Retrospective assessment of a collaborative digital asthma program for Medicaid-enrolled children in southwest Detroit: reductions in short-acting beta-agonist (SABA) medication use

Background: The COPD assessment test (CAT) is an 8-item questionnaire widely used in clinical practice to assess patient burden of disease. Digital health platforms that leverage electronic medication monitors (EMMs) are used to track the time and date of maintenance and short-acting beta-agonist (SABA) inhaler medication use and record patient-reported outcomes. The study examined changes in CAT and SABA inhaler use in COPD to determine whether passively collected SABA and CAT scores changed in a parallel manner.Methods: Patients with self-reported COPD enrolled in a digital health program, which provided EMMs to track SABA and maintenance inhaler use, and a companion smartphone application (“app”) to provide medication feedback and reminders. Patients completing the CAT questionnaire in the app at enrollment and at 6 months were included in the analysis. Changes in CAT burden category [by the minimally important difference (MID)] and changes in EMM-recorded mean SABA inhaler use per day were quantified at baseline and 6 months.Results: The analysis included 611 patients. At 6 months, mean CAT improved by −0.9 (95% CI: −1.4, −0.4; p < 0.001) points, and mean SABA use decreased by −0.6 (−0.8, −0.4; p < 0.001) puffs/day. Among patients with higher burden (CAT ≥ 21) at enrollment, CAT improved by −2.0 (−2.6, −1.4; p < 0.001) points, and SABA use decreased by −0.8 (−1.1, −0.6; p < 0.001) puffs/day.Conclusion: Significant and parallel improvement in CAT scores and SABA use at 6 months were noted among patients enrolled in a digital health program, with greater improvement for patients with higher disease burden.

Introduction: Electronic medication monitors (EMM) passively record inhaler use in patients with asthma and COPD. Continuous medication monitoring can help determine objective trends and patterns of use, which can be used to enhance care. Aim: Compare short-acting beta-agonist (SABA) and controller inhaler use among COPD and asthma patients. Methods: Data from 3,375 adults (≥40 years) who self-reported a diagnosis of COPD (n=1,346) or asthma (n=2,029) was studied. Eligible patients using an EMM-compatible SABA and/or controller inhaler were studied during their first 30 days of use. Comparisons of inhaler use and adherence in COPD and asthma patients were stratified by age (40-59 years, 60+ years) and gender. Results: For patients aged 40-59 years, COPD patients used 55% more SABA than asthma patients (1.97(SD 2.8) vs. 1.27(SD 2.1) puffs/ day; p Conclusion: Patients with COPD demonstrated significantly higher SABA use than patients of similar age with asthma. Patients ≥60 years exhibited higher controller adherence than those 40-59. These data can be used to target interventions for populations with higher rescue use and lower adherence rates.

Impact of a Digital Asthma Intervention on Short-acting Beta-agonist (SABA) Medication Use Among Medicaid-enrolled Children in Southwest Detroit

Digital health platforms for asthma self-management have demonstrated promise in improving clinical and quality of life outcomes. However, few studies have examined such an approach in a real-world, fully remote setting. As such, we evaluated the benefit of an evidence-based digital self-management platform for asthma—both on its own and when integrated into an established virtual clinical service. We compared six-month outcomes of a digital self-management program plus virtual clinical oversight, called a therapeutic resource center, (DP + TRC) with a digital self-management-only (DP) program in patients with uncontrolled asthma. The DP included electronic medication sensors that captured the date and time of both short-acting beta agonist (SABA) and controller medication usage. The TRC included remote care oversight to promote inhaler adherence and address symptom worsening. SABA usage, controller adherence and program retention were assessed retrospectively using regression models controlling for age, enrollment year, controller/SABA use, and baseline asthma control status.18,584 DP patients (mean age (SD): 33 (14.6) yrs; 89.9% uncontrolled asthma) and 3440 DP + TRC patients (mean age (SD): 43.7 (15.6) yrs); 48.6% uncontrolled) were assessed. We observed significantly better six-month program retention (55% vs. 41%, p < 0.001) and controller adherence (54% vs. 45%, p < 0.001), but no statistically significant differences in mean SABA use (0.76 vs. 0.87 mean puffs/day; p = 0.158) for the DP + TRC vs. DP groups, respectively. From baseline to six months, both groups had similar reductions in mean daily SABA use (both p < 0.001) and improvements in the percent of SABA-free days (both p < 0.001). The proportion of patients with ≥80% controller adherence declined in both groups, but a larger relative decline was noted in the DP vs. DP + TRC group. A digital self-management platform for asthma management combined with virtual clinical oversight may offer a scalable solution that not only achieves reduced SABA use, but also promotes medication adherence and increases program retention.

ObjectivesAsthma is a disease affecting significant number of children and young people (CYP) in the United Kingdom (UK) but outcomes for these patients are poor. The excess prescription of short-acting...

The fraction of exhaled nitric oxide (FeNO), a measure of airway inflammation, is a potential noninvasive tool to guide asthma management in children. It remains unclear, however, if FeNO adds any information beyond clinical assessment of asthma control. We evaluated the associations of FeNO level with short acting beta agonist use and compared it with other clinical asthma assessments. We examined a prospective cohort study of 225 tobacco-smoke-exposed children aged 6-12 years with doctor-diagnosed asthma, including measures of FeNO, reported days of short acting beta agonist use, and unscheduled asthma visits. FeNO was analyzed in relation to current and future (3 months later) short acting beta agonist use. Mean FeNO at baseline, 6, and 12 months was 15.5, 15.7, and 16.8 ppb. In multivariable analyses, higher FeNO level was associated with increased short acting beta agonist use but only among children who were not on inhaled corticosteroids. Among those not on an inhaled steroid, there was a 12% increase in current and 15% increase in future days of short acting beta agonist use for every 10 ppb increase in FeNO level. FeNO levels remained associated with current short acting beta agonist use even after adjusting for unscheduled asthma visits. FeNO levels remained associated with future short acting beta agonist use even after adjusting for current short acting beta agonist use or unscheduled asthma visits. We conclude that FeNO levels are associated with short acting beta agonist use but only among children who are not on an inhaled corticosteroid.

Aim: Short-acting beta-agonist (SABA) use is an important aspect of asthma management. As patient reports can be hard to elicit, medical records are sometimes used to infer SABA use. We assessed whether database (DB) evaluation of SABA use reliably reflects patient reported (PR) use. Methods: We used a UK research database to select clinical records of patients aged 18–60yrs with an asthma diagnosis, no other chronic respiratory diseases and not receiving maintenance oral steroids. DB SABA prescribing over one year was calculated from prescription records. PR SABA use was computed from asthma questionnaire responses from the same year (assessing PR reliever use in the last week) with one "use" assumed to be 2 puffs (=200µg salbutamol) and extrapolating over 1yr. DB and PR SABA use were cross tabulated and strength of association assessed using Kendall's Tau-b (τ b ) test. Results: Among the 2425 patients (60% female, 25% current smokers), PR SABA use was consistently lower than the number of inhalers actually prescribed resulting in a weak/significant association between DB and PR SABA use (τ b =0.21; p&lt;0.001). Association between DB &amp; PR SABA use PR SABA uses in previous week scaled to I/Y DB SABA prescribed (I/Y) 0(%) 1(%) 2(%) 3(%) 4(%) ≥5(%) 0(%) 0 20 15 13 15 14 1(%) 44 19 15 13 8 9 2(%) 29 22 18 11 14 8 3(%) 9 8 11 12 7 7 4(%) 8 9 12 15 15 9 ≥5(%) 11 22 29 38 43 53 I/Y=inhalers per year Conclusions: The discrepancy between PR and DB SABA use may reflect under-reporting by patients, prescribing of “spares”, and/or asthma is a variable condition poorly characterised by data from a single week. The difference should be acknowledged in DB studies reporting SABA use.

Relationship between recent short-acting β-agonist use and subsequent asthma exacerbations

Background: Question 4 (Q4) of the Asthma Control Test (ACT) asks patients to report their SABA use over the prior 4 weeks, a criterion for evaluating the impairment domain of asthma control. Biases in recall may lead to a misclassification of asthma control and has implications for asthma control determination and management strategies.Objective: To correlate objective electronic-recorded short-acting beta-agonist (SABA) use with self-reported use via Q4 of the ACT.Methods: Patients ≥18 years of age with a self-reported diagnosis of asthma were enrolled in a digital health electronic medication monitoring (EMM) platform, which recorded the date and time of SABA actuations and prompted the completion of the ACT. The correlations between ACT Q4 responses and EMM-recorded SABA use were evaluated using Spearman’s rank correlation coefficients.Results: 1,062 patients (mean age: 35.4 years, mean ACT: 16.3) were included in analyses. Higher Q4 scores, indicating lower SABA use, were moderately and negatively correlated with EMM-recorded SABA use (ρ = -0.59 [95% CI: -0.63, -0.54]). Thirty-five percent of patients underreported SABA use when comparing Q4 to EMM-recorded SABA use.Conclusions: While ACT Q4 and EMM-recorded use were moderately correlated, underreported SABA use on the ACT highlights the need for objective measures of SABA use in asthma control assessments. The use of EMM-recorded SABA data has the potential for clinicians to more accurately determine asthma control, guide changes to controller therapy, and estimate imminent exacerbation risk.

Patterns of Inhaled Asthma Medication Use: A 3-Year Longitudinal Analysis of Prescription Claims Data From British Columbia, Canada

BackgroundDigital health programs assist patients with chronic obstructive pulmonary disease (COPD) to better manage their disease. Technological and adoption barriers have been perceived as a limitation.ObjectiveThe aim of the research was to evaluate a digital quality improvement pilot in Medicare-eligible patients with COPD.MethodsCOPD patients were enrolled in a digital platform to help manage their medications and symptoms as part of their routine clinical care. Patients were provided with electronic medication monitors (EMMs) to monitor short-acting beta-agonist (SABA) use passively and a smartphone app to track use trends and receive feedback. Providers also had access to data collected via a secure website and were sent email notifications if a patient had a significant change in their prescribed inhaler use. Providers then determined if follow-up was needed. Change in SABA use and feasibility outcomes were evaluated at 3, 6, and 12 months.ResultsA total of 190 patients enrolled in the pilot. At 3, 6, and 12 months, patients recorded significant reductions in daily and nighttime SABA use and increases in SABA-free days (all P<.001). Patient engagement, as measured by the ratio of daily active use to monthly active use, was >90% at both 6 and 12 months. Retention at 6 months was 81% (154/190). Providers were sent on average two email notifications per patient during the 12-month program.ConclusionsA digital health program integrated as part of standard clinical practice was feasible and had low provider burden. The pilot demonstrated significant reduction in SABA use and increased SABA-free days among Medicare-eligible COPD patients. Further, patients readily adopted the digital platform and demonstrated strong engagement and retention rates at 6 and 12 months.

Beta agonists have been used to treat asthma for thousands of years initially as a naturally occurring compound in the Chinese herbal medicine ma-huang (Ephedra equisetina). In the early 1900s, ephedrine and subcutaneous adrenaline (epinephrine) entered Western Medicine pharmacopoeia as the first short-acting beta agonists (SABA). However, it was the development of beta2-selective SABA such as salbutamol (albuterol) and the advent of metered dose inhalers (MDI) in the 1950s that laid the foundation for modern inhaled beta agonist therapy. SABA use quickly became widespread. Over subsequent decades, shifting opinions and emerging evidence on the optimal use of beta agonists have resulted in a changing role for SABA in asthma management. The recommendation that SABA monotherapy no longer be used for mild asthma1—an approach that had previously been both widely recommended and widely practiced—is the latest such change Soon after SABA use became widespread, risks associated with specific beta agonists emerged.2, 3 In the early 1960s, a sharp rise in asthma mortality was noted in countries such as England, Australia and New Zealand. Epidemiological evidence implicated isoprenaline forte MDI; asthma deaths markedly declined following regulatory warnings and a reduction in the use of isoprenaline forte. In the 1970s, a second asthma mortality epidemic occurred in New Zealand, coinciding with the introduction of fenoterol, a new beta agonist. Fenoterol use in New Zealand was much higher than in other countries and its increasing market share coincided with a rise in asthma mortality. Similar to isoprenaline forte, fenoterol was a potent, poorly selective beta2 agonist which was marketed as a high-dose preparation, equivalent to four times the equivalent bronchodilator dose of salbutamol. A series of case–control studies demonstrated that fenoterol use was associated with an increased risk of mortality. In response, fenoterol was removed from the New Zealand drug tariff, a regulatory move which effectively removed it from clinical practice, and mortality rates reduced by two-thirds within 12 months. Following these asthma mortality epidemics, the use of more beta2-selective agents such as salbutamol and terbutaline increased and SABA became one of the most commonly prescribed medications. The efficacy of SABA in relieving bronchospasm when used 'as required' resulted in a move towards 'regular' inhaled SABA therapy, irrespective of symptoms. Early and small studies suggested improved asthma control, but the change to regular SABA use occurred without evidence that this strategy was superior, in terms of preventing serious asthma events, or similar, in terms of safety, when compared to as required SABA. It is now well established that regular beta agonist therapy in asthmatic patients at best offers no benefit4 and, at worst, causes increased bronchial hyper-responsiveness, tachyphylaxis, deteriorating lung function, worsening asthma control and increased exacerbation frequency.2 These findings resulted in a return to as required SABA therapy in the late 1990s. Beta agonist drug discovery and development was not limited to SABA, with long-acting beta agonists (LABA) entering the market in the late 1990s. Evidence that LABA improve symptom control and lung function, coupled with the prevailing view at the time (that regular beta agonist was helpful irrespective of symptoms and independent of inhaled corticosteroids (ICS)), meant LABA use became widespread. Mirroring the 1990s data on deleterious effects of regular SABA use, data from salmeterol and formoterol trials raised concerns about an increased risk of severe asthma events and mortality. Subsequently, LABA delivered in the context of ICS–LABA combination therapy were shown to be safe, and post-marketing safety trials of ICS–LABA products, mandated by the Food and Drug Administration (FDA), demonstrated no increase in serious asthma-related events when compared with ICS therapy.5 The early 2000s saw the development of regimens based on the fast-onset LABA formoterol delivered as a combination inhaler with ICS used for both maintenance and reliever therapy (MART) in moderate and severe asthma. The MART regimen reduced the number of severe asthma exacerbations and the number of beta agonist overuse episodes in adolescents and adults when compared with ICS–LABA combination therapy given as maintenance with SABA reliever therapy.6, 7 With LABA monotherapy contraindicated in asthmatic patients, ICS–LABA combination therapy was increasingly used and ICS were recommended for all asthmatic patients with at least moderately severe disease. SABA monotherapy in mild asthma remained as the last example of guideline-recommended bronchodilator therapy delivered without concomitant anti-inflammatory ICS. For context, it is useful to consider the parallels and differences in the respective roles of beta agonist bronchodilator therapy in asthma and nitroglycerin-based coronary vasodilator therapy in angina pectoris. In both conditions, short- and long-acting agents exist to achieve broncho- or vaso-dilatation. However, as required or regular short-acting sublingual glyceryl nitroglycerin would not be recommended as first-line treatment in all patients diagnosed with angina pectoris without simultaneously commencing therapies, such as statin, beta blocker and antiplatelet agents, alongside personalized recommendations that address relevant traits such as obesity and hypertension, to target the underlying pathophysiology of a given patient's symptomatic coronary artery disease. In contrast, until very recently, SABA monotherapy without ICS has been recommended as the first-line treatment for mild asthma in most guidelines, despite the increasingly recognized importance of airway inflammation across the asthma disease spectrum. Consequently, treatment of mild asthma has historically not attempted to modify the underlying disease pathogenesis. Previously, only as asthma severity increases, and patients move stepwise through treatment recommendations, has the importance of anti-inflammatory ICS-based treatment been emphasized; this is despite the evidence that early ICS therapy reduces exacerbations and improves lung function.8 Symptom-directed SABA monotherapy in mild asthma, where most patients begin their asthma treatment journey, contradicts subsequent advice with increasing disease severity, where regular ICS therapy is emphasized regardless of symptom burden; this creates confusion for patients and doctors. Furthermore, by generating an association between SABA use and symptoms early in the disease journey, clinicians may engender SABA reliance in their patients that could persist when asthma is severe or remains uncontrolled. Physicians themselves can find it difficult to move away from SABA prescribing for symptom control; one survey reported that more than 90% of physicians who prescribe MART regimens also prescribe a SABA 'at least some of the time'.9 In 2019, the Global Initiative for Asthma (GINA) guidance changed significantly to no longer recommend SABA monotherapy, citing evidence that SABA monotherapy can provide short-term symptom control but does not protect patients from severe exacerbations. The importance of exacerbation risk reduction in mild asthma is illustrated by the observation that while exacerbations are more likely in those with more severe asthma, mild asthma is common and numerically more exacerbations occur in patients receiving bronchodilator monotherapy (step one).10 Furthermore, the UK National Review of Asthma Deaths reported that 9% of asthma deaths were in patients treated with SABA alone and 39% were associated with excess prescriptions for SABA.11 GINA now recommend that all adults and adolescents with asthma should receive either symptom-driven (in mild asthma) or regular ICS-containing treatment.1 This advice is supported by four pivotal trials. SYGMA 1 and SYGMA 2 demonstrated that as required budesonide-formoterol was superior to as required terbutaline and as effective as regular budesonide maintenance therapy (with lower total ICS exposure), in terms of preventing severe exacerbations.12, 13 SYGMA 1 and SYGMA 2 were conducted in rigidly selected groups of patients in a tightly supervised clinical trial context with high rates of adherence to maintenance therapy and a requirement to cease treatment with specific agents (including low-dose ICS) to qualify for enrolment, raising questions about the generalizability of their findings to the large number of patients with mild asthma being treated outside of clinical trials, predominantly with SABA monotherapy. The Novel START trial, conducted in mild asthmatic patients receiving SABA monotherapy, demonstrated that as required budesonide-formoterol was superior to as required salbutamol (and also superior to regular budesonide maintenance with lower ICS exposure), in terms of reducing severe asthma exacerbations.14 The recently published PRACTICAL study demonstrated that as required budesonide-formoterol resulted in a one-third reduction in severe exacerbation risk compared with regular budesonide and as required SABA therapy in patients with mild to moderate asthma, despite the budesonide-formoterol group using about 60% of the dose of budesonide.15 Budesonide-formoterol reliever therapy reduces the FeNO, a marker of eosinophilic airway inflammation,14 thereby suggesting that this therapeutic regimen could be ideally referred to as 'anti-inflammatory reliever therapy' in clinical practice. These trials did not include children younger than 12 years and, therefore, the safety and efficacy of as required budesonide-formoterol in a paediatric population is unknown. While SABA were the first effective treatment for asthma, their importance in the contemporary management of asthma is diminishing. Commencing SABA monotherapy as the default first-line treatment for mild asthmatic patients is not supported by evidence, in terms of either efficacy or safety. We argue that in the current treatment landscape, most adult and adolescent patients across the spectrum of asthma severity should receive a fast-onset LABA (formoterol) co-formulated with an ICS, as anti-inflammatory reliever therapy either alone in mild asthma or as MART in more severe asthma. The existing literature indicates that this strategy has both greater efficacy and a better safety profile than SABA reliever therapy. Clinical practice now needs to change, as recommended by the 2019 GINA strategy report.1 The Medical Research Institute of New Zealand receives Independent Research Organisation funding from the Health Research Council of New Zealand. T.H. has no competing interests to declare. R.B. reports grants from Genentech, AstraZeneca, GlaxoSmithKline; and personal fees from AstraZeneca and Theravance.

Adherence to asthma long-term controller medications is one of the key drivers to improve asthma management among patients with persistent asthma. While suboptimal use of controller medications has been found to be associated with more frequent use of oral corticosteroids (OCS), few studies exist regarding the relationship between adherence to controller therapy and the use of short-acting beta2-agonists (SABAs). A better understanding of the association between adherence to asthma controller agents and use of reliever medications will help health care providers and decision makers enhance asthma management. To determine if there is a relationship between asthma controller adherence, risk of exacerbation requiring OCS, and use of asthma rescue agents. Texas Medicaid claims data from January 1, 2008, to August 31, 2011, were retrospectively analyzed. Continuously enrolled patients aged 5-63 years with a primary diagnosis of asthma (ICD-9-CM code 493) and with 4 or more prescription claims for any asthma medication in 1 year (persistent asthma) were included. The index date was the date of the first asthma controller prescription, and patients were followed for 1 year. The primary outcome variables were SABA (dichotomous: less than 6 vs. ≥ 6) and OCS (continuous) use. The primary independent variable was adherence (proportion of days covered [PDC]) to asthma long-term controller medications. Covariates included demographics and nonstudy medication utilization. Multivariate logistic and linear regression analyses were employed to address the study objective. The study sample (n = 32,172) was aged 15.0 ± 14.5 years, and adherence to controller therapy was 32.2% ± 19.7%. The mean number of SABA claims was 3.7 ± 3.1, with most patients having 1-5 claims (73.2%), whereas 19.4% had ≥ 6 SABA claims. The mean number of OCS claims was 1.0 ± 1.4. Adherent (PDC ≥ 50%) patients were 96.7% (OR = 1.967; 95% CI = 1.826-2.120) more likely to have ≥ 6 SABA claims when compared with nonadherent (PDC less than 50%) patients (P less than 0.001). As for OCS use, adherent patients had 0.11 fewer claims compared with nonadherent patients (P less than 0.001). Importantly, patients with ≥ 6 SABA claims had 0.7 more OCS claims compared with patients with less than 6 claims for SABA (P less than 0.001). The odds of having ≥ 6 SABA claims were higher for concurrent dual therapy users, older age, males, African Americans and higher number of nonstudy medications (P less than 0.001). Dual therapy users, younger age, Hispanic ethnicity, and higher number of nonstudy medications were associated with an increase in OCS use (P less than 0.005). Adherence to long-term controller medications was suboptimal among patients with asthma. Adherent patients had fewer OCS claims, indicating that adherence to controller therapy is critical in preventing asthma exacerbations requiring OCS use. Although there was a positive relationship between adherence to long-term controller medication and SABA use, increased SABA use served as a predictor of increased OCS use, which indicates poor asthma control. Health care providers should be aware of OCS and SABA use among patients who are both adherent and nonadherent to asthma controller medications.

<b>Background</b> Mobile health technology has demonstrated impacts on improving asthma outcomes, but few studies have evaluated outcomes in a controlled study in a real-world clinical setting. <b>Aims and Objectives</b> We aimed to determine whether a sensor-enabled, clinically-integrated mobile health asthma quality improvement program could reduce the frequency of short-acting beta agonist (SABA) use, and increase asthma-free days, asthma control and controller medication adherence. <b>Methods</b> Adult patients with asthma and a SABA prescription were enrolled (n=125). Participants randomized to the intervention group (IG) (n=67) received electronic inhaler sensors to track their medication use, and access to smartphone and online applications that provided visualizations of their data, reminders to promote adherence, and personalized, guidelines-based education. Clinical care managers viewed IG patients9 data in an online dashboard to guide care. Participants in the control group (CG) (n=58) received sensors, but neither the patient nor the care manager received access to their data. Mixed effects regression models with random intercepts were used to compare outcomes between groups at 6 months. <b>Results</b> The IG demonstrated significant improvements compared to the CG on all clinical outcomes, including controller medication adherence, daily SABA use, asthma-free days, and asthma control (all p&lt;0.001), including a 21-point improvement in adherence for the IG. <b>Conclusions</b> This mobile health program, with sensor-enabled data collection and patient and provider access to the data, improved asthma outcomes, including asthma SABA use, control, and adherence in a real-world clinical setting.

Background : Asthma impairment is defined by short-acting beta-agonist (SABA) use, symptoms, functional limitations, and pulmonary function. Objective measures of impairment rely on SABA records but the Respiratory Effectiveness Group believe SABA use may vary by management step and smoking status. Methods: Real-life study pooling records from the UK’s Optimum Patient Care &amp; Clinical Practice Research Databases for asthma patients aged 16–70yrs. Average daily SABA use was evaluated over one year (total annual dose prescribed/365) and split by management step (inhaled corticosteroid [ICS] initiation or step up) and smoking status (current, non- and ex-smoker). Results: For both ICS initiation and step-up populations, the distribution of SABA dosage varied significantly by smoking status (p&lt;0.001). More current smokers used ≥800µg, and fewer ≤200µg SABA daily than non- or ex-smokers. ICS Initiation* Smoking status SABA Daily Dosage (µg) Non smoker n(%) Ex-smoker n(%) Current smoker n(%) ≤200 20169 (52.4) 11886 (52.1) 10106 (39.5) 201-800 16288 (42.3) 9713 (42.6) 12643 (49.3) ≥800 2081 (5.4) 1213 (5.3) 2884 (11.3) *p&lt;0.001 (SABA distribution by smoking status) ICS Step-up* Smoking Status SABA Daily Dosage (µg) Non smoker n(%) Ex-smoker n(%) Current smoker n(%) ≤200 7612 (35.6) 3460 (33.9) 2349 (21.9) 201-800 10836 (50.6) 5200 (51.0) 5529 (51.4) ≥800 2950 (13.8) 1544 (15.1) 2873 (26.7) *p&lt;0.001 (SABA distribution by smoking status) Conclusions: Average SABA use is higher among ICS step-up compared with ICS initiation patients. Current smokers use more SABA than non- or ex-smokers, irrespective of management step. Further work is required to set meaningful SABA thresholds for objective measures of real-life asthma impairment.