The Elm

Smoking has fallen nationwide except among older adults. Prioritizing age-friendly tobacco treatment, research, and harm reduction can improve health and quality of life in this overlooked age group.

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Over the past several decades, tobacco control has been one of public health's greatest success stories. Smoking prevalence in the United States has fallen to the lowest levels ever recorded, preventing millions of premature deaths and improving the health of countless Americans. Yet amid this remarkable progress, one population has largely been left behind: older adults.

While smoking has steadily declined among younger and middle-aged adults, smoking prevalence among adults 65 years and older has remained remarkably stable for at least two decades, hovering around 8 to 10 percent.(1) Because the U.S. population is aging, the absolute number of older adults who smoke continues to grow even as overall smoking rates decline. The number of older adults who smoke increased by over half a million in recent years while numbers for all other age groups decreased. (2) Today, there are about 4.6 million older adults who smoke in the United States — roughly 3 million more than adults 18 to 24 years old.

This trend has important implications for health care. Smoking remains the leading preventable cause of disease, disability, and death, but much of its burden is concentrated in later life. (3) Chronic obstructive pulmonary disease, cardiovascular disease, stroke, cancer, osteoporosis, impaired wound healing, and functional decline all become more common with age, and smoking accelerates each of these conditions. Smoking-related health care expenditures also are substantially higher among older adults than among younger adults who smoke.(4)

Importantly, the consequences of smoking in later life are not simply measured in years of life lost. Many older adults spend years — or even decades — living with preventable disability, breathlessness, chronic pain, limited mobility, and loss of independence attributable to smoking. Helping older adults reduce or stop smoking is therefore not only about extending life, it also is about improving quality of life and supporting healthy aging.

Older Adults Who Smoke Are Not Simply Older Versions of Younger Smokers

A growing body of research suggests that older adults who smoke differ from younger smokers in meaningful ways. (5) Compared with younger adults, they generally have smoked for many more years, smoke more heavily, exhibit greater nicotine dependence, and make fewer attempts to quit. (6, 7) They also have more misconceptions regarding the risks and benefits of tobacco products. (8, 9)

For example, older adults are more likely to think that medical evidence demonstrating that smoking is harmful is exaggerated and that smoking behavior is something they can do little to change (10, 11). These misconceptions can become important barriers to treatment because they reduce motivation to engage in cessation efforts.

Fortunately, decades of research tell a different story. Reducing or stopping smoking — even after age 70 — is associated with substantial health benefits, including lower mortality risk and improvements in health and functioning. It is never too late to benefit from quitting smoking. (12-15)

Why Has Progress Stalled?

Perhaps the most surprising aspect of this issue is how little we know.

Despite experiencing the greatest burden of smoking-related disease, older adults have historically received relatively little attention in tobacco research. Our own work has shown that older adults have frequently been overlooked — or even intentionally excluded — from tobacco studies, leaving important questions unanswered about how best to help this population reduce or stop smoking.(16)

Emerging evidence suggests that many traditional tobacco control strategies may be less effective for the oldest adults. For example, European studies have found that policies such as cigarette taxes, smoke-free laws, public information campaigns, advertising restrictions, warning labels, and expanded cessation services were associated with reduced smoking among younger adults but showed little measurable impact among adults over age 65. (17, 18) Similarly, U.S. research suggests that increases in cigarette taxes may reduce smoking only modestly among older adults, many of whom live on fixed incomes and may absorb higher costs rather than quit smoking. (18-20)

These findings do not suggest that tobacco control policies are ineffective. Rather, they remind us that interventions developed largely with younger populations in mind may not fully address the needs, priorities, and experiences of older adults.

Tobacco Use Also Is an Aging Equity Issue

Like many other substance use disorders, tobacco use intersects with longstanding health disparities.

Older Black men who smoke, for example, are at higher risk for lung cancer and face higher cancer-related mortality rates. (21) Smoking also remains highly prevalent among individuals receiving treatment for other substance use disorders, contributing to significant health inequities in populations already burdened by chronic disease and social disadvantage. (22)

As our population continues to age, addressing tobacco use among older adults represents an important opportunity to reduce disparities while improving longevity and quality of life.

What Does Age-Friendly Tobacco Care Look Like?

As health care systems increasingly adopt age-friendly models of care, tobacco treatment should be considered an essential component of healthy aging. (23)

Age-friendly care encourages clinicians to understand “what matters most” to each patient. For many older adults, quitting smoking may not be primarily about preventing disease decades in the future. Instead, their goals may include breathing more comfortably, remaining independent, maintaining mobility, recovering more quickly from surgery, reducing medications, spending more active time with grandchildren, or preserving cognitive and physical function.

Framing tobacco treatment around these personally meaningful goals may resonate more strongly than emphasizing distant health risks alone.

Equally important is recognizing that not every patient is ready to quit smoking immediately. Evidence-based treatments — including counseling and FDA-approved cessation medications — should remain the foundation of care. At the same time, age-friendly care encourages clinicians to meet patients where they are. For some individuals, this may involve motivational conversations that explore their beliefs about smoking, correct misconceptions about the benefits of quitting later in life, and discuss realistic strategies for reducing harm while working toward cessation. (24)

As our understanding of tobacco treatment continues to evolve, there is growing recognition that harm reduction strategies, including the potential role of electronic cigarettes for adults who smoke and have been unable to quit using established treatments, may support quitting or reducing smoking. (25) Recent guidance from the American Society on Addiction Medicine highlights the role of e-cigarettes in smoking cessation conversations. (26)

The principles of harm reduction are also highly consistent with age-friendly care and geriatric medicine. (27) Age-friendly care emphasizes understanding “what matters most” to each older adult and tailoring treatment to support their health goals, function, and independence. Similarly, harm reduction recognizes that patients exist along a continuum of readiness for change and that meaningful improvements in health can occur even when abstinence is not immediately achievable. For older adults who have smoked for decades, incorporating harm reduction into tobacco treatment may help clinicians engage patients who are not yet ready or able to quit completely. Supporting smoking reduction can foster more productive conversations, strengthen therapeutic relationships, and create opportunities for gradual movement toward smoking cessation while improving health along the way.

Regardless of the approach, the overarching goal remains the same: helping patients move away from combustible cigarette smoking, which remains by far the most harmful form of nicotine use.

Looking Ahead

The dramatic decline in smoking across the United States demonstrates what is possible when science, public health, and clinical care work together. Yet older adults who smoke remain an overlooked population despite bearing the greatest burden of tobacco-related disease.

As researchers continue to develop age-tailored interventions and clinicians increasingly embrace age-friendly care, we have an opportunity to close this gap. Doing so will require viewing tobacco treatment and harm reduction as an essential strategy for promoting healthy aging, preserving independence, and improving quality of life.

As our population ages, ensuring that they are no longer forgotten in research, treatment, and policy aimed at reducing tobacco smoking should become a public health priority.

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Bethea (Annie) Kleykamp is an assistant professor in the Department of Psychiatry at the University of Maryland School of Medicine (UMSOM) and director of research and evaluation of UMSOM’s Maryland Addiction Consultation Service.

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