COPD Prevention

Prevention: Taking the right steps forward

COPD is a preventable condition. Investing in prevention is the most effective approach to reduce the burden of COPD at all levels. Prevention of COPD encompasses both the prevention of the disease itself (primary prevention) and the prevention of its progression (secondary prevention). It requires a holistic approach leading to behavioural changes, population interventions and legislation aimed at reducing exposure to risk factors (smoking, indoor and outdoor air pollution), and occupational risks. Avoiding smoking is the most effective measure for preventing COPD. In Europe, cigarette smoking has effectively decreased, and second-hand smoking has also been reduced thanks to the enforcement of smoke-free environments in public indoor spaces. On the contrary, e-cigarettes and vaping represent new hazards for public health.

Exposure to poor air quality is another major risk factor for COPD. In recent years, ambient air pollution has garnered some attention, but emission levels only target specific pollutants. Furthermore, even though people spend most of their time in their homes, indoor air quality continues to receive less attention. Patients’ associations have played a huge role in raising awareness of the importance of air quality for public health, advocating for a non-siloed approach when regulating air quality. Public authorities should complement these efforts with robust and prompt actions.

“There is a growing awareness among patients of the need to quit smoking and on the influence of air quality as a cause of respiratory diseases and exacerbations.”

COPD Patient, Spain

“The government is planning to increase the age of smoking to 21 years and to ban the sale of disposable vapes.”

COPD Patient, Ireland

“The “smoker’s stigma” should not prevent the correct management of patients with COPD.”

COPD Patient, Ireland

“More financial support for cessation programmes is needed.”

COPD patient, Germany

“The public authorities could do more to control air pollution.”

COPD patient, France

“There should be more specific smoking zones, even outside. There should be bans on smoking in public places.”

COPD patient, Germany

COPD Patient Testimonial: From early exposure to quitting smoking, France (French)

The patient recounts how early exposure to second-hand smoke from a young age and later smoking habits, led to a pulmonary embolism. She shares how she stopped without treatment, motivated by the serious health risks associated with continued smoking.

©Copyright by La Fédération française des associations et amicales de malades insuffisants ou handicapés respiratoires (FFAAIR), 2019.

Reduce exposure to cigarette smoking and vaping

Cigarette smoking causes 80% of COPD cases in high-income countries. Consequently, smoking cessation support, campaigns, and legislation to ban smoking and vaping are effective measures to prevent COPD. Research demonstrates that a decrease in smoking leads to a decrease in the prevalence of COPD, particularly moderate to severe COPD [1].
In its 2013 report, EFA identified access to smoking cessation services for all smokers as a priority to halt the prevalence of COPD. In 2023, all 19 countries considered in this report have taken a step forward in terms of smoke-free legislation, despite some weaknesses in terms of implementation, particularly as regards smoking outdoors and vaping.

Box 7

More than half of current smokers have attempted to quit

Only a quarter of smokers who quit or attempted to quit smoking used smoking cessation methods (including nicotine gums or patch) and only 6% used medical support or stop smoking services (such as a Quitline). These figures are similar to previous data collected in 2017 [3].

COPD Patient Testimonial: Jean-Paul Vasseur, France (French)

Jean-Paul describes how COPD symptoms began with breathlessness and fatigue, eventually leading to a diagnosis at 40. He quit smoking and became an advocate for COPD patients joining FFAAIR.

©Copyright by La Fédération française des associations et amicales de malades insuffisants ou handicapés respiratoires (FFAAIR), 2019.

Access to smoking cessation services for COPD patients

A randomised clinical trial of 5,887 middle-aged volunteers with asymptomatic airway obstruction found that a 10-day smoking cessation programme, that included counselling, nicotine replacement therapy, and long-term maintenance measures, significantly increased survival after 5 years and even in the long-term (i.e., 14.5-year survival) [2]. Therefore, smoking cessation programmes are an important part of the prevention and management of COPD and should be offered to anyone at-risk, regardless of their status and condition.

All countries considered in this report have developed smoking cessation guidelines based on scientific evidence and best practice and offer smoking cessation services (Eurobarometer, 2021). However, access to smoking cessation services is not available for all that need it, due to geographical distribution, reimbursement policies, or organisational barriers.

Different healthcare institutions in different countries provide smoking cessation services. Most countries have specialised centres for cessation and counselling, often based in hospitals [4]. Consequently, access to specialised services may be difficult for people living in rural and less populated areas. In Austria, some healthcare facilities offer support in quitting through on-site specialists or in cooperation with health insurances. Remarkably, specialised centres employ mainly tobaccologists and/or nurses, and there is a lack of coordination with pulmonologists. If implemented, this synergistic approach would also improve early detection of COPD cases among smokers and allow for timely action to halt disease progression. Notably, there are no preferential access or specific services for COPD patients who want to quit smoking. Furthermore, GPs or specialists often advise COPD patients to contact a smoking cessation service, but specific interventions should be enforced to facilitate access to these services for patients with a COPD diagnosis or other conditions.

Primary care physicians and GPs do not routinely provide smoking cessation services. Notably, smoking cessation is not generally part of their medical training. Nevertheless, primary care doctors are increasingly providing information about smoking cessation options and prescribing nicotine replacement therapies. Similar to the Dutch guidelines for smoking cessation [5], physicians in the Netherlands are required to inquire about the patient’s smoking status during routine examinations and offer smoking cessation advice. In Sweden, 40% of smokers are offered smoking cessation services in primary care. In some countries, such as in the Czech Republic, pharmacists and nurses offer smoking cessation programmes [4].

Telephone support programmes (Quitlines) are available in all countries surveyed, and some countries are implementing apps and/or online support. The Irish governmental Health Service Executive has a website (quit.ie) dedicated to smokers wishing to quit. Smokers can enrol free of charge by registering on the website to receive daily support via email or text messaging. They also receive 1-to-1 support from a trained advisor who offers advice about nicotine replacement therapies and information about prescriptions. Moreover, smokers can track their progress online. Quit.ie also provides a specific support dedicated to quitting e-cigarettes.

Nicotine replacement therapies are effective, particularly in combination with counselling, to support quitting smoking. To effectively reduce the burden of smokers willing to quit, nicotine replacement therapy should be easily accessible and should be reimbursed. In the European Union, only half of the countries have low-cost schemes or reimbursement schemes for nicotine replacement therapy [4]. In Ireland, nicotine replacement therapy is free for some categories of patients or under specific programmes (e.g., the ‘We Can Quit’ targeted to women in disadvantageous areas) (DG SANTE, 2021) and for those on medical cards (low-income population), but it has to be paid for those without a card with a price cap of 80 euros per month. In the UK, nicotine replacement therapy is available free of charge. Since 2019, France has reimbursed 65% of the cost of nicotine substitutes [4]. In Italy and Spain, only specific drugs are fully reimbursed, whereas in Finland and Portugal they are partially reimbursed (DG SANTE, 2021). In Spain, smoking cessation is mainly prescribed in primary care; social security pays for complementary treatment twice a year, but nicotine replacement therapy is covered only once per year. Conversely, in the Netherlands, smoking cessation medicines are available free of charge only if they are accompanied by behavioural changes, and reimbursement is offered regardless of the number of attempts to quit.

Access to services may be improved by incentivising primary care physicians, pharmacists, and nurses to organise these services. Furthermore, quitlines and new technologies like apps can provide first level access to the services and follow-up. Finally, there is no uniformity at the EU level in terms of reimbursement for nicotine replacement therapies.

COPD Patient Testimonial as: How smoking led to a lung a transplant, France (French)

The patient shares how a smoking addiction led to critical lung damage. After a life-threatening pneumonia and a double lung transplant, she urges others to avoid starting smoking or to seek help to quit.

Box 8

Know the difference: Nicotine replacement therapy versus e-cigarettes

Nicotine replacement therapies are medications designed to address nicotine dependence, which, when combined with counselling, can aid in quitting smoking. They must be approved by European and other national medicine regulatory agencies based on rigorous criteria of efficacy and safety.

E-cigarettes and heated tobacco devices are not nicotine replacement therapies. E-cigarettes contain more nicotine than do replacement therapies, and they create addiction. They are not approved for smoking cessation purposes. Moreover, there is a lack of evidence on the effectiveness of e-cigarettes in quitting smoking while their short- and long-term harmful effects are documented.

Vaping and e-cigarettes: The smoking epidemic 2.0

Vaping and e-cigarettes are an emerging health threat. A study commissioned by the European Commission reported a 10% sales volume increase for e-cigarettes and heated tobacco products in at least five Member States, and the sales volume of heated tobacco products exceeded 2.5% of total sales of tobacco products at Union level [9]. The percentage of people who start smoking with e-cigarettes is increasing (+2 points in 2020 versus 2017), whereas the proportion of people start to smoke with cigarettes (either hand-rolled or boxed) has remained stable since 2017 [3]. The use of e-cigarettes is growing, particularly among the young and adolescents. A quarter of people aged 15-24 years have tried e-cigarettes, compared with 8% of the respondents aged 55 or over [3]. In the UK, the number of 11–17-year-olds who have used an e-cigarette has quadrupled in a ten-year period. In France, more than half of 17-year-olds have tried a vape, and in Italy, the percentage of 11-17-year-olds who have used an e-cigarette in the past month has doubled since 2014.

Vaping and e-cigarette advertising campaigns are specifically targeted at young people. [10]. E-cigarettes come in a variety of flavours and in colourful and attractive packaging designed to attract younger consumers who may find them appealing. Flavours mimic the ones of candies, fruits, desserts, or popular beverages. Colourful, eye-catching packaging resembles that of popular snacks or beverages. In addition, e-cigarette marketing often employs social media influencers and celebrities to give a “cool” image. These marketing strategies have raised concerns among healthcare professionals, public health advocates, and policymakers, as they may encourage the initiation of e-cigarette use.

Adult smokers mistakenly perceive vaping and heated tobacco products as less harmful than cigarettes. They are considered a healthier alternative to cigarette smoking and a means to quit cigarette smoking [10]. Among smokers, stopping or reducing tobacco consumption is the most frequently mentioned reason for taking up e-cigarettes [3]. This misbelief is tied to “harm reduction strategies” not supported by scientific evidence and are opposed by healthcare professionals, including the European Respiratory Society, which states that alternative nicotine delivery products can potentially have a negative impact on public health [7]. Recent studies have demonstrated the association between e-cigarette use and the risk of developing COPD and asthma [11] and the correlation between vaping and self-reported COPD, even among non-smokers [12].

Another reason for e-cigarettes’ attractiveness is circumventing smoking bans [3] [10]. Although most countries have extended the rules for tobacco smoking to e-cigarettes or have enforced some form of vaping ban in public spaces (Figure 8), there is a general perception that e-cigarettes are allowed in places where cigarette smoking is banned [3]. Smoking ban compliance for e-cigarettes seems to be more difficult to implement. In November 2022, the EU issued a Commission Delegated Directive (EU 2022/2100) in which prohibits heated tobacco tastes and establishes strict labelling requirements for heated tobacco products, similar to cigarettes. The Directive also prohibits placing flavoured heated tobacco products on the market. How the Directive will be implemented by Member States must be monitored and its effects may be seen in the near future [13].

COPD Patient Testimonial: From 46 Years of Smoking to the Journey of Quitting, France (French)

The patient shares his struggle with quitting smoking after 46 years. Despite the challenges, it’s possible with the right support, such as patches and medical guidance.

©Copyright by La Fédération française des associations et amicales de malades insuffisants ou handicapés respiratoires (FFAAIR), 2019

Smoke-free policies: In the right direction

Smoke-free policies have protected millions of Europeans from the dangers of second-hand smoking and have been shown to be beneficial in reducing morbidity and mortality caused by tobacco use and exposure. Over the past ten years, the effectiveness of these rules has increased, leading to their widespread application, albeit restricted to specific areas. Following the requirement of Article 8 of the WHO Framework Convention on Tobacco Control (WHO FCTC) on the protection from exposure to tobacco smoke, the 2009 EU Council Recommendation on Smoke-Free Environments (2009/C296/02) led to the introduction of comprehensive smoke-free laws by Member States. Smoking is now banned in all public indoor spaces in Europe (Table 3). Most surveyed countries successfully implement national smoke-free regulations, with high levels of compliance [14]. Only Bulgaria, Poland, Portugal, and Serbia report weak compliance [14]. In the Czech Republic, Germany, and Switzerland, the implementation of the smoking ban is weak or limited. This is due to a lack of national regulation in Germany and Switzerland, where restrictions vary by region. In fact, some have comprehensive smoking bans in place, while others allow for designated smoking areas in certain establishments.

While the smoking ban in public indoor spaces, such as schools, offices, and restaurants, is well established, the current regulation still does not ban smoking everywhere. In particular, the ban often excludes outdoor public spaces such as public parks, beaches, or streets, as well as private areas like homes and cars. While such measures would have a limited impact on exposure to second-hand smoke, they would nevertheless serve as deterrents for smokers. Some municipalities in Italy now ban smoking in outdoor playgrounds and parks, but the measure is not widespread. In 2024, France will ban smoking in public spaces, including all beaches, public parks, and some other public areas, such as around schools. Legislators are also discussing the ban of single-use disposable e-cigarettes. Various countries, such as Italy and Wales, prohibit smoking in the presence of pregnant women. In these countries, smoking or vaping in cars is also banned. However, due to a lack of information on these restrictions, compliance is low. Indeed, as noted in the DG SANTE report, smoke-free rules are most effective when accompanied by appropriate enforcement mechanisms (e.g., fines, mandatory signposting), like it was the case for the smoking bans in bars and restaurants.

Table 3. Information from smoke-free map

Country	Restaurants & bars	Terraces	Indoor workplaces	Outdoor workplaces	Sports venues & stadiums	Schools & universities	Hospitals	Public transport	Private cars	Parks & beaches
Austria
Belgium
Bulgaria
Czech Republic
Finland
France
Germany
Iceland
Ireland
Italy
Netherlands
Poland
Portugal
Serbia
Spain
Sweden
Switzerland
Turkey
United Kingdom

Based on a survey circulated in 43 countries in the course of 2021. The data used refers to the legislation passed as of 1 June 2022, meaning any legislation or implementation improvements after this date are not included.

Source: Smoke Free Partnership. Accessed on November 2023.

Figure 8. Smoking ban implementation in European countries

Complete ban
Partial ban
No ban

Complete ban: e-cigarettes are equated to tobacco cigarettes. Partial ban: some ban is enforced. No ban: e-cigarettes are not equated to cigarettes

Data from the Smoke-free Partnership

Box 9

Spain

The risk of COPD and other serious respiratory diseases has not slowed smoking. Tobacco regulations are more restrictive than 10 years ago but are still insufficient despite the demands of patient associations and scientific societies.

Iceland

Awareness campaigns are a thing of the past as smokers are almost extinct!

Sweden

Smoking has decreased to approximately 6% of daily smokers in the general population

Turkey

Health authorities have not sufficiently addressed issues related to the prevention of smoking

Air quality: An invisible health factor

While cigarette smoking remains the main risk factor for COPD, in recent years, researchers shed light on the link between air pollution and COPD, or, more specifically, between prolonged exposure to air with elevated pollutant concentrations and genetic factors in the onset of COPD. Epidemiological evidence shows that both outdoor and indoor air pollution, along with occupational exposure to dust, gases, and harmful particles, have adverse effects on human health and are closely linked to respiratory diseases, including COPD. Most of the effects of long-term exposure to air pollutants are not immediately visible, and they may appear even several years after the exposure [15]. Furthermore, exposure to air pollutants can lead to worsened existing symptoms, compromised lung function, and higher rates of hospitalisation and mortality [16].

Box 10

Outdoor air pollution

Outdoor air pollution contains numerous substances of both natural (e.g., pollen, mould spores, dust) and anthropogenic (human-caused) origin.

Indoor air quality refers to the air quality within and around buildings and structures, especially as it relates to the health and comfort of building occupants.

From US Environmental Protection Agency https://www.epa.gov/

Outdoor air quality: Confronting the leading environmental killer

Outdoor air pollution is a major public health issue that affects all parts of the world [17]. Ambient air pollution can exert both acute and long-term effects on human health. Many epidemiological studies show that exposure to ambient particulate matter (PM) or nitrogen dioxide (NO2) is associated with daily mortality, with a primary focus on respiratory and cardiovascular diseases [18] [19].

The European Environmental Agency (EEA) reported that approximately 96% of EU residents live in areas that fail to meet the WHO’s standards for particulate matter sized 2.5 mm (PM2.5) air quality [20]. The European Respiratory Society (ERS) and the European Lung Foundation (ELF) jointly urged the European Union to fully comply with the WHO’s 2021 Air Quality Guidelines [21] [22]. Countries should prioritise the adoption of strategies to reduce air pollution concentrations to levels in accordance with WHO recommendations and tackle poor indoor air quality.

The major sources of outdoor pollution include residential energy for cooking and heating, vehicles, power generation, agriculture/waste incineration, and industry. Policies and investments that support energy-efficient housing, cleaner household energy and transport, sustainable land use, power generation, industry, and better municipal waste management can effectively reduce key sources of ambient air pollution.

EFA is advocating for a revised ambient and air quality Directive to ensure access to timely, accurate and real-time public information on air quality. This information must be accompanied with relevant health advice tailored to vulnerable populations.

In particular, the Directive should:

Establish information thresholds for all major pollutants covered by the Directive, including PM10, PM2.5, NO2 and SO2 (currently there is only for O3);
Ensure that the proposed national Air Quality Indices are fit-for-purpose, involving health-related messaging and advice, and based on an EU framework for AQIs.

Can Air Pollution Cause COPD? (Turkish)

This video discusses how air pollution can contribute to COPD and worsen symptoms, offering tips for patients to reduce exposure. Presented in Turkish.

Indoor air quality: promoting ventilation

People spend almost 90% of their time in indoor environments, such as private households, schools, workplaces, public establishments, and means of transportation [23]. Dust, mould, dampness, heating, cooking emissions, building materials, furnishings, and tobacco smoke are only some of the many factors that may pollute indoor air to the extent that it is significantly harmful for health.

Both indoor and outdoor pollutant sources play a pivotal role in indoor air quality, and indoor air may often be significantly more polluted compared to the outside [24]. Furthermore, warmer temperatures and higher humidity increase indoor air pollution.

The socio-economic status is also associated with risks from indoor air pollution: people with low income are more likely to live in areas with high levels of pollution and low-quality buildings, and poor households are less likely to afford healthy renovations. Schemes designed to support disadvantaged populations play a role in improving indoor air quality. For example, the “Warmth and Wellbeing Pilot Scheme” of Ireland foresees free home energy upgrades for people in need and with disabilities.

Ventilation plays a pivotal role in reducing indoor air pollution by circulating air and diluting concentrations of indoor pollutants. Ensuring that well-functioning ventilation, together with appropriate inspection systems, is in place is hugely important. Reformed policies should encourage significant investment in building construction and maintenance.
In addition, mandatory indoor air quality certificates for all new and renovated buildings would be key to ensure public health and would enable transparent access to information on the quality of indoor air. These could consist of an annex to the existing Energy Performance Certificates (EPC), with information about ventilation rate, air quality monitoring and control, and winter and summer thermal comfort.

Although the European Union has a well-structured ambient air quality policy framework, the legislation addressing indoor air quality is fragmented [23]. Furthermore, although researchers made substantial progress in identifying common indoor pollutants, there is still a gap in finding effective solutions to tackle these issues.
Besides the difficulties in keeping under control the air quality indoors, a more holistic approach to reduce air pollution in terms of definitions, targets, preventive and support measures, is needed.

Air quality and COPD

While it is difficult to evaluate the evidence, recent published studies indicate that long-term exposure to air pollution may play a role in the development of COPD. Notably, heightened exposure to elevated levels of PM2.5 emerged as a significant factor in increasing the incidence of COPD. Furthermore, exposure to NO2 seemed to be associated with the risk of developing COPD [25].

Indoor air quality has a significant impact on health. As their condition may force them to spend more time indoors, people living with COPD are among the first to experience the impact of indoor pollution [08]. Long-term exposure to polluted air indoors can result in the development or aggravation of respiratory symptoms in individuals with COPD, leading to reduced lung function. Ramírez-Venegas and colleagues (2006) found that non-smoking women exposed to household biomass fumes for cooking and heating in poorly ventilated dwellings developed COPD and were at increased risk of mortality, similar to tobacco smokers [26].

Climate change: A risk to lung health

The ongoing climate change emergency poses significant risks to the health of people in Europe. Rising temperatures, more frequent and intense heatwaves, and an increase in the number of wildfires contribute to a challenging environment for people with respiratory conditions. Studies using data from 15 European countries have demonstrated a strong association between heat exposure and mortality due to respiratory diseases, with an elevated risk for heat-related mortality in older age groups and stronger heat effects in socioeconomically deprived areas (EXHAUSTION Project, 2024).

Elevated temperatures can make it harder for individuals with COPD to breathe comfortably. Heatwaves can intensify air pollution, thereby worsening the overall air quality and triggering respiratory distress. Wildfires, exacerbated by climate change, release large amounts of PM and harmful pollutants into the air. These fine particles can penetrate deep into the lungs, aggravating COPD symptoms and leading to acute exacerbations [27].

In adapting to climate change, it becomes crucial to develop strategies to protect the respiratory health of individuals with COPD. This includes effective air quality management, early warning systems for extreme heat events, and comprehensive measures to mitigate the impact of wildfires. More precisely, prioritising green mobility is extremely helpful in reducing transport emissions that harm health. In tackling heatwaves, measures to ‘break’ the so-called ‘heat-island’ effect should be enforced, which include the development of more parks and green spaces. Investment in healthy renovations can significantly contribute not only to better indoor air quality but also to reducing energy emissions of buildings to the outdoor environment. Finally, public information and alert mechanisms should be timely and accessible and always tailored to vulnerable groups. Addressing climate change not only benefits the planet but also plays a vital role in safeguarding the wellbeing of those vulnerable to respiratory conditions like COPD [28].

Box 11

EFA’s initiative on F-Gases contained in inhalers

As part of the European green deal policies, the European Union placed a ban on F-Gases and health: need for a specific EU impact assessment

Fluorinated greenhouse gases, known as F-Gases, are powerful greenhouse gases. However, they are also an important element in liquid inhaler devices that are used to treat asthma and COPD patients. Liquid inhalers use F-Gases as a propellant to quickly release the medication into the lungs. They are mainly prescribed for patients who, due to their young age (children), old age (older people) or their disease severity (severe stage of pulmonary obstruction), have difficulties breathing in deeply from other devices (i.e., dry-powder inhalers) that do not contain F-Gases. While COPD patients recognise the urgency of taking steps to improve air quality and combat climate change, treatment needs must be considered. There is a concrete risk that phasing down pMDI could negatively impact the health and wellbeing of asthma and COPD patients, particularly the most vulnerable. Therefore, EFA call governments, researchers, and pharmaceutical companies to work together to develop new, more sustainable technologies to deliver vital medications to the lungs. On the other hand, patients and doctors must be educated about F-Gases-containing devices in order to choose the best device for each patient.

Full text is available here

Conclusion: Healthy air for all

COPD can be prevented, and its impact can be reduced. Eliminating the factors that trigger the onset of COPD (particularly smoking and poor air quality) is crucial. Quitting smoking is the most effective preventive measure against COPD. While cigarette smoking has effectively decreased in Europe, e-cigarettes, and vaping pose new health risks, particularly for the youth. In terms of air quality, outdoor air pollution has received some attention in recent years. Conversely, policymakers have largely overlooked indoor air quality, despite vulnerable individuals spending most of their time in enclosed spaces. Finally, the threats posed by climate change have a negative impact on respiratory disease development and exacerbations. For many years, patients’ associations have played a huge role in initiatives to raise awareness about the importance of air quality for public health, advocating for concrete measures to tackle the issues. These efforts should be paired with strong and timely actions by public authorities and decision makers to achieve the goal of healthy air for all.

Recommendations

Investing in Lung Health through Public Health Initiatives

Since COPD is a preventable disease, investing in lung health requires public health policies and actions aimed at preventing risk factors exposure and improving health literacy. Both angles, legislation and education, are fundamental to decrease the prevalence of COPD and improve healthcare outcomes.

At national level:

Disseminate information on COPD risk prevention: Support the dissemination of information on the prevention of risk factors for COPD, through public health measures aimed at increasing health literacy.
Adopt and enforce public health laws to protect lung health: Implement and enforce public health legislation to protect lung health, including measures to reduce smoking and vaping, limit exposure to second-hand smoke for vulnerable groups and groups-at-risk, and offer free-of-charge support for smokers who wish to quit, including accessible smoking cessation programmes.
Reduce outdoor air pollution and provide public information: Implement ambitious measures to tackle outdoor air pollution and improve access to public information on air quality, with advice specifically addressed at vulnerable groups such as chronic respiratory disease patients, especially in areas impacted by exceeding air pollution levels, such as big size cities, industrial and mining areas and regions dependent on the burning of fossil and solid fuels.
Improve indoor air quality: Adopt a comprehensive framework to reduce indoor air pollution, including national and local schemes for health-based renovations (i.e., incentivising renovations in buildings where COPD patients live in), ventilation improvements and building maintenance.
Prioritise measures to reduce the impact of climate change related risks on COPD patients: Prioritise actions towards vulnerable populations, like people living with COPD and reduced lung function. Such actions should include early warning systems, healthcare systems and information plans to address risks such as wildfires and floods, expand green areas in urban environments to combat heatwaves, and reinforce civil protection mechanisms.

At European level:

Strive for a ‘Tobacco-Free Generation’ by 2040: Escalate efforts to achieve a tobacco-free generation before 2040 through additional restrictions on the commercialisation and use of smoking and vaping products, and by expanding the enforcement of smoke-free environments to all indoor and public spaces, and private spaces where children are exposed.
Align EU air quality legislation with WHO standards: Align European air quality legislation with WHO ambient air pollutant standards and ensure effective implementation at the national level.
Propose harmonised indoor air quality measures: Harness scientific evidence to propose basic harmonised measures to address indoor air quality standards and performance.
Act on the WHO/Europe Budapest Declaration Commitments on Environment and Health: Act on the commitment made in order to address the environmental and climate crisis that affect lung health.
Set minimum standards for civil protection services and promote research on the impact of climate hazards on lung health: Propose minimum standards for civil protection services and for information during climate emergencies that affect air quality. Promote research on the impact of climate hazards on lung health, particularly on people with chronic respiratory diseases.

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COPD Prevention

COPD Prevention

Prevention: Taking the right steps forward

COPD Patient Testimonial: From early exposure to quitting smoking, France (French)

Reduce exposure to cigarette smoking and vaping

Box 7

More than half of current smokers have attempted to quit

COPD Patient Testimonial: Jean-Paul Vasseur, France (French)

Access to smoking cessation services for COPD patients

COPD Patient Testimonial as: How smoking led to a lung a transplant, France (French)

Box 8

Know the difference: Nicotine replacement therapy versus e-cigarettes

Vaping and e-cigarettes: The smoking epidemic 2.0

COPD Patient Testimonial: From 46 Years of Smoking to the Journey of Quitting, France (French)

Smoke-free policies: In the right direction

Box 9

Air quality: An invisible health factor

Box 10

Outdoor air pollution

Outdoor air quality: Confronting the leading environmental killer

Can Air Pollution Cause COPD? (Turkish)

Indoor air quality: promoting ventilation

Air quality and COPD

Climate change: A risk to lung health

Box 11

EFA’s initiative on F-Gases contained in inhalers

Conclusion: Healthy air for all

Recommendations

Investing in Lung Health through Public Health Initiatives

At national level:

At European level:

References

About

What is copd

Burden of copd

Cost of COPD

Disease awareness

COPD Prevention

COPD Early Diagnosis

COPD Care Acces

Quality of Life with COPD

Digital Health for COPD

The Impact of COVID-19 on COPD Care

Recommendations