Race and Gender Differences in the Effects of Smoking on Lung Function

doi:10.1378/chest.117.3.764

Chest

Volume 117, Issue 3, March 2000, Pages 764-772

https://doi.org/10.1378/chest.117.3.764 Get rights and content

Study objective

To assess the extent to which the relationship between smoking and lung function in adults varies by gender and race/ethnicity.

Design

A random-effects metaregression analysis to synthesize results from common cross-sectional regression models fit to participants in each of 10 gender-race strata in each of eight large population-based observational studies or clinical trials.

Setting

Source data collected as part of the most recently completed examination cycle for each of the participating studies.

Participants

Participants ranged in age from 30 to 85 years, although the age, race, gender, and general health characteristics of each of the populations varied greatly.

Interventions

Most of the studies were observational in nature, although some did involve lifestyle interventions. All treatment assignments were ignored in the analysis.

Measurements and results

All studies measured lung function using standardized methods with centrally trained and certified technicians. Study findings confirm statistically significant, dose-related smoking effects in all race-gender groups studied. Significant gender differences in the effects of cigarette smoking were seen only for blacks; black men who smoked had greater smoking-related declines in FEV₁ than did black women. This effect was present in only one of two smoking models, however. Significant racial differences in the effects of smoking were seen only for men, with Asian/Pacific Islanders having smaller smoking-related declines than white men in both models.

Conclusions

In summary, this analysis generally failed to support the hypothesis of widespread differences in the effects of cigarette smoking on lung function between gender or racial subgroups.

Section snippets

Selected Studies

We restricted the analysis to data from eight large, NHLBI-funded studies (Table 1 ) involving adults (aged 30 to 85 years), and having data on gender, pulmonary function, smoking status, and race.^15,^16,^17,^18,^19,^20,^21,²² These studies were asked to submit the results of cross-sectional analyses conducted using data from their most recently completed examination cycle. A ninth study, the Lung Health Study,²³ also submitted data but was excluded from this analysis because its participants were

Results

Table 5 presents, as a point of reference, the estimated annual changes in FEV₁ (milliliters per year) for nonsmokers in each gender-race subgroup. The estimates were computed as a weighted average of the β₁ coefficients from model 1. Nonsmoking male subjects are consistently estimated to have larger annual declines in lung function than female subjects within each racial group, although these differences were only statistically significant among whites (p = 0.011). Further, within each gender

Discussion

This collaborative analysis of cross-sectional data from several large, well-controlled NHLBI-funded studies supports the results from numerous prior studies that cigarette smoking is associated with an accelerated rate of decline of lung function. This association is present in both male and female subjects and in all racial groups studied. It is also dose related. We found no consistent evidence that these smoking effects differ either between male and female subjects or among various

ACKNOWLEDGMENT

The authors wish to thank the investigators and participants of the following epidemiologic studies who contributed the data for this report: Atherosclerosis Risk in Communities Study (ARIC), CARDIA, CHS, HHP, MRFIT, Third National Health and Nutrition Examination Survey (NHANES III), Respiratory Diseases Among New Mexico Hispanics Study (NewMex), and SHS. We also acknowledge the encouragement and financial support of the NHLBI program office and, in particular, Drs. Teri Manolio and Suzanne

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We analyzed data from 13,896 black and white participants, aged 45–64 years at the 1987–1989 baseline clinical examination. Using spirometry data collected at baseline and two follow-up visits, we estimated annual population-averaged mean changes in forced expiratory volume in one second (FEV₁) and forced vital capacity (FVC) by race, sex, and smoking status using inverse-probability-weighted independence estimating equations conditioning-on-being-alive.
Estimated rates of FEV₁ decline estimated using inverse-probability-weighted independence estimating equations conditioning on being alive were higher among white than black participants at age 45 years (e.g., male never smokers: black: −29.5 ml/year; white: −51.9 ml/year), but higher among black than white participants by age 75 (black: −51.2 ml/year; white: −26). Observed differences by race were more pronounced among men than among women. By smoking status, FEV₁ declines were larger among current than former or never smokers at age 45 across all categories of race and sex. By age 60, FEV₁ decline was larger among former and never than current smokers. Estimated annual declines generated using unweighted generalized estimating equations were smaller for current smokers at younger ages in all four groups of race and sex compared with results from weighted analyses that accounted for attrition.
Using methods accounting for dropout from an approximately 25-year health study, estimated rates of lung function decline varied by age, race, sex, and smoking status, with largest declines observed among current smokers at younger ages.
Obstructive Lung Disease in Mexican Americans and Non-Hispanic Whites : An Analysis of Diagnosis and Survival in the National Health and Nutritional Examination Survey III Follow-up Study
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Citation Excerpt :
Lung function is heritable, and Coultas et al31 have shown that the lung function of Hispanic offspring correlates with that of their parents. Sood et al32 and Vollmer et al33 have demonstrated that both Hispanic female and male smokers have higher FEV1 measurements than their respective white counterparts. Additionally, Bruse et al12 suggested that Hispanic subjects may be less susceptible to COPD (a component of OLD), because of protective alleles that may be more frequent in their genetic background (or their Native American ancestry).
Although obstructive lung disease (OLD), which includes COPD, affects all the populations, Hispanics seem to be protected against COPD development and progression. Whether this advantage translates into a survival benefit for this population is unknown. We aimed to determine the risk for OLD in Mexican Americans, the largest US Hispanic subgroup, compared with non-Hispanic whites and to assess all-cause mortality in subjects with OLD.
We assessed the relationships between Mexican American ethnicity and spirometric OLD and risk of death among 6,456 US adults aged ≥ 40 years who participated in the Third National Health and Nutritional Examination Survey Follow-up Study. We used logistic and Cox regression analyses to estimate the OR for OLD among Mexican Americans and the hazard ratio (HR) for all-cause mortality among Mexican Americans with OLD, respectively.
After adjustment for demographic factors, socioeconomic status, and COPD risk factors, Mexican Americans had decreased odds of OLD diagnosis compared with whites (OR, 0.72 [95% CI, 0.54-0.95]). Among the 1,734 participants with OLD, 1,054 (60.8%) died during median follow-up of 12 years. In an adjusted model, Mexican Americans had no advantage in mortality from all causes (HR, 0.88 [95% CI, 0.69-1.13]). After accounting for the fact that some Mexican Americans may have moved back to Mexico and died there (thus, had no US death certificate), there was still no difference in mortality between these groups.
Although Mexican Americans appear to have lower risk for OLD, subjects of this ethnicity with OLD do not seem to have a survival advantage.
Effect of smoking on spirometry of African American and white subjects
2008, Chest
Smoking is the single most important risk factor for COPD, yet there is still disagreement about the differences in the effect of smoking between white and African-American people. We hypothesized that the results of spirometry between smokers of the two races are equivalent if reference equations and lower limits of normal appropriate for each race are used.
We retrospectively analyzed all spirometry results in smokers over a 1-year period from the G.V. (Sonny) Montgomery VA Medical Center and excluded those that did not meet American Thoracic Society standards, or those from patients with additional medical problems. The remaining patients were classified by race and then matched for age and smoking history; 108 patients in each group were included, which met the power analysis goal of 98. The two groups were similar in age (57.5 years vs 57.0 years), smoking history (46.1 pack-years vs 46.0 pack-years), and body mass index (27.0 kg/m² vs 28.3 kg/m²) for African Americans and whites, respectively. Data were analyzed using the unpaired t test, and p values were adjusted for multiple comparisons using the Bonferroni factor.
There were statistically significant differences between African American and white smokers in FVC (3.67 ± 0.07 L vs 4.26 ± 0.08 L, p = 0.001) and FEV₁ (2.33 ± 0.07 L vs 2.72 ± 0.08 L, p = 0.002), as expected from the normal populations; however, there were no differences in FVC as percentage of predicted (89.1 ± 1.3% vs 86.7 ± 1.5%, p = 0.71) and FEV₁ as percentage of predicted (71.9 ± 2.1% vs 72.2 ± 1.8%, p = 1.00) when the reference equations appropriate for race were used (third National Health and Nutrition Examination Survey). There were also no differences between the number of subject with abnormal FEV₁/FVC results (56 African Americans vs 58 whites, p = 1.00) when the appropriate lower limits of normal were used.
There are no differences in spirometry findings between African Americans and whites when abnormality is defined appropriately using reference equations and lower limits of normal for each race. By using either percentage cutoffs for abnormality, or by adjusting for African-American equations only appropriate for whites, we were able to mimic with our data conflicting results in the literature.
Responses to tiotropium in African-American and Caucasian patients with chronic obstructive pulmonary disease
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Sparse information exists about chronic obstructive pulmonary disease (COPD) outcomes among different ethnic groups. To determine whether the effect of tiotropium on COPD exacerbation differs between African Americans and Caucasians, we performed a post hoc analysis of African-American (n = 150) and Caucasian (n = 1670) subgroups from a previously reported 6-month trial of tiotropium in patients with moderate-to-very-severe COPD. Compared with placebo, tiotropium reduced the likelihood of having at least 1 exacerbation in the entire group (RR, 0.81; 95% CI, 0.66–0.99, P = 0.037) with no statistically significant difference between African-American and Caucasian subgroups (P = 0.34). For African Americans, tiotropium significantly reduced the number of antibiotic days for COPD, hospitalizations for exacerbations, and hospitalization days for COPD. For Caucasians, tiotropium significantly reduced the number of exacerbations, exacerbation days, unscheduled clinic visits for COPD, and hospitalizations for exacerbations. Tiotropium reduced the frequencies of antibiotic days and of COPD hospital days to a significantly greater extent in African Americans compared with Caucasians (P = 0.027 and P = 0.025, respectively). No statistically significant ethnic-related differences were observed in the effect of tiotropium on the frequencies of exacerbations, exacerbation days, systemic corticosteroid days, unscheduled clinic visits, or COPD hospitalizations. Spirometry improved to a similar extent in both subgroups for the entire duration of the 6-month trial. African Americans used fewer respiratory medications than Caucasians in this study. We conclude that tiotropium reduces COPD exacerbations and associated health-care use to a similar extent in African Americans compared with Caucasians.
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Citation Excerpt :
Two further cohort studies showed non-significant increased risks of COPD hospitalisation among women for a given number of pack years,9 and in another cohort10 the incidence of COPD among those with respiratory symptoms was greater (although again not significantly) for female smokers compared with their male counterparts. In contrast, a meta-analysis of eight cross sectional studies showed no evidence of significant sex differences in the age, height and race adjusted effects of smoking on absolute FEV111 while conversely an analysis of the Framingham Offspring Cohort12 reported that male smokers had a small but significantly increased rate of FEV1 decline. One potential explanation for the conflicting results is the known controversy over the use of a simple fixed FEV1/forced vital capacity (FVC) ratio to confirm a diagnosis of COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) definition) or the additional use of a threshold for per cent of predicted FEV1 values to define lung function impairment (recommended by the National Institute for Health and Clinical Excellence (NICE)).
Some previous studies suggest there are sex differences in susceptibility to, and prevalence of, chronic obstructive pulmonary disease (COPD) but findings are inconsistent. In this study, whether different diagnostic criteria for COPD may contribute to these conflicting findings was examined.
Cross sectional analysis of data from the 1995, 1996 and 2001 Health Survey for England was undertaken, including participants of white ethnicity, aged 40+ years with a valid smoking history and lung function data. COPD was defined using Global Initiative for Chronic Obstructive Lung Disease (GOLD), National Institute for Health and Clinical Excellence (NICE) and lower limit of normal (LLN) spirometric criteria, in the absence of a diagnosis of asthma.
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The study indicates that sex differences in risk of COPD reported in previous studies are influenced by the definition used for COPD. When using a statistically driven definition (LLN), no independent sex difference was found and there was no evidence of an increased susceptibility to COPD among female compared with male smokers.

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Chest

Clinical InvestigationsPULMONARY FUNCTION TESTINGRace and Gender Differences in the Effects of Smoking on Lung Function

Study objective

Design

Setting

Participants

Interventions

Measurements and results

Conclusions

Section snippets

Selected Studies

Results

Discussion

ACKNOWLEDGMENT

Chest

Chest

J Chronic Dis

J Chronic Dis

Chest

The UCLA population studies of chronic obstructive pulmonary diseases: VIII. Effects of smoking cessage on lung function; a prospective study of a free-living population

Am Rev Respir Dis

Longitudinal changes in forced expiratory volume in one second in adults: effects of smoking and smoking cessation

Am Rev Respir Dis

Prevalence of respiratory symptoms in an unpolluted area of Northern Italy

Eur Respir J

Cumulative and reversible effects of lifetime smoking on simple tests of lung function in adults

Am Rev Respir Dis

Effects of cigarette smoking on rate of loss of pulmonary function in adults: a longitudinal assessment

Am Rev Respir Dis

Longitudinal methods for describing the relationship between pulmonary function, respiratory symptoms and smoking in elderly subjects: the Tucson Study

Eur Respir J

Relationship between the Single breath N2test and age, sex, and smoking habit in three North American cities

Am Rev Respir Dis

Adult passive smoking in the home environment: a risk factor for chronic airflow limitation

Am J Epidemiol

Increased susceptibility to lung dysfunction in female smokers

Am Rev Respir Dis

Smoking, changes in smoking habits, and rate of decline in FEV1: new insight into gender differences

Eur Respir J

Effects of smoking and changes in smoking habits on the decline of FEV1

Eur Respir J

Differences in pulmonary function related to smoking habits and race

Am Rev Respir Dis

Pulmonary function testing in population-based studies: summary of an NHLBI workshop

Am J Respir Crit Care Med

Clinical Investigations
PULMONARY FUNCTION TESTING
Race and Gender Differences in the Effects of Smoking on Lung Function

Relationship between the Single breath N₂test and age, sex, and smoking habit in three North American cities

Effects of smoking and changes in smoking habits on the decline of FEV₁