Effect of indoor air pollution from biomass combustion on prevalence of asthma in the elderly. (Research).In this study I examined the effect of cooking smoke on the reported prevalence of asthma among elderly men and women ([greater than or equal to] 60 years old). The analysis is based on 38,595 elderly persons included in India's second National Family Health Survey conducted in 1998-1999. Effects of exposure to cooking smoke, ascertained by type of fuel used for cooking (biomass fuels, cleaner fuels, or a mix of biomass and cleaner fuels), on the reported prevalence of asthma were estimated using logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. . Because the effects of cooking smoke are likely to be confounded with effects of age, tobacco smoking, education, living standard, and other such factors, the analysis was carried out after statistically controlling for such factors. Results indicate that elderly men and women living in households using biomass fuels have a significantly higher prevalence of asthma than do those living in households using cleaner fuels [odds ratio (OR) = 1.59; 95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. (95% CI), 1.30-1.94], even after controlling for the effects of a number of potentially confounding confounding when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies. confounding factor factors. Active tobacco smoking was also associated with higher asthma prevalence in the elderly, but not environmental tobacco smoke environmental tobacco smoke (ETS/passive smoke), n the gaseous by-product of burning tobacco products, including but not limited to commercially manufactured cigarettes and cigars; contains toxic elements harmful to the health of adults and children . Availability of a separate kitchen in the house and a higher living standard of the household were associated with lower asthma prevalence. The adjusted effect of cooking smoke on asthma was greater among women (OR = 1.83; 95% CI, 1.32-2.53) than among men (OR = 1.46; 95% CI, 1.14-1.88). The findings have important program and policy implications for countries such as India, where large proportions of the population rely on polluting pol·lute tr.v. pol·lut·ed, pol·lut·ing, pol·lutes 1. To make unfit for or harmful to living things, especially by the addition of waste matter. See Synonyms at contaminate. 2. biomass fuels for cooking and space heating Space heating is the heating of a space, usually enclosed, such as a house or room. A space heater keeps the air and surroundings at a comfortable temperature for people or animals, or even plants in a greenhouse. . More epidemiologic research with better measures of smoke exposure and clinical measures of asthma is needed to validate the findings. Key words: asthma, biomass fuels, cooking smoke, elderly, indoor air pollution, respiratory health, tobacco smoking. Environ Health Perspect 111:71-77 (2003). [Online 3 December 2002] doi:10.1289/ehp.5559 available via http://dx.doi.org/ ********** Increasing prevalence of asthma in both developed and developing countries has been a major public health challenge for more than two decades (Anderson 1997; Platts-Mills and Woodfolk 1997; World Resources Institute Founded in 1982, the World Resources Institute (WRI) is an environmental think tank based in Washington, D.C. WRI is an independent, non-partisan and nonprofit organization with a staff of more than 100 scientists, economists, policy experts, business analysts, statistical 1998). Asthma is a chronic respiratory disease Noun 1. respiratory disease - a disease affecting the respiratory system respiratory disorder, respiratory illness adult respiratory distress syndrome, ARDS, wet lung, white lung - acute lung injury characterized by coughing and rales; inflammation of the characterized by sudden attacks of labored breathing, chest tightness, and coughing. It is a complex multifactorial multifactorial /mul·ti·fac·to·ri·al/ (mul?te-fak-tor´e-al) 1. of or pertaining to, or arising through the action of many factors. 2. disease with both genetic and environmental components. A rapid increase in asthma in recent years cannot be ascribed to changes in genetic (heritable her·i·ta·ble adj. 1. Capable of being passed from one generation to the next; hereditary. 2. Capable of inheriting or taking by inheritance. ) factors; the focus of interventions for the increased prevalence of asthma, therefore, should be on environmental factors. A number of studies have suggested that ambient air pollution can trigger asthma attacks (Bjorksten 1999; Koren and Utell 1997). Exposure to several specific air pollutants pollutants see environmental pollution. , such as respirable respirable /res·pir·a·ble/ (re-spir´ah-b'l) 1. suitable for respiration. 2. small enough to be inhaled. res·pi·ra·ble adj. 1. Fit for breathing, as air. particulate matter particulate matter n. Abbr. PM Material suspended in the air in the form of minute solid particles or liquid droplets, especially when considered as an atmospheric pollutant. Noun 1. [[less than or equal to] 10 [micro]m in aerodynamic diameter Drug particles for pulmonary delivery are typically characterized by aerodynamic diameter rather than geometric diameter. The velocity at which the drug settles is proportional to the aerodynamic diameter, da. (P[M.sub.10])], carbon monoxide carbon monoxide, chemical compound, CO, a colorless, odorless, tasteless, extremely poisonous gas that is less dense than air under ordinary conditions. It is very slightly soluble in water and burns in air with a characteristic blue flame, producing carbon dioxide; (CO), ozone ([O.sub.3]), sulfur dioxide sulfur dioxide, chemical compound, SO2, a colorless gas with a pungent, suffocating odor. It is readily soluble in cold water, sparingly soluble in hot water, and soluble in alcohol, acetic acid, and sulfuric acid. (S[O.sub.2]), and nitrogen dioxide nitrogen dioxide n. A poisonous brown gas, NO2, often found in smog and automobile exhaust fumes and synthesized for use as a nitrating agent, a catalyst, and an oxidizing agent. Noun 1. (N[O.sub.2]), has been associated with increased asthma symptoms (Baldi et al. 1999; Bates Bates , Katherine Lee 1859-1929. American educator and writer best known for her poem "America the Beautiful," written in 1893 and revised in 1904 and 1911. 1995; Castellsague et al. 1995; de Diego Damia et al. 1999; Greer et al. 1993; Hajat et al. 1999; Koren 1995; Zhang et al. 1999). In indoor environments, home bioallergens such as dust mites dust mite House dust mite, see there , molds, cockroach cockroach or roach, name applied to approximately 3,500 species of flat-bodied, oval insects forming the order Blattodea. Cockroaches have long antennae, long legs adapted to running, and a flat extension of the upper body wall that conceals the parts, and animal dander animal dander See Dander. (Dales et al. 1991; Lewis et al. 2002; Litonjua et al. 1997; Rosenstreich et al. 1997; Thorn thorn, in botany thorn, sharp-pointed projection on some plants, usually protective in function. Botanically, thorns are distinguished as modified stems (as in the honey locust and hawthorn) from spines, which are modified leaves (as in the barberry), and et al. 2001; Togias et al. 1997; Weiss et al. 1993), and household cleaning agents, pesticides, and mosquito mosquito (məskē`tō), small, long-legged insect of the order Diptera, the true flies. The females of most species have piercing and sucking mouth parts and apparently they must feed at least once upon mammalian blood before their eggs can coil smoke (Azizi and Henry 1991; Azizi et al. 1995; Weiss et al. 1993) have been linked to increased risk of developing asthma. A number of lifestyle-related factors, such as outdoor activity and exercise, have also been associated with modifying asthma (Platts-Mills and Woodfolk 1997). Numerous studies have suggested that exposure to tobacco smoke can increase the risk of developing asthma (Azizi and Henry 1991; Azizi et al. 1995; Flodin et al. 1995; Martinez et al. 1992; Strachan and Cook 1998; Thorn et al. 2001). According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. one estimate, children have about twice the risk of developing asthma if one or both parents smoke (NHLBI NHLBI, n.pr See National Heart, Lung, and Blood Institute. 1995). Several studies have found that exposure to tobacco smoke can increase the frequency and severity of attacks in asthmatics (Althuis et al. 1999; Beeh et al. 2001; Eisner et al. 1998; Siroux et al. 2000), but some fail to link tobacco smoking to onset of asthma in adults (Ben-Noun 1999; Siroux et al. 2000; Vesterinen et al. 1988). Much of the research on factors affecting asthma has been in urban areas of developed countries. In many homes in developing countries, however, a major source of exposure to indoor air pollutants is cooking smoke, when people rely on unprocessed biomass fuels such as wood, crop residues There are two types of agricultural crop residues. Field residues are materials left in an agricultural field or orchard after the crop has been harvested. These residues include stalks and stubble (stems), leaves, and seed pods. , and dung DUNG. Manure. Sometimes it is real estate, and at other times personal property. When collected in a heap, it is personal estate; when spread out on the land, it becomes incorporated in it, and it is then real estate. Vide Manure. cakes for cooking and space heating. According to some estimates, more than half of the world's population still relies on unprocessed biomass fuels for cooking and heating (Bruce et al. 2000). In the developing countries of South Asia This article is about the geopolitical region in Asia. For geophysical treatments, see Indian subcontinent. South Asia, also known as Southern Asia and sub-Saharan Africa, this proportion is as high as 80% or more (Holdren and Smith 2000). These fuels are typically burned indoors in simple household cookstoves, such as a pit, three pieces of brick, or a U-shaped construction made from mud, which burn these fuels inefficiently and are often not vented with flues or hoods to take the pollutants to the outside. Even when the cookstoves are vented to the outside, combustion of unprocessed solid fuels produces enough pollution to significantly affect local "neighborhood" pollution levels, with implications for total exposures (Smith 2002). Under these conditions, high volumes of a number of health-damaging airborne pollutants, including P[M.sub.10], CO, N[O.sub.x], S[O.sub.x] (more from coal), formaldehyde formaldehyde (fôrmăl`dəhīd'), HCHO, the simplest aldehyde. It melts at −92°C;, boils at −21°C;, and is soluble in water, alcohol, and ether; at STP, it is a flammable, poisonous, colorless gas with a suffocating , and dozens of toxic polycyclic aromatic hydrocarbons polycyclic aromatic hydrocarbon n. Any of a class of carcinogenic organic molecules that consist of three or more rings containing carbon and hydrogen and that are commonly produced by fossil fuel combustion. (e.g., benzo[a]pyrene) and other organic matter, are generated indoors. Because cookstoves are usually used for several hours each day at times when people are present indoors, their exposure effectiveness is high; that is, the percentage of their emissions that reach people's breathing zones is much higher than for outdoor sources. The individual peak and mean exposures experienced in such settings are often much greater than the safe levels recommended by the World Health Organization (WHO 1997). Bruce et al. (2000) compared typical levels of CO, P[M.sub.10], and P[M.sub.2.5] in homes in developing countries that use biomass fuels, with the U.S. Environmental Protection Agency's standards for 24-hr average and concluded that indoor concentrations of these pollutants in homes that use biomass fuels usually exceed the guideline guideline Medtalk A series of recommendations by a body of experts in a particular discipline. See Cancer screening guidelines, Cardiac profile guidelines, Gatekeeper guidelines, Harvard guidelines, Transfusion guidelines. levels by several-fold. The poorest and most vulnerable populations in developing countries are most exposed to indoor air pollution from biomass combustion for cooking and heating. Exposure levels are usually much higher among women who tend to do most of the cooking (Behera et al. 1988) and among young children who are often held on their mother's back or lap during cooking times (Albalak 1997). The elderly and the disabled also tend to stay indoors and therefore have higher exposure levels. High exposures to air pollutants in biomass smoke have been associated with a host of respiratory diseases, including acute respiratory infections Noun 1. respiratory infection - any infection of the respiratory tract respiratory tract infection infection - the pathological state resulting from the invasion of the body by pathogenic microorganisms (Armstrong and Campbell 1991; Collings et al. 1990; Smith et al. 2000), chronic bronchitis chronic bronchitis n. Inflammation of the bronchial mucous membrane, characterized by cough, hypersecretion of mucus, and expectoration of sputum over a long period of time and associated with increased vulnerability to bronchial infection. (Albalak et al. 1999; Bruce et al. 1998; Pandey 1984), and tuberculosis (Mishra et al. 1999; Perez-Padilla et al. 2001). But the evidence on the effect of cooking smoke on asthma is mixed (Bruce et al. 2000), even though it contains some of the same pollutants that are found in ambient air pollution or tobacco smoke, both of which have been associated with asthma. Anecdotal anecdotal /an·ec·do·tal/ (an?ek-do´t'l) based on case histories rather than on controlled clinical trials. anecdotal adjective Unsubstantiated; occurring as single or isolated event. association of asthma with cooking smoke is common, but few epidemiologic studies epidemiologic study A study that compares 2 groups of people who are alike except for one factor, such as exposure to a chemical or the presence of a health effect; the investigators try to determine if any factor is associated with the health effect seem to have been done (Smith 2002). Of the limited research that does exist on this subject, some studies have found a positive association between cooking smoke and asthma (Mohammed et al. 1995; Pistelly 1997; Thorn et al. 2001; Xu et al. 1996), whereas others found no relationship (Azizi et al. 1995; Maier et al. 1997; Noorhassim et al. 1995; Qureshi 1994) or found a protective effect (Volkmer et al. 1995; von Mutius et al. 1996). The mechanisms by which cooking smoke might influence asthma are not well understood. Air pollutants commonly found in biomass smoke have been associated with compromised pulmonary immune defense mechanisms in both animals and humans (Chang et al. 1990; Fujii et al. 2001; Green et al. 1977; Hardin et al. 1992; Kong et al. 1994; Mukae et al. 2001; Schnizlein et al. 1982; Tan et al. 2000; Taszakowski and Dwornicki 1992; van Eeden et al. 2001; Wang and Hu 1992; Zelikoff 1994). It is plausible that exposure to cooking smoke can impair im·pair tr.v. im·paired, im·pair·ing, im·pairs To cause to diminish, as in strength, value, or quality: an injury that impaired my hearing; a severe storm impairing communications. pulmonary defense mechanisms and increase the risk of developing asthma or increase the frequency and severity of attacks in asthmatic people. In this article I examine the effect of cooking smoke on the prevalence of asthma among the elderly in a developing country--India--using data from a nationally representative sample. Materials and Methods Data. Data are from India's second National Family Health Survey (NFHS-2) conducted in 1998-1999. NFHS-2 collected demographic, socioeconomic, and health information from a nationally representative probability sample of 92,486 households. All states of India are represented in the sample, covering more than 99% of the country's population. The sample is a multistage mul·ti·stage adj. 1. Functioning in more than one stage: a multistage design project. 2. Relating to or composed of two or more propulsion units. cluster sample with an overall response rate of 98%. Details of sample design, including sampling frame and sample implementation, are provided in the basic survey report for all India All India is a phrase used to refer the all the states/regions of India together, esp. during the pre-independence days of India. During the period "All India" essentially included what is now as separate nations such as Pakistan, Bangladesh. (IIPS IIPS Industry Interactive Procurement System IIPS Institute for International Policy Studies IIPS International Intellectual Property Society IIPS Institute for International Peace Studies IIPS Institutional Information Processing System and ORC Orc monstrous sea creature; devours human beings. [Ital. Lit.: Orlando Furioso] See : Monsters Macro 2000). The analysis here is based on 38,595 persons 60 or more years old living in the sample households. Response variable. The survey asked several questions relating to relating to relate prep → concernant relating to relate prep → bezüglich +gen, mit Bezug auf +acc the current health status of household members, including whether each member suffered from asthma. The question was (referring to the listing of persons in the household) "Does anyone listed suffer from asthma?" The household head or other knowledgeable adult in the household reported for each household member. The survey was conducted using an interviewer-administered questionnaire in the native language of the respondent using a local, commonly understood term for asthma. A total of 18 languages were used in the survey. No effort was made to clinically test for the disease. It is important to recognize that reported asthma is not as accurate as clinical measures of asthma. Because the disease carries a stigma stigma: see pistil. Stigma mark of Cain God’s mark on Cain, a sign of his shame for fratricide. [O. T.: Genesis 4:15] scarlet letter , reported prevalence of asthma may be underestimated because of intentional concealment or lack of knowledge, especially for children and young adults. For the elderly, however, there is not much stigma attached to the disease and it is not considered contagious contagious /con·ta·gious/ (-jus) capable of being transmitted from one individual to another, as a contagious disease; communicable. con·ta·gious adj. 1. Of or relating to contagion. like tuberculosis, so underreporting due to intentional concealment should not be a major problem. There is also a possibility of overreporting because some other disease conditions with similar symptoms, such as chronic bronchitis or chronic obstructive pulmonary disease chronic obstructive pulmonary disease n. Abbr. COPD A chronic lung disease, such as asthma or emphysema, in which breathing becomes slowed or forced. , may be reported as asthma. In India, where clinical data on asthma are mostly unavailable or very weak, this reported prevalence of asthma from a representative national sample provides a unique opportunity to examine the factors associated with asthma prevalence among the elderly. In our analysis, this reported prevalence of asthma is the response variable. Predictor variables Noun 1. predictor variable - a variable that can be used to predict the value of another variable (as in statistical regression) variable quantity, variable - a quantity that can assume any of a set of values . Exposure to cooking smoke is ascertained indirectly by type of fuel used for cooking or heating. The survey used a 10-item classification of cooking fuel: wood, crop residues, dung cakes, coal/coke/lignite, charcoal, kerosene kerosene or kerosine, colorless, thin mineral oil whose density is between 0.75 and 0.85 grams per cubic centimeter. A mixture of hydrocarbons, it is commonly obtained in the fractional distillation of petroleum as the portion boiling off , electricity, liquid petroleum gas, biogas bi·o·gas n. A mixture of methane and carbon dioxide produced by bacterial degradation of organic matter and used as a fuel. biogas Noun gaseous fuel produced by the fermentation of organic waste , and a residual category of other fuels. The question was "What type of fuel does your household mainly use for cooking?" followed by the above list of fuels. The survey also included a second question, "What other types of fuel does your household commonly use for cooking or heating?" with the same 10-item classification of fuels. This second question was a multiple response question, meaning a respondent could choose more than one fuel. We used information from these questions to group households into three categories representing the extent of exposure to cooking smoke--high-exposure group (households using only biomass fuels: wood, crop residues, or dung cakes), low-exposure group (households using only cleaner fuels: kerosene, petroleum gas, biogas, or electricity), and medium-exposure group (a mix of biomass fuels and cleaner fuels or coal/coke/lignite/charcoal). This three-category classification of fuels is the principal predictor variable. The survey also collected information on tobacco smoking (both current and lifetime) for each household member. For all persons in the sampled households, the NFHS-2 asked "Does anyone listed smoke?" For current nonsmokers, the survey asked "Has any (other) person listed ever smoked regularly?" The information from these two questions was used to ascertain exposure to tobacco smoke--active smoking (person currently smokes or has smoked regularly in the past), passive smoking (one or more other persons in the household smoke currently), no smoking (the person has never smoked regularly and no other person in the household smokes currently). Because the effects of exposure to cooking smoke as well as tobacco smoke on the prevalence of asthma are likely to be confounded with the effects of other risk factors, it is necessary to statistically control, or adjust, for such factors. Control variables included in this study were age, sex, marital status marital status, n the legal standing of a person in regard to his or her marriage state. , education, religion of household head, caste/tribe of household head, house type, availability of a separate kitchen in the house, crowding in the household, living standard of the household, urban/rural residence, and geographic region. For definition of variables, see Table 1. Analysis. Because our response variable--prevalence of asthma--is dichotomous di·chot·o·mous adj. 1. Divided or dividing into two parts or classifications. 2. Characterized by dichotomy. di·chot , we use logistic regression to estimate the effects of cooking smoke (from biomass fuel use relative to cleaner fuel use) and tobacco smoke (both active and passive) on asthma prevalence with the other 12 demographic and socioeconomic variables mentioned above as controls. Because of large sex differentials sex differential The ♂ to ♀ difference in M&M; in general, when all causes of death are considered, the mortality rate is lower, the likelihood of survival greater, and life expectancy longer in ♀. See Men, Sex-specific mortality rate, Women. in the exposure to cooking smoke and tobacco smoke, the analysis is also carried out separately for men and women. Results are presented in the form of odds ratios (ORs) with 95% confidence intervals (95% CI). The estimation of confidence intervals takes into account design effects due to clustering at the level of the primary sampling unit. The logistic regression models were estimated using the STATA statistical software package (Stata Corporation 2001). Before carrying out the multivariate The use of multiple variables in a forecasting model. models, we tested for the possibility of multicollinearity between the predictor variables. In the correlation matrix Noun 1. correlation matrix - a matrix giving the correlations between all pairs of data sets statistics - a branch of applied mathematics concerned with the collection and interpretation of quantitative data and the use of probability theory to estimate population of predictor variables, all pairwise Pearson correlation coefficients Correlation Coefficient A measure that determines the degree to which two variable's movements are associated. The correlation coefficient is calculated as: are < 0.5, suggesting that multicollinearity is not a problem. In the survey, certain states and certain categories of households were oversampled. In all our analysis, weights are used to restore the representativeness of the sample (IIPS and ORC Macro 2000). Results Profile of the elderly. According to the NFHS-2, about 8% of India's population is [greater than or equal to] 60 years old (IIPS and ORC Macro 2000). Table 1 shows the distribution of elderly people by selected background characteristics. Fifty-nine percent of the elderly live in households using biomass fuels (wood, dung cakes, or crop residues), 15% live in households using cleaner fuels (kerosene, liquid petroleum gas, biogas, or electricity), and the remaining 26% live in households that use a mix of biomass fuels and cleaner fuels or coal/coke/lignite or charcoal. Forty-seven percent of elderly men and 6% of elderly women currently smoke tobacco or have smoked regularly in the past. Another 10% of men and 36% of elderly women live in households where someone else smokes. The proportion of elderly declines by age, as expected. Sixty-two percent are currently married (81% of men and 41% of women). About two-thirds are illiterate ILLITERATE. This term is applied to one unacquainted with letters. 2. When an ignorant man, unable to read, signs a deed or agreement, or makes his mark instead of a signature, and he alleges, and can provide that it was falsely read to him, he is not bound by , and only 12% have middle school or higher education higher education Study beyond the level of secondary education. Institutions of higher education include not only colleges and universities but also professional schools in such fields as law, theology, medicine, business, music, and art. . The proportion illiterate is much higher for women than for men (82% and 50%, respectively), as expected. Distribution by religion and caste/tribe resembles that in the total population, with a little more than four out of five elderly belonging to Hindu religion and one out of four belonging to a scheduled caste sched·uled caste n. Any of the historically disadvantaged Indian castes of low rank, now under government protection. [From such castes having been entered on a list or "schedule" during British rule.] or scheduled tribe. About one-third live in pucca (higher-quality) houses, about one-half live in houses without a separate kitchen, and more than one-third live in houses with three or more persons per room. Two of five live in households with a low standard of living, and one of five lives in a household with a high standard of living. Three of four live in rural areas, and one of two lives in the central and east region. Prevalence of asthma among the elderly. Asthma is a serious problem among the elderly in India. According to the NFHS-2, one of every 10 people [greater than or equal to] 60 years old suffers from asthma (IIPS and ORC Macro 2000). Table 2 shows that the prevalence of asthma is higher among elderly men than among elderly women and higher in rural areas than in urban areas. By type of cooking fuel, elderly living in households using biomass fuels are about two times more likely to suffer from asthma (11.9%) than are those living in households using cleaner fuels (6.6%). Elderly who smoke (or have ever smoked regularly in the past) are also much more likely to suffer from asthma than are those who have never smoked. Elderly with middle school or more education are less likely to suffer from asthma than are those with less or no education. The prevalence of asthma is considerably lower among the elderly living in households with a separate kitchen and among elderly living in households with a high standard of living. The prevalence is also somewhat lower among elderly living in pucca houses and among those living in houses with fewer than three persons per room. The prevalence does not vary much by other characteristics. Differentials in the prevalence of asthma by sex are similar to those discussed above for both men and women combined. Effects of cooking smoke on asthma. Table 3 shows the estimated effects of cooking smoke, tobacco smoke, and selected demographic and socioeconomic variables on the prevalence of asthma among the elderly (> 60 years old) in alternative models. Model 1 in Table 3 shows that unadjusted odds of suffering from asthma are almost two times higher among the elderly living in households using biomass fuels for cooking than among those living in households using cleaner fuels for cooking (OR = 1.92; 95% CI, 1.67-2.19). Elderly living in households using a mix of biomass fuels and cleaner fuels or coal/coke/lignite or charcoal are also at a considerably higher risk of suffering from asthma (OR = 1.40; 95% CI, 1.21-1.62). Controlling for exposure to tobacco smoke (in Model 3) reduces the effect of biomass fuel use on asthma prevalence slightly (OR = 1.75; 95% CI, 1.53-2.01). The effect of biomass fuel use remains virtually unchanged when the two demographic variables--age and sex--are additionally controlled in Model 4. Even when the 10 socioeconomic control variables are included in Model 5, cooking with biomass fuels still has a large and statistically significant effect (OR = 1.59; 95% CI, 1.30-1.94) on the prevalence of asthma among the elderly. In the full model (Model 5), the elderly living in households using a mix of biomass and cleaner fuels or coal/coke/lignite or charcoal also have a significantly higher risk of suffering from asthma compared with those living in households that use cleaner fuels (OR = 1.24; 95% CI, 1.04-1.49). Effects of tobacco smoke on asthma. Elderly men and women who currently smoke tobacco or have ever smoked regularly in the past are at a considerably higher risk of suffering from asthma (OR = 1.79; 95% CI, 1.63-1.96) than do those who have never smoked and do not live in a household with other smokers (Model 2, Table 3). This effect is reduced somewhat when the effect of cooking smoke is controlled (OR = 1.66; 95% CI, 1.51-1.82) and reduced further when respondent's age and sex are additionally controlled (OR = 1.54; 95% CI, 1.39-1.71). In the full model (Model 5), when the effects of cooking fuel type and the 12 other variables are controlled, the odds of suffering from asthma are 1.55 (95% CI, 1.39-1.73) times higher among the elderly who are current smokers or have ever smoked regularly than among those who have never smoked tobacco regularly and do not live in a household with other smokers. Passive smoking does not seem to have any significant effect on the risk of asthma among the elderly. Elderly men and women who have never smoked tobacco regularly but who live in households where other household members smoke are about as likely to suffer from asthma as those who never smoked who live in households where no one else smokes (OR = 1.09; 95% CI, 0.97-1.22). Effects of the control variables on asthma. The discussion of the adjusted effects of the control variables focuses on the full model (Model 5) in Table 3. With other variables controlled, age has a positive effect on the prevalence of asthma and women have a considerably lower prevalence of asthma than do men. Effects of both age and sex are statistically significant. Elderly men and women with middle school or higher education have significantly lower prevalence of asthma than do those with less or no education. As expected, elderly living in households with a separate kitchen have a significantly lower prevalence of asthma than do those living in households without a separate kitchen. Also as expected, household living standard has a significant negative effect on asthma prevalence among the elderly. However, contrary to the expectation, elderly living in higher-quality (pucca) housing have a significantly higher risk of asthma do than those living in kachha (lower-quality) houses. Crowding within the house also has a negative effect on the prevalence of asthma, but the effect of crowding is not significant statistically. With other variables controlled, the prevalence of asthma among the elderly does not vary significantly by urban/rural residence. Marital status of the elderly at the time of the survey, religion, and membership in a scheduled caste or scheduled tribe also do not have significant effects on asthma prevalence in the elderly. By geographic region, elderly in the western region have significantly higher prevalence of asthma than do those in other regions. Sex differences in effects. Because women tend to do the cooking and are much more exposed than are men to cooking smoke, because men are much more likely than are women to smoke tobacco, and because there are sex differences in nutritional status nutritional status, n the assessment of the state of nourishment of a patient or subject. , susceptibility to disease, and access to treatment and care, the effects of cooking smoke on asthma are likely to vary by sex. To examine this, we repeated the above analysis separately for men and women. Only adjusted effects in full models are presented in Table 4. The adjusted effect of exposure to cooking smoke (biomass fuel use relative to cleaner fuel use) on the prevalence of asthma is large and statistically significant for both elderly men and women. The adjusted effect is larger for women (OR = 1.83; 95% CI, 1.32-2.53) than for men (OR = 1.46; 95% CI, 1.14-1.88). Elderly women in households using a mix of biomass and cleaner fuels also have significantly higher asthma prevalence than do those in households using only cleaner fuels (OR = 1.48; 95% CI, 1.12-1.97), but this adjusted effect of fuel mix for elderly men is small and not significant statistically (OR = 1.12; 95% CI, 0.89-1.41). The adjusted effects of active tobacco smoking (ever smoked tobacco regularly) on asthma are also large and statistically significant for both men and women. Again, the effect is larger for women (OR = 1.89; 95% CI, 1.49-2.39) than for men (OR = 1.50; 95% CI, 1.33-1.69). Adjusted effects of passive smoking (others in the household smoke) are much smaller for both men and women and statistically not significant. With the effects of cooking smoke, tobacco smoke, and other variables controlled, only age, household living standard, and geographic region have significant effects on asthma prevalence for both men and women. Availability of a separate kitchen has a significant negative effect on asthma prevalence in men, but this effect is relatively small and not statistically significant for women. Education has a significant negative effect for men, but for women the relationship is reversed and the effect is not statistically significant. Both elderly men and women in pucca houses have higher prevalence of asthma than do those living in kachha houses, but these effects are also not significant. Effects of all other control variables are small and not significant statistically. Discussion Results from this study suggest that exposure to cooking smoke is strongly associated with the prevalence of asthma among elderly men and women, independent of exposure to tobacco smoke, age, education, living standard, and other factors. Active tobacco smoking also has substantial effects, but passive smoking tends not to have any significant effect. Effects of both cooking smoke and tobacco smoke are greater for women than for men. The finding that the effect of cooking smoke is greater for women than for men is consistent with expectation, because women are more exposed than men to cooking smoke. However, given the relatively low status of women in India The status of women in India has been subject to great many changes over the past few millennia. From a largely unknown status in ancient times through the low points of the medieval period, to the promotion of equal rights by many reformers, the history of women in India has been , asthma may be less likely to be reported to be spoken of; to be mentioned, whether favorably or unfavorably. See also: Report for women than for men, especially in households that use biomass fuels for cooking. For this reason, the sex differential in the effect of cooking smoke on asthma may be greater than indicated by our analysis. A larger effect of tobacco smoking in women than in men may reflect greater vulnerability of women because of their compromised respiratory system respiratory system: see respiration. respiratory system Organ system involved in respiration. In humans, the diaphragm and, to a lesser extent, the muscles between the ribs generate a pumping action, moving air in and out of the lungs through a from cooking smoke, poorer nutritional status, and less access to treatment and care compared with men. A larger negative effect of availability of a separate kitchen for men than for women is consistent with expectation became availability of a separate kitchen in the household is more likely to reduce cooking smoke exposures in men than in women, who do much of the cooking. To the extent that the effect of cooking smoke on asthma is cumulative over time, previous shifts from biomass fuels to cleaner fuels tend to downwardly bias our estimates of the effect. Our estimated effect is also downwardly biased to the extent that asthma is more likely to be underreported for persons from households that use biomass fuels. On the other hand, our estimated effect may be upwardly biased to the extent households that use biomass fuels are more likely to report some other disease condition with similar symptoms as asthma. To the extent that this happens, our results represent the association of biomass combustion with chronic respiratory disorders Noun 1. respiratory disorder - a disease affecting the respiratory system respiratory disease, respiratory illness adult respiratory distress syndrome, ARDS, wet lung, white lung - acute lung injury characterized by coughing and rales; inflammation of the in elderly Indians, including asthma. In cases where asthma might have been confused with some other chronic respiratory disorder, it is not possible from our data to separate the effect on asthma from the effect on some other condition with similar symptoms. Moreover, we are not able to control directly for extent of use of medical services in connection with asthma, although our set of control variables includes several measures of socioeconomic status socioeconomic status, n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion. , which is correlated with access to and use of medical services. Well-designed epidemiologic studies with better measures of smoke exposure and clinical measures of asthma are needed to validate the findings of this study and to better understand the pathogenesis pathogenesis /patho·gen·e·sis/ (path?ah-jen´e-sis) the development of morbid conditions or of disease; more specifically the cellular events and reactions and other pathologic mechanisms occurring in the development of disease. of asthma. The findings from this study have important policy and program implications, including the need for public information campaigns designed to inform people about the risks of exposure to cooking smoke and, where shifts to cleaner fuels are not feasible, programs to promote improved cookstoves designed to reduce exposure to smoke by means of improved combustion and improved venting venting, n an exit passage constructed in a casting mold to allow gases to escape during the casting process. venting Ventilation Psychology The verbalization* of one's 'emotional baggage' to another person; qvetching . For such programs to be effective, local needs and community participation should be given high priority. Programs to reduce exposure to tobacco smoke should be promoted, in addition to strengthening asthma prevention and treatment programs.
Table 1. Variable definitions and distribution of elderly
([greater than or equal to] 60 years old) by selected
characteristics, India, 1998-1999.
Characteristic Male Female Total
Cooking smoke (a)
Biomass fuels 59.6 57.6 58.7
Fuel mix 25.8 27.0 26.4
Cleaner fuel 14.6 15.4 14.9
Tobacco smoke
Active smoking 46.8 6.0 27.4
Passive smoking 9.7 36.3 22.4
No smoking 43.5 57.7 50.2
Age
60-64 35.7 38.9 37.2
65-69 24.5 25.7 25.0
70-74 21.0 17.7 19.4
[greater than or equal to] 75 18.8 17.7 18.3
Marital status
Currently married 81.3 40.6 62.0
Not married 18.7 59.4 38.0
Education
Illiterate 49.8 82.3 65.3
Literate, < middle completed 31.5 13.6 23.0
Middle completed or higher 18.7 4.0 11.7
Religion
Hindu 82.5 82.7 82.6
Muslim 10.7 10.6 10.7
Other (b) 6.8 6.7 6.8
Caste/tribe (c)
Scheduled caste/scheduled tribe 26.5 25.4 26.0
Other 73.5 74.6 74.0
House type (d)
Pucca 31.6 33.3 32.4
Semi-pucca 36.2 35.7 36.0
Kachha 32.1 31.0 31.6
Separate kitchen
Yes 55.0 55.7 55.3
No 45.0 44.3 44.7
Crowding
< 3 persons per room 63.7 64.2 63.9
[greater than or equal to] 3 persons 36.3 35.8 36.1
per room
Standard of living (e)
Low 40.6 42.3 41.4
Medium 39.7 37.8 38.8
High 19.8 20.0 19.9
Residence
Urban 23.3 25.2 24.2
Rural 76.7 74.9 75.8
Region (f)
North and Northeast 4.1 3.6 3.9
Central and East 52.8 49.5 51.2
West 18.7 20.6 19.6
South 24.3 26.3 25.3
Number of elderly (g) 20,418 18,177 38,595
(a) Biomass fuels: wood, dung, or crop residues; fuel mix: mix of
biomass and cleaner fuels or coal/coke/lignite; cleaner fuel: kerosene,
petroleum gas, biogas, or electricity. (b) Sikh, Buddhist, Christian,
Jain, Jewish, Zorastrian. (c) Castes and tribes identified by the
Government of India as socially and economically backward and needing
protection from social injustice and exploitation. (d) Pucca houses
are made from high-quality materials (bricks, tiles, cement, and
concrete) throughout, including roof, walls, and floor; kachha houses
are made from mud, thatch, or other low-quality materials. Semi-pucca
houses are made from a combination. (e) Standard of living index is
calculated by adding the scores assigned to the durable goods in the
household as following: 4 for a car or tractor; 3 each for a
moped/scooter/motorcycle, telephone, refrigerator, or color television;
2 each for a bicycle, electric fan, radio/transistor; and 1 each for
a mattress, pressure cooker, chair, cot/bed, table, or clock/watch.
Index scores range from 0-5 for low SLI, 6-15 for medium SLI, to 16-42
for high SLI. (f) North and northeast: Jammu, Kashmir, Himachal
Pradesh, Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram,
Nagaland, Sikkim, Tripura; central and east: Haryana, Punjab, Delhi,
Uttar Pradesh, Madhya Pradesh, Bihar, West Bengal, Orissa; west:
Maharashtra, Goa, Gujarat, Rajasthan; south: Andhra Pradesh, Karnataka,
Kerala, Tamil Nadu. (g) Number of elderly varies slightly for
individual variables depending on the number of missing values.
Table 2. Reported prevalence of asthma among the
elderly ([greater than or equal to] 60 years old) by
selected characteristics, India, 1998-1999.
Characteristic Male Female Total
Cooking smoke
Biomass fuels 13.9 9.7 11.9
Fuel mix 10.1 7.9 9.0
Cleaner fuel 7.7 5.5 6.6
Tobacco smoke
Active smoking 14.4 14.6 14.4
Passive smoking 12.2 8.5 9.4
No smoking 9.4 7.9 8.6
Age
60-64 9.5 7.5 8.5
65-69 12.2 8.1 10.2
70-74 14.5 9.6 12.4
[greater than or equal to] 75 14.0 10.5 12.4
Marital status
Currently married 11.8 8.1 10.6
Not married 13.3 8.9 10.0
Education
Illiterate 13.7 8.8 10.8
Literate, < middle completed 12.1 8.0 10.9
Middle completed or higher 7.5 6.3 7.3
Religion
Hindu 12.1 8.5 10.4
Muslim 13.2 9.5 11.4
Other 9.9 8.5 9.2
Caste/tribe
Scheduled caste/tribe 13.0 9.1 11.2
Other 11.4 8.3 10.0
House type
Pucca 9.9 7.8 8.9
Semi-pucca 12.8 8.4 10.8
Kachha 13.2 9.5 11.5
Separate kitchen
Yes 10.4 7.6 9.1
No 14.0 9.8 12.0
Crowding
< 3 persons per room 11.6 8.2 10.0
[greater than or equal to] 3 persons 12.8 9.1 11.1
per room
Standard of living
Low 14.2 10.2 12.2
Medium 12.2 7.8 10.1
High 7.4 6.5 7.0
Residence
Urban 9.6 7.0 8.3
Rural 12.8 9.1 11.0
Region
North and Northeast 10.3 8.4 9.5
Central and East 12.1 8.6 10.5
West 12.6 9.9 11.3
South 11.7 7.5 9.6
Number of elderly (a) 20,414 18,168 38,582
(a) Number of elderly varies slightly for individual variables
depending on the number of missing values. For variable
definitions, see Table 1.
Table 3. Unadjusted and adjusted effects (OR, 95% CI) of cooking smoke,
tobacco smoke, and other factors on asthma among the elderly
([greater than or equal to] 60 years old), India 1998-1999.
Characteristic Model 1 Model 2
Cooking smoke
Biomass fuels 1.92 (1.67, 2.19)
Fuel mix 1.40 (1.21, 1.62)
Cleaner fuel (a) --
Tobacco smoke
Active smoking 1.79 (1.63, 1.96)
Passive smoking 1.10 (0.99, 1.22)
No smoking (a) --
Age
60-64 (a)
65-69
70-74
[greater than or equal to] 75
Sex
Male (a)
Female
Marital status
Currently married
Not married (a)
Education
Illiterate (a)
Literate, < middle completed
Middle completed or higher
Religion
Hindu (a)
Muslim
Other
Caste/tribe
Scheduled caste/scheduled
tribe
Other (a)
House type
Pucca
Semi-pucca
Kachha (a)
Separate kitchen
Yes
No (a)
Crowding
< 3 persons per room (a)
[greater than or equal to] 3
persons per room
Standard of living
Low (a)
Medium
High
Residence
Urban
Rural (a)
Region
North and Northeast
Central and East
West
South (a)
Number of elderly 38,389 38,549
Characteristic Model 3 Model 4
Cooking smoke
Biomass fuels 1.75 (1.53, 2.01) 1.77 (1.54, 2.34)
Fuel mix 1.32 (1.14, 1.53) 1.32 (1.14, 1.53)
Cleaner fuel (a) -- --
Tobacco smoke
Active smoking 1.66 (1.51, 1.82) 1.54 (1.39, 1.71)
Passive smoking 1.03 (0.93, 1.15) 1.08 (0.97, 1.20)
No smoking (a) -- --
Age
60-64 (a) --
65-69 1.25 (1.12, 1.38)
70-74 1.53 (1.37, 1.71)
[greater than or equal to] 75 1.54 (1.37, 1.73)
Sex
Male (a) --
Female 0.83 (0.75, 0.91)
Marital status
Currently married
Not married (a)
Education
Illiterate (a)
Literate, < middle completed
Middle completed or higher
Religion
Hindu (a)
Muslim
Other
Caste/tribe
Scheduled caste/scheduled
tribe
Other (a)
House type
Pucca
Semi-pucca
Kachha (a)
Separate kitchen
Yes
No (a)
Crowding
< 3 persons per room (a)
[greater than or equal to] 3
persons per room
Standard of living
Low (a)
Medium
High
Residence
Urban
Rural (a)
Region
North and Northeast
Central and East
West
South (a)
Number of elderly 38,297 38,297
Characteristic Model 5
Cooking smoke
Biomass fuels 1.59 (1.30, 1.94)
Fuel mix 1.24 (1.04, 1.49)
Cleaner fuel (a) --
Tobacco smoke
Active smoking 1.55 (1.39, 1.73)
Passive smoking 1.09 (0.97, 1.22)
No smoking (a) --
Age
60-64 (a) --
65-69 1.22 (1.10, 1.36)
70-74 1.52 (1.35, 1.70)
[greater than or equal to] 75 1.51 (1.33, 1.71)
Sex
Male (a) --
Female 0.80 (0.71, 0.89)
Marital status
Currently married 0.94 (0.85, 1.04)
Not married (a) --
Education
Illiterate (a) --
Literate, < middle completed 1.03 (0.92, 1.16)
Middle completed or higher 0.83 (0.70, 0.98)
Religion
Hindu (a) --
Muslim 0.97 (0.82, 1.15)
Other 1.02 (0.84, 1.22)
Caste/tribe
Scheduled caste/scheduled 0.96 (0.87, 1.63)
tribe
Other (a) --
House type
Pucca 1.17 (1.03, 1.34)
Semi-pucca 1.03 (0.93, 1.15)
Kachha (a) --
Separate kitchen
Yes 0.83 (0.75, 0.92)
No (a) --
Crowding
< 3 persons per room (a) --
[greater than or equal to] 3 0.93 (0.85, 1.03)
persons per room
Standard of living
Low (a) --
Medium 0.89 (0.80, 0.98)
High 0.75 (0.63, 0.88)
Residence
Urban 1.05 (0.91, 1.20)
Rural (a)
Region --
North and Northeast 0.99 (0.83, 1.19)
Central and East 1.04 (0.92, 1.19)
West 1.37 (1.18, 1.59)
South (a) --
Number of elderly 36,520
For variable definitions, see Table 1.
(a) Reference category.
Table 4. Adjusted effects (OR, 95% CI) of cooking smoke, tobacco smoke,
and other factors on asthma among the elderly ([greater than or
equal to] 60 years old) by sex, India, 1998-1999.
Characteristic Male Female
Cooking smoke
Biomass fuels 1.46 (1.14, 1.88) 1.83 (1.32, 2.53)
Fuel mix 1.12 (0.89, 1.41) 1.48 (1.12, 1.97)
Cleaner fuel (a) -- --
Tobacco smoke
Active smoking 1.50 (1.33, 1.64) 1.89 (1.49, 2.39)
Passive smoking 1.20 (0.99, 1.46) 1.05 (0.91, 1.21)
No smoking (a) -- --
Age
60-64 (a) -- --
65-69 1.35 (1.17, 1.57) 1.06 (0.90, 1.26)
70-74 1.68 (1.44, 1.93) 1.32 (1.09, 1.60)
[greater than or equal to] 75 1.57 (1.34, 1.85) 1.42 (1.18, 1.71)
Marital status
Currently married 0.90 (0.78, 1.03) 0.97 (0.84, 1.12)
Not married (a) -- --
Education
Illiterate (a) -- --
Literate, < middle completed 0.99 (0.87, 1.12) 1.17 (0.92, 1.45)
Middle completed or higher 0.77 (0.64, 0.93) 1.18 (0.78, 1.77)
Religion
Hindu (a) -- --
Muslim 0.94 (0.76, 1.15) 1.03 (0.80, 1.32)
Other 0.97 (0.77, 1.20) 1.05 (0.81, 1.38)
Caste/tribe
Scheduled caste/scheduled 0.96 (0.84, 1.09) 0.96 (0.82, 1.12)
tribe
Other (a) -- --
House type
Pucca 1.16 (0.97, 1.38) 1.20 (0.99, 1.46)
Semi-pucca 1.05 (0.92, 1.20) 1.02 (0.88, 1.21)
Kachha (a) -- --
Separate kitchen
Yes 0.81 (0.72, 0.93) 0.86 (0.75, 1.00)
No (a) -- --
Crowding
< 3 persons per room (a) -- --
[greater than or equal to] 3 0.91 (0.81, 1.02) 0.97 (0.83, 1.12)
persons per room
Standard of living
Low (a) -- --
Medium 0.95 (0.84, 1.08) 0.79 (0.67, 0.92)
High 0.72 (0.58, 0.89) 0.76 (0.59, 0.98)
Residence
Urban 1.09 (0.91, 1.30) 1.00 (0.80, 1.23)
Rural (a) -- --
Region
North and Northeast 0.86 (0.69, 1.09) 1.19 (0.91, 1.54)
Central and East 0.98 (0.83, 1.15) 1.14 (0.95, 1.37)
West 1.25 (1.04, 1.50) 1.56 (1.26, 1.92)
South (a) -- --
Number of elderly 19,329 17,191
For variable definitions see Table 1.
(a) Reference category.
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WHO. 1997. Health and Environment for Sustainable Development Sustainable development is a socio-ecological process characterized by the fulfilment of human needs while maintaining the quality of the natural environment indefinitely. The linkage between environment and development was globally recognized in 1980, when the International Union : Five Years after the Earth Summit. Geneva Geneva, canton and city, Switzerland Geneva (jənē`və), Fr. Genève, canton (1990 pop. 373,019), 109 sq mi (282 sq km), SW Switzerland, surrounding the southwest tip of the Lake of Geneva. : World Health Organization. World Resources Institute. 1998. World Resources 1998-99: A Guide to the Global Environment. Oxford: Oxford University Press. Xu X, Niu T, Christiani DC, Weiss ST, Chen C, Zhou Y, et al. 1996. Occupational and environmental risk factors for asthma in rural communities in China. Int J Occup Environ Health 2:172-176. Zelikoff JT. 1994. Woodsmoke emissions: effects on host pulmonary immune defense. CIAR CIAR Canadian Institute for Advanced Research CIAR Center for Indoor Air Research CIAR Cooper Institute for Aerobics Research (Dallas, Texas) CIAR Cast Iron Applications Router (Cast Iron Inc) Curr November, 1-3. Zhang J, Qian Z, Kong L, Zhou L, Yan L, Chapman RS. 1999. Effects of air pollution on respiratory health of adults in three Chinese cities. Arch Environ Health 54:373-381. Vinod Mishra East-West Center The East-West Center (EWC), headquartered in Honolulu, Hawaii, is an education and research organization established by the U.S. Congress in 1960 to strengthen relations and understanding among the peoples and nations of Asia, the Pacific and the United States. , Honolulu, Hawaii For the city and county of Honolulu, see City & County of Honolulu. “Honolulu” redirects here. For other uses, see Honolulu (disambiguation). Honolulu is the capital as well as the most populous community of the State of Hawaii, United States. , USA Address correspondence to V. Mishra, Population and Health Studies, East-West Center, 1601 East-West Rd, Honolulu, HI 96848-1601 USA. Telephone: (808) 944-7452. Fax: (808) 944-7490. E-mail: mishra@hawaii.edu I thank G. Yamashita for assistance in preparing data files, S. Dai for assistance with bibliographic search and preparation of tables, and R. Retherford, K. Smith, and three anonymous reviewers for comments on an earlier draft of the manuscript. A shorter version of this article was presented at the Indoor Air 2002 conference in Monterey, California For other uses, see Monterey (disambiguation). The City of Monterey is located on Monterey Bay along the Pacific coast in central California. As of 2005, the city population was 30,641. , USA, 30 June-5 July 2002. Human subjects informed consent: The analysis presented in this article is based on secondary analysis of existing survey data with all identifying information removed. The survey personnel obtained informed consent from each respondent before asking questions. This research was supported by a grant from the Hewlett Foundation Hewlett Foundation: see William and Flora Hewlett Foundation. (2001-6265). Received 26 February 2002; accepted 17 June 2002. |
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