Why Is It So Hard for Older Adults to Quit Smoking?

A failure to reach adult smokers where they work, live and play

Smokers between the ages of 40 and 64 are disproportionately drawn from marginalized groups, including adults with lower levels of income and education. Among people with a GED or less schooling, smoking rates are up to 30 percent, says Kalousova. By contrast, among people with college degrees, the rates are around 5 percent.

Older smokers may also cluster in occupations that lack the protections afforded to other professions — construction rather than white-collar work. That means they may not benefit from smoke-free policies in buildings, campuses, restaurants and elsewhere.

And while increased taxes on cigarettes (another tool states use to discourage smoking at the population level) are effective at reducing cigarette use among young people, they are not as successful among older smokers, according to research by Kalousova and others. (Kalousova notes that taxes on cigarettes do work to reduce smoking, overall.)

Other adult smokers may also lack access to the medications needed to stop using cigarettes. While Medicaid covers such medications, Medicare, on its own, does not. That means a person on Medicare, but without Medicaid, may need to cover the cost of medication out of pocket. Brand-name medications cost between $20 and $80 for a 30-day supply, depending on where a person purchases them; a 14-day supply of the patch, for instance, costs around $40 on Amazon.

“That’s a barrier,” says Vijayaraghavan, who adds that any cuts to Medicaid and Medicare may further reduce the number of people who can access tobacco-cessation treatment.

And because American society is so deeply stratified across educational and socioeconomic divisions, smokers and nonsmokers are often segregated, says Kalousova. That creates an unintended disconnect between the folks who study and write about smoking cessation and the people who actually smoke, which may further explain why policies and interventions haven’t been effective. “That’s a really important part of the story,” she says.

New solutions for adults who smoke

Standard medications that support quitting smoking include drugs that block nicotine receptors in the brain and make smoking less enjoyable, as well as therapies that provide dosed nicotine — as a gum, patch or nasal spray — to provide an alternative to combustible cigarettes.

Cytisincline, the first new medicine in the U.S. to treat smoking in two decades, has yet to be cleared by the FDA, but its manufacturer says it plans to submit for federal approval this summer. In a late-stage clinical trial, researchers found it had fewer side effects than varenicline (known as Chantix), which, though rare, can cause severe mental health problems.

Cytisincline is also widely used in other countries; in Canada, it’s even available over the counter. But the cost of cytisincline, and the degree to which it is covered by insurance, will play a role in its adoption, Meza says. Chantix, for instance, is now available as a generic and has dropped in price as a result. Researchers are also looking into whether GLP-1 medications like Ozempic and Wegovy, which have been “effective for controlling obesity and diabetes,” may be useful for smoking cessation as well, says J. Lee Westmaas, scientific director of Tobacco Control Research at the American Cancer Society.

E-cigarettes and nicotine pouches are also new, and somewhat controversial, tools that may be useful for stopping smoking. Both are less harmful than cigarettes, with nicotine pouches being the safest (because they don’t expose a person’s lungs to any smoke). But presently, there are no clinical or public health societies that recommend them for that purpose. In part, that’s because there’s concern that e-cigarettes will lead to more smoking overall, particularly because cigarette companies produce e-cigarettes and thus have an imperative to attract new smokers.

It can be difficult to implement policies and messaging that protect young people from e-cigarettes while also finding ways “to bring e-cigarettes into the arsenal to help people quit. The challenge has been, ‘How can we do those two things at the same time?’” says Meza.

Another potential new approach to reach adult smokers is through an initiative established by the National Cancer Institute, which integrates smoking cessation interventions with lung cancer screenings.

Lung cancer screening is not as common as screenings for other cancers, like breast or colon cancer, but is recommended for people ages 50 to 80 who smoke or used to smoke and have a 20 pack-year history of smoking. (A pack-year is equal to smoking one pack per day for a year.) This includes people who quit more than 15 years ago.

If the screenings could reach the people who need them, they might have a “considerable impact on reducing lung cancer mortality,” says Meza. And if at these screenings, people could also be assisted to help quit smoking, that would not only decrease the incidence of lung cancer but also bring down smoking rates and reduce other smoking health impacts such as heart disease, COPD, high blood pressure and other conditions.

“The potential really is there for a double whammy,” Meza says.

Relatedly, says Kalousova, there is some evidence that when a person experiences a “new health diagnosis, that is a moment when they’re more likely to be receptive to changing their health habits.” Even people who have false positive cancer diagnoses are very likely to quit smoking, says Kalousova.

And because chronic conditions typically emerge in middle age and beyond, such targeted lifestyle-change recommendations might conceivably be bundled in with appointments about managing a new diagnosis. That’s also important because clinicians are less likely to bring up smoking cessation with patients who have smoked for a long time. And, says Westmaas, when clinicians inquire about patients’ smoking status, advise that they quit and provide information on “where or how to access treatment,” it’s been shown to “increase quitting and reduce smoking rates.”

There are also important gender differences that drive people to smoke, and that may need to be taken into consideration to support adults to stop using cigarettes. Women may be more likely to smoke because of previous traumas, especially women who experienced adverse childhood experiences and started smoking at a young age. So while both men and women benefit from medication and counseling and a trauma-informed approach to cessation, women in particular may benefit from such approaches, says Vijayaraghavan.

The health impacts on women as they age are also important to consider, she says. While smoking hurts everyone’s health — it’s the leading cause of preventable death — it hurts menopausal women in particular. Research has linked smoking in women to early menopause, worse menopause symptoms and an increased risk for health conditions such as cardiovascular disease.

“People differ in what types of interventions they may find most appealing or effective for cessation,” says Westmaas. “If we can understand people’s preferences, it may be possible to tailor our messages and interventions to target them. It may not be just a matter of age but also gender, personality and social support that we need to consider when promoting a particular message or providing information on quitting.”