Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of morbidity and mortality in the industrialized and the developing countries. During 1997, COPD has been estimated to be the number four cause of death after cardiovascular diseases, tumors and cerebrovascular diseases in the United States. In 2020 COPD will probably become the third leading cause of death all over the world, following the trend of increasing prevalence of lung cancer. The impact of this respiratory disease worldwide is expected to increase with a heavy economic burden on individuals and society. In the United States direct and indirect costs of COPD were estimated at about USD24 billion in 1993. Unfortunately, there are few data on health-care utilization despite the great interest in COPD among researchers. As all chronic diseases, the prevalence of COPD is strongly associated with age. Data collected in a general population sample (living in Italy) showed a progressive increase of the prevalence of chronic bronchitis and emphysema with age, both in males and in females. COPD is determined by the action of a number of various risk factors either singly or interacting among themselves in a synergistic way. Among these, the most important is cigarette smoking, ranking at the first level for developing chronic bronchitis and emphysema. Also air pollution and some occupational exposures represent risks for developing COPD. Many epidemiological studies have indicated an association between the prevalence of chronic bronchitis and a low socioeconomic status. Furthermore, in the etiology of COPD we must consider endogenous risk factors such as gender, genetic features, presence of respiratory troubles in childhood, and family history. To date, epidemiologic studies have been of great importance for the characterization of the disease at a population level, indicating possible causes and assessing its impact on the individual and on society as a whole. Unfortunately, international standards for the diagnosis of COPD are lacking, which complicates the organization of appropriate epidemiological surveys.

1.
Medical Research Council: Questionnaire on respiratory symptoms. London, Medical Research Council, 1966.
2.
Medical Research Council’s Committee on the Aetiology of Chronic Bronchitis: Definition and classification of chronic bronchitis for clinical and epidemiological purposes. Lancet 1965;i:775–779.
3.
ATS: Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995;152:S77–S120.
4.
Siafakas NM, Vermeire P, Pride NB, et al: Optimal assessment and management of chronic obstructive pulmonary disease (COPD). ERS Consensus Statement. Eur Respir J 1995;8:1398–1420.
5.
Doll R, Peto R, Wheatley K, et al: Mortality in relation to smoking: 40 years’ observation on male British doctors. Br Med J 1994;309:901–911.
6.
Doll R: Risk from tobacco and potentials for health gain. Int J Tuberc Lung Dis 1999;3:90–99.
7.
Lam TH, He Y, Li LS, et al: Mortality attributable to cigarette smoking in China. JAMA 1997;278:1505–1508.
8.
Chen Z, Xu Z, Collins R, Li W, et al: Early health effects of the emerging tobacco epidemic in China. JAMA 1997;278:1500–1504.
9.
O’Connor GT, Sparrow D, Weiss ST: A prospective longitudinal study of methacholine airway responsiveness as a predictor of pulmonary-function decline: The Normative Aging Study. Am J Respir Crit Care Med 1995;152:87–92.
10.
Tashkin PD, Detels R, Simmons M, et al: The UCLA population studies of chronic obstructive respiratory disease. XI. Impact of air pollution and smoking on annual change in forced expiratory volume in one second. Am J Respir Crit Care Med 1994;149:1209–1217.
11.
Fletcher CM, Peto R, Tinker CM, Speizer FE: The Natural History of Chronic Bronchitis and Emphysema. Oxford, Oxford University Press, 1976.
12.
Viegi G, Paoletti P, Prediletto R, et al: Prevalence of respiratory symptoms in an unpolluted area of Northern Italy. Eur Respir J 1988;1:311–318.
13.
Viegi G, Paoletti P, Vellutini M, et al: Effects of daily cigarette consumption on respiratory, symptoms and lung function in a general population sample of North Italian men. Respiration 1991;58:282–286.
14.
Viegi G, Pedreschi M, Baldacci S, et al: Prevalence rates of respiratory symptoms and diseases in general population samples of North and Central Italy. Int J Tuberc Lung Dis 1999;3:1034–1042.
15.
Viegi G, Paoletti P, Carrozzi L, et al: CO diffusing capacity in a general population sample: Relationships with cigarette smoking and airflow obstruction. Respiration 1993;60:155–161.
16.
Collins MH, Moessinger AC, Kleinerman J, et al: Fetal lung hypoplasia associated with maternal smoking: A morphometric analysis. Pediatr Res 1985;19:408–412.
17.
Hanrahan JP, Tigwer I, Segal MR: The effects of maternal smoking during pregnancy on early infant lung function. Am Rev Respir Dis 1992;145:1129–1135.
18.
Davis R: The epidemiology of cigarette smoking and its impact on chronic obstructive pulmonary disease. Am Rev Respir Dis 1989;140:S82–S84.
19.
Cook DG, Strachan DP: Summary of effects of parental smoking on the respiratory health of children and implications for research. Thorax 1999;54:357–366.
20.
Jaakkola MS: Environmental tobacco smoke and respiratory diseases. Respiratory Epidemiology in Europe. Eur Respir Monogr 2000;15:322–383.
21.
Leech JA, Wilby K, McMullen E: Environmental tobacco smoke exposure patterns: A subanalysis of the Canadian Human Time-Activity Pattern Survey. Can J Public Health 1999;90:244–249.
22.
Rothenbacher D, Arndt V, Fraisse E, et al: Chronic respiratory disease morbidity in construction workers: Patterns and prognostic significance for permanent disability and overall mortality. Eur Respir J 1997;10:1093–1099.
23.
Becklake MR: Occupational exposure: Evidence for a causal association with chronic obstructive pulmonary disease. Am Rev Respir Dis 1989;140:s85–s91.
24.
Carrozzi L, Viegi G, Paoletti P: Fattori di rischio e prevenzione delle malattie respiratorie. Aggiornamento II dell’Enciclopedia Medica Italiana, 2000, vol 3, pp 5007–5021.
25.
Hendrick DJ: Occupation and chronic obstructive pulmonary disease. Thorax 1996;51:947–955.
26.
Viegi G, Prediletto R, Paoletti P, et al: Respiratory effects of occupational exposure in a general population sample in North ltaly. Am Rev Respir Dis1991;143:510–515.
27.
Viegi G, Carrozzi L, Di Pede F, et al: Risk factors for chronic obstructive pulmonary disease in a North Italian rural area. Eur J Epidemiol 1994;10:725–731.
28.
Post WK, Heederik D, Kromhout D: Occupational exposures estimated by a population specific job exposure matrix and 25 year incidence rate of chronic nonspecific lung disease (CNSLD): The Zutphen Study. Eur Respir J 1994;7:1048–1055.
29.
American Thoracic Society Committee on Occupational Contribution to Burden of Airway Disease. Am J Respir Crit Care Med 2001, in press.
30.
Dockery DW, Pope CA III: Acute respiratory effects of particulate air pollution. Annu Rev Public Health 1994;15:107–132.
31.
Touloumi G, Katsouyanni K, Zmirou D, et al: Short-term effects of ambient oxidant exposure on mortality: A combined analysis within the APHEA project. Air Pollution and Health: A European Approach. Am J Epidemiol 1997;146:177–185.
32.
Sunyer J, Schwartz J, Tobìas A, et al: Patients with chronic obstructive pulmonary disease are at risk of death associated with urban particle air pollution: A case-crossover analysis. Am J Epidemiol 2000;151:50–56.
33.
Dockery DW, Pope CA III, Xu X, et al: An association between air pollution and mortality in six US cities. N Engl J Med 1993;329:1753–1759.
34.
Pope CA III, Thun MJ, Namboodiri MM, et al: Particulate air pollution as a predictor of mortality in a prospective study of US adults. Am J Respir Crit Care Med 1995;151:669–674.
35.
Viegi G, Paoletti P, Carrozzi L, et al: Prevalence rates of respiratory symptoms in Italian general population samples, exposed to different levels of air pollution. Environ Health Perspect 1991;94:95–99.
36.
Zemp E, Elsässer S, Schindler C et al: Long-term ambient air pollution and respiratory symptoms in adults (SAPALDIA study). The SAPALDIA Team. Am J Respir Crit Care Med 1999;159:1257–1266.
37.
Ackermann-Liebrich U, Leuenberger P, Schwartz J, et al: Lung function and long-term exposure to air pollutants in Switzerland. Study on Air Pollution and Lung Diseases in Adults (SAPALDIA) Team. Am J Respir Crit Care Med 1997;155:122–129.
38.
Committee of the Environmental and Occupational Health Assembly of the American Thoracic Society. Health effects of outdoor air pollution. Am J Respir Crit Care Med 1996;153:3–50.
39.
ATS: What constitutes an adverse health effect of air pollution? Am J Respir Crit Care Med 2000;16:665–673.
40.
Viegi G, Annesi-Maesano I: Lung diseases induced by indoor and outdoor pollutants; in Mapp CE (ed): Occupational Lung Disorders. Eur Respir Monogr 1999;11:214–241.
41.
Rogot E, Sorlie PD, Johnson NJ, et al: A mortality study of 1.3 million persons by demographic, social and economic factors: 1979–1985 follow-up: US National Longitudinal Mortality Study. Bethesda, National Institutes of Health, July 1992; NIH publication No 92-3297.
42.
Strachan DP: Epidemiology: A British perspective; in Calverley P, Pride N (eds): Chronic Obstructive Pulmonary Disease. London, Chapman & Hall, 1995, pp 47–68.
43.
Menezes AMB, Victora CG, Rigatto M: Prevalence and risk factors for chronic bronchitis in Pelotas, Brazil: A population-based study. Thorax 1994;49:1217–1221.
44.
Bakke PS, Hanoa R, Gulsvik A: Educational level and obstructive lung disease given smoking habits and occupational airborne exposure: A Norwegian community study. Am J Epidemiol 1995;141:1080–1088.
45.
Britten N, Daves JMC, Colley JRT: Early respiratory experience and subsequent cough and peak expiratory flow rate in 36-year-old men and women. BMJ 1987;294:1317–1320.
46.
Chapman KM, Winter L: COPD: Using nutrition to prevent respiratory function decline. Geriatrics 1996;51:37–42.
47.
Strachan DP, Cox BD, Erzinclioglu SW, et al: Ventilatory function and winter fresh fruit consumption in a random sample of British adults. Thorax 1991;46:624–629.
48.
Britton J, Pavord I, Richards K, et al: Dietary magnesium, lung function, wheezing, and airway hyperreactivity in a random adult population sample. Lancet 1994;344:357–362.
49.
Shahar E, Folsom AR, Melnick SL, et al: Dietary n-3 polyunsaturated fatty acids and smoking-related chronic obstructive pulmonary disease. Atherosclerosis risk in Communities Study Investigators. N Engl J Med 1994;331:228–233.
50.
Tockman MS, Khoury MJ, Cohen BH: The epidemiology of COPD; in Petty TL (ed): Chronic Obstructive Pulmonary Disease. New York, Marcel Dekker, 1985, pp 78–79.
51.
Gold DR, Wang X, Wypij D, et al: Effects of cigarette smoking on the pulmonary function in adolescent boys and girls. N Engl J Med 1996;335:931–937.
52.
Prescott E, Bjerg AM, Andersen PK, et al: Gender difference in smoking effects on lung function and risk for hospitalization for COPD. Results from a Danish longitudinal population study. Eur Respir J 1997;10:822–827.
53.
WHO: Alpha1-antitrypsin deficiency: Memorandum from a WHO meeting. Bull World Health Organ 1997;75:397–415. (http://www.who.int/inf-fs/en/fact206.html)
54.
Silverman EK, Chapman HA, Drazen JM, et al: Genetic epidemiology of severe, early-onset chronic obstructive pulmonary disease. Risk to relatives for airflow obstruction and chronic bronchitis. Am J Respir Crit Care Med 1998;157:1770–1778.
55.
Sandford AJ, Weir TD, Parè PD, et al: Genetic risk factors for chronic obstructive pulmonary disease. Eur Respir J 1997;10:1380–1391.
56.
Krzyzanowsky M, Sherrill DL, Lebowitz MD: Longitudinal analysis of the effect of acute lower respiratory illness on pulmonary function in an adult population. Am J Epidemiol 1990;131:412–422.
57.
Barker DJP, Godfrey KM, Fall C, et al: Relation of birth weight and childhood respiratory infection to adult lung function and death from chronic obstructive lung disease. BMJ 1991;303:671–675.
58.
Shaheen SO, Barker DJP, Shiell AW, et al: The relationship between pneumonia in early childhood and impaired lung function in late adult life. Am Rev Respir Dis 1994;149:616–619.
59.
Shaheen SO, Sterne JAC, Tucker JS, Florey CDV: Birth weight, childhood lower respiratory tract infection and adult lung function. Thorax 1998;53:549–553.
60.
Johnston IDA, Strachan DP, Anderson HR: Longitudinal study of the effect of pneumonia and whooping cough in childhood on adult lung function. N Engl J Med 1998;338:581–587.
61.
Paoletti P, Prediletto R, Carrozzi L, et al: Effects of childhood and adolescence-adulthood respiratory infections in a general population. Eur Respir J 1989;2:428–436.
62.
Annesi I, Kauffmann F: Is respiratory mucus hypersecretion really an innocent disorder? A 22-year mortality survey of 1,061 working men. Am Rev Respir Dis 1986;134:688–693.
63.
Krzyzanowski M, Jedrychowski W, Wysocki M: Factors associated with the change in ventilatory function and the development of chronic obstructive pulmonary disease in a 13-year follow-up of the Cracow study. Am Rev Respir Dis 1986;134:1011–1019.
64.
Connors AF Jr, Dawson NV, Thomas C, et al: Outcomes following acute exacerbation of severe chronic obstructive lung disease. Am J Respir Crit Care Med 1996;154:959–967.
65.
Seneff MG, Wagner DP, Wagner RP, et al: Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA 1995;274:1852–1857.
66.
Carrozzi L, Paoletti P, Prediletto R, et al: Malattie respiratorie dell’infanzia e predisposizione familiare per malattie dell’apparato respiratorio. Med Torac 1988;10:257–262.
67.
Bodner C, Godden D, Seaton A: Family size, childhood infections and atopic diseases. The Aberdeen WHEASE Group. Thorax 1998;53:28–32.
68.
The National Lung Health Education Program Executive Committee: Strategies in Preserving Lung Health and Preventing COPD and Associated Diseases. Chest 1998;113:123s–163s.
69.
Dati Ministero della Sanità relativi alle SDO (scheda di dimissione ospedaliera) del 1997. Sito Internet: www.sanita.it/sdo/Dati97.
70.
ISTAT: Indagine multiscopo sulle famiglie. Roma, 1994.
71.
Cook DG, Kussick SJ, Shaper AG: The respiratory benefits of stopping smoking. J Smoking Related Dis 1990;1:45–58.
72.
Benson V, Marano MA: Current estimate from the National Health Interview Survey,1993. Washington, National Center for Health Statistics, Vital and Health Statistics 10 (190), 1994;DHHS publication No (PHS) 95-1518.
73.
Wilder C: Prevalence of selected chronic respiratory conditions: United States, 1970. Washington, National Center for Health Statistics, Vital and Health Statistics 10 (84), 1973;DHEW publication No (HRA) 74-1511.
74.
National Heart, Lung, and Blood Institute: Morbidity and Mortality: 1996 Chartbook on Cardiovascular, Lung and Blood Diseases. Bethesda, National Institutes of Health, MD, 1996.
75.
Lacasse Y, Brooks D, Goldstein RS: Trends in the epidemiology of COPD in Canada, 1980 to 1995. COPD and Rehabilitation Committee of the Canadian Thoracic Society. Chest 1999;116:306–313.
76.
Keistinen T, Vilkman S, Tuuponen T, Kivela S-L: Hospital admission for chronic obstructive pulmonary disease in the population aged 55 years or over in Finland during 1972–1992. Scand J Soc Med 1997;25:238–242.
77.
Murray CJ, Lopez AD: Evidence-based health policy-lessons from the Global Burden of Disease Study. Science 1996;274:740–743.
78.
Anthonisen NR, Connett JE, Kiley JP, et al: Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1: The Lung Health Study. JAMA 1994;272:1497–1505.
79.
Mannino DM, Gagnon RC, Petty TL, Lydick E: Obstructive lung disease and low lung function in adults in the United States: Data from the National Health and Nutrition Examination Survey, 1988–1994. Arch Intern Med 2000;160:1683–1689.
80.
Peto R, Speizer FE, Cochrane AL, et al: The relevance in adults of air-flow obstruction, but not of mucus hypersecretion, to mortality from chronic lung disease: Results from 20 years of prospective observation. Am Rev Respir Dis 1983;128:491–500.
81.
Higgins M: Epidemiology of COPD: State of the art. Chest 1984;85(suppl):3S–8S.
82.
Ferris BG Jr, Anderson DO: The prevalence of chronic respiratory disease in a New Hampshire town. Am Rev Respir Dis 1962;86:165–177.
83.
Higgins MW, Keller JB, Landis JR, et al: Risk of chronic obstructive pulmonary disease: Collaborative assessment of the validity of the Tecumseh index of risk. Am Rev Respir Dis 1984;130:380–385.
84.
Mueller RE, Keble DL, Plummer J, Walker SH: The prevalence of chronic bronchitis, chronic airway obstruction, and respiratory symptoms in a Colorado city. Am Rev Respir Dis 1971;103:209–228.
85.
Lebowitz MD: The trends in airway obstructive disease morbidity in the Tucson epidemiological study. Am Rev Respir Dis 1989;140:S35–S41.
86.
Atti del convegno: L’indagine epidemiologica di Porto Tolle: II° fase trasversale. Porto Tolle (RO), nov 1993. Porto Tolle, Cartotecnica Veneziana, 1994.
87.
Viegi G, Paoletti P, Prediletto R, et al: Carbon monoxide diffusing capacity, other indices of lung function, and respiratory symptoms in a general population sample. Am Rev Respir Dis 1990;141:1033–1039.
88.
Baldacci S, Carrozzi L, Viegi G, Giuntini C: Assessment of respiratory effect of air pollution: Study design on general population samples. JETPO 1997;16:77–83.
89.
 (a) American Thoracic Society: Evaluation of impairment/disability secondary to respiratory disorders. Am Rev Respir Dis 1986;133:1205–1209. 89 (b) Viegi G, Pedreschi M, Pistelli F, et al: Prevalence of airways obstruction in a general population. European Respiratory Society vs American Thoracic Society definition. Chest 2000;117:339S–345S.
90.
Lundback B, Nystrom L, Rosenhall L, et al: Obstructive lung disease in northern Sweden: Respiratory symptoms assessed in a postal survey. Eur Respir J 1991;4:257–266.
91.
Dow L, Coggon D, Osmond C, Holgate ST: A population survey of respiratory symptoms in the elderly. Eur Respir J 1991;4:267–272.
92.
Enright PL, Kronmal RA, Higgins MW, et al: Prevalence and correlates of respiratory symptoms and disease in the elderly. Chest 1994;106:827–834.
93.
Petty TL: Scope of the COPD problem in North America: Early studies of prevalence and NHANES III data: Basis early identification and interpretation. Chest 2000;117:326S–331S.
94.
Murray CJ, Lopez AD: Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet 1997;349:1498–1504.
95.
Monthly Vital Statistics Report 1997;45:11(S)2.
96.
La Vecchia C, Levi F, Lucchini F, et al: Trends in mortality from major diseases in Europe, 1980–1993. Eur J Epidemiol 1998;14:1–8.
97.
ISTAT: Cause di morte, anno 1994, ed 1997.
98.
Viegi G, Carrozzi L, Desideri M, Boccuzzo G: The diseases of the respiratory system; in La mortalità in Italia nel periodo 1970–1992: Evoluzione and geografia. Roma, ISTAT, 1999, pp 213–237.
99.
Hurd SS: International efforts directed at attacking the problem of COPD. Chest 2000;117:336S–338S.
100.
Crockett AJ, Cranston JM, Moss JR, et al: Trends in chronic obstructive pulmonary disease mortality in Australia. Med J Aust 1994;161:600–603.
101.
Montnemery P, Adelroth E, Heuman K, et al: Prevalence of obstructive lung disease and respiratory symptoms in southern Sweden. Respir Med 1998;92:1337–1345.
102.
Sullivan SD, Ramsey SD, Lee TA: The economic burden of COPD. Chest 2000;117: 5–9.
103.
Strassels SA: Economic consequences of chronic obstructive pulmonary disease. Curr Opin Pulm Med 1999;5:100–104.
104.
Rutten-van Molken MP, Postma MJ, Joore MA, et al: Current and future medical costs of asthma and chronic obstructive pulmonary disease in The Netherlands. Respir Med 1999;93:779–787.
105.
Rampulla C, Arossa W, Cerveri I, Viegi G: Epidemiologia ed aspetti socio-economici; in Broncopneumopatie Croniche Ostruttive: Stato dell’ arte. Rass Patol App Respir 1998;13:460–465.
106.
Mc Michael AJ, Anderson HR, Brunekreef B, et al: Inappropriate use of daily mortality analyses to estimate longer-term mortality effect of air pollution. Int J Epidemiol 1998;27:450–453.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.