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Smoking and the Asthma Patient

The RT’s challenge: educate the 25% of adults with asthma who also smoke.

Don't smoke! Everyone knows it's bad for you, but respiratory therapists still encounter many asthma patients who smoke or expose their loved ones to dangerous second-hand smoke. This article, appearing in AARC Times, while containing some medical terminology, may alert you to the importance of tobacco avoidance as an asthma sufferer.
Editor

In my early years in respiratory therapy it never occurred to me how self-inflicted triggers were so significant in patients with asthma. I had assumed that most smokers did not already have a chronic lung disease—because they certainly would not want to damage their lungs any more than they already were. Right? Wrong! I soon found out that nothing could be further from the truth. More to the point, cigarette smoking (whether it is firsthand or secondhand) is dangerous for all people but is even more so for those with asthma. Secondhand smoke inhalation presents its own reason for us to be concerned for patients with asthma. There is nothing more disheartening than to see a car with children in the back seat while adults are smoking cigarettes in the front seat. It doesn’t matter whether the child has asthma or not. Of course, in this situation the child with asthma is forced to endure a potentially deadly trigger.

Living in self-denial
The relationship between patients with asthma and smoking is even more astounding when you consider that a large proportion of patients with asthma smoke themselves. It is estimated that in developed countries, 25% of adults with asthma are current cigarette smokers.1 This is an interesting statistic because it differs little with the proportion of smokers in the general population at large in the United States. Also, there is no difference between those with and without asthma as it relates to the age of smoking initiation in the adolescent.2 This is noteworthy because this age group is one that large numbers of patients with asthma inhabit. Perhaps an opportunity for intervention lies within.

The first place a patient with asthma will go to if an exacerbation cannot be managed at home will be to the local emergency department. A recent multi-center study by Silverman et al noted that in 64 emergency departments 35% of asthmatic admissions were acknowledged smokers. Astoundingly, 50% of them stated they understood that smoking worsened their condition but smoked anyway.3 This is incredible self-denial.

Making matters worse
While one would think that with an acute respiratory disease like asthma, a patient would not want to make their condition any worse by smoking, in fact, that is exactly what happens.

Smoking cigarettes may actually modify the inflammatory process to the point that there may be corticosteroid resistance, which ultimately will interfere with the very medications that serve to prevent symptoms of the disease.4 This interaction is just now being understood, and it is speculated that it could be due to alterations in airway inflammatory cell phenotypes, changes in glucocorticoid receptor alpha to beta ratio, and reduced histone deacetylase activity. Smoking also can increase the clearance of drugs such as theophylline by induction of metabolizing enzymes.5 The symptoms that smokers with asthma exhibit are realized with daily respiratory sequela, primarily that of sputum production with nocturnal shortness of breath and wheezing.6 As we learn more about this relationship, there may be a need to evaluate other means of inflammatory control. But the best remedy is to stop smoking. Smoking cessation may actually serve to restore corticosteroid responsiveness in asthmatic ex-smokers.

Particularly troubling is the teenage smoker with asthma. Making it even more of a challenge is the fact that this is a difficult age group to influence. Studies have shown that it may be easier for teenaged girls (as compared to boys) to quit smoking as they are often more concerned with image and appearance. In large part, there needs to be a motivating factor.7 Of particular concern is that this is also the age when most lifelong smokers start their habit: teenagers’ smoking initiation starts early. A study by Robinson et al found that initial smoking occurred at a mean age of less then 12 years and daily smoking at age 13 years.8 The reasons for starting were the same whether or not the child had asthma. This is an age group that is in need of targeted smoking-cessation intervention.

Motivating our patients
While smoking is certainly dangerous for all (whether primary or secondary), once hooked, smoking cessation is the only viable alternative. This is certainly a role that respiratory therapists can play, whether it is in the hospital or in the community. Our influence can potentially make a difference to smokers who wish to stop smoking and until they do so are at risk for worsening symptoms. We should never assume that patients with chronic lung disease will withstand the temptation to keep on smoking. We need to provide them with reasons why they should stop and the necessary help along the way. •

References

1. 1. Thomson NC, Chaudhuri R, Livingston E. Asthma and cigarette smoking. Eur Respir J 2004; 24(5):822-833.
2. 2. Zimmerman DM, Sehnert SS, Epstein DH, et al. Smoking topography and trajectory of asthmatic adolescents requesting cessation treatment. Prev Med 2004; 39(5):940-942.
3. 3. Silverman RA, Boudreaux ED, Woodruff PG, et al. Cigarette smoking among asthmatic adults presenting to 64 emergency departments. Chest 2003; 123(5):1472-1479.
   4. Livingston E, Thomson NC, Chalmers GW. Impact of smoking on asthma therapy: a critical review of clinical evidence. Drugs 2005; 65(11):1521-1536.
4. 5. Thompson NC, Spears M. The influence of smoking on the treatment response in patients with asthma. Curr Opin Allergy Clin Immunol 2005; 5(1):57-63.
5. 6. Suzuki K, Tanaka H, Kaneko S, et al. Respiratory symptoms and cigarette smoking in 3,197 pulmonologist-based asthmatic patients with a highly prevalent use of inhaled corticosteroid. J Asthma 2003; 40(3):243-250.
6. 7. Turner LR, Mermelstein R. Motivation and reasons to quit: predictive validity among adolescent smokers. Am J Health Behav 2004; 28(6):542-550.
7. 8. Robinson ML, Berlin I, Moolchan ET. Tobacco smoking trajectory and associated ethnic differences among adolescent smokers seeking cessation treatment. J Adolesc Health. 2004; 35(3):217-224.

Smoking may actually modify the inflammatory process and cause corticosteroid resistance, which ultimately will interfere with the medications that prevent disease symptoms.

About the Author
Thomas J. Kallstrom, BS, RRT, AE-C, FAARC, is associate executive director and chief operating officer of the AARC. He is also a member of the NAEPP Coordinating Committee and is a certified asthma educator.