Males Females 70 + (9 Non-iInhalers 60 + EES3 Inhalers 50 F oO oO 3 = 40 Fr > 2 a * 30F 1-14 35+ Cigarettes/Day FIGURE 1.—Age-standardized rates (percent) of chronic nonspecific respiratory disease* by inhaling and current cigarette smoking *Criteria for diagnosis were as follows: (1) Chronic bronchitis: Affirmative response to the question— Do you bring up phlegm from chest six or more times a day for four days a week for three months a year for the past three years or more? (2) Asthma: Affirmative response that bronchial asthma had been diagnosed and was still present. (3) Chronic obstructive lung disease: Affirmative response to one or more of the following: wheezing or whistling in the chest occurred most days or nights; the subject had to stop for breath when walking at his own pace on the level; FEV: less than 60 per cent of the FVC. These could occur in various combinations and were not mutually exclusive. SOURCE: Ferris, B.G., Jr. (22). smoking histories were comparable. Rawbone et al., in a ques- tionnaire survey of 10,498 secondary school children aged 11 to 17 in London, found a significantly higher frequency of cough, 151 TABLE 10.— Respiratory symptoms and diseases in male (M) and female (F) participants in Charleswood (C)—urban— and in Portage La Prairie (P)—rural—expressed as percent of respondents Respiratory Nonsmokers Ex-Smokers Smokers Symptom/Disease Cc P Cc P Cc P Cough on most days, at least 3 months/year M 8.3 4.0 8.1 2.9 25.4 31.5 F — 4.0 _ 10.0 20.3 31.7 Phlegm on most days, at least 3 months/year M — 4.0 10.8 5.7 16.9 24.7 F — 4.0 _— 5.0 10.2 25.4 Wheezing apart from colds M 4.2 8.0 10.8 14.3 26.8 31.5 F 3.5 8.0 12.1 20.0 25.4 30.2 Attack of short- ness of breath and wheezing M 4.2 8.0 13.5 11.4 11.3 17.8 F _— 12.0 6.1 15.0 13.5 20.6 Shortness of breath compared to per- sons of same sex and age M 8.3 4.0 5.4 5.8 5.6 12.3 F 7.0 12.0 6.1 5.0 22.1 17.5 SOURCE: Manfreda, J. (39). colds, and exertional dyspnea in regular smokers as compared to nonsmokers (45), There was no appreciable difference in the frequency of cough between male and female smokers or be- tween male and female nonsmokers. Colley et al. examined the influence of smoking, lower respiratory tract illness under 2 years of age, social class of father, and air pollution on respira- tory symptoms in a cohort of 20-year-olds followed since birth (15). Their data (Table 12) suggest that respiratory symptoms were closely related to current smoking. Symptoms were also related to a history of lower respiratory tract infection in the first 2 years of life but were not related to social class or air pollution. 152 Sot TABLE 11.—Smoking and the prevalence of respiratory symptoms in girls from two different cities in England Prevalence of Symptom With Each Group Experimental Smoker* Smokert Nonsmoker Symptom Residence N % N % N % Significance* Cough in the morning Kent 10 31.3 51 9.8 73 6.9 P <0.001 Derbyshire 14 18.9 50 8.4 138 6.7 P <0.001 Cough day or night Kent 17 53.1 148 28.0 195 18.4 P <0.001 Derbyshire 35 47.3 176 29.5 458 22.1 P <0.001 Cough for 3 months of year Kent 5 15.6 43 8.2 55 5.2 P <0.01** Derbyshire 10 13.5 32 5.4 82 4.0 P <0.001 +Smoker =a child who smoked at least one cigarette a week. +Experimental smoker = a child who had smoked at sometime but less than one cigarette a week. *Test for significant association of cough and smoking habit. Chi-square 2 x 3 table. **Smokers and experimental smokers combined to give chi-square on a 2 x 2 table. SOURCE: Bewley, B.R. (9). cT > 20-year-olds followed since birth TABLE 12.—Prevalence (percent) of respiratory symptoms by sex and smoking habit in cohort of 3,898 Persistent Winter Cough Day Cough 3 Winter Phlegm Day Phlegm 3 Cough and Morning or Night Months in Morning or Night Months in Plegm History of Cough in Winter Winter Phlegm in Winter Winter Q.1(e) Cigarette Population Q.1(a)* Q.1(b)* Q.1(c)+ Q.2(a)* Q.2(b)* Q.2(c)* +2(c)t Smoking M F M F M F M F M F M F M F M F Never smoked cigarettes 802 1093 1.6 4.0 5.2 6.5 1.5 3.2 4.8 5.2 6.4 3.9 3.7 3.2 0.9 1.9 Ex-smokers of cigarettes 101 57 3.0 18 TA 10.5 3.0 1.8 11.0 1.9 10.2 9.1 6.0 0.0 2.0 0.0 Present smoker of cigarettes 1009 678 13.0 13.2 13.9 16.0 8.1 ¥iR) 14.1 11.9 11.6 11.2 8.3 5.5 4.9 3.5 No data on cigarette smoking 92 48 8.7 11.8 9.1 18.8 4.5 0.0 0.0 6.7 48 0.0 4.8 0.0 4.8 0.0 All 2022 1876 7.7 74 9.8 10.2 5.0 4.7 9.9 1.6 9.3 6.7 6.2 3.9 3.0 2.4 +1, (a) Do you usually cough first thing in the morning in the winter? (b) Do you usually cough during the day or at night in the winter? If “Yes” to either question 1(a) or (b) (c) Do you cough like this on most days for as much as three months each winter? SCT 2. (a) Do you usually bring up any phlegm (spit from the chest) first thing in the morning in the winter? (b) Do you usually bring up any phlegm (spit from the chest) during the day or at night in the winter? If “Yes” to either question 2(a) or (b) (c) Do you bring up phlegm (spit from the chest) on most days for as much as three months each winter? SOURCE: Colley, J.R.T. (15). TABLE 13.—Percentages of nonsmokers and smokers with abnormal test results in three North American cities, using combined reference values“ Men Women Nonsmokers Smokers Nonsmokers Smokers AS i} Total AS NS} Total AS Ss Total AS Ss Total (95)* (27) (122) (12) (115) (236) (145) (46) (191) (107) (98) (205) Upper limit + 1.6 0.2 1.8 1.8 1.8 2.6 2.1 0.6 2.4 L7 1.7 2.4 Lower limit + 11.6 20.0 10.6 10.6 10.9 8.7 10.0 15.0 9.1 11.1 11.5 9.0 1. Abnormal test FEV-FVC 6 11 q 5 7 6 4 20 8 7 25 16 CVIVC 2 q 3 13 17 15 6 11 7 23 26 25 CC/TLC 2 7 3 20 32 26 8 17 10 20 29 25 AN/L 1 qT 3 17 13 15 qT 24 11 27 37 32 RV/TLC 6 ll 7 9 9 9 8 9 8 11 13 12 *Reference values for nonsmokers derived from asymptomatic nonsmokers in the three cities. **Numbers in parenthesis = number of subjects in each group. *Upper and lower limits in the expected 5 percent abnormal results. AS = asymptomatic; S = symptomatic SOURCE: Buist, A.S. (11). In a longitudinal study of elderly Edinburgh residents aged 61 to 90, Millne and Williamson found the prevalence of persist- ent cough and sputum production was significantly greater in smokers of both sexes than in their nonsmoking counterparts (40). Male prevalence rates were three times higher than those in females; however, no attempt was made to determine the relationship of respiratory symptoms to life-time tobacco expo- sure. In summary, many recent studies demonstrate a higher fre- quency of respiratory symptoms in women who smoke as com- pared to women who do not smoke. This is true in surveys in- cluding children, adolescents, young adults, working age, and elderly women. The effect of cigarette smoking is related in terms of both the number of cigarettes and years smoked. The majority of studies indicate a greater prevalence of respiratory symptoms among men who smoke than among women who smoke; however, these differences often disappear when the study is carefully controlled for smoking history. Smoking and Pulmonary Function The insensitivity of cough and sputum production in the adult as a predictor of future development of COLD has been empha- sized by Fletcher and Peto (29). Pulmonary function testing of- fers an objective method for measuring the adverse effects of smoking. However, current tests of pulmonary function display a marked variability between individuals and may not detect the development of COLD until irreversible damage of the lung has occurred. Also, none of the presently used pulmonary func- tion tests can predict which of those individuals with slightly abnormal pulmonary function will progress to debilitating and life-threatening emphysema and chronic bronchitis. Becklake and Permutt have recently reviewed the objectives and prob- lems of the tests of lung function commonly used for early de- tection of COLD (7). A large number of studies have established a higher fre- quency of pulmonary functional abnormalities in smokers as compared to nonsmokers. These studies have examined (a) the relationship of smoking to abnormal tests of small airway func- tion and (b) the relationship of smoking to measurements of standard spirometry. The majority of epidemiologic surveys in- vestigating the prevalence of functional abnormalities in smok- ers have employed spirometric measurements, usually the forced expiratory volume (FEV) and vital capacity (VC). Meas- urements of airway resistance, diffusing capacity, lung volume, and nitrogen mixing have been used much less frequently. 156 604 Males @ Portage ia Prairie 4 CJ Charleswood iaodds 60 + Females cm anile RV%TLO = CV%VCE CC%TLC- Sipiil FEV,,%FVC Percentage Percentage » o i FIGURE 2.—Prevalence of lung function abnormalities among smokers in an urban (Charleswood) and a rural (Portage La Prairie) community SOURCE: Manfreda, J. (39). SMOKING AND “EARLY” FUNCTIONAL ABNORMALITIES The most widely used measurements for detecting early change of chronic airflow obstruction are the single-breath ni- trogen washout curve or a maximum forced expiratory volume curve. A limited number of recent studies using tests of small airway function have included appreciable numbers of female subjects. They have demonstrated a higher frequency of abnormalities in tests of small airway function in smokers than in nonsmokers or ex-smokers. A definite dose-response relationship has been found in some of these studies but not in others (10,11,12). Table 13 shows the data from one of these studies (11). For all meas- ures of small airway function, the frequency of abnormalities was higher among smokers than nonsmokers in both men and women. The frequency of abnormal measurements was consid- erably higher in female smokers than in male smokers except for closing capacity, in which equal proportions of male and 157 female smokers performed abnormally. However, the frequency of abnormalities among female nonsmokers was also greater than among male nonsmokers. The authors speculate that the traditional view of chronic airflow obstruction as being predom- inantly a disease of males may be accurate only when male smokers outnumber female smokers and when males smoke more cigarettes than females. They suggest that when women’s smoking habits become comparable to those of men, the effect on lung function may be similar. Manfreda et al. used the single-breath nitrogen test in a large group of subjects in two Canadian cities (Figure 2) (39). Almost all smokers (85 percent) reported that they inhaled their cigarettes. Smokers had a greater prevalence of abnormalities than nonsmokers regardless of sex. The prevalence of abnormal values in women who smoke was slightly less than in male smokers. In a volunteer population of 530 cigarette smokers attending an emphysema screening center, Buist and Ross found an equivalent frequency of abnormalities of the slope of phase III among male and female smokers of less than 20 cigarettes per day (Figure 3) with both sexes having significantly higher pre- valence of abnormalities among smokers of more than 20 cigarettes per day (12). In the groups smoking more than 20 cigarettes a day, a greater proportion of females demonstrated abnormalities than males. However, the age composition of each group (male and female) was not identical. A recent study of small airway function in 205 young volun- teer smokers aged 18 to 25 has suggested that smoking may exert its effects at different anatomic locations in the lungs of men and women (21). All subjects smoked fairly heavily (more than 20 cigarettes per day) for a short period of time (average: 2.4 pack-years). Male smokers showed frequent abnormalities in tests of small airway function but female smokers did not ex- hibit these abnormalities. Both male and female smokers showed decreased forced expiratory flows at high lung volumes, suggesting the presence of large-airway dysfunction in young smokers. Male and female smokers differed significantly in their response to He-O2z inhalation. Female smokers showed at least as great an improvement in forced expiratory flows with He-O, as did female nonsmokers. In contrast male smokers showed a much smaller response to the He-O, at high lung vol- umes. Thus, the predominant female response to habitual cigarette smoking appears to have been involvement of the large airways, but men who smoked appeared to have developed abnormalities in small airway function. The reason(s) for the differences in the data derived from this study and previously 158 Males | Females n= 350 n=173 100% 100 - 80 + 74%" 60% t 60 be % 45% ‘ 4 A2% qerega1%° peed sok 38% mT 20+ 0 scat = 137 74 173 77 <10 10-20 20-40 Cigarettes/Day FIGURE 3.—Percentage of male and female cigarette smokers with an abnormal change in nitrogen concentration (ANz2) per liter according to their daily cigarette consumption *Indicates a significant difference between groups using 20 to 40 cigarettes per day as the reference group (P <0.05). *Indicates significant differences between males and females (P <0.05). SOURCE: Buist, A.S. (12). cited reports relating smoking to small airway dysfunction (11,12,39) is unclear. In summary, a limited number of recent studies have demon- strated a higher frequency of abnormalities in tests of small airway function in female smokers as compared to female nonsmokers and ex-smokers. It is not clear whether these ab- normalities are dose-related. Female smokers may have more frequent abnormalities in the slope of phase III than male Smokers. Male smokers may have more frequent abnormalities In closing volume than female smokers. The meaning of these differences is unclear. One study has suggested that the earliest 159 effects of smoking on lung function may occur in the large air. ways in women and small airways in men. SMOKING AND VENTILATORY FUNCTION The majority of studies examining the relationship of smok. ing to ventilatory capacity have used some measurement of forced expiratory volume. Most of these studies have focused on male populations and have found a close relationship between cigarette smoking and the presence of abnormal pulmonary function (2,6,16,20). Furthermore, the decrement in perform- ance measured by simple spirometry is dose-related to the numbers of cigarettes smoked (6,16,20). Relatively few studies have included appreciable numbers of females. Woolf examined pulmonary function in 500 women volunteers (65). Smokers demonstrated significantly lower values for FVC, FEV, FEF 25-75 percent, and specific conductance than nonsmokers and ex-smokers who had not smoked for over a year; this suggests that at least some abnormalities of pulmo- nary function are reversible with smoking cessation. Higgins and Keller examined the relationship of smoking to seven derivatives of the forced vital capacity curve in 3,109 males and 3,256 females aged 10 and older (35). Nonsmokers performed better than smokers in both sexes. Values consis- tently decreased with increasing cigarette consumption. The largest differences were in FEV and FEF 25-75 percent. Seltzer et al. examined the relationship of smoking to FVC in 65,086 white, black, and Asian subjects aged 20 to 79 who had attended a Kaiser-Permanente multiphasic health clinic (49). The authors found a significant reduction in FVC among white women who smoked as compared to nonsmoking white women. No such differences were found for black and Asian subjects, however. No explanation for this racial difference was apparent from their data. In a study by Buist et al., the prevalence of abnormalities of FEVi/FVC was higher in female smokers than nonsmokers (11). The frequency of abnormalities in FEV:/FVC among female smokers was twice that of male smokers (Table 12). Gibson et al. examined the relationship of smoking to measurements of the forced vital capacity in 18,359 men and women in Australia (30). Nonsmokers had better lung functions than smokers. Among smokers of 10 or more cigarettes a day, men showed a greater decrement in lung function than women. Burrows et al. examined the relationship of smoking to measurements of forced expiratory volume in 883 men and 1,166 women in Tucson, Arizona (13). Nonsmokers performed better 160 (34) 3.0 FvC 2.0 a a ae (2) w Nonsmoker - a Heavy Smoker 1.0 4 i L 1 j 30 40 50 60 70 80 Age - Years FIGURE 4.—Changes in forced vital capacity (FVC) by age in various female cohorts Results have been standardized to 155 cm and are body temperature and pressure saturated (BTPS). Numbers in parentheses are number in that cohort. Heavy smokers are those who smoke 25 or more cigarettes per day. SOURCE: Ferris, B.G., Jr. (23). than ex-smokers or smokers, and ex-smokers performed better than smokers in both sexes. Smokers of more than 20 cigarettes per day performed worse than smokers of fewer than 20 cigar- ettes per day. There were no significant differences in the re- gression for FEV:/FVC on pack years in men and women, suggesting that men and women with equivalent smoking habits have similar decrements in FEV:/FVC. The long-term effects of smoking on pulmonary function have been scrutinized in two prospective studies. In the Framingham study, 5,209 adults have been followed since 1948 with biennial examinations including measurements of forced vital capacity (3). Longitudinally, cigarette smokers showed a more rapid de- cline in forced vital capacity than nonsmokers. Men and women who continued to smoke had a more rapid decline in FVC than those who had stopped. The rate of decline in pulmonary func- tion was appreciably steeper in male smokers than female smokers. The authors suggest that these differences could be due to differences in smoking habits. In a longitudinal study of residents of Berlin, New Hamp- shire, Ferris examinéd the changes in pulmonary function by smoking status in the various age cohorts (23). Among females, heavy and moderate smokers had lower values for FVC and FEV: as compared to nonsmokers, and the values fell more 161 3.0¢r FEV, 2.0F (8) a Nonsmoker 1.0F LL a Heavy Smoker I L i L l al 30 40 50 60 70 80 Age-Years FIGURE 5.—Changes in forced expiratory volume in 1 second (FEV, ,.) by age in various female cohorts Results have been standardized to 155 cm and are body temperature and pressure saturated (BTPS). Numbers in parentheses are number in that cohort. Heavy smokers are those who smoke 25 or more cigarettes per day. SOURCE: Ferris, B.G., Jr. (23). rapidly with age. These relationships for heavy smokers (25 or more cigarettes a day) are presented in Figures 4 and 5. In summary, women smokers perform worse on spirometric testing than do female ex-smokers or nonsmokers. This rela- tionship appears to be dose-related to the number of cigarettes smoked. The differential effects of smoking on pulmonary func- tion in males and females is unclear. One study demonstrated that men and women with equivalent smoking habits have simi- lar decrements in FEV:/FVC. The long-term effect of smoking on pulmonary function has been evaluated in two studies which included appreciable numbers of females. Longitudinally, women who smoke show a more rapid decline in forced vital capacity than women who do not smoke. Women who continue to smoke have a more rapid decline in forced vital capacity than those who stop; however, men who continue to smoke have an even more rapid decline in pulmonary function than women who continue to smoke. The long-term relationship between respiratory symptoms and airflow obstruction in women is un- known. One large prospective study could not find a relation- ship between symptoms and the ultimate development of chronic airflow obstruction in men (29). 162 Summary 1. Recent statistics indicate a rising death rate due to chronic obstructive lung disease (COLD) among women. The data avail- able demonstrate an excess risk of death from COLD among smoking women over that of nonsmoking women. This excess risk is much greater for heavy smokers than for light smokers. 2. Women’s total risk of COLD appears to be somewhat lower than men’s, a difference which may be due to differences in prior smoking habits. 3. The prevalence of chronic bronchitis varies directly with cigarette smoking, increasing with the number of cigarettes smoked per day. 4. There is conflicting evidence regarding differences in the prevalence of chronic bronchitis in women and men. Several recent studies suggest that there is no significant difference in the prevalence of chronic bronchitis between male and female smokers. This may be the result, however, of increasingly simi- lar smoking behavior of women and men. 5. The presence of emphysema at autopsy exhibits a dose- response relationship with cigarette smoking during life. 6. There is a close relationship between cigarette smoking and chronic cough or chronic sputum production in women, which increases with total pack-years smoked. 7. Women current smokers have poorer pulmonary function by spirometric testing than do female ex-smokers or nonsmok- ers, a relationship which is dose-related to the number of cigarettes smoked. References (1) AMERICAN COLLEGE OF CHEST PHYSICIANS. AMERICAN THORACIC SOCIETY. Pulmonary terms and symbols. A report of the ACCP-ATS Joint Committee on Pulmonary Nomenclature. Chest 67: 583-593, 1975. (2) ASHFORD, J.R., BROWN, S., DUFFIELD, D.P., SMITH, C.S., FAY, J.W.J. The relation between smoking habits and physique, respiratory symptoms, ventilatory function, and radiopneumoconiosis amongst coal workers at three Scottish collieries. British Journal of Preventa- tive and Social Medicine 15: 106-117, 1961. (3) ASHLEY, F.. KANNEL, W.B., SORLIE, P.D., MASSON, R. Pulmonary function: Relation to aging, cigarette habit and mortality. The Framingham Study. Annals of Internal Medicine 82(5): 739-745, 1975. (4) AUERBACH, O., GARFINKEL, L., HAMMOND, E.C. Relation of smok- ing and age to findings in lung parenchyma: A microscopic study. - Chest 65(1): 29-35, 1974. (5) AUERBACH, 0., HAMMOND, E.C., GARFINKEL, L., BENANTE, C. Relation of smoking and age to emphysema. Whole-lung section study. New England Journal of Medicine 286(16): 853-857, 1972. (6) BALCHUM, 0O.J., FLETON, J.S., JAMISON, J.N., GAINES, R.S., CLARKE, D.R., OWAN, D. The Industrial Health Committee, The 163 (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) 164 Tuberculosis and Health Association of Los Angeles County. A survey of chronic respiratory disease in an industrial city. Preliminary re- sults. American Review of Respiratory Disease 86(5): 675-685, November 1962. BECKLAKE, M., PERMUTT, S. The Lung in Transition Between Health and Disease. New York, Marcel Dekker, Inc., 1979, pp. 345-387, BEST, E.W.R., JOSIE, G.H., WALKER, C.B. A Canadian study of mor. tality in relation to smoking habits: A preliminary report. Canadian Journal of Public Health 52: 99-106, March 1961. BEWLEY, B.R., BLAND, J.M. Smoking and respiratory symptoms in two groups of school children. Preventative Medicine 5: 63-69, 1976, BUIST, A.S., FLEET, L.V., ROSS, B.B. A comparison of conventional spirometric tests and the test of closing volume in an emphysema screening center. American Review of Respiratory Disease 107: 735-~ 743, 1978. BUIST, A.S., GHEZZO, H., ANTHONISEN, N.R., CHERNIAK, R.M., DUCIC, S., MACKLEM, P.T., MANFREDA, J., MARTIN, R.R., MCCARTHY, D., ROSS, B.B. Relationship between the single breath Nz test and age, sex, smoking habit in the North American cities. American Review of Respiratory Disease 120: 305-318, 1979. BUIST, A.S., ROSS, B.B. Quantitative analysis of the alveolar plateau in the diagnosis of early airway obstruction. American Review of Res- piratory Disease 108: 1078-1087, 1973. BURROWS, B., KNUDSON, R.J., CLINE, M.B., LEBOWITZ, M.D. Quantitative relationships between cigarette smoking and ventilatory function. American Review of Respiratory Disease 115: 195-205, 1977. CEDERLOF, R., FRIBERG, L., HRUBEC, Z., LORIER, V. The Rela- tionship of Smoking and Some Social Covariables to Mortality and Cancer Morbidity. A Ten Year Follow-up in a Probability Sample of 55,000 Swedish Subjects Age 18-69. Part 1 and 2. Stockholm, Sweden. The Karolenska Institute, Department of Environmental Hygiene, 1975, 201 pp. COLLEY, J.R.T., DOUGLAS, J.W.B., REID, D.D. Respiratory disease in young adults: Influence of early childhood lower respiratory tract ill- ness, social class, air pollution, and smoking. British Medical Journal 3: 195-198, July 1973. DENSEN, P.M., JONES, E.W., BASS, H.E., BREUER, J., REED, E. A survey of respiratory disease among New York City postal and transit workers. 2. Ventilatory function tests results. Environmental Re- search 2(4): 277-296, July 1969. DOLL, R., GRAY, R., PETO, R. Mortality in relation to smoking: Obser- vations on female doctors. (Unpublished manuscript) DOLL, R., PETO, R. Mortality in relation to smoking: 20 years observa- tions on male British doctors. British Medical Journal 2(6051): 1525- 1536, December 25, 1976. DUNN, J.E., LINDEN, G., BRESLOW, L. Lung cancer mortality experi- ence of men in certain occupations in California. American Journal of Public Health 50(10): 1475-1487, October 1960. EDELMAN, N.H., MITTMAN, C., NORRIS, A.H., COHEN, B.H., SHOCK, N.W. The effects of cigarette smoking upon spirometric per- formance of community dwelling men. American Review of Respira- tory Disease 94(3): 421-429, September 1966. ENJETTI, 8., HAZELWOOD, B., PERMUTT, S., MENKES, H., TERRY, P. Pulmonary function in young smokers. Male-female differences. American Review of Respiratory Disease 118: 667-675, 1978. (22) (23) (24) (25) (26) (87) (28) (29) (30) (81) (32) ($3) ($4) (33) (36) (3?) FERRIS, B.G., JR. Chronic bronchitis and emphysema. Medical Clinics of North America 57: 637-649, 1973. FERRIS, B.G., JR. Smoking and lung function: Epidemiological evi- dence. Proceedings of the Third World Conference on Smoking and Health 2. U.S. Department of Health, Education, and Welfare. Public Health Service. National Institutes of Health, p. 115-129, 1975. FERRIS, B.G., JR., CHEN, H., PULEO, S., MURPHY, R.L.H., JR. Chronic nonspecific diseases in Berlin, New Hampshire, 1967-1973. American Review of Respiratory Disease 113: 475-485, 1976. FERRIS, B.G., JR., HIGGINS, 1.T.T., HIGGINS, J.M., PETERS, J.M., VAN GANSE, W.F., GOLDMAN, M.W. Chronic nonspecific respiratory disease, Berlin, New Hampshire, 1961-1967: A cross-sectional study. American Review of Respiratory Disease 104: 232-244, 1971. FERRIS, B.G., JR., HIGGINS, 1.T.T., PETERS, J.M., VAN GANSE, W.F., GOLDMAN, M. Chronic nonspecific respiratory disease, Berlin, New Hampshire, 1961-1967: A cross-sectional study. American Review of Respiratory Diease 104: 232~244, 1971. FLETCHER, C.M. (Editor). Terminology, definitions, classification of chronic pulmonary emphysema and related conditions. A report of the conclusions of a Ciba Guest Symposium. Thorax 14: 286-299, 1959. FLETCHER, C.M., JONES, N.L., BURROWS, B., NIDEN, A.H. Ameri- can emphysema and British bronchitis. A standardized comparative study. American Review of Respiratory Disease 90: 1-13, 1964. FLETCHER, C., PETO, R. The natural history of chronic airflow obstruction. British Medical Journal 1: 1645-1648, 1977. GIBSON, J., GALLAGHER, H., JOHANSON, A., WEBSTER, I. Lung function in an Australian population. 2. Spirometric performance and cigarette smoking habits. Medical Journal of Australia 1: 354-358, 1979, - HAMMOND, E.c. Smoking in relation to the death rates of one million men and women. In: Haenszel, W. (Editor). Epidemilogical Approaches to the Study of Cancer and other Chronic Diseases. National Cancer Institute Monograph 19. U.S. Department of Health, Education, and Welfare, U.S. Public Health Service, National Cancer Institute, January 1966, pp. 127-204. HAMMOND, E.C., HORN, D. Smoking and death rates— Report on forty-four months of follow-up on 187,783 men. I. Total mortality. Jour- nal of the American Medical Association 166(10): 1159-1172, March 8, 1958. HIGGINS, LT.T. Respiratory symptoms, bronchitis and disability in a random sample of an agricultural population. British Medical Journal 2: 1198-1203, 1957. HIGGINS, 1.T.T., COCHRAN, J.B. Respiratory symptoms, bronchitis and disability in a random sample of an agricultural community in Dunfrieshire. 39: 296-301, 1958. HIGGINS, M.W., KELLER, J.B. Seven measures of ventilatory lung function. American Review of Respiratory Disease 108: 258-272, 1973. HUBTI, E. Prevalence of respiratory symptoms, chronic bronchitis and pulmonary emphysema in a Finnish rural population. Field survey of age 40-64 in the Harjavolta area. Aeta (Supplement) 61: 11, 1965. KAHN, H.A. The Dorn study of smoking and mortality among U.S. vet- erans. Report on 8 and one-half years of observation. In: Haenszel, W. ; (Editor). Epidemiological Approaches to the Study of Cancer and Other Chronic Diseases. National Cancer Institute Monograph 19. U.S. De- partment of Health, Education, and Welfare, Public Health Service, 165 (38) (39) (40) (41) (42) (43) (44) (45) (46) 7) (48) (49) (50) (51) (52) (53) (54) (55) 166 National Cancer Institute, January 1966, pp. 1-125. LEIBOWITZ, M., BURROWS, B. Quantitative relationships between cigarette smoking and chronic productive cough. International Jour- nal of Epidemiology 6: 107-113, 1977. MANFREDA, J., NELSON, N., CHERNIACK, R.M. Prevalence of respi- ratory abnormalities in a rural and an urban community. American Review of Respiratory Disease: 117: 215-226, 1978. MILLNE, J., WILLIAMSON, J. The relationship of respiratory function tests to respiratory symptoms and smoking in older people. Respira- tion 29: 206-213, 1972. MUELLER, RE., KEBLE, D., PLUMMER, J., WALKER, S.H. The pre- valence of chronic bronchitis, chronic airway obstruction, and respira- tory symptoms in a Colorado city. American Review of Respiratory Disease 103: 209-228, 1971. NATIONAL CENTER FOR HEALTH STATISTICS. Vital Statistics of the United States, 1960-1977. U.S. Department of Health, Education, and Welfare, Public Health Service, Office of Health Policy, Research and Statistics, National Center for Health Statistics. OSWALD, N.C., MEDVEL, V.C. Chronic bronchitis: the effect of cigarette smoking. Lancet 2: 843-844, October 22, 1955. PAYNE, M., KJELSBERG, M. Respiratory symptoms, lung function, and smoking habits in an adult population. American Journal of Public Health 54: 261-277, 1964. RAWBONE, R., KEELING, C., JENKINS, A., GUZ, A. Cigarette smok- ing among secondary school children in 1975. Journal of Epidemiology and Community Health 32: 53-58, 1978. REMINGTON, J. Chronic bronchitis, smoking and social class. A study among working people in the towns of East and Mid Cheshire. British Journal of Disease of the Chest 63(4): 193-205, 1969. RUSH, D. Changes in respiratory symptoms related to smoking in a teenage population: The results of tow linked surveys separated by one year. International Journal of Epidemiology 5(2): 173-178, 1976. RYDER, R., DUNNILL, M., ANDERSON, J. A quantitative study of bronchial mucous gland volume, emphysema and smoking in a nec- ropsy population. SELTZER, C.C., SIEGELAUB, A.B., FRIEDMAN, G.D., COLLEN, M.-F. Differences in pulmonary function related to smoking habits and race. American Review of Respiratory Disease 110(5): 598-608, November 1974. SPAIN, D.M., SIEGEL, H., BRADES, V.S. Emphysema in apparently healthy adults. Journal of the American Medical Association 224: 322-325, 1973. TAGER, I.B., SPEIZER, F.E. Risk estimates for chronic bronchitis in smokers: A study of male-female differences. American Review of Res- piratory Diseases: 113: 619-625, 1976. THURLBECK, W.M. Aspects of chronic airflow obstruction. Chest 72: 341-349, 1977. THURLBECK, W.M. Chronic airflow obstruction in lung disease. V. Major Problems in Pathology. Philadelphia, W.B. Sanders Co., 1976, pp. 235-287. THURLBECK, W.M., RYDER, R., STERNLY, N. A comparative study of severity of emphysema in necropsy population in three different countries. American Review of Respiratory Disease 109: 239-248, 1974. U.S. PUBLIC HEALTH SERVICE. The Health Consequences of Smok- ing. A Public Health Service Review: 1967. U.S. Department of Health (56) (57) (58) (59) (60) (61) (62) (68) (64) (65) (66) Service, Health Services and Mental Health Administration. DHEW Publication No. 1969, Revised, January 1968, 227 pp. U.S. PUBLIC HEALTH SERVICE. The Health Consequences of Smok- ing, 1968. Supplement to the 1967 Public Health Service Review. U.S. Department of Health, Education, and Welfare, Public Health Service, Health Services and Mental Health Administration. DHEW Publica- tion No. 1969, 1968, 117 pp. U.S. PUBLIC HEALTH SERVICE. The Health Consequences of Smok- ing, 1969. Supplement to the 1967 Public Health Service Review. U.S. Department of Health, Education, and Welfare, Public Health Service, Health Services and Mental Health Administration. DHEW Publica- tion No. 1969-2, 1969, 98 pp. U.S. PUBLIC HEALTH SERVICE. The Health Consequences of Smok- ing. A Report of the Surgeon General. 1971. U.S. Department of Health Services and Mental Health Administration. DHEW Publication No. 71-7513, 1971, 458 pp. U.S. PUBLIC HEALTH SERVICE. The Health Consequences of Smok- ing. A Report of the Surgeon General: 1972. U.S. Department of Health Services and Mental Health Administration. DHEW Publication No. (HSM) 72-7516, 1972, 158 pp. U.S. PUBLIC HEALTH SERVICE. The Health Consequences of Smok- ing. 1973. U.S. Department of Health, Education, and Welfare, Public Health Services, Health Services and Mental Health Administration. DHEW Publication No. (HSM) 73-8704, 1973, 249 pp. U.S. PUBLIC HEALTH SERVICE. The Health Consequences of Smok- ing: 1974. U.S. Department of Health, Education, and Welfare, Public Health Service, Health Services and Mental Health Administration. DHEW Publication No. (CDC) 74-8704, 1974, 124 pp. U.S. PUBLIC HEALTH SERVICE. The Health Consequences of Smok- ing: 1975. U.S. Department of Health, Education, and Welfare, Public Health Service, Health Services and Mental Health Administration. DHEW Publication No. (CDC) 76-8704, 1975, 235 pp. U.S. PUBLIC HEALTH SERVICE. Smoking and Health. Report of the Advisory Committee to the Surgeon General of the Public Health Serv- ice. U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control. PHS Publication No. 1103, 1964, 387 pp. U.S. PUBLIC HEALTH SERVICE. Smoking and Health. A report of the Surgeon General, U.S. Department of Health, Education, and Welfare, Public Health Service. Office of the Assistant Secretary for Health, Office on Smoking and Health. DHEW Publication No. (PHS) 79-50066, 1979, pp. 1251. WOOLF, C.R. Clinical findings, sputum examinations, and pulmonary function tests related to the smoking habits of 500 women. Chest 66: 652-659, 1974. WOOLF, C., SUERO, J. The respiratory effects of regular cigarette smoking in women. American Review of Respiratory Disease. 103: 26-37, 1971. 167 INTERACTION BETWEEN SMOKING AND OCCUPATIONAL EXPOSURES. INTERACTION BETWEEN SMOKING AND OCCUPATIONAL EXPOSURES The 1979 Surgeon General’s Report on the health conse- quences of smoking (18) examines the interaction of smoking and occupational exposure. Ways in which smoking may inter- act with the occupational environment are described and examples of these interactions are discussed. Briefly, these types of interaction are: 1. Tobacco products may serve as vectors by becoming con- taminated with toxic agents found in the workplace, thus facilitating entry of the agent by inhalation, ingestion, and/or skin absorption of the agent. 2. Workplace chemicals may be transformed into more harm- ful agents by smoking. 3. Certain toxic agents in tobacco products and/or smoke may also inhabit the workplace, thus increasing exposure to the agent. 4, Smoking may contribute to an effect comparable to that which can result from exposure to toxic agents found in the workplace, thus causing an additive biological effect. 5. Smoking may act synergistically with toxic agents found in the workplace to cause a much more profound effect than that anticipated simply from the separate influences of the agent and smoking added together. 6. Smoking may contribute to accidents in the workplace. Although few of the studies discussed in the 1979 Surgeon General’s Report included enough women to adequately deter- mine the health risks of smoking and the occupational environ- ment, it is reasonable to hypothesize that women with the same occupational exposure and smoking behavior as men would de- velop health effects similar to those demonstrated in men. How- ever, the interaction of smoking and the occupational environ- ment and its effect on women differs in at least two ways: First, smoking patterns among women are different from those among men—women are less likely to smoke, and if they do, they smoke fewer cigarettes per day, inhale less, and are more likely to smoke lower “tar” and nicotine cigarettes (7,14,18). Second, smoking and occupational exposure may ad- versely affect the fetus or the health of the mother during preg- nancy. Smoking and occupational exposure may also interact with methods of contraception chosen by women. This chapter reviews each of these reasons for a differential health impact on men and women and examines two occupa- tional exposures where interactions with smoking have been clearly demonstrated for women workers. 171 TABLE 1.—Smoking habits of working women by title and industry Percent of Current Percent Female Labor Non- Ex- Industry Foree* Smokers Smokers Present Smokers