Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Smoking in Late Life
TOOLS
The 4-As Approach for a structured Screening or Brief Intervention comprises the following – Ask, Assess, Assist, and Arrange
Step 1 - ASK
All patients should be asked if they use tobacco & should have their tobacco status documented on a regular basis
- Check on changes in patient’s smoking status, quit attempts & interventions applied
Family physicians can assess the smoking behavior of their patients in a few minutes, using carefully chosen questions
The CAGE questionnaire for smoking (modified from the familiar CAGE questionnaire for alcoholism), the “four Cs” test and the Fagerström Test for Nicotine Dependence help assess tobacco use and make the diagnosis of nicotine dependence based on standard criteria.
CAGE Questionnaire for Smoking
The CAGE questionnaire is a simple, accurate tool that has been used for many years to screen patients for addictive disorders (Crowe RR et al 1997) (Morton JL et al, 1996)
The CAGE questions have been revised to apply to smoking behavior, and can be included in a clinical interview (Lairson DR 1996)
1-3 min.
Quit Smoking and Save
Useful motivational tool. Based on the number of cigarettes smoked per day, the online Quit Smoking and Save calculator provides insight into the often dramatic savings achieved over any number of years, as well as the even greater savings if the money spent cigarettes were to be invested.
1-3 min.
Four C's Test for Nicotine Addiction
The Four Cs test can be used to assess a patient's dependence on nicotine.
Family physicians who feel comfortable discussing psychologic issues with their patients may prefer this approach, which documents a DSM-IV–based diagnosis of nicotine dependence (Miller NS, 1991)
1-3 min.
Fagerström Test
The Fagerström test for nicotine dependence helps family physicians document the severity of nicotine dependence, and indications for prescribing medication for nicotine withdrawal (Fagerstrom KO, 1989) (Heatherton TF, 1991)
The test is available in 4 versions for Adults, Adolescents, E-Cigarettes, and for Smokeless Tobacco
The Adults test is available online.
5-10 min
Step 2 - ASSESS
Additional questions can be used to determine and document the individual patient's reasons and patterns of smoking, readiness to change (smokers profile), and to determine whether this is an appropriate moment to initiate a quit smoking program (Stages of Change - smokers).
Smoker's Profile
The Smoker's Profile scores the intensity of seven reasons why people smoke cigarettes
It provides useful insight into the individual's smoking addiction, and direction for personalised intervention.
5-10 min
Stages of Change - Smoking
The Stages of Change tool helps Individuals to visualise and understand where they are along their journey of recovery,
The tool includes handy notes for carers pertaining to mindset, intervention and processes for each stage.
Steps 3 & 4 – ASSIST & ARRANGE
Smoking Recovery Calculator
Useful motivational tool. The online Smoking Recovery Calculator provides a timeline for the process of recovery after smoking cessation, including estimated life expectancy gain, and the dates of the anticipated health improvements.
1-3 min.
There are likely to be several national Quit Smoking organisations, programs and counsellors/facilitators. utilising the insights gained from the preceding brief screening tools, choose the referral best suited to the elderly person in your care.
Smokefree60+ is an excellent American free online program that can easily be used worldwide.
EPIDEMIOLOGY
Today’s elderly persons achieved adulthood during a time when smoking was socially acceptable and highly prevalent in all age groups.
The prevalence of smoking increased markedly after World War II and reached a plateau during the 1970s. Cigarette smoking at that time was widely promoted in the media for its “beneficial” effects on mood, weight control, and social appeal. Smoking was allowed in physician offices and in hospitals.
It was not until 1960 that the distribution of free cigarettes was stopped at annual medical and public health meetings; until 1969 elderly patients at nursing homes were still being given free cigarettes on the annual “Respect for the Aged” holiday.
In America, the first Surgeon General’s Report linking smoking and lung cancer was issued in 1964. In the same year, however, the American Medical Association supported the tobacco industry’s objection to labeling cigarettes as a health hazard, citing a lack of scientific evidence to support the relationship of smoking to lung cancer.
However, as more research data and epidemiological evidence accumulated, citizens around the world became aware of the hazards of smoking and initiated anti-smoking campaigns. Smoking cessation became a recognized public health effort, and awareness of the addictive properties of tobacco spread. (Elhassan A, 2007)
With over 8 million tobacco-related deaths a year, tobacco use continues to be one of the biggest public health threats and tobacco control remains a global health priority (WHO 2023)
The long duration of continuous and cumulative injurious effects of tobacco use has resulted in a disproportionately high incidence of tobacco-related diseases among the elderly. The most common causes accounting for excess smoking-related mortality in patients over age 60 are lung cancer, cardiovascular disease, and chronic obstructive pulmonary disease. Smoking is implicated in 84% of lung cancers and in the great majority of patients with chronic obstructive lung disease. It is estimated that 50% of long-time smokers will die from a tobacco-related illness (Burns DM, 2000)
Approximately 40% of European ex-smokers aged ≥65 years reported medical problems, and presumably smoking related conditions, as their main reason for quitting smoking. In agreement with a study on the general Italian adult population, this proportion was highest among men and less educated subjects (Gallus S et al, 2013)
Smoking cessation reduces morbidity and mortality in smokers, even for those who have smoked continuously for more than 30 years. The benefits of cessation are more immediate for cardiovascular disease, and are seen over a longer term for pulmonary disease (Morgan GD et al, 1996)
The degree of improvement depends on the reversibility of the disease processes at the time of cessation. Though the long-term smoking geriatric patient stands to benefit from cessation, insidious irreversible pathological processes may have already taken root.
NATIONAL INTERVENTIONS
Today there is robust evidence that comprehensive smoke-free laws result in reduced hospital admissions for acute coronary syndrome and reduced mortality from smoking-related illnesses (Frazer K et al,, 2016) (Ferrante D, 2012)
Smoke-free laws also reduce neonatal and infant mortality, as well as adult deaths and illness from respiratory disease and heart disease (Hone T et al, 2020) (Kalkhoran S, 2015)
The number of countries covered by comprehensive smoke-free environments has increased from 10 in 2007 to 74 in 2022
( WHO report on the global tobacco epidemic, 2023. Geneva: WorldHealth Organization; 2023)
The burden caused by second-hand smoke is huge.
The most recent Global Burden of Disease (2019) estimates that 1.3 million of the 8.7 million tobacco-related deaths each year are among non-smokers exposed to SHS – almost equivalent to the number of people that die in road traffic crashes every year (Global Burden of Disease, 2019)
In addition to deaths, many people suffer ill-health as a consequence of SHS exposure. In adults, SHS exposure is associated with stroke, coronary heart disease, cancer, chronic obstructive pulmonary disease, respiratory infections and other conditions.
( WHO report on the global tobacco epidemic, 2023. Geneva: WorldHealth Organization; 2023)
Severe asthma, respiratory tract infections, ear infections, and sudden infant death syndrome are all more common among children exposed to second hand smoke (Kalkhoran S et al, 2015), (Hone T et al, 2020)
(Smoke free homes [factsheet]. Copenhagen: WHO Regional Office for Europe; 2023)
PERSONAL INTERVENTIONS
Older smokers are less likely than younger smokers to attempt quitting.
The Stages of Change Model (Okuyemi KS et al, 2006) provides a framework for understanding behavior change in adults. Geriatric patients are more likely to reside in the pre-contemplation stage than their younger counterparts.
Many smokers who have continued to smoke into their 60s have done so because they are not interested in quitting. However, the older patient who attempts to quit is more likely to be successful.(Burns DM,2000)
This trend is consistent among all smoking cessation interventions, which include behavioral therapy and pharmacotherapy. This phenomenon may result from the personal insights or self-motivation gained through personally experiencing the symptoms or clinical sequelae of long-term tobacco use. Hence, encouraging the older smoker to move from the precontemplation stage to the contemplation or action stage can result in a positive behavioral change, despite decades of continuous smoking (Elhassan A, 2007)
Older smokers (75+ years) are less likely to report that they were attempting to quit smoking or seek help from a GP, despite being less nicotine-dependent. GPs raised smoking as a topic equally across all age groups, but smokers aged 70+ were more likely not to be referred for NRT or other support (Jordan H et al 20017).
Smokers in more deprived socioeconomic groups are just as likely as those in higher groups to try to stop and use aids to cessation but there is a strong gradient across socioeconomic groups in success, with those in the lowest group being half as likely to succeed compared with the highest (Kotz D, 2009)
COUNSELLING
Counseling about smoking cessation is recommended in every visit a patient makes to his/her primary care provider. It is of special importance in older smokers, as they are more likely to smoke due to nicotine dependence rather than behavioral or psychosocial factors.(Appel DW, 2003)
In patients age 60 years and over, the rate of smoking cessation was significantly higher in those who received counseling by their primary care physician and a nurse offering advice on smoking cessation in a non-urgent visit when compared to routine primary care (14% vs 9%)
Step 1 - ASK
All patients should be asked if they use tobacco & should have their tobacco status documented on a regular basis
- Check on changes in patient’s smoking status, quit attempts & interventions applied
Step 2 - ASSESS
Smokers should be strongly urged to quit at every physician encounter.
Advice should be clear, personalized, supportive and non-judgemental.
Increasing the number of attempts to quit plays an important role in improving abstinence rates
Use the easily administered and quick online Quit Smoking And Save tool, as an early eye opener and motivation.
Assess the patient's smoking patterns using the Smoker's Profile tool.
Reasons Patient May be Unwilling to Quit include :
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Lack of information regarding the benefits of quitting & the harmful effects of tobacco (ie cancer, stroke, cardiovascular diseases, & chronic pulmonary diseases)
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Previous failed attempts may have demoralized patient- Severe withdrawal symptoms during previous quit attempts
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Presence of other tobacco users in home or workplace
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Lack of required resources
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Fear/concerns regarding quitting (eg fear of weight loss, fear of losing benefits or function of smoking such as overcoming feelings of boredom, stress, anxiety)
Use the Stages of Change - Smoking tool to assess the patient’s readiness to stop and the individual's ability to adapt to smoking cessation interventions prior to undertaking therapies
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The patient in the pre-contemplation stage, where he is not willing to quit or has not thought about quitting, should be provided with motivation to quit
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The patient in the contemplation stage, where he has thought about stopping but has not made a decision to quit, should be provided with motivation to quit
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The patient in the preparation stage, where he has thought of quitting within the next 30 days & has already made changes such as cutting back, should be introduced to the means and support available in quitting
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The patient is in the action stage when he already stopped smoking within the last 6 months. The patient is in the maintenance stage if the patient has adapted to smoking cessation therapies for >6 months. Encourage these individuals to persist, explore concerns and determine need for support.
Steps 3 & 4 – ASSIST & ARRANGE
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For patients willing to quit within the next 30 days, set a quit date & create an individualized quit plan, continue smoking cessation counseling and discuss the risk of relapse. Consider utilising online tools such as SmokeFree60+
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For patients not willing to quit within the next 30 days, address patient’s concerns, consider decreasing amount of smoking & aim to set a quit date
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Use the easily administered and quick online Smiking Recovery Calculator tool, for motivation and education..
MEDICATION
Pharmacological therapy is most effective when used together with behavioral therapy
Choice of therapy should be based on patient’s past experience, preference, medical conditions, & potential
side effects
First-Line Medications
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Eg Nicotine Replacement Therapies (NRT), bupropion SR and varenicline
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Involves the use of a product that contains nicotine to replace the nicotine previously provided by smoking.Helps patients unwilling or unable to stop smoking to lessen their cigarette consumption
Second-Line Medications
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Eg Nortriptyline, Cytisine, Clonidine
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Should be considered only if 1st-line medications have failed or are contraindicated
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Evaluate for correct medication usage if initial therapy failed
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Patients should be assessed for specific contraindications, precautions & side effects
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May try lowering dose or switching to an alternative agent if w/ intolerable side effects
Other Medications
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There were no significant effects found on the following antidepressants: Fluoxetine, Paroxetine, Sertraline, Moclobemide, or Venlafaxine
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Antinicotine vaccines are currently undergoing clinical studies, with varying results
MEDICATION ALGORITHM
An algorithm was developed in 2009 by a panel of international experts (Bader P et al, 2009).
By prioritising factors to consider in prescribing pharmacotherapy, it adds value to current knowledge and existing algorithms (Le Foll BL, 2007), (Selbt P, 2007), (Hughes J, 2009)
Bader P, McDonald P, Selby P. An algorithm for tailoring pharmacotherapy for smoking cessation: results from a Delphi panel of international experts.
Tob Control. 2009 Feb;18(1):34-42. doi: 10.1136/tc.2008.025635. Epub 2008 Oct 9. PMID: 18845621; PMCID: PMC2614465.
GUIDE FOR USING THE ALGORITHM
The guide for using the algorithm includes information on :
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Monotherapy
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Combinations of pharmacotherapy
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Specific combinations of pharmacotherapy
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Impact of comorbidities on selection of pharmacotherapy
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Frequency of monitoring
The guide also includes guidance for each first-line medication on :
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Dose
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Side effects and drug interactions
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Comments on use
SUMMARY OF PRODUCT CHARACTERISTICS
(NCSCT online)
The summary includes information for all medication used to quit smoking on :
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Indications
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Posology and method of administration
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Contraindications
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Special warnings and precautions for use
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Interaction with other medicinal products and other forms of interaction
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Fertility, pregnancy and lactation
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Effects on ability to drive and use machines
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Undesirable effects
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Overdose
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Pharmacological properties
GUIDE TO DRUG INTERACTIONS WITH TOBACCO SMOKING
(NHS, 2020)
Decreased CYP1A2 activity after smoking cessation increases the risk of adverse drug reactions thus requiring adjustment to the dosage of some medications.
The change in metabolism/drug dose can occur with anyone who is reducing smoking. People considered light smokers may still need dose adjustment depending on the way they smoke (eg. compensatory smoking – inhaling more deeply).
This guide summarises those drug interactions with tobacco smoking that are considered to be most clinically important.n includes :
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The Effect of smoking on certain drugs
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The Effect of smoking cessation on certain drugs
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The Impact on dosage required when the client smokes and/or stops smoking
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An indication of the clinical importance
FOLLOW-UP
The principle for follow-up is to monitor the status of the program that was given to the patient.
Physician follow-up should be arranged soon after the quit date (within the first 2 weeks after initiating medical therapy), at 12-week intervals, then at therapy completion
Points for assessment during follow-up visits:
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Success of smoking cessation
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Patient should be congratulated if successful & strongly encouraged to remain abstinent
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Motivational level
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Presence of withdrawal symptoms should be discussed and pointers on what to do should be given
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Symptoms of Nicotine withdrawal usually peak within 1-2 weeks and then diminish
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Discuss problems encountered and challenges that may occur in the future
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Assess pharmacotherapy useand problems
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If required, consider specialist referral for more intensive treatment
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If patient smoked, review circumstances & encourage re-commitment to complete abstinence
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Lapse should be seen as a learning experience
RELAPSE
Smoking relapse is common and usually occurs within the first 3 months of quitting & can occur months to years after the quit date
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Risks include stress, frequent cravings, alcohol consumption, drug use or abuse (eg stimulants, narcotics), being with family or friends who smoke, <1 year since stopping smoking, or currently on medical therapy for smoking cessation
Consider restarting primary therapy with combination NRT or Varenicline
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Use the pharmacotherapeutic agent that was previously effective for the patient as repeated attempts at quitting using the same therapy are needed to obtain long-term cessation
Consider switching to other 1st-line agents before trying 2nd-line agents
Physicians need to continually be involved in relapse prevention interventions especially if risk for relapse is high
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Continue counseling & behavioral therapy, consider medical therapy to maintain abstinence, & review the benefits
of remaining abstinent from smoking
FREE online training courses in Brief Intervention
for Healthcare Professionals
SBIRT (Indiana University)
The primary goal of SBIRT efforts is to identify and respond to patients who use substances, including alcohol, in a hazardous, risky, or harmful manner. A secondary benefit of SBIRT is that patients with substance use disorders (i.e. abuse, dependency) are recognized too and may be referred for additional assessment and/or specialty addiction treatment.
Understanding SBRIT : All about SBRIT and how to use it
Beyond SBRIT : All about Detox, Relapse, Specialized care, Abusable medications
Duration : 2 hours each
Requires registration. Does not include certificate of completion.
Go to : Understanding SBRIT course
Go to : Beyond SBRIT course
HSC Public Agency (Queen's University Belfast)
Aim : To equip Health and Wellbeing advisers with the knowledge and skills necessary to deliver effective brief interventions in practice.
Following completion of this course you should be able to:
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apply the model of behaviour change to your practice
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outline the principles of effective communication
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raise the subjects of smoking, alcohol consumption or physical inactivity with patients in routine practice
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advise on the risks to health posed by smoking, alcohol and physical inactivity
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assist patients/clients by signposting and providing additional information sources.
Duration : 2 hours
Requires registration. Includes certificate of completion.
Go to HSC Public Agency course
Look in e-learning page, under Public Health
This is one of several topics presented in the Thorny Issues sector of this toolkit
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