Chronic obstructive pulmonary disease (COPD) remains a formidable public health challenge worldwide. In Spain, it is currently the third leading cause of death and affects nearly 12% of the adult population. This high burden places a significant strain on healthcare resources, as disease severity is directly associated with increased use of emergency services and hospital admissions. The socioeconomic impact is also profound, with direct medical costs for disease management and complications, such as hospitalisations and primary care visits, amounting to an estimated annual burden of >€2.4 billion [1]. Its heterogeneous nature, driven by ageing populations, shifting tobacco smoking patterns, emerging environmental threats, and the enduring consequences of the COVID-19 pandemic, demands continuous and rigorous surveillance. Spain has been a pioneer in pneumology, having completed 3 landmark multicentre, population-based studies on the prevalence of COPD over 2 decades, based on post-bronchodilator spirometry: IBERPOC (1997) [2], EPISCAN (2007) [3], and EPISCAN II (2017) [4]. These studies have collectively transformed our understanding of COPD, revealing persistently high underdiagnosis rates of approximately 75% and, more recently, a hopeful reduction in prevalence among specific age groups [5].

A compelling argument is now made for a fourth epidemiological study in 2027, tentatively called SCOPES, the Spain COPD Epidemiological Study. As detailed in the accompanying position paper [6], this would not be a mere repetition of past efforts. Instead, it represents a necessary qualitative leap towards a multidimensional, precision-medicine approach to COPD in Spain. Six key justifications support this initiative.

First, secular trend monitoring in COPD is essential. Although EPISCAN II suggested a potential decline in prevalence among those aged 40–69 years between 1997 and 2017 [5], we must confirm whether this trend has continued, stabilised, or reversed. The impact of intensified tobacco control policies, along with the emergence of novel nicotine delivery systems, including vaping, heated tobacco products, and white snus, and newly available chemical entities [7], needs to be quantified. Several issues of recent relevance should be explored further, including the ever-expanding ageing population, multimorbidity, frailty, and the growing clinical complexity of patients with COPD, all of which are likely to contribute substantially to the associated future healthcare burden.

Second, new exposures and phenotypes demand attention. Traditional risk factors, such as smoking, are now joined by ambient air pollution, including PM2.5 and NO2, indoor pollutants, and occupational exposures in non-traditional settings. Furthermore, the increasing recognition of COPD in never-smokers, particularly women and people born preterm, and phenotypes such as asthma-COPD overlap and pre-COPD/young COPD require specific characterisation [8]. A 2027 study would allow the population impact of these factors to be measured.

Third, the integration of novel diagnostic tools offers an opportunity for earlier and more precise detection. EPISCAN II [4] already reported spirometry results using both the fixed ratio and the lower limit of normal according to the Global Lung Function Initiative [9,10]. Beyond post-bronchodilator spirometry, incorporating low-dose chest CT could quantify emphysema, air trapping, and bronchiectasis. Oscillometry and novel capnography may detect small airway disease well before spirometric abnormalities appear [11,12]. Blood biomarkers, including eosinophils and systemic inflammatory markers, and exhaled breath condensate analysis could refine phenotyping and predict therapeutic responses. The population burden of other conditions, such as interstitial lung disease or bronchiectasis, could also be assessed indirectly by chest CT imaging. The feasibility of implementing these and other advanced assessments within either a large-scale population-based study or subsequent clinical practice should be explored.

Fourth, we must validate and improve screening and diagnostic tools. Despite decades of awareness, underdiagnosis remains unacceptably high. New strategies combining enhanced questionnaires beyond COPD-PS, peak-flow metres, microspirometers, or artificial intelligence-based voice analysis could be tested against reference-standard spirometry within the same population. Updated Spanish reference equations for spirometry are also urgently needed.

Fifth, the post-COVID-19 era has fundamentally altered healthcare delivery and respiratory health. We need to evaluate whether the pandemic has left pulmonary sequelae that overlap with or accelerate COPD, and how it has affected diagnostic and follow-up care. Updated data on healthcare resource utilisation, productivity loss, and health-related quality of life are crucial for rational resource allocation.

Finally, a 2027 study would create a prospective cohort for translational research. Previous studies provided cross-sectional snapshots. A new study with biobanking, longitudinal follow-up, and repeated assessments would allow us to better understand lung function and the natural history of COPD, identify predictors of rapid progression, and evaluate the real-world effectiveness of new biological therapies and personalised prevention strategies.

In all likelihood, the practicalities and financing model for this ambitious endeavour must also evolve. IBERPOC was supported by Boehringer Ingelheim, whereas EPISCAN and EPISCAN II received backing from GlaxoSmithKline [5]. For 2027, a diversified, sustainable model is proposed. Public funding from the Instituto de Salud Carlos III and the CIBERES network, alongside EU Horizon Europe grants, particularly missions on chronic diseases and climate change, should form a core pillar. An innovative public-private consortium could include multiple pharmaceutical companies, health technology firms, including those developing portable spirometers, telemonitoring, and artificial intelligence tools, and insurance companies interested in chronicity management. In addition, value-added data access agreements for the prospective cohort, under strict governance, and even crowdfunding for specific components should be explored to guarantee scientific independence and methodological rigour [5]. Overall, the institutional leadership and support of the Spanish Society of Pneumology and Thoracic Surgery, within the COPD and young researchers’ areas, might provide a route to success.

Some may argue that a fourth study is costly, or that EPISCAN II already provided robust data recently. However, the epidemiological landscape is shifting rapidly. The generational change in smoking habits, the rise of e-cigarettes and other nicotine delivery devices, the long-term respiratory effects of COVID-19, and advances in imaging and biomarkers mean that data from 2017 may no longer fully represent current reality. As seen internationally, repeated cross-sectional surveys are essential to capture dynamic disease patterns [13]. Spain lags behind asthma studies in Finland, in which 54320 subjects aged 25–74 years were examined in 7 independent cross-sectional population surveys conducted every 5 years between 1982 and 2012 [14]. Furthermore, there is a need to wait patiently, but eagerly, for birth cohorts initially established for asthma to age from early adulthood into COPD cohorts [15].