Tobacco smoke exposure in early life and adolescence in relation to lung function

Smoking exposure trajectories and pulmonary function in early adulthood in a Brazilian cohort

OBJECTIVES

To investigate smoking trajectories and their association with pulmonary function (PF) and respiratory symptoms at age 22.

METHODS

Data from a population-based cohort study of 3350 individuals and their spirometries were analysed. The outcomes were: forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), forced expiratory flow at the mid expiratory phase (FEF25-75 %), FEV1/FVC and FEF25-75/FVC ratio. Smoking data were collected at perinatal follow-up (gestational exposure) and 15, 18 and 22 years. Group-based trajectory model was applied.

RESULTS

Four groups were identified: no exposure (NE), gestational (GE), gestational and adulthood (GAE) and continuous (CE) exposure. Both CE and GAE trajectories were associated with lower values of FEV1/FVC (-1.77pp; p = 0.01 and -1.58 pp; p<0.001 respectively) and FEF25-75/FVC ratio (-7.27pp; p = 0.019 and -6.04pp; p<0.001 respectively) compared to the NE trajectory. Lower FEV1 and FEF25-75 % values were also related to the GAE trajectory (-68 ml; p = 0.03 and -253 ml/s; p<0.001 respectively). Compared to those who never smoked, individuals who smoked 10 or more cigarettes daily presented a reduction in the FEV1/FVC ratio by 1.37pp (p<0.001), FEF25-75 % by 126 ml (p = 0.012) and FEF25-75 %/FVC ratio by 3.62pp (p = 0.011). CE trajectory showed higher odds of wheezing (OR 4.14; p<0.001) and cough (OR 2.39; p = 0.002) compared to the non-exposed group.

CONCLUSIONS

The in-uterus exposure to maternal smoking reduces PF later in life. However, the perpetuation of smoking behaviour throughout adolescence and early adulthood is determinant for PF main reduction and the emergence of respiratory-related symptoms.

Parental smoking is associated with adolescent loneliness: evidence from 71 low- and middle-income countries

Introduction

The association between parental smoking and adolescent mental health is not well understood. We aimed to examine the association between parental smoking and adolescent loneliness using global data collected from the Global School-based Student Health Survey (GSHS) between 2009 and 2019.

Methods

A total of 187,552 adolescents aged 12-15 years in 71 low- and middle-income countries (LMIC) from the GSHS with cross-sectional design were included in this study. Loneliness was defined as feeling lonely sometimes or more frequently in the past 12 months. Parental smoking, reported by the adolescent, was defined as the use of any form of tobacco by the father and/or mother. Logistic regression models were used to examine the odds ratio (OR) of adolescent loneliness according to parental smoking status.

Results

Compared with neither parent smoking, parental smoking was associated with adolescent loneliness (father only: OR = 1.18, 95% CI = 1.10-1.26; mother only: OR = 1.39, 95% CI = 1.15-1.67; both: OR = 1.65, 95% CI = 1.41-1.93) after adjustment for potential covariates. Subgroup analyses stratified by sex, age, and WHO region showed similar results (except not in the African and Western Pacific regions).

Discussion

Parental smoking is associated with loneliness in adolescents from LMIC. Our finding expands the well-known physical damage of parental smoking in adolescents to the psychological damage. Strict policies and strategies should be established to encourage smoking cessation for parents who are current smokers.

Electroacupuncture may protect pulmonary dysplasia in offspring with perinatal nicotine exposure by altering maternal gut microbiota and metabolites

Background

Perinatal nicotine exposure (PNE) induces pulmonary dysplasia in offspring and it increases the risk of respiratory diseases both in offspring and across generations. The maternal gut microbiota and its metabolites, such as short-chain fatty acids (SCFAs), can regulate fetal lung development and are susceptible to nicotine exposure. Therefore, modulation of PNE-induced changes in maternal gut microbiota and SCFAs may prevent the occurrence of pulmonary dysplasia in offspring.

Objective

Our previous studies demonstrated that electroacupuncture (EA) ameliorated PNE-induced impairment in offspring lung development. To further our study, we aimed to determine whether the protective effect of EA is associated with the modulation of changes in maternal gut microbiota and SCFAs.

Methods

We observed changes in maternal gut microbiota and serum SCFA levels in both mother and offspring after EA treatment using a PNE rat model. Furthermore, using broad-spectrum antibiotics, we established a pseudo-germ-free PNE rat model to explore whether EA can protect offspring's pulmonary function and lung morphology in the presence of depleted maternal gut microbiota.

Results

Our study revealed that EA increased the community richness (Sobs index) of perinatal nicotine-exposed maternal gut microbiota and the abundance of beneficial bacteria (RF39, Clostridia, Oscillospirales, etc.). This was accompanied by an upregulated serum levels of acetate, butyrate, and total SCFAs in both mother and offspring rats, as well as stimulated expression of SCFA receptors (GPR41 and GPR43) in the lung tissue of offspring rats. However, the beneficial effects of EA on offspring pulmonary function (FVC, PEF, PIF, and Cdyn) and lung morphology (alveolar number and MLI) were lost after maternal gut microbiota depletion.

Conclusion

These findings suggest that EA may exert its therapeutic effects on PNE-induced lung phenotype by altering maternal gut microbiota. The likely mechanism involves the associated improvement in serum SCFA levels in both mother and offspring, as well as the upregulation of SCFA receptors in the lung tissue of offspring.

Secondhand Smoke Exposure and Its Impact on Pediatric Lung Function, Aerobic Fitness, and Body Mass: Evidence from a Cross-Sectional Study

BACKGROUND

Several studies have documented the detrimental impacts of secondhand smoke (SHS) exposure to a range of pediatric respiratory conditions, including asthma, bronchitis, and reduced lung function. The aim of the study was to investigate the influence of SHS exposure on lung function, physical fitness, and body mass index (BMI) in children aged 10 to 14 years.

METHODS

This cross-sectional study included children aged 10 to 14 years at the Elementary School "Trilj" in Trilj, Croatia. Data on SHS exposure were collected using a questionnaire. Antropometric and spirometry measurements were performed. Physical fitness was assessed using the shuttle run (BEEP) test.

RESULTS

This study included 157 children, 89 (56.69%) boys and 68 (43.31%) girls. Children exposed to every day SHS in households had significantly lower values of forced vital capacity (FVC), forced expiratory volume in one second (FEV1), FEV1/FVC, peak expiratory flow (PEF) (p < 0.001) and higher z-score BMI levels (p = 0.018) in comparison to unexposed children. Logistic regression showed that children unexposed to SHS had higher odds for better results in the BEEP test (OR 62.45, 95% CI 21.26-179.24, p < 0.001). Children with poorer physical fitness, expressed by lower BEEP score levels, had significantly lower FVC, FEV1, FEV1/FVC, and PEF (p < 0.001).

CONCLUSIONS

Every day SHS exposure in children was associated with poorer lung function, higher BMI, and poorer physical fitness.

Global association of secondhand smoke exposure locations and smoking behaviour among adolescents in 99 countries

AIM

This study classified 99 countries into four income groups and then analysed the impact of secondhand smoke (SHS) exposure at home, in public places and at school, on current cigarette smoking prevalence.

METHODS

We utilised data from the WHO Global Youth Tobacco Survey and a meta-analysis was conducted to evaluate the prevalence and weighted odds ratios (wORs) of adolescent smoking behaviour and SHS exposure locations.

RESULTS

Both smoking behaviours increased with higher national income levels. Smoking behaviours in high and upper-middle-income countries (HICs and UMICs) exhibited an association with SHS exposure in public places (HIC: wOR, 3.50 [95% CI, 2.85-4.31]; UMIC: wOR, 2.90 [2.60-3.23]) compared to home. Low- and lower-middle-income countries (LICs and LMICs) showed an association with SHS exposure in the home (LIC: wOR, 5.33 [3.59-7.93]; LMIC: wOR, 2.71 [2.33-3.17]) than public places. The association between current cigarette smoking and SHS exposure at home increased with lower income levels, while anticipated future use of any form of tobacco with SHS exposure in public places rose in lower income countries.

CONCLUSIONS

Targeted interventions based on income levels are essential, emphasising home strategies in lower income countries and public place efforts in higher income countries.

Clinical applications of forced oscillation technique (FOT) for diagnosis and management of obstructive lung diseases in children

Obstructive lung diseases such as bronchial asthma, COPD, and cystic fibrosis are a burden on many patients across the globe. Spirometry is considered the gold standard for diagnosing airflow obstruction, but it can be difficult for pediatric patients to do and requires a lot of effort. As a result, healthcare providers need new, effortless methods to diagnose airway obstructions, particularly in young children and individuals unable to perform the spirometry maneuver. The forced oscillation technique is a modern method requiring only tidal breathing combined with the application of external, source of low-amplitude oscillations to evaluate the respiratory system's response. It might be essential for identifying early respiratory changes caused by smoking, childhood asthma, and may prove more sensitive than spirometry in identifying peripheral airway disturbances or evaluating the long-term success of therapy. This review describes the methodology and the indications for the forced oscillation technique and outlines its relevance in clinical practice.

Physical activity and body mass related to catch-up lung function growth in childhood: a population-based accelerated cohort study

OBJECTIVE

The existence of catch-up lung function growth and its predictors is uncertain. We aimed to identify lung function trajectories and their predictors in a population-based birth cohort.

METHODS

We applied group-based trajectory modelling to z-scores of forced expiratory volume in 1 second (zFEV1) and z-scores of forced vital capacity (zFVC) from 1151 children assessed at around 4, 7, 9, 10, 11, 14 and 18 years. Multinomial logistic regression models were used to test whether potential prenatal and postnatal predictors were associated with lung function trajectories.

RESULTS

We identified four lung function trajectories: a low (19% and 19% of the sample for zFEV1 and zFVC, respectively), normal (62% and 63%), and high trajectory (16% and 13%) running in parallel, and a catch-up trajectory (2% and 5%) with catch-up occurring between 4 and 10 years. Fewer child allergic diseases and higher body mass index z-score (zBMI) at 4 years were associated with the high and normal compared with the low trajectories, both for zFEV1 and zFVC. Increased children's physical activity during early childhood and higher zBMI at 4 years were associated with the catch-up compared with the low zFEV1 trajectory (relative risk ratios: 1.59 per physical activity category (1.03-2.46) and 1.47 per zBMI (0.97-2.23), respectively). No predictors were identified for zFVC catch-up growth.

CONCLUSION

We found three parallel-running and one catch-up zFEV1 and zFVC trajectories, and identified physical activity and body mass at 4 years as predictors of zFEV1 but not zFVC catch-up growth.

Lifestyle modifies the associations of early-life smoking behaviors and genetic susceptibility with type 2 diabetes: A prospective cohort study involving 433,872 individuals from UK Biobank

BACKGROUND

To investigate whether and what lifestyle factors in later life modify the associations of early-life smoking behaviors and genetic susceptibility with type 2 diabetes (T2D).

METHODS

In the UK Biobank, in utero tobacco exposure (n = 354,493) and age of smoking initiation (n = 353,557) were self-reported. A composite lifestyle score was calculated based on diet, physical activity, nicotine exposure, sleep duration, and BMI. Hazard ratio (HR) and absolute risk difference (ARD) were used to estimate the associations of early-life smoking behaviors and genetic risk with incident T2D, as well as the effect modification of the lifestyle score.

RESULTS

During a median follow-up of 14.6 years, the HRs (95 % CIs) of T2D for in utero tobacco exposure, and smoking initiation in adulthood, adolescence, and childhood, compared with no smoking behavior, were 1.19 (1.16-1.23), 1.34 (1.29-1.39), 1.58 (1.53-1.64), 2.22 (2.11-2.32), respectively (P for trend<0.001). Early-life smoking behaviors and high genetic risk (vs no smoking behavior and low genetic risk) were associated with a 302%-593 % higher T2D risk (P for additive interaction<0.05). Compared to participants with early-life smoking behaviors, high genetic risk, and an unfavorable lifestyle, those who adhered to a favorable lifestyle had a lower T2D risk in all subgroups (HRs from 0.05 to 0.36 and ARD from -14.97 % to -9.51 %), with the highest ARD attributable to lifestyle in participants with early-life smoking behaviors and high genetic risk.

CONCLUSIONS

The T2D risk associated with early-life smoking behaviors and genetic risk was modified by a favorable lifestyle.

Lifestyle Behaviors of Childhood and Adolescence: Contributing Factors, Health Consequences, and Potential Interventions

In this narrative review, we summarized evidence from peer-reviewed articles, published before February 2024, that investigated lifestyle behaviors among children (≤12 years) and adolescents (13-18 years) representing different geographic descents. These behaviors included dietary patterns, screen time, physical activity, smoking, alcohol consumption, oral hygiene, unsafe sex, and sleep duration and quality. We documented the significant impacts of parental, school, and sociodemographic factors on the adoption of numerous lifestyle behaviors in this age category. Several health consequences could be attributed to unhealthy lifestyle behaviors during childhood and adolescence. For example, poor dietary habits can lead to a higher risk of obesity and cardiovascular disease. Physical inactivity contributes to the development of musculoskeletal and psychological disorders. Excessive screen time is associated with visual acuity problems, poor sleep, and psychological and behavioral problems. Tobacco use poses a significant risk for severe respiratory and cardiovascular diseases. Risky sexual behaviors are related to sexually transmitted infections and exposure to violence. Short sleep duration is associated with a lack of physical fitness and poor cognitive function. However, potential interventions, such as school-based health programs, community outreach initiatives, and national health policies and regulations, can improve lifestyle behaviors among children and adolescents.

Construction and evaluation of a nomogram prediction model for aspiration pneumonia in patients with acute ischemic stroke

Background

Aspiration Pneumonia (AP) is a leading cause of death in patients with Acute Ischemic Stroke (AIS). Early detection, diagnosis and effective prevention measures are crucial for improving patient prognosis. However, there is a lack of research predicting AP occurrence after AIS. This study aimed to identify risk factors and develop a nomogram model to determine the probability of developing AP after AIS.

Method

A total of 3258 AIS patients admitted to Jinshan Hospital of Fudan University between January 1, 2016, and August 20, 2022, were included. Among them, 307 patients were diagnosed with AP (AP group), while 2951 patients formed the control group (NAP group). Univariate and multivariate logistic regression analyses were conducted to identify relevant risk factors for AP after AIS. These factors were used to establish a scoring system and develop a nomogram model using R software.

Results

Univariate analysis revealed 20 factors significantly associated (P < 0.05) with the development of AP after AIS. These factors underwent multivariate logistic regression analysis, which identified age (elderly), National Institute of Health Stroke Scale (NIHSS) score, dysphagia, atrial fibrillation, cardiac insufficiency, renal insufficiency, hepatic insufficiency, elevated Fasting Blood Glucose (FBG), elevated C-Reactive Protein (CRP), elevated Neutrophil percentage (NEUT%), and decreased prealbumin as independent risk factors. A nomogram model incorporating these 11 risk factors was constructed, with a C-index of 0.872 (95 % CI: 0.845-0.899), indicating high accuracy. Calibration and clinical decision analyses demonstrated the model's reliability and clinical value.

Conclusion

A nomogram model incorporating age, NIHSS score, dysphagia, atrial fibrillation, cardiac insufficiency, renal insufficiency, hepatic insufficiency, FBG, CRP, NEUT%, and prealbumin effectively predicts AP risk in AIS patients. This model provides guidance for early intervention strategies, enabling the identification of high-risk individuals for timely preventive measures.

Window of opportunity for respiratory oscillometry: A review of recent research

Oscillometry has been around for almost 70 years, but there are still many unknowns. The test is performed during tidal breathing and is therefore free from patient-dependent factors that could influence the results. The Forced Oscillation Technique (FOT), which requires minimal patient cooperation, is gaining ground, particularly with elderly patients and children. In pulmonology, it is a valuable tool for assessing obstructive conditions (with a distinction between central and peripheral obstruction) and restrictive disorders (intrapulmonary and extrapulmonary). Its sensitivity allows the assessment of bronchodilator and bronchoconstrictor responses. Different lung diseases show different patterns of changes in FOT, especially studied in asthma and chronic obstructive pulmonary disease. Because of these differences, many studies have analysed the usefulness of this technique in different areas of medicine. In this paper, the authors would like to present the basics of oscillometry with the areas of its most recent clinical applications.

Childhood Cigarette Smoking and Risk of Chronic Obstructive Pulmonary Disease in Older U.S. Adults

Rationale: It is not certain the extent to which childhood smoking adds chronic obstructive pulmonary disease (COPD) risk independent of lifetime cigarette exposure. Objectives: We examined the association between age started smoking cigarettes regularly, current smoking status, smoking history, and risk of COPD. Methods: Cross-sectional survey of U.S. adults ⩾40 years old in the 2020 National Health Interview Survey. Respondents who were ever cigarette smokers were asked when they began smoking regularly. Multivariable analysis assessed self-report of COPD diagnosis as a function of age started smoking (<15 yr vs. ⩾15 yr) adjusting for current smoking, cigarette pack-years, and covariates. Measurements and Main Results: Overall, 7.1% reported that they had COPD, 2.6% for never-smokers compared with 23.1% and 11.6% for smoking onset <15 and ⩾15 years, respectively. Persons who began smoking regularly at <15 years of age had higher pack-years of smoking (median, 29 vs. 15, respectively), and higher smoking intensity (median, 20 cigarettes/d for <15 yr vs. 10 cigarettes/d for ⩾15 yr for current smokers). In the multivariable analysis, the relative risk for COPD among childhood smokers was 1.41 (95% confidence interval, 1.22-1.63) compared with later-onset smokers. Substituting smoking duration for pack-years confounded the association between current smoking and COPD but did not change the childhood smoking estimate. In a stratified analysis, higher risk for childhood smoking was found at all current smoking intensity levels. Conclusions: Among adults aged ⩾40 years, one-fifth of childhood smokers have COPD. Lifetime cigarette smoking explained some but not all of the higher risk. If replicated, this suggests a lung development window of enhanced vulnerability to cigarette smoking.

Effect of smoking on the development of chronic obstructive pulmonary disease in young individuals: a nationwide cohort study

Background

Cigarette smoking is an important risk factor for developing chronic obstructive pulmonary disease (COPD). However, the effect of smoking on the development of COPD in young individuals remains unclear. We aimed to evaluate the effect of smoking on COPD development in young individuals.

Methods

Using the Korean National Health Information Database, we screened individuals aged 20-39 years who participated in the national health check-up between 2009 and 2012. We defined physician-diagnosed COPD based on health insurance claims and searched the database until December 2019. We identified 6,307,576 eligible individuals, and 13,789 had newly developed COPD. We used multivariate Cox proportional hazards models to estimate the adjusted hazard ratio (aHR) of risk factors for COPD.

Results

The incidence rate for developing COPD was 0.26/1000 person-year. The risk of developing COPD was significantly higher in current smokers [aHR 1.46, 95% confidence interval (CI) 1.39-1.53] and former smokers (aHR 1.21, 95% CI 1.14-1.29) than in non-smokers. Furthermore, the risk increased with increasing smoking amounts (≥20 pack-years, aHR 2.24; 10-20 pack-years, aHR 1.55; <10 pack-years, aHR 1.27). Female participants had a higher relative risk of developing COPD due to smoking, compared with their male counterparts.

Conclusion

Cigarette smoking increased the risk of developing COPD in young individuals. Current and heavy smokers had higher risks of developing COPD than non-smokers. Female smokers were more likely to develop COPD than male smokers.

Classification, Perception, and Toxicity of Emerging Flavored Oral Nicotine Pouches

INTRODUCTION

Oral Nicotine Pouches (ONPs) are the new form of nicotine pouches that have become a type of emerging smokeless tobacco product sold by various tobacco companies. These smokeless tobacco products are marketed for usage all over as snus containing tobacco-derived nicotine (natural) or as tobacco-free nicotine (synthetic) as substitutes for other tobacco products. Based on perception and socio-behavioral aspects, ONPs have become popular tobacco products among adolescents/young adults, and over 50% of young adult users of ONP use flavored ONPs, such as menthol/mint, tobacco, dessert/candy, and fruity, which are the most popular flavors. Various new ONP flavors are currently popular locally as well as in the online market. Tobacco, menthol, and fruit-flavored ONPs could motivate cigarette smokers to change to ONPs.

METHODS

We expanded our knowledge on natural/synthetic ONP flavor wheels to available data on ONPs, describing, in detail, their flavors and brands (US and Europe) in both natural and synthetic ONP categories. We classified over 152 snus and 228 synthetic ONPs into the following flavor categories: "Tobacco", "Menthol/Mint", "Fruity", "Candy/Deserts", "Drink", "Aroma", "Spices", and "Mixed Flavors".

RESULTS

Based on total numbers, we found the most popular ONP flavors, sold as tobacco and menthol, to be among natural ONPs; among synthetic ONPs, fruity and menthol are the most prominent flavors, with varying concentrations of nicotine and other flavoring chemicals, including coolant WS-23. We also showed possible molecular targets and toxicities, due to exposure to ONPs, activating several signaling cascades such as AKT and NF-kappaB, which might possibly lead to apoptosis and epithelial mesenchymal transition (EMT).

CONCLUSIONS

Considering the marketing of ONP products with various flavor profiles and with most of these products containing tobacco/menthol/fruit flavor, it is likely to have regulation and a marketing disclaimer on some of these products. Further, it would be logical to determine how the market reacts in terms of compliance and non-compliance with flavor restrictions by the regulatory agencies.

Do tobacco and cannabis use and co-use predict lung function: A longitudinal study

BACKGROUND

Use of tobacco and cannabis is common and has been reported to predict lung function. Less is known about co-use of tobacco and cannabis and their impact on changes in lung function to early adulthood.

RESEARCH QUESTION

The study examines whether cigarette smoking or cannabis use and co-use are each associated with lung function in a population sample of young adults.

STUDY DESIGN AND METHODS

Data are from a prospective cohort study of cigarette smoking, cannabis use and co-use at 21 and 30 years of age and lung function (FVC, FEV1, FEV1/FVC) measured at 30 years. Lung function results are transformed using Global Lung Function Formulae. Subjects are the children of pregnant women who were recruited into the cohort study over the period 1981-3. Respondents were administered a spirometry assessment at 21 and 30 years of age. These respondents completed a smoking and cannabis use questionnaire at 21- and 30-year follow-ups.

RESULTS

Cigarette smoking (with or without cannabis use) is associated with reduced airflow. There is no consistent association between cannabis use and measures of lung function. The co-use of tobacco and cannabis appears to entail no additional risk to lung function beyond the risks associated with tobacco use alone.

INTERPRETATION

Persistent cigarette smoking is associated with reduced airflow even in young adults. Cannabis use does not appear to be related to lung function even after years of use.

Early-life and health behaviour influences on lung function in early adulthood

RATIONALE

Early-life exposures may influence lung function at different stages of the life course. However, the relative importance of characteristics at different stages of infancy and childhood are unclear.

OBJECTIVES

To examine the associations and relative importance of early-life events on lung function at age 24 years.

METHODS

We followed 7545 children from the Avon Longitudinal Study of Parents and Children from birth to 24 years. Using previous knowledge, we classified an extensive list of putative risk factors for low lung function, covering sociodemographic, environmental, lifestyle and physiological characteristics, according to timing of exposure: 1) demographic, maternal and child; 2) perinatal; 3) postnatal; 4) early childhood; and 5) adolescence characteristics. Lung function measurements (forced vital capacity (FVC), forced expiratory volume in 1 s (FEV₁), FEV₁/FVC and forced expiratory flow at 25-75% of FVC) were standardised for sex, age and height. The proportion of the remaining variance explained by each characteristic was calculated. The association and relative importance (RI) of each characteristic for each lung function measure was estimated using linear regression, adjusted for other characteristics in the same and previous categories.

RESULTS

Lower maternal perinatal body mass index (BMI), lower birthweight, lower lean mass and higher fat mass in childhood had the largest RI (0.5-7.7%) for decreased FVC. Having no siblings, lower birthweight, lower lean mass and higher fat mass were associated with decreased FEV₁ (RI 0.5-4.6%). Higher lean mass and childhood asthma were associated with decreased FEV₁/FVC (RI 0.6-0.8%).

CONCLUSIONS

Maternal perinatal BMI, birthweight, childhood lean and fat mass and early-onset asthma are the factors in infancy and childhood that have the greatest influence on early-adult lung function.

Regional differences in the contribution of smoking, dietary and cooking behaviours to airflow obstruction in China: A population-based case-control study

BACKGROUND AND OBJECTIVE

The major contributing risk factors to airflow obstruction (AO) in China remain largely unknown. We examined the environmental and lifestyle risk factors of unrecognized AO in the baseline of a population-based cohort drawn from 115 urban and rural communities across 12 provinces in China.

METHODS

Amongst 46,285 adults recruited from 2005 to 2009, 3686 were identified with AO on spirometry (defined by the ratio of forced expiratory volume in the first second to forced vital capacity <0.7) and without known chronic lung disease. These cases were age- and sex-matched to 11,129 controls with normal spirometry and no chronic lung disease from the same community. Conditional multivariable adjusted OR and population attributable fraction (PAF) were calculated for each identified risk factor and their combined effect.

RESULTS

Compared to controls, smoking initiation age <20 years (OR 1.22 [95% CI 1.01-1.48]), smoking duration ≥40 years (OR 1.82 [1.50-2.22]), low vegetables (OR 1.86 [1.67-2.07]) and fruits (OR 1.14 [1.02-1.29]) intake, cooking with biomass fuels (OR 2.54 [2.32-2.78]) and poor kitchen ventilation (OR 1.37 [1.19-1.58]) were significantly associated with elevated risks of unrecognized AO. The combined effect of these lifestyle factors significantly elevated the odds by 25 fold (18.6-34.3). The addition of prior tuberculosis and low socioeconomic status further increased the odds to 40.1 (28.2-57.0) and the PAF to 66.7% (51.1-78.1).

CONCLUSION

Smoking, unhealthy diet, biomass cooking fuels and low socioeconomic status are strongly associated with AO. Addressing these risk factors could substantially reduce the burden of AO in China.

Multi-omic association study identifies DNA methylation-mediated genotype and smoking exposure effects on lung function in children living in urban settings

Impaired lung function in early life is associated with the subsequent development of chronic respiratory disease. Most genetic associations with lung function have been identified in adults of European descent and therefore may not represent those most relevant to pediatric populations and populations of different ancestries. In this study, we performed genome-wide association analyses of lung function in a multiethnic cohort of children (n = 1,035) living in low-income urban neighborhoods. We identified one novel locus at the TDRD9 gene in chromosome 14q32.33 associated with percent predicted forced expiratory volume in one second (FEV1) (p = 2.4x10-9; βz = -0.31, 95% CI = -0.41- -0.21). Mendelian randomization and mediation analyses revealed that this genetic effect on FEV1 was partially mediated by DNA methylation levels at this locus in airway epithelial cells, which were also associated with environmental tobacco smoke exposure (p = 0.015). Promoter-enhancer interactions in airway epithelial cells revealed chromatin interaction loops between FEV1-associated variants in TDRD9 and the promoter region of the PPP1R13B gene, a stimulator of p53-mediated apoptosis. Expression of PPP1R13B in airway epithelial cells was significantly associated the FEV1 risk alleles (p = 1.3x10-5; β = 0.12, 95% CI = 0.06-0.17). These combined results highlight a potential novel mechanism for reduced lung function in urban youth resulting from both genetics and smoking exposure.

Does Physical Activity Reduce the Risk of Perceived Negative Health in the Smoking Population?

BACKGROUND

Smoking is associated with poor health status. Increased prevalence of multiple diseases has been found in populations of smokers and ex-smokers. Physical activity (PA) could reduce the negative effects of smoking.

AIMS

To analyze the relationships between smoking and self-perceived health and between PA level and self-perceived health, according to the relationship with smoking in the Spanish population. To calculate the risks of perceiving negative health in relation to smoking, according to the PA level of the population.

HYPOTHESIS

A higher level of PA reduces the risk of perceiving negative health in the Spanish smoking population.

DESIGN AND METHODOLOGY

Cross-sectional study with data from 17,708 participants, 15-69 years old, interviewed in the Spanish National Health Survey 2017. Intergroup differences were studied. Odds ratios (OR) and relative risks (RR) and their confidence intervals (95% CI) were calculated for negative self-perceived health. A Spearman's rho correlation study was performed between the variables of interest.

RESULTS

Dependency relationships were found between self-perceived health and PA levels, in both genders and in different relationships with smoking (x2 < 0.001). Inactivity was related to higher prevalences of negative health perception (p < 0.05) in all groups analyzed. Inactive smokers (OR: 6.02. 95% CI: 3.99-9.07. RR: 5.24. 95% CI: 3.56-7.73) presented increased risks of negative health perception compared to people with low/medium PA levels, similarly found in other relationships with tobacco.

CONCLUSIONS

Increasing the PA level of the smoking population could reduce the negative effects on their perceived health. Medium and high PA levels reduce the risk of negative health perception in the Spanish population, both in smokers, ex-smokers, and non-smokers.

The causal association between maternal smoking around birth on childhood asthma: A Mendelian randomization study

To explore the causal relationship between maternal smoking around birth and childhood asthma using Mendelian randomization (MR). Using the data from large-scale genome-wide association studies, we selected independent genetic loci closely related to maternal smoking around birth and maternal diseases as instrumental variables and used MR methods. In this study, we considered the inverse variance weighted method (MR-IVW), weighted median method, and MR-Egger regression. We investigated the causal relationship between maternal smoking around birth and maternal diseases in childhood asthma using the odds ratio (OR) as an evaluation index. Multivariable MR (MVMR) included maternal history of Alzheimer's disease, illnesses of the mother: high blood pressure and illnesses of the mother: heart diseaseas covariates to address potential confounding. Sensitivity analyses were evaluated for weak instrument bias and pleiotropic effects. It was shown with the MR-IVW results that maternal smoking around birth increased the risk of childhood asthma by 1.5% (OR = 1.0150, 95% CI: 1.0018-1.0283). After the multivariable MR method was used to correct for relevant covariates, the association effect between maternal smoking around birth and childhood asthma was still statistically significant (P < 0.05). Maternal smoking around birth increases the risk of childhood asthma.

Flavor Classification/Categorization and Differential Toxicity of Oral Nicotine Pouches (ONPs) in Oral Gingival Epithelial Cells and Bronchial Epithelial Cells

Oral nicotine pouches (ONPs) are a modern form of smokeless tobacco products sold by several brands in the U.S., which comprise a significant portion of non-combustible nicotine-containing product (NCNP) sales to date. ONPs are available in various flavors and may contain either tobacco-derived nicotine (TDN) or tobacco-free nicotine (TFN). The growth in popularity of these products has raised concerns that flavored ONPs may cause adverse oral health effects and promote systemic toxic effects due to nicotine and other ONP by-products being absorbed into the circulatory system through oral mucosa. We hypothesized that flavored ONPs are unsafe and likely to cause oral and pulmonary inflammation in oral and respiratory epithelial cells. Before analyzing the effects of ONPs, we first classified ONPs sold in the U.S. based on their flavor and the flavor category to which they belonged using a wheel diagram. Human gingival epithelial cells (HGEP) were treated with flavored ONP extracts of tobacco (original, smooth), menthol (wintergreen and cool cider), and fruit flavor (americana and citrus), each from the TDN and TFN groups. The levels of ONP-induced inflammatory cytokine release (TNF-α, IL-6, and IL-8) by ELISA, cellular reactive oxygen species (ROS) production by CellRox Green, and cytotoxicity by lactate dehydrogenase (LDH) release assay in HGEP cells were assessed. Flavored ONP extracts elicited differential toxicities in a dose- and extract-dependent manner in HGEP cells 24 h post-treatment. Both fruit TDN and TFN extracts resulted in the greatest cytotoxicity. Tobacco- and fruit-flavored, but not menthol-flavored, ONPs resulted in increased ROS production 4 h post-treatment. Flavored ONPs led to differential cytokine release (TNF-α, IL-6, and IL-8) which varied by flavor (menthol, tobacco, or fruit) and nicotine (TDN vs. TFN) 24 h post-treatment. Menthol-flavored ONPs led to the most significant TNF-α release; fruit TFN resulted in the most significant IL-6 release; and fruit TDN and tobacco TFN led to the highest release of IL-8. Subsequently, human bronchial epithelial cells (16-HBE and BEAS-2B) were also treated with flavored ONP extracts, and similar assays were evaluated. Here, the lowest concentration treatments displayed increased cytotoxicity. The most striking response was observed among cells treated with spearmint and tobacco flavored ONPs. Our data suggest that flavored ONPs are unsafe and likely to cause systemic and local toxicological responses during chronic usage.

Association of advanced paternal age with lung function at school age

BACKGROUND

Epidemiological studies suggest that advanced paternal age impact offspring health, but its impact on respiratory health is unclear. This study aimed to investigate the association of paternal age with lung function and fraction of exhaled nitric oxide (FeNO) in children.

METHODS

We analyzed data from 1330 single-born children (576 girls, 43.3%; mean age, 6.4 years), who participated in the Longitudinal Investigation of Global Health in Taiwanese Schoolchildren (LIGHTS) cohort and received measurements of lung function and FeNO at 6-year follow-up visits. Covariate-adjusted regression analyses were applied.

RESULTS

Every 5-year increase in paternal age at birth was associated with 0.51% decrease in FEV1/FVC ratio (95% CI - 0.86 to - 0.15; p = 0.005) and 19.86 mL/s decrease in FEF75 (95% CI: - 34.07 to - 5.65; p = 0.006). Stratified analyses revealed that increasing paternal age at birth was associated with decreasing FEV1/FVC ratio and FEF75 only among children with prenatal exposure to environmental tobacco smoke (ETS) or not being breastfed. Sensitivity analyses using paternal age as a categorical variable found decreasing FEV1/FVC ratio and FEF75 in the groups of paternal age 35-39 and ≥ 40 years. There was no association of paternal age at birth with FeNO.

CONCLUSION

Our findings provide novel evidence linking advanced paternal age at birth with decreasing lung function in children at school age. Children with prenatal exposure to ETS or not being breastfed are more vulnerable to the adverse effect of advanced paternal age on childhood lung function. Further studies are warranted to confirm this novel adverse effect of advanced paternal age.

Associations of residential greenness with lung function and chronic obstructive pulmonary disease in China

BACKGROUND

Studies on the association of greenness with respiratory health are scarce in developing countries, and previous studies in China have focused on only one or two indicators of lung function.

OBJECTIVE

The study aims to evaluate the associations of residential greenness with full-spectrum lung function indicators and prevalence of chronic obstructive pulmonary disease (COPD).

METHODS

This nationwide cross-sectional survey included 50,991 participants from the China Pulmonary Health study. Lung function indicators included four categories: indicators of obstructive ventilatory dysfunction (FEV₁, FVC and FEV₁/FVC); an indicator of large-airway dysfunction (PEF); indicators of small-airway dysfunction (FEF_25-75% and FEV₃/FEV₆); and other indicators. Residential greenness was assessed by the Normalized Difference Vegetation Index (NDVI). Multivariable linear regression models and logistic regression models were used to analyze associations of greenness with lung function and COPD prevalence.

RESULTS

Within the 500 m buffer, an interquartile range (IQR) increase in NDVI was associated with higher FEV₁ (24.76 mL), FVC (16.52 mL), FEV₁/FVC (0.38), FEF_50% (56.34 mL/s), FEF_75% (33.43 mL/s), FEF_25-75% (60.73 mL/s), FEV₃ (18.59 mL), and FEV₆ (21.85 mL). However, NDVI was associated with lower PEF. In addition, NDVI was significantly associated with 10% lower odds of COPD. The stratified analyses found that the associations were only significant in middle-young people, females, and nonsmokers. The associations were influenced by geographic regions.

CONCLUSIONS

Residential greenness was associated with better lung function and lower odds of COPD in China. These findings provide a scientific basis for healthy community planning.

Lifetime exposure to smoking, epigenetic aging, and morbidity and mortality in older adults

BACKGROUND

Cigarette smoke is a major public health concern. Epigenetic aging may be an important pathway by which exposure to cigarette smoke affects health. However, little is known about how exposure to smoke at different life stages affects epigenetic aging, especially in older adults. This study examines how three epigenetic aging measures (GrimAge, PhenoAge, and DunedinPoAm38) are associated with parental smoking, smoking in youth, and smoking in adulthood, and whether these epigenetic aging measures mediate the link between smoke exposure and morbidity and mortality. This study utilizes data from the Health and Retirement Study (HRS) Venous Blood Study (VBS), a nationally representative sample of US adults over 50 years old collected in 2016. 2978 participants with data on exposure to smoking, morbidity, and mortality were included.

RESULTS

GrimAge is significantly increased by having two smoking parents, smoking in youth, and cigarette pack years in adulthood. PhenoAge and DunedinPoAm38 are associated with pack years. All three mediate some of the effect of pack years on cancer, high blood pressure, heart disease, and mortality and GrimAge and DunedinPoAm38 mediate this association on lung disease.

CONCLUSIONS

Results suggest epigenetic aging is one biological mechanism linking lifetime exposure to smoking with development of disease and earlier death in later life. Interventions aimed at reducing smoking in adulthood may be effective at weakening this association.

Time-Specific Factors Influencing the Development of Asthma in Children

Susceptibility to asthma is complex and heterogeneous, as it involves both genetic and environmental insults (pre- and post-birth) acting in a critical window of development in early life. According to the Developmental Origins of Health and Disease, several factors, both harmful and protective, such as nutrition, diseases, drugs, microbiome, and stressors, interact with genotypic variation to change the capacity of the organism to successfully adapt and grow in later life. In this review, we aim to provide the latest evidence about predictive risk and protective factors for developing asthma in different stages of life, from the fetal period to adolescence, in order to develop strategic preventive and therapeutic interventions to predict and improve health later in life. Our study shows that for some risk factors, such as exposure to cigarette smoke, environmental pollutants, and family history of asthma, the evidence in favor of a strong association of those factors with the development of asthma is solid and widely shared. Similarly, the clear benefits of some protective factors were shown, providing new insights into primary prevention. On the contrary, further longitudinal studies are required, as some points in the literature remain controversial and a source of debate.

Exposure to second-hand smoke during early life and subsequent sleep problems in children: a population-based cross-sectional study

BACKGROUND

Previous studies have revealed that current secondhand smoke exposure showed highly suggestive evidence for increased risk of simultaneous sleep problems in children. Data on the associations between early-life exposure to SHS with subsequent sleep problems in children were scarce. We aimed to evaluate the associations of early-life SHS exposure with sleep problems in children.

METHODS

In this cross-sectional study, children were recruited from elementary and middle schools in Liaoning Province, China between April 2012 and January 2013. We assessed early-life SHS exposure (pregnancy and the first 2 years of life) via questionnaires. Sleep problems and different types of sleep-related symptoms were measured based on the validated tool of the Sleep Disturbance Scale for Children (SDSC). Generalized linear mixed models were applied to estimate the associations of early-life SHS exposure with sleep problems.

RESULTS

We included a total of 45,562 children (22,657 [49.7%] males; mean [SD] age, 11.0 [2.6] years) and 6167 of them (13.5%) were exposed to early-life SHS during both pregnancy and the first 2 years of life. Compared with unexposed counterparts, children exposed to early-life SHS had higher total T-scores of SDSC (β = 4.32; 95%CI: 4.06, 4.58) and higher odds of increased sleep problems (OR = 2.14; 95%CI: 1.89, 2.42). When considering different sleep-related symptoms, the associations between early-life SHS exposure and symptom of sleep-wake transition disorders (i.e., bruxism) were the strongest in all analyses.

CONCLUSIONS

Early-life SHS exposure was associated with higher odds of global sleep problems and different sleep-related symptoms in children aged 6-18 years. Our findings highlight the importance to strengthen efforts to support the critical importance of maintaining a smoke-free environment especially in early life.

Focus on Early COPD: Definition and Early Lung Development

Chronic obstructive pulmonary disease (COPD) is a disease with high incidence rate and mortality rates worldwide. It is the third leading cause of death in the world. Nevertheless, little progress has been made in treating and preventing the disease. Under these circumstances, the concept of “early COPD” was proposed. Although this concept is not new, most health-care workers do not fully understand early COPD and tend to confuse it with mild COPD. In this review, we mainly discuss the definition of early COPD and the developmental trajectory of lung function. Although patients with early COPD have no symptoms, their lung function is already lower than that of normal people. A relatively complete definition is needed to identify this group of people. Reduced lung function is the diagnostic criterion for COPD, but lung development is a long-term dynamic process. In addition to smoking and air pollution, we should pay more attention to prenatal and childhood risk factors, for example, parents smoking, birth weight, preterm birth, mode of delivery, childhood respiratory infections and childhood asthma. Health-care workers need to be fully aware of early COPD, to reduce the morbidity of COPD and take effective measures to prevent these risk factors.

Tobacco smoke exposure and fractional exhaled nitric oxide levels among U.S. adolescents

BACKGROUND

Fractional exhaled nitric oxide (FeNO) can objectively guide clinical practice in the assessment, diagnosis, and treatment of eosinophilic airway inflammation. FeNO values may be affected by current smoking, but the role of tobacco smoke exposure (TSE) is understudied.

OBJECTIVE

This study investigated the associations between biochemically validated and self-reported TSE and FeNO levels among U.S. nonsmoking adolescents without asthma.

METHODS

National Health and Nutrition Examination Survey 2007-2012 data were used. TSE was assessed via serum cotinine and self-reported measures. We assessed FeNO continuously and using cutpoints of >35 ppb and >50 ppb to indicate likely eosinophilic inflammation in children and adults, respectively. We conducted linear and logistic regression adjusting for potential covariates.

RESULTS

Overall, 34.0% of adolescents had low cotinine (0.05-2.99 ng/ml), 6.2% had high cotinine (≥3.00 ng/ml), and 11.9% had home TSE. Compared to adolescents with no/minimal cotinine, adolescents with high cotinine were at reduced odds to have FeNO >35 ppb (adjusted odds ratio [aOR] = 0.54, 95%CI = 0.43,0.69). Adolescents with low cotinine had lower FeNO values (β = -2.05, 95%CI = -3.61,-0.49), and were also at decreased odds to have FeNO >35 ppb (aOR = 0.74, 95%CI = 0.66,0.83) and FeNO >50 ppb (aOR = 0.62, 95%CI = 0.53,0.72). Adolescents with home TSE were at reduced odds to have FeNO >50 ppb (aOR = 0.72, 95%CI = 0.57,0.91) than adolescents without home TSE. Adolescents with a higher number of cigarettes/day smoked inside their home were at reduced odds to have FeNO >35 ppb (OR = 0.98, 95%CI = 0.97,0.99) and FeNO >50 ppb (OR = 0.98, 95%CI = 0.96,0.99).

CONCLUSIONS

TSE was associated with decreased FeNO levels. The addition of TSE may be clinically important when interpreting thresholds for FeNO.

The Relationship Between Bonding Impairment and Maternal Postpartum Smoking

OBJECTIVES

Maternal postpartum smoking is associated with several negative outcomes for mother and child. The relationship between bonding impairment (BI) and maternal postpartum smoking is less known. The aim of the present study was to assess the relationship between BI and maternal postpartum smoking at 6 to 8 months after childbirth in a primary care sample of low-income mothers who had depression during the previous pregnancy.

METHODS

We performed a cross-sectional, secondary analysis from a community trial with 356 postpartum women from public primary care clinics in São Paulo, Brazil. The main outcome measure was maternal postpartum smoking. The main exposure variable was BI assessed with the Postpartum Bonding Questionnaire. A socio-demographic questionnaire evaluated maternal and obstetric characteristics. Postpartum depression was assessed with the Patient Health Questionnaire. Crude and adjusted prevalence ratios (PR) of the association between BI and maternal postpartum smoking, with 95% confidence intervals (CI), were calculated using Poisson regression. Multivariate analysis was performed using three models (Model 1 adjusted for randomization during pregnancy, Model 2 adjusted for Model 1 plus mother's socioeconomic and obstetric characteristics, and Model 3 adjusted for Model 2 plus postpartum depression).

RESULTS

Maternal postpartum smoking occurred in 16.7% of our sample. In the multivariable analysis, BI was associated with maternal postpartum smoking (PR:2.04; CI 95% 1.08:3.84).

CONCLUSIONS FOR PRACTICE

Women presenting bonding problems are at higher risk of smoking after childbirth. Intervention to enhance mother-child bonding may have the potential to decrease maternal postpartum smoking.

Associations between Second-Hand Tobacco Smoke Exposure and Cardiorespiratory Fitness, Physical Activity, and Respiratory Health in Children

BACKGROUND

Cardiorespiratory fitness (CRF) and physical activity (PA) are associated with a plethora of positive health effects. Many UK children fail to meet the recommended level of PA, with an observed decline in CRF levels over recent decades. Second-hand tobacco smoke (SHS) is responsible for a significant proportion of the worldwide burden of disease, but little is understood regarding the impact of SHS exposure on CRF and PA in children. The aim of this study was to test the associations between SHS exposure and CRF, PA, and respiratory health in children.

METHOD

Children (9-11 years) from UK primary schools in deprived areas participated (n = 104, 38 smoking households). Surveys determined household smoking, and exhaled carbon monoxide was used to indicate children's recent SHS exposure. CRF (VO_2peak) was assessed via maximal treadmill protocol using breath-by-breath analysis. Fractional exhaled nitric oxide and spirometry were utilised as indicators of respiratory health.

RESULTS

Linear regression models demonstrated that SHS exposure was negatively associated with allometrically scaled VO_2peak (B = -3.8, p = 0.030) but not PA or respiratory health.

CONCLUSION

The results indicate that SHS is detrimental to children's CRF; given that approximately one-third of children are regularly exposed to SHS, this important finding has implications for both public health and the sport and exercise sciences.

Shared Decision-Making Model for Adolescent Smoking Cessation: Pilot Cohort Study

The control of tobacco use in adolescents is a critical public health issue that has long been studied, yet has received less attention than adult smoking cessation. Shared decision making (SDM) is a method that highlights a patient’s preference-based medical decision. This study aimed to investigate the effects of a novel SDM-integrated cessation model and early intervention on the control of tobacco use in adolescents. The SDM-integrated model provides psychological support and motivational enhancement by involving the participants in making decisions and plans through the three-talk model of the SDM principle. The primary outcome shows positive effects by both increasing the cessation rate (a 25% point abstinence rate at 3 month follow up) and decreasing the number of cigarettes smoked per day (60% of the participants at 3 month follow up) among 20 senior high school participants (mean age, 17.5 years; 95% male). The results also show that the model can achieve the goal of SDM and optimal informed decision making, based on the positive SURE test and the satisfaction survey regarding the cessation model. The SDM cessation model can be further applied to different fields of adolescent substance cessation, yielding beneficial effects regarding reducing potential health hazards. The dissemination of the model may help more adolescent smokers to cease smoking worldwide.

How secondhand smoke exposure affects tobacco use and smoking susceptibility of adolescents: Sex and school differences

INTRODUCTION

Secondhand smoke (SHS) exposure affects tobacco related health behaviors during adolescence and persists into adulthood. This study aimed to investigate the influence of SHS exposure on tobacco use among adolescents stratified by school and gender, and provide recommendations for controlling tobacco use in youth.

METHODS

Through stratified random cluster sampling, 12278 selected students (aged 13-18 years) from schools in China were administered questionnaires. Multiple logistic regression was used to analyze whether SHS exposure would increase the smoking risk and susceptibility of adolescents.

RESULTS

The prevalence of SHS exposure among the participating students was 74.8%. Adolescents exposed to SHS were at higher odds of being susceptible and currently smoking. Students with SHS exposure at both home and public places accounted for 36.6%, greatly increasing the current smoking risk and smoking susceptibility. Home SHS exposure had greater impact on the current tobacco use of boys (OR=2.13; 95% CI: 1.50-3.03) and junior school students (OR=4.67; 95% CI: 2.41-9.06). Exposure from public places increased the risk of current smoking in boys (OR=4.20; 95% CI: 2.31-7.65) and smoking susceptibility of vocational school students (OR=1.51; 95% CI: 1.07-2.15). Students with highlevel exposure to SHS had 2.25 times higher odds of e-cigarette use.

CONCLUSIONS

The prevalence of SHS exposure is still high among adolescents in China and is associated with increased risk for tobacco use regardless of gender and school level. Effective smoke-free strategies should be developed and strictly implemented. Boys and junior school students constitute vulnerable populations exposed to SHS at home.

Trends of maternal waterpipe, cigarettes, and dual tobacco smoking in Jordan. A decade of lost opportunities

Background

Maternal tobacco use is a global public health problem. In the literature, the focus was mainly on cigarette smoking, minimally on waterpipe use, and totally ignored dual use among pregnant women. We estimated the prevalence of current maternal tobacco use by tobacco product (cigarette, waterpipe, and dual use) over a period of ten years (2007 to 2017), and examined the socio-demographic patterning of maternal tobacco use.

Methods

A secondary analysis of Jordan DHS four data waves was conducted for women who reported to be pregnant at the time of the survey. Current cigarette and waterpipe tobacco use were investigated. Prevalence estimates for cigarette-only, waterpipe-only, and dual use, as well as for cigarette, regardless of waterpipe, and waterpipe, regardless of cigarette, were reported. The effect of independent variables on cigarette smoking, waterpipe use, and dual use was assessed. Logistic regression models assessed the adjusted effects of socio-demographic variables on cigarette smoking, waterpipe use, and on dual use. For each outcome variable, a time-adjusted and a time-unadjusted logistic models were conducted.

Results

Over the last decade, the prevalence estimates of current cigarette-only smoking slightly decreased. The prevalence estimates of current waterpipe-only use exceeded those for cigarette-only after 2007 and showed a steady overall increase. Current dual use showed a continuous rise especially after 2009. Gradual increase in cigarette smoking (4.1%, in 2007, and 5.7% in 2017) and in waterpipe use (2.5% to 6.4%) were detected. Education showed an inverse relationship with cigarette and waterpipe smoking. Household wealth demonstrated a positive association with cigarette and waterpipe smoking.

Conclusions

Tobacco use epidemic is expanding its roots among pregnant women in Jordan through not only waterpipe use but also dual cigarette–waterpipe smoking. Maternal and child services should consider tobacco counseling and cessation.

Low-level exposure to polycyclic aromatic hydrocarbons is associated with reduced lung function among Swedish young adults

BACKGROUND

Exposure to polycyclic aromatic hydrocarbons (PAHs) has been linked to adverse pulmonary effects. However, the impact of low-level environmental PAH exposure on lung function in early adulthood remains uncertain.

OBJECTIVES

To evaluate the associations between urinary PAH metabolites and lung function parameters in young adults.

METHODS

Urinary metabolites of pyrene, phenanthrene, and fluorene were analysed in 1000 young adults from Sweden (age 22-25 years) using LC-MS/MS. Lung function and eosinophilic airway inflammation were measured by spirometry and exhaled nitric oxide fraction (FeNO), respectively. Linear regression analysis was used to evaluate associations between PAH metabolites and the outcomes.

RESULTS

Median urinary concentrations of 1-OH-pyrene, ∑OH-phenanthrene, and ∑OH-fluorene were 0.066, 0.36, 0.22 μg/L, respectively. We found inverse associations of ∑OH-phenanthrene and ∑OH-fluorene with FEV1 and FVC, as well as between 1-OH-pyrene and FEV1/FVC ratio (adjusted P < 0.05; all participants). An increase of 1% in ∑OH-fluorene was associated with a decrease of 73 mL in FEV1 and 59 mL in FVC. In addition, ∑OH-phenanthrene concentrations were, in a dose-response manner, inversely associated with FEV1 (B from -109 to -48 compared with the lowest quartile of ∑OH-phenanthrene; p trend 0.004) and FVC (B from -159 to -102 compared with lowest quartile; p-trend <0.001). Similar dose-response associations were also observed between ∑OH-fluorene and FEV1 and FVC, as well as between 1-OH-pyrene and FEV1/FVC (p-trend <0.05). There was no association between PAH exposure and FeNO, nor was there an interaction with smoking, sex, or asthma.

CONCLUSION

Low-level PAH exposure was, in a dose-response manner, associated with reduced lung function in young adults. Our findings have public health implications due to i) the widespread occurrence of PAHs in the environment and ii) the clinical relevance of lung function in predicting all-cause and cardiovascular disease mortality.

Arsenic exposure and its joint effects with cigarette smoking and physical exercise on lung function impairment: Evidence from an occupational cohort study

BACKGROUND

Arsenic (As) is an established toxic metal, but its effect on longitudinal lung function change among occupational workers is less conclusive.

METHODS

1243 participants were recruited in a coke-oven plant and followed up from 2010 to 2014. Each individual provided 20 mL morning urine sample at baseline, which was then used for urinary levels of As (U-As) and polycyclic aromatic hydrocarbon (PAH) metabolites detecting. Lung function levels at both baseline and the end of follow-up were determined. Multiple linear regression models were used to analyze the associations between U-As with annual lung function changes, and to evaluate the joint effects of U-As with cigarette smoking and regular physical exercise.

RESULTS

Among all participants, each 2-fold increase in U-As was associated with -12.09 (95%CI: -19.37, -4.81) mL, -0.32% (95%CI: -0.54%, -0.10%), -15.04 (95%CI: -24.62, -5.46) mL, and -0.36% (95%CI: -0.64%, -0.08%) annual changes in reduced forced expiratory volume in 1 second (FEV1), percent predicted FEV1 (ppFEV1), forced vital capacity (FVC), and percent predicted FVC (ppFVC), respectively. These effects were more pronounced among coke-oven workers with smoking (especially heavy smoking with pack-years≥15) and without regular physical exercise. Compared to low-As-exposed (≤4.70 μg/mmol creatinine) non-smokers with regular physical exercise, the high-As-exposed (>4.70 μg/mmol creatinine) smokers without regular physical exercise had the worst annual declines in FEV1 [β (95%CI) = -69.01 (-106.67, -31.34) mL], ppFEV1 [β (95%CI) = -1.94% (-3.02%, -0.87%)], FVC [β (95%CI) = -78.66 (95%CI: -129.46, -27.86) mL], and ppFVC [β (95%CI) = -1.80% (-3.23%, -0.37%)].

CONCLUSIONS

The findings in our prospective cohort study suggested the positively linear dose-response relationship of U-As with annual lung function decline. The adverse effects of As could be enhanced by cigarette smoking and attenuated by regular physical exercise. Specific emphasizes on tobacco control and physical exercise were suggested to prevent As exposure induced pulmonary impairment.

Prenatal and Perinatal Environmental Influences Shaping the Neonatal Immune System: A Focus on Asthma and Allergy Origins

It is suggested that programming of the immune system starts before birth and is shaped by environmental influences acting during critical windows of susceptibility for human development. Prenatal and perinatal exposure to physiological, biological, physical, or chemical factors can trigger permanent, irreversible changes to the developing immune system, which may be reflected in cord blood of neonates. The aim of this narrative review is to summarize the evidence on the role of the prenatal and perinatal environment, including season of birth, mode of delivery, exposure to common allergens, a farming environment, pet ownership, and exposure to tobacco smoking and pollutants, in shaping the immune cell populations and cytokines at birth in humans. We also discuss how reported disruptions in the immune system at birth might contribute to the development of asthma and related allergic manifestations later in life.

Natural history and mechanisms of COPD

The natural history of COPD is complex, and the disease is best understood as a syndrome resulting from numerous interacting factors throughout the life cycle with smoking being the strongest inciting feature. Unfortunately, diagnosis is often delayed with several longitudinal cohort studies shedding light on the long 'preclinical' period of COPD. It is now accepted that individuals presenting with different COPD phenotypes may experience varying natural history of their disease. This includes its inception, early stages and progression to established disease. Several scenarios regarding lung function course are possible, but it may conceptually be helpful to distinguish between individuals with normal maximally attained lung function in their early adulthood who thereafter experience faster than normal FEV₁ decline, and those who may achieve a lower than normal maximally attained lung function. This may be the main mechanism behind COPD in the latter group, as the decline in FEV₁ during their adult life may be normal or only slightly faster than normal. Regardless of the FEV₁ trajectory, continuous smoking is strongly associated with disease progression, development of structural lung disease and poor prognosis. In developing countries, factors such as exposure to biomass and sequelae after tuberculosis may lead to a more airway-centred COPD phenotype than seen in smokers. Mechanistically, COPD is characterized by a combination of structural and inflammatory changes. It is unlikely that all patients share the same individual or combined mechanisms given the heterogeneity of resultant phenotypes. Lung explants, bronchial biopsies and other tissue studies have revealed important features. At the small airway level, progression of COPD is clinically imperceptible, and the pathological course of the disease is poorly described. Asthmatic features can further add confusion. However, the small airway epithelium is likely to represent a key focus of the disease, combining impaired subepithelial crosstalk and structural/inflammatory changes. Insufficient resolution of inflammatory processes may facilitate these changes. Pathologically, epithelial metaplasia, inversion of the goblet to ciliated cell ratio, enlargement of the submucosal glands and neutrophil and CD8-T-cell infiltration can be detected. Evidence of type 2 inflammation is gaining interest in the light of new therapeutic agents. Alarmin biology is a promising area that may permit control of inflammation and partial reversal of structural changes in COPD. Here, we review the latest work describing the development and progression of COPD with a focus on lung function trajectories, exacerbations and survival. We also review mechanisms focusing on epithelial changes associated with COPD and lack of resolution characterizing the underlying inflammatory processes.

Effect of PM10 on pulmonary immune response and fetus development

Despite numerous reports that ambient particulate matter is a key determinant for human health, toxicity data produced based on physicochemical properties of particulate matters is very lack, suggesting lack of scientific evidence for regulation. In this study, we sampled inhalable particulate matters (PM10) in northern Seoul, Korea. PM10 showed atypical- and fiber-type particles with the average size and the surface charge of 1,598.1 ± 128.7 nm and -27.5 ± 2.8, respectively, and various toxic elements were detected in the water extract. On day 90 after the first pulmonary exposure, total cell number dose-dependently increased in the lungs of both sexes of mice. PM10 induced Th1-dominant immune response with pathological changes in both sexes of mice. Meanwhile, composition of total cells and expression of proteins which functions in cell-to-cell communication showed different trends between sexes. Following, male and female mice were mated to identify effects of PM10 to the next generation. PM10 remained in the lung of dams until day 21 after birth, and the levels of IgA and IgE increased in the blood of dams exposed to the maximum dose compared to control. In addition, the interval between births of fetuses, the number of offspring, the neonatal survival rate (day 4 after birth) and the sex ratio seemed to be affected at the maximum dose, and particularly, all offspring from one dam were stillborn. In addition, expression of HIF-1α protein increased in the lung tissue of dams exposed to PM10, and level of hypoxia-related proteins was notably enhanced in PM10-exposed bronchial epithelial cells compared to control. Taken together, we suggest that inhaled PM10 may induce Th1-shifting immune response in the lung, and that it may affect reproduction (fetus development) by causing lung hypoxia. Additionally, we propose that further study is needed to identify particle-size-dependent effects on development of the next generation.

How the constituents of fine particulate matter and ozone affect the lung function of children in Tianjin, China

As the pollution of fine particulate matter (≤ 2.5 μg/m³ in aerodynamic diameter; PM_2.5) and ozone (O₃) is becoming more and more serious in developing countries, we, hereby, investigated the effects of PM_2.5, constituents of PM_2.5 and O₃ on the lung function of children in Tianjin, China. The lung functions of 198 pupils from nine primary schools in Tianjin were examined (repeated five times) during the months of October to December in 2016, 2017 and 2018, respectively. And the mixed-effect models were used to evaluate the effects of air pollutants. A 10 μg/m³ increase in PM_2.5 and O₃-8h might lead to reductions of forced vital capacity (FVC) in 1.03% (- 1.87 to - 0.19%) and 21.09% (- 25.54 to - 16.58%), respectively, while a 10 ng/m³ increment in ANY might account for the 166.44% (- 221.32 to - 112.31%) decreases in FVC. PM_2.5 and O₃-8h might be more harmful to the lung functions of female students and participants with PS exposure at home. And the main sources of pollution resulting in the decrease in pulmonary function might be traffic pollution and coal combustion.

Clinical Application of Forced Oscillation Technique (FOT) in Early Detection of Airway Changes in Smokers

The forced oscillation technique (FOT) is a non-invasive method to assess airway function by emitting oscillatory signals into the respiratory tract during tidal ventilation. This opinion piece discusses the current use, trialled modification and future directions in utilizing FOT as a novel diagnostic tool for early detection of small airway changes in smokers. The published evidence to date has shown that FOT parameters could be a sensitive diagnostic tool to detect early respiratory changes in smokers. Multiple frequencies and the frequency dependence of resistance and reactance can provide the most valuable and early information regarding smoking induced changes in airways. Considering its non-invasiveness, lower level of discomfort to patients than spirometry, feasibility, and cost effectiveness, it could be the first-choice diagnostic technique for detection of early respiratory changes in smokers. The finding of FOT could further be supported and correlated with inflammatory markers.

Characterisation of pulmonary function trajectories: results from a Brazilian cohort

BACKGROUND

Pulmonary function (PF) trajectories are determined by different exposures throughout the life course. The aim of this study was to investigate characteristics related to PF trajectories from 15 to 22 years in a Brazilian cohort.

METHODS

A birth cohort study (1993 Pelotas Birth Cohort) was conducted with spirometry at 15, 18 and 22 years. PF trajectories were built based on z-score of forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and their ratio using a group-based trajectory model. Associations with exposures reported from perinatal to 22 years were described.

RESULTS

Three trajectories, low (LT), average (AT) and high (HT) were identified in 2917 individuals. Wealthiest individuals belonged to the HT of FEV1 (p=0.023). Lower maternal pregestational body mass index (BMI) (22.4±0.2; p<0.001 and 22.1±0.14; p<0.001) and lower birth weight (3164.8±25.4; p=0.029 and 3132.3±19.4; p=0.005) were related to the LT of FEV1 and FVC. Mother's smoking exposure during pregnancy (37.7%; p=0.002), active smoking at ages 18 and 22 years (20.1% and 25.8%; p<0.001) and family history of asthma (44.8%; p<0.001) were related to the LT of FEV1/FVC. Wheezing, asthma and hospitalisations due to respiratory diseases in childhood were related to the LT of both FEV1 and FEV1/FVC. Higher BMIs were related to the HT of FEV1 and FVC at all ages.

CONCLUSIONS

PF trajectories were mainly related to income, pregestational BMI, birth weight, hospitalisation due to respiratory diseases in childhood, participant's BMI, report of wheezing, medical diagnosis and family history of asthma, gestational exposure to tobacco and current smoking status in adolescence and young adult age.

Tobacco Smoke Exposure, Respiratory Health, and Health-care Utilization Among US Adolescents

BACKGROUND

Tobacco smoke exposure adversely affects respiratory health. However, the effects of exposure on adolescents without asthma are not well known.

RESEARCH QUESTION

To what degree are biochemically measured and self-reported tobacco smoke exposure associated with pulmonary function and health-care utilization among US nonsmoking adolescents?

STUDY DESIGN AND METHODS

We analyzed 2007-2012 National Health and Nutrition Examination Survey data (N = 2,482). Tobacco smoke exposure was assessed with serum cotinine and self-reported home exposure. We built multiple regression, logistic regression, and Poisson regression models, depending on the outcome.

RESULTS

Approximately 3% of adolescents had high cotinine (3.00-15.00 ng/mL), 35.7% had low cotinine (0.05-2.99 ng/mL), and 10.9% had home exposure. Adolescents with high cotinine had significantly lower FEV₁% (mean, 97.4; SE, 2.09; β, -8.99; 95% CI, -15.64 to -2.33) and FVC% (mean, 97.4; SE, 2.06; β, -8.42; 95% CI, -14.74 to -2.11) than adolescents with no/minimal cotinine (< 0.05 ng/mL; mean, 101.0; SE, 0.45; mean, 99.9; SE, 0.46, respectively). Adolescents with high cotinine were less likely to have a past year health-care visit (adjusted OR [aOR], 0.57; 95% CI, 0.38 to 0.88), but more likely to have an overnight hospital stay (aOR, 4.82; 95% CI, 2.58 to 9.00), and at increased risk of having a higher number of overnight hospital stays (adjusted relative risk [aRR], 4.04; 95% CI, 2.27 to 7.21). Adolescents with low cotinine were less likely to have a health-care visit (aOR, 0.84; 95% CI, 0.71 to 0.99), but more likely to have an overnight hospital stay (aOR, 4.82; 95%CI, 2.58 to 9.00) than adolescents with no/minimal cotinine. Adolescents with low cotinine were at increased risk of having a higher number of health-care visits (aRR, 1.06; 95% CI, 1.02 to 1.11) and overnight hospital stays (aRR, 2.02; 95% CI, 1.46 to 2.81). Adolescents with home exposure had lower FEV₁% (mean, 99.9; SE, 1.17; β, -5.11; 95% CI, -9.26 to -0.96) and FVC% (mean, 100.0; SE, 1.16; β, -5.36; 95% CI, -9.30 to -1.42) than adolescents with no home exposure (mean, 101.0; SE, 0.38; mean, 100.2; SE, 0.39, respectively). Adolescents with home exposure were more likely to have an overnight hospital stay (aOR, 5.65; 95% CI, 3.66 to 8.73) and at increased risk of having a higher number of overnight hospital stays (aRR, 4.08; 95% CI, 2.76 to 6.03).

INTERPRETATION

Detectable serum cotinine levels and self-reported home exposure were distinctively associated with decreased pulmonary function and increased health-care utilization.

A decade on: Follow-up findings of indigenous children with bronchiectasis

OBJECTIVE

The sole prospective longitudinal study of children with either chronic suppurative lung disease (CSLD) or bronchiectasis published in the current era was limited to a single center. We sought to extend this study by evaluating the longer-term clinical and lung function outcomes and their associated risk factors in Indigenous children of adolescents from Australia, Alaska, and New Zealand who participated in our previous CSLD or bronchiectasis studies during 2004-2010.

METHODS

Between 2015 and 2018, we evaluated 131 out of 180 (72.8%) children of adolescents from the original studies at a single follow-up visit. We administered standardized questionnaires, reviewed medical records, undertook clinical examinations, performed spirometry, and scored available chest computed tomography scans.

RESULTS

Participants were seen at a mean age of 12.3 years (standard deviation: 2.6) and a median of 9.0 years (range: 5.0-13.0) after their original recruitment. With increasing age, rates of acute lower respiratory infections (ALRI) declined, while lung function was mostly within population norms (median forced expiry volume in one-second = 90% predicted, interquartile range [IQR]: 81-105; forced vital capacity [FVC] = 98% predicted, IQR: 85-114). However, 43 out of 111 (38.7%) reported chronic cough episodes. Their overall global rating judged by symptoms, including ALRI frequency, examination findings, and spirometry was well (20.3%), stable (43.9%), or improved (35.8%). Multivariable regression identified household tobacco exposure and age at first ALRI-episode as independent risk factors associated with lower FVC% predicted values.

CONCLUSION

Under our clinical care, the respiratory outcomes in late childhood or early adolescence are encouraging for these patient populations at high-risk of premature mortality. Prospective studies to further inform management throughout the life course into adulthood are now needed.

Airway Resistance Caused by Sphingomyelin Synthase 2 Insufficiency in Response to Cigarette Smoke

Sphingomyelin synthase is responsible for the production of sphingomyelin (SGM), the second most abundant phospholipid in mammalian plasma, from ceramide, a major sphingolipid. Knowledge of the effects of cigarette smoke on SGM production is limited. In the present study, we examined the effect of chronic cigarette smoke on sphingomyelin synthase (SGMS) activity and evaluated how the deficiency of Sgms2, one of the two isoforms of mammalian SGMS, impacts pulmonary function. Sgms2-knockout and wild-type control mice were exposed to cigarette smoke for 6 months, and pulmonary function testing was performed. SGMS2-dependent signaling was investigated in these mice and in human monocyte-derived macrophages of nonsmokers and human bronchial epithelial (HBE) cells isolated from healthy nonsmokers and subjects with chronic obstructive pulmonary disease (COPD). Chronic cigarette smoke reduces SGMS activity and Sgms2 gene expression in mouse lungs. Sgms2-deficient mice exhibited enhanced airway and tissue resistance after chronic cigarette smoke exposure, but had similar degrees of emphysema, compared with smoke-exposed wild-type mice. Sgms2-/- mice had greater AKT phosphorylation, peribronchial collagen deposition, and protease activity in their lungs after smoke inhalation. Similarly, we identified reduced SGMS2 expression and enhanced phosphorylation of AKT and protease production in HBE cells isolated from subjects with COPD. Selective inhibition of AKT activity or overexpression of SGMS2 reduced the production of several matrix metalloproteinases in HBE cells and monocyte-derived macrophages. Our study demonstrates that smoke-regulated Sgms2 gene expression influences key COPD features in mice, including airway resistance, AKT signaling, and protease production.

Dietary antioxidant intake in school age and lung function development up to adolescence

Dietary antioxidant intake has been hypothesised to influence lung function. The association between total antioxidant capacity (TAC) of the diet at age 8 years and lung function development up to 16 years in 2307 participants from the Swedish population-based birth cohort BAMSE (Children, Allergy, Milieu, Stockholm, Epidemiology) was investigated.

Information on TAC was obtained from a food frequency questionnaire at 8 years. Lung function was measured by spirometry at 8 and 16 years, impulse oscillometry (IOS) and exhaled nitric oxide fraction (F_eNO) at 16 years. Low lung function was defined as forced expiratory volume in 1 s (FEV₁) z-score below the 25th percentile. Longitudinal associations between TAC and lung function were analysed by mixed effect models adjusted for potential confounders. Stratification by asthma at 8 years was performed to examine effect modification.

The median TAC intake was 10 067 μmol Trolox equivalents (TE)·g⁻¹, with males having a lower mean compared to females (9963 versus 10 819 μmol TE·g⁻¹). In analyses of lung function change between 8 and 16 years, there were no statistically significant associations between TAC in tertiles and spirometry results for the total study population. Among children with asthma at 8 years (prevalence 7%), higher TAC was associated with higher mean FEV₁ (0.46 sd, 95% CI 0.11–0.80) and decreased odds of low lung function at 16 years (OR 0.28, 95% CI 0.12–0.65). There were no associations between TAC and forced vital capacity or IOS/F_eNO results.

High dietary antioxidant intake in school age may be associated with improved lung function development from school age to adolescence among children with asthma.

Dietary antioxidant intake at school age may influence lung function development as measured by FEV₁ up to adolescence among children with asthma. In contrast, no association was observed among children without asthma.http://bit.ly/2CzEZ8W

Lung functional development and asthma trajectories

Early life environmental risk factors are associated with chronic respiratory morbidity in child- and adulthood. A possible mechanism for this sustained effect is their influence on early life lung functional growth and development, a susceptible phase of rapid lung growth with increased plasticity. We summarize evidence of hereditary and environmental ante-, peri-, and early postnatal factors on lung functional development, such as air pollution, tobacco exposure, nutrition, intrauterine growth retardation, prematurity, early life infections, microbiome, and allergies and their effect on lung functional trajectories. While some of the factors (e.g., prematurity) directly impair lung growth, the influence of many environmental factors is mediated through inflammatory processes (e.g., recurrent infections or oxidative stress). The timing and nature of these influences and their impact result in degrees of impaired maximal lung functional capacity in early adulthood; and they potentially impact future long-term respiratory morbidity such as chronic asthma or chronic obstructive airway disease (COPD). We discuss possibilities to prevent or modify such early abnormal lung functional growth trajectories and the need for future studies and prevention programs.

Timing of secondhand smoke, pet, dampness or mould exposure and lung function in adolescence

BACKGROUND

The relevance of timing of exposure in the associations of secondhand tobacco smoke (SHS), pets, and dampness or mould exposure with lung function is unclear. We investigated the relevance of timing of these exposures for lung function in adolescence.

METHODS

We used data from participants of the Dutch Prevention and Incidence of Asthma and Mite Allergy (PIAMA) cohort with spirometric measurements at ages 12 and 16 years (n=552). Data on residential exposure to SHS, pets, and dampness or mould were obtained by repeated parental questionnaires. We characterised timing of exposure through longitudinal patterns using latent class growth modelling and assessed associations of these patterns with FEV₁ and FVC at ages 12 and 16 and FEV₁ and FVC growth between ages 12 and 16 using linear regression models.

RESULTS

Childhood SHS exposure was associated with reduced FEV₁ growth/year (95% CI) (-0.34% (-0.64% to -0.04%)). Late childhood and early life pet exposure was associated with increased FEV₁ growth (0.41% (0.14% to 0.67%)) and reduced FVC growth (-0.28% (-0.53% to -0.03%)), respectively, compared with very low exposure. Early life dampness or mould exposure was associated with reduced lung function growth. All time windows of SHS exposure tended to be associated with lower attained lung function and pet exposure tended to be associated with higher FEV₁.

CONCLUSION

SHS exposure during childhood could lead to reduced lung function growth and lower attained lung function in adolescence. While pet exposure in late childhood may not adversely affect lung function, early childhood pet exposure may slow down FVC growth in adolescence.

Linking COPD epidemiology with pediatric asthma care: Implications for the patient and the physician

What are the implications of a lower than expected forced expiratory volume in one second (FEV1) in childhood on respiratory health later in adulthood? Lung function is known to track with age, and there is evidence from recent epidemiologic studies that impaired lung function early in life is associated with later chronic airflow limitation, or even chronic obstructive pulmonary disease, COPD. This risk seems particularly strong in subjects with persistent and severe forms of childhood asthma. Can we translate findings from longitudinal cohort studies to individual risk predictions and preventive guidelines in our pediatric care? In this review, we discuss the clinical implementations of recent epidemiological respiratory studies and the importance of preserved lung health across the life course. Also, we evaluate available clinical tools, primarily lung function measures, and profiles of risk factors, including biomarkers, that may help identifying children at risk of chronic airway disease in adulthood. We conclude that translating population level results to the individual patient in the pediatric care setting is not straight forward, and that there is a need for studies specifically designed to evaluate performance of prediction of risk profiles for long-term sequelae of childhood asthma and lung function impairment.

Lost in the transition from pediatric to adult healthcare? Experiences of young adults with severe asthma

Objective: Asthma is a multifaceted disease, and severe asthma is likely to be persistent. Patients with severe asthma have the greatest burden and require more healthcare resources than those with mild-to-moderate asthma. The majority with asthma can be managed in primary care, while some patients with severe asthma warrant referral for expert advice regarding management. In adolescence, this involves a transition from pediatric to adult healthcare. This study aimed to explore how young adults with severe asthma experienced the transition process.Methods: Young adults with severe asthma were recruited from an ongoing Swedish population-based cohort. Qualitative data were obtained through individual interviews (n = 16, mean age 23.4 years), and the transcribed data were analyzed with systematic text condensation.Results: Four categories emerged based on the young adults' experiences: "I have to take responsibility", "A need of being involved", "Feeling left out of the system", and "Lack of engagement". The young adults felt they had to take more responsibility, did not know where to turn, and experienced fewer follow-ups in adult healthcare. Further, they wanted healthcare providers to involve them in self-management during adolescence, and in general, they felt that their asthma received insufficient support from healthcare providers.Conclusions: Based on how the young adults with severe asthma experienced the transition from pediatric to adult healthcare, it is suggested that healthcare providers together with each patient prepare, plan, and communicate in the transition process for continued care in line with transition guidelines.