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Remember elephants and icebergs… “Your lung function should be here, but it is there!”

In the present issue of the European Respiratory Journal , Kotz et al. 1 report on a study aimed at determining the incremental benefit of spirometry in a smoking cessation intervention in individuals with as yet undiagnosed airflow obstruction compatible with mild and moderate chronic obstructive pulmonary disease (COPD). In a randomised clinical trial (RCT) study design, the authors compared an experimental group (nortriptyline and medium-intensity advice with spirometry) with two control groups: C1 (nortriptyline and medium-intensity advice without spirometry) and C2 (passive physician advice). The primary end-point was sustained cessation at week 52 with urinary cotinine-validated definitions. Regrettably, the study did not provide evidence that the confrontational approach increases the rate of long-term abstinence from smoking compared with an equally intensive treatment in which smokers were not confronted with spirometry.

In contrast, both the British Lung Age RCT by Parkes et al. 2 and the Swedish RCT by Stratelis et al. 3, along with the large Polish cross-sectional study by Bednarek et al. 4, add support to the notion that giving information about lung damage to smokers improves cessation rates. Why do these results differ? There are many possible explanations. It is likely that a reduced sample size and the high failure rates (>88%) in the trial by Kotz et al. 1 …