Long-term exposure to low-level air pollution and incidence of chronic obstructive pulmonary disease: The ELAPSE project.

BACKGROUND: Air pollution has been suggested as a risk factor for chronic obstructive pulmonary disease (COPD), but evidence is sparse and inconsistent. OBJECTIVES: We examined the association between long-term exposure to low-level air pollution and COPD incidence. METHODS: Within the 'Effects of Low-Level Air Pollution: A Study in Europe' (ELAPSE) study, we pooled data from three cohorts, from Denmark and Sweden, with information on COPD hospital discharge diagnoses. Hybrid land use regression models were used to estimate annual mean concentrations of particulate matter with a diameter < 2.5 µm (PM2.5), nitrogen dioxide (NO2), and black carbon (BC) in 2010 at participants' baseline residential addresses, which were analysed in relation to COPD incidence using Cox proportional hazards models. RESULTS: Of 98,058 participants, 4,928 developed COPD during 16.6 years mean follow-up. The adjusted hazard ratios (HRs) and 95% confidence intervals for associations with COPD incidence were 1.17 (1.06, 1.29) per 5 µg/m3 for PM2.5, 1.11 (1.06, 1.16) per 10 µg/m3 for NO2, and 1.11 (1.06, 1.15) per 0.5 10-5m-1 for BC. Associations persisted in subset participants with PM2.5 or NO2 levels below current EU and US limit values and WHO guidelines, with no evidence for a threshold. HRs for NO2 and BC remained unchanged in two-pollutant models with PM2.5, whereas the HR for PM2.5 was attenuated to unity with NO2 or BC. CONCLUSIONS: Long-term exposure to low-level air pollution is associated with the development of COPD, even below current EU and US limit values and possibly WHO guidelines. Traffic-related pollutants NO2 and BC may be the most relevant

Long-term low-level ambient air pollution exposure and risk of lung cancer - A pooled analysis of 7 European cohorts.

BACKGROUND/AIM: Ambient air pollution has been associated with lung cancer, but the shape of the exposure-response function - especially at low exposure levels - is not well described. The aim of this study was to address the relationship between long-term low-level air pollution exposure and lung cancer incidence. METHODS: The "Effects of Low-level Air Pollution: a Study in Europe" (ELAPSE) collaboration pools seven cohorts from across Europe. We developed hybrid models combining air pollution monitoring, land use data, satellite observations, and dispersion model estimates for nitrogen dioxide (NO2), fine particulate matter (PM2.5), black carbon (BC), and ozone (O3) to assign exposure to cohort participants' residential addresses in 100 m by 100 m grids. We applied stratified Cox proportional hazards models, adjusting for potential confounders (age, sex, calendar year, marital status, smoking, body mass index, employment status, and neighborhood-level socio-economic status). We fitted linear models, linear models in subsets, Shape-Constrained Health Impact Functions (SCHIF), and natural cubic spline models to assess the shape of the association between air pollution and lung cancer at concentrations below existing standards and guidelines. RESULTS: The analyses included 307,550 cohort participants. During a mean follow-up of 18.1 years, 3956 incident lung cancer cases occurred. Median (Q1, Q3) annual (2010) exposure levels of NO2, PM2.5, BC and O3 (warm season) were 24.2 µg/m3 (19.5, 29.7), 15.4 µg/m3 (12.8, 17.3), 1.6 10-5m-1 (1.3, 1.8), and 86.6 µg/m3 (78.5, 92.9), respectively. We observed a higher risk for lung cancer with higher exposure to PM2.5 (HR: 1.13, 95% CI: 1.05, 1.23 per 5 µg/m3). This association was robust to adjustment for other pollutants. The SCHIF, spline and subset analyses suggested a linear or supra-linear association with no evidence of a threshold. In subset analyses, risk estimates were clearly elevated for the subset of subjects with exposure below the EU limit value of 25 µg/m3. We did not observe associations between NO2, BC or O3 and lung cancer incidence. CONCLUSIONS: Long-term ambient PM2.5 exposure is associated with lung cancer incidence even at concentrations below current EU limit values and possibly WHO Air Quality Guidelines

Determinants of frequent attendance in Danish general practice:a cohort-based cross-sectional study

BACKGROUND: Previous studies addressing determinants of frequent attendance have mainly focused on socio-demographic, psychosocial and medical factors, and few had data on lifestyle and gender-specific factors. This study aims to describe determinants of general practice frequent attendance in Danish adult population, by examining lifestyle, socio-demographic, medical and gender-specific factors. METHOD: For 54,849 participants of the Danish Diet, Cancer and Health cohort (50–65 year old) we obtained data on visits to general practitioner (GP) from the Danish National Health Service Register at cohort baseline (1993–97), when information on medical conditions and lifestyle, socio-demographic and gender-specific factors was collected by questionnaire. Logistic regression was used to identify determinants of frequent attendance, defined as top 10 % GP users at the year of recruitment into the cohort (baseline) in the period between 1993 and 1997. RESULTS: Frequent attenders accounted for 40 % of all face-to-face GP consultations with a mean 12 visits/year. Women were more likely to be frequent attenders, in crude (Odds ratio: 1.95; 95 % Confidence Interval: 1.85–2.06) and fully adjusted (1.26; 1.09–1.47) model. In a fully adjusted model, strongest determinants of frequent attendance were pre-existing medical conditions, with hypertension (2.58; 2.42–2.75), diabetes (2.24; 1.94–2.59), and mental illness (2.29; 2.09–2.52) more than doubling the odds of being FA. High education (0.63; 0.57–0.69, >4 years higher education vs. no vocational training) and employment (0.61; 0.57–0.65) were inversely associated with frequent attendance. Finally, obesity (1.54; 1.14–2.08), smoking (1.21; 1.12–1.30, current vs. never), physical activity (0.84; 0.80–89), alcohol consumption (0.83; 0.78–0.87 above vs. below recommended level), and hormone therapy in women (1.52; 1.42–1.63) were all significant determinants of frequent attendance. CONCLUSIONS: In addition to pre-existing medical conditions, gender, socio-demographic and gender-specific factors, lifestyle (obesity, smoking, exercise and alcohol use) is also an independent determinant of frequent attendance at general practitioner

Determinants related to gender differences in general practice utilization:Danish Diet, Cancer and Health Cohort

Objective: This study aims to describe the determinants related to gender differences in the GP utilization in Danish population aged 50–65 years. Design: Cohort-based cross-sectional study. Setting: Danish general practice. Subjects: Totally, 54,849 participants of the Danish Diet, Cancer and Health cohort (50–65 years). Main outcome measures: The sum of cohort members’ face-to-face consultations with general practitioner (GP) at the cohort baseline year (1993–1997). We obtained data on GP visits from the Danish National Health Service Register at the cohort baseline (1993–1997), when information on lifestyle (smoking, body mass index (BMI), alcohol use, physical activity), medical conditions (somatic and mental), employment, education, gravidity, and hormone therapy (HT) use was collected by questionnaire. Results: Women had on average 4.1 and men 2.8 consultations per year. In a crude model, women had 47% higher rate of GP visits than men (incidence rate ratio: 1.47; 95% Confidence Interval: 1.45–1.50), which remained unchanged after adjustment for lifestyle, socio-demographic and medical factors, but attenuated to 18% (1.18; 1.13–1.24) after adjustment for female factors (gravidity and post-menopausal HT. In a fully adjusted model, subjects with hypertension (1.63; 1.59–1.67), mental illness (1.63; 1.61–1.66), diabetes (1.56; 1.47–1.65), angina pectoris (1.28; 1.21–1.34), and unemployed persons (1.19; 1.18–1.21) had highest rates of GP visits. Conclusions: Gravidity and HT use explain a large proportion, but not all of the gender difference in GP utilization. Medical conditions (somatic and mental) and unemployment are the main determinants of GP utilization in men and women, while lifestyle has minor effect.Key points Female gender remained a dominant determinant of GP utilization, after adjustment for lifestyle, socio-demography, medical and gender specific factors, with females consulting their GP 18% more often than males. Female reproductive factors (use of postmenopausal hormone therapy and gravidity) explained a large proportion of the gender variation in use of GP. Strongest determinants for GP use among Danish adults aged 50–65 years were the presence of medical conditions (somatic and mental) and unemployment, while lifestyle factors (e.g., body mass index, alcohol consumption and smoking) had minor effect