Smoking cessation in COPD patients

Dr Thomas Round examines the evidence for smoking cessation interventions in COPD patients.

Confrontation with spirometry results may be helpful in those with COPD
Confrontation with spirometry results may be helpful in those with COPD

Approximately 21% of the adult population are smokers and smoking is the main cause of preventable morbidity and premature death in the UK.

About 20% of smokers will develop significant COPD. Smoking cessation is the single most effective way to reduce the risk of developing COPD and improve outcomes at all stages of the condition.

However, recommended interventions are often based on evidence from smokers in general, and cessation rates in patients with COPD remain poor.

The NICE guidelines recommend recording a smoking history for all patients with COPD, encouraging all patients to stop and offering help, with nicotine replacement therapy (NRT), varenicline or bupropion (unless contraindicated).1

Cessation interventions

A study in 2011 aimed to identify effective smoking interventions from a Cochrane review, and included 16 papers (13 quantitative and three qualitative).2 Key results and recommendations included:

  • Behavioural and pharmacological interventions were better than no treatment or behavioural interventions on their own.

This included behavioural interventions and bupropion giving prolonged abstinence of 27.3% versus 8.3% with placebo.

  • Annual spirometry, brief smoking cessation advice and a letter from a physician had a significantly higher abstinence rate at three years among smokers with COPD (25%) compared with smokers with normal lung function (7%).
  • A positive attitude from patients towards smoking cessation was a significantly and positively correlated predictor of abstinence at one year.
  • Some patients felt that a certain level of tobacco consumption was safe or quitting was pointless because they had friends who had stopped smoking, then died.
  • Perceived barriers to quitting included the feeling that smoking helped breathing.
  • There is still a lack of high quality evidence for effective smoking cessation interventions for patients with COPD.

Relapse prevention

A 2009 Cochrane review3 and a related NHS evidence review4 describe relapse prevention as applying to interventions that explicitly seek to reduce relapse rates after acute treatment is completed, or at some time after the patient's attempted quit date.

The inclusion criteria for the Cochrane review were randomised or quasi-randomised controlled trials. A total of 54 studies were identified, with heterogeneous populations and interventions, and only a small number had adequate sample sizes.

The key results of the review included:

  • The available evidence does not support the use of any specific behavioural intervention.
  • There is little evidence for extended bupropion or NRT in preventing relapse.
  • Extended varenicline for an extra 12 weeks of treatment showed a 7% reduction in relapse rate at one year, from 63% to 56%, with an NNT of 14.
Learning points
  • Consider training needs/update on brief interventions and motivational interviewing for behavioural change, with a view to wider health promotion, not just smoking cessation.
  • Familiarise yourself with service provision for smoking cessation in your practice or locality, and how to access/refer to this service.

If you are a prescriber of smoking cessation pharmacotherapy, consider an update on

  • Different modalities of smoking cessation, including NRT, bupropion and varenicline.
  • How to counsel patients about the choice and use of these medications.
  • How to prescribe appropriately.

Summary

Clinicians should always enquire about smoking status in patients who have COPD.

Those who smoke should be encouraged to stop and offered help to do so. Combined behavioural and pharmacological support, or behavioural interventions on their own, is better than no treatment in patients with COPD.

Confrontation with spirometry results may be helpful in these patients, although there is a lack of high quality evidence for this strategy.

For relapse prevention interventions, the evidence does not support the use of any specific behavioural interventions and there is little evidence for the use of extended bupropion or NRT in preventing relapse. However, extended varenicline for an extra 12 weeks of treatment can decrease relapse rates.

  • Dr Round is a GP in London and RCGP Essential Knowledge Update Development Fellow

References

1. NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). CG101. London, NICE, June 2010.

2. Coronini-Cronberg S, Heffernan C, Robinson M. Effective smoking interventions for COPD patients: a review of the evidence. J R Soc Med Sh Rep 2011; 2: 78.

3. Hajek P, Stead LF, West R et al. Relapse prevention interventions for smoking cessation (review). Cochrane Database Syst Rev 2009; (1): CD003999.

4. Relapse interventions for smoking cessation. NHS Evidence Quality, Innovation, Productivity and Prevention (QIPP): Cochrane Quality and Productivity Topics. February 2012.

Resources

1. RCGP Essential Knowledge Update 10. www.elearning.rcgp.org.uk

2. NHS smoking advice for patients. smokefree.nhs.uk.

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