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Editorial: Smoking in the elderly.

Charles Lamb's couplet from A Farewell to Tobacco may have sinister undertones today, but it still expresses only too clearly the merciless power with which the smoking habit enslaves its victims. Few people, even hardened smokers, will disagree with James I that it is "a custom loathsome to the eye, hateful to the nose, harmful to the brain and dangerous to the lungs," but in spite of his views and the more scientifically based warnings sounded by the Royal College ofPhysicians 350 years later millions of otherwise rational men and women continue to smoke. By so doing they expose themselves (most of them wittingly) to the risk of premature death from lung cancer, chronic bronchitis, and coronary heart disease. There are certain circumstances in which doctors have a clear duty to put relentless pressure on their patients to stop smoking. Such pressure must be applied to all healthy young and middle aged people, patients with chronic bronchitis whatever their age, and those who have developed coronary heart disease or peripheral arterial disease in their 40's and 50's. These are people who, by giving up smoking, can either increase their life expectancy significantly or, in the case of patients who have already developed chronic bronchitis or coronary artery disease, improve their prognosis. There might, however, be a case for adopting a less rigid attitude towards smoking in the elderly. To many old people, particularly those who are living alone and have no outside interests, smoking may be one of their few remaining pleasures. If they are to be urged to give up the habit, they are entitled to know what benefits are likely to accrue from what to them may be a traumatic experience. It has been shown that when men stop smoking their death rate from lung cancer falls to 5000 of the rate in heavy smokers in five years and to 25%/o in 10 years' and that there is also a substantial reduction in mortality from chronic bronchitis. If, however, a smoker has survived to retiring age without developing chronic bronchitis or lung cancer any benefit he or she is likely to derive in terms of increased longevity from abandoning the habit will be relatively small. Even this may in later years be offset by deteriorating health from other causes, notably cerebrovascular disease. In the case of coronary artery disease there is even less justification for advising healthy men over the age of 65 to stop smoking, since according to a recent report2 the risk at that age of developing the disorder is essentially the same whether they continue to smoke or not. In the end a decision on whether or not to advise an elderly patient to give up smoking must depend on individual circumstances. Only a fanatical antismoking propagandist would, for example, impose this advice on a contented old man who has puffed happily at his pipe for 40 years or deny the comfort of an occasional cigarette to a patient in the terminal stages of chronic bronchitis or lung cancer. On the other hand, it is equally irresponsible not to try to convince an elderly cigarette smoker with a distressing cough that this symptom would improve if he or she smoked fewer cigarettes or preferably none at all. There is another hazard of smoking which is often forgottenthe risk of fire. No figures are available to show how many old people living alone or in inadequately staffed institutions die from this cause, but the number may be considerable. A lighted match or a live cigarette dropped from an old man's shaky fingers can be just as lethal as lung cancer.