Asthma Management Handbook

Smoking and asthma management

Recommendations

Advise all patients with asthma to avoid tobacco smoke.

How this recommendation was developed

Consensus

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

For those who smoke, advise quitting and support them to quit.

How this recommendation was developed

Adapted from existing guidance

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

  • Zwar et al. 20111

Repeatedly offer help to quit smoking, whether or not the person shows interest in quitting.

How this recommendation was developed

Adapted from existing guidance

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

  • Zwar et al. 20111

Follow the national smoking cessation guidelines for health professionals, including prescribing nicotine-replacement therapy and other pharmacotherapy as indicated.

How this recommendation was developed

Adapted from existing guidance

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

  • Zwar et al. 20111

Advise and support older patients to quit smoking; explain that quitting has health benefits at any age and discuss all quitting options, considering any potential drug-to-drug interactions.

How this recommendation was developed

Adapted from existing guidance

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

  • Zwar et al. 20111

If prescribing smoking cessation therapies, check for potential drug–drug interactions with asthma medicines and other medicines.

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 using the person’s spirometry readings to motivate them to quit.

How this recommendation was developed

Consensus

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

Do not encourage the use of electronic cigarettes, even for the purpose of smoking cessation.

How this recommendation was developed

Consensus

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

For people with asthma who continue to smoke or are exposed to tobacco smoke, consider:

  • prescribing an inhaled corticosteroid, even if the person experiences few or ‘mild’ symptoms
  • whether the person is experiencing a reduced response to their prescribed inhaled corticosteroids
  • whether the person may benefit from regular treatment with montelukast.

Table. Steps for conducting a treatment trial

  1. Document baseline lung function.
  2. Document baseline asthma control using a validated standardised tool such as the Asthma Score.
  3. Discuss treatment goals and potential adverse effects with the person.
  4. Run treatment trial for agreed period (e.g. 4–8 weeks, depending on the treatment and clinical circumstances, including urgency).
  5. At an agreed interval, measure asthma control and lung function again and document any adverse effects.
  6. If asthma control has not improved despite correct inhaler technique and good adherence, resume previous treatment and consider referral for specialist consultation.

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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.

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):

  • Chaudhuri et al. 20032
  • Chaudhuri et al. 20063
  • Lazarus et al. 20074
  • Pedersen et al. 19965
  • Tamimi et al. 20126
  • Thomson and Chaudhuri, 20097
  • Tomlinson et al. 20058

After a person with asthma quits smoking, review preventer dose requirements and step down, if possible.

How this recommendation was developed

Consensus

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

Arrange follow-up to maximise the person’s chance of staying smoke-free, based on the individual's needs and according to the national smoking cessation guidelines.

How this recommendation was developed

Adapted from existing guidance

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

  • Zwar et al. 20111

More information

Benefits of quitting smoking for people with asthma

Evidence from cohort studies suggests that smoking cessation can reverse the effects of smoking on airways of people with asthma. Epithelial characteristics in ex-smokers with asthma are similar to those in people with asthma who have never smoked.9

Within 6 weeks of quitting smoking, people with asthma show improvement in lung function and a reduction in airway inflammation, compared with people with asthma who continue to smoke, based on evidence from a nonrandomised comparative cohort study.2

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Supporting patients to quit smoking

In the past, health professionals were sometimes advised to attempt to identify patients who are ready to quit smoking and focus interventions on these people. However, recent evidence suggests that offering all smokers help to quit is more effective than offering help only to those who express interest quitting.10

People with asthma may find it very difficult to quit, even compared with other smokers,711 so they may need extra support and encouragement from health professionals.

Some health professionals use graphs showing the rate of smoking-associated lung function decline to motivate people with asthma to quit.

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

When prescribing smoking cessation medicines for patients taking any other medicines, consider potential drug–drug interactions (e.g. bupropion toxicity may be increased when taken concomitantly with aminophylline or corticosteroids).

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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,12 and effects on lung function are unclear.13

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.14
  • Some e-cigarettes may contain potentially harmful chemicals such as propylene glycol (a respiratory irritant), formaldehyde, formaldehyde-forming hemiacetals, and potentially toxic particulate matter.131516
  • A study reported that inhalation of e-cigarette solutions was associated with airway inflammation and airway hyperresponsiveness in a mouse model.17
  • 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.18
  • A study using a mouse model reported that neonatal exposure to e-cigarette emissions impaired lung growth.19

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.20

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.15

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.15

Lung Foundation Australia recommends people quit smoking rather than try e-cigarettes.12

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.21

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Smoking and older adults

Older people who smoke may believe that the damage has already been done and therefore there is no benefit in attempting to quit, or believe that smoking is less risky in older people.22

However, older people can successfully quit smoking, and may even be less likely to relapse than younger adults.22

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Effects of smoking on asthma control and medicines

Smoking reduces the probability of achieving good asthma control.23 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.24

Smoking reduces response to inhaled corticosteroids and oral corticosteroids in people with asthma.234, 5, 8 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.8

Therapeutic response to montelukast appears to be unchanged by smoking.4 Therefore, montelukast may be useful in smokers with mild asthma.6, 7

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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Stepping down regular asthma medicines in adults

The main aim of medical treatment for asthma is to achieve good asthma control and minimise the risks of asthma with the lowest effective dose of preventer medicines for each individual.

Stepping down is considered when the patient has experienced good asthma control for 2–3 months and is at low risk of flare-ups.

Figure. Stepped approach to adjusting asthma medication in adults Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/31

General tips

It is important to ascertain the person’s actual treatment regimen before stepping down, because many patients may already be taking their preventer only intermittently.

Those who deliberately avoid taking their preventer due to concerns about inhaled corticosteroids may accept regular daily treatment at a lower dose, with an action plan to deal with flare-ups.

Steps down should be planned before the patient has finished their current inhaler, so that the previous dose can be resumed immediately if asthma control deteriorates.

Patients should be advised to step back up if they or their clinician judge that their asthma is worse overall (not just after the first time they experience asthma symptoms after stepping down). Patients and clinicians should agree beforehand on criteria for worsening asthma control.

Some patients are very concerned about reducing their dose (despite the risk of treatment-related adverse effects) and may prefer to stay on high doses for long periods. To enable early detection of deterioration in control during step-down, patients can be asked to monitor their peak flow for 2 weeks before, and 3–4 weeks after, the dose reduction.

Stepping down inhaled corticosteroid dose

For many patients with well-controlled asthma taking inhaled corticosteroid/long-acting beta2 agonist combinations or inhaled corticosteroids alone, the inhaled corticosteroid dose can be reduced without loss of asthma control if downward dose adjustments are made gradually.2526

The dose can be reduced by stepping down through the available formulations.

Note: TGA-registered fluticasone furoate/vilanterol combinations contain moderate-to-high doses of inhaled corticosteroid (100/25 mcg and 200/25 mcg respectively).

Ceasing inhaled corticosteroid

Patients with well-controlled asthma who stop taking regular low-dose inhaled corticosteroid treatment have an increased risk of flare-ups, compared with those who continue inhaled corticosteroids.27

It may sometimes be necessary to stop treatment temporarily in order to confirm the diagnosis of asthma in a person taking inhaled corticosteroids. In this situation, close monitoring of symptom control is needed.

Table. Confirming the diagnosis of asthma in a person using preventer treatment Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/9

Table. Definitions of ICS dose levels in adults

Inhaled corticosteroid Daily dose (mcg)
Low Medium High
Beclometasone dipropionate † 100–200 250–400 >400
Budesonide 200–400 500–800 >800
Ciclesonide 80–160 240–320 >320
Fluticasone furoate* 100 200
Fluticasone propionate 100–200 250–500 >500

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate).

*Fluticasone furoate is not available as a low dose. TGA-registered formulations of fluticasone furoate contain a medium or high dose of fluticasone furoate and should only be prescribed as one inhalation once daily.

Note: The potency of generic formulations may differ from that of original formulations. Check TGA-approved product information for details.

Sources

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic Guidelines Limited, Melbourne, 2009.

GlaxoSmithKline Australia Pty Ltd. Product Information: Breo (fluticasone furoate; vilanterol) Ellipta. Therapeutic Goods Administration, Canberra, 2014. Available from: https://www.ebs.tga.gov.au/

GlaxoSmithKline Australia Pty Ltd. Product Information: Arnuity (fluticasone furoate) Ellipta. Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/

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Ceasing long-acting beta2 agonist

Patients whose asthma is well controlled with an inhaled corticosteroid/long-acting beta2 agonist combination (either as conventional maintenance treatment plus short-acting beta2 agonist reliever, or as budesonide/formoterol maintenance-and-reliever therapy) can continue taking this regimen long-term. The dose can be reduced by stepping down through the available formulations.

Alternatively, for patients taking an inhaled corticosteroid/long-acting beta2 agonist combination as maintenance treatment, the combination can be replaced with an inhaled corticosteroid inhaler at the same dose. However, a meta-analysis of several studies reported deterioration in asthma control after ceasing long-acting beta2 agonist treatment in patients with asthma previously stabilised on inhaled corticosteroid/long-acting beta2 agonist combination. Therefore, if inhaled corticosteroid/long-acting beta2 agonist is replaced by inhaled corticosteroid only, patients should be advised to start taking their old combination inhaler again if asthma worsens within the first few days after switching.

Note: For patients taking fluticasone furoate/vilanterol, no studies are available to guide stepping down. Options include stepping down to inhaled corticosteroid alone (recommended in the TGA-approved Product Information),28 or stepping down to a different inhaled corticosteroid/long-acting beta2 agonist combination that will achieve a lower inhaled corticosteroid dose. (e.g. Stepping down from treatment with once-daily medium dose fluticasone furoate/vilanterol [100/25 mcg] can be achieved by switching to twice-daily low-dose fluticasone propionate/salmeterol [100/50 mcg or 50/25 mcg]). With either option, patients need careful explanation, including clear written instructions, to avoid potential confusion when changing between inhaler devices and dosing frequencies.

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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. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  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: 282-287. Available from: http://thorax.bmj.com/content/60/4/282.full
  9. 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
  10. Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance. Addiction. 2012; 107: 1066-1073. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03770.x/full
  11. Avallone KM, McLeish AC, Zvolensky M, et al. Asthma and its Relation to Smoking Behavior and Cessation Motives among Adult Daily Smokers. J Health Psychol. 2012; 18: 788-99. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22947893
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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
  19. 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
  20. 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
  21. Quit Victoria, E-cigarettes policy. **, . Available from: http://www.quit.org.au/resource-centre/policy-advocacy/policy/e-cigarettes1
  22. Gibson PG, McDonald VM, Marks GB. Asthma in older adults. Lancet. 2010; 376: 803-813. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20816547
  23. 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
  24. 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
  25. Reddel HK, Gibson PG, Peters MJ, et al. Down-titration from high-dose combination therapy in asthma: removal of long-acting. Respir Med. 2010; 104: 1110-1120. Available from: http://www.resmedjournal.com/article/S0954-6111(10)00156-3/fulltext
  26. Hagan JB, Samant SA, Volcheck GW, et al. The risk of asthma exacerbation after reducing inhaled corticosteroids: a systematic review and meta-analysis of randomized controlled trials. Allergy. 2014; 69: 510-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24571355
  27. Rank MA, Hagan JB, Park MA, et al. The risk of asthma exacerbation after stopping low-dose inhaled corticosteroids: a systematic review and meta-analysis of randomized controlled trials. J Allergy Clin Immunol. 2013; 131: 724-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23321206
  28. GlaxoSmithKline Australia Pty Ltd. Product Information: Breo (fluticasone furoate; vilanterol) Ellipta. Therapeutic Goods Administration, Canberra, 2014. Available from: https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf