Blackwell Science, LtdOxford, UK

RESRespirology1323-77992003 Blackwell Science Asia Pty Ltd

82June 2003
460
COPD in Asia–Pacific
WC Tan
et al.
10.1046/j.1323-7799.2003.00460.x
Original Article192198BEES SGML

Respirology (2003) 8, 192–198

ORIGINAL ARTICLE

COPD prevalence in 12 Asia–Pacific countries and regions:

Projections based on the COPD prevalence estimation model
REGIONAL COPD WORKING GROUP*

COPD prevalence in 12 Asia–Pacific countries and regions: Projections based on the COPD
prevalence estimation model
REGIONAL COPD WORKING GROUP. Respirology 2003; 8: 192–198
Objective: COPD is a leading cause of mortality and morbidity worldwide. Despite the high rates
of cigarette smoking, and the wide use of biomass fuels, there is very little objective data on the
prevalence of COPD in Asia.
Methodology: We used a COPD prevalence model to estimate the prevalence of COPD in 12 Asian
countries. This model is a validated, computerized tool that uses epidemiological relationships and
risk factor prevalence to project the prevalence of COPD within a given population aged 30 years
and older.
Results: The total number of moderate to severe COPD cases in the 12 countries of this region, as
projected by the model, is 56.6 million with an overall prevalence rate of 6.3%. The COPD prevalence
rates for the individual countries range from 3.5% (Hong Kong and Singapore) to 6.7% (Vietnam).
Conclusions: The COPD prevalence rates projected by the model reflect the high prevalence of the
risk factors for the disease in Asia. The combined prevalence of 6.3% for these countries is consid-
erably higher than the overall rate of 3.8% as extrapolated from WHO data for this region. These
estimates highlight the need for further epidemiological studies to support appropriate allocation
of resources for the prevention and management of COPD.

Key words: Asia, chronic bronchitis, cigarette smoking, COPD, emphysema, environmental pollu-
tion, epidemiology, indoor air pollution predictive model, obstructive airways disease, prevalence.

INTRODUCTION dicted that it would rise in rank to be the third leading

The World Health Organization (WHO) global burden
of disease study reported that COPD was the sixth
leading cause of death worldwide in 1990 and pre-
Correspondence: Wan C. Tan, Department of Medi-
cine, National University of Singapore, 5 Lower Kent
Ridge Road, Singapore 119074, Republic of Singapore.
Email: mdctanwc@nus.edu.sg
Professor Wan C. Tan took no part in the decision-
making process with respect to this manuscript.
* Members of Regional COPD Working Group include:
Professor Wan C Tan, Singapore; Professor J. Paul Seale,
Australia; Professor Suchai Charaoenratanakul, Thai-
land; Dr Teresita de Guia, Philippines; Professor Mary
Ip, Hong Kong (S.A.R., China); Dr Aziah Mahayiddin,
Malaysia; Dr Hadiarto Mangunnegoro, Indonesia; Pro-
fessor Kwen-Tay Luh, Taiwan; Professor Young-Soo
Shim, Korea; Professor Nan-Shan Zhong, China and Dr
Brigitte Schau, Germany.
Received 10 May 2002; revised 23 October 2002;
accepted for publication 24 October 2002.
cause of death after ischaemic heart disease and cere-
brovascular disease by the year 2020.1,2
COPD is formally defined by spirometric criteria
as a slowly progressive disorder characterized by
airways obstruction (FEV1 < 80% predicted and
FEV1/FVC ratio < 70% predicted) that is not revers-
ible.3,4 This broad definition may encompass several
different clinical and pathological entities, includ-
ing peripheral airways obstruction from chronic
bronchitis, emphysema, and bronchiectasis and
tuberculosis.
Cigarette smoking is a major risk factor worldwide
for COPD, although it is not known why only about
15% of smokers develop clinically significant COPD.
Cigarette smoking has been estimated to account for
80–90% of all COPD in the population.5 Smoking
prevalence rates for Asian countries are extremely
high and continue to increase. According to the WHO
estimates, the number of COPD cases in Asia exceeds
by three times the total number of COPD cases for the
rest of the world.1,5
Both indoor and outdoor air pollution are recog-
nized risk factors for COPD. The use of solid fuels for
indoor cooking or heating with poor ventilation may
COPD in Asia–Pacific
produce significant air pollution, which may account
for the development of COPD. This causal factor may
be particularly relevant in several Asia–Pacific coun-
tries, where biomass fuel use is common. It has been
reported that up to 77% of the rural population in the
Asia–Pacific region may be using wood and dung or
crop residue for fuel.6
Epidemiological studies of COPD in the Asia–
Pacific region are scant. A study of elderly Chinese
living in Hong Kong found a COPD prevalence of
6.8%.7 The crude prevalence of chronic bronchitis
has been reported to be over 18% in a rural commu-
nity in Nepal.8 There is a need for more reliable data
on the prevalence of COPD in individual countries of
the Asia–Pacific region. Such information is essential
for the development of national health policies and
strategies for the prevention and control of the
disease.
Community-based survey data would provide the
most reliable estimates of COPD prevalence but it
is unlikely that most countries in Asia will have
the resources to conduct such detailed surveys in the
immediate future. An alternative approach is to use
an epidemiological model to estimate the prevalence
of COPD.9 This approach has the advantages of being
less costly, and being able to promptly provide an
interim estimate of the size of the problem using stan-
dardized methodology and hence facilitate cross-sec-
tional and serial comparisons between and within
countries. We report the prevalence of COPD for 12
Asian countries using such a model.
METHODS
Description of model
The COPD Prevalence Estimation Model is an algo-
rithm embedded in a software program.9 It estimates
the current COPD population for a specific region or
country, based on the local prevalence of risk factors
for COPD. Figure 1 shows the high level model pro-
cess flow. The model estimates the number of COPD
patients in the 30 years and older population.
Figure 1 Model scheme and process flow.
193
Model inputs
The model is based on a systematic review of the
published literature for the identification and quanti-
fication of major risk factors for COPD. Model inputs
were derived from studies that provided data quanti-
fying the relationship between COPD, its risk factors
and its prevalence.10–20 Choice of input categories was
also based on the use of data that would be readily
available to the end user, from relevant clinical and
epidemiological sources found in most countries.
Although there exist additional risk factors beyond
those utilized in the model, it was felt that four fac-
tors were key and that the effects of these factors
could be assumed to equally impact on the preva-
lence across a population and to account for the
majority of risk. These factors included smoking,
biomass fuel exposure, air pollution, and high-risk
occupations.
The populations exposed to these factors are first
determined in the model algorithm. This determina-
tion is derived from user input of the following data:
smoking prevalence by age and sex, per cent of pop-
ulation living in urban areas (as a surrogate for
moderate to severe air pollution), per cent of popu-
lation in high-risk occupations, and population
exposed to biomass fuel. If the user is unable to
determine the above inputs, the model assigns
default values for these based on evidence from the
literature.
Model outputs
The outputs or projections of the model are based on
the relationships of the major risk factors for COPD to
the prevalence of COPD. Once the user has entered
the relevant data, the populations exposed to each of
the risk factors are calculated by the model algorithm.
Based on the figures generated from the literature
for cigarette smokers,10,11 users of biomass fuel,6,12–15
those in high-risk occupations,16,17 those living in
areas with moderate/severe air pollution,18–20 and
those unexposed to any of the above,16 the model then
determines the prevalence of COPD for each of these
population categories.
Additional features of the model include projec-
tions of the distribution of COPD cases into moder-
ate/severe or mild disease, and future projections for
the prevalence of COPD based on changing demo-
graphics. (Details of the model development process
and its features are available in reference or by writing
to WCT).
Data collection for application model
A questionnaire was developed to assist in collect-
ing the data required to populate the model. This
questionnaire contained fields for all the manda-
tory as well as optional data elements required for
input into the model. Mandatory data consisted of
194
status of country as developed or developing, pop-
ulation size by age groups, smoking prevalence and
percentage of population living in urban or rural
areas. Optional data consisted of percentage of
population exposed to non-smoking risk factors for
COPD and percentage of smokers who develop
COPD. The questionnaires were sent to representa-
tive COPD experts from each participating country
along with standardized guidelines for completing
the questionnaires. The experts were requested to
provide the data for each country and to specify
the source from which each data element was
obtained. For smoking prevalence rates, the experts
were asked to use the most recent figures available
from each country. Official population figures for
the year 2000 provided by the Census Bureau from
each country were used to populate the model. If
these figures were not available, the year 2000 pop-
ulation was estimated based on the last census, and
the annual change in the population observed over
the last 5 years. The percentages of the population
living in urban and rural areas were similarly based
on the figures from the last census performed in
the country.
WC Tan et al.
Data management and analysis
All data were then returned to the data coordinator
for input into the computer model. The mandatory
data elements were available for all the countries, but
the optional data elements were not available for
most countries. To ensure consistency, only the man-
datory data elements were ‘input’ into the model for
all the countries. Default values derived from pub-
lished studies are provided by the model algorithm for
use in case the optional data elements are not avail-
able. These default values were then used as the
optional data elements for each country in order to
generate the model projections. Figures 2 and 3 illus-
trate the main mandatory data elements collected
from each country. The model projections for moder-
ate to severe COPD were then generated for each
country for its population in the year 2000 (Table 1).
RESULTS
As projected by the model, the total number of mod-
erate to severe COPD cases among individuals 30
Figure 2 Smoking prevalence
by country and gender.
Figure 3 Urban population as
per cent of total population by
country.
COPD in Asia–Pacific 195

years and older within all the 12 identified countries,
is 56.6 million. This translates to a mean COPD prev-
alence rate of 6.3% for the region. Table 1 shows the
data for each country. The COPD prevalence rates
vary twofold between the 12 Asian countries and
range from a minimum of 3.5% (Hong Kong and
Singapore) to a maximum of 6.7% (Vietnam).
Table 2 compared the overall result from the
present study with similar estimates made for other
countries using the same model. The rate for the Asia–
Pacific region was intermediate between those of the
USA and Nepal, but was closer to those of Denmark
and Norway. Table 2 also shows that the estimates
vary depending on the criteria used to define COPD
in the individual studies. For instance, some studies
used spirometry alone, while others used symptoms,
with or without spirometry. In addition, countries
Table 1 Model projections of the prevalence of moderate
to severe COPD in those 30 years and older for 12 countries
in the Asia–Pacific region
report prevalence as a percentage of the entire adult
population or by specific ages within the population.
The overall smoking prevalence rates, which have
the greatest impact on the model projections, also
vary considerably between these countries (14% in
Hong Kong and 36% in Japan and Vietnam). Differ-
ences in smoking prevalence rates between the
female population (range 2–21%) and male popula-
tion (range 27–73%) may contribute to these varia-
tions between the countries of the region (Fig. 2).
The proportion of the population living in urban
areas, another major factor in the model projections,
also differs widely between the countries. The highest
urban populations are in Singapore and Hong Kong
(100%), while the lowest urbanization is reported
from Thailand (12%) (Fig. 3, Table 3).
Table 3 shows the estimated number of cases
attributed to smoking (tobacco exposure) versus non-
smoking causes (occupational exposure, biomass
fuel exposure and outdoor air pollution). The ratio
of COPD cases from smoking versus non-smoking
causes ranged from 1.52 for Thailand to 5.81 for
Japan.

Moderate/severe
Country COPD cases Prevalence DISCUSSION

1. Australia 558 000 4.7% In the implementation phase of global practice guide-
2. China 38 160 000 6.5% lines (GOLD), information on the burden of disease is
3. Hong Kong 139 000 3.5% essential for the planning and allocation of healthcare
4. Indonesia 4 806 000 5.6% resources.21 Epidemiological data on the prevalence
5. Japan 5 014 000 6.1% of COPD are available from very few countries, mak-
6. South Korea 1 467 000 5.9% ing it necessary to generate estimates for understand-
7. Malaysia 448 000 4.7% ing the global size of the problem. In the WHO Global
8. Philippines 1 691 000 6.3% Burden of Disease study, data for the burden of COPD
9. Singapore 64 000 3.5% were presented according to three categories: estab-
10. Taiwan 636 000 5.4% lished market economies, former socialist economies
11. Thailand 1 502 000 5.0% of Europe and a third category called demographi-
12. Vietnam 2 068 000 6.7% cally developing regions which included China, India
Total 56 553 000 6.3% and ‘other Asian islands’.3 There is, therefore, insuffi-
cient focus and detailing of the countries in the Asia–

Table 2 Comparison of model estimates of COPD prevalence in various countries with the overall model estimate of COPD
prevalence in the Asia–Pacific region

Country No. COPD cases COPD prevalence by model* COPD prevalence in literature

Asia–Pacific* 56 553 000 6.3% 3.8%a

UK 1 817 000 5.0% 2.1–3.9%b
US 7 477 000 4.8% 6.8%c
Denmark 214 000 6.4% 3.7%d
Norway 167 000 6.3% 5.4%e
Nepal 897 000 11.1% 18.3%f
Russia 6 526 000 7.6% N/A

*Sum of the figures for 12 countries in the Asia–Pacific region in this study in those 30 years of age and older
a
WHO by extrapolation.
b
40–74 year olds by symptoms.
c
≥ 17 year olds by spirometry.
d
20–90 year olds by spirometry.
e
18–70 year olds by symptoms and spirometry.
f
≥ 20 years age group by symptoms.
N/A, not applicable.
196 WC Tan et al.

Table 3 Projected number of cases of COPD due to smoking and non-smoking causes in those 30 years and older in 12
Asia–Pacific countries

Non-smoking details
COPD cases Population Urban (exposure)*
Non- Rural Urban Air Rural (exposure)**
Country Smoking Smoking % % pollution Occupational Occupational Biomass Unexposed

Australia 436 000 122 000 20% 80% 96% 4% 5% 0% 95%

China 29 394 000 8 767 000 69% 31% 96% 4% 1% 87% 12%
Hong Kong 91 000 48 000 0% 100% 96% 4% 0% 0% 0%
Korea 1 241 000 226 000 22% 78% 96% 4% 5% 0% 95%
Malaysia 354 000 94 000 44% 57% 96% 4% 5% 0% 95%
Philippines 1 269 000 422 000 70% 30% 96% 4% 1% 87% 12%
Singapore 42 000 22 000 0% 100% 96% 4% 0% 0% 0%
Taiwan 524 000 113 000 20% 80% 96% 4% 5% 0% 95%
Vietnam 1 643 000 424 000 60% 40% 96% 4% 1% 87% 12%
Thailand 906 000 595 000 88% 12% 96% 4% 1% 87% 12%
Indonesia 3 410 000 1 396 000 64% 36% 96% 4% 1% 87% 12%
Japan 4 278 000 736 000 10% 90% 96% 4% 5% 0% 95%

*Urban exposure, outdoor air pollution and occupational; **rural exposure, biomass and occupational.

Pacific region which is distinctive in several ways. It is
a heterogeneous region that is geographically and
economically diverse, and includes countries with
developed established market economies such as
Japan and Australia, and countries from the develop-
ing regions such as China and Southeast and East
Asia. The region is the most populous and arguably
the most economically dynamic with rapidly chang-
ing demographics, lifestyle and disease patterns.
The present study was initiated with the aim of pro-
ducing estimates of the prevalence of COPD for this
vast region using a validated algorithm model which
utilized easily obtainable and reasonably reliable
national statistics and standardized epidemiological
default data as inputs in order to generate preva-
lence estimates for intercountry and interregion
comparisons.
The model is especially applicable to Asia because
it also incorporates COPD cases caused by non-
smoking factors, which are increasingly being
recognized as having a significant impact on COPD
prevalence in developing countries.
The results from the model provided an estimate of
the size of the problem for individual countries where
no previous data existed. The extent of the variation
in smoking prevalence between the countries in the
Asia Pacific region is unique compared with that in
the Western countries as the high rates are found not
only in countries with established economies such as
Australia and Japan but also in developing countries
such as Vietnam and China. The size of the tobacco
problem highlights the urgent need for effective
national tobacco control programs as the key to the
primary prevention of COPD and the consequent
reduction of the burden of disease.
The study clearly shows that there are considerable
variations in the prevalence of COPD (range 3.5–
6.7%) in the countries of the Asia–Pacific region. The
major determinants of this variation are differences
between countries in smoking prevalence and in the
proportion of the population living in rural areas. The
presumed risk for COPD in rural dwellers is exposure
to biomass fuels, which are commonly used for cook-
ing and heating in poorly ventilated dwellings, lead-
ing to high levels of particulate matter in indoor
air.6,12–15 The contributions to the burden of COPD
from occupational exposure and from outdoor air
pollution are small compared with that of cigarette
smoking. The countries with the lowest prevalence
have the lowest rates of smoking and the lowest pro-
portion of rural dwellers. Although these figures for
different risk factors are estimates, nevertheless they
are helpful for healthcare planning.
The overall prevalence of 6.3% for COPD in the 12
countries surveyed is higher than the figure of 3.8%
that has been extrapolated from data in the WHO
report.1,2 This rate has been derived to provide a com-
parison of the prevalence rate for a similar region to
the 12 countries in the present study.
There are several reasons why the estimate in the
present study varies from the WHO data of Murray
and Lopez.2 First, the demographic regions reported
by Murray and Lopez (1997) to have a prevalence of
3.8% were designated ‘China and other Asian islands’.
The 12 countries reported in the present study to have
a prevalence of 6.3% included China and nine other
countries in common with those reported by Murray
and Lopez.2 However, the present study also included
Japan and Australia, both of which have a prevalence
greater than 3.8% (4.7 and 6.2%, respectively) but the
present study did not include India.
Second, the data of Murray and Lopez were
recorded as the total prevalence aggregated across
several age bands, one of which was 15–44 years. To
determine the prevalence in the population aged 30
years and older (to compare with the data in the
present study), it was necessary to make an estimate
of what proportion of the age band between 15 and
44 years was over the age of 30. Hence, there is some
imprecision in this estimate.
COPD in Asia–Pacific
Third, our data on smoking prevalence, which is
the major determinant of COPD prevalence, is prob-
ably accurate as it has been sourced from national
databases in the respective countries, which are
reported in the present study. In contrast, Murray and
Lopez had to resort to ‘encouraging experts to make
estimates in regions where no data were available’.
Compared with the literature8,23–25 cited for the
countries in Table 2, the model appears to both over-
estimate and underestimate depending on factors
such as the criteria for definition of COPD and the
age group of the study population. One of the issues
is that the model predicts in the population aged
over 30 years, while the studies cited vary in their
populations. Also, for Nepal8 in particular, the diag-
nosis is by symptoms for two rural communities. It is
unclear whether this number truly reflects the total
COPD population in the country. The UK study
quoted is for chronic bronchitis symptoms only.23
The Norway study design is population-based and
uses both symptoms and spirometry (5.4% is the
overall prevalence).16 There is one prevalence study
for Estonia (a former Soviet Republic) where the
English abstract stated merely that ‘5.5% to 9.3% of
the population corresponded to the definition of
chronic airway disease’ (Table 2). To date, when
actual population-based studies of prevalence using
symptoms and spirometry for definition16 and the
model have been compared, differences have been
small. For example, for Norway the model estimates
a prevalence of 6.3% and an actual study reported a
prevalence of 5.4%.16
The model also projected for COPD cases that were
due to non-smoking factors which comprise exposure
to high-risk occupations, biomass fuel and ambient
air pollution. Although air pollution has decreased
significantly in developed countries, it is becoming a
major concern in many cities in developing countries.
It is unclear which components of ambient air pollu-
tion are the most harmful, but there is evidence that
particles in polluted air add to the individual’s inhaled
burden. There is also no information on the long-
term cumulative effects of repeated severe exacerba-
tions of air pollution.
The projection for COPD cases due to non-
smoking risk factors may have been overestimated
for some countries in the study. In both Hong Kong
and Singapore, the proportion of non-smoking
COPD cases is higher than that in other regions.
Both regions were considered to be entirely urban
areas. The model’s default calculations enhance the
contribution of air pollution to the non-smoking
COPD cases for urban regions. This may result in an
overestimation of total COPD cases. Although air
pollution has been considered an important factor
in respiratory disease, its exact role in causing
COPD is not clear.18–20 Until further studies can
quantify the impact of air pollution, it appears rea-
sonable to include air pollution as a risk factor for
COPD development.
The main limitation of the model is that it is
extremely sensitive to estimates of smoking preva-
lence, and errors in smoking rates will greatly influ-
ence the prevalence predictions. Hence, the model is
197
highly dependent upon the accuracy of smoking
rates. We believe that we have obtained accurate
information on smoking for the countries included in
the present study. Another drawback of the model is
that it does not take into account the influence of the
interaction of several concurrent risk factors on
the prevalence of COPD.
Furthermore the model does not include all of the
potential risk factors for a population, particularly
those genetic factors associated with ethnicity. How-
ever, objective information of this type is currently
limited in the literature. In addition, the intent of the
model is to provide a reliable estimate of COPD in a
population to help guide policy makers and health-
care advocates. We believe the current model ade-
quately fulfills this important role.
It must also be noted that it is possible that these
estimates of COPD prevalence may be underesti-
mates because the model’s logic is based on the spiro-
metric definition of obstruction based on FEV1/FVC
which is widely used in published studies. The use of
absolute FEV1/FVC ratio in defining COPD may result
in the potential underestimation of the COPD burden
in the population due to a number of technical fac-
tors. The variation of the lower normal limit of FEV1/
FVC ratio with age may result in an underestimation
of the total disease burden. Furthermore, the use of
FEV1/FVC ratio rather than FEV1/VC may also result
in an overestimation of the ratio (hence underestima-
tion of the burden) as the FVC is lower than the VC
because of earlier airway closure due to a forced
manoeuvre in patients with airway obstruction.22
Finally, the model’s focus on moderate-to-severe
cases is likely to result in overall underestimation of
total COPD burden.
The present study may appear to have overesti-
mated the prevalence to a small extent as has been
shown in countries where direct comparison between
the prevalence determined by field studies and the
model has been made. However, for the reasons
stated above, it is probably a more accurate estimate
than the previous estimate of Murray and Lopez.2
Nevertheless, the COPD prevalence figures in this
report should be interpreted with caution because
they are derived from a statistical model, which
requires further validation in other epidemiological
settings in order to confirm its accuracy. Despite
these limitations the main value of the model lies in
its ease of application and ability to provide system-
atic estimates of COPD prevalence and to provide
some insight into the relative contributions of
tobacco and non-tobacco risk factors for planning
purposes. Because these figures are only statistical
estimates there is still a need for properly conducted
population-based studies of COPD in the Asia–
Pacific region in order to confirm their accuracy.
While we await the results of these field studies, the
model has given us a very good idea of the extent of
the problem of COPD in the region. These figures
from the model are important as they have generated
hypotheses that await further research and can be
used to assist policy makers as the first step in deter-
mining COPD expenditures and establishing
resource allocation priorities.
198
ACKNOWLEDGEMENTS
We would like to thank Dr Carol Zaher, Dr Ahmar
Iqbal, Dr Manuel Distel and Ms Serene Hsu for their
invaluable and indispensable help in coordinating
the preparation of the manuscript.
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