From the Guidelines
Using inhalers in current cigarette smokers poses significant dangers, primarily due to reduced effectiveness of inhaled medications and accelerated disease progression, emphasizing the need for smoking cessation as the most critical intervention. The primary concern is reduced effectiveness of inhaled medications, particularly corticosteroid inhalers used for asthma and COPD, as cigarette smoke contains chemicals that cause airway inflammation and can directly counteract the anti-inflammatory effects of inhaled corticosteroids, making them less effective at controlling symptoms 1. Additionally, smoking damages the airway's ciliary clearance mechanism, which can reduce medication deposition in the lungs. For bronchodilator inhalers like beta-agonists (albuterol, salmeterol) and anticholinergics (tiotropium, ipratropium), smoking diminishes their effectiveness by causing persistent inflammation and accelerated airway remodeling.
Key points to consider include:
- The importance of smoking cessation in improving inhaler effectiveness and overall respiratory health 1
- The need for regular assessment of inhaler technique to ensure optimal medication delivery 1
- The potential for combination inhalers containing both corticosteroids and long-acting bronchodilators to have diminished benefits in current smokers
- The role of other interventions, such as pulmonary rehabilitation and vaccination, in managing COPD and improving quality of life 1
Continued smoking while using inhalers can lead to faster disease progression, more frequent exacerbations, and poorer overall disease control. Patients using combination inhalers containing both corticosteroids and long-acting bronchodilators (such as Advair, Symbicort, or Breo) may experience particularly diminished benefits. The most important intervention for these patients is smoking cessation, which can significantly improve inhaler effectiveness and overall respiratory health, as highlighted in the global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report 1.
From the Research
Dangers of Using Inhalers in Current Cigarette Smokers
- The use of inhalers in patients who are current cigarette smokers can be associated with several risks, including:
- Reduced efficacy of inhaler medications due to continued smoke exposure 2
- Increased risk of cardiovascular disorders with the use of inhaled beta-2 agonists 2
- Potential for increased mortality with the use of ipratropium, an inhaled short-acting anti-muscarinic bronchodilator 2
- Antimuscarinic adverse effects, including cardiac, visual, and buccal disorders, with the use of tiotropium and other inhaled long-acting antimuscarinics 2
- Smoking cessation is a crucial aspect of managing chronic obstructive pulmonary disease (COPD) and can improve treatment outcomes 3, 4
- Pharmacological strategies for smoking cessation, including nicotine replacement therapy, varenicline, bupropion, and cytisine, can be effective in helping smokers quit 4
- The use of alternative tobacco products can complicate smoking cessation efforts and act as gateway devices for new generations of smokers 3
Specific Risks Associated with Inhaler Use in Smokers
- Inhaled corticosteroids can cause pneumonia, candidiasis, dysphonia, and adrenal insufficiency, with fluticasone seeming to have more adverse effects than other inhaled corticosteroids 2, 5
- Theophylline has uncertain efficacy on symptoms of COPD and carries a risk of serious adverse effects, making it not recommended for use in COPD 2
- Roflumilast, a phosphodiesterase-4 inhibitor, can reduce moderate to severe exacerbations in patients with severe COPD, but its use should be carefully considered due to potential adverse effects 6