Cost-benefit analysis of funding smoking cessation before surgery.

BACKGROUND: Smoking at the time of surgery is associated with postoperative complications. Quitting smoking before surgery is linked to fewer complications during the hospital stay. This work analysed whether a smoking cessation intervention before surgery is economically worthwhile when funded by the National Health System (NHS) in Spain. METHODS: The economic analysis considered costs and benefits of the intervention to the NHS for the year 2016. The population who would benefit comprised adult smokers who were ready to quit and for whom surgery requiring admission to hospital was planned. The intervention, a combination of medical counselling and use of a smoking cessation drug which should occur 12 weeks before surgery, considered one attempt only to quit smoking. Benefits were costs avoided by averting postoperative complications if cessation was successful. The analysis compared the net economic outcome (benefit minus cost of intervention) and the return on investment, for intervention funded by the NHS versus the current situation without funding. RESULTS: Smoking cessation increased by 21·7 per cent with funding; the rate was 32·5 per cent when funded versus 10·7 per cent without funding, producing 9611 extra quitters. The cost per averted smoker was €1753 with a benefit of €503, achieving a net economic benefit of €4·8 million per year. Given the annual cost of the intervention (€17·4 million, of which €5·6 million (32·5 per cent) represents drugs), the return on investment was 28·7 per cent annually, equivalent to €1·29 per €1 of investment. CONCLUSION: From the perspective of the Spanish NHS, the benefit of funding smoking cessation before surgery, in terms of healthcare cost savings, appears to greatly outweigh the costs.

ANTECEDENTES: Ser fumador activo hasta el momento de la cirugía se asocia con complicaciones postoperatorias. Se ha descrito una disminución de las complicaciones durante la hospitalización al abandonar el hábito de fumar antes de la cirugía. Este trabajo analizó si una intervención preoperatoria para dejar de fumar es económicamente beneficiosa cuando se financia por el Sistema Nacional de Salud (SNS) en España. MÉTODOS: En el análisis económico se consideraron tantos los costes como los beneficios de la intervención para el SNS, en euros, correspondientes al año 2016. La población que se beneficiaría eran fumadores adultos dispuestos a dejar de fumar, en los que se programase una intervención quirúrgica con hospitalización. La intervención, una combinación de asesoramiento médico y tratamiento farmacológico para dejar de fumar, se llevó a cabo a las 12 semanas antes de la cirugía, considerando únicamente un intento para dejar de fumar. Los beneficios fueron los costes evitados por una reducción en la tasa de complicaciones postoperatorias en los casos en los que se hubiese conseguido la eliminación del hábito. El análisis comparó el resultado económico neto (beneficio menos coste de la intervención) y el retorno de la inversión (return on investment, ROI), cuando la intervención era financiada por el SNS en comparación con la situación actual sin financiamiento público. RESULTADOS: La tasa de abandono del hábito tabáquico aumentó en un 21,8%; 32,5% cuando se financiaba frente al 10,7% sin financiación, consiguiendo un extra de 9.611 personas que dejaron de fumar. El coste por fumador rescatado fue de €1753 con un beneficio de €503, por lo que el beneficio económico neto conseguido fue de €4,8 millones por año. Dado que el coste anual de la intervención (€17,4 millones, de los cuales €5,6 millones corresponden a fármacos (32%)), el ROI anual fue del 28,7% con un beneficio de €1,29 por cada €1 de inversión. CONCLUSIÓN: Desde la perspectiva del SNS español, los beneficios de financiar el abandono del hábito de fumar en el preoperatorio de los pacientes, en términos de ahorro de costes parecen ser muy superiores a los costes de la intervención.

Searching for phenotypes in smoking cessation treatment.

BACKGROUND: It is important to define smoking phenotypes according to different variables, such as age, sex and degree of dependence, for which available treatments could have different efficacies. OBJECTIVE: The main objective of our study was aimed at defining different combinations of these variables to allow the best possible treatment to be chosen in routine clinical practice. METHODS: We reviewed the clinical records of smokers who had been treated in our Smoking Cessation Service. In all cases, the treatment programme consisted of a combination of behavioural therapy and optional drug treatment. RESULTS: The group consisted of 3622 subjects, specifically 1757 men (48.5%). The mean age of the participants in the group was 48.11 ± 11.19 years. The mean score of the FTCD-questionnaire was 6.66 ± 2.38. In addition, 78% of the subjects smoked their first cigarette within 30 min after waking. For the total sample, continuous abstinence rate from 9 to 24 weeks was 57.7%. A multivariate analysis using the logistic regression model was implemented, and it showed that: (i) Nicotine Replacement Therapy was less effective in patients with high tobacco dependence, (ii) young subjects can be highly resistant to all treatments and (iii) subjects with low tobacco dependence can be treated with any treatment, but bupropion and varenicline provided the best results. CONCLUSION: It was possible to identify several smoking phenotypes in which different treatments have different efficacies.

Smoking cessation treatment for COPD smokers: the role of pharmacological interventions.

Because stopping smoking is such a pressing necessity for COPD smokers physicians should use smoking cessation treatments aggressively. For optimal efficacy smoking cessation in COPD smokers should combine behavioral and pharmacological treatments. Three types of pharmacological treatments are proven to be safe and effective: Nicotine Replacement Therapy (NRT), Bupropion and Varenicline. Use of NRT, bupropion or varenicline, single or in combination, at standard doses or at high doses, for 8-12 weeks or for more than 6-12 months have proven to help these patients to quit. For optimizing efficacy these medications can also be introduced some weeks before actual quitting. In COPD smoking patients that are not interested in stopping completely or abruptly these medications can be used to aid cessation in a more gradual way. Pharmacotherapy to aid cessation in COPD smokers have proven to be highly cost effective.

Smoking cessation treatment for COPD smokers: the role of counselling.

Smoking cessation is the only therapeutic intervention that can prevent COPD smokers from the chronic progression of their disorder. The most important intervention for helping these smokers to quit is a combination of counseling plus pharmacological treatment. The characteristics of the counseling should be different depending if this intervention is offered to smokers with a previous diagnosis of COPD or if the intervention is offered to smokers who have been recently diagnoses with COPD. The counseling of patients who have been recently diagnosed should include: a) explanation of the direct relationship between smoking and COPD, b) encouraging these patients to quit and c) using of spirometry and measurements of CO as a motivational tools. The counseling of patients who have been previously diagnosed should include: a) encouragement to make a serious quit attempt, b) an intervention that increases motivation, self-efficacy and self-esteem, c) and the intervention should also control depression and be directed to weight gain control.

Changing patterns in tobacco consumption among Spanish military personnel under stressful conditions.

OBJECTIVE: A study is made to determine the prevalence of smoking and its variation over time in a group of Spanish military personnel (MP) under stressful conditions. METHODS: A questionnaire specifically designed for this study was administered to the entire MP contingent assigned to Banghis province (Afghanistan) between July and October 2009. A descriptive analysis was made (p < 0.05, 95%CI). RESULTS: The study sample comprised 254 MP (males 239; mean age 32 years (SD 9)). A total of 39.8% (95%CI; 33.7 - 45.8) were smokers, while 3.1% (95%CI; 1.0 - 5.3%) were former smokers. Regarding smoking habit before and at the end of deployment, one-half (50.5%) of the smokers declared that they smoked the same as before, 20.8% more than before, and 18.8% less than before. In turn, 5.9% of the smokers claimed to have started to smoke in the course of deployment, while 4% of the former smokers declared that they had quit smoking. The MP who quit smoking were younger than those who began to smoke (24 +/- 5 vs 39 +/- 9 years, p = 0.038). Moreover, the heavy smokers (> or = 15 cigarettes/day) reduced tobacco consumption, while the less heavy smokers increased the habit (p < 0.0001). CONCLUSIONS: The prevalence of daily smokers is high among MP. The majority of smokers smoke the same at the end of deployment. Those who quit smoking during the mission are significantly younger than those who begin to smoke. In turn, heavy smokers reduced their habit, while less heavy smokers increased smoking.

Recent trends in COPD prevalence in Spain: a repeated cross-sectional survey 1997-2007.

We aimed to describe changes in the prevalence of chronic obstructive pulmonary disease (COPD) in Spain by means of a repeated cross-sectional design comparing two population-based studies conducted 10 yrs apart. We compared participants from IBERPOC (Estudio epidemiológico de EPOC en España) (n = 4,030), conducted in 1997, with those of EPI-SCAN (Epidemiologic Study of COPD in Spain) (n = 3,802), conducted in 2007. Poorly reversible airflow obstruction compatible with COPD was defined according to the old European Respiratory Society definitions. COPD prevalence in the population between 40 to 69 yrs of age dropped from 9.1% (95% CI 8.1-10.2%) in 1997 to 4.5% (95% CI 2.4-6.6%), a 50.4% decline. The distribution of COPD prevalence by severity also changed from 38.3% mild, 39.7% moderate and 22.0% severe in 1997, to 85.6% mild, 13.0% moderate and 1.4% severe in 2007, and in the 40-69 yr EPI-SCAN sub-sample to 84.3% mild, 15.0% moderate and 0.7% severe. Overall, underdiagnosis was reduced from 78% to 73% (not a significant difference) and undertreatment from 81% to 54% (p<0.05) within this 10-yr frame. The finding of a substantial reduction in the prevalence of COPD in Spain is unexpected, as were the observed changes in the severity distribution, and highlights the difficulties in comparisons between repeated cross-sectional surveys of spirometry in the population.

[Bibliometric analysis of IBERPOC and EPI-SCAN studies. Contribution of the smoking variable on the iberpoc study]. / Análisis bibliométrico de los estudios IBERPOC y EPI-SCAN. Contribución de la temática tabaquismo al estudio IBERPOC.

OBJECTIVES: The aim of this study was to perform a bibliometric analysis of EPI-SCAN and IBERPOC studies using the Science Citation Index and Scopus databases, and to determine the overall impact with the impact of smoking on IBERPOC as a secondary objective. METHOD: A general searching was conducted in Science Citation Index-Expanded through the Web of Science (WoS) (Thomson Reuters) platform and Scopus on 23 March 2015. The search strategy included the terms "iberpoc" OR "episcan" was performed on 15 October 2015. RESULTS: A total of 24 publications were obtained; 13 from IBERPOC study (9 on "COPD" and 4 for "tobacco"), with 11 from the EPI-SCAN (All COPD) study. A total of 841 WoS citations were obtained (445 IBERPOC [99 of tobacco]), and 1,442 from Scopus (963 IBERPOC [144 tobacco]). The theme "tobacco" contributed with 22.24% and 14.95% of total citations in WoS and Scopus, respectively to the IBERPOC study. It was found that Scopus citations were newer, and a similar impact from both WoS studies was detected, although the IBERPOC impact was greater in Scopus. Collaborative networks of institutions and authors of both studies were identified. CONCLUSIONS: There is an important productivity and impact of both studies. Scopus citations are newer than those in WoS. The "tobacco" variable added IBERPOC impact and visibility. There was high density, accessibility, and cohesion in collaborative networks of both studies.

[Analysis of quality of life in patients with Chronic Obstructive Pulmonary Disorder (COPD) who give up smoking]. / Análisis de la calidad de vida en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) que dejan de fumar.

OBJECTIVE: To analyse the impact in COPD patients' quality of life who stop smoking. PATIENTS AND METHODS: We studied a group of COPD patients who received smoking cessation treatment. All patients were treated with bronchodilators according to the severity of their disorder. This treatment was not changed during the process of smoking cessation. Patients received a smoking cessation programme that consisted of a combination of pharmacological treatment plus cognitive-behavioural treatment. All subjects fill in CAT questionnaire before starting smoking cessation programme and after 6 months of abstinence. All subjects included had stop smoking. RESULTS: The study included 59 patients, with 27 (45.8%) males, and a mean age of 61.8 (7.5) years. Mean CAT score before quitting was 18.9 (7.3) points, and after 6 months of abstinence was 8.1 (6.1) points, P=.038. Multiple regression analysis showed: a) the higher the baseline CAT score the greater is the difference after quitting, at 6 months, at same age, gender, and grade of severity of COPD, and b) the older the age, the lower is the difference between baseline CAT score and the 6 months CAT score. CONCLUSIONS: Smoking cessation is associated with improvement in the quality of life in COPD patients. Those with worse quality of life get the biggest benefit from quitting, although this difference can be diminished in ageing patients.

Papel de N-acetilcisteína (NAC) en pacientes con tabaquismo / Role of N-acetylcysteine (NAC) in patients with smoking

Antecedentes y objetivo. El tabaquismo es el principal factor de riesgo de la enfermedad pulmonar obstructiva crónica (EPOC). N-acetilcisteína (NAC) es un agente mucolítico con propiedades antioxidantes y antiinflamatorias que ha demostrado ser eficaz en la reducción de la tasa de exacerbaciones y mejoría clínica de los pacientes con EPOC. El objetivo del trabajo es conocer la opinión de terapeutas expertos acerca del perfil o perfiles de los pacientes fumadores que pueden ser candidatos al uso de NAC. Métodos. Se efectuó una encuesta distribuida a las unidades de tabaquismo de España y una Reunión de Expertos en tabaquismo y EPOC, en la que los Expertos pudieron debatir abiertamente los tópicos seleccionados. Resultados. Los expertos reconocieron el papel del tabaquismo en la generación de estrés oxidativo y concordaron en emplear la terapia mucolítica/antioxidante para fumadores o exfumadores con síntomas respiratorios. Se debatió la necesidad de ampliar las indicaciones de esta terapia a otros perfiles de pacientes. Se señaló también el potencial efecto preventivo de la NAC sobre el daño pulmonar por su acción antioxidante, aunque se necesitaría más evidencia en este ámbito específico del tabaquismo. Se puso énfasis en diferenciar la dosis de NAC como mucolítico (600 mg/día)o antioxidante (1.200 mg/día). Conclusiones. Los expertos valoraron a NAC como un fármaco bien tolerado, de sencillo uso, con un conocido buen perfil de seguridad y un gran potencial para lograr los objetivos terapéuticos por su alta capacidad antioxidante. (AU)

Background and objective. The smoking habit is the main risk factor for chronic obstructive pulmonary disease (COPD). N-Acetylcysteine (NAC) is a mucolytic agent with antioxidant and anti-inflammatory properties that has been demonstrated to be effective in the reduction of the rate of exacerbations and clinical improvement of patients with COPD. This study aims to know the opinion of the expert therapists on the profile(s) of the patients who smoke and who may be candidates for the use of NAC. Methods. A survey was performed, distributing it to the smoking units in Spain and to a Meeting of Experts on the smoking habit and COPD in which the Experts could openly debate on the selected topics. Results. The experts recognized the role of the smoking habit in the generation of oxidative stress and agreed to use the mucolytic/antioxidant treatment for smokers or ex-smokers with respiratory symptoms. The need to extend the indications of this therapy to other patient profiles was debated. The potential preventive effect of NAC on lung damage due to its antioxidant action was also pointed out, although more evidence in this special area of the smoking habit would be necessary. Emphasis was placed on differentiating the NAC dose as a mucolytic (600 mg/day) or as an antioxidant (1,200 mg/day). Conclusions. The experts evaluated NAC as a drug that is well-tolerated, easy-to-use, with a known good safety profile and having great potential to achieve the therapeutic objectives due to its high antioxidant capacity. (AU)

Effectiveness and safety of varenicline and nicotine replacement therapy among mental health patients: A retrospective cohort study.

OBJECTIVE: To analyse the effectiveness and safety of two smoking cessation medications (varenicline and nicotine patches) in patients with controlled psychiatric disorders in daily practice in a Smoking Cessation Service. METHODS: This is a retrospective cohort study. It was carried on at a smoking cessation clinic in Madrid and used a convenience sampling strategy. We reviewed medical records of patients diagnosed with psychiatric disorders who attended a Smoking Cessation Service. All patients received similar treatment programme: a combination of pharmacological treatment (varenicline or nicotine replacement therapy) and intensive cognitive-behavioural therapy. RESULTS: The group included 349 patients (38.4% men). Mean age (SD) 49.6 (10.5) years. 28.3 (12.8) cigarettes per day. 156 subjects achieved 9-24 weeks continuous abstinence (44.7%), in 39% of those who used nicotine patches and in 53.7% of those who used varenicline. OR: 1.64 (95% CI: 1.03-2.61; p=0.036). Success rates were higher in men; OR 1.85 (95% CI: 1.12-3.04; p=0.016). High levels of CO and high daily cigarette use were associated with poorer success rates (OR: 0.98, 95% CI: 0.96-0.99, p=0.007; and OR: 0.98, 95% CI: 0.96-1.00, p=0.045), respectively. Nausea and pruritus were the most common adverse events. No cases of suicidal ideation or behaviour were found. CONCLUSIONS: Varenicline and nicotine patches could be safe and effective smoking cessation treatments for patients with psychiatric disorders in daily clinical practice.

Smoking characteristics and cessation in patients with thromboangiitis obliterans.

AIM: Describe the smoking characteristics and the results of a smoking intervention programme involving 27 cigarette smokers with Thromboangiitis Obliterans (TAO). METHODS: Clinical records of all cigarette smokers with TAO that attended our smoking treatment clinic from 1990 to 2004 were reviewed. Demographic and smoking characteristics, the type of smoking treatment received and its efficacy and safety up to 12 months was abstracted. Treatment consisted of the combination of behavioural and pharmacological treatment. The behavioural treatment was delivered in eight individual visits: one baseline visit and seven follow-up visits. Pharmacological treatment consisted of combinations of nicotine patches and nicotine gum (NRT) and/or bupropion. This is an 'intent to treat' analysis. A descriptive analysis of the variables was performed. Qualitative variable relationships were tested using the chi-square test for independence, or Fisher's Exact Test when expected values were less than five. Statistical significance was accepted at a level of p < 0.05. RESULTS: 27 cigarette smokers (23 male and 4 female), mean (SD) age 36.07 (7.23), mean FTND-score 8.4 (1.4), smoked a mean of 29.6 (7.71) cigarettes daily. They attended our clinic a mean of 45.48 (8.63) months after onset of TAO. Their mean number of attempts to stop was 3.22 (2.75). The continuous abstinence rate decreased from 29% at the end of treatment to 18.5% at 12-month follow up. The seven day point prevalence abstinence rate at the 12th month of follow up was 40.7%. We found that continuous abstinence at 6 and 12 months was more frequent among those with multiple previous stop attempts (p = 0.003 and p = 0.001, respectively). There were no significant differences in abstinence outcomes between groups. Incidence of adverse effects was similar to other smokers seeking treatment. All the smokers who achieved continuous tobacco abstinence had improvement in their disease and none of them underwent amputation, compared to 50% of those who resumed smoking and later required an amputation. CONCLUSIONS: Continuous abstinence rates among treated cigarette smokers with TAO are relatively low, but abstinence does improve symptoms and reduce the likelihood of amputation. More aggressive treatment programmes need to be developed for this high risk, highly tobacco dependent population.

Protocolo asistencial clínico-psicológico para el tratamiento del tabaquismo con citisina / Clinical-psychological care protocol for the treatment of smoking with cytisine

Citisina es un tratamiento farmacológico del tabaquismo que ha sido introducido recientemente en nuestro país. Los estudios realizados con el mismo durante los últimos años muestran que es un tratamiento eficaz y seguro utilizado a dosis decrecientes durante un periodo de 25 días. Sus específicas características de dosis y tiempo de duración hacen recomendable que se diseñe un protocolo asistencial clínico-psicológico para ser desarrollado durante la utilización de citisina. Un grupo multidisciplinario de profesionales sanitarios expertos en tabaquismo han consensuado un protocolo que recomiendan para llevar a cabo en aquellos pacientes a los que se prescriba citisina como fármaco para dejar de fumar. (AU)

Cytisine is a smoking cessation medication that has appeared recently in Spain. It is effective and safe for helping smokers to quit using for 25 days. Its specific characteristicis in doses and duration recommends to desing a protocol clinical-psychological. A multidisciplinary group of health professionals experts on smoking cessation has designed a protocol to develop with patients who are receiving cytisineas medication for smoking cessation. (AU)

Geographic variations in prevalence and underdiagnosis of COPD: results of the IBERPOC multicentre epidemiological study.

OBJECTIVES: To ascertain the prevalence, diagnostic level, and treatment of COPD in Spain through a multicenter study comprising seven different geographic areas. DESIGN AND PARTICIPANTS: This is an epidemiologic, multicenter, population-based study conducted in seven areas of Spain. A total of 4,035 men and women (age range, 40 to 69 years) who were randomly selected from a target population of 236,412 subjects participated in the study. INTERVENTIONS: Eligible subjects answered the European Commission for Steel and Coal questionnaire. Spirometry was performed, followed by a bronchodilator test when bronchial obstruction was present. RESULTS: The prevalence of COPD was 9.1% (95% confidence interval [CI], 8.1 to 10.2%), 15% in smokers (95% CI, 12.8 to 17.1%), 12.8% in ex-smokers (95% CI, 10.7 to 14.8%), and 4.1% in nonsmokers (95% CI, 3.3 to 5.1%). The prevalence in men was 14.3% (95% CI, 12.8 to 15. 9%) and 3.9% in women (95% CI, 3.1 to 4.8%). Marked differences were observed between sexes in smoking; the percentage of nonsmokers was 23% in men and 76.3% in women (p<0.0001). The prevalence of COPD varied among the areas, ranging from 4.9% (95% CI, 3.2 to 7.0%) in the area of the lowest prevalence to 18% (95% CI, 14.8 to 21.2%) in the area of the highest. There was no previous diagnosis of COPD in 78.2% of cases (284 of 363). Only 49.3% of patients with severe COPD, 11.8% of patients with moderate COPD, and 10% of patients with mild COPD were receiving some kind of treatment for COPD. Multivariate analysis showed that individuals had a higher probability of having received a previous diagnosis of COPD if they lived in urban areas, were of male gender, were > 60 years old, had higher educational levels, had > 15 pack-year smoking history, or had symptoms of chronic bronchitis. CONCLUSIONS: COPD is a very frequent disease in Spain, and presents significant geographic variations and a very low level of previous diagnosis and treatment, even in the most advanced cases.

Smoking characteristics: differences in attitudes and dependence between healthy smokers and smokers with COPD.

OBJECTIVE: To ascertain the differences in smoking characteristics between a group of smokers with COPD and another group of healthy smokers, both of which were identified in a population-based epidemiologic study. DESIGN AND PARTICIPANTS: This is an epidemiologic, multicenter, population-based study conducted in seven areas of SPAIN: A total of 4,035 individuals, men and women aged 40 to 69 years, who were selected randomly from a target population of 236,412 subjects, participated in the study. INTERVENTIONS: Eligible subjects answered the European Commission for Steel and Coal questionnaire. Spirometry was performed followed by a bronchodilator test when bronchial obstruction was present. The Fagerström questionnaire was used for study of the degree of physical nicotine dependence, and the Prochazka model was followed for analysis of the smoking cessation phase. RESULTS: Of 1,023 active smokers, 153 (15%) met the criteria for COPD. Smokers with COPD were more frequently men (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.21 to 3.95), were > or = 46 years of age (OR, 1.97; 95% CI, 1.18 to 3.31), had a lower educational level (OR, 1.96; 95% CI, 1.23 to 3.14), and had smoked > 30 pack-years (OR, 3.70; 95% CI, 2.42 to 5.65). Smokers with COPD showed a higher dependence on nicotine than healthy smokers (mean [+/- SD] Fagerström test score, 4.77 +/- 2.45 vs 3.15 +/- 2.38, respectively; p < 0.001) and higher concentrations of CO in exhaled air (mean concentration, 19.7 +/- 16.3 vs 15.4 +/- 12.1 ppm, respectively; p < 0.0001). Thirty-four percent of smokers with COPD and 38.5% of smokers without COPD had never tried to stop smoking. CONCLUSIONS: Smokers with COPD have higher tobacco consumption, higher dependence on nicotine, and higher concentrations of CO in exhaled air, suggesting a different pattern of cigarette smoking. Cases of COPD among smokers predominate in men and in individuals with lower educational levels. A significant proportion of smokers have never tried to stop smoking; thus, advice on cessation should be reinforced in both groups of smokers.

Bronchoalveolar lavage in smokers: quantification of alveolar macrophages and neutrophils as markers of bronchial obstruction.

Increased concentrations of neutrophils and alveolar macrophages are recovered in the bronchoalveolar lavage (BAL) of smokers compared with non-smokers. We designed a study to determine the relationship between neutrophils and alveolar macrophages recovered by BAL and the degree of air-flow obstruction, measured by spirometry (chronic air-flow obstruction was defined as: FEV1 < 80% of predicted and FEV1/FVC ratio < 70% of predicted) in healthy smokers. We found a significant correlation between spirometric values and the number of neutrophils and alveolar macrophages in BAL fluid obtained from healthy smokers. Our findings suggest that counts of 13-15x1000 neutrophils/ml and/or 430-450x1000 alveolar macrophages/ml in BAL fluid could be used as markers of air-flow obstruction in smokers.

[Costs of chronic obstructive pulmonary disease in Spain. Estimation from a population-based study]. / Costes de la EPOC en España. Estimación a partir de un estudio epidemiológico poblacional.

OBJECTIVE: In the studies carried out to date, the cost of chronic obstructive pulmonary disease (COPD) may have been overestimated due to the inclusion of previously diagnosed patients seeking medical attention for their symptoms. As a result, the severity of the cases included in these studies may have been greater than in an unselected sample of the general population. The aim of the present study was to estimate the direct cost of COPD on the basis of a representative sample of the overall Spanish population between 40 and 69 years of age (from the IBERPOC study). METHOD: The cost was evaluated retrospectively by means of a questionnaire completed by the 363 patients with COPD from the IBERPOC study with questions referring to the previous year. Standardized spirometry was performed on all the patients by a pneumologist in each of the 7 geographical areas in which the study was carried out. RESULTS: Hospitalization accounted for the greatest expenditure (41% of total), followed by drug therapy (37%). The cost was euro;98.39 per patient, and euro;909.50 per previously diagnosed patient. The cost per person of severe COPD was more than 3 times that of moderate COPD and more than 7 times that of mild COPD. The estimated annual cost of COPD in Spain was euro;238.82 million (for 1997). CONCLUSION: The present study, which was the first to estimate the cost of COPD in a representative sample of the general population, found the cost to be lower than in studies analyzing samples of patients with previous diagnoses of COPD. The cost distribution is not in line with recommended health care practices, underlining the need to optimize resources used to monitor and treat the disease, with an emphasis on early diagnosis.

[Respiratory symptoms and diagnosis of COPD in smokers of various types to tobacco. Results from the IBERPOC study]. / Síntomas respiratorios y diagnóstico de EPOC en fumadores de distintas labores de tabaco. Resultados del estudio IBERPOC.

BACKGROUND: The aim of this study was to investigate the sociodemographic characteristics, smoking habits, the prevalence of respiratory symptoms and chronic obstructive pulmonary disease (COPD) in four groups of smokers: of cigarettes (SCt), of cigars (SCigar), of both (SB), of cigars currently but of cigarettes in the past (SCigarExCt) and of cigarettes currently but of cigars in the past (SCtExCigar). METHOD: A multicenter epidemiological study enrolling 4,035 subjects aged between 40 and 69 years. One thousand nine hundred sixty-three were non-smokers and 1,146 were current smokers. Among the smokers, 869 were SCt, 37 were SCigar, 97 were SB, 86 were SCigarExCt and 57 were SCtExCigar. We analyzed sociodemographic characteristics, smoking and the prevalence of respiratory symptoms and COPD. RESULTS: Cigar smokers were usually men, of lower socioeconomic status (p < 0.001) and older than cigarette smokers (p < 0.001), but CO concentrations in expired air were lower in the SCigar group than in the SCt group (5 ppm vs 15.7; p < 0.001). Informants who believed their smoking was not detrimental to their health or to that of second-hand smokers made up 86.5% of the SCigar group and 79.1% of the SCigarExCt group. COPD was diagnosed in 13.2% of the SCt group, in 24.7% of the SB group, and in 12.8% of the SCigarExCt group, in comparison with 4% of the non-smokers (p < 0.001 for all comparisons). CONCLUSIONS: SCigar are mainly older men with lower educational levels. Their concentrations of CO in expired air are low and they have little awareness of the health risks posed by their habit. SCigar who were once smokers of cigarettes have a higher prevalence of respiratory symptoms and COPD than non-smokers and the same prevalence of COPD as SCt.

[Prevalence of and attitudes towards smoking in a population over 40 years of age]. / Prevalencia y actitudes sobre tabaquismo en población mayor de 40 años.

OBJECTIVES: Smoking is the main cause of preventable death in developed countries. One of the most relevant health care interventions is convincing smokers to quit. To achieve that end, it is important to know, in addition to the prevalence of smoking, the degree of physical addiction to nicotine and smokers' attitudes toward tobacco. MATERIAL AND METHODS: This study collects results from a Spanish national epidemiological study (the IBERPOC study) related to smoking addiction, smokers' degree of addiction to nicotine and smokers attitudes toward their habits. The data has been obtained by surveying 4,035 individuals selected randomly from census data in seven different parts of the country. Information was obtained from questionnaires and CO in expired air was measured. RESULTS: One thousand fifty-nine respondents were smokers (26%) and 968 were ex-smokers (24%). Female smokers were younger (47 versus 51 years old) and had started smoking later (at age 22 versus 17 years), smoked fewer cigarettes per day (15 versus 21) and had lower concentrations of CO in expired air (13.4 versus 17 ppm) (p < 0.001 for all comparisons). Six hundred fifty-nine smokers (62.2%) had tried to quit at least once. The most important reasons given for trying to quit were related to improving health. CONCLUSIONS: The 26% of the surveyed population smoked. Women generally started later, smoked fewer cigarettes and were less physically addicted to nicotine. Most smokers had tried at least once to quit, particularly if motivated to improve health. These results should be considered when proposing strategies for smoking cessation.

[Estimation of initial interobserver variability of forced spirometry in the multicenter epidemiological study IBERPOC. Scientific Committee of the IBERPOC study]. / Estimación de la variabilidad inicial interobservador de la espirometría forzada en el estudio epidemiológico multicéntrico IBERPOC. Comité Científico del Estudio IBERPOC.

To estimate the interobserver variability and degree of agreement for basic spirometric parameters before beginning field work for the IBERPOC Project. Study of agreement between 7 observers (pneumologists) and a gold standard, using a scheme of incomplete balanced and randomized blocks with an equal number of spirometric measurements (n = 3) per patient and an equal number of measurements (n = 9) per observer performed at the same session. The study population consisted of 14 patients with different degrees of air flow obstruction and 7 normal volunteers. Statistically significant differences attributable to subjects (inter-patient variability) were found for the three variables analyzed. Variability attributable to the observer was found for FVC and FEV1 but not for FEV1/FVC. The greatest interobserver differences were found for FEV1, such that 4 of the 7 observers recorded values that were significantly different from the mean (p < 0.05). The differences were less marked for FVC and for the FEV1/FVC ratio, with only 2 observers recording significantly different values for each variable. The high degree of reproducibility as well as the excellent interobserver agreement found in this standardization session provide an a priori guarantee of validity for spirometric measurements and rule out the existence of differential bias in data recorded at the various geographic areas involved in the study.

[Analysis and evolution of bibliometric indicators of productivity and readership of articles on smoking appearing in Archivos de Bronconeumología from 1970 to 2000. A comparison to others topics in respiratory medicine]. / Análisis y evolución de los indicadores bibliométricos de producción y consumo del área de tabaquismo a través de Archivos de Bronconeumología (período 1970-2000). Comparación con otras áreas neumológicas.

OBJECTIVES: To analyze the evolution of bibliometric indexes for research on smoking published in Archivos de Bronconeumología (AB) from 1970 through 2000, to compare indexes for each of the three decades under study, and to compare the indexes for smoking research with those of other topics in respiratory medicine. MATERIAL AND METHODS: We reviewed all articles published by AB between 1970 and 2000, recording data on 13 characteristics. RESULTS: Of 2,198 documents reviewed, 45 (2.04%) were about smoking; 71% of them were published in the last five years. The research came mainly from the most productive four provinces and five hospitals, which produced 68.1% and 50% of the reports, respectively. The first authors were pneumologists in 78.4% of the articles. The productivity index was 1.65, and the mean number of authors per document (collaboration index) was 4 3. The total number of references was 1,230 and the number of references per paper was 27.3 26. AB was the most cited journal. We found no change in obsolescence indexes. Insularity and self citation indexes tended to increase. Topics with productivity indexes that were higher than the index for smoking research were asthma (p < 0.05), respiratory insufficiency and sleep disorders, non-tuberculosis infection, oncology and pleural and interstitial diseases (p < 0.001). The insularity index was higher for tuberculosis than for smoking (p < 0.05). CONCLUSIONS: Smoking research increased considerably during the period studied. Pulmonologists predominated among the authors of studies on smoking. Bibliometric indexes for smoking evolved as did the indexes for other research. The most frequently cited journal was AB.