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ORIGINAL ARTICLE
ABSTRACT
Background There is limited data on the risk factors
and phenotypical characteristics associated with
spirometrically conrmed COPD in never-smokers in the
general population.
Aims To compare the characteristics associated with
COPD by gender and by severity of airway obstruction in
never-smokers and in ever-smokers.
Method We analysed the data from 5176 adults aged
40 years and older who participated in the initial crosssectional phase of the population-based, prospective,
multisite Canadian Cohort of Obstructive Lung Disease
study. Never-smokers were dened as those with a
lifetime exposure of <1/20 pack year. Logistic
regressions were constructed to evaluate associations for
mild and moderate-severe COPD dened by FEV1/FVC
<5th centile (lower limits of normal). Analyses were
performed using SAS V.9.1 (SAS Institute, Cary, North
Carolina, USA).
Results The prevalence of COPD (FEV1/FVC<lower
limits of normal) in never-smokers was 6.4%,
constituting 27% of all COPD subjects. The common
independent predictors of COPD in never-smokers and
ever-smokers were older age, self reported asthma and
lower education. In never-smokers a history of
hospitalisation in childhood for respiratory illness was
discriminative, while exposure to passive smoke and
biomass fuel for heating were discriminative for women.
COPD in never-smokers and ever-smokers was
characterised by increased respiratory symptoms,
respiratory exacerbation events and increased residual
volume/total lung capacity, but only smokers had
reduced DLCO/Va and emphysema on chest CT scans.
Conclusions The study conrmed the substantial
burden of COPD among never-smokers, dened the
common and gender-specic risk factors for COPD in
never-smokers and provided early insight into potential
phenotypical differences in COPD between lifelong
never-smokers and ever-smokers.
Trial registration number NCT00920348
(ClinicalTrials.gov); study ID number: IRO-93326.
INTRODUCTION
To cite: Tan WC, Sin DD,
Bourbeau J, et al. Thorax
2015;70:822829.
822
Key messages
What is the key question?
Denitions
Ever-smokers and never-smokers
The whole cohort was stratied into ever-smokers and neversmokers. Never-smokers were dened as individuals who had
not smoked in their lifetime, more than 1 cigarette per day for
1 year (<1/20 pack years).15
Exposures
Passive smoking at home was evaluated by asking the question:
has anyone living in your home (besides yourself ) smoked a cigarette, pipe, or cigar in your home during the past two weeks.
Biomass fuel exposure was dened as a lifetime exposure of
10 years or greater from the use of indoor re using (1) coal or
coke; (2) wood, crop residues or dung as the primary means of
cooking or heating (details in online supplementary le).
Statistical analysis
All statistical analyses were performed using SAS V.9.1 (SAS
Institute, Cary, North Carolina, USA). A two-sided p<0.05,
with adjustment for multiple comparisons using the HolmBonferroni correction was considered statistically signicant.
Descriptive statistics are shown as counts and percentages for
categorical data and means and SDs for continuous variables,
unless otherwise stated.
Comparisons of variables between ever-smokers and neversmokers and between non-COPD and COPD were performed
using Kruskal-Wallis test and 2 test for continuous variables and
categorical variables, respectively. Unweighted and weighted
prevalences of COPD were calculated by smoking status for
men and women.
To address the determinants for COPD, multivariable logistic
regression models ( parsimonious and full) were constructed to
evaluate associations in all never-smokers and all ever-smokers;
separately by sex and by COPD severity qualied by post- bronchodilator FEV1% predicted 80% and <80%. Covariates in
the model included: age, body mass index (BMI) and years of
education; exposure to organic dust, inorganic dust, biomass
fuel (cooking or heating), environmental/passive tobacco smoke;
history of childhood hospitalisation; cardiovascular comorbidity
(heart disease, hypertension or diabetes); asthma and TB (details
in online supplementary le).
RESULTS
Of 5176 participants, 4893 (94%) individuals had spirometric
measurements, which satised the American Thoracic Society
(ATS) acceptability and repeatability criteria21 and were used in
the analysis in the study.
823
Table 1 Demographic, exposure and clinical characteristics of the study population by smoking status (never-smokers vs ever-smokers)
Sex (men)
Ethnicity (Caucasian)
Age, year, meanSD
Age, years
4049
5059
6069
70+
BMI, kg/m2, meanSD
Education, year, meanSD
Pack years >20
Exposures
Organic dust
Inorganic dust
Gases/vapours
Biomass fuel
10 years cooking
10 years heating
Passive smoking at home
Childhood hospitalisation for respiratory illness
Comorbidities, ever
HD/HT/DM
Asthma
TB
Use of respiratory medications
Prescribed medication
Bronchodilator
Inhaled steroid
Oral steroid
Anti-inflammatory (other)
OTC medication
Never-smokers
n=2295
Per cent
Ever-smokers
n=2598
Per cent
Adjusted p value*
891
2019
55.6911.17
38.82
88.0
1205
2456
58.1811.03
46.38
94.5
702
750
501
342
27.515.66
16.063.51
30.59
32.68
21.83
14.90
672
811
674
441
28.275.96
14.813.49
1231
25.87
31.22
25.94
16.97
47.38
0.0023
0.0022
0.0021
0.0020
0.0019
0.0018
202
46
89
8.80
2.00
3.88
243
112
155
9.35
4.31
5.97
1.0000
0.0017
0.0112
196
246
106
111
12.03
15.10
4.62
4.84
225
312
361
173
13.16
18.25
13.90
6.66
1.0000
0.1639
0.0016
0.0871
728
369
31
746
416
272
332
10
16
306
31.72
16.08
1.35
32.6
18.2
11.9
14.5
0.4
0.7
13.4
999
424
35
855
534
373
428
10
21
290
38.45
16.32
1.35
32.9
20.6
14.4
16.5
0.4
0.8
11.2
0.0015
1.0000
0.9914
1.0000
0.149
0.1224
0.4432
1.0000
1.0000
0.1341
Data are meanSD or count and %. p Values of tests between never-smokers and ever-smokers; Kruskal-Wallis test (without assumption of normal distribution of data) and 2 test are
used for continuous variables and categorical variables, respectively.
*p Values adjusted after Holm-Bonferroni correction.
Calculated based on six sites with available biomass data.
Heart disease, systemic hypertension or diabetes.
Includes antihistamines, decongestants and antitussives.
BMI, body mass index; HD/HT/DM, heart disease/ systemic hypertension/diabetes mellitus.
824
DISCUSSION
COPD, the additional common risk factor was childhood hospitalisation for respiratory disease, while exposure to biomass
fuel used for heating purposes for at least 10 years was a discriminative factor in women. Using the alternative denition for
COPD (FEV1/FVC <0.7) and grading of mild (FEV1%pred
80%) and moderate-severe (FEV1%pred <80%), the results
(not shown) remained unchanged.
Table 2 Adjusted OR (aOR) for independent predictors associated with risk of different severity of COPD defined by lower limits of normal in
male and female never-smokers
COPD mild
COPD moderate-severe
Variables
All
Men
Women
All
Men
6.09* (1.14 to 35.4)
0.96 (0.83 to 1.10)
0.44 (0.08 to 2.42)
0.69 (0.08 to 6.21)
10.1* (3.71 to 27.5)
1.48 (0.57 to 3.90)
7.34* (3.01 to 17.9)
Women
3.54* (1.23 to 10.1)
0.94 (0.86 to 1.03)
3.58* (1.42 to 9.01)
1.65 (0.46 to 5.88)
2.24 (0.73 to 6.84)
1.07 (0.53 to 2.16)
3.89* (2.02 to 7.50)
Data are aORs and 95% CI. Adjustment made for all other covariates in model: BMI, exposure to organic dust, inorganic dust, gases/vapours, biomass cooking 10 years and TB. Plus
sex (for all cohorts).
*Significant at 5% level (all variables shown in online supplementary table X2).
Calculated based on six sites with available biomass data.
Heart disease, systemic hypertension or diabetes.
BMI, body mass index; HD/HT/DM, heart disease/ systemic hypertension/diabetes mellitus.
825
COPD moderate-severe
Variables
All
Men
Women
All
Men
Women
Data are aORs and 95% CI. Adjustment made for all other covariates in the table plus sex (for all cohorts), exposures to organic dust, inorganic dust, gases/vapours, biomass cooking
10 years, biomass heating 10 years and childhood hospitalisation for respiratory illness, HD/HT/DM and tuberculosis.
*Significant on 5% level (all variables shown in online supplementary table X3).
Calculated based on six sites with available biomass data.
BMI, body mass index; HD/HT/DM, heart disease/ systemic hypertension/diabetes mellitus.
826
Limitations
There are potential limitations in this study. First, the ideal definition for COPD remains controversial.34 35 In this analysis, we
827
CONCLUSION
In summary, the study conrmed the substantial burden of
COPD among never-smokers, dened the common and genderspecic risk factors for COPD in never-smokers and provided
early insight into potential phenotypical differences in COPD
between lifelong never-smokers and ever-smokers. The establishment of phenotypical differences for COPD in never-smokers
and ever-smokers could provide clearer outcomes needed for
better COPD management and for clinical trials to evaluate
novel treatments for COPD.
Author afliations
1
University of British Columbia, Heart Lung Innovation, Vancouver, British Columbia,
Canada
2
Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute,
McGill University Health Centre, McGill University, Montral, Quebec, Canada
3
Department of Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax,
Nova Scotia, Canada
4
Department of Respiratory Medicine, University of Toronto, Toronto, Ontario,
Canada
5
Departments of Medicine and Community Health Sciences, University of Calgary,
Calgary, Alberta, Canada
6
Department of Respiratory Medicine, University of British Columbia, Vancouver,
British Columbia, Canada
7
Department of Respiratory Medicine, University of Saskatchewan, Saskatoon,
Saskatchewan, Canada
8
Centre de Pneumologie de lHopital Laval, Respirology, Quebec City, Quebec,
Canada.
9
Oregon Health Sciences University, Portland, Oregon, USA
10
Department of Radiology, St Pauls Hospital, Vancouver, British Columbia, Canada
11
Department of Medicine/Physiology, Queens University, Kingston, Ontario, Canada
12
Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
Acknowledgements The authors thank the men and women who participated in
the study and individuals in the CanCOLD Collaborative research Group: Executive
Committee: Jean Bourbeau, (Mcgill University, Montreal, QC, Canada); Wan C Tan,
J Mark FitzGerald; D D Sin. (UBC, Vancouver, BC, Canada); D D Marciniuk (University
of Saskatoon, Saskatoon, SASK, Canada) D E ODonnell (Queens University,
Kingston, ON, Canada); Paul Hernandez (University of Halifax, Halifax, NS, Canada);
Kenneth R Chapman (University of Toronto, Toronto, ON, Canada); Robert Cowie
(University of Calgary, Calgary, AB, Canada); Shawn Aaron (University of Ottawa,
Ottawa, ON, Canada); F Maltais (University of Laval, Quebec City, QC, Canada);
International Advisory Board: Jonathon Samet (the Keck School of Medicine of USC,
California, USA); Milo Puhan ( John Hopkins School of Public Health, Baltimore, USA
); Qutayba Hamid (McGill University, Montreal, Qc, Canada); James C Hogg (UBC
James Hogg Research Center, Vancouver, BC, Canada). Operations Center: Jean
Bourbeau (PI), Carole Baglole, Carole Jabet, Palmina Mancino, Yvan Fortier,
(University of McGill, Montreal, QC, Canada); Wan C Tan (co-PI), Don Sin, Sheena
Tam, Jeremy Road, Joe Comeau, Adrian Png, Harvey Coxson, Miranda Kirby, Jonathon
Leipsic, Cameron Hague (University of British Columbia James Hogg Research Center,
Vancouver, BC, Canada). Economic Core: Mohsen Sadatsafavi (University of British
Columbia, Vancouver, BC). Public Health core: Teresa To, Andrea Gershon (University
828
of Toronto) Data management and Quality Control: Wan C Tan, Harvey Coxson, (UBC,
Vancouver, BC, Canada); Jean Bourbeau, Pei-Zhi Li, Jean-Francois Duquette, Yvan
Fortier, Andrea Benedetti, Denis Jensen (Mcgill University, Montreal, QC,Canada),
Denis ODonnell (Queens University, Kingston, ON, Canada. Field Centers: Wan C
Tan (PI), Christine Lo, Sarah Cheng, Cindy Fung, Nancy Ferguson, Nancy Haynes,
Junior Chuang, Licong Li, Selva Bayat, Amanda Wong, Zoe Alavi, Catherine Peng, Bin
Zhao, Nathalie Scott-Hsiung, Tasha Nadirshaw (UBC James Hogg Research Center,
Vancouver, BC); Jean Bourbeau (PI), Palmina Mancino, David Latreille, Jacinthe Baril,
Laura Labonte (McGill University, Montreal, QC, Canada ); Kenneth Chapman (PI),
Patricia McClean, Nadeen Audisho, (University of Toronto, Toronto, ON, Canada);
Robert Cowie (PI), Ann Cowie, Curtis Dumonceaux, Lisette Machado(University of
Calgary,Calgary, AB, Canada); Paul Hernandez (PI), Scott Fulton, Kristen Osterling
(University of Halifax, Halifax, NS, Canada ); Shawn Aaron (PI), Kathy Vandemheen,
Gay Pratt, Amanda Bergeron (University of Ottawa, Ottawa, ON, Canada); Denis
ODonnell (PI), Matthew McNeil, Kate Whelan (Queens University, Kingston, ON,
Canada); Francois Maltais (PI), Cynthia Brouillard (University of Laval, Quebec City,
QC, Canada); Darcy Marciniuk (PI), Ron Clemens, Janet Baran (University of
Saskatoon, Saskatoon, SK, Canada).
Collaborators CanCOLD Collaborative Research Group (listed in
acknowledgements).
Contributors WCT contributed to the conception and design of the study, the
acquisition of the data, the analysis of the data and the writing. She assembled the
data set and takes responsibility for the integrity of the data and the accuracy of the
data analysis. JB, JMF, RC, KRC, PH, SDA, DDM, DEO, FM, CH, JL and JR contributed
to the acquisition of the data and the writing and revision of the article. ASB and JCH
contributed to the conception, design of the study and the revision of the article. DDS,
MK, HC contributed to the analysis and interpretation of the data and the writing of
the article. All authors approved the nal version of the manuscript.
Funding The Canadian Cohort of Obstructive Lung Disease (COLD/CanCOLD) is
funded by the Canadian Institute of Heath Research (CIHR/Rx&D Collaborative
Research Program Operating Grants- 93326); the Respiratory Health Network of the
FRSQ; the Canadian Respiratory Research Network (CRRN); the Canadian Institutes
of Health Research (CIHR)Institute of Circulatory and Respiratory Health; Canadian
Lung Association (CLA)/Canadian Thoracic Society (CTS); British Columbia Lung
Association; industry partners Astra Zeneca Canada, Boehringer-Ingelheim Canada,
GlaxoSmithKline Canada, Merck, Novartis Pharma Canada, Nycomed Canada, Pzer
Canada; The funders had no role in the study design, data collection and analysis,
decision to publish or preparation of the manuscript.
Competing interests WCT and JB report unrestricted educational grants from
GSK, Pzer, BI, AZ for the epidemiological COLD study; grants from funding for the
operations of CanCOLD Longitudinal Epidemiological Study from the Canadian
Institute of Heath Research (CIHR/Rx&D Collaborative Research Program Operating
Grants93326) with industry partners AZ Canada, BI Canada, GSK Canada, Merck,
Novartis Pharma Canada, Nycomed Canada, Pzer Canada, outside the submitted
work. WCT also received personal fees from GSK board membership. DDM, an
employee of the University of Saskatchewan, received funding from the Canadian
Institutes of Health Research (via McGill University) to undertake this research. KRC
reports grants from Novartis, grants from Almirall, grants from Boehringer Ingelheim,
grants from Forest, grants from GSK, grants from AstraZeneca, grants from Amgen,
grants from Roche, grants from CSL Behring, grants from Grifols, grants from
Genentech, grants from Kamada, during the conduct of the study; others from
CIHRGSK Research Chair in Respiratory Health Care Delivery, outside the submitted
work. P H reports grants from Canadian Institute Health Research, during the
conduct of the study; grants and personal fees from AstraZeneca, Boehringer
Ingelheim, GlaxoSmithKline, Merck, Novartis, Takeda, Grifols, CSL Behring, Pzer,
Almirall outside the submitted work. FM received fees for speaking at conferences
sponsored by Boehringer Ingelheim, GlaxoSmithKline and Novartis and Grifols. He
received research grants for participating in multicentre trials sponsored by
GlaxoSmithKline, Boehringer Ingelheim, Astra Zeneca, Nycomed and Novartis. He
received unrestricted research grant from Boehringer Ingelheim and GlaxoSmithKline.
He holds a CIHR/GSK research chair on COPD. DDS reports personal fees from
Almirall, personal fees from AstraZeneca, grants from AstraZeneca, personal fees
from Novartis, personal fees from Amgen, outside the submitted work; SDA, ASB,
JCH, JMF, CH, JL, JR, MK, HC, DEO and RC have no conicts of interest to declare.
Ethics approval The study was approved by the respective university and
institutional ethical review boards :UBC/ PHC Research Ethics Board, P05-006
(Vancouver); Biomedical-C Research Ethics Board, BMC-06-002 (Montreal); UHN
REB, 06-0421-B (Toronto); Capital Health Research Ethics Board, CDHA-RS/
2007-255 (Halifax); Conjoint Health Research Ethics Board, ID21258 (Calgary);
DMED-1240-09 (Kingston); 2009519-01H (Ottawa); Bio-REB09-162 (Saskatoon);
CER20459 (Quebec City).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data sharing is available via the CANCOLD process
through WCT (e mail: wan.tan@hli.ubc.ca) and JB (e mail: jean.bourbeau@mcgill.ca).
Tan WC, et al. Thorax 2015;70:822829. doi:10.1136/thoraxjnl-2015-206938
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample
of the general U.S. population. Am J Respir Crit Care Med 1999;159:17987.
Bourbeau J, Tan WC, Benedetti A, et al. Canadian Cohort Obstructive Lung Disease
(CanCOLD): Fullling the need for longitudinal observational studies in COPD.
COPD 2012;11:12532.
Barr RG, Berkowitz EA, Bigazzi F, et al. A combined pulmonary-radiology workshop
for visual evaluation of COPD: study design, chest CT ndings and concordance
with quantitative evaluation. COPD 2012;9:1519.
Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir
J 2005;26:31938.
Birring SS, Brightling CE, Bradding P, et al. Clinical, radiologic, and induced sputum
features of chronic obstructive pulmonary disease in nonsmokers: a descriptive
study. Am J Respir Crit Care Med 2002;166:107883.
Ramirez-Venegas A, Sansores RH, Quintana-Carrillo RH, et al. FEV1 decline in
patients with chronic obstructive pulmonary disease associated with biomass
exposure. Am J Respir Crit Care Med 2014;190:9961002.
Lange P, Parner J, Vestbo J, et al. A 15-year follow-up study of ventilatory function
in adults with asthma. N Engl J Med 1998;339:1194200.
Rehfuess E, Mehta S, Pruss-Ustun A. Assessing household solid fuel use: multiple
implications for the Millennium Development Goals. Environ Health Perspect
2006;114:3738.
Sorheim IC, Johannessen A, Gulsvik A, et al. Gender differences in COPD: are
women more susceptible to smoking effects than men? Thorax 2010;65:4805.
Dijkstra A, Vonk JM, Jongepier H, et al. Lung function decline in asthma:
association with inhaled corticosteroids, smoking and sex. Thorax 2006;61:10510.
Svanes C, Sunyer J, Plana E, et al. Early life origins of chronic obstructive pulmonary
disease. Thorax 2010;65:1420.
Thomsen M, Nordestgaard BG, Vestbo J, et al. Characteristics and outcomes of
chronic obstructive pulmonary disease in never smokers in Denmark: a prospective
population study. Lancet Respir Med 2013;1:54350.
Wedzicha JA, Brill SE, Allinson JP, et al. Mechanisms and impact of the frequent
exacerbator phenotype in chronic obstructive pulmonary disease. BMC Med
2013;11:181.
Han MK, Agusti A, Calverley PM, et al. Chronic obstructive pulmonary disease
phenotypes: the future of COPD. Am J Respir Crit Care Med 2010;182:598604.
Tan WC, Bourbeau J, Hernandez P, et al. Exacerbation-like respiratory symptoms in
individuals without chronic obstructive pulmonary disease: results from a
population-based study. Thorax 2014;69:70917.
Vestbo J. COPD: denition and phenotypes. Clin Chest Med 2014;35:16.
Mannino DM, Sonia Buist A, Vollmer WM. Chronic obstructive pulmonary
disease in the older adult: what denes abnormal lung function? Thorax
2007;62:23741.
Guder G, Brenner S, Angermann CE, et al. GOLD or lower limit of normal
denition? A comparison with expert-based diagnosis of chronic obstructive
pulmonary disease in a prospective cohort-study. Respir Res 2012;13:13.
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Notes