The efficacy and cost-effectiveness of confrontational counselling for smoking cessation in smokers with previously undiagnosed COPD: a randomised controlled trial.

Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. Although COPD is a major cause of chronic morbidity and mortality worldwide, the true burden of the disease is not usually recognised until it is clinically apparent and moderately advanced. Smoking is the most important risk factor for the development and progression of COPD. Smoking cessation is the single most effective - and cost-effective - intervention to reduce the risk of developing COPD and affecting the outcome in patients at all stages of the disease. Usual care for smoking cessation in the Netherlands involves the use of a protocol for low intensity health education and promotion (the so-called "Minimal Intervention Strategy" for the general practitioner and his/her assistant, H-MIS). Although the H-MIS is an effective aid in helping smokers to quit (8% prolonged abstinence after 12 months compared to 3% in the control group), there is much room for improvement. Smokers with respiratory complaints are more motivated to stop smoking when they know that they are at risk of developing a chronic lung disease such as COPD. Smokers usually minimize their own perceived risk of developing a smoking-related disease, or deny or avoid information about the dangers of smoking in order to reduce cognitive dissonance. We therefore expect that confronting smokers with an objectively (by spirometry) identified negative consequence of smoking (COPD) will positively affect the outcome of their quit attempt. The primary aim of this randomized trial is to analyse the efficacy and cost-effectiveness of confrontational counselling for smoking cessation delivered by specialised pulmonary nurses for smokers with previously undiagnosed mild to moderate COPD with regard to prolonged abstinence from smoking during a period of 12 months. Furthermore, we want to analyse the effect of smoking cessation on lung function, perceived specific health-related complaints, quality of life and mental health. We have therefore conducted a randomized controlled trial is comparing (1) confrontational counselling delivered by a pulmonary nurse and pharmacotherapy, (2) health education and promotion delivered by a pulmonary nurse and pharmacotherapy and (3) "care as usual" delivered by the general practitioner. Early detection of smokers with mild to moderate COPD is achieved by means of a telephone interview in combination with spirometry.

Confrontation with the results from spirometry as part of counselling for smoking cessation in smokers with not earlier diagnosed mild to moderate COPD is effective with regard to prolonged abstinence from smoking during a period of 12 months.

Intervention groups:
1. Confrontational counselling delivered by a pulmonary nurse and pharmacotherapy; 2. Health education and promotion delivered by a pulmonary nurse and pharmacotherapy; or
3. "Care as usual" delivered by the general practitioner.