P1. Risk factor reduction

P1.1 Smoking cessation

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

A comprehensive review of smoking cessation in patients with respiratory diseases has been published by the European Respiratory Society (http://www.ers-education.org/media/2007/pdf/44007.pdf) (Tonnesen et al., 2007) A successful tobacco control strategy involves integration of public policy, information dissemination programs and health education through the media and schools. (NHLBI/WHO Workshop Report, April 2001) Smoking prevention and cessation programs should be implemented and be made readily available (NHLBI/WHO Workshop Report, April 2001), (World Health Organization, 1999) [evidence level I]. Pharmacotherapies double the success of quit attempts. Behavioural techniques further increase the quit rate. (US Public Health Service, 2000),(Peters and Morgan, 2002),(Wilson et al., 1990),(Britton and Knox, 1999),(Kottke et al., 1988),(Baillie et al., 1994),(van der Meer et al., 2003) [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 and Morgan, 2002)

Smoking cessation has been shown to be effective in both sexes, in all racial and ethnic groups tested, in pregnant women (NHLBI/WHO Workshop Report, April 2001) and people with COPD. (van der Meer et al., 2003) There is good evidence that smoking cessation strategies in people with COPD are cost-effective, both for counselling and pharmacotherapy, with low costs per quality-adjusted life years gained. (Hoogendoorn et al., 2010b) A small body of evidence suggests that counselling combined with nicotine replacement therapy is more effective than other combinations and single smoking cessation treatments in COPD, with an odds ratio compared to usual care alone of 5.08. (Strassmann et al., 2009)  A range of health professionals can help smokers quit (Lancaster and Stead, 2004),(Rice and Stead, 2004),(Tonnesen et al., 2006), 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.(NHLBI/WHO Workshop Report, April 2001) Personalising smoking cessation advice based on lung function results increase cessation rates.(Parkes et al., 2008) Currently accepted best practice is summarised in the 5-A strategy:(NHLBI/WHO Workshop Report, April 2001)

• Ask and identify smokers
• Advise smokers about the risks of smoking and benefits of quitting and discuss options
• Assess the degree of nicotine dependence and motivation or readiness to quit
• Assist cessation — this may include specific advice about pharmacological interventions or referral to a formal cessa­tion program if available
• 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 maintaining abstinence (maintenance) before achieving long-term success. The most strenu­ous efforts should be made with those smokers ready to quit or quitting. Cessation rates increase with the amount of support and intervention, including practical counselling and social support arranged outside of treatment.