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      Impact of active and passive smoking as risk factors for asthma and COPD in women presenting to primary care in Syria: first report by the WHO-GARD survey group

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          The burden of chronic respiratory disease (CRD) is alarming. International studies suggest that women with CRD are undersurveyed and underdiagnosed by physicians worldwide. It is unclear what the prevalence of CRD is in the general population of Syria, particularly among women, since there has never been a survey on CRD in this nation. The purpose of this study was to investigate the impact of different patterns of smoking on CRD in women.

          Materials and methods

          We extracted data on smoking patterns and outcome in women from the Global Alliance Against Chronic Respiratory Diseases survey. Using spirometric measurements before and after the use of inhaled bronchodilators, we tracked the frequency of CRD in females active and passive narghile or cigarette smokers presenting to primary care. We administered the questionnaire to 788 randomly selected females seen during 1 week in the fiscal year 2009–2010 in 22 primary care centers in six different regions of Syria. Inclusion criteria were age >6 years, presenting for any medical complaint. In this cross-sectional study, three groups of female subjects were evaluated: active smokers of cigarettes, active smokers of narghiles, and passive smokers of either cigarettes or narghiles. These three groups were compared to a control group of female subjects not exposed to active or passive smoking.


          Exposure to active cigarette smoke but not narghile smoke was associated with doctor-diagnosed chronic obstructive pulmonary disease (COPD). However, neither cigarette nor narghile active smoking was associated with increased incidence of spirometrically diagnosed COPD. Paradoxically, exposure to passive smoking of either cigarettes or narghiles resulted in association with airway obstruction, defined as forced expiratory volume in 1 second (FEV 1)/forced vital capacity (FVC) < 70% according to the Global initiative for chronic Obstructive Lung Disease criteria; association with FEV 1 < 80% predicted, evidencing moderate to severe GOLD spirometric grade, and doctor-diagnosed COPD. Physicians tend to underdiagnose COPD in women who present to primary care clinics. Whereas around 15% of enrolled women had evidence of COPD with FEV 1/FVC < 70% after bronchodilators, only 4.8% were physician-diagnosed. Asthma did not appear to be a significant spirometric finding in these female subjects, although around 11% had physician-diagnosed asthma. One limitation is FEV 1/FVC < 70% could have also resulted from uncontrolled asthma. The same limitation has been reported by the Proyecto Latinoamericano de Investigacion en Obstruccion Pulmonar (PLATINO) study.


          Contrary to popular belief in developing countries, women exposed to tobacco smoke, whether active or passive, and whether by cigarettes or narghiles, like men are at increased risk for the development of COPD, although cultural habits and taboos may decrease the risk of active smoking in some women.


          These findings will be considered for country and region strategy for noncommunicable diseases, to overcome underdiagnosis of CRD in women, fight widespread female cigarette and narghile smoking, and promote behavioral research in this field.

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          Most cited references 16

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          Reconsidering sex-based stereotypes of COPD.

          Chronic obstructive pulmonary disease (COPD) has historically been considered a disease of older, white, male smokers, as illustrated in Frank Netter's classic images of the 'pink puffer' and 'blue bloater'. However, women may be more susceptible to COPD than men, and the disease course may be reflective of that increased susceptibility. From a review of epidemiological data of COPD, we found differences in the way men and women present with COPD symptoms, a bias in the way COPD symptoms are treated in men and women, and differences in susceptibility to airway obstruction based on age, sex, and smoking history. These data show that classic stereotypes of COPD - including male predominance - should be abandoned, and that there are not two but multiple COPD phenotypes, which are characterised by differences between women and men in susceptibility, symptoms, and disease progression. These differences impact on physician perception. Although further research into this concept is needed, the differences we found should prompt, in the short term, changes in the way (and in whom) COPD is evaluated, diagnosed, and treated; in the long term, these differences should prompt research into the prognosis of COPD based on sex differences.
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            Environmental tobacco smoke exposure and asthma in adults.

             S T Weiss,  M J Utell,  J Samet (1999)
            Environmental tobacco smoke (ETS) contaminates indoor air in homes and workplaces. Although the adverse effects of active cigarette smoking on the respiratory tract have been extensively characterized, the effects of ETS exposure on adult asthma have not yet been investigated extensively and the available data are limited. This article examines the evidence for ETS exposure as a cause of asthma and asthma exacerbation in adults, and for ETS exposure in the workplace specifically as contributing to these health effects. It addresses methodological barriers that limit the available data and evaluates the adequacy of the data for risk assessment.
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              International study of asthma and allergies in childhood: phase 3 in the Syrian Arab Republic.

              The International Study of Asthma and Allergies in Childhood (ISAAC) uses standardized symptom-based questionnaires to describe the prevalence of symptoms of asthma, rhinoconjunctivitis and eczema in children worldwide. Three governorates in the Syrian Arab Republic (Aleppo, Lattakia and Tartous) participated in ISAAC phase 3 in 2001-03. Adolescents in the 13-14 year age group and parents of the 6-7-year-old children completed the questionnaire about asthma symptoms. The prevalence of current symptoms of asthma (wheezing in the last 12 months) in different centres ranged from 4.7% to 5.7% for 6-7-year-olds and 3.9% to 6.5% for 13-14-year-olds. In 13-14-year-olds the prevalence of severe speech-limiting wheeze was 2.0%-3.5%, of rhinoconjunctivitis was 8.6%-14.6% and of eczema was 3.3%-4.2%.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                02 October 2013
                : 8
                : 473-482
                [1 ]National Center for Research in Chronic Respiratory Diseases, Tishreen University School of Medicine, Latakia, Syria
                [2 ]Ministry of Health, Damascus, Syria
                [3 ]Global Alliance Against Chronic Respiratory Diseases, World Health Organization, Geneva, Switzerland
                [4 ]Department of Respiratory Diseases, University Hospital, Hôpital Arnaud de Villeneuve, Montpellier, France
                [5 ]Inserm, CESP Centre for Research in Epidemiology and Population Health, U1018, Respiratory and Environmental Epidemiology Team, Villejuif, France
                [6 ]Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
                Author notes
                Correspondence: Yousser Mohammad, National Center for Research in Chronic Respiratory Diseases, Tishreen University, PO Box 1479, Latakia, Syria, Tel +963 93 375 5240, Email ccollaborating@
                © 2013 Mohammad et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research

                Respiratory medicine

                passive smoking, women, copd, asthma, narghile, water pipe, behavior


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