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Occupational exposures and incidence of chronic bronchitis and related symptoms over two decades: the European Community Respiratory Health Survey
  1. Theodore Lytras1,2,
  2. Manolis Kogevinas1,2,3,4,
  3. Hans Kromhout5,
  4. Anne-Elie Carsin1,2,3,
  5. Josep Maria Antó1,2,3,4,
  6. Hayat Bentouhami6,
  7. Joost Weyler6,
  8. Joachim Heinrich7,
  9. Dennis Nowak7,
  10. Isabel Urrutia8,
  11. Jesús Martínez-Moratalla9,10,
  12. José Antonio Gullón11,
  13. Antonio Pereira Vega12,
  14. Chantal Raherison Semjen13,
  15. Isabelle Pin14,15,16,
  16. Pascal Demoly17,18,
  17. Bénédicte Leynaert19,
  18. Simona Villani20,
  19. Thorarinn Gíslason21,22,
  20. Øistein Svanes23,24,
  21. Mathias Holm25,
  22. Bertil Forsberg26,
  23. Dan Norbäck27,
  24. Amar J Mehta28,
  25. Nicole Probst-Hensch29,
  26. Geza Benke30,
  27. Rain Jogi31,
  28. Kjell Torén32,
  29. Torben Sigsgaard33,
  30. Vivi Schlünssen33,34,
  31. Mario Olivieri35,
  32. Paul D Blanc36,
  33. John Watkins37,38,
  34. Roberto Bono39,
  35. A. Sonia Buist40,
  36. Roel Vermeulen5,
  37. Deborah Jarvis37,38,39,41,42,
  38. Jan-Paul Zock1,2,3
  1. 1 Barcelona Institute of Global Health (ISGlobal), Barcelona, Spain
  2. 2 Universitat Pompeu Fabra (UPF), Barcelona, Spain
  3. 3 CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
  4. 4 Hospital del Mar Medical Research Institute, Barcelona, Spain
  5. 5 IRAS, University of Utrecht, Utrecht, The Netherlands
  6. 6 Department of Epidemiology and Social Medicine (ESOC), Faculty of Medicine and Health Sciences, StatUA Statistics Centre, University of Antwerp, Antwerp, Belgium
  7. 7 Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Comprehensive Pneumology Centre, German Centre for Lung Research, University Hospital of Ludwig-Maximilians-University, Munich, Germany
  8. 8 Pulmonology Department, Galdakao Hospital, Galdakao, Spain
  9. 9 Servicio de Neumología, Complejo Hospitalario Universitario, Albacete, Spain
  10. 10 Facultad de Medicina Albacete, University of Castilla-La Mancha, Ciudad Real, Spain
  11. 11 Respiratory Department, Hospital Universitario San Agustín, Avilés, Spain
  12. 12 Pulmonology and Allergy Clinical Unit, University Hospital Juan Ramón Jiménez, Huelva, Spain
  13. 13 Inserm, Bordeaux Population Health Research Center, Team EPICENE, UMR 1219, Université de Bordeaux, Bordeaux, France
  14. 14 Department of Pédiatrie, CHU de Grenoble Alpes, Grenoble, France
  15. 15 U1209, IAB, Team of Environmental Epidemiology applied to Reproduction and Respiratory Health, INSERM, Grenoble, France
  16. 16 Université Grenoble Alpes, Grenoble, France
  17. 17 University Hospital of Montpellier, Montpellier, France
  18. 18 Sorbonne Universités, Paris, France
  19. 19 Inserm UMR 1152-Equipe Epidémiologie, Université Paris Diderot, Paris, France
  20. 20 Section of Epidemiology and Medical Statistics, Department of Health Sciences, University of Pavia, Pavia, Italy
  21. 21 Department of Respiratory Medicine and Sleep, Landspitali University Hospital, Reykjavik, Iceland
  22. 22 Faculty of Medicine, University of Iceland, Reykjavik, Iceland
  23. 23 Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
  24. 24 Department of Clinical Science, University of Bergen, Bergen, Norway
  25. 25 Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
  26. 26 Occupational and Environmental Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
  27. 27 Department of Medical Sciences, Uppsala University, Uppsala, Sweden
  28. 28 Office of Research and Evaluation, Boston Public Health Commission, Boston, Massachusetts, USA
  29. 29 Department Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
  30. 30 Monash Centre for Occupation and Environmental Health, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  31. 31 Lung Clinic, Tartu University Hospital, Tartu, Europe
  32. 32 Section of Occupational and Environmental Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  33. 33 Section for Environment, Occupation and Health, Department of Public Health, Danish Ramazzini Center, Aarhus University, Aarhus, Denmark
  34. 34 National Research Center for the Working Environment, Copenhagen, Denmark
  35. 35 Unit of Occupational Medicine, University Hospital of Verona, Verona, Italy
  36. 36 San Francisco Veterans Affairs Medical Center, University of California San Francisco, San Francisco, California, USA
  37. 37 School of Medicine, Cardiff University, Cardiff, Wales, UK
  38. 38 Public Health Wales, Cardiff, Wales, UK
  39. 39 Department of Public Health and Pediatrics, University of Turin, Turin, Italy
  40. 40 Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
  41. 41 Population Health and Occupational Disease, National Heart and Lung Institute, MRC-PHE Centre for Environment and Health, Imperial College London, London, UK
  42. 42 MRC-PHE Centre for Environment and Health, Imperial College London, London, UK
  1. Correspondence to Dr Theodore Lytras, Barcelona Institute of Global Health (ISGlobal), Barcelona 08003, Spain; thlytras{at}


Objectives Chronic bronchitis (CB) is an important chronic obstructive pulmonary disease (COPD)-related phenotype, with distinct clinical features and prognostic implications. Occupational exposures have been previously associated with increased risk of CB but few studies have examined this association prospectively using objective exposure assessment. We examined the effect of occupational exposures on CB incidence in the European Community Respiratory Health Survey.

Methods Population samples aged 20–44 were randomly selected in 1991–1993, and followed up twice over 20 years. Participants without chronic cough or phlegm at baseline were analysed. Coded job histories during follow-up were linked to the ALOHA Job Exposure Matrix, generating occupational exposure estimates to 12 categories of chemical agents. Their association with CB incidence over both follow-ups was examined with Poisson models using generalised estimating equations.

Results 8794 participants fulfilled the inclusion criteria, contributing 13 185 observations. Only participants exposed to metals had a higher incidence of CB (relative risk (RR) 1.70, 95% CI 1.16 to 2.50) compared with non-exposed to metals. Mineral dust exposure increased the incidence of chronic phlegm (RR 1.72, 95% CI 1.43 to 2.06). Incidence of chronic phlegm was increased in men exposed to gases/fumes and to solvents and in women exposed to pesticides.

Conclusions Occupational exposures are associated with chronic phlegm and CB, and the evidence is strongest for metals and mineral dust exposure. The observed differences between men and women warrant further investigation.

  • epidemiology
  • respiratory
  • longitudinal studies
  • retrospective exposure assessment

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  • Contributors Study idea and design: TL, MK, JPZ, HK, JMA, KT, DJ. Data collection: MK, HK, AEC, JMA, HB, JW, JH, DN, IU, JMM, JAG, APV, CRS, IP, PD, BL, SV, TG, OS, MH, BF, DN, AJM, NPH, GB, RJ, KT, TS, VS, MO, PDB, JW, RB, ASB, RV, DJ, JPZ. Data analysis: TL, JPZ. Data interpretation: all authors. Initial manuscript draft: TL, MK, JPZ. Critical revision of the manuscript for important intellectual content: all authors. Final approval of the manuscript for publication: all authors.

  • Funding Financial support for ECRHS I for the local centres included in this study: Australia: Asthma Foundation of Victoria, Allen and Hanbury’s, Belgium: Belgian Science Policy Office, National Fund for Scientific Research, Estonia: Estonian Science Foundation, grant number 1088, France: Ministère de la Santé, Glaxo France, Insitut Pneumologique d’Aquitaine, Contrat de Plan Etat-Région Languedoc-Rousillon, CNMATS, CNMRT (90MR/10, 91AF/6), Ministre delegué de la santé, RNSP, France; GSF, Germany: Bundesminister für Forschung und Technologie, Italy: Ministero dell’Università e della Ricerca Scientifica e Tecnologica, CNR, Regione Veneto grant RSF number 381/05.93, Norway: Norwegian Research Council project number 101422/310, Spain: Fondo de Investigación Sanitaria (91/0016-060-05/E, 92/0319 and 93/0393), Hospital General de Albacete, Hospital General Juan Ramón Jiménez, Dirección Regional de Salud Pública (Consejería de Sanidad del Principado de Asturias), CIRIT (1997 SGR 00079) and Servicio Andaluz de Salud; Sweden: The Swedish Medical Research Council, the Swedish Heart Lung Foundation, the Swedish Association Against Asthma and Allergy; Switzerland: Swiss National Science Foundation grant 4026-28099; UK: National Asthma Campaign, British Lung Foundation, Department of Health, South Thames Regional Health Authority, USA: US Department of Health, Education and Welfare Public Health Service (grant number 2 S07 RR05521-28). Financial support for ECRHS II for the local centres included in this study: Australia: National Health and Medical Research Council, Belgium: Antwerp: Fund for Scientific Research (grant code G.0402.00), University of Antwerp, Flemish Health Ministry; Estonia: Tartu Estonian Science Foundation grant number 4350, France: (All) Programme Hospitalier de Recherche Clinique–Direction de la Recherche Clinique (DRC) de Grenoble 2000 number 2610, Ministry of Health, Ministère de l’Emploi et de la Solidarité, Direction Génerale de la Santé, Centre Hospitalier Universitaire (CHU) de Grenoble, Bordeaux: Institut Pneumologique d’Aquitaine; Grenoble: Comite des Maladies Respiratoires de l’Isere Montpellier: Aventis (France), Direction Regionale des Affaires Sanitaires et Sociales Languedoc-Roussillon; Paris: Union Chimique Belge- Pharma (France), Aventis (France), Glaxo France, Germany: Erfurt GSF–National Research Centre for Environment and Health, Deutsche Forschungsgemeinschaft (grant code FR1526/1-1). Hamburg: GSF–National Research Centre for Environment and Health, Deutsche Forschungsgemeinschaft (grant code MA 711/4-1). Iceland: Reykjavik, Icelandic Research Council, Icelandic University Hospital Fund; Italy: Pavia GlaxoSmithKline Italy, Italian Ministry of University and Scientific and Technological Research (MURST), Local University Funding for Research 1998 and 1999; Turin: Azienda Sanitaria Locale 4 Regione Piemonte (Italy), Azienda Ospedaliera Centro Traumatologico Ospedaliero/Centro Traumatologico Ortopedico–Istituto Clinico Ortopedico Regina Maria Adelaide Regione Piemonte Verona: Ministero dell’Universita e della Ricerca Scientifica (MURST), Glaxo Wellcome, Norway: Bergen: Norwegian Research Council, Norwegian Asthma and Allergy Association, Glaxo Wellcome, Norway Research Fund; Spain: Fondo de Investigacion Santarias (grant codes 97/0035-01, 99/0034-01 and 99/0034 02), Hospital Universitario de Albacete, Consejeria de Sanidad; Barcelona: Sociedad Espanola de Neumologıa y Cirugıa Toracica, Public Health Service (grant code R01 HL62633-01), Fondo de Investigaciones Santarias (grant codes 97/0035-01, 99/0034-01 and 99/0034-02), Consell Interdepartamentalde Recerca i Innovacio Tecnologica (grant code 1999SGR 00241), Instituto de Salud Carlos III; Red de Centros de Epidemiologıa y Salud Publica, C03/09, Redde Basesmoleculares y fisiologicas de las Enfermedades Respiratorias, C03/011 and Red de Grupos Infancia y Medio Ambiente G03/176; Huelva: Fondo de Investigaciones Santarias (grant codes 97/0035-01, 99/0034-01 and 99/0034-02); Galdakao: Basque Health Department Oviedo: Fondo de Investigaciones Sanitaria (97/0035-02, 97/0035, 99/0034-01, 99/0034-02, 99/0034-04, 99/0034-06, 99/350, 99/0034–07), European Commission (EU-PEAL PL01237), Generalitat de Catalunya (CIRIT 1999 SGR 00214), Hospital Universitario de Albacete, Sociedad Española de Neumología y Cirugía Torácica (SEPAR R01 HL62633-01), Red de Centros de Epidemiología y Salud Pública (C03/09), Red de Bases moleculares y fisiológicas de las Enfermedades Respiratorias (C03/011) and Red de Grupos Infancia y Medio Ambiente (G03/176; 97/0035-01, 99/0034-01 and 99/0034-02); Sweden: Göteborg , Umea, Uppsala: Swedish Heart Lung Foundation, Swedish Foundation for Health Care Sciences and Allergy Research, Swedish Asthma and Allergy Foundation, Swedish Cancer and Allergy Foundation, Swedish Council for Working Life and Social Research (FAS), Switzerland: Basel Swiss National Science Foundation, Swiss Federal Office for Education and Science, Swiss National Accident Insurance Fund; UK: Ipswich and Norwich: Asthma UK (formerly known as National Asthma Campaign). USA: Portland: American Lung Association of Oregon, Northwest Health Foundation, Collins Foundation, Merck Pharmaceutical. Financial support for ECRHS III for the local centres included in this study: Australia: National Health and Medical Research Council, Belgium: Antwerp South, Antwerp City: Research Foundation Flanders (FWO), grant code G.0.410.08.N.10 (both sites), Estonia: Tartu-SF0180060s09 from the Estonian Ministry of Education. France: (All) Ministère de la Santé. Programme Hospitalier de Recherche Clinique (PHRC), National 2010. Bordeaux: INSERM U897, Université Bordeaux Segalen, Grenoble: Comite Scientifique AGIRadom 2011. Paris: Agence Nationale de la Santé, Région Ile de France, domaine d’intérêt majeur (DIM). Germany: Erfurt: German Research Foundation HE 3294/10-1 Hamburg: German Research Foundation MA 711/6-1, NO 262/7-1 Iceland: Reykjavik, The Landspitali University Hospital Research Fund, University of Iceland Research Fund, ResMed Foundation, California, USA, Orkuveita Reykjavikur (geothermal plant), Vegagerðin (the Icelandic Road Administration, ICERA). Italy: All Italian centres were funded by the Italian Ministry of Health, Chiesi Farmaceutici. In addition, Verona was funded by Cariverona Foundation, Education Ministry (MIUR). Norway: Norwegian Research Council grant number 214123, Western Norway Regional Health Authorities grant number 911631, Bergen Medical Research Foundation. Spain: Fondo de Investigación Sanitaria (PS09/02457, PS09/00716 09/01511, PS09/02185, PS09/03190), Servicio Andaluz de Salud, Sociedad Española de Neumología y Cirurgía Torácica (SEPAR 1001/2010); Sweden: All centres were funded by the Swedish Heart and Lung Foundation, the Swedish Asthma and Allergy Association, the Swedish Association Against Lung and Heart Disease. Fondo de Investigación Sanitaria (PS09/02457). Barcelona: Fondo de Investigación Sanitaria (FIS PS09/00716). Galdakao: Fondo de Investigación Sanitaria (FIS 09/01511). Huelva: Fondo de Investigación Sanitaria (FIS PS09/02185) and Servicio Andaluz de Salud Oviedo: Fondo de Investigación Sanitaria (FIS PS09/03190). Sweden: All centres were funded by the Swedish Heart and Lung Foundation, the Swedish Asthma and Allergy Association, the Swedish Association Against Lung and Heart Disease. Swedish Research Council for Health, Working Life and Welfare (FORTE). Göteborg : Also received further funding from the Swedish Council for Working Life and Social Research. Umea also received funding from Vasterbotten Country Council ALF grant. Switzerland: The Swiss National Science Foundation (grant numbers 33CSCO-134276/1, 33CSCO-108796, 3247BO-104283, 3247BO-104288, 3247BO-104284, 3247-065896, 3100-059302, 3200-052720, 3200-042532, 4026-028099). The Federal Office for Forest, Environment and Landscape, The Federal Office of Public Health, The Federal Office of Roads and Transport, the Canton’s Government of Aargan, Basel-Stadt, Basel-Land, Geneva, Luzern, Ticino, Valais and Zürich, the Swiss Lung League, the Canton’s Lung League of Basel Stadt/ Basel, Landschaft, Geneva, Ticino, Valais and Zurich, SUVA, Freiwillige Akademische Gesellschaft, UBS Wealth Foundation, Talecris Biotherapeutics, Abbott Diagnostics, European Commission 018996 (GABRIEL), Wellcome Trust WT 084703MA, UK: Medical Research Council (grant number 92091). Support also provided by the National Institute for Health Research through the Primary Care Research Network. The coordination of the ECRHS 3 was funded through the Medical Research Council (grant number 92091). ISGlobal is a member of the CERCA Programme/Generalitat de Catalunya.

  • Competing interests DJ reports grants from European Commission during the conduct of the study. VS reports grants from the Wood Dust Foundation (Project No 444508795) during the conduct of the study. IP reports non-financial support and other from Novartis, personal fees and other from Astra Zeneca, non-financial support and other from Chiesi, outside the submitted work. PD reports personal fees from ALK, Stallergènes Greer, Chiesi, Thermo Fisher Scientific, Ménarini, Bausch&Lomb and Mylan, outside the submitted work. RJ reports grants from Estonian Research Council (personal research grant number 562) during the conduct of the study, personal fees and non-financial support from GSK, personal fees from Novartis and Boehringer, outside the submitted work.

  • Ethics approval Ethical approval for each centre was obtained from their respective competent bodies, and written informed consent was obtained from all participants.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.