Table 3– Possible treatment options for asthmatic smokers beyond smoking cessation
Therapeutic options
Step 1Short-acting β2-agonist therapy as needed
Step 2Low dose ICS
Despite most smokers with asthma having reduced sensitivity to corticosteroids, it seems appropriate that asthmatics who smoke receive ICS because not all smokers are insensitive to ICS and steroid treatment may reduce the rate of decline in lung function in smokers [60–62]
Leukotriene receptor antagonists
Leukotriene receptor antagonists may have preferential beneficial effect on PEF in smokers with mild asthma compared to nonsmokers with mild asthma [39]
The preliminary findings of a randomised, parallel-group 6-month study to evaluate the efficacy of oral montelukast, fluticasone propionate and placebo in 1019 patients with chronic asthma who smoke cigarettes reported that both interventions produced small improvements in the percentage of asthma-control days (primary outcome) compared to placebo (www.clinicaltrials.gov; NCT00284856)
Steps 3 and 4Many smokers with asthma continue to be symptomatic despite low-dose ICS and in these patients a step-up in therapy will be required Additional therapies include one or more of the following options:
Long acting β2-agonist plus low-to-medium dose ICS
Combination of inhaled fluticasone and salmeterol produced significant improvements in airway hyperresponsiveness, airway calibre and annual exacerbation rate compared to doubling the dose of inhaled fluticasone [42, 95]
Similar benefits were reported with the combination of inhaled budesonide and formoterol [86]
High-dose ICS
Short-term treatment with high-dose ICS produces improvements in lung function in smokers with asthma [40], but long-term treatment with ICS may increase the risk of adverse effects
Leukotriene receptor antagonists
Benefit in smokers with asthma unknown
Low dose theophylline
The addition of low-dose sustained release theophylline restores ICS sensitivity as measured by lung function in smokers with asthma [96]
Tiotropium
Possible benefit particularly in smokers with asthma associated with persistent airflow obstruction [97]

  • The therapeutic options are based on the Global Initiative for Asthma guidelines steps [51]. ICS: inhaled corticosteroids; PEF: peak expiratory flow.