Copyright and property of Scotty Silva, Director of Pulmonary Services, UNM Hospital

1. Smoking and Asthma: An
Inconvenient Truth
Daniel “Scotty” Silva, RRT
- Director, University of New Mexico Hospital
- Consultant, New Mexico Medical Society
2nd Annual Asthma Symposium
April 25, 2009

2. 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.

3. 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?

4. 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 Children's 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.

5. 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 mother's 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

6. 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.

7. 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

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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!

14. 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

15. 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)

16. 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.

17. 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

18. 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

19. 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

20. 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

21. The Real Reason!
 Asthma is REVERSIBLE
 Smoking is AVOIDABLE
 Smoking-related Death is PREVENTABLE
 The difference that you can make is
IMMEASURABLE

22. Thank You!
 Questions?
Scotty Silva
dssilva@salud.unm.edu
(505) 272-9522