Smoking cessation strategies for patients with asthma: improving patient outcomes

Figures & data

Table 1 Key points

Smoking is as common in those with asthma as in the general adult community, and even higher in adolescents with asthma. Smokers with asthma are predisposed to worse symptoms and greater deficits in lung function

As current asthma and personal smoking may interact to worsen lung function, the excess individual deficits provide another compelling reason to quit, ideally at the earliest possible age

Smoking cessation in people with asthma has been associated with positive outcomes such as better asthma control and improved lung function. The introduction of smoke-free environments has also improved asthma outcomes

Adult smokers with asthma may have greater difficulty in quitting than those who do not have a chronic illness, yet current smoking cessation strategies do not specifically target this subgroup, largely due to a lack of evidence recommended in order to facilitate a sustained quit attempt

Smoking cessation and other strategies aimed at optimizing asthma control should be addressed at every opportunity, with early follow-up and electronic systems. More research is needed with regard to the use of electronic nicotine delivery devices

Emerging asthma-specific smoking cessation strategies include reminders by cellular phone and education via online, web-based, computer-delivered,

For children with asthma, motivational interviewing with carers might be a useful approach to reduce asthma symptoms. For adolescents, training older peers to deliver asthma education is another promising strategy

Considering the specific needs of current smokers with asthma may facilitate a smoking cessation intervention that is more individualized and aimed at improving quit rates in the longer term

Table 2 Key studies that examined personal smoking and adverse asthma outcomes

References	N	Participants	Findings
Thomson et al^Citation29	760	BTS Severe Asthma Registry with severe refractory asthma 69 (9%) current smokers 210 (28%) ex-smokers 461 (62%) never smokers	Compared with never smokers, current smokers had poorer asthma control (ACQ 4.1 vs 2.9, P<0.001), more unscheduled health care visits (6 vs 4, P=0.008), more rescue oral steroids (6 vs 4 courses, P=0.04), higher anxiety (13 vs 8, P<0.001), and depression (10 vs 6, P<0.001), but no differences in spirometry
To et al^Citation28	519	From eight Canadian primary care practices, 137 of 519 with physician-diagnosed, mild-to-moderate asthma were smokers at baseline; after 12 months, 11% (n=15/137) quit, and 4% (n=16/382) of those not smoking at baseline commenced	Compared with continuous smokers (within a 12 month period), individuals who quit had less chest tightness (OR, 0.21; 95% CI, 0.06, 0.82) and fewer nocturnal symptoms (OR, 0.24; 95% CI, 0.07, 0.85), but no difference in acute health care utilization. Those who became smokers had increased chest tightness, nighttime symptoms, and ≥1 asthma attack within 6 months
Cerveri et al^Citation7	9092	ECRHS I (n=17,840 from 28 centers) and II (n=10,296), where 1,045 of 9,092 participants in the current analysis had asthma at baseline	26% of current smokers with asthma (n=949) continued to smoke despite significantly more having chronic cough and sputum production than never and ex-smokers (52% vs 42% and 43%). There was no difference in FEV1 % of predicted or FEV1/FVC between smoking subgroups with asthma
Boulet et al^Citation27	893	Telephone survey of Canadian adults 108 (12%) current smokers 268 (30%) past smokers 514 (58%) nonsmokers	Current smokers were more likely to have daytime asthma symptoms (30% vs 17% nonsmokers and 18% ex-smokers), and report asthma symptoms as a reason for absenteeism (P<0.01)
Zheng et al^Citation32	4070	Meta-analysis of ten controlled studies in smokers vs nonsmokers with asthma using inhaled corticosteroids	Compared with nonsmokers with asthma, smoking was associated with an attenuated inhaled corticosteroid response, reduced mean change in FEV1, reduced posttreatment FEV1, and increased use of concomitant medication

Notes: FEV₁/FVC, the ratio between FEV₁ and forced vital capacity as a measure of airflow limitation/obstruction.

Abbreviations: ACQ, Asthma Control Questionnaire; BTS, British Thoracic Society; ECRHS, European Community Respiratory Health Survey; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; OR, odds ratio.

Table 3 The “five As” strategic model for treating tobacco use and dependence, for the patient willing to quit

Strategy	“As”	Action
A1	Ask	Systematically identify all tobacco users at every visit Current | former| never
A2	Advise	Strongly urge all tobacco users to quit “Continuing to smoke makes your asthma worse, and quitting may dramatically improve your health” “Quitting smoking may reduce the number of ear infections (and asthma attacks) your child has”
A3	Assess	Determine willingness to make a quit attempt Determine stage of change^a “How do you feel about your smoking at the moment?” “Are you ready to stop smoking now?”
A4	Assist	Aid the patient in quitting (provide medication and counseling) Help the patient with a quit plan Recommend the use of approved medication except when contraindicated or the evidence is insufficient Provide practical counseling (total abstinence, make the home smoke free, build positively on past quit experiences, avoid alcohol, and other triggers) Provide supplementary materials (National Quitline network)
A5	Arrange	Ensure follow-up contact, within a week of the quit date

Note: Adapted from Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; 2008.^{62 a}The Australian Clinical Guidelines now emphasize the “stages of change”, as opposed to “readiness to quit”.⁶¹

Table 4 Asthma-specific considerations when quitting

Consideration		Asthma-specific action
1	Importance	Recommend to quit smoking at every opportunity Target adolescents and young adults for whom smoking cessation can have the greatest benefit
2	Information	Discuss “lung age” to illustrate the lung function deficit from smoking ± asthma Describe corticosteroid insensitivity as a mechanism of worsening asthma control Highlight that smokers with asthma often have repeated and more frequent attempts to quit and emphasize that the process is cumulative Offer written asthma-specific information that might be web based
3	Management	Optimize asthma management while planning to nominate the quit date, which might necessitate increasing doses of ICS and/or other add-on therapy Use the current standard approach for smoking cessation, until there is an evidence base that differs for smokers with asthma
4	Admission	Regard this opportunity as a “teachable moment” In the absence of contraindications, inpatient NRT and counseling can be given as a priority, and other pharmacotherapies can be commenced as appropriate
5	Follow-up	Close and longer-term follow-up is essential, given those with asthma have a tendency to relapse, have more quit attempts and not complete asthma educational programs. Consider reminder text messages and educational prompts by cellular phone for those interested

Abbreviations: ICS, inhaled corticosteroid; NRT, nicotine replacement therapy.

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