James Friend

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Tobacco smoking is the single most important cause of chronic obstructive pulmonary disease (COPD), and smoking cessation is the most important measure in improving the long-term outlook for people with COPD.

What good does stopping smoking do?

The damage that smoking does to health is well known. It is estimated that someone who smokes 20 cigarettes a day during adult life has a 50% likelihood of dying of a smoker's disease, with an average loss of life expectancy of 8 years, or up to 11min of life lost per cigarette smoked. The three major smokers' diseases include lung cancer, now the commonest cause of cancer deaths in the UK in both men and women; ischaemic heart disease; and COPD. On top of all this, a range of other malignancies and vascular diseases are commoner in smokers, and together all these diseases account for about 120000 UK deaths per year in a population of 55 million—the biggest preventable cause of ill-health and death.

Most people know and accept that smoking does some harm to health, but the level of risk is not usually known or acknowledged. There is a tendency for smokers to feel that the risks of smoking may not be very large, and that the consequences are likely to be far in the future, and in any case, 'the damage has probably been done'. Health advisers have a responsibility to explain to smokers that the risks are considerable, that many of the diseases are often prolonged, disabling and miserable (and here COPD is pre-eminent) and that the benefits of stopping smoking are quick and important.

In the case of COPD, the average loss of forced expiratory volume in one second is 50-80 mL per year. However, people with COPD who stopped smoking in the Lung Health Study [1] showed an average increase of forced expiratory volume in 1s (FEV1) of 57mL in the first year. Over 5 years, a person with COPD who stopped smoking had an average decline in FEV1 of 34 mL per year, which is very similar to the 'normal' decline in FEV1 in lifelong non-smokers as a result of ageing. In other words, there is good evidence to be able to say to smokers with COPD, 'If you stop smoking now, not only will your lung function stop getting rapidly worse, but there may be a small improvement in your lungs; and there is a good chance that you will live longer.'

Within 1-2 years of stopping smoking, the excess risk of death from heart disease is halved, and after 15 years, reaches almost the level of lifelong non-smokers. On top of this, smokers who stop smoking reduce their risk of developing lung cancer to 30-50% of that of continuing smokers within 10 years of stopping. Similar benefits accrue in terms of the risks of many of the other smokers' diseases. The health benefits of stopping smoking are not in doubt, and the financial benefits can be substantial—for example, in the UK in 2001, the average 20-a-day smoker spends over £1500 every year on cigarettes.

Finding out about smokers and their smoking—ask!

A careful smoking history is essential to a full understanding of smokers in deciding which approach is most likely to help them to stop smoking. The smoking history is as important a part of the history as the patient's name and age, or the presenting symptoms, or the recording of vital signs. After the first question, 'Do you smoke?' it is also essential to add, for those who say 'No', 'Have you ever been a smoker?' We have all come across clinical records which record 'non-smoker' for a patient who stopped smoking only weeks or days ago.

The next part of the smoking history is to gauge the lifetime dose of tobacco smoke and some idea of smoking behaviour. The following questions may also give an idea of lifetime habits and 'dose':

• 'How old were you when you started smoking?'

• 'How many cigarettes a day have you smoked on average over the years?'

In the USA, it is common to estimate cigarette smoke consumption in 'pack-years', assuming a pack to contain 20 cigarettes. The calculation is simply made by multiplying the number of packs smoked per day by the number of years smoked; so to smoke a pack a day for 10years makes for a 10 pack-year smoker, and 30 cigarettes (one and a half packs) a day for 30 years would be a 45 pack-year smoker.

Another area of enquiry relates to how well the smoker manages without nicotine doses, to gain some idea of the level of dependence on nicotine. Various measures have been developed for this, including the Fagerstrom Test for Nicotine Dependence (FTND) [2], in which the subject is asked the series of questions shown in Table 8.1). Many other scales and questionnaires have also been developed. However, in practice, asking about the number of cigarettes smoked each day and the time to the first cigarette probably give a simple idea of the level of dependence.

Table 8.1 The Fagerstrom Test for Nicotine Dependence (FTND) [2], in which the subject is asked a series of questions. A score of 6 or more on this scale is usually considered to represent high nicotine dependency.

Question Answer Score

Table 8.1 The Fagerstrom Test for Nicotine Dependence (FTND) [2], in which the subject is asked a series of questions. A score of 6 or more on this scale is usually considered to represent high nicotine dependency.

Question Answer Score

How soon after you wake up do you have your

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