Smoking in Chronic Lung Disease
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Smoking in Chronic Lung Disease
Karl Fagerström, Ph.D.
Smokers Information Centre,
Helsingborg, Sweden
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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).
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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)
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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
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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
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COPD - Reasons to smoke:
Avoid strong withdrawal symptoms
Treat cognitive deficits
Control depression
Help clearing the airways
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Smokers with high dependence, depression or
COPD have less success in breaking the tobacco
dependence
Tönnesen 1986
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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
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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
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Carbon Monoxide: Approximate cut offs.
Non-Smokers 1-3 ppm
Average Smokers 10-20 ppm
Heavy Smokers 21-70 ppm
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PHARMACOTHERAPY
• NICOTINE REPLACEMENT
• BUPROPION
• (NORTRYPTILENE)
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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
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Combining NR products has usuallyyielded higher success rates.
Because of
A. Higher doseB. A tool to deal with break-through
cravings
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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
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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.
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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
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What to do with those unable or unwilling to stop abruptly?
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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
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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
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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
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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
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TEŞEKKÜR EDERİM