Never too old to quit: You can help the elderly stop smoking
■ Older smokers face a unique set of challenges when it comes to kicking the cigarette habit, and primary care physicians are central to their success.
You know the patient. He's 68. His pallor is gray. He exhibits a chronic cough and complains about diminishing stamina. It's obvious he needs to stop smoking. But when was the last time you asked him about his habit or counseled him to quit?
It's a question that deserves your attention -- at least as much as the other vital signs you chart.
According to the American Medical Association, physicians should screen adults for tobacco use and provide cessation counseling at every patient encounter. The advice should be personal, medically oriented, clear and strong. Studies show that even very brief counseling sessions, less than three minutes, result in modest but statistically significant improvements in tobacco-cessation rates, notes the American College of Preventive Medicine.
However, even these interventions are often easier said than done. And when the smoker in front of you is older, that challenge can seem even more daunting.
That's why a recent draft Medicare coverage decision is viewed as a step forward. In December 2004, the Bush administration announced that the Centers for Medicare & Medicaid Services intends to provide new coverage allowing certain Medicare beneficiaries who smoke to receive tobacco cessation counseling services.
The policy is based on evidence indicating that, regardless of a smoker's age, kicking the habit will lead to immediate and long-term benefits, including lowered blood pressure, improved lung function and reduced risk for heart attack. Ultimately, the coverage could save as many as 95,000 years of life over a 10-year period, experts predict.
For now, though, they hope the Medicare draft decision will boost physicians' focus on cessation intervention for this population. Older smokers, considered hard core in their habit by others while lacking quitting confidence in themselves, sometimes slip by without support. An additional complication is physicians' lack of training in cessation counseling or lack of familiarity with referral options.
Still, experts say guidelines and resources now available are the best ever, and by simply asking about smoking status, physicians can make a difference.
"There is no evidence that older adults are any less receptive," said C. Tracy Orleans, PhD, a Robert Wood Johnson Foundation senior scientist and a principal author of Clear Horizons, a quit-smoking guide for people older than 50. "Really, some of their circumstances are different, but the strategies are the same."
The Dept. of Health and Human Services estimates that 9.3% of Americans 65 or older smoke cigarettes. Many of them became addicted during the era when tobacco's link to death and disability was not concrete.
As a result, some seniors believe that they are invulnerable -- if it hasn't hit them yet, it is not going to, explained AMA Trustee Ronald M. Davis, MD, director of the Henry Ford Health System Center for Health Promotion and Disease Prevention in Detroit. Others believe the damage is already done. "Both of these beliefs are wrong. It's never too late," he said.
These smokers have generally already lived through multiple failed quit attempts or have quit and relapsed. On the positive side, it gives them "an experiential base," said Michael Fiore, MD, MPH, a professor of medicine and director of the University of Wisconsin Center for Tobacco Research and Intervention in Madison. They know what helped before, what led to their relapses and what extra resources might lead to success this time.
The downside is that many now function as discouraged quitters, he added. "They believe they cannot quit." This conviction is sometimes reinforced by the medical community.
"There are two or three big myths that impede our ability to provide high-quality care to this population," said Tim McAfee, MD, chief medical officer of Seattle-based Free & Clear, a company that administers state tobacco quitline support services and tobacco treatment programs for more than 50 U.S. health plans.
First is the myth that seniors don't smoke or smoke less as a group than younger populations. Actually, a significant number do, he said. Depending on the age subset and region, the levels reach 10% to 15%. Still, the misconception leads physicians to ask these patients about smoking less frequently. In turn, the patients don't ask about quitting, Dr. Fiore noted.
"Silence is a message," agreed Dr. McAfee, a family physician. "If a clinician doesn't ask, [he or she] has said something to that patient.
Another myth is that they don't want to quit. But according to 2002 Centers for Disease Control and Prevention estimates, 57% of smokers age 65 or older reported a desire to quit.
In Wisconsin, Dr Fiore's center joined forces with the Wisconsin Women's Health Foundation to offer access to free nicotine patches for the state's older smokers. The only eligibility requirements were that they had to be 65 or older and they had to call the state's tobacco quitline.
"We assumed we had enough patches for more than 10,000 people, and we assumed that [supply] would last us for about six months," he said. "What we found is that within one month we had more than 10,000 older smokers call." The bottom line: When help was marketed to them as a specific population, seniors took advantage of it.
Selling the idea
Indeed, successful intervention involves not only knowing the strategy, but aiming it at your audience.
"Treating Tobacco Use and Dependence," a Public Health Service clinical practice guideline first produced in 2000, offers physicians a set of broad strokes that can be tailored in this manner to the older patient.
First, the guideline sets out the need for physicians to recognize the chronic nature of smoking. "By recognizing tobacco dependence as a chronic condition, physicians will better understand the relapsing nature of the ailment and the requirement for ongoing, rather than just acute, care," according to a 2001 educational article produced by the American College of Chest Physicians.
A key part of the strategy is the five A's -- a list of steps considered the gold standard in smoking interventions: ask about tobacco use, advise tobacco users to quit, assess their willingness, assist in the quit attempt and arrange follow-up.
For reluctant patients, the guideline offers the five R's, each targeting motivation. Specifically, they focus the patient on why quitting is personally relevant in addition to the risks that accompany continued smoking, the rewards of stopping and the roadblocks they might confront. Finally, repetition -- these messages should be repeated during every unmotivated patient's visit.
The document also recommends the use of smoking cessation pharmacotherapies and provides advice regarding first- and second-line choices.
Meanwhile, to reach older smokers, most experts urge physicians to emphasize the enhanced health and quality of life that will result -- that it is not too late for them. Both the surgeon general and groups like Partnership for Prevention have reported that the benefits of quitting extend to older people, even those who have smoked for 30 or more years.
The excess risk of coronary heart disease caused by smoking, for instance, falls by about half after one year of abstinence. It then declines gradually.
"[The risk reduction] is slower for cancer," Dr. Davis said. He added that in cases of other diseases, such as emphysema, breaking the habit simply keeps the risks from continuing to climb. Tobacco use also can blunt or alter responses of other medications.
Certain approaches seem to resonate with the post-65 crowd.
"Provide these patients with a sense of hope," Dr. McAfee said. "They have been smoking for many decades and need assurance that you believe they can quit and know others like them who have."
Dr. Orleans agrees. "It is important for these patients to see examples of success among their peers."
Dr. McAfee also recommends avoiding the temptation to be negative, the if-you-don't-quit-you-are-more-likely-to-die-early warning. "Reframe it. Be positive."
And Dr. Orleans encourages physicians to highlight the immediate changes patients can expect, such as better sleeping and breathing and improved energy levels and circulation. Explain to them that quitting smoking is "like reversing the aging process," she said. "Older smokers assume it is age that is slowing them down. It is usually the smoking."
In addition, she reminds physicians that self-help and informational materials about tobacco cessation for seniors should be available in easy-to-read large print.
But ultimately, it all begins with that first "A" -- the "ask" -- and physicians still are often hesitant.
"There are lots of reasons why physicians don't do better," Dr. Davis said. "The typical medical practice is very harried these days." Patient encounters only last between 15 and 20 minutes, and physicians are usually focused on the acute problem.
There are other reasons, too. Reimbursement has historically been ambiguous, Dr. McAfee said. "At least as important: the dearth of high-quality, easily accessible referral resources for people who want to quit," he said.
Identifying tobacco use status and offering brief personalized quit advice are not difficult. "The other A's are where we run into problems," he said. These take the most time and effort, but also make the most impact. "It's complex to do in medical practices. It requires a set of behavioral counseling skills not emphasized in medical training."
The ability of a practice to develop consistent relationships with quit lines or some other resource helps with this challenge, Dr. Orleans said.
Last year HHS started a national network of smoking cessation quit lines (800-QUITNOW) to provide all U.S. smokers with help kicking the habit. One of the advantages is that the system provides a single access point for smokers. "It's a very large step in the right direction," Dr. McAfee said.
But again, if a physician is going to provide cessation counseling or assistance, he or she has to know which patients need it.
"The first [step] is to institutionalize the identification and documentation of smokers at every visit," said Dr. Fiore, who chaired the panel that developed the Public Health Service guideline. "The simplest way, of course, is to expand vital signs to include smoking status so that when your medical assistant or nurse or even you take the vital signs that you also ask the simple question: Are you a current or former smoker."
Involving the entire office staff is helpful, and placing a stamp or sticker on patient records to identify smokers is an effective reminder.
"This works," he said. "Every time a physician picks up the chart, it's in his or her face: 'Boy, I didn't realize that I've got a smoker in front of me.' "