Beyond Nicotine Replacement Therapy: Smoking Cessation for Older Americans

Author

Chelsea Boyd

Resident Research Fellow, Harm Reduction

Table of Contents

• Older Americans and Smoking
• Nicotine Replacement Therapy (NRT)
• Smoking Cessation Opportunities
• Policies to Support Smoking Cessation Among Older Americans

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Older Americans and Smoking

Smoking remains a leading cause of preventable death and disease in the United States. Of the roughly 480,000 smoking-related deaths in the United States each year, more than 70 percent occur among smokers aged 60 or older. Americans aged 50 and older also smoke cigarettes at higher rates than their younger counterparts. A 2024 Gallup poll showed that 18 percent of Americans aged 50 to 64 and 9 percent of Americans aged 65 or older smoke cigarettes. Not only do older Americans smoke at higher rates than younger Americans, they are also less likely to try to quit. In fact, only 5 to 6 percent of people over 50 who smoke successfully quit each year.

Nicotine Replacement Therapy (NRT)

Nicotine is the chemical in cigarettes that causes people to become addicted to smoking, leading to physically unpleasant symptoms when a person initially stops smoking. NRT is a tool designed to lessen the symptoms associated with discontinuing smoking by providing nicotine without exposing a person to the other harmful chemicals in tobacco smoke. Approved by the U.S. Food and Drug Administration to help people quit smoking, NRT comes in several forms including gums, patches, and lozenges, all available over the counter (OTC).

Although NRT increases successful quit rates by 50 to 70 percent, only 29 percent of smokers aged 65 and older used NRT during a quit attempt (based on 2015 data). Using NRT during a quit attempt can be helpful, but some factors may discourage older smokers from using it. First, OTC medications (including OTC forms of NRT) are not covered by Medicare, potentially creating a cost barrier for older smokers—especially those on fixed incomes. However, Medicare’s prescription coverage will cover the two prescription-only NRT products: a nasal spray and an inhaler. The extra step of getting a prescription from a healthcare provider can also discourage NRT use. Another challenge with NRT is that it does not deliver as much nicotine as quickly as smoking does. For heavy or habitual smokers (which older smokers often are), using multiple and/or higher-dose NRT products for longer periods can be beneficial; unfortunately, it can also increase cost.

NRT is an important tool in the arsenal of methods to help people quit smoking; however, there are additional opportunities to improve quit rates among older Americans who smoke.

Smoking Cessation Opportunities

Although NRT alone is proven to help older people stop smoking, there is evidence that combining smoking cessation methods can increase NRT’s effectiveness. Cognitive behavioral therapy (CBT), a psychological therapy method focused on changing behaviors and thought patterns by teaching coping skills, is one tool that can increase the odds that a person will quit smoking. Quitting smoking involves managing the physical symptoms that occur after abstaining from nicotine as well as the psychological and environmental factors that help maintain the habit. CBT can give people strategies to address the psychological and environmental reminders that make them want to smoke. For example, while one study found that 62 percent of smokers over age 50 increased their cigarette consumption during stressful periods, a different study found that quit rates among smokers over age 50 increased by 150 percent after engaging in CBT to cope with stress. Finding ways to incorporate CBT into cessation programs can be especially helpful for older smokers.

Loneliness is a common challenge for older adults, with one study identifying it as the greatest cessation barrier for this group. Appropriate social support is another factor that can increase the odds of an older smoker successfully quitting. Buddy-system programs and support groups can help older smokers counter the stress of social isolation and provide accountability in their quit attempts. Thus, building programs that facilitate social support is another opportunity to increase quit rates among older adults.

Finally, products that deliver nicotine without combustion, such as e-cigarettes and nicotine pouches, could offer another opportunity to help older smokers quit. Evidence supports the fact that e-cigarettes can help people stop smoking; however, many older smokers incorrectly perceive e-cigarettes as equally or more harmful than combustible cigarettes. This can make them less likely to use e-cigarettes during a quit attempt. While correcting this misperception may encourage older smokers to try e-cigarettes, there are other barriers to their use among this group. The small components of e-cigarettes can present physical challenges, and unfamiliarity with technology can further discourage use. Nevertheless, some evidence shows that attention to user experience and design, such as simplified devices, can decrease barriers to use among older smokers. Education about non-combustible nicotine products can also increase comfort with the products.

Policies to Support Smoking Cessation Among Older Americans

Although older adults benefit from quitting smoking, they are less aware of cessation quitlines and websites than other age groups and use these resources less frequently. When designing health campaigns for this population, ensuring the information is relevant, accessible, and available in appropriate formats and locations is particularly important. Interventions and educational materials should be targeted and designed thoughtfully to help older smokers find a pathway to better health. Additionally, education campaigns targeting healthcare providers could benefit older smokers, as providers are less likely to advise quitting, refer older adults to counseling, or prescribe NRT for this age group.

Policies that decrease environmental triggers can also benefit older smokers. Restricting smoking in public establishments with comprehensive smoke-free laws is one method of decreasing environmental triggers. Policymakers can also ensure tobacco taxes are risk-proportionate, such that non-combustible nicotine delivery products are not taxed at higher rates than combustible cigarettes. Some evidence shows that older smokers do not respond to higher cigarette prices by decreasing use. Since this population is less sensitive to cigarette price increases, keeping alternative nicotine product prices lower than combustible cigarettes is even more important so as not to further discourage their use.

Quitting smoking benefits a person’s health regardless of their age. If decreasing tobacco-related deaths is the goal, then providing multiple cessation mechanisms to older Americans who smoke is particularly important.