P1.1 Smoking cessation

Smoking cessation reduces the rate of decline of lung function (Fletcher 1977Tashkin 1996Anthonisen 2002) [evidence level I].

A comprehensive review of smoking cessation in patients with respiratory diseases has been published by the European Respiratory Society (https://erj.ersjournals.com/content/erj/29/2/390.full.pdf) (Tonnesen 2007). A successful tobacco control strategy involves integration of public policy, information dissemination programs and health education through the media and schools (Global Initiative for Chronic Obstructive Lung Disease 2016). Smoking prevention and cessation programs should be implemented and be made readily available (Global Initiative for Chronic Obstructive Lung Disease 2016, World Health Organization 1999) [evidence level I]. Pharmacotherapies double the success of quit attempts (Cahill 2013). Behavioural techniques further increase the quit rate (Eisenberg 2008, Hartmann-Boyce 2014, Stead 2013b, Civljak 2013, Stead 2013a, Whittaker 2012, Cahill 2010, Stead 2005, Lancaster 2005) [evidence level I].

People who continue to smoke despite having pulmonary disease are highly nicotine dependent and may require treatment with pharmacological agents to help them quit (US Public Health Service 2000, Peters 2002). People with COPD often have barriers to smoking cessation. There is evidence that smokers with COPD report lower self-efficacy and lower self-esteem, impairing their ability to quit. Co-existing depression is common with depression reported in 44% of hospitalised patients with COPD (Jimenez-Ruiz 2015).

Smoking cessation has been shown to be effective in both sexes, in all racial and ethnic groups tested and in pregnant women (Global Initiative for Chronic Obstructive Lung Disease 2016). International data show that smoking cessation strategies are cost effective but with a 10-fold range in cost per life-year gained depending on the intensity of the program and the use of pharmacological therapies (Global Initiative for Chronic Obstructive Lung Disease 2016). A range of health professionals can help smokers quit (Rice 2013, Stead 2013a, Carr 2012, Sinclair 2004) but relapse is common. [evidence level I]

Brief counselling is effective [evidence level I] and every smoker should be offered at least this intervention at every visit (Global Initiative for Chronic Obstructive Lung Disease 2016). Comprehensive treatment of tobacco dependence involves providing both behavioural support and pharmacotherapy (Zwar 2014). The 2016 update of the Cochrane Review (van Eerd 2016) on smoking cessation for people with COPD includes 16 studies involving 13,123 participants. Only two studies were rated as high quality. The review found high-quality evidence from a meta-analysis of four (1,540 participants) of the 16 studies that a combination of behavioural treatment and pharmacotherapy is effective in helping smokers with COPD to quit smoking.

A systematic review of behaviour change techniques to support smoking cessation in patients with COPD found that four techniques were associated with higher rates of cessation. The behaviour change techniques found to be effective (usually in comparison to usual care) were; facilitate action planning/develop treatment plan,prompt self-recording, advise on methods of weight control, and advise on/facilitate use of social support. In addition linking COPD and smoking was found to result in significantly larger effect sizes (Bartlett 2014) [evidence level 1]. Personalising smoking cessation advice based on lung function results increase cessation rates (Parkes 2008) [evidence level II]. Currently accepted best practice is summarised in the 5-A strategy (Zwar 2014):

  • Ask and identify smokers. Document smoking status in the medical record.
  • Assess the degree of nicotine dependence and motivation or readiness to quit
  • Advise smokers about the risks of smoking and benefits of quitting and discuss options
  • Assist cessation — this may include specific advice about pharmacological interventions or referral to a formal cessa­tion program such as the Quitline
  • Arrange follow-up to reinforce messages

Cessation of smoking is a process rather than a single event, and smokers move between various stages of being not ready (pre-contemplation), unsure (contemplation), ready (preparation), quitting (action) and possibly relapsing (maintenance) before achieving long-term success. People at all stages can be offered assistance but advice tailored on the basis of the patient’s readiness to quit (Zwar 2004). Brief interventions for smoking cessation involve opportunistic advice, encouragement and referral. Referral options are the Quitline (13 7848) and an accredited tobacco treatment specialist (aascp.org.au). Cessation rates increase with the amount of support and intervention, including practical counselling and social support arranged outside of treatment.

Smoking tobacco can alter the metabolism of a number of medicines. This is primarily due to substances in tobacco smoke, such as hydrocarbons or tar-like products that cause induction of some liver enzymes (CYP 1A2, in particular). When a person stops smoking, the enzyme activity returns to normal, which may result in increased levels of these medicines in the blood. Monitoring and dosage reduction may often be required. For information on medicines affected by smoking see appendix 3 of the RACGP smoking cessation guidelines (https://www.apsad.org.au/ascp-sig). Heavy marijuana smoking (> 20 joint-years of exposure) increases the risk of COPD and accelerates FEV1 decline in concomitant tobacco smokers beyond that observed with tobacco alone (Tan 2019).