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Background Patients with COPD have had a lower tendency to quit smoking compared to patients with coronary heart disease (CHD). We wanted to investigate if this is still true in a Norwegian population. Methods Our data came from the fifth and sixth Tromsø surveys, which took place in 2001–2002 and 2007–2008. The predictors of smoking cessation were evaluated in a cohort of 4,497 participants who had stated their smoking status in both surveys. Results Of the 4,497 subjects in the cohort, 1,150 (25.6%) reported daily smoking in Tromsø 5. In Tromsø 6, 428 had quit (37.2%). A new diagnosis of obstructive lung disease (asthma or COPD) and CHD were both associated with increased quitting rates, 50.6% (P=0.01) and 52.1% (P=0.02), respectively. In multivariable logistic regression analysis with smoking cessation as outcome, the odds ratios (ORs) of a new diagnosis of obstructive lung disease and of CHD were 1.7 (1.1–2.7) and 1.7 (1.0–2.9), respectively. Male sex had an OR of 1.4 (1.1–1.8) compared to women in the multivariable model, whereas the ORs of an educational length of 13–16 years and ≥17 years compared to shorter education were 1.6 (1.1–2.2) and 2.5 (1.5–4.1), respectively. Conclusion The general trend of smoking cessation in the population was confirmed. Increased rates of smoking cessation were associated with a new diagnosis of heart or lung disease, and obstructive lung disease was just as strongly linked to smoking cessation as was CHD. This should encourage the pursuit of early diagnosis of COPD.
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International Journal of COPD 2016:11 1453–1458
International Journal of COPD Dovepress
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ORIGINAL RESEARCH
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/COPD.S108046
A new diagnosis of asthma or COPD is linked
to smoking cessation – the Tromsø study
Signe Elise Danielsen1
Maja-Lisa Løchen1
Astri Medbø1
Monica Linea Vold2
Hasse Melbye3
1Department of Community Medicine,
The Arctic University of Norway,
2Department of Respiratory Medicine,
University Hospital of North Norway,
3General Practice Research Unit,
Department of Community Medicine,
UiT The Arctic University of Norway,
Tromsø, Norway
Background: Patients with COPD have had a lower tendency to quit smoking compared to
patients with coronary heart disease (CHD). We wanted to investigate if this is still true in a
Norwegian population.
Methods: Our data came from the fifth and sixth Tromsø surveys, which took place in
2001–2002 and 2007–2008. The predictors of smoking cessation were evaluated in a cohort of
4,497 participants who had stated their smoking status in both surveys.
Results: Of the 4,497 subjects in the cohort, 1,150 (25.6%) reported daily smoking in Tromsø 5.
In Tromsø 6, 428 had quit (37.2%). A new diagnosis of obstructive lung disease (asthma or
COPD) and CHD were both associated with increased quitting rates, 50.6% (P=0.01) and
52.1% (P=0.02), respectively. In multivariable logistic regression analysis with smoking ces-
sation as outcome, the odds ratios (ORs) of a new diagnosis of obstructive lung disease and of
CHD were 1.7 (1.1–2.7) and 1.7 (1.0–2.9), respectively. Male sex had an OR of 1.4 (1.1–1.8)
compared to women in the multivariable model, whereas the ORs of an educational length of
13–16 years and 17 years compared to shorter education were 1.6 (1.1–2.2) and 2.5 (1.5–4.1),
respectively.
Conclusion: The general trend of smoking cessation in the population was confirmed. Increased
rates of smoking cessation were associated with a new diagnosis of heart or lung disease, and
obstructive lung disease was just as strongly linked to smoking cessation as was CHD. This
should encourage the pursuit of early diagnosis of COPD.
Keywords: smoking cessation, cohort study, COPD, asthma, coronary heart disease
Background
Smoking cessation is crucial for a better prognosis in patients with coronary heart disease
(CHD)1–3 and COPD.2,4,5 Acute heart attacks are associated with high smoking cessation
rates. In patients with a first myocardial infarction (MI) in the 1970s,3 among whom
78% were smoking, the quitting rate was 55%. In a systematic review from 2003, the
mean rate of smoking cessation within a year after a new diagnosis of CHD was found
to be 45%.1 A lower quitting rate was observed in patients with COPD, in particular
in subjects not participating in smoking cessation programs. Among smoking COPD
patients in a Swedish study, 10% of those receiving usual care had stopped smoking
after 3 years, compared to 38% of those who took part in smoking cessation groups.6
Among hospitalized patients with respiratory and cardiac diseases who took part in
an intensive smoking cessation program in Singapore, 60% of the cardiac patients and
40% of the respiratory patients were still abstinent from smoking after 2 months.7
The mortality due to CHD has decreased considerably in the Western world in the
last few decades.8 Evidence shows that decreased smoking prevalence in the general
population, particularly among patients with heart disease, is an important reason for
Correspondence: Hasse Melbye
General Practice Research Unit,
MH-building, Department of Community
Medicine, UiT The Arctic University of
Norway, 9037 Tromsø, Norway
Email hasse.melbye@uit.no
Journal name: International Journal of COPD
Article Designation: Original Research
Year: 2016
Volume: 11
Running head verso: Danielsen et al
Running head recto: New diagnosis and smoking cessation
DOI: http://dx.doi.org/10.2147/COPD.S108046
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Danielsen et al
this decrease.8–11 The mortality due to COPD has decreased
less.12 A stronger tendency of persistent smoking among
COPD patients may partly explain this difference.
COPD patients’ reluctance to quit smoking may lead to a
feeling of hopelessness among the doctors who treat them.13
Our aim was to determine how the quitting rate in adults is
influenced by getting a diagnosis of obstructive lung disease
in the population-based Tromsø study. We also wanted
to investigate whether influence from this life event differs
from being diagnosed with CHD.
Methods
Subjects
A large proportion of the adult population in Tromsø has
participated in health surveys (the Tromsø study) since 1974.
Tromsø is a university city in northern Norway with ~72,600
inhabitants. The Tromsø study so far consists of six surveys,
and this study deals with subjects who participated in both
Tromsø 5 (2001–2002) and Tromsø 6 (2007–2008). The
attendance rates (of those invited) in Tromsø 5 and Tromsø 6
were 79% and 66%, respectively. Details of the participants
have previously been described.14 We included participants
who answered the questions on smoking in both surveys. No
smoking cessation support was offered during the surveys.
The Regional committee for Medical and Health Research
Ethics and the Norwegian Data Inspectorate approved the
Tromsø 5 and Tromsø 6 surveys with a license for further
analysis on non-identifiable data, like this study. All the
participants gave written informed consent.
Examinations
In both surveys, the invitation included a questionnaire with
questions on smoking habits, education, and diseases. We
classified subjects reporting daily smoking in Tromsø 5, but
not in Tromsø 6, as quitters. We divided length of education
into three categories, 12 years, 13–16 years, and 17 years.
Table 1 shows the reported diseases. For each disease in the
questionnaire the participants were asked whether they have
or have had the disease in question. We classified diseases
reported in Tromsø 6 and not in Tromsø 5 as new diagnoses.
We categorized MI and angina pectoris as “CHD” and asthma
and COPD as “obstructive lung disease”.
Statistical analysis
The frequencies of current smoking at baseline (in Tromsø 5)
and smoking cessation among smokers were calculated by
subject characteristics, and the statistical differences between
subgroups were analyzed by chi-square statistics. We analyzed
predictors of smoking cessation by binary logistic regression.
Significant variables in univariable analysis (P0.1), as well
as age and sex, were entered in the multivariable analysis.
For the statistical analyses, we used the IBM SPSS statistic,
Version 21 (IBM Corporation, Armonk, NY, USA).
Table 1 Daily smoking according to characteristics of the cohort
of 4,497 participants in Tromsø 5 (2001–2002) who also took
part in Tromsø 6 (2007–2008)
n Smoking, n (%) P-valuea
Sex
Men 1,852 462 (24.9) 0.4
Women 2,645 688 (26.0)
Age (years)
30–49 671 233 (34.7) 0.001b
50–69 2,879 733 (26.8)
70–81 947 144 (15.2)
Education
0–12 years 3,265 869 (26.6) 0.001b
13–16 years 691 168 (24.3)
16 years 407 75 (18.4)
Not answered 134 38 (28.3)
Self-reported diseases
Asthma
Yes 366 91 (24.9) 0.7
No 4,048 1,040 (25.7)
Not answered 85 19 (22.3)
COPD
Yes 192 84 (43.8) 0.001
No 4,201 1,036 (24.1)
Not answered 104 30 (28.8)
Asthma or COPD
Yes 482 145 (30.1) 0.02
No 3,923 982 (25.1)
Not answered 94 23 (24.5)
Angina pectoris
Yes 314 55 (17.5) 0.001
No 4,078 1,072 (26.3)
Not answered 105 23 (25.3)
MI
Yes 238 53 (22.3) 0.2
No 4,168 1,076 (25.8)
Not answered 91 21 (23.1)
CHD (angina or infarction)
Yes 442 84 (19.0) 0.001
No 3,962 1,046 (26.4)
Not answered 93 20 (21.5)
Diabetes
Yes 137 30 (21.9) 0.3
No 4,275 1,099 (25.7)
Not answered 85 21 (24.7)
Stroke
Yes 105 19 (18.1) 0.08
No 4,280 1,103 (25.8)
Not answered 112 28 (25.0)
Notes: aStatistical signicance of difference between subgroups, “not answered”
excluded. bChi-square trend.
Abbreviations: MI, myocardial infarction; CHD, coronary heart disease.
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New diagnosis and smoking cessation
Results
A total of 4,631 subjects participated in both the fifth and
the sixth surveys of the Tromsø study, and 4,497 subjects
comprising 1,852 men and 2,645 women answered the
questions on smoking in both surveys. The mean time dif-
ference between attending the two surveys was 6.2 years
(standard deviation 0.5 years). The mean age at Tromsø
5 was 61.1 years (range 30–81 years); 1,150 (25.6%)
reported daily smoking and 1,753 (39.0%) reported former
smoking. The highest prevalence of smoking (43.8%)
was found in subjects with self-reported COPD, whereas
the frequency among those with self-reported CHD was
19.0%. The characteristics of the population in Tromsø
5 and the respective frequencies of smoking are listed in
Table 1.
In the sixth survey, 765 subjects (17.0%) reported current
smoking, and 428 of the 1,150 who had been smoking in
Tromsø 5 had quit (37.2%). A significantly higher quitting
rate was found in men compared to women, and the quitting
rate increased with the length of education. Self-reported
diseases registered in Tromsø 5 had no significant impact
on the quitting rate (Table 2). The number of days between
attending the two surveys had no impact on the quitting rate
(odds ratio =1, P=0.8).
Table 3 shows the frequencies of new self-reported
diseases reported in Tromsø 6, but not in Tromsø 5, and
the association between a new diagnosis and smoking ces-
sation. New diagnoses of asthma/COPD (n=79) and CHD
(n=73) were both associated with increased frequency of
quitting, 50.6% (P=0.01) and 52.1% (P=0.008), respec-
tively. A new diagnosis of asthma/COPD or CHD was
reported in 144 subjects. Both men and women belonging
to any of these diagnostic groups showed increased quit-
ting rates, 54.9% vs 39.8% (P=0.02) in men and 47.1% vs
32.7% (P=0.009) in women. The impact of getting these
new diagnoses was particularly strong among the subjects
with education length no longer than 12 years (P=0.001;
Figure 1). Subjects with education length up to 12 years
were also more frequently diagnosed with these diseases
compared to those with higher education, 16.0% and
9.5% (P=0.01), respectively. Among subjects with higher
education, a high quitting rate was independent of a new
diagnosis (Figure 1).
A new diagnosis of both CHD and obstructive lung
disease was significantly associated with smoking cessation
when analyzed by logistic regression and also after adjusting
for sex and education level in multivariable logistic regres-
sion analyses (Table 4).
Discussion
Main ndings
Half of the participants with a new diagnosis of asthma/
COPD or angina/MI quit smoking during the 6 years of
follow-up. However, the association between these new diag-
noses and smoking cessation was found only in participants
Table 2 Smoking cessation between 2001–2002 (Tromsø 5)
and 2007–2008 (Tromsø 6) according to characteristics of 1,150
smoking participants in Tromsø 5
n Quit smoking, n (%) P-valuea
Sex
Men 462 194 (42.0) 0.006
Women 688 234 (34.0)
Age (years)
30–49 233 87 (37.7) 0.6b
50–69 773 292 (37.8)
70–81 144 49 (34.0)
Education
0–12 years 869 300 (34.5) 0.001b
13–16 years 168 74 (44.0)
16 years 75 42 (56.0)
Not answered 38 12 (31.6)
Self-reported diseases
Asthma
Yes 91 26 (28.6) 0.8
No 1,040 394 (37.9)
Not answered 19 6 (31.6)
COPD
Yes 84 35 (41.7) 0.4
No 1,036 384 (37.1)
Not answered 30 9 (30.0)
Asthma or COPD
Yes 145 51 (35.2) 0.5
No 982 371 (37.8)
Not answered 23 6 (26.1)
Angina pectoris
Yes 55 17 (30.9) 0.3
No 1,072 402 (37.5)
Not answered 23 9 (39.1)
MI
Yes 53 17 (32.1) 0.4
No 1,076 403 (37.5)
Not answered 21 8 (38.1)
CHD (angina or infarction)
Yes 84 28 (33.3) 0.3
No 1,046 392 (37.5)
Not answered 20 8 (40.0)
Diabetes
Yes 30 7 (23.3) 0.1
No 1,099 412 (37.5)
Not answered 21 9 (42.9)
Stroke
Yes 19 6 (31.6) 0.6
No 1,103 412 (37.4)
Not answered 28 10 (35.7)
Notes: aStatistical signicance of difference between subgroups, “not answered”
excluded. bChi-square trend.
Abbreviations: MI, myocardial infarction; CHD, coronary heart disease.
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Danielsen et al
smoking was strongly related to serum thiocyanate if the
question was asked in a neutral setting.16 Although the
questions on smoking were included in a self-administered
questionnaire, underreporting of daily smoking among those
with a new diagnosis cannot be ruled out.
All diagnoses were self-reported, and their correctness
could not be confirmed. Shift in diagnosis based on the same
illness from Tromsø 5 to Tromsø 6, for instance, between
asthma and COPD, may have taken place in some subjects.
Such a change has been counted as a new diagnosis. This is
no longer a problem when asthma and COPD are combined
into one category (asthma and/or COPD) and subjects with
a new diagnosis of any of these diseases are compared with
those with neither of the diagnoses at both Tromsø 5 and
Tromsø 6.
Although we have found associations between a new
diagnosis and smoking cessation, we do not know for sure
whether the extra cessations in the subgroups with a new
diagnosis were really preceded by a new diagnosis. Subjects
in these subgroups could have stopped smoking before the
diagnosis was given. In these cases, it is likely that symptoms
from a pulmonary or heart disease had raised their awareness
of the risk of continued smoking.
Comparisons with previous studies
No previous study has, to our knowledge, described smoking
cessation in relation to a new diagnosis of heart or lung
disease. Most previous studies evaluated smoking cessation
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Figure 1 Percentage of participants who quit smoking between 2001–2002 (Tromsø 5)
and 2007–2008 (Tromsø 6) among 1,064 participants, by education length, and heart
and lung disease.
Table 3 Smoking cessation between 2001–2002 (Tromsø 5) and
2007–2008 (Tromsø 6) according to new diagnosis in the same
period
n Quit smoking, n (%) P-valuea
New diagnosis
Asthma
Yes 42 20 (47.6) 0.2
No 967 365 (37.7)
COPD
Yes 75 36 (48.0) 0.05
No 933 342 (36.7)
Asthma or COPD
Yes 79 40 (50.6) 0.01
No 903 331 (36.7)
Angina pectoris
Yes 33 15 (45.5) 0.3
No 1,017 379 (37.3)
MI
Yes 58 30 (51.7) 0.02
No 995 365 (36.7)
CHD (angina or infarction)
Yes 73 38 (52.1) 0.008
No 955 348 (36.4)
Diabetes
Yes 33 12 (34.4) 0.9
No 1,035 391 (37.8)
Stroke
Yes 37 12 (32.4) 0.5
No 1,037 389 (37.5)
Notes: aStatistical signicance of difference between participants with a new
(possibly combined) diagnosis and participants without a new (possibly combined)
diagnosis in Tromsø 5. In each analysis, participants who reported the diagnosis
in question in Tromsø 5, and those who have not answered the question on the
diagnosis in any of the surveys, have been excluded.
Abbreviations: MI, myocardial infarction; CHD, coronary heart disease.
with education length up to 12 years. The much higher
smoking rate among those with asthma and, in particular,
those with COPD at baseline than in those with CHD indi-
cates a shift in attitude toward smoking cessation among
subjects with COPD.
Strengths and limitations
The high number of participants and the high attendance
rates among those invited are strengths of the study. The
prevalences of daily smoking among all the attendees in
Tromsø 5 and Tromsø 6 were 31% and 22%, respectively,11
which are close to the national prevalences of 29% and
21%, as registered by Statistics Norway (https://www.ssb.
no)15 in 2002 and 2008, respectively. In our study sample,
the prevalence was lower at both points of time, 25.6% and
17.0%, respectively, and a healthy survivor effect may have
contributed to the low frequency of daily smoking in our
subsample. The study is based on questionnaires and not on
objective measurements of smoking, such as cotinine and
thiocyanate. In a previous Norwegian study, self-reported
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New diagnosis and smoking cessation
Table 4 ORs for smoking cessation between Tromsø 5 (2001–2002) and Tromsø 6 (2007–2008) according to characteristics of 1,024
smoking participants in Tromsø 5 and new diagnosis reported in Tromsø 6
Univariable Multivariable
OR (95% CI) P-value OR (95% CI) P-value
Age 1.0 (1.0–1.0) 0.9 1.0 (1.0–1.0) 0.6
Male sex 1.4 (1.1–1.8) 0.01 1.4 (1.1–1.8) 0.02
Education (years)
13–16 1.5 (1.0–2.1) 0.03 1.6 (1.1–2.2) 0.02
17 2.3 (1.4–3.8) 0.001 2.5 (1.5–4.1) 0.001
New diagnosis of CHD 1.7 (1.1–2.8) 0.02 1.7 (1.0–2.9) 0.04
New diagnosis of asthma or COPD 1.7 (1.1–2.6) 0.02 1.7 (1.1–2.7) 0.02
Abbreviations: OR, odds ratio; CHD, coronary heart disease.
programs, and control groups in such studies can be com-
pared with our participants. However, the quitting rate of
41.7% among subjects with a COPD diagnosis reported in
Tromsø 5 was more similar to the rate of 38% among the
COPD patients, who had taken part in the smoking cessation
program in a Swedish study, than the rate of 10% among
the COPD patients on usual care.6 In a study from primary
care, where smokers received smoking cessation advice and
were followed up annually with spirometry, higher rates of
abstinence were found among those with COPD than among
those with normal lung function.17 This result is in line with
our findings. We found that the quitting rate increased with
increasing length of education, and this association is well
known from previous studies.18
Qualitative studies have shown that patients with a COPD
diagnosis may have several reasons for not quitting despite
the knowledge of harming themselves,19 and they do not
always believe that quitting would give them a better life.20
COPD patients often show little interest in receiving help
from medication and describe unassisted quitting as the best
method to stop smoking, based on willpower, strong motiva-
tion, and internal strength.21 In our study, a new diagnosis
of COPD or CHD might have given many participants the
motivation they needed to quit without assistance. In another
qualitative study, the interviewees who had stopped smoking
emphasized that persons close to them had a strong influence
on their decision to quit.22 This gives a reason to believe that
the decreasing acceptance of smoking in the society also
influences COPD patients.
Conclusion
It has been suggested that a hard core of smokers will con-
stitute an increasing proportion of COPD patients who still
smoke.23 The high quitting rates among subjects with both an
established and a new diagnosis of COPD in our study con-
tradicts this pessimism. The study supports pursuit of early
diagnosis of COPD and gives reasons for a more optimistic
attitude among health workers when they discuss smoking
cessation with their COPD patients.
Acknowledgment
The authors would like to thank the participants of the
Tromsø study.
Author contributions
All authors contributed toward data analysis, drafting and
revising the paper and agree to be accountable for all aspects
of the work.
Disclosure
The authors report no conflicts of interest in this work.
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... Mathias et al. found that smoking cessation was related to the number of years of smoking and the level of education received, and the quit rate of middle-aged smokers was signi cantly higher 12 . In addition, a new diagnosis of asthma was associated with an increased rate of quitting smoking in a Norwegian study of general trends in smoking cessation 13 . These factors may be predictors of smoking cessation. ...
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Objective Smoking is a trigger for asthma, which has led to an increase in asthma incidence in China. In smokers, asthma management starts with smoking cessation. Data on predictors of smoking cessation in Chinese patients with asthma are scarce. The objective of this study was to find the differences in clinical characteristics between current smokers and former smokers with asthma in order to identify factors associated with smoking cessation. Patients and Methods Eligible adults with diagnosed asthma from the hospital outpatient clinics (n = 2312) were enrolled and underwent a clinical evaluation, asthma control test (ACT), and pulmonary function test. Information on demographic and sociological data, lung function, laboratory tests, ACT and asthma control questionnaire (ACQ) scores was recorded. Patients were divided into a current smokers group and a former smokers group based on whether they had quit smoking. Logistic regression analysis was used to analyze the factors associated with smoking cessation. Results Of all patients with asthma, 34.6% were smokers and 65.4% were former smokers, and the mean age was 54.5 ± 11.5 years. Compared with current smokers, the former smokers were older, had more pack-years, had smoked for longer, had heavier dyspnea and had worse asthma control. The logistic regression model showed that smoking cessation was positively correlated with age, female sex, pack-years, years of smoking, FEV1 and FEV1/FVC, but was negatively correlated with ACT, or widowed status, and body mass index (BMI). Conclusions More than 30% of asthma patients in the study were still smoking. Among those who quit smoking, many quit late, often not realizing they need to quit until they have significant breathing difficulties. The predictors of smoking cessation identified in this study indicate that there are still differences between continuing smokers and former smokers, and these predictors should be focused on in asthma smoking cessation interventions to improve the prognosis of patients with asthma.
... Mathias et al. found that smoking cessation was related to the number of years of smoking and the level of education received, and the quit rate of middle-aged smokers was signi cantly higher 12 . In addition, a new diagnosis of asthma was associated with an increased rate of quitting smoking in a Norwegian study of general trends in smoking cessation 13 . These factors may be predictors of smoking cessation. ...
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Full-text available
Objective Smoking is a trigger for asthma, which has led to an increase in asthma incidence in China. In smokers, asthma management starts with smoking cessation. Data on predictors of smoking cessation in Chinese patients with asthma are scarce. The objective of this study was to find the differences in clinical characteristics between current smokers and former smokers with asthma in order to identify factors associated with smoking cessation. Patients and Methods Eligible adults with diagnosed asthma from the hospital outpatient clinics (n = 2312) were enrolled and underwent a clinical evaluation, asthma control test (ACT), and pulmonary function test. Information on demographic and sociological data, lung function, laboratory tests, ACT and asthma control questionnaire (ACQ) scores was recorded. Patients were divided into a current smokers group and a former smokers group based on whether they had quit smoking. Correlations of pack-years and years of smoking with clinical parameters were evaluated using Spearman’s rank correlation analysis. Logistic regression analysis was used to analyze the factors associated with smoking cessation. Results Of all patients with asthma, 34.6% were smokers and 65.4% were former smokers, and the mean age was 54.5 ± 11.5 years. Compared with current smokers, the former smokers were older, had more pack-years, had smoked for longer, had heavier dyspnea and had worse asthma control. The Spearman’s rank correlation analysis showed that pack-years and years of smoking were negatively correlated with forced expiratory volume in 1 second (FEV1), FEV1%predicted, FEV1/forced vital capacity (FVC) and ACT scores, but positively correlated with ACQ scores in all patients. Interestingly, pack-years and years of smoking were negatively correlated with serum immunoglobulin E (IgE), fractionated exhaled nitric oxide (FeNO), blood eosinophils, and blood neutrophils in all patients. The logistic regression model showed that smoking cessation was positively correlated with age, female sex, pack-years, years of smoking, FEV1, FEV1/FVC and blood eosinophils, but was negatively correlated with ACT, or widowed status, and body mass index (BMI). Conclusions More than 30% of asthma patients in the study were still smoking. Among those who quit smoking, many quit late, often not realizing they need to quit until they have significant breathing difficulties. The predictors of smoking cessation identified in this study indicate that there are still differences between continuing smokers and former smokers, and these predictors should be focused on in asthma smoking cessation interventions to improve the prognosis of patients with asthma.
... General smoking prevalence is correlated with CHD mortality: between 1981 and 2000 CHD mortality rates in England and Wales decreased substantially due to evidence-based treatment options and risk factor control and 48% of this decrease was estimated attributable to smoking [34]. In the same period comparable trends of falling CHD mortality due to improved treatment and risk factor control were observed in the USA, there, the risk reduction attributable to smoking was estimated 12% [35]. ...
Thesis
Background Tobacco smoking is accountable for more than one in ten deaths in patients with cardiovascular disease. Thus, smoking cessation has a high priority in secondary prevention of coronary heart disease (CHD). The present study meant to assess smoking cessation patterns, identify parameters associated with smoking cessation and investigate personal reasons to change or maintain smoking habits in patients with established CHD. Methods Quality of CHD care was surveyed in 24 European countries in 2012/13 by the fourth European Survey of Cardiovascular Disease Prevention and Diabetes. Patients 18 to 79 years of age at the date of the CHD index event hospitalized due to first or recurrent diagnosis of coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction or acute myocardial ischemia without infarction (troponin negative) were included. Smoking status and clinical parameters were iteratively obtained a) at the cardiovascular disease index event by medical record abstraction, b) during a face-to-face interview 6 to 36 months after the index event (i.e. baseline visit) and c) by telephone-based follow-up interview two years after the baseline visit. Parameters associated with smoking status at the time of follow-up interview were identified by logistic regression analysis. Personal reasons to change or maintain smoking habits were assessed in a qualitative interview and analyzed by qualitative content analysis. Results One hundred and four of 469 (22.2%) participants had been classified current smokers at the index event and were available for follow-up interview. After a median observation period of 3.5 years (quartiles 3.0, 4.1), 65 of 104 participants (62.5%) were classified quitters at the time of follow-up interview. There was a tendency of diabetes being more prevalent in quitters vs non-quitters (37.5% vs 20.5%, p=0.07). Higher education level (15.4% vs 33.3%, p=0.03) and depressed mood (17.2% vs 35.9%, p=0.03) were less frequent in quitters vs non-quitters. Quitters more frequently participated in cardiac rehabilitation programs (83.1% vs 48.7%, p<0.001). Cardiac rehabilitation appeared as factor associated with smoking cessation in multivariable logistic regression analysis (OR 5.19, 95%CI 1.87 to 14.46, p=0.002). Persistent smokers at telephone-based follow-up interview reported on addiction as wells as relaxation and pleasure as reasons to continue their habit. Those current and former smokers who relapsed at least once after a quitting attempt, stated future health hazards as their main reason to undertake quitting attempts. Prevalent factors leading to relapse were influence by their social network and stress. Successful quitters at follow-up interview referred to smoking-related harm done to their health having had been their major reason to quit. Interpretation Participating in a cardiac rehabilitation program was strongly associated with smoking cessation after a cardiovascular disease index event. Smoking cessation counseling and relapse prophylaxis may include alternatives for the pleasant aspects of smoking and incorporate effective strategies to resist relapse.
... The diagnosis of respiratory diseases, awareness of symptoms of respiratory problems, and guidance from doctors accounted for 83% of the reasons for quitting smoking, indicating that medical factors play a major role in quitting smoking. Previous studies have shown that the diagnosis of COPD is associated with smoking cessation behavior 43,44 , and the results of this study are consistent with those findings. Previous studies have shown that guidance by doctors is useful even if the guidance is simple 45 , and this study also showed that guidance on smoking cessation is important for patients with COPD. ...
Article
Introduction: Smoking is the leading cause of chronic obstructive pulmonary disease (COPD), and smoking cessation is the most effective treatment for patients with COPD. However, few studies have investigated the continuation/cessation of smoking and heated tobacco products (HTP) in patients with COPD. The objective of this study was to examine the characteristics of patients with COPD, those who are current smokers and those who switched from cigarettes to HTP, and to examine the reason for the continuation or cessation of smoking. Methods: This multicenter, cross-sectional study included 411 outpatients with COPD. Data for this study were part of a study conducted for a comprehensive evaluation of the smoking status and clinical factors in patients with COPD and their families. Results: Logistic regression analysis revealed that a younger age, longer duration of smoking, fewer daily cigarettes, and lower modified Medical Research Council (mMRC) dyspnea score, and a lower Simplified Nutritional Appetite Questionnaire (SNAQ) score for appetite, were characteristics of current smokers (age OR=0.94; duration of smoking OR=1.07; number of cigarettes per day OR=0.94; mMRC OR=0.68; SNAQ OR=0.83; p<0.05). The logistic regression analysis model showed that a younger age and higher education level were associated with the use of HTP (age OR=0.83; higher education level OR=4.63; p<0.05). Many of the current smokers displayed smoking behaviors that are not guaranteed to be safe, such as reducing smoking or switching to lighter cigarettes or HTP. Conclusions: Patients with COPD who continue smoking tended to have low appetite as well as smoking behaviors that are not guaranteed to be safe. Physicians should provide appropriate guidance to these patients on smoking cessation.
... accessed on 5 January 2021). Smoking was found to be an important risk factor for asthma and COPD [49,50]. Studies also indicated that smoke exposure impairs immune function and increases infection risk [51,52]. ...
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Previous studies have demonstrated that outdoor temperature exposure was an important risk factor for respiratory diseases. However, no study investigates the effect of indoor temperature exposure on respiratory diseases and further assesses cumulative effect. The objective of this study is to study the cumulative effect of indoor temperature exposure on emergency department visits due to infectious (IRD) and non-infectious (NIRD) respiratory diseases among older adults. Subjects were collected from the Longitudinal Health Insurance Database in Taiwan. The cumulative degree hours (CDHs) was used to assess the cumulative effect of indoor temperature exposure. A distributed lag nonlinear model with quasi-Poisson function was used to analyze the association between CDHs and emergency department visits due to IRD and NIRD. For IRD, there was a significant risk at 27, 28, 29, 30, and 31°C when the CDHs exceeded 69, 40, 14, 5, and 1 during the cooling season (May to October), respectively, and at 19, 20, 21, 22, and 23°C when the CDHs exceeded 8, 1, 1, 35, and 62 during the heating season (November to April), respectively. For NIRD, there was a significant risk at 19, 20, 21, 22, and 23°C when the CDHs exceeded 1, 1, 16, 36, and 52 during the heating season, respectively; the CDHs at 1 was only associated with the NIRD at 31°C during the cooling season. Our data also indicated that the CDHs was lower among men than women. We conclude that the cumulative effects of indoor temperature exposure should be considered to reduce IRD risk in both cooling and heating seasons and NIRD risk in heating season and the cumulative effect on different gender.
... Several previous studies have also demonstrated a protective effect of ICS on the risk of lung cancer (21); however, these findings should be interpreted with caution, given the small sample size. With respect to smoking habit modification, early COPD diagnosis can help motivate smoking cessation (22), the most effective measure to improve future prospects for the patients (1). As shown in our study, current smokers were more often seen in patients with incidental COPD compared to both non-COPD and prior COPD, which could pose an additional risk of death from lung cancer (23). ...
Article
Background: A two-phase study (clinical and genomic-based) was conducted to evaluate the effect of timing of chronic obstructive pulmonary disease (COPD) diagnosis on lung cancer outcomes. Methods: The prognostic influence of COPD was investigated in a clinical cohort of 1,986 patients who received surgery for stage I lung cancer; 823 (41.4%) of them also had COPD, including 549 (27.6%) incidental COPD (diagnosed within 6-months of lung cancer diagnosis) and 274 (13.8%) prior COPD (>6 months before lung cancer diagnosis). The genomic variations were analyzed from another cohort of 1,549 patients for association with 384 lung cancer-related single nucleotide polymorphisms (SNPs). Results: Older age (≥70 years), smokers, and respiratory symptoms were independent predictors of incidental COPD in lung cancer (all P<0.05). Similar to prior COPD, incidental COPD increased postoperative complications and worsened quality-of-life related to dyspnea (both P<0.05). Multivariate Cox regression analysis showed lung cancer survival decreased significantly in incidental COPD (HR, 1.30; 95% CI, 1.02-1.66), but not in prior COPD (HR, 1.15; 95% CI, 0.87-1.52). Among prior COPD, median survival showed a trend for being better in those with fewer exacerbations (0-1 vs. ≥2 exacerbation/year; 6.1 vs. 4.1 years; P=0.10). The SNP-based analysis identified ADCY2:rs52827085 was significantly associated with risk of incidental COPD (OR, 1.76; 95% CI, 1.30-2.38) and NRXN1:rs1356888 associated with prior COPD complicated with lung cancer (OR, 1.73; 95% CI, 1.29-2.33). Conclusions: Different long-term survival and genomic variants were observed between lung cancer patients with incidental and with prior COPD, suggesting timing of COPD diagnosis should be considered in lung cancer clinical management and mechanistic research.
... The COVID-19 pandemic can be considered a naturally occurring cueing event that has motivated smokers to engage in preventive behaviors for reducing their risk of contracting COVID-19 [18]. For example, studies have shown that receiving a new disease diagnosis is associated with quitting smoking [19,20]. Indeed, public health professionals have advised smokers to use interventions that are proven to be effective in helping smokers quit smoking, which can reduce their risk of SARS-CoV-2 infection and COVID-19-related complications [21][22][23]. ...
Article
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Background: Smoking is a plausible risk factor for covid-19 progression and complications. Smoking cessation digital platforms transcend pandemic-driven social distancing and lockdown measures to assist smokers in their quit attempts. Objective: To examine trends in the number of visitors, followers, and subscribers to smoking cessation digital platforms from January to April of 2020 compared to traffic observed during the same four-months period in 2019. Examining pre- and post-pandemic trends in traffic to smoking cessation digital platforms can reveal interest in smoking cessation among smokers that is attributable to the covid-19 pandemic. Methods: Cross-sectional data from daily visitors to SmokeFree.gov, followers of six social media accounts, and subscribers to SmokeFree text messaging and mobile application interventions of the National Cancer Institute's SmokeFree.gov initiative (SFGI) platforms that are publicly available to US smokers were obtained. Average daily percentage changes (ADPC) measured trends for the entire January-to-April study period, whereas daily percentage changes (DPC) measured trends for each time segment of change within the four-month period. Data analysis was conducted in May and June 2020. Results: New daily visitors to SmokeFree.gov (DPC= 18.79%, CI: 5.16%, 34.19% between days 39 and 44) and subscribers of adult-focused interventions, QuitGuide (DPC=1.11%, CI: 0.80%, 1.43% between days 11 and 62) and SmokeFreeTXT (DPC= 0.23%,CI: 0.004%, 0.47% between days 11 and 89), increased but were followed by declines in traffic. No comparable peaks were observed in 2019. New daily subscribers of quitSTART, the teen-focused intervention, trended downward in 2020 (ADPC= -1.02%, CI: -1.88%, -0.15%), whereas the overall 2019 trend was insignificant. Followers of SmokeFree social media accounts showed a steady increase of less than 0.1% over the four-month study period in 2019 and 2020. Conclusions: Peaks in traffic to SmokeFree.gov and adult-focused interventions in 2020 could be attributed to an increased interest in smoking cessation among smokers during the covid-19 pandemic. Coordinated campaigns should emphasize smoking cessation as a preventive measure against covid-19 especially among adolescents and raise awareness of digital smoking cessation platforms capitalizing on heightened interest during the pandemic. Clinicaltrial:
... L'annonce d'un diagnostic, une pathologie aiguë, une hospitalisation pour une exacerbation aiguë d'une pathologie chronique, la réalisation et/ou le résultat d'un examen complémentaire constituent des « teachable moments » [98]. Dans une étude norvégienne [99], chez 4497 sujets, un diagnostic de maladie bronchique obstructive (BPCO ou asthme) ou de maladie coronaire au cours des 6 années séparant les deux enquêtes, étaient associés à une augmentation des taux d'arrêt du tabac, comparativement à l'absence de diagnostic au cours de la même période : OR = 1,7 (IC95 % : 1,1-2,7) ; p = 0,02 et OR = 1,7 (IC95 % : 1,0-2,9) ; p = 0,04, respectivement. [35], chez 1801 adultes asthmatiques venus aux urgences pour exacerbation d'asthme, observaient que les fumeurs actuels avaient moins souvent consulté un médecin spécialiste de l'asthme au cours des 12 derniers mois (OR = 0,59 ; IC95 % : 0,37-0,93 ; p = 0,02), comparativement aux nonfumeurs actuels. ...
Article
Résumé Introduction La prévalence du tabagisme chez les patients asthmatiques est identique ou plus élevée qu’en population générale. Objectifs Cette revue systématique étudie les conséquences du tabagisme sur l’asthme, les stratégies de sevrage tabagique (ST) chez l’asthmatique et les conséquences du ST sur l’asthme. Résultats Le tabagisme actif ou passif peut favoriser le développement de l’asthme et a des nombreux effets délétères sur l’asthme. Les rares études sur le ST chez les fumeurs asthmatiques montrent l’efficacité des stratégies classiques du ST chez ces patients (substituts nicotiniques, varénicline, bupropion, thérapies cognitives et comportementales). L’arrêt du tabagisme des parents ayant des enfants asthmatiques est essentiel et repose sur les mêmes stratégies. La cigarette électronique peut être une aide utile à l’arrêt du tabac chez certains patients. L’arrêt du tabagisme est bénéfique chez les fumeurs asthmatiques : réduction des symptômes, des exacerbations aiguës, de l’hyperréactivité bronchique et de l’inflammation bronchique ; diminution du recours aux médicaments d’urgence et des doses de corticostéroïdes inhalés ; amélioration du contrôle de l’asthme, de la qualité de vie et de la fonction respiratoire. Conclusion Chez les patients asthmatiques, il est essentiel d’évaluer le statut tabagique et les professionnels de santé doivent les aider à arrêter de fumer.
... Thus, the difficult task of life-style change was up to the patient, which could be difficult to obtain in this population. Many patients with COPD are unsuccessful in smoking cessation [20], or lack motivation [21]. Studies have shown that the physician's attitude to physical activity might have an impact on the patient's motivation to engage in physical activity [22,23]. ...
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Background In Denmark, general practitioners (GPs) have the main responsibility for chronic obstructive pulmonary disease (COPD) management. Internationally, COPD appears to be significantly under-treated, which could be explained by ‘therapeutic nihilism’ or lack of knowledge. Aim To investigate: (1) To what extent COPD management provided by GPs includes the core elements of pharmacological treatment, smoking cessation and physical activity, and (2) To what extent GPs need educational support and consulting with a specialist in pulmonary medicine. Design A national cross-sectional web-based survey conducted in April–June 2019. The survey included items on COPD management and educational support needs. Setting Danish general practice. Subjects A population of approximately 3400 GPs (all GPs in Denmark). Results We received response from 470 GPs (14% response rate). Overall, the respondents reported that they offered COPD management including all relevant treatment elements. Smoking cessation was supported in 58% and physical activity was supported in 23% of the respondents. Future consultations on smoking cessation were planned by 35% and physical activity by 15% respondents. GPs responded to ‘needing educational support in COPD management’ to a ‘high degree’ in 8% and to ‘some degree’ in 43%. Conclusion The survey suggested that COPD maintenance support provided by GPs seemed to be inadequate regarding smoking cessation and physical activity. Moreover, some GPs expressed a need for educational support in COPD management. More research is needed to understand the potential barriers to evidence-based delivery of COPD-management. • Key points • In Denmark, general practitioners (GPs) have the main responsibility for the management of chronic obstructive pulmonary disease (COPD). • The present study shows that non-pharmacological interventions such as supporting smoking cessation and particularly promoting physical activity received less attention than pharmacological treatment. • The study suggests a need for educational support of the GPs in COPD management.
... Exacerbations of HF and COPD are major causes of admittance to emergency departments. 1,2 HF and COPD are not curable diseases, but early diagnosis can lead to preventive measures, including smoking cessation, 3 that can prolong life and reduce the number of acute exacerbations. 2,4 Heart failure and COPD might be underdiagnosed at an early stage partly due to unspecific early symptoms. ...
Article
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Aims Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are main causes of dyspnoea, and echocardiography and spirometry are essential investigations for these diagnoses. Our aim was to determine the prevalence of HF and COPD in a general population, also how the diseases may be identified, and to what extent their clinical characteristics differ. Methods and results In the seventh survey of Tromsø study (2015–16), subjects aged 40 years or more were examined with echocardiography, spirometry, lung sound recordings, questionnaires, including the modified Medical Research Council (mMRC) questionnaire on dyspnoea, and N‐terminal pro‐brain natriuretic peptide analysis. A diagnosis of HF (HF with reduced ejection fraction, HF with mid‐range ejection fraction, or HF with preserved ejection fraction) or COPD was established according to current guidelines. Predictors of HF and COPD were evaluated by logistic regression and receiver operating characteristic curve analysis. A total of 7110 participants could be evaluated for COPD, 1624 for HF, and 1538 for both diseases. Age‐standardized prevalence of HF was 6.8% for women and 6.1% for men; the respective figures for COPD were 5.2% and 5.1%. Among the 1538 evaluated for both diseases, 139 subjects fulfilled the HF criteria, but only 17.1% reported to have the disease. Of those fulfilling the COPD criteria, 31.6% reported to have the disease. Shortness of breath at exertion was a frequent finding in HF; 59% of those with mMRC ≥2 had HF, while such shortness of breath was found in 24% among those with COPD. Reporting mMRC ≥2 had an odds ratio for HF of 19.5 (95% confidence interval 11.3–33.7), whereas the odds ratio for COPD was 6.3 (95% confidence interval 3.5–11.6). Current smoking was the strongest predictor of COPD but did not predict HF. Basal inspiratory crackles were significant predictors of HF in multivariable analysis. Among the subtypes of HF, an age <70 years was most frequently found in HF with reduced ejection fraction, in 51.7%. Clinical scores based on the predictive value in multivariable analysis of history, symptoms, and signs predicted HF and COPD with areas under the curve of 0.833 and 0.829, respectively. Conclusions Study participants with HF and COPD were in most cases not aware of their condition. In general practice, when an elderly patient present with shortness of breath, both diseases should be considered. Previous cardiovascular disease points at HF, while a history of smoking points at COPD. The threshold should be low for ordering echocardiography or spirometry for verifying the suspected cause of dyspnoea.
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Background: Coronary heart disease (CHD) mortality rates have been decreasing in Iceland since the 1980s. We examined how much of the decrease between 1981 and 2006 could be attributed to medical and surgical treatments and how much to changes in cardiovascular risk factors.
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Background Smokers with chronic obstructive pulmonary disease (COPD) seem to be a special subgroup of smokers that have a more urgent need to quit smoking but might find it more difficult to do so. This study aimed to explore which justifications for tobacco smoking and experiences of quitting were commonly shared in smokers with and without COPD, and which, if any, were specific to smokers with COPD. Methods In ten primary healthcare centres in the Netherlands, we conducted semi-structured, in-depth interviews in 10 smokers with and 10 smokers without COPD. Results Three themes were generated: ‘balancing the impact on health of smoking’, ‘challenging of autonomy by social interference’, ‘prerequisites for quitting’. All participants trivialized health consequences of smoking; those with COPD seemed to be less knowledgeable about smoking and health. Both groups of smokers found autonomy very important. Smokers with COPD were indignant about a perceived lack of empathy in their communication with doctors. Furthermore, smokers with COPD in particular had little faith in the efficacy of smoking cessation aids. Lastly, motivation for quitting was dominated by fluctuation and smokers with COPD specifically maintained that their vision of life was linked with quitting. Conclusions The participants showed many similarities in their reasoning about smoking and quitting. The corresponding themes argue for a less paternalistic regime in the communication with smokers with attention required for the motivational stage and room made for smokers’ own views, and with clear information and education. Furthermore, addressing social interactions, health perceptions and moral agendas in the communication with smokers with COPD may help to make smoking cessation interventions more suitable for them. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0382-y) contains supplementary material, which is available to authorized users.
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The development of prescription medication for smoking cessation and the introduction of evidence-based guidelines for health professionals has increasingly medicalised smoking cessation. There are debates about whether medicalisation is a positive development, or whether it has devalued unassisted quitting. In this debate the views of smokers have been neglected. This study explored the attitudes of smokers towards a range of quitting methods, and their considerations when judging their value. We conducted semi-structured interviews with 29 smokers and analysed data using thematic analysis. The results show that the perceived nature of an individual smoker's addiction was central to judgments about the value of pharmacological cessation aids, as was personal experience with a method, and how well it was judged to align with an individual's situation and personality. Unassisted quitting was often described as the best method. Negative views of pharmacological cessation aids were frequently expressed, particularly concerns about side effects from prescription medications. Smokers' views about the value of different methods were not independent: attitudes about cessation aids were shaped by positive attitudes towards unassisted quitting. Examining smokers' attitudes towards either assisted or unassisted quitting in isolation provides incomplete information on quitting preferences.
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Between 1990 and 2010, chronic obstructive pulmonary disease (COPD) moved from the fourth to third most common cause of death worldwide. Using data from the Global Burden of Disease programme we quantified regional changes in the number of COPD deaths and COPD mortality rates between 1990 and 2010. We estimated the proportion of the change that was attributable to gross national income per capita and an index of cumulative smoking exposure, and quantified the difference in mortality rates attributable to demographic changes. Despite a substantial decrease in COPD mortality rates, COPD deaths fell only slightly, from three million in 1990 to 2.8 million in 2010, because the mean age of the population increased. The number of COPD deaths in 2010 would have risen to 5.2 million if the age- and sex-specific mortality rates had remained constant. Changes in smoking led to only a small increase in age- and sex-specific mortality rates, which were strongly associated with changes in gross national income. The increased burden of COPD mortality was mainly driven by changes in age distribution, but age- and sex-specific rates fell as incomes rose. The rapid response to increasing affluence suggests that changes in COPD mortality are not entirely explained by changes in early life. Copyright ©ERS 2015.
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Background Worsening of pulmonary diseases is associated with a decrease in oxygen saturation (SpO2). Such a decrease in SpO2 and associated factors has not been previously evaluated in a general adult population. Aim We sought to describe SpO2 in a sample of adults, at baseline and after 6.3 years, to determine whether factors predicting low SpO2 in a cross-sectional study were also associated with a decrease in SpO2 in this cohort. Methods As part of the Tromsø Study, 2,822 participants were examined with pulse oximetry in Tromsø 5 (2001/2002) and Tromsø 6 (2007/2008). Low SpO2 by pulse oximetry was defined as an SpO2 ≤95%, and SpO2 decrease was defined as a ≥2% decrease from baseline to below 96%. Results A total of 139 (4.9%) subjects had a decrease in SpO2. Forced expiratory volume in 1 second (FEV1) <50% of the predicted value and current smoking with a history of ≥10 pack-years were the baseline characteristics most strongly associated with an SpO2 decrease in multivariable logistic regression (odds ratio 3.55 [95% confidence interval (CI) 1.60–7.89] and 2.48 [95% CI 1.48–4.15], respectively). Male sex, age, former smoking with a history of ≥10 pack-years, body mass index ≥30 kg/m2, and C-reactive protein ≥5 mg/L were also significantly associated with an SpO2 decrease. A significant decrease in FEV1 and a new diagnosis of asthma or chronic obstructive pulmonary disease during the observation period most strongly predicted a fall in SpO2. A lower SpO2 decrease was observed in those who quit smoking and those who lost weight, but these tendencies were not statistically significant. Conclusion A decrease in SpO2 was most strongly associated with severe airflow limitation and a history of smoking. Smoking cessation and reducing obesity seem to be important measures to target for avoiding SpO2 decreases in the general population.
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With growing recognition of stagnant rates of attempted cigarette smoking cessation, the current study examined demographic and psychometric characteristics associated with successful and attempted smoking cessation in a nationally representative sample. This additional understanding may help target tobacco cessation treatments toward sub-groups of smokers in order to increase attempts to quit smoking. Data were used from the 2011 U.S. National Health and Wellness Survey (n = 50,000). Current smoking status and demographics, health characteristics, comorbidities, and health behaviors. In 2011, 18%, 29%, and 52% of U.S. adults were current, former, or never smokers, respectively. Over one quarter (27%) of current smokers were attempting to quit. Current smokers (vs. others) were significantly more likely to be poorer, non-Hispanic White, less educated, ages 45-64, and uninsured, and they had fewer health-conscious behaviors (e.g., influenza vaccination, exercise). Attempting quitters vs. current smokers were significantly less likely to be non-Hispanic White and more likely to be younger, educated, insured, non-obese, with family history of chronic obstructive pulmonary disease, and they had more health-conscious behaviors. Smokers, attempting quitters, and successful quitters differ on characteristics that may be useful for targeting and personalizing interventions aiming to increase cessation attempts, likelihood, and sustainability.
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To understand the concerns and challenges faced by general practitioners (GPs) and respiratory physicians about primary care management of acute exacerbations in patients with chronic obstructive pulmonary disease (COPD). 21 focus group discussions (FGDs) were performed in seven countries with a Grounded Theory approach. Each country performed three rounds of FGDs. Primary and secondary care in Norway, Germany, Wales, Poland, Russia, The Netherlands, China (Hong Kong). 142 GPs and respiratory physicians were chosen to include urban and rural GPs as well as hospital-based and out patient-clinic respiratory physicians. Management of acute COPD exacerbations is dealt with within a scope of concerns. These concerns range from 'dealing with comorbidity' through 'having difficult patients' to 'confronting a hopeless disease'. The first concern displays medical uncertainty regarding diagnosis, medication and hospitalisation. These clinical processes become blurred by comorbidity and the social context of the patient. The second concern shows how patients receive the label 'difficult' exactly because they need complex attention, but even more because they are time consuming, do not take responsibility and are non-compliant. The third concern relates to the emotional reactions by the physicians when confronted with 'a hopeless disease' due to the fact that most of the patients do not improve and the treatment slows down the process at best. GPs and respiratory physicians balance these concerns with medical knowledge and practical, situational knowledge, trying to encompass the complexity of a medical condition. Knowing the patient is essential when dealing with comorbidities as well as with difficult relations in the consultations on exacerbations. This study suggests that it is crucial to improve the collaboration between primary and secondary care, in terms of, for example, shared consultations and defined work tasks, which may enhance shared knowledge of patients, medical decision-making and improved management planning.
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