Pulmonary function, smoking cessation and 30 year mortality in middle aged Finnish men

Cardiovascular Morbidity in Individuals with Impaired FEV1

PURPOSE OF REVIEW

This review is intended to give an overview of the epidemiology of cardiovascular morbidity and mortality in patients with impaired lung function with an emphasis on patients with COPD.

RECENT FINDINGS

Despite shared risk factors, lung disease is an emerging independent risk factor for cardiovascular disease and cardio-vascular disease (CVD) outcomes. Both CVD and chronic lung disease contribute significantly to overall mortality. Especially patients with chronic obstructive pulmonary disease (COPD) are at high risk for CVD-related mortality. In patients with chronic lung disease, a low index of suspicion should be maintained to assess for CVD and vice versa. Early detection of chronic lung disease as a potentially modifiable CVD risk factor could have important impact on patient outcomes.

Association of cardiovascular health with mortality among COPD patients: National Health and Nutrition Examination Survey III

BACKGROUND

All-cause and cardiovascular disease (CVD) mortality are higher among patients with chronic obstructive pulmonary disease (COPD). We examined the association between American Heart Association's Life's Simple 7 (LS7) metrics and all-cause as well as CVD mortality in patients with COPD.

METHODS

We examined 1513 US adults with COPD aged ≥ 40, without prior CVD, from the National Health and Nutrition Examination Survey III. COPD was defined as FEV₁/FVC<0.7 in absence of asthma. Adjusted Cox regression was used to assess the relation of LS7 metrics with all-cause and CVD mortality.

RESULTS

Overall, only 74 participants (4.9%) had ideal 5-7 LS7 metrics. Over a mean follow-up of 14.2±7.9 years, 1162 individuals died, of which 315 were due to CVD. Age, sex, and ethnicity-adjusted HRs (95% CI) for all-cause mortality were 0.53 (0.41-0.68), 0.45 (0.34-0.59), 0.66 (0.49-0.87) and 0.75 (0.56-1.00) among those with ideal vs poor control of smoking, diet, physical activity and fasting blood glucose, respectively. However, the ideal and intermediate LS7 metrics were not significantly associated with lower risk of CVD mortality, except for a BMI between 25-29.9 kg/m². Those with 5-7 vs 0-1 ideal metrics had adjusted HRs 0.50 (0.40-0.87) for all-cause and 0.53 (0.21-1.36) for CVD mortality.

CONCLUSION

Ideal levels of multiple behavioral and health factors are associated with substantially lower risks for all-cause mortality, with a trend for lower CVD mortality among US adults with COPD.

New therapeutic targets for the prevention of infectious acute exacerbations of COPD: role of epithelial adhesion molecules and inflammatory pathways

Chronic respiratory diseases are among the leading causes of mortality worldwide, with the major contributor, chronic obstructive pulmonary disease (COPD) accounting for approximately 3 million deaths annually. Frequent acute exacerbations (AEs) of COPD (AECOPD) drive clinical and functional decline in COPD and are associated with accelerated loss of lung function, increased mortality, decreased health-related quality of life and significant economic costs. Infections with a small subgroup of pathogens precipitate the majority of AEs and consequently constitute a significant comorbidity in COPD. However, current pharmacological interventions are ineffective in preventing infectious exacerbations and their treatment is compromised by the rapid development of antibiotic resistance. Thus, alternative preventative therapies need to be considered. Pathogen adherence to the pulmonary epithelium through host receptors is the prerequisite step for invasion and subsequent infection of surrounding structures. Thus, disruption of bacterial-host cell interactions with receptor antagonists or modulation of the ensuing inflammatory profile present attractive avenues for therapeutic development. This review explores key mediators of pathogen-host interactions that may offer new therapeutic targets with the potential to prevent viral/bacterial-mediated AECOPD. There are several conceptual and methodological hurdles hampering the development of new therapies that require further research and resolution.

Joint statement for the diagnosis, management, and prevention of chronic obstructive pulmonary disease for Gulf Cooperation Council countries and Middle East-North Africa region, 2017

Smoking and subsequent development of COPD is an ever-increasing epidemic in Arabian Gulf and Middle East countries, with no signs of decline. The important fact to be highlighted is that this COPD epidemic of increasing incidence and prevalence is mostly unrecognized by patients, due to the common attribution of symptoms to "smoker's cough", and the underdiagnosis and undertreatment by physicians because the common signs and symptoms masquerade as asthma. Consequently, there are long-term adverse effects of missing the diagnosis. The purpose of this review article is to focus upon the status of COPD in Arabian Gulf and Middle East countries, stressing the increasing burden of smoking and COPD, to emphasize the specific factors leading to rise in prevalence of COPD, to bring to light the underdiagnosis and undermanagement of COPD, and to treat COPD in conformity with standard guidelines with local and regional modifications. This review ends with suggestions and recommendations to the health department to formulate policies and to generate awareness among the general public about the side effects of smoking and consequences of COPD.

Strategies for Management of the Early Chronic Obstructive Lung Disease

Lung function reportedly declines with age and that this decline is accelerated during disease progression. However, a recent study showed that the decline might peak in the mild and moderate stage. The prognosis of chronic obstructive pulmonary disease (COPD) can be improved if the disease is diagnosed in its early stages, prior to the peak of decline in lung function. This article reviews recent studies on early COPD and the possibility of applying the U.S. Preventive Services Task Force recommendation 2008 and 2015 for early detection of COPD in Korea.

Behavioural Risk Factors in Mid-Life Associated with Successful Ageing, Disability, Dementia and Frailty in Later Life: A Rapid Systematic Review

BACKGROUND

Smoking, alcohol consumption, poor diet and low levels of physical activity significantly contribute to the burden of illness in developed countries. Whilst the links between specific and multiple risk behaviours and individual chronic conditions are well documented, the impact of these behaviours in mid-life across a range of later life outcomes has yet to be comprehensively assessed. This review aimed to provide an overview of behavioural risk factors in mid-life that are associated with successful ageing and the primary prevention or delay of disability, dementia, frailty and non-communicable chronic conditions.

METHODS

A literature search was conducted to identify cohort studies published in English since 2000 up to Dec 2014. Multivariate analyses and a minimum follow-up of five years were required for inclusion. Two reviewers screened titles, abstracts and papers independently. Studies were assessed for quality. Evidence was synthesised by mid-life behavioural risk for a range of late life outcomes.

FINDINGS

This search located 10,338 individual references, of which 164 are included in this review. Follow-up data ranged from five years to 36 years. Outcomes include dementia, frailty, disability and cardiovascular disease. There is consistent evidence of beneficial associations between mid-life physical activity, healthy ageing and disease outcomes. Across all populations studied there is consistent evidence that mid-life smoking has a detrimental effect on health. Evidence specific to alcohol consumption was mixed. Limited, but supportive, evidence was available relating specifically to mid-life diet, leisure and social activities or health inequalities.

CONCLUSIONS

There is consistent evidence of associations between mid-life behaviours and a range of late life outcomes. The promotion of physical activity, healthy diet and smoking cessation in all mid-life populations should be encouraged for successful ageing and the prevention of disability and chronic disease.

Physiological impairment in mild COPD

Chronic obstructive pulmonary disease (COPD) is a common and often progressive inflammatory disease of the airways, alveoli and microvasculature that is both preventable and treatable. It is well established that smokers with mild airway obstruction, as spirometrically defined, represent the vast majority of patients with COPD, yet this population has not been extensively studied. An insidious preclinical course means that mild COPD is both underdiagnosed and undertreated. In this context, recent studies have confirmed that even patients with mild COPD can have extensive physiological impairment, which contributes to poor perceived health status compared with non-smoking healthy controls. This review describes the heterogeneous pathophysiology that can exist in COPD patients with only mild airway obstruction on spirometry. It exposes the compensatory adaptations that develop in such patients to ensure that the respiratory system fulfils its primary task of maintaining adequate pulmonary gas exchange for the prevailing metabolic demand. It demonstrates that adaptations such as increased inspiratory neural drive to the diaphragm due to combined effects of increased mechanical loading and chemostimulation underscore the increased dyspnoea and exercise intolerance in this population. Finally, based on available evidence, we present what we believe is a sound physiological rationale for earlier diagnosis in this population.

Should mild COPD be treated? Evidence for early pharmacological intervention

Chronic obstructive pulmonary disease (COPD) is a common and often progressive inflammatory disease of the airways that is both preventable and treatable. It is well established that those with mild-to-moderate disease severity represent the majority of patients with COPD, yet this subpopulation is relatively under-studied. Because of an insidious pre-clinical phase, COPD is both under-diagnosed and under-treated. Recent studies have confirmed that even patients with mild, grade 1 COPD [i.e. those with a reduced forced expiratory volume in one second (FEV1)/forced vital capacity ratio but normal FEV1], have measurable physiological impairment with increased morbidity and a higher risk of mortality compared with non-smoking healthy controls. Beyond the imperative of smoking cessation-the pivotal intervention in all COPD stages-the role of pharmacotherapy for prevention of disease progression has yet to be established. The main objective of this review is to provide a concise overview of the heterogeneous pathophysiology of COPD with only mild airway obstruction on spirometry and obstacles for early diagnosis. We emphasize that the absence of sufficiently powered trials involving a large number of patients precludes definitive recommendations in support of (or against) long-term pharmacological treatment in mild COPD. Despite these limitations, we present a rationale for earlier pharmacological intervention derived from recent physiological studies performed in symptomatic patients with mild COPD.

New developments in the assessment of COPD: early diagnosis is key

Chronic obstructive pulmonary disease (COPD) is the most common chronic lung disease in the world, and its associated health burdens and costs are mounting. Until recently, it was generally accepted that targeting the diagnosis of COPD early in its course was a relatively fruitless effort, since treatments other than already ubiquitous smoking-cessation efforts were unlikely to alter its course. However, there is strong evidence to suggest that the majority of patients with objective COPD are not aware of their condition, and this leads to a significant delay in diagnosis, more aggressive smoking-cessation intervention, and potential treatment. Novel methods of diagnostic testing, community health programs, and primary-care provider recommendations hold promise to expand the recognition of COPD in its incipient stages - where recent evidence suggests a rapid decline in lung function occurs and may be prevented if acted upon. This review explores the evidence to support the efforts to justify programs aimed at early diagnosis, alternative diagnostic strategies that may augment traditional spirometry, therapeutic modalities that could potentially be used in the future to alter early lung-function decline, and emphasizes the necessary cooperative role that physicians, patients, communities, and governments need to play to realize the significant health impact that stands to be gained.

Diagnosis of COPD and clinical course in patients with unrecognized airflow limitation

Chronic obstructive pulmonary disease (COPD) is frequently under-recognized and underdiagnosed. To determine the natural history of recognized and unrecognized COPD, we studied the rate of diagnosis, health care utilization, and mortality in patients with airflow limitation (AFL). Three hundred forty-seven outpatients at the Cincinnati Veterans Administration Medical Center performed spirometry and completed a respiratory questionnaire. Patients were followed for a minimum of 30 months and medical records were reviewed for COPD diagnosis, mortality, respiratory-related health care utilization, comorbidities, and respiratory medications. Three hundred twenty-five of 347 (94%) patients performed technically adequate spirometry and completed questionnaires. When AFL was defined by fixed ratio (FR, forced expiratory volume in 1 second [FEV(1)]/forced vital capacity [FVC] < 0.7), patients with AFL and a diagnosis of COPD had a higher annual mortality rate (7.1% ± 2% versus 2.4% ± 0.8%, P = 0.01), more hospitalizations per year (0.2 ± 0.06 versus 0.04 ± 0.01, P < 0.001 mean ± standard error of the mean), increased respiratory symptoms (12.0 ± 0.9 versus 7.2 ± 0.6, P < 0.0001), and higher Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage compared with undiagnosed patients. Ninety-two of 137 patients with AFL (67%) had unrecognized AFL; 16 (17%) of the 92 were subsequently diagnosed. When AFL was defined by the lower limit of normal (LLN, FEV(1)/FVC < LLN), 67 of 103 patients (65%) had unrecognized AFL; 12 (18%) of the 67 were subsequently diagnosed. Patients with AFL defined by FR who were subsequently diagnosed had more emergency department visits per year (0.33 ± 0.11 versus 0.11 ± 0.05, P = 0.009), increased respiratory symptoms (10.2 ± 1.6 versus 6.5 ± 0.7, P < 0.05), and higher GOLD stage, but similar mortality and hospitalizations compared with the persistently undiagnosed patients. The annual rate of documented COPD diagnosis was 7% for both FR and LLN definitions. Patients with AFL and a diagnosis of COPD have more severe disease, higher health care utilization, and mortality than undiagnosed patients. The annual rate of COPD diagnosis is 7% among individuals with unrecognized AFL. Worse AFL, increased respiratory symptoms, and ED visits are associated with a subsequent COPD diagnosis in individuals with unrecognized AFL.

Emphysema scores predict death from COPD and lung cancer

OBJECTIVE

Our objective was to assess the usefulness of emphysema scores in predicting death from COPD and lung cancer.

METHODS

Emphysema was assessed with low-dose CT scans performed on 9,047 men and women for whom age and smoking history were documented. Each scan was scored according to the presence of emphysema as follows: none, mild, moderate, or marked. Follow-up time was calculated from time of CT scan to time of death or December 31, 2007, whichever came first. Cox regression analysis was used to calculate the hazard ratio (HR) of emphysema as a predictor of death.

RESULTS

Median age was 65 years, 4,433 (49%) were men, and 4,133 (46%) were currently smoking or had quit within 5 years. Emphysema was identified in 2,637 (29%) and was a significant predictor of death from COPD (HR, 9.3; 95% CI, 4.3-20.2; P < .0001) and from lung cancer (HR, 1.7; 95% CI, 1.1-2.5; P = .013), even when adjusted for age and smoking history.

CONCLUSIONS

Visual assessment of emphysema on CT scan is a significant predictor of death from COPD and lung cancer.

Earlier diagnosis and earlier treatment of COPD in primary care

Chronic obstructive pulmonary disease (COPD) is a progressive disease that begins many years before a diagnosis is usually made. The need for an early and confirmed diagnosis of COPD is increasingly appreciated by primary care physicians in whose hands the ability to make improvements in early diagnosis largely rests. Case-finding of patients with symptoms of lifestyle limitation is probably the most practical way to achieve early diagnosis. Evidence suggests a burden of early COPD on afflicted people and their families. Early encouragement of smoking cessation, in conjunction with management of symptoms and treating activity limitation and exacerbations by appropriate non-pharmacologic and pharmacologic management at the earliest possible stage, could positively affect the impact and progression of the disease.

Determinants of 40-year all-cause mortality in the European cohorts of the Seven Countries Study

If a few risk factors had predictive power for all-cause mortality in different geographical-cultural areas, then preventive efforts might be concentrated on these. Thirteen potential risk factors were measured in 6,554 men aged 40-59 around 1960 in Northern, Southern and Eastern European areas of the Seven Countries Study. In 40 years 85.3% of men died in the pooled areas (87.9, 81.8 and 87.9% in Northern, Southern and Eastern Europe, respectively). Six risk factors were significant predictors of events in all three areas: directly for age, smoking habits, mean blood pressure, heart rate and ECG abnormalities; inversely for forced expiratory volume. In a pooled model also father and mother life status, socio-economic status, and arm circumference (the last one in an inverse way) had significant coefficients that were not heterogeneous across areas (except for socio-economic status). Serum cholesterol was around significance. ROC curves had values of 0.833, 0.806 and 0.819 respectively in Northern, Southern and Eastern Europe, and 0.827 in the pooled areas. Correlation coefficients between observed and expected cases in deciles of estimated risk were between 0.98 and 0.99. Survivors after 40 years in the lower half of the estimated risk were 10.7, 23.6 and 13.3% in Northern, Southern and Eastern Europe, respectively. Under- or over-estimate of cross-applying risk functions did not exceed 15%. All-cause mortality and survival in middle aged men during 40 years were strongly associated with a few, mainly cardiovascular, risk factors, whose predictive power was similar in different cultures across Europe.

Systematic review of the evidence relating FEV1 decline to giving up smoking

BACKGROUND

The rate of forced expiratory volume in 1 second (FEV1) decline ("beta") is a marker of chronic obstructive pulmonary disease risk. The reduction in beta after quitting smoking is an upper limit for the reduction achievable from switching to novel nicotine delivery products. We review available evidence to estimate this reduction and quantify the relationship of smoking to beta.

METHODS

Studies were identified, in healthy individuals or patients with respiratory disease, that provided data on beta over at least 2 years of follow-up, separately for those who gave up smoking and other smoking groups. Publications to June 2010 were considered. Independent beta estimates were derived for four main smoking groups: never smokers, ex-smokers (before baseline), quitters (during follow-up) and continuing smokers. Unweighted and inverse variance-weighted regression analyses compared betas in the smoking groups, and in continuing smokers by amount smoked, and estimated whether beta or beta differences between smoking groups varied by age, sex and other factors.

RESULTS

Forty-seven studies had relevant data, 28 for both sexes and 19 for males. Sixteen studies started before 1970. Mean follow-up was 11 years. On the basis of weighted analysis of 303 betas for the four smoking groups, never smokers had a beta 10.8 mL/yr (95% confidence interval (CI), 8.9 to 12.8) less than continuing smokers. Betas for ex-smokers were 12.4 mL/yr (95% CI, 10.1 to 14.7) less than for continuing smokers, and for quitters, 8.5 mL/yr (95% CI, 5.6 to 11.4) less. These betas were similar to that for never smokers. In continuing smokers, beta increased 0.33 mL/yr per cigarette/day. Beta differences between continuing smokers and those who gave up were greater in patients with respiratory disease or with reduced baseline lung function, but were not clearly related to age or sex.

CONCLUSION

The available data have numerous limitations, but clearly show that continuing smokers have a beta that is dose-related and over 10 mL/yr greater than in never smokers, ex-smokers or quitters. The greater decline in those with respiratory disease or reduced lung function is consistent with some smokers having a more rapid rate of FEV1 decline. These results help in designing studies comparing continuing smokers of conventional cigarettes and switchers to novel products.

Airway obstructive diseases in older adults: from detection to treatment

Asthma and chronic obstructive pulmonary disease occur commonly and may overlap among older adults. Smoking, air pollution, and bronchial hyperresponsiveness are the main risk factors. The treatment of these diseases in older adults does not differ from the available guidelines but may be complicated by the presence of comorbidities. Smoking cessation is essential for smokers, and pulmonary rehabilitation must be considered regardless of the age of the patient.

Apolipoprotein E genotype modifies the association between midlife lung function and cognitive function in old age

BACKGROUND/AIMS

Because poor lung function may be a risk factor for cognitive decline, we aimed to test the association of respiratory function with cognitive function and dementia later in life, as well as potential effect modification by APOE epsilon4 carrier status.

METHODS

In a prospective population-based cohort study, forced vital capacity and forced expiratory flow were measured around 1965 in 857 men aged 45-64 years (394 from Finland, 208 from The Netherlands, and 255 from Italy). The Mini-Mental State Examination scores around 1990, 1995 and 2000 were analyzed using multilevel regression models and the Clinical Dementia Rating score around 1990 using multinomial logistic regression analyses.

RESULTS

Midlife lung function was positively associated with cognitive function in old age in APOE epsilon4 non-carriers, but not in carriers (p < 0.05 for interaction). In Finland and Italy, 18.6% had questionable to mild dementia and 2.8% moderate to severe dementia after 25 years of follow-up. Dementia was inversely related to midlife lung function in APOE epsilon4 non-carriers, but not in carriers (p < 0.05 for interaction).

CONCLUSIONS

Small lung volumes were prospectively associated with an increased risk for poor cognitive function and dementia in non-carriers of the APOE epsilon4 gene.

Chronic obstructive pulmonary disease: an update on diagnosis and management issues in older adults

Chronic obstructive pulmonary disease (COPD) is a debilitating disease of the elderly that causes significant morbidity and mortality. Despite being a treatable and preventable disease, the prevalence continues to rise because of the worldwide epidemic of smoking. COPD is associated with enormous healthcare costs. It has systemic effects, and common co-morbid conditions such as cardiovascular disease, muscle wasting and osteoporosis may all be linked through a common systemic inflammatory cascade. Depression, anxiety and malnutrition are also common in elderly COPD patients. These factors not only affect quality of life (QOL) but also compliance with therapy. Malnutrition is an independent predictor of mortality and poor outcome. Spirometry is essential for the diagnosis of COPD, but the criteria defining airflow limitation are not clear cut for elderly patients and could result in over-diagnosis. However, older patients perceive their symptoms differently, and COPD could also be under-diagnosed in this population. Acute exacerbations result in worsening symptoms that necessitate additional treatment, and may cause a more rapid decline in lung function and QOL. The management of elderly patients with COPD should encompass a multidisciplinary approach. An evaluation of patients' nutritional status and mental health should be undertaken, in addition to assessing their lung function and functional impairment. Significant underlying co-morbidities should be evaluated and treated to derive the maximal benefit of therapy. Specific therapy for COPD should start with cessation of exposure to the most important risk factor, tobacco smoke. Smoking cessation rates in the elderly have not declined, and this may reflect an underlying reluctance by physicians to counsel and offer smoking cessation therapies to the elderly. Unlike oxygen therapy in hypoxaemic patients, bronchodilators and corticosteroids do not decrease mortality in COPD patients and they are primarily directed towards symptom relief. However, they do have a positive effect on QOL and exacerbation rates. The choice of delivery devices for inhaled medications is important in the elderly, and patients' inhaler technique and manual dexterity should be frequently assessed. Pulmonary rehabilitation and nutritional supplementation are other important components of care. End-of-life issues should be adequately addressed in the elderly with COPD, and an approach integrating curative and palliative interventions is recommended.

Life expectancy and years of life lost in chronic obstructive pulmonary disease: findings from the NHANES III Follow-up Study

RATIONALE

Previous studies have demonstrated that chronic obstructive pulmonary disease (COPD) causes increased mortality in the general population. But life expectancy and the years of life lost have not been reported.

OBJECTIVES

To quantify mortality, examine how it varies with age, sex, and other risk factors, and determine how life expectancy is affected.

METHODS

We constructed mortality models using the Third National Health and Nutrition Examination Survey, adjusting for age, sex, race, and major medical conditions. We used these to compute life expectancy and the years of life lost.

MEASUREMENTS AND MAIN RESULTS

Pulmonary function testing classified patients as having Global Initiative on Obstructive Lung Disease (GOLD) stage 0, 1, 2, 3 or 4 COPD or restriction. COPD is associated with only a modest reduction in life expectancy for never smokers, but with a very large reduction for current and former smokers. At age 65, the reductions in male life expectancy for stage 1, stage 2, and stages 3 or 4 disease in current smokers are 0.3 years, 2.2 years, and 5.8 years. These are in addition to the 3.5 years lost due to smoking. In former smokers the reductions are 1.4 years and 5.6 years for stage 2 and stages 3 or 4 disease, and in never smokers they are 0.7 and 1.3 years.

CONCLUSIONS

Persons with COPD have an increased risk of mortality compared to those who do not, with consequent reduction in life expectancy. The effect is most marked in current smokers, and this is further reason for smokers to quit.

Treatment of mild chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is an epidemic in many parts of the world. Most patients with COPD demonstrate mild disease. The cornerstone of management of mild disease is smoking cessation, which is the only proven intervention to relieve symptoms, modify its natural history and reduce mortality. For asymptomatic patients, it is the only required therapy. Short-acting bronchodilators can be added on an as needed basis for those with intermittent symptoms and regularly for those with persistent symptoms. Long-acting bronchodilators can be substituted for those who remain symptomatic despite regular use of short-acting bronchodilators. Inhaled corticosteroids do not modify the natural history of COPD and as such cannot be recommended as standalone therapy for mild COPD. However, for patients with refractory and intractable symptoms, they may be used in combination with long-acting beta-2 agonists. Influenza and pneumococcal vaccination and pulmonary rehabilitation are other therapies that may be considered for select patients with mild disease. In this paper, we summarize the current standard of care for patients with mild COPD.

Smoking: relationship to chronic bronchitis, chronic obstructive pulmonary disease and mortality

PURPOSE OF REVIEW

To describe the recent findings concerning the relationship between smoking, chronic bronchitis, chronic obstructive pulmonary disease and mortality.

RECENT FINDINGS

During their lifetime, over 40% of smokers develop chronic bronchitis. Chronic bronchitis is associated with an accelerated decline in lung function - a risk of developing chronic obstructive pulmonary disease and mortality. Approximately one-quarter of smokers can be affected by clinically significant chronic obstructive pulmonary disease. The incidence of chronic obstructive pulmonary disease is also substantial in young adults. Smokers may reduce their risk of developing chronic obstructive pulmonary disease by physical activity and increase their survival by smoking reduction. In adults and the elderly population, severe chronic obstructive pulmonary disease is associated with the most rapid decline in lung function, which is, in turn, associated with chronic obstructive pulmonary disease-related hospitalization and mortality. Using a fixed forced expiratory volume in 1 s/force vital capacity ratio (0.7) to define obstruction in chronic obstructive pulmonary disease at old age is acceptable. In chronic obstructive pulmonary disease patients, the disease is still underreported on death certificates. Chronic mucus production and being a female are associated with chronic obstructive pulmonary disease mentioned on death certificates.

SUMMARY

Chronic bronchitis is a marker identifying high-risk individuals. With respect to chronic obstructive pulmonary disease and mortality, interventions to promote smoking cessation are important to reduce these risks.

Asthma and COPD in primary health care, quality according to national guidelines: a cross-sectional and a retrospective study

BACKGROUND

In recent decades international and national guidelines have been formulated to ensure that patients suffering from specific diseases receive evidence-based care. In 2004 the National Swedish Board of Health and Welfare (SoS) published guidelines concerning the management of patients with asthma and COPD. The guidelines identify quality indicators that should be fulfilled. The aim of this study was to survey structure and process indicators, according to the asthma and COPD guidelines, in primary health care, and to identify correlations between structure and process quality results.

METHODS

A cross-sectional study of existing structure by using a questionnaire, and a retrospective study of process quality based on a review of measures documented in asthma and COPD medical records. All 42 primary health care centres in the county council of Ostergötland, Sweden, were included.

RESULTS

All centres showed high quality regarding structure, although there was a large difference in time reserved for Asthma and COPD Nurse Practice (ACNP). The difference in reserved time was reflected in process quality results. The time needed to reach the highest levels of spirometry and current smoking habit documentation was between 1 and 1 1/2 hours per week per 1000 patients registered at the centre. Less time resulted in fewer patients examined with spirometry, and fewer medical records with smoking habits documented. More time did not result in higher levels, but in more frequent contact with each patient. In the COPD group more time resulted in higher levels of pulse oximetry and weight registration.

CONCLUSION

To provide asthma and COPD patients with high process quality in primary care according to national Swedish guidelines, at least one hour per week per 1000 patients registered at the primary health care centre should be reserved for ACNP.

Cancer incidence in patients with schizophrenia and their first-degree relatives - a meta-analysis

OBJECTIVE

Controversy concerning cancer incidence in schizophrenia exists because of heterogeneous study findings.

METHOD

A meta-analysis was performed on standardized incidence ratios (SIR) of cancer in patients with schizophrenia and first-degree relatives and compared with general population samples.

RESULTS

The pooled overall cancer incidence in patients was not significantly increased (SIR = 1.05, CI 0.95-1.15). Lung cancer incidence was slightly increased (SIR = 1.31, CI 1.01-1.71), but was reduced after adjusting for smoking prevalence. The incidence of several cancers unrelated to smoking was reduced in patients. Breast cancer rates were significantly increased in female patients. The pooled overall cancer incidence in siblings (SIR = 0.89, CI 0.84-0.94) and parents (SIR = 0.90, CI 0.88-0.93) was significantly reduced. A meta-regression detected a significant relationship between cancer risk in the general population and relative risk in patients.

CONCLUSION

The meta-analysis aided exploration of inconsistent study findings. There is a discrepancy between cancer risk exposure and cancer incidence in schizophrenia consistent with a protective effect.

Longitudinal association of body mass index with lung function: the CARDIA study

Background

Lung function at the end of life depends on its peak and subsequent decline. Because obesity is epidemic in young adulthood, we quantified age-related changes in lung function relative to body mass index (BMI).

Methods

The Coronary Artery Risk Development in Young Adults (CARDIA) study in 1985–86 (year 0) recruited 5,115 black and white men and women, aged 18–30. Spirometry testing was conducted at years 0, 2, 5 and 10. We estimated 10 year change in FVC, FEV₁ and FEV₁/FVC according to baseline BMI and change in BMI within birth cohorts with initial average ages 20, 24, and 28 years, controlling for race, sex, smoking, asthma, physical activity, and alcohol consumption.

Measurements and Main Results

Participants with baseline BMI < 21.3 kg/m² experienced 10 year increases of 71 ml in FVC and 60 ml in FEV₁ and neither measure declined through age 38. In contrast, participants with baseline BMI ≥ 26.4 kg/m² experienced 10 year decreases of 185 ml in FVC and 64 ml in FEV₁. FEV₁/FVC increased with increasing BMI. Weight gain was also associated with lung function. Those who gained the most weight over 10 years had the largest decrease in FVC, but FVC increased with weight gain in those initially thinnest. In contrast, FEV₁ decreased with increasing weight gain in all participants, with maximum decline in obese individuals who gained the most weight during the study.

Conclusion

Among healthy young adults, increasing BMI in the initially thin participants was associated with increasing then stable lung function through age 38, but there were substantial lung function losses with higher and increasing fatness. These results suggest that the obesity epidemic threatens the lung health of the general population.

Smoking cessation: significance and implications for children

A number of people in the USA who are still current smokers remain a staggering figure. Although this number continues to decrease, there is still a considerable amount of second-hand smoke. More importantly and for the purpose of this review, the detrimental effects of passive smoke in children is significant. We will not review the specific health effects of passive smoke, but for pediatricians, in particular, it is important to place in perspective programs that are available to influence the parents of children to stop smoking. Indeed, approximately 25% of all children aged 3-11 live in a household with at least one smoker. Despite the increasing number of communities in the states that have instituted restrictions or complete bans on smoking in the workplace and in many public areas, the principal site of smoking remains the home.

Nested case-control study on associations between lung function, smoking and mortality in Japanese population

OBJECTIVES

Only a few long-term follow-up studies with a focus on the association between lung function and mortality in the Japanese population have been undertaken. In this study, we examined the associations of lung function, smoking and the results of allergy skin tests with mortality in a longitudinal study of the Japanese population.

METHODS

Baseline measurements were performed on residents of Fukui, Japan in 1972, and a follow-up survey was conducted in 2002. By employing a nested case-control design, 596 cases (deaths) and 596 age and sex-matched controls (survivals) were selected. Lung function was assessed using forced vital capacity (FVC) expressed as the normal percent predicted (FVC %pred) and the ratio of forced expiratory volume in 1 second (FEV(1)) to FVC (FEV(1)/FVC). Allergy skin tests were performed with extracts of house dust, candidia and mixed fungal samples (bronchomycosis). The Brinkman index was used to assess smoking intensity. The Cox proportional hazards model was used to evaluate whether lung function was associated with mortality after adjustment for other potential confounding variables.

RESULTS

Those categorized into the first- or second-lowest quartile of FVC %pred had a higher mortality [hazard ratios (HRs) and 95% confidence intervals (CIs): 2.01 (1.26-3.19) and 1.84 (1.11-3.05)], respectively. On top of these, heavy smoking (BI≥400) was associated with a higher mortality [HR and 95% CI: 1.73 (1.18-2.53)]. There were only weak of associations between the results of allergy skin tests and mortality.

CONCLUSIONS

These results suggest that FVC %pred of lung function and smoking can serve as long-term independent predictors of mortality.

Pulmonary impairment after tuberculosis

BACKGROUND

Pulmonary impairment subsequent to a cure of pulmonary tuberculosis has been described only in selected populations.

METHODS

We compared pulmonary function in a case-control study of 107 prospectively identified patients with pulmonary tuberculosis who had completed at least 20 weeks of therapy and 210 patients with latent tuberculosis infection (LTBI).

RESULTS

Both groups had similar risk factors for pulmonary impairment. Impairment was present in 59% of tuberculosis subjects and 20% of LTBI control subjects. FVC, FEV1, FEV1/FVC ratio, and the midexpiratory phase of forced expiratory flow were significantly lower in the treated pulmonary tuberculosis patients than in the comparison group. Ten patients with a history of pulmonary tuberculosis (9.4%) had less than half of their expected vital capacity vs one patient (0.53%) in the LTBI group. Another 42 patients (39%) with tuberculosis had between 20% and 50% of the expected vital capacity vs 36 patients with LTBI (17%). After adjusting for risk, survivors of tuberculosis were 5.4 times more likely to have abnormal pulmonary function test results than were LTBI patients (p > 0.001; 95% confidence interval, 2.98 to 9.68). Birth in the United States (odds ratio [OR], 2.64; p = 0.003) and age (OR, 1.03; p = 0.005) increased the odds of impairment. Pulmonary impairment was more common in cigarette smokers; however, after adjusting for demographic and other risk factors, the difference did not reach statistical significance (p = 0.074).

CONCLUSIONS

These findings indicate that pulmonary impairment after tuberculosis is associated with disability worldwide and support more aggressive case prevention strategies and posttreatment evaluation. For many persons with tuberculosis, a microbiological cure is the beginning not the end of their illness.

Advances in the management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD), the fourth leading cause of death, seems to be increasing in worldwide prevalence, and carries with it a significant health and economic burden. Smoking cessation is the only available intervention proven to halt disease progression. The authors discuss the role of the newly approved agent, varenicline, in promotion of smoking cessation. The remainder of presently available therapies treat the symptoms of COPD, but do not impact progression of disease. As the understanding of the pathogenesis of COPD improves, new targets for therapies are emerging. Given the large number of potential targets and the results of recent studies, it seems unlikely that a single new agent will result in a cure. Rather, management of COPD should involve a multi-pronged approach including smoking cessation, bronchodilators, treatment of infection, and eventual targeting of inflammatory pathways and genetic predispositions. In this article, the authors discuss presently available therapies as well as agents under development.

Thirty-year cumulative incidence of chronic bronchitis and COPD in relation to 30-year pulmonary function and 40-year mortality: a follow-up in middle-aged rural men

PURPOSE

To describe the 30-year cumulative incidence of chronic bronchitis and COPD in relation to smoking habits. The effect of chronic bronchitis on pulmonary function and mortality was also examined.

METHODS

Middle-aged men belonging to two rural Finnish cohorts of the Seven Countries Study (n = 1,711 in 1959) were followed up for up to 40 years until 2000. Standard questionnaires were used to measure chronic bronchitis, and repeated spirometry was used to evaluate pulmonary function during the 30 years. Forty-year mortality data were examined.

RESULTS

The cumulative incidence of chronic bronchitis and COPD was 42% and 32%, respectively, in continuous smokers, compared to 26% and 14% in ex-smokers and 22% and 12% in never-smokers. During the follow-up, subjects with chronic bronchitis had on average 252 mL (95% confidence interval, 211 to 293 mL) lower forced expiratory volume than those without it. The decrease in forced expiratory volume attributable to chronic bronchitis was most pronounced in those with persistent symptoms and in smokers. In subjects with chronic bronchitis, all-cause mortality was increased by a hazard ratio of 1.30 (95% confidence interval, 1.02 to 1.65). Smokers with chronic bronchitis who decreased their daily cigarette consumption increased their median life span by 2.4 years.

CONCLUSIONS

The lifetime risk of chronic bronchitis among smokers is approximately two in five, and almost one half of smokers who have chronic bronchitis also acquire COPD. Chronic bronchitis is related to earlier death, also in never-smokers, probably partly through a rapid decline in pulmonary function.

Clinical differences in the Global Initiative for Chronic Obstructive Lung Disease Stage 0

This study was to examine the clinical differences between Stage 0 and normal subjects, using low-dose chest computed tomography (CT) and pulmonary function tests. Enrolled subjects performed as a health check for lung cancer screening including low-dose CT and pulmonary function tests. Subjects were divided into Stage 0, chronic obstructive pulmonary disease according to pulmonary function tests, and normal subjects. The severity of emphysema (visual score) was calculated on three low-dose CT slices. Low-dose CT and pulmonary function tests were performed in 1359 men and 888 women. The numbers and percentages of men and women smokers were 1076 (79.2%), and 107 (12.0%), respectively. A total of 722 individuals had one or more respiratory symptoms, such as cough (69.8%), sputum (75.8%), or shortness of breathing (0.83%). Of the 722 subjects, 71 (9.8%) individuals satisfied the criteria of chronic respiratory symptoms. Among the normal subjects, smoking caused differences in airflow limitation as a result of pulmonary function tests. The proportion of smokers and the visual score were significantly higher in Stage 0 than those in the normal subjects. The percentages of the maximal mid-expiratory flow (%MMF) and of the peak expiratory flow rate were significantly lower in Stage 0 than in the normal subjects. %MMF and the proportion of visual score were significantly lower in the smoking Stage 0 than in the nonsmoking Stage 0 subjects. Smoking would indicate early signs of emphysematous change between Stage 0 and normal subjects in comparison of pulmonary function tests and visual score of low-dose CT.

Smokers with airway obstruction are more likely to quit smoking

BACKGROUND

Chronic obstructive pulmonary disease (COPD), usually caused by tobacco smoking, is one of the leading causes of morbidity and mortality. Smoking cessation at an early stage of the disease usually stops further progression. A study was undertaken to determine if diagnosis of airway obstruction was associated with subsequent success in smoking cessation, as advised by a physician.

METHODS

4494 current smokers (57.4% men) with a history of at least 10 pack-years of smoking were recruited from 100 000 subjects screened by spirometric testing for signs of airway obstruction. At the time of screening all received simple smoking cessation advice. 1177 (26.2%) subjects had airway obstruction and were told that they had COPD and that smoking cessation would halt rapid progression of their lung disease. No pharmacological treatment was proposed. After 1 year all subjects were invited for a follow up visit. Smoking status was assessed by history and validated by exhaled carbon monoxide level.

RESULTS

Nearly 70% attended a follow up visit (n = 3077): 61% were men, mean (SD) age was 52 (10) years, mean (SD) tobacco exposure 30 (17) pack-years, and 33.3% had airway obstruction during the baseline examination. The validated smoking cessation rate in those with airway obstruction was 16.3% compared with 12.0% in those with normal spirometric parameters (p = 0.0003). After correction for age, sex, nicotine dependence, number of cigarettes smoked daily, and lung function, success in smoking cessation was predicted by lower lung function, lower nicotine dependence, and lower tobacco exposure.

CONCLUSIONS

Simple smoking cessation advice combined with spirometric testing resulted in good 1 year cessation rates, especially in subjects with airway obstruction.

Paradoxical results in the study of risk factors of chronic obstructive pulmonary disease (COPD) re-admission

We have previously reported an apparently paradoxical association between medical care related factors and an increased risk of chronic obstructive pulmonary disease (COPD) re-hospitalisation, in a cohort of 346 COPD subjects from Barcelona, Spain. Confounding by severity or by indication is a plausible explanation. We tested the confounding effect of severity-related variables on these paradoxical associations. Forced expiratory volume in one second (FEV1), arterial oxygen pressure (PO2) and previous COPD admissions were associated with: (1) the presence of medical care related factors, and (2) re-admission during follow-up. Risks of readmission associated with most of the medical care related factors were reduced after adjustment for the severity variables. The risk associated with long-term oxygen therapy use changed from a crude OR of 2.36 (95% CI: 1.79-3.11) to an adjusted OR of 1.38 (0.95-2.00), while that associated with anticholinergics use varied from 3.52 (2.37-5.21) to 2.10 (1.32-3.36)). We concluded that the excess risk of COPD re-admission associated with medical care related factors might be partially due to confounding by indication. Residual confounding may still account for part of the remaining excess risk. True adverse effects of some pharmacological treatments cannot be excluded.

New therapies for chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the most common lung disease, carrying a significant mortality and morbidity. None of the therapeutic interventions currently available alter the progression of the disease. As our understanding of the basic mechanisms of alveolar destruction and airflow limitation improves, new targets are identified that may eventually result in treatment options which will affect the progression of this disease. In this review, we discuss some of the novel therapeutic options recently developed that may have an impact on the management of COPD. Future directions in research and development of pharmacological agents based on improved understanding of COPD are also discussed.

Delaying decline in pulmonary function with physical activity: a 25-year follow-up

The importance of physical activity for health is well recognized, but little is known about the influence of physical activity on pulmonary function. We have examined whether physical activity could slow down the decline in pulmonary function among the southwestern rural Finnish cohort of the Seven Countries Study. Physical activity was estimated by kilometers walked, cycled, and skied daily. We had complete data for 429 men for 10 years, 275 men for 20 years, and 186 men for 25 years. During the first 10 years, the decline in FEV was 9.8 ml/year less among men in the highest tertile of baseline physical activity than in men in the lowest tertile. According to the mean physical activity over either 20 or 25 years, men in the highest tertile also lost less pulmonary function (p = 0.009 and p = 0.043, respectively). A similar beneficial effect was observed in all smoking categories. In mortality analysis, continued high physical activity and an increase in activity to high level were associated with lower mortality. In conclusion, results indicated that physical activity is associated with a slower decline in pulmonary function and with lower mortality, and thus, middle-aged and older people should be encouraged to enjoy exercise.

Lung function and mortality in the United States: data from the First National Health and Nutrition Examination Survey follow up study

BACKGROUND

A study was undertaken to define the risk of death among a national cohort of US adults both with and without lung disease.

METHODS

Participants in the first National Health and Nutrition Examination Survey (NHANES I) followed for up to 22 years were studied. Subjects were classified using a modification of the Global Initiative for Chronic Obstructive Lung Disease criteria for chronic obstructive pulmonary disease (COPD) into the following mutually exclusive categories using the forced expiratory volume in 1 second (FEV(1)), forced vital capacity (FVC), FEV(1)/FVC ratio, and the presence of respiratory symptoms: severe COPD, moderate COPD, mild COPD, respiratory symptoms only, restrictive lung disease, and no lung disease. Proportional hazard models were developed that controlled for age, race, sex, education, smoking status, pack years of smoking, years since quitting smoking, and body mass index.

RESULTS

A total of 1301 deaths occurred in the 5542 adults in the cohort. In the adjusted proportional hazards model the presence of severe or moderate COPD was associated with a higher risk of death (hazard ratios (HR) 2.7 and 1.6, 95% confidence intervals (CI) 2.1 to 3.5 and 1.4 to 2.0), as was restrictive lung disease (HR 1.7, 95% CI 1.4 to 2.0).

CONCLUSIONS

The presence of both obstructive and restrictive lung disease is a significant predictor of earlier death in long term follow up.

Risk of hospital admission for COPD following smoking cessation and reduction: a Danish population study

BACKGROUND

Little is known about the effects of changes in smoking habits on the subsequent risk of chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate the relationship between smoking cessation and reduction and admission to hospital for COPD in a general population sample.

METHODS

A total of 19,709 participants from three prospective population studies in Copenhagen were followed with record linkage for date of first hospital admission for COPD until 1998 (mean follow up 14 years). Heavy smokers (>/=15 cigarettes/day) who reduced their tobacco consumption by at least 50% between the two initial examinations without quitting and smokers who stopped smoking during this time were compared with continuous heavy smokers using a Cox proportional hazards model.

RESULTS

During the follow up period 1,260 subjects (741 men and 519 women) were admitted to hospital for COPD. After multivariate adjustment, quitting smoking was associated with a significant reduction in the risk of hospital admission. The relative hazard (HR) was 0.57 (95% confidence interval (CI) 0.33 to 0.99). Those who reduced smoking did not show a significantly lower risk of hospitalisation than continuing heavy smokers (HR 0.93 (95% CI 0.73 to 1.18)). Exclusion of events during the first 5 study years, detailed adjustment for lung function, or restriction of analyses to participants with impaired pulmonary function did not reverse the observed trend.

CONCLUSIONS

Self-reported smoking cessation is associated with a reduction in the risk of COPD morbidity of approximately 40%; the benefit of smoking reduction is questionable.

Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms

BACKGROUND

Two clinical trials, one British and one American, have shown that early, prophylactic elective surgery does not improve five-year survival among patients with small abdominal aortic aneurysms. We report long-term outcomes in the United Kingdom Small Aneurysm Trial.

METHODS

We randomly assigned 1090 patients, 60 to 76 years of age, with small abdominal aortic aneurysms (diameter, 4.0 to 5.5 cm) to one of two groups: 563 were assigned to undergo early elective surgery, and 527 were assigned to undergo surveillance by ultrasonography. Patients were followed in the trial until June 1998 and thereafter until August 2001; the mean duration of follow-up was 8 years (range, 6 to 10).

RESULTS

The mean duration of survival was 6.5 years among patients in the surveillance group, as compared with 6.7 years among patients in the early-surgery group (P=0.29). The adjusted hazard ratio for death from any cause in the early-surgery group as compared with the surveillance group was 0.83 (95 percent confidence interval, 0.69 to 1.00; P=0.05). The 30-day operative mortality in the early-surgery group (5.5 percent) led to an early disadvantage in terms of survival. The survival curves crossed at three years, and at eight years, mortality in the early-surgery group was 7.2 percentage points lower than that in the surveillance group (P=0.03). There was no evidence that age, sex, or the initial size of the aneurysm modified the hazard ratio or that delayed surgery in the surveillance group increased 30-day postoperative mortality. Death was attributable to a ruptured aneurysm in 19 of the 411 men who died (5 percent) and in 12 of the 85 women who died (14 percent) (P=0.001). The rate of early cessation of smoking was higher in the early-surgery group than in the surveillance group.

CONCLUSIONS

Among patients with a small abdominal aortic aneurysm, we found no long-term difference in mean survival between the early-surgery and surveillance groups, although after eight years, total mortality was lower in the early-surgery group. This difference may be attributed in part to beneficial changes in lifestyle adopted by members of the early-surgery group.

Smoking cessation, decline in pulmonary function and total mortality: a 30 year follow up study among the Finnish cohorts of the Seven Countries Study

BACKGROUND

Permanent smoking cessation reduces loss of pulmonary function. Less is known in the long term about individuals who give up smoking temporarily or quitters with lower initial pulmonary function. Little is known also about the relationship between decline in pulmonary function and mortality. We examined these aspects and the association between smoking, decline in pulmonary function, and mortality.

METHODS

Two middle aged male Finnish cohorts of the Seven Countries Study and their re-examinations on five occasions during a 30 year period of follow up were analysed.

RESULTS

During the first 15 years (n=1007) adjusted decline in forced expiratory volume in 0.75 seconds (FEV(0.75)) was 46.4 ml/year in never smokers, 49.3 ml/year in past smokers, 55.5 ml/year in permanent quitters, 55.5 ml/year in intermittent quitters, and 66.0 ml/year in continuous smokers (p<0.001 for trend). Quitters across the entire range of baseline FEV(0.75) had a slower decline in FEV(0.75) than continuous smokers. Among both continuing smokers and never smokers, non-survivors had a significantly (p<0.001) more rapid decline in FEV(0.75) than survivors. The adjusted relative hazard for total mortality was 1.73 (95% confidence interval (CI) 1.41 to 2.11) and 1.24 (95% CI 1.02 to 1.52) in the lowest and middle tertiles of decline in FEV(0.75). Never smokers, past smokers, and quitters had significantly lower total mortality than continuous smokers, partly because of their slower decline in FEV(0.75).

CONCLUSION

These results highlight the positive effect of smoking cessation, even intermittent cessation, on decline in pulmonary function. Accelerated decline in pulmonary function was found to be a risk factor for total mortality. The beneficial effect of smoking cessation on mortality may partly be mediated through a reduced decline in pulmonary function.

Smoking cessation, decline in pulmonary function and total mortality: a 30 year follow up study among the Finnish cohorts of the Seven Countries Study

BACKGROUND

Permanent smoking cessation reduces loss of pulmonary function. Less is known in the long term about individuals who give up smoking temporarily or quitters with lower initial pulmonary function. Little is known also about the relationship between decline in pulmonary function and mortality. We examined these aspects and the association between smoking, decline in pulmonary function, and mortality.

METHODS

Two middle aged male Finnish cohorts of the Seven Countries Study and their re-examinations on five occasions during a 30 year period of follow up were analysed.

RESULTS

During the first 15 years (n=1007) adjusted decline in forced expiratory volume in 0.75 seconds (FEV0.75) was 46.4 ml/year in never smokers, 49.3 ml/year in past smokers, 55.5 ml/year in permanent quitters, 55.5 ml/year in intermittent quitters, and 66.0 ml/year in continuous smokers (p<0.001 for trend). Quitters across the entire range of baseline FEV0.75 had a slower decline in FEV0.75 than continuous smokers. Among both continuing smokers and never smokers, non-survivors had a significantly (p<0.001) more rapid decline in FEV0.75 than survivors. The adjusted relative hazard for total mortality was 1.73 (95% confidence interval (CI) 1.41 to 2.11) and 1.24 (95% CI 1.02 to 1.52) in the lowest and middle tertiles of decline in FEV0.75. Never smokers, past smokers, and quitters had significantly lower total mortality than continuous smokers, partly because of their slower decline in FEV0.75.

CONCLUSION

These results highlight the positive effect of smoking cessation, even intermittent cessation, on decline in pulmonary function. Accelerated decline in pulmonary function was found to be a risk factor for total mortality. The beneficial effect of smoking cessation on mortality may partly be mediated through a reduced decline in pulmonary function.