key: cord-0995680-bz050d1j authors: Yao, Yao; Liu, Keyang; Zhang, Junfeng (Jim); Iso, Hiroyasu; Lam, Tai Hing title: Tobacco smoking and older people amid the COVID-19 pandemic: An elephant in the room date: 2021-07-26 journal: Age Ageing DOI: 10.1093/ageing/afab170 sha: f35ab65f8759d30789131be64c4c7a901b8726eb doc_id: 995680 cord_uid: bz050d1j nan Although the global prevalence of smoking in the total population of all ages has slightly declined since 1990, population growth and ageing will lead to greater number of smokers and smoking-attributable diseases and deaths. 1 Older people, too often ignored like the 'elephant in the room', are the most vulnerable during the double pandemic of tobacco and COVID-19. 2 The risk of viral transmission is higher if the older person is a smoker, as the act of smoking involves unmasking and contact of fingers with the lips. Although the World Health Organisation (WHO) has warned that older smokers have higher risk of severe COVID-19 outcomes including death, little attention has been paid to older people. 3 By stark contrast with the previous themes of World No Tobacco Day (WNTD) specifically targeting youth, women, and the poor, no theme to date has highlighted the great vulnerability of older people and the urgent needs to protect them from the harms of smoking and second-hand smoke (SHS). 4 The reasons for such negligence are unknown. WHO warns that one out of two smokers will be killed by tobacco; and the rate could be higher in older people. 4, 5 Our Guangzhou Biobank Cohort Study showed that 2 out of 3 older Chinese smokers born after 1949 could be killed by smoking, which corroborates evidence from the UK, US and Australia. 6 The CHANCES consortium including 25 cohorts with 503,905 participants aged 60+ showed that smoking was a strong independent risk factor of cardiovascular events and mortality, and that smokers died of cardiovascular diseases (CVD) more than five years earlier than non-smokesr. 7 Although some older smokers are 'hardcore' smokers, studies from Europe, North America, and Asia showed substantial benefits of smoking cessation, such as reducing the excess risk of CVD and death even at an advanced age. 4, 6, 8 The 2021 theme of WNTD was 'Commit to quit'. This campaign aimed to support 100 million people (8.8% of the current smokers worldwide) in their attempt to give up tobacco through various initiatives and digital solutions. 2 However, the existing quit-smoking campaigns need to be revisited for older people, as they are less likely to benefit from the conventional tobacco control policies and the online campaign. 8 An analysis from 10 European countries indicated that tobacco control policies, including pricing schemes and smoke-free regulations, reduced the prevalence of smoking among people aged 50-64 but not in those aged 65+. 9 Digital solutions, such as toll free quit lines and mobile phone-based interventions for smoking cessation, effective for teenagers and young adults may not work in older people due to the 'Digital Divide'. 10 Moreover, a large UK study found that older smokers appeared less interested in quitting and were less likely to be offered cessation support from doctors, despite being less addicted to nicotine than younger smokers. 11 Healthcare professionals often have stereotypes about older smokers, misbelieving that they were reluctant to quit smoking and would be less responsive to, and benefit less from, tobacco cessation. 11 Hence, face-to-face smoking cessation counselling, especially for those who have experienced recent adverse health events and have more time after retirement, should still be an effective way to help older people quit smoking. 12 New trials on the effectiveness of innovative interventions on older smokers are needed. New policies to support commissioning of health services for older people in general need to ensure that older smokers are not missing out on smoking cessation therapies to receive health benefits of cessation. About 40% of children and one-third adult non-smokers were exposed to SHS worldwide. 13 Conventional epidemiologic studies often lag behind the expanding epidemic of exposure and disease burden. It has always been the case that the disease burden from active and passive smoking is underestimated at a given time when new harms are yet to be recognised later. 14 At present, the number of older people who are exposed to tobacco smoke is still rising, and the tobacco industry is still powerful to influence older people. Meanwhile, new challenges associated with the use of novel tobacco and nicotine products are immerging, the adverse effects of these products on older people are largely unknown. Older people often have false perceptions about the effectiveness and safety of e-cigarettes, as they are easily misled to use e-cigarettes for cessation and to circumvent no-smoking policies. 15 The lack of commitment by governments (and WHO too) towards a total ban of all tobacco products, conventional and novel, is disappointing. While the evidence regarding the harms of active and passive smoking is sufficient to support more and stronger tobacco control initiatives. 7 Meanwhile, we strongly advocate the warning that one out of two, and possibly two out of three older smokers, will be killed by smoking. This can be the simple yet effective warning especially to those with limited education attainment. We recommend this warning be widely disseminated, as tobacco-caused deaths to older smokers are not something in the distant future of their lives. 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