muscle [3]. Also, there is some evidence of a positive effect on life expectancy if people stop smoking in early old age [4]. These subtle but important potential benefits of smoking cessation (SC) in older adults should now be viewed as part of the justification for encouraging people to stop smoking, alongside the huge and clear health gains from SC earlier in life or lifelong non-smoking [5]. Consequent upon the evidence, it has been argued that SC in older adults should receive the same attention as other modifiable risk factors such as hypertension and diabetes [6]. How might this be achieved?Clinicians are familiar with the difficulties of SC at any age, and the general experience of SC being more difficult in old age has been confirmed in some studies [6–9], though older people have been found to be as willing as younger adults to try to give up smoking [6]. Among older patients, a number of barriers to SC have been found in formal studies that will come as no surprise to the practising clinician. These include a belief that ‘the damage has already been done’ or scepticism about the harm caused by smoking [10]. For some people there was also emphasis on the positive aspects of smoking, such as it being an integral part of the smoker's social lifestyle [9]. This has led to a search for predictors that enable the identification of people likely to have a successful outcome from interventions to support SC. Factors associated with sustained quitting in elderly adults included living with others, abstinence from alcohol, shorter smoking history and a history of smoking more cigarettes per day [8]. Final SC in older patients has also been found to be associated with a critical change in health status, such as a hospital admission for an acute respiratory or cardiovascular illness [9, 11]. Similar questions have been posed as to the benefit of pharmacological interventions to support SC. There is a dearth of studies specifically addressing the use of drug treatments to aid SC in old age. However, nicotine replacement therapy (NRT) alongside structured personal support was found in one study to lead to a higher SC success rate, particularly for older men with high anxiety levels [11].
From all the SC literature it is clear that successfully quitting requires a person to have an intention to do so, a plan of action, and a sustained determination to execute that plan by using whatever means of support are available. These behaviours require sophisticated cognitive input and it was hypothesised by the authors of a paper in this edition of Age and Ageing [12] that impaired executive cognitive ability would be expected to negatively influence attempts at SC. They tested this contention as part of the San Luis Valley Aging Study in Colorado. By comparing performance on the Behavioural Dyscontrol Scale (BDS—a measure of cognitive executive function developed for use in older people) with the smoking history of individuals they found a higher score on the BDS to be predictive of successful SC, and the mean BDS of current smokers was lower than that of ex-smokers. Of course, executive cognitive deficits become more prevalent with rising age, particularly after the age of 65, so it might be expected that a higher proportion of people will have a cognitive barrier to SC in old age.
What are the implications of this finding for clinical practice? The general message is clear: people with clinically significant degrees of cognitive, particularly executive, impairment are unlikely to be able to carry out actions, sustain effort or learn new behaviours. This has been observed for attempts to acquire motor techniques such as the use of inhalers and spirometry [13, 14] and influences the responses to rehabilitation [15]. We now have compelling evidence that this also applies to stopping smoking. Such cognitive deficits are not always obvious. So, in clinical practice there is a strengthening case for screening for the mild to moderate degrees of cognitive impairment that might subvert attempts to engage patients to take part in new treatments or behaviours for therapeutic or preventive purposes. In the same way as there is a need to seek alternatives to inhaler or insulin self-administration for elderly people with impaired cognition, it is apparent that alternative approaches to SC should be considered. Some people with mild to moderate cognitive deficits might derive meaningful health benefits from SC, so there is now a need for research to identify effective SC strategies for that large and growing part of the population.
The Royal Bournemouth Hospital, Castle Lane East, Bournemouth, Dorset, BH7 7DW, UK.
E-mail: Stephen.allen{at}rbch.nhs.uk
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  R. Martin and D. O'Neill What determines the ability to stop smoking in old age? Age Ageing, March 1, 2009; 38(2): 248 - 248. [Full Text] [PDF]
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