Cessation of smoking in COPD: a reality check

Abstract

I read with great interest the edifying and dispassionate commentary by Professor Don Tashkin [1] about our recent study [2]. Slowing down disease progression, reducing respiratory exacerbations, and improving quality of life are unmet needs in the management of patients with COPD. Cessation of smoking is the only proven method known to improve prognosis, but it is discouraging that most smoking cessation schemes do not seem to work for the vast majority of COPD smokers and that many COPD patients continue smoking despite their symptoms. Tobacco harm reduction is required as an alternative to the “quit or die” scenario. Patients with COPD who are having difficulty at stopping smoking should consider substituting conventional cigarettes with combustion-free nicotine delivery alternatives (i.e., e-cigarettes, and heated tobacco products). Although not risk-free, key literature reviews have acknowledged that these products release far less toxic emissions compared to combustible cigarettes [3, 4]. Our study evaluated health consequences of the use of heated tobacco products in COPD patients [2]. I agree with Tashkin that the study is rather small with a relatively limited follow-up duration of 3 years. However, the mantra of dismissing small sample size studies as fundamentally useless by default must cease. In the specific case of our study, not only results are consistently significant and clinically relevant throughout the whole duration of the study (in spite of the small sample size, suggesting that the possibility of chance findings is highly unlikely), but—and most importantly—findings were not unexpected. The conclusion is consistent with what we have learned about tobacco smoke chemical composition and COPD pathogenesis over the last 30–40 years, that we are almost certain that substituting tobacco cigarettes with non-combustible sources of nicotine (i.e., vaping or heated tobacco products) would produce significant improvement. Consequently, it is over simplistic to suggest that our study—which confirms what might reasonably be predicted—is inadequately powered to draw any conclusions. We already had a conclusion and near certainty about it. The same obvious conclusion was reached in another—also relatively small—study of COPD patients followed up for 5 years, in which tobacco smoking was replaced by the use of other combustion-free technologies (i.e., vaping products) [5]. Such switching studies accomplished the valuable scientific step of performing a reality check on the predictions using a different approach, just to make sure. This approach led to the expected results (i.e., switching looks a lot like just quitting, in terms of these outcomes). Only if such studies failed to produce the expected result, then sample size and/ or study duration should be seriously questioned. The innuendo that speculation about potential harms from the low-risk products implies that smoking cessation medications must be better is questionable. In fact, it cannot be overlooked that also drug therapies may cause harms. Last but not least, people are not just machines in need of fixing. Even if someone’s body might be a bit more functional under a quitting regimen, it is a reality that most people are likely to be a lot happier getting to continue to consume some product. And that is especially true for COPD patients for whom anything that can improve their quality of life should not be dismissed lightheartedly. * Riccardo Polosa [email protected]