Nicotine dependence and smoking cessation

It is never too late to quit. Epidemiological data show that even among people in their 70s, stopping smoking reduces mortality towards that of non-smokers within a short enough time to justify actively encouraging quitting. Benefits for vascular and lung disease are rapid.

Additional geriatric gains. Slower decline in FEV1, better wound and fracture healing, reduced risk of stroke, myocardial infarction, cancer, cataract, macular degeneration, osteoporosis and dementia, and reduced fire and burn risk in frail or oxygen-dependent patients.

Assessment of dependence. Pack-years, the Fagerström Test for Nicotine Dependence, and above all the time to the first cigarette of the day (<30 minutes indicates high dependence); exhaled CO; previous quit attempts and reasons for relapse; readiness to change. Screen for depression, alcohol use and COPD.

Behavioural framework. The 5 A's — Ask, Advise, Assess, Assist, Arrange, with the 5 R's (Relevance, Risks, Rewards, Roadblocks, Repetition) for the unmotivated. Brief physician advice alone raises quit rates; combine with counselling and quitlines. In India — the National Tobacco Control Programme (NTCP), Tobacco Cessation Centres, COTPA 2003, and the national quitline 1800-11-2356.

Pharmacotherapy. Nicotine replacement therapy — combination of a long-acting patch with a short-acting gum/lozenge is most effective. Varenicline — nicotinic partial agonist, the most effective single agent; dose-reduce if eGFR <30; causes nausea and vivid dreams. Bupropion SR — lowers the seizure threshold, contraindicated in seizure and eating disorders, and interacts through CYP2D6.

Geriatric precautions. Nicotine patches need caution in unstable angina, recent MI and arrhythmia. Critically, stopping smoking removes CYP1A2 induction — plasma levels of clozapine, olanzapine, theophylline and the effect of warfarin rise, so doses must be reviewed and reduced. Combine cessation with pulmonary and cardiac rehabilitation.

Cytisinicline (cytisine) — the first new cessation drug in two decades. A plant-derived nicotinic acetylcholine receptor partial agonist. The Phase 3 ORCA-2 and ORCA-3 trials (JAMA 2023; JAMA Internal Medicine 2024) showed significantly higher biochemically confirmed abstinence versus placebo, sustained to 24 weeks, with fewer gastrointestinal adverse effects than varenicline. The NICE 2025 evidence review and ICER 2025 report rate its efficacy as comparable to varenicline; it is already inexpensive and available in several countries, although US approval was delayed in 2026 by a manufacturing-related Complete Response Letter. Source note: the uploaded textbooks cover the rationale and epidemiology of cessation in old age but do not detail pharmacotherapy protocols; points 3–6 follow standard tobacco-dependence guidance (NICE NG209 / USPHS 5A framework) integrated with geriatric prescribing principles. If asked for 15 marks, add: neurobiology of nicotine dependence (α4β2 receptor upregulation); a full timeline of health benefits after quitting (20 min → 15 years); detailed NRT dosing by cigarettes/day; e-cigarettes and the current evidence and controversy; smokeless tobacco (khaini, gutkha, zarda) and its dominance in older Indians; COTPA 2003 and the 2019 e-cigarette ban; and relapse prevention.