Introduction
Asthma is a widespread health problem and is a growing burden on our society in terms of morbidity, mortality, health care costs, and quality of life. The prevalence of asthma is raising both nationally and locally. Among asthma triggers, tobacco smoke is very powerful. Hence the main purpose of the study is to investigate the association of smoking and secondhand smoke with level of asthma control, severity, and quality of life among adult asthmatics.
Asthma is a chronic inflammatory disorder of the airways characterized by episodic and reversible airflow obstruction and airway hyperresponsiveness. Clinical manifestations include wheezing, coughing, and shortness of breath (Moorman et al., 2007). Hyperresponsiveness, the exaggerated narrowing of the airways after the inhalation of various stimuli, is a key feature of asthma (Eder, Ege, & Von Mutius, 2006). Causative factors that provoke asthma include viral infections, allergy, exercise, and airborne irritants such as cigarette smoke, strong odors, dusts, and other inhaled irritants (Fireman, 2003). The exact causative mechanism of asthma is unknown, but it is believed that there is a combination of both environmental and genetic factors during the development of an individual’s immune system that leads to susceptibility of asthma. Asthma can develop during childhood, or as an adult, and the disease is believed to have strong familial ties with complex genetic derivation.
Asthma is a widespread public health problem that has increased in the past two decades in Texas and the United States (Mannino, Homa, Akinbami, Moorman, Gwynn, & Redd, 2002), and there are approximately 21 million people in the United States with the diagnosis of asthma, of which 7 million are under the age of 18 (Moorman et al., 2007). Thus, the vast majority of individuals with asthma are adults. The prevalence is higher in African-American adults, and is higher among adult women than men. Women with asthma report more symptoms and poorer quality-of-life than do men, although measures of airflow obstruction are comparable (Osborne, Vollmer, Linton, & Buist, 1998). In Texas, approximately 1,000,000 adult Texans report having asthma, and many adult Texans are not in control of their asthma symptoms. Also, health related quality of life is lower in adults with asthma compared to adults without asthma (Texas Asthma Program, 2004). In Texas, 822 people have died of asthma since 1998, and asthma is responsible for approximately 25,000 hospitalizations per year – costing Texas more than 200,000,000 dollars per year in hospital charges (Texas Asthma Program, 2004). Thus, asthma poses to be a growing burden on our society in terms of disease related morbidity, health care costs, and quality of life (Fuhlbrigge et al., 2002). Hence, disease management is in the best interest of not only asthmatics, but our society as a whole.
Asthma Control, Severity & Quality of Life among Asthmatics
Being that asthma is a disease of chronic nature, it cannot be cured; however, the clinical manifestations can be controlled. Control is the degree to which symptoms of asthma are minimized and the goals of therapy are met (Myers & Op’t Holt, 2008). Therefore, achieving respiratory symptom control is one of the main targets in the management of patients with asthma (Nieuwenhof et al., 2006). Costa, De Oliveira, Caetano, Santoro, & Fernandez (2008) suggests that “When uncontrolled, asthma can put severe limits on daily life and can even be fatal” (p. 579). By accomplishing optimal control of asthma, the risk of life-threatening symptoms of asthma can be easily controlled and reduced. According to Thorsteinsdottir, Volcheck, Madsen, Patel, Li, & Lim (2008) the attainment of asthma control correlates with improved quality of life and reduced health care use, thus the importance of obtaining asthma control. This idea is substantiated in a prior study by Vollmer et al. (1999) who found that the number of asthma control problems showed marked highly significant cross-sectional associations with self reported health care utilization relating to quality of life in patients.
To help manage the treatment of asthmatics, the National Heart, Lung, and Blood Institute (NHLBI) and the National Asthma Education and Prevention Program (NAEPP) released the Expert Panel Report 3 (EPR-3). The EPR-3 provides the most comprehensive, evidence-based guidance for the diagnosis and management of asthma to date (National Heart, Lung, and Blood Institute, 2007). Following such medical management guidelines and avoiding exposure to environmental allergens, triggers and irritants that are known to exacerbate asthma are factors that can contribute to long-term and effective management of asthma (Moorman et al., 2007).
The assessment of asthma control is a key concept in asthma management. The goal of asthma control assessment is the definition of well-controlled asthma and poorly controlled or not well-controlled asthma. Simple validated tools that measure asthma control are recommended as a means of defining asthma control (Schatz et al., 2007). Recent statistics suggest that asthma remains poorly controlled in most (53-58 %) patients (Chapman, Boulet, FitzGerald, McIvor, & Zimmerman, 2005). Despite laudable efforts to improve asthma care over the past decade, a sizeable number of patients have not benefited from advances in asthma treatment. A substantial number of adult patients with asthma are inadequately controlled despite the availability of effective asthma treatment (Nieuwenhof et al., 2006). According to Lavoie et al. (2008) achieving optimal asthma control relies upon several behavioral factors including self monitoring, and more importantly, patients’ adherence to treatment regimens including trigger and exacerbation avoidance. Backer et al., (2007) found that “Compliance with therapy is a very important component of treatment failure” (p. 379). This idea is mirrored by Rabe, Vermeire, Soriano, & Maier (2000) who continue on to suggest that patients are inadequately treated and that adherence to asthma treatment guidelines is generally poor. As a consequence of poor adherence, there is general failure to achieve the set guideline goals. In formulating the treatment of asthma, to achieve optimal control the domains of both impairment and risk need to be assessed and monitored (Busse & Lemanske Jr, 2007).
Many individual factors have been previously associated with asthma control. The main causes of uncontrolled asthma are costs of health care utilization and absence from work or school (De Vries, Van Den Bemt, Lince, Muris, Thoonen, & Van Schayck, 2005), and also exposure to asthma triggers like allergens and tobacco smoke. Previous studies (Connolly, Chan, & Prescott, 1989; Lin, Fitzgerald, Hwang, Munsie, & Stark, 1999) have shown that lower income class and lower social class were associated with poor asthma control and higher rates of hospitalization due to asthma. Also, several authors (Althius, Sexton, & Prybylski, 1999; Connolly, et al., 1989; Siroux, Pin, Oryszczyn, Moual, & Kauffmann, 2000) have shown that current smokers have a higher frequency of bothersome asthma symptoms, attacks, and higher level of asthma severity than non-smokers. According to Myers & Op’t Holt (2008), “There is no more toxic substance to the asthmatic lung than tobacco smoke” (p. 5).
Tobacco Smoke
Both environmental or secondhand smoke and active tobacco smoking are detrimental to asthmatics. Secondhand smoke contains more than 4,000 chemicals, 250 of which are proven harmful (National Toxicology, 2005). There is no safe level of exposure to secondhand smoke (U.S. Department of Health & Human Services, 2006). This is because tobacco smoke burning from the end of a lit cigarette does not pass through the filter, thus, all of the toxins are released into the air. Silverman et al. (2003) go on to find that overall, 35% of asthmatic patients between the ages of 18 and 54 years old were current smokers, 23% were former smokers, and only 42% did not have a history of smoking cigarettes or were currently smoking. In 2005, an estimated 20.9% (45.1 million) of U.S. adults were current cigarette smokers (Mariolis et al., 2006).
Several deleterious effects have been described in asthma because of smoking: accelerated decline in lung function, more severe symptoms, impairment in quality of life and diminished therapeutic response to steroids (Baena-Cagnani, Maximiliano-Gomez, & Canonica, 2009). Similarly, exposure to environmental tobacco smoke, as reported by parents, has been linked to diminished pulmonary function and more frequent exacerbations of asthma in children with the disease (Chilmonczyk et al., 1993). Withers, Low, Holgate, & Clough (1998) suggest that “Smoking, either active or passive, was shown to be significantly associated with current, persistant, and late-onset [asthma] symptoms” (pp. 352-357).
Several other studies (Larsson, 1995; Strachan, et al., 1996; Withers, et al., 1998) have also shown that active smoking is associated with new onset of asthma in adolescents and adults. But these studies included few adults (only up to age 33) and focused on the specificity of new onset disease. However, as with much of the previous literature found, these studies focused on children, teens, and adolescents. However, in an adult study, Niedoszytko, Gruchala-Niedoszytko, Chelminska, Sieminska, & Jassem (2008) reconfirm that “Cigarette smoking is a well-recognized factor triggering symptoms of asthma” (pp. 495-497) and that active smoking is a powerful but very avoidable asthma trigger. Despite the numerous detrimental effects tobacco smoke has on individuals that have chronic disease, adults with asthma do not appear to selectively avoid cigarette smoking (Eisner, Yelin, Trupin, & Blanc, 2001). Others have mirrored this view:
Many adults presenting to the emergency department with acute asthma are active cigarette smokers. Given the irritating effects of tobacco smoke, as well as the association of cigarette smoke with respiratory illness, patients with asthma would seem to be a group that would avoid smoking entirely (Silverman, Boudreaux, Woodruff, Clark, & Camargo, 2003, p. 1473).
A British study found that asthma incidence in individuals aged 17 to 33 had a strong association with active cigarette smoking (Strachan, Butland, & Anderson, 1996). But this study was performed on a large nationally representative sample. Another study went deeper and found that nearly 1 in 10 adults with asthma indicated current smoking, and more than half of subjects indicated past smoking, which were associated with increased asthma severity, worse asthma-specific quality of life, and worse mental health status (Eisner & Iribarren, 2007). Their data results indicate that smoking is a potentially major issue for asthmatic adults. Eisner & Iribarren (2007) further conclude that both current and past smoking had similar adverse effects on measures of disease severity and health status, whereas current smoking had a greater impact on the prospective risk of hospitalization for asthma. The previous was an excellent study and included many desired associations; however, again, it was limited to patients acutely hospitalized or presenting to the emergency department with a primary or secondary diagnosis of asthma and does not reflect populations enrolled in voluntary asthma education programs. Moreover, they made no correlation to secondhand smoke, its subsequent association with asthma severity, control, or quality of life.
Asthma Education Program
Robichaud et al. (2004) suggests that “Emergency department visits for asthma may reflect poor asthma control, often due to insufficient asthma education and medical follow-up” (p. 1495). A key component of many asthma management guidelines is the recommendation for patient education and regular medical review (Gibson et al., 2009). This notion is mirrored by Costa et al. (2008) who have also suggested that “Education is fundamental in a good clinical practice, because if patients do not understand asthma, they will not be motivated to provide the self-care necessary to achieve asthma control (p. 579). One of the many purposes of an asthma education program is to focus on trigger identification. If we can pinpoint the problematic foci, then we can remove it from the individual’s environment, thus leading to better asthma control and quality of life.
This idea is reiterated succinctly by the results of an asthma education study by Lucas et al., (2001) whom suggest that “participants’ quality of life, functional status, and appropriate use of health care resources improved and was sustained for two years after program completion” (p.329). A number of studies (De Oliveira, et al., 1997; De Oliveira, et al., 1999; Cabral, et al., 1998) have also suggested that asthma education programs can significantly improve asthma self-management skills, which has resulted in fewer patients seeking medical attention, as well as considerable improvement in quality of life. These studies have evaluated the effectiveness of asthma education programs; however they have not documented the number of adult patients presenting that actively smoke and/or are exposed to secondhand smoke. Further, none have inferred on the subsequent association between smoking and secondhand smoke with level of asthma control, severity, and quality of life.
Need for the Research Activity
Properly managing asthma is a crucial keystone in obtaining an appropriate level of asthma control. A major part of this is identifying and removing asthma triggers. Since tobacco smoke is a very avoidable trigger, theoretically, removing tobacco smoke and obtaining control should be an easily achievable goal. Despite this, the ability of individuals with asthma to avoid this potentially harmful trigger, many adult asthmatics continue to actively smoke, and subject themselves to secondhand smoke.
The subsequent associations between smoking and secondhand smoke on level of asthma control, severity, and quality of life have been extensively studied in the past. However, much of the previous published literature focuses on children, teens, and adolescents; and virtually no studies, to my knowledge, exist which focus on the association of these variables among adults enrolled in asthma education programs. Previous studies have gathered data from asthmatics that required emergency department visits, acute hospitalization, and nationally representative samples. Because asthma severity, control, and quality of life are vital concepts in the management of asthma, it is important to study it’s associations in patients presenting to asthma education programs. The subsequent benefits may not only adhere to asthmatics, but to our society as a whole.