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Environmental Correlates of Impaired Lung Function in Non-Smokers With

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Environmental Correlates of Impaired Lung Function in Non-Smokers With Thorax 1998;53:939–943 939 Environmental correlates of impaired lung Thorax: first published as 10.1136/thx.53.11.939 on 1 November 1998. Downloaded from function in non-smokers with severe á1-antitrypsin deficiency (PiZZ) Eeva Piitulainen, Göran Tornling, Sten Eriksson Abstract for the development of emphysema in AAT Background—Active smoking is the most deficiency.23 Since even non-smoking PiZZ important risk factor for pulmonary em- individuals may develop lung disease, it has physema in subjects with severe á1- been suggested that other environmental antitrypsin (AAT) deficiency. The aim of and/or intrinsic factors may aVect lung func- this study was to analyse the eVects of tion in PiZZ individuals.45 environmental risk factors other than To facilitate study of the natural history, risk active smoking on lung function and on factors, and clinical features of AAT deficiency, respiratory symptoms in non-smoking a national AAT deficiency register was estab- PiZZ individuals. lished in Sweden in 1991.5 All individuals aged Methods—Lifetime exposure to passive 18 years or older living in Sweden and carrying smoking, domiciliary use of a kerosene the phenotypes PiZ or Pinull were invited to be (paraYn) heater or gas cooker, and all included in the register. The initial plasma occupations since leaving school were protein analysis resulting in the final PiZ diag- reported by 205 non-smoking PiZZ indi- nosis was performed either because of lung viduals (95 men and 110 women) included disease, other disease (liver, joint symptoms, infection, increased erythrocyte sedimentation in the Swedish AAT deficiency register. 6 Lung function test results and histories of rate, etc) or screening (family, neonatal or respiratory symptoms (chronic bronchi- other screening). Other data for the register were elicited by questionnaire as previously tis, recurrent wheezing, and exertional 5 dyspnoea) were elicited from the AAT described. Results of lung and liver function register records. tests, diagnosis and treatment are reported regularly by the attending physician while Results—After adjustment for age, agri- cultural employment and domiciliary symptoms, smoking habits, occupation, and employment status are reported by the PiZ kerosene heater usage, but not gas cooker http://thorax.bmj.com/ usage or passive smoking, were both asso- individuals themselves. In a previous study of a group of non- ciated with significantly decreased lung smoking PiZZ individuals included in the function. Multiple linear regression Swedish AAT deficiency register5 we found analysis showed age, sex, kerosene heater lung function to be significantly decreased in usage, and agricultural employment to be the men and in individuals aged 50 years or independent determinants of lung func- more. Moreover, self-reported occupational Division of Lung tion impairment. Age and passive smok- Medicine exposure to gas, fumes or dust, which was more E Piitulainen ing for 10 years or more, both at home and frequent among the men than among the on September 25, 2021 by guest. Protected copyright. at the work place, were associated with the women, was associated with decreased lung presence of chronic bronchitis. Age and Department of function in the older age group. Thus, the Medicine agricultural employment for 10 years > results suggested that occupational exposure to E Piitulainen were associated with recurrent wheezing S Eriksson airway irritants may be associated with a risk of and exertional dyspnoea. decreased lung function in PiZZ individuals. Lund University, Conclusions—Domiciliary kerosene The aim of the present study was to analyse University Hospital, heater usage and an agricultural occupa- in detail the impact of environmental factors— S205 02 Malmö, tion therefore appear to be environmental such as indoor air pollution (passive smoking, Sweden factors associated with decreased lung domiciliary use of kerosene, and gas stoves) function in non-smoking PiZZ individu- and occupational exposure to airway Division of als, and passive smoking is associated with Respiratory Medicine, irritants—on lung function and respiratory Department of an increased frequency of chronic bron- symptoms in never smoking PiZZ individuals. Medicine, Karolinska chitis, but not with impaired lung func- Institute, Stockholm, tion. Sweden (Thorax 1998;53:939–943) G Tornling Methods PATIENTS Keywords: á1-antitrypsin deficiency; passive smoking; Correspondence to: indoor air pollution; occupational exposure; emphy- All individuals aged 20 years or more included Professor S Eriksson. sema in the Swedish AAT deficiency register up to August 1995 who reported never having Received 9 February 1998 Returned to authors smoked regularly were invited to participate in 8 April 1998 The relationship between severe á1-antitrypsin the study. Most of the study participants were Revised version received (AAT) deficiency, phenotype PiZZ, and pul- included in our previous study.5 In addition to 18 May 1998 1 Accepted for publication monary emphysema is well known. Smoking is smoking habits reported in the standard regis- 3 June 1998 the most important environmental risk factor try questionnaire,5 detailed questions about 940 Piitulainen, Tornling, Eriksson Table 1 Distribution of the respiratory symptoms by sex, age and environmental risk groups Thorax: first published as 10.1136/thx.53.11.939 on 1 November 1998. Downloaded from Chronic bronchitis Wheezing Dyspnoea on exertion n OR 95% CI OR 95% CI OR 95% CI Age group <50 years 109 1 1 1 >50 years 96 2.7† 1.2 to 5.8 3.7‡ 2.0 to 6.7 9.9‡ 5.1 to 19.2 Sex Men 95 1 1 1 Women 110 1.1 0.5 to 2.3 1.7 1.0 to 3.1 1.7 1.0 to 3.1 Passive smoking 0 years 105 1 1 1 >10 years 71 1.6* 1.3 to 2.4 1.1 0.7 to 1.6 1.2 0.8 to 1.8 Agricultural employment 0 years 175 1 1 1 >10 years 17 1.6 0.9 to 2.9 1.8* 1.01 to 3.3 1.8* 1.01 to 3.3 *p<0.05; †p<0.01 ; ‡p<0.001 (chi-squared test). smoking history were included in the present in restaurants, lunch rooms or public places study questionnaire answered by each partici- was not considered to constitute passive smok- pant. ing. The present study questionnaire, sent to 258 All occupations reported by the study individuals who reported that they had never participants were classified according to the regularly smoked, was answered by 235 (91%). Standard Swedish Classification of Occupational Fifteen of the responders reported a daily con- Categories compiled by Statistics Sweden (Sta- sumption of more than one cigarette for a year tistiska Centralbyrån), the National Bureau of and another 15 individuals were under 20 years Statistics. In each case classification was done of age. Data for the remaining 205 individuals without knowledge of the patient’s lung (95 men and 110 women) were included in the function test results or respiratory symptoms, statistical analysis. In 105 individuals (51%) and the number of years spent in each occupa- AAT deficiency had been identified during tional category was noted in the case of any investigation for diseases other than lung individual who had worked in more than one disease, 45 (22%) had been identified by field. screening, and only 55 (27%) because of lung Self-reported data about respiratory symp- disease. toms were elicited from answers to the standard registry questionnaire.5 Data for the following items were included in the statistical QUESTIONNAIRE analysis: daily cough with phlegm at least three The present study questionnaire included the months per year, called “chronic bronchitis” in following questions: (1) active smoking (yes/ this report (item answered by yes/no), recur- no; if yes, the year started and, if ex-smokers, rent wheezing (yes/no), and exertional dys- http://thorax.bmj.com/ the year they stopped, and the mean daily con- pnoea (yes/no). sumption of cigarettes, cigars or tobacco (grams)); (2) passive smoking since birth (yes/ no; if yes, location (home or work place), LUNG FUNCTION TESTS intensity in days per week, and duration in The results of lung function tests including forced expiratory volume in one second (FEV ) years; (3) domiciliary kerosene (paraYn) 1 heater usage (yes/no; if yes, duration in years); and vital capacity (VC) were elicited from reg- (4) domiciliary gas cooker usage (yes/no; if yes, istry records. Lung function test results were duration in years); and (5) education and all expressed as a percentage of reference values 7 on September 25, 2021 by guest. Protected copyright. occupations since leaving school. published by Berglund and co-workers. Only Those reporting daily consumption of more pre-bronchodilator values were analysed. All than one cigarette for at least one year during lung function tests were performed at the their lives were considered to be smokers (or patient’s local hospital. ex-smokers) and were excluded from the study. For the purposes of statistical analysis the lower PIZZ DIAGNOSIS limit of passive smoking was one year of either In all cases Pi phenotypes were determined by domiciliary exposure to smoking for seven days isoelectric focusing at the Department of a week, or exposure at the work place for five Clinical Chemistry, University Hospital, days a week. Occasional exposure to smoking Malmö.8 All individuals were identified as phe- notype PiZZ (though naturally a few cases of Table 2 Distribution of sex, mean (range) duration of occupation, and mean (SD) FEV 1 PiZ0 cannot be excluded without family stud- values (% predicted) according to the one-digit level of the Classification of Occupations by Statistics Sweden ies or DNA analysis, but none was Pi00). FEV (% of 1 STATISTICAL ANALYSIS Occupation category M/F* Duration (years) predicted) The ÷2 test and Fisher’s exact test were used to Technical scientific, teaching 24/18 17 (1–43) 87 (29) compare categorical variables.
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