Smoking cessation: time for action.
Authors: M J Jarvis
Journal: Thorax (1995)

Objective.To determine whether a program incorporating smoking intervention and use of an inhaled bronchodilator can slow the rate of decline in forced expiratory volume in 1 second (FEV') in smokers aged 35 to 60 years who have mild obstructive pulmonary disease.Design.Randomized clinical trial.Participants randomized with equal probability to one of the following groups: (1) smoking intervention plus bronchodilator, (2) smoking intervention plus placebo, or (3) no intervention.Setting.Ten clinical centers in the United States and Canada.Participants.A total of 5887 male and female smokers, aged 35 to 60 years, with spirometric signs of early chronic obstructive pulmonary disease.Interventions.Smoking intervention: intensive 12-session smoking cessation program combining behavior modification and use of nicotine gum, with continuing 5-year maintenance program to minimize relapse.Bronchodilator: ipratropium bromide prescribed three times daily (two puffs per time) from a metered- dose inhaler.Main outcome measures.Rate of change and cumulative change in FEV' over a 5-year period.Results.Participants in the two smoking intervention groups showed significantly smaller declines in FEV' than did those in the control group.Most of this difference occurred during the first year following entry into the study and was attributable to smoking cessation, with those who achieved sustained smoking cessation experiencing the largest benefit.The small noncumulative benefit associated with use of the active bronchodilator vanished after the bronchodilator was discontinued at the end of the study.Conclusions.An aggressive smoking intervention program significantly reduces the age-related decline in FEV' in middle-aged smokers with mild airways obstruction.Use of an inhaled anticholinergic bronchodilator results in a relatively small improvement in FEV' that appears to be reversed after the drug is discontinued.Use of the bronchodilator did not influence the long-term decline of FEV'.(JAMA 1994;272:1497-505) Writing in 1977, Fletcher and Peto suggested that "severe or fatal obstructive lung disease could be pre- vented by screening smokers' lung function in early middle age if those with reduced function could be induced to stop smoking".'The reasoning behind their view was straightforward.Observed declines in lung function with age were reduced in men who stopped smoking compared with those who continued to smoke, and reverted to the normal rate seen in non-smokers.2Similar arguments about preventing coronary heart dis- ease have also been advanced based on the reduction in observed risk of myocardial infarction in men who give up smoking.But sceptics could counter that those who elect to give up smoking are a self-selected group who may differ in ways relevant to risk of disease, so that observational studies may not provide a reliable guide to the value of smoking interventions.Only ran- domized trials can answer the question definitively.In the case of the Multiple Risk Factor Intervention Trial (MRFIT) no significant reduction in deaths from heart disease was seen in high risk men in the intervention condition by comparison with controls, although it was seen in those who stopped smoking compared with those who did not.3Similar findings emerged in that study regarding rate of decline in lung function.4Perhaps the main reason the MRFIT did not find an effect on death rates or on lung function was that the smoking intervention was not very successful in achieving ces- sation.5The Lung Health Study summarised in the introductory article, by contrast, has rightly been hailed S22