COPD:Prevention

Elizabeth Fomby, MD, MBAAssociate Director, Scott & White Family Medicine Residency, Temple, TX

Gemma Kim, MD, MSAssociate 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, MPHAssociate 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):

– 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 infarctionCerebral vascular accidentPeripheral vascular disease

• CancerLung BladderKidney EsophagusLarynx PancreasHead and neck StomachBreast

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 MethodsCounseling essentials:

• “5 A’s” behavioral counseling construct developed by the National Cancer Institute (SOR: A)

– 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. Group counseling

B. Individual counseling

C. Brief physician advice

D. Motivational interviewing

Smoking Cessation

Nonpharmacologic methodsCounseling 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 adviceStead, 2005, 2008; Lai, 2010; Sorio, 2006; Rolnick, 2010

Smoking Cessation

Nonpharmacologic methodsCounseling 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 Generic CostRx 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– Hot peppery taste

– Sneezing

– Cough

– Watery eyes

– Runny nose

• Cost: $$$

Smoking CessationNicotine 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

– 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. Nicotine patch plus bupropion

B. Nicotine patch plus paroxetine

C. Nicotine patch plus nicotine gum

D. Nicotine patch plus varenicline

Smoking CessationCombination therapy effective (SOR: A)

MedicationsEstimated odds ratio (95% CI)

Estimated abstinence rate (95% CI)

Placebo 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)

CI = confidence interval.

Adapted from Fiore, 2008

Smoking Cessation

System approachesTobacco 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 therapiesInsufficient 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• Age: older than 65 years• FEV1 ≤ 50% of predicted• ≥ 3 exacerbations in past 12 months• Poor physical activity• Poor social support• Comorbidities

– 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• 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

monthsPuhan, 2005

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