Smoking and Asthma: An Inconvenient TruthDaniel “Scotty” Silva, RRT- Director, University of New Mexico Hospital- Consultant, New Mexico Medical Society2nd Annual Asthma SymposiumApril 25, 2009
in·con·ven·ient / truth a.) Not convenient; giving trouble, uneasiness, or annoyance; hindering progress or success; uncomfortable; disadvantageous; incommodious; inopportune; n.) The practice of speaking what is true; freedom from falsehood; veracity.
Inconvenient Truth #1 Smoking and Asthma: Correlation or Cause. - There is a definitive correlation between smoking and asthma. - There is probable cause that some asthma may be caused by smoking. - 1, 040,000 “results” on Google on the topic. - Is smoking simply one cause of asthma or is it Trigger # 1? - Have we settled on treating the symptoms of asthma, while choosing to simply ignore the root of the problem? - Why have we seen the prevalence of asthma increasing while the prevalence of smoking is decreasing?
Maternal and Grand maternal Smoking Patterns are Associated with Early Childhood Asthma Yu-Fen Li, PhD;Bryan Langholz, PhD; Muhammad T. Salam, MBBS, MS; Frank D. Gilliland, MD, PhD Design, Setting, and Participants: We conducted a case-control study nested within the Childrens Health Study in southern California. The case patients consisted of 338 children with asthma that had been diagnosed in the first 5 years of life, and 570 control subjects were counter matched on in utero exposure to maternal smoking within grade, sex, and community of residence. Measurements: Detailed maternal and household smoking histories and other asthma risk factor information was obtained by telephone interview.
Findings; In utero exposure to maternal smoking was associated with increased risk for asthma diagnosed in the first 5 years of life (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.0 to 2.3), and for persistent asthma (OR, 1.5; 95% CI, 1.0 to 2.3). Children whose mothers smoked throughout the pregnancy had an elevated risk of asthma in the first 5 years of life (OR, 1.6; 95% CI, 1.0 to 2.6). Children of mothers who quit smoking prior to the pregnancy showed no increased risk (OR, 0.9; 95% CI, 0.5 to 1.5). We were unable to assess the association of smoking cessation during pregnancy because very few mothers were reported to have done so (15%). Asthma risk did not increase in a monotonic pattern with smoking intensity during pregnancy. Postnatal secondhand smoke exposure was not independently associated with asthma. Grand maternal smoking during the mothers fetal period was associated with increased asthma risk in her grandchildren (OR, 2.1; 95% CI, 1.4 to 3.2). Maternal and grand maternal smoking during pregnancy may increase the risk of childhood asthma. Chest. 2005;127(4):1232-1241
CAN SMOKING CAUSE ADULT- ONSET ASTHMA? Piipari R Jaakkola JJK, Jaakkola N, Jaakkola MS- The patient population was taken from adults between 21 and 63.- All newly diagnosed cases of asthma, recruited during a period of two and a half years.- Diagnostic criteria; the presence of at least one asthma symptom and airway obstruction that was reversible with a bronchodilator.- A total of 521 patients were recruited for the study, along with 932 controls who were matched for age and selected randomly from among residents of the study area. Information on smoking was collected via self-administered questionnaires that inquired about current smoking status, number of cigarettes smoked per day, and time since starting smoking or since quitting.- Lung function data, including spirometry, two-week diurnal peak expiratory flow surveillance, and a two-week oral corticosteroid test (if necessary for diagnosis) were obtained for those suspected of having asthma.- The study controlled for potential confounders such as pets, dampness and mold problems, and environmental tobacco smoke.
Findings; Asthma patients were younger and more likely to be women. Asthma patients had more relatives with allergies. They were also more likely than controls to be current or former smokers. Asthma risk was strongly related to both former and current smoking, with ex- smokers having the greater risk. Asthma risk increased with number of cigarettes smoked per day up to 14 but was lower in those who smoked 15 or more cigarettes per day. The same trend held true for cigarette years, with asthma risk being higher in the 1- to-199 cigarette years category, and lower in the over 200 category. The joint effect of female sex and current smoking added up to a 143% increase in asthma risk The joint effect and female sex and ex-smokers had a 138% increase in asthma risk. Eur Respir J. 2004 Nov; 24(5): 734-9
The Link Between Asthma and Childhood Exposure to Environmental Tobacco Smoke Chest -- Larsson et al. 120 (3): 711 Swedish study that looked at 6489 diagnosed asthmatic patients The study tried to determine; 1.) If childhood exposure to environmental tobacco smoke is associated with an increased prevalence of asthma among adult non-smokers. 2.) If childhood exposure to environmental tobacco smoke increases the chance that exposed children will smoke in adulthood.
Findings; Among never-smokers with childhood exposure to ETS, the prevalence of physician diagnosed asthma was 7.6 percent versus 5.9 percent among non-exposed. In never-smokers without a family history of asthma, the prevalence of physician-diagnosed asthma in subjects reporting childhood ETS was 6.8 percent versus 3.8 percent among non-exposed. People with childhood exposure to ETS were more likely to smoke as adults. The prevalence of ever-smokers (smoked at one time) was 54.5 percent versus 33.8 percent in non-exposed subjects.
Inconvenient Truth # 2 The psychological effects of smoking are as important as the physical effects of smoking and should not be ignored! Physical Effects (4000+ chemicals, including 60+ Group A Carcinogens); - Increased Risk of Cancer, Stroke, and Heart Disease - Decreased Mucociliary Function - Increased Risk of Lung Disease (Asthma, COPD, Emphysema) Psychological Effects (Nicotine); - Is Smoking An Addiction? 1.) A highly controlled or compulsive pattern of use. 2.) Psychoactive, or mood-altering effects involved in the pattern of use with no consideration of consequence. 3.) Does it function as a reinforcement to strengthen behavior and lead to further use.
How Does It Work? Nicotinic Acetylcholine Receptor (nAChR) nAChR also binds the addictive drug nicotine Specifically, activating alpha4beta2 nicotinic receptors, results in neurotransmitter stimulation of the brain.
Inconvenient Truth # 3 Smoking Cessation should be an essential element of your Asthma Education Program. Are we content to simply treat the symptoms? Smoking cessation is totally based on the patients willingness to quit! - You cannot do it for them! - You can only be a resource. - You are part of a continuum Willingness to quit is proportional to the patients motivation to change.
Motivation to Change? DARN D = DESIRE to Change A = ABILITY to Change R = REASON to Change N = NEED to Change - The diagnosis of Asthma can be a natural conduit to making a life-changing decision! - Unlike other smoking-related diagnosis’, asthma presents the patients with empowerment and the ability to change, limit, or control the effects of the disease. - When it comes to smoking cessation the average asthma patient has the greatest gift of all – TIME!
Inconvenient Truth # 4 Integrating Smoking Cessation Into Their Clinical Practice is the Biggest Challenge that Clinicians Face. The Tyranny of T-I-M-E The Factor of C-O-S-T The Balance of W-H-Y
The 5 A’s ASK - Does EVERY patient get asked about their smoking history? ADVISE – Do we actively advise our smoking patient’s to quit? ASSESS – Do we incorporate smoking cessation into our assessment and provide opportunities for our patient to pursue quitting options. ASSIST – Do we incorporate smoking cessation into the treatment / care plan? ARRANGE – Do we provide the patient with the necessary resources to be successful after discharge? (community resources, relapse plan, support)
Explore Their Ambivalence! What is AMBIVALENCE? Webster’s defines ambivalence as; “Simultaneous conflicting feelings” “I want to quit smoking and I don’t want to quit smoking” “I know that my smoking effects my asthma, but I really love to smoke”! DEVELOP DISCREPANCY – Differentiate between the patient’s present state and their desired goals. Without discrepancy there is no ambivalence and if there is no ambivalence, there is no potential for change! You can’t have Motivational Interviewing without ambivalence.
Motivational Interviewing Collaboration (Not Confrontation): - Working in partnership and consultation with the patient Evocation (Not Education): - Listening more than talking Autonomy (Not Authority): - Being respectful and honoring the patients autonomy, resourcefulness, and ability to choose
What is the Cost? Current estimated asthma prevalence of 20 million Americans (7.7% of the population) 28.4% of asthma patients are current smokers Estimated total cost of $18.3 billion; including $10.1 billion in direct costs -- medicines and healthcare services including $8.2 billion in indirect costs (lost productivity due to missed days at school or work.) 10–12 Million lost work days annually 13-15 Million lost school days annually Cost estimates determined by: The Asthma and Alergy Foundation of Amer
Revenue? In 2008 new CPT Codes were published for smoking cessation. The codes can be found in the Preventative Medicine Section under Evaluation and Management Services. 99406 – smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes. 99407 - smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
Why? 440,000 smoking-related deaths annually in the US. 2100 smoking-related deaths annually in the New Mexico. 1 in 5 or 20% of all deaths in the US are attributable to cigarette smoking. 90% of ALL smokers start smoking before age 21 Approximately 5 million children under the age of 18 have asthma. Approximately 6 million patients have asthma and smoke
The Real Reason! Asthma is REVERSIBLE Smoking is AVOIDABLE Smoking-related Death is PREVENTABLE The difference that you can make is IMMEASURABLE