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(Chest. 2001;119:1365-1370.)
© 2001 American College of Chest Physicians

Smoking Characteristics*

Differences in Attitudes and Dependence Between Healthy Smokers and Smokers With COPD

Carlos A. Jiménez-Ruiz, MD, PhD; Fernando Masa, MD, PhD; Marc Miravitlles, MD, PhD; Rafael Gabriel, MD, PhD; José Luis Viejo, MD, PhD; Carlos Villasante, MD, PhD; Victor Sobradillo, MD, PhD and and the IBERPOC Study Investigators{dagger}

* From the Servicio de Neumología (Dr. Jiménez-Ruiz), Hospital de la Princesa, Madrid, Spain; Unidad de Neumología (Dr. Masa), Hospital San Pedro de Alcántara, Cáceres, Spain; Servicio de Neumología (Dr. Miravitlles), Hospital General Vall d’Hebron, Barcelona, Spain; Unidad de Epidemiología Clínica (Dr. Gabriel), Hospital de la Princesa, Madrid, Spain; Servicio de Neumología (Dr. Viejo), Hospital General Yagüe, Burgos, Spain; Servicio de Neumología (Dr. Villasante), Hospital La Paz, Madrid, Spain; and Unidad de Patología Respiratoria (Dr. Sobradillo), Hospital de Cruces, Baracaldo (Vizcaya), Spain. {dagger} A complete list of the participants in the IBERPOC study is given in the Appendix.

Correspondence to: Carlos A Jiménez-Ruiz, MD, PhD, Servicio de Neumología (Unidad de Tabaquismo), Hospital Universitario de la Princesa, C/Diego de León 62, 28006 Madrid, Spain; e-mail: victorina{at}ctv.es


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Appendix 1
 References
 
Objective: To ascertain the differences in smoking characteristics between a group of smokers with COPD and another group of healthy smokers, both of which were identified in a population-based epidemiologic study.

Design and participants: This is an epidemiologic, multicenter, population-based study conducted in seven areas of Spain. A total of 4,035 individuals, men and women aged 40 to 69 years, who were selected randomly from a target population of 236,412 subjects, participated in the study.

Interventions: Eligible subjects answered the European Commission for Steel and Coal questionnaire. Spirometry was performed followed by a bronchodilator test when bronchial obstruction was present. The Fagerström questionnaire was used for study of the degree of physical nicotine dependence, and the Prochazka model was followed for analysis of the smoking cessation phase.

Results: Of 1,023 active smokers, 153 (15%) met the criteria for COPD. Smokers with COPD were more frequently men (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.21 to 3.95), were >= 46 years of age (OR, 1.97; 95% CI, 1.18 to 3.31), had a lower educational level (OR, 1.96; 95% CI, 1.23 to 3.14), and had smoked > 30 pack-years (OR, 3.70; 95% CI, 2.42 to 5.65). Smokers with COPD showed a higher dependence on nicotine than healthy smokers (mean [± SD] Fagerström test score, 4.77 ± 2.45 vs 3.15 ± 2.38, respectively; p < 0.001) and higher concentrations of CO in exhaled air (mean concentration, 19.7 ± 16.3 vs 15.4 ± 12.1 ppm, respectively; p < 0.0001). Thirty-four percent of smokers with COPD and 38.5% of smokers without COPD had never tried to stop smoking.

Conclusions: Smokers with COPD have higher tobacco consumption, higher dependence on nicotine, and higher concentrations of CO in exhaled air, suggesting a different pattern of cigarette smoking. Cases of COPD among smokers predominate in men and in individuals with lower educational levels. A significant proportion of smokers have never tried to stop smoking; thus, advice on cessation should be reinforced in both groups of smokers.

Key Words: COPD • epidemiology • smoking • smoking cessation


   Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Appendix 1
 References
 
The close relationship between COPD and smoking has been reported by several authors.1 2 3 4 5 6 7 Analysis of these studies shows smoking to be the cause of 75 to 85% of COPD cases1 2 3 ; approximately 15 to 20% of smokers develop COPD.1 5 6 A significant inverse relationship exists between the number of cigarettes smoked per day and the cumulative cigarette consumption measured in pack-years and FEV1 values.5 6 7 The cessation of smoking is followed by a reduction in FEV1 decline and even a certain recovery of FEV1 values.2 3 4 5 6

On the other hand, studies analyzing the smoking characteristics of smokers with COPD or seeking differences with those of healthy subjects are scarce. Some authors indicate that smokers with COPD have a lower abstinence success rate in different cessation programs and a greater degree of physical nicotine dependence than healthy smokers.8 9 The motivation of COPD smokers to stop smoking and the stage of the process of self-change of smoking are not well-known. The analysis of these factors and the determination of differences with healthy smokers may be of interest to design strategies to help smokers with COPD to quit smoking.

The present work analyzes data from a national epidemiologic study (the IBERPOC study), which was aimed at investigating the prevalence of COPD in Spain through the study of seven different geographic areas.10 Herein, we analyze the characteristics of smoking habits and the dependence of smokers and investigate the differences between healthy smokers and those with COPD.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Appendix 1
 References
 
This was an epidemiologic study conducted from October 1996 to April 1997 in seven different geographic areas of Spain. A trained pneumologist was responsible in each area for contacting participants, distributing the questionnaires, and performing spirometry testing. The European Community for Steel and Coal questionnaire, which was translated and validated in Spanish,11 and a questionnaire on smoking and socioeconomic level12 were used. Together with the questionnaires, participants underwent a forced spirometry test, as described below. Candidates for inclusion in the study were selected randomly from the census database by a specially designed computer program. The detailed description of the study together with the overall prevalence of COPD and its prevalence in the different areas has been published.13 14

Spirometry and Co-oximetry
Spirometry was performed following the SEPAR15 guidelines with the same portable spirometer (DATOSPIR-200; Sibel SA; Barcelona, Spain) in all areas. Subjects with FEV1/FVC values < 88% of predicted in men or < 89% of predicted in women underwent a bronchodilator test (BDT) with two inhalations of salbutamol using an inhalation camera. The results of a BDT were considered to be positive if the difference between FEV1 or FVC before and after the test was > 200 mL and its relative increase was > 12%. A BDT was considered to normalize spirometry if, after the latter was performed, the FEV1/FVC quotient as a percentage of predicted was > 88% in men and 89% in women. Co-oximetry in exhaled air was performed with a co-oximeter (Micro Medical; Rochester, UK).16

Diagnostic Criteria
The functional criteria of the European Respiratory Society17 were used for the diagnosis of COPD. A FEV1/FVC quotient < 88% in men and < 89% in women was required for COPD diagnosis, together with a negative or positive result for a BDT, but in the latter case, spirometric values had to remain below the above-mentioned percentages.

Replies to the European Community for Steel and Coal questionnaire were used for the diagnosis of respiratory symptoms. An individual was considered to have an habitual cough when any of the following questions were answered affirmatively: Do you usually cough on rising? Do you cough almost every day for 3 months of the year? Have you coughed every day for 3 months of the year, for > 2 consecutive years? For an individual to be considered a habitual expectorator, an affirmative reply was required to any of the following questions: Do you usually cough up phlegm on rising? Do you cough up phlegm during the day or at night? Do you cough up phlegm almost every day or night for 3 months of the year? The following question was considered for diagnosis of dyspnea: do you become short of breath when climbing stairs at normal speed? The presence of wheezing was assessed with the following question: Have you ever heard wheezes in your chest? Chronic bronchitis was considered to be present if the patient experienced cough and expectoration for > 3 months of the year for > 2 consecutive years.

A smoker was defined as an individual smoking at least one cigarette, pipe, or cigar a day. The complete cessation of the consumption of any type of tobacco from at least 6 months prior to the start of the study was required for classification as an ex-smoker.

The Fagerström questionnaire in its revised version was used for the study of the degree of physical nicotine dependence.18 The Prochazka model was followed for analysis of the cessation phase of smoking.19

Quality Control of the Study
The following methods were applied for quality control: (1) The field work was carried out by seven pneumologists with the same equipment in all the areas. (2) Prior to the start of the study, the seven pneumologists completed a concordance test in performing spirometry, with highly satisfactory results.20 (3) Review of the spirometric tracings obtained in the study revealed the following: an independent observer (MM) reviewed 537 randomly selected spirometry tests, which corresponded to 11.9% of those performed. A variation in FVC or FEV1 values of > 5% was observed in only 22 cases, which represented 4.1% of all the spirometry tests reviewed. (4) All questionnaires delivered to the central office (Pharma Consult Services, SA; Barcelona, Spain) were reviewed by two monitors to filter inconsistencies, absent values, or out-of-range values. (5) A review of clinical histories of subjects who declined to participate in the study was conducted.

Statistical Study
Descriptive analysis was first performed (mean, proportions) for each dependent variable. The prevalence of respiratory symptoms, chronic bronchitis, and COPD by age, sex, degree of exposure to tobacco, and social level was calculated in overall samples and in subgroups of smokers with and without COPD with their percentages. Quantitative variables were described using their mean values and SDs.

Comparisons of intergroup proportions were performed with the {chi}2 test. The Student’s t test was used for comparison between the means of quantitative variables. A multivariate logistic regression analysis was performed to investigate the relationship of different variables with the diagnosis of COPD in smokers. The dependent variable was the diagnosis of COPD, and the independent variables were the following: sex; age, coded as "< 46 vs 46 or older"; educational level, coded as "low vs middle and high"; socioeconomic class, coded as "low vs middle and high"; tobacco consumption, coded as "30 or more pack-years vs < 30"; Fagerström test results, coded as "6 or less vs > 6 points"; and co-oximetry results were included as a continuous variable. Age was included in the model as a dichotomous variable with a cutoff point of 46 years to give a clear message that even at that "early" age, the risk of COPD in smokers may already be significantly increased, thereby reinforcing the message of the importance of quitting at an early age. Pack-years also were categorized with the cutoff point used throughout the data analysis.13 Using this statistical approach, the two variables showed no significant interaction in the model. A difference was considered to be significant when the p value was < 0.05. Statistical analysis was performed with a commercially available software package (SPSS for Windows, version 7.5.2S; SPSS; Chicago, IL).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Appendix 1
 References
 
Study Population
The target population of this study consisted of 236,412 subjects aged 40 to 69 years residing in the geographic areas studied. A random sample of 5,103 subjects was obtained, and a total of 4,035 subjects were studied (participation rate, 79%). Of these, 1,023 subjects (25%) were active smokers, who, for our purposes, were divided into two groups according to whether they presented or did not present bronchial obstruction criteria on spirometry12 ; 870 smokers (85%) had no obstruction; and the remaining 153 subjects (15%) met the criteria for COPD. The demographic characteristics of each group are shown in Table 1 . Percentages of healthy subjects and subjects with COPD according to the number of pack-years consumed and sex are depicted in Table 2 , in which it can be observed how, as tobacco consumption increases in men, so does the significant prevalence of COPD (p < 0.001). This was not, however, observed in women. In multiple logistic regression analysis, male sex, age > 46 years, a low educational level, and the consumption of > 30 pack-years of tobacco were significantly associated with the diagnosis of COPD in smokers (Table 3 ).


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  		Table 1. Demographic Characteristics of Smokers With and Without COPD*

 

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  		Table 2. Relationship Between COPD Prevalence and Number of Pack-years by Sex*

 

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  		Table 3. Factors Significantly Associated With the Diagnosis of COPD in Smokers and Results of Multivariate Logistic Regression Analysis*

 
Characteristics of Smoking
It is noteworthy that in the group of smokers with COPD, a significant increase was observed in the number of cigarettes smoked per day and in carbon monoxide levels in exhaled air. An analysis of the Fagerström test revealed a significant increase in the degree of physical dependence on nicotine in smokers with COPD vs those without COPD (Table 4 ). However, multivariate analysis failed to show a significant association between the diagnosis of COPD and the scoring of the Fagerström test or of concentrations of CO in exhaled air.


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  		Table 4. Smoking Characteristics*

 
Attitudes Toward Smoking
No significant differences were observed between the groups regarding the stage of the process of self-change and the number of attempts to quit (Table 5 ). This type of difference also failed to appear when the motives for stopping smoking that were cited by each of the smoker groups were analyzed (Table 6 ).


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  		Table 5. Phase of Smoking Cessation*

 

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  		Table 6. Motives for Stopping Smoking*

 

   Discussion
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Appendix 1
 References
 
The results showed that 15% of smokers had COPD. Multivariate analysis revealed that smokers who were men, > 46 years of age, had low educational levels, and a cumulative tobacco consumption of > 30 pack-years had a higher probability of having COPD.

Some of these findings have been described previously and may be explained by a greater number of pack-years consumed by older smokers and by some genetic differences in men. Of the 717 men who comprised our sample, 132 (19.1%) had COPD, whereas COPD was diagnosed in only 16 of the 306 women (5.2%). Furthermore, Table 2 shows how, among men, the prevalence of COPD rises as tobacco consumption increases, whereas this does not occur in women. This effect can be explained, at least in part, by the small number of heavy smokers who are women in our population. Nevertheless, other studies have found that women develop COPD more frequently.21 22 A further interesting fact that emerges from the study is that individuals with a low educational level are more likely to develop COPD. A plausible explanation for this is that smokers with a higher educational level attribute the onset of respiratory symptoms to smoking sooner than those with a lower level and, consequently, take appropriate prevention measures earlier. Studies from the National Institutes of Health23 24 have shown that individuals with high levels of education stopped smoking more frequently than those with lower levels. On the other hand, worse hygienic, dietary, and general health conditions in lower educational groups may contribute to the development of COPD.25 26

Smokers who develop COPD, besides consuming a greater number of cigarettes, smoke them with a particular inhalation pattern (they inhale a greater volume of smoke and more deeply), thus permitting a higher quantity of oxidant substances, which eventually lead to the development of COPD, to reach the alveoli. Jarvis et al16 demonstrated that exhaled CO levels can be indicative of a different pattern of inhalation. Smokers who inhale more deeply are those with higher CO levels. In a 1998 study, Clark et al27 showed that the rise in CO levels in inhaled air 5 min after smoking a cigarette, which is a reliable index of smoke inhalation, was significantly higher in smokers with emphysema than in those without. This index depends on the volume of smoke inhaled and the duration of inhalation. Thus, the distinct tobacco inhalation pattern appears to be closely related to the development of lung damage.27 28 29 In agreement with these observations, we detected a significant rise in CO levels in the exhaled air of smokers with COPD than in those without COPD (10.7 vs 15.4, respectively; p < 0.0001). However, CO concentrations were not independently associated with COPD once the remaining variables (including tobacco consumption) were included in the multivariate model. Higher CO levels in our group of smokers with COPD may be indicative of a different pattern of inhalation, but as the time since the last cigarette was not standardized, we cannot rule out the possibility of the differences in CO levels reflecting a shorter interval from the last cigarette smoked among heavier smokers.

Significant differences were found for the degree of physical nicotine dependence, as measured by the Fagerström test, between the two groups studied. The majority of smokers with COPD had a moderate-to-high degree of dependence compared with the majority of healthy subjects who had a low-to-moderate degree of dependence. It should be emphasized that two of three smokers with COPD registered >= 4 points on the Fagerström test and that almost 30% had >= 7 points. Almost 50% of smokers with COPD were in a precontemplation phase and up to 34% of these smokers had never tried to stop smoking.

These data reveal a high percentage of smokers with COPD who are in the precontemplation phase, have never attempted to stop smoking, and have moderate-to-high nicotine dependence. The findings have decisive practical implications in these patients for the treatment of smoking, which is essential and should range from medical advice to more intensive interventions.30 Different studies31 32 33 have shown that smokers with abnormal spirometric results are less likely than other smokers to quit over the next year. Abnormal spirometry results may identify the heaviest smoker or the more addicted smoker who is less likely to quit.34

Finally, it should be noted that no differences were observed in motivation to stop smoking between the groups, and it was surprising that the motive "smoking damages your health" was brandished equally by both groups, when smokers with COPD would be expected to have more symptoms attributable to smoking than those without COPD and, therefore, would be more motivated to stop smoking. However, a further explanation might be that these smokers with COPD did not attribute their symptoms to smoking, as could be reflected by the fact that up to 34% have never tried to stop. Further studies are required to clarify whether informing the patient of abnormal spirometric results may influence his/her motivation to stop smoking34 35 and compare this strategy with less expensive measures such as revealing an impaired peak flow or simply giving advice against smoking.34 36

In summary, the demographic and smoking characteristics obtained from a population-based epidemiologic study of two groups of smokers, one healthy and the other with COPD, were analyzed. We found that 15% of smokers had COPD and that, in these smokers, higher age, male sex, lower cultural level, and number of pack-years smoked were major risk factors for developing COPD. A greater degree of nicotine dependence also was detected in smokers with COPD, who, moreover, were for the most part in earlier phases of the cessation process. Up to 34% of these smokers had never tried to stop smoking and failed to show more motivation to do so than healthy smokers.


   Appendix 1
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Appendix 1
References
 
IBERPOC Project Organization
Organizing Institutions:
Sociedad Española de Neumología y Cirugía Torácica (SEPAR); and Área de Trabajo sobre Insuficiencia Respiratoria y Trastornos del Sueño (IRTS), Barcelona, Spain.

Sponsoring Institution: Boehringer Ingelheim España, S.A., Barcelona, Spain.

Scientific Committee
SEPAR:
V. Sobradillo Peña (coordinator), Unidad de Patología Respiratoria, Hospital de Cruces, Baracaldo (Biscay), Spain; L. Fernández-Fau, Servicio de Cirugía Torácica, Hospital Universitario de la Princesa, Madrid, Spain; C. Villasante Fernández-Montes, Servicio de Neumología, Hospital La Paz, Madrid, Spain; J.F. Masa Jiménez, Unidad de Neumología, Hospital San Pedro de Alcántara, Cáceres, Spain; J.L. Viejo Bañuelos, Servicio de Neumología, Hospital General Yagüe, Burgos, Spain; and C.A. Jiménez Ruiz, Servicio de Neumología, Hospital Universitario de la Princesa, Madrid, Spain.

Asociación Española para el Desarrollo de la Epidemiología Clínica (AEDEC):
R. Gabriel Sánchez, Unidad de Epidemiología Clínica, Hospital Universitario de la Princesa, Madrid, Spain.

Fieldwork Coordinator:
M. Miravitlles, Pharma Consult Services, S.A., Barcelona, Spain.

Collaborating Institutions:
Sibel S.A.; Unidad de Investigación en Servicios Sanitarios IMIM, Barcelona, Spain; and Soikos Center d’Estudis en Economia de la Salut i de la Política Social S.L., Barcelona, Spain.

Coordinators and Local Investigators
Asturias:
J. Martínez González del Rio (SEPAR coordinator), Servicio de Neumología, Hospital de Asturias, Oviedo, Spain; and J.A. Gullón Blanco (investigator).

Burgos:
J.L. Viejo Bañuelos (SEPAR coordinator); and L. Lázaro Asegurado (investigator), Servicio de Neumología Hospital General Yaque, Burgos.

Cáceres:
J.F. Masa Jiménez (SEPAR coordinator); and L. Ramos Casado (investigator), Unidad de Neumología, Hospital S. Pedro Alcantara, Caceres.

Madrid:
C. Villasante Fernández-Montes (SEPAR coordinator); C.A. Jiménez Ruiz (SEPAR coordinator); and A. Dorgham (investigator), Servicio de Neumologia, Hospital Princesa, Madrid.

Seville:
J. Castillo Gómez (SEPAR coordinator), Servicio de Neumología, Hospital Virgen del Rocío; J. Fernández Guerra (investigator); and F. Valenzuela (investigator).

Manlleu:
J. Serra-Batlle (SEPAR coordinator), Servicio de Neumología, Hospital General de Vic; and J. Casadevall Escayola (investigator).

Biscay:
V. Sobradillo Peña (SEPAR coordinator); and P. Gil Alaña (investigator), Servicio de Neumología, Hospital de Cruces, Baracaldo, Vizcaya.


   Footnotes
 
Abbreviation: BDT = bronchodilator test

The IBERPOC study is an initiative of the workshop "Insuficiencia Respiratoria y Trastornos del Sueño (IRTS)" of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR).

The IBERPOC study is funded by an unrestricted grant from Boehringer Ingelheim Spain S.A.

Received for publication December 22, 1999. Accepted for publication December 14, 2000.


   References
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Appendix 1
 References
 

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