Smoking Cessation (out of print)

The history of the evolving opinion of physicians regarding tobacco is briefly reviewed here.

The position of chest physicians has been influenced more by the progressive expansion of specialised medicine than by a specific gift of chest physicians. Nevertheless, their professional associations, which dealt with a large public health challenge, namely tuberculosis, were prepared to be rapidly sensitised by the new challenge, again concerning mainly the lungs, represented by the tobacco smoking epidemics.

The ERS itself urges chest physicians to be part of challenging the disease represented by nicotine dependence, by means of both a training including expertise in smoking cessation and being in close relationship with behaviour specialists if they do not want to improve their skills in that specific area.

As regards what happens in schools, it is quite difficult to identify the chest physicians among the promoters of health education scenarios concerning smoking, but it can be stated that the Belgian Society of Pneumology officially encourages its members to use a slide kit developed by a chest physician in the schools in the vicinity of their practices.

If what is happening in hospitals regarding smoking cessation during or before hospital stay is considered, it is clear that lung or heart and lung departments are most active in this field. Again chest physicians can be identified among the promoters in their own country, but most of these activities are not published or appear only in the grey literature.

The economic burden of smoking-related diseases, such as cardiovascular disease, chronic obstructive pulmonary disease, stroke and lung cancer, borne by healthcare systems and society as a whole is relevant.

Even when effective healthcare programmes aimed at the early detection of lung cancer in long-term heavy smokers are not cost effective compared to not screening, since the cost per quality-adjusted life year gained may reach >2,300,000 US dollars (USD), well over the threshold of USD50,000 reported in the literature. This poor result can be explained by the consideration that costs and consequences related to not screening become evident in the future and should be valued less highly than those accruing at the time of screening.

All interventions aimed at stopping smoking are highly cost-effective compared to other healthcare programmes. In the UK, the cost per year of life saved following smoking cessation interventions ranged from 354 Euros (EUR; general practitioner's brief advice to stop smoking) to EUR1,458 (general practitioner's advice plus self-help plus advice to purchase nicotine replacement therapy with specialist services) when inflated to 1998 prices.

However, a favourable incremental cost-effectiveness ratio is probably not the only relevant criterion to be considered whenever policies and strategies targeted at smoking cessation have to be implemented. Information on the clusters of the population that seem to have major problems with cigarette consumption compared to the rest of society (worse-off people, low-schooling persons and manual workers) should be taken into account, since they are usually poorly compliant with smoking cessation therapies. Enrolling such patients into ad hoc smoking cessation programmes may initially increase the cost per year of life (or per quality-adjusted life year) saved by these interventions, but will probably reduce the global prevalence of smokers in the future to a greater extent.

Certain assessments of the smoker can be important to make in order to better diagnose and understand the smoker’s dependence and what sort of help might best fit the smoking patient. For that purpose, it is important to understand what motivation the patient has for changing the smoking behaviour, their degree of dependence upon tobacco and any possible comorbid condition that interacts with smoking cessation. The instantaneous measurement of carbon monoxide in exhaled air is another assessment that can be very helpful for increasing motivation and checking progress.

Physicians are normally constrained for time and may need to be very effective in their communication with patients. This often results in directive one-way communication. Such a communication style does not work so well when the objective is behaviour change, especially not with a drug addiction that the patient may like and identify with. One of the goals of motivational communication is to establish a good rapport. This is more likely to occur if the communication does not take the form of direct orders and the use of guilt and blame is avoided. It is important that the physician be understanding and empathic. It is preferable that the patients do most of the talking and that the physicians steer the conversation into relevant areas, with open questions and reinforcing remarks. This style of communication is often referred to as motivational interviewing. An algorithm showing how a smoker can be managed using this style is included.

The main objective of using pharmacotherapies during the smoking cessation process is to alleviate withdrawal syndrome and thus to facilitate smoking abstinence.

Three medications are in common use: NRT, for which there are six different products, bupropion and varenicline. Other medications have been proven efficacious for smoking cessation but are used less frequently: nortriptyline, and clonidine. There are some other medications not currently recommended for smoking cessation: some antidepressants, mecamylamine, monoamine oxidase inhibitors, some anxiolytics, naltrexone, lobeline, silver acetate, nicobrevin, and rimonabant. Nicotine vaccine is being studied in several randomised clinical trials and is the most promising new treatment aimed at aiding smokers to quit.

NRT is the most well-studied and well-documented pharmacological approach to helping smokers to quit. This treatment acts by replacing some of the nicotine smokers would have received from their cigarettes, and, in doing so, reducing the severity of withdrawal syndrome. The last meta-analysis carried out demonstrated that the OR for abstinence with the different types of NRT compared with controls was 1.77 (95% CI 1.66–1.88).

Bupropion was the first non-nicotine medication to be licensed for smoking cessation. It is presumed that it acts on the nucleus accumbens, inhibiting neuronal reuptake of dopamine. It also inhibits neuronal reuptake of noradrenalin in the nucleus ceruleus. In 31 trials, bupropion was used as the sole pharmacotherapy and was found to double the odds of cessation (OR 1.94; 95% CI 1.72–2.19).

Varenicline is the first drug specifically developed to aid smokers quitting smoking. It acts as a selective partial agonist for the nicotinic receptor. A meta-analysis that reviewed four clinical trials found that this drug was significantly more effective than placebo for achieving continuous abstinence at the end of 1 yr of follow-up (OR 2.96; 95% CI 2.12–4.12).

It has been demonstrated that ICSs are much less effective in asthmatic smokers. Most smokers are believed to take their asthma medications in the place in which they smoke, and some of them report delivering the inhaled drug just after the last cigarette puff. This behaviour raises the possibility that drug particles might interact with particulate matter present in smokers’ airways due to ETS or residual tobacco smoke (mainstream tobacco smoke polluting the lung after the last puff). The conglomeration of aerosol particles is a well-known physical phenomenon that takes place very quickly and results in an increase in particle diameter. In order to verify such a possibility, the fluticasone dry powder aerodynamic profile was studied in the presence of clean air or ETS; when delivered in the presence of cigarette smoke, a 15% increase in particles sized ≥3.00 μm was observed compared to the aerodynamic profile of the drug in clean air. The results of the survey concerning place and timing of smoking/inhaled drug actuation showed that most smokers smoke at home, and actuate the inhaler in the room in which they have smoked. Moreover, 50% of smokers deliver the drug during the first 20 min after smoking, and 22% within 5 min after the last cigarette. None of the smokers had received suggestions from their doctor regarding smoking/inhaler timing and place. These results indicate that ICSs delivered in the presence of tobacco smoke undergo changes in aerodynamic profile, leading to a possible decrease in the percentage of respirable particles. This phenomenon could be one of the explanations for the steroid resistance demonstrated in asthmatic smokers. Smokers should be advised to actuate their ICSs after a reasonable time from their last cigarette puff, and should take care to avoid drug inhalation in environments polluted by ETS.