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Tobacco and Asthma

Mini Lecture 3
Module: Tobacco effects on respiratory system

Objectives of the Module

GOAL OF MINI LECTURE: Provide students with knowledge
on the harmful effects of tobacco on asthma, and skill to
address smoking and to provide smoking cessation
counseling for asthma patients and their parents

Learners will be able to:
Understand the burden of smoking among asthma patients
Understand the association between smoking and asthma,
and impact of smoking on asthma management and
Conduct counseling to encourage asthma patients or their
parents to quit smoking


Tobacco and asthma

Mini Lecture 3
Module: Tobacco effects on respiratory system

Global Burden of Adult Asthma

In 2001, asthma was the 25th leading cause of DALY lost.

Global prevalence of clinical asthma ranged from 0.7% in

Macau to 18.4% in Scotland
The highest case-fatality rate of asthma: in China (36.7
deaths per 100,000 population).
Prevalence of clinical asthma in South East Asia: 3.3%

Access to asthma treatment is poor in many low-income

countries in African region.
(Global Initiative for Asthma, 2004; WHO, 2007)

Impact of active smoking on

asthmatic patients
Smoking induces bronchial and peripheral airways
inflammation signalled by increased inflammatory cell
Smoking influences cytokines and mediators production
increased IL-8, decreased IL-18, reduced eNO levels
Severe airway remodelling alteration of mechanical
properties of the airway wall
Smoking might influence immunological response to
allergen in asthma

(Thomson et al., 2004)

Impact of passive smoking on

asthmatic patients
Environmental tobacco smoke (ETS) is a risk factor for
developing asthma and having severe asthma attack.
Exposure to ETS doubles the prevalence of children with
asthma, and increases the risk of current asthma by 25%.
The National Childrens Health Survey in the US showed a
statistically significant association between household
smoking and risk of asthma, independent of outdoor quality
and socio-economic level.
In-utero smoke exposure from maternal smoking reduces
respiratory function and increase the chance of wheezing.
(Baena-Cagnani et al., 2009)

Smoking and quality of life in

children with asthma
Among children aged 13-14 years:
Active smoking did not associated with reported asthma,
however, it increased the chance of current wheeze
significantly by three folds (OR=2.9).
Exposure to active and passive smoking increased the
probability of doctor visit in the last 12 months,
independent of wheeze severity and treatment taken.
Exposure to passive smoking also increased school
absence and impairment of home activities.
Asthmatic children who smoked has 40% higher chance
of interference with physical education.
(Austin et al., 2005)

Smoking, cessation and asthma

Effects of smoking on asthma treatment
Reduced efficacy and therapeutic effects of
Increased clearance of theophylline by 58-100%
63% decrease of theophyllline half-life.
Effects of smoking in asthmatics are reversible
1 week smoking cessation can reduce the
theophylline elimination rate by 35%
Reversal of corticosteroid resistance following
improvement of peak expiratory flow
(Thomson et al., 2004; Adis Data Information BV, 2006)

Clinical approach for asthmatic

patient who smokes
Assessing and addressing smoking behavior is important
in clinical management of asthma patient
Exclude the diagnosis of COPD
First line therapy: smoking cessation
Second line therapy: Leucotriene receptor antagonist
(LRTA), theophylline, high dose inhaled corticosteroid (up
to 1600 g per day), or combination of inhaled
corticosteroid and long-acting 2-agonist or theophylline.
Need more evidences from drug clinical trials.
(Haughney et al., 2008)


Tobacco and asthma

Mini Lecture 3
Module: Tobacco effects on respiratory system

Global Burden of Children Asthma

The prevalence of children

with .
Current wheeze in last year

6-7 years

13-14 years

History of asthma



Severe asthma attack



In low-middle income vs. high income countries:

Lower prevalence of current wheeze
Higher prevalence of severe asthma episodes
(Lai et al., 2009)

Asthma in Indonesia
The prevalence of clinical asthma in Indonesia was 1.1%
This prevalence is the lowest in the Southeast Asia
region, compare to Thailand (6.5%), the Philippines
(6.2%) and Singapore (4.9%).
(Global Initiative for Asthma, 2009)

The prevalence of wheezing during the last 12 months:

- 2.1% in children aged 13-14 years
- 4.1% in children aged 6-7 years
(Mitchell and Stewart, 2001)

Mechanisms of steroid resistance

in asthma patients
- Pharmacokinetics: mucosal permeability and secretions
- Down-regulation of b2-adrenergic receptor function
- Changes in inflammatory cell phenotypes lead to
impaired responses of corticosteroid
- Changes in cytokine and mediators levels
- Changes in glucocorticoid receptor numbers or binding
- Overexpression of pro-inflammatory transcription factor
- Changes in corticosteroid cell-signalling systems
(Thomson et al., 2004; Thomson and Spears, 2005)

Smoking and health care utilization

among asthma patients
Compared to persistent-asthma patient who did not smoke,
patients who smoked are more likely to:
Report night-time symptoms (67% in smokers vs. 58% in
non-smokers, p<0.015).
Visit emergency department because of asthma
exacerbation (16% in smokers vs. 10% in non-smokers,
Go for hospitalization (18% in smokers vs. 11% in nonsmokers, p=0.004).
(Shavit et al., 2007)

Smoking and quality of life in

asthma patients
General Quality of Life or Asthma Control questionnaires
may inaccurately assess asthma patients quality of life.
The SF8 instrument provides better information.
Using the SF8, the National Health and Wellness Survey
in UK, Germany and France showed:
Non-smokers asthma patient has better mental health
component score than smokers (mean of 45.6 vs.
42.1, respectively, p<0.001)
Similar physical component score between smokers
and non-smokers (mean of 43.0 vs. 43.4, p=0.07)
(Shavit et al., 2007)