Chronic obstructive pulmonary disease (COPD) is a major contributor to global mortality and morbidity. In Korea, the prevalence of COPD is 12.9%, and COPD is the sixth leading cause of death.1,2 COPD has a negative impact not only on patients but also on family members who have to take care of them.3 In 2010, COPD accounted for 2.8 billion US dollars in direct medical expenses in Korea.4 Therefore, the medical, social, and economic burdens of COPD are extremely substantial.

Cigarette smoking is the most common risk factor for COPD. Smokers have a higher prevalence of respiratory symptoms and lung function abnormalities and a greater mortality rate than nonsmokers.5 The Global Initiative for Chronic Obstructive Lung Disease consensus report was developed to provide a more uniform set of recommendations for the diagnosis and management of COPD and to increase awareness and understanding of this condition among patients and the public.5 Public awareness of COPD is poor, due to the disease receiving less media attention than other common chronic diseases, such as asthma or diabetes.6 The lack of awareness of COPD means that the disease is substantially underdiagnosed and typically missed or delayed until the condition is advanced.6,7 According to one study, only 2.5% of subjects in Korea with airflow limitation confirmed by spirometry were treated for COPD.1 In addition to preventing timely diagnosis of the disease, the absence of awareness impedes implementation of optimal standards of care and appropriate prevention strategies.6

We previously examined COPD awareness among those with the disease.8 However, no studies have investigated the attitudes of smokers to COPD among those who are at risk of developing the disease in Korea. We present the results of a survey of the attitudes to COPD held by smokers participating in a smoking-cessation program.

In this study, we found that 68.2% of smokers had COPD-related symptoms, and 19.7% were in poor health. Although the duration of COPD-related symptoms (except for resting dyspnea) was at least 4 years in all subjects, 41.6% of symptomatic subjects did not do anything about their symptoms, such as quitting smoking or visiting a clinic. This suggests that a number of smokers have a positive perception of their health status, despite the presence of respiratory symptoms. This finding is consistent with previous findings that only 50.3% of COPD patients accepted that smoking was responsible for their respiratory symptoms6 and that COPD patients adapted their lifestyle to compensate for their deteriorating health.9

In addition, most of the subjects (99%) in the current study did not name COPD as a respiratory disease. The 1% of subjects who were aware that COPD was a respiratory disease is much lower than the 17.0% figure reported in the CONOCEPOC study conducted in Spain.10 A total of 21.8% of the participants knew that COPD was a respiratory disease, and awareness of COPD was the same among subjects with and without COPD-related symptoms. Furthermore, only 2.4% of current smokers had been diagnosed with COPD and received treatment, a figure that is comparable with that of the general population in Korea.1 The findings indicate that COPD is underdiagnosed and undertreated, even in current smokers who are willing to quit smoking. They also reveal that awareness of COPD is very poor in smokers, highlighting the need to increase public awareness of the diagnosis and treatment of COPD in this population.

Airflow limitation, which is a characteristic feature of COPD, is usually progressive. Current medications for COPD cannot change the natural course of the disease. Such change can only be achieved by smoking cessation, which is also necessary to reduce related mortality.5 A previous study reported that patients who had little knowledge of COPD were more likely to have poor adherence to treatment.11 Therefore, patient education is an important aspect of COPD management. The most important aspects of education are providing basic information on COPD and advice on smoking cessation.5 As reported previously, quitting smoking before the age of 40 years compared with continuing smoking reduces the risk of death by about 90%.12 Therefore, improving awareness of the consequences of smoking for respiratory health is important, and smoking cessation advice should be offered repeatedly in patients with early COPD.7 In this study, 91.3% of subjects responded that smoking was the cause of COPD, and 84.1% responded that their willingness to quit smoking increased after being informed about COPD. This increase in the willingness to give up smoking may be exaggerated in this study, as all the subjects had already participated in a smoking cessation program. However, it could also indicate that the willingness to quit smoking could increase dramatically through education on COPD. A new study targeting smokers who had not participated in a smoking cessation program previously is warranted to clarify the role of enhanced awareness of COPD in the motivation to quit.

On the other hand, 5.5% of the study subjects responded that their smoking-cessation willingness decreased after being informed about COPD, and 8.7% showed no change in smoking-cessation willingness. The proportion of smokers who were less willing to quit smoking was higher among those who were aware of COPD or who had COPD-related symptoms. As only one-half of COPD patients accepted that smoking was responsible for their respiratory illness,6 stereotypical education about COPD may be ineffective in some smokers. Instead, a personalized education program may be needed to enhance awareness of COPD and motivate subjects to quit smoking.13 In the current study, only 66.7% of subjects said they would seek medical help if they developed COPD. Thus, undertreatment continues to be a problem in COPD management, despite early detection of the disease. Enhancing awareness of COPD may be helpful in addressing this problem.

In this study, a large number of subjects (57.1%) acquired information about COPD from television, whereas only a small number (15.9%) obtained information on the disease from doctors. These figures are quite different from those reported in the BREATHE study,6 which reported that two-thirds of subjects were informed by physicians and 10.1% claimed to obtain information from television. One study conducted in Korea previously clarified that the most frequently utilized health information source was mass media. 14 Therefore, it is possible that the discrepancy from BREATHE study was caused by the cultural difference reflected in the more powerful effects of mass media in Korea. Additionally, in the current study, 68.2% of subjects also said that television was the most reliable source of information about COPD treatment. This finding is consistent with the previous study, which found that mass media was the most understandable (35.2%) and the second-most reliable (22.9%) information source.14 As mentioned above, television is a powerful information source in Korea; therefore, health care providers should widely use this medium for COPD education or campaigns.

Another study reported that 88% of COPD patients in Korea felt that they had received sufficient information about the disease from doctors; however, only 57.7% of these patients knew the exact diagnosis of their medical condition.8 The gap between what patients felt they knew and what they actually knew may come from the paternalistic culture and one-way communication from doctors to patients in Korea. These results indicate that new educational strategies are needed to deliver accurate information on COPD to the general population. For example, given that people who are accustomed to the Internet will automatically use this medium to search for information about diseases,9 it may be a useful resource for COPD education.

There are several limitations in our study. First, we excluded subjects younger than 45 years, as COPD is a disease that affects older individuals. To assess public awareness of COPD, studies are needed that include young smokers. Second, we classified subjects into only two groups according to education level: high-school level or less and college level or more. Awareness of COPD was not different between these education-based groups; however, stratifying the subjects into additional groups based on educational level might have shown an effect of education on awareness of COPD. However, as only about one-fifth of the subjects in each education-based group knew about COPD, efforts to increase awareness of the disease should target people of all educational levels.

In conclusion, we found that awareness of COPD was very poor in current smokers in Korea. Many smokers perceived their health status as good, despite the presence of COPD-related symptoms. In addition, smokers thought that television was a better source of information about COPD than physicians. Smoking-cessation willingness increased after being informed about COPD; however, the level of increased smoking-cessation willingness differed between the subjects with or without awareness of COPD or COPD-related symptoms. Therefore, initiatives other than patient education in the clinic are required to enhance public awareness. A personalized education program with various educational tools should be implemented to improve awareness of COPD and smoking-cessation willingness. To the best of our knowledge, this is the first study to explore awareness of COPD among smokers in Korea. The results of this study could provide basic data for developing a policy to increase public awareness of the disease in Korea.