Smoking and Asthma

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Summary of practice points

Level of evidence
Brief smoking cessation advice from doctors delivered opportunistically during routine consultations improves quit rates. I
Set up a system to identify and document tobacco use in all patients. This can almost double the rate of clinician intervention and improves cessation rates among patients. II
Smoking cessation advice from all health professionals is effective in increasing quit rates. I
Follow-up is effective in increasing quit rates. I
Relapse prevention advice can reduce relapse rates. II
Telephone call-back counselling services (e.g. Quit program) are effective in assisting smokers who are ready to quit. II
Nicotine replacement therapy and bupropion sustained release are effective in helping motivated people to quit smoking. I
Regardless of the treatment setting, all forms of nicotine replacement therapy (e.g. gum, transdermal patches, nasal spray, inhaler, sublingual tablets) approximately double quit rates at 5- to 12-month follow-up, compared with placebo. I
In smokers who are highly nicotine-dependent, combinations of different forms of nicotine replacement therapy are more effective than one form alone. II
Bupropion sustained release is effective in smoking cessation. I
Acupuncture or hypnotherapy are ineffective in assisting smoking cessation. I
Offer pneumococcal vaccination to all smokers [√] 

Smoking ranks second after overweight as a major cause of premature death and illness among Australians.1 About one in two regular smokers dies of a smoking-related disease.2

People with asthma have even more reason than those without asthma to avoid smoking. In addition to the known adverse health effects of smoking in the general community, the fact that cigarette smoking worsens asthma and reduces the effectiveness of medication warrants serious efforts by health professionals and patients to eradicate smoking.

Smoking rates in Australia

About 19% of males and 16% of females over 14 smoke daily.3

  • Smoking rates are highest among people in their twenties: approximately one in four people aged 20-29 years smokes.3
  • Approximately 11% of teenagers (14-19 years) smokes daily or weekly.3

Although fewer Australians are smoking than in the past, smoking rates are now disproportionately high in particular groups.

  • Smoking rates are directly proportional to level of socioeconomic disadvantage. Of all demographic groups, smoking rates are highest among young men (18-34 years) living in the most socioeconomically disadvantaged areas.4
  • Indigenous people aged 18 years or over are twice as likely as non-Indigenous people to be current smokers.5 Approximately half (49%) of Indigenous Australians aged 15 years and over smoke daily.6 In comparison, approximately 17% of non-Indigenous Australians aged 14 and over smoke daily.3
  • Approximately 50%-80% of people with mental illness smoke.6,7
  • Approximately 17% of women report smoking while pregnant. Rates of smoking during pregnancy are particularly high among teenagers (42%) and Aboriginal and Torres Strait Islander women (52%).8

Exposure to environmental tobacco smoke among children

  • Over 600,000 Australian children are exposed to tobacco smoke inside the home. Smoking inside the home is reported in approximately 12% of households with children under 14 years.1
  • Among children with asthma aged 14 years or less, 41% live in a household with one or more regular smokers and therefore risk potential exposure to cigarette smoke. In comparison, approximately 38% of children of the same age group without asthma live with one or more smokers.4
  • Among children with asthma, those from areas of relative socioeconomic disadvantage are most likely to be living with a regular smoker.4

Active smoking rates among people with asthma

Despite advice against smoking, people with asthma are no less likely to smoke than those without asthma.

  • Overall, 26% of people with current asthma smoke: 27% of males (compared with 28% of males without asthma) and 25% of females (compared with 21% of females without asthma).4
  • Among people with asthma, those aged 18-34 years are most likely to smoke.4

Effects of smoking on asthma

Effects of active smoking in people with asthma

People with asthma who smoke suffer additional morbidity.

  • People with asthma who smoke experience more respiratory symptoms, worse asthma control, more airway inflammation, an inferior short-term response to inhaled corticosteroid treatment, and an accelerated decline in lung function than those who do not smoke.4,9
  • Smoking increases the risk of chronic obstructive pulmonary disease (COPD). In people with asthma, this can result in overlapping of COPD symptoms with those of asthma, which can delay the diagnosis of COPD and complicate management. For more information see COPD and Asthma.

Emerging evidence suggests that smoking is causally associated with the development of adult-onset asthma.10,11

Effects of exposure to environmental tobacco smoke in people with asthma

Exposure to environmental tobacco smoke has been shown to contribute to a variety of health problems in children: respiratory infections, middle ear infections, onset and worsening of wheezing and asthma, impaired lung function, eye and nose irritation, low birth weight, sudden infant death syndrome and increased use of medical services.12

  • In utero exposure to cigarette smoke is associated with reduced lung function13 and increased risk of respiratory illnesses including wheeze14 and asthma.15
  • The link between exposure to environmental tobacco smoke in early childhood and increased risk of respiratory illnesses, including asthma, has been well documented in epidemiological studies.15
  • Exposure to environmental tobacco smoke aggravates pre-existing asthma in children, and contributes to approximately 8% of childhood asthma in Australia (46,500 children). Children of mothers who smoke heavily (more than 10 cigarettes per day are most at risk.16
  • In adults, exposure to cigarette smoke has been shown to increase asthma morbidity.17

Make the car and home a smoke-free zone

Health professionals and parents should aim for a smoke-free home for all children, including those with asthma. Where children with asthma live in households with at least one smoker, an absolute ban on smoking inside the home has been shown to reduce levels of nicotine in the air and to reduce levels of cotinine (a breakdown product of nicotine) in children's urine.18

Mechanisms for effects of smoking on asthma

Increased bronchial hyperresponsiveness and increased levels of atopy are the mechanisms most likely to explain the onset or worsening of asthma due to tobacco smoke exposure.

  • Among children with asthma, those with mothers who smoke show greater variability in peak expiratory flow rates over a 24-hour period19 and have airways that are more sensitive to adverse pharmacological or physical stimuli.20
  • Rates of atopy are higher among children of smoking mothers than children of non-smoking mothers.21, 22 Biological markers of atopy (e.g. elevated serum immunoglobulin levels) are observed more frequently in children exposed to environmental tobacco smoke than in unexposed children.23
  • In utero exposure to environmental tobacco smoke may adversely modify neonatal immune responses.24,25
  • Importantly, cigarette smoking also reduces the efficacy of inhaled corticosteroid (ICS) treatment in people with asthma. Following ICS treatment, smokers appear to achieve less benefit than non-smokers according to asthma exacerbations, lung function measures and inflammatory markers.26,27

Practice tip

Tell patients that their preventer treatment cannot work properly if they smoke.

Clinical interventions to help patients quit smoking

Advice given during primary care consultations, even if brief, can effectively influence patients to quit (Figure 1). Information and advice should be tailored to the patient's circumstances and preferences and may involve directing the person to Quitline, formal referral to a Quit program, or counselling by a GP, practice nurse or pharmacist.

For more information on smoking cessation, see SNAP guidelines (PDF, 955KB)  by the Royal Australian College of General Practitioners.

The Lifestyle prescriptions tools developed for the Australian Government Department of Health and Ageing offer a suggested structure for assessing and dealing with smoking cessation issues in general practice, and can be incorporated into organisational systems that involve GPs, practice nurses and administrative staff.

Advice and counselling

Practice points
  • Brief smoking cessation advice from doctors delivered opportunistically during routine consultations improves quit rates. (I)
  • Set up a system to identify and document tobacco use in all patients. This can almost double the rate of clinician intervention and improves cessation rates among patients. (II)
  • Smoking cessation advice from all health professionals is effective in increasing quit rates. (I)
  • Follow-up is effective in increasing quit rates. (I)
  • Relapse prevention advice can reduce relapse rates. (II)
  • Telephone call-back counselling services (e.g. Quit program) are effective in assisting smokers who are ready to quit. (II)
  • Offer pneumococcal vaccination to all smokers [√]

Health professionals can effectively help people to quit smoking.

  • Brief advice from a doctor to stop smoking, given during a routine consultation, achieves a small increase in the proportion of patients who successfully quit smoking during the following 6-12 months.28
  • Simply establishing a system to identify smokers is associated with an abstinence rate of 6.4% at six months follow-up. Instituting a system to identify and document tobacco use almost doubles rate of clinician intervention and results in higher rates of cessation.2
  • Asking smokers how they feel about smoking and whether they are ready to quit helps identify a suitable approach.2
  • All smokers should be advised to quit in a way that is clear and unambiguous. Health professionals should provide this advice in a way that is supportive and non-confrontational.2
  • There is clear evidence that patients are more likely to succeed in smoking cessation if followed up, e.g. within the first week of the quit attempt and at about one month after quit day. Relapse prevention advice can reduce relapse rates.2
  • Telephone call-back counselling services (e.g. Quit program) are effective in assisting smokers who are ready to quit. Telephone counselling can also be effective in assisting cessation in smokers who are not ready to quit.2

Pneumococcal vaccination

All smokers should be offered pneumococcal vaccination, regardless of their readiness to quit, because of the increased risk of invasive pneumococcal disease.29

Drug therapy

Practice points
  • Nicotine replacement therapy and bupropion sustained release are effective in helping motivated people to quit smoking. (I)
  • Regardless of the treatment setting, all forms of nicotine replacement therapy (e.g. gum, transdermal patches, nasal spray, inhaler, sublingual tablets) approximately double quit rates at 5- to 12-month follow-up, compared with placebo. (I)
  • In smokers who are highly nicotine-dependent, combinations of different forms of nicotine replacement therapy are more effective than one form alone. (II)
  • Bupropion sustained release is effective in smoking cessation. (I)
  • Acupuncture or hypnotherapy are ineffective in assisting smoking cessation. (I)

Nicotine replacement therapy and bupropion sustained release are effective in helping motivated people to quit smoking. Smokers using pharmacotherapy should be encouraged to use it for a sufficient period (8 weeks with nicotine replacement therapy and at least 7 weeks with bupropion sustained release).2

  • Regardless of the treatment setting, all forms of nicotine replacement therapy approximately double quit rates at 5- to 12-month follow-up, compared with placebo. Nicotine gum, nicotine transdermal patches, nicotine nasal spray, nicotine inhaler and nicotine sublingual tablets are all effective.2
  • In smokers who are highly nicotine-dependent, combinations of different forms of nicotine replacement therapy are more effective than one form alone. Combination nicotine replacement therapy should be offered if patients are unable to remain abstinent or continue to experience withdrawal symptoms using one type of therapy.2
  • Bupropion sustained release is effective in smoking cessation, both alone and in combination with nicotine replacement therapy. Combination treatment with bupropion and nicotine patch should be considered for those who have not achieved smoking cessation during an adequate trial of either therapy alone. Blood pressure should be monitored during treatment.2

Other strategies for quitting

  • Introducing smoking restrictions into the home can assist quitting smoking successfully.2
  • Acupuncture or hypnotherapy are ineffective in assisting smoking cessation.2

Information for smokers is available at www.quitnow.gov.au

Figure 1. GP time expenditure for smoking cessation30-32

Adapted from Lifescripts Division Kit30
*Estimated increase in quit rates over 12 months among patients attending the practice, compared with not applying the intervention.

Practice tips

Supportive organisational infrastructure (no consulting time)

  • Set up a system for routine systematic identification of patients' smoking status
  • Flag patient records with smoking status and interest in quitting
  • Place self-help materials in waiting areas
  • Display ‘stop smoking' posters
  • Train all practice staff to promote Quitline

Brief intervention (< 1 minute)

  • Discuss patient's smoking status
  • Assess person's motivation to quit and nicotine dependence
  • Affirm decision to quit
  • Give brief advice and support
  • Offer written self-help materials
  • Negotiate a separate smoking cessation appointment
  • Refer the person to Quitline

Further intervention (≤ 5 minutes' consulting time)

  • Assess barriers to quitting and confidence to attempt quitting
  • Take a quit history
  • Help the person identify high-risk situations
  • Help the person explore motivation to quit
  • Give advice on dependence, habit, triggers and dealing with negative emotions
  • ‘Brainstorm' with the person to find solutions to barriers
  • Prescribe drug treatment (e.g. nicotine replacement therapy, bupropion)
  • Offer ongoing support and referral to Quitline
  • Organise a follow-up appointment

Intensive intervention (full consultation time)

  • Use motivational interviewing techniques to explore the person's motivations, sources of ambivalence and confidence about quitting
  • Discuss drug treatments
  • Help the person develop a plan for quitting
  • Plan ongoing support

Adapted from National Quality Committee of the RACGP 2005 31

Key points

Recommendations from current smoking cessation guidelines for Australian general practice2

  • Set up and use a system for identifying all smokers who visit the practice.
  • Offer all smokers brief advice to quit.
  • Assessment of the person's readiness to quit is a valuable step in planning treatment.
  • Offer brief cessation advice during routine consultations whenever possible (at least once a year).
  • Offer follow-up to all smokers attempting to quit.
  • Offer relapse prevention advice to all smokers attempting to quit.
  • Where you cannot offer smokers adequate counselling within the practice, offer referral to other services.
  • In the absence of contraindications, offer nicotine replacement therapy or bupropion to all motivated smokers who have evidence of nicotine dependence. The choice of pharmacotherapy is based on clinical suitability and patient choice.
  • Based on the available evidence, acupuncture and hypnotherapy are not recommended as aids to smoking cessation.

For more information, including a full list of recommendations see Smoking Cessation Guidelines for Australian General Practice.

Public policy

Australian public policy initiatives are vitally important to reduce smoking rates and, consequently, exposure to environmental tobacco smoke. Smoking policy should be informed by documented evidence for influences on smoking uptake and quitting.

Influences on smoking uptake

  • Parental smoking strongly influences the likelihood of children taking up regular smoking,33,34 while keeping the home smoke-free reduces children's chances of taking up the habit.35
  • Addiction to nicotine at age 15 years carries a high risk of continuing to smoke beyond 35 years. Smoking at age 35 years carries a cumulative 50% of premature death and reduced healthy years of life.36,37

Promotion of smoking cessation

Public policy initiatives that are effective in reducing smoking include the following:

  • Comprehensive bans on tobacco advertising and promotion, prominent warning labels, restrictions on smoking in public places, and increased access to nicotine replacement treatments 36,38
  • Tax increases that raise the price of cigarettes36,38
  • Improvements in the quality and extent of information on smoking-related health risks.

The Royal Australasian College of Physicians and the Royal Australian and New Zealand College of Psychiatrists advocate the adoption and implementation of a range of policies on smoking by Australian state and territory governments.36 These include:

  • encouraging medical practitioners and healthcare institutions to diagnose smoking as a major health condition
  • supporting smoking cessation programs by subsidising professional services and pharmaceuticals
  • supporting medical schools in systematically training medical students in smoking cessation interventions.

For a comprehensive list of RACP policies, see The Royal Australasian College of Physicians and the Royal Australian and New Zealand College of Psychiatrists. Tobacco policy: using evidence for better outcomes. Sydney: RACP and RANZCP, 2005.36