"The prevalence of smoking in patients with chronic obstructive pulmonary disease or asthma is high-the relevance of anamnesis and of the use of biomarkers in clinical practice." - Ubiratan de Paula Santos.
Smoking is the leading preventable risk factor for death. It is estimated to have been
responsible for 6.3 million deaths globally in 2010. (
11 Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K,Adair-Rohani H, et al. A
comparative risk assessment of burden of disease and injury attributable to 67 risk
factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for
the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224-60. Erratum in:
Lancet. 2013;381(9867):628; Lancet. 2013;381(9874):1276
http://dx.doi.org/10.1016/S0140-6736(12)61766-8 .
http://dx.doi.org/10.1016/S0140-6736(12)...
) Studies have suggested that smokers live, on average, 10 years shorter than
nonsmokers and that one in every two smokers will die from a tobacco-related
disease.(
22 Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to
smoking: 50 years' observations on male British doctors. BMJ.
2004;328(7455):1519.
http://dx.doi.org/10.1136/bmj.38142.5544...
,
33 Pirie K, Peto R, Reeves GK, Green J, Beral V; Million Women Study
Collaborators. The 21st century hazards of smoking and benefits of stopping: a
prospective study of one million women in the UK. Lancet.
2013;381(9861):133-41.
http://dx.doi.org/10.1016/S0140-6736(12)...
) The reason for such an impact is the presence, in the smoke inhaled from
burning tobacco, of approximately 5,300 chemicals, including 250 toxic components, 72
carcinogens (600 trillion molecules of carcinogens per cigarette smoked), and 4 ×
109 fine particles/cm³ of inhaled smoke.(
44 IARC Working Group on the Evaluation of Carcinogenic Risks to Humans.
Personal habits and indoor combustions. Volume 100 E. A review of human carcinogens.
IARC Monogr Eval Carcinog Risks Hum. 2012;100(Pt E):1-538.
) Among the major impairments associated with smoking are airway and
interstitial respiratory diseases, especially COPD and more than 10 types of cancer,
including head and neck cancer(
55 Almeida AÁ, Bandeira CM, Gonçalves AJ, Araújo AJ. Nicotine dependence
and smoking habits in patients with head and neck cancer. J Bras Pneumol.
2014;40(3):286-93.
http://dx.doi.org/10.1590/S1806-37132014...
) and lung cancer, which is ranked 1st in the global ranking of cancer
deaths,(
66 World Health Organization. International Agency for Research on Cancer
[homepage on the Internet]. Geneva: WHO; [cited 2015 Mar 17]. Globocan 2012:
Estimated cancer Incidence, Mortality and Prevalence Worldwide 2012. Available from:
http://globocan.iarc.fr/ia/World/atlas.html
http://globocan.iarc.fr/ia/World/atlas.h...
) smoking being responsible for more than 80% of cases. In addition to these
known morbidities, evidence from new studies suggest that smoking increases the risk of
death from renal failure, intestinal ischemia, breast cancer, and prostate
cancer,(
77 Carter BD, Abnet CC, Feskanich D, Freedman ND, Hartge P, Lewis CE, et
al. Smoking and mortality--beyond established causes. N Engl J Med.
2015;372(7):631-40.
http://dx.doi.org/10.1056/NEJMsa1407211...
) thereby broadening the spectrum and dimension of the effects of smoking. In
other diseases such as asthma, although various studies have suggested that smoking is a
causal factor, there is still controversy over it; however, evidence confirms that smoking
or exposure to environmental tobacco smoke makes asthma control difficult and makes
exacerbations more frequent.(
88 U.S. Department of Health and Human Services. The Health Consequences of
Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S.
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; 2014.
) Because of greater knowledge of the risks and because of the measures adopted
by countries, the prevalence of smokers has been gradually declining, especially in Brazil,
with a reduction in the prevalence of smokers, in the population aged 18 years or older,
from 35.4% to 16.8% between 1989 and 2010.(
99 Levy D, de Almeida LM, Szklo A. The Brazil SimSmoke policy simulation
model: the effect of strong tobacco control policies on smoking prevalence and
smoking-attributable deaths in a middle income nation. PLoS Med.
2012;9(11):e1001336.
http://dx.doi.org/10.1371/journal.pmed.1...
)
In this issue, the Brazilian Journal of Pulmonology publishes an interesting
study(
1010 Stelmach R, Fernandes FL, Carvalho-Pinto RM, Athanazio RA, Rached SZ,
Prado GF, et al. Comparison between objective measures of smoking and self-reported
smoking status in patients with asthma or COPD: are our patients telling us the
truth? J Bras Pneumol. 2015;41(2):124-132 .
) involving patients with COPD or asthma and a control group of healthy smokers
and nonsmokers, comparing smoking markers to determine the accuracy of the self-report of
smoking status. The data are impressive: 29% of the patients with asthma or COPD who
self-reported being nonsmokers had high urinary cotinine values and high exhaled CO values.
If we consider urinary cotinine levels alone, whose cut-off value of 200 ng/mL is used in
order to discriminate smokers from nonsmokers, they were too high to be explained only by
the exposure to environmental tobacco smoke, and the prevalence of self-reported nonsmokers
who had high levels of this marker reached 38% (29% and 47% of the patients with asthma and
COPD, respectively). As indicated in the article,(
1010 Stelmach R, Fernandes FL, Carvalho-Pinto RM, Athanazio RA, Rached SZ,
Prado GF, et al. Comparison between objective measures of smoking and self-reported
smoking status in patients with asthma or COPD: are our patients telling us the
truth? J Bras Pneumol. 2015;41(2):124-132 .
) the values observed for false information were higher than those observed in
other studies, which can be explained, in part, by differences in the prevalence of smokers
in the local populations during the various study periods. Research conducted in various
countries has shown that the prevalence of smokers among patients with COPD(
1111 Tønnesen P. Smoking cessation and COPD. Eur Respir Rev.
2013;22(127):37-43.
http://dx.doi.org/10.1183/09059180.00007...
,
1212 Vozoris NT, Stanbrook MB. Smoking prevalence, behaviours, and cessation
among individuals with COPD or asthma. Respir Med.
2011;105(3):477-84.
http://dx.doi.org/10.1016/j.rmed.2010.08...
) or asthma(
1212 Vozoris NT, Stanbrook MB. Smoking prevalence, behaviours, and cessation
among individuals with COPD or asthma. Respir Med.
2011;105(3):477-84.
http://dx.doi.org/10.1016/j.rmed.2010.08...
,
1313 Lemiere C, Boulet LP. Cigarette smoking and asthma: a dangerous mix. Can
Respir J. 2005;12(2):79-80.
) is similar to that observed among smokers in general. In the study by Stelmach
et al.,(
1010 Stelmach R, Fernandes FL, Carvalho-Pinto RM, Athanazio RA, Rached SZ,
Prado GF, et al. Comparison between objective measures of smoking and self-reported
smoking status in patients with asthma or COPD: are our patients telling us the
truth? J Bras Pneumol. 2015;41(2):124-132 .
) since it was carried out at a specialized care hospital, we should also
consider the possibility of patients fearing discontinuation of follow-up as one of the
factors influencing such a large number of false reports.
The study(
1010 Stelmach R, Fernandes FL, Carvalho-Pinto RM, Athanazio RA, Rached SZ,
Prado GF, et al. Comparison between objective measures of smoking and self-reported
smoking status in patients with asthma or COPD: are our patients telling us the
truth? J Bras Pneumol. 2015;41(2):124-132 .
) results strongly suggest that, in the approach to patients with asthma or
COPD, the question on smoking status be reiterated and this status be assessed (including
with the use of biomarkers) at each visit, especially in patients with more frequent
exacerbations, and that help be offered to those who wish to quit smoking. Although
cotinine is a more accurate marker of tobacco smoke exposure than is the measure of exhaled
CO, the latter can be used for this purpose, since it is inexpensive, it is measured
instantaneously, and its values do not differ significantly between smokers with COPD and
those without.(
1414 Chatkin G, Chatkin JM, Aued G, Petersen GO, Jeremias ET, Thiesen FV.
Evaluation of the exhaled carbon monoxide levels in smokers with COPD. J Bras
Pneumol. 2010;36(3):332-8.
http://dx.doi.org/10.1590/S1806-37132010...
) A study conducted in the United Kingdom revealed that only 13% of smokers
received prescriptions for smoking cessation treatment, although those with COPD were
particularly likely to be prescribed such treatment.(
1515 Huang Y, Britton J, Hubbard R, Lewis S. Who receives prescriptions for
smoking cessation medications? An association rule mining analysis using a large
primary care database. Tob Control. 2013;22(4):274-9.
http://dx.doi.org/10.1136/tobaccocontrol...
) In addition, another study by the same group(
1616 Dias-Júnior SA, Pinto RC, Angelini L, Fernandes FL, Cukier A, Stelmach
R. Prevalence of active and passive smoking in a population of patients with asthma.
J Bras Pneumol. 2009;35(3):261-5.
) revealed a high (17%) prevalence of exposure to environmental tobacco smoke in
asthma patients, and such exposure is known to be associated with
exacerbations.(
88 U.S. Department of Health and Human Services. The Health Consequences of
Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S.
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; 2014.
) Although studies have suggested that, with the aid of medications, patients
with chronic disease have rates of cessation similar to those of patients without chronic
disease,(
1111 Tønnesen P. Smoking cessation and COPD. Eur Respir Rev.
2013;22(127):37-43.
http://dx.doi.org/10.1183/09059180.00007...
) it is possible that patients with chronic lung disease who continue smoking
have more difficulty in quitting smoking, requiring greater support as compared with
smokers without such comorbidities, including greater screening for psychological
morbidities associated with smoking,(
1717 Afonso MF, Alves MG. Psychological morbidity as a moderator of intention
to quit smoking: a study of smokers and former smokers. J Bras Pneumol.
2013;39(4):461-8.
http://dx.doi.org/10.1590/S1806-37132013...
) which can influence cessation success.
References
-
1Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K,Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224-60. Erratum in: Lancet. 2013;381(9867):628; Lancet. 2013;381(9874):1276 http://dx.doi.org/10.1016/S0140-6736(12)61766-8 .
» http://dx.doi.org/10.1016/S0140-6736(12)61766-8 -
2Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ. 2004;328(7455):1519.
» http://dx.doi.org/10.1136/bmj.38142.554479.AE -
3Pirie K, Peto R, Reeves GK, Green J, Beral V; Million Women Study Collaborators. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381(9861):133-41.
» http://dx.doi.org/10.1016/S0140-6736(12)61720-6 -
4IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Personal habits and indoor combustions. Volume 100 E. A review of human carcinogens. IARC Monogr Eval Carcinog Risks Hum. 2012;100(Pt E):1-538.
-
5Almeida AÁ, Bandeira CM, Gonçalves AJ, Araújo AJ. Nicotine dependence and smoking habits in patients with head and neck cancer. J Bras Pneumol. 2014;40(3):286-93.
» http://dx.doi.org/10.1590/S1806-37132014000300012 -
6World Health Organization. International Agency for Research on Cancer [homepage on the Internet]. Geneva: WHO; [cited 2015 Mar 17]. Globocan 2012: Estimated cancer Incidence, Mortality and Prevalence Worldwide 2012. Available from: http://globocan.iarc.fr/ia/World/atlas.html
» http://globocan.iarc.fr/ia/World/atlas.html -
7Carter BD, Abnet CC, Feskanich D, Freedman ND, Hartge P, Lewis CE, et al. Smoking and mortality--beyond established causes. N Engl J Med. 2015;372(7):631-40.
» http://dx.doi.org/10.1056/NEJMsa1407211 -
8U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. 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; 2014.
-
9Levy D, de Almeida LM, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med. 2012;9(11):e1001336.
» http://dx.doi.org/10.1371/journal.pmed.1001336 -
10Stelmach R, Fernandes FL, Carvalho-Pinto RM, Athanazio RA, Rached SZ, Prado GF, et al. Comparison between objective measures of smoking and self-reported smoking status in patients with asthma or COPD: are our patients telling us the truth? J Bras Pneumol. 2015;41(2):124-132 .
-
11Tønnesen P. Smoking cessation and COPD. Eur Respir Rev. 2013;22(127):37-43.
» http://dx.doi.org/10.1183/09059180.00007212 -
12Vozoris NT, Stanbrook MB. Smoking prevalence, behaviours, and cessation among individuals with COPD or asthma. Respir Med. 2011;105(3):477-84.
» http://dx.doi.org/10.1016/j.rmed.2010.08.011 -
13Lemiere C, Boulet LP. Cigarette smoking and asthma: a dangerous mix. Can Respir J. 2005;12(2):79-80.
-
14Chatkin G, Chatkin JM, Aued G, Petersen GO, Jeremias ET, Thiesen FV. Evaluation of the exhaled carbon monoxide levels in smokers with COPD. J Bras Pneumol. 2010;36(3):332-8.
» http://dx.doi.org/10.1590/S1806-37132010000300011 -
15Huang Y, Britton J, Hubbard R, Lewis S. Who receives prescriptions for smoking cessation medications? An association rule mining analysis using a large primary care database. Tob Control. 2013;22(4):274-9.
» http://dx.doi.org/10.1136/tobaccocontrol-2011-050124 -
16Dias-Júnior SA, Pinto RC, Angelini L, Fernandes FL, Cukier A, Stelmach R. Prevalence of active and passive smoking in a population of patients with asthma. J Bras Pneumol. 2009;35(3):261-5.
-
17Afonso MF, Alves MG. Psychological morbidity as a moderator of intention to quit smoking: a study of smokers and former smokers. J Bras Pneumol. 2013;39(4):461-8.
» http://dx.doi.org/10.1590/S1806-37132013000400010
Publication Dates
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Publication in this collection
Mar-Apr 2015