Asthma Management Handbook

Smoking and asthma assessment

Recommendations

Take a smoking history for all patients. Ask patients about exposure to environmental tobacco smoke as well as smoking.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Zwar et al. 20111

Consider scheduling planned asthma check-ups every 6 months for people who smoke to assess recent asthma symptom control and frequency of flare-ups. Explain that this is necessary because smoking increases a person’s risk of asthma flare-ups even if they have few symptoms, and because their lungs may be deteriorating faster than for a person who does not smoke.

Figure. Lung function decline in smokers and non-smokers with or without asthma Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/7

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Dijkstra et al. 20062
  • James et al. 20053
  • O'Byrne et al. 20094
  • Osborne et al. 20075
  • Pedersen et al. 20076

Check the patient's smoking status at regular intervals.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider the possibility of coexisting COPD and asthma in people who smoke.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source:

  • Abramson et al. 20127

More information

Effects of smoking on lung health

Smokers with asthma show changes in airway epithelium, which are associated with increased asthma symptoms, such as shortness of breath and mucus production.8 Exposure to cigarette smoke in people with asthma alters the inflammatory disease mechanism to become more like that seen in people with chronic obstructive pulmonary disease (COPD).9

Smoking reduces lung function in people with or without asthma. In those with asthma, smoking accelerates decline in lung function over a lifetime.4, 2, 3

Figure. Lung function decline in smokers and non-smokers with or without asthma Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/7

However, treatment with inhaled corticosteroids helps prevent lung function decline in smokers with asthma.4

Smoking home-grown or illegally produced loose tobacco (‘chop-chop’) is likely to be at least as harmful as smoking branded cigarettes.10 Smoking any substance is likely to damage lungs.

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Effects of exposure to environmental tobacco smoke on asthma

Among adults with asthma, exposure to cigarette smoke (smoking or regular exposure to environmental tobacco smoke within the previous 12 months) has been associated with a significantly increased risk of needing acute asthma care within the next 2–3 years.5

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Effects of smoking on asthma control and medicines

Smoking reduces the probability of achieving good asthma control.6 Among adults with asthma, exposure to cigarette smoke (smoking or regular exposure to environmental tobacco smoke within the previous 12 months) has been associated with a significantly increased risk of needing acute asthma care within the next 2–3 years.5

Smoking reduces response to inhaled corticosteroids and oral corticosteroids in people with asthma.111213, 14, 15 People who smoke may need higher doses of inhaled corticosteroids to receive the same benefits (improvement in lung function and reduction in flare-ups) as non-smokers.15

Therapeutic response to montelukast appears to be unchanged by smoking.13 Therefore, montelukast may be useful in smokers with mild asthma.9, 16

Note: PBS status as at October 2016: Montelukast treatment is not subsidised by the PBS for people aged 15 years or over. Special Authority is available for DVA gold card holders, or white card holders with approval for asthma treatments.

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Electronic cigarettes (e-cigarettes)

Electronic cigarettes (e-cigarettes) are battery powered devices that create a mist, allowing people to simulate cigarette smoking. Most deliver nicotine in a vapour. Many also contain flavouring chemicals.

Safety concerns

E-cigarettes produce fewer toxins than conventional cigarettes, but there is very little evidence about their long-term safety,17 and effects on lung function are unclear.18

Concerns have been raised about the potential adverse effects on airway health:

  • In a small controlled study conducted among healthy smokers, short-term use of e-cigarettes was associated with increase in respiratory flow resistance, increase in impedance, and decrease in exhaled nitric oxide, compared with use of the device after removal of the cartridge containing the vapourisable liquid.19
  • Some e-cigarettes may contain potentially harmful chemicals such as propylene glycol (a respiratory irritant), formaldehyde, formaldehyde-forming hemiacetals, and potentially toxic particulate matter.182021
  • A study reported that inhalation of e-cigarette solutions was associated with airway inflammation and airway hyperresponsiveness in a mouse model.22
  • An in vitro study reported that some constituents of liquid flavourings in e-cigarettes evoked a cellular physiological response in mouse tracheal epitheleal cells, which suggests that flavourings in e-cigarettes could harm airways.23
  • A study using a mouse model reported that neonatal exposure to e-cigarette emissions impaired lung growth.24

Very few studies have assessed potential benefits and harms in people with asthma. A small cohort study reported improvements in respiratory symptoms, lung function, airway hyperresponsiveness, and asthma control (measured by ACQ score) in people with asthma who switched from smoking conventional cigarettes to e-cigarettes.25

Positions and guidance by Australian organisations

The National Health and Medical Research Council (NHMRC) statement on e-cigarettes concludes: There is currently insufficient evidence to conclude whether e-cigarettes can benefit smokers in quitting, or about the extent of their potential harms. It is recommended that health authorities act to minimise harm until evidence of safety, quality and efficacy can be produced.20

NHMRC advises that studies show that e-cigarettes expose both users and bystanders to particulate matter (very small particles) that may worsen existing illnesses, or increase the risk of developing diseases such as cardiovascular or respiratory disease.20

Lung Foundation Australia recommends people quit smoking rather than try e-cigarettes.17

Quit Victoria warns that the short- and long-term health impacts of using e-cigarettes remain unknown, noting that e-cigarettes currently on the market have not passed through the extensive safety and efficacy evaluation required for products involving delivery of chemicals to the lung. Quit Victoria recommends that people use quitting aids approved by the Therapeutic Goods Administration, which have good safety profiles and have been shown to increase long-term quitting rates.26

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References

  1. Zwar N, Richmond R, Borland R, et al. Supporting smoking cessation: a guide for health professionals. Updated 2012. The Royal Australian College of General Practitioners (RACGP), Melbourne, 2011. Available from: http://www.racgp.org.au/your-practice/guidelines/
  2. Dijkstra A, Vonk JM, Jongepier H, et al. Lung function decline in asthma: association with inhaled corticosteroids, smoking and sex. Thorax. 2006; 61: 105-10. Available from: http://thorax.bmj.com/content/61/2/105.long
  3. James AL, Palmer LJ, Kicic E, et al. Decline in lung function in the busselton health study: The effects of asthma and cigarette smoking. Am J Respir Crit Care Med. 2005; 171: 109-114. Available from: http://ajrccm.atsjournals.org/content/171/2/109.full
  4. O'Byrne PM, Lamm CJ, Busse WW, et al. The effects of inhaled budesonide on lung function in smokers and nonsmokers with mild persistent asthma. Chest. 2009; 136: 1514-20. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1090203
  5. Osborne ML, Pedula KL, O'Hollaren M, et al. Assessing future need for acute care in adult asthmatics: the Profile of Asthma Risk Study: a prospective health maintenance organization-based study. Chest. 2007; 132: 1151-61. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1085456
  6. Pedersen SE, Bateman ED, Bousquet J, et al. Determinants of response to fluticasone propionate and salmeterol/fluticasone propionate combination in the Gaining Optimal Asthma controL study. J Allergy Clin Immunol. 2007; 120: 1036-42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17935765
  7. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
  8. Broekema M, ten Hacken NH, Volbeda F, et al. Airway epithelial changes in smokers but not in ex-smokers with asthma. Am J Respir Crit Care Med. 2009; 180: 1170-1178. Available from: http://ajrccm.atsjournals.org/content/180/12/1170.full
  9. Tamimi A, Serdarevic D, Hanania NA. The effects of cigarette smoke on airway inflammation in asthma and COPD: therapeutic implications. Respir Med. 2012; 106: 319-28. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22196881
  10. Australian Government Department of Health and Ageing. The medical consequences of smoking 'chop-chop' tobacco. Australian Government Department of Health and Ageing, Canberra, 2004. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-pub-tobacco-chopchop-cnt.htm
  11. 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: 1308-1311. Available from: http://ajrccm.atsjournals.org/content/168/11/1308.full
  12. Chaudhuri R, Livingston E, McMahon AD, et al. Effects of Smoking Cessation on Lung Function and Airway Inflammation in Smokers with Asthma. Am J Respir Crit Care Med. 2006; 174: 127-133. Available from: http://ajrccm.atsjournals.org/content/174/2/127.full
  13. Lazarus SC, Chinchilli VM, Rollings NJ, et al. Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in asthma. Am J Respir Crit Care Med. 2007; 175: 783-790. Available from: http://www.atsjournals.org/doi/full/10.1164/rccm.200511-1746OC
  14. Pedersen B, Dahl R, Karlström R, et al. Eosinophil and neutrophil activity in asthma in a one-year trial with inhaled budesonide. The impact of smoking. Am J Respir Crit Care Med. 1996; 153: 1519-29. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8630596
  15. 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: 282-287. Available from: http://thorax.bmj.com/content/60/4/282.full
  16. Thomson NC, Chaudhuri R. Asthma in smokers: challenges and opportunities. Curr Opin Pulm Med. 2009; 15: 39-45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19077704
  17. Lung Foundation Australia. E-cigarettes. Lung Foundation Australian position statement.. Milton, Queensland, 2014. Available from: http://lungfoundation.com.au/wp-content/uploads/2014/05/Lung-Foundation-Australia-E-Cigarettes-Position-Statement-18-June-2014.pdf
  18. Cooke, A., Fergeson, J., Bulkhi, A., Casale, T. B.. The Electronic Cigarette: The Good, the Bad, and the Ugly. The journal of allergy and clinical immunology. In practice. 2015; 3: 498-505. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26164573
  19. Vardavas, C. I., Anagnostopoulos, N., Kougias, M., et al. Short-term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide. Chest. 2012; 141: 1400-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22194587
  20. National Health and Medical Research Council. CEO Statement: Electronic cigarettes (e-cigarettes). NHMRC, Canberra, 2015. Available from: http://www.nhmrc.gov.au/filesnhmrc/publications/attachments/ds13nhmrcceostatementecigarettes.pdf
  21. Zwar N. e-Cigarettes: a safe way to quit?. NPS, 2014. Available from: http://www.nps.org.au/publications/health-professional/health-news-evidence/2014/e-cigarettes
  22. Lim, H. B., Kim, S. H.. Inhallation of e-Cigarette Cartridge Solution Aggravates Allergen-induced Airway Inflammation and Hyper-responsiveness in Mice. Toxicological research. 2014; 30: 13-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24795794
  23. Sherwood, C. L., Boitano, S.. Airway epithelial cell exposure to distinct e-cigarette liquid flavorings reveals toxicity thresholds and activation of CFTR by the chocolate flavoring 2,5-dimethypyrazine. Respiratory research. 2016; 17: 57. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27184162
  24. McGrath-Morrow, S. A., Hayashi, M., Aherrera, A., et al. The effects of electronic cigarette emissions on systemic cotinine levels, weight and postnatal lung growth in neonatal mice. PloS one. 2015; 10: e0118344. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25706869
  25. Polosa, R., Morjaria, J. B., Caponnetto, P., et al. Persisting long term benefits of smoking abstinence and reduction in asthmatic smokers who have switched to electronic cigarettes. Discovery medicine. 2016; 21: 99-108. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27011045
  26. Quit Victoria, E-cigarettes policy. **, . Available from: http://www.quit.org.au/resource-centre/policy-advocacy/policy/e-cigarettes1