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CME

Lung Age May Motivate Smokers to Quit Smoking

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Charles Vega, MD
  • CME Released: 3/12/2008
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 3/12/2009
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Target Audience and Goal Statement

This article is intended for primary care clinicians, pulmonary medicine specialists, and other specialists who care for patients who smoke.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe epidemiologic factors associated with smoking and chronic obstructive pulmonary disease.
  2. Identify the efficacy of measuring and communicating lung age to smokers.


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Author(s)

  • Laurie Barclay, MD

    Laurie Barclay, MD, is a freelance reviewer and writer for Medscape.

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Editor(s)

  • Brande Nicole Martin

    Brande Nicole Martin is the News CME editor for Medscape Medical News.

    Disclosures

    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Charles P Vega, MD

    Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine

    Disclosures

    Disclosure: Charles Vega, MD, has disclosed an advisor/consultant relationship to Novartis, Inc.


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CME

Lung Age May Motivate Smokers to Quit Smoking

Authors: News Author: Laurie Barclay, MD CME Author: Charles Vega, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME Released: 3/12/2008

Valid for credit through: 3/12/2009

processing....

March 12, 2008 — Telling patients their lung age, or the age of the average healthy person with similar lung function to theirs, was an incentive for smokers to quit smoking and may be a strategy for general practitioners to use, according to the results of the Step2quit randomized controlled trial reported in the March 7 Online First issue of the BMJ.

"Early diagnosis of chronic obstructive pulmonary disease [COPD] with communication of lung damage to patients could improve targeting of smoking cessation programmes and improve quit rates in individuals most vulnerable to lung damage," write Gary Parkes, MD, general practitioner, from the The Limes Surgery in Hoddesdon, Hertfordshire, United Kingdom, and colleagues. "The concept of 'lung age' (the age of the average person who has an FEV1 [forced expiratory volume in 1 second] equal to the individual) was developed in 1985 as a way of making spirometry data easier to understand and also as a potential psychological tool to show smokers the apparent premature ageing of their lungs. We tested the hypothesis that telling smokers their lung age would lead to successful smoking cessation, especially in those with most damage."

At 5 general practices in Hertfordshire, England, 561 current smokers 35 years and older were offered spirometry to evaluate lung function. In the intervention group, participants received their results in terms of lung age, or the age of the average healthy individual who would perform similar to them on spirometry. In the control group, participants received a raw figure for FEV1. Both groups were counseled to stop smoking and were offered referral to local National Health Services smoking cessation services.

The main endpoint was verified cessation of smoking by salivary cotinine testing 12 months after recruitment, and secondary endpoints were reported changes in number of cigarettes smoked daily and in identification of new diagnoses of chronic obstructive lung disease. The follow-up rate was 89%.

At 12 months, independently verified quit rates were 13.6% in the intervention group and 6.4% in the control group (difference, 7.2%; P = .005; 95% confidence interval, 2.2% - 12.1%; number needed to treat, 14). Participants with higher spirometric lung age were no more likely to have quit than those with normal lung age in either the intervention group or the control group.

Cost per successful quitter was estimated to be £280 (€366, $US 556). A total of 16% of participants (89/561) received a new diagnosis of obstructive lung disease (17% in the intervention group and 14% in the control group).

"Telling smokers their lung age significantly improves the likelihood of them quitting smoking, but the mechanism by which this intervention achieves its effect is unclear," the study authors write. "Presentation of information in an understandable and visual way, whether the news is positive or negative, seems to encourage higher levels of successful smoking cessation than when patients are given feedback that is not easily understandable.... Given the heavy health and economic burden of smoking, we believe that formal economic evaluation of this new and simple intervention should be a research priority."

The Health Foundation funded this study. The authors have disclosed no relevant financial relationships.

In an accompanying editorial, Raphaël Bize, MD, and Jacques Cornuz, MD, MPH, from the University of Lausanne in Switzerland, note that this study did not look at the potential health benefit of screening for COPD because all participants underwent spirometry testing. Other limitations include the lack of data about the comparability of the study sample with the entire recruitment population, the longer duration of contact between participants and caregivers in the intervention group than in the control group, and outcome data limited to point-prevalence abstinence.

"On the basis of the evidence so far, general practitioners have to decide whether to wait for a trial comparing the potential benefit for smoking cessation of spirometry testing using lung age feedback versus no spirometry testing or whether to adopt the strategy suggested by Parkes and colleagues," Drs. Bize and Comuz write. "Despite these limitations, however, providing feedback on lung age with graphic displays seems to be the best option so far for communicating the results of spirometry. This strategy might also be an opportunity for general practitioners to tailor smoking cessation messages to the individual, as recommended in the recent National Institute for Health and Clinical Excellence (NICE) guidance on smoking cessation."

Drs. Bize and Comuz have disclosed no relevant financial relationships.

BMJ. Published online March 8, 2008.

Clinical Context

Approximately one quarter of smokers can expect to develop COPD, but this figure may under-represent the true cost of smoking in terms of lung function. In the United Kingdom, half of the individuals who meet criteria for COPD are undiagnosed, and the mean duration from the onset of COPD to clinical diagnosis can be as high as 20 years. Spirometry can generally detect lung damage after 20 pack-years of smoking.

While COPD is an important public health concern, it remains unclear whether objective measures of pulmonary function can be used to help patients quit smoking. The current article uses a randomized controlled design to test this hypothesis.

Study Highlights

  • Study subjects included smokers in 1 of 4 general practices in England. All participants were 35 years or older. Patients receiving oxygen and those with lung disease other than COPD were excluded from study participation.
  • All participants underwent a baseline medical history interview and spirometry.
  • Lung age was calculated as the relative decrease in FEV1 values in study individuals compared with predicted levels for their age.
  • Subjects were randomized to an intervention or control group. Those in the intervention group were told that their spirometry results were normal if their lung age matched their chronological age. However, they were informed with counseling and graphically of how their lungs were aging prematurely if their lung age was higher than their chronological age. Subjects in the control group were not informed of their lung age.
  • The main study outcome was smoking cessation at 12 months after the initial examination. Smoking cessation was verified with measurements of exhaled carbon monoxide and cotinine levels in the saliva. The number of daily cigarettes consumed and the incidence of new diagnoses were secondary outcomes.
  • 561 participants were recruited for the study. The mean age of the entire cohort was 53 years, and the mean FEV1/force vital capacity was 74%. The mean number of cigarettes consumed daily was 17.4 in the intervention group and 16.5 in the control group.
  • 20% of all subjects had other significant comorbid conditions. Baseline characteristics were similar between treatment groups, although the rate of stroke was 4.2% in the control group vs 0.8% in the intervention group.
  • Most subjects in both groups were not actively preparing to quit smoking at the time of study entry.
  • According to British Thoracic Society cutoff values, the rates of abnormal lung function were 23.5% and 26.8% in the control and intervention groups, respectively.
  • Quit rates at 12 months were 13.6% and 6.4% in the intervention and control groups, respectively. This result was statistically significant and translated into a number needed to treat to produce 1 extra quitter of 14. There was no difference between study groups in the use of other treatments to aid quitting.
  • There was no evidence that the degree of lung age deficit influenced the superiority of the intervention over control treatment. Lung age, whether normal or abnormal, helped smokers quit.
  • The average number of cigarettes consumed daily decreased in both groups, but to a greater mean level in the intervention (11.7 cigarettes) vs control (13.7 cigarettes) cohorts.
  • The authors estimated that their intervention cost approximately ₤20 per patient, translating to a cost of ₤280 per subject who quit smoking.
  • The incidence of a new diagnosis of COPD at 12 months was 17% in the intervention group and 14% in the control group.

Pearls for Practice

  • COPD affects approximately one quarter of smokers but may be undiagnosed in half of patients. While patients with a 20 pack-year history of smoking have evidence of COPD on spirometry, the delay in diagnosis of COPD from its incipient stages can be 20 years.
  • The current study finds that informing smokers of their lung age can improve the mean quantity of cigarettes smoked as well as smoking cessation rates at 12 months, but there was no evidence of an improvement in the incidence of COPD.

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