Allergy Asthma Immunol Res.  2014 Mar;6(2):114-120. 10.4168/aair.2014.6.2.114.

Integrating Evidence for Managing Asthma in Patients Who Smoke

• Price D
• Bjermer L
• Popov TA
• Chisholm A

• KMID: 2260254
• DOI: http://doi.org/10.4168/aair.2014.6.2.114

Abstract

Cigarette smoking among asthma patients is associated with worsening symptoms and accelerated decline in lung function. Smoking asthma is also characterized by increased levels of neutrophils and macrophages, and greater small airway remodeling, resulting in increased airflow obstruction and impaired response to corticosteroid therapy. As a result, smokers are typically excluded from asthma randomized controlled trials (RCTs). The strict inclusion/exclusion criteria used by asthma RCTs limits the extent to which their findings can be extrapolated to the routine care asthma population and to reflect the likely effectiveness of therapies in subgroups of particular clinical interest, such as smoking asthmatics. The inclusion of smokers in observational asthma studies and pragmatic trials in asthma provides a way of assessing the relative effectiveness of different treatment options for the management of this interesting clinical subgroup. Exploratory studies of possible treatment options for smoking asthma suggest potential utility in: prescribing higher-dose ICS; targeting the small airways of the lungs with extra-fine particle ICS formulations; targeting leukotreines, and possibly also combinations of these options. However, further studies are required. With the paucity of RCT data available, complementary streams of evidence (those from RCTs, pragmatic trials and observational studies) need to be combined to help guide judicious prescribing decisions in smokers with asthma.

Keyword

Smoking; asthma; leukotriene receptor antagonists (LTRAs); small airways; inhaled glucocorticosteroids (ICS); extra-fine particle

MeSH Terms

Airway Remodeling
Asthma*
Humans
Lung
Macrophages
Neutrophils
Pragmatic Clinical Trials as Topic
Rivers
Smoke*
Smoking
Smoke

Figure

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  Fig. 1 Relationship between the number of cigarettes smoked per day and asthma control.3 Reproduced with permission from the Primary Care Respiratory Journal. Clatworthy J, Price D, Ryan D, Haughney J, Horne R. The value of self-report assessment of adherence, rhinitis and smoking in relation to asthma control. Prim Care Respir J. 2009;18(4):300-305. DOI: http://dx.doi.org/10.4104/pcrj.2009.00037.

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  Fig. 2 Mean (95%) difference between non-smokers and smokers with asthma in change in morning PEF (L/min) on different doses of inhaled beclomethasone. *P<0.01 for smokers with asthma vs non-smokers with asthma.26 Reproduced from Thorax, Tomlinson JEM, McMahon AD, Chaudhuri R, Thompson JM, Wood SF, Thomson NC. Efficacy of low and high dose inhaled corticosteroid in smokers versus non-smokers with mild asthma. 60:282-287. 2005. With permission from BMJ Publishing Group Ltd.

• 

  Fig. 3 Smoothed spline plot of percentage of days with asthma control by treatment group versus smoking history (in pack years; A) and FEV1 percent predicted at baseline (B).27 Reprinted from the Journal of Allergy and Clinical Immunology, 131(3). Price D, Popov TA, Bjermer L, Lu S, Petrovic R, Vandormael K, Mehta A, Strus JD, Polos PG, Philip G. Effect of montelukast for treatment of asthma in cigarette smokers. 2013;131(3):763-71. with permission from Elsevier.

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