Lewis Samuel Feuer
AOD included asthma, chronic bronchitis, and emphysema there were so few cases of emphysema that it was not analyzed separately.
One reason is that many mortality studies use composite ICD codes instead of minor groupings or individual codes, which would have greater specificity. A second is that because asthma and chronic bronchitis are rarely fatal, mortality studies tend to be insensitive to any relationship between an environmental or occupational exposure and long-term respiratory effects.
Finally, although emphysema is the respiratory effect that is the exception because it can be fatal, most emphysema deaths are related to cigarette-smoking. Respiratory mortality findings in several large-scale cohorts have been reported: Veterans who lived within 50 meters of a major roadway were compared with those who lived more than meters away.
By virtue of their age mean age They were drawn from the general population of southeastern Massachusetts, and they had not been treated in a VA medical center in the year before being surveyed.
Estimates of individual exposure were based on current residential address without information on residential history linked to road type and traffic-count data in a geographic information system. Living near a major roadway appeared to be associated with increased reporting of persistent wheeze OR 1.
Self-reports of physician-diagnosed asthma or COPD defined as chronic bronchitis or emphysema were analyzed as confounders and effect modifiers. Associations were adjusted for cigarette-smoking, age, and occupational exposure to dust. The authors noted that limitations of the study include lack of information on duration of residence at each address and information about home exposure to NO x from cooking or heating. A study of parents of schoolchildren was performed on 4, adults who resided in four school districts of three major cities.
The self-reported symptoms ascertained were cough, phlegm, wheeze, and persistent cough and phlegm PCP, an indicator of chronic bronchitis. Exposure to air pollution was determined on the basis of ambient air pollution data from monitoring stations in each district.
A separate report covered findings on schoolchildren, but this young population is not relevant to Gulf War veterans. NOx were assessed to estimate long-term exposure to outdoor air pollution. The differences for SO 2 and NO x were less pronounced. The findings suggest that increased TSP concentration is associated with increased symptoms.
Physician-diagnosed asthma and bronchitis showed inconsistent trends. For bronchitis acute or chronic , ORs for mothers followed the same trend as respiratory symptoms Lanzhou OR 9. A limitation of the study is that it did not associate air-pollution concentrations themselves with health outcomes; it only associated residence in some regions with health outcomes.
The authors cautioned that nonmeasured between-city factors may have been responsible for the associations. In an ecologic study in Sweden Bjornsson et al. There was no difference in the prevalence of self-reported asthma. Although Gotborg was more polluted, there were also differences in climate and SES that could have accounted for the findings.
An ecologic study evaluated the relation between short-term SO 2 peaks and emergency-department visits for asthma in low income neighborhoods in New York City in — Goldstein and Weinstein Limitations include the lack of control for confounding factors, such as smoking and sociodemographic characteristics, and the likelihood that emergency-department visits reflected exacerbation of pre-existing asthma rather than incident asthma cases.
Two other studies compared the prevalence of asthma or chronic bronchitis among geographic regions that had different air-pollution magnitudes. The geographic areas probably differ in other important ways, such as sociodemographic characteristics of the inhabitants, smoking prevalence, and allergen exposure.
Because there were no specific measurements of air pollution, it is difficult to draw any inferences from the studies Papageorgiou et al. The Woods et al. The self-reported-exposure measure is suspect, however, in that persons who have respiratory disease may be more likely to remember and report perceived air-pollution annoyance.
An ecologic study in Brisbane, Australia, examined the association between weekly smoke density coefficient of haze and admissions to the casualty department of the Royal Brisbane Hospital at night Derrick Hastings and Jardine evaluated the association between measured particulate air pollution and upper respiratory disease rates in soldiers deployed to Bosnia in — No specific information on asthma, chronic bronchitis, or COPD was presented.
Additionally, several studies for example, Aditama ; Kunii et al. Domestic gas-stove use releases NO 2 , a potential respiratory irritant, into the indoor environment Samet et al. Many epidemiologic studies examining the effects of gas-stove use have focused on healthy members of the adult population Dow et al. In those studies, the effect of gas stove exposure on the development of respiratory symptoms, including asthma symptoms and pulmonary function impairment has been inconclusive.
The city of Rotorua, New Zealand, is above a geothermally active area with substantial hydrogen sulfide H 2 S exposure. A series of studies by Bates et al.
The impetus for the studies was a World Health Organization report that recommended research in Rotorua to take advantage of the natural conditions to study the health effects of H 2 S. Rotorua has a higher density of Maori residents than other areas of New Zealand. In a subsequent report, Bates used hospital-discharge data over a 3-year period — to calculate standardized incidence ratios SIRs for respiratory and other diseases and subgroupings in Rotorua residents.
Exposure was designated as high, medium, and low on the basis of area of residence where H 2 S was mapped outdoors with passive sampling. The authors had no information on smoking and SES as potential confounders. In a third report, Bates et al. No exposure groups were designated. CORD was not increased.
A major limitation of the series of Bates studies for purposes of the present report is the grouping of respiratory diseases without specifying whether they were asthma, bronchitis, COPD, or individual conditions. Additionally, the Bates studies were the only epidemiologic studies of H 2 S found by the committee that examined long-term health outcomes.
Due to the paucity of literature, the committee did not make a separate conclusion on H 2 S. Individual exposures were to respirable dust and to SO 2 at relatively low concentrations less than 1. Exposures were estimated based on the basis of job-specific measurements and linkage to worker-specific job titles and employment duration.
Average duration of employment was 14 years. The estimates included a measure of cumulative exposure, average exposure, and most recent exposure. It is notable that the plant had been closed in the 6 months preceding the study, so the evaluation of outcome probably occurred after an exposure-free interval. Respiratory symptoms were ascertained with a translated version of the ATS respiratory-disease questionnaire.
Lung function was also measured and reported separately Osterman et al. Although all symptoms occurred more frequently in current smokers For cumulative SO 2 exposure, the highest exposure over 3 ppm-years had OR The strong SO 2 -symptom associations persisted and were almost identical with those obtained from regression models that did not include a dust variable.
There was no evidence of a dust-SO 2 interaction. The association was more closely related to exposure concentration rather than to duration. A similar dose-dependent association was observed between SO 2 exposure and chronic wheeze.
The associations with respirable dust were generally negative. Because the study measured symptoms only 6 months after cessation of exposure, it is not known whether they were reduced or eliminated after a longer exposure-free period. In a companion article, Osterman et al. No effects of a dust-SO 2 interaction were seen. Studies of respiratory-system mortality in particular occupations are often difficult to interpret.
Other studies examine occupations that entail exposure to chemicals of uncertain relevance to Gulf War veterans, including studies of urban firefighters Aronson et al. Although most mortality studies had negative results, three found higher mortality from emphysema Maizlish et al. A separate analysis of the ACS prospective study found that emphysema mortality was not meaningfully increased among workers exposed to diesel exhaust, after adjustment for the effects of smoking Boffetta et al.
A large study of firefighters in 27 states over 5, The effects of occupational exposure to engine exhaust were studied in Copenhagen street-cleaners in comparison with a similar number of cemetery workers Raaschou-Nielsen et al.
Environmental monitoring confirmed that street cleaners had higher average exposures to air pollutants except ozone than did cemetery workers, but similar wages and similar exertion. Cemetery workers were younger and less likely to smoke cigarettes. The study did not indicate whether the symptom questionnaire was sent after an exposure-free interval, but the likelihood is that there was no interval, inasmuch as this was a study of current workers.
The study found, after adjustment for age and smoking, that street-cleaners were at higher risk for chronic bronchitis OR 2. Asthma and chronic bronchitis were defined on the basis of responses to the standard questionnaire by the British Medical Research Council. The average duration of employment was 5—9 years.
A limitation of the study is the potential for nonmeasured differences between the two types of workers that could confound the exposure-outcome relationships. Occupational exposure to diesel-exhaust emissions was associated with increased self-reported symptoms of cough and sputum and with lower pulmonary function in coal miners vs matched controls Reger et al.
When disparities in various health characteristics between workers in or at diesel-using mines and their matched controls were related to an index of diesel exposure, they showed no noteworthy trends. Although a pattern consistent with early airway disease was shown, factors other than diesel may be responsible inasmuch as exposure duration and concentrations were low. The respiratory health of workers at five salt mines was evaluated with a questionnaire and spirometry Gamble and Jones ; no direct exposure measurements were available.
Comparisons within the study population showed a dose-related association of phlegm and diesel-exhaust exposure, no noteworthy trend for cough and dyspnea, and no association with spirometry was seen.
The factory also emitted azodicarbonamide, which has been associated with occupational asthma. Investigators evaluated clerical and industrial workers in four engineering factories in Brisbane, Australia Smithurst and Williams Although cough and phlegm were more common among industrial than clerical workers, there was no specific evaluation of exposure to combustion products.
There also was no statistical control for potentially confounding variables, such as SES. A study of 1, men 22—54 years old living in Norway found that self-reported occupational exposure to SO 2 was associated with a greater decline in FEV 1 from initial examination — to followup — Investigators demonstrated a decline in FEV 1 after occupational diesel-exhaust exposure, but the decline normalized after an exposure-free period of 3 days Ulfvarson et al.
Several other morbidity studies assessed occupational exposures but were limited by lack of exposure information or other features. One study Fleming and Charlton found that.
Occupational exposure to engine exhaust was not associated with adult asthma in a study in Sweden Toren et al. Other studies are limited in that they did not provide specific estimates of exposure to combustion products but rather studied exposures to a composite category for example, vapors, gas, dust, or fumes Flodin et al. Some studies have assessed the effect of forest firefighting on various intermediate measures or indexes of pulmonary function rather than on respiratory diseases themselves.
Most forest-firefighter studies, however, did not examine effects on lung function after an exposure-free period. An exposure-free period is important for distinguishing between reversible, short-term outcomes and long-term outcomes.
In one study that had an exposure-free period of 2. Crews worked full-time in May—November. Findings were independent of smoking. The duration of the exposure-free interval between fire exposure and testing appears to have been at most 2 weeks, so it is difficult to determine whether effects are short-term effects, which may reverse, or long-term effects.
A prospective study of 1, urban firefighters in — found no exposure-related decline in pulmonary function. A study of retirees from the same urban fire department did not find appreciably reduced respiratory function that was unrelated to smoking Musk et al.
Urban-firefighter studies, however, are probably less relevant to Gulf War veterans see above than are studies of rural firefighters, because of the nature of the materials in urban fires. Several studies evaluated the effects of exposure to products of biomass fuel combustion for heating or cooking, which includes combustion of wood, dung, and agricultural residue. The homes in question often do not have a separate kitchen or a way to vent fumes. The studies assessed exposure by self-reporting of duration of cooking-fuel use and, in some cases, by measurement of air quality at the time of the survey.
On the basis of survey items about 10 cooking fuels, the author classified cooking-smoke exposure as high only biomass fuels , medium a mix of biomass and cleaner fuels, such as kerosene, petroleum gas, biogas, or electricity , and low only cleaner fuels. The risk was also increased for the medium group mixed fuels vs clean fuels OR 1.
The asthma results were stronger for women OR 1. The strengths of the study are its population-based design, thorough ascertainment of fuel use, and control for confounding. Limitations include the cross-sectional design and the use of a self-reported definition of asthma that did not require symptoms or a physician diagnosis. No information is available on duration of exposure. The villages were similar, except that one used indoor cooking and the other outdoor cooking.
They were given a Spanish translation of the British Medical Research Council questionnaire for chronic bronchitis. Measured kitchen PM 10 was substantially higher in the indoor-cooking village; total daily integrated PM 10 exposure based on a time-budget analysis was also much higher.
The outdoor-cooking village had a lower risk of chronic bronchitis, after adjustment for age, sex, and exclusion of smokers OR 0. The villages were similar in a variety of socioeconomic indicators. The validation of exposure with direct ambient-air monitoring specifically PM 10 is a strength of the study. Although duration of residence was not reported, air monitoring was carried out over a month period, and a case of chronic bronchitis was identified by uninterrupted cough for at least 3 months over 2 years.
They had reported a range of 2. There were four different groups: The primary exposure was to wood smoke while cooking. The selection of controls that had tuberculosis or interstitial lung disease is suspect because such subjects may differ from persons who have chronic airway disease in a variety of important ways.
In analyses that used the other control groups, wood-smoke exposure was associated with a greater risk of chronic bronchitis without chronic airway obstruction than in ENT controls OR 3. The analysis controlled for age, cigarette-smoking, region of origin, income, education, and place of residence.
Wood-smoke exposure was not associated with the risk of chronic airway obstruction without chronic bronchitis. Wood-smoke exposure was associated with a greater risk of chronic airway obstruction plus chronic bronchitis compared with ENT controls OR 5. Cumulative lifetime exposure the product of average hours per day of exposure and years of exposure was also linearly related to a greater risk of chronic bronchitis only than in the ENT or visitor controls. Findings in the tuberculosis and interstitial-lung-disease control groups are difficult to interpret, because these conditions could be related to wood-smoke exposure; alternatively, the conditions, because they are severe diseases, might reduce the likelihood of cooking and consequent exposure.
In addition, wood-smoke exposure could be a cause of the ENT conditions and result in a bias toward the null value in the analyses. The small sample resulted in imprecise estimates with wide confidence intervals. A study in the hill region of Nepal evaluated 1, people Pandey They reported exposure to domestic smoke produced by burning firewood, straw, and other biomass fuels, and. The cross-sectional prevalence of chronic bronchitis increased with hours spent near the fireplace.
In women, chronic bronchitis was observed among smokers, ex-smokers, and never smokers. In men, it was observed in all groups except nonsmokers. However, the study did not control for SES. Quereshi randomly selected two villages in Kashmir.
In Gujjar, inhabitants live in single-room hutments and burn firewood in a mud hearth for cooking and heating. In Wahidpora, living conditions are better; kerosene stoves, gas stoves, and electric heaters are more commonly used.
The SES was lower in Gujjar, and the prevalence of cigarette-smoking was also lower. The prevalence of chronic bronchitis was higher in Gujjar Among Gujjar residents, the prevalence of chronic bronchitis increased with average hours spent near the fireplace no statistical testing was performed. In a pooled analysis of both villages, the prevalence of chronic bronchitis among women but not men varied with hours spent near the fireplace. A major limitation of the study is the lack of control for confounding variables, such as cigarette-smoking and SES, both within and between villages.
A case-control study in Saudi Arabia recruited 50 people who had COPD defined by airflow obstruction with pulmonary-function testing and 71 healthy controls Dossing et al. A serious limitation of the study is the lack of control for smoking, age, SES, and other factors.
Cases and controls averaged more than 15 years of wood use, usually beginning in childhood or adolescence. Use of wood as a cooking fuel was associated with a greater risk of obstructive airways disease OR 3. A study strength is the use of pulmonary-function testing to define cases. Limitations include the lack of control for SES and the limited evaluation of wood-smoke exposure in multivariate analysis for example, no exposure-response relationship was examined.
In addition, the recruitment process in a variety of inpatient and outpatient settings did not clearly result in controls that were comparable with cases. Investigators examined the use of planchas wood-burning chimney stoves compared with open wood fires by women in the rural highlands of Guatemala Bruce et al.
Although cough and phlegm production were less common among those using planchas, the risk of chronic bronchitis was similar OR 0. The investigators noted that use of planchas was related to other indicators of higher SES, such as radio ownership, spousal employment in business and trade, and cement or tile floors as opposed to dirt floors. The authors commented on the potential for strong confounding in studies that use fuel type as an exposure measure.
A population-based study in India evaluated 3, nonsmoking women in their homes in villages of Chandigarh in northern India Behera and Jindal Cooking with a chulla—which uses dung, crop residues, and agricultural wastes—was associated with a higher. There was no statistical difference in the prevalence of asthma, but there were very few cases. A major limitation of the study is the lack of control for confounding factors apart from sex and smoking, such as SES.
Investigators in Finland conducted a mail-based survey of Finnish university students to examine the effect of wood-stove heating during childhood age 0—6 years on the development of asthma and allergic conditions in young adulthood age 18—25 years Kilpelainen et al. There was no association between wood-stove exposure during childhood and ever having a self-reported physician diagnosis of asthma OR 0.
Study limitations include the cross-sectional survey design and the lack of control for cigarette-smoking. Additional studies have linked biomass-smoke exposure to impaired pulmonary function with spirometry Pandey et al.
The committee excluded some reports because they contained no specific information about asthma, chronic bronchitis, or COPD Amoli ; Perez-Padilla et al. Another study was excluded because the statistical analysis could not be clearly interpreted Golshan et al. The series of related studies of Seventh-Day Adventists comprise the only high quality study of asthma incidence related to outdoor air pollution in adults. The studies found that new cases of asthma were associated with combustion-product exposure in air pollutants Abbey et al.
Although the other key Gulf War study based on the Iowa cohort Lange et al. The study of Mishra also supports an association between biomass combustion and prevalent asthma. Other studies of biomass-fuel combustion and outdoor air pollution support a relationship between combustion exposure and asthma Baldi et al. Chronic bronchitis is defined by symptoms of chronic cough and sputum production.
A major prospective study of outdoor air pollution with more than a decade of exposure Abbey et al. Supporting findings were reported by five other studies Dennis et al.
The study of Gulf War veterans in Iowa of Lange showed no relationship between exposure to oil-well fires and chronic bronchitis, but the standard epidemiologic definition of chronic bronchitis was not used, so acute and chronic bronchitis could not be distinguished.
Although the studies reviewed by the committee indicate a probable relationship between long-term over 1 year exposure to combustion products and chronic bronchitis, a key unresolved issue is whether shorter-term exposures less than 1 year can cause the condition. The committee found inadequate published data that address the effect of shorter-term combustion-product exposures less than 1 year on the risk of developing chronic bronchitis.
A related issue is the exposure-free period after combustion-product exposure. Will chronic bronchitis remit after exposure cessation? If so, how long does it take for symptoms to remit? Only one of the studies in this chapter examined people after an exposure-free period. They found strong symptom-SO 2 associations after adjusting for the effects of dust exposure. The study suggests that chronic-bronchitis symptoms can persist for at least 6 months after cessation of combustion-product exposure, but there are no data from this study or others to indicate whether chronic-bronchitis symptoms might abate thereafter.
It is instructive to examine the influence of smoking on the natural history of chronic bronchitis. Smoking is the dominant risk factor for chronic bronchitis. It is well known that chronic bronchitis, when defined as mucous hypersecretion, usually remits after smoking cessation Fletcher ; Kanner et al. In the Lung Health Study, most of the people who had COPD defined by airway obstruction and chronic cough had resolution of the cough by a year after sustained smoking cessation Kanner et al.
At 5-year followup, remission of symptoms persisted among the sustained quitters. Similarly, Fletcher showed that the most people who had chronic bronchitis had resolution of their symptoms after smoking cessation. Onset of chronic bronchitis RR 1. Outdoor-kitchen village associated with lower risk of chronic bronchitis than indoor-kitchen village.
Consequently, even if it could be shown that long-term exposure to combustion products caused chronic bronchitis, it might be expected to remit after exposure cessation without long-term health consequences. The committee found inadequate published data to evaluate the natural history of chronic bronchitis after cessation of exposure to combustion products.
Emphysema is a pathologic process involving air-space enlargement distal to the terminal bronchioles accompanied by destruction of the bronchiolar walls. Its major risk factor is cigarette-smoking. The ACS prospective study found that emphysema mortality was not considerably increased among workers exposed to diesel exhaust after adjustment for the effects of smoking Boffetta et al. A study of veterans exposed to oil-well fires did not find a relationship with emphysema Smith et al.
Other studies that included emphysema in the analysis were methodologically inadequate. The committee did not identify any high-quality studies that evaluated the effect of exposure to combustion products on the risk of COPD, as defined by objective evidence of irreversible airflow obstruction with spirometry, for example, GOLD criteria Pauwels et al.
Several studies of biomass-smoke exposure used measures of airflow obstruction but had methodologic limitations that precluded clear conclusions about the connection between combustion exposure and COPD Dennis et al.
Although some toxicologic studies do provide mechanistic insight as to how inhaled combustion products might act to bring about symptoms associated with asthma or COPD for example, reviewed in Barnes ; Ichinose et al. Most controlled-exposure studies either are of short duration, fail to examine long-term residual effects, or use compromised animal models. Chronic disease associated with long-term concentrations of nitrogen dioxide.
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Environmental Health Perspectives The effect of smoke inhalation on lung function and airway responsiveness in wildland fire fighters. After World War II. He constantly challenged the leaders of the student movement and appeared in a widely publicized debate with student leader Mario Savio.
He left Berkeley to go to the University of Toronto. His last teaching position was as University Professor at the University of Virginia , and was Professor Emeritus at the time of his death in Feuer visited the Soviet Union during one of the first academic exchanges in the period after Stalin's death, often referred to as "the Thaw" and was expelled for challenging Soviet orthodoxies regarding Marxist thought. His experiences at Berkeley, where he challenged left wing student movements and professors who ceded to their demands, led Feuer to reject left wing, radical politics and he wrote continuously after this period about the corrupting influences of ideology on thought, the dangers of totalitarianism in the modern world and the role of the United States as a bulwark against tyranny and authoritarianism in the modern world.
His edited collection, Karl Marx and Friedrich Engels: Basic Writings on Politics and Philosophy is one of the most widely used readers on Marxian thought ever published.
Politically, he was closely allied with the philosophical anti-communism of Sidney Hook. His work ranged across a wide range of fields such as Marxist and neo-Marxist thought, the sociology of knowledge , the sociology of science , sociological theory, ideology and intellectuals, the history of ideas , the sociology of generations , the history and sociology of Jews and Judaism, and philosophy.
He was one of the earliest interpreters of the relationship between psychoanalysis and philosophy and produced many studies of the psychoanalytic dimensions of ideology and intellectual life. His extensive knowledge of the more arcane intricacies of Marx's life and a deep love of the fictional character of Sherlock Holmes were the basis for a novel entitled The Case of the Revolutionists Daughter: Sherlock Holmes Meets Karl Marx