Smoking cessation is the most important factor in preventing COPD, as well as the cornerstone of COPD treatment to prevent exacerbations and progressive loss of pulmonary function (Man et al., 2003). The decline in pulmonary function as measured by FEVj can be halved (from 60 to 30 mL/ year) if COPD patients quit smoking (Anthonisen et al., 1994). Avoidance of secondary exposure to smoke, especially in the household, is also important. Physician advice to quit smoking alone has some impact, and combined interventions (counseling plus education or group strategies plus pharmacologic treatment with nicotine, bupropion) can achieve at least 25% long-term quit rates even in COPD patients. Use of spirometry for screening and early diagnosis of COPD to enhance smoking cessation interventions among smokers has not been shown to increase smoking cessation rates or other clinical outcomes.

Influenza vaccine should be administered every year; it can reduce hospitalizations and deaths from pneumonia, cardiovascular disease, and all causes by 30% to 40% (Govaert et al, 1994; Nichol et al, 2003). Pneumococcal vaccine is also indicated in all patients with COPD, and patients should be revaccinated after 10 years if the first pneumococcal vaccine was administered before age 65 years. Vaccination rates are increasing nationwide, but they are still significantly lower among the uninsured and among racial and ethnic minority populations (CDC, 2003b). Family physicians can improve vaccination rates in their own practice by establishing standing orders for influenza and pneumococcal vaccination (CDC, 2003c; 2009).

One critical role for the family physician in the chronic management of COPD is to facilitate open discussions with the patient and family members about end-of-life issues such as therapy during acute exacerbations. Although this has become routine in the management of cancer patients, the 5-year survival of patients with severe stages of COPD (as well as heart failure and other chronic organ failure) is often worse than that of many cancers. Many patients have a strong desire to avoid mechanical ventilation, only to end up intubated, unconscious, and having difficulty being weaned from the ventilator. Often, family members are asked to assist in end-of-life decision making when complications occur during a protracted downturn in the course of COPD, even though they have not previously discussed such issues with the patient. Facilitating such family discussions, providing templates for living wills and health care power of attorney forms, and referring for legal or psychological or pastoral counseling can dramatically ease a family's confusion and pain during these episodes and ultimately in dealing with the patient's death.

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