Respiratory Research Review Issue 216 2023 PDF

Respiratory RESEARCH REVIEW Making Education Easy In this issue: Living and caring for people with chronic breathlessness Physical and psychological symptoms for COPD in primary care Impact of multimorbidity on COPD deprioritisation in primary care Triple inhaler vs. dual bronchodilator therapy in...

Respiratory RESEARCH REVIEW Making Education Easy In this issue: Living and caring for people with chronic breathlessness Physical and psychological symptoms for COPD in primary care Impact of multimorbidity on COPD deprioritisation in primary care Triple inhaler vs. dual bronchodilator therapy in COPD Dupilumab for COPD with type 2 inflammation Airway smooth muscle area predicts response to ICS for COPD Associations of air pollution with chronic lung diseases Tea consumption and lung diseases risk Decreased dynamic hyperinflation after endobronchial valve treatment Smoking cessation: anxiety/depression in adults ± psychiatric disorders Abbreviations used in this issue COPD = chronic obstructive pulmonary disease FEV = forced expiratory volume HR = hazard ratio ICS = inhaled corticosteroid LABA = long-acting β-agonist LAMA = long-acting muscarinic antagonist RACP MyCPD Program participants can claim the time spent reading and evaluating research reviews as CPD in the online MyCPD program. Please contact [email protected] for any assistance. www.researchreview.co.nz ™ Issue 216 – 2023 Welcome to the final issue of Respiratory Research Review of 2023. COVID-19 has certainly not gone away; however, many of us who have had a chance to take a break this year are regaining the energy to move forward in the management of other illnesses. The Global Initiative for Chronic Obstructive Lung Disease (Gold 2023) is of assistance with its synthesis of more than 300 publications, a new definition of COPD and new therapeutic regimens with less of an emphasis on ICSs. The journal Prim Care Respir Med summarised the freely available comment on ‘Gold 2023: highlights for primary care’ (npj Prim Care Respir Med 2023;33:28). Personally, I like its more inclusive diagnosis that describes COPD “as a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnoea, cough, expectoration and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction”. This definition recognises COPD as a heterogeneous disease, and explicitly describes the main structural, functional and clinical manifestations of the disease. It encompasses the many pathophysiological mechanisms, and reduces the angst of trying to define the specific process. In a similar vein, I enjoyed the sentiment expressed in the Eur Respir J editorial triggered by this more inclusive definition of COPD: ‘Can we call all obstructive lung diseases COPD?’ (Eur Respir J 2023;61:2300462). The new definition of COPD omits the statement that COPD is caused by ‘significant exposure to noxious particles or gas’ and thereby becomes more inclusive. The normal lung function trajectory can be altered by childhood disadvantages like prematurity, respiratory infections or poor nutrition. Other causes and risk factors for COPD include poverty, HIV, post-tuberculosis infections, asthma and environmental pollutions. The new guidelines also emphasise well-established, evidence-based and effective nonpharmacological treatments: smoking cessation, vaccinations, physical activity, self-management, nutritional and psychological support, pulmonary rehabilitation, oxygen therapy and ventilatory support, and end-of-life and palliative care. In a treatable trait-like approach, the guidelines also nudge us to look out for common comorbidities like cardiovascular disease, lung cancer, bronchiectasis, sleep apnoea (14%), osteoporosis, diabetes, gastro-oesophageal reflux disease, anaemia and mental health disorders, in particular anxiety and depression. ‘Rational use of inhaled corticosteroids for the treatment of COPD’ (npj Prim Care Respir Med 2023;33:27) is one of the most learned reviews; it is written by Jennifer Quint, Amnon Ariel and Peter J Barnes. They start with the observation that ICSs are overprescribed, and include a table of possible causes, including that the similarities between asthma and COPD often lead to the assumption (or wishful thinking) that ICSs, which are so effective in asthma, may work in COPD as well. Here are five of their 15 key points: • ICS use should be limited to patients with eosinophilic COPD and those with concomitant asthma. • The major benefit of ICSs in COPD is a reduction in exacerbations by about 25%. • ICS-containing therapies increase the risk of many unwanted side effects, especially pneumonia, in patients with COPD. • Withdrawal of ICSs should be considered in patients who do not fulfil the guidelines for ICS use. • With sufficient bronchodilation in place, ICS withdrawal does not have a detrimental effect in patients at low risk of exacerbations. In case catching up on COPD management makes it onto your reading list, here are three more articles providing great insights: i) ‘Caring for patients with advanced COPD: beyond the inhalers…’ (Breathe 2023;19:220229); ii) ‘Lung imaging in COPD part 1 – clinical usefulness’ (Chest 2023;164:69–84) – this article starts with the sobering observation that for most patients it is easier to obtain a CT chest than spirometry; and iii) the best article over the last 12 months needs mentioning again – it is positive, practical and promising: ‘Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission’ (Lancet 2022;400:921–72). I leave you with best wishes for the holiday season and three suggestions for further reading. Firstly, ‘Health disparities: interventions for pulmonary disease – a narrative review’ (Chest 2023;164:179–89), which is an encouraging read, even if not the most cheerful. Secondly, ‘Illness, chocolate and Harry Potter’ (Respirology 2023;28:798–9) is Natasha Smallwood’s personal reflection, and is closer to the Christmas spirit; however, it does address some serious statistics. Thirdly, Joan Soriano and Christine Jenkins come closest to the spirit of Christmas and reflections for a new year with their philosophical applications: ‘How should good lung health be defined at the population and individual levels?’ (Eur Respir J 2023;62:2301166). Thank you for the feedback and communication, and best wishes for the festive season. Kind regards, Professor Lutz Beckert [email protected] CLICK HERE to read previous issues of Respiratory Research Review a RESEARCH REVIEW™ publication 1 Respiratory RESEARCH REVIEW ™ “It’s like a forgotten issue sometimes …”: qualitative study of individuals living and caring for people with chronic breathlessness 4-6§ Authors: Sunjaya A et al. Summary: Thirteen patients living with chronic breathlessness and two of their carers participated in in-depth semistructured interviews to gain their perspectives on current provision of care in Australia, care expectations and self-management needs. The responses identified the following four principle themes: i) living with breathlessness; ii) diagnosis delays, misdiagnoses and knowledge gaps; iii) symptom relief and improving quality of life; and iv) self-management and the limited support available for it. Comment: I am continually learning to appreciate the richness that qualitative data adds to our understanding of illness, patient experience and diversity of insights. This article is led by a researcher from The George Institute and supported by some of our most senior respiratory researchers. Some patients are frustrated by delayed diagnosis and some by premature diagnoses. Others feel frustrated because doctors never ask about breathlessness or report that ‘doctors only give more Ventolin® and no advice on how to improve my illness’. Bottom line: patients with chronic breathlessness report a lack of awareness, discontinuity of care and too few self-management options. Reference: Clin Respir J 2023;17:694–700 Abstract Independent commentary by Professor Lutz Beckert Professor Lutz Beckert is the Associate Dean Medical Education with the University of Otago, Christchurch. He is also a Respiratory Physician at Canterbury District Health Board with particular clinical interests in interstitial lung disease, pulmonary vascular disease, respiratory physiology and COPD (chronic obstructive pulmonary disease). FOR FULL BIO CLICK HERE For more information, please go to www.medsafe.govt.nz www.researchreview.co.nz Independent Content: The selection of articles and writing of summaries and commentary in this publication is completely independent of the advertisers/sponsors and their products. Privacy Policy: Research Review will record your email details on a secure database and will not release them to anyone without your prior approval. Research Review and you have the right to inspect, update or delete your details at any time. Disclaimer: This publication is not intended as a replacement for regular medical education but to assist in the process. The reviews are a summarised interpretation of the published study and reflect the opinion of the writer rather than those of the research group or scientific journal. It is suggested readers review the full trial data before forming a final conclusion on its merits. Research Review publications are intended for New Zealand health professionals. a RESEARCH REVIEW™ publication 2 Respiratory RESEARCH REVIEW ™ High prevalence and burden of physical and psychological symptoms in a chronic obstructive pulmonary disease population in primary care settings in South Africa Authors: Nkhoma KB et al. Summary: This cross-sectional survey study from South Africa examined the prevalence and burden of symptoms and concerns, and identified predictors of symptom burden, in 387 patients with COPD. Three models of global, psychological and physical symptom distress were all found to be significantly, positively associated with impairment on respondents’ lives, difficulties in performing activities of daily living and low social support. There were also significant associations of more advanced age with lower global symptom, psychological and physical distress, and missing ≥1 medication dose was significantly associated with greater global and physical symptom distress. Comment: The prevalence of COPD is growing more rapidly in low- and middleincome countries and more than 90% of deaths occur in such countries. Tobacco smoking is a risk factor; however, up to a third of cases are in people who have never smoked. COPD occurs in people following pulmonary tuberculosis, after occupational dust exposure, or biomass fuel smoke exposure through cooking and heating. The authors report symptoms in order of prevalence and impact on the patient. Bottom line: the top ten COPD symptoms are shortness of breath, pain, cough, drowsiness, lack of energy, sleeping difficulties, worry, feeling sad, dry mouth and numbness. Does multimorbidity result in de-prioritisation of COPD in primary care? Authors: Smith C et al. Summary: To examine deprioritisation for COPD (not having ≥1 physician checkup over a 2-year period) in multimorbid patients, factors associated with regular primary-care nurse or physician COPD review were evaluated for 713 participants from the Swedish PRAXIS study; 66% had ≥1 checkup during the study period. Compared with participants who did not receive such checkups, those who did were more likely to have ≥3 comorbid conditions (31.9% vs. 24.6%) and exacerbations (35.1% vs. 21.7%). Compared with participants without comorbidities, those with ≥3 were more likely to have consultations discussing COPD with only a physician (risk ratio 5.63 [95% CI 2.68, 11.79]), only a COPD nurse (1.67 [0.83, 3.37]) or both (2.11 [1.09, 4.06]). Comment: This study explored the evidence behind the narrative that comorbid COPD patients are reviewed less frequently by a GP than patients without comorbidities, due to time constraints. The fear is that these patients become deprioritised, i.e. they are not seen by a doctor at least once in a 2-year period. Interestingly, secondary to the shortage of GPs in Sweden, 18% of COPD care is supervised by a nurse specialist. Reassuringly, this study found the opposite was true. Bottom line: patients with COPD and comorbidities see GPs more often than patients without comorbidities. Reference: NPJ Prim Care Respir Med 2023;33:2 Abstract Reference: Int J Chron Obstruct Pulmon Dis 2023:18:1665–79 Abstract Pharmacy Council of New Zealand Te Pou Whakamana Kaimatū o Aotearoa Journal reading (including Pharmacy Research Review and other Research Reviews) and completing online activities may be considered a professional development activity as part of the ‘Keeping up to Date Recertification Guidance’. For more information go to https://pharmacycouncil.org.nz/pharmacist/recertification/ Research Review publications, videos and e-Learning modules have been endorsed by The Royal New Zealand College of General Practitioners (RNZCGP) and have been approved for up to 1 CME credit per learning hour for Continuing Professional Development (CPD) purposes. Please CLICK HERE to download RNZCGP Dashboard. Time spent reading this publication has been approved for CNE by The College of Nurses Aotearoa (NZ) for RNs and NPs. For more information on how to claim CNE hours please CLICK HERE. ANORO Ellipta offers symptomatic patients with COPD greater improvement in lung function vs. other LAMA/LABAs in the class1,3 Up to 1.4x* superior improvement in lung function vs. Spiolto Respimat (180mL vs. 128mL; p<0.001)1 *ANORO showed superiority on the primary endpoint of trough FEV1 compared to Spiolto Respimat (tiotropium/olodaterol 5/5mcg).1 Trough FEV1 improved to 180mL for ANORO (n=225) versus 128mL for Spiolto Respimat (n=224) over an 8-week treatment period in adults with symptomatic moderate COPD (mMRC ≥2 and post-bronchodilator FEV1 50–70%); difference 52mL (95% CI: 28, 77; p<0.001) in ITT population.1 An 8-week, randomised, open-label, non-inferiority, two-period crossover study in symptomatic patients with moderate COPD (post-bronchodilator FEV1 ≤70% and ≥50% of predicted value) and not receiving ICS at inclusion. Primary endpoint: change from baseline in trough FEV1 at Week 8; NI margin -50mL.1 For New Zealand healthcare professionals only. References 1. Feldman GJ et al. Adv Ther 2017;34(11):2518-2533 2. GlaxoSmithKline New Zealand. Anoro Ellipta Data Sheet. GSK NZ; 2020. Available at https://medsafe.govt.nz/profs/datasheet/a/ anoroelliptapowder.pdf 3. Maltais F et al. Adv Ther 2019;36:2434-2449. Anoro Ellipta (umeclidinium bromide/vilanterol trifenatate inhaler 62.5/25mcg per inhalation) is a prescription medicine. Anoro Ellipta is indicated as a long-term maintenance bronchodilator treatment to relieve symptoms in adult patients with Chronic Obstructive Pulmonary Disease (COPD). Anoro Ellipta is a fully funded medicine; Special Authority criteria apply. Before prescribing Anoro Ellipta, please review the data sheet for information on dosage, contraindications, precautions, interactions and adverse effects. The data sheet is available at www.medsafe.govt.nz. Anoro Ellipta is not licensed for the treatment of asthma2. Spiolto Respimat is a registered trade mark of Boehringer Ingelheim. Anoro and Ellipta are registered trade marks of the GlaxoSmithKline group of companies. © 2022 GSK Group of Companies or its licensor. Anoro Ellipta was developed in collaboration with Innoviva Inc. Marketed by GlaxoSmithKline NZ Limited, Auckland. Adverse events involving GlaxoSmithKline products should be reported to GSK Medical Information on 0800 808 500. TAPS DA2245GS-PM-NZ-UCVADVT-220001 Date of Approval: 04 2022 Date of Expiry: 04 2024 Full Healthcare Mandatory Information is available at https://www.researchreview.co.nz/RR/media/Secured-Documents/NZ/Prescribing-Info/NZ-Anoro-Ellipta-HCP-mandatories-2021.pdf For more information, please go to www.medsafe.govt.nz www.researchreview.co.nz a RESEARCH REVIEW™ publication 3 Respiratory RESEARCH REVIEW ™ Each month we highlight a particularly excellent paper with our butterfly symbol. Triple inhaler versus dual bronchodilator therapy in COPD Authors: Suissa S et al. Summary: This retrospective study used real-world data from the UK Clinical Practice Research Datalink to compare triple therapy with a LAMA, a LABA and an ICS (117,729 patients) versus LAMA plus LABA combinations (26,666 patients) on major COPD outcomes. For triple versus dual combinations, the adjusted HR for all-cause mortality was 1.17 (95% CI 1.04, 1.31), for severe exacerbations it was 1.19 (1.08, 1.32) and for pneumonia it was 1.29 (1.16, 1.45). Mortality risk was not increased with triple therapy in patients with asthma (HR 0.99 [95% CI 0.74, 1.34]), those with ≥2 prior exacerbations (0.88 [0.70, 1.11]) or those with an FEV1 of >30% (1.66 [1.08, 2.55]). Comment: This is a fascinating population-based study based on the UK Clinical Practice Research Datalink. Over the period from 2002 to 2018, the Canadian researchers identified almost 120,000 patients with COPD who were started on triple inhaler therapy with a LAMA, LABA and ICS. Over the same time, just over 25,000 patients were started on LAMA-LABA therapy. Patients stayed on the triple therapy for approximately 5.5 months and on the dual bronchodilator therapy for 4.8 months before it was adjusted. Bottom line: patients started on triple therapy had a modest increase in allcause mortality and severe exacerbations compared with patients started on LAMA-LABA therapy. Reference: COPD 2022;19:1–9 Abstract Dupilumab for COPD with type 2 inflammation indicated by eosinophil counts Authors: Bhatt SP et al., for the BOREAS Investigators Summary: Patients with COPD and a blood eosinophil count ≥300 cells/µL who were at increased risk of exacerbation despite standard triple therapy were randomised to receive subcutaneous dupilumab 300mg (n=468) or placebo (n=471) once every 2 weeks in this phase 3 trial. Compared with placebo, dupilumab recipients had a significantly lower annualised moderate or severe exacerbation rate (primary endpoint; 0.78 vs. 1.10; rate ratio 0.70 [95% CI 0.58, 0.86]), an increase in prebronchodilator FEV1 at week 12 (least squares mean difference, 83mL [p<0.001]), which was maintained out to week 52, and improvements in St. George’s Respiratory Questionnaire and Evaluating Respiratory Symptoms in COPD scores at week 52 (respective least squares mean differences, –3.4 [p=0.002] and –1.1 [p=0.001]). The two arms were similar for adverse events leading to discontinuation, serious adverse events and mortality due to adverse events. Comment: Dupilumab is not approved or funded in NZ; however, it is exciting to see a new treatment for COPD in the N Engl J Med. The biological therapy for eosinophilic asthma can lead to dramatic improvements. In this trial, the investigators randomised about 1000 patients with COPD and a blood eosinophil count of >300 cells/µL to dupilumab or placebo. Interestingly, 30% of the patients continued to smoke, almost all were on triple inhaler therapy and a third were on high-dose ICSs. Bottom line: patients with COPD and an elevated blood eosinophil count treated with dupilumab had fewer exacerbations, better lung function and improved quality of life. Reference: N Engl J Med 2023;389:205–14 Abstract Learn to Live Again! Airway smooth muscle area to predict steroid responsiveness in COPD patients receiving triple therapy (HISTORIC) Authors: Stolz D et al. Summary: Patients with GOLD stage B–D COPD (n=190) underwent bronchoscopy with endobronchial biopsy and were stratified into those with high (>20%) or low (≤20%) airway smooth muscle cell area and received a 6-week run-in of triple therapy with inhaled aclidinium-formoterol-budesonide 400µg/12µg/400µg twice daily, after which they were randomised to continue this triple therapy or switch to dual therapy with budesonide replaced with placebo. Compared with dual therapy, triple therapy was associated with an improvement in FEV1 after 12 months (primary endpoint) in participants with an airway smooth muscle cell area of >20% (difference 183.0 mL/year [p=0.020]), but not in those with lower airway smooth muscle cell areas (50.6 mL/year [p=0.675]). Comment: In this fascinating study, our colleagues in Basel and Freiburg performed bronchoscopies with endobronchial biopsies on about 200 COPD patients. They identified about a third of the patients as having a high density of airway smooth muscle cells. This subgroup experienced a remarkable benefit from ICSs: improved FEV1, reduced FeNO (fractional exhaled nitric oxide) and gas trapping. It may explain why the effect of ICSs is significant but rather modest across the whole group of patients with COPD. Bottom line: detailed histological endotyping of airway smooth muscle density provides a new therapeutic target, and identifies a subgroup of patients with COPD who respond well to ICSs. Reference: Eur Respir J 2023;62:2300218 Abstract MERRY CHRISTMAS & A HEALTHY, HAPPY 2024! FROM THE TEAM AT KINDLY SUPPORTED BY Are you a general practitioner or nurse practitioner looking for something different? NZLocums and NZMedJobs are dedicated to assisting you in finding and securing exciting career opportunities. There are vacancies for your skills in the country’s most beautiful locations. We have a wide range of job options, including locum, long-term, and permanent positions in both rural and urban medical practices throughout Aotearoa New Zealand. With extensive experience and knowledge in both rural and urban health, don’t miss the chance to experience a new life in Aotearoa New Zealand, contact us for more information. Visit our website, https://htrhn.org.nz/recruitment/ or contact us at 0800 695 628 or [email protected] to learn more. www.researchreview.co.nz a RESEARCH REVIEW™ publication 4 Respiratory RESEARCH REVIEW ™ Air pollution associated with incidence and progression trajectory of chronic lung diseases Impact of bronchoscopic lung volume reduction with endobronchial valves on dynamic hyperinflation Authors: Wang X et al. Summary: The impact of air pollution on progression from healthy to chronic lung disease, subsequent chronic lung multimorbidity and mortality was explored in a cohort of 265,506 adults free of chronic lung disease at enrolment in the UK Biobank. Over a median of 11.9 years of follow-up, 13,863 enrolees developed ≥1 chronic lung disease, 1055 developed chronic lung multimorbidity, and there were 12,772 deaths. Differential associations of air pollution with different trajectories of chronic lung multimorbidity were identified, with the strongest associations seen for fine particulate matter with five transitions (HRs for each 5 µg/m3 increase, 1.31 [95% CI 1.22, 1.42] and 1.27 [1.01, 1.57] for transitions from healthy to incident chronic lung disease and from incident chronic lung disease to chronic lung multimorbidity, respectively, and 1.32 [1.21, 1.45], 1.24 [1.01, 1.53] and 1.91 [1.14, 3.20] for mortality risk from healthy, incident chronic lung disease and chronic lung multimorbidity, respectively). Authors: Fumat R et al. Summary: In the PIERCE study, 39 patients with severe emphysema who underwent bronchoscopic lung volume reduction using endobronchial valves were assessed by incremental cycle ergometry before and 3 months after treatment. After treatment, there were improvements in change in inspiratory capacity by +214mL (primary outcome; p=0.004), tele-expiratory volume by –713mL (p<0.001), FEV1 by +177mL (p<0.001), residual volume by –600mL (p<0.0001) and 6-minute walk distance by +33m (p<0.0001). Comment: It is widely accepted that air pollution has a detrimental effect on the respiratory system; however, until publication of the present paper, research supporting this claim was sparse. This group of Chinese and American researchers used data from 250,000 patients in the UK Biobank, and followed them for about 12 years. During this time, about 14,000 developed a chronic lung condition and 13,000 died. The authors were able to establish a correlation between exposure to fine particles, particularly ultrafine particles (diameter <2.5µm), and the development of chronic lung disease. Bottom line: this is the first large-scale study demonstrating that ambient air pollution leads to chronic lung disease and death. Reference: Thorax 2023;78:698–705 Abstract Tea consumption and risk of lung diseases Authors: Chen L et al. Summary: Relationships between black tea intake and a range of respiratory disorders were examined in this two-sample Mendelian randomisation analysis using inverse variance weighting in 447,385 individuals. There was no evidence of a significant causal relationship between tea intake and COPD (odds ratio 1.001 [95% CI 0.993, 1.006]), idiopathic pulmonary fibrosis (0.997 [0.994, 1.000]), lung cancer (1.003 [0.998, 1.008]), acute bronchitis (0.919 [0.536, 1.576]), tuberculosis (1.002 [0.998, 1.008]) or pneumonia (0.789 [0.583, 1.068]), with consistent results seen in four additional Mendelian randomisation analyses as well as sensitivity testing. Comment: Observational studies can give conflicting results. A metaanalysis has suggested that drinking black tea is linked with an increased risk of developing lung cancer. Other studies have reported that the antioxidant, immunomodulatory and anti-inflammatory effects protect against exacerbations of asthma and COPD. These Chinese researchers correlated the data of about 450,000 participants of the UK biobank with their habits of drinking black tea – on average 3.51 cups per day. Using a Mendelian analysis, the authors report: bottom line: black tea seems to neither protect from nor aggravate COPD, lung cancer, pneumonia, idiopathic pulmonary fibrosis, acute bronchitis or tuberculosis. Reference: BMC Pulm Med 2023;23:461 Abstract www.researchreview.co.nz © 2023 RESEARCH REVIEW Comment: Bronchoscopic lung volume reduction surgery is becoming a viable treatment option for some patients with severe emphysema and no collateral ventilation. In this paper, a group of French authors report on the effect of endobronchial valves in 39 patients recruited from a population of about 1.5 million over 4 years. In this carefully selected group, FEV1 improved by about 177mL, forced vital capacity by about 300mL and 6-minute walk distance by about 33m. Patients also reported a reduction in their breathlessness. Bottom line: in addition to the static lung function improvements, these authors demonstrated a reduction of air trapping during exercise. Reference: Respirology 2023;28:525–32 Abstract Smoking cessation and changes in anxiety and depression in adults with and without psychiatric disorders Authors: Wu AD et al. Summary: Changes in mental health following smoking cessation were assessed in 4260 participants from a large smoking cessation randomised controlled trial. The mean Hospital Anxiety and Depression Scale anxiety and depression scores at baseline were 3.68 and 2.44, respectively, with smoking cessation leading to significant decreases in both, after adjustments for demographics and baseline variables, of –0.40 and –0.47 points, compared with continuing smoking. Similar reductions were confirmed in propensity score-adjusted models, and the findings were robust to sensitivity and subgroup analyses, with larger effect sizes noted in the 55.4% of participants who had a history of mental illness. Comment: Many people report that smoking relieves stress and offers mental health benefits, which makes discussion around smoking cessation challenging. A Cochrane review suggested that smoking cessation was associated with improved mental health, but randomised controlled trials to continue or quit smoking are not feasible. These UK authors designed a cohort study based on the data obtained from a randomised trial on smoking cessation. The authors reported on about 4000 participants, around half of whom had a history of mental illness. Bottom line: smoking cessation leads to sustained improvement in mental health and reduced anxiety, in both those with and those without psychiatric disorders. Reference: JAMA Netw Open 2023;6:e2316111 Abstract New Zealand Research Review subscribers can claim CPD/CME points for time spent reading our reviews from a wide range of local medical and nursing colleges. Find out more on our CPD page. a RESEARCH REVIEW™ publication 5