Clinical aspects of smoking cessation Jean-Pierre Zellweger, MD Swiss Lung Association and Int. Union against TB and Lung Disease (The Union)

COPD and smoking Smoking is closely related to COPD and one of the main causes of the disease Smoking cessation is the only intervention with a proven impact on the mortality Smoking cessation is cost-effective

The natural history of chronic airflow obstruction (Fletcher C, 1977)

Reduction in health risk after smoking cessation

Impact of smoking cessation on the decline in lung functtion (The Lung Health Study, 1994)

Impact of smoking cessation on survival (The Lung Health Study)

Smoking cessation: Role of the smoker: –Decision –Change in habits –Overcoming the obstacles –Acceptance of the dependence Role of the Health-care professional (MD, nurse) Role of the social environment and relatives

Efficacy of resident’s training: smoking habits of the patients after 1 year trained control

Treating tobacco use and dependence, US DHHS 2008 update

Treating tobacco use and dependence, the principles (US DHHS 2008 update) Tobacco dependence is a chronic condition Effective treatment exist Health care providers should identify, document and offer treatment to every tobacco user Clinicians should encourage smokers to make a quit attempt Brief tobacco dependence treatment is effective Problem solving and social support are both important parts of the intervention The effectiveness of counseling is increased by medication Interventions for smoking cessation are highly cost-effective

Treating tobacco use and dependence, US DHHS 2008 update

Treating tobacco use and dependence, the strategy: five « A »

Treating tobacco use and dependence, the strategy: addressing the obstacles

tobacco depression COPD

Treating tobacco use and dependence, the strategy : addressing the obstacles

Treating tobacco use and dependence: medication Nicotine Replacement Therapy (NRT) –Gum, Inhaler, Lozenge, Nasal spray, Patch Bupropion Varenicline All with proven efficacy (increase the success rate by a factor 2 to 3) Can be combined with other interventions All attenuate the withdrawal symptoms Not available or very expensive in many countries

Treating tobacco use and dependence: medication Nicotine Replacement Therapy (NRT) –Replace nicotine needed by central nervous system –Nicotine alone does not induce cancer, COPD, cardio-vascular disease but promotes dependence (which is already present in most long- term smokers!) Bupropion –Effective but some side effects –Can be combined with NRT Varenicline –Effective but some side effects –Cannot be combined with NRT

The position of the Int Union against TB and Lung Diseases (The Union) The Union runs programmes on respiratory diseases with public health impact: TB (historical), COPD, asthma Smoking (and passive smoking) has a major impact on lung health in developing countries and increases the risk of tuberculosis COPD and tuberculosis are linked together Both affect growingly developing countries Specific intervention for smokers with tuberculosis have been developed Smoking intervention improves the cure rate of tuberculosis

The position of the Union Smoking cessation intervention based on brief advice is feasible in developing countries Brief advice is given to patients under treatment for tuberculosis The advice is repeated at regular intervals to patients unwilling to quit The intervention is integrated in a pilot project « Comprehensive Approach to Lung Health » in Benin, China and Soudan and will be extended to further countries The intervention benefits tuberculosis patients and other patients (effect of training the Health Care providers)

Impact of training the HCW and enrolling patients in smoking cessation program on the outcome of TB El Sony A, Int J Tuberc Lung Dis 2007;11(2):150-5

GLOBAL MANDATE FOR COPD CARE AND COPD PATIENTS’ BILL OF RIGHTS The right to receive early and accurate diagnosis The right for information and education about COPD The right for support and understanding The right to receive care and treatment that will benefit them The right to their fair share of society’s involvement and investment in their welfare and care The right to advocate with other COPD patients and supporters for improved COPD care and COPD prevention The right to safe air and environment

Smoking cession and COPD: the take-home messages Smoking cessation is the most important intervention/action for improving the outcome of COPD Smoking counseling is cost-effective, even (and particularly) the minimal intervention by all Health-Care Workers and related professionals Smoking counseling may be frustrating on individual level but is rewarding at society level Patients willing to stop smoking should approach their physician/HCW Physicians and HCW have to be trained in smoking counseling