Smoking cessation remains the single most effective intervention to slow the progression of COPD. Short-term benefits on lung function and quality of life are also seen. GPs should aim to identify all current, or relapsed, smokers at every consultation as each brief counselling intervention increases the chance of successful cessation by 5 to 10%.26 No single cessation plan works for all; a discussion is needed with each patient to find the best technique. As few smokers are successful in their first attempt at quitting, persistence by everyone is important. Smoking cessation is usually a long-term process rather than a single event, with episodes of relapse before long-term success is achieved. The five As can be used as a framework for helping patients to quit smoking (Box 3 and Box 4).27
Nicotine dependence is most effectively treated with a combination of nicotine replacement therapy (NRT), behavioural support and pharmacotherapy. NRT (available as a patch, gum, lozenge, sublingual tablet and inhaler) is widely available, and more than one form of NRT can be used concurrently with increased success rates and no safety risks. All forms of NRT monotherapy can increase the rate of quitting by 50 to 70%. Higher-dose forms of NRT (4 mg) are more effective than lower-dose forms (2 mg) for more addicted smokers.
Varenicline is a nicotinic receptor partial agonist that more than doubles the chances of quitting compared with placebo. Adverse effects include unusual mood change, depression, behaviour disturbance and suicidal thoughts. A Cochrane review found that varenicline helped about 50% more people to quit than nicotine patches and ‘other’ forms of NRT (tablets, sprays, lozenges and inhalers), and about 70% more people than nicotine gum.28 Combining two types of NRT was as effective as using varenicline, and helped more people to quit than single types of NRT.
Bupropion, a non-nicotine oral therapy, significantly increases cessation rates compared with placebo. It has been shown to be effective for smokers with depression, cardiac disease and respiratory diseases, including COPD. A recent Cochrane review found evidence that smokers with COPD who received a combination of high-intensity behavioural support and medication were more than twice as likely to quit as people who received behavioural support alone. It found no clear evidence that one particular form of behavioural support or medication is better than another.29
Influenza immunisation can reduce the incidence of serious illness and death in patients with COPD, and a significant reduction in the number of exacerbations has been seen in immunised patients.5,10 All patients with COPD should be offered annual influenza vaccination. Development of an immune response takes at least two weeks. The protective efficacy of the vaccine is largely determined by the closeness of the match between the circulating influenza virus strains and the vaccine, and will vary from year to year. One multicentre study suggested that influenza vaccine efficacy decreases in older adults as frailty increases.30 Despite this, a recent meta-analysis suggested that older adults receiving influenza vaccination may have a lower risk of influenza and lower respiratory tract infections than those not vaccinated.31 Repeat vaccination later in the influenza season may also be considered in the elderly and in those with underlying severe airways disease.
Previously, a history of anaphylaxis or a serious allergic reaction to eggs was an absolute contraindication to influenza vaccination. However, several studies now suggest that most people with an egg allergy, including anaphylaxis, can safely receive influenza vaccines that contain less than 1 mcg of ovalbumin per dose.32 Review of the guidelines of the Australasian Society of Clinical Immunology and Allergy and specialist opinion should be considered in these patients. Influenza vaccine should not be given to patients with a current febrile illness or history of Guillain-Barré syndrome.