title: Impact of active and passive smoking as risk factors for asthma and COPD in women presenting to primary care in Syria: first report by the WHO-GARD survey group.
abstract: BACKGROUND
  The burden of chronic respiratory disease (CRD) is alarming. International studies suggest that women with CRD are undersurveyed and underdiagnosed by physicians worldwide. It is unclear what the prevalence of CRD is in the general population of Syria, particularly among women, since there has never been a survey on CRD in this nation. The purpose of this study was to investigate the impact of different patterns of smoking on CRD in women.
  
  
  METHODS
  We extracted data on smoking patterns and outcome in women from the Global Alliance Against Chronic Respiratory Diseases survey. Using spirometric measurements before and after the use of inhaled bronchodilators, we tracked the frequency of CRD in females active and passive narghile or cigarette smokers presenting to primary care. We administered the questionnaire to 788 randomly selected females seen during 1 week in the fiscal year 2009-2010 in 22 primary care centers in six different regions of Syria. Inclusion criteria were age >6 years, presenting for any medical complaint. In this cross-sectional study, three groups of female subjects were evaluated: active smokers of cigarettes, active smokers of narghiles, and passive smokers of either cigarettes or narghiles. These three groups were compared to a control group of female subjects not exposed to active or passive smoking.
  
  
  RESULTS
  Exposure to active cigarette smoke but not narghile smoke was associated with doctor-diagnosed chronic obstructive pulmonary disease (COPD). However, neither cigarette nor narghile active smoking was associated with increased incidence of spirometrically diagnosed COPD. Paradoxically, exposure to passive smoking of either cigarettes or narghiles resulted in association with airway obstruction, defined as forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) < 70% according to the Global initiative for chronic Obstructive Lung Disease criteria; association with FEV1 < 80% predicted, evidencing moderate to severe GOLD spirometric grade, and doctor-diagnosed COPD. Physicians tend to underdiagnose COPD in women who present to primary care clinics. Whereas around 15% of enrolled women had evidence of COPD with FEV1/FVC < 70% after bronchodilators, only 4.8% were physician-diagnosed. Asthma did not appear to be a significant spirometric finding in these female subjects, although around 11% had physician-diagnosed asthma. One limitation is FEV1/FVC < 70% could have also resulted from uncontrolled asthma. The same limitation has been reported by the Proyecto Latinoamericano de Investigacion en Obstruccion Pulmonar (PLATINO) study.
  
  
  CONCLUSIONS
  Contrary to popular belief in developing countries, women exposed to tobacco smoke, whether active or passive, and whether by cigarettes or narghiles, like men are at increased risk for the development of COPD, although cultural habits and taboos may decrease the risk of active smoking in some women.
  
  
  CONCLUSIONS
  These findings will be considered for country and region strategy for noncommunicable diseases, to overcome underdiagnosis of CRD in women, fight widespread female cigarette and narghile smoking, and promote behavioral research in this field.
authors.affiliation: National Center for Research in Chronic Respiratory Diseases, Tishreen University School of Medicine, Latakia, Syria.
authors.forename: Yousser
authors.initials: Y
authors.lastname: Mohammad
authors.forename: Rafea
authors.initials: R
authors.lastname: Shaaban
authors.forename: Bassam Abou
authors.initials: BA
authors.lastname: Al-Zahab
authors.forename: Nikolai
authors.initials: N
authors.lastname: Khaltaev
authors.forename: Jean
authors.initials: J
authors.lastname: Bousquet
authors.forename: Basim
authors.initials: B
authors.lastname: Dubaybo
mesh_terms: D000293:Adolescent; D000328:Adult; D001249:Asthma / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D001993:Bronchodilator Agents / Q000627:therapeutic use; D002648:Child; D003430:Cross-Sectional Studies; D005260:Female; D005541:Forced Expiratory Volume; D006306:Health Surveys; D006801:Humans; D016015:Logistic Models; D008168:Lung / Q000187:drug effects / Q000503:physiopathology*; D008875:Middle Aged; D016017:Odds Ratio; D015995:Prevalence; D011320:Primary Health Care; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D012307:Risk Factors; D012737:Sex Factors; D012907:Smoking / Q000009:adverse effects* / Q000453:epidemiology*; D013147:Spirometry; D011795:Surveys and Questionnaires; D013593:Syria / Q000453:epidemiology; D014028:Tobacco Smoke Pollution / Q000009:adverse effects*; D014797:Vital Capacity; D014932:Women's Health Services; D014944:World Health Organization; D055815:Young Adult
chemical_list: D001993:Bronchodilator Agents; D014028:Tobacco Smoke Pollution
keywords: COPD; asthma; behavior; narghile; passive smoking; water pipe; women