The effect of a minimal contact smoking cessation programme in out-patients with chronic obstructive pulmonary disease: a pre-post-test study

Biochemical Verification of Tobacco Use and Abstinence: 2019 Update

BACKGROUND

The changing prevalence and patterns of tobacco use, the advent of novel nicotine delivery devices, and the development of new biomarkers prompted an update of the 2002 Society for Research on Nicotine and Tobacco (SRNT) report on whether and how to apply biomarker verification for tobacco use and abstinence.

METHODS

The SRNT Treatment Research Network convened a group of investigators with expertise in tobacco biomarkers to update the recommendations of the 2002 SNRT Biochemical Verification Report.

RESULTS

Biochemical verification of tobacco use and abstinence increases scientific rigor and is recommended in clinical trials of smoking cessation, when feasible. Sources, appropriate biospecimens, cutpoints, time of detection windows and analytic methods for carbon monoxide, cotinine (including over the counter tests), total nicotine equivalents, minor tobacco alkaloids, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol are reviewed, as well as biochemical approaches to distinguishing cigarette smoking from use of electronic nicotine delivery devices (ENDS).

CONCLUSIONS

Recommendations are provided for whether and how to use biochemical verification of tobacco use and abstinence. Guidelines are provided on which biomarkers to use, which biospecimens to use, optimal cutpoints, time windows to detection, and methodology for biochemical verifications. Use of combinations of biomarkers is recommended for assessment of ENDS use.

IMPLICATIONS

Biochemical verification increases scientific rigor, but there are drawbacks that need to be assessed to determine whether the benefits of biochemical verification outweigh the costs, including the cost of the assays, the feasibility of sample collection, the ability to draw clear conclusions based on the duration of abstinence, and the variability of the assay within the study population. This paper provides updated recommendations from the 2002 SRNT report on whether and how to use biochemical markers in determining tobacco use and abstinence.

Consistency and reliability of smoking-related variables: longitudinal study design in asthma and COPD

Introduction: Smoking has a significant impact on the development and progression of asthma and chronic obstructive pulmonary disease (COPD). Self-reported questionnaires and structured interviews are usually the only way to study patients' smoking history. In this study, we aim to examine the consistency of the responses of asthma and COPD patients to repeated standardised questions on their smoking habits over the period of 10 years. Methods: The study population consisted of 1329 asthma and 959 COPD patients, who enrolled in the study during years 2005-2007. A follow-up questionnaire was mailed to the participants 1, 2, 4, 6, 8, and 10 years after the recruitment. Results: Among the participants who returned three or more questionnaires (N = 1454), 78.5 % of the patients reported unchanged smoking status (never smoker, ex-smoker or current smoker) across the time. In 4.5% of the answers, the reported smoking statuses were considered unreliable/conflicting (first never smoker and, later, smoker or ex-smoker). The remainder of the patients changed their status from current smoker to ex-smoker and vice versa at least once, most likely due to struggling with quitting. COPD patients were more frequently heavy ex- or current smokers compared to the asthma group. The intraclass coefficient correlations between self-reported starting (0.85) and stopping (0.94) years as well as the consumption of cigarettes (0.74) over time showed good reliability among both asthma and COPD patients. Conclusion: Self-reported smoking data among elderly asthma and COPD patients over a 10-year follow-up is reliable. Pack years can be considered a rough estimate for their comprehensive consumption of tobacco products over time. We also observed that the questionnaire we used was not designed for dynamic changes in smoking which are rather common among heavy smokers especially when the follow-up time is several years, as in our study.

[COPD and smoking cessation: Patients' expectations and responses of health professionals]

The importance of smoking cessation in the management of COPD is well-established: the benefit of quitting smoking as regards morbidity and mortality outcomes in patients, is unquestioned. The smoking cessation in COPD patients is difficult: high levels of consumption, the duration of smoking, high dependence level, psychological co-morbidities such as anxiety and depression, lower socio-economic and intellectual level, constitute barriers. Studies have shown that patients often minimize the risks of smoking, that others do not believe in the benefits of quitting or doubt their ability to quit smoking. The patients' experience, and expectations with regard to smoking cessation are incompletely satisfied: are considered, the smoking characteristics of these patients, the understanding of the tobacco dependence, the beliefs and ideas of smokers, the knowledge of smoking cessation methods, the role of validated aids and alternative treatments, failure management. The answers of the health professionals can be in several directions: establishment of a better communication patient-doctor (empathy), more centered on the needs of the smoker, the role of the motivation and the place of the motivational interview, the understanding of the mechanisms of addiction, a better individualisation of therapeutics, the necessity of a extended follow-up, the contribution of modern technologies, the electronic cigarette, the smoking cessation in respiratory rehabilitation, guidelines that address smoking cessation treatment.

Effectiveness of intensive smoking reduction counselling plus combination nicotine replacement therapy in promoting long-term abstinence in patients with chronic obstructive pulmonary disease not ready to quit smoking: Protocol of the REDUQ trial

INTRODUCTION

Limited tobacco dependence treatment resources exist for smoking COPD patients not ready to quit. Smoking reduction may be a viable treatment approach if it prompts quit attempts and subsequent abstinence. This article describes the protocol of the REDUQ (REDUce and Quit) study, which examines whether smoking reduction counselling plus combination nicotine replacement therapy (NRT) is (cost-)effective in achieving long-term abstinence in smoking COPD patients not ready to quit.

METHODS/DESIGN

We conducted a two-centre, parallel-group, randomised controlled trial with 18 months follow-up in smoking outpatients with COPD. Patients not ready to quit within the next month but willing to reduce their smoking, were randomised to receive either intensive smoking reduction counselling plus combination NRT or a single information meeting plus self-help manual. Outcomes were assessed at baseline, 6, 12 and 18 months. The primary outcome is ≥ 1-year prolonged abstinence. Secondary outcomes are point prevalence abstinence, successful (i.e. ≥ 50%) smoking reduction, and incidence of quit attempts reported at follow-up assessments. Smoking status is biochemically verified by salivary cotinine and expired CO. Other variables include smoking-related cognitions, intention and motivation to reduce and quit smoking, withdrawal symptoms, health-related quality of life, symptoms of anxiety and depression, state of mindfulness, lung function, use of health care resources, and costs.

DISCUSSION

The outcomes of the REDUQ trial will advance knowledge on treatment of smoking COPD patients not ready to quit. If (cost-)effective, the smoking reduction intervention can be offered to this difficult-to-treat target group as a valuable adjunct to smoking cessation treatment.

Nurses' and patients' communication in smoking cessation at nurse-led COPD clinics in primary health care

BACKGROUND

Smokers with chronic obstructive pulmonary disease (COPD) have high nicotine dependence making it difficult to quit smoking. Motivational interviewing (MI) is a method that is used in stimulating motivation and behavioral changes.

OBJECTIVE

To describe smoking cessation communication between patients and registered nurses trained in MI in COPD nurse-led clinics in Swedish primary health care.

METHODS

A prospective observational study with structured quantitative content analyses of the communication between six nurses with basic education in MI and 13 patients in non-smoking consultations.

RESULTS

Only to a small extent did nurses' evoke patients' reasons for change, stimulate collaboration, and support patients' autonomy. Nurses provided information, asked closed questions, and made simple reflections. Patients' communication was mainly neutral and focusing on reasons for and against smoking. It was uncommon for patients to be committed and take steps toward smoking cessation.

CONCLUSION

The nurses did not adhere to the principles of MI in smoking cessation, and the patients focused to a limited extent on how to quit smoking.

PRACTICE IMPLICATIONS

To make patients more active, the nurses need more education and continuous training in motivational communication.

Strategies used by respiratory nurses to stimulate self-management in patients with COPD

AIMS AND OBJECTIVES

To gain an insight into strategies, adopted by Dutch respiratory nurses during clinic sessions, to improve self-management of patients with chronic obstructive pulmonary disease.

BACKGROUND

Chronic obstructive pulmonary disease is highly prevalent and a significant cause of morbidity and mortality, impacting on quality of life and healthcare expenditure. Health promotion is therefore an important consideration. By applying specific strategies, respiratory nurses can play a major role in the promotion of self-management. Research has shown that respiratory nurses, who run clinics, have insufficient knowledge of evidence-based strategies that can be adopted to promote self-management among chronic obstructive pulmonary disease patients. It appears that respiratory nurses adopt their own strategies during clinic sessions.

DESIGN

A qualitative research study was carried out using Grounded Theory method.

METHODS

Data were collected during open interviews conducted by an external researcher with a nursing background. The interviews were analysed through coding after which categories were developed.

RESULTS

Fourteen respiratory nurses were interviewed. The results show that respiratory nurses emphasise quitting smoking during the consult. Attention is also paid to inhalation medication and techniques. Other self-management strategies that respiratory nurses use are: application of specific interviewing techniques, referring to other healthcare professionals and providing tools for coping with the illness in everyday life.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

The main emphasis during the clinic session is directed at quitting smoking. Other self-management strategies such as providing information regarding nutrition and exercise, instilling confidence and becoming an equal discussion partner, gain less attention. During the clinic session, respiratory nurses should also focus on these self-management strategies in addition to quitting smoking. Further research should be directed at self-management strategies used by respiratory nurses in relation to different characteristics of patients. In this way, a more patient-oriented form of consultation could be developed for chronic obstructive pulmonary disease patients.

Cost-effectiveness of an intensive smoking cessation intervention for COPD outpatients

INTRODUCTION

To determine the cost-effectiveness of a high-intensity smoking cessation program (SmokeStop Therapy; SST) versus a medium-intensity treatment (Minimal Intervention Strategy for Lung patients [LMIS]) for chronic obstructive pulmonary disease outpatients.

METHODS

The cost-effectiveness analysis was based on a randomized controlled trial investigating the effectiveness of the SST compared with the LMIS with 12-month follow-up. The primary outcome measure was the cotinine-validated continuous abstinence rate based on intention to treat. A health care perspective was adopted, with outcomes assessed in terms of (incremental) additional quitters gained, exacerbations prevented, and hospital days prevented. Health care resource use, associated with smoking cessation, was collected at baseline and 12 months after the start of the interventions. Monte Carlo simulations were performed to evaluate the robustness of the results.

RESULTS

The average patient receiving SST generated €581 in health care costs, including the costs of the smoking cessation program, versus €595 in the LMIS. The SST is also associated with a lower average number of exacerbations (0.38 vs. 0.60) and hospital days (0.39 vs. 1) per patient and a higher number of quitters (20 vs. 9) at lower total costs. This leads to a dominance of the SST compared with the LMIS.

CONCLUSIONS

The high-intensive SST is more cost-effective than the medium-intensive LMIS after 1 year. This is associated with cost savings per additional quitter, prevented exacerbations, and hospital days at lower or equal costs.

The process of trying to quit smoking from the perspective of patients with chronic obstructive pulmonary disease

AIM

To investigate why some patients with chronic obstructive pulmonary disease (COPD) have difficulty quitting smoking and to develop a theoretical model that describes their perspectives on these difficulties.

METHODS

Grounded theory method was used from the selection of participants to the analyses of semi-structured interviews with 14 patients with COPD. Four additional interviews were conducted to ensure relevance.

RESULTS

The analysis resulted in a theoretical model that illustrates the process of 'Patients with COPD trying to quit smoking'. The model illuminates factors related to the decision to try to quit smoking, including pressure-filled mental states and constructive or destructive pressure-relief strategies. The constructive strategies lead either to success in quitting or to continuing to try to quit. The destructive strategies can lead to losing hope and becoming resigned to continuing to smoke.

CONCLUSION

The theoretical model 'Patients trying to quit smoking' contributes to a better understanding of the pressure-filled mental states and destructive strategies experienced by some patients with COPD in the process of trying to quit. This better understanding can help nurses individualise counselling. Moreover, patients' own awareness of these states and strategies may facilitate their efforts to quit. The information in the model can also be used as a supplement to methods such as motivational interviewing (MI).

Assessing smoking status in disadvantaged populations: is computer administered self report an accurate and acceptable measure?

Background

Self report of smoking status is potentially unreliable in certain situations and in high-risk populations. This study aimed to determine the accuracy and acceptability of computer administered self-report of smoking status among a low socioeconomic (SES) population.

Methods

Clients attending a community service organisation for welfare support were invited to complete a cross-sectional touch screen computer health survey. Following survey completion, participants were invited to provide a breath sample to measure exposure to tobacco smoke in expired air. Sensitivity, specificity, positive predictive value and negative predictive value were calculated.

Results

Three hundred and eighty three participants completed the health survey, and 330 (86%) provided a breath sample. Of participants included in the validation analysis, 59% reported being a daily or occasional smoker. Sensitivity was 94.4% and specificity 92.8%. The positive and negative predictive values were 94.9% and 92.0% respectively. The majority of participants reported that the touch screen survey was both enjoyable (79%) and easy (88%) to complete.

Conclusions

Computer administered self report is both acceptable and accurate as a method of assessing smoking status among low SES smokers in a community setting. Routine collection of health information using touch-screen computer has the potential to identify smokers and increase provision of support and referral in the community setting.

Effective smoking cessation interventions for COPD patients: a review of the evidence

OBJECTIVES

To review the effectiveness of smoking cessation interventions offered to chronic obstructive pulmonary disease (COPD) patients, and identify barriers to quitting experienced by them, so that a more effective service can be developed for this group.

DESIGN

A rapid systematic literature review comprising computerized searches of electronic databases, hand searches and snowballing were used to identify both published and grey literature.

SETTING

A review of studies undertaken in north-western Europe (defined as: United Kingdom, Ireland, France, Germany, Benelux and Nordic countries).

PARTICIPANTS

COPD patients participating in studies looking at the effectiveness of smoking cessation interventions in this patient group, or exploring the barriers to quitting experienced by these patients.

METHOD

Quantitative and qualitative papers were selected according to pre-specified inclusion and exclusion criteria, critically appraised, and quantitative papers scored against the NICE Levels of Evidence standardized hierarchy.

MAIN OUTCOME MEASURE

Percentages of successful quitters and length of quit, assessed by self-report or biochemical analysis. Among qualitative studies, identified barriers to smoking cessation had to be explored.

RESULTS

Three qualitative and 13 quantitative papers were finally selected. Effective interventions and barriers to smoking cessation were identified. Pharmacological support with Buproprion combined with counselling was significantly more efficacious in achieving prolonged abstinence than a placebo by 18.9% (95% CI 3.6-26.4%). Annual spirometry with a brief smoking cessation intervention, followed by a personal letter from a doctor, had a significantly higher ≥1 year abstinence rate at three years among COPD patient smokers, compared to smokers with normal lung function (P < 0.001; z = 3.93). Identified barriers to cessation included: patient misinformation, levels of motivation, health beliefs, and poor communication with health professionals.

CONCLUSION

Despite the public health significance of COPD, there is a lack of high-quality evidence showing which smoking cessation support methods work for these patients. This review describes three effective interventions, as well as predictors of quitting success that service providers could use to improve quit rates in this group. Areas that would benefit from urgent further research are also identified.

Validation of smoking cessation self-reported by patients with chronic obstructive pulmonary disease

PURPOSE

The present study reports on the biochemical validation of the self-reported smoking status of patients with chronic obstructive pulmonary disease (COPD). The objective is to establish the proportion of overestimation of self-reported success rates.

METHODS

A cross-sectional smoking-status validation study including 60 patients with COPD who reported that they had stopped smoking. In the analysis of urine samples, a cut-off point of 50 ng/mL of cotinine was used.

RESULTS

At the time of biochemical validation, 55 patients reported that they had quit smoking while five patients resumed smoking. Smoking status was biochemically confirmed for 43 patients (78%) and 12 patients (22%) were classified as smokers. The sensitivity of the self- report of smoking was 29% and the specificity was 100%.

CONCLUSION

Many primary care patients with COPD do not provide valid information on their smoking status, which hamper adequate therapeutic interventions. Integration of biochemical validation in daily care could overcome this problem, but may harm the doctor-patient relationship.

Clinical pharmacy-led disease and medicine management programme for patients with COPD

AIM

The aim was to investigate the impact of a disease and medicine management programme, focusing on self-management in patients with chronic obstructive pulmonary disease (COPD).

METHODS

One hundred and seventy-three patients (mean age 67 years; 54% female) were recruited; 86 patients were randomly assigned to an intervention group and 87 to a usual care (control) group. Intervention patients received education on disease state, medications and breathing techniques. Patients were given booklets and a customized action plan (antibiotic and oral steroid to be initiated promptly by patients for exacerbations). Patients were followed up at 6 and 12 months during a scheduled visit. The St George's Respiratory Questionnaire (SGRQ), COPD Knowledge and Morisky adherence questionnaires were administered to all patients at baseline, 6 and 12 months. Outcome measures included hospital admissions, emergency department (ED) visits, health-related quality of life (HRQoL) and medication adherence.

RESULTS

Over the 12-month period in the intervention group, ED visits decreased by 50% (P= 0.02) and hospitalization by approximately 60% (P= 0.01). On the SGRQ, differences reached statistical significance on the symptom (-7.5; P= 0.04) and impact (-7.4; P= 0.03) subscales but not on the physical activity subscale. There was a significant difference between the intervention and usual care groups regarding knowledge scores (75.0 vs. 59.3; P= 0.001) and good adherence to medication (77.8% vs. 60.0%, P= 0.019). There was no significant difference regarding smoking between study groups.

CONCLUSIONS

The clinical pharmacy-led management programme can improve adherence, reduce the need for hospital care in patients with COPD and improve aspects of their HRQoL.

Clinical pharmacy-led disease and medicine management programme for patients with COPD

AIM

The aim was to investigate the impact of a disease and medicine management programme, focusing on self-management in patients with chronic obstructive pulmonary disease (COPD).

METHODS

One hundred and seventy-three patients (mean age 67 years; 54% female) were recruited; 86 patients were randomly assigned to an intervention group and 87 to a usual care (control) group. Intervention patients received education on disease state, medications and breathing techniques. Patients were given booklets and a customized action plan (antibiotic and oral steroid to be initiated promptly by patients for exacerbations). Patients were followed up at 6 and 12 months during a scheduled visit. The St George's Respiratory Questionnaire (SGRQ), COPD Knowledge and Morisky adherence questionnaires were administered to all patients at baseline, 6 and 12 months. Outcome measures included hospital admissions, emergency department (ED) visits, health-related quality of life (HRQoL) and medication adherence.

RESULTS

Over the 12-month period in the intervention group, ED visits decreased by 50% (P= 0.02) and hospitalization by approximately 60% (P= 0.01). On the SGRQ, differences reached statistical significance on the symptom (-7.5; P= 0.04) and impact (-7.4; P= 0.03) subscales but not on the physical activity subscale. There was a significant difference between the intervention and usual care groups regarding knowledge scores (75.0 vs. 59.3; P= 0.001) and good adherence to medication (77.8% vs. 60.0%, P= 0.019). There was no significant difference regarding smoking between study groups.

CONCLUSIONS

The clinical pharmacy-led management programme can improve adherence, reduce the need for hospital care in patients with COPD and improve aspects of their HRQoL.

The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status

INTRODUCTION

Smoking is a leading cause of premature mortality and preventable morbidity. Surveillance is most often based on self-reported data, but studies have shown that self-reports tend to underestimate smoking status.

METHODS

This study systematically reviewed the literature to measure the concordance between self-reported smoking status and smoking status determined through measures of cotinine in biological fluids. Four electronic databases were searched to identify observational and experimental studies on adult populations over the age of 18 years.

RESULTS

Searching identified 67 studies that met the eligibility criteria and examined the relationship between self-reported smoking and smoking confirmed by cotinine measurement. Overall, the data show trends of underestimation when smoking prevalence is based on self-report and varying sensitivity levels for self-reported estimates depending on the population studied and the medium in which the biological sample is measured. Sensitivity values were consistently higher when cotinine was measured in saliva instead of urine or blood. Meta-analysis was not appropriate because of the substantial heterogeneity among the cutpoints used to define smokers and the poor reporting on outcomes of interest.

DISCUSSION

Further research in this field would benefit from the standardization of cutpoints to define current smokers and the implementation of standard reporting guidelines to enhance comparability across studies. Accurate estimation of smoking status is important as data from population studies such as those included in this review are used to generate regional and national estimates of smoking status and in turn are used to allocate resources and set health priorities.

An exploration of the smoking-related health beliefs of older people with chronic obstructive pulmonary disease

AIM

To explore the smoking-related health beliefs of older people with chronic obstructive pulmonary disease (COPD).

BACKGROUND

Globally, smoking is a major cause of COPD and symptoms present typically mid to later life. Substantial numbers of people with COPD continue to smoke even though smoking cessation is known to slow the rate of disease progression and prevent further deterioration in lung function. There is evidence to suggest that, although older long-term smokers can successfully quit smoking with the help of specialist structured programmes, those with COPD find it more difficult to achieve sustained cessation. An understanding of the health beliefs of people with COPD will assist professionals to provide the most appropriate support with cessation attempts.

DESIGN

A secondary analysis of qualitative interview data.

METHODS

Twenty-two current and former smokers with COPD who used the outreach service of an inner city hospital in Scotland were interviewed in their own homes using semi-structured interviews which were transcribed verbatim. The main concepts of the Health Belief Model were used as an analysis framework.

FINDINGS

Interviews were carried out with 15 women and seven men with a median age of 68 years. Almost 90% lived in areas of the highest socio-economic deprivation according to DEPCAT scores. Almost two-thirds of the individuals in this study continued to smoke even though they largely perceived smoking as a threat to health. Individuals who continued to smoke cited various barriers to quitting smoking and all had, at some time, attempted smoking cessation. Over half were still attempting to quit. Cues to action came from external sources rather than increasing disease severity.

CONCLUSIONS

Cessation is challenging and knowledge of a person's health beliefs is a prerequisite to supporting behaviour change.

RELEVANCE TO CLINICAL PRACTICE

Findings emphasize the need for frontline health professionals to reflect on their current practice with a view to providing sustained encouragement and support towards smoking cessation and relapse prevention for people with COPD.

Smoking cessation interventions in chronic obstructive pulmonary disease and the role of the family: a systematic literature review

AIM

This paper is a report of a systematic review to assess the effectiveness of family-focused smoking cessation interventions for people with chronic obstructive pulmonary disease and to determine what data on families are documented in studies of smoking cessation interventions.

BACKGROUND

Chronic obstructive pulmonary disease is a major public health problem and cigarette smoking is the most important factor contributing to its development and progression. However, smoking cessation rates are low and relapse is common. The role of families in smoking cessation efforts has received little attention.

METHODS

All studies were included in the review that (i) addressed an evaluation of a psycho-social/educational smoking cessation intervention for people with chronic obstructive pulmonary disease, (ii) addressed some information on the family (i.e. living arrangements, marital status, smoking history of family members, support for quitting) and/or included the family as part of the intervention and (iii) were published between 1990 and 2006. Electronic data sources, existing systematic reviews of smoking cessation interventions and the grey literature were reviewed.

RESULTS

Seven studies were included. Six studies (11 papers) included data on marital status, smoking status of household members, support for quitting smoking and related variables. In two of the studies, the variable on the family was used to analyse smoking cessation outcomes. One additional study met the inclusion criterion of an evaluation of a smoking cessation intervention, which also included a family focus in the intervention.

CONCLUSION

No conclusions about the effectiveness of a family-focused smoking cessation intervention could be drawn from this review. Further research is needed to determine if a more family-focused intervention, in conjunction with pharmacological and counselling approaches, would lead to improved smoking cessation outcomes.

Can we trust national smoking prevalence figures? Discrepancies between biochemically assessed and self-reported smoking rates in three countries

BACKGROUND

National smoking prevalence estimates are the primary basis for assessing progress in tobacco control across the world. They are based on surveys of self-reported cigarette smoking. It has been assumed that this is sufficiently accurate for policy purposes, but this assumption has not been adequately tested.

METHODS

We report data from the 2003 Health Survey for England, the U.S. National Health and Nutrition Examination Survey for 2001-2002, and the 2004 national smoking behaviors survey in Poland as examples of countries at different stages in the "tobacco epidemic." Self-reported cigarette and total tobacco smoking prevalence were assessed by means of the standard questions used in each country. In subsamples, specimens were collected for analysis of cotinine (saliva, N = 1,613 in England; serum, N = 4,687 in the United States; and saliva, N = 388 in Poland) providing an objective means of determining active smoking. A cut point of 15 ng/mL was used to discriminate active smoking from passive smoke exposure.

RESULTS

Self-reported cigarette smoking prevalence using the standard methods underestimated true tobacco smoking prevalence by an estimated 2.8% in England, 0.6% in the United States, and 4.4% in Poland. Cotinine concentrations in those misclassified as nonsmokers were indicative of high levels of smoke intake.

INTERPRETATION

Underestimation of smoking prevalence was minimal in the United States but significant in England and Poland. A review of methodologies for assessing tobacco smoking prevalence worldwide is urgently needed.

Action plans for chronic obstructive pulmonary disease

BACKGROUND

The effectiveness of action plans as treatment for chronic obstructive pulmonary disease (COPD) is not known.

OBJECTIVES

To assess the efficacy of action plans in the management of COPD.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, CINAHL and the National Research Register of Ongoing Trials. We also searched reference lists of identified studies. The search was completed in August 2004.

SELECTION CRITERIA

Randomised controlled trials of action plans in COPD. Studies with a primary diagnosis of asthma excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Investigators were contacted for additional information when necessary. Study results were combined in meta-analyses using the Cochrane Collaboration software RevMan.

MAIN RESULTS

There was evidence of a positive effect of action plans on self-management knowledge. The mean difference (MD) for recognition of a severe exacerbation was 2.50; 95% confidence interval 1.04 to 3.96, for self-action in severe exacerbations MD 1.50; 95% confidence interval 0.62 to 2.38 and the use of antibiotics MD 6.00; 95% confidence interval 2.68 to 9.32. There was also evidence of a positive effect on the initiation of antibiotics (odds ratio (OR) 10.16; 95% confidence interval 2.02 to 51.09) and/or oral steroids (OR 6.58; 95% confidence interval 1.29 to 33.62). However, there was no evidence of significant effects on healthcare utilisation, health-related quality of life, lung function, functional capacity, symptom scores, mortality, anxiety, or depression. No trials used as outcomes: number of exacerbations, length of exacerbations, or days lost from work.

AUTHORS' CONCLUSIONS

This review shows there is evidence that action plans aid people with COPD in recognising and reacting appropriately to an exacerbation of their symptoms via the self-initiation of antibiotics or steroids. Further research needs to be completed with more comprehensive outcomes measures in order to ascertain whether this results in significantly decreased morbidity and/or mortality.

Managing COPD: no more nihilism!

This special issue of Patient Education and Counseling is long overdue. During most of the last two decades asthma, and notably asthma self-management has been in the spotlight, while COPD has had to endure a nihilistic approach. The first sign that interest was shifting to the treatment of COPD came from a few large randomized trials on the use of inhaled corticosteroids (ICS) in COPD. Although these studies demonstrated a moderate effect of ICS in COPD, it has become clear that true improvements in the management of this chronic disease will have to come from behavioral interventions. This special issue of Patient Education and Counseling is dedicated solely to the non-pharmaceutical management of COPD. It addresses many issues related to behavioral therapy, such as smoking cessation, exercise training, nutritional aspects, and self-management programs, including action plans to self-treat exacerbations. With the availability of all the treatment and management options, described in this special issue, a nihilistic attitude toward the patient with COPD is no longer justified.