key: cord-0984338-uhephduq
authors: Toghyani, Arash; Sadeghi, Somayeh
title: Association of demographic variables and smoking habits with the severity of lung function in adult smokers
date: 2022-02-18
journal: J Res Med Sci
DOI: 10.4103/jrms.jrms_854_21
sha: 2a827e2b7d6cb81e5bca92f9b96656d3489974f8
doc_id: 984338
cord_uid: uhephduq

BACKGROUND: This study aims to evaluate the association between demographic and smoking variables with the severity of lung function loss (Stage I to IV) and spirometry data in smokers. MATERIALS AND METHODS: Three hundred and fifty smoker men over the age of 20 who had visited in AL-Zahra hospital were involved. Spirometry tests were performed for measuring forced vital capacity (FVC), FEV1, and FEV1%FVC. COPD was categorized into four stages by the (Global Initiative for Chronic Obstructive Lung Disease) criteria of postbronchodilator FEV1/FVC <0.70. FEV1/FVC <70%, in combination with FEV1 ≥80% (Stage I), or 50%≤FEV1 <80% (Stage II), or 30%≤FEV1 <50% (Stage III), or FEV1 ≤30% (Stage IV). Independent t-test, Spearman correlation analysis was used for data analysis. To determine the predicting factors for pulmonary function multiple regressions analysis was performed. RESULTS: 43 (19.5%) of men were defined as Chronic Obstructive Lung Disease (COPD) which 7% of them were Stage I, 23.3% were Stage II, 39.5% were III and 30.2% were stage IV. In 60 (27.1%) of men, the index of Fev1/FVC was <80%. The criteria of PRIS in 74 (33.5%) of the patients and BDR in 59 (26.7%) of participation was positive. There were significant differences in the mean of FEV1 with respect to history of lung disease in relatives (P = 0.035), lung disease hospitalization (P < 0.001) and previous diagnosis of asthma variables (P < 0.001). The mean of FVC was significantly different in patients categorized based on lung disease hospitalization (P < 0.001) and previous diagnosis of asthma (P = 0.018). Furthermore, there was a significant difference in the mean of FEV1/FVC for variables as follows: Time to start smoking after waking up (P = 0.007), lung disease hospitalization (P < 0.001) and previous diagnosis of asthma (P < 0.001). There was a significant association between stages of lung function loss and age of onset of smoking (β-0.355 P = 0.019) and pack per year (β = 0.354 P = 0.02). A linear regression model showed that lung disease hospitalization and age were the influential variables on FEV1 with (B = −21.79 confidence interval [CI]: −28.7, −14.87, P < 0.001and B = −0.418 CI: −0.63, −0.21, P < 0.001), respectively. The only significant influential variable on FVC was lung disease hospitalization (B = −15.89 CI: −21.49, −10.296, P < 0.001). Body mass index, lung disease hospitalization, time to start smoking after waking up in the morning and age had significant relationship on FEV1/FVC with (B = 0.71CI: 0.32, 1.11, P < 0.001, B = −14.29, CI: −19.61,-8.97, P < 0.001, B = 6.54, CI: 2.26, 10.82, P = 0.003 and B = −0.44, CI: −0.59, −0.28, P < 0.001), respectively. CONCLUSION: The age of onset of smoking and pack-year appears to be associated with the severity of COPD. Hospitalization history due to lung disease, age, the time between waking up in the morning and first cigarette use, BMI, lung disease history in relatives, previous diagnosis of asthma have a negative relationship with lung function.

The main reason for chronic obstructive pulmonary disease is smoking. [1, 2] COPD is a chronic lung disease characterized by persistent airflow restriction. COPD is a progressive disease and is caused by a combination function in the diagnosis and monitoring of COPD. [6] According to the Global Initiative for Chronic Obstructive Pulmonary Disease, a postbronchodilator FEV 1 /forced vital capacity (FVC) <0.70 confirms the presence of COPD and is an essential element in the diagnosis of COPD. [3] Postbronchodilator spirometry is not only required when detecting COPD; it is also an essential tool in assessing the severity of COPD because the classification of severity of airflow limitation in COPD is based on postbronchodilator FEV 1 . [3] Previous studies showed that smoking reduces pulmonary function, including FVC, forced expiratory volume per second (FEV 1 ), and FEV 1 /FVC. [7] The use of FEV1/FVC is a traditional amount of obstruction in airways to detect airways obstruction during spirometry testing. [8] Smoking burden is regularly measured in pack-years, a product of the average number of packs of cigarettes smoked a day and smoking length in years. [9] Walter et al. detailed that more seasoned smokers with histories of expansive numbers of pack-years had lower FVC levels than nonsmokers, whereas youthful adult smokers had FVC levels similar to or higher than age-equivalent nonsmokers. [10] A study of 100 male smokers, age ranging from 18 to 60 years appeared that those who smoked more than 10 pack-year are related with accelerated decrease in lung function. [11] Smoking duration and participant's age might unfavorably influence lung capacity by declining the FVC and FEV1 test. On the other hand, nonsignificant correlation was found between the number of cigarettes smoked per day and lung function parameters FVC and FEV 1 . [12] In addition to smoking, history of respiratory diseases in the family, poor financial status, aging, body mass index (lower BMI), age, regular of hookah use, and history of seasonal allergies are other risk factors for COPD. [13, 14] Few studies also have reported the association between lung function loss and a range of smoking burdens consisting of demographic and nondemographic factors in smoking patients. [15, 16] In this cross-sectional study, we evaluated the association of demographic variables and smoking habits with the severity of lung function and spirometry data in adult smokers visiting the Al-Zahra Hospital of Isfahan University.

This cross-sectional study was performed in AL Zahra hospital, the main referral hospital of Isfahan University of Medical Sciences from November 2019 to April 2020. This study was approved in Isfahan University of medical sciences with ethics code IR.MUI.MED.REC.1398.710. There were originally 350 men smokers over the age of 20 who had visited AL Zahra hospital, however, 129 participants were removed according to the exclusion criteria of this study. Therefore, 221 participants were involved in this study. Each participant signed a self-written consent to take part in the study. The exclusion criteria of the study were as followed: (a) presence of acute Respiratory Infection, (b) presence of lung disease counting lung cancer, interstitial lung disease, Tuberculosis, Neuromuscular Disorders, Pneumothorax, (c) unable to perform technically acceptable respiratory function tests.

All participants filled out a checklist requesting information on demographic data, smoking habits, and a history of diseases and respiratory symptoms. And then, they were tested for their lungs function. The demographic data included age, level of education (Illiterate, High school, Diploma, Associate Degree, Bachelor's, Master's degree), and BMI. The following variables of smoking habits were also recorded in the checklist including the age of the onset of smoking, duration of smoking (years), number of cigarette packs consumed daily, pack-year (was defined as the number of years of daily smoking multiplied by the number of cigarettes smoked daily divided by 20 , [9] amount of time between getting up in the morning and the first cigarette. Other requesting information were questions with yes/no answers including the use of hookah, addiction, a history of chronic lung disease in first-degree relatives, seasonal allergies, previous lung disease hospitalizations, and previous diagnosis of asthma Pulmonary function assessment Spirometry was performed before and 15 min after 400 micrograms of salbutamol managed by a trained technician in accordance with the American Thoracic Society (ATS) and European Respiratory Society standards. [17] While the participants were sitting they were asked to make a forced exhalation followed by a forced inhalation. FVC, forced expiratory volume in1s (FEV1), and FEV1 percent in relation to the maximal FVC (FEV1%FVC) were registered. FVC was characterized as the biggest of either forced expiratory or forced inspiratory vital capacity from technically acceptable curves. The reported FEV1 is considered to be a good biological marker of the risk of obstructive pulmonary disease. If the Spirometric quality was not satisfactory, the maneuver would be repeated until the best quality was obtained. The highest value of FVC and the highest value of FEV1 were selected from the measurements for which the repeatability criteria were met. A pulmonologist reviewed the quality of all the tests. Bronchodilator responsiveness (BDR) was calculated change of >12% of the baseline forced expiratory volume in 1 s (FEV1) if this also exceeds 200 mL according to ATS guidelines. [18] COPD was defined by the Global Initiative for Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria of postbronchodilator FEV1/FVC <0.70. FEV1/ FVC <70%, in combination with FEV1 ≥80% (Stage I), or 50%≤FEV1 <80% (Stage II), or 30%≤FEV1 <50% (Stage III), or FEV1 ≤30% (Stage IV). [19] Participants with normal ratio but postbronchodilator FEV1 <80% predicted were categorized to have the GOLD unclassifiable disease or Preserved Ratio Impaired. [20] Postbronchodilator FEV1/FVC <80% were predicted to be considered unclassifiable airway obstruction. [21] For evaluation of bronchodilator response (BDR), we used ATS guidelines (post FEV1-preFEV1/preFEV1 × 100 more than 12%).

Data are presented as mean (standard deviation) or frequency (percent). For comparing the mean of pulmonary functions in categories of variables, independent t-test is used. Spearman correlation analysis was performed to get the association between the severity of long loss and study variables. Further analysis using multiple regressions was conducted to confirm the predictors of the pulmonary functions. The level of significance is taken as P < 0.05. Statistical analysis was conducted using the SPSS software version 16 (SPSS Inc., Chicago, Illinois, USA).

Two hundred and twenty-one men participated in the study. -Forty-three men (19.5%) had COPD so most of them were in stage III [ Table 1 ]. In 27.1% of men, the index of FEV1/FVC was <80%. The criteria of PRIS in 74 (41.6%) were positive. BDR was positive in 59 (26.7%) of participation 53 (24.0) of participants were used short-acting beta-agonist inhalers, 16 (7.2) used long-acting muscarinic antagonist, 27 (12.2) used short-acting muscarinic antagonist, 2 (0.9) used inhaled corticosteroids and 16 (7.2) used long-acting beta-agonist and inhaled corticosteroids.

The mean of FEV1, FVC, and FEV1/FVC after use of bronchodilator with respect to different categorization is shown in Table 2 . The mean of FEV1 for men without a history of lung disease in relatives (P = 0.035), without lung disease hospitalization (P < 0.001), without previous diagnosis of asthma (P < 0.001) was significantly more than others. Also the mean of FVC between categories of variables lung disease hospitalization (P < 0.001), without previous diagnosis of asthma (P = 0.018) was statistically different. Finally the mean of FEV1/FVC for men who started smoking after waking up in the morning after 30 min (P = 0.007), without lung disease hospitalization (P < 0.001), without previous diagnosis of asthma (P < 0.001), was more and according to independent t-test these differences were statistically significant.

The relationship between stages of lung function loss and other variables in the study, is shown in Table 3 . According this table there was a significant association between stages of lung function loss and age of onset of smoking (β = −0.355 P = 0.019) and pack per year (β = 0.354 P = 0.02). When the age of onset smoking decreases, the stages of lung function Table 4 . In first model, lung disease hospitalization and age were the influential variables on fev1 with (B = −21.79 CI: −28.7, −14.87 P < 0.001 and B = −0.418 CI: −0.63, −0.21 P < 0.001), respectively. With regards to B coefficients when age increases the FEV1 decreases and there was an inverse relationship between the lung disease hospitalization and FEV1. The only significant influential variable on FVC were lung 

Education, time to start smoking after waking up in the morning, Hookah, History of lung disease in relatives, Allergies, lung disease hospitalization, Asthma, Saba: Short-acting beta-agonist, Lama: Long-acting muscarinic antagonist, Sama: Short-acting muscarinic antagonist, Icslaba: Inhaled corticosteroids and long-acting beta-agonist, Ics inhaled corticosteroids, Addiction, Age, BMI, Age of onset of smoking, Pack year

In this cross-sectional study of a population of male adult smokers, we found that age of onset of smoking and pack-year was closely associated with the severity of lung function loss The present study demonstrates that the mean of onset of smoking was 16.54 (6.01) in Stage IV, 23.12 (8.06) in Stage III, 23.30 (6.41) in Stage II, and 18 [2] in Stage I of COPD smokers. This means that the age of onset of smoking is connected to poorer pulmonary function. [7] It was found that more smoking measured as pack-year was associated with poorer pulmonary function. The impact of cigarette smoking on lung function is dose dependent, so it is expected that the sooner smoking begins the worse the lung function becomes. A finding that seems to be of secondary importance is that people who started smoking earlier are more likely to continue smoking and are heavier smokers. [22] Kurmi et al. examined the relationship between smoking and airway obstruction in men and women found that airway obstruction was strongly associated with smoking and the onset of smoking at an early age. In both sexes, the OR was more extreme in those who started to smoke at a younger age (P < 0.0001 in men and 0.0063 in women). [23] A previous study by Ballah, et al. that compared the lung function between smokers and nonsmokers indicated that there is a statistical relationship between pack-year of smoking and FEV1 levels. They also found out that the onset of smoking at a younger age is associated with a lower value of FEV1. [24] A study was also conducted involving 10,187 participants that showed a significant correlation between airflow obstruction (FEV1/FVC) and pack-year (regression coefficient β = −0.023 ± SE0.003; P = 0.003).

The present study demonstrates that The mean of FEV1, FVC andFEV1/FVC for smokers without previous diagnosis of asthma and without any history of pulmonary disease hospitalization was significantly higher compared to smokers with these variables according to independent t-test. Accordingly, the linear regression model to evaluate the effect of study variables on FEV1, FVC, and FEV1/FVC showed that the history of hospitalization for pulmonary diseases in the present study is inversely related to FEV1, FVC, and FEV1/FVC. Hunter, et al. examined the risk factors for subsequent admission to COPD and found that prior admission to COPD or respiratory disease was a risk factor that agrees with the present study. [25] Prognosis in patients with COPD indicated that Increasing age, low BMI, decreased FEV1, and prior respiratory or cardiovascular admission hospitalization were predictors of poor outcome. [26] Polese et al. Evaluated the lung function, and pulmonary diffusion for carbon monoxide (DLCO) in patients between 15 and 30 days after discharge admission for severe COVID-19 showed a restrictive pattern with a reduction in FVC in 54% of individuals. [27] Lange, et al. compared lung function in people with asthma and people without asthma who identify themselves as asthmatics, there were substantially greater declines in FEV1 levels over time than those who did not. Subjects with asthma and smokers had a more noteworthy decrease in FEV1 than those without asthma and nonsmokers, respectively. [28] In the current study, the average fev1 level for smokers without a history of lung disease in relatives was significantly higher than smokers with a history of lung disease in relatives. In addition, the mean of FEV1/ FVC for smokers who started smoking within 30 min after waking up was significantly higher in comparison with those who started smoking at least 30 min after waking up.

Accordingly, linear regression model demonstrated started smoking ≤ 30 min after waking more decreased FEV1/FVC. A recent study indicated that compared to current smokers with a late start of smoking cigarettes, those who smoked their first cigarette at an early age had a higher risk of chronic obstructive pulmonary disease. [29] According to the linear regression model, age was inversely related to FEV1 and FVC as well as BMI as directly related to FEV1/FVC. Rewashed, Rawashdeh et al. calculated the connection between the smoking duration, the number of cigarettes smoked per day, age, and pulmonary function parameters that suggested smoking duration and participant age could reduce the volume associated with the FVC, FEV1. [12] An increase in FEV1/FVC among participants with a high BMI in our study may be due to elasticity loss because of gaining weight has a greater effect on FVC than FEV1. [30] Our results are in contrast to a study that showed that FEV1/FVC was lower in the obese group than in the other groups. [31] CONCLUSION In a population of male adult smokers, age of onset of smoking and pack-year appears to have a strong relationship with the stages of lung function loss. History of pulmonary disease hospitalization, age, amount of time between getting up in the morning and the first cigarette, BMI, history of lung disease in relatives, previous diagnosis of asthma have a negative impact on lung function.

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This study has been funded by Isfahan University of Medical Sciences. The authors thank the participants of this study for their contributions.

Nil.

There are no conflicts of interest.