An important factor in treatment is focusing on active reduction of risk factors, especially smoking. The 5 As can help begin the process. The 5 As are: Ask, Advise, Assess, Assist and Arrange.

Ask patients if they smoke, or have ever smoked. If the response is “yes,” advise them to quit. Clinical studies on smoking cessation show that patients often report that their health care provider knew they smoked, but didn’t say anything about it. In my practice I always tried to remember to tell my patients to stop smoking, but some of them have told me I didn't do enough. Now, every time I see them, I remind them that they have to quit smoking. More important, you have to assure patients that they are not going to be alone. You are going to work on this together.

Assess the patient's willingness to make a quit attempt. Assist them in the quit attempt, and then Arrange for a follow-up. These 5 As are essential for understanding the principles of smoking cessation. When you ask and you know they have the disease and then you advise they have to stop smoking, you try to identify and assess the willingness of the patient to quit. Then you’re going to provide support, assisting the patient to quit as well and arranging follow-up. This is not something the patients are going to do alone, this is what the patients are going to do working with you. You’re going to do it together, understanding the need to remove this important risk factor of COPD.

You Ask, you Advise, but how can you help the patient stay motivated to quit smoking? The tobacco prevention and dependency guidelines published by the CDC (see Resources) and the National Institute of Health have established what is called the 5 Rs, to increase an individual’s motivation to cease smoking. They are Relevance, Risks, Rewards, Roadblocks and Repetition. We will go over these because they are going to be essential when you establish your patient's plan for smoking cessation.

The first R is Relevance. Encourage patients to identify why quitting is relevant. It’s relevant for their condition. It is relevant for the people around them.

Risks. Ask the patient to identify potential negative consequences of tobacco use like being short of breath, having heart disease, developing cancer. Point out it’s a bad role model for young people. Today we also recognize the effects of secondhand smoke on people around smokers. We know that children of parents who are smokers are more likely to develop chronic airway disease, more likely to develop asthma, more likely to have more bronchitis when they are in their 20s and it carries over to their 40s and 50s.

Rewards. Ask the patient to identify potential benefits of stopping tobacco use. They are going to cough less, improve their exercise capacity, live longer, and they are going to save money. It’s very expensive to smoke today.

Roadblocks. Sit with your patients and identify the potential barriers to smoking cessation, impediments to quitting. It’s not going to be an easy road. They are going to have to work hard, but in the end it is going to be very fruitful for them.

Repetition is the fifth R. Repeat this message at each interaction. Every time you see your patients you have to do the 5 As and the 5 Rs. You need to ask “do you continue to smoke?” If the answer is yes, you need to give them reasons why they have to be motivated to stop smoking.

I tell my patients that smoking cessation is a combination of behavior modification and pharmacotherapy. Using pharmacotherapy alone is not going to do the job. Behavior modification or support groups alone are not going to work. You have to marry both of these interventions. Smoking is a habit that is part of the patient's way of life. Just like the way they walk, the way they talk, the way they comb their hair, smoking is a part of them. So, they need to identify where they smoke and what they do when they smoke. Then you have to start behavioral interventions. There is a lot of support for people trying to quit smoking. There is support on-line, there are 24-hour support telephone numbers, there are support groups and other support programs.

Clinical studies for pharmacological interventions have been very successful in showing that smoking cessation can be achieved. There is considerable evidence to support the view that cigarette smoking is primarily maintained by an addiction to nicotine. Nicotine creates a dependency and as a consequence of that, we can intervene in different ways.

There are five forms of nicotine replacement therapy: the nicotine gum, the patch, the nasal spray, the inhaler, the lozenge. My recommendation, based on what I prescribe for my patients, is to give either a gum or a nasal spray to use when patients feel the urge to smoke. It provides the acute relief and acute satisfaction experienced when they smoke.

Buproprion, an antidepressive, has demonstrated efficacy in clinical studies. More recently the Cochrane study looked at interventions with a new drug, varenicline, that have demonstrated that it is more effective than buproprion in smoking cessation.

Varenicline is a non-nicotinic agent. The mechanism of action is a partial agonist of the nicotine receptor in the brain. This is the area in the brain where patients receive satisfaction and that is where nicotine attaches when the patient smokes. This compound is an agonist that blocks that receptor so the patient has already experienced the satisfaction. There are two placebo controlled trials that demonstrate in a continuous abstinence the superiority of varenicline versus buproprion when it is given, and the studies show different designs. In one clinical study the patients received the medication for up to twelve weeks. In the other clinical study the patients received another course of therapy three months after they had stopped smoking. The second study concluded that varenicline is more efficacious against placebo, nicotine replacement, and buproprion. More important, it proved that after your patient has stopped smoking if you repeat the course of therapy three months later, at the end of the year the patient will be more likely to have stopped smoking.

In any discussion of pharmacotherapy it is essential to first review treatment goals. The GOLD guidelines as well as those of the ACP, the American College of Family Physicians and many other primary care and specialties organizations, have established goals for therapy for COPD. We want to prevent disease progression. We want to relieve the symptoms, but at the same time we want to improve the health status. We want to increase exercise tolerance. We want to prevent and treat exacerbations and treat complications. We want to prevent or minimize side effects from treatment.

At the end of the day what we want to do is change the course of the disease. We would like to prolong survival with a better quality of life. We want to decrease mortality. To achieve all this, we also want to minimize any treatment related adverse events. The goals GOLD has developed are very different from what we had ten years ago. In the past, our goals were to make the patient feel better, to breathe better for four to six hours. We didn’t understand the implications of having the long-acting bronchodilators we have now. We never thought that we could change the goals of the treatment of this disease. Now we have broadened the goals and we can impact the course of COPD. Achieving these goals is possible today because of the tools, pharmacotherapies and interventions that we now have available to us.