No significant variation in risk by type of disorder or timing of child’s exposure
Include dedicated support for these disorders in maternal healthcare, say researchers

Eating disorders in mums-to-be are linked to a heightened risk of asthma and wheezing in their children, irrespective of the type of disorder, presence of co-existing depression/anxiety, or the timing of their child’s exposure, finds research published online in the journal Thorax.

The findings prompt the researchers to call for the inclusion of dedicated support in the healthcare of pregnant women with eating disorders to improve the respiratory health of their children.

To date, research on the effects of maternal mental health on children’s respiratory health has focused predominantly on depression, anxiety, and broadly defined stress, with limited evidence on less common conditions like eating disorders, note the researchers.

And while the evidence on the consequences of maternal eating disorders has consistently reported on their children’s cognitive, social, emotional, behavioural and eating behaviours, the evidence is less consistent for physical health outcomes.

To strengthen the evidence base, the researchers analysed data from 131,495 mother and child pairs from 7 distinct European birth cohorts in the EU Child Cohort Network (EUCCN), looking at potential associations between maternal eating disorders before pregnancy and their children’s preschool wheezing and school age asthma.

They subsequently explored potential associations between women who didn’t have depression or anxiety by type of eating disorder (anorexia or bulimia) and period of exposure (pregnancy or after birth).

The prevalence of maternal eating disorders before pregnancy ranged from nearly 1% to 17% across the 7 cohorts. And the prevalence of co-existing depression/anxiety among women with eating disorders ranged from 11% to 75%.

The prevalence of preschool wheezing ranged from 21% to nearly 50%, while that of school age asthma ranged from just over 2% to nearly 17.5%.

An eating disorder before pregnancy was associated with an overall 25% heightened risk of preschool wheeze, although this varied considerably in each cohort, and with a 26% heightened risk of school age asthma, which was much more consistent across the cohorts.

These heightened risks weakened slightly after excluding mothers who had depression/anxiety.

Similar associations with childhood asthma were found for anorexia and bulimia, while preschool wheezing was associated with bulimia only.

Although the observed associations differed slightly across exposure periods (before, during, or after pregnancy), no distinct window of susceptibility emerged.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect, and the prevalence of eating and respiratory disorders varied widely across the cohorts.

“Although this may make some of the findings less comparable, the direction and the magnitude of the associations were relatively stable in all the analyses,” explain the researchers.

But they add: “The mechanisms underlying the associations between maternal mental health and childhood respiratory outcomes remain unclear.”

They suggest that mental ill health and associated stress may activate the hypothalamic-pituitary-adrenal axis, disrupting the baby’s lung development during pregnancy and maturation of the child’s immune system, thereby increasing susceptibility to immune mediated conditions, including asthma.

“Children born to mothers with [eating disorders] are at an increased risk of foetal growth restriction, prematurity, Caesarean delivery and low birth weight. These are also well-known risk factors for respiratory morbidity, suggesting multiple possible mediating pathways in the link between maternal [eating disorders] and childhood respiratory outcomes,” they point out.

“In addition, research has shown that both mental health disorders and asthma involve dysregulation in immune response and inflammatory pathways, suggesting a common genetic basis that may contribute to both conditions,” they add.

They conclude: “There is a need to include maternal [eating disorders] in research on early- life respiratory risk factors and to integrate [eating disorder] screening and support into maternal healthcare to improve respiratory outcomes in offspring.”

02/12/2025

Notes for editors
Research: Maternal eating disorders and respiratory outcomes in childhood: findings from the EU Child Cohort Network Doi: 10.1136/thorax-2025-223718
Journal: Thorax

About the journal
Thorax is one of 70 journals published by BMJ Group. The title is co-owned with the British Thoracic Society.
https://thorax.bmj.com

External funding: EU Horizon 2020 research and innovation programme

Link to Academy of Medical Sciences Press Release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post Eating disorders in mums-to-be linked to heightened risk of asthma and wheezing in their kids first appeared on BMJ Group.

They run risk of COPD, heightened further if they are childhood passive smokers themselves
Findings highlight intergenerational harms of smoking, say researchers

A father’s exposure to passive smoking as a child may impair the lifelong lung function of his children, putting them at risk of COPD—a risk that is heightened further if they are childhood passive smokers themselves—finds research published online in the respiratory journal Thorax.

The findings highlight the intergenerational harms of smoking, say the researchers, who urge fathers to intercept this harmful legacy by avoiding smoking around their children.

Chronic obstructive pulmonary disease, more usually known by its acronym of COPD, includes chronic bronchitis and emphysema. Now the third leading cause of death around the world, COPD kills around 3 million people every year, say the researchers.

Several factors throughout the lifespan may increase the risk of poor lung function and subsequent COPD, and attention is now beginning to focus on the potential role of intergenerational factors, they explain.

While previously published research showed that passive smoking during a father’s childhood may be linked to a heightened risk of asthma in his children by the time they are 7, it’s not clear if compromised lung function may extend into middle age and beyond, they add.

To explore this further, the researchers drew on 8022 child participants in the Tasmanian Longitudinal Health Study (TAHS), all of whom had tests to assess their lung function (spirometry).

Their parents completed an initial comprehensive survey on their and their children’s respiratory health. Further check-ups ensued when those children were 13, 18, 43, 50 and 53. These included spirometry to assess 2 measures of lung function (FEV1 and FVC) as well as questionnaires on demographics and respiratory symptoms/disease.

Of the 7243 parents who were alive and could be traced in 2010, 5111 were re-surveyed about whether either of their own parents had smoked when they were under the age of 5 and/or up to when they were 15.

Among the 5097 respondents with complete data, 2096 were fathers. The final analysis included 890 father-child pairs with data on the father’s passive smoke exposure before puberty and lung function data for their children up to the age of 53.

More than two thirds of the fathers (nearly 69%) and more than half of their children (56.5%) had been exposed to passive smoking during their childhoods.

Around half of the children (49%) had a history of active smoking by middle age, and just over 5% of them had developed COPD by this time point, as assessed by spirometry.

After adjusting for potentially influential factors, including the father’s lifetime history of asthma/wheeze and his age, his passive smoke exposure as a child was associated with 56% higher odds of below average FEV1, but not FVC, across the lifespan of  his children.

Similarly, fathers’ childhood passive smoke exposure was also associated with a doubling in the odds of an early low-rapid decline in FEV1/FVC in their children. This was statistically significant even after adjusting for potentially influential factors.

And paternal exposure to passive smoking as a child was also associated with a doubling in the risk of COPD by the age of 53 in his children, although this was no longer statistically significant after adjusting for potentially influential factors.

But children whose fathers had been exposed to passive smoking as a child were twice as likely to have below average FEV1 if they, too, had been exposed to passive smoking during their childhood.

The observed associations were only partly mediated through smoking and respiratory illnesses in fathers and their children (each contributing less than 15%).

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. And the researchers acknowledge that TAHS lacks data on paternal lung function and genetics, preventing assessment of familial aggregation as a potential mechanism.

And their children’s childhood passive smoke exposure was defined as at least one parent smoking 6 days a week, which might have misclassified moderate/light smokers as non-smokers, they add.

But the period before puberty is especially critical for boys, when exposure to harmful substances may change gene expression and modify repair mechanisms, which may then become heritable, say the researchers by way of an explanation for their findings.

“Our findings are novel as this is the first study to investigate and provide evidence for an adverse association of paternal prepubertal passive smoke exposure, rather than just active smoking, on impaired lung function of offspring by middle age,” they write.

“This is of importance from a public health perspective, as passive smoke exposure affects about 63% of adolescents, which is significantly higher than the approximately 7% affected by active smoking.”

They conclude:  “These findings suggest that smoking may adversely affect lung function not only in smokers but also in their children and grandchildren…Fathers exposed to tobacco smoke during prepuberty may still reduce risk for future generations by avoiding smoking around their children.” 

02/09/2025

Notes for editors
Research: Paternal prepubertal passive smoke exposure is related to impaired lung function trajectories from childhood to middle age in their offspring  Doi: 10.1136/thorax-2024-222482
Journal: Thorax

Link to Academy of Medical Sciences Press Release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational; data analysis
Subjects: People

The post Dad’s childhood passive smoking may confer lifelong poor lung health onto his kids first appeared on BMJ Group.

Further research warranted, but limiting consumption may help curb global toll of the disease

A higher intake of ultra processed food (UPF) is linked to an increased risk of lung cancer, suggests research published online in the respiratory journal Thorax.

Further research is warranted in different population groups, but limiting consumption of these foods may help curb the global toll of the disease, say the researchers.

Lung cancer is the most common cancer in the world. And in 2020 alone there were an estimated 2.2 million new cases and 1.8 million deaths from the disease worldwide, they note.

UPF typically undergo multiple processing steps, contain long lists of additives and preservatives, and are ready-to-eat or heat. High consumption has been linked to a heightened risk of several health conditions, and the researchers wanted to know if this might also include lung cancer.

They drew on data from the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trials, involving 155,000 participants aged 55–74 who were randomly assigned to either a screening or comparison group between November 1993 and July 2001. Cancer diagnoses were tracked until the end of 2009 and cancer deaths until the end of 2018.

Some 101,732 people (50,187 men and 51,545 women; average age 62) who completed a Food Frequency questionnaire on their dietary habits on entry to the trials were included in the present study. Foods were categorised as: unprocessed or minimally processed; containing processed culinary ingredients; processed; and ultra processed.

The researchers focused in particular on UPF that included sour cream, as well as cream cheese, ice cream, frozen yoghurt, fried foods, bread, baked goods, salted snacks, breakfast cereals, instant noodles, shop-bought soups and sauces, margarine, confectionery, soft drinks, sweetened fruit drinks, restaurant/shop-bought hamburgers, hot dogs, and pizza.

Average energy adjusted UPF consumption was nearly 3 servings/day, but ranged from 0.5 to 6. The three types of food that featured the most were lunch meat (11%), diet or caffeinated soft drinks (just over 7%) and decaffeinated soft drinks (nearly 7%).

During an average tracking period of 12 years, 1706 new cases of lung cancer were diagnosed, including 1473 (86%) cases of non-small cell lung cancer (NSCLC) and 233 (14%) of small cell lung cancer.

Case numbers were higher among those eating the most UPF than they were among those eating the least (495/25,434 vs 331/25,433).

After accounting for potentially influential factors, including smoking and overall diet quality, participants in the highest quarter of energy-adjusted UPF consumption were 41% more likely to be diagnosed with lung cancer than those in the lowest quarter.

Specifically, they were 37% more likely to be diagnosed with NSCLC and 44% more likely to be diagnosed with SCLC.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. And the researchers acknowledge that they weren’t able to factor in smoking intensity, which may have been influential. Dietary information was collected only once, so couldn’t account for changes over time, and the number of cancer diagnoses was small.

But the researchers highlight the low nutritional value of UPF and the excessive amounts of sugar, salt, and fats they usually contain.

“Worse still, over the past two decades, the consumption of UPF has significantly increased worldwide, regardless of development or economic status. The rise in UPF consumption may have driven global increases in obesity, cardiovascular disease, metabolic disorders, cancer and mortality, as these foods are confirmed risk factors for such conditions,” they suggest.

A high intake of UPF may effectively elbow out healthy foods, such as whole grains, fruit, and vegetables, which are known to protect against cancer, suggest the researchers, by way of an explanation for their findings.

“Industrial processing alters the food matrix, affecting nutrient availability and absorption, while also generating harmful contaminants,” they add, highlighting acrolein, which is found in grilled sausages and caramel sweets, and is a toxic component  of cigarette smoke. Packaging materials may also have a role to play, they suggest.

They conclude: “These findings need to be confirmed by other large-scale longitudinal studies in different populations and settings….If causality is established, limiting trends of UPF intake globally could contribute to reducing the burden of lung cancer.”

30/07/2025

Notes for editors
Research: Association between ultra-processed food consumption and lung cancer risk: a population based cohort study  Doi: 10.1136/thorax-2024-222100
Journal: Thorax

External funding: Chongqing Talent Plan; Chongqing Shapingba District Technological Innovation Project

Link to Academy of Medical Sciences Press Release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed?Yes
Evidence type: Observational
Subjects: People

The post Higher ultra processed food intake linked to increased lung cancer risk first appeared on BMJ Group.

Better suppresses usual nocturnal worsening of asthma than dosing at other times
May lead to better outcomes without increasing steroid-related side effects or costs

A single daily preventer dose of inhaled corticosteroid (beclomethasone), taken mid afternoon, may be the best timing for effective asthma control as it suppresses the usual nocturnal worsening of symptoms more effectively than dosing regimens at other times of the day, suggest the results of a small clinical trial published in the journal Thorax.

If the findings are confirmed in larger studies, this approach may lead to better clinical outcomes for patients without increasing unwanted steroidal side effects or medical costs, suggest the researchers.

Aligning the timing of drug treatment with the body clock, known as chronotherapy, can enhance the therapeutic effects of medicines, say the researchers.

This may be particularly important in asthma, which has a distinct daily rhythm, with the cardinal effects of airflow obstruction and airway inflammation peaking overnight, when 80% of fatal asthma attacks occur, they explain.

Drawing on their previously published research, showing enhanced immune cell responsiveness to steroids mid afternoon, the researchers wanted to find out if a single dose of preventer inhaler at this time would better suppress the usual nocturnal worsening of asthma symptoms than either morning or standard twice-daily dosing, and without increasing the risk of steroidal side effects.

Twenty five people (aged 18-65) with confirmed mild to moderate asthma lasting at least a year, and common respiratory allergies to cat hair, dust mites, or grass pollen, were randomly assigned to one of three dosing regimens for 28 days each.

These comprised a single daily dose of 400 µg beclomethasone between 0800 and 0900 hours; the same once daily dose between 1500 and 1600 hours; and a twice daily dose of 200 µg beclomethasone between 0800 and 0900 hours and between 20.00 and 21.00 hours.

At the end of each 28 day period, participants swapped their dosing regimen after a 14 to 21 day gap until all three trial arms had been completed.

Spirometry readings and blood biomarkers (inflammatory cells, levels of cortisol and salbutamol from reliever inhalers) were measured every 6 hours for 24 hours at the start and end of each of the 28 day periods.

Twenty one people (84%), all of whom had similar sleep-wake cycles, completed all three of the trial arms.

Compared with baseline measurements, all the treatment arms improved night time lung function. But the timing of the improvement differed according to the dosing regimen. The largest Improvement, measured at 22:00 hours, was associated with the once daily mid afternoon dose (100 ml more than the morning dose).

Similarly, all the dosing regimens suppressed airway inflammation compared with baseline levels. And this was significantly lower at 22.00 and 0400 hours with the once daily mid afternoon dose than it was with the twice daily dose.

There was no difference in cortisol levels between the three dosing regimens, compared with baseline levels, suggesting that there was no additional impairment in the body’s ability to produce the hormone—a potential side effect of inhaled steroid treatment.

The researchers acknowledge the small number of participants involved and the short length of their study, but suggest that the findings might form the basis of further larger trials.

“Our findings further support the hypothesis that the optimal timing of [inhaled corticosteroid] administration is at 16:00, coincident with enhanced glucocorticoid sensitivity at that time,” they say.

“The notion that the onset of the inflammatory cascade begins mid-afternoon may also explain the findings we observed, and the attenuation of the predictable rhythmic recruitment of airway inflammatory cells at this time point may abolish the subsequent excessive nocturnal dip in lung function in asthma,” they suggest.

In a linked editorial, Drs Richard  Russell and Nicola Smallcombe of, respectively, the King’s Centre for Lung Health, King’s College London,and the Royal Free London NHS Foundation Trust, point out that the mid afternoon dosing regimen did not result in better symptom control.

But they explain: “This lack of translation to patient outcomes may be attributed to the short duration of the follow-up period, the small numbers, and the relatively low symptom burden of participants at baseline, so there was no headroom for improvement.”

Because participants had mild to moderate asthma, and long acting beta agonist inhalers—recommended in the latest treatment guidelines—weren’t included, the results might not be applicable more widely, they suggest.

“Additionally, when one considers the translation of these findings into clinical practice, with adherence to asthma therapies being the greatest challenge – around 30–40% of the general population struggles with inhaler compliance – introducing a specific time for inhaler use could potentially complicate matters further,” they surmise.

But they conclude: “This study offers promising insights into the potential benefits of using chronotherapy with inhaled corticosteroids for asthma patients. We believe that this is most likely to benefit those with more severe asthma, where marginal gains in lung function and a reduced eosinophil count are more likely to translate into better control and risk reduction.”

16 April 2025

Notes for editors
Research: The impact of dosage timing for inhaled corticosteroids in asthma: a randomised three-way crossover trial Doi: 10.1136/thorax-2024- 222073
Editorial: Chronotherapy in asthma: BD or not BD? That is the question  Doi: 10.1136/thorax-2025-223094
Journal: Thorax

External funding: JP Moulton Charitable Foundation (research)

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes (research); No (editorial)
Evidence type: Randomised cross over trial; Opinion
Subjects: People

The post Single mid-afternoon preventer inhaler dose may be best timing for asthma control first appeared on BMJ Group.

Linked to near doubling in asthma attack risk + 60% greater odds of emergency care visits
Findings reinforce importance of healthcare policy in promoting equitable access

Despite a fall in the number of people with asthma over the past decade who say that cost has stopped them taking their meds as prescribed, financial hardship still remains a deterrent for 1 in 6 with the condition, suggests research published online in the respiratory medicine journal Thorax.

Failure to stick to their drug treatment was associated with a near doubling in the risk of an asthma attack and a more than 60% heightened risk of an emergency department visit, the findings indicate.

The findings reinforce the importance of healthcare policy in promoting equitable access to drug treatment, concludes a linked editorial.

In 2021, the Centers for Disease Control and Prevention estimated that around 20 million adults (8%) had asthma in the USA. Although the condition can be well controlled with medication, the prevalence of non-adherence to treatment is high, note the researchers.

To find out what factors might be driving this among patients with asthma, the researchers drew on the survey responses of 30,793 adults with the condition (about 8% or 19.38 million of the US population), to the nationally representative annual National Health Interview Survey (NHIS) from 2011 to 2022.

Survey respondents were asked if, over the past 12 months: they had skipped medication doses; or taken fewer doses; or delayed repeating their prescriptions to save money. Answering yes to any of these questions was defined as not sticking to their treatment regimen as prescribed because of its cost.

Respondents were also asked if, over the past 12 months: they had had an episode of asthma/asthma attack; or had had to visit emergency care or an urgent care center because of their asthma.

Overall, 18% of survey respondents with asthma said they couldn’t afford to take their meds as prescribed, equivalent to just short of 3 million of the US population with the condition.

To save money, 12% (1.95 million equivalent) of respondents said they skipped medication doses; 12.5% (2.06 million equivalent) said they took fewer doses; and 15% (2.54 million equivalent) said they delayed repeating their prescription.

The proportion citing cost as a reason for not sticking to their treatment regimen fell significantly during the 12-year period, from 23% in 2011 to 13% in 2022.  But that still left the equivalent of 1 in 6 adults with asthma citing financial hardship as the reason for not taking their meds as prescribed in 2022.

Those aged 18–60, women, and Black people were more likely to report not taking their meds as prescribed because of the expense. Other influential factors included living in Southern US states, low educational attainment, lack of health insurance, low household income, co-existing conditions, and living alone.

Those citing financial hardship had nearly double the the odds of an asthma attack and a more than 60% heightened risk of visiting emergency care than those for whom cost wasn’t a factor.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. The researchers also acknowledge that their study relied on subjective assessment rather than on diagnostic tests and medical records, and they weren’t able to evaluate the potential impact of asthma severity on medicines compliance either.

They suggest that the falling trend in people citing cost as a reason not to take their meds as prescribed might be due to the introduction of the Patient Protection and Affordable Care Act in 2010, which aimed to improve access to health insurance and services, and the expansion of Medicaid in 2014.

“With fewer barriers to accessing healthcare, including medications, patients may be more willing to fill prescriptions for medications to control their asthma than before,” they suggest.

In a linked editorial, Emily Graul and Dr Christer Janson of, respectively, Emory University School of Medicine, Atlanta, and the Department of Medical Sciences, Uppsala University, Sweden, point out that asthma meds make up around half of the total spend on the condition.

“Therefore, efforts to reduce cost-related medication non-adherence not only lessen the financial burden on the US health system but also support people’s ability to improve their disease symptoms,” they suggest, adding that continued policy and legislation efforts are needed to ensure this happens.

“The Inflation Reduction Act’s associated Medicare Drug Price Negotiation Program lowered drug costs for several chronic conditions, but so far this has not included drugs for respiratory conditions, including asthma despite their high gross annual spending.

“The results of this study beg the question: should certain asthma medications be part of the next batch of drug negotiations?”

10/12/2024

Notes for editors
Research: Cost-related non-adherence to medications among adults with asthma in the USA, 2011–2022  Doi: 10.1136/thorax-2024-221778
Editorial:  Cost-related non-adherence to medication among people with asthma in the United States: findings that reinforce the relevance of history and healthcare reform Doi: 10.1136/thorax-2024-222662

External funding: None declared

Link to Academy of Medical Sciences Press Release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes (research); No (editorial)
Evidence type: Data analysis; Opinion
Subjects: People

The post Cost stops 1 in 6 US adults with asthma from taking meds as prescribed, study suggests first appeared on BMJ Group.

Call prompted by treating first 8 cases of artificial stone silicosis reported in UK

It may now be time to ban artificial stone—a firm favourite for kitchen worktops in the UK— to ward off the incurable lung disease caused by its manufacturing and fitting, say a team of doctors in the journal Thorax after treating the first 8 cases of artificial stone silicosis reported in the UK.

Silicosis is caused by breathing in crystalline silica dust, and millions of people around the world are at risk of developing it as a result of their jobs in mining, quarrying, stone-cutting and construction, they note.

Made from crushed rocks bound together with resins and pigments, artificial stone, also known as engineered or reconstituted stone, or ‘quartz’, has surged in popularity over the past 20 years, particularly for use in kitchen worktops, they explain.

It has aesthetic appeal. It’s easier to work with due to the absence of natural imperfections, and it’s more resistant to damage than natural stone, they add.

But its increasing popularity has been accompanied by the emergence of a severe and rapidly progressive form of silicosis (artificial stone silicosis), largely driven by its high (more than 90%) silica content compared with marble (3%) and granite (30%), and the fine dust it generates when cut.

When worktops are prepared for installation, they are also often ‘dry’ cut and polished with an angle grinder or other hand tools without the use of water to suppress dust generation, further boosting the volume of fine dust, explain the authors.

Cases of artificial stone silicosis have been reported from Israel, Spain, Italy, the USA, China, Australia and Belgium since 2010. But while artificial stone has been used in the UK for a similar period, no cases had been reported until mid-2023, when 8 men were referred to a specialist occupational lung disease clinic.

Their average age was 34, but ranged from 27 to 56 at the time of diagnosis. Six were born outside the UK and seven smoked or used to smoke.

Their average cumulative exposure to stone dust was 12.5 years, but ranged from 4–40 years. Four of them had been exposed to stone dust for between 4 and 8 years and estimated that 50%–100% of the materials they had used were artificial stone with, in some, additional granite, marble, and other ‘natural’ stones.

Two were assessed for lung transplant; 3 were assessed for autoimmune disease. Two were treated for opportunistic lung infection caused by non-tuberculous mycobacteria.

All the men worked for small companies with fewer than 10 employees. Although none worked in worktop manufacture or installation they all carried out the ‘finishing’ process, specifically cutting and polishing the worktops before installation.

They all reported that this was done without consistent water suppression, and without what they felt was appropriate respiratory protection. And even where workshop ventilation was present, the men stated that the system had not been serviced or cleaned regularly. None of them was aware of active airborne dust monitoring in the workplace.

Against medical advice, three continue to work with artificial stone, and have subsequently reported reduced exposure to visible dust after the introduction of powered respirators and water suppression. Two are no longer working; one has continued to work, but is no longer exposed to the dust; one has died; and one has been lost to further check-ups.

“Onset of disease is likely to relate to exposure levels, suggesting levels, at least for some of the UK cases…were extremely high and implying that employers failed to control dust exposure and to adhere to health and safety regulations,” point out the authors.

“The [artificial stone] market is dominated by small companies in which regulation has been shown to be challenging to implement. Furthermore, at least some worktop manufacturers may fail to provide adequate technical information relating to potential risks,” they add.

“Even with cessation of exposure, disease progression has been noted in over 50% of cases over [an average] of 4 years. Prevention of disease is therefore critical,” they emphasise.

While the number of workers exposed to silica dust isn’t known, global experience indicates that cases are likely to increase significantly in the coming years, they point out.

Current UK guidance recommends monitoring workers in the industry after 15 years, but that  is very likely to miss cases and fails to account for intensity, not just length, of exposure, they suggest.

“A concerted effort is required in the UK to prevent the epidemic seen in other countries. The cases we present illustrate the failure of the employer to take responsibility for exposure control in their workplaces. National guidelines are urgently needed, as well as work to enumerate the at-risk population and identify cases early,” they insist.

“The introduction of a legal requirement to report cases of [artificial stone] silicosis, implementation of health and safety regulation with a focus on small companies, and a UK ban on artificial stone (as introduced in Australia in 2024) must be considered,” they urge.

In a linked editorial, Dr Christopher Barber, of Sheffield Teaching Hospitals says that history is instructive, citing the observations of Dr Calvert Holland in 1843 on the health of Sheffield cutlery workers.

These workers shaped metal forks using a rotating grindstone and developed incurable ‘grinders asthma’ as a result of the very high levels of dust generated by ‘dry grinding’ forks (without water).

Barber comments: “By design, [artificial stone] worktops (like grindstones) have a very high silica content to make them more hard wearing and durable. Dry processing of [it] with powered tools without the use of water suppression, local exhaust ventilation, and respiratory protective equipment exposes workers to very high levels of airborne silica dust, in many cases two orders of magnitude greater than legal exposure limits.”

Holland noted the vulnerability of the cutlery workers, and Barber draws parallels with those working with artificial stone.

“Many of those at risk of [artificial stone] silicosis in the UK, Australia, and USA are migrant workers whose first language is not English, who may have poor understanding of health risks, and limited access to healthcare,” he writes.

And they are more likely to have limited financial options, forcing some to continue harmful exposures against medical advice, he adds.

“Considering the availability of [artificial stone] kitchen worktops, the arrival of [artificial stone] silicosis in the UK is one which has been feared by clinicians for some time,” he says.

But UK doctors may struggle to differentiate the signs and symptoms from sarcoidosis, a condition that is unrelated to silica inhalation, but which has similar clinical features, he suggests.

“Greater awareness of [artificial stone] silicosis is also required among a wider range of healthcare professionals due to the increased risk of mycobacterial, renal, and autoimmune connective [tissue] disease,” he says.

The UK is currently reviewing exposure limits for crystalline silica dust amid mounting international concerns about its health impacts.

To inform the current debate about permissible levels of exposure, researchers in a separate study reviewed for the first time the available evidence published up to the end of February 2023  to establish cumulative risk and identify the exposure level at which that risk would be reduced.

They searched for studies drawing on x-rays, post mortem examination results, and death certificates for silicosis, spanning an average period of more than 20 years since participants’ first employment in the stone cutting industry.

Eight studies out of an initial haul of 52 met the eligibility criteria, involving 8792 cases of silicosis among 65,977 participants. Six of the studies involved miners.

The cumulative risk estimates varied substantially, depending on which methodological approach had been used, so the researchers pooled the raw data to recalculate the lifetime cumulative risk and the level at which the absolute risk of developing the disease would be reduced.

The results showed that among miners halving cumulative exposure from 4 mg/m³ (equivalent to 40 years of work at 0.1 mg/m³ or 420 cases/1000 workers) to 2 mg/m³ (equivalent to 40 years of work at 0.05 mg/m³ intensity) of breathable silica dust corresponded to a substantial reduction in risk of 77%, resulting in 323 fewer cases/1000 workers.

The equivalent figures for those working in other industries were a reduction in risk of 45% and 23 fewer cases per 1000 workers down from 51. But, importantly, these figures are based on only 2 studies, highlight the researchers.

“There is current debate regarding respirable crystalline silica exposure limits in the UK and recent debate among miners in the USA. This research supports the reduction of permissible exposure limits from 0.1 mg/m³ to 0.05 mg/m³” over an 8-hour working shift, conclude the researchers.

07/08/2024

Notes for editors
Short report: Artificial stone silicosis: a UK case series Doi: 10.1136/thorax-2024-221715
Editorial: Artificial stone silicosis arrives in the UK: a tragic case of history repeating Doi: 10.1136/thorax-2024-221806
Systematic review + meta analysis: Relationship between cumulative silica exposure and silicosis: a systematic review and dose response meta-analysis Doi: 10.1136/thorax-2024-221447
Journal: Thorax

External funding: None declared

Link to Academy of Medical Sciences Press Release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes; No (editorial)
Evidence type: Case series; Opinion; Systematic review + meta analysis
Subjects: People

The post Think about banning kitchen worktop favourite to ward off incurable lung disease, urge doctors first appeared on BMJ Group.

Combo lowers blood oxygen and raises heart rate, even in young and healthy
May be time to consider restricting access to alcohol on long haul flights, say researchers

The combination of alcohol plus cabin pressure at cruising altitude may threaten sleeping plane passengers’ heart health, particularly on long haul flights, suggests the first study of its kind, published online in the respiratory journal Thorax.

The duo lowers the amount of oxygen in the blood (SpO2) and raises the heart rate for a protracted period, even in the young and healthy, the findings indicate.

The higher the alcohol consumption, the greater these effects might be, particularly among older passengers and those with pre-existing medical conditions, say the researchers, who suggest that it may now be time to consider restricting on-board access to alcohol on long haul flights.

Atmospheric pressure decreases exponentially with altitude, causing a drop in blood oxygen saturation level to around 90% (73 hPa) in healthy passengers at cruising altitude, explain the researchers.

A further drop in SpO2 below this threshold is defined as hypobaric hypoxia—or low blood oxygen level at higher altitude.

Alcohol relaxes blood vessel walls, increasing the heart rate during sleep, an effect similar to that of hypobaric hypoxia, so the researchers wanted to find out if the combination of alcohol plus cabin pressure at cruising altitude might have an additive effect on sleeping passengers.

They therefore randomly allocated 48 people between the ages of 18 and 40 to two groups stratified by age, gender, and weight (BMI). Half were assigned to a sleep lab under normal ambient air pressure conditions (sea level) and half to an altitude chamber that mimicked cabin pressure at cruising altitude (2438 m above sea level).

Twelve people in each group slept for 4 hours having drunk no alcohol, while 12 slept for 4 hours having drunk alcohol for 1 night, followed by 2 recovery nights, and then a further night in which the process was reversed.

Participants drank the equivalent of 2 cans of beer (5%) or 2 glasses of wine (175 ml, 12%) in pure vodka at 11.15 pm, and their sleep cycle, SpO2, and heart rate were monitored continuously until 4 am. 

The final analysis included the results of 23 people in the sleep lab and 17 in the altitude chamber.

This showed that the combination of alcohol and simulated cabin pressure at cruising altitude prompted a fall in SpO2 to an average of just over 85%  and a compensatory increase in heart rate to an average of nearly 88 beats/minute during sleep. 

This compares with just over 88% SpO2 and just under 73 beats/minute among those sleeping in the altitude chamber who had not drunk alcohol.

Among those in the sleep lab who drank alcohol the equivalent figures were just under 95% SpO2,  and just under 77 bpm heart rate and just under 96% and just under 64 bpm for those who hadn’t.

Oxygen levels below the healthy clinical norm (90%) lasted for 201 minutes with the combination of alcohol plus simulated cabin pressure at cruising altitude. This compares with a period lasting 173 minutes without alcohol and 0 minutes with and without alcohol under sleep lab conditions. 

Deepest sleep (N3 stage of the sleep cycle) was reduced to 46.5 minutes under the combined exposure of alcohol and simulated cabin pressure at cruising altitude compared with both sleep lab conditions: after alcohol: 84 minutes; without alcohol 67.5 minutes.

The period of REM sleep was also shorter among those exposed to hypobaric hypoxia and alcohol. Both N3 and REM sleep are important phases of the recuperative stages of sleep.

The researchers acknowledge the small sample size of their study and that the participants were young and healthy so don’t reflect the general population.

What’s more, participants slept in the supine position, a luxury usually only afforded to those flying first class, so the findings might not equally apply to the bulk of plane passengers who fly economy, they add. 

Nevertheless, they state: “Together these results indicate that, even in young and healthy individuals, the combination of alcohol intake with sleeping under hypobaric conditions poses a considerable strain on the cardiac system and might lead to exacerbation of symptoms in patients with cardiac or pulmonary diseases.”  

These effects might be even greater in older people, they suggest, adding: “Cardiovascular symptoms have a prevalence of 7% of inflight medical emergencies, with cardiac arrest causing 58% of aircraft diversions.” 

And they conclude: “Practitioners, passengers and crew should be informed about the potential risks, and it may be beneficial to consider altering regulations to restrict the access to alcoholic beverages on board aeroplanes.”

04/06/2024 

Notes for editors
Research: Effects of moderate alcohol consumption and hypobaric hypoxia: implications for passengers’ sleep, oxygen saturation and heart rate on long-haul flights Doi: 10.1136/thorax-2023-220998
Journal: Thorax

External funding: DLR Aeronautics Program

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

External peer review? Yes
Evidence type: Randomised controlled trial
Subjects: People

The post Inflight alcohol + cabin pressure may threaten sleeping passengers’ heart health first appeared on BMJ Group.

7+ daily hours associated with more than doubling in risk among 10 to 25 year olds
Findings reinforce concerns about marketing clout of these platforms, say researchers

The more time spent on social media, the greater the likelihood that children and young people will both smoke and/or vape, suggests research published online in the respiratory  journal Thorax.

Clocking up a weekday tally of 7 or more hours was associated with a more than a doubling in risk among 10 to 25 year olds, the findings indicate, reinforcing concerns about the marketing clout of these platforms, say the researchers.

The existing body of research on social media use and smoking and vaping mostly concerns the USA, so to better assess the situation in the UK, the researchers drew on data from 10 to 25 year olds taking part in the UK Household Longitudinal Study 2015–21. 

Participants were asked to report their normal weekday social media use as well as current cigarette smoking and vaping activity.

Among 10,808 participants with a total of 27,962 reported observations, just over 8.5% reported current cigarette smoking in at least one survey, and 2.5% reported current vaping. Just over 1% reported dual use.

Analysis of the responses showed that cigarette smoking, vaping, and dual use were all more common among participants reporting heavier social media use. 

Just 2% of those who said they didn’t use social media reported current cigarette smoking compared with nearly 16% of those who said they spent 7 or more hours/weekday on it. 

Similarly, current vaping ranged from less than 1% among non-users of social media to 2.5% among those spending 7 or more hours on it every weekday.

The likelihood of smoking, vaping, and dual use also rose in tandem with the amount of time spent on social media.

Those who said they spent less than 1 hour/day on social media were 92% more likely to be current smokers than those who said they spent no time on it, while those clocking up 7 or more hours/day were more than 3.5 times as likely to be current smokers.

And those who said they spent 1–3 hours a day on social media were 92% more likely to report current vaping than those who said they spent no time on it.

And those spending 7 or more hours/day on social media were nearly 3 times as likely to report current vaping than those who said they didn’t spend any time on these platforms.

Heavier social media use was associated with a greater likelihood of dual use. Those reporting spending 1–3 hours/day on it were more than 3 times as likely to be dual users as those who said they didn’t spend any time on social media. 

But those spending 7 or more hours/day on social media were nearly 5 times as likely to both smoke and vape.

The findings were independent of other factors associated with a heightened risk of smoking and vaping, including age, sex, household income, and parental smoking and vaping.

When the analysis was broken down by sex and household income, similar associations emerged for smoking, but not for vaping. Males, those under the legal age of sale, and those from higher income households were more likely to vape.

This is an observational study, and as such, no firm conclusions can be drawn about causal factors. The researchers also acknowledge that the study relied on self reported data, and that they didn’t have any information on the social media platforms used, or how they were being used. But they proffer some explanations for their findings.

“First, and most straightforwardly, there is evidence that the corporations behind cigarette smoking and vaping make use of social media to advertise and promote their products,” write the researchers.

“This includes direct advertising which is algorithmically targeted and the use of paid social media influencers who present smoking and vaping as a fashionable and desirable activity. Greater time spent on social media is likely to increase exposure to these forms of influence,” they explain.

“Second, social media use has been shown to have features in common with reward-seeking addictive behaviour.High social media use may increase susceptibility to other addictive behaviours like smoking,” they add.

“Third, as a space that is largely unsupervised by parents/caregivers, social media use may encourage behaviours that are transgressive, including cigarette smoking and vaping.”

They conclude: “The companies that own social media platforms have substantial power to modify exposure to material that promotes smoking and vaping if they choose to or are compelled to. Voluntary codes seem unlikely to achieve this, and the introduction and enforcement on bans on material that promote this should be considered. 

“In general, we think that algorithms should not be promoting products to individuals that they cannot legally buy. Legislation and enforcement around this and other corporate determinants of health concerns should be considered a core part of online safety and child protection.”

In a linked editorial, Dr Kim Lavoie of the University of Montreal, voices concerns about the popularity of e-cigarettes and vaping products among young people.

Aside from the addictive nature of nicotine and the relative affordability and accessibility of these products, “the answer may lie in the subtle and creative ways e-cigarette manufacturers have managed to reach, and entice, youth into taking up vaping,” which include social media, she suggests.

“The policy implications of this paper are important, particularly as they pertain to regulation of advertising and algorithms targeting under-age users,” she writes.

17/05/2024 

Notes for editors
Research: Association of time spent on social media with youth cigarette smoking and e-cigarette use in the UK: a national longitudinal study Doi: 10.1136/thorax-2023-220569
Editorial: Strengthening the evidence base to support stronger regulation of social media based advertising of e-cigarette products to youth Doi: 10.1136/thorax-2023-221169
Journal: Thorax

External funding: Cancer Research UK (research); Canada Research Chairs Program (editorial)

Link to Academy of Medical Sciences labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes (research); No (editorial)
Evidence type: Observational; Opinion
Subjects: People

The post Likelihood of kids and young people smoking and vaping linked to social media use first appeared on BMJ Group.

Improving care of asthma patients could help NHS meet its net zero target, say researchers

Patients whose asthma is poorly controlled have eight times excess greenhouse gas emissions compared with those whose condition is well controlled—equivalent to that produced by 124,000 homes each year in the UK—indicates the first study of its kind, published online in the journal Thorax.

Improving the care of asthma patients could achieve substantial carbon emissions savings, and help the NHS meet its net zero target, say the researchers.

Healthcare is a major contributor to greenhouse gas emissions and in 2020 the NHS set an ambitious target of reducing its carbon footprint by 80% over the next 15 years, with the aim of reaching net zero by 2045, note the researchers.

Asthma is poorly controlled in around half of those with the condition in the UK and Europe, increasing the risk of hospital admission and severe illness as well as healthcare costs.

To gauge the environmental footprint of asthma care in the UK, the researchers retrospectively analysed the anonymised health records of 236,506 people with asthma whose data had been submitted to the Clinical Practice Research Datalink between 2008 and 2019.

Greenhouse gas (GHG) emissions, measured as carbon dioxide equivalent (CO2e), were estimated for asthma-related medication use, healthcare resource utilisation and severe exacerbations during follow-up of patients with asthma.

Well controlled asthma was categorised as no episodes of severe worsening symptoms and fewer than 3 prescriptions of short-acting beta-agonists (SABAs) reliever inhalers in a year.

Poorly controlled asthma was categorised as 3 or more SABA canister prescriptions or 1 or more episodes of severe worsening symptoms in a year.

A severe exacerbation of asthma was defined as worsening symptoms requiring a short course of oral corticosteroids, an emergency department visit, or hospitalisation.

Excess GHG emissions due to suboptimal asthma control included at least 3 or more SABA canisters per year, severe exacerbations and any GP visits within 10 days of hospitalisation or an emergency department visit.

The researchers calculated that the overall carbon footprint attributed to asthma care when scaled to the entire UK asthma population added up to 750,540 tonnes CO22/year.

Asthma was poorly controlled in just under half (47%; 111,844) of the patients. And poorly controlled asthma contributed to excess greenhouse gas emissions of 303,874 tonnes CO2e/year—equivalent to emissions from more than 124,000 homes in the UK, they estimate. The excess GHG emissions were 8-fold higher on average for a person with poorly controlled asthma than in the well controlled asthma patients.

The excess GHG emissions were 90% comprised of inappropriate SABA use with the remainder mostly due to healthcare resource utilisation such as GP and hospital visits, required to treat severe worsening symptoms.

Poorly controlled asthma generated 3-fold higher greenhouse gas emissions on average for a person with poorly controlled asthma compared with well controlled asthma when taking into account GHG emissions related to all aspects of asthma care including routine prescribing and management.

The researchers acknowledge various limitations to their findings, including that the study results were largely descriptive in nature. And factors other than the level of asthma symptom control, such as prescribing patterns, may also have contributed to high SABA use.

But they nevertheless write: “Our study indicates that poorly controlled asthma contributes to a large proportion of asthma-care related greenhouse gas emissions with inappropriate SABA use emerging as the single largest contributor.”

The Global Initiative for Asthma no longer recommends SABA used alone as the preferred reliever for acute asthma symptoms, they add.

The authors conclude that efforts to improve asthma treatment practices including curtailing inappropriate SABA use and implementing evidence-based treatment recommendations, could result in substantial carbon savings.

28/02/2024

Notes for editors
Research: Greenhouse gas emissions associated with suboptimal asthma care in the UK: the SABINA healthCARe-Based envirONmental cost of treatment (CARBON) study doi: 10.1136/thorax-2023-220259
Journal: Thorax

Funding: AstraZeneca

Link to Academy of Medical Sciences labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Observational study
Subjects: People

The post Poorly controlled asthma emits same quantity of greenhouse gas as 124,000 homes each year in the UK first appeared on BMJ Group.

Miscarriage, stillbirth, infertility, and having 3 or more children additional risk factors

A range of reproductive factors, including age when periods first start and an early menopause, are all linked to a heightened risk of COPD—the umbrella term for progressive lung conditions that cause breathing difficulties—finds research published online in the journal Thorax.

Miscarriage, stillbirth, infertility, and having 3 or more children are also associated with a heightened risk of COPD, which includes emphysema and chronic bronchitis, the findings show.

Recent evidence indicates substantial gender  differences in susceptibility to, and severity of, COPD, note the researchers. Women seem to develop severe COPD at younger ages than men. And while smoking is a major risk factor, non-smokers with COPD are more likely to be women, they add.

Previously published studies looking at the potential influence of female hormones on COPD risk have been hampered by methodological flaws, note the researchers. To try and get round these issues, they drew on the International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events (InterLACE) consortium.

This is a collection of 27 observational studies, pooling individual level data from more than 850,000 women in 12 countries.

For the purposes of the current study, the researchers included three groups of women (283,070; average age 54) with data on reproductive factors and COPD: the Australian Longitudinal Study on Women’s Health 1946–51 (ALSWH-mid); the UK Biobank; and the Swedish Women’s Lifestyle and Health Study (WLH).

In the ALSWH-mid and UK Biobank groups, women were tracked until the end of December 2019. Women in WLH were tracked up to the end of 2010.

Information on reproductive factors was collected at study entry or at subsequent data collection points, along with potentially influential factors: birth year (before or after 1950), ethnicity, educational level, duration of smoking, asthma (never and ever), and weight (BMI).

COPD was retrospectively and prospectively identified through self-report and medical records, which included prescriptions, hospital admissions, emergency care visits, and death registry data.

The women’s health was monitored for an average of 11 years. During this time, 10,737 (4%) women developed COPD at an average age of 63. 

Women with COPD were more likely to be older when recruited to their studies, to have fewer than 10 years of formal education, to be obese, to have smoked for at least 10 years, and to have asthma–all risk factors for the condition. Some 53, 205 (16%) women were excluded because of missing data.

Several reproductive factors were associated with the risk of COPD, including age when periods first started; number of children; a history of infertility, miscarriage or stillbirth, especially multiple miscarriages or stillbirths; and age at menopause.

A U-shaped pattern emerged for the age at which periods first started. Those who began menstruating before or at the age of 11 were 17% more likely to develop COPD than those who did so at the age of 13; after the age of 16, the risk was 24% higher.

Women with children were at higher risk of COPD than childless women. Compared with having 2 children, more than 3 was associated with a 34% higher risk, while women with one child were at 18% higher risk.

Women who experienced infertility also had a 13% higher risk of COPD than women who were fertile. 

And among those who had ever been pregnant, a history of miscarriage was associated with a 15% higher risk of COPD, with the risk rising in tandem with the number of miscarriages: 28% higher for 2; and 36% higher for 3 or more.

Similarly, stillbirth was associated with a 42% overall higher risk of COPD, with the risk rising in tandem with the number of stillbirths.

Menopause before the age of 40 was associated with a 69% higher risk, compared with those experiencing it naturally at the age of 50-51, while the risk was 21% lower for those who went through it at or after the age of 54.

This is an observational study, so can’t establish cause, and the researchers acknowledge various limitations to their findings, including potentially influential factors. 

For example, they had no detailed information on hormonal contraception and HRT use, and data on parental history of COPD, childhood respiratory infections, secondhand smoking or occupational exposures, weren’t available for all 3 of the groups. 

But by way of an explanation for their findings, they suggest that the female hormone oestrogen is likely to have a key role in COPD risk in women, because of its various effects on the lung. 

“The overall effect of oestrogen might differ depending on the timing,” they suggest. “In the early or middle reproductive stage, long or higher accumulated exposure to oestrogen would be detrimental to the lung, leading to a higher risk of COPD among women with early menarche or multiple live births. 

“In the later stage, oestrogen may be protective, since earlier age at menopause or [ovary removal] (indicates shorter exposure to oestrogen) were associated with a higher risk of COPD.” 

Other factors, including autoimmune disease, such as type 1 diabetes, and social and environmental factors, such as air pollution, underweight, and socioeconomic deprivation, might also be influential, they add.

14/02/2024 

Notes for editors
Research: Female reproductive histories and the risk of chronic obstructive pulmonary disease doi: 10.1136/thorax-2023-220388
Journal: Thorax

Funding: Australian National Health and Medical Research Council 

Link to Academy of Medical Sciences Press releases labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational (cohort study)
Subjects: Women

The post Age when periods first start and early menopause linked to heightened COPD risk first appeared on BMJ Group.