CME: Identifying Smoking-Related Disease

CME: Identifying Smoking-Related Disease
Author Information (click to view)

Elizabeth A. Regan, MD, PhD

Associate Professor, Division of Rheumatology
Department of Medicine
National Jewish Health

Elizabeth A. Regan, MD, has indicated to Physician’s Weekly that she has no financial interests to disclose.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:


  1. Discuss the findings of a study that set out to determine whether or not patients with a heavy smoking history, but who did not meet spirometric criteria for COPD, had hidden lung disease.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at

Credit Available(click to view)


CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.


AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.


Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)


Christopher Cole, Senior Editor
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Elizabeth A. Regan, MD, PhD
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.


Elizabeth A. Regan, MD, PhD (click to view)

Elizabeth A. Regan, MD, PhD

Associate Professor, Division of Rheumatology
Department of Medicine
National Jewish Health

Elizabeth A. Regan, MD, has indicated to Physician’s Weekly that she has no financial interests to disclose.

A study suggests that the effect of chronic smoking on the lungs is substantially underestimated when using spirometry alone.
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Among current and former adult smokers, symptoms like productive cough, dyspnea, and exercise intolerance may be viewed as a part of normal aging, particularly among older former smokers. Smoking cessation may reduce respiratory symptom severity and slow the rate of lung function decline, but it does not eliminate progressive lung disease risk.

Few studies have assessed the effects of smoking on patients without COPD. A group of researchers has suspected that spirometry may be insensitive to early disease or subclinical lung pathology and that current and former cigarette smokers without spirometric evidence of COPD may have impairments in physical function, quality of life, and respiratory symptoms that can go untreated. High-resolution CT scanning in this patient population may demonstrate significant lung disease, but comprehensive data has been lacking.

Finding Hidden Lung Disease

“There are no disease-modifying treatments for patients identified with smoking-related lung disease,” explains Elizabeth A. Regan, MD, PhD, “but there are many treatments that improve their symptoms, allow them to breath better, enable them to exercise, and improve quality of life.” For a study published in JAMA Internal Medicine, Dr. Regan and colleagues set out to determine whether or not patients with a heavy smoking history, but who did not meet spirometric criteria for COPD, had hidden lung disease.

Dr. Regan and colleagues completed evaluations on more than 10,000 current and former smokers aged 45 to 80 with at least a 10 pack-year smoking history and a comparison group of more than 100 never smokers of similar ages. Evaluations included high-resolution chest CT scans, spirometry, 6-minute walking tests, and multiple questionnaires about respiratory symptoms, comorbidities, and quality of life. Their analysis focused on the 4,388 smokers who did not have evidence of obstruction on their spirometry.

Among patients with a heavy smoking history but normal spirometry results, more than half had respiratory-related impairments as determined by CT scans. “These patients have real disease,” says Dr. Regan. “It’s important that abnormalities were demonstrated on the CT scans because most clinicians are not likely to order a high-resolution CT scan for this patient population. Our findings suggest that doing so is worthwhile.”

Other Key Findings

When compared with never smokers, current and former heavy smokers without COPD by spirometry had worse quality of life. The results confirm that chronic smokers even without a diagnosis of COPD have many similar symptoms and limitations as COPD patients.  Among smokers, 15.0% had a 6-minute walking test result of 1,000 feet, compared with a rate of 4.0% observed among never smokers. CT scans also found that 42.3% of smokers had evidence of emphysema or airway thickening. Whereas current smokers had more respiratory symptoms, former smoking was associated with greater emphysema and gas trapping. Significant dyspnea was found in 23.5% of smokers, compared with just 3.7% of never smokers. Current and former smokers were also more likely to have one or more impairments (54.1% vs 24.1%).

“We also found that as people age, they increasingly stop smoking,” says Dr. Regan (Figure). “However, the lung disease that was triggered by the smoking exposure does not stop; it actually progresses with time. Although less than half of those aged 60 or older are smokers, the percentage of those who have emphysema and gas trapping increases with age.” Dr. Regan and colleagues hope their findings help debunk the myth of the healthy smoker as well as stress the importance of smoking prevention and cessation in preventing lung disease.

Important Implications

The study findings suggest that clinicians should ask their patients who are current and former smokers about respiratory symptoms during evaluations, according to Dr. Regan. “It’s worthwhile to ask these patients if they have chronic bronchitis or whether or not they’re short of breath,” she says. “Current smokers with these symptoms should be advised on the importance of smoking cessation. Informing patients about research showing that shortness of breath is a sign of real lung disease caused by their smoking could be more impactful than a vague suggestion to quit smoking.”

Looking Ahead

Dr. Regan explains that she and her colleagues have been following the study cohort by touching base via phone or email every 6 months. “Patients are now coming in for a second phase of visits after 5 years to undergo repeat CT scans, spirometry, and other testing to assess their progress,” she says. “Nearly 3,500 patients have come back, and we’re at the point where we can assess whether or not those identified as having disease are progressing. If the signs of early disease in this patient population predict a long-term impact, that will further stress the importance of early disease identification.”

Readings & Resources (click to view)

Regan E, Lynch D, Curran-Everett, et al. Clinical and radiologic disease in smokers with normal spirometry. JAMA Intern Med. 2015. Jun 22 [Epub ahead of print]. Available at

The 2004 United States Surgeon General’s report: the health consequences of smoking. N S W Public Health Bull. 2004;15:107.

Mohamed Hoesein  F, de Hoop  B, Zanen  P, et al. CT-quantified emphysema in male heavy smokers: association with lung function decline. Thorax. 2011;66:782-787.

Kim  S, Yagihashi  K, Stinson  D, et al. Visual assessment of CT findings in smokers with nonobstructed spirometric abnormalities in the COPDGene study. Chronic Obstr Pulm Dis (Miami). 2014;1:88-9

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