VI Brazilian Congress on AsthmaII Brazilian Congress on COPD

II Brazilian Congress on SmokingBelo Horizonte, August 22-25, 2007

DURATA: 20’

Smoking morbidity and mortality

Giovanni Viegi, MD. Director of Research, Italian National Research Council,

Head, Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Pisa – Italy

. Professor of “Health Effects of Pollution”, School of Environmental Sciences, University of Pisa - Italy

. 2006-07 Past-President, European Respiratory Society (ERS)

COPD the impact of stopping smoking on treatment response

Contents

1. Introduction

2. Key points of recommendations

3. Tobacco/nicotine addiction

4. Epidemiology of smoking-related respiratory diseases

5. Assessments

6. Characteristics of respiratory patients who smoke

7. Psychological and behavioural interventions8. Pharmacological treatment for smoking cessation9. Other interventions10. Smoking reduction11. Organisational anchorage and education12. The costs of smoking and economics of smoking cessation13. Research prospects14. References

3. Tobacco dependence/nicotine addiction

3.3. Definition of tobacco dependence

The World Health Organization (WHO) International Classification of Diseases (ICD-10) classifies tobacco smoking as F17: Mental and behavioural disorders due to use of tobacco. Subdivisions are:

F17.0, Acute intoxication;

F17.1, Harmful use;

F17.2, Dependence syndrome;

F17.3, Withdrawal state;

F17.8, Other mental and behavioural disorder;

F17.9, Unspecified mental and behavioural disorder

Z72.0, Tobacco use (which excludes F17.2 Tobacco dependence).

F17.2 Tobacco dependence can be defined as “a cluster of behavioural, cognitive and physiological phenomena that develop after repeated use and typically include a strong desire to smoke, difficulty in controlling its use, persisting in its use despite harmful consequences, increased tolerance to nicotine, and a (physical) withdrawal state.”tobacco smoking/nicotine addiction can be regarded as a chronic, recurrent disease or disorder with an expected successful cessation rate after treatment of 15-35% after 1 year, similar to other addictive disorders

4. Epidemiology of smoking related respiratory diseases

4.1 Tobacco smoking - the extent of the problem

According to the World Bank, in 1995 there were about 1.1 billion smokers aged 15 years or more worldwide (29% of the global population; 47% of males, 12% of females). This number is estimated to grow to 1.6 billion by 2025.

Tonnesen et al, ERJ 2007

4.3. COPD

According to the WHO Global Burden of Disease study, COPD, which in 1990 was the sixth leading cause of death worldwide, is expected to rank third by 2020 [37].

Cigarette smoking is the most important risk factor for COPD, and it can also promote the onset of exacerbations [40].

Part I of II

Smokers with COPD have higher tobacco consumption, higher CO levels in exhaled air and higher dependence on nicotine than “healthy” smokers [44].

Many studies have suggested that females could be more susceptible to the harmful effects of tobacco smoke in developing COPD [45].

Smoking cessation programmes seem likely to lead to significant reduction of mortality in patients with COPD [49].

Part II of II

4.4. Smoking and respiratory symptoms

Data collected from general population samples have confirmed that respiratory symptoms occur more frequently among smokers than non-smokers, in both males and females [41,50]

Smoking cessation significantly reduces the presence of respiratory symptoms [52].

4.5. Smoking and lung function

Smoking reduces the growth velocity of FEV1 during adolescence, causing a lower maximal attained FEV1 [54].

Smoking brings forward the time of onset of FEV1 decline in early adulthood, thus shortening the plateau phase during which lung function remains almost constant [55].

Part I of III

Smoking accelerates the decline of FEV1 in late adulthood and the elderly [3,53,56].

In the Lung Health Study (LHS) the average annual loss of FEV1 was around 60 mL/year among continuing smokers at the 11 year follow-up point [57].

Stopping smoking reduces the decline of FEV1 approximately to that of the never smoker [3,58].

Part II of III

FEV1 may increase somewhat after smoking cessation, but it will not achieve the level expected for a never smoker [55].

An association has been observed between decrease in diffusing capacity (DLCO) and cumulative cigarette consumption, even in “healthy” subjects [62] and DLCO can improve in subjects who quit smoking [63].

In COPD patients, smoking cessation reduces airway responsiveness to methacholine but it does not revert it to normal levels [48]. Part III of III

5. Assessments

5.1. Smoking status

Smoking status should be prominently noted in the patient’s record that includes the type of tobacco use (cigarettes, cheroots, cigars or pipe) and quantity inclusive pack-years (cigarettes per day x years smoked divided by 20).

Part I of II

5.2. Motivation to give up

There is no good, validated measure for assessing degree of motivation.

To assess motivation, ask the patient to rate on a 10 point scale: “How important is it for you to give up smoking”?, with 10 representing “extremely important” and 0 being of “no importance”.

To have an idea of perceived self-efficacy, ask the patient: “If you were to decide to stop smoking, how confident are you that you would succeed?”, with 10 points being “entirely certain that I would succeed” and 0 ”entirely certain I would fail”[77].

Part II of II

Motivation

Low High

Self-efficacy

Low motivation and self-efficacy need to be built up

treatment and support are critical for success

High effective health education is critical

a quit date can be set immediately

Normally the patient expects to be told to stop smoking in a direct and clear way, but such a way may make the patient embarrassed, and sometimes covertly, if not overtly, aggressive and defensive. Therefore an approach where smoking can be discussed in an unthreatening, respectful and emphatic way is required.

5.3. Dependence

Table 2. The Fagerström Test for Nicotine Dependence (FTND)

Question Response Points

1 How soon after you wake up do you smoke your first cigarette?

Within 5 min6-30 min31-60 minAfter 60 min

3210

2 Do you find it difficult to refrain from smoking in places where it is forbidden?

YesNo

10

3 Which cigarette would you hate most to give up? The first one in the morningAny other

10

4 How many cigarettes per day do you smoke? 1011-2021-30 31

0123

5 Do you smoke more frequently during the first hours after waking than during the rest of the day?

YesNo

10

6 Do you smoke if you are so ill that you are in bed most of the day?

YesNo

10

Total score (0-10)

5.4. Earlier smoking cessation experience

Enquire about the longest period without smoking, the difficulties and withdrawal symptoms, any methods used that helped, what trigged relapse and whether anything positive was experienced during abstinence

5.5. Carbon monoxide

Demonstrating the “CO effect” in smokers is of great motivational value.

The CO concentration can easily be obtained by asking the smoker to exhale into a CO analyser.

The measurement unit is CO in parts per million (ppm), which can easily be converted to carboxyhaemoglobin (COHb).

Part I of II

During normal environmental conditions, a non-smoker’s CO value should not exceed 4 ppm [85].

Smoker readings: around 10-20 ppm (2-5% COHb).

Within one or two days after the last cigarette the CO will be normal.

Part II of II

5.6. Spirometry and smoking cessation

Lung function tests are strongly advised during baseline assessment of smokers from the general population.

The aims are to detect lung diseases in susceptible smokers [87-90] and to increase smoking cessation rates, as a consequence of a reinforced motivation to quit caused by the objective demonstration of lung function impairment [91].

6. Characteristics of respiratory patients who smoke

6.1. Why respiratory smokers are a difficult target?

Smokers with respiratory complaints seem more motivated to stop smoking than those with no such complaints [8], particularly if they believe that smoking is a cause of their respiratory symptoms [100].

At some stage in the development of respiratory symptoms, advice from a GP is likely to have been given, perhaps repeatedly, and so the selection process goes on, with more and more recalcitrant smokers remaining in the population.

Part I of II

It is also possible that respiratory patients at some stage develop “tolerance” to the quit advice, particularly if the same procedures or treatments are repeatedly suggested.

It follows from this selection hypothesis that the more severe the lung disease, the more difficult it is to give up smoking.

Part II of II

6.2. Self-medication for co-morbidity

The anxiety level, which often is a part of depression, is higher among COPD smokers [107].

These patients suffer from alexithymia or lack of emotional expression [108].

Smoking may be helpful and be a kind of self-medication that controls anxiety and emotions: relapsing after a quit attempt may be a way to escape from depressive mood and anxiety.

6.3. Dependence

Smokers with COPD have a higher FTND score than average smokers [110,111]. The same has been found for lung cancer patients [112,113].

This higher dependence contributes to increasing the risk of contracting a respiratory disease and also makes it more difficult to give up, further reinforcing the selective attrition of smokers to leave a “hard core” of highly dependent smokers.

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

6.4. Smoke inhalation pattern

Smokers with COPD tend to inhale more deeply and rapidly compared to healthy smokers [110,115].

6.5. Weight control

Low body mass index (BMI) is a problem for many end-stage COPD patients, and is associated with a poorer prognosis. For this group of patients the weight gain of 4 5 kg typically observed during the first year after quitting smoking might be an advantage. Also, in lung cancer patients with decreased appetite, theoretically this might be beneficial.

For COPD patients with high BMI, the advantage of quitting smoking with regard to preservation of lung function is much more important than adverse effects from weight gain.

Smoking cessation in COPD

Tønnesen et al, 2005:

Nurse-conducted smoking cessation in patients with COPD, using nicotine sublingual tablets and behavioral support

Smoking cessation in COPD

NRT versus placebo:

6 months quit rate: 23 % vs 10 %

12 months quit rate: 17 % vs 10 % (OR 2.0)

Smoking reduction in COPD

NRT versus placebo:

6 months reduction rate: 21 % vs 15 %

12 months reduction rate: 12 % vs 13 %

SGRQ in COPD (12 Months)

Quitters ReducersSmokers

Symptoms -28 -21 -2

Activity -6 -8 -2

Impact -8 -5 -4

Total score -10.9 -8.5 -2.9

FEV1 in COPD (12 Months)

Smokers Reducers Quitters

FEV1 -160 ml -5 ml + 60ml

Definition.

Decrease in cigarette consumption, with the ultimate goal of complete cessation.

Reduction in daily cigarette consumption by at least 50% compared to baseline, sustained from week 6 until month 4, verified by a sustained decrease in expired CO.

Smoking cessation through smoking reduction

Six randomised placebo controlled studies that evaluated the efficacy of either nicotine gum or nicotine inhaler for smoking reduction.

All of them had similar design which allowed the results to be pooled.

Tonnesen et al. Thorax. 2005.

Results at 12th months.

Active Group:

(N=1215)

Placebo Group:

(N=1209)

Success at 4th month

Success at 12th month.

193

81 2.4%

8.6%104

29

15.9%

6.7%

Smokers who do not quit

Smoking cessation through smoking reduction.

0%

5%

10%

15%

20%

25%

<50% >=50%

Active

Placebo

PP reduction at month 4

% q

uit

at

mo

nth

12

Subjects from 6 studies; present at m4 and m12

n=391 n=441 n=303 n=234

Does Reduction Promote Cessation?

Other studies also support that smoking reduction promotes cessation

Farkas et al.1999

Carpenter et al. 2004

Falba et al. 2004

SMOKING REDUCTION IN COPD.

• Demographics characteristics– 17 recalcitrant COPD smokers:

• 15 male• 2 female

– Mean age:• 55(15)

– FEV1 less than 50%

– Jiménez-Ruiz et al. Respiration 2002.

SMOKING REDUCTION IN COPD.

• Methods.

– Reducing NCD.

– Using pieces 4 mg nicotine gum.

– Reduction in the levels of expired CO.

SMOKING REDUCTION IN COPD.

– Results. Reduction.

• At 18th month.– 5 patients reduced5 patients reduced.

• At 24th month.– 3 patients reduced.3 patients reduced.– 2 patients stopped,2 patients stopped,

SMOKING REDUCTION IN COPD.

– Results in successful reducers at 18 months.

• NCD: From 39 to 5

• CO: From 31 to 11

• Improvement in respiratory symptoms

• Improvement in FEV1 and FCV.

• Increase of motivation to quit.

– Jiménez-Ruiz et al. Respiration. 2002.

SMOKING REDUCTION IN ASTHMATICS.

– Prospective open study.

– 220 asthmatics smokers.

– Three groups: Reduction. Cessation. Continuing smokers.

– Nicotine gum or nicotine inhaler.

– Tonnesen et al. Nicotine Tobacco Research. 2005.

SMOKING REDUCTION IN ASTHMATICS.

– Results.• In abstainers.

– ASQL score– Rescue beta 2 agonists.– Inhaled corticosteroids– Asthma symptoms.– Bronchial hyperreactivity

• In reducers.– Rescue beta 2 agonists.– Inhaled corticosteroids.– Bronchial hyperreactivity.

Tonnesen et al. Nicotine Tobacco Research. 2005.

SMOKING CESSATION THROUGH REDUCTION.

– Conclusions.

• Smoking reduction seems to be a gateway to smoking cessation.

• The use of NRT is safe and efficacious to obtain smoking reduction.

• Using this new approach is possible to enrol more smokers in smoking cessation programmes.

Thank you!

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