COPD in Women: Key Findings

COPD in Women Increasing More Rapidly Worldwide

Background: COPD in women receives little attention as a health issue even though more women die of COPD each year than of breast cancer and lung cancer combined. The general perception that COPD is a disease of older men is outdated. Throughout the world, COPD is increasing more rapidly in women than in men. Since 2000, more women than men in the United States die of COPD.

Dr. Jenkins has written about COPD in women

Professor Christine Jenkins

Review: Dr. Christine Jenkins of Sydney, Australia, and co-authors described the impact of female sex on COPD in a review article in the March 2017 issue of Chest, volume 151; pages 686-696.

Key Findings about COPD in Women: 1. For the same amount of smoking or exposure to irritants in the air, women are more susceptible to developing COPD. 2. The reasons for smoking may differ between sexes. Dr. Jenkins proposed that female empowerment through tobacco smoking and weight control are likely two reasons that women smoke. 3. Women with COPD are generally younger, smoke less, and have a lower body weight for their height than men. 4. Women tend to have more shortness of breath than men for the same level of breathing tests results. 5. In a 3-year study in the US, it was found that women had more frequent flare-ups (exacerbations) of COPD than men.

Female with COPD

How Does COPD Affect Women? In many studies it was noted that women have poorer health status and quality of life compared with men. Women with COPD report higher levels of anxiety and depression than men with COPD which adds to the burden of the disease in women.

Treating Women with COPD: Smoking cessation is an important treatment for anyone with COPD. However, women may be less successful with long-term smoking cessation than men, especially with nicotine replacement therapy. Current evidence shows that inhaled bronchodilators work the same in women as in men.

COPD in Women

Summary: The authors concluded that it is important to raise awareness of COPD in women and to develop new strategies to prevent the disease.  They also emphasized the need for educational programs for women with COPD and their families to manage their disease better.

My Comments: I offer the following two general impressions based on my pulmonary practice, although I have no explanation for these observations. 1. Women with COPD seem more motivated to “get better” and use prescribed inhalers as recommended. 2. Women are more likely than men to actually participate in pulmonary rehabilitation programs.

 

Lung Cancer Screening With a Counseling and Shared Decision-Making Visit

Lung Cancer Screening: Impacts of a Counseling Visit

Background: In 2013 the American Cancer Society issued an initial guideline for lung cancer screening. These recommendations were a result of the National Cancer Institute’s National Lung Screening Trial.  The findings indicated that lung cancer screening could save lives.

The guideline recommended that health care professionals should talk about screening with apparently healthy individuals between 55 and 74 years of age who have smoked at least a pack of cigarettes per day for 30 years (or equivalent) and who currently smoke or have quit in the past 15 years.  A counseling and shared decision-making visit with a health care professional has been mandated to help individuals with the decision whether to have low-dose computed tomography (CT scan) screening or not.  

 Study: In the March 2017 issue of the journal CHEST, Dr. Mazzone and colleagues at the Cleveland Clinic reported on their experience with lung cancer screening counseling and shared decision-making visits. 

Results: A total of 423 patients had a shared decision-making visit between April 2015 and April 2016. Of these, 23 individuals, or about 5%, decided not have low-dose CT scan of the chest. Eleven of the 23 chose not to proceed with the CT scan after the discussion. Nine of the 23 did not meet the screening requirements. 

Starting in November 2015, patients were asked to complete a survey about their knowledge of lung cancer screening before and immediately after the visit. Prior to the visit, most patients had a poor understanding about the required age and smoking history to be screened as well as the benefits and harms of screening. There was a significant improvement in the knowledge of patients about these requirement after the visit.

Conclusions: The authors concluded that a counseling and shared decision-making visit improves the knowledge of patients about who is eligible for screening as well as benefits and possible harms of CT scan screening.

My Comments: The mandated visit for lung cancer screening counseling and shared decision-making is typically available at academic medical center or large teaching hospitals.

Anyone who has COPD due to smoking cigarettes has an increased risk of lung cancer.  The purpose of screening with CT scan is to find a lung cancer early with the hope that surgical treatment will remove it completely. However, if you have advanced COPD, it is likely that your lung function would be too low to tolerate possible lung surgery. If so, lung cancer screening would not make sense.

Women Who Never Smoked are Vulnerable to Develop COPD

African-American Women are Susceptible to COPD

Background: COPD is the 3rd leading cause of death in the United States and a main cause of disability.  The prevalence (how often it occurs) has been higher among women than men in most age groups for over 20 years. One reason is that females have narrower breathing tubes allowing cigarette smoke to be more concentrated in their overall smaller lungs. Although cigarette smoking is the major risk factor for the disease, never-smokers may also develop COPD.

Study:  Esme Fuller-Thomson, Ph.D., and colleagues from the University of Toronto published the results of an observational study to examine gender and racial differences for developing COPD among never smokers. The researchers reviewed information on 129,535 Caucasians and African-Americans who were 50 years of age and older who had never smoked. The findings were published in the 2016 International Journal of Chronic Diseases.  http://dx.doi.org/10.1155/2016/5862026

Never-smoking African-American women are at risk for COPD

African-American woman at risk for COPD

Results: Women had a significantly higher chance of developing COPD than men. In particular, African-American women had the highest prevalence of COPD (7.0%) followed by Caucasian women (5.2%), Caucasian men (2.9%), and African-American men (2.4%).

Discussion: The authors suggested that differences in lung size may be a factor for higher likelihood in females. Other possibilities are the role of hormones and exposure to second-hand smoke. Dr. Fuller-Thomson commented that, “We cannot determine causality with this data set, but poverty is associated with increased exposure to city environments. Future research needs to investigate if these factors play a role in the greater vulnerability of African-American females.”

My Comments: These results raise many questions. Why are there sex differences in never smokers developing COPD? Why are there differences in COPD between Caucasian and African-American females?

It is important that health care professionals consider testing older individuals who complain of shortness of breath or persistent cough including those who are never smokers.

150 Lung Cell Mutations Each Year from Cigarette Smoking

Smoking Causes Cell Mutations or Genetic Damage

Background: A cell mutation is the permanent change in the sequence, or order, of the DNA in genes within a cell. Cell mutations play a part in both cancer and the immune system (fights infection and inflammation). Mutations may be harmless, but the more there are, the greater the risk that one or more of them will wind up causing cancer.

Cigarette smoking causes 150 cell mutations each year

Cigarette smoking causes 150 cell mutations each year in the lung

Study Results: On November 3, 2016, researchers reported in the journal Science a direct link between the number of cigarettes smoked in a lifetime and the number of mutations in cells. The findings are based on a genetic analysis of 5,243 cancers, including 2,490 from smokers and 1,063 from patients who said they had never smoked tobacco cigarettes.

In lung cells, there were on average 150 mutations in each cell each year with smoking a pack of cigarettes per day. Smoking did not only affect cells in the lung. On average, there were 97 mutations in each cell of the larynx (voice box), 39 mutations for the pharynx (throat), 18 for the bladder, and 6 mutations in every cell of the liver each year.

Number of cell mutations due to smoking a pack per day

Number of cell mutations due to smoking a pack per day

Conclusions: “The way tobacco smoking causes cancer is more complex than we thought,” commented study coauthor Dr. Mike Stratton, director of the Wellcome Trust Sanger Institute in England.

The researchers said they think these kinds of mutations have the effect of speeding up the “clock” inside of cells. The faster a cellular clock runs, the more chances the cell’s DNA has to mutate.

My Comments: This study provides clear proof that cigarette smoking causes cancer. Smoking kills 6 million people a year worldwide. If the current trend continues, the World Health Organization predicts more than 1 billion tobacco-related deaths in this century.

If you smoke, ask your health care provider for help to quit. Medications are available to help people quit smoking, while numerous professional organizations offer various support services.

 

According to the CDC, COPD Deaths Down for Most Americans

From 2000-2014, 12% Drop in COPD deaths in the US

Background: COPD is the 3rd leading cause of death in the United States after heart disease and cancer. None of the available medical treatments for those with COPD, such as inhaled medications, have been shown to affect mortality.

Report: The Center for Disease Control and Prevention, known as the CDC, reported on September 8, 2016, that between 2000 and 2014, there was a 12% overall drop in COPD deaths. Dr. Hanyu Ni, a co-author of the findings, commented that the findings were not unexpected because, “they are consistent with the declines in the prevalence of current smoking for men and women in the United States.” The results were reported in the US National Center for Health Statistics.

COPD includes chronic bronchitis and emphysema.

COPD includes chronic bronchitis and emphysema.

COPD deaths were analysed by sex and race. For women, there was little change for Caucasians, while African-Americans had a 4% increase in death rate over the 14 years. For men, Caucasians experienced a drop of 21%, and African-Americans had a decline of about 24%.

Reduced smoking may explain the overall decline in COPD deaths.

Man and woman smoking a igarettte

Dr. Ni commented that the analysis did not explore the reasons for the trends. However, he stated that the figures weren’t unexpected noting that the declines in COPD deaths are consistent with fewer women and men currently smoking in the U.S.

David Mannino, M.D., Professor and Chair of the Department of Preventive Medicine and Environmental Health at the University of Kentucky.

David Mannino, M.D., Professor and Chair of the Department of Preventive Medicine and Environmental Health at the University of Kentucky.

Dr. David Mannino suggested that additional factors unrelated to smoking might affect COPD deaths. He proposed that poverty and/or lack of access to health care “may explain some the racial differences.”

Childhood Asthma May Lead to COPD Due to Reduced Lung Growth

Childhood Asthma and Reduced Lung Growth are Risks for COPD 

A long-term study of those with childhood asthma and daily symptoms was published on May 12, 2016, in the New England Journal of Medicine (volume 374, pages 1842-1852). Michael McGeachie, Ph.D., from Harvard Medical School was the first author. The findings are relevant to the diagnosis of COPD.

Background: Cigarette smoking is the major risk factor for COPD. However, it is estimated that 15 – 20% of those with COPD have not smoked. Other possible causes for developing COPD include inhaling irritants in the air (such as construction workers) over a long time and persistent asthma with permanent damage to the breathing tubes (called airway remodeling).

Study: 684 children with persistent (daily symptoms) of asthma were studied until an average age of 26 years. Breathing tests (pulmonary function tests) were performed frequently over approximately 20 years.

Child using inhaler with spacer

Child using inhaler with spacer as asthma treatment

Results: The authors found that the changes fit into four groups:

♦  Normal lung growth and no early decline – 25%

♦  Normal lung growth and an early decline – 26%

♦  Reduced lung growth only – 23%

♦ Reduced lung growth and an early decline – 26%

73 in the study (11%) had findings consistent with COPD as young adults. They did not smoke cigarettes and there was no evidence of long term exposure to inhaling irritants in the home.

Child receiving a Nebulized Treatment for Asthma

Child receiving a Nebulized Treatment for Asthma

Conclusions: Children with persistent asthma and reduced lung growth are at risk for possible COPD in early adulthood.

My Comments: The results of this study suggest that some children with daily asthma symptoms may develop or progress into COPD as young adults. Whether aggressive asthma therapy during childhood might prevent the development of COPD is unknown.

I Want to Quit Smoking: Can e-cigarettes Help Me Give Up Tobacco?

Should I try e-cigarettes to quit smoking?

Dear Dr. Mahler:

What are your thoughts about e-cigarettes? I want to quit smoking cigarettes and have tried the patch, gum, and Chantix without success. Do they work? Are they safe? I am 59 and have “moderately severe” COPD according to my doctor. She says electronic cigarettes do not have all of the chemicals that are in cigarettes.

Cam from Kingston, Ontario, Canada

Dear Cam:

Your question is important and timely. Before I answer it, here is some brief information on electronic cigarettes.

There are numerous types for vaping e-cigarettes.

Various electronic cigarettes displayed in a store.

Electronic cigarettes contain no tobacco. The burning of tobacco produces smoke (combustion) which makes particles and gases that can cause cancer (carcinogens). Thousands of toxins have been identified in tobacco smoke.

 

With electronic cigarettes, the vapor contains only trace or no toxins and no carbon monoxide gas. The vapor usually includes flavorings and  a chemical called propylene glycol. Current evidence shows that e-cigarette vapor is much less toxic then cigarette smoke. Nicotine is the major chemical in e-cigarettes and is highly addictive as everyone knows.

Experts state that the greatest potential but unproven benefit of e-cigarettes is to help people quit smoking cigarettes. So far, there are two studies that have examined the success of e-cigarettes in helping someone quit smoking. Overall, about 10% of individuals using e-cigarettes were able to quit tobacco smoking, which was similar to use of nicotine patch.

Although many young people are experimenting with vaping e-cigarettes, most of these are already smoking regular cigarettes. Studies in animals show that the developing brain is vulnerable to the effects of cigarettes. Thus, preventing sales of electronic cigarettes to youth as proposed by the FDA is important.

Person vaping e-cigarette

A person vaping e-cigarette.

Finally, most experts suggest that e-cigarettes should meet safety standards and be regulated. Right now, there is no regulation as to what additives or how much nicotine is actually in electronic cigarettes.

When someone in my practice asks the same question as you have, I provide a brief explanation, and then state that vaping electronic cigarettes appears to be safer then smoking cigarettes. Ideally, someone might use e-cigarettes as a way to quit smoking cigarettes, and then eventually quit vaping.

Of course, you should discuss this with you health care provider.

For more information, see Point and Counterpoint: Does the Risk of Electronic Cigarettes Exceed Potential Benefits? in the journal CHEST, September 2015.

Best wishes on quitting,

Donald A. Mahler, M.D.

 

 

 

 

 

Help to Stop Smoking

Dear Dr. Mahler:

Do you have any advice on helping me stop smoking?  I have quit many times, and have used the patch, gum, Chantix, and finally tried hypnosis. The longest time that I quit was for 3 weeks, but then I craved a cigarette after going out with my friends for dinner. Now I smoke a pack most days. My doctor diagnosed me with COPD six months ago, and I take an inhaler twice a day. My father had emphysema and died of a heart attack.   Carl from Bend, OR

Dear Carl,

As you know, nicotine in cigarette smoke can be addicting for my people. This addicting feature is evident at many medical centers where you can see employees standing outside in the rain, snow, and/or cold while smoking in designated areas. In the United States, about 18% of adults smoke cigarettes daily.

Two women smoking outdoors during winter

Two women smoking outdoors during winter

Man smoking outdoors in the winter

Man smoking outdoors in the winter

 

 

 

 

 

Here are parts of a letter sent to me from a friend and former patient. He grew up in the United Kingdom, and now lives in the US. His comments provide a message for anyone facing the challenge of quitting smoking. He gave me permission to share what worked for him in the hope that it may help others.

“As one who smoked from an early age in my teens in England, I made various attempts to give up this very addictive, legalized, tax generating, drug. When in 2000 I finally did after 40+ years of smoking, I tried an approach which may be helpful to pass on, via you, to others.

My previous attempts to stop were all based on stopping ‘tomorrow.’ All failed. With the tomorrow approach, the addict usually smokes heavily the night before trying to stop smoking. Even using patches, he “needs” his tobacco fix next morning, usually upon waking, that is when the withdrawal starts of course.

  I was to head off on two flights to the U.S. West Coast and I had decided to enjoy my last morning pipe/fix before the taxi came to take me to the airport and the ‘no smoking’ environment that entails. Taxi arrived, pipes consigned to the trash bin, I set off.
 
At the airport, I learned at the pharmacy there, that it would likely cost me around $400 in patches to give up the native American weed. No way was I going to spend that sort of money, however good the cause was, that’s a lot of golf balls !
 
Instead, every time I reached for my pipe, I said to myself, sometimes aloud, ” I don’t smoke do I!” Breaking my journey in Newark Airport, NJ, I refrained from accepting my traveling colleague’s tempting offer to wait for me, if I wanted to use the then available smoking bar. Instead I boarded the flight to San Francisco, muttering to myself through gritted teeth, ‘I don’t smoke do I!!’
 
Once on the West Coast almost a day had past and ready for bed I went smoke free, day one. By staying for the most part in non smoking environments, I continued as the cold turkey effects came one , but remembering to say, I don’t smoke, when the urge for my soothing pipe grew strong. Having the odd strip of sugar free gum helped too.
 
 It was not easy, but day by day it became normal to be a non smoker, my sense of smell and taste became more pleasingly acute, and then, secondhand smoke became abhorrent to me. About that time I too realized that as even a pipe smoker, one smells akin to an ash can to non smokers. Saving lots of money by not buying expensive, highly taxed tobacco in the UK, then paid for my annual dues at a local golf club, and my health was improving too.
 
To stop smoking and save money and your health ; The secret being, get the morning fix, then get into a non smoking space to stop smoking forever. Remember, ‘I don’t smoke do I.’ After all, we were not born as nicotine addicts.”
thantismoking1
I hope that these comments are helpful.
Donald A. Mahler, M.D.

 

What are Chronic Bronchitis and Emphysema?

Dear Dr. Mahler:

I was recently diagnosed as having COPD by my primary care doctor. She mentioned both chronic bronchitis and emphysema, but I didn’t quite understand what she meant by these terms. Can you explain?

Jack from Tacoma, WA

Dear Jack,

I assume that you had breathing tests (called pulmonary function tests) in order for your doctor to diagnose COPD. COPD consists of two types: chronic bronchitis and emphysema. The figure below shows that the breathing tubes (airways) divide many times and end in air sacs (alveoli).

The breathing tubes (bronchus) divide many times and end in air sacs (alveoli).

The breathing tubes (bronchus) divide many times and end in air sacs (alveoli).

If inhaling cigarette smoke and other irritants mainly damages your breathing tubes, then the airways become red and swell (inflammation) and glands that line the inner lining of the tubes produce a thick substance called mucus. It is usually white or gray in color. Most people with this condition cough up mucus most days, especially in the morning. This is called chronic bronchitis. It is diagnosed if you report coughing up mucus most days for three months over a two year period. A cough productive of mucus is a common complaint or symptom.

Views of the inside of a normal breathing tube on left and of chronic bronchitis on the right. Note the white-yellow mucus lining the inside of the airway in chronic bronchitis.

Views of the inside of a normal breathing tube on left and of chronic bronchitis on the right. Note the white-yellow mucus lining the inside of the airway in chronic bronchitis.

If inhaling cigarette smoke and other irritants mainly damages your air sacs (alveoli), these areas are destroyed. This is called emphysema. It is usually diagnosed by a specific type of breathing test called diffusing capacity. In emphysema, the diffusing capacity is lower than normal. Emphysema can also be diagnosed if you have a CT scan of the chest that shows typical changes. Shortness of breath with activities is the most common complaint or symptom.

Microscopic view of the air sacs (alveoli) in the top right showing emphysema (destruction and enlargement).

Microscopic view of the air sacs (alveoli) in the top right showing emphysema (destruction and enlargement).

It is possible that you have a combination of both chronic bronchitis and emphysema which is quite common.

At the present time, treatments for COPD are the same whether you have chronic bronchitis or emphysema.

I suggest that you ask your doctor the same question that you asked me for more specific information about your condition.

Sincerely,

Donald A. Mahler, M.D.