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Clinical guidelines

Supporting smoking cessationA guide for health professionals

People with smoking-related diseases

This is a critical group where the issue of smoking and the offer of smoking cessation support should be central to the clinical encounter. There is clear evidence that people with a smoking-related disease or with other risk factors for cardiovascular disease (such as diabetes, lipid disorders and hypertension) who continue to smoke greatly increase their risk of further illness. It is important to target this population of smokers for smoking cessation, given the role that smoking plays in exacerbating these conditions.11 For example, second heart attacks are more common among cardiac patients if they continue to smoke and people with successfully treated cancers who continue to smoke are at increased risk of a second cancer.205 People with diabetes who smoke increase their risk of cardiovascular disease, peripheral vascular disease, progression of neuropathy and nephropathy. Smoking also increases the risk associated with hospitalisation for surgery. Quitting smoking after a heart attack or cardiac surgery can decrease a person’s risk of death by at least one-third.205

Smoking has an ongoing impact on patients with chronic airways disease, such as COPD and asthma. There is a clear relationship between continued smoking and progression of COPD.7 Smoking in those with COPD is associated with a faster decline in lung function and an increase in symptoms – as well as an increased risk for respiratory tract infection and hospitalisation.206,207 In people with asthma, smoking further impairs lung function, increases symptoms and impairs the effectiveness of treatment.208,209 First line management of all smokers with asthma should always be strong encouragement to quit.

Many studies have found significant associations between cigarette smoking and the development of diabetes, impaired glycaemic control and diabetic complications.24 Smokers with type 2 diabetes need a larger insulin dose to achieve metabolic control similar to that in patients who do not smoke.210 Smoking is associated with increased risk of type 2 diabetes in both men and women.211–213 Health professionals should be aware that smoking cessation is a crucial aspect of diabetes care for adequate glycaemic control and limiting development of complications.24

There is strong evidence that people with cardiovascular disease are highly motivated to quit smoking and success rates can be high, especially where they understand the link between their health problem and their smoking. It is recommended that smoking cessation programs are integrated into the routine chronic disease management programs for this population of smokers. High-intensity behavioural interventions are effective. There is some evidence that adding NRT, bupropion or varenicline to intensive counselling is effective in this group.214–216

Recommended smoking cessation treatment

  • Use the medical condition as an opportunity to integrate quitting into a management program.
  • Intensive cognitive behavioural counselling may be worthwhile.
  • Encourage use of smoking cessation pharmacotherapy after assessment of nicotine dependence and clinical suitability.

Evidence

Continued smoking is a major factor in the recurrence or increasing severity of smoking-related diseases. Level III

Recommendation

Smoking cessation should be a major focus of the management of people with smoking-related diseases. Strength A

References

  1. Zwar N, Richmond R, Borland R, Stillman S, Cunningham M, Litt J. Smoking cessation guidelines for Australian general practice: practice handbook. Canberra: Australian Government Department of Health and Ageing, 2004.
  2. Fiore MC, Jaén CR, Baker TB, Bailey WC, et al. for the Guideline Panel. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, May 2008. Available at http://www.ncbi.nlm.nih.gov/books/NBK63952/ [accessed 20 March 2011].
  3. US Department of Health and Human Services. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.
  4. Critchley JA, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev 2004, Issue 1. Art. no. CD003041.
  5. Stockley RA, Mannino D, Barnes PJ. Burden and pathogenesis of chronic obstructive pulmonary disease. Proc Am Thorac Soc 2009;6:524–6.
  6. Gritz ER, Vidrine DJ, Fingeret MC. Smoking cessation a critical component of medical management in chronic disease populations. Am J Prev Med 2007;33(6 Suppl):S414–22.
  7. Chaudhuri R, Livingston E, McMahon AD, et al. Cigarette smoking impairs the therapeutic response to oral corticosteroids in chronic asthma. Am J Respir Crit Care Med 2003;168:1308–11.
  8. Tomlinson JE, McMahon AD, Chaudhuri R, et al. Efficacy of low and high dose inhaled corticosteroid in smokers versus non-smokers with mild asthma. Thorax 2005;60:282–7.
  9. Targher G, Alberiche M, Zenere MB, et al. Cigarette smoking and insulin resistance in patients with noninsulin-dependent diabetes mellitus. J Clin Endocrinol Metab 1997;82:3619–24.
  10. Will JC, Galuska DA, Ford ES, Mokdad A, Calle EE. Cigarette smoking and diabetes mellitus: evidence of a positive association from a large prospective cohort study. Int J Epidemiol 2001;30:540–6.
  11. Manson JE, Ajani UA, Liu S, Nathan DM, Hennekens CH. A prospective study of cigarette smoking and the incidence of diabetes mellitus among US male physicians. Am J Med 2000;109:538–42.
  12. Rimm EB, Manson JE, Stampfer MJ, et al. Cigarette smoking and the risk of diabetes in women. Am J Public Health 1993;83:211–4.
  13. Rigotti N, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev 2007, Issue 3. Art. no. CD001837.
  14. Rigotti NA, Pipe AL, Benowitz NL, et al. Efficacy and safety of varenicline for smoking cessation in patients with cardiovascular disease: a randomized trial. Circulation 2010;121:221–9.
  15. Ockene I, Salmoirago-Blotcher E. Varenicline for smoking cessation in patients with coronary heart disease. Circulation 2010;121:188–90.
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