SMOKING CESSATION IN THE ELDERLY PATIENT

Cost-Effectiveness of Smoking Cessation Interventions in the Lung Cancer Screening Setting: A Simulation Study

BACKGROUND

Guidelines recommend offering cessation interventions to smokers eligible for lung cancer screening, but there is little data comparing specific cessation approaches in this setting. We compared the benefits and costs of different smoking cessation interventions to help screening programs select specific cessation approaches.

METHODS

We conducted a societal-perspective cost-effectiveness analysis using a Cancer Intervention and Surveillance Modeling Network model simulating individuals born in 1960 over their lifetimes. Model inputs were derived from Medicare, national cancer registries, published studies, and micro-costing of cessation interventions. We modeled annual lung cancer screening following 2014 US Preventive Services Task Force guidelines plus cessation interventions offered to current smokers at first screen, including pharmacotherapy only or pharmacotherapy with electronic and/or web-based, telephone, individual, or group counseling. Outcomes included lung cancer cases and deaths, life-years saved, quality-adjusted life-years (QALYs) saved, costs, and incremental cost-effectiveness ratios.

RESULTS

Compared with screening alone, all cessation interventions decreased cases of and deaths from lung cancer. Compared incrementally, efficient cessation strategies included pharmacotherapy with either web-based cessation ($555 per QALY), telephone counseling ($7562 per QALY), or individual counseling ($35 531 per QALY). Cessation interventions continued to have costs per QALY well below accepted willingness to pay thresholds even with the lowest intervention effects and was more cost-effective in cohorts with higher smoking prevalence.

CONCLUSION

All smoking cessation interventions delivered with lung cancer screening are likely to provide benefits at reasonable costs. Because the differences between approaches were small, the choice of intervention should be guided by practical concerns such as staff training and availability.

Smoking Assessment and Intervention: An Essential Part of Disease Treatment

Approximately 45.8 million Americans smoke. Smoking is a leading cause of preventable disease, disability, and death. The Wellness Division of VNA Care Plus, recognizing the relationship between tobacco use and disease, now empowers smokers to progress toward cessation. It has adapted the National Cancer Institute Smoking Cessation Model for Primary Care Sites. The agency's assessment tool and benefits and barriers survey affecting tobacco use are included. The profile of smokers and "Tips for Treating Elder Smokers" are described. Recommendations include standardized protocol, consistent interventions from providers, and suggestions for further study.

Pharmacological Smoking Cessation Therapies in Older Adults: A Review of the Evidence

Nearly 12% of adults 65 years and over in Europe and 9% in the USA are current cigarette smokers. Numerous studies have demonstrated tangible benefits of smoking cessation, regardless of advanced age. However, it is unclear which pharmacotherapy strategies are most effective in the elderly population. To that end, the literature on smoking cessation in older adults was reviewed with the aim of identifying the safest and most effective cessation pharmacotherapies. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for all articles pertaining to elderly smoking cessation strategies. Randomized controlled trials and cohort studies were included. Studies were included without regard to population or intervention, as long as results were analyzed with a group of smokers aged 60 years and above and at least one arm of the study involved a pharmacotherapy. Only 12 studies were identified that met our inclusion criteria. The limited existing literature does not allow for a definitive answer to the most effective pharmacotherapy for smoking cessation in older adult smokers. Nicotine replacement therapy (NRT) is the pharmacotherapy most studied in older adults, and the limited evidence that exists suggests that NRT is effective for smoking cessation among this population. Higher-quality studies that directly compare cessation strategies, including bupropion and varenicline, are needed in the older population in order to guide treatment decision making.

Substance Use and Associated Health Conditions throughout the Lifespan

A life stage perspective is necessary for development of age-appropriate strategies to address substance use disorders (SUDs) and related health conditions in order to produce better overall health and well-being. The current review evaluated the literature across three major life stages: adolescence, adulthood, and older adulthood.

FINDINGS

1) Substance use is often initiated in adolescence, but it is during adulthood that prevalence rates for SUDs peak; and while substance involvement is less common among older adults, the risk for health complications associated with use increases. 2) Alcohol, tobacco, marijuana, and, increasingly, prescription medications, are the most commonly misused substances across age groups; however, the use pattern of these and other drugs and the salient impact vary depending on life stage. 3) In terms of health outcomes, all ages are at risk for overdose, accidental injury, and attempted suicide. Adolescents are more likely to be in vehicular accidents while older adults are at greater risk for damaging falls. Adulthood has the highest rates of associated medical conditions (e.g., cancer, sexually transmitted disease, heart disease) and mental health conditions (e.g., bipolar disorder, anxiety disorders, antisocial personality disorder).

CONCLUSION

Prolonged heavy use of drugs and/or alcohol results in an array of serious health conditions. Addressing SUDs from a life stage perspective with assessment and treatment approaches incorporating co-occurring disorders are necessary to successfully impact overall health.

Tabagismo em idosos

O tabagismo representa um importante acelerador do processo de envelhecimento, comprometendo não apenas a expectativa, mas a qualidade de vida também. Fumantes com idade superior a 50 anos apresentam maior dependência da nicotina, fumam há mais tempo e um maior número de cigarros, tendo mais problemas de saúde relacionados ao tabagismo, e dificuldade maior em parar de fumar. As principais causas de morte por tabagismo são as doenças cardiovasculares, a doença pulmonar obstrutiva crônica e o câncer de pulmão. Atualmente, há uma série de estratégias farmacológicas e não-farmacológicas para o auxílio do abandono do tabagismo, que também podem ser uma alternativa para os idosos. O objetivo desta revisão é relatar dados do tabagismo no Brasil e no mundo, as patologias envolvidas e os efeitos tóxicos dos componentes do cigarro, bem como sugerir estratégias de tratamento, principalmente para os idosos. A revisão da literatura foi feita nas bases: Pubmed, Scielo, Portal Capes, Ministério da Saúde, Instituto Nacional do Câncer, IBGE e Organização Mundial da Saúde. Concluiu-se, através da literatura consultada, que o tabagismo representa uma fonte de risco e a causa principal de inúmeras doenças. Porém, o desejo de parar de fumar é maior entre aqueles que reconhecem ser esse hábito prejudicial à saúde. Apesar de os benefícios, com a interrupção do hábito de fumar, serem maiores entre os mais jovens, o abandono do tabagismo, em qualquer idade, reduz o risco de morte e melhora a condição geral de saúde.

Fatores associados ao tabagismo em idosos residentes na cidade de Londrina, Brasil

OBJETIVO: Descrever as características e fatores associados ao tabagismo em uma população idosa. MÉTODOS: Estudo transversal realizado com 344 idosos (>60 anos) residentes na cidade de Londrina, estado do Paraná, em 2008. A variável dependente foi o tabagismo e as demais variáveis estudadas foram: fatores socioeconômicos, escolaridade, condição referida de saúde e uso de serviço de saúde. Os dados foram coletados por inquérito domiciliar. Estatísticas descritivas das variáveis do estudo foram utilizadas para avaliar associações entre o tabagismo (atual e passado) e as variáveis exploratórias. RESULTADOS: A prevalência de tabagismo atual e passado foi de 23,8% e 37,6% entre os homens e de 12,7% e 21,8% entre as mulheres, respectivamente (p<0,0001). Entre os tabagistas atuais, não houve diferença entre homens e mulheres em relação ao consumo de cigarros diário e o grau de dependência do tabaco. A idade também não demonstrou diferença entre os grupos (fumante atual, ex-fumante e nunca fumante). Houve uma associação independente e negativa com escolaridade e condição socioeconômica (renda familiar) e associação positiva com percepção ruim ou muito ruim de saúde. CONCLUSÃO: O tabagismo constituiu um problema de saúde pública entre os idosos da comunidade estudada. A baixa escolaridade e a condição socioeconômica devem ser consideradas em programas específicos de cessação do tabagismo entre idosos.

Smoking increases risk for cognitive decline among community-dwelling older Mexican Americans

OBJECTIVES

Few studies have investigated smoking and cognitive decline (CD) among older Mexican Americans. In this study, the authors explore the relationship between smoking status and cognitive changes over time in a large sample of community-dwelling older adults of Mexican descent.

DESIGN

Latent growth curve analyses were used to examine the decreasing growth in the number of correct responses on a test of cognitive functioning with increasing age (7 years with four data collection points).

SETTING

In-home interviews were obtained from participants residing in the Southwest United States.

PARTICIPANTS

Participants were community-dwelling older Mexican Americans.

MEASUREMENTS

Cognitive functioning was assessed at each of the four data collection points with the Mini-Mental State Examination. Participants' self-reports of health functioning and smoking status were obtained at baseline.

RESULTS

With the inclusion of health variables and other control variables, the effect of smoking status on cognitive functioning was significant such that the decrease in the number of correct responses over time was greater for smokers than for nonsmokers.

CONCLUSIONS

Smoking increases risk for CD among community-dwelling older Mexican Americans. There are numerous health benefits in quitting smoking, even for older adults who have been smoking for many years. Further efforts to ensure that smoking cessation and prevention programs are targeted toward Hispanics are necessary.

Smoking cessation behavior in older adults by race and gender: the role of health problems and psychological distress

INTRODUCTION

Initial research on older smokers suggests that a subgroup of smokers with higher levels of psychological distress and health problems may be more likely to quit smoking than older smokers with fewer such problems. The present study, based on prospective data from a biracial sample of older adults (N = 4,162), examined characteristics of older adult smokers by race and gender.

METHODS

The present study uses both cross-sectional and prospective data to examine the association between smoking behavior, smoking cessation, health functioning, and psychological distress in a biracial sample of community-dwelling older adults.

RESULTS

We found baseline psychological distress to be associated with poor health functioning. Consistent with hypotheses, baseline (Time 1) psychological distress predicted smoking cessation 3 years later (Time 2). Moreover, the change in health problems between Time 1 and Time 2 fully mediated the association between Time 1 distress and smoking cessation.

DISCUSSION

Smoking cessation behavior of older adults is best explained by higher levels of distress and health problems regardless of race or gender. These findings may have important treatment implications regarding smoking cessation programs among older adults. Older adult smokers with higher levels of psychological distress and health problems may be more motivated to quit smoking than those with fewer such problems. These difficulties should be targeted within the context of the smoking cessation protocol. Also, we identified a subgroup of older smokers who are reporting fairly good health and lower levels of distress and who are less likely to quit smoking. Motivational methods may need to be developed to engage this group in smoking cessation treatment.

Smoking after the age of 65 years: a qualitative exploration of older current and former smokers' views on smoking, stopping smoking, and smoking cessation resources and services

The aim of this study was to explore older current/former smokers' views on smoking, stopping smoking, and smoking cessation resources and services. Despite the fact that older smokers have been identified as a priority group, there is currently a dearth of age-related smoking cessation research to guide practice. The study adopted a qualitative approach and used the health belief model as a conceptual framework. Twenty current and former smokers aged>or=65 years were recruited through general practices and a forum for older adults in the West of Scotland. Data were collected using a semistructured interview schedule. The audio-taped interviews were transcribed and then analysed using content analysis procedures. Current smokers reported many positive associations with smoking, which often prevented a smoking cessation attempt. The majority were aware that smoking had damaged their health; however, some were not convinced of the association. A common view was that 'the damage was done', and therefore, there was little point in attempting to stop smoking. When suggesting a cessation attempt, while some health professionals provided good levels of support, others were reported as providing very little. Some of the participants reported that they had never been advised to stop smoking. Knowledge of local smoking cessation services was generally poor. Finally, concern was voiced regarding the perceived health risks of using nicotine replacement therapy. The main reasons why the former smokers had stopped smoking were health-related. Many had received little help and support from health professionals when attempting to stop smoking. Most of the former smokers believed that stopping smoking in later life had been beneficial to their health. In conclusion, members of the primary care team have a key role to play in encouraging older people to stop smoking. In order to function effectively, it is essential that they take account of older smokers' health beliefs and that issues, such as knowledge of smoking cessation resources, are addressed.

Condições de saúde e tabagismo entre idosos residentes em duas comunidades brasileiras (Projetos Bambuí e Belo Horizonte)

O objetivo deste trabalho foi determinar a prevalência do tabagismo e verificar os fatores associados a este hábito entre idosos (> 60 anos). O estudo foi conduzido na Região Metropolitana de Belo Horizonte e na Cidade de Bambuí, ambas localizadas em Minas Gerais, Brasil. Foram selecionados 1.774 idosos na Região Metropolitana e 1.742 em Bambuí. Na Região Metropolitana, a prevalência de tabagismo atual e passado foi de 19,6% e 39,2% entre os homens, e 8,1% e 14,1% entre as mulheres, respectivamente. Em Bambuí, os dados correspondentes foram 31,4% e 40,2% entre os homens, e 10,3% e 11,2% entre as mulheres, respectivamente. Na Região Metropolitana, os indicadores de pior condição de saúde e pior capacidade funcional apresentaram associações significantes com o tabagismo passado, mas estas associações não foram observadas em Bambuí. Entre os fumantes atuais, as associações pesquisadas não foram consistentes. Estes resultados mostram a grande heterogeneidade dos fatores associados ao tabagismo, como observado em países desenvolvidos. As estratégias para a redução do tabagismo nessa população devem considerar esta ausência de associação entre sinais e sintomas e o hábito de fumar.

Factors associated to smoking habit among older adults (The Bambuí Health and Aging Study)

OBJECTIVE: To describe the characteristics and associated factors of the smoking habit among older adults. METHODS: A population-based study was carried out comprising 1,606 (92.2%) older adults (>60 years old) living in the Bambuí town, Southeastern Brazil in 1997. Data was obtained by means of interview and socio-demographic factors, health status, physical functioning, use of healthcare services and medication were considered. The multiple multinomial logistic regression was used to assess independent associations between smoking habits (current and former smokers) and the exploratory variables. RESULTS: The prevalence of current and past smoking was 31.4% and 40.2% among men, and 10.3% and 11.2% among women, respectively (p<0.001). Among current smokers, men consumed a larger number of cigarettes per day and started the habit earlier than women. Among men, current smoking presented independent and negative association with age (>80 years) and schooling (>8 years) and positive association with poor health perception and not being married. Among women, independent and negative associations with current smoking were observed for age (75-79 and >80 years) and schooling (4-7 and >8 years). CONCLUSIONS: Smoking was a public health concern among older adults in the studied community, particularly for men. Yet, in a low schooling population, a slightly higher level was a protective factor against smoking for both men and women. Programs for reducing smoking in the elderly population should take these findings into consideration.

A Pharmacist Approach to Wellness Maintenance in the Community Elderly

Wellness prevention in the elderly has similar goals as prevention in nonelderly adults, which is to improve lifestyles and habits to prevent disease (primary prevention) or the progression of disease (secondary prevention). Pharmacists who interact with the community elderly have a great opportunity of helping to keep our elderly healthy and preventing lifelong chronic problems that can contribute to a decrease in function of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). This article focuses on the key prevention interventions that a pharmacist can target in helping to promote health maintenance.

Alcohol, drugs and much more in later life

Elderly adults are greater consumers of prescription and 'over the counter' medications than any other age group and polypharmacy, including the co-use of alcohol, is common in this group. Age related physiological changes which influence drug concentrations, metabolism, polypharmacy and interaction of other drugs with alcohol can negatively influence functional capacity, psychomotor ability, and cognition, including attention and memory, placing the older person at greater risk of accident, injury, isolation and ultimately institutionalisation. It is argued that DSM-IV criteria used to define "abuse" or "dependence" are of limited value to the majority of elderly 'problem' alcohol or drug users, with ICD-10 criteria that identify those who are experiencing 'a risk' of or where use "is actually" causing "early" harm, more appropriate. Impediments to psychiatrists and other medical practitioners identifying 'problem' alcohol and other drug use, and appropriate assessment and intervention procedures are briefly discussed. The potential for decreasing the incidence and severity of physical and psycho/social events following a reduction or cessation in problem alcohol or other drug use means that assessment and intervention should be one cornerstone of management practice for this often disenfranchised and vulnerable group.

Tailoring smoking cessation for older adults

BACKGROUND

Older adults are an important audience for smoking cessation programs. Over 4.5 million older adults (older than 65) continue to smoke, and the majority are long term, heavy smokers. There is evidence that smoking cessation programs tailored to older smokers can be effective. American Cancer Society (ACS) materials and programs represent an important opportunity to meet the needs of older smokers.

METHODS

This article reviews the rationale for tailoring programs to older adults. A 10-step model is presented. The Clear Horizons program is provided as an example of a tailored program.

RESULTS

The Clear Horizons program demonstrated that a tailored program results in significantly higher rates of quitting--20% of Clear Horizons participants reported not smoking at 12 months compared with 15% for the generic guide.

CONCLUSIONS

Older smokers were highly responsive to a tailored program. The ACS should consider opportunities for tailoring new and existing programs to meet the needs of older smokers.