| Abstract [eng] |
Chronic Obstructive Pulmonary Disease is a major cause of chronic illness and premature death worldwide, affecting hundreds of millions and placing a substantial burden on healthcare systems. Cigarette smoking accounts for most cases in high income countries and remains the key modifiable driver of disease progression. Despite diagnosis, many patients continue to smoke. This reflects not simply a lack of willpower, but the complex neurobiological, psychological, and social basis of tobacco dependence, which is often more severe in patients with Chronic Obstructive Pulmonary Disease than in the general smoking population. This narrative review synthesises evidence on smoking cessation in patients with established Chronic Obstructive Pulmonary Disease. A structured search of PubMed, EMBASE, the Cochrane Library, and MEDLINE was conducted for studies published between 2000 and 2024, with inclusion of earlier landmark work where justified. The review includes randomised controlled trials, systematic reviews, meta analyses, and cohort studies, and evaluates pharmacological, behavioural, combined, digital, and pulmonary rehabilitation based interventions. The key finding is that smoking cessation is the most effective disease modifying intervention in Chronic Obstructive Pulmonary Disease. Evidence is consistent across study designs and populations. Smoking cessation slows the accelerated decline in forced expiratory volume in one second, reduces exacerbation frequency and severity, lowers hospitalisation rates, and improves quality of life. A survival benefit is evident even in severe disease, challenging the perception that cessation has limited value at advanced stages. Among pharmacological options, varenicline is the most effective single agent, achieving 12 month abstinence rates three to four times higher than placebo in disease specific trials. Concerns regarding neuropsychiatric safety have been addressed by the EAGLES trial. Combination nicotine replacement therapy and bupropion are effective alternatives when varenicline is not suitable. Across all treatments, combining medication with structured behavioural support produces better outcomes than pharmacotherapy alone and is recommended as standard care in current guidelines. Behavioural interventions, including brief clinician advice, motivational interviewing, cognitive behavioural therapy, and telephone support, all improve cessation outcomes. There is a clear relationship between intensity of support and success. Motivational interviewing is particularly relevant due to common ambivalence, fatalism, and self blame. Integrating cessation support into pulmonary rehabilitation is an underused but effective strategy. Important gaps remain. Patients with severe disease and psychiatric comorbidity are underrepresented in trials, long term data beyond 12 months are limited, and evidence for digital tools and electronic cigarettes remains uncertain. Overall, the evidence supports routine integration of smoking cessation into Chronic Obstructive Pulmonary Disease care, alongside screening for depression and anxiety and development of structured cessation pathways. |
