Chronic obstructive pulmonary disease (COPD) is a major public health problem. Cigarette smoking is the main cause of COPD. The prevalence of COPD is still increasing worldwide, as is the mortality rate.^1–4 The importance of identifying smokers with COPD at an early stage and supporting smoking cessation is unquestionable, and is recognised in several national and international guidelines.^1,5,6 An important role of physicians in primary care is early detection of COPD and motivating smokers to stop smoking, as smoking cessation is the only intervention that has been proved to prevent further decline in lung function.^7–9 Since smoking has a wide range of serious effects on health, even a small improvement in cessation rates has been considered clinically important.¹⁰ The purpose of this article is to show the benefits of working in a more proactive way for the early detection of the disease.

Patient or Doctor Delay
COPD still remains relatively unknown or ignored by the public as well as by public health officials, resulting in either underdiagnosis or delayed diagnosis of COPD.^11–13 Thus, in principle the underdiagnosis of COPD is theoretically caused by delays by the patient or the doctor. The main causes of patient delay are low knowledge of the disease and adaptation to the disease. Data from the Third National Health and Nutrition Examination Survey (NHANES III) showed that a significant proportion of patients with severe COPD (forced expiratory volume in one second [FEV1] < 50% of predicted) may not report symptoms. The symptoms reported most frequently were wheezing and shortness of breath, in 64 and 65% of subjects, respectively.¹⁴ On the other hand, knowledge of the disease (or any labelling synonymous with COPD, i.e. emphysema, smoker’s lung) was acknowledged by only 39% of subjects.¹⁵ In combination with the inherent adaptation to the symptoms of the disease, this low level of awareness results in a considerable degree of patient delay. The discrepancy between lung function and subjective health resulting in an adaptation is schematically illustrated in Figure 1.

The concept of patient and doctor delay was considered in the epidemiological study by Lindberg et al.16 Although all COPD-diagnosed subjects (>45 years of age) reported respiratory symptoms, only about 50% had consulted the healthcare system (patient delay) and a minority of those (16%) were diagnosed as having COPD (doctor delay). The reasons for doctor delay are multifactorial. General practitioners (GPs) are busy with other groups such as those with hypertension, heart diseases, diabetes, respiratory infections, psychiatric disorders and orthopaedic diseases. Other important factors may be a lack of time and spirometry equipment and/or education in primary care. In most countries, primary care clinicians treat the vast majority of patients with chronic respiratory diseases, as exemplified by the UK and The Netherlands, where approximately 85% of patients with asthma and COPD are managed almost entirely by GPs and primary care nurses.¹⁷ Access to spirometry is increasing in primary care. In Sweden about 90% of primary healthcare centres (PHCCs) have access to spirometry.¹⁸ However, it is reported that primary care physicians seldom use spirometry to discover COPD among smokers or people with respiratory symptoms.¹⁹ A report from the National Lung Health Education Program in the US recommends that smokers >45 years of age and actively smoking should be examined by spirometry regardless of their cause for seeking medical attendance or presence of symptoms.²⁰

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