Nicholas R. Anthonisen, MD; Melissa A. Skeans, MS; Robert A. Wise, MD; Jure Manfreda, MD; Richard E. Kanner, MD; John E. Connett, PhD; Lung Health Study Research Group*
Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE, Connett JE, et al. The Effects of a Smoking Cessation Intervention on 14.5-Year Mortality: A Randomized Clinical Trial. Ann Intern Med. 2005;142:233-239. doi: 10.7326/0003-4819-142-4-200502150-00005
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Published: Ann Intern Med. 2005;142(4):233-239.
461 of 3923 patients died in the special intervention group vs. 270 of 1964 patients in the usual care group ( = 0.031, log-rank test). LHS = Lung Health Study.
The only significant difference was in respiratory disease other than lung cancer (log-rank test). CHD = coronary heart disease; CVD = cardiovascular disease.
Rates were significantly different for coronary heart disease (CHD ), cardiovascular disease (CVD ), lung cancer, and other causes of death (log-rank test).
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Video News Release - Best Proof Yet That Smoking Causes Death
Gregory J. Bombassei
February 21, 2005
Smoking Cessation and Mortality
I read with interest Anthonisen and colleagues' article on smoking cessation and mortality in a recent issue of the Annals. Because this report dealt with the effectiveness and cost of a smoking cessation strategy, its endpoints were concerned with treatment differences between those patients who were offered the smoking cessation intervention and those who were not.
However, I who counsel patients in practice to quit smoking am even more interested in treatment differences between those patients who actually quit smoking compared to those who continue to smoke, either continuously or intermittently. Knowing these data from a randomized clinical trial would improve my ability to inform my patients of the health benefits of smoking cessation.
It took a close read of the data, for example, to determine that among 5887 patients in this study, 957 were sustained quitters and 4930 were continuous or intermittent smokers. Even Figure 3 in the article, giving rates of death "per 1000 person-years" for each of several causes of death, is not straightforward. That is, the raw data are unknown to the reader, who is instead treated to a "sanitized" version, in which the "rate of death per 1000 person-years" is substituted for a simpler quantity, the proportion of patients who died.
I am interested to know to what extent quitting smoking reduces mortality. I am particularly interested in a Kaplan-Meier curve plotting the proportion of patients surviving versus time for sustained quitters compared to continuous or intermittent smokers.
Can the authors provide this information?
The authors write that "since death rates between special [smoking cessation] intervention and usual care participants with similar smoking habits did not differ, the differences observed in the groups as a whole were almost certainly due to differential cessation rates." Comparing the Kaplan-Meier curve depicted in Figure 1 (All-cause 14.5-year survival in the smoking cessation intervention group and the usual care group) to the Kaplan-Meier curve I suggest (All-cause 14.5-year survival in those who quit smoking and those who did not) would allow the reader to judge that for himself.
Stephen L. Hansen
February 24, 2005
Political Conclusions From An Activist
1)It's an outrage that most health plans still do not cover tobacco cessation services by physician! The Calif.Tobacco Control Alliance has a bill this year to fix that here.
2)The good news is that Medicare will begin cessation coverage in March,and has finally espoused a new preventive medicine ethic.
3)The relative ease and benignity of the abrupt cessation experienced by inmates in prisons (with no tobacco cues)is quite interesting,also. The mileau matters. And quitting is easier in smokefree states,too. California's 32 prisons go tobacco-free (no person may take any form of tobacco inside the gates) on 1 July,2005. Six pilot programs showed very few problems even with psychiatric and violent inmates. Most said:"Thanks,Doc,I couldn't have done this with everyone else still smoking."
4)Cessation reduces disease costs best in those most at risk of serious illness in the near-term.Therefore, teach all clinicians to do cessation,fund clinical efforts,provide support for quitters---including discounted premiums. Or increase premiums for smokers:KY,WV and AL have done this,a la life insurance actuaries (Actuaries ALWAYS knew the results of quitting on life expectancy!) Cheers,SH
Milan C Mathew
Memorial Hospital of Rhode Island/Brown University
March 9, 2005
The Effects of Smoking Cessation Intervention on Mortality: The "Interventions"
I read with great interest the article by Anthonisen et.al., regarding the effects of a smoking cessation intervention on 14.5 year mortality in the Lung Health Study. The authors conclude that 'smoking cessation intervention programs can have a substantial effect on subsequent mortality, even when successful in a minority of participants.' The generalizability of the study results being potentially limited to heavy smokers with pre-existing airway obstruction.
The study provides convincing evidence that smoking cessation lowers all-cause mortality. The mortality experience between the two study groups, the 'usual' care group and 'special' intervention group, did not differ significantly between those with similar smoking habits and hence the decrease in mortality is attributable to differential cessation rates between the two study groups.
However, the article fails to adequately recognize and/or address the role of the 'other' intervention received by those in the special intervention group. In addition to the smoking cessation program that included a strong physician message and 12 two-hour group sessions, using behavior modification and nicotine gum and followed by 5-years of reinforcement, they received either an 'iptratopium' or a 'placebo' inhaler. It is noteworthy that mortality did not differ significantly between those assigned to iptratropium or placebo groups. The presence of an additional intervention raises the question of what led to the differential smoking cessation rates between the special intervention and usual care groups: Was it the cessation program, the inhaler, or was it a combination of both. It can be argued that use of inhalers, irrespective of the ingredient, by heavy smokers in the special intervention group encouraged them to quit when compared to the usual care group. Furthermore, it can be argued that the role played by the inhalers in promoting cessation in this study is as significant or even more significant than the smoking cessation intervention itself. Of note is that smoking status established at 5 years in the study, changed relatively little over the next six years, especially among sustained quitters.
In summary, it would have been more appropriate to conclude that smoking cessation intervention programs in conjunction with use of inhalers lead to increased smoking cessation and decreased all-cause mortality among heavy smokers with pre-existing air-way disease. By not recognizing the role played by the co-intervention, the 'inhalers,' the article inordinately focuses the readers attention on only one of the interventions.
Weill Medical College of Cornell University
March 18, 2005
Letter to Editor
In reference to the article by Anthonisen et al (1) on the effects of a smoking cessation intervention on 14.5-year mortality among chronic obstructive pulmonary disease subjects, we would like to submit the following comments.
In this randomized controlled trial, a subgroup analysis shows significant increase in mortality among younger subjects and those who smoked more than 40 cigarettes per day (p < 0.05). However, United States population data(2) suggests that the prevalence of smoking is higher among the age groups 45 and 64 years. As study subjects between 35 and 44 years of age at baseline would have aged during the course of the study, one may conclude that the number of cigarettes smoked per day may reflect age related increase in smoking behavior. Therefore, cigarette smoking or age alone may not have an independent effect on the mortality as described in the study. The readers will certainly be interested to learn whether there is an interaction between age and number of cigarettes smoked. In addition, the relatively high prevalence of smoking among the study groups (31 cigarettes per day) compared to the general population (2) (11 "“ 18 cigarettes per day) may limit this study finding to heavy cigarette smokers.
References: 1.Anthonisen NR et al. for the Lung Health Study Research Group. The Effects of a Smoking Cessation Intervention on 14.5-Year Mortality: A Randomized Clinical Trial. Ann Intern Med 2005; 142: 233-239 2.Schoenborn CA, Adams PF, Barnes PM, Vickerie JL, Schiller JS. Health Behaviors of Adults: United States, 1999"“2001. National Center for Health Statistics. Vital Health Stat 10(219). 2004.
Nicholas R Anthonisen
University of Manitoba
April 13, 2005
Dr. Mathew rightly points out that the Lung Health Study smoking cessation program was accompanied by the prescription of inhalers, and believes that we may not have considered the latter adequately. He agrees that the content of the inhalers [placebo or bronchodilator] didn't make any difference, and appears to accept that it was differences in smoking habits that determined the improved survival in the special intervention group. It therefore follows that if the inhalers were important, it was because they made the smoking cessation program more effective. Maybe so, but we are unapologetic about attributing smoking cessation largely to the program we designed to induce it. Inhalers per se probably have little to no effect on smoking habits, as evidenced by the fact that smoking rates are about as high in asthmatics as they are in the general population [1,2].
Dr. Bombassi is interested in Kaplan-Meier survival curves in Lung health Study participants who quit smoking as compared to those who did not. In the paper we indicated that mortality was 6.04 per 1000 person- years in sustained quitters, 7.77 per 1000 person years in intermittent quitters, and 11.09 per 1000 person-years in continuing smokers. We have sent a figure that will be published in the Annals.
N.R. Anthonisen, MD
Nicholas R. Anthonisen, MD email@example.com University of Manitoba, Winnipeg, Manitoba, Canada
References 1. Higenbottam TW, Feyeraband C, Clark TJ. Cigarette smoking in asthma. Br J Dis Chest 1980; 49: 881-884. 2. Silverman RA, Boudreaux ED, Woodruff PG, Clark S, Camargo CA. Cigarette smoking among asthmatic adults presenting to 64 emergency departments. Chest 2003; 123: 1472-1479.
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