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(Chest. 2005;128:3685-3687.)
© 2005 American College of Chest Physicians

High Cessation Rates of Cigarette Smoking in Subjects With and Without COPD*

Brigitte Willemse, MSc; Ivonne Lesman-Leegte, MSc; Wim Timens, MD, PhD; Dirkje Postma, MD, PhD and Nick ten Hacken, MD, PhD

* From the Departments of Pulmonology (Ms. Lesman-Leegte, Dr. Postma, and Dr. ten Hacken) and Pathology (Ms. Willemse and Dr. Timens), University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.

Correspondence to: Nick ten Hacken, MD, PhD, Department of Pulmonology, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands; e-mail: N.H.T.Ten.Hacken{at}int.umcg.nl


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background/objective: In general, smoking cessation programs have low success rates. We evaluated the effectiveness of a 1-year smoking cessation program. This program was part of a research project investigating the effects of smoking cessation.

Participants: In this longitudinal study on the effects of 1 year of smoking cessation, 38 smokers with COPD or chronic bronchitis (mean age, 55 years; 20 men) and 25 healthy subjects (mean age, 50 years; 11 men) who smoked on average 22 cigarettes per day were recruited.

Methods and results: An experienced nurse and a researcher conducted an intensive nonpharmacologic smoking cessation program based on 15 group meetings of 8 to 10 participants. A uniquely high number of 16 COPD or chronic bronchitis patients (42%) and 17 healthy subjects (68%) did not smoke 1 year after stopping smoking.

Conclusion: We suggest that frequent and intensive motivational support in a research setting accounts for the high cessation rates.

Key Words: asymptomatic smokers • COPD • smoking cessation


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Smoking cessation programs generally have low success rates. In a 1-year study on the differential effects of smoking cessation in COPD and healthy subjects, we offered an intensive nonpharmacologic smoking cessation program. Apart from effects on physiology and quality of life (to be reported elsewhere), effectiveness of the intervention program was evaluated.


   Materials and Methods
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 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Subjects
Smoking subjects with and without COPD or chronic bronchitis (defined according to the American Thoracic Society/European Respiratory Society task force, 2004) were recruited by means of advertisements and from our pulmonary outpatient clinic. Subjects were included into a research project studying the effects of smoking cessation on airway inflammation, which was approved by the local Medical Ethics Committee. All subjects gave written informed consent.

Study Design
Before entering the smoking cessation program, all subjects were characterized by pulmonary function tests, measurement of bronchial hyperresponsiveness, sputum induction (two times), quality-of-life and respiratory symptom questionnaires, cognitive dysfunction tests, and bronchoscopy. Subjects visited the hospital seven times before entering the smoking cessation program. During follow-up, sputum inductions were performed 2 months, 6 months, and 12 months after smoking cessation. After 12 months of smoking cessation, all baseline tests were repeated. Urinary cotinine levels were measured to verify smoking cessation at baseline, 2 months, 6 months, and 12 months after smoking cessation. Most measurements were conducted by one researcher (B.W.), and the duration of the measurements ranged from 1 to 2.5 h.

Smoking Cessation
Our 1-year smoking cessation program was originally developed by the Foundation for Community Health and Smoking in the Netherlands (Defacto). This program is based on cognitive behavioral therapy, in which aspects such as motivation and self-efficacy play an important role. In addition, the program focused on relapse prevention, based on the model of Marlatt.1 The behavioral program consisted of nine group meetings of 8 to 10 smokers during 6 weeks. The mean duration of each meeting was 2 h. After the second meeting, the subjects had to quit smoking. Meetings 2 to 6 were used to guide subjects through the cessation phase, while meetings 7 to 9 were used to maintain smoking cessation and focus on coping with side effects and difficult situations. The original program was extended for another six meetings throughout the rest of the year. Aside from mental support, the program paid particular attention to benefits of smoking cessation and how to cope with increasing weight. Individual telephone and/or personal support between the meetings was offered with easy access for the participants. A nurse specialist trained in asthma and COPD (J.L.L.) and a researcher (B.W.) conducted the program and provided the personal support between the meetings. A quitter was defined as someone who refrained from smoking for at least 1 year, with negative cotinine levels (ie, <25 ng/mL) at 2 months, 6 months, and 12 months after smoking cessation.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Thirty-eight smokers with COPD or chronic bronchitis and 25 asymptomatic smokers were included. Age and pack-years were significantly higher in COPD patients than in asymptomatic smokers (Table 1 ). The overall cessation rate was 52%. Sixteen COPD patients (42%) and 17 asymptomatic smokers (68%) did not smoke 12 months after the first cessation day (Fig 1 ), as confirmed by urinary cotinine levels.


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  		Table 1.. Characteristics of Participating Subjects*

 


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  		Figure 1.. Cessation rates 2 months, 6 months, and 12 months after smoking cessation in subjects with and without COPD or chronic bronchitis.

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
In this 1-year study on the effects of smoking cessation, we offered smokers with and without COPD an intensive nonpharmacologic smoking cessation program. Uniquely high cessation rates were obtained both in smokers with COPD or chronic bronchitis (42%) and asymptomatic smokers (68%).

Surprisingly little data are available in the literature on smoking cessation in COPD. A Cochrane analysis described two small randomized controlled trials using psychosocial intervention.2 Brandt et al3 used the diagnosis "smokers lung" to encourage smoking cessation and reported a 1-year cessation rate of 40%. Pederson et al4 used individual counseling and a self-help manual and reported a 6-month cessation rate of 33%. Two large randomized controlled trials combined psychosocial and pharmacologic treatment; one study5 reported a 1-year cessation rate of 34%, and the other6 reported a half-year cessation rate of 16%. Thus, cessation rates of our program exceeded all success percentages previously reported. This difference is not easily explained, since in other studies the provided information about the smoking cessation intervention, eg, intensity of person-to-person clinical contact, total time of group sessions, type of counseling and behavioral therapies, was very limited. In addition, the severity of COPD of the participants varied between the studies, although this could not explain the differences observed. An explanation for the difference in success rates between our study and previous ones could be that our participants were better motivated to quit smoking. Unfortunately, we and others have not used a valid instrument to assess motivation.

With respect to the factors leading to the high cessation rates of this study, we hypothesize the following. Firstly, our subjects were offered a high number of group sessions conducted by a nurse trained in smoking cessation guidance and a motivated researcher. Secondly, easily accessible telephone or personal contacts allowed intensive support to persist in smoking cessation. Finally, we think the research setting may have made the participants feel responsible for a favorable study outcome. The frequent lung function and other measurements were appreciated by all participants and may have contributed as well. Additionally, most of the measurements were conducted by the researcher and this was another opportunity to give the participants extra advice/support before the smoking cessation program started and during the rest of the year. In total, all participants attended 15 group meetings for the smoking cessation program, 7 hospital visits before the program started and 3 hospital visits throughout the year (after 2 months, 6 months, and 12 months). We therefore suggest that the frequent and intensive contacts in a dedicated research project may constitute an optimal setting to obtain high cessation rates.

Consequently, the question rises whether other researchers and health-care workers could have more benefit from our finding that a smoking cessation program for COPD patients in a research or research-like setting seems to have two major advantages. First it is possible to reach unexpectedly high cessation rates in a research setting, and secondly it meets the increased need for studies investigating the effect smoking cessation in COPD. This is important as there are few studies on smoking cessation in COPD and the available studies have not focused on interesting new outcome variables for COPD such as exacerbation frequency, exercise tolerance, muscle depletion, and systemic inflammation.

We therefore put the challenge forward: who will take up the gauntlet?


   Acknowledgements
 
The authors thank Dr. A.E.J. Dubois for revising the manuscript.


   Footnotes
 
Funding was provided by the Dutch Asthma Foundation (NAF 37.97.74).

Received for publication January 17, 2005. Accepted for publication May 5, 2005.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Larimer, ME, Palmer, RS, Marlatt, GA (1999) Relapse prevention: an overview of Marlatt’s cognitive-behavioral model. Alcohol Res Health 23,151-160[ISI][Medline]
  2. van der Meer, RM, Wagena, EJ, Ostelo, RW, et al Smoking cessation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2003;(2),CD002999
  3. Brandt, CJ, Ellegaard, H, Joensen, M, et al Effect of diagnosis of "smoker’s lung" [letter]. RYLUNG Group. Lancet 1997;349,253[CrossRef][ISI][Medline]
  4. Pederson, LL, Wanklin, JM, Lefcoe, NM The effects of counseling on smoking cessation among patients hospitalized with chronic obstructive pulmonary disease: a randomized clinical trial. Int J Addict 1991;26,107-119[ISI][Medline]
  5. Scanlon, PD, Connett, JE, Waller, LA, et al Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease: the Lung Health Study. Am J Respir Crit Care Med 2000;161,381-390[Abstract/Free Full Text]
  6. Tashkin, D, Kanner, R, Bailey, W, et al Smoking cessation in patients with chronic obstructive pulmonary disease: a double-blind, placebo-controlled, randomised trial. Lancet 2001;357,1571-1575[CrossRef][ISI][Medline]



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Home page
 Eur Respir JHome page
B. W. M. Willemse, N. H. T. ten Hacken, D. S. Postma, and W. Timens
From the authors
Eur. Respir. J., April 1, 2006; 27(4): 861 - 862.
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