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COPD:
Prevention
Elizabeth Fomby, MD, MBA
Associate Director, Scott & White Family Medicine Residency, Temple, TX
Gemma Kim, MD, MS
Associate Director, Scott & White Family Medicine Residency, Temple, TX
John L. Manning, MD
Program Director, Scott & White Family Medicine Residency, Temple, TX
Janice K. Smith, MD, MPH
Associate Director, Scott & White Family Medicine Residency, Temple, TX
Educational Objectives
At the end of this presentation, the learner should be able to …
•
Describe the importance of chronic obstructive pulmonary disease (COPD)
prevention given its tremendous medical and economic burden
•
Discuss methods for primary prevention of COPD:
– Smoking prevention
– Avoidance of environmental causes
– Smoking cessation
•
Discuss nonpharmacologic methods for secondary prevention of COPD
(primarily prevention of exacerbation):
–
–
–
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Avoidance of environmental factors
Limiting risks associated with exacerbations
Immunization strategies
Pulmonary rehabilitation
Background
• Significance of tobacco use is profound
– Primary cause of COPD
– Greatest cause of preventable death in U.S.
– Estimated to have caused 5.4 million deaths in 2004 and 100
million deaths during 20th century
• Epidemiology
– 1.22 billion people were smoking in 2000; predicted to rise to
1.45 billion in 2010 and 1.5-1.9 billion by 2025
– Smoking 5 times more prevalent among males than females
• Gender gap declines with younger age
– Shift in prevalence of tobacco smoking to a younger
demographic
Lopez, 2006
Background
• Health effects of tobacco use
– Risk of contracting COPD directly proportional to smoke
exposure time and tar content or amount smoked
– If someone stops smoking, at one year the risk of contracting
heart disease is half that of continuing smoker
– After 15 years of abstinence, risk similar to that for people who
have never smoked.
– Smoking “light” cigarettes does not reduce one’s risks.
• Tobacco use forms
– Cigarettes, chewing tobacco, cigars, hookahs, snuff
Surgeon General’s Report: The Health Consequences of Smoking, 2004
Background
Mortality
• Male and female smokers lose an average of
13.2 and 14.5 years of life, respectively
• Smokers are 3 times as likely to die before age
60 or 70 as nonsmokers
• In the U.S. cigarette smoking and exposure
results in at least 443,000 premature deaths
annually
CDC, 2002; Mamun, 2004
Background
Youth tobacco use
• In U.S., each day ~3,900 youths between 12 and 17
years of age smoke their first cigarette
• Estimated 1,000 youth become daily cigarette smokers
• 20% of high school students were current smokers in
2007 (18.7% females and 21.3% males)
• TAR WARS
– Tobacco free education program by American Academy of
Family Physicians (AAFP) for children since 1988
– Provides students with tools to make positive health decisions
and promote personal responsibility for their own well-being.
– Has reached more than 8 million children with its tobacco-free
message.
CDC, 2002; Mamun, 2004
Background
Major health consequences of tobacco use
• COPD
• Cardiovascular disease
Myocardial infarction
Cerebral vascular accident
Peripheral vascular disease
• Cancer
Lung
Kidney
Larynx
Head and neck
Breast
Bladder
Esophagus
Pancreas
Stomach
Doherty, 1998; Almeida, 2002; Anstey, 2007; Jacobsen, 2004; Ness 1999
Background
Other health consequences of tobacco use
• Influenza risk
• Lung infection
• Erectile dysfunction/decreased fertility
• Osteoporosis
• Behavioral
• Cognitive function
• Pregnancy
– Miscarriage
– Premature birth
– Low birth weight
Doherty, 1998; Almeida, 2002; Anstey, 2007; Jacobsen, 2004; Ness, 1999
Prevention of Cigarette Smoking
Public health and legislative measures
• Mass media education campaigns
• Smoke-free policies in workplace shown to double quit
rates
• Legislation to restrict smoking in public places, including
schools - Smoke free legislation
• Restricting minor’s access to tobacco products
• Higher costs for tobacco products through increased
excise taxes
• Legislation to reduce tobacco advertising, promotions,
and commercial availability of tobacco products
Bauer, 2005; Bala, 2008
Prevention of Cigarette Smoking
Global Tobacco Surveillance System
(GTSS)
• Purpose is to enhance countries’ capacity to
monitor tobacco use, guide national tobacco
prevention and control programs, and facilitate
comparison of tobacco-related data at national,
regional, and global levels
Prevention of Cigarette Smoking
Youth tobacco prevention
• Advertising for tobacco products and smoking in
movies, TV shows, etc. has been shown to increase
new tobacco use in adolescents
• Media campaigns against smoking (e.g., TV and
radio commercials, posters, magazine ads, etc.)
• School-based tobacco-use prevention policies and
programs (e.g., Tar Wars)
Sowden, 2000; Lovato, 2003; Thomas, 2006
Prevention of Cigarette Smoking
AAFP’s Tar Wars Program
• Developed and sponsored by AAFP since 1988
• Reaches more than 400,000 youth per year in U.S. and
abroad
• Taught by volunteer physicians, teachers, medical students,
residents, school nurses, and community members
• Targets 4th and 5th graders with focus on:
– Short-term, image-based consequences
– Costs associated with tobacco use
– Advertising techniques used by tobacco industry to
influence youth
• Short-term effectiveness measured in several studies
Cain, 2006; Mahoney, 2002; Mahoney, 1998
Prevention of Cigarette Smoking
U.S. Preventive Services Task Force
(USPSTF)
• Recommends that clinicians ask all adults
about tobacco use and provide tobacco
cessation interventions for those who use
tobacco products
– Grade A recommendation
USPSTF, 2010
Prevention of COPD
Avoidance of environmental factors
• Environmental tobacco smoke (ETS) / passive exposure to
cigarette smoke
– Smoking bans and restrictions
– Community education to reduce ETS in home
• Occupational dusts and chemicals
– Organic and inorganic dusts and chemical agents and fumes—
use of masks/respirators in high-exposure occupations
• Indoor air pollution
– Burning of other biomass fuels such as wood, animal dung, crop
residues, and coal in open fires or poorly functioning stoves
• Outdoor air pollution
– Ozone, particulate matter
Jindal, 2006
Smoking Cessation
Treating Tobacco Use and Dependence:
2008 Update (U.S. Dept. of Health and
Human Services)
• Completed in 2008 to assist physicians in identifying
counseling and medication treatments to aid/help
patients quit smoking
• Created by 24-member panel that reviewed more than
8,700 research articles between 1975 and 2007
Fiore, 2008; U.S. Dept. of Health and Human Services, 2008
Smoking Cessation
Treating Tobacco Use and Dependence: 2008 Update
Basic Findings
• Tobacco dependence is a chronic condition
• Seven first-line, FDA-approved medications were
identified that increase success of quitting
• Using counseling and medication treatment together
increased success rates (Strength of Evidence [SOR]: A)
• Quitlines (telephone or self-help web sites) are effective
(SOR: B)
• Individual, group, and telephone counseling works
Fiore, 2008; U.S. Dept. of Health and Human Services
Smoking Cessation
Healthcare Effectiveness Data and Information Set
(HEDIS)*: 2010
• Measures current smokers who were seen by
practitioner during measurement year
– Received advice to quit
– Cessation medications recommended and discussed
– Cessation methods recommended or discussed
*—HEDIS is a tool used by more than 90% of America's health plans to
measure performance on important dimensions of care and service. Widely
used to measure physician’s performance.
Smoking Cessation
Combining Two Strategies Works Best
• Nonpharmacologic Methods
– Counseling
• Individual
• Groups
• Telephone
• Pharmacologic Methods
– Seven first-line drugs
• Nicotine replacement therapy (NRT)
• Psychotropic agents
• Partial nicotine receptor agonist
– Second-line drugs (not yet FDA approved for cessation)
– Combination drug therapy (NRT & other medication)
Fiore, 2008; U.S. Dept. of Health and Human Services
Smoking Cessation
Nicotine withdrawal symptoms
•
•
•
•
•
•
•
•
Anxiety
Depression
Insomnia
Irritability
Frustration and anger
Increased appetite
Increased cravings
Decreased concentration
Smoking Cessation
Nonpharmacologic Methods
Counseling essentials:
• “5 A’s” behavioral counseling construct developed by the National Cancer
Institute (SOR: A)
–
–
–
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Ask: Do you smoke? Use any tobacco products? Ask at every visit
Advise: You should quit
Assess: Willingness to quit or history of attempts to quit
Assist: If willing, design a quit plan. If not ready, motivate. If already quit, relapse
prevention.
– Arrange: Follow up. Are you still not smoking?
•
Brief counseling (SOR: A)
– Ask: Do you smoke?
– Advise: You should quit
– Refer: Other resources, such as tobacco quit line
Question
Which of these counseling techniques do you think
provides the greatest likelihood of achieving
successful tobacco cessation?
A.
B.
C.
D.
Group counseling
Individual counseling
Brief physician advice
Motivational interviewing
Smoking Cessation
Nonpharmacologic methods
Counseling essentials:
• Brief physician advice: Link to Ask & Act
– Increases quit rates
• Individual counseling
– Variable success
– In adolescent population, counseling approximately doubles
long-term abstinence rates (SOR: B)
• Group counseling
– More effective than self-help materials and brief advice
• Motivational interviewing
– More successful than brief advice
Stead, 2005, 2008; Lai, 2010; Sorio, 2006; Rolnick, 2010
Smoking Cessation
Nonpharmacologic methods
Counseling essentials:
• Telephone support (SOR: A)
– 3 or more telephone calls increases chances of quitting
• Quitlines
– Provide important route of access and support
– 1-800-QUIT-NOW (1-800-784-8669)
• Self-help interventions
– May increase quit rates, but minimal impact
• E-health tobacco interventions
– Showing positive results
Fiore, 2008; Stead, 2006; Lancaster, 2005
Smoking Cessation
Pharmacologic Therapy
• Long-term use
– Can be beneficial to patients who have persistent withdrawal
symptoms
– Long-term use of nicotine replacement therapy (NRT) appears to
not have any long-term health risks
– FDA recommends
• Bupropion for up to 6 months
• Varenicline for 12 weeks, may repeat for an additional 12 weeks
• Combination therapy
– Increased long-term abstinence with combination of nicotine
patch + other NRT (i.e.,gum or spray) (SOR: A)
– Nicotine patch with bupropion more effective than patch alone
(SOR: A)
Fiore, 2008
Smoking Cessation
NRT Formulation
Availability
Rx
Generic
Cost
OTC
Gum


$$$
Lozenge


$$$
Transdermal patch

$$
Nasal spray

$$$
Oral inhaler

$$$
Rx = prescription; OTC = over-the-counter; $ = <$50/month; $$ = $50-100; $$$ = $100-200; $$$$ =
$200-300; $$$$$ = $>300.
Stead, 2008
Smoking Cessation
NRT
• Mechanism of action
– Binds to central nervous system (CNS) and peripheral nicotine
cholinergic receptors
– Works by reducing physical craving for nicotine
• Allows patient to focus on behavioral and psychological aspects of
tobacco cessation
• Precautions
– Recent myocardial infarction (MI) within past 2 weeks
– Serious arrhythmia
– Unstable angina
Fiore, 2008; Stead, 2008
Smoking Cessation
NRT
• Side effects
– Mouth soreness
– Dyspepsia
– Hiccups
• Not recommended
–
–
–
–
Smokeless tobacco users
Smokers using fewer than 10 cigarettes per day
Adolescents
Pregnancy
Smoking Cessation
Nicotine gum (SOR: A)
• Amount
– > 25 cigarettes per day: 4 mg, 1 piece every 1-2 hours for first 6
weeks
– < 25 cigarettes per day: 2 mg, 1 piece every 1-2 hours for first 6
weeks, then begin tapering
• Directions for chewing
– Chew slowly
– Stop chewing after noticing peppery taste or tingling sensation
– Store in between cheek and gum
• Cost: $$$
Smoking Cessation
Nicotine lozenges (SOR: B)
• Amount
– Based on time of first cigarette of day
– If cigarette within 30 minutes of waking, use 4-mg
lozenge
– Dosing forms 2 mg and 4 mg
• Directions
– Use every 1-2 hours for first 6 weeks, then tapering to
every 2-4 hours
• Cost: $$$
Smoking Cessation
Nicotine nasal spray (SOR: A)
• Amount
– Start with 2 sprays, one squirt in each nostril
•
Directions
– One squirt in each nostril, using 1-2 doses every hour, (maximum
dosing - 5 doses per hour)
• Side effects
–
–
–
–
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Hot peppery taste
Sneezing
Cough
Watery eyes
Runny nose
• Cost: $$$
Smoking Cessation
Nicotine inhaler (SOR: A)
• Amount
– Delivers 4 mg of nicotine
• Directions
– Start with 6 cartridges daily for first 3-6 weeks
– Maximum: 16 cartridges daily
– Recommended for up to 3 months
• Side effects
–
–
–
–
–
Cough
Headache
Rhinitis
Dyspepsia
Mouth irritation
• Cost: $$$
Smoking Cessation
Nicotine patch (SOR: A)
• Amount
– Dosing forms: 7, 14, and 21 mg
– < 10 cigarettes per day: start with 14-mg patch for 6 weeks,
decreasing to 7 mg for additional 2 weeks
– > 10 cigarettes per day: start with 21-mg patch for 6 weeks,
reducing to 14 mg for 2 weeks, and 7 mg for 2 weeks
• Directions
– Apply to upper body/upper outer part of arm
• Side effects
– Localized itching burning and tingling
• Cost: $$
Smoking Cessation
Bupropion SR (SOR: A)
• Mechanism of action
– Antidepressant
– Inhibit uptake of norepinephrine, serotonin, and dopamine
– Decreases craving of cigarettes and reduces symptoms of
nicotine withdrawal
• Dosing and directions
– 150 mg every morning for 3 days, then increase to 150 mg twice
daily
– Start therapy before quitting, 1-2 weeks
– Can be safely used with NRT
– Duration: 7-12 weeks
Smoking Cessation
Bupropion SR
• Side effects
–
–
–
–
Dry mouth
Insomnia
Lowered seizure threshold
Nervousness and difficulty concentrating
• Precautions and adverse effects
–
–
–
–
Seizures
Careful if patient has hepatic cirrhosis
Pregnancy (Category C)
Avoid using in patients undergoing abrupt discontinuation of
alcohol or sedatives
• Cost: $$$
Smoking Cessation
Varenicline (SOR: A)
• Mechanism of action
– Nicotine acetylcholine receptor partial agonist: newest type of
therapy for smokers
– Competitively inhibits binding of nicotine
• Dosing and directions
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–
–
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Days 1-3: 0.5 mg daily
Days 4-7: 0.5 mg twice daily
Weeks 2-12: 1 mg twice daily
Patient should begin therapy 1 week before quit date
Duration of treatment: 12 weeks, up to 24 weeks
Not to be used with NRT
Jorenby, 2006
Smoking Cessation
Varenicline
• Side effects
–
–
–
–
Nausea
Insomnia
Nightmares
Abnormally vivid dreams
• Precautions and adverse effects
– Neuropsychiatric symptoms (e.g., behavior changes, agitation,
depressed mood, suicidal ideation)
– Caution with severe renal impairment
– Pregnancy (Category C)
• Cost: $4.90-$5.18 daily
Smoking Cessation
Second-line pharmacologic therapy
Clonidine
• May be used under a physician's supervision
(SOR: A); not FDA approved for this use
• Approximately doubles abstinence rates
• Dose varies from 0.1 to 0.75 mg per day and
delivered transdermally or orally
• Cost: Oral $, transdermal $$$
Fiore, 2008
Smoking Cessation
Second-line pharmacologic therapy
Nortriptyline
• Almost doubles a smoker's likelihood of
achieving long-term cessation
• 75 to 100 mg per day for 6 to 13 weeks of
treatment
• Cost: $
Fiore, 2008
Question
Which of the following combination therapies
are contraindicated for use as a tobacco
cessation aid?
A.
B.
C.
D.
Nicotine patch plus bupropion
Nicotine patch plus paroxetine
Nicotine patch plus nicotine gum
Nicotine patch plus varenicline
Smoking Cessation
Combination therapy effective (SOR: A)
Estimated odds
ratio (95% CI)
Estimated abstinence
rate (95% CI)
1.0
13.8
Patch (> 14 weeks) + ad lib
gum or spray
3.6 (2.5-5.2)
36.5 (28.6-45.3)
Patch + bupropion
2.5 (1.9-3.4)
28.9 (23.5-35.1)
Patch + nortriptyline
2.3 (1.3-4.2)
27.3 (17.2-40.4)
Patch + inhaler
2.2 (1.3-3.6)
25.8 (17.4-36.5)
Patch + paroxetine or
venlafaxine
2.0 (1.2-3.4)
24.3 (16.1-35.0)
Medications
Placebo
CI = confidence interval.
Adapted from Fiore, 2008
Smoking Cessation
System approaches
Tobacco use treatments cost-effective
• Evidence-based tobacco dependence interventions
produce favorable return on investment for employers
and health plans
• Insurance coverage of tobacco cessation counseling and
pharmacologic treatment increases quit rates
– Tobacco cessation counseling is reimbursable and has specific
ICD-9 and E/M codes.
– Medicare covers cost of up to 8 counseling sessions per year for
tobacco cessation
Fiore, 2008
Smoking Cessation
Recommendations for clinical practice (SOR:A)
• All patients should be asked if they use tobacco
• Clinic screening systems significantly increase rates of clinician
intervention
– Expand the vital signs to include tobacco use status
– Use of other reminder systems such as chart stickers or computer
prompts
• Every tobacco user should be offered at least a minimal intervention
including brief physician advice
• Most smokers have multiple quit attempts (7-20) before being
successful. Follow-up support and praise for efforts important
Fiore, 2008
Smoking Cessation
Recommendations for clinical practice (SOR: A)
• Strong dose-response relation between session length of
person-to-person contact and successful treatment
outcomes
• Counseling plus medication is better than either method
alone
• Some combination drug therapies may be more effective
than single drug therapy
• All physicians should strongly advise every patient who
smokes to quit
Fiore, 2008
Smoking Cessation
Alternative therapies
Insufficient evidence regarding effectiveness of these
and other non-traditional modalities for cessation of
tobacco use or prevention of COPD exacerbations:
•
•
•
•
•
•
Herbal medicines (e.g., St. John’s wort, ginsing, lobelia)
Acupuncture
Massage therapy
Homeopathic medicine
Nicobrevin or silver acetate
Hypnotherapy
Fiore, 2008; Berge, 2009
Secondary Prevention
Secondary prevention focuses on prevention of
acute exacerbations
An acute exacerbation is defined as …
“an event in the natural course of the disease
characterized by a change in the patient’s baseline
dyspnea, cough, and /or sputum that is beyond normal
day-to-day variations, is acute in onset and may
warrant a change in regular medication”
Rabe 2007
Secondary Prevention
Exacerbations are thought to be related to an
interaction of host factors, bacteria, viruses, and changes in
air quality, leading to increased inflammation of the lower
respiratory tract.
Early recognition and treatment of acute exacerbations can
significantly reduce:
•
•
•
•
Morbidity
Poor health-related quality of life
Health care expenditures
Mortality related to this disease
White, 2003; Rohde, 2003
Secondary Prevention
Risk factors for exacerbation
•
•
•
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Age: older than 65 years
FEV1 ≤ 50% of predicted
≥ 3 exacerbations in past 12 months
Poor physical activity
Poor social support
Comorbidities
–
–
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–
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Coronary disease
Heart failure
Diabetes
Renal failure
Hepatic failure
• Low body weight: body mass index (BMI) ≤ 20 kg/m2
Garcia-Aymerich, 2001
Secondary Prevention
Methods for secondary prevention
•
•
•
•
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Avoidance of environmental factors
Lowering risks for exacerbation
Immunization strategies
Pulmonary rehabilitation
Long-term oxygen therapy and other
pharmacologic interventions
American Thoracic Society, 2004
Secondary Prevention:
Environmental Factors
• Ozone, sulphur dioxide, nitrogen dioxide, and particulate
matter including diesel particulates
– Increase airway inflammation
– Stimulate production of pro-inflammatory cytokines, neutrophil
production, and methylhistamine
– Potentially lead to exacerbations
• Epidemiologic studies have shown …
– Increased hospitalization rates when atmospheric pollution high
– Increased risk of death in COPD patients with increased urban
particle air pollution
White, 2003; Laumbach, 2010
Secondary Prevention:
Environmental Factors
Preventive measures
• Public health measures/legislation to decrease air
pollution
• Physicians and patients awareness of air quality index
(AQI) in community (AQI forecast link for U.S.)
• For patients at high risk of exacerbations, when AQI is >
100 …
– Limit/avoid outdoor air exposure
– Minimize physical exertion
White, 2003; Laumbach, 2010
Secondary Prevention
Improvement in certain modifiable risks associated
with COPD exacerbations may serve to prevent
severe exacerbations
• Better control of comorbidities
–
–
–
–
Heart failure
Cardiac ischemia
Diabetes
Renal and hepatic failure
• Physical activity and improved fitness
• Maintain body weight (BMI > 20 kg/m2)
McCrory, 2001
Secondary Prevention
Immunization strategies
• Influenza vaccine
– Annual vaccination reduces total number of
exacerbations, outpatient visits, and hospitalizations
(SOR: A)
• Pneumococcal vaccine
– Vaccination recommended for all patients with COPD,
and those with FEV1 < 40% (SOR: C)
Poole, 2008; Menon, 2008; Granger, 2007
Secondary Prevention
Early pulmonary rehabilitation after
hospitalization for acute exacerbations
(SOR: A)
• Improves exercise capacity
• Decreases risk for hospital readmission
• Decreases mortality
• Improves health-related quality of life at 3
months
Puhan, 2005
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AAFP. Tar wars. http://www.tarwars.org/online/tarwars/home.html
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