What is the recommended smoking cessation management for a 70‑year‑old male chronic smoker with emphysema?

Smoking Cessation in a 70-Year-Old Male Chronic Smoker with Emphysema

This patient requires immediate, high-intensity smoking cessation intervention combining pharmacotherapy (varenicline OR bupropion PLUS nicotine replacement therapy) with intensive behavioral counseling—this is the ONLY intervention proven to slow COPD progression, reduce mortality, and improve quality of life. 1, 2

Why Smoking Cessation is Critical in This Patient

• Smoking cessation is the single most important intervention that alters the natural history of COPD by reducing lung function decline, decreasing exacerbation frequency, and improving survival—no other medication achieves this. 1, 3
• Even at age 70, quitting smoking increases life expectancy; patients who stop at age 50 gain approximately 6 years of life compared to continued smokers, with benefits extending to older ages. 3
• Former smokers with COPD have a 43% reduction in hospital admission risk compared to current smokers (HR 0.57). 3
• Smoking cessation reduces COPD exacerbation risk (adjusted HR 0.78), with greater benefit the longer the patient abstains. 2, 3

Recommended Pharmacotherapy Protocol

Combination pharmacotherapy is superior to monotherapy and should be the standard approach:

First-Line Regimen (Choose One):

• Varenicline 1 mg twice daily (after 1-week titration: days 1-3 at 0.5 mg once daily, days 4-7 at 0.5 mg twice daily, then 1 mg twice daily) for 12 weeks, with consideration for an additional 12-week course to increase long-term abstinence. 1, 4

PLUS

• Nicotine replacement therapy (NRT): Combine long-acting patch with rapid-acting form (gum, lozenge, inhaler, or nasal spray) for breakthrough cravings. 1, 2, 5

Alternative First-Line Regimen:

• Bupropion SR PLUS combination NRT (patch plus rapid-acting form). 1, 2

Key Pharmacotherapy Principles:

• Never use pharmacotherapy alone—it must be combined with behavioral support to maximize effectiveness. 1, 5
• Extend treatment beyond 12 weeks if needed; the most effective NRT approach uses combination therapy for extended duration. 6
• For patients with severe renal impairment (CrCl <30 mL/min), reduce varenicline to 0.5 mg once daily, titrating to maximum 0.5 mg twice daily if tolerated. 4

Intensive Behavioral Support (Non-Negotiable)

High-intensity behavioral counseling is essential and directly correlates with success:

• Provide intensive individual counseling sessions with telephone follow-up contacts—this high-intensity approach reduces exacerbations (0.38 vs 0.60 per patient) and hospital days (0.39 vs 1.00 per patient) compared to medium-intensity strategies. 2
• Set a definite quit date within 1-2 weeks of the first consultation. 1
• Emphasize complete abstinence as the goal—advise abrupt cessation rather than gradual reduction, as gradual withdrawal rarely achieves complete cessation. 2, 7, 3
• Arrange weekly follow-up sessions for at least 4 weeks, checking abstinence by measuring expired carbon monoxide. 1
• Encourage the patient to find a quit partner for mutual support. 1
• Counseling delivered by health professionals significantly increases quit rates over self-initiated strategies. 1

Realistic Expectations and Multiple Attempts

• With effective resources and intensive support, long-term quit success rates of up to 25% can be achieved. 1
• Approximately one-third of patients succeed with support; expect multiple quit attempts as repeated efforts are often necessary. 2, 3, 8
• Heavy smokers with multiple previous quit attempts require even more intensive support. 2, 7
• Success rates: 3-5% with unassisted attempts, 7-16% with behavioral intervention alone, up to 24% with combined pharmacotherapy and behavioral support. 5

Concurrent COPD Management

While initiating smoking cessation, simultaneously optimize COPD treatment:

• Initiate or optimize inhaled bronchodilator therapy (β2-agonist or anticholinergic like tiotropium) even if spirometric improvement is modest, as symptom relief can occur regardless of FEV1 changes. 2, 7
• Administer annual influenza vaccine to reduce serious illness, death, and exacerbations. 1
• Provide pneumococcal vaccinations (PCV13 and PPSV23) as recommended for all patients ≥65 years. 1
• Teach proper inhaler technique at first prescription and verify at each visit. 1, 7

Critical Pitfalls to Avoid

• Do not recommend gradual smoking reduction as the primary strategy—it rarely achieves complete cessation and should only be considered for patients unwilling to quit abruptly. 2, 7, 3, 4
• Do not rely on pharmacotherapy alone without establishing intensive behavioral support—the combination is consistently more effective. 2, 5
• Do not discontinue efforts after one failed attempt—tobacco dependence is a chronic condition requiring repeated intervention. 9
• Do not underestimate the benefit at age 70—smoking cessation improves outcomes at any age and remains the only intervention that slows COPD progression. 3

Follow-Up Schedule

• Schedule close follow-up within 2-4 weeks to assess smoking cessation progress, medication tolerance, and symptom improvement. 2, 7
• Continue weekly behavioral support sessions for at least 4 weeks, then monthly monitoring. 1
• Perform regular spirometry to monitor disease progression even after successful cessation, as COPD remains progressive despite quitting. 7, 3