Risks and illnesses
Lung cancer: a worrying epidemic for women
There is a continual increase in cases of lung cancer for women in most European countries, linked to women smoking en masse which began in the 1960s. Women’s lung cancer has its own characteristics, such as different risk factors and profile.
Women’s lung cancer: continually on the rise
The number of cases of lung cancer has gone down for men in most developed countries but it is showing a steep increase for women, resulting in a high increase in fatalities for women with this type of cancer. Lung cancer is in fact a cancer that has a poor prognosis. Between 1985 and 1995, the number of cases of lung cancer practically doubled in France. (1) In Switzerland, the number of women affected by lung cancer doubled between 1983 and 2007. (2)
In Europe, the mortality rate for lung cancer is on the way to overtaking breast cancer. A recent study on the estimation of mortality rates reveals that deaths caused by lung cancer have gone up 9% in Europe and that the number of deaths attributed to lung cancer in women is likely to be higher than the number of deaths caused by breast cancer in 2015. (3) The exact figures won’t be known for a few years yet. The United Kingdom and Poland have the highest number of deaths due to lung cancer in women, namely 21 and 17 cases per 100,000 women respectively. In the United States, lung cancer has already been responsible for more deaths than breast cancer since 1987. The lung cancer epidemic for women will increase yet further over the next 30 years in a number of European countries, France included, linked to the history of women’s smoking.
Women’s lung cancer: an epidemic linked to smoking which seems to be more harmful for women
The principal risk factor for lung cancer is smoking. The increase in the prevalence of women’s lung cancer is linked to the evolution in women’s smoking habits. Women’s smoking has progressively increased since the end of the Second World War. However, lung cancer is a cancer which appears after 20 to 30 years of smoking. In the United States where women began smoking at the end of the Second World War, the rates of lung cancer went up 266% between 1968 and 1999. (4)
Up until the 1970s lung cancer was uncommon for women in France, then as the female population that had been exposed to tobacco grew older, the number of occurrences increased. The number of cases of lung cancer was 3.6 per 100,000 women in 1980 and 12.6 per 100,000 women in 2005, which represents an annual variation of 5.1%. The increase was most notable between 2000 and 2005 with an annual variation of 5.8%. (5)
As with men, the occurrence of lung cancer in women is determined by the length of time they have smoked, the number of cigarettes smoked each day and the age that they began smoking. A tripling of the number of cigarettes smoked per day increases the risk of lung cancer by 3, whilst a tripling of the time spent smoking increases this risk by 100. (6) There is no minimum level of consumption under which the risk of lung cancer is zero. (7) The risk of lung cancer is also increased depending on how young the person was when he/she started smoking. (8) The relative risk of having lung cancer is 7.6 times more for a woman who smokes than for one who does not, Gandini (9)
However, a number of studies have shown a more tenuous link for women, between lung cancer and smoking, than for men. Tobacco only explains 70% of women’s lung cancers. 70% of non-smokers who have lung cancer are women. (10) The magnitude of growth in lung cancer risk in women and the weaker link with tobacco consumption suggests that there are perhaps biological and genetic predispositions as well. A number of studies, in particular from North America, have shown that smoking presents a risk of developing lung cancer for women 1.5 to 3 times that for men. (11) Furthermore, 3 times as many women as men who are non-smokers have lung cancer, doubtless in part linked to the effects of passive smoking. (12) Women seem to be more sensitive to the carcinogens in tobacco smoke. Different mechanisms have been suggested to explain this possible predisposition (as yet unproven). The adducts of DNA induced by tobacco smoke are more often found in women’s lungs than in men’s and the ability for repairing DNA is inferior in the case of women (13); women present a greater incidence of the gene CYP1A1 whilst this gene encourages the carcinogenic effect of products contained in cigarette smoke; women have reduced activity of GTSM1 (Glutathione S-transferase M1) which leads to less effective detoxification of tobacco carcinogens (14); the widespread presence of gastrin-releasing peptides (rGRP) in women, peptides that play an important role in the stimulation of cellular proliferation, could also explain the extra sensitivity to tobacco carcinogens (15)... The possible role of hormones, particularly oestrogens, is also called into question. Various studies have shown that early menopause, having fewer than three children, short menstrual cycles, taking of hormone-replacement therapy (HRT) and hormone-dependent cancer antecedents are risk factors in women’s lung cancer and that there is a correlation between oestrogen and tobacco. (16) (17) (18) (19) (20) A study of various European registers has shown that women, particularly younger women, who had had lung cancer were more at risk of developing breast or ovarian cancer. (21) On the other hand, studies showed a beneficial effect of anti-oestrogens. (22)
It seems that oestrogen can encourage chromosome and genetic mutations (the interaction between EGFR and oestrogen in particular) which can lead to adenocarcinomas. Oestrogen can also be a direct carcinogen. It is, in fact, possible that oestrogen encourages the formation of DNA adducts. Experimental elements such as the presence of oestrogen receptors (ERβ) in healthy lung tissue as well as in tumour cells confirm the possible role of hormones in the occurrence of lung cancers. (23)
Lung cancer: a different profile of lung cancer in men
The risk of lung cancer is increased in relation to deficiencies in respiratory function (chronic bronchitis, emphysema…). This risk is even greater for women than for men, as women have a greater chance of developing respiratory illnesses. (24) Lung cancer tends to occur in women at an earlier age. Different clinical studies have shown that women are usually diagnosed with cancer at a younger age than men. (25) A Mayo Clinic prospective study showed that women were significantly younger than men when they were diagnosed: 66 as opposed to 68 years. (26)
Women have more adenocarcinomas than men (one of the three sub-types of non-small cell lung cancer). Nearly 50-65% of women suffering from non-small cell lung cancer have an adenocarcinoma (versus 25-40% of men). (27) This could be partly explained because more women smoke ‘light’ cigarettes. These encourage deeper inhalation and penetration of smoke and tar. (28) Lung cancer in women produces more activating mutations of the EGFR (Epidermal Growth Factor Receptor). Studies have shown that the mutation of the EGFR gene is only found in adenocarcinomas. A specific treatment can be suggested when this EGFR mutation is detected. Another mutation is also more common in women, that of the K-RAS gene (20% of women having an adenocarcinoma as opposed to 17% of men) but there is currently no treatment for this molecular target. (30)
Finally, women with lung cancer show fewer clinical signs than men. (31)
In conclusion, specific biological, genetic and hormonal factors relating to lung cancer in women are leading to new research, with the hope of finding specific treatments for women. One of the most advanced lines of research is hormone treatment, in particular associated with EGFR tyrosine kinase inhibitors.
Graphs and Statistics
on cardiovascular disease
Find in this document some graphics and key figures on cardiovascular diseases, their association with smoking and mortality on their part.
Other references :
For France : Heart French Federation
For Belgium : League cardiology Belgian
For Canada : Canadian Cardiovascular Society
Benefits at any age
Elderly people, who have generally been smoking for a very long time, are at much higher risk of developing cancer and heart problems. Smoking cessation is beneficial at any age, including after 60. However, senior citizens require specific care and specialized programs to help them quit.
Quitting smoking is beneficial for the elderly
People who are now retired started smoking in an age where smoking was seen as acceptable, and even encouraged. In 1953, 69% of men and 6% of women smoked (1). Women smoked relatively little until the end of the 1960s. It is estimated that over a quarter of our senior citizens began smoking in the 1960s, before the age of 25. As a result, smoking causes more problems in the over-60s than in young smokers thanks to the much longer exposure period to cigarettes. In the USA, for example, more than 70% of the 416 000 smoking-related deaths each year occur to people aged 65 and over, despite the fact that fewer people in this age category smoke than in the rest of the population. Smoking is one of the leading causes of death among senior citizens, often following cancer (especially lung cancer), cardiovascular diseases, and respiratory diseases (emphysema, COPD, etc.). It is estimated that 50% of long-term smokers will die of smoking-related illnesses. Smoking also increases the risk of osteoporosis and dementia. So why do senior citizens continue to smoke, despite all the health campaigns? They often say that smoking is relaxing, it's a pleasure, they enjoy it, and they think that quitting so late in life won't bring any benefits. (2) However, even at an advanced age, smoking cessation does bring real benefits. Smoking cessation reduces the mortality rate among smokers, including those who smoked for more than 30 years. The effects of quitting are more immediate on cardiovascular diseases. Smokers who stop at age 65 add two years onto their expectancy on average. Independence and quality of life improve after just a few months. (3)
Elderly smokers need special care to help them quit smoking
Studies have shown that smoking cessation is more difficult for elderly people who have been smoking for a long time. These people need more help to quit, undoubtedly because smoking for them is not limited to mere nicotine addiction but contributes to defining their personal and social identity. For senior citizens, quitting smoking can mean huge life changes. A study carried out in Switzerland showed that quitting also seemed more difficult for retired women than men. The women seemed to be more attached to the smell of cigarette smoke. This could explain why gums and patches are less effective for women than men. (4) We also know that elderly people pay attention to their doctor's advice when it comes to quitting smoking. Health professionals therefore have an important role to play, especially by reminding their elderly patients of the risks linked to smoking (often underestimated in this section of the population) and by explaining that quitting smoking is beneficial, even late in life.
Specific treatments can be used by elderly people, especially if they are addicted smokers. Nicotine replacement therapy is generally fine, provided extra care is taken if there is a past history of heart problems. Bupropion (Zyban) can be used, but in smaller doses. (5) The results of research carried out over twenty years ago also showed that advice and support were effective among elderly people. For senior citizens who have smoked for a long time, more specialized care should be available, such as individual counselling, telephone helplines, and cognitive behavioral therapy (CBT). Other studies showed that prevention programs can be just as successful for elderly people as for young people, as long as they are adapted. The programs should highlight the benefits of smoking cessation and the risks that it can avoid for senior citizens, help them to set a quit date, use behavioural techniques to break old habits, provide coping mechanisms for dealing with stress, and treat nicotine withdrawal symptoms. (6) Specific programs therefore need to be put in place, including in retirement homes. At present, very few of these have anti-smoking programs in place.
Factors that help elderly people to successfully quit smoking
Elderly people do not decide to stop smoking for the same reasons as younger people. Previous health problems feature more prominently in their desire to stop smoking. Having at least one chronic illness that bothers them significantly increases an elderly person's chances of quitting smoking. Studies have highlighted several indicators that predict successful smoking cessation in elderly people: having quit successfully in the past for at least one year, a milder nicotine addiction, having not started smoking regularly until later, a partner who is a non-smoker and few or no friends who smoke, and frequent trips to the pharmacy or doctor for those who use patches. What is the profile of the ideal senior candidate for quitting successfully? Someone who is married and well informed about the dangers of passive smoking, with a degree and a comfortable income, ticks all the boxes. At the other end of the scale, people who have a low level of education, receive no regular care and suffer from a psychological disorder or anxiety have a lower chance of joining the community of ex-smokers. Psycho-behavioral therapy may help these people. Programs used to help elderly people should take into account these indicators that predict successful and unsuccessful smoking cessation.
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Diabetes and smoking
Few people know it, but smoking increases your risk of contracting diabetes. Furthermore, diabetic smokers are more likely to develop other complications. Here are the details based on existing research.
Smoking puts people at higher risk of contracting type 2 diabetes
Numerous studies carried out since the 1990s have highlighted a link between smoking and type 2 diabetes. A study carried out in 1996 showed that the prevalence of smoking among diabetic patients is significantly higher than that among non-diabetic patients (27% vs. 33%). Well before that, a cohort study carried out between 1959 and 1972 (on 275 190 men and 434 637 women) found that smokers ran an increased risk of contracting diabetes and that the more they smoked, the higher the risk was. Among those who smoked fewer than 20 cigarettes a day, men had a 5% higher risk and the risk for women was not higher. For people who smoked 20 to 40 cigarettes per day, the increase was 19% for men and 21% for women. And for those who smoked more than 40 cigarettes a day, the risk rose to 45% for men and 74% for women. (1) The Physicians Health Study showed that smokers of fewer than 20 cigarettes a day ran a 50% higher risk of developing type 2 diabetes than non-smokers, while those who smoked more than 20 cigarettes a day increased their risk by 70%. According to recent studies, the percentage of type 2 diabetes cases attributable to smoking stands at 2%. This rate may, however, be much higher for heavy smokers. Several explanations have been put forward for the link between smoking and diabetes, including the idea, advanced by some studies, that the substances contained within tobacco, and in particular nicotine, affect the body's sensitivity to insulin. As a cigarette contains 3 500 different components, and 500 gaseous components are released when it is burned, it is difficult to determine precisely which component is responsible. Smoking also has a significant clinical effect on intravenous and oral tests for glucose tolerance, which could influence the detection of diabetes. This could be directly linked to nicotine or to other components. Two cohort studies have studied the effect of smoking cessation. That of Will et al. showed that when men stopped smoking for 10 years and women stopped smoking for 5 years, the risk of developing diabetes fell to the same level as for non-smokers. (2) The second study indicated that quitting smoking produced visible benefits on middle aged men after 5 years and that the risk of diabetes had fallen to the level of that of non-smokers after 20 years. (3) It's therefore best to stop smoking as early as possible!
Diabetic smokers run a higher risk of complications
Smoking worsens the complications of diabetes, whether it's type 1 or type 2. We know that the risk of complications associated with both smoking and diabetes is nearly 14 times higher if you have both of these risk factors than if you have only one. Evidence from studies on diabetes shows the very strong link between smoking and mortality. Smoking basically presents an increased risk of macro-vascular complications (strokes, heart attacks) and micro-vascular complications (kidney failure, sight problems, nerve damage) which lead to more chronically ill people in the population and a higher mortality rate. Various studies have shown that smokers secrete more albumin than non-smokers, which is linked to the second group of health problems because it can lead to microalbuminuria, where small quantities of protein are present in the urine. This is the first sign of deterioration in kidney function. The risk of microvascular complications is higher for type 1 diabetes. The risks of macrovascular complications (problems with the arteries, strokes, etc.) are higher for people who have type 2 diabetes. The UK Prospective Diabetes Study has demonstrated that smoking constituted an important, independent risk factor for macrovascular complications in sufferers of type 2 diabetes. (4) Smoking cessation is therefore of prime importance in the treatment of diabetes, for both the control of blood sugar levels and for limiting the development of complications. Various studies have highlighted the importance of quitting smoking as soon as possible after diabetes is diagnosed.
Specific things that diabetics should bear in mind when quitting smoking
Diabetics who smoke often exhibit a high level of dependency and find it difficult to quit. In a study by Ardron et al. involving 60 people, only one had managed to quit smoking after 6 months. (5) Furthermore, diabetic smokers who are hospitalized seem less interested in smoking cessation programs than other patients (6) and smoking cessation proves difficult for diabetics. Several possibilities have been put forward to explain why diabetics find it so difficult to quit. The fear of gaining weight is first and foremost .Various studies have shown that diabetics think that smoking helps them to eat less and thus to control their weight. However, weight gain after quitting smoking is generally minimal and presents less of a health risk than carrying on smoking. In addition, it is possible to limit potential weight gain when quitting by practicing moderate physical exercise. Diabetics also have a higher risk of suffering from depression than the rest of the population. That often leads to a higher rate of tobacco consumption and we know that stress can hinder smoking cessation. For these reasons, smoking cessation programs should be adapted to serve diabetic people. The level of dependency on cigarettes should be evaluated by each individual diabetic smoker. In order to manage it, we recommend that diabetic smokers try nicotine replacement therapy which can be supplemented by cognitive-behavioral therapy. It may also be useful to include support concerning nutrition, to help patients control their weight while quitting. Lastly, it would be useful to assess their psychological state: depressive diabetics or those who have a history of depression should be helped accordingly, by therapies and/or medication. In order to make diabetics more aware of the risks of smoking, the idea of a "glucose equivalent" has been developed in diabetes treatment clinics in Taiwan. Based on the study of a large cohort of patients from Asia, the risk posed by smoking is said to be equivalent, on average, to a 41mg/dl increase in blood sugar in a non-diabetic and 68mg/dl increase in a diabetic. This concept could help doctors to convince diabetic smokers of the need to quit. Finally, young people suffering from type 1 diabetes deserve a mention. These people represent a vulnerable group because it seems that they are more likely to turn to smoking after first being diagnosed with diabetes. Prevention and cessation programs should therefore be specially targeted at them.
Author: Anne-Sophie Glover-Blondeau, August 2012.
(1) JC Will, DA Galuska, ES Ford, A Mokdad, E. E. Calle, Cigarette smoking and diabetes mellitus: evidence of a positive association from a large prospective cohort study- International journal of Epidemiology, 2001 - IEA
(2) JC Will, DA Galuska, ES Ford, A Mokdad, E. E. Calle, Cigarette smoking and diabetes mellitus: evidence of a positive association from a large prospective cohort study- International journal of Epidemiology, 2001 - IEA
(3) SG Wannamethee, AG Shaper, Ivan J. Perry, Smoking as a modifiable risk factor for type 2 diabetes in middle-aged men, Diabetes Care, 2001 - Am Diabetes Assoc
(4)Turner RC, Millns H, Neil HA, Stratton IM, Manley SE, Matthews DR, et al, Risk factors for coronary artery disease in non-insulin dependant diabetes mellitus: united Kingdom Prospective Diabetes Study, BMJ 1998; 316:823-8
(5) Ardron M, MacFarlane I, Robinson C,Heyningen C, Calverley P: Anti-smoking advice for young diabetic smokers: is it a waste of breath? Diabet Med 5 : 6 6 7 - 6 7 0 ,1 9 8 8
(6) D Haire-Joshu, RE Glasgow, Tiffany L. Tibbs, Smoking and Diabete, Diabetes care, 1999 - Am Diabetes Assoc
(7) CP Wen, TYD Cheng, SP Tsai, HL Hsu, Hui TC, Chih CH, Exploring the relationships between diabetes and smoking: With the development of "glucose equivalent" concept for diabetes management, - Diabetes research and Clinical Practice, 2006 - Elsevier
Willi C, Bodenmann P, Ghali WA, Faris PD, Cornuz J, Active Smoking and the Risk of Type 2 Diabetes. A Systematic Review and Meta-analysis, JAMA. 2007 Dec 12;298(22):2654-64.
Eric L. Ding, ScD; Frank B. Hu, MD, PhD, Smoking and Type 2 Diabetes: Underrecognized Risks and Disease Burden, JAMA. 2007;298(22):2675-2676.
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CP Wen, TYD Cheng, SP Tsai, HL Hsu, Hui TC, Chih CH, Exploring the relationships between diabetes and smoking: With the development of "glucose equivalent" concept for diabetes management, - Diabetes research and Clinical Practice, 2006 - Elsevier
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How smoking cessation affects the progression of COPD
Quitting smoking is beneficial for everyone, at every age, and this is especially true for people suffering from chronic obstructive pulmonary disease (COPD), an illness that occurs when a patient has chronic bronchitis and/or emphysema. Quitting smoking is the main treatment, and that applies at all stages. Here is a summary of the latest knowledge on the topic.
Smoking cessation – the main treatment for COPD
Studies carried out since the 1990s, which remain relatively few despite the widespread nature of COPD, show that smoking cessation brings numerous benefits to smokers suffering from this disease. In less serious forms of COPD, it leads to an improvement in symptoms such as coughing and wheezing. In severe cases of the illness, smoking cessation enables loss of breath to be stabilized, and reduces the frequency of coughing and expectoration. (1) Smoking cessation slows down the decline in the forced expiratory volume of air expelled in one second (FEV1). A study from 2000 showed that smoking cessation restored the annual decline of breath capacity to a level approaching normal: the annual decrease of FEV1 was -30ml/year for a non-smoker, -31ml/year for an ex-smoker and -62ml/year for a smoker. (2) In addition, smoking cessation reduces bronchial bacterial colonization and allows some recovery of the body's natural defences, which in turn reduces the risk of aggravation. If the patient's symptoms do become aggravated, long periods of antibiotic treatment, or even hospitalization, may be necessary. Lastly, smoking cessation improves the effectiveness of medication, especially corticoids, which do not work if the patient smokes. (3) Smoking cessation produces a considerable decrease in the COPD mortality rate. On the whole, the studies carried out support the notion that even in severe cases of COPD, smoking cessation improves the chances of survival compared to a smoker who continues smoking. The benefits of smoking cessation on the effects of the illness appear quickly: a study showed that participants who stopped smoking saw their FEV1 improve in the following year, including heavy smokers, elderly smokers, and smokers with weak lung capacity or bronchial hyperreactivity. (4) The Lung Health Study came to the same conclusions – from one year in, people who had stopped smoking presented fewer symptoms of COPD, namely chronic coughing, expectorations, dyspnea and wheezing. Note: it would seem that women benefit even more than men from smoking cessation from the point of view of lung function. Smoking cessation is therefore the primary treatment for COPD. It is also the only treatment that stops the continued obstruction of the bronchi and increasing shortness of breath.
Smoking cessation is difficult for COPD sufferers
It is difficult for someone who suffering from COPD to quit smoking. Why exactly is that? Reasons include that the person often smokes a large quantity of tobacco, has been smoking for a long time, has a strong addiction, is usually quite inactive, and may have a difficult socio-economic or educational background. Women seem to find it harder to quit than men, and have an increased risk of developing anxiety or depression. (5) Reducing the amount of tobacco smoked can be the first goal, even if complete cessation is the ultimate objective. In fact, reducing the amount smoked can produce some positive effects. It is enough to curb the reduction of FEV1. The Lung Health Study showed, among other things, that smokers who hovered between quitting and re-starting smoking experienced less decline in lung function than persistent smokers (-63ml/year for smokers, -34/year if the person successfully quit and -44ml/year if the person stopped smoking for a while). Another advantage of reducing the quantity of tobacco smoked is that it encourages people who did not aim to quit full stop to think about doing so.
COPD and emphysema – smoking cessation in practice
COPD sufferers must without a doubt receive help in order to quit smoking. The first treatment is nicotine replacement (patches, gum, lozenges, and so on). The Lung Health Study carried out for 11 years on 5887 patient suffering from COPD showed that allowing people to chew 2mg nicotine gum during group support sessions achieved three times more success in enabling smokers to quit than the placebo used on the control group. The rate of smoking cessation was 22% in the group that used nicotine replacement, a good result. Nicotine replacement was handled well by all the participants, with no notable side effects. The Lung Health Study was also able to show that this treatment reduces the mortality rate. (8) Bupropion also seems to be an effective aid which is handled well. A study carried out in 2011 showed that taking bupropion on a continual basis practically doubled the number of smokers in the early or medium phases of COPD who succeeded in quitting for more than 12 weeks. The effects lasted until 3 months after quitting. (6) Bupropion appears to be particularly useful in cases where nicotine replacement therapy has failed, especially for women who have a history of depression. Recent studies have highlighted that bupropion may lead to a reduction in the amount of tobacco smoked and an increase in the success rate when cessation is later attempted (7). Another medicine which has been the subject of a study on smoking cessation among COPD sufferers is varenicline. A study conducted in 2011 on 504 smokers suffering from slight-to-moderate COPD revealed that between weeks 9 to 12, the rate of abstinence obtained was much higher in the group who used varenicline than in the placebo group. Long programs of cognitive behavioral therapies must be combined with medication for best results.
(1) Pr Bertrand Dautzenberg, Arrêt du tabac traitement de première et de deuxième intention de la BPCO, présentation à la SFT, 2010
(2) Scanlon PD, Connett JE, Waller LA, Altose MD, Bailey WC, Buist AS, Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease, Am J Respir Crit Care Med. 2000 Feb;161(2 Pt 1):381-90.
(3) Lazarus SC, Chinchilli VM, Rollings NJ, Boushey HA, Cherniack R et al. Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in asthma. Am J Respir Crit Care Med 2007;175:783-90
(4) Scanlon PD, Connett JE, Waller LA, Altose MD, Bailey WC, Buist AS, Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease, Am J Respir Crit Care Med. 2000 ;161(2 Pt 1):381-90.
(5) J. Perriot, Sevrage tabagique des patients atteints de BPCO - État des connaissances et propositions en vue de l'optimisation de leur prise en charge tabacologique, Le Courrier des Addictions, N° 4 Décembre 2004
(6) Tashkin D, Kanner R, Bailey W, Buist S, Anderson P, Nides M, Gonzales D, Dozier G, Patel MK, Jamerson B., Smoking cessation in patients with chronic obstructive pulmonary disease: a double-blind, placebo-controlled, randomised trial, Lancet. 2001 ;357(9268):1571-5.
(7) Hatsukami DK, Rennard S, Patel MK, Kotlyar M, Malcolm R, Nides MA, Dozier G, Bars MP, Jamerson BD., Effects of sustained-release bupropion among persons interested in reducing but not quitting smoking. Am J Med. 2004;116(3):151-7.
(8) Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE, Connett JE; 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(4):233-9.
• J. Perriot, Sevrage tabagique des patients atteints de BPCO - État des connaissances et propositions en vue de l'optimisation de leur prise en charge tabacologique, Le Courrier des Addictions, N° 4 Décembre 2004
• Pr Bertrand Dautzenberg, Arrêt du tabac traitement de première et de deuxième intention de la BPCO, présentation à la SFT, 2010
• Willemse BW, ten Hacken NH, Rutgers B, Lesman-Leegte IG, Postma DS, Timens W., Effect of 1-year smoking cessation on airway inflammation in COPD and asymptomatic smokers, Eur Respir J. 2005 Nov;26(5):835-45.
• Godtfredsen NS, Lam TH, Hansel TT, Leon ME, Gray N, Dresler C, Burns DM, Prescott E, Vestbo J., COPD-related morbidity and mortality after smoking cessation: status of the evidence, Eur Respir J. 2008 Oct;32(4):844-53.
• Godtfredsen NS, Vestbo J, Osler M, Prescott E, Risk of hospital admission for COPD following smoking cessation and reduction: a Danish population study, Thorax 2002;57:967–972
• TS Lapperre, DS Postma, MME Gosman, J B Snoeck-Stroband, N H T ten Hacken, P S Hiemstra, W Timens, P J Sterk, T Mauad, Relation between duration of smoking cessation and bronchial inflammation in COPD, Thorax 2006;61:115-121
• Scanlon PD, Connett JE, Waller LA, Altose MD, Bailey WC, Buist AS, Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease, Am J Respir Crit Care Med. 2000 Feb;161(2 Pt 1):381-90.
• Willemse BW, Postma DS, Timens W, ten Hacken NH., The impact of smoking cessation on respiratory symptoms, lung function, airway hyperresponsiveness and inflammation, Eur Respir J. 2004 Mar;23(3):464-76.
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