Counseling COPD Patients on Smoking Cessation on Every Visit

Cigarette smoking accounts for 8 of 10 chronic obstructive pulmonary disease (COPD) related deaths. Among the 16 million adults diagnosed with COPD, 38% continue to smoke.¹

The most effective intervention for halting COPD’s progression is smoking cessation. The public should be informed about the COPD-smoking connection, as patients often mistake symptoms of dyspnea for normal aging.

Smokers with COPD have higher rates of depression and nicotine dependence, and often find it difficult to quit smoking. Smoking cessation studies have shown that an initial quit rate of 50% to 60% can be achieved in the first 3 months. The 1 year quit rate is only 25% to 35% because almost 50% of COPD patients relapse.²

Most smokers take 4 to 7 attempts to successfully quit smoking.³A combination of behavioral interventions and pharmacotherapy is required in smokers with COPD to break this cycle. Offering retreatment and counseling at every step increases the abstinence levels in these patients.

Non pharmacologic Interventions

Behavioral interventions of self-help programs, brief advice and counselling (individual, group or telephonic) have all been shown effective in smoking cessation.⁴In smokers with COPD, the behavior change techniques most effective for smoking cessation were development of a treatment plan, prompt self-recording, advice on weight maintenance, and use of social support.⁵

Pharmacotherapy

Nicotine replacement therapy (NRT), bupropion, and varenicline are the available pharmacologic options for smoking cessation. A nurse-conducted smoking cessation trial in an outpatient pulmonary clinic evaluated the efficacy of nicotine tablets (2 mg) in COPD patients. Abstinence rates were significantly higher in the intervention group at 6 (23% vs 10%) and 12 months (17% vs 10%) compared to the placebo group.⁶

Varenicline is an agonist at the nicotinic acetylcholine receptors and prevents nicotine binding at receptor sites. In a double-blind randomized controlled trial (n=504), researchers evaluated varenicline’s efficacy and safety in smokers with mild to moderate COPD. For 9 to 12 weeks, continuous abstinence rate (CAR) was significantly higher in the varenicline group (42.3%) than the placebo group (8.8%). In patients with mild to moderate COPD, varenicline was more effective than placebo for smoking cessation.⁷In patients on long term NRT, varenicline with counseling was effective in assisting patients to quit NRT.⁸

Tailor Interventions

In the stage of change model proposed by Prochaska and colleagues, quitting smoking is compartmentalized into 5 stages: precontemplation, contemplation, preparation for action, action and maintenance. With each patient, tailor interventions appropriately to each stage to increase the chances of quitting. The Agency for Health Resources and Quality offers information here: Tobacco Use Counseling Fact sheets and resource, www.ahrq.gov

Despite pharmacotherapy’s evidence of effectiveness for smoking cessation in COPD patients, the average prescription rate for any smoking cessation medication was only 3.64% between 2007 and 2012. Patients with COPD have a greater urgency to quit smoking than an average smoker to improve disease prognosis.

Evaluate smoking status at every clinic visit and encourage patients to quit smoking at every available opportunity. In COPD patients, quitting smoking leads to better outcomes and reduced risk of death, hospitalization and emergency department visits.

References

1. CDC Tobacco Free. Smoking and COPD. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/diseases/copd.html. Published April 1, 2019. Accessed April 11, 2019.
2. Tønnesen P. Smoking cessation and COPD.Eur Respir Rev. 2013;22(127):37-43. doi:10.1183/09059180.00007212
3. Jiménez-Ruiz CA, Andreas S, Lewis KE, et al. Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit.Eur Respir J. 2015;46(1):61-79. doi:10.1183/09031936.00092614
4. Tønnesen P, Carrozzi L, Fagerström KO, et al. Smoking cessation in patients with respiratory diseases: a high priority, integral component of therapy.Eur Respir J. 2007;29(2):390-417. doi:10.1183/09031936.00060806
5. Bartlett YK, Sheeran P, Hawley MS. Effective behaviour change techniques in smoking cessation interventions for people with chronic obstructive pulmonary disease: a meta-analysis.Br J Health Psychol. 2014;19(1):181-203. doi:10.1111/bjhp.12071
6. Tønnesen P, Mikkelsen K, Bremann L. Nurse-conducted smoking cessation in patients with COPD using nicotine sublingual tablets and behavioral support.Chest. 2006;130(2):334-342. doi:10.1378/chest.130.2.334
7. Tashkin DP, Rennard S, Hays JT, Ma W, Lawrence D, Lee TC. Effects of varenicline on smoking cessation in patients with mild to moderate COPD: a randomized controlled trial.Chest. 2011;139(3):591-599. doi:10.1378/chest.10-0865
8. Tønnesen P, Mikkelsen K. Varenicline to stop long-term nicotine replacement use: a double-blind, randomized, placebo-controlled trial.Nicotine Tob Res Off J Soc Res Nicotine Tob. 2013;15(2):419-427. doi:10.1093/ntr/nts146