The Science Journal of the American Association for Respiratory Care


October 2002 / Volume 47 / Number 10 / Page 1145

Equality for Women Is Not Fair

"You've come a long way, baby," the theme of many cigarette ads directed toward women, emphasizing the glamour and sexiness of smoking, has now paid off. A recent study by the Centers for Disease Control (CDC),1 which is reprinted in this issue of RESPIRATORY CARE, showed that chronic obstructive pulmonary disease (COPD) death among women more than equaled that among men in the year 2000 (59,936 vs 59,118). This is more than equality—it's a disaster!

A number of studies have suggested that smoking women are more susceptible to developing COPD than are men.2-4 Women who are susceptible may develop COPD at an earlier age and with less duration or intensity of smoking, and women have a greater degree of nonspecific bronchial hyperreactivity than men, as demonstrated in the Lung Health Study.5 So women should be very alert to the risk of developing COPD and, for that matter, related lung cancer.

See the Special Article on Page 1184

It appears that the tobacco industry may be stalking women. Their emphasis on women in recent advertising campaigns is an example. Remember the long brown cigarette ads? "How can you smoke a long brown cigarette?" the man asks. "Easy," replies the woman, "I want more of a good thing." Another scene shows a woman with a long cigarette. "That cigarette's so long, we'll miss the wedding," the bridesmaid says. "I'm the bride; they'll wait." A favorite in my series of slides I sometimes present at grand rounds as "Seduced by Smoking" shows a man and a woman under an umbrella in a rainstorm. "How do you keep such a long cigarette dry?" he asks. "I only date men with big umbrellas," she replies. Give me a break!

Though only 1 in 5 smokers develops COPD, no one knows who will develop the disease, unless there is a strong family history or occupational risk. It is well known that COPD has few or even no symptoms until it becomes far advanced. The alarming rise in COPD deaths among women is only half the problem. COPD deaths among men also continue to rise. If mortality trends continue, there will be more than 120,000 COPD deaths in 2002. COPD is now the fourth most common cause of death and the only disease in the top 10 killers that continues to rise. This is despite advances in care of advanced COPD, including oxygen in selected cases, pulmonary rehabilitation, and improved methods of managing acute respiratory failure.6

The recently released CDC study1 indicates that as many as 50% of patients with COPD are undiagnosed today. A similar conclusion was drawn from the National Health and Nutrition Examination Survey study.7 Thus, the major challenge is obvious: to identify mild-to-moderate stages of lung disease, as a basis for intervention.

The National Lung Health Education Program (NLHEP) was launched in 1997 as a major grassroots initiative designed to identify and treat patients with mild-to-moderate stages of disease.8 "Test Your Lungs, Know Your Numbers" is the motto of the NLHEP. The NLHEP is in partnership with the American Association for Respiratory Care. Thus, some 130,000 respiratory therapists are the foot soldiers for the NLHEP, working in nearly every hospital in the United States. Today a grassroots effort for early identification of COPD and related disorders is underway. NLHEP recommends spirometric testing of all current or former smokers age 45 or older and of anyone with chronic cough, dyspnea on exertion, mucus hypersecretion, or wheeze.9 The Lung Health Study demonstrated that both men and women who successfully stop smoking have an initial improvement in air flow, as measured by forced expiratory volume in the first second, followed by a slow decline over 5 years, compared with those who continued to smoke, who have a much more rapid rate of decline.10 The spirometer is the key instrument for diagnosis. It must be used in all primary care physicians' offices and in the offices of many specialists who see patients with dyspnea, such as cardiologists.

Although the tobacco industry has been giving preferential treatment to women to entice them to start smoking, this is not fair, because women are so susceptible to the harmful effects of tobacco. Today some progress is being made in modifying youth smoking behavior and there has been a slight decline in student smoking.11

One hopeful conclusion from the CDC study1 is a reduction of the prevalence of mild-to-moderate COPD in people under age 55. If we can reduce teenage smoking and find the middle-age smokers with incipient stages of disease, we may be able to stop the upward trend of hospitalization and mortality.

It is time for a call to arms. Early identification and treatment of COPD can make an impact. Smoking cessation and the use of a growing number of bronchoactive drugs can improve the outcome of COPD. We can prevent or forestall the progress into the advanced stages of the disease. "Test Your Lungs, Know Your Numbers," stay healthy, and enjoy life in a smoke-free environment.

Thomas L Petty MD
National Lung Health Education Program
University of Colorado Health Sciences Center
Denver, Colorado


  1. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance - United States, 1971-2000. MMWR Surveillance Summaries 2002;51(SS06);1-16. Available at Respir Care 2002;47(10):1184-1199.
  2. Chen Y, Horne SL, Dosman JA. Increased susceptibility to lung dysfunction in female smokers. Am Rev Respir Dis 1991;143(6):1224-1230.
  3. Gold DR, Wang X, Wypij D, Speiger FE, Ware JH, Dockery DW. Effects of cigarette smoking on pulmonary function in adolescent boys and girls. N Engl J Med 1996;335(13):931-937.
  4. Prescott E, Bjerg AM, Andersen PK, Lange P, Vestbo J. Gender difference in smoking effects on lung function and risk of hospitalization for COPD: results from a Danish longitudinal population study. Eur Respir J 1997;10(4):822-827.
  5. Tashkin DP, Altose MD, Bleecker ER, Connett JE, Kanner RE, Lee WW, Wise R. The Lung Health Study: airway responsiveness to inhaled methacholine in smokers with mild to moderate airflow limitation. The Lung Health Study Research Group. Am Rev Respir Dis 1992;145(2 Pt 1):301-310.
  6. Rennard S, Carrera M, Agusti AG. Management of chronic obstructive pulmonary disease: are we going anywhere? Eur Respir J 2000;16(6):1035-1036.
  7. Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med 2000;160(11):1683-1689.
  8. Strategies in preserving lung health and preventing COPD and associated diseases. The National Lung Health Education Program (NLHEP). Chest 1998;113(2Suppl):123s-163s.
  9. Ferguson GT, Enright PL, Buist AS, Higgins MW. Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program. Chest 2000;117(4):1146-1161.
  10. Anthonisen NR, Connett JE, Kiley JP, Altose MD, Bailey WC, Buist AS, et al. Effects of smoking intervention and use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA 1994;272(19):1497-1505.
  11. Trends in cigarette smoking among high school students - United States 1991-2001. MMWR Morb Mortal Wkly Rep 2002;51(19):409-412.

Correspondence: Thomas L Petty MD, National Lung Health Education Program, 899 Logan St, 2nd Floor, Denver CO 80203-3130.

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