Tobacco smoking in seven Latin American cities: the CARMELA study

Low-intensity daily smoking and mortality risk among Mexican women

OBJECTIVE

To examine the association between low-intensity smoking (10 or less cigarettes per day) and all-cause and cause-specific mortality risk among women who smoke and by age at cessation among women who previously smoked.

METHODS

In this study, 104 717 female participants of the Mexican Teachers' Cohort Study were categorised according to self-reported smoking status at baseline (2006/2008) and were followed for mortality through 2019. We estimated HRs and 95% CIs for all-cause and cause-specific mortality using multivariable Cox proportional hazards regression models with age as the underlying time metric.

RESULTS

Smoking as few as one to two cigarettes per day was associated with higher mortality risk for all causes (HR: 1.36; 95% CI 1.10 to 1.67) and all cancers (HR: 1.46; 95% CI 1.05 to 2.02), compared with never smoking. Similarly, slightly higher HRs were observed among participants smoking ≥3 cigarettes per day (all causes HR: 1.43; 95% CI 1.19 to 1.70; all cancers HR: 1.48; 95% CI 1.10 to 1.97; cardiovascular disease HR: 1.58; 95% CI 1.09 to 2.28).

CONCLUSIONS

In this large study of Mexican women, low-intensity smoking was associated with higher mortality risk for all causes and all cancers. Interventions are needed to promote cessation among women who smoke at low-intensity in Mexico, regardless of how few cigarettes they smoke per day.

Breast cancer subtype and clinical characteristics in women from Peru

Introduction

Breast cancer is a heterogeneous disease, and the distribution of the different subtypes varies by race/ethnic category in the United States and by country. Established breast cancer-associated factors impact subtype-specific risk; however, these included limited or no representation of Latin American diversity. To address this gap in knowledge, we report a description of demographic, reproductive, and lifestyle breast cancer-associated factors by age at diagnosis and disease subtype for The Peruvian Genetics and Genomics of Breast Cancer (PEGEN-BC) study.

Methods

The PEGEN-BC study is a hospital-based breast cancer cohort that includes 1943 patients diagnosed at the Instituto Nacional de Enfermedades Neoplásicas in Lima, Peru. Demographic and reproductive information, as well as lifestyle exposures, were collected with a questionnaire. Clinical data, including tumor Hormone Receptor (HR) status and Human Epidermal Growth Factor Receptor 2 (HER2) status, were abstracted from electronic medical records. Differences in proportions and mean values were tested using Chi-squared and one-way ANOVA tests, respectively. Multinomial logistic regression models were used for multivariate association analyses.

Results

The distribution of subtypes was 52% HR+HER2-, 19% HR+HER2+, 16% HR-HER2-, and 13% HR-HER2+. Indigenous American (IA) genetic ancestry was higher, and height was lower among individuals with the HR-HER2+ subtype (80% IA vs. 76% overall, p=0.007; 152 cm vs. 153 cm overall, p=0.032, respectively). In multivariate models, IA ancestry was associated with HR-HER2+ subtype (OR=1.38,95%CI=1.06-1.79, p=0.017) and parous women showed increased risk for HR-HER2+ (OR=2.7,95%CI=1.5-4.8, p<0.001) and HR-HER2- tumors (OR=2.4,95%CI=1.5-4.0, p<0.001) compared to nulliparous women. Multiple patient and tumor characteristics differed by age at diagnosis (<50 vs. >=50), including ancestry, region of residence, family history, height, BMI, breastfeeding, parity, and stage at diagnosis (p<0.02 for all variables).

Discussion

The characteristics of the PEGEN-BC study participants do not suggest heterogeneity by tumor subtype except for IA genetic ancestry proportion, which has been previously reported. Differences by age at diagnosis were apparent and concordant with what is known about pre- and post-menopausal-specific disease risk factors. Additional studies in Peru should be developed to further understand the main contributors to the specific age of onset and molecular disease subtypes in this population and develop population-appropriate predictive models for prevention.

Does the association between smoking and mortality differ due to frailty status? A secondary analysis from the Mexican Health and Aging Study

BACKGROUND

despite the well-known adverse health effects of smoking, evidence of these effects on frail individuals is still scarce.

AIMS

to assess whether frailty influences the association between smoking and mortality.

METHODS

individuals ≥50 years from the Mexican Health and Aging Study were analysed. Mortality rates from a 17-year follow-up were compared between smoking status groups (never, previous and current) and other smoking behaviour-related characteristics (pack-years, age commenced and cessation). Baseline variables were included to adjust the Cox regression models. First, models were adjusted for the whole sample, including an interaction term between the frailty index (FI) and smoking variables. A second set of models were stratified by FI levels: 0.00-0.10, 0.11-0.20, 0.21-0.30 and ≥ 0.31.

RESULTS

from a total 14,025 individuals, mean age was 62.4 (95% confidence interval [95% CI]: 62.1-62.8) and 53.9% were women (95% CI: 52.4-55.6). Main results from the survival analyses showed that when including FI interaction term with smoking status, comparing current to never smoking, the hazard ratio (HR) was 2.03 (95% CI: 1.07-3.85, P = 0.029), and comparing current to previous smoking, the HR was 2.13 (95% CI: 1.06-4.26, P = 0.032). Models stratified by FI levels showed a significant HR only for the two highest level groups. Similar results were found for the smoking behaviour-related characteristics.

DISCUSSION

our results suggest that frailty could modify smoking mortality risk. Other smoking characteristics were impacted by frailty, in particular, cessation. It was noteworthy that having ≥10 years of tobacco cessation was beneficial for frail individuals.

CONCLUSIONS

smoking has a higher toll on frail individuals, but ceasing is still beneficial for this group.

Trends and geographical variation in mortality from coronary disease in Peru

Background

Coronary disease (CD) is the main cause of mortality worldwide. Data about trends and geographical variation in CD mortality is available in some American countries. This information varies among countries since CD risk factors frequencies vary.

Objective

To describe the trend and geographical variation of coronary disease (CD) mortality in Peru, 2005–2017.

Methods

Analysis of secondary data of the Peruvian Ministry of Health’s registry of deaths. We analyzed CD mortality. We described the absolute and relative frequency of deaths and age-standardized mortality rate (ASMR) by natural regions, departments, age, sex, and year. We also described the change of ASMR between two periods (2005–2010 vs. 2011–2017).

Results

There were 64,721 CD deaths between 2005 and 2017 (4.12% among all deaths). The absolute frequency of CD deaths was 5,665 and 6,565 in 2005 and 2017, respectively. CD mortality was more frequent in men and older adults. The ASMR varied among natural regions, being higher in the Coast (19.61 per 100,000 inhabitants). The change between the two periods revealed that almost all departments reduced their ASMRs, except for Callao, Lambayeque, and Madre de Dios.

Conclusion

CD mortality has increased in Peru. Mortality was higher in men and older adults, and it varied among departments. More political efforts are needed to reduce these trends.

Direct Oral Anticoagulants vs. Warfarin in Latin American Patients With Atrial Fibrillation: Evidence From Four post-hoc Analyses of Randomized Clinical Trials

Background

Several studies have investigated the effect of direct oral anticoagulants (DOACs) in Latin American patients with atrial fibrillation (AF), but the results remain controversial. Therefore, we aimed to compare the efficacy and safety of DOACs vs. warfarin in Latin American patients with AF.

Methods

We systematically searched the PubMed and Embase databases until November 2021 for studies that compared the effect of DOACs vs. warfarin in Latin patients with AF. Adjusted hazard ratios (HRs) and 95% CIs were pooled by a random-effects model using an inverse variance method.

Results

Four post-hoc analyses of randomized clinical trials (RCTs) involving 42,411 DOACs and 29,270 warfarin users were included. In Latin American patients with AF, for the effectiveness outcomes, the use of DOACs compared with warfarin was significantly associated with decreased risks of stroke or systemic embolism (SSE) (HR = 0.78; 95%CI.64–0.96), stroke (HR = 0.75; 95%CI.57–0.99), hemorrhagic stroke (HR = 0.14; 95%CI.05–0.36), all-cause death (HR = 0.89; 95% CI.80–1.00), but not ischemic stroke and cardiovascular death. For the safety outcomes, compared with warfarin, the use of DOACs was associated with reduced risks of major or non-major clinically relevant (NMCR) bleeding (HR = 0.70; 95% CI.57–0.86), major bleeding (HR = 0.70; 95%CI.53–0.92), intracranial hemorrhage (ICH) (HR = 0.42; 95%CI.24–0.74), or any bleeding (HR = 0.70;95% CI.62–0.78), but not gastrointestinal bleeding. In non-Latin American patients with AF, for the effectiveness outcomes, the use of DOACs compared with warfarin was significantly associated with decreased risks of SSE (HR = 0.87; 95%CI.75–1.00), hemorrhagic stroke (HR = 0.41; 95%CI.28–0.60), cardiovascular death (HR = 0.87; 95% CI.81–0.94), all-cause death (HR = 0.90; 95% CI.85–0.94). Conversely, the risk of myocardial infarction increased (HR = 1.34; 95% CI 1.13–1.60), but not ischemic stroke. For the safety outcomes, compared with warfarin, the use of DOACs was associated with reduced risks of major or NMCR bleeding (HR = 0.75; 95%CI.61–0.92), major bleeding (HR = 0.76; 95%CI.63–0.92), ICH (HR = 0.42; 95%CI.36–0.52), and any bleeding (HR = 0.81; 95% CI.71–0.92), but not gastrointestinal bleeding.

Conclusion

Current pooled data from the four post-hoc analyses of RCTs suggested that compared with warfarin, DOACs appeared to have significant reductions in SSE, stroke, hemorrhagic stroke, all-cause death, major or NMCR bleeding, major bleeding, ICH, and any bleeding, but comparable risks of ischemic stroke, cardiovascular death, and gastrointestinal bleeding in Latin American patients with AF. DOACs appeared to have significant reductions in SSE, hemorrhagic stroke, all-cause death, cardiovascular death, major or NMCR bleeding, major bleeding, ICH, and any bleeding, and increased the risk of myocardial infarction, but comparable risks of stroke, ischemic stroke, and gastrointestinal bleeding in non-Latin American patients with AF.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Prevalence and determinants of tobacco use amongst South African adults with mental illness in the Eastern Cape

Background

Given the physical and mental health consequences of tobacco use amongst individuals with mental illness, it was imperative to assess the burden of tobacco use in this population.

Aim

This study examined the patterns and factors associated with tobacco use in individuals attending the outpatient unit.

Setting

Cecilia Makiwane Hospital Mental Health Department in Eastern Cape province, South Africa.

Methods

Lifetime (ever use) use and current use of any tobacco products were examined in a cross-sectional study of 390 individuals between March and June 2020. A logistic regression was fitted to determine the correlates of lifetime and current use of any tobacco products.

Results

The rates of ever use and current use of tobacco products were 59.4% and 44.6%, respectively. Of the participants interviewed, lifetime tobacco use was more prevalent amongst individuals with schizophrenia (67.9%) and cannabis-induced disorders (97.3%) and lower in those with major depressive disorders (36.1%) and bipolar and related disorders (43.5%). Men were six times more likely to have ever used or currently use tobacco products in comparison to women. Also, those who had a salaried job or owned a business were over three times more likely to have ever used or currently use tobacco products compared with those receiving government social grants.

Conclusions

The prevalence of tobacco use in this study was significantly higher than the general population in the Eastern Cape. Therefore, smoking prevention and cessation interventions targeted at the general population should target this often neglected sub-population in the region.

Adolescent Tobacco Exposure in 31 Latin American Cities before and after the Framework Convention for Tobacco Control

Our objective was to describe the prevalence and changes in tobacco use and tobacco control policies in Latin American countries and cities before and after ratification of the 2003 Framework Convention on Tobacco Control (FCTC). Country-level tobacco policy data came from reports on the global tobacco epidemic (World Health Organization, 2007-2014). Global Youth Tobacco Survey data, 2000-2011, came from six countries (Argentina, Brazil, Chile, Colombia, Mexico, Peru), 31 cities and 132,065 students. Pre- and post-FCTC prevalence and relative changes were estimated. All countries showed improvements in tobacco control policies but Mexico and Peru showed the smallest improvements. In general, adolescents reduced their tobacco use, reported less exposure to smoking at home, more tobacco education, and more retailer refusals to sell them cigarettes. Adolescents reported smaller reductions in secondhand smoke exposure outside the home and no change in exposure to tobacco media/promotions. Pre-FCTC prevalence and relative changes during the post-FCTC period were more heterogeneous across cities than across countries. Despite overall improvements in tobacco policies and the decline in exposure to tobacco, policies related to media/promotions and secondhand smoke need strengthening. There was wide variation in adolescent exposure to tobacco between cities (within countries), which suggested major heterogeneity of policy implementation at the local level.

Peripheral Artery Disease in Type 2 Diabetes Mellitus: Survival Analysis of an Ecuadorian Population in Primary Care

Background

Peripheral artery disease (PAD) is associated with cardiovascular risk in type 2 diabetes mellitus (DM). The ankle-brachial index (ABI) is used for diagnosis of PAD.

Objectives

Establish the prevalence and incidence rate for PAD and determine the associated factors and survival time for the development of PAD.

Methods

Retrospective cross-sectional cohort study (follow up: 10 years) in 578 DM patients with at least 1 ABI measurement in a primary level of care diabetes clinic. Data was collected from clinical records. Sociodemographic and laboratory variables were analyzed determining its association (mean difference and bivariate logistic regression). Survival was calculated through life tables and Kaplan-Meier analysis.

Results

The prevalence of PAD was 13.98%. The incidence rate through the time of follow up was 23.38 per 1000 person-year (95% CI: 19.91-27.26). The group that developed PAD showed higher glycated hemoglobin levels ( P = .025), more years of DM ( P < .001) and lower glomerular filtration rate (GFR, P = .003). The median time for developing PAD was 26.97 years (95% CI: 26.89-27.05). The risk for PAD was higher in females (95% CI: 1.51-4.38), GFR <60 mL/min/m2 (95% CI: 1.05-2.22) and use of metformin plus insulin (95% CI: 1.10-2.35).

Conclusion

Half of a DM patient’s population in primary level of care will develop PAD in the third decade of disease. There are identifiable risk factors for PAD development in DM in the primary level of care such as low GFR, female sex, and use of metformin plus insulin.

Lung Cancer in the Young

INTRODUCTION

Median age at diagnosis of lung cancer is 70 years. Its presentation in patients 40 or younger is uncommon and it has been proposed that maybe it is a different disease due to its clinical characteristics and genetic makeup. There are a limited number of studies in this population and they report different clinic-pathological characteristics in comparison with older patients.

METHODS

We described the incidence of lung cancer patients diagnosed at age 40 or younger at the Instituto Nacional de Enfermedades Neoplasicas (INEN), Lima-Peru; from 2009 to 2017 and evaluated the characteristic of NSCLC. Epidemiologic and clinic-pathological data was collected from clinical files. Analysis was carried out using SPSSvs19 software.

RESULTS

We identified 3823 patients with lung cancer seen at INEN during the study period. Among these, 166 (4.3%) patients were 40 years or younger, and 137/166 (82.5%) were NSCLC. Median age at diagnosis was 36 years (range 14-40 years) and 59.1% of patients were female. A smoking history was present in 14.4% of patients. Frequent symptoms at diagnosis were cough (62.0%), chest pain (51.8%) and dyspnea (40.9%). Adenocarcinoma was the most common histological type (63.3%). Most patients had advanced disease at diagnosis (84.7%). The median overall survival was 8.2 months.

CONCLUSIONS

The proportion of young patients with lung cancer in our population is higher than that reported in the most recent literature. Lung cancer in the young is mostly sporadic, more frequent in women, usually adenocarcinoma type and it presents with advanced disease, resulting in a very poor survival.

Prevalence and determinants of cardiovascular disease risk factors using the WHO STEPS approach in Cochabamba, Bolivia

BACKGROUND

Cardiovascular diseases (CVDs) are considered the number one cause of death worldwide, especially in low- and middle-income countries, Bolivia included. Lack of reliable estimates of risk factor distribution can lead to delay in implementation of evidence-based interventions. However, little is known about the prevalence of risk factors in the country. The aim of this study was to assess the prevalence of preventable risk factors associated with CVDs and to identify the demographic and socioeconomic factors associated with them in Cochabamba, Bolivia.

METHODS

A cross-sectional community-based study was conducted among youth and adults (N = 10,704) with permanent residence in Cochabamba, selected through a multistage sampling technique, from July 2015 to November 2016. An adapted version of the WHO STEPS survey was used to collect information. The prevalence of relevant behavioural risk factors and anthropometric measures were obtained. The socio-demographic variables included were age, ethnicity, level of education, occupation, place of residence, and marital status. Proportions with 95% confidence intervals were first calculated, and prevalence ratios were estimated for each CVD risk factor, both with crude and adjusted models.

RESULTS

More than half (57.38%) were women, and the mean age was 37.89 ± 18 years. The prevalence of behavioural risk factors were: current smoking, 11.6%; current alcohol consumption, 42.76%; low consumption of fruits and vegetables, 76.73%; and low level of physical activity, 64.77%. The prevalence of overweight was 35.84%; obesity, 20.49%; waist risk or abdominal obesity, 54.13%; and raised blood pressure, 17.5%. Indigenous populations and those living in the Andean region showed in general a lower prevalence of most of the risk factors evaluated.

CONCLUSION

We provide the first CVD risk factor profile of people living in Cochabamba, Bolivia, using a standardized methodology. Overall, findings suggest that the prevalence of CVD risk factors in Cochabamba is high. This result highlights the need for interventions to improve early diagnosis, monitoring, management, and especially prevention of these risk factors.

Low cigarette smoking prevalence in peri-urban Peru: results from a population-based study of tobacco use by self-report and urine cotinine

Background

A recent study found lower self-reported prevalence of tobacco smoking in a peri-urban area of Lima, Peru than previously reported in urban samples. These regions encompass substantial proportions of Peru’s population – ones at greater risk of disease due to reduced healthcare access – but have been less often studied. We validate low smoking prevalence with urine cotinine and characterize chronic disease and lung function outcomes between non-, occasional, and daily smokers.

Methods

Data are from the CRONICAS Cohort Study, a population-based longitudinal study in four low-resource Peruvian settings, which began in 2010. Of a baseline cohort of 2978 adults, we prospectively followed 2583 (87%) to determine prevalence of chronic illness.

Results

In a baseline sub-sample of 382 participants, median adjusted cotinine was 0.0 mcg/mg (IQR 0–0) for both self-reported non-smokers and occasional smokers compared to 172.3 mcg/mg (IQR 0–709.2) for daily smokers. Creatinine-adjusted cotinine validated daily smoking prevalence of 4.7% at a cutoff of 100 mcg/mg. Kappa statistic for daily smoking and creatinine- adjusted cotinine ≥100 mcg/mg was 0.65 (95% CI 0.47, 0.83), indicating substantial agreement. At baseline, we found 3.3% daily and 8.9% occasional smoking by self-report for the full cohort. Follow-up indicated little difference in chronic disease prevalence between groups. Daily smokers trended toward having a greater decline in FVC (−1%; 95% CI -2.9, 0.8) and FEV₁ (−1.3%; 95% CI -3.2, 0.6) over 40 months when compared to non-smokers, whereas the decline in lung function for occasional smokers was similar compared to non-smokers (−0.2% FVC; 95% CI -1.5, 1.0) and (0% FEV₁; 95% CI -1.3, 1.3).

Conclusions

Our data places Peru within a previously-described pattern of smoking found in much of Latin America, favoring occasional over daily smoking and low cigarette consumption. We determine that there are not significant differences between smoking groups concerning chronic disease outcomes. We favor distinguishing between daily and occasional smokers in order to accurately characterize these low-use populations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12971-017-0137-8) contains supplementary material, which is available to authorized users.

Smoking and heavy drinking patterns in rural, urban and rural-to-urban migrants: the PERU MIGRANT Study

Background

Previous studies have found mixed results about cigarette and alcohol consumption patterns among rural-to-urban migrants. Moreover, there are limited longitudinal data about consumption patterns in this population. As such, this study aimed to compare the smoking and heavy drinking prevalence among rural, urban, and rural-to-urban migrants in Peru, as well as the smoking and heavy drinking incidence in a 5-year follow-up.

Methods

We analyzed the PERU MIGRANT Study data from rural, urban, and rural-to-urban migrant populations in Peru. The baseline study was carried out in 2006–2007 and follow-up was performed five years later. For the baseline data analysis, the prevalence of lifetime smoking, current smokers, and heavy drinking was compared by population group using prevalence ratios (PR) and 95% confidence intervals (95% CI). For the longitudinal analysis, the incidence of smoking and heavy drinking was compared by population group with risk ratios (RR) and 95% CI. Poisson regression with robust variance was used to calculate both PRs and RRs.

Results

We analyzed data from 988 participants: 200 rural dwellers, 589 migrants, and 199 urban dwellers. Compared with migrants, lifetime smoking prevalence was higher in the urban group (PR = 2.29, 95% CI = 1.64–3.20), but lower in the rural group (PR = 0.55, 95% CI = 0.31–0.99). Compared with migrants, the urban group had a higher current smoking prevalence (PR = 2.29, 95% CI = 1.26–4.16), and a higher smoking incidence (RR = 2.75, 95% CI = 1.03–7.34). Current smoking prevalence and smoking incidence showed no significant difference between rural and migrant groups. The prevalence and incidence of heavy drinking was similar across the three population groups.

Conclusions

Our results show a trend in lifetime smoking prevalence (urban > migrant > rural), while smoking incidence was similar between migrant and rural groups, but higher in the urban group. In addition, our results suggest that different definitions of smoking status could lead to different smoking rates and potentially different measures of association. The prevalence and incidence of heavy drinking were similar between the three population groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4080-7) contains supplementary material, which is available to authorized users.

Cigarette smoking, dietary habits and genetic polymorphisms in GSTT1, GSTM1 and CYP1A1 metabolic genes: A case-control study in oncohematological diseases

AIM

To analyze the association between oncohematological diseases and GSTT1/GSTM1/CYP1A1 polymorphisms, dietary habits and smoking, in an argentine hospital-based case-control study.

METHODS

This hospital-based case-control study involved 125 patients with oncohematological diseases and 310 control subjects. A questionnaire was used to obtain sociodemographic data and information about habits. Blood samples were collected, and DNA was extracted using salting out methods. Deletions in GSTT1 and GSTM1 (null genotypes) were addressed by PCR. CYP1A1 MspI polymorphism was detected by PCR-RFLP. Odds ratio (OR) and 95%CI were calculated to estimate the association between each variable studied and oncohematological disease.

RESULTS

Women showed lower risk of disease compared to men (OR 0.52, 95%CI: 0.34-0.82, P = 0.003). Higher levels of education (> 12 years) were significantly associated with an increased risk, compared to complete primary school or less (OR 3.68, 95%CI: 1.82-7.40, P < 0.001 adjusted for age and sex). With respect to tobacco, none of the smoking categories showed association with oncohematological diseases. Regarding dietary habits, consumption of grilled/barbecued meat 3 or more times per month showed significant association with an increased risk of disease (OR 1.72, 95%CI: 1.08-2.75, P = 0.02). Daily consumption of coffee also was associated with an increased risk (OR 1.77, 95%CI: 1.03-3.03, P = 0.03). Results for GSTT1, GSTM1 and CYP1A1 polymorphisms showed no significant association with oncohematological diseases. When analyzing the interaction between polymorphisms and tobacco smoking or dietary habits, no statistically significant associations that modify disease risk were found.

CONCLUSION

We reported an increased risk of oncohematological diseases associated with meat and coffee intake. We did not find significant associations between genetic polymorphisms and blood cancer.

Regional research priorities in brain and nervous system disorders

The characteristics of neurological, psychiatric, developmental and substance-use disorders in low- and middle-income countries are unique and the burden that they have will be different from country to country. Many of the differences are explained by the wide variation in population demographics and size, poverty, conflict, culture, land area and quality, and genetics. Neurological, psychiatric, developmental and substance-use disorders that result from, or are worsened by, a lack of adequate nutrition and infectious disease still afflict much of sub-Saharan Africa, although disorders related to increasing longevity, such as stroke, are on the rise. In the Middle East and North Africa, major depressive disorders and post-traumatic stress disorder are a primary concern because of the conflict-ridden environment. Consanguinity is a serious concern that leads to the high prevalence of recessive disorders in the Middle East and North Africa and possibly other regions. The burden of these disorders in Latin American and Asian countries largely surrounds stroke and vascular disease, dementia and lifestyle factors that are influenced by genetics. Although much knowledge has been gained over the past 10 years, the epidemiology of the conditions in low- and middle-income countries still needs more research. Prevention and treatments could be better informed with more longitudinal studies of risk factors. Challenges and opportunities for ameliorating nervous-system disorders can benefit from both local and regional research collaborations. The lack of resources and infrastructure for health-care and related research, both in terms of personnel and equipment, along with the stigma associated with the physical or behavioural manifestations of some disorders have hampered progress in understanding the disease burden and improving brain health. Individual countries, and regions within countries, have specific needs in terms of research priorities.

Socioeconomic variations in nicotine dependence in rural southwest China

Background

This study examines how nicotine dependence is distributed across socioeconomic gradients in rural Yunnan province, which has the most ethnic minorities in one province in southwest China.

Methods

A cross-sectional survey was conducted in four rural areas of Yunnan province among 17,158 consenting individuals aged ≥18 years in 2011. Information on demographic characteristics and smoking habits was obtained using a standard questionnaire. The Fagerstrom Test for Nicotine Dependence (FTND) was applied to assess nicotine dependence. Multilevel logistic regression was used to model the variation in prevalence of nicotine dependence.

Results

In the study population, the overall prevalence of current smokers and nicotine dependence was 32.4 % and 31.6 %, respectively. Females were much less likely to have nicotine addiction than males: odds ratio (OR) of 0.01 (95 % CI: 0.008 – 0.012). Higher annual household income was associated with a greater risk of nicotine dependence (OR 1.09, 95 % CI: 1.01 – 1.17). Adults who grew tobacco were more likely to have nicotine addiction (OR 1.22, 95 % CI 1.07 – 1.41). Individual educational level was inversely associated with the probability of nicotine dependence (OR 0.63, 95 % CI 0.55 – 0.72), lower community educational level was also associated with an increased risk of nicotine dependence (OR 0.94, 95 % CI 0.92 – 0.98).

Conclusions

Nicotine dependence showed significant variations across different indicators of both contextual and individual socioeconomic status in rural southwest China. Future interventions on tobacco cessation should give increased attention to men, tobacco farmers, less educated or poorer persons, and lower educational level communities.

Association between exposure to household cigarette smoking behavior and cigarette smoking in Hispanic adults: Findings from the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Cigarette smoking behavior is highly determined by social influences during childhood and adolescence. This phenomenon has not been fully evaluated in the Hispanic/Latino population.

PURPOSE

To examine the association between exposure to household cigarette smoking behavior (HCSB) and adult cigarette smoking among a diverse Hispanic/Latino population living in four US urban centers. The effect of acculturation on cigarette smoking was also evaluated.

METHODS

Data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) (n=13,231, ages 18-74years, collected between March 2008 and June 2011) were analyzed using logistic regression.

RESULTS

HCSB exposure was an independent risk factor for adult current cigarette smoking in Hispanic/Latinos (OR 1.7; 95% CI 1.4, 2.1) after controlling for relevant confounders including socio-demographic and cultural factors. Cubans and Puerto Ricans had the highest prevalence of HCSB exposure (59% and 47% respectively) and highest prevalence of current cigarette smoking (26% and 32%) compared with other Hispanic/Latino groups, (p<.01).

CONCLUSIONS

Our data suggest that exposure to HCSB in Hispanics/Latinos living in the US is an independent predictor of adult cigarette smoking, and this association appears to be strongest in Cubans and Puerto Ricans.

Delivery by caesarean section and risk of childhood obesity: analysis of a Peruvian prospective cohort

Objectives. We aimed to assess if Caesarean section is a risk factor for overnutrition in early- and late-childhood, and to assess the magnitude of the effect of child- versus family-related variables in these risk estimates.

Methods. Longitudinal data from Peruvian children from the Young Lives Study was used. Outcomes assessed were overweight, obesity, overnutrition (overweight plus obesity), and central obesity (waist circumference) at the age 5 (first follow-up) and 7 (second follow-up) years. The exposure of interests was delivery by Caesarean section. Relative risks (RR) and 95% confidence intervals (95% CI) were calculated using multivariable models adjusted for child-related (e.g., birth weight) and family-related (e.g., maternal nutritional status) variables.

Results. At baseline, mean age was 11.7 (± 3.5) months and 50.1% were boys. Children born by Caesarean section were 15.6%. The 10.5% of the children were overweight and 2.4% were obese. For the obesity outcome, data from 6,038 and 9,625 children-years was included from baseline to the first and second follow-up, respectively. Compared to those who did not experience Caesarean delivery, the risk of having obesity was higher in the group born by Caesarean: RRs were higher at early-childhood (first follow-up: 2.25; 95% CI [1.36–3.74]) than later in life (second follow-up: 1.57; 95% CI [1.02–2.41]). Family-related variables had a greater effect in attenuating the risk estimates for obesity at the first, than at the second follow-up.

Conclusion. Our results suggest a higher probability of developing obesity, but not overweight, among children born by Caesarean section delivery. The magnitude of risk estimates decreased over time, and family-related variables had a stronger effect on the risk estimates at early-childhood.

Prevalence and profile of daily smokers seen at three primary health care units in Pelotas, southern Brazil

OBJECTIVES

To estimate the prevalence of daily smoking among users of three primary health care units affiliated with a university hospital in the municipality of Pelotas, southern Brazil, and to identify factors associated with daily tobacco consumption.

METHODS

This cross-sectional study included all individuals over 14 years of age who sought treatment at the health care units between June 29, 2009, and February 23, 2010, and lived in the area covered by the unit. Interviews were conducted during home visits to collect data on sociodemographic characteristics and health behaviors; the Mini International Neuropsychiatric Interview (MINI) was used to assess the presence of mood disorders; and a question from the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) on the daily use of tobacco in the past 3 months was used to assess smoking.

RESULTS

The total sample comprised 1,848 individuals, mostly female (72.9%), aged between 46 and 60 years (28.5%), and belonging to socioeconomic class C (61%). The prevalence of daily smoking was 23.4% (n = 432), and there was a statistically significant difference between men and women: 27 vs. 22.1% (p < 0.050).

CONCLUSION

Our findings confirm a high prevalence of smoking among users of primary health care units, underscoring the need for a more accurate process of diagnosis and treatment at these facilities.

The enduring effects of smoking in Latin America

OBJECTIVES

We estimated smoking-attributable mortality, assessed the impact of past smoking on recent mortality, and computed expected future losses in life expectancy caused by past and current smoking behavior in Latin America and the Caribbean.

METHODS

We used a regression-based procedure to estimate smoking-attributable mortality and information for 6 countries (Argentina, Brazil, Chile, Cuba, Mexico, and Uruguay) for the years 1980 through 2009 contained in the Latin American Mortality Database (LAMBdA). These countries jointly comprise more than two thirds of the adult population in Latin America and the Caribbean and have the region's highest rates of smoking prevalence.

RESULTS

During the last 10 years, the impact of smoking was equivalent to losses in male (aged ≥ 50 years) life expectancy of about 2 to 6 years. These effects are likely to increase, particularly for females, both in the study countries and in those that joined the epidemic at later dates.

CONCLUSIONS

Unless innovations in the detection and treatment of chronic diseases are introduced soon, continued gains in adult survival in Latin America and the Caribbean region may slow down considerably.

Nicotine dependence in an isolated population of Kashubians from North Poland: a population survey

BACKGROUND

Tobacco use is a complex, multistage behaviour. The particular stages of this behaviour, including nicotine dependence (ND), are influenced by both genetics and the environment. Surveys on factors influencing tobacco use and ND, conducted in ethnically homogenous populations, can provide results less influenced by genetic and cultural heterogeneity. We aimed to assess ND in a sample of current smokers, derived from the geographically and culturally isolated population of Kashubians from North Poland, and evaluate its potential association with age, sex, and self-reported comorbidities. In addition, we attempted to replicate - for the first time in this population - previous findings on the association between ND and several variants within the CHRNA5A3-A5-B4 nicotine receptor subunit gene cluster.

METHODS

The study sample consisted of 969 unrelated subjects who were all current smokers. ND was evaluated using four measures: the Fagerstrom Test for Nicotine Dependence (FTND), the Heavy Smoking Index (HSI), the number of cigarettes per day (CPD) and the time to first cigarette after waking (TTF). All subjects underwent genotyping for CHRNA5 rs16969968, CHRNA3 rs578776, and CHRNB4 rs12914008 variants. Multivariate regression analysis was used for the assessment of the studied correlations. A significance level of 0.05 with the Bonferroni correction for multiple testing was set for a type 1 error in the analyses.

RESULTS

The mean CPD, FTND and HSI scores in the study sample were 17.3 ± 7.7, 3.9 ± 2.3 and 2.6 ± 1.5, respectively. No association between ND defined by FTND, HSI or TTF and age was found. In turn, heavy smoking was significantly associated with older age (odds ratio (OR) = 1.72, 95% confidence interval (CI): 1.14-2.59, p = 0.009), and men were more likely than women to be heavy smokers (OR = 1.70, 95% CI: 1.09-2.65, p = 0.018). Chronic comorbidity did not significantly influence ND. An analysis of association of studied polymorphisms with ND showed a borderline association of rs16969968 with CPD (OR = 1.63, 95% CI: 1.09-2.45, p = 0.017).

CONCLUSION

Our study showed a low to moderate level of ND in the Kashubians, influenced by age, sex, as well as the CHRNA5 rs16969968 variant.

Current perspective of the impact of smoking on the progression and treatment of periodontitis

This literature review provides an overview of the current scenario regarding the impact of smoking on the progression and treatment of periodontitis; clinical, microbiological and immunological data from studies from our and other groups are presented. In general, preclinical and clinical data are unanimous in demonstrating that smokers present increased susceptibility, greater severity and faster progression of periodontal disease compared with nonsmokers. The evidence further demonstrates that smokers lose more teeth and have a less favorable response to therapy than do nonsmokers. Although it is well established that smoking significantly impacts on the onset, progression and outcome of periodontal disease, the mechanisms involved remain unclear. More importantly, some of the reported deleterious effects of smoking on periodontal tissues have been reported to be reversible upon participation in smoking-cessation programs. Therefore, clinicians should strongly advise smokers to enroll in cessation strategies, even temporarily, in order to improve the overall outcome.

Smoking and perceived stress in relation to short salivary telomere length among caregivers of children with disabilities

Telomere length (TL), the length of repeated DNA sequence that forms protective caps at the end of chromosomes, has emerged as a novel biomarker of cell aging and oxidative stress. There is increasing research exploring the associations of smoking and perceived stress with TL, and the results are inconsistent. This study aimed to examine whether smoking and perceived stress were associated with shortened salivary TL among primary caregivers of children with disabilities. Using a quantitative polymerase chain reaction method, salivary TL was assessed among 89 caregivers aged 19-69 years (87% were women) who took care of disabled children in the Patagonia Region, Chile. Interviewer-administered questionnaires were used to collect information on sociodemographic and lifestyle factors. The 14-item Perceived Stress Scale was used to assess perceived stress. Mean relative TL was 0.92 (standard error = 0.03). Smokers had age-adjusted mean TL that was 0.07 units lower (β = -0.07, standard error = 0.03; p = 0.012) than non-smokers. Smokers were 2.17 times more likely to have shorter TL ( < 0.73, the lowest quartile of TL) than non-smokers (odds ratio = 3.17; 95% confidence interval = 1.05-9.52) with adjustment for age and perceived stress. Caregivers with higher perceived stress were 2.13 times more likely to have shorter TL (odds ratio = 3.13; 95% confidence interval = 1.03-9.55) than caregivers with lower perceived stress after adjustment for age and smoking. This study provides the first evidence of strong associations between smoking and perceived stress and shortened salivary TL among caregivers of children with disabilities. Larger studies with detailed information on smoking status are warranted to confirm our findings.

Prevalence of obesity, tobacco use, and alcohol consumption by socioeconomic status among six communities in Nicaragua

OBJECTIVE

To describe the prevalence of noncommunicable disease (NCD) risk factors (overweight/obesity, tobacco smoking, and alcohol consumption) and identify correlations between these and sociodemographic characteristics in western and central Nicaragua.

METHODS

This was a cross-sectional study of 1 355 participants from six communities in Nicaragua conducted in September 2007-July 2009. Demographic and NCD risk-related health behavior information was collected from each individual, and their body mass index (BMI), blood pressure, diabetes status, and renal function were assessed. Data were analyzed using descriptive statistics, bivariate analyses, and (non-stratified and stratified) logistic regression models.

RESULTS

Of the 1 355 study participants, 22.0% were obese and 55.1% were overweight/obese. Female sex, higher income, and increasing age were significantly associated with obesity. Among men, lifelong urban living correlated with obesity (Odds Ratio [OR] = 4.39, 1.18-16.31). Of the total participants, 31.3% reported ever smoking tobacco and 47.7% reported ever drinking alcohol. Both tobacco smoking and alcohol consumption were strikingly more common among men (OR = 13.0, 8.8-19.3 and 15.6, 10.7-22.6, respectively) and lifelong urban residents (OR = 2.42, 1.31-4.47 and 4.10, 2.33-7.21, respectively).

CONCLUSIONS

There was a high prevalence of obesity/overweight across all income levels. Women were much more likely to be obese, but men had higher rates of tobacco and alcohol use. The rising prevalence of NCD risk factors among even the poorest subjects suggests that an epidemiologic transition in underway in western and central Nicaragua whereby NCD prevalence is shifting to all segments of society. Raising awareness that health clinics can be used for chronic conditions needs to be priority.

Planning cancer control in Latin America and the Caribbean

Non-communicable diseases, including cancer, are overtaking infectious disease as the leading health-care threat in middle-income and low-income countries. Latin American and Caribbean countries are struggling to respond to increasing morbidity and death from advanced disease. Health ministries and health-care systems in these countries face many challenges caring for patients with advanced cancer: inadequate funding; inequitable distribution of resources and services; inadequate numbers, training, and distribution of health-care personnel and equipment; lack of adequate care for many populations based on socioeconomic, geographic, ethnic, and other factors; and current systems geared toward the needs of wealthy, urban minorities at a cost to the entire population. This burgeoning cancer problem threatens to cause widespread suffering and economic peril to the countries of Latin America. Prompt and deliberate actions must be taken to avoid this scenario. Increasing efforts towards prevention of cancer and avoidance of advanced, stage IV disease will reduce suffering and mortality and will make overall cancer care more affordable. We hope the findings of our Commission and our recommendations will inspire Latin American stakeholders to redouble their efforts to address this increasing cancer burden and to prevent it from worsening and threatening their societies.

Patterns and socioeconomic influences of tobacco exposure in tobacco cultivating rural areas of Yunnan Province, China

Background

This study describes the patterns and socioeconomic influences of tobacco use among adults in tobacco-cultivating regions of rural southwest China.

Methods

A cross-sectional survey was conducted in 8681 adults aged ≥18 years in rural areas of Yunnan Province, China from 2010 to 2011. A standardized questionnaire was administered to obtain data about participants’ demographic characteristics, individual socioeconomic status, ethnicity, self-reported smoking habits, and exposure to secondhand smoke (SHS). The socioeconomic predictors of current smoking, nicotine addiction, and SHS exposure were analyzed using multivariate logistic regression.

Results

The prevalence rates of tobacco use were much higher in men compared with women (current smoking 68.5% vs. 1.3%; and nicotine dependence 85.2% vs. 72.7%). However, the rate of SHS exposure was higher in women compared with men (76.6% vs. 70.5%). Tobacco farmers had higher prevalence rates of current smoking, nicotine dependence, and SHS exposure compared with participants not engaged in tobacco farming (P<0.01). Most tobacco users (84.5%) reported initiating smoking during adolescence. A total of 81.1% of smokers smoked in public places, and 77.6% smoked in workplaces. Individuals belonging to an ethnic minority had a lower probability of SHS exposure and nicotine dependence. Individual educational level was found to be inversely associated with the prevalence of current smoking, exposure to SHS, and nicotine dependence. Higher annual household income was associated with a greater risk of nicotine dependence.

Conclusions

This study suggests that tobacco control efforts in rural southwest China must be tailored to address tobacco-cultivating status and socioeconomic factors.

Pulse wave velocity as marker of preclinical arterial disease: reference levels in a uruguayan population considering wave detection algorithms, path lengths, aging, and blood pressure

Carotid-femoral pulse wave velocity (PWV) has emerged as the gold standard for non-invasive evaluation of aortic stiffness; absence of standardized methodologies of study and lack of normal and reference values have limited a wider clinical implementation. This work was carried out in a Uruguayan (South American) population in order to characterize normal, reference, and threshold levels of PWV considering normal age-related changes in PWV and the prevailing blood pressure level during the study. A conservative approach was used, and we excluded symptomatic subjects; subjects with history of cardiovascular (CV) disease, diabetes mellitus or renal failure; subjects with traditional CV risk factors (other than age and gender); asymptomatic subjects with atherosclerotic plaques in carotid arteries; patients taking anti-hypertensives or lipid-lowering medications. The included subjects (n = 429) were categorized according to the age decade and the blood pressure levels (at study time). All subjects represented the “reference population”; the group of subjects with optimal/normal blood pressures levels at study time represented the “normal population.” Results. Normal and reference PWV levels were obtained. Differences in PWV levels and aging-associated changes were obtained. The obtained data could be used to define vascular aging and abnormal or disease-related arterial changes.

Epidemiology of tobacco use and dependence in adults in a poor peri-urban community in Lima, Peru

BACKGROUND

Tobacco smoking is an important public health concern worldwide leading to both chronic disease and early death. In Latin America, smoking prevalence is estimated at approximately 30% and prior studies suggest that the prevalence in Peru is 22% to 38%. We sought to determine the prevalence of daily smoking in a poor peri-urban community in Lima, Peru.

METHODS

We conducted a cross-sectional survey in a random sample of adults ≥40 years of age living in Pampas de San Juan de Miraflores, Lima, Peru. We asked participants to respond to a survey that included questions on sociodemographics, tobacco use and dependence.

RESULTS

We enrolled 316 participants. Average monthly household income was ≤ 400 USD and nearly all homes had running water, sewage, and electricity. Most individuals had not completed high school. Smoking prevalence was 16% overall, yet daily smoking prevalence was 1.9%. Former daily smokers comprised 3.8% of current nonsmokers and 9.1% current occasional smokers. Average scores for the Fagerstrom Test for Nicotine Dependence for daily smokers and occasional smokers were 1.5 and 0, respectively.

CONCLUSIONS

Daily use of tobacco is uncommon among adults in peri-urban communities of Lima, Peru, unlike their counterparts in Lima and other Latin American capital cities. Tobacco dependence is also low. Hence, efforts aimed at primary prevention are of utmost importance in these communities. This study provides an accurate baseline using an internationally recognized assessment tool (Global Adult Tobacco Survey), allowing for accurate assessment of tobacco control interventions over time.

Prevalence of hypertension and associated risk factors in six Nicaraguan communities

OBJECTIVE

Describe the prevalence of hypertension.

DESIGN

Population based cross-sectional survey.

SETTING

Six Nicaraguan communities with varying economies.

PARTICIPANTS

1,355 adults aged 20-60 years who completed both self-reported and quantitative measures of health.

MAIN OUTCOME MEASURES

Prevalence of hypertension (systolic > or = 140 mm Hg, diastolic > or = 90 mm Hg, or self-reported medical history with diagnosis by a health care professional), uncontrolled hypertension (systolic > or = 140 mm Hg or diastolic > or = 90 mm Hg), diabetes (urinary glucose excretion > or = 100 mg/ dL or self-reported medical history diagnosed by a health care professional), and uncontrolled diabetes (urinary glucose excretion > or =100 mg/dL only).

RESULTS

The prevalence of hypertension was 22.0% (19.2% in men, 24.2% in women). Blood pressure was controlled in 31.0% of male hypertensives and 55.1% of female hypertensives (odds ratio [OR] 2.86; 95% confidence interval [Cl] 1.74-4.69). Older age and higher body mass index were strongly associated with hypertension. Women who completed primary school had a lower risk of hypertension (OR .40; 95% Cl .19-.85) compared to those with no formal education. A history of living in both urban and rural settings was associated with lower prevalence of hypertension (OR .52; 95% CI .34-.79). Diabetes mellitus was found in 1.2% of men and 4.3% of women. Male sex was independently associated with decreased risk of diabetes (OR .31; 95% Cl .11-.86).

CONCLUSIONS

At least one cardiovascular risk factor was found in half of this Nicaraguan sample. Cardiovascular risk factors should be the target of educational efforts, screening, and treatment.

Integrated Evaluation of Age-Related Changes in Structural and Functional Vascular Parameters Used to Assess Arterial Aging, Subclinical Atherosclerosis, and Cardiovascular Risk in Uruguayan Adults: CUiiDARTE Project

This work was carried out in a Uruguayan (South American) population to characterize aging-associated physiological arterial changes. Parameters markers of subclinical atherosclerosis and that associate age-related changes were evaluated in healthy people. A conservative approach was used and people with nonphysiological and pathological conditions were excluded. Then, we excluded subjects with (a) cardiovascular (CV) symptoms, (b) CV disease, (c) diabetes mellitus or renal failure, and (d) traditional CV risk factors (other than age and gender). Subjects (n = 388) were submitted to non-invasive vascular studies (gold-standard techniques), to evaluate (1) common (CCA), internal, and external carotid plaque prevalence, (2) CCA intima-media thickness and diameter, (3) CCA stiffness (percentual pulsatility, compliance, distensibility, and stiffness index), (4) aortic stiffness (carotid-femoral pulse wave velocity), and (5) peripheral and central pressure wave-derived parameters. Age groups: ≤20, 21-30, 31-40, 41-50, 51-60, 61-70, and 71-80 years old. Age-related structural and functional vascular parameters profiles were obtained and analyzed considering data from other populations. The work has the strength of being the first, in Latin America, that uses an integrative approach to characterize vascular aging-related changes. Data could be used to define vascular aging and abnormal or disease-related changes.

Global teens and tobacco: a review of the globalization of the tobacco epidemic

Worldwide, the burden of suffering to children caused by tobacco does not just originate from exposure to tobacco smoke or smoking, but includes exposure to tobacco-friendly media, poverty associated with money spent on tobacco, increased incidence of tobacco-related fires, and the harms related to child labor in tobacco cultivation. Despite global efforts through human rights acts, the Framework Convention on Tobacco Control, and the MPOWER report, tobacco use continues to accelerate in most countries. While the efforts that have been taken, such as smoking bans in public, are worthy actions, not enough is being done to protect children and teens. More can be done at the policy level, by individuals, and by health care providers.

Detection and follow-up of chronic obstructive pulmonary disease (COPD) and risk factors in the Southern Cone of Latin America: the pulmonary risk in South America (PRISA) study

BACKGROUND

The World Health Organization has estimated that by 2030, chronic obstructive pulmonary disease will be the third leading cause of death worldwide. Most knowledge of chronic obstructive pulmonary disease is based on studies performed in Europe or North America and little is known about the prevalence, patient characteristics and change in lung function over time in patients in developing countries, such as those of Latin America. This lack of knowledge is in sharp contrast to the high levels of tobacco consumption and exposure to biomass fuels exhibited in Latin America, both major risk factors for the development of chronic obstructive pulmonary disease. Studies have also demonstrated that most Latin American physicians frequently do not follow international chronic obstructive pulmonary disease diagnostic and treatment guidelines. The PRISA Study will expand the current knowledge regarding chronic obstructive pulmonary disease and risk factors in Argentina, Chile and Uruguay to inform policy makers and health professionals on the best policies and practices to address this condition.

METHODS/DESIGN

PRISA is an observational, prospective cohort study with at least four years of follow-up. In the first year, PRISA has employed a randomized three-staged stratified cluster sampling strategy to identify 6,000 subjects from Marcos Paz and Bariloche, Argentina, Temuco, Chile, and Canelones, Uruguay. Information, such as comorbidities, socioeconomic status and tobacco and biomass exposure, will be collected and spirometry, anthropometric measurements, blood sampling and electrocardiogram will be performed. In year four, subjects will have repeat measurements taken.

DISCUSSION

There is no longitudinal data on chronic obstructive pulmonary disease incidence and risk factors in the southern cone of Latin America, therefore this population-based prospective cohort study will fill knowledge gaps in the prevalence and incidence of chronic obstructive pulmonary disease, patient characteristics and changes in lung function over time as well as quality of life and health care resource utilization. Information gathered during the PRISA Study will inform public health interventions and prevention practices to reduce risk of COPD in the region.