It is becoming increasingly clear that the antenatal and preschool years are critical in determining long-term outcomes. This has been highlighted by a recent report1 in which adults were recruited before age 40 and then followed for >20 years. Of those who did not attain a normal FEV₁, 26% developed COPD (or premature airflow obstruction as many prefer to call it2). An equally large group with COPD at follow-up had a normal FEV₁ at recruitment, but an accelerated loss of lung function, which could not be related to any adult factors, and was presumably also determined by genetic factors or adverse exposures prior to recruitment. So, if we are to turn back COPD from rising up the list of Death Stars, we need to intervene very early.

The key and most pressing early childhood adverse events which need to be tackled across the world to improve long-term lung health are tobacco exposure, outdoor pollution, indoor pollution (in particular in low-income and middle-income countries) and poverty (which are to some extent interlinked). Obesity is obviously also of general and respiratory importance at least in the …