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The prevalence of respiratory symptoms and the smoking habits of 224 industrial `executives' aged 30 to 69 years in Social Classes I and II were ascertained by means of the Medical Research Council's questionnaire on respiratory symptoms; 31% had persistent cough, 25% had persistent phlegm, and 21% were short of breath on hurrying or going up a hill; 9% had had one or more chest illnesses in the past three years lasting for about a week, and 4% had `chronic bronchitis'—defined as persistent phlegm and one or more chest illnesses in the past three years; 67% were smokers, 21% smoking more than 25 cigarettes (or equivalent tobacco) per day; another 20% had stopped smoking. The prevalence of cough, phlegm, and breathlessness was closely related to smoking habit.
Data for those aged 40 to 59 years are compared with that obtained from London Transport Board workers and a sample of the population studied by the College of General Practitioners. The latter was further analysed and suggests that the prevalence of cough and phlegm is more closely related to the amount smoked than to social class. The prevalence of chest illness is probably more closely related to social class and less to the amount smoked. It is suggested that, although smoking may initiate irritative respiratory symptoms, the precursors of bronchitis, additional factors are important in causing progression to disabling or fatal chronic bronchitis.
PMCID: PMC1008262  PMID: 14278803
2.  A community survey of respiratory disease among East Indian and African adults in Guyana 
Thorax  1971;26(3):331-338.
The belief that chronic bronchitis is more prevalent among Indians than Africans in the Caribbean area was investigated by a community survey in Guyana. Respiratory symptoms were assessed by a standard questionnaire, ventilatory capacities were measured, and chest radiographs were taken of some 800 African and Indian men and women aged 35 to 54 years living in adjacent and similar communities. Histories of morning cough, chronic cough, morning phlegm, and chronic phlegm (chronic bronchitis) were more common in Indians than Africans. Although these respiratory symptoms were much more common in smokers than non-smokers, the higher prevalence rates in Indians could not be explained by smoking habits which were similar in the two races. Chronic bronchitis occurred in 17·3% of Indian and 2·4% of African male smokers and in 16·1% and 2·2% of Indian and African female non-smokers respectively. Judging by the history, lung function, and clinical signs, chronic bronchitis was more severe in Indians than Africans. The condition was more common among field labourers on sugar estates but, although the majority of field labourers were Indian, this occupational difference only partially explained the difference in prevalence between Indians and Africans. Indians, for reasons unknown, appear to have a greater susceptibility than Africans to chronic bronchitis.
PMCID: PMC1019092  PMID: 5089501
3.  Childhood exposure to environmental tobacco smoke and chronic respiratory symptoms in non-smoking adults: The Singapore Chinese Health Study 
Thorax  2005;60(12):1052-1058.
Background: Childhood exposure to environmental tobacco smoke has been extensively associated with childhood respiratory illness; fewer studies have addressed the effects on adults.
Methods: Childhood environmental tobacco smoke exposure in relation to chronic cough, phlegm, and asthma diagnosis was studied in never smokers from a cohort of Singaporeans of Chinese ethnicity aged 45–74 years at enrolment from 1993 to 1998. From 1999 to 2004 subjects were interviewed regarding environmental tobacco smoke exposure before and after the age of 18 and the presence and duration of current symptoms of chronic cough and phlegm production and asthma diagnosis.
Results: Among 35 000 never smokers, fewer had smoking mothers (19%) than fathers (48%). Although few subjects currently lived (20%) or worked (4%) with smokers, 65% reported living with a daily smoker before the age of 18 years. Living with a smoker before the age of 18 increased the odds of chronic dry cough (149 cases, odds ratio 2.1, 95% CI 1.4 to 3.3) and, to a lesser extent, phlegm, after adjustment for age, sex, dialect group, and current and past exposure to smokers at home and at work after the age of 18. Associations strengthened with higher numbers of smokers in childhood. There was no association with asthma or chronic bronchitis. There was evidence to suggest a stronger association among subjects with a lower adult intake of fibre which has previously been found to be protective for respiratory symptoms.
Conclusions: In this large study of non-smokers, living with a smoker in childhood was associated with chronic dry cough and phlegm in adulthood, independent of later exposures to environmental tobacco smoke.
PMCID: PMC1414787  PMID: 16131525
4.  Childhood exposure to environmental tobacco smoke and chronic respiratory symptoms in nonsmoking adults: The Singapore Chinese Health Study 
Thorax  2005;60(12):1052-1058.
Childhood exposure to environmental tobacco smoke has been extensively associated with childhood respiratory illness; fewer data address adult effects.
We examined childhood environmental tobacco smoke exposure in relation to chronic cough, phlegm and asthma diagnosis among never smokers from a cohort of Singaporeans of Chinese ethnicity, aged 45–74 at enrollment from 1993 to 1998. From 1999 to 2004, subjects were interviewed regarding environmental tobacco smoke exposure before and after age 18 and the presence and duration of current symptoms of chronic cough and phlegm production and asthma diagnosis.
Among 35,000 never smokers, fewer had smoking mothers (19%) than fathers (48%). Although few subjects currently lived (20%) or worked (4%) with smokers, 65% reported living with a daily smoker before age 18 years. Living with a smoker before age 18 increased the odds of chronic dry cough (149 cases, OR = 2.1, 95% CI 1.4–3.3) and, to a lesser extent, phlegm, after adjustment for age, gender, dialect group and current and past exposure to smokers at home and at work after age 18. Associations strengthened with higher numbers of smokers in childhood. There was no association with asthma or chronic bronchitis. We found suggestive evidence of a stronger association among subjects with lower adult intake of fiber, which we previously found to be protective for respiratory symptoms.
In this large study of nonsmokers, living with a smoker in childhood was associated with chronic dry cough and phlegm in adulthood, independently of later exposures to environmental tobacco smoke.
PMCID: PMC1414787  PMID: 16131525
Tobacco smoke pollution; asthma; Signs and Symptoms; Respiratory; Bronchitis; chronic; Dietary Fiber
5.  Respiratory symptoms as predictors of 27 year mortality in a representative sample of British adults. 
BMJ : British Medical Journal  1989;299(6695):357-361.
OBJECTIVE--To examine associations between reported respiratory symptoms (as elicited by questionnaire) and subsequent mortality. DESIGN--Prospective cohort study. SETTING--92 General practices in Great Britain. PARTICIPANTS--A nationally representative sample of 1532 British men and women aged between 40 and 64. MAIN OUTCOME MEASURES--Mortality from all causes, cardiovascular disease, lung cancer, and chronic bronchitis. RESULTS--Subjects were interviewed in 1958 regarding various respiratory symptoms (including cough, phlegm, breathlessness, and wheeze) by using a questionnaire which formed the basis of the Medical Research Council's questionnaire on respiratory symptoms. By the end of 1985, 889 deaths had been reported, including 51 in men due to chronic bronchitis. After adjustment for differences in age and smoking habits death rates from chronic bronchitis in men who reported symptoms were greater than those in men who did not for each of the symptoms examined. The adjusted mortality ratios were 3.4 (95% confidence interval 1.8 to 6.5) for morning cough, 3.7 (2.0 to 6.9) for morning phlegm, 6.4 (3.0 to 13.8) for breathlessness when walking on the level, and 10.5 (4.4 to 24.6) for wheeze most days or nights. Mortality ratios were also significantly raised for four episodic symptoms not usually included in more recent respiratory symptom questionnaires--namely, occasional wheeze (mortality ratio 6.0; 95% confidence interval, 2.4 to 15.1), weather affects chest (5.7; 3.1 to 10.3), breathing different in summer (4.9; 2.8 to 8.6), and cold usually goes to chest (3.7; 2.0 to 6.8). The excess mortality associated with these symptoms remained significant after further adjustment for breathlessness or phlegm. Ratios for all cause mortality in men and women were also significantly raised for most respiratory symptoms, death rates being some 20-50% higher in people reporting symptoms after adjustment for age, sex, and smoking. Breathlessness was the only symptom significantly associated with excess mortality from cardiovascular disease (mortality ratio 1.4 (95% confidence interval 1.0 to 1.9) for breathlessness when walking on the level). Ratios were generally around unity and not significant for mortality due to lung cancer. CONCLUSIONS--The results suggest that episodic symptoms, which often do not appear in standard respiratory questionnaires, predict subsequent mortality from chronic obstructive airways disease. This supports the hypothesis that reversible airflow obstruction may be a precursor of progressive and irreversible decline in ventilatory function.
PMCID: PMC1837252  PMID: 2506967
6.  Chronic productive cough in school children: prevalence and associations with asthma and environmental tobacco smoke exposure 
The relationships between chronic productive cough (CPC), environmental tobacco smoke (ETS) exposure, and asthma are not clearly established in children. Therefore, we wished to determine the prevalence of CPC and examine the relationships between CPC, ETS exposure, and asthma in young teenagers.
We performed a cross sectional survey of 2397 Seattle middle school students, 11–15 years old, using written and video respiratory-symptom questionnaires. We defined CPC as – daily cough productive of phlegm for at least 3 months out of the year; current asthma as – yes to "Have you had wheezing or whistling in your chest in the past 12 months?" and yes in the past year to any of the four video wheezing/asthma video scenarios; and ETS exposure as exposed to tobacco smoke at least several hours each day. We used multilogistic regression to examine relationships between CPC, asthma, and ETS exposure and included in the model the potentially confounding variables race, gender, and allergic rhinitis.
The prevalence of CPC was 7.2%. Forty-seven percent (82/173) of children with CPC met criteria for current asthma, while only 10% (214/2224) of those without CPC had current asthma. Current asthma had the strongest associated with CPC, odds ratio (OR) 6.4 [95% CI 4.5–9.0], and ETS was independently associated with both CPC, OR 2.7 [1.8–4.1] and asthma, OR 2.7 [1.5–4.7].
In a population of young teenagers, CPC was strongly associated with report of current asthma symptoms and also with ETS exposure. This suggests that asthma and ETS exposure may contribute to CPC in children. However, this study was not designed to determine whether asthma was the actual cause of CPC in this population of children.
PMCID: PMC1770929  PMID: 17192188
7.  Air pollution and bronchitic symptoms in Southern California children with asthma. 
Environmental Health Perspectives  1999;107(9):757-760.
The association of air pollution with the prevalence of chronic lower respiratory tract symptoms among children with a history of asthma or related symptoms was examined in a cross-sectional study. Parents of a total of 3,676 fourth, seventh, and tenth graders from classrooms in 12 communities in Southern California completed questionnaires that characterized the children's histories of respiratory illness and associated risk factors. The prevalences of bronchitis, chronic phlegm, and chronic cough were investigated among children with a history of asthma, wheeze without diagnosed asthma, and neither wheeze nor asthma. Average ambient annual exposure to ozone, particulate matter (PM(10) and PM(2.5); [less than/equal to] 10 microm and < 2.5 microm in aerodynamic diameter, respectively), acid vapor, and nitrogen dioxide (NO(2)) was estimated from monitoring stations in each community. Positive associations between air pollution and bronchitis and phlegm were observed only among children with asthma. As PM(10) increased across communities, there was a corresponding increase in the risk per interquartile range of bronchitis [odds ratio (OR) 1.4/19 microg/m(3); 95% confidence interval (CI), 1.1-1.8). Increased prevalence of phlegm was significantly associated with increasing exposure to all ambient pollutants except ozone. The strongest association was for NO(2), based on relative risk per interquartile range in the 12 communities (OR 2.7/24 ppb; CI, 1.4-5.3). The results suggest that children with a prior diagnosis of asthma are more likely to develop persistent lower respiratory tract symptoms when exposed to air pollution in Southern California.
PMCID: PMC1566453  PMID: 10464077
8.  Prevalence of chronic cough and phlegm among male cigar and pipe smokers: results of the Scottish Heart Health Study. 
Thorax  1993;48(11):1163-1167.
BACKGROUND--Previous studies investigating the effect of cigar or pipe smoking on the occurrence of chronic cough and chronic phlegm have reported prevalences among cigar and pipe smokers lying between those of non-smokers and current cigarette smokers. This study uses data on previous cigarette consumption, current cigar or pipe consumption, and biochemical markers of smoking to provide a detailed analysis of chronic cough and chronic phlegm among cigar and pipe smokers. METHODS--A total of 10,359 men and women aged 40-59 years were sampled for the Scottish Heart Health Study between 1984 and 1986. Prevalence of chronic cough and chronic phlegm among male cigar and pipe smokers (non-cigarette smokers) was compared with those who had never smoked, between ex-smokers of cigarettes and those who had never smoked cigarettes, between cigar-only and pipe-only smokers, and by cigar or pipe consumption levels. RESULTS--In all, 463 ex-smokers of cigarettes and 154 who had never smoked cigarettes were cigar or pipe smokers; 1080 had never smoked any form of tobacco. Ex-cigarette smokers smoked and inhaled more than those who had never smoked cigarettes. Among the ex-cigarette smokers, cigar or pipe smokers had 1.63-1.71 times the prevalence of both chronic cough and chronic phlegm than those who had never smoked (1.31-1.36 among cigar only smokers; 2.23-2.84 among pipe only smokers). A strong positive dose-response effect was found between the prevalence of symptoms and cigar or pipe consumption. CONCLUSIONS--Cigar and pipe smokers have a higher prevalence of chronic cough and phlegm than those who have never smoked, and the difference is more marked in pipe-only smokers than in cigar-only smokers. Both categories show a positive dose-response effect. Among cigar and pipe smokers, ex-cigarette smokers have a higher prevalence of symptoms than those who have never smoked cigarettes, which may be because they inhale more or may be attributable to previous cigarette smoking.
PMCID: PMC464910  PMID: 8296263
9.  Mutually exclusive groups of bronchitics and non-bronchitics in males 
Seven mutually exclusive groups of non-bronchitics and chronic bronchitics are derived from 10,816 steel workers questioned and examined at Port Talbot. These groups are based on various combinations of responses to the Medical Research Council questionnaire on cough, phlegm, dyspnoea, increased cough and phlegm, and chest illness. The groups are formed on defined criteria of (1) a reasonable number of men in each group; (2) impairment of lung function (FEV1) related to the severity of chronic bronchitis symptoms; and (3) impairment of lung function from certain other diseases.
The ideal group of non-bronchitics (NB 0) answered `no' to every symptomatology question (46·4%). Non-bronchitics grade 1 (NB 1) were either symptom-free or had only occasional cough and phlegm with either or both increased cough and phlegm and chest illness (24·2%). Non-bronchitics grade 2 (NB 2) complained of dyspnoea in the absence of persistent cough and phlegm (4·3%). Chronic bronchitics grade 1 (CB 1) had persistent cough and phlegm in the absence of any other complaint (11·3%). Chronic bronchitics grade 2 (CB 2) had the additional impairment of increased cough and phlegm and/or chest illness (8·1%). Grade 3 (CB 3) complained of dyspnoea with or without increased cough and phlegm (2·5%). Grade 4 (CB 4) had both dyspnoea and chest illness (3·2%).
Lung function (FEV1) in three of the groups of chronic bronchitics (CB 1, CB 2, CB 3: 21·9%) was no worse than in the two groups of non-bronchitics with complaints of other respiratory disorders (NB 1, NB 2: 28·6%). An overall comparison on a binary division between non-bronchitics and bronchitics hides the severity of some of the bronchitic groups. For this reason it is recommended that epidemiological studies of chronic bronchitis should separate the suggested grades of bronchitics (CB 1, 2, 3, and 4) and compare them with the ideal group of non-bronchitics (NB 0: 46·4%) which has the lowest prevalence of heart trouble and asthma and those who have had pneumonia.
PMCID: PMC478855  PMID: 4414747
10.  Respiratory symptoms and impairment in shipyard welders and caulker/burners. 
All 607 men, aged 17 to 69, comprising a stratified sample of workers from one shipyard completed a respiratory questionnaire, clinical examination, and detailed spirometry. Chest radiographs were available on 332 men. Among the men aged 50-69 the prevalence of persistent cough and phlegm (chronic bronchitis) was 40%, of wheeze on most days 25%, and undue breathlessness on exertion 25%. After allowing for age the relative risk of welders and caulker/burners having these symptoms were respectively 2.8, 2.2, and 3.1 compared with other shipyard tradesmen. The effects were of comparable magnitude to and interacted with those of current smoking. Among the welders and caulker/burners who smoked, the relative risk of developing chronic bronchitis or undue breathlessness was related to the average fume exposure; the relative risk of wheeze was related to the average fume exposure in all smoking categories, with the strongest association in the ex-smokers. The occurrence of wheeze was also associated with a history of previous metal fume fever. A history of pleurisy but not of pneumonia was related to the fume exposure in the welders. After allowing for age and stature, forced expiratory volume (FEV1) was on average higher in young welders (age less than 30) than other tradesmen. In welders and caulker/burners who were current or ex-smokers, FEV1 and PEF were reduced in relation to the average fume exposure (mean reductions respectively 0.25 l and 0.99 l s-1). The FEV1% (of forced vital capacity), the flow rates at small lung volumes (MEF50%FVC and MEF25%FVC), the mean transit time, and its standard deviation were also reduced by fume exposure or the declines with age were increased, or both. No impairment was demonstrable in the non-smokers and many men had given up smoking with apparently beneficial results. The occupational component of the respiratory impairment related mainly to exposures in the past; information was needed on the effects of present conditions in the industry.
PMCID: PMC1009771  PMID: 2751927
11.  Cigarette tar content and symptoms of chronic bronchitis: results of the Scottish Heart Health Study. 
STUDY OBJECTIVE--The aim was to determine if there was a relationship between cigarette tar yield and rates of chronic cough and chronic phlegm. SETTING--22 districts across Scotland were used for the Scottish Heart Health Study (SHHS) which was conducted between 1984 and 1986 and from which the data for this analysis were obtained. SUBJECTS--10,359 men and women aged 40-59 years were studied. Of these, 2801 current cigarette smokers whose brand of cigarette smoked was known were selected. MEASUREMENTS AND MAIN RESULTS--Data on self reported smoking habits and prevalence of chronic cough and chronic phlegm were obtained from the SHHS. Tar yield was divided into three groups: low (less than or equal to 12 mg/cigarette); middle (13-14 mg/cigarette); high (greater than or equal to 15 mg/cigarette). The average tar yield consumed per person was 13.2 mg/cigarette. Women in the middle and high tar groups had smoked for longer and had significantly higher breath carbon monoxide levels, serum thiocyanate levels, serum cotinine levels, and daily cigarette consumption than the women in the low tar group. This pattern was not seen in men for any of these five smoking variables. Rates of chronic cough and chronic phlegm were higher with higher tar yield of cigarettes smoked for women (low tar v high tar: p less than 0.001) but not for men. Daily cigarette consumption and the number of years of smoking were the most significant risk factors for chronic cough and chronic phlegm for both men and women. Tar was still a significant risk factor (p less than 0.05) for women after controlling for these two risk factors and social class. CONCLUSIONS--Both sexes show strong effects of daily cigarette consumption and years of smoking on respiratory symptoms; women show an additional effect of cigarette tar content while men do not. The spread of tar yield in both sexes was small but there were more women on low tar cigarettes and this may have enabled a weak effect of tar to be seen better in them. On the other hand, tar level in women was confounded with other factors. Statistical methods of controlling for this may not have removed this confounding completely.
PMCID: PMC1059462  PMID: 1795148
12.  Passive smoking and chronic obstructive pulmonary disease: cross-sectional analysis of data from the Health Survey for England 
BMJ Open  2011;1(2):e000153.
There is increasing evidence that passive smoking is associated with chronic respiratory diseases, but its association with chronic obstructive pulmonary disease (COPD) requires more study. In this cross-sectional analysis of data from 3 years of the Health Survey for England, the association between passive smoking exposure and risk of COPD is evaluated.
Cross-sectional analysis of the 1995, 1996 and 2001 Health Surveys for England including participants of white ethnicity, aged 40+ years with valid lung function data. COPD was defined using the lower limit of normal spirometric criteria for airflow obstruction. Standardised questions elicited self-reported information on demography, smoking history, ethnicity, occupation, asthma and respiratory symptoms (dyspnoea, chronic cough, chronic phlegm, wheeze). Passive smoking was measured by self-report of hours of exposure to cigarette smoke per week.
Increasing passive smoke exposure was independently associated with increased risk of COPD, with adjusted OR 1.05 (95% CI 0.93 to 1.18) for 1–19 h and OR 1.18 (95% CI 1.01 to 1.39) for 20 or more hours of exposure per week. Similar patterns (although attenuated and non-significant) were observed among never smokers. More marked dose–response relationships were observed between passive smoking exposure and respiratory symptoms, but the most marked effects were on the development of clinically significant COPD (airflow obstruction plus symptoms), where the risk among never smokers was doubled (OR 1.98 (95% CI 1.03 to 3.79)) if exposure exceeded 20 h/week.
This analysis adds weight to the evidence suggesting an association between passive smoking exposure and COPD.
Article summary
Article focus
Passive exposure to cigarette smoke is established as an important independent risk factor for the development of chronic conditions such as heart disease and lung cancer.
Although there is growing evidence implicating passive smoking in asthma and other respiratory diseases, the evidence for its effect on chronic obstructive pulmonary disease (COPD) is inconsistent.
Using cross-sectional data from the annual Health Survey for England, we examined the association between self-reported exposure to passive smoking and COPD.
Key messages
We have demonstrated a significant dose–response relationship between hours of exposure to passive smoking and increasing risk of COPD.
The most marked effects were observed on the development of clinically significant COPD (airflow obstruction plus symptoms), where the risk among never smokers was doubled (OR 1.98 (95% CI 1.03 to 3.79)) if exposure exceeded 20 h/week.
Passive smoking is prevalent worldwide, and even after the 2007 public smoking ban in the UK, 20% of the adult English population are still exposed to up to 20 h of passive smoking per week, with 5% exposed to more than 20 h/week; further measures are needed to investigate and reduce exposures in the home and elsewhere.
Strengths and limitations of this study
Our study has the advantage of being a large sample representative of the English population (>21 000 participants), conducted over 3 separate years, with a standardised protocol and objective measure of lung function.
However, due to the cross-sectional nature of the design, temporal associations cannot necessarily be inferred.
The Health Survey for England was not designed for the specific analyses presented in this paper, and thus some of the measures are crude.
Self-reported passive smoke exposure is only a proxy for true exposure levels, but is accepted as the most practical method of assessment.
PMCID: PMC3191589  PMID: 22021874
13.  The impact of quitting smoking on symptoms of chronic bronchitis: results of the Scottish Heart Health Study. 
Thorax  1991;46(2):112-116.
Scotland has high rates of death from diseases of the respiratory system and high rates of smoking, especially among women. Data on self reported smoking and prevalence of chronic cough and chronic phlegm among 10,359 men and women aged 40-59 years were obtained from the Scottish Heart Health Study. Overall, current cigarette smokers had rates of chronic cough and chronic phlegm four to five times those of never smokers after standardisation for age (32.3% v 6.5% for men and 24% v 5.5% for women for chronic cough; 31% v 8.3% for men and 21% v 5.5% for women for chronic phlegm). Ex-smokers' symptom rates were a little above those of never smokers and were significant for chronic cough among women and chronic phlegm among men. Men had higher symptom rates than women and this was true for smokers, ex-smokers, and never smokers. The higher rates among men could not be explained by higher cotinine concentrations. Tests to detect "deceivers" among ex-smokers and never smokers using biochemical validation suggested that 87 (1.5%) respondents were in fact smoking; they were excluded from analyses. There were substantially lower rates of chronic cough and chronic phlegm within a year of stopping smoking, and two to four years after stopping 89-99% of the difference between current smokers and never smokers was accounted for (99% and 93% for men and women with chronic cough, 96% and 89% for men and women with chronic phlegm). Even 10 years after stopping, rates of symptoms among ex-smokers remained a little above those of never smokers (except for women with chronic phlegm), though these differences were not statistically significant. Former heavy smokers continued to have rates of chronic cough and chronic phlegm that were higher than those of former light and moderate smokers (though not significantly so). These are cross sectional data, but they emphasise the importance for chronic bronchitis symptoms of giving up cigarette smoking, though the amount previously smoked continues to exert a small influence.
PMCID: PMC462964  PMID: 2014491
14.  Passive cigarette smoke, coal heating, and respiratory symptoms of nonsmoking women in China. 
Environmental Health Perspectives  1993;101(4):314-316.
In this study we evaluated data from a sample of 973 never-smoking women, ages 20-40, who worked in three similar textile mills in Anhui Province, China. We compared prevalence rates of respiratory symptoms across homes with and without coal heating and homes with different numbers of smokers. Multiple logistic regression models that controlled for age, job title, and mill of employment were also estimated. Respiratory symptoms were associated with combined exposure to passive cigarette smoke and coal heating. Effects of passive cigarette smoke and coal heating on respiratory symptoms appeared to be nearly additive, suggesting a dose-response relationship between respiratory symptoms and home indoor air pollution from these two sources. The prevalence of chest illness, cough, phlegm, and shortness of breath (but not wheeze) was significantly elevated for women living in homes with both smokers and coal heating.
PMCID: PMC1519818  PMID: 8275988
15.  Study of the aetiology of wheezing illness at age 16 in two national British birth cohorts. 
Thorax  1996;51(7):670-676.
BACKGROUND: Data from two national British birth cohorts were used to measure the increase in prevalence of wheezing illness at age 16 between 1974 and 1986, and to investigate the role of several potential risk factors in the increase. METHODS: The occurrence of self-reported asthma or wheezy bronchitis within the past year, and the frequency of attacks of wheezing illness at age 16, were compared in 11,262 and 9266 children born in one week of 1958 and 1970, respectively. The effects of several putative risk factors for asthma--including birth weight, maternal age, birth order, breast feeding, maternal smoking in pregnancy, child's personal smoking, and father's social class--on the change in occurrence of wheezing illness at age 16 were assessed by multiple logistic regression. RESULTS: The annual period prevalence of asthma or wheezy bronchitis at age 16 increased from 3.8% in 1974 to 6.5% in 1986 (prevalence ratio (PR) = 1.71, 95% CI 1.52 to 1.93). The proportion of children experiencing attacks more than once a week increased from 0.2% to 0.7% (PR = 3.77, 95% CI 2.28 to 6.23). The prevalence of self-reported eczema and hayfever within the past year doubled between 1974 and 1986, suggesting that the increase in asthma was part of a general increase in the prevalence of atopic disease. However, in the complete dataset, after adjustment for the effects of the risk factors studied, the prevalence odds ratio for asthma or wheezy bronchitis in 1986 compared with 1974 was virtually unchanged from the unadjusted value at 1.77 (95% CI 1.46 to 2.15). CONCLUSION: The prevalence of wheezing illness in British teenagers increased by approximately 70% between 1974 and 1986. This increase appears to have occurred in the context of a general increase in atopic disease and was largely unexplained by changes in the distribution of maternal age, birth order, birth weight, infant feeding, maternal smoking, active smoking by the child, or father's social class.
PMCID: PMC472487  PMID: 8882071
16.  Influence of family factors on the incidence of lower respiratory illness during the first year of life. 
In a study of a cohort of over 2000 children born between 1963 and 1965, the incidence of bronchitis and pneumonia during their first year of life was found to be associated with several family factors. The most important determinant of respiratory illness in these infants was an attack of bronchitis or pneumonia in a sibling. The age of these siblings, and their number, also contributed to this incidence. Parental respiratory symptoms, including persistent cough and phlegm, and asthma or wheezing, as well as parental smoking habits, had lesser but nevertheless important effects. Parental smoking, however, stands out from all other factors as the one most amenable to change in seeking to prevent bronchitis and pneumonia in infants.
PMCID: PMC478967  PMID: 1009269
17.  Respiratory symptoms and ventilatory capacity in swine confinement workers. 
A group of 59 workers (41 men and 18 women) employed in swine confinement areas was studied to assess the presence of acute and chronic respiratory symptoms and the prevalence of abnormalities in ventilatory function. A control group of 46 (31 men and 15 women) unexposed workers was studied for the prevalence of chronic respiratory symptoms. For both male and female swine confinement workers complaints of chronic cough, dyspnoea, and chest tightness were significantly more frequent than among control workers. Male workers also complained more of chronic phlegm. Male swine confinement workers who were smokers had significantly higher prevalences of chronic cough, chronic phlegm, and chronic bronchitis than male non-smoking swine confinement workers. The frequency of acute symptoms associated with the workshift was high among the swine confinement workers with more than half of the workers complaining of cough and dyspnoea associated with work. Significant acute across shift reductions in lung function occurred in swine confinement workers, being largest for FEF25. All Monday preshift ventilatory capacity measurements in male confinement workers were significantly lower than predicted values; FVC and FEV1 were found to be lower than predicted values for women. The data indicate that exposure in swine confinement buildings is associated with the development of acute and chronic respiratory symptoms and impairment of lung function. Smoking appears to aggravate these changes.
PMCID: PMC1012126  PMID: 1606030
18.  Occupation and three-year incidence of respiratory symptoms and lung function decline: the ARIC Study 
Respiratory Research  2012;13(1):24.
Specific occupations are associated with adverse respiratory health. Inhalation exposures encountered in these jobs may place workers at risk of new-onset respiratory disease.
We analyzed data from 8,967 participants from the Atherosclerosis Risk in Communities (ARIC) study, a longitudinal cohort study. Participants included in this analysis were free of chronic cough and phlegm, wheezing, asthma, chronic bronchitis, emphysema, and other chronic lung conditions at the baseline examination, when they were aged 45-64 years. Using data collected in the baseline and first follow-up examination, we evaluated associations between occupation and the three-year incidence of cough, phlegm, wheezing, and airway obstruction and changes in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) measured by spirometry. All associations were adjusted for age, cigarettes per day, race, smoking status, and study center.
During the approximately three-year follow-up, the percentage of participants developing chronic cough was 3%; chronic phlegm, 3%; wheezing, 3%; and airway obstruction, defined as FEV1 < lower limit of normal (LLN) and FEV1/FVC < LLN, 2%. The average annual declines in FEV1 and FVC were 56 mL and 66 mL, respectively, among men and 40 mL and 52 mL, respectively, among women. Relative to a referent category of managerial and administrative support occupations, elevated risks of new-onset chronic cough and chronic phlegm were observed for mechanics and repairers (chronic cough: RR: 1.81, 95% CI: 1.02, 3.21; chronic phlegm: RR: 2.10, 95% CI: 1.23, 3.57) and cleaning and building service workers (chronic cough: RR: 1.85, 95% CI: 1.01, 3.37; chronic phlegm: RR: 2.28, 95% CI: 1.27, 4.08). Despite the elevated risk of new-onset symptoms, employment in cleaning and building services was associated with attenuated lung function decline, particularly among men, who averaged annual declines in FEV1 and FVC of 14 mL and 23 mL, respectively, less than the declines observed in the referent population.
Employment in mechanic and repair jobs and cleaning and building service occupations are associated with increased incidence of respiratory symptoms. Specific occupations affect the respiratory health of adults without pre-existing respiratory health symptoms and conditions, though long-term health consequences of inhalation exposures in these jobs remain largely unexplored.
PMCID: PMC3352304  PMID: 22433119
ARIC study; epidemiology; occupation; respiratory tract disease
19.  Outcome of children of parents with atopic asthma and transient childhood wheezy bronchitis 
Thorax  1997;52(11):953-957.
BACKGROUND: Childhood asthma and wheeze only in the presence of respiratory infection (wheezy bronchitis) appear to have different prognoses and may differ in their aetiology and heritability. In particular, slight reductions in lung function may be associated with episodes of wheezing associated with intercurrent viral infection. METHODS: Outcomes for wheezing symptoms and lung function were studied in 133 offspring of three distinct groups of 69 middle aged probands with childhood histories of (1) atopic asthma (n = 18), (2) wheeze associated with upper respiratory tract infection (wheezy bronchitis, n = 24), and (3) no symptoms (n = 27). Probands were selected from a previously studied cohort in which outcomes of wheezy bronchitis and asthma had been shown to differ. RESULTS: Children of probands with wheezy bronchitis had a lower prevalence of current wheezing symptoms. Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) in boys of probands with a history of wheezy bronchitis were significantly reduced compared with either of the other two groups (p < 0.0001). In a multivariate analysis, grouping based on parent proband had a significant effect on lung function, independent of factors such as symptoms, atopy or smoking history. CONCLUSIONS: The different symptomatic and lung function outcome in children of probands with wheezy bronchitis and asthma provides further evidence that wheezy bronchitis and asthma differ in their natural history and heritability, and suggests that there may be familial factors specific to each wheezing syndrome. 

PMCID: PMC1758443  PMID: 9487342
20.  The nature and causes of chronic obstructive pulmonary disease: A historical perspective 
Chronic obstructive pulmonary disease (COPD) is the currently favoured name for the diseases formerly known as emphysema and bronchitis. COPD has been recognized for more than 200 years. Its cardinal symptoms are cough, phlegm and dyspnea, and its pathology is characterized by enlarged airspaces and obstructed airways. In the 19th century, the diagnosis of COPD depended on its symptoms and signs of a hyperinflated chest, and reduced expiratory breath sounds. The airflow obstruction evident on spirometry was identified in that century, but did not enter into clinical practice. Bronchitis, and the mechanical forces required to overcome its obstruction, was believed to be responsible for emphysema, although the inflammation present was recognized. The causes of bronchitis, and hence emphysema, included atmospheric and domestic air pollution, as well as dusty occupations. Cigarette smoking only became recognized as the dominant cause in the 20th century. The lessons learned of the risks for COPD in 19th-century Britain are very pertinent to the world today.
PMCID: PMC2687842  PMID: 19262908
Bronchitis; COPD; Cotton; Emphysema; Pollution; Tobacco
21.  Interaction of atopy and smoking on respiratory effects of occupational dust exposure: a general population-based study 
For individual exposures, effect modification by atopy or smoking has been reported on the occurrence of occupational airway disease. It is unclear if effect modification can be studied in a general population by an aggregated exposure measure. Assess relationship between airway obstruction and occupational exposure using a job-exposure-matrix (JEM) classifying jobs into 3 broad types of exposure, and test for effect modification by atopy, and smoking.
Data from 1,906 subjects were analyzed, all participants of the European Community Respiratory Health Survey. Job titles were categorized by an a priori constructed job exposure matrix into three classes of exposure to respectively organic dust, mineral dust, and gases/ fumes. Relationships were assessed for 'current wheeze', bronchial hyperresponsiveness (BHR), 'current asthma' (wheeze+BHR), and 'chronic bronchitis' (morning phlegm or morning cough), and lung function.
Subjects with organic dust exposure in their work environment more frequently had 'current asthma' (OR 1.48, 95% C.I. 0.95;2.30), and a lower FEV1 (-59 mL, 95% C.I. -114;-4). The relationship was only present in asthmatic workers, and their risk was four-fold greater than in subjects with either atopy or exposure alone. Mineral dust exposure was associated with 'chronic bronchitis' (OR 2.22, 95% C.I. 1.16;4.23) and a lower FEV1/FVC ratio (-1.1%, 95% C.I. -1.8;-0.3). We observed an excess risk in smokers, greater than the separate effects of smoking or mineral dust exposure together.
Occupational exposure to organic dust is associated with an increased risk of asthma, particularly in atopics. Chronic bronchitis occurs more frequently among individuals exposed to mineral dust, and smoking doubles this risk.
PMCID: PMC443511  PMID: 15175108
22.  Health effects of passive smoking. 3. Parental smoking and prevalence of respiratory symptoms and asthma in school age children 
Thorax  1997;52(12):1081-1094.
BACKGROUND: A systematic quantitative review of the evidence relating parental smoking to the prevalence of asthma and respiratory symptoms was conducted amongst school age children. METHODS: Sixty relevant studies were identified after consideration of 1593 articles selected by electronic search of the Embase and Medline databases using keywords relevant to passive smoking in children. The search was completed in April 1997 and identified 25 studies of asthma, 41 of wheeze, 34 of chronic cough, seven of chronic phlegm and six of breathlessness which were included in a quantitative overview. RESULTS: The pooled odds ratios for either parent smoking were 1.21 (95% CI 1.10 to 1.34) for asthma, 1.24 (95% CI 1.17 to 1.31) for wheeze, 1.40 (95% CI 1.27 to 1.53) for cough, 1.35 (95% CI 1.13 to 1.62) for phlegm, and 1.31 (95% CI 1.08 to 1.59) for breathlessness. Adjustment for confounding had little effect. Evidence of heterogeneity between studies appeared largely explicable by publication bias with a superfluity of small studies with large odds ratios. However, excluding these had little effect on the pooled odds ratios. The prevalence of all symptoms increased with the number of parents who smoked. While maternal smoking had a greater effect than paternal smoking, the effect of father only was clearly significant. CONCLUSIONS: The relationship between parental smoking and respiratory symptoms seems very likely to be causal given statistical significance, robustness to adjustment for confounding factors, consistency of the findings in different countries, and evidence of dose response. The raised risk in households where the father, but not the mother, smoked argues for a postnatal effect. 

PMCID: PMC1758471  PMID: 9516904
23.  Predictors of respiratory symptoms in a rural Canadian population: A longitudinal study of respiratory health 
Predictors of new and long-term respiratory symptoms for rural residents are not well defined.
To identify early predictors of respiratory symptoms in a rural community population.
The study population consisted of 871 adults living in the rural community of Humboldt, Saskatchewan, who participated in two cross-sectional respiratory studies conducted in 1993 and 2003. Questionnaire information obtained at both time points included respiratory symptoms (cough, phlegm and wheeze), history of allergy, smoking, and information regarding home and farm environments. Transitional modelling, in which measurement in a longitudinal sequence is described as a function of previous outcomes, was used to predict later outcomes of cough, phlegm and wheeze. Asymptomatic individuals in 1993 were assessed to determine factors associated with the development of symptoms during the study period.
The prevalences of cough, phlegm and wheeze in 1993 were 16.1%, 18.1% and 25.5%, respectively. Change in symptoms over time was significant for cough, phlegm and wheeze. The adjusted ORs (95% CI) from separate transitional models for each respiratory outcome in 1993 that predicted the same symptom in 2003 were 6.32 (4.02 to 9.95) for cough, 14.36 (9.01 to 22.89) for phlegm and 6.40 (4.40 to 9.32) for wheeze. For asymptomatic individuals in 1993, home dampness, allergic reaction to inhaled allergens and cigarette smoking were major risk factors associated with respiratory symptoms that were reported in 2003.
The presence of previous respiratory symptoms, allergies and environmental exposures can predict the occurrence of future respiratory symptoms in adults.
PMCID: PMC3328873  PMID: 21766078
Cough; Longitudinal respiratory symptoms; Phlegm; Predictors; Wheeze
24.  Respiratory symptoms in Manitoba farmers: association with grain and hay handling. 
Canadian Medical Association Journal  1980;122(11):1259-1264.
Of a random sample of farmers in two crop districts of Manitoba mailed a respiratory questionnaire in 1976, 833 (82% of those currently farming in the area) replied. More than half were grain farmers and nearly half had never smoked cigarettes. The prevalence of chronic cough and phlegm production, wheezing and exertional dyspnea was positively related to the amount of smoking but was also higher than expected in nonsmokers. Acute dyspnea, sometimes of delayed onset and accompanied by fever, was most commonly related to handling old grain and was reported by 44% of the farmers. Current smokers were more susceptible than nonsmokers to this type of dyspnea. Farmers with history of acute dyspnea while handling grain were more likely to wear masks, but the overall rate of mask wearing, even among those at highest risk, was low.
PMCID: PMC1802054  PMID: 7388722
25.  Evaluation of the respiratory health of dock workers who load grain cargoes in British Columbia. 
OBJECTIVES--To investigate the respiratory health of dock workers who load grain cargoes. METHODS--The respiratory health of 118 dock workers who load grain cargoes in the ports of Vancouver and Prince Rupert was compared with that of 555 grain elevator workers from the same regions. 128 civic workers were used as an unexposed control group. RESULTS--The prevalences of chronic cough and phlegm were at least as high in dock workers as those found in the elevator workers, and when adjusted for differences in duration of employment and smoking, dock workers had an eightfold higher risk of developing chronic phlegm than did civic workers. Symptoms of eye and skin irritation that were experienced at least monthly were highest for dock workers. Average percentage of the predicted FEV1 and FVC for dock workers (mean 100.6% and 105.3% respectively) were similar to the civic workers but significantly higher than those found for elevator workers. Higher subjective estimates of duration of exposure to grain dust (hours/day) were associated with lower values of FEV1. CONCLUSIONS--The more intermittent grain dust exposure patterns of dock workers may have allowed for some recovery of lung function, but chronic respiratory symptoms were less labile.
PMCID: PMC1128207  PMID: 7795744

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