Smoking is the cause of numerous diseases of the respiratory system, including cancers of the throat and lungs, chronic obstructive pulmonary disease (COPD) and chronic bronchitis. The effects of smoking on cancer treatment are discussed in Section 3.15.4 and the effects of smoking on the treatment of other respiratory diseases are discussed herein.
3.15.5.1 Chronic obstructive pulmonary disease (COPD)
COPD is a progressive lung disease characterised by shortness of breath and chronic cough, described in detail in Section 3.2.4.1. Smoking is the main cause of COPD.1 Smoking cessation is recommended and reduces lung function decline and COPD exacerbations compared to continued smoking.2 Medications such as bronchodilators, corticosteroids and antibiotics can be used to help manage symptoms of COPD, but the disease remains progressive and often fatal.
Numerous studies have found that people who smoke have a poorer response to treatments for COPD compared former smokers, such as the antibiotic azithromycin,3 inhaled corticosteroids4 and triple therapy.5-7 A systematic review found that people who currently smoke had more COPD exacerbations than former smokers, and people who smoked heavily (>36 pack years) had more COPD exacerbations than lighter smokers (≤ 36 pack years), when treated with inhaled corticosteroids.8 However there are some inconsistencies in the results of various trials that measured lung function decline with treatments for COPD in people who smoke, compared to non-smokers.8,9 Further research is therefore required to fully characterise the effects of smoking on treatments for COPD.
3.15.5.2 Asthma
Smoking exacerbates asthma in adults and leads to poor control of asthma (see Section 3.2.5.1).1 Randomised controlled trials have shown that inhaled corticosteroids for the treatment of asthma were less effective in people who smoke compared to non-smokers.1,10-12 People with asthma who smoke may need additional medications, such as long-acting beta agonists with corticosteroids for asthma control.13
3.15.5.3 Other respiratory conditions
Percutaneous transthoracic needle biopsy is performed to obtain lung tissue samples for diagnostics. A study has shown that smoking status and smoking intensity are associated with outcomes and side effects from this procedure.14 People who smoke were more likely to get false negative results, but less likely to cough up blood after the biopsy. People who smoke heavily were more likely to experience pneumothorax, where air leaks into the space between the lung and chest wall, causing lung collapse.14
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References
1. US Department of Health and Human Services. The health consequences of smoking: 50 years of progress. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf.
2. Jimenez-Ruiz CA, Andreas S, Lewis KE, Tonnesen P, van Schayck CP, et al. Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit. European Respiratory Journal, 2015; 46(1):61-79. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25882805
3. Han MK, Tayob N, Murray S, Dransfield MT, Washko G, et al. Predictors of chronic obstructive pulmonary disease exacerbation reduction in response to daily azithromycin therapy. American Journal of Respiratory and Critical Care Medicine, 2014; 189(12):1503-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779680
4. Bhatt SP, Anderson JA, Brook RD, Calverley PMA, Celli BR, et al. Cigarette smoking and response to inhaled corticosteroids in COPD. European Respiratory Journal, 2018; 51(1). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29348179
5. Lipson DA, Barnhart F, Brealey N, Brooks J, Criner GJ, et al. Once-daily single-inhaler triple versus dual therapy in patients with COPD. New England Journal of Medicine, 2018; 378(18):1671-80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29668352
6. Pascoe S, Barnes N, Brusselle G, Compton C, Criner GJ, et al. Blood eosinophils and treatment response with triple and dual combination therapy in chronic obstructive pulmonary disease: analysis of the IMPACT trial. The Lancet Respiratory Medicine, 2019; 7(9):745-56. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31281061
7. Celli BR, Christenson S, Rabe KF, Han MK, van den Berge M, et al. Current smoker: A clinical COPD phenotype affecting disease progression and response to therapy. American Journal of Respiratory and Critical Care Medicine, 2025; 211(5):729-36. Available from: https://www.ncbi.nlm.nih.gov/pubmed/39938077
8. Sonnex K, Alleemudder H, and Knaggs R. Impact of smoking status on the efficacy of inhaled corticosteroids in chronic obstructive pulmonary disease: a systematic review. BMJ Open, 2020; 10(4):e037509. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32300001
9. Bardsley S, Fageras M, Marshall J, Martin N, Psallidas I, et al. Current smoking and pharmacological treatment responses in chronic obstructive pulmonary disease: Not clear-cut. American Journal of Respiratory and Critical Care Medicine, 2025; 211(11):2223-4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/40680218
10. Chalmers GW, Macleod KJ, Little SA, Thomson LJ, McSharry CP, et al. Influence of cigarette smoking on inhaled corticosteroid treatment in mild asthma. Thorax, 2002; 57(3):226-30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11867826
11. Lazarus SC, Chinchilli VM, Rollings NJ, Boushey HA, Cherniack R, et al. Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in asthma. American Journal of Respiratory and Critical Care Medicine, 2007; 175(8):783-90. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17204725
12. Tomlinson JE, McMahon AD, Chaudhuri R, Thompson JM, Wood SF, et al. Efficacy of low and high dose inhaled corticosteroid in smokers versus non-smokers with mild asthma. Thorax, 2005; 60(4):282-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15790982
13. Chatkin JM and Dullius CR. The management of asthmatic smokers. Asthma Research and Practice, 2016; 2:10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27965778
14. Lim WH, Lee JH, Park H, Park CM, and Yoon SH. Effect of smoking on the diagnostic results and complication rates of percutaneous transthoracic needle biopsy. European Radiology, 2024; 34(10):6514-26. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38528137