Biologics helped smokers with severe asthma as much as never-smokers

Design

Retrospective real-world registry study

Population

3,876 adults with severe asthma starting biologics in 16 European countries

Primary outcome

Change in control, exacerbations, quality of life and oral steroid use at 1 year

Effect

Improvements in all smoking groups; magnitude not significantly different

The European Respiratory Society's SHARP registry analysed 3,876 adults with severe asthma in 16 countries who started a biologic: 2,383 never-smokers, 1,352 former smokers and 141 current smokers. Outcomes were measured after one year.

In all groups, asthma control and quality of life improved, frequent exacerbations fell and oral steroid use dropped, and the size of improvement did not differ significantly by smoking status. A survey found that 29% of participating countries reported resistance to prescribing biologics to current smokers.

Registry data carry selection bias: smokers who were prescribed a biologic may have been the most typical eosinophilic responders. Current smokers were few. Still, the results argue against withholding a biologic solely because of smoking history when a patient meets the eligibility criteria. Smoking cessation remains part of the treatment, not a precondition.

• Assess eligibility for biologics in severe asthma on phenotype and exacerbations, not smoking status alone.
• Offer smoking cessation support alongside, not as a condition of, biologic therapy.
• Consider overlapping COPD in heavy former smokers before attributing all symptoms to asthma.
• Reassess response at one year using exacerbations, oral steroid use and control scores.

Why it matters

A common prescribing bias may be denying effective treatment to a group with severe disease.

Don't overread it

Registry data from selected patients; current smokers were few.

The statistics, in plain English

A non-significant difference between groups means the data did not detect a smaller response in smokers, not that responses were proven identical. With only 141 current smokers, a modest difference could be missed.

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