A neglected population

Although tobacco cessation success is poor overall with only 8% effectiveness, the prevalence in persons over 65 has remained constant over the last 12 years. The chart below shows the trends by age band. Meza et al

How can this be explained? Is there a bind spot for seniors who smoke cigarettes?

Several recent government publications including the 2024 Surgeon General’s Report should make us ask if the Department of Health and Human Services and the Centers for Disease Control understand the impact of smoking on health and health care costs for seniors?

The latest Surgeon Generals’ Report on Eliminating Tobacco Related Disease and Death explores disparities by race and ethnicity, level of income, level of education, sexual orientation, gender identity, type of occupation, geography, and behavioral health status but omits discussion of a major demographic group-SENIORS! Eliminating Tobacco-Related Disease and Death: Addressing Disparities Certainly older smokers in these disparately impacted populations are at greatest risk, but seniors as a group are the population with the greatest concentration of smokers.

People over the age of sixty-five who smoke cigarettes are the most likely to be burdened by a lifetime of tobacco related illness which leads to their premature death. The most recent Surgeon Generals’ Report 1estimates that over 490,000 people die of tobacco related diseases each year. Most of those people are seniors who on average die ten years sooner than non-smokers. Tobacco-related diseases profoundly affect the quality of life for over 16 million people and are estimated to contribute 8.6 percent of the total medical expense in the USA. The data summarized below suggests that clinicians who care for seniors are performing poorly on tobacco cessation services and that seniors are not getting the message about the availability of resources to help them stop.

Part of the problem is that physicians do a poor job of advising their patients to quit smoking. The 2020 Surgeon General’s Report on Smoking showed that most smokers want to quit, yet more than two-thirds of adult cigarette smokers who tried to quit during the past year did not use evidence-based treatment such as counselling or medication. This shortfall in use of effective interventions contributes to high rates of relapse. The cumulative effect of decades of inadequate delivery of cessation advice to seniors is to allow accumulation of a high number or seniors who continue to smoke. A recent study showed that smoking prevalence decreased from 2011 to 2022 in all age groups except adults 65 years or older.  Trends in US Adult Smoking Prevalence, 2011 to 2022 | Health Policy | JAMA Health Forum | JAMA Network

Unpublished claims data from my former employer (Aetna) shows that fewer than 1% of Medicare Advantage members received both smoking cessation counseling and medication. While commercial insurers have state of the art benefit design and skilled resources available for all members who request them, these resources are not aggressively promoted.

Data from electronic medical records of a large health system in Pennsylvania and Maryland show that smoking cessation counseling is rarely billed, with only 4.7 percent receiving counselling over a 3 year period. A Lost Opportunity in Tobacco Cessation Care: Impact of Underbilling in a Large Health System - ScienceDirect

Scholars agree that senior smoking is neglected. The key arguments for greater action are outlined by Tim McAfee Ignoring our elders: tobacco control’s forgotten health equity issue | Tobacco Control (bmj.com).  Kleykamp and Kulak argue that the intense focus on youth adoption of tobacco in all its forms may have drawn away from appropriate attention to current smokers. Cigarette Use Among Older Adults: A Forgotten Population - ProQuest.

HHS and other groups may have a blind spot. The recently released HHS Framework to Support and Accelerate smoking cessation does not reference seniors as one of the groups with a disparate impact, when in fact most of the effects of disparities become manifest among seniors. HHS Framework to Support and Accelerate Smoking Cessation 20244. While there is extensive presentation of the many tobacco control initiatives since 1980, there is no analysis of their limitations. The new framework presented is laudable but is likely to underperform if clinicians do not provide the basic services of tobacco cessation.

The CMS Universal Foundation for Aligning Quality Measures released in 2023 does not include smoking cessation. Aligning Quality Measures across CMS — The Universal Foundation | New England Journal of Medicine (nejm.org)

The highly detailed assessment of the Million Hearts Program run by the CDC does not include measures of tobacco cessation medications or counseling, and scant reference to tobacco use status which would have the highest impact of all modifiable risk factors. Evaluation of the Million Hearts® Cardiovascular Disease Risk Reduction Model Final Evaluation Report (cms.gov)

At a meeting with CMS, held on 11/9/2022, representatives of ATTUD presented 2019 data showing that “Medicare currently is only spending $11.3 million annually on reimbursing for the current smoking cessation codes”. If the average reimbursement for those codes is $14.00, then there were approximately 800,000 counseling sessions. With over 65 million Medicare enrollees at that time, and a prevalence of 9%, this suggests that fewer than 1/7 smokers received cessation services.

Although NCQA has recognized the inadequacies of its CAHPS-based measure on advice to quit smoking, there is no haste in replacing it with a more reliable HEDIS measure. NCQA HEDIS measures and Medicare Stars measures have had a profound impact on physician practice but there has never been a STARS measure linked to tobacco. NCQA is exploring the development of two new measures related to tobacco use and lung cancer screening. These measures would potentially become part of HEDIS no earlier than measurement year 2026. CMS is considering proposing these measures for the Star Ratings pending future rulemaking. Summary of Changes in the 2025 Advance Notice (healthmine.com). Let’s make sure they adopt NQF 0028 Quality ID #226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention – National Quality Strategy Domain: Community / Population Health - Claims (cms.gov)

Medicare does not provide coverage for over the counter medication and as a result Medicare members do nAccess to effective smoking cessation medications in patients with medicare, medicaid and private insurance - ScienceDirect

There is much more that HHS, CMS, can do in working with health insurers, Accountable Care Organizations, hospitals and clinicians to improve cessation services to seniors. Perhaps with the change of leadership in these government organizations, appropriate attention can be paid.