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Occupational exposures and 20-year incidence of COPD: the European Community Respiratory Health Survey
  1. Theodore Lytras1,2,
  2. Manolis Kogevinas1,2,3,4,
  3. Hans Kromhout5,
  4. Anne-Elie Carsin1,2,
  5. Josep M Antó1,2,3,4,
  6. Hayat Bentouhami6,
  7. Joost Weyler6,7,
  8. Joachim Heinrich8,
  9. Dennis Nowak8,
  10. Isabel Urrutia9,
  11. Jesús Martinez-Moratalla10,11,
  12. José Antonio Gullón12,
  13. Antonio Pereira-Vega13,
  14. Chantal Raherison-Semjen14,
  15. Isabelle Pin15,16,17,
  16. Pascal Demoly18,19,
  17. Bénédicte Leynaert20,
  18. Simona Villani21,
  19. Thorarinn Gislason22,23,
  20. Cecilie Svanes24,25,
  21. Mathias Holm26,
  22. Bertil Forsberg27,
  23. Dan Norbäck28,
  24. Amar J Mehta29,
  25. Nicole Probst-Hensch30,31,
  26. Geza Benke32,
  27. Rain Jogi33,
  28. Kjell Torén34,
  29. Torben Sigsgaard35,
  30. Vivi Schlünssen35,36,
  31. Mario Olivieri37,
  32. Paul D Blanc38,
  33. Roel Vermeulen5,
  34. Judith Garcia-Aymerich1,2,3,4,
  35. Deborah Jarvis39,40,
  36. Jan-Paul Zock1,2,3
  1. 1 Barcelona Institute of Global Health (ISGlobal), Barcelona, Spain
  2. 2 Universitat Pompeu Fabra (UPF), Barcelona, Spain
  3. 3 CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
  4. 4 Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
  5. 5 IRAS, University of Utrecht, Utrecht, The Netherlands
  6. 6 Department of Epidemiology and Social Medicine (ESOC), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
  7. 7 StatUA Statistics Centre, University of Antwerp, Antwerp, Belgium
  8. 8 Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital of Ludwig Maximilians University, Comprehensive Pneumology Centre Munich, German Centre for Lung Research, Munich, Germany
  9. 9 Pulmonology Department, Galdakao Hospital, Bizkaia, Spain
  10. 10 Servicio de Neumología, Complejo Hospitalario Universitario, Albacete, Spain
  11. 11 Facultad de Medicina Albacete, Universidad de Castilla-La Mancha, Ciudad Real, Spain
  12. 12 Respiratory Department, Hospital Universitario San Agustín, Aviles, Spain
  13. 13 Respiratory and Allergy Clinical Unit, Universitary Hospitalary Complex, Huelva, Spain
  14. 14 Université de Bordeaux, Inserm, Bordeaux Population Health Research Center, team EPICENE, UMR 1219, Bordeaux, France
  15. 15 Department of Pédiatrie, CHU de Grenoble Alpes, Grenoble, France
  16. 16 Inserm, U1209, IAB, Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, Grenoble, France
  17. 17 Université Grenoble Alpes, Grenoble, France
  18. 18 University Hospital of Montpellier, Montpellier, France
  19. 19 Sorbonne Universités, Paris, France
  20. 20 Inserm UMR 1152-Equipe Epidémiologie, Université Paris Diderot, Paris, France
  21. 21 Department of Health Sciences, Experimental and Forensic Medicine - Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
  22. 22 Department of Respiratory Medicine and Sleep, Landspitali University Hospital, Reykjavik, Iceland
  23. 23 Faculty of Medicine, University of Iceland, Reykjavik, Iceland
  24. 24 Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
  25. 25 Centre for International Health, University of Bergen, Bergen, Norway
  26. 26 Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
  27. 27 Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, Umeå, Sweden
  28. 28 Department of Medical Sciences, Uppsala University, Uppsala, Sweden
  29. 29 Research and Evaluation Office, Boston Public Health Commission, Boston, Massachusetts, USA
  30. 30 Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
  31. 31 University of Basel, Basel, Switzerland
  32. 32 Monash Centre for Occupation and Environmental Health, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
  33. 33 Lung Clinic, Tartu University Hospital, Tartu, Estonia
  34. 34 Section of Occupational and Environmental Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  35. 35 Department of Public Health, Section for Environment, Occupation and Health, Danish Ramazzini Center, Aarhus University, Aarhus, Denmark
  36. 36 National Research Center for the Working Environment, Copenhagen, Denmark
  37. 37 Unit of Occupational Medicine, University Hospital of Verona, Verona, Italy
  38. 38 University of California San Francisco, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
  39. 39 Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College London, London, UK
  40. 40 MRC-PHE Centre for Environment and Health, Imperial College London, London, UK
  1. Correspondence to Dr Theodore Lytras, Barcelona Institute of Global Health (ISGlobal), Barcelona 08003, Spain; thlytras{at}


Background Occupational exposures have been associated with an increased risk of COPD. However, few studies have related objectively assessed occupational exposures to prospectively assessed incidence of COPD, using postbronchodilator lung function tests. Our objective was to examine the effect of occupational exposures on COPD incidence in the European Community Respiratory Health Survey.

Methods General population samples aged 20–44 were randomly selected in 1991–1993 and followed up 20 years later (2010–2012). Spirometry was performed at baseline and at follow-up, with incident COPD defined using a lower limit of normal criterion for postbronchodilator FEV1/FVC. Only participants without COPD and without current asthma at baseline were included. Coded job histories during follow-up were linked to a Job-Exposure Matrix, generating occupational exposure estimates to 12 categories of agents. Their association with COPD incidence was examined in log-binomial models fitted in a Bayesian framework.

Findings 3343 participants fulfilled the inclusion criteria; 89 of them had COPD at follow-up (1.4 cases/1000 person-years). Participants exposed to biological dust had a higher incidence of COPD compared with those unexposed (relative risk (RR) 1.6, 95% CI 1.1 to 2.3), as did those exposed to gases and fumes (RR 1.5, 95% CI 1.0 to 2.2) and pesticides (RR 2.2, 95% CI 1.1 to 3.8). The combined population attributable fraction for these exposures was 21.0%.

Interpretation These results substantially strengthen the evidence base for occupational exposures as an important risk factor for COPD.

  • copd epidemiology
  • occupational lung disease

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  • Contributors Study idea and design: TL, MK, JPZ, HK, JMA, KT, DJ. Data collection: MK, HK, AEC, JMA, HB, JW, JH, DN, IU, JMMR, JAG, APV, CRS, IP, PD, BL, SV, TG, CRS, MH, BF, DN, AJM, NPH, GB, RJ, KT, TS, VS, JGA, DJ, JPZ. Data analysis: TL, MK, JPZ. Data interpretation: all authors. Initial manuscript draft: TL, MK, JPZ. Critical revision of the manuscript for important intellectual content: all authors. Final approval of the manuscript for publication: all authors.

  • Funding Financial support for ECRHS I, for the localcentres included in this study: Australia: Asthma Foundation of Victoria, Allenand Hanbury’s, Belgium: Belgian Science Policy Office, National Fundfor Scientific Research, Estonia: Estonian Science Foundation, grantno 1088, France: Ministère de la Santé, Glaxo France, InsitutPneumologique d’Aquitaine, Contrat de Plan Etat-RégionLanguedoc-Rousillon, CNMATS, CNMRT (90MR/10, 91AF/6), Ministredelegué de la santé, RNSP, France; GSF, Germany: Bundesminister für Forschung und Technologie, Italy: Ministero dell’Università edella Ricerca Scientifica e Tecnologica, CNR, Regione Veneto grantRSF n. 381/05.93, Norway: Norwegian Research Council project no.101422/310; Spain: Fondo de Investigación Sanitaria(#91/0016-060-05/E, 92/0319 and #93/0393), Hospital General deAlbacete, Hospital General Juan Ramón Jiménez, DirecciónRegional de Salud Pública (Consejería de Sanidad del Principado deAsturias), CIRIT (1997 SGR 00079) and Servicio Andaluz de Salud; Sweden: The Swedish Medical Research Council, the Swedish Heart LungFoundation, the Swedish Association against Asthma and Allergy;Switzerland: Swiss national Science Foundation grant 4026-28099; UK:National Asthma Campaign, British Lung Foundation, Department ofHealth, South Thames Regional Health Authority. Financial Support for ECRHS III: Australia: National Health & Medical ResearchCouncil, Belgium: Antwerp South, Antwerp City: Research FoundationFlanders (FWO), grant code G.0.410.08.N.10 (both sites), Estonia:Tartu- SF0180060s09 from the Estonian Ministry of Education. France:(All) Ministère de la Santé. Programme Hospitalier de RechercheClinique (PHRC) national 2010. Bordeaux: INSERM U897 UniversitéBordeaux segalen, Grenoble: Comite Scientifique AGIRadom 2011. Paris:Agence Nationale de la Santé, Région Ile de France, domained’intérêt majeur (DIM) Germany : Erfurt: German ResearchFoundation HE 3294/10-1 Hamburg: German Research Foundation MA711/6-1, NO 262/7-1 Iceland: Reykjavik, The Landspitali UniversityHospital Research Fund, University of Iceland Research Fund, ResMedFoundation, California, USA, Orkuveita Reykjavikur (Geothermalplant), Vegagerðin (The Icelandic Road Administration (ICERA). Italy: All Italian centres were funded by the Italian Ministry ofHealth, Chiesi Farmaceutici SpA, in addition Verona was funded byCariverona foundation, Education Ministry (MIUR). Norway: NorwegianResearch council grant no 214123, Western Norway Regional HealthAuthorities grant no 911631, Bergen Medical Research Foundation. Spain: Fondo de Investigación Sanitaria (PS09/02457, PS09/0071609/01511) PS09/02185 PS09/03190), Servicio Andaluz de Salud, SociedadEspañola de Neumología y Cirurgía Torácica (SEPAR 1001/2010);Sweden: All centres were funded by The Swedish Heart and LungFoundation, The Swedish Asthma and Allergy Association, The SwedishAssociation against Lung and Heart Disease. Fondo de InvestigaciónSanitaria (PS09/02457 Barcelona: Fondo de Investigación Sanitaria(FIS PS09/00716) Galdakao: Fondo de Investigación Sanitaria (FIS09/01511) Huelva: Fondo de Investigación Sanitaria (FIS PS09/02185)and Servicio Andaluz de Salud Oviedo: Fondo de InvestigaciónSanitaria (FIS PS09/03190) Sweden: All centres were funded by TheSwedish Heart and Lung Foundation, The Swedish Asthma and AllergyAssociation, The Swedish Association against Lung and Heart Disease. Swedish Research Council for health, working life and welfare (FORTE)Göteborg : Also received further funding from the Swedish Council for Working life and Social Research. Umea also received funding fromVasterbotten Country Council ALF grant. Switzerland: The SwissNational Science Foundation (grants no 33CSCO-134276/1,33CSCO-108796, 3247BO-104283, 3247BO-104288, 3247BO-104284,3247-065896, 3100-059302, 3200-052720, 3200-042532, 4026-028099) TheFederal office for forest, environment and landscape, The FederalOffice of Public Health, The Federal Office of Roads and Transport, the canton’s government of Aargan, Basel-Stadt, Basel-Land, Geneva,Luzern, Ticino, Valais and Zürich, the Swiss Lung League, thecanton’s Lung League of Basel Stadt/ Basel, Landschaft, Geneva,Ticino, Valais and Zurich, SUVA, Freiwillige AkademischeGesellschaft, UBS Wealth Foundation, Talecris Biotherapeutics GmbH,Abbott Diagnostics, European Commission 018996 (GABRIEL), WellcomeTrust WT 084703MA, UK: Medical Research Council (Grant Number 92091).Support also provided by the National Institute for Health Researchthrough the Primary Care Research Network The coordination of the ECRHS III was fundedthrough the Medical Research Council (Grant Number 92091). ISGlobal is a member of the CERCA Programme /Generalitat de Catalunya. The present analyses are part of the Ageing Lungsin European Cohorts (ALEC) Study (, which hasreceived funding from the European Union’s Horizon 2020 research andinnovation programme under grant agreement No. 633212.

  • Competing interests None declared.

  • Ethics approval Local committees for each study centre.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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