http://dx.doi.org/10.4046/trd.2011.71.2.114 ISSN: 1738-3536(Print)/2005-6184(Online) Tuberc Respir Dis 2011;71:114-119 CopyrightC2011. The Korean Academy of Tuberculosis and Respiratory Diseases. All rights reserved. 호흡기내과외래로내원한환자들에대한금연프로그램의단기간효과 가톨릭대학교의과대학내과학교실 여창동, 강현희, 강지영, 김성경, 김명숙, 김승수, 이상학, 문화식 Original Article A Short-Term Effectiveness of Smoking Cessation Intervention in Outpatient Department of Pulmonology Chang Dong Yeo, M.D., Hyeon Hui Kang, M.D., Ji Young Kang, M.D., Sung Kyoung Kim, M.D., Myung Sook Kim, M.D., Seung Soo Kim, M.D., Sang Haak Lee, M.D., Hwa Sik Moon, M.D. Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea Background: There is very limited data present on smoking cessation rates in outpatient departments of pulmonology. In this study, we aimed to investigate the effectiveness of a brief smoking cessation intervention program in an outpatient department of pulmonology and identify predictors of smoking cessation failure. Methods: After a brief recommendation of smoking cessation from pulmonologists, smokers willing to quit smoking were given individual counseling and supplement drugs. Fifty smokers were included in this study and baseline characteristics, smoking history and success rate were reviewed at 3 months. Results: The mean age of the patients was 58.3±14.6 years and the total group of patients included 3 women. The rate of smoking cessation success was 74% at 3 months, and there were no differences in age, spirometric indexes and associated diseases between the smoking cessation success and failure group. The rate of supplement drug usage was not different in both groups either. However, body weight, mean number of cigarette usage per day and nicotine dependence scores in the failure group were significantly higher than in the success group. In multivariate analysis, body weight and mean number of cigarette usage per day were significant. Two smokers with a depressive disorder failed the smoking cessation. Conclusion: A smoking cessation intervention program in the outpatient department of pulmonology showed a favorable success rate. More intensive interventions are needed to unfavorable groups which include the obese and heavy smokers. Key Words: Smoking Cessation; Outpatients 서 흡연은만성폐쇄성폐질환, 폐암등의호흡기질환뿐만아니라다른암의발생과중대한심혈관합병증과관련되어있는등, 그심각성이널리알려져있다. 하지만흡연은 Address for correspondence: Sang Haak Lee, M.D. Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, 620-56, Jeonnong 1-dong, Dongdaemun-gu, Seoul 130-709, Korea Phone: 82-2-961-4500, Fax: 82-2-968-7250 E-mail: mdlee@catholic.ac.kr Received: Jun. 14, 2011 Accepted: Jul. 23, 2011 론 극복하기어려운중독행위로, 본인의의지만으로금연을시도하는사람중 2 3% 만이 1년후에도금연을유지할정도로성공률이매우낮다 1. 그리고의료기관에서시행하는금연프로그램에대한인식이낮아, 미국의경우흡연자의 70% 가금연에관심을가지고있고, 그중 40% 는금연을시도하고있지만, 실제로 5 14% 만이금연프로그램을이용하고있는실정이다 2. 우리나라에서도 2008년기준으로성인남성의흡연율이 40.4% 로여전히높아 3, 선진국수준으로흡연율을감소시키고자, 보건복지부의 '2005 년도국가흡연예방및금연사업 ' 등의활발한금연사업이시행되고있다 4. 현재시행중인대부분의금연프로그램은금연에대한 114
Tuberculosis and Respiratory Diseases Vol. 71. No. 2, Aug. 2011 교육및상담등을통한행동요법과환자개개인에맞는니코틴대체요법, 약물요법의조합으로구성된다 5. 하지만지금까지발표된금연프로그램의효과에대한보고는금연의지가있는건강한성인을대상으로한것이대부분이어서 6, 호흡기내과진료실에서접하는흡연자집단에대한보고는잘알려져있지않다. 이에본연구에서는호흡기내과로내원한흡연자에게의사가간략한금연권유를한후, 이에동기화된흡연자들을대상으로금연프로그램의 3개월단기간효과를평가하고, 흡연재발에영향을미치는인자를규명하고자하였다. 대상및방법 2007년 1월부터 2007년 7월까지가톨릭대학교성바오로병원호흡기내과를방문할당시일년이상, 하루평균 5개비이상흡연하고있던환자를대상으로, 3개월이상추적관찰이가능하였던연속적인환자 50명을후향적으로조사하였다. 대상자들은의사가진료시흡연력을물어본후간략한금연권유를하였고, 이에금연동기화가이루어진경우, 자기기입식설문지를작성하고, 금연상담간호사가금연교육을시행하였다. 금연상담간호사의교육내용으로는금연으로인한신체적이득을설명하고, 식이요법, 운동요법및금단증상에대처하는방법등의중재에대한내용을안내받았으며, 이후 3개월동안금연상담간호사가금연여부를확인하고, 금연을지속하도록격려하였다. 약물요법은담당의사가환자와상의한후개별적으로 bupropion 150 mg을하루두차례복용하도록하였다. 해당환자들의의무기록을임상적특징, 흡연력, 기저병력, 폐기능검사등의네가지로분류하여평가하였다. 임상적특징으로는성별, 나이, 체중, 체질량지수 (body mass index, BMI), 음주력, 내원이유를조사하였다. 흡연력으로흡연시작연령 (smoking start age), 일일흡연개비수 (mean number of cigarettes/day), 총흡연량 (packyear), 과거금연시도횟수 (previous quit attempt), 니코틴의존도 (nicotine dependence score) 를확인하였다. 이중니코틴의존도는자기기입식설문인 Fagerström Test for Nicotine Dependence (FTND) 를이용하였다. 기저병력으로고혈압, 당뇨, 결핵, 천식, 만성폐쇄성폐질환, 간질환, 우울증등으로구분하여조사하였고, 폐기능검사항목으로 1초간노력성호기량 (forced expiratory volume in one second, FEV 1 ), 노력성폐활량 (forced vital capacity, FVC), FEV 1 /FVC, 총폐용적 (total lung capacity, TLC), 잔기량 (residual volume, RV), 폐확산능 (Diffusing capacity for carbon monoxide, DL CO ) 등을확인하였다. 대상자들은매월방문하여금연여부에대해응답하였으며, 의사및금연상담간호사가금연지속을격려하였다. 금연시작 3개월째에한개비의담배도피지않았다고응답한대상자중, 소변코티닌검사가음성인경우를금연성공군으로분류하였고, 그외에는금연실패군으로판정하였다. 모든통계분석은 SPSS version 11.5 (SPSS Inc., Chicago, IL, USA) 프로그램을이용하였다. 기술적자료의표시는평균 ± 표준편차및백분율로나타내었고, 각군간의범주형변수의경우에는 Chi-square 검정또는 Fisher's exact test를, 연속형변수의경우에는 unpaired t-test 또는 Mann-Whitney test를시행하였고, logistic regression analysis 를사용하여금연성공과관련된인자를분석하였다. p값이 0.05 미만인경우를통계적으로유의한차이가있는것으로처리하였다. Table 1. Baseline characteristics of the subjects Clinical characteristics n=50 Age 58.3±14.6 Sex (male/female) 47 (94)/3 (6) BMI, kg/m 2 22.0±3.3 Smoking history Mean number of cigarettes/day 21.1±9.6 Pack-years 38.1±21.6 Smoking start age 21.6±5.4 Previous quit attempt 15 (30) FTND 4.9±2.0 Pulmonary function test, % FEV 1 pred. 81.6±28.1 FVC pred. 87.1±20.8 FEV 1/FVC 65.5±16.9. Associated diseases Hypertension 12 (24) Diabetes mellitus 5 (10) Bronchial asthma 8 (16) COPD 21 (42) Depression 2 (4) Values are expressed as mean±sd or number (%) BMI: body mass index; FTND: fagerström test for nicotine dependence; FEV 1: forced expiratory volume at one second; FVC: forced vital capacity; COPD: chronic obstructive pulmonary disease; SD: standard deviation. 115
CD Yeo et al: Smoking cessation in outpatient department of pulmonology 결과 1. 대상환자의특성총 50명중남자는 47명이었고, 평균나이는 58.3 세 ( 범위, 21 82 세 ) 였고, 모두기침및객담, 호흡곤란등의증상과호흡기질환의평가를위해내원한환자들이었다. 대상자모두에게적극적인금연상담및교육이이루어졌고, 약물요법으로 bupropion 을투여받은환자는그중 29명이었다. 흡연력은평균일일흡연량은 21.1개비, 총흡연량은 38.1 갑년, 과거에금연을시도했던자는 15명이었고, FTND 로측정한니코틴의존도는평균 4.9점이었다 (Table 1). 폐기능검사에서는 FEV 1 /FVC 이평균 65.5% 로감소되어있고, FEV 1 이평균 81.6% 로측정되어, 대상자들은전반적으로폐쇄성폐질환의양상을보였다. 동반질환으로는만성폐쇄성폐질환이 21명으로많았으며, 기관지천식 8명, 우울증이 2명있었다. 2. 금연성공군과실패군의비교총 50명중, 3개월째금연에성공한자는 37명으로금연성공률은 74% 였다. 금연성공군과금연실패군간임상적특징의비교에서, 여성은 3명모두금연에성공하였으나, 성별에따른통계학적차이는없었다. 음주력도결과에영향을미치지못하였으나, 금연실패군에서체중이유의하게높았다 (Table 2). 흡연력의비교에서는총흡연량과흡연시작나이, 과거금연시도횟수는유의하게차이를보이지않았으나, 일일평균흡연개비수와니코틴의존도를나타내는 FTND 점수는금연실패군에서의미있게높은결과를보였다. 약물요법이금연성공에끼치는영향을알아보기위해양군을각각비교하였으나, 유의한차이는관찰되지않았다. 동반질환에대한분석에서, 고혈압, 당뇨병, 천식, 결핵, 만성폐쇄성폐질환의경우에양군간에빈도의차이는없었으나, 우울증의경우 2명모두금연에실패하여, 경계역의차이를보였다. 폐기능검사수치에서양군간의의미있는차이는없었고, 폐쇄성지표를 Table 2. Comparison of clinical data with quitters and non-quitters Quitter (n=37) Non-quitter (n=13) p-value Age, yr 60.6±13.8 51.7±15.4 0.06 Sex (male/female) 34/3 13/0 0.56 Weight, kg 58.7±8.6 66.9±11.6 0.01 BMI 21.5±3.0 23.6±3.9 0.07 Smoking history Mean number of cigarettes/day 18.6±7.1 28.5±12.1 0.003 Pack-years 36.6±19.9 42.3±26.3 0.41 Smoking start age 21.7±5.7 21.5±4.4 0.95 Previous quit attempt 13/37 (35.1) 2/13 (15.4) 0.29 FTND 4.5±1.8 5.9±2.2 0.04 Pulmonary function test, % FEV 1 pred. 80.8±29.2 84.1±25.1 0.75 FVC pred. 87.6±21.9 85.1±17.1 0.75 FEV 1/FVC 64.2±17.3 70.0±15.8 0.34 FEV 1/FEV <70 20/37 4/13 0.47 Associated disease Hypertension 8/37 (21.6) 4/13 (30.8) 0.71 Diabetes mellitus 5/37 (13.5) 0/13 (0.0) 0.31 Bronchial asthma 7/37 (18.9) 1/13 (7.7) 0.66 COPD 16/37 (43.2) 5/13 (38.5) 0.76 Depression 0/37 (0.0) 2/13 (15.4) 0.06 Supplement drug 21/37 (56.8) 8/13 (61.5) 0.76 Values are expressed as mean±sd or number (percent). BMI: body mass index; FTND: Fagerström test for nicotine dependence; FEV 1: forced expiratory volume at 1 second; FVC: forced vital capacity; COPD: chronic obstructive pulmonary disease; SD: standard deviation. 116
Tuberculosis and Respiratory Diseases Vol. 71. No. 2, Aug. 2011 Table 3. Multivariate logistic regression analysis of factors predicting smoking cessation success Variables OR 95% CI p-value Weight 1.154 1.032 1.292 0.012 Mean number of 1.158 1.001 1.340 0.049 cigarettes/day FTND 1.377 0.744 2.548 0.308 FTND: Fagerström test for nicotine dependence; OR: odds ratio; CI: confidence interval. 나타내는 FEV 1 /FVC를 0.7 기준으로나누어비교한분석에서도양군간의의미있는성공률의차이는없었다. 단변량분석에서차이를보인체중, 일일평균흡연개비수, FTND 점수등의변수들을다중회귀분석방법으로분석한결과, 체중과일일평균흡연개비수가통계적으로유의한차이가있음이관찰되었다 (Table 3). 고 금연이건강한사람에서흡연과관련된암및여러폐질환의발생을예방한다는것은주지의사실이다. 그리고건강한사람이아닌호흡기질환이있는환자에게서도금연이기저질환의악화를예방하고, 예후를향상시킨다고알려져있다. 조기폐암환자에서적극적인금연으로생존율및재발률이의미있게향상되었으며 7, 만성폐쇄성폐질환환자에게서도금연이호흡기증상의개선과폐기능의악화예방및사망률의감소에중요한효과가있음이널리밝혀져있다 8. 이러한사실은건강한성인뿐만아니라, 이미호흡기증상또는질환이있는흡연자들에게도적극적으로금연을권고하고, 금연을치료의중요한부분으로인식해야하는근거가된다. 본연구에서는 3개월금연성공률이 74% 로비교적높게측정되었다. 국내에서발표된한자료에의하면, 농촌지역의건강한성인흡연자들을대상으로한금연프로그램에서행동요법만을시행하였을때 1개월성공률 65.5%, 3개월 54.5%, 6개월 54.5% 로보고되었으며 9, Gonzales 등 10 의보고에서는약물요법으로 bupropion 과 varenicline 을각각투여한흡연자에게 12주째조사한금연성공률이각각 29.5%, 44.0% 로알려져있다. 따라서본연구의 3개월금연성공률은상당히높은수치라평가할수있는데, 이는대상자들이건강한성인이아닌호흡기증상을보이는흡연자여서, 금연에대한동기부여가더많이되었을가능성 찰 이있다. 또한각각독립적인금연효과가있는행동요법과약물요법을적극적으로병행한상승작용의효과로설명할수있다. 따라서본연구의결과는금연에대한의사의관심과적극적인금연중재프로그램이용으로많은호흡기질환자에게금연치료를성공적으로이끌수있음을보여주는고무적인결과이다. 금연치료는크게행동요법과약물요법으로나눌수있다 11. 행동요법은의사의간단한금연권유부터금연상담간호사에의한금연교육, 문자메시지나이메일을이용한안내, 금연장려금지급등의다양한방법이포함되며, 약물치료는흡연자개개인에맞는니코틴대체요법과 bupropion, varenicline 등의금연보조제를투여하는방법이이에해당된다. 환자의기저질환과특성을고려하여, 여러금연중재방법들을함께사용하는경우, 금연성공에상승적인효과가있음이널리알려져있고 12,13, 이는비용 효과적인측면에서도매우경제적인방법으로보고되었다 14. 이러한이유로 American College of Chest Physicians (ACCP) 가발표한가이드라인에따르면, 금연의지가있는흡연자에게는 five As모델을 (1 Ask about tobacco use at every visit, 2 Advise tobacco users to quit, 3 Assess the willingness to attempt quitting, 4 Assist the patient with method for quitting, 5 Arrange for follow-up contact via phone or face to face), 금연의지가없는흡연자에게는 five Rs모델을 (1 Relevance of quitting for the patient, 2 Risk of illness related to continued tobacco use, 3 Rewards/benefits of smoking cessation, 4 Roadblocks for quitting, internal and external, 5 Repetition of the motivation intervention at each encounter) 제시하였고, 이로써홉연자들을많이진료하는호흡기내과의사의역할을명확히하였다. 금연실패와관련되어알려진주요원인들로는스트레스, 주변환경, 개인의의지부족, 강한니코틴중독등이알려져있는데, Kenford 등 15 은니코틴의존도 (FTND), 일일흡연량, 혈중니코틴농도, 호기이산화탄소농도가금연실패와강한연관이있다고보고하였다. FTND 는 1978 년도부터사용되어, 현재에도니코틴의존도를평가하는데가장널리이용되는도구이다 16. 이설문은총 6가지문항으로구성되어있으며, 4개문항은 0 1점, 2개문항은 0 3점으로배정하여총점수의범위는 0 10점이며, 점수가높을수록니코틴의존도가높음을의미한다. 본연구에서도금연실패군에서일일흡연개비수와 FTND점수가유의하게높아, 기존보고와일치라는결과를보였 117
CD Yeo et al: Smoking cessation in outpatient department of pulmonology 다. 또한흡연과비만은유전적으로공통된뇌의보상경로를갖고있어, 비만인흡연자들은금연후나타나는긍정적강화에취약한것으로알려져있다 17. 따라서, 니코틴의존도가높고비만인흡연자에서금연실패의위험성이높게예상이되므로, 이러한흡연자들에게는더욱더다양하고적극적인중재프로그램이이루어지고, 반복적인교육과장기간의추적관찰이필요할것이다. 흡연과우울증과의상호관련성은이미여러보고를통해잘알려져있다. Glassman 등 18 의보고에의하면, 흡연자들이비흡연자에비해더많은우울증상을보였으며, 과거주요우울삽화가있는흡연자는금연실패율이 2배높았다 19. 또한우울증이있었던흡연자들에서금연초기에더욱강렬한금단증상을보였으며, 심한금단증상은금연실패와연관이있는것으로알려져있다 20. 본연구에서도 2명의우울증환자에서모두금연에실패하여, 위보고와일치하는결과를보여주었다. 금연실패와관련된위험인자로서우울증상이영향을끼칠뿐만아니라, 우울증발생의위험인자로서도흡연이관련되어있음이알려져있으므로 21, 이는많은흡연자들을진료하는호흡기내과의사에게, 우울증상에대한관심과치료가금연성공률을높이는중요한접근방법임을시사하는결과이다. 결론적으로본연구는많지않은환자들을대상으로, 3개월이라는짧은기간의추적관찰을후향적으로조사한제한점은있으나, 호흡기내과로내원한흡연자에게의사의간략한금연권유와금연상담간호사에의한적극적인금연중재프로그램은상당히높은금연성공률을보여주었고, 체중이높고, 일일흡연개비수가많거나니코틴의존도가높았던경우, 우울증이동반된경우에는금연실패의위험이높음을제시하였다. 감사의글 We authors thank Sun Hee Gang, a nurse in outpatient department of pulmonology, for data collection and management. 참고문헌 1. Volpp KG, Troxel AB, Pauly MV, Glick HA, Puig A, Asch DA, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med 2009;360:699-709. 2. Fiore MC, McCarthy DE, Jackson TC, Zehner ME, Jorenby DE, Mielke M, et al. Integrating smoking cessation treatment into primary care: an effectiveness study. Prev Med 2004;38:412-20. 3. Kim YH, Lee SH. Smoking cessation. Tuberc Respir Dis 2010;69:153-62. 4. Kim MH. Updates in smoking cessation programs. Korean J Health Psychol 2005;10:259-76. 5. Goodfellow LT, Waugh JB. Tobacco treatment and prevention: what works and why. Respir Care 2009;54: 1082-90. 6. Cheong YS, Ahn SH. Effect of multi-modal interventions for smoking cessation in a university setting: a short course of varenicline, financial incentives, e-mail and short message service. Korean J Fam Med 2010;31:355-60. 7. Parsons A, Daley A, Begh R, Aveyard P. Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. BMJ 2010;340:b5569. 8. Andreas S, Hering T, Mühlig S, Nowak D, Raupach T, Worth H. Smoking cessation in chronic obstructive pulmonary disease: an effective medical intervention. Dtsch Arztebl Int 2009;106:276-82. 9. Seo NS, Kim YH, Kang HY. The effects of a group smoking cessation program among adult smokers in a rural community. J Korean Acad Nurs 2007;37:1139-48. 10. Gonzales D, Rennard SI, Nides M, Oncken C, Azoulay S, Billing CB, et al. Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA 2006;296: 47-55. 11. Pohlig C. Smoking cessation counseling: a practice management perspective. Chest 2006;130:1231-3. 12. Bars MP, Banauch GI, Appel D, Andreachi M, Mouren P, Kelly KJ, et al. "Tobacco free with FDNY": the New York City Fire Department World Trade Center tobacco cessation study. Chest 2006;129:979-87. 13. Hotta K, Kinumi K, Naito K, Kuroki K, Sakane H, Imai A, et al. An intensive group therapy programme for smoking cessation using nicotine patch and internet mailing supports in a university setting. Int J Clin Pract 2007;61:1997-2001. 14. Rennard SI, Daughton DM. Smoking cessation. Chest 2000;117(5 Suppl 2):S360-4. 15. Kenford SL, Fiore MC, Jorenby DE, Smith SS, Wetter D, Baker TB. Predicting smoking cessation. Who will quit with and without the nicotine patch. JAMA 1994; 118
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