Primary Care Respiratory Journal (2006) 15, 81—83

EDITORIAL Smoking and COPD: will they ever vanish into smoke?

The most effective available treatment for chronic encouraging the smoker to quit [7]. It would seem obstructive pulmonary disease (COPD) is smoking that general practitioners (GPs) are already using cessation. There is mounting evidence that the this knowledge, as they seem more likely to advise rate of development of COPD can be reduced smokers to quit smoking if they perceive the when patients at risk of developing the disease patient’s symptoms to be smoking-related. stop smoking. The first indications came from However, only 24—47% of all smokers develop a longitudinal cohort study which showed that airflow obstruction depending on the number of subjects who continued to smoke had a much cigarettes smoked per day [5]. If a smoker does steeper decline in lung function than those who not develop COPD, it shouldn’t be an excuse not to had stopped smoking, whilst smokers who stopped stop smoking, since there are many other diseases smoking had a steeper decline than people who which are smoking-related. Since smoking is still had never smoked [1]. Important evidence from one of the most important avoidable causes of the Lung Health Study [2] confirmed that smoking death, it is astonishing that smoking prevalence in cessation could reduce this smoking-related steep the European region remains at a 30% level and is decline in lung function. Further follow-up showed even higher in specific subgroups. that repeatedCopyright attempts to quit General smoking, even with PracticeIn the current Airways issue of this JournalGroup an interesting subsequent relapses, could preventReproduction loss of lung paper prohibited from Greece reports that more than 40% function especially in patients with mild COPD [3], of the medical students, medical doctors and and that there were fewer respiratory symptoms teachers in Northern Greece who were questioned, after prolonged abstinence [4]. When a smoker smoke [9]. For the medical doctors and teachers with severely impaired lung function stops smoking, — professionals who should be giving an example he/she will not recover lost lung function, but to their patients and to their students —– smoking the subsequent rate of decline in lung function is prevalence rates were 45% and 46 % respectively. likely to revert to normal [5]. Smoking cessation How can a doctor or teacher give stop-smoking at an early stage of the disease has been shown advice when he or she is still smoking themselves? It to improve prognosis [1,2,5]. There are even is therefore highly unlikely that anti-smoking advice indications that smoking cessation at an early stage will be given. More than 95% of the medical students of COPD is more effective than in the later stages and medical doctors and 80% of the teachers [6]. studied were aware that their smoking behaviour Smokers seem to be intrinsically more motivated was dangerous to their health, but only 20—30% had to stop smoking if they realize that their respiratory (unsuccessfully) tried to quit recently. complaints are caused by smoking and that they are Since only 4% of the subjects in this study at risk of developing COPD [7] or other smoking- requested medical assistance to stop smoking, related diseases [8]. The knowledge that a smoker there is considerable room for improvement. The at risk of developing a smoking-related disease literature shows that there is a dose-response is more motivated to stop smoking than someone relationship between the abstinence rate and the who is not at risk should help the physician in duration and number of sessions provided by a

1471-4418/$30.00 © 2006 General Practice Airways Group. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.pcrj.2006.01.006 82 Editorial physician [10]. Not only should the role of the In 1998, tobacco caused 33% of all male deaths physician in the cessation process be reinforced, between the ages of 25—69 in Hong Kong [18]. but in addition, the use of pharmacological What these studies are telling us is that smoking aids for smoking cessation - such as nicotine cessation efforts in the future should be worldwide. replacement therapy and bupropion - can increase If current smoking patterns persist it has been the abstinence rate. The chance of being a estimated that by 2030 cigarettes will cause 3 successful quitter after one year increases from millions deaths a year in the western world, and 3—5% for quitting ‘cold turkey’, to 7—16% if 7 million deaths a year in the developing world using behavioural interventions alone, and up to [19]. COPD will become the fifth leading cause of 11—24% if using pharmacological treatment plus disability and the third leading cause of death in the behavioural support [11—14]. The Greek Ministry coming decades [20]. In the Netherlands, analyses of Health and Welfare have recently made an of different theoretical models has provided important step forward and have founded special estimates of the effects of different rates of smoking cessation consulting centres in 15 main smoking, and smoking cessation, on costs due to hospitals in Greece [9]. COPD in 2010 [21]. Even an ‘extreme smoking Governments in Ireland, Italy and Sweden have reduction’ scenario with a reduction in smoking recently passed legislation banning smoking in all prevalence from the current 28% of the population public places including public houses and bars. in 2005, to 8% in 2010, does not lead to any direct Why does it take so long for other European benefits in health economic terms. In this extreme countries to follow this successful example? What scenario, the costs due to COPD will still increase influence does the tobacco industry have on by 48% by 2010. European governments? A few years ago we were Therefore, any smoking reduction measures will asked by the Dutch Government to investigate only have an impact - in terms of mortality, the effectiveness of reimbursement for smoking morbidity and healthcare costs - over the very long cessation treatment. Although we have shown term. This means that it is difficult putting political clearly that reimbursement is effective, not only pressure on Health Ministers to encourage them in terms of using medication but also in terms to introduce successful anti-smoking legislation, of increased rates of smoking cessation [15], the since politicians normally think in the short- present Dutch minister of Health has decided term and not in the long-term. However, the not to reimburse smoking cessation treatment. UK government has recently responded to the His rationale seems to be that starting smoking sustained pressure exerted on them because of is a behaviouralCopyright decision General and that smoking- Practicethe perceived Airways ineffectiveness Group of their ‘partial ban’ related diseases are consequentlyReproduction self-inflicted. smoking prohibited proposals. There has been a ‘free’ vote in One wonders whether or not the decision to start the UK House of Commons when these proposals smoking is a rational decision or a decision based on were debated, allowing UK Members of Parliament peer-pressure; the decision to stop smoking seldom to vote as they wish and not according to party results in a successful fight against addiction. political lines: this will likely lead to a full ban on In the developing world, enormous efforts have smoking in restaurants, public houses, and bars. been made over the last few years by the major We need to take action now to prevent a terrible tobacco companies to increase their markets and future of rising mortality, morbidity, and healthcare sales of cigarettes, and this will certainly lead to costs, as a consequence of COPD due to cigarette alarming increases in smoking prevalence in the smoking. However, the possibility of smoking and large populations of Asia, Africa and Latin America. COPD vanishing into smoke seems very unlikely at In China, with 20% of the world’s population present. smoking 30% of the world’s cigarettes, massive retrospective and prospective studies have been undertaken to predict the development of deaths References attributable to tobacco use. On the basis of current smoking patterns, the number of tobacco deaths [1] Xu X, Dockery DW, Ware JH, Speizer FE, Ferris BG. Effects in China is estimated to rise from 0.6 million per of cigarette smoking on rate of loss of pulmonary function year in 1990 to about 3 million deaths a year by the in adults: a longitudinal assessment. Am Rev Respir Dis middle of this century [16,17]. These predictions of 1992;146:1345—8. a large increase in tobacco-attributable mortality [2] Anthonissen NR, Conett JE, Kiley JP, Altose MD, Bailey WC, Buist AS. Effects of smoking intervention and of the are supported by case-controlled data from Hong use of an inhaled anticholinergic bronchodilator on the Kong, where cigarette consumption reached its rate of decline of FEV1: the Lung Health Study. JAMA peak 20 years earlier than in mainland China. 1995;273:1497—505. Editorial 83

[3] Murray RP, Anthonisen NR, Connett JE, et al. Effects of [15] Kaper J, Wagena EJ, Willemsen MS, Schayck CP van. multiple attempts to quit smoking and relapses to smoking Reimbursement for smoking cessation treatment may on pulmonary function. J Clin Epid 1998;51:1317—26. double the abstinence rate: results of a randomized trial. [4] Kanner RE, Connett JE, Williams DE, Buist AS. Effects of Addiction 2005;100:1012—20. randomised assignment to a smoking cessation intervention [16] Liku BQ, Peto R, Chen ZM, et al. Emerging tobacco hazards and changes in smoking habits on respiratory symptoms in in China: 1. Retrospective proportional mortality study of smokers with early chronic obstructive pulmonary disease: one million deaths. BMJ 1998;317:1411—22. The Lung Health Study. Am J Med 1999;106:410—6. [17] Niu SR, Yang GH, Chen ZM, et al. Emerging tobacco hazards [5] Fletcher C, Peto R, Tinker C. The natural history of chronic in China: 2. Early mortality results for a prospective study. airflow obstruction. BMJ 1977;1:1645—8. BMJ 1998;317:1423—4. [6] Wagena EJ, Knipschild P, Huibers MJH, Wouters EFM, [18] Lam TH, Ho Y, Hedly AJ, Mak KH, Peto R. Mortality and Schayck CP van. The efficacy of bupropion and nortiptyline smoking in Hong Kong: a case-control study of all adults for smoking cessation among people who are at risk for or deaths in 1998. BMJ 2001;323:361—7. have chronic obstructive pulmonary disease: a randomised, [19] Lopez AD. Counting the dead in China. BMJ placebo-controlled trial. Arch Int Med 2005;165:2286—92. 1998;317:1399—400. [7] Zielinsky J, Bednarek M. Early detection of COPD in a [20] Murray CJL, Lopez AD. Mortality by cause for eight regions high-risk population using spirometric screening. Chest of the world: global burden of disease study. Lancet 2001;119:731—6. 1997;349:1269—76. [8] Humerfelt S, Eide GE, Kvale G, Aaro LE, Gulsvik A. [21] van Rutten-Molken MPM, Postma MJ, Joore MA, van Effectiveness of postal smoking cessation advice: a Genugten MLL, Leidl R, Jager JC. Current and future randomised controlled trial in young men with reduced medical costs of asthma and chronic obstructive pulmonary FEV1 and asbestos exposure. Eur Respir J 1998;11:284—90. disease in the Netherlands. Respir Med 1999;93:779— [9] Sichletidis LT, Chloros D, Tsiotsios I, et al. High Prevalence 87. of Smoking in Northern Greece. Primary Care Resp J 2006;15(2):92—7. [10] Fiore MC, Bailey WC, Cohen SJ. Treating Tobacco Use and ∗ Dependence. Clinical Practice Guideline. Rockville, MD: C.P. (Onno) van Schayck U.S. Department of Health and Human Services, Public Janneke Kaper Health Service; 2000. Department of General Practice, [11] Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine Research Institute CAPHRI, University of replacement therapy for smoking cessation (Cochrane Maastricht, PO Box 616, 6200 MD Maastricht, Review). In: The Cochrane Library, Issue 2. Oxford: Update The Netherlands Software; 2002. [12] Lancaster T, Stead LF. Individual behavioural counselling ∗ Corresponding author. Tel.: +31 43 3882152; for smoking cessation (Cochrane Review). In: The Cochrane Library, Issue 1. Oxford: Update Software; 2004. fax: +31 43 3619344. [13] Stead LF, Lancaster T. Group behaviour therapy for smoking E-mail address: cessation (Cochrane Review). In: The Cochrane Library, [email protected] Issue 1.Copyright Oxford: Update Software; General 2004. Practice Airways(C.P. Group (Onno) van Schayck) [14] Hughes JR, Stead LF, LancasterReproduction T. Antidepressants for prohibited smoking cessation (Cochrane Review). In: The Cochrane 11 January 2006 Library, Issue 1. Oxford: Update Software; 2004.

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