Electronic cigarette use and respiratory symptoms in the French population-based Constances cohort.

BACKGROUND: Knowledge about the consequences of electronic cigarette (EC) use on respiratory health is still limited. We aimed to assess whether EC use is associated with the occurrence of asthma symptoms and chronic bronchitis among the French adult population, with a specific focus on never combustible cigarettes (CC) smokers. We further investigated whether the association differed in men and women. METHODS: Constances is a population-based cohort of adults aged 18-69 years at inception. We analyzed baseline data collected in 136,276 participants recruited in 2015-2019. Associations of current and former EC use with respiratory symptoms (asthma symptom score and chronic bronchitis) were assessed, controlling for CC smoking, cannabis use, demographics, education and body mass index (BMI). RESULTS: Increased frequencies of respiratory symptoms were observed in both current and former EC users (for the asthma symptom score, adjusted mean score ratio (aMSR): 1.34 [95 % confidence interval: 1.28-1.41] and 1.39 [1.33-1.45], respectively; for chronic bronchitis, adjusted prevalence ratio (aPR): 1.27 [1.19-1.36] and 1.40 [1.32-1.48], respectively). Among never CC smokers, ever EC use was associated with an increased asthma symptom score in both men and women (aMSR = 1.44 [1.09-1.90] and 1.36 [1.01-1.83], respectively), and with a higher prevalence of chronic bronchitis only in women (aPR = 1.97 [1.27-3.05]). CONCLUSION: EC use is associated with symptoms of asthma and chronic bronchitis, independently of CC smoking and cannabis use. The fact that these associations are observed among individuals who have never smoked tobacco adds further evidence of the deleterious effects of EC on respiratory health.

Impact of asthma on working life: an analysis of the French CONSTANCES cohort.

OBJECTIVES: Asthma has significant occupational consequences. The objective of our study was to investigate the links between asthma and the career path, taking into account gender and age at asthma onset. METHODS: Using cross-sectional data collected at inclusion in the French CONSTANCES cohort in 2013-2014, we studied the links between each career path indicator (number of job periods, total duration of employment, numbers of part-time jobs and work interruptions due to unemployment or health issues, employment status at inclusion) on the one hand, and current asthma and asthma symptom score in the last 12 months on the other hand, as reported by the participants. Multivariate analyses were performed separately for men and women using logistic and negative binomial regression models adjusted for age, smoking status, body mass index and educational level. RESULTS: When the asthma symptom score was used, significant associations were observed with all of the career path indicators studied: a high symptom score was associated with a shorter total duration of employment as well as a greater number of job periods, part-time jobs and work interruptions due to unemployment or health issues. These associations were of similar magnitude in men and women. When current asthma was used, the associations were more pronounced in women for some career path indicators. CONCLUSION: The career path of asthmatic adults is more often unfavourable than that of those without asthma. Efforts should be made to support people with asthma in the workplace, in order to maintain employment and facilitate the return to work.

Underdiagnosis of obstructive lung disease: findings from the French CONSTANCES cohort.

BACKGROUND: The burden of undiagnosed obstructive lung disease (OLD) (mainly asthma and chronic obstructive pulmonary disease) is not fully established, and targets for corrective action are yet to be identified. We assessed the underdiagnosis of OLD and its determinants in France. METHODS: CONSTANCES is a French population-based cohort of adults aged 18-69 years at inception. We analysed data collected at inclusion in 2013-2014. Undiagnosed OLD was defined as spirometry-confirmed airflow limitation (FEV1/FVC < lower limit of normal) without prior diagnosis of asthma, chronic obstructive pulmonary disease, or bronchiectasis. Multivariate analysis was performed with weighted robust Poisson regression models to estimate the adjusted prevalence ratios (aPR) of undiagnosed OLD. RESULTS: Spirometry results were available for 19,398 participants. The prevalence of airflow limitation was 4.6%. Overall, 64.4% of adults with airflow limitation did not report a previous diagnosis of OLD. Individuals with high cumulative tobacco consumption (≥ 10 pack-years) (aPR: 1.72 [1.28-2.32]), without respiratory symptoms (aPR: 1.51 [1.28-1.78]), and with preserved lung function (aPR: 1.21 [1.04-1.41] for a 10-point increase in FEV1% predicted) had a higher risk of being undiagnosed. Half of symptomatic individuals with airflow limitation (45% of those with moderate to severe airflow limitation) were undiagnosed with OLD. CONCLUSION: Underdiagnosis of OLD is very common among French adults, even in patients with respiratory symptoms. Efforts should be made in France to raise awareness about OLD in the general population, improve the detection of respiratory symptoms, and increase the use of spirometry among primary care professionals.

Obstructive sleep apnea: A sharp increase in the prevalence of patients treated with nasal CPAP over the last decade in France.

INTRODUCTION: Obstructive sleep apnea (OSA) is a frequent condition. In the absence of treatment, OSA is associated with a higher risk of traffic accidents and a large variety of diseases. The objectives of this study were to describe the characteristics of patients treated for OSA in France and assess the time trends in treatment. METHODS: The French National Health Data System is an individual database with data on all healthcare reimbursements for the entire French population. Based on this database, we included all patients aged 20 years or over who were treated with continuous positive airway pressure (CPAP) or mandibular advancement splint (MAS) between 2009 and 2018. Negative binomial models, adjusted for age, were used to assess time trends in treatment prevalence and incidence rates. RESULTS: In 2017, 2.3% of French adults aged ≥20 years were treated with CPAP (men: 3.3%; women: 1.3%). The highest prevalence was observed in people aged 70-74 years (5.0%). From 2009 to 2018, the annual prevalence of CPAP increased 3-fold and the annual incidence 1.9-fold. During the same period, the rate of patients reimbursed for MAS (first prescription or renewal) was multiplied by 7.6. The proportion of patients treated with CPAP in 2017 who were no longer treated in the subsequent year was 6.9%. DISCUSSION: The sharp increase in the incidence of OSA treatment probably reflects a better recognition of the disease in France. However, the prevalence of OSA treatment remains lower than expected based on the international literature. Further studies are needed to identify the obstacles to an optimal management of individuals with OSA in France.

Changes in tobacco-related morbidity and mortality in French women: worrying trends.

BACKGROUND: The high prevalence of smoking among French women since the 1970s has been reflected over the past decade by a strong impact on the health of women. This paper describes age and gender differences in France of the impact of smoking on morbidity and mortality trends since the 2000s. METHODS: Smoking prevalence trends were based on estimates from national surveys from 1974 to 2017. Lung cancer incidence were estimated from 2002-12 cancer registry data. Morbidity data for chronic obstructive pulmonary disease (COPD) exacerbation and myocardial infarction were assessed through hospital admissions data, 2002-15. For each disease, number of deaths between 2000 and 2014 came from the national database on medical causes of death. The tobacco-attributable mortality (all causes) was obtained using a population-attributable fraction methodology. RESULTS: The incidence of lung cancer and COPD increased by 72% and 100%, respectively, among women between 2002 and 2015. For myocardial infarction before the age of 65, the incidence increased by 50% between 2002 and 2015 in women vs. 16% in men and the highest increase was observed in women of 45-64-year-olds. Mortality from lung cancer and COPD increased by 71% and 3%, respectively, among women. The estimated number of women who died as a result of smoking has more than doubled between 2000 and 2014 (7% vs. 3% of all deaths). CONCLUSIONS: The increase in the prevalence of smoking among women has a major impact on the morbidity and mortality of tobacco-related diseases in women and will continue to increase for a number of years.

Correction: Wheezing phenotypes and risk factors in early life: The ELFE cohort.

[This corrects the article DOI: 10.1371/journal.pone.0196711.].

Wheezing phenotypes and risk factors in early life: The ELFE cohort.

OBJECTIVE: Different phenotypes of wheezing have been described to date but not in early life. We aim to describe wheezing phenotypes between the ages of two months and one year, and assess risk factors associated with these wheezing phenotypes in a large birth cohort. METHODS: We studied 18,041 infants from the ELFE (French Longitudinal Study of Children) birth cohort. Parents reported wheezing and respiratory symptoms at two and 12 months, and answered a complete questionnaire (exposure during pregnancy, parental allergy). RESULTS: Children with no symptoms (controls) accounted for 77.2%, 2.1% had had wheezing at two months but no wheezing at one year (intermittent), 2.4% had persistent wheezing, while 18.3% had incident wheezing at one year. Comparing persistent wheezing to controls showed that having one sibling (ORa = 2.19) or 2 siblings (ORa = 2.23) compared to none, nocturnal cough (OR = 5.2), respiratory distress (OR = 4.1) and excess bronchial secretions (OR = 3.47) at two months, reflux in the child at 2 months (OR = 1.55), maternal history of asthma (OR = 1.46) and maternal smoking during pregnancy (OR = 1.57) were significantly associated with persistent wheezing. These same factors, along with cutaneous rash in the child at 2 months (OR = 1.13) and paternal history of asthma (OR = 1.32) were significantly associated with increased odds of incident wheezing. Having one sibling (ORa = 1.9) compared to none, nocturnal cough at 2 months (OR = 1.76) and excess bronchial secretions at 2 months (OR = 1.65) were significantly associated with persistent compared to intermittent wheezing. CONCLUSION: Respiratory symptoms (cough, respiratory distress, and excessive bronchial secretion) were significantly associated with a high risk of persistent wheezing at one year. Smoking exposure during pregnancy was also a risk factor for persistent and incident wheezing.

Asthma-Like Symptoms in Homeless Children in the Greater Paris Area in 2013: Prevalence, Associated Factors and Utilization of Healthcare Services in the ENFAMS Survey.

INTRODUCTION: Asthma remains poorly studied in homeless children. We sought to estimate the prevalence of asthma-like symptoms (ALS) and to identify the factors associated with ALS and healthcare service utilisation. MATERIALS AND METHODS: A cross-sectional survey of a random sample of sheltered homeless families was conducted by interviewing 801 parents of children (0-12 years) in 17 languages. ALS were defined as wheezing or night cough without fever during the previous year. Poisson regression models with robust error variance were used to compute prevalence ratios (PR) for factors associated with ALS and healthcare service utilisation for ALS. RESULTS: The prevalence of ALS among the children was 19.9%. Poor housing sanitation was significantly associated with ALS, as being born in the European Union. Most of the children with ALS had used healthcare services (85.4%). The main barriers to accessing such services were having lived in France for less than 49 months, having difficulties in French and living in poor housing conditions. CONCLUSION: ALS prevalence seemed lower than in the general child population, possibly because of the children's origins. Environmental factors associated with ALS point to the need to improve the indoor environment of family shelters. The relatively high rate of healthcare service utilisation should not overshadow existing barriers.

Symptoms of sleep apnea syndrome: high prevalence and underdiagnosis in the French population.

OBJECTIVE: To determine the prevalence of symptoms evocative of obstructive sleep apnea (SE-OSA) and the magnitude of obstructive sleep apnea (OSA) underdiagnosis. METHODS: We used data from a cross-sectional survey conducted in 2008 in a representative sample of the French general population. Data were collected through interviews and self-administrated questionnaires and were complete for 12,203 adults (≥16 years old). SE-OSA was defined by snoring almost every night plus witnessed apneas or excessive daytime sleepiness (Epworth sleepiness scale score>10). RESULTS: The prevalence of SE-OSA was 4.9% (95% CI: 4.5-5.3), and that of self-reported OSA diagnosis was 2.4% (2.1-2.7). The prevalence of SE-OSA was 8% among people with hypertension and 11% among obese people. A previous sleep monitoring session was reported by 2.7% (2.4-3.0) of the participants and by 15.1% of people with SE-OSA. This latter proportion increased with age (24% in people with SE-OSA aged 60 years or over) and was higher in obese people (26%) and in those with chronic diseases (27% among people with hypertension). CONCLUSION: The prevalence of SE-OSA is high in France and OSA remains underdiagnosed, even in people with obesity or hypertension. Further efforts are needed to improve the diagnosis of OSA.

Chronic bronchitis in the general population: influence of age, gender and socio-economic conditions.

Chronic bronchitis (CB) is an indicator of an increased risk of developing COPD, but its symptoms are often underestimated. Demographic and socio-economic conditions might influence its prevalence, reporting and impact. Data from a large epidemiological survey of the French general population were analyzed to determine the burden of CB, the magnitude of under-diagnosis and the influence of age, gender and socio-economic conditions. Altogether, 9050 participants aged 45 years or more provided complete data. The prevalence of symptoms and diagnosis of CB was 3.5% and 3.4%, respectively. CB was associated with impaired health status and activity and, in women, work loss. Among subjects with symptoms of CB, only 28.6% declared a known diagnosis of respiratory disease. Factors associated with symptoms of CB in multivariate analysis were male gender, active smoking, lower income and occupational category: the highest prevalence was observed in manual workers (5.6%) and self-employed subjects (5.2%). The under-diagnosis of CB was more marked in men and subjects of higher socio-economic categories. These results confirm that CB is markedly under-diagnosed in the general population. Socio-economic conditions influence both its prevalence (higher in low categories) and rate of diagnosis (lower in high categories), which should be considered when elaborating prevention and detection campaigns.

Asthma and major depressive episode in adolescents in France.

RATIONALE: The association between asthma and anxiety disorders in teenagers is well documented, but data about the association with mood disorders are scarce. METHODS: We analyzed data from a cross-sectional study conducted among ninth grade schoolchildren in France in 2003-2004. The teenagers were selected by two-stage sampling and interviewed by school doctors/nurses using a standardized questionnaire including questions about asthma and asthma-like symptoms. They also completed a self-administered questionnaire in which the occurrence of major depressive episodes (MDEs) during the past 12 months was assessed by the Composite International Diagnostic Interview-Short Form. RESULTS: A total of 7000 teenagers (mean age 15.1 years) were included. The prevalence of wheezing in the past 12 months was 10.0% and that of current asthma (wheezing in the past 12 months in children who had already had asthma attacks, or treatment for wheezing or asthma in the past 12 months) was 8.5%. The prevalence of MDE during the past year was 14.2% in teenagers with current asthma versus 9.2% among the others. The association between current asthma and past-year MDE remained significant after adjustment for age, gender, family structure, and the father's employment status. Asthma was uncontrolled (at least four attacks of wheezing, one awakening per week due to wheezing, one severe wheezing, four unplanned medical visits, or one hospitalization for a wheezing attack in the past year) in more than half (58.3%) of asthmatic teenagers with an MDE in the past year versus 35.3% of those without an MDE. CONCLUSION: Asthma is associated with a higher prevalence of MDE. Among adolescents with asthma, MDE is associated with poorer asthma control. These findings highlight the need for a comprehensive care management of asthma in France that takes the psychological dimension into account.

Hospitalizations for asthma in children are linked to undertreatment and insufficient asthma education.

BACKGROUND: Most hospital admissions for asthma exacerbation are avoidable with adequate disease management. OBJECTIVES: The objective of this study was to describe the characteristics of children hospitalized with an asthma exacerbation to identify modifiable factors leading to hospitalization. METHODS: The study was conducted in 14 pediatric units and included children 3-17 years of age who were hospitalized for an asthma exacerbation. The present analysis covers 498 children with known asthma. Staff physicians used a standardized questionnaire to collect data. Asthma history came from a parental interview and included usual asthma care, frequency of symptoms and quick-relief medication use in the previous month, frequency of exacerbations and number of unscheduled healthcare visits during the past year, and prior asthma-related hospitalizations. RESULTS: More than half the children had previously been hospitalized for an exacerbation, 42% used continuous inhaled corticosteroids, and 57% had a regular follow-up for asthma. Asthma had been well controlled over the past year for 11%, 12% had experienced exacerbations during the past year but that had been optimally controlled during the previous month, and 11% had recently become poorly controlled (infrequent exacerbations in the previous year and non-optimal control in the previous month). The remaining 327 children (66%) were consistently poorly controlled (non-optimal asthma control in the previous month and frequent exacerbations over the previous year). Among this group, 69% had at least one of the following preventable risk factors for hospitalization: no regular controller therapy (49%), no asthma action plan (40%), or no follow-up for asthma (35%). CONCLUSIONS: Two-thirds of the children with asthma hospitalized for an exacerbation had been consistently poorly controlled during the previous year. They were frequently undertreated and insufficiently educated about asthma. Further efforts are needed to improve asthma treatment and education in France.

Hospital admissions related to acute exacerbations of chronic obstructive pulmonary disease in France, 1998-2007.

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) necessitating hospital admission have a major impact on patient outcome and management costs. We examined temporal trends in AE-COPD-related hospital admissions in France between 1998 and 2007. METHODS: Data were obtained from the French national hospital discharge database for patients aged at least 25 years. AE-COPD was identified with both a "narrow" and a "broad" definition, according to the position (primary or associated) of diagnoses, in order to ensure robustness. RESULTS: In 2007, among adults aged 25 years or more, the crude AE-COPD-related admission rates were 23/10000 in men and 10/10000 in women using the narrow definition. Using the broad definition, these rates were respectively 38 and 16/10000. With the narrow definition, the annual number of AE-COPD-related admissions increased by 38% between 1998 and 2007, while in-hospital lethality decreased from 7.6% to 6.0%. The proportion of male patients decreased from 72% to 68%. Similar trends were found using the broad definition. The age-standardized AE-COPD-related admission rate increased by 4.4% per year in women and by 1.6% per year in men with the narrow definition, and by respectively 3.8% and 1.2% with the broad definition. A strong seasonal pattern of admissions for AE-COPD was found, matching that of general practitioners visits for influenza-like illness. CONCLUSION: Hospitalization rates for AE-COPD have increased in France in recent years, especially among women. By contrast, AE-COPD-related in-hospital lethality has decreased.

Deaths with asthma in France, 2000-2005: a multiple-cause analysis.

Mortality from asthma has decreased in many countries since the 1990s. Mortality statistics are usually based only on the underlying cause of death. The objectives of this study were to describe the characteristics of deaths and the trends in asthma-related mortality using multiple-cause analysis. Data were obtained from the French Centre of Epidemiology on Medical Causes of Death. Because ICD-10 was implemented in 2000, the analysis covers the period 2000-2005. In 2004-2005, asthma was the underlying cause of 42% of deaths with certificates mentioning asthma. The age-standardised rates of death from asthma decreased from 2000 through 2005 (-12% and -11%/year in the 1-44 and 45-64 age groups, respectively). The decline for all deaths with asthma was less pronounced (-9%/year in the 1-44 age group and -8%/year in the 45-64). Among adults aged 65 or older, the decrease in asthma-related mortality was higher in men (-12%/year for underlying cause, -9% for multiple-cause) than women (-5% and -3%, respectively). Since 2002, age-standardised rates of asthma-related mortality have been higher in women than men. In people aged 1-44 years, in-hospital deaths have declined between 2000 and 2005 while the proportion of non-hospital deaths increased from 53% to 67%. Regardless of the definition used, the age-standardised rate of asthma-related deaths decreased from 2000 to 2005, and the faster decline for underlying cause than for multiple-cause mortality argues for a real decline in mortality attributable to asthma. Using multiple cause-of-death analysis provides additional information for asthma mortality surveillance.

Short-term effect of pollen exposure on antiallergic drug consumption.

BACKGROUND: Several studies have investigated the association between pollen exposure and asthma emergency admissions, but only 2 have investigated the effect of airborne allergens on consultations for rhinitis or conjunctivitis and none has used drug consumption as the health indicator. OBJECTIVE: To analyze the short-term association between pollen exposure and antiallergic drug consumption in the urban area of Clermont-Ferrand, France, taking into account the potentially confounding effect of air pollution and meteorological factors. METHODS: We used the French health insurance database to select all individuals from the Clermont-Ferrand urban area having benefited from reimbursement for antiallergic treatment from January 1, 2000, through December 31, 2001, and from January 1, 2003, through December 31, 2004. An episode of treated allergic rhinitis, rhinosinusitus, or conjunctivitis (ARC) was defined as the association of an oral antihistamine and a local antiallergic drug on the same prescription. The relations between daily changes in pollen concentrations and daily changes in the number of treated ARC cases were analyzed using a Poisson regression model with penalized spline functions. RESULTS: The risk of treated ARC associated with an interquartile increase in pollen concentration increased significantly for Poaceae (5%, P < .001), Fraxinus (7%, P < .001), Betula (7%, P < .001), and Corylus (2%, P < .02). This increase was significant in all age groups for Poaceae and Fraxinus pollen and in people younger than 65 years for Betula pollen. The effect was mainly concentrated on the present day, except for Poaceae pollens, for which the risk remained significantly (P < .001) increased until 3 days lag time. CONCLUSIONS: This study showed a significant increase in treated ARC cases related to Poaceae, Fraxinus, and Betula. Specific risks are difficult to evaluate for species that share the same pollination period. Time-series studies based on drug consumption are useful to highlight and to supervise pollen-related diseases requiring ambulatory care.

[The heat wave of August 2003: what happened?]. / La vague de chaleur d'août 2003: que s'est-il passe?

A heat wave of exceptional intensity occurred in France in August 2003, 2003 was the warmest of the last 53 years in terms of minimal, maximal and average temperatures, and in terms of duration. In addition, high temperatures and sunshine, causing the emission of pollutants, significantly increased the atmospheric ozone level. Some epidemiological studies were rapidly implemented during the month of August in order to asses the health impact of this heat wave. Excess mortality was estimated at about 14 800 additional deaths. This is equivalent to a total mortality increase of 60% between August 1st and 20th, 2003 (Inserm survey). Almost the whole country was concerned by this excess-mortality, even in locations where the number of very hot days remained low. Excess-mortality clearly increased with the duration of extreme temperatures. These studies also described the features of heat-related deaths. They showed that the death toll was at its highest among seniors and suggested that less autonomous or disabled or mentally ill people were more vulnerable. So, they provided essential information for the setting up of an early warning system in conjunction with emergency departments. The public health impact of the Summer 2003 heat wave in various European countries was also assessed. Different heat waves in term of intensity had occurred at different times in many countries with each time deaths in excess. But, it does seem that France was the most affected country. However, implementation of standardized methods of data collection through all countries is necessary to afford further comparisons. Collaborative studies will be conducted in this way. After theses first descriptive studies, further etiologic studies on risk factors and heat-related deaths were launched and are now in progress. Considering the health impact of the heat wave, national health authorities decided to launch an Heat Wave National Plan including a provisional Heat Watch Warning System (HWWS) for 2004. Developed in collaboration with Metéo France, this HWWS is based upon an analysis of historical daily mortality data and meteorological indicators in 14 French cities in order to define the best indicators and triggers. The public health impact of the heat wave of August 2003 was major. This exceptional event raises questions about anticipating phenomena which are difficult to predict. The collaborative efforts which were developed and the group of actions and studies which were implemented in a context of emergency are now useful for the setting up of early warning strategies and thus efficient prevention.