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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
significant differences in smoking cessation. To show a significant difference of 5% between groups of smokers with AL and NLF with p ⫽ 0.05 and  ⫽ 0.2, the number of smokers in each group should be 603. We suggested in the “Discussion” section that the fact that more smokers with moderate/severe disease as compared to those with mild disease quit smoking might result from more symptoms observed in more advanced disease. We have now looked into our database for more details: 66% of smokers with AL vs 68% of smokers with NLF produced sputum (not significant), and 71% vs 60%, respectively, complained of cough (p ⬍ 0.05). There was also an increasing trend in the phlegm production in more severe disease, but we have not found significant differences in symptoms after stratifying the patients with AL according to disease severity. Our results (10.1% of patients with COPD and 8.4% of those with NLF who remained nonsmoking after 12 months) compare favorably with the results of the Italian study3 (6.5% of smokers offered spirometric testing and counseling quit as compared to 4.5% of control subjects offered minimal intervention), and the Norwegian study4 in male subjects with low lung function resulting in a 5.6% quit rate at 12 months after sending a personalized letter explaining the results of spirometric testing with advice to stop smoking, as compared to 3.5% in control subjects (p ⬍ 0.01) who were not informed about their lung function. We have also found, after additional random telephone screening of smokers who did not attend the follow-up visit, that only smokers with airflow limitation quit smoking (an additional four patients who stopped smoking). Also, smokers with the diagnosis of AL were more successful in reducing the number of cigarettes smoked (five fewer cigarettes per day, p ⬍ 0.05), as compared to smokers without AL (two fewer cigarettes per day, not significant). We believe therefore that the diagnosis of AL motivated smokers to try to quit. Every effort should be made to make people stop smoking. This is especially true for smokers at risk and with early diagnosis of COPD. This issue is now being discussed, in trying to assess the role of spirometric testing in motivating smokers to quit.5– 8 We agree with Dr. Kaminsky and Dr. Marcy that larger studies are needed, including a control group of smokers given stopsmoking advice without spirometry, to assess the cost-effectiveness of spirometry as part of a smoking cessation program. But as Krahn and Chapman7 have quoted, “even modest quit rates attributable to screening spirometry may result in highly favorable cost effectiveness ratios.” Dorota Go´ recka, MD, FCCP Institute of Tuberculosis and Lung Diseases Warsaw, Poland Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: Dorota Go´ recka, MD, FCCP, Professor of Medicine, Institute of Tuberculosis and Lung Diseases, Plocka 26, 01-138 Warsaw, Poland; e-mail: [email protected]
References 1 Gorecka D, Bednarek M, Nowinski A, et al. Diagnosis of airflow limitation combined with smoking cessation advice increases stop-smoking rates. Chest 2003; 123:1916 –1923 2 Czajkowska-Malinowska M, Nowinski A, Go´ recka D, et al. Effects of spirometric screening in the community on smoking cessation [abstract]. Eur Respir J 2001; 18(suppl):117s 3 Segnan N, Ponti A, Battista RN, et al. A randomized trial of smoking cessation interventions in general practice in Italy. Cancer Causes Control 1991; 2:239 –246 4 Humerfelt S, Eide GE, Kvale G, et al. Effectiveness of postal smoking cessation advice: a randomized controlled trial in www.chestjournal.org
5
6
7 8
young men with reduced FEV1 and asbestos exposure. Eur Respir J 1998; 11:284 –290 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 Enright PL, Crapo RO. Controversies in the use of spyrometer for early recognition and diagnosis of chronic obstructive pulmonary disease in cigarette smokers. Clin Chest Med 2002; 21:645– 652 Krahn M, Chapman KR. Economic issues in the use of office spirometry for lung health assessment. Can Respir J 2003; 10:320 –326 Anthonisen NR. Spirometric testing: how much is enough? Can Med Assoc J 1997; 156:202–204
Early Mobilization in Pneumonia To the Editor: Mundy et al1 (September 2003) performed a very welldesigned, group randomized, controlled trial investigating the benefits of early mobilization in patients admitted to the hospital with community acquired-pneumonia. They reported that early mobilization resulted in improved outcomes, specifically a 1.1day decrease in hospital length of stay with a concomitant savings of approximately $1,000 per patient in the intervention group. I want to believe the improvement was due to the intervention, as it would provide a simple but powerful tool to improve my patient’s outcomes. But, alas, I don’t believe it. If one examines Table 2 of this study carefully, one sees that 61% of the control (usual care) group received early mobilization and 73% of the intervention group received early mobilization, for an absolute difference of only 12% or approximately one eighth of the patient population. This means that if the intervention alone was responsible for the outcome differences noted among the entire patient population, then the magnitude of improvement due to the intervention would have to be eight times the improvement noted among the population as a whole. In other words, we would have to believe that early mobilization resulted in an 8.8-day decline in the length of stay and a cost savings of $8,800. The above scenario is unlikely for two reasons. It is not biologically plausible that mobilization could decrease the length of stay more than the average length of stay for communityacquired pneumonia. Furthermore, if the results were this compelling, I would have expected them to have been presented. What then could explain the results that were noted, if they were not due to the intervention? Several were appropriately noted by the authors and in the accompanying editorial. One possible explanation not noted is that the intervention group received their initial antibiotics a mean of 1.2 h quicker than the usual care group. Although not statistically significant, this may have been clinically significant, as a shorter time to initial antibiotics has been associated with improved patient outcomes.2 In conclusion, I believe that early mobilization is likely to benefit some patients with pneumonia; however, I do not believe that this study can be used as evidence of that benefit. Perhaps, if further analysis of the data from this study demonstrated that patients who actually received the intervention did better than those who did not, we would have stronger evidence in support of early mobilization. Mark Metersky, MD, FCCP University of Connecticut School of Medicine Farmington, CT CHEST / 125 / 5 / MAY, 2004
1959
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
significant differences in smoking cessation. To show a significant difference of 5% between groups of smokers with AL and NLF with p ⫽ 0.05 and  ⫽ 0.2, the number of smokers in each group should be 603. We suggested in the “Discussion” section that the fact that more smokers with moderate/severe disease as compared to those with mild disease quit smoking might result from more symptoms observed in more advanced disease. We have now looked into our database for more details: 66% of smokers with AL vs 68% of smokers with NLF produced sputum (not significant), and 71% vs 60%, respectively, complained of cough (p ⬍ 0.05). There was also an increasing trend in the phlegm production in more severe disease, but we have not found significant differences in symptoms after stratifying the patients with AL according to disease severity. Our results (10.1% of patients with COPD and 8.4% of those with NLF who remained nonsmoking after 12 months) compare favorably with the results of the Italian study3 (6.5% of smokers offered spirometric testing and counseling quit as compared to 4.5% of control subjects offered minimal intervention), and the Norwegian study4 in male subjects with low lung function resulting in a 5.6% quit rate at 12 months after sending a personalized letter explaining the results of spirometric testing with advice to stop smoking, as compared to 3.5% in control subjects (p ⬍ 0.01) who were not informed about their lung function. We have also found, after additional random telephone screening of smokers who did not attend the follow-up visit, that only smokers with airflow limitation quit smoking (an additional four patients who stopped smoking). Also, smokers with the diagnosis of AL were more successful in reducing the number of cigarettes smoked (five fewer cigarettes per day, p ⬍ 0.05), as compared to smokers without AL (two fewer cigarettes per day, not significant). We believe therefore that the diagnosis of AL motivated smokers to try to quit. Every effort should be made to make people stop smoking. This is especially true for smokers at risk and with early diagnosis of COPD. This issue is now being discussed, in trying to assess the role of spirometric testing in motivating smokers to quit.5– 8 We agree with Dr. Kaminsky and Dr. Marcy that larger studies are needed, including a control group of smokers given stopsmoking advice without spirometry, to assess the cost-effectiveness of spirometry as part of a smoking cessation program. But as Krahn and Chapman7 have quoted, “even modest quit rates attributable to screening spirometry may result in highly favorable cost effectiveness ratios.” Dorota Go´ recka, MD, FCCP Institute of Tuberculosis and Lung Diseases Warsaw, Poland Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: Dorota Go´ recka, MD, FCCP, Professor of Medicine, Institute of Tuberculosis and Lung Diseases, Plocka 26, 01-138 Warsaw, Poland; e-mail: [email protected]
References 1 Gorecka D, Bednarek M, Nowinski A, et al. Diagnosis of airflow limitation combined with smoking cessation advice increases stop-smoking rates. Chest 2003; 123:1916 –1923 2 Czajkowska-Malinowska M, Nowinski A, Go´ recka D, et al. Effects of spirometric screening in the community on smoking cessation [abstract]. Eur Respir J 2001; 18(suppl):117s 3 Segnan N, Ponti A, Battista RN, et al. A randomized trial of smoking cessation interventions in general practice in Italy. Cancer Causes Control 1991; 2:239 –246 4 Humerfelt S, Eide GE, Kvale G, et al. Effectiveness of postal smoking cessation advice: a randomized controlled trial in www.chestjournal.org
5
6
7 8
young men with reduced FEV1 and asbestos exposure. Eur Respir J 1998; 11:284 –290 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 Enright PL, Crapo RO. Controversies in the use of spyrometer for early recognition and diagnosis of chronic obstructive pulmonary disease in cigarette smokers. Clin Chest Med 2002; 21:645– 652 Krahn M, Chapman KR. Economic issues in the use of office spirometry for lung health assessment. Can Respir J 2003; 10:320 –326 Anthonisen NR. Spirometric testing: how much is enough? Can Med Assoc J 1997; 156:202–204
Early Mobilization in Pneumonia To the Editor: Mundy et al1 (September 2003) performed a very welldesigned, group randomized, controlled trial investigating the benefits of early mobilization in patients admitted to the hospital with community acquired-pneumonia. They reported that early mobilization resulted in improved outcomes, specifically a 1.1day decrease in hospital length of stay with a concomitant savings of approximately $1,000 per patient in the intervention group. I want to believe the improvement was due to the intervention, as it would provide a simple but powerful tool to improve my patient’s outcomes. But, alas, I don’t believe it. If one examines Table 2 of this study carefully, one sees that 61% of the control (usual care) group received early mobilization and 73% of the intervention group received early mobilization, for an absolute difference of only 12% or approximately one eighth of the patient population. This means that if the intervention alone was responsible for the outcome differences noted among the entire patient population, then the magnitude of improvement due to the intervention would have to be eight times the improvement noted among the population as a whole. In other words, we would have to believe that early mobilization resulted in an 8.8-day decline in the length of stay and a cost savings of $8,800. The above scenario is unlikely for two reasons. It is not biologically plausible that mobilization could decrease the length of stay more than the average length of stay for communityacquired pneumonia. Furthermore, if the results were this compelling, I would have expected them to have been presented. What then could explain the results that were noted, if they were not due to the intervention? Several were appropriately noted by the authors and in the accompanying editorial. One possible explanation not noted is that the intervention group received their initial antibiotics a mean of 1.2 h quicker than the usual care group. Although not statistically significant, this may have been clinically significant, as a shorter time to initial antibiotics has been associated with improved patient outcomes.2 In conclusion, I believe that early mobilization is likely to benefit some patients with pneumonia; however, I do not believe that this study can be used as evidence of that benefit. Perhaps, if further analysis of the data from this study demonstrated that patients who actually received the intervention did better than those who did not, we would have stronger evidence in support of early mobilization. Mark Metersky, MD, FCCP University of Connecticut School of Medicine Farmington, CT CHEST / 125 / 5 / MAY, 2004
1959