Smoking in Chronic Lung Disease

Karl Fagerström, Ph.D.

Smokers Information Centre,

Helsingborg, Sweden

REDUCE RISK FACTORSIN COPD: KEY POINTS

• Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD.

• Smoking cessation is the single most effective-and cost-effective- intervention to reduce the risk of developing COPD and stop its progression (Evidence A).

Smoking Cessation and Respiratory Symptoms

AmerStudy: 5887 ADULT SMOKERS WITH EARLY COPD FOLLOWED UP FOR 5 YEARS

• 2/3 UNDERWENT SMOKING INTERVENTIONS; 1/3 USUAL CARE

• SMOKING CESSATION IN 22% vs 5%• LESS PREVALENCE OF CHRONIC COUGH,

CHRONIC PHLEGM, WHEEZING AND SHORTNESS OF BREATH (p<0.0001)

• RESPIRATORY SYMPTOMS ASSOCIATED WITH GREATER LOSS IN FEV1 (p<0.001)

• . Lung (Kanner RE et al., Am J Med 1999)

Smoking Cessation & Lung Function

5887 ADULT SMOKERS WITH EARLY COPD FOLLOWED UP FOR 5 YEARS

• MEAN ANNUAL RATE OF LOSS IN FEV1:– QUITTERS (1st y.) -0.33% (+/-0.05)– INTERMITTENT SM. -0.58% (+/-0.05)– SMOKERS -1.18% (+/-0.03)

Murray, Anthonisen et al. J.Clin Epidem. 1998

SMOKING CESSATION DECREASES MORTALITY

American Lung Health Study

At 14,5 years follow up

The group randomized to smoking cessation had significantly less all cause mortality, OR 1,18 (1,02-1,37)

Anthonisen et al Ann Intern Med 2005

COPD - Reasons to smoke:

Avoid strong withdrawal symptoms

Treat cognitive deficits

Control depression

Help clearing the airways

Smokers with high dependence, depression or

COPD have less success in breaking the tobacco

dependence

Tönnesen 1986

SMOKERS

COPD N=153 HEALTHY N=870

DEPENDENCE 4.8 3.1 p<.001(FTND)

CARB. MONOX. 19.7 ppm 15.4 ppm p<.000

Jimenéz-Ruiz et al. 2001

CARBON MONOXIDE CAN BE USED TO:

A. Indicate smoke intake

B. Indicate dependence

C. Increase motivation to give up

D. Monitor progress when quitting and reducing smoking

Carbon Monoxide: Approximate cut offs.

Non-Smokers 1-3 ppm

Average Smokers 10-20 ppm

Heavy Smokers 21-70 ppm

PHARMACOTHERAPY

• NICOTINE REPLACEMENT

• BUPROPION

• (NORTRYPTILENE)

Assumptions in nicotine intake

1 cigarette 1,5 mg 2 mg gum 1,2 4 mg gum 2,8 21 mg patch 21 15 mg patch 15

Combining NR products has usuallyyielded higher success rates.

Because of

A. Higher doseB. A tool to deal with break-through

cravings

USING NR BEFORE QUITTING

Two studies used NR before quitting with

increased results. Before quitting At quttingHerrera, Fagerström et al. 1995 61% 52%*

Schuurmans, Bolliger et al 2004 22% 12%

Rose et al. 2006 15% 6%*

* At six weeks

Many heavy smokers have bronchial Inflammation and obstruction

Many relapse early to find relief from exacerbationsTherefore preventive treatment has been tried

72 smokers, normal LF, randomized to

NRT +beta2 stimulant NRT

Smoke free 86% 47%

Anotov, Sakharova 2006.

85

90

95

100

1 7 14 30

FE

V1

%

60

65

70

75

1 7 14 30

FE

F2

5-7

5%

85

90

95

100

105

110

1 7 14 30

FV

C%

80

85

90

95

100

1 7 14 30 180

FE

V1

102

104

106

108

110

112

1 7 14 30 180

FV

C%

50

55

60

65

70

1 7 14 30 180

FEF2

5-75

%

NRTNRT + β2 adrenergic stimulant

Anotov, Sakharova 2006Days

What to do with those unable or unwilling to stop abruptly?

Do we serve more smokers by offering reduction?

Two samples (N=106, N=236) from an HMO coming for outpatient surgery were offered advice to stop or reduce smoking.

Selection Reduction by 2/3 Abrupt cess. Nothing

Sample 1 39% 38% 23%

Sample 2 22% 12% 65%

Glasgow et al. 2006

How Much Smoking Reduction Is Neededfor Harm Reduction to take place?

50% has gradually developed as a standard

< 8 cigarettes per day?

Clearly the less smoked the better

DAGNOSING THE SMOKER

ASSESSMENTS

Motives and motivationfor quitting

Amount smoked

Dependence level Fagerstrom test / Nicotine / Cotinine

Carbon monoxide in exhaled air

Spirometry

Earlier quitting experience

Psychic comorbidity

Chinese Monkey Gives up Smoking After 16 Years

The 27 year old monkey Ai Ai that has smoked for 16 yearshas given up. Ai Ais guard has successfully helped hergive up with walks after breakfast, music after lunch and exercise after supper. “In the beginning Ai Ai had cravings forcigarettes but as her life became richer she was able to for-get the cigarettes” says the guard.The nicotine dependence began when Ai Ai suffered from lonli-ness and sorrow after two caretakers died. In 1989 in SafariPark “Shaanxi” she began to smoke as her first caretaker died.1997 she became a chain-smoker when her second caretakerdied and her daughter was transfered to another Zoo.Wherefrom the monkey got her first cigarette and how smoking was maintained is not told. The Zoo will now find a newcaretaker for her. APA Oct. 3 2005

TEŞEKKÜR EDERİM