Multiple studies have revealed that a combination of ICS and long-acting beta-2 agonists may be a more effective approach in asthmatic smokers than increasing the dose of corticosteroids.1 Emerging evidence suggests that leukotriene agonists may represent another treatment option in this population, and the use of oral vitamin D3, statins, and macrolides are currently being investigated.1

Pulmonology Advisor spoke with Gregory B. Diette, MD, MHS, professor of medicine in the Division of Epidemiology and Environmental Health Sciences at Johns Hopkins University in Baltimore, Maryland, to gain more insight into treating smokers with asthma.


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Please note this interview has been lightly edited for length and clarity.

Pulmonology Advisor: How does smoking affect the prognosis of patients with asthma?

Dr Diette: Smoking is a big problem in people with asthma, whether the asthmatic individual is a smoker themselves or exposed to secondhand smoke from other people. Tobacco smoke provokes airway inflammation and oxidative stress, and leads to increased symptoms, poor control, and exacerbations.

Pulmonology Advisor: What are some of the top treatment recommendations for clinicians managing these patients?

Dr Diette: It is important to determine whether the patient is an active smoker. It is easy to assume that no one with asthma would want to smoke, but unfortunately that is not true. It is also necessary to find out whether there are other people who smoke around the patient. Treatment recommendations focus on smoking cessation for the active smoker and finding ways for them to avoid other people who smoke. Asthmatic smokers should be encouraged to have a “smoking ban” in their homes to assure that their friends and family smoke elsewhere. When it is not possible to totally avoid smoke, we recommend using a high-efficiency particulate air (HEPA) filter in the home to help to reduce the harmful effects of tobacco smoke lingering in the air. 

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Pulmonology Advisor: What are the most effective ways in which clinicians can help these patients stop smoking?

Dr Diette: There are many components to successful smoking cessation. It starts with assessing the patient’s current smoking status at every clinic visit, and if an individual is an active smoker, determining their willingness to quit. If they are ready, a combination of counseling and medications is effective. The counseling can be brief and focused. Medications proven to aid in cessation include nicotine replacement with varenicline and bupropion.

Pulmonology Advisor: What should be the focus of future research in this area?

Dr Diette: Key areas for additional research include finding better prevention strategies, especially for young people, to ensure that they never start smoking. We also need to continue research on the harmful effects of secondhand smoke across the age spectrum, from in utero through childhood and into older adulthood. 

References

  1. Chatkin JM, Dullius CR. The management of asthmatic smokers. Asthma Res Pract. 2016;2:10.
  2. Coogan PF, Castro-Webb N, Yu J, O’Connor GT, Palmer JR, Rosenberg L. Active and passive smoking and the incidence of asthma in the Black Women’s Health Study. Am J Respir Crit Care Med. 2015;191(2):168-176.
  3. Westergaard CG, Porsbjerg C, Backer V. The effect of varenicline on smoking cessation in a group of young asthma patients.Respir Med. 2015;109(11):1416-1422.
  4. Polosa R, Morjaria J, Caponnetto P, et al. Effect of smoking abstinence and reduction in asthmatic smokers switching to electronic cigarettes: evidence for harm reversal.Int J Environ Res Public Health. 2014;11(5):4965-4977.
  5. Thomson NC. Addressing corticosteroid insensitivity in adults with asthma. Expert Rev Respir Med. 2015;10(2):137-156.