Tabakentwöhnung bei COPD

[Smoking Cessation in Patients with COPD]

Tobacco dependence is a common comorbidity in patients with COPD (Chronic Obstructive Pulmonary Disease) that negatively affects the course of the disease. However, clinically relevant improvement in COPD can only be achieved by complete and permanent abstinence. Therefore, abstinence from tobacco use is a central therapeutic concept in smoking patients with COPD and requires specific and targeted treatment.After detailed documentation of smoking behaviour and motivational counseling outlining the risks of smoking, all such patients shall be offered a structured therapy for tobacco cessation. There is high-quality evidence for the effectiveness of a combination therapy of behavioral therapy and medication (to treat the withdrawal syndrome). Due to insufficient data, there is currently no recommendation for the use of e-cigarettes as a primary option for a cessation attempt.Smoking is the most important cause of COPD. Smoking cessation is the most effective and cost-efficient single intervention to reduce the risk of developing and progressing COPD.

The Effectiveness of E-Cigarettes for Smoking Cessation

BACKGROUND

Our primary aim was to assess-in the German population-the effectiveness of e-cigarettes (ECs; with or without nicotine), nicotine replacement therapy (NRT), and no use of evidence-based aids in smoking cessation.

METHODS

Analysis of cross-sectional data from a representative survey of the population (age 14-96 years) conducted in 2016-2021. All current smokers and recent ex-smokers (< 12 months since quitting) who had made ≥ 1 attempt to quit in the past 12 months (n = 2740) were included. They were asked about use of cessation aids in their most recent quit attempt and their current smoking status.

RESULTS

Two hundred thirty-nine respondents had used ECs, 168 NRT, and 2333 no aid. After adjustment for potential confounders, the odds of abstinence were 1.78 times higher for smokers who had used ECs in their quit attempt than in the group that had used no aids (95% confidence interval [1.09; 2.92]; p = 0.02) and 1.46 times higher than in the NRT group ([0.68; 3.13]; p = 0.34, Bayes factor = 1.26). Compared with the unaided group, the odds of abstinence were 2.34 times higher ([1.21; 4.53]; p = 0.01) in the subgroup using ECs with nicotine and 1.48 times higher ([0.68; 3.26]; p = 0.33) in the subgroup using ECs without nicotine. The unadjusted abstinence rates in people who had started their quit attempt > 6 months earlier were 15.6% [9.4; 23.8] in the ECs group and 13.8% [7.3; 22.9] in the NRT group.

CONCLUSION

In Germany, use of ECs in an attempt to quit smoking is associated with a higher rate of abstinence than attempting to quit unaided.

Clinical Practice Guideline: Chronic Cough

BACKGROUND

Chronic cough, i.e., cough lasting longer than eight weeks, affects approximately 10% of the population and is a common reason for outpatient medical consultation. Its differential diagnosis is extensive, and it is generally evaluated in poorly structured fashion with a variety of diagnostic techniques. The German Clinical Practice Guideline on Acute and Chronic Cough was updated in 2021 and contains a description of the recommended stepwise, patient-centered, and evidence-based procedure for the management of chronic cough.

METHODS

The guideline has been updated in accordance with the findings of a systematic search of the literature for international guidelines and systematic reviews. All recommendations were developed in an interdisciplinary manner and agreed upon by formal consensus. The target group consists of adult patients with cough.

RESULTS

History-taking, after the exclusion of red flags, should include questioning about smoking status, medications, and relevant present and past illnesses (COPD, asthma). Subsequent diagnostic testing should include a chest x-ray and pulmonary function tests. If the patient is taking an ACE inhibitor, a test of drug discontinuation can be carried out first. Radiologically detected pulmonary masses or evidence of rare diseases (interstitial lung diseases, bronchiectasis) are an indication for chest CT or for direct referral to an appropriate specialist. If the imaging studies and pulmonary function tests are normal, the patient is most likely suffering from a disease entity that can be treated empirically, such as upper airway cough syndrome or cough variant asthma. Any patient with an unexplained or refractory cough must receive proper patient education; individual therapeutic trials of physiotherapeutic or speechtherapeutic methods are possible, as is the off-label use of gabapentin or morphine.

CONCLUSION

Chronic cough should be evaluated according to an established diagnostic algorithm in collaboration with specialists. Treatments such as inhaled corticosteroids should be tested exhaustively in accordance with the guidelines, and the possibility of multiple causes as well as the role of patient compliance should be kept in mind before a diagnosis of unexplained or intractable cough is assigned.

[Potential Savings in Treatment Costs of COPD through Smoking Cessation: Modeling for DMP COPD in Germany - Scientific Action Group on Tobacco Cessation (WAT) e. V.]

Based on real-life data for the stage distribution of COPD patients (GOLD) and the actual stage-related treatment costs in a large nationwide cohort study (COSYCONET) 1, the influence of the reduced smoking rate on treatment costs was determined for the scenario of a reduction in the smoking rate of 26 % in this patient group by 10 percentage points to 16 %. The assumption was made that with a reduced smoking rate, lower stages (I/II) will be more strongly represented, while higher and more cost-intensive stages (III/IV) will be proportionally reduced. The intervention to achieve tobacco abstinence was calculated for the rough model calculations with the typical costs of a guideline-compliant treatment by a behavioral therapy group cessation program and the parallel use of medication support 2 3. The result showed a potential reduction of case costs by 10.5 %, not including reduction in costs associated with treatment of comorbidities.

[Pulmonary Rehabilitation in Patients with Chronic Obstructive Airway Diseases]

Pulmonary rehabilitation of asthma and COPD patients can improve their physical performance and quality of life, maintain participation in social and professional life and actively promote self-help. In addition, the resources for acute medical treatment can be spared. In case of COPD, rehabilitation directly after exacerbation can also improve the poor survival prognosis and reduce the risk of emergency hospital readmission. Therefore, pulmonary rehabilitation is an essential component of evidence-based long-term management of both bronchial asthma and, in particular, COPD. In the German healthcare system, however, pneumological rehabilitation is offered only for a small fraction of patients. Despite a very good evidence of pulmonary rehabilitation, especially in COPD patients, their share in all rehabilitation services is remarkably low. It does not even amount to 3 % of all medical rehabilitation measures approved by the German Pension Insurance.

[COVID-19 and Smoking - A Position Paper by the DGP Taskforce for Smoking Cessation]

Tobacco smoking is associated with severe health risks. In 2020, the WHO estimated that 8 million people have died due to smoking. Furthermore, smoking tobacco is a well-known risk factor for various infectious pulmonary diseases. The question raised, whether smoking is facilitating SARS-CoV-2-infections and increases adverse outcomes of COVID-19. To answer these questions a narrative review was conducted, finally including 7 systematic reviews with meta-analyses published in January and February 2021. Tobacco smoking was associated with an increased COVID-19 disease severity (odds ratio range of active vs. never smokers 1.55-2.19 and former vs. never smokers 1.20-2.48) and an increased COVID-19 in-hospital mortality (odds ratio range of active vs. never smokers 1.35-1.51 and former vs. never smokers 1.26-2.58). Beside immediate pulmonary toxic effects through active smoking, the cumulative livelong tobacco exposition and subsequent tobacco-associated diseases seem to predominantly predict adverse outcomes in patients with COVID-19. Data regarding an increased risk of infection among smokers is conflicting. However, a large observational study from England with 2.4 million persons reported an association between tobacco smoking and typical symptoms of COVID-19. For e-cigarettes and vaping less data exist, but experimental and first clinical investigations also suggest an increased risk for adverse outcomes for their use and SARS-CoV-2 infections. Especially during the current SARS-CoV-2 pandemic with limited therapeutic options it is particularly important to advise smokers of their increased risks for unfavourable COVID-19 outcomes. Evidence based support for smoking cessation should be offered. In Germany, the existing and well-established methods to support tobacco cessation need to be reimbursed by statutory health insurances.

Smoking Cessation Attempts and Common Strategies Employed

BACKGROUND

Clinical guidelines on smoking cessation contain recommendations for various evidence-based methods. The goal of this study was to provide a represen- tative analysis for Germany of the percentage of smokers who try to quit smoking at least once per year, the use of evidence-based methods and other methods of smoking cessation, and potential associations of the use of such methods with the degree of tobacco dependence and with socioeconomic features.

METHODS

Data from 19 waves of the German Smoking Behavior Questionnaire (Deutsche Befragung zum Rauchverhalten, DEBRA), from the time period June/July 2016 to June/July 2019, were analyzed. Current smokers and recent ex-smokers (<12 months without smoking) were asked about their smoking cessation attempts in the past year and the methods they used during the last attempt (naming more than one method was permitted). The degree of tobacco dependence in current smokers was assessed with the Heaviness of Smoking Index.

RESULTS

Out of 11 109 current smokers and 407 recent ex-smokers, 19.9% (95% confidence interval: [19.1; 20.6]) had tried to quit smoking at least once in the preceding year. 13.0% of them [11.6; 14.5] had used at least one evidence-based method during their last attempt. The stronger the tobacco dependence, the more likely the use of an evidence-based method (odds ratio [OR] = 1.27 [1.16; 1.40]). Pharmacotherapy (nicotine replacement therapy, medication) was used more com- monly by persons with higher incomes (OR = 1.44 per 1000 euro/month [1.28; 1.62]). Electronic cigarettes were the most commonly used single type of smoking cessation support (10.2 % [9.0; 11.6]).

CONCLUSION

In Germany, only one in five smokers tries to quit smoking at least once per year. Such attempts are only rarely supported by evidence-based methods and are thus likely to fail. The high cost of treatment must be borne by the individual and thus fall disproportionately on poorer smokers. It follows that there is an urgent need for vered by health insurance pro- viders, in order to give all smokers fair and equal access to the medical care they need.

Public attitudes towards healthcare policies promoting tobacco cessation in Germany: results from the representative German study on tobacco use (DEBRA study)

OBJECTIVE

The aim of this study was to assess public acceptance of four possible healthcare policies supporting tobacco dependence treatment in line with the Framework Convention for Tobacco Control, Article 14 recommendations in Germany.

DESIGN

Cross-sectional household survey.

SETTING

Data were drawn from the German population and collected through computer-assisted, face-to-face interviews.

PARTICIPANTS

Representative random sample of 2087 people (>14 years) from the German population.

OUTCOME MEASURES

Public acceptance was measured regarding (1) treatment cost reimbursement, (2) standard training for health professionals on offering cessation treatment, and making cessation treatment a standard part of care for smokers with (3) physical or (4) mental disorders. Association characteristics with smoking status and socio-economic status (SES) were assessed.

RESULTS

Support for all policies was high (50%-68%), even among smokers (48%-66%). Ex-smokers and never-smokers were more likely to support standard training on cessation for health professionals than current smokers (OR 1.43, 95% CI 1.07 to 1.92; OR 1.43; 95% CI 1.14 to 1.79, respectively). Ex-smokers were also more likely than current smokers to support cessation treatment for smokers with mental disorders (OR 1.39, 95% CI 1.11 to 1.73). Men were less likely than women to support cessation treatment for smokers with physical diseases (OR 0.74, 95% CI 0.60 to 0.91) and free provision of treatment (OR 0.80, 95% CI 0.66 to 0.97). Offering cessation treatment to smokers with physical disorders was generally more accepted than to those with mental health issues.

CONCLUSIONS

The majority of the German population supports healthcare policies to improve the availability and affordability of tobacco dependence treatment. Non-smokers were more supportive than current smokers of two of the four policies, but odds of support were only about 40% higher. SES characteristics were not consistently associated with public acceptance.

TRIAL REGISTRATION NUMBER

DRKS00011322.

The Use of Tobacco, E-Cigarettes, and Methods to Quit Smoking in Germany

BACKGROUND

Current data on tobacco use are a necessary prerequisite for the study of the implementation of tobacco control measures in the general population. The German Study on Tobacco Use (Deutsche Befragung zum Rauchverhalten, DEBRA) provides previously lacking data on key indicators of smoking behavior and on the consumption of new products such as e-cigarettes. The continual acquisition and accumulation of data permits the analysis of trends and precise statistical evaluation.

METHODS

Data were obtained by repeated face-to-face interviews, at 2-month intervals, of representative samples of approximately 2000 persons across Germany aged 14 years and above. For this article, data from 12 273 persons that were acquired in 6 waves of the survey (June/July 2016 to April/May 2017) were aggregated and weighted.

RESULTS

The one-year prevalence of current tobacco consumption was 28.3% (95% confidence interval: [27.5; 29.1]) in the overall survey population and 11.9% [8.9; 14.9] among persons under age 18. Higher tobacco consumption was correlated with lower educational attainment and lower income. 28.1% of the smokers had tried to quit smoking in the past year; the most commonly used method of quitting was e-cigarettes (9.1%). Brief physician advice or pharmacotherapy for smoking cessation were tried by 6.1% and 7.0%, respectively. 1.9% of the overall survey population but only 0.3% of persons who had never smoked were current consumers of e-cigarettes.

CONCLUSION

Tobacco consumption is very high in Germany compared to other countries in Western and Northern Europe, and its distribution across the population is markedly uneven, with a heavy influence of socioeconomic status.

Advance care planning in severe COPD: it is time to engage with the future

Advance care planning should be part of our clinical routine in severe COPD http://ow.ly/Cshs30i8FS9.

[Choosing wisely together with the patient]

Within the framework of the Choosing wisely initiative of the German Society for Internal Medicine, all scientific societies associated with internal medicine were requested to highlight the unnecessary or underused medical tests or procedures out of the 60 defined examples, which are of immediate relevance within the doctor-patient interaction. Each of the 12 scientific internal medicine societies compiled and substantiated 2 recommendations. This resulted in a spectrum of important recommendations covering the entire field of internal medicine. In difficult situations these recommendations should contribute to developing and supporting the dialogue with patients on an evidence-based level.

Asthma management practices in adults--findings from the German Health Update (GEDA) 2010 and the German National Health Interview and Examination Survey (DEGS1) 2008-2011

OBJECTIVES

In Germany, population-wide data on adherence to national asthma management guidelines are lacking, and performance measures (PM) for quality assurance in asthma care are systematically monitored for patients with German national asthma disease management program (DMP) enrollment only. We used national health survey data to assess variation in asthma care PM with respect to patient characteristics and care context, including DMP enrollment.

METHODS

Among adults 18-79 years with self-reported physician-diagnosed asthma in the past 12 months identified from a recent German National Health Interview Survey (GEDA 2010: N = 1096) and the German National Health interview and Examination Survey 2008-2011 (DEGS1: N = 333), variation in asthma care PM was analyzed using logistic regression analysis.

RESULTS

Overall, 38.4% (95% confidence interval: 32.5-44.6%) of adults with asthma were on current inhaled corticosteroid therapy. Regarding non-drug asthma management, low coverage was observed for inhaler technique monitoring (35.2%; 31.2-39.3%) and for provision of an asthma management plan (27.3%; 24.2-30.7%), particularly among those with low education. Specific PM were more complete among persons with than without asthma DMP enrollment (adjusted odds ratios ranging up to 10.19; 5.23-19.86), even if asthma patients were regularly followed in a different care context.

CONCLUSIONS

Guideline adherence appears to be suboptimal, particularly with respect to PM related to patient counseling. Barriers to the translation of recommendations into practice need to be identified and continuous monitoring of asthma care PM at the population level needs to be established.

Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit

Chronic obstructive pulmonary disease (COPD), lung cancer, asthma and pulmonary tuberculosis are common pulmonary diseases that are caused or worsened by tobacco smoking. Growing observational evidence suggests that symptoms and prognosis of these conditions improve upon smoking cessation. Despite increasing numbers of (small) randomised controlled trials suggesting intensive smoking cessation treatments work in people with pulmonary diseases many patients are not given specific advice on the benefits or referred for intensive cessation treatments and, therefore, continue smoking.This is a qualitative review regarding smoking cessation in patients with COPD and other pulmonary disorders, written by a group of European Respiratory Society experts. We describe the epidemiological links between smoking and pulmonary disorders, the evidence for benefits of stopping smoking, how best to assess tobacco dependence and what interventions currently work best to help pulmonary patients quit. Finally, we describe characteristics and management of any "hardcore" smoker who finds it difficult to quit with standard approaches.