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COPD and Smoking Cessation Motivation
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COPD and Smoking Cessation Motivation To the Editor: As pulmonologists interested in detecting early airways disease and helping our patients stop smoking, we are enthusiastic about the publication of the consensus statement on office spirometry by the National Lung Health Education Program in 2000.1 However, the pulmonary community has yet to see convincing evidence that screening of smokers at high risk of COPD will enhance smoking cessation.2 The recent publication by Gorecka and colleagues (June 2003)3 is pertinent to this issue, but we have concerns about the interpretation of this study. These authors prospectively assessed the effects of voluntary participation in a spirometry screening and smoking intervention program in smokers. Those smokers who had moderate and severe airflow limitation on spirometric screening were more likely to have quit smoking when contacted 1 year later, compared to those with mild or no airflow limitation. The authors concluded that “the diagnosis of airflow limitation motivated smokers to attempt to quit smoking.” However, there is no direct evidence that the spirometric results, per se, influenced the smokers. Rather, low lung function was a predictor of success in smoking cessation, and simply may have served as a marker of those smokers with more severe symptoms, as the authors do acknowledge. In addition, the title of the study is misleading because it implies that the diagnosis of airflow limitation of any degree increased the smoking cessation rate, when in fact the cessation rates of the two groups (normal lung function and airflow limitation) were not statistically different. Only the subgroup of individuals with moderate and severe airflow limitation had increased smoking cessation rates. Furthermore, this study did not test the hypothesis that spirometry would enhance smoking cessation because there was no control group that did not receive spirometric testing or, at least, did not have their spirometric findings used in the smoking cessation intervention. There are good reasons to perform screening spirometry in middle-aged persons with a smoking history,1 and we applaud Gorecka and colleagues3 from Poland on their work in population 1958
screening. However, we still need well-designed trials to determine whether and how we should use screening spirometry specifically for the purpose of encouraging smoking cessation. Unfortunately, prior randomized controlled trials of other types of biofeedback (eg, genetic testing) have not improved cessation rates.4,5 David A. Kaminsky, MD, FCCP Theodore W. Marcy, MD, MPH, FCCP University of Vermont College of Medicine Burlington, VT Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: David A. Kaminsky, MD, FCCP, Pulmonary Disease-Critical Care, University of Vermont, Given C-317, Burlington, VT 05405; e-mail: [email protected]
References 1 Ferguson GT, Enright PL, Buist AS, et al. Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program. Chest 2000; 117:1146 –1161 2 Enright PL, Crapo RO. Controversies in the use of spirometry for early recognition and diagnosis of chronic obstructive pulmonary disease in cigarette smokers. Clin Chest Med 2000; 21:645– 652 3 Gorecka D, Bednarek M, Nowinski A, et al. Diagnosis of airflow limitation combined with smoking cessation advice increases stop-smoking rate. Chest 2003; 123:1916 –1923 4 Lerman C, Gold K, Audrain J, et al. Incorporating biomarkers of exposure and genetic susceptibility into smoking cessation treatment: effects on smoking-related cognitions, emotions, and behavior change. Health Psychol 1997; 16:87–99 5 McBride C, Bepler G, Lipkus I, et al. Incorporating genetic susceptibility feedback into a smoking cessation program for African-American smokers with low income. Cancer Epidemiol Biomarkers Prev 2002; 11:521–528 To the Editor: We appreciate the comments of Dr. Kaminsky and Dr. Marcy regarding our study (June 2003).1 We agree that our study has limitations: it was not a randomized, controlled trial. But our goal was not to assess the value of spirometric testing in making people stop smoking. We rather wanted to see if the diagnosis of airflow limitation (AL) made at the time of spirometric screening of middle-aged smokers for COPD, when combined with a doctor’s stop-smoking advice, influenced the cessation rate. We offered every smoker advice to stop smoking while explaining the results of the spirometric test. In our study, the overall difference in the smoking cessation rate between those with abnormal lung function and those with normal lung function (NLF) was very small (1.7%). However, there were significant differences in cessation rates of smokers with moderate/severe disease (16.5%) as compared to those with mild disease (6.4%, p ⬍ 0.001) and smokers with NLF (8.4%, p ⬍ 0.05). In another Polish study,2 the differences between cessation rates in smokers with AL (15%) and those with NLF (4.5%) were more pronounced. It seems that our study was underpowered to show statistically Communications to the Editor
COPD and Smoking Cessation Motivation To the Editor: As pulmonologists interested in detecting early airways disease and helping our patients stop smoking, we are enthusiastic about the publication of the consensus statement on office spirometry by the National Lung Health Education Program in 2000.1 However, the pulmonary community has yet to see convincing evidence that screening of smokers at high risk of COPD will enhance smoking cessation.2 The recent publication by Gorecka and colleagues (June 2003)3 is pertinent to this issue, but we have concerns about the interpretation of this study. These authors prospectively assessed the effects of voluntary participation in a spirometry screening and smoking intervention program in smokers. Those smokers who had moderate and severe airflow limitation on spirometric screening were more likely to have quit smoking when contacted 1 year later, compared to those with mild or no airflow limitation. The authors concluded that “the diagnosis of airflow limitation motivated smokers to attempt to quit smoking.” However, there is no direct evidence that the spirometric results, per se, influenced the smokers. Rather, low lung function was a predictor of success in smoking cessation, and simply may have served as a marker of those smokers with more severe symptoms, as the authors do acknowledge. In addition, the title of the study is misleading because it implies that the diagnosis of airflow limitation of any degree increased the smoking cessation rate, when in fact the cessation rates of the two groups (normal lung function and airflow limitation) were not statistically different. Only the subgroup of individuals with moderate and severe airflow limitation had increased smoking cessation rates. Furthermore, this study did not test the hypothesis that spirometry would enhance smoking cessation because there was no control group that did not receive spirometric testing or, at least, did not have their spirometric findings used in the smoking cessation intervention. There are good reasons to perform screening spirometry in middle-aged persons with a smoking history,1 and we applaud Gorecka and colleagues3 from Poland on their work in population 1958
screening. However, we still need well-designed trials to determine whether and how we should use screening spirometry specifically for the purpose of encouraging smoking cessation. Unfortunately, prior randomized controlled trials of other types of biofeedback (eg, genetic testing) have not improved cessation rates.4,5 David A. Kaminsky, MD, FCCP Theodore W. Marcy, MD, MPH, FCCP University of Vermont College of Medicine Burlington, VT Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: David A. Kaminsky, MD, FCCP, Pulmonary Disease-Critical Care, University of Vermont, Given C-317, Burlington, VT 05405; e-mail: [email protected]
References 1 Ferguson GT, Enright PL, Buist AS, et al. Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program. Chest 2000; 117:1146 –1161 2 Enright PL, Crapo RO. Controversies in the use of spirometry for early recognition and diagnosis of chronic obstructive pulmonary disease in cigarette smokers. Clin Chest Med 2000; 21:645– 652 3 Gorecka D, Bednarek M, Nowinski A, et al. Diagnosis of airflow limitation combined with smoking cessation advice increases stop-smoking rate. Chest 2003; 123:1916 –1923 4 Lerman C, Gold K, Audrain J, et al. Incorporating biomarkers of exposure and genetic susceptibility into smoking cessation treatment: effects on smoking-related cognitions, emotions, and behavior change. Health Psychol 1997; 16:87–99 5 McBride C, Bepler G, Lipkus I, et al. Incorporating genetic susceptibility feedback into a smoking cessation program for African-American smokers with low income. Cancer Epidemiol Biomarkers Prev 2002; 11:521–528 To the Editor: We appreciate the comments of Dr. Kaminsky and Dr. Marcy regarding our study (June 2003).1 We agree that our study has limitations: it was not a randomized, controlled trial. But our goal was not to assess the value of spirometric testing in making people stop smoking. We rather wanted to see if the diagnosis of airflow limitation (AL) made at the time of spirometric screening of middle-aged smokers for COPD, when combined with a doctor’s stop-smoking advice, influenced the cessation rate. We offered every smoker advice to stop smoking while explaining the results of the spirometric test. In our study, the overall difference in the smoking cessation rate between those with abnormal lung function and those with normal lung function (NLF) was very small (1.7%). However, there were significant differences in cessation rates of smokers with moderate/severe disease (16.5%) as compared to those with mild disease (6.4%, p ⬍ 0.001) and smokers with NLF (8.4%, p ⬍ 0.05). In another Polish study,2 the differences between cessation rates in smokers with AL (15%) and those with NLF (4.5%) were more pronounced. It seems that our study was underpowered to show statistically Communications to the Editor