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      Lifetime environmental tobacco smoke exposure and the risk of chronic obstructive pulmonary disease

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          Exposure to environmental tobacco smoke (ETS), which contains potent respiratory irritants, may lead to chronic airway inflammation and obstruction. Although ETS exposure appears to cause asthma in children and adults, its role in causing COPD has received limited attention in epidemiologic studies.


          Using data from a population-based sample of 2,113 U.S. adults aged 55 to 75 years, we examined the association between lifetime ETS exposure and the risk of developing COPD.

          Participants were recruited from all 48 contiguous U.S. states by random digit dialing. Lifetime ETS exposure was ascertained by structured telephone interview. We used a standard epidemiologic approach to define COPD based on a self-reported physician diagnosis of chronic bronchitis, emphysema, or COPD.


          Higher cumulative lifetime home and work exposure were associated with a greater risk of COPD. The highest quartile of lifetime home ETS exposure was associated with a greater risk of COPD, controlling for age, sex, race, personal smoking history, educational attainment, marital status, and occupational exposure to vapors, gas, dusts, or fumes during the longest held job (OR 1.55; 95% CI 1.09 to 2.21). The highest quartile of lifetime workplace ETS exposure was also related to a greater risk of COPD (OR 1.36; 95% CI 1.002 to 1.84). The population attributable fraction was 11% for the highest quartile of home ETS exposure and 7% for work exposure.


          ETS exposure may be an important cause of COPD. Consequently, public policies aimed at preventing public smoking may reduce the burden of COPD-related death and disability, both by reducing direct smoking and ETS exposure.

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          Most cited references 45

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          Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study.

          Plausible projections of future mortality and disability are a useful aid in decisions on priorities for health research, capital investment, and training. Rates and patterns of ill health are determined by factors such as socioeconomic development, educational attainment, technological developments, and their dispersion among populations, as well as exposure to hazards such as tobacco. As part of the Global Burden of Disease Study (GBD), we developed three scenarios of future mortality and disability for different age-sex groups, causes, and regions. We used the most important disease and injury trends since 1950 in nine cause-of-death clusters. Regression equations for mortality rates for each cluster by region were developed from gross domestic product per person (in international dollars), average number of years of education, time (in years, as a surrogate for technological change), and smoking intensity, which shows the cumulative effects based on data for 47 countries in 1950-90. Optimistic, pessimistic, and baseline projections of the independent variables were made. We related mortality from detailed causes to mortality from a cause cluster to project more detailed causes. Based on projected numbers of deaths by cause, years of life lived with disability (YLDs) were projected from different relation models of YLDs to years of life lost (YLLs). Population projections were prepared from World Bank projections of fertility and the projected mortality rates. Life expectancy at birth for women was projected to increase in all three scenarios; in established market economies to about 90 years by 2020. Far smaller gains in male life expectancy were projected than in females; in formerly socialist economies of Europe, male life expectancy may not increase at all. Worldwide mortality from communicable maternal, perinatal, and nutritional disorders was expected to decline in the baseline scenario from 17.2 million deaths in 1990 to 10.3 million in 2020. We projected that non-communicable disease mortality will increase from 28.1 million deaths in 1990 to 49.7 million in 2020. Deaths from injury may increase from 5.1 million to 8.4 million. Leading causes of disability-adjusted life years (DALYs) predicted by the baseline model were (in descending order): ischaemic heart disease, unipolar major depression, road-traffic accidents, cerebrovascular disease, chronic obstructive pulmonary disease, lower respiratory infections, tuberculosis, war injuries, diarrhoeal diseases, and HIV. Tobacco-attributable mortality is projected to increase from 3.0 million deaths in 1990 to 8.4 million deaths in 2020. Health trends in the next 25 years will be determined mainly by the ageing of the world's population, the decline in age-specific mortality rates from communicable, maternal, perinatal, and nutritional disorders, the spread of HIV, and the increase in tobacco-related mortality and disability. Projections, by their nature, are highly uncertain, but we found some robust results with implications for health policy.
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            Maximum likelihood estimation of the attributable fraction from logistic models.

            Bruzzi et al. (1985, American Journal of Epidemiology 122, 904-914) provided a general logistic-model-based estimator of the attributable fraction for case-control data, and Benichou and Gail (1990, Biometrics 46, 991-1003) gave an implicit-delta-method variance formula for this estimator. The Bruzzi et al. estimator is not, however, the maximum likelihood estimator (MLE) based on the model, as it uses the model only to construct the relative risk estimates, and not the covariate-distribution estimate. We here provide maximum likelihood estimators for the attributable fraction in cohort and case-control studies, and their asymptotic variances. The case-control estimator generalizes the estimator of Drescher and Schill (1991, Biometrics 47, 1247-1256). We also present a limited simulation study which confirms earlier work that better small-sample performance is obtained when the confidence interval is centered on the log-transformed point estimator rather than the original point estimator.
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              American Thoracic Society Statement: Occupational contribution to the burden of airway disease.


                Author and article information

                Environ Health
                Environmental Health
                BioMed Central (London )
                12 May 2005
                : 4
                : 7
                [1 ]Department of Medicine, University of California, San Francisco, UCSF Box 0924, San Francisco, CA 94113-0924, USA
                [2 ]Division of Occupational and Environmental Medicine, Department of Medicine, University of California, San Francisco, UCSF Box 0924, San Francisco, CA 94113-0924, USA
                [3 ]Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, UCSF Box 0924, San Francisco, CA 94113-0924, USA
                [4 ]Institute for Health Policy Studies, University of California, San Francisco, UCSF Box 0920, San Francisco, CA 94113-0920, USA
                Copyright © 2005 Eisner et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



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