Management of stable COPD : smoking cessation ( PULMO HANDBOOK OF COPD )

Tuesday, March 17, 2009

1. Points

· Smoking is an addiction and a chronic relapsing disorder.

· Smoking should be routinely evaluated whenever a patient presents to a healthcare facility

· All smokers should be offered the best chance to treat this disorder.

· Permanent remissions can be achieved in a substantial percentage of smokers with currently available treatments.

· Successful treatment of this disorder can have a substantial benefit in reducing many secondary complications of which chronic obstructive pulmonary disease (COPD) is one.

· Smoking cessation activities and support for its implementation should be integrated into the healthcare system.

2. Background

A. Smoking as a primary disorder

Cigarette smoking is an addiction and a chronic relapsing disorder regarded as a primary disorder by the Department of Health and Human Services Guidelines in the USA and by the World Health Organization. Therefore, treating tobacco use and dependence should be regarded as a primary and specific intervention. Preventing the development and progression of COPD can be regarded as one of the secondary effects prevented by treating the primary disorder, because although cigarette smoking is the single most important cause of COPD, it is also a major risk factor for many other diseases including atherosclerotic vascular disease, cancer, peptic ulcer and osteoporosis.

B. Smoking prevention

Effective primary prevention of smoking would eliminate the need for smoking cessation. Unfortunately, measures to decrease smoking initiation have had limited success. Yet, the following measures have been shown to prevent smoking addiction:

- increasing the price of cigarettes

- enforced programmes which limit access to cigarettes

- society can have a major effect on smoking behaviour and it is hoped that

- comprehensive programmes designed to control smoking initiation can have similar benefits.

C. Smoking in COPD

Smokers experience an accelerated rate of decline in lung function. Individual susceptibility, however, varies greatly and depends on a complex interaction of many genetic and environmental factors. It is often stated that 15% of smokers will develop COPD. This dramatically underestimates the impact of smoking because the majority of smokers will develop loss of lung function,and reduced lung function, at any level, is predictive of increased mortality. Many smokers with undiagnosed COPD have symptoms. It is necessary to identify and properly diagnose individuals earlier in the course of the disease when physiological limitation and symptoms are milder. Quitting smoking can slow the progressive loss of lung function and can reduce symptoms at any point in time. Yet, the beneficial impact of smoking cessation on the natural history of COPD is greatest the earlier cessation is achieved. Adolescents who quit smoking will have increased lung growth

D. Passive smoking and COPD

Smoking during pregnancy is associated with low birth weight, and infants with low birth weight appear to have a greater risk of developing COPD. Smoking and probably passive smoke exposure in childhood compromises lung growth leading to diminished maximal lung function in young adulthood. Passive smoke exposure is a risk factor for symptoms of cough and sputum production, and may account for some of the COPD that develops in nonsmokers.

3. Brief intervention

A brief intervention can be effective for many smokers and should be practiced in all clinical settings. Often this can take the form of several minutes during a routine visit. The key steps in the algorithm for brief intervention are the “5 As”.

· Ask: systematically identify all tobacco users at every visit; implement an office-wide system that ensures that tobacco-use status is queried and documented for every patient at every clinic visit.

· Advise: strongly urge all tobacco users to quit, in a clear, strong and personalized manner.

· Assess: determine willingness to make a quit attempt.

· Assist: help the patient with a quit plan, provide practical counselling, provide intratreatment social support, help the patient obtain extra-treatment social support, recommend use of approved pharmacotherapy (except in special circumstances) and provide supplementary materials.

· Arrange: schedule follow-up contact, either in person or via the telephone.

4. Intensive intervention

Intensive intervention refers to behavioural programmes more extensive than the brief intervention described above. Review of multiple studies demonstrates a dose-response effect, indicating that quit rates increase with the intensity, duration and frequency of behavioural support sessions. All smokers willing to participate in intensive intervention should be offered the opportunity as quit rates will increase. Many smokers, however, will not wish to participate in such programmes and, for these individuals, properly executed brief intervention is the best alternative. Intensive intervention can be provided by any suitably trained clinician with adequate resources. Availability of such a programme should be an essential part of every healthcare system, particularly those caring for COPD patients.

5. Systems approach

A major impediment in the delivery of established treatments to treat tobacco use and dependence has been lack of appropriate institutional support. Adequately trained staff with access to the necessary materials and with sufficient time to diagnose, stage and treat the smoking patient must be provided by all reputable healthcare systems. Systems approaches are particularly important as coordinated interventions, involving healthcare providers at a variety of levels, are both more effective and more cost efficient. The healthcare provider has the obligation to provide state-of-the art behavioural and pharmacological treatments. The healthcare administrator has a clear responsibility to insure that smoking cessation services are adequately provided. The healthcare purchaser should expect that tobacco intervention, at the most effective level, will be a contractually covered obligation of insurers and providers. Patients have a reasonable expectation that the most preventable threat to their health will be addressed.

6. Intervention in the smoker not ready to make a quit attempt

Empathetic, nonconfrontational interactions that maximise patient participation are believed to be most effective when dealing with smokers not ready to make a quit attempt. The “5 Rs” can serve as a guide permitting the clinician to focus on the important issues, recognising that multiple interactions are likely to be required in order to achieve a quit attempt.

· Relevance: personalise the reasons to quit. This may include issues in addition to COPD.

· Risks: both acute (i.e. dyspnoea, cough, exacerbations, increased carbon monoxide), chronic (i.e. COPD progression, cancer, cardiovascular disease, osteoporosis, peptic ulcer) and other environmental risks (i.e. disease risk to spouse, household members, increased risk of smoking in children).

· Rewards: such as improved health, improved self image, regaining sense of taste and smell, and saving money.

· Roadblocks: such as withdrawal symptoms, fear of failure, weight gain, lack of support, depression and the enjoyment of tobacco.

· Repetition: most smokers make several quit attempts before achieving long-term abstinence; smoking can be regarded as a chronic relapsing condition, but prolonged remissions are possible A variety of interventions including acupuncture, hypnosis and aversive training methods, among others, have been suggested to aid cessation. None have been shown to be more effective than behavioural interventions alone.

7. Intervention in the smoker ready to make a quit attempt

Every effort should be made to maximise the chances of success in the smoker ready to make a quit attempt, and the following should be offered: behavioural support, pharmacological treatment and follow-up.

· Pharmacological treatment

All smokers willing to make a serious quit attempt should be offered pharmacological support The approach to males and females and to racial and ethnic groups should not vary. Pregnant women should quit, although use of medications in pregnancy has undefined risks. Smoking cessation treatments can be initiated in hospitalised patients. Patients with concurrent psychiatric morbidities may require specific treatment of these conditions. Smoking cessation treatment in adolescence is difficult. The same approaches used in adults can be tried. Quit rates approximately double with first-line pharmacological treatments. First-line treatments include various forms of nicotine replacement treatment and bupropion. Second-line treatments can be considered for smokers unsuccessful with or unable to utilise first-line medication.

First-line treatments

· Nicotine replacement is available in five approved formulations and several others are in development. Their different routes of administration permit individual preference. All that have been assessed are similar in efficacy.

· Nicotine polacrilex (gum) contains nicotine bound to a polacrilex resin together with a buffering agent. Chewing releases the nicotine from the polacrilex. Varying the rate of chewing varies the rate of nicotine release. Once released, nicotine is present in the saliva and is absorbed across the buccal mucosa. Low oral pH causes the nicotine base to ionise and the charged form is absorbed much more slowly. Both 2- and 4-mg formulations are available. Eight to 10 gums per day should be recommended, but are often difficult to chew. Treatment for 3–6 months is recommended, but some smokers will substitute gum for smoking and sustain their addiction with gum.

· Transdermal nicotine system or “patch” is applied to the skin in a nonhairy area of the torso or proximal area of the extremities. Each device contains an adhesive, a reservoir that contains nicotine and an impermeable backing. Nicotine diffuses from the reservoir through the skin and is absorbed into the capillary blood of the skin. Absorption is continuous and relatively slow. Several formulations are available. Transdermal nicotine reduces the intensity, but does not eliminate, withdrawal symptoms. Treatment with nicotine patches is generally recommended at “full dose” for 4–6 weeks. This is often followed by a tapering regimen for several additional weeks.

· Nicotine inhaler consists of a mouthpiece and a nicotine-containing cartridge. Nicotine is released when air is inhaled through the device. Most of the nicotine is deposited in the mouth and absorbed through the buccal mucosa. The device should not, therefore, be inhaled like a cigarette as very little nicotine will reach the lower respiratory tract. Because the nicotine is absorbed through the buccal mucosa, absorption is into the venous circulation. The device contains ~10 mg of nicotine, of which ~1 mg is released with ~100 inhalations.

· Nicotine nasal spray consists of an aqueous solution of nicotine. It is delivered by direct spray to the nasal mucosa [23]. One spray in each nostril delivers 1 mg of nicotine. The nicotine is absorbed into the venous blood in the nasal mucosa. Absorption, however, is relatively rapid with peak levels being achieved in ~10 min. This comes closest to that observed with smoking. As a result, the nicotine nasal spray has increased potential for prolonging nicotine dependence as compared to other nicotine replacement therapies. Local irritation is exceedingly common and can be severe, although most individuals are able to adjust to the local effects with continued use.

· Nicotine lozenges are the most recently approved formulation of nicotine as an aid for smoking cessation [24]. It is approved for over-the-counter use in the USA and is available in 2- and 4-mg nicotine doses. The smoker is allowed to select the dose based on the time from awakening to the first cigarette, a measure of intensity of addiction. Those who use a cigarette within 30 min of awakening are advised to use the 4-mg nicotine dose. Dosing is recommended at nine lozenges per day, one every 1–2 h for up to 6 weeks, followed by tapering of daily use with discontinuation after 6 months.

· Combined modality treatment with several formulations, while not approved by regulatory agencies, has been reported to improve efficacy. Retreatment after a failed attempt can be successful. Treatment is generally started on the quit day. Variable durations of treatment have been suggested. Nicotine replacement can be discontinued abruptly, but gradual tapering is generally preferred. Concurrent cardiac disease should always engender caution, but evidence does not demonstrate an increase in acute cardiac events with the use of nicotine replacement.

· Bupropion is a non-nicotine drug previously approved for use as an anti-depressant .

o It approximately doubles quit rates compared to placebo.

o Treatment is usually initiated at 150 mg daily and increased to 150 mg twice daily after 3 days, if tolerated.

o The quit day should be after 1 week of treatment.

o Treatment is generally continued for 7–12 weeks.

o Bupropion may be more effective than nicotine replacement therapy for individuals with a past history of depression.

o It may also be useful for those concerned about weight gain since it has been shown to delay but not prevent weight gain during cessation.

o Bupropion may cause insomnia and dry mouth. It has been reported to cause seizure in patients with known history of seizure disorder.

o Bupropion can be combined with nicotine replacement treatment, although this may lead to worsening of hypertension.

o Contraindications include increased seizure risk, bulimia, concurrent use of monoamine oxidase inhibitors or a bupropion preparation for depression.

Second-line treatments

· Clonidine has been evaluated in several trials, and while results are equivocal, efficacy is supported by a meta-analysis.

· Nortriptyline is also supported by two studies. Neither second-line treatment currently has an indication for smoking cessation approved by regulatory agencies, but both are approved for other indications and may be used by the experienced clinician “off label” for smoking cessation. Use of other medications for smoking cessation is not supported by currently available data.

8. Harm Reduction

For the smoker who is unable or unwilling to quit, there are few options. The concept that the toxic effects of smoking can be partially mitigated while smoking continues is termed harm reduction . Several strategies are possible, including partial nicotine replacement, substituting cigarettes for less harmful tobacco products and engineering the cigarette to produce less toxins. None of these approaches have been demonstrated to have clinical benefit.


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