COPD is a health-care problem, both at the individual as well as the population level.1 There are currently estimated to be 210 million people with COPD world-wide.2 The limited use of spirometry as a populational screening tool is partially responsible for the surprisingly high and homogenous underdiagnosis of COPD, which is from 80% to 90% in several regions of the world and in various scenarios. Therefore, estimating the number of people with COPD is useful, but these data must be used with caution.3 In general, the prevalence of COPD in the general population is estimated to be from 8% to 10% or more among those over the age of 40.

The EPI-SCAN study has estimated that the current prevalence of COPD in Spain in the population aged 40–80 was 10.2% (15.1% in males and 5.7% in women),4 meaning that there are currently 2185764 people with COPD in Spain, representing some 1.57 million men and more than 600000 women. Compared with the previous IBERPOC study,5 the underdiagnosis of COPD in Spain went down slightly, from 78% to 73%, although a great reduction in undertreatment was observed in this 10-year period, from 81% to 54% (P<.05).6 As for its main cause, smoking is estimated to cause 60000 deaths annually in Spain, and it is considered the most important cause of COPD and lung cancer.7

The underdiagnosis of COPD may be related with the lack of understanding of the disease and its determinants in the general population, as demonstrated in a study done in Spain in 2002.8 The study concluded that, in Spain, many people with respiratory symptoms did not request medical care and did not try to quit smoking, and also that there was a general lack of knowledge about COPD, and recommended that doctors more actively inform their patients about COPD and increase the use of spirometry.

The COPD Strategy of the National Healthcare System (NHS), approved June 3, 2009 by the Interregional NHS Council,9 sets as one of its priorities the development of strategies, objectives and recommendations in COPD for its application in the provinces. Likewise, the new Spanish COPD guidelines (GesEPOC) emphasize the role that the Strategy may play in the diffusion of information about this disease amongst the general population.10

The main objective of this CONOCEPOC study is to determine the current level of knowledge and understanding about COPD as well as its determinants in the general Spanish population. The secondary objectives were to analyze the changes observed almost ten years later, and at the same time to increase awareness about the importance of COPD. As a whole, the CONOCEPOC initiative intends to promote correct, early diagnoses of COPD in Spain.

CONOCEPOC is an observational, cross-sectional epidemiologic study done in September 2011 following an identical design to the study done in 2002.8 The inclusion criteria for participating in CONOCEPOC were men and women aged 40 and older who agreed to answer a telephone survey. In short, the survey was done in the 17 Autonomous Communities (provinces) in Spain. Participation was voluntary, confidential and anonymous, using randomized dialing of home phone numbers.11 In Spain, 80.6% of residences have a home phone.12 The sample was done with the following stratification criteria: sex, age according to decade (40–50, 51–60, 61–70 and >70); place of residence in a rural (<10000 inhabitants) or urban (≥10000 inhabitants) area. We obtained quotas of equal age, sex and place of residence within each of the 17 Spanish Autonomous Communities, requiring a total of 384 responses in each. This sample size offers precision in the samples by Community in population estimates with an error of 5% and a power of 80% for prevalences of different variables higher than 5%; thus the overall sample obtained is representative of each of the autonomous communities and is stratified by age groups and setting (rural vs urban).

Out of a total of 104349 telephone contacts, a final sample was obtained of 6528 participants, with a response percentage of 13.1%, meaning 6528 final responses from 49861 residences identified with adults over the age of 40. The STROBE flow diagram of participants and non-participants are presented in Fig. 1.

Fig. 1.

STROBE flowchart of the sample.

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53.1% of participants were women, and the mean age of the population was 59.8. Table 1 presents the distribution of other sociodemographic, clinical and smoking variables according to sex. As for tobacco use, 19.4% were current smokers (17.9% in women and 21.1% in men) while 27.9% reported being ex-smokers (18.1% in women and 38.9% in men) (P<.05). Tobacco exposure measured in pack-years was greater in men (25.1±24.5) than in women (15.2±15.2) (P<.05). In smokers, 62.9% had tried to kick the habit, with a mean±SD number of attempts of 2.7±2.1, which was the same for both sexes. Only 9.6% of participants reported having had a spirometry at some time, including 8.4% of women and 10.9% of men (P<.05), distributed into three strata: 7.3% in those without respiratory symptoms or diagnoses; 68.2% in those with COPD diagnosis; and 47.2% in those with high risk for COPD (see Methods). From among the participants who reported respiratory symptoms, 53.8% had consulted a doctor, more often in Primary (68.1%) than in Specialized Care (31.9%). And among those who reported respiratory symptoms and had consulted a doctor, 62% had done a spirometry. There were no differences in the self-declared respiratory diseases or in the state of health for either sex or region, but there were differences depending on age groups (Table 1).

It is interesting to observe that the diagnostic flow of the participants with respiratory symptoms who consulted with their physicians remains nearly the same compared to the previous survey (56% in 2002, and currently 53.8%), but there is an observed substantial increase in the use of spirometry in the subjects who consulted with their doctors due to respiratory symptoms (42.6% in 2002 and 62.0% at present) (P<.05) (Fig. 2).

Fig. 2.

Diagnostic flow of participants with respiratory symptoms [in 2002] and in 2011.

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As for spontaneous knowledge about COPD, it was higher in women (18.1%) than in men (15.7%) (P<.05) (Table 2), and showed a decreasing tendency with age: 19.9% between 40 and 50, 23.6% between 51 and 60, 16.4% between 61 and 70 and only 8.8% in those over 70 (Chi2 tendency P<.05). Of these, 39.8% knew of COPD through the media. Knowledge of COPD showed great geographical variability (Fig. 3): residents in the province of Valencia knew the least about COPD (10.4%), while Aragón was the province to have the highest percentage of residents who knew about COPD (21.9%) (P<.05). From among those who declared knowing about COPD, their knowledge of the symptoms may be considered acceptable, as they were able to identify breathlessness (81.1%), cough (29.0%) and expectoration (10.6%) as the main symptoms of COPD, results that show improvement over those obtained in 2002 (P<.05). In fact, the perception of severity of COPD was very high 8.3±1.5, and only surpassed by angina, while in both sexes the perception of diabetes severity remained above the perception of severity of diabetes, hypertension, stomach ulcer and osteoarthritis/arthritis (Table 2).

Fig. 3.

Map by Autonomous Community of the (a) knowledge about what COPD is, and (b) knowledge about there being a National COPD Strategy.

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Only 4.7% of the population knows that there is a National COPD Strategy, and once again there was great geographical variability (Fig. 3). The Community of Madrid had the lowest degree of knowledge (2.9%), while Extremadura had the highest (7.3%) (P<.05).

Compared with the survey done in 2002, there are some significant changes seen in the current survey. The spontaneous knowledge about COPD doubled, going from 8.6% in 2002 to 17.0% in 2011 (P<.05) (Table 2). The knowledge about COPD symptoms also improved. In contrast, there were no significant differences in the source of knowledge of COPD or of the perception of its severity compared with other chronic diseases.

Due to the absence of current statistics, the prevalence of smoking has been described according to province (Table 3). In women, Cantabria and Extremadura presented the highest current prevalence of smoking (22.1% and 21.1%, respectively), while Catalonia was significantly lower at 12.3%. In men, the extremes were Asturias, Galicia and Madrid with 23.9% compared with the lowest in Cantabria at 15.6% (P<.05).

Finally, although the support received by the new Anti-Tobacco Law (Ley 42/2010, in place since January 2, 2011) was from 86% of the population, we explored the factors related with having an unfavorable/very unfavorable opinion in the remaining 14%. At the non-adjusted level, being male, young, with COPD or being susceptible to developing it, and being a current or ex-smoker was associated with this attitude. Nevertheless, in a multivariate analysis, only obesity (BMI>30kg/m2) and being either a current or ex-smoker maintained the association with an unfavorable/very unfavorable opinion of the new Anti-Tobacco Law (Table 4). These values maintained their magnitude and direction when we also adjusted for Autonomous Community (data not shown).

The main results of this survey are: only 17% of the Spanish population spontaneously knows anything about COPD, and the rates are higher among women and young adults than in older individuals. This represents a relative increase over the 8.6% observed in 2002,8 but it should still be considered a low percentage. The perception of severity of COPD is comparable to other frequent and severe diseases, such as angina. However, only half of people with symptoms who are compatible with COPD consult with their doctors, and only 62% of them had done spirometry. There is a notable variability by Autonomous Community about what COPD is and about the National COPD Strategy, although 86.0% of the population have a favorable/very favorable opinion about the new Anti-Tobacco Law. Last of all, the only individual factors that are independently associated with having an unfavorable/very unfavorable opinion about the new Anti-Tobacco Law were obesity and being either a current or ex-smoker.

The lack of knowledge about COPD and its determinants in the general Spanish population is still high (at least since 2002), and therefore more and better interventions are necessary in order to raise public awareness.

Almirall S.A. has supported the CONOCEPOC study, while in 2002 it was Boehringer-Ingelheim and Pfizer who supported the study. The telephone surveys were done by Saatchi&Saatchi Health.

The authors have no conflict of interest to declare.