Impact of smoking on asthma symptoms, healthcare resource use, and quality of life outcomes in adults with persistent asthma

The clinical characteristics of patients with asthma exposed to different environmental risk factors: A cross-sectional study

BACKGROUND

Smoking, biomass, and occupational exposure are the main environmental risk factors for asthma. The purpose of this study was to analyze the clinical characteristics of exposure to these risk factors in patients with asthma.

METHODS

This cross-sectional study enrolled patients with asthma from an outpatient department according to the Global Initiative for Asthma. Demographics, forced expiratory volume in 1 s (FEV1), FEV1%pred, FEV1/forced vital capacity (FVC), laboratory tests, asthma control test (ACT), asthma control questionnaire (ACQ) scores, and the inhaled corticosteroid (ICS) dose were recorded. A generalized linear mixed model was used to adjust for potential confounders.

RESULTS

A total of 492 patients with asthma were included in this study. Of these patients, 13.0% were current smokers, 9.6% were former smokers, and 77.4% were never smokers. Compared with never smokers, the current and former smokers had a longer duration of asthma; lower ACT scores, FEV1, FEV1%pred, and FEV1/FVC; and higher ACQ scores, IgE, FeNO, blood eosinophils, and ICS dose (p < .05). In addition, the patients exposed to biomass alone were older; had higher exacerbation in the past year; a longer duration of asthma; and lower FEV1, FEV1%pred, FEV1/FVC, IgE, and FeNO compared with smoking or occupational exposure alone. Compared with smoking exposure alone, patients with occupational exposure alone had a longer duration of asthma and lower FEV1, FEV1%pred, FVC, IgE, FeNO, and ICS dose (p < .05).

CONCLUSIONS

There are significant differences in the clinical characteristics of patients with asthma depending on the smoking status. In addition, significant differences also observed among smoking, biomass, and occupational exposure.

Different clinical characteristics of current smokers and former smokers with asthma: a cross-sectional study of adult asthma patients in China

Smoking is a trigger for asthma, which has led to an increase in asthma incidence in China. In smokers, asthma management starts with smoking cessation. Data on predictors of smoking cessation in Chinese patients with asthma are scarce. The objective of this study was to find the differences in clinical characteristics between current smokers and former smokers with asthma in order to identify factors associated with smoking cessation. Eligible adults with diagnosed asthma and smoking from the hospital outpatient clinics (n = 2312) were enrolled and underwent a clinical evaluation, asthma control test (ACT), and pulmonary function test. Information on demographic and sociological data, lung function, laboratory tests, ACT and asthma control questionnaire (ACQ) scores was recorded. Patients were divided into a current smokers group and a former smokers group based on whether they had quit smoking. Logistic regression analysis was used to analyze the factors associated with smoking cessation. Of all patients with asthma, 34.6% were smokers and 65.4% were former smokers, and the mean age was 54.5 ± 11.5 years. Compared with current smokers, the former smokers were older, had longer duration of asthma, had higher ICS dose, had more partially controlled and uncontrolled asthma, had more pack-years, had smoked for longer, and had worse asthma control. The logistic regression model showed that smoking cessation was positively correlated with age, female sex, pack-years, years of smoking, partially controlled asthma, uncontrolled asthma, and body mass index (BMI), but was negatively correlated with ACT, FEV1, FEV1%predicted, and widowed status. More than 30% of asthma patients in the study were still smoking. Among those who quit smoking, many quit late, often not realizing they need to quit until they have significant breathing difficulties. The related factors of smoking cessation identified in this study indicate that there are still differences between continuing smokers and former smokers, and these factors should be focused on in asthma smoking cessation interventions to improve the prognosis of patients with asthma.

Exposome Profiles and Asthma among French Adults

Rationale: Although previous studies in environmental epidemiology focused on single or a few exposures, a holistic approach combining multiple preventable risk factors is needed to tackle the etiology of multifactorial diseases such as asthma. Objectives: To investigate the association between combined socioeconomic, external environment, early-life environment, and lifestyle-anthropometric factors and asthma phenotypes. Methods: A total of 20,833 adults from the French NutriNet-Santé cohort were included (mean age, 56.2 yr; SD, 13.2; 72% women). The validated asthma symptom score (continuous) and asthma control (never asthma, controlled asthma, and uncontrolled asthma) were considered. The exposome (n = 87 factors) covered four domains: socioeconomic, external environment, early-life environment, and lifestyle-anthropometric. Cluster-based analyses were performed within each exposome domain, and the identified profiles were studied in association to asthma outcomes in negative binomial (asthma symptom score) or multinomial logistic (asthma control) regression models. Measurements and Main Results: In total, 5,546 (27%) individuals had an asthma symptom score ⩾1, and 1,206 (6%) and 194 (1%) had controlled and uncontrolled asthma, respectively. Three early-life exposure profiles ("high passive smoking-own dogs," "poor birth parameters-daycare attendance-city center," or "⩾2 siblings-breastfed" compared with "farm-pet owner-molds-low passive smoking") and one lifestyle-anthropometric profile ("unhealthy diet-high smoking-overweight" compared with "healthy diet-nonsmoker-thin") were associated with more asthma symptoms and uncontrolled asthma. Conclusions: This large-scale exposome-based study revealed early-life and lifestyle exposure profiles that were at risk for asthma in adults. Our findings support the importance of multiinterventional programs for the primary and secondary prevention of asthma, including control of specific early-life risk factors and promotion of a healthy lifestyle in adulthood.

The Impact of Tobacco Smoking on Adult Asthma Outcomes

Background: Tobacco smoking is associated with more severe asthma symptoms, an accelerated decline in lung function, and reduced responses to corticosteroids. Our objective was to compare asthma outcomes in terms of disease control, exacerbation rates, and lung function in a population of asthmatic patients according to their smoking status. Methods: We compared patients’ demographics, disease characteristics, and lung-function parameters in current-smokers (CS, n = 48), former-smokers (FS, n = 38), and never-smokers (NS, n = 90), and identified predictive factors for asthma control. Results: CS had a higher prevalence of family asthma/atopy, a lower rate of controlled asthma, impaired perception of dyspnea, an increased number of exacerbations, and poorer lung function compared to NS. The mean asthma control questionnaire’s (ACQ) score was higher in CS vs. NS and FS (1.9 vs. 1.2, p = 0.02). Compared to CS, FS had a lower rate of exacerbations, a better ACQ score (similar to NS), a higher prevalence of dyspnea, and greater lung-diffusion capacity. Non-smoking status, the absence of dyspnea and exacerbations, and a forced expiratory volume in one second ≥80% of predicted were associated with controlled asthma. Conclusions: CS with asthma exhibit worse clinical and functional respiratory outcomes compared to NS and FS, supporting the importance of smoking cessation in this population.

[Asthma 2020 Nursing Consensus Document]

Asthma is a chronic respiratory disease which presents with a risk of exacerbations. Good patient management and continuous monitoring are crucial for good disease control, and pharmacological and non-pharmacological interventions are essential for proper treatment. Nurses specialised in asthma can contribute to the correct management of asthmatic patients. They play a key role in diagnostic tests, administration of medication, and patient follow-up and education. This consensus arose from the need to address an aspect of asthma management that does not appear in the specific recommendations of current guidelines. This document highlights and updates the role of specialized nurses in the care and management of asthma patients, offering conclusions and practical recommendations with the aim of improving their contribution to the treatment of this disease. Proposed recommendations appear as the result of a nominal consensus which was developed during 2019, and validated at the beginning of 2020.

Impact of Air Pollution on Asthma Outcomes

Asthma is a chronic respiratory disease characterized by variable airflow obstruction, bronchial hyperresponsiveness, and airway inflammation. Evidence suggests that air pollution has a negative impact on asthma outcomes in both adult and pediatric populations. The aim of this review is to summarize the current knowledge on the effect of various outdoor and indoor pollutants on asthma outcomes, their burden on its management, as well as to highlight the measures that could result in improved asthma outcomes. Traffic-related air pollution, nitrogen dioxide and second-hand smoking (SHS) exposures represent significant risk factors for asthma development in children. Nevertheless, a causal relation between air pollution and development of adult asthma is not clearly established. Exposure to outdoor pollutants can induce asthma symptoms, exacerbations and decreases in lung function. Active tobacco smoking is associated with poorer asthma control, while exposure to SHS increases the risk of asthma exacerbations, respiratory symptoms and healthcare utilization. Other indoor pollutants such as heating sources and molds can also negatively impact the course of asthma. Global measures, that aim to reduce exposure to air pollutants, are highly needed in order to improve the outcomes and management of adult and pediatric asthma in addition to the existing guidelines.

The Relationship of Psychological Factors and Asthma Control to Health-Related Quality of Life

BACKGROUND

Psychological variables (anxiety, depression, and coping strategies) and asthma control (assessed from the patient's perspective or from the physician's perspective) affect health-related quality of life (HRQoL) in asthmatic patients. However, no study has simultaneously evaluated these variables to understand the independent contribution of each one of these factors to HRQoL.

OBJECTIVE

To determine the impact of anxiety, depression, coping strategies, and asthma control on HRQoL, and to compare the impact of asthma control on HRQoL when it is established by the physician versus when it is considered by the patient.

METHODS

A total of 373 asthmatics completed the Hospital Anxiety and Depression Scale, Coping Orientations to Problems Experienced Inventory, 36-Item Short-Form Health Survey, and St. George Respiratory Questionnaire. Asthma control was measured by the patient with Asthma Control Test and by the physician with the classification asthma control of Global Initiative for Asthma. Demographic and clinical characteristics were also collected.

RESULTS

Anxiety, depression, and poor patient-rated asthma control status were associated with worse HRQoL in all dimensions (except Mental Health for asthma control). Physician-rated asthma control was related to worse HRQoL in physical generic and specific dimensions. Among coping strategies, only avoidant coping impacted HRQoL in a few dimensions.

CONCLUSIONS

Anxiety, depression, and asthma control (especially patient-rated asthma control) were important independent predictors of asthma HRQoL, and all of them should therefore be considered in interventions to improve HRQoL in asthmatic patients.

Effect of smoking status on the efficacy of the SMART regimen in high risk asthma

BACKGROUND AND OBJECTIVE

The optimal management of people with asthma with a significant smoking history is uncertain. The aim of this study was to determine whether the efficacy/safety profile of single combination inhaled corticosteroid (ICS)/long acting beta-agonist (LABA) inhaler maintenance and reliever therapy is influenced by smoking status.

METHODS

We undertook secondary analyses from an open-label 24-week randomized study of 303 high risk adult asthma patients randomized to budesonide/formoterol 200/6-µg-metred dose inhaler for maintenance (two actuations twice daily) and either budesonide/formoterol 200/6-µg-metred dose inhaler one actuation ('single ICS/LABA maintenance and reliever therapy (SMART)' regimen) or salbutamol 100 µg 1-2 actuations for symptom relief ('Standard' regimen). Smoking status was classified in to three groups, as 'current', 'ex' or 'never', and a smoking/treatment interaction term tested for each outcome variable. The primary outcome variable was number of participants with at least one severe exacerbation.

RESULTS

There were 59 current, 97 ex and 147 never smokers included in the analyses. The smoking status/treatment interaction term was not statistically significant for any of the outcome measures. With adjustment for smoking status, the number of participants with severe exacerbations was lower with the SMART regimen (OR 0.45, 95% CI: 0.26-0.77, P = 0.004; P value for interaction between smoking status and treatment 0.29).

CONCLUSION

We conclude that the favourable safety/efficacy profile of the SMART regimen applies to patients with high risk asthma, irrespective of smoking status.

Demographic and disease-related predictors of abnormal lung function in patients with established inflammatory polyarthritis and a comparison with the general population

Objectives

To identify demographic and clinical predictors of obstructive lung disease (OLD) and restrictive lung disease (RLD) in patients with established inflammatory polyarthritis (IP) and to compare the prevalence of respiratory symptoms in patients with IP and the general population.

Method

A total of 421 patients with IP underwent a spirometry test 15 years after inclusion in the Norfolk Arthritis Register (NOAR). Logistic regression analyses were performed to assess the predictive ability of demographic and clinical characteristics obtained at inclusion in NOAR and to assess their association with OLD or RLD at 15 years (age- and gender-adjusted). In addition, the prevalence of OLD and RLD was compared with a matched population (1:4) of people participating in the European Prospective Investigation of Cancer-Norfolk, a representative sample of the general population in Norfolk, UK.

Results

In this IP population, current smoking was the strongest predictor for OLD and functional disability for RLD. In the comparison study, 11.6% had OLD in the IP population and 4.9% in the general population (adjOR 2.01, 95% CI 1.26 to 3.22). The prevalence of RLD was not statistically different between the IP population and the general population (14.6% vs 17.5%; adjOR 0.76, 95% CI 0.53 to 1.10).

Conclusions

OLD, but not RLD, is more prevalent in the IP population than in the general population. Functional disability is especially associated with RLD whereas smoking is associated with OLD. The latter finding, and the known association between smoking and a poor disease prognosis, underlines the importance of smoking cessation in patients with IP.

Smoking and nonsmoking asthma: differences in clinical outcome and pathogenesis

Cigarette smoking in asthma is frequently present and is associated with worsening of symptoms, accelerated lung-function decline, a higher frequency of hospital admissions, a higher degree of asthma severity, poorer asthma control and reduced responsiveness to corticosteroids. Furthermore, it is associated with reduced numbers of eosinophils and higher numbers of mast cells in the submucosa of the airway wall. Airway remodeling is increased as evidenced by increased epithelial thickness and goblet cell hyperplasia in smoking asthmatics. The pathogenesis responsible for smoking-induced changes in airway inflammation and remodeling in asthma is complex and largely unknown. The underlying mechanism of reduced corticosteroid responsiveness is also unknown. This article discusses differences between smoking and nonsmoking asthmatics regarding the clinical expression of asthma, lung function, response to corticosteroids, airway inflammation and remodeling processes. Possible pathogenetic mechanisms that may explain the links between cigarette smoking and changes in the clinical expression of asthma will be discussed, as well as the beneficial effects of smoking cessation.

Association of Smoking Status With Quality of Life in a Cross-sectional Population-Based Sample of Iranian Adults

This study aimed to examine the association between smoking status and quality of life (QOL) in a population-based sample of Iranian adults. The study used data from the Isfahan Healthy Heart Program (IHHP). A total of 5830 participants were included. They were categorized as current, former, or never smokers. QOL was evaluated using the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), Persian version. Data entry was performed using SPSS (SPSS Inc, Chicago, IL) software version 13.0. QOL was associated with marital status ( P = .014), education ( P = .001), occupation ( P = .007), and income ( P < .000) among current smokers. After adjusting for sociodemographic characteristics, smoking decreased QOL among current (odds ratio [OR] = 0.98; 95% confidence interval [CI] = 0.97-0.99) and past (OR = 0.97; 95%CI = 0.95-0.98) smokers relative to never smokers. QOL is lower among Iranian current and past smokers, and the relation is independent of underlying sociodemographic factors.

Greater severity of new onset asthma in allergic subjects who smoke: a 10-year longitudinal study

BACKGROUND

Little is known about the association between cigarette smoking and asthma severity. We assessed smoking as a determinant of disease severity and control in a cohort of clinic-referred allergic subjects who developed new onset asthma.

METHODS

Allergic rhinitis subjects with no asthma (n = 371) were followed-up for 10 years and routinely examined for asthma diagnosis. In those who developed asthma (n = 152), clinical severity and levels of asthma control were determined. Among these subjects, 74 (48.7%) were current smokers, 17 (11.2%) former smokers, and 61 (40.1%) never smokers.

RESULTS

When comparing current or past smokers to never smokers they had a higher risk of severe asthma in the univariate analysis, which became non-significant in the multivariate analysis. On the other hand, the categories of pack-years were significantly related to severe asthma in a dose response relationship in both the univariate and multivariate analysis: compared to 0 pack years, those who smoked 1-10 pack-years had an OR(95% CI) of 1.47(0.46-4.68), those who smoked 11-20 pack-years had an OR of 2.85(1.09-7.46) and those who smoked more than 20 pack-years had an OR of 5.59(1.44-21.67) to develop more severe asthma. Smokers with asthma were also more likely to have uncontrolled disease. A significant dose-response relationship was observed for pack-years and uncontrolled asthma. Compared to 0 pack years, those who smoked 1-10 pack-years had an OR of 5.51(1.73-17.54) and those who smoked more than 10 pack-years had an OR of 13.38(4.57-39.19) to have uncontrolled asthma.

CONCLUSIONS

The current findings support the hypothesis that cigarette smoking is an important predictor of asthma severity and poor asthma control.

Asthma and cigarette smoking: a review of the empirical literature

The purpose of this review paper is to present and evaluate the empirical literature on the association between asthma and cigarette smoking. The authors conducted a literature search utilizing electronic search engines (i.e., PsycINFO and MEDLINE) to examine databases using the following key word algorithms: smoking OR nicotine OR tobacco AND asthma. Only articles that focused on active tobacco smoking and analyzed groups with asthma patients only were examined in the present review. Overall, empirical evidence suggests that (1) smoking is more prevalent among individuals with asthma than those without; (2) smoking is a risk candidate for the development of asthma; (3) smoking is associated with decreased asthma control and increased risk of mortality and asthma attacks and exacerbations; (4) smokers with and without asthma may have different risk factors for smoking onset as well as different smoking motives and outcome expectancies; and (5) smoking cessation is associated with improvements in lung functioning and asthma symptoms. Future work in this domain of study will lead to clinically relevant health care advances as well as the development of theoretically driven, methodologically diverse lines of research exploring asthma-smoking comorbidity issues.

Multicenter study of cigarette smoking among patients presenting to the emergency department with acute asthma

BACKGROUND

Many studies have focused on smoking and chronic asthma severity. However, research on the relationship between smoking and acute asthma severity in an acute care setting is sparse.

OBJECTIVES

To determine the smoking prevalence among emergency department (ED) patients with acute asthma and to investigate the relationships between smoking and acute asthma severity.

METHODS

A 63-site medical record review study of ED patients, ages 14 to 54 years, with a principal diagnosis of acute asthma was performed. Patients with chronic obstructive pulmonary disease were excluded. Measurements for acute asthma severity included sociodemographic factors, asthma medical history, ED presentation, clinical course, medications administered, and return visit within 48 hours.

RESULTS

A total of 4,052 patient medical records were reviewed. A total of 1,332 patients (33%; 95% confidence interval, 31%-34%) were documented as smokers. No statistically significant differences were found between smokers and nonsmokers in vital signs, oxygen saturation, peak expiratory flow, and administration of asthma medications. By contrast, smokers were more likely than nonsmokers to receive antibiotics in the ED (12% vs 9%, P < .001) or at discharge (23% vs 14%, P < .001). A multivariate analysis confirmed that smoking status was independently associated with antibiotic administration (odds ratio, 1.6; 95% confidence interval, 1.3-1.8).

CONCLUSIONS

One-third of ED patients with acute asthma smoked cigarettes. Smokers and nonsmokers did not differ in their acute asthma severity. Asthmatic smokers, however, were more likely to receive antibiotics, even when adjusting for other possible confounders.

Allergic rhinitis in patients with asthma: the Swiss LARA (Link Allergic Rhinitis in Asthma) survey

OBJECTIVE

To determine the characteristics of asthma (A) and allergic rhinitis (AR) among asthma patients in primary care practice.

RESEARCH DESIGN AND METHODS

Primary care physicians, pulmonologists, and allergologists were asked to recruit consecutive asthma patients with or without allergic rhinitis from their daily practice. Cross-sectional data on symptoms, severity, treatment and impact on quality of life of A and AR were recorded and examined using descriptive statistics. Patients with and without AR were then compared.

RESULTS

1244 asthma patients were included by 211 physicians. Asthma was controlled in 19%, partially controlled in 27% and not controlled in 54%. Asthma treatment was generally based on inhaled corticosteroids (ICS) with or without long acting beta 2 agonists (78%). A leukotriene receptor antagonist (LTRA) was used by 46% of the patients. Overall, 950 (76%) asthma patients had AR (A + AR) and 294 (24%) did not (A - AR). Compared to patients with A - AR, A + AR patients were generally younger (mean age +/- standard deviation: 42 +/- 16 vs. 50 +/- 19 years, p < 0.001) and fewer used ICS (75% vs. 88%, p < 0.001). LTRA usage was similar in both groups (46% vs. 48%). Asthma was uncontrolled in 53% of A + AR and 57% of A - AR patients. Allergic rhinitis was treated with a mean of 1.9 specific AR medications: antihistamines (77%), nasal steroids (66%) and/or vasoconstrictors (38%), and/or LTRA (42%). Rhinorrhoea, nasal obstruction, or nasal itching were the most frequently reported AR symptoms and the greatest reported degree of impairment was in daily activities/sports (55%).

CONCLUSIONS

Allergic rhinitis was more common among younger asthma patients, increased the burden of symptoms and the need for additional medication but was associated with improved asthma control. However, most asthma patients remained suboptimally controlled regardl-ess of concomitant AR.