ENVIRONMENTAL
RESEARCH
Chronic
14, 14 - 21 (1977)
Nonspecific Lung Disease Consumption
M. SARIS, S. LuCIC-PALAI~, ltrsritufefor Medical U.S. Ewironmental
Research Protection
AND
and Alcohol
R. J. M. HORTON
rmd Occtrpational Health, Zagreb, Agency. Research Triangle Park.
Received March
Yugoslavia, and North Carolina
19, 1976
The relationship of the symptoms and signs of chronic nonspecific lung disease and alcohol consumption was studied in a group of 763 male workers aged 20-59. mean age 37 years. The effects of concurrent smoking habit and age were also considered. The results obtained indicate that in addition to being associated with the use of tobacco and age, respiratory symptoms and ventilatory impairment are also related to alcohol consumption. This is particularly true for the syndrome of chronic bronchitis.
INTRODUCTION
In the study of the prevalence and incidence of chronic nonspecific lung disease alcohol consumption is only occasionally mentioned as a possibly significant factor. Besides clinical experience which points out that diseases of the lung and respiratory impairment are related to alcoholism (Chomet and Gach, 1967; Banner, 1973) there are epidemiological studies which support the assumption that alcoholism plays a role in the development of chronic nonspecific lung disease (Pell and D’Alonzo, 1968; Hrubec et crl., 1973). Experiments on animals revealed that alcohol acts by reducing the resistance to infections (Stillman, 1924; Pickerel], 1938). This seems to be the result of a disturbed function of the ciliary apparatus in the bronchioli, and of alveolar macrophages which take part in the clearance of bacteria from the lung (Laurenzi and Guarneri, 1966; Rylander, 1968; Green and Green, 1968). This paper discusses the relationship between the symptoms and signs of chronic nonspecific lung disease and alcohol consumption in a group of industrial workers, with reference to smoking habit and age. SAMPLE AND METHOD
The study was carried out in a group of 763 workers, males aged 20-59 (x = 37 years; SD = 8.9 years) employed in two factories: a ferromanganese and electrode production (559) and a light metal plant (204). The subgroups did not differ in the consumption of tobacco or alcohol. Therefore they were not treated separately in this analysis. Also, as described elsewhere (Sari6 ef al., 1974), the subgroups did not differ markedly in the rate of respiratory impairment. Although all the workers examined were not engaged in the same type of work, none was exposed to distinct respiratory irritants. About 5% of the workers who were invited to be examined did not respond because of absence from work (sick leave, annual leave, etc). 14 Copyright All rights
0 1977 by Academic Press. Inc. of reproduction in any form reserved.
ISSN 0013-972,
CHRONIC
NONSPECIFIC
LUNC;
DISEASE
AND
ALCOHOL
CONSUMPTION
15
Data concerning alcohol consumption were gathered by means of a part of a (Drinking Habits) of the Division of Medical Sciences, National Research Council, U.S. National Academy of Sciences (1967). Data concerning respiratory symptoms and smoking habit were obtained in an interview based on the questionnaire of the Committee on Aetiology of Chronic Bronchitis of the British Medical Research Council (1965). Forced expiratory volumes were also measured. Among recorded respiratory symptoms the following were analysed: Phlegm part day-in the morning or during the day and/or night for longer than 3 months in the last year, Regular wheezing in the chest-independent of chest cold, Chronic bronchitis4efined as phlegm in the morning and during day and/or night for at least 3 winter months in the last 2 years or longer. FVC and FEV,,,, values are shown as percentages of the predicted values according to nomograms of Morris et al. (1971). The values of FVC and FEV,.,, which were 79% or less of the predicted were considered as reduced. “phlegm part day” does not include workers who have By definition, symptoms defined as chronic bronchitis and vice versa. However in other cases of analysed respiratory symptoms and signs an overlapping per men is possible. The intention was to analyze the relation between alcohol consumption and different types and degrees of respiratory findings. The analysis included workers who regularly or occasionally consume any kind of alcoholic drink. Those who regularly drink only wine (domestic) or wine and strong alcoholic drinks were considered separately. Wine consumption is expressed quantitatively. The categories of smokers were arranged according to Brinkman and Coates (1963). Present smokers were divided into: (a) light smokers, if the product of the average number of cigarettes smoked per day and the number of years of smoking did not exceed 200, (b) moderate smokers if the product ranged between 201 and 600, and (c) heavy smokers if the product exceeded 600. Among past smokers were grouped workers who smoked more than one cigarette a day, but stopped smoking at least 1 month prior to examination. Nonsmokers were considered workers who had never smoked or did smoke but not more than one cigarette a day. For the statistical analysis of results a method proposed by Mantel (1963) was used (chi-square tests with one degree of freedom: extensions of the Mantel-Haenszel procedure). questionnaire
RESULTS
Tables l-5 show the relationship between the prevalence of symptoms and signs of respiratory impairment and alcohol consumption considering also smoking habit and age. As seen from Table 1, the prevalence of “phlegm part day” did not differ significantly in subgroups of alcohol consumers, with the exception of those who daily drink more than 11 of wine and spirits and who had the highest rate of this symptom. At the same time the rate of “phlegm part day” appears to be higher in
16
SARI&
LUCIC-P.~LAIC$,
AND
HORTON
TABLE 1 PHLEGM PART DAY ACCORDING TO ALCOHOLCONSUMPTION Daily more than
11wine and
None or occasional alcohol
Daily up to tVz1 wine
Age and smoking habit
N
f
%
Nf%
N
f
%
Nf
20-29 30-39 M-49 50-59
26 36 20 1
I 3 3 0
3.8 8.3 15.0 0
65 2 3.1 100 11 11.0 73 7 9.6 11 3 27.3
51 160 147 44
4 23 12 6
7.8 14.4 8.2 13.6
4 12 LO 3
1 2 1 1
25.0 16.7 10.0 33.3
146 8 5.5 308 39 12.7 250 23 9.2 59 10 16.9
Nonsmokers Past smokers Current smokers Light Moderate Heavy
43 11 29 12 12 5
1 1 5 2 2 1
2.3 9.1 17.2 16.7 16.7 20.0
128 5 3.9 32 1 3.1 89 17 19.1 44 8 18.2 35 8 22.9 10 1 10.0
169 58 175 68 85 22
22 5 18 3 12 3
13.0 8.6 10.3 4.4 14.1 13.6
12 4 13 3 8 2
1 1 3 1 2 0
8.3 25.0 23.1 33.3 25.0 0
352 105 306 127 140 39
29 8.2 8 7.6 43 14.1 14 11.0 24 17.1 5 12.8
Total
83
7
8.4
249 23
402
45
11.2
29
5
17.2
763
80
part part part part part part part
day-alcohol day-smoking day-age day-alcohol day-alcohol day-smoking day-all three
Phlegm Phlegm Phlegm Phlegm Phlegm Phlegm Phlegm
9.2
Daily more than t/21 wine
consumption habit consumption combined with smoking consumption combined with age habit combined with age factors combined
habit
x2 x2 x2 x2 x2 x2 x2
spirits
= = = = = = =
2.185 6.548 2.511 8.635 4.362 8.823 10.776
Total %
Nf’%
10.5
NS P c 0.02 NS P < 0.01 P < 0.05 P < 0.01 P < 0.01
smokers than in nonsmokers or past smokers. In the workers examined there were no smokers of pipes or cigars, but only cigarette smokers. Workers in the age group 50-59 had a higher rate of the same symptom than the others. The statistical analysis also shows a significant association of “phlegm part day” with smoking. Alcohol consumption combined with smoking was associated with the rate of this symptom in the same way as smoking habit combined with age factor. The syndrome of chronic bronchitis (Table 2) was most frequent in those who daily drink more than 11 of wine and spirits but its prevalence also shows an increase in workers who daily drink more than l/21 of wine compared with those who do not drink alcohol (or drink alcohol occasionally) or those who daily drink less than 1/l of wine. As shown in the same table, chronic bronchitis was also dependent on smoking habit and age. Statistical evaluation demonstrates that all three factors (alcohol, smoking, age) combined are closely associated with chronic bronchitis. When each of these factors is considered separately. smoking seems to show the closest association with chronic bronchitis (x2 is the highest), then with alcohol consumption and age. Smoking combined with age, alcohol consumption combined with smoking, and alcohol consumption combined with age are also highly associated with chronic bronchitis. Table 3 shows that the prevalence of the symptom of regular wheezing in the chest was also highest in those who daily drink more than 11of wine and spirits,
CHRONIC
NONSPECIFIC
LUNG
DISEASE
AND
TABLE CHRONIC
Age and smoking habit 20-29 30-39 40-49 50-59 Nonsmokers Past smokers Current smokers Light Moderate Heavy Total
ACCORDING
Daily up to 1b51wine
Nf
Nf%
Nf
65 2 3.1 100 7 7.0 73 10 13.7 11 2 18.2
51 160 147 44
128 9 7.0 32 1 3.1 89 I1 12.4 44 4 9.1 35 5 14.3 10 2 20.0 249 21
%
26 36 20 1 43 11 29 12 12 5
I 2 2 1 2 0 4 0 3 1
3.8 5.6 10.0 100.0 4.7 0 13.8 0 25.0 20.0
83
6
7.2
8.4
Age and smoking habit
Nf
Nf%Nf%
20-29 30-39 40-49 50-59
26 36 20 1
1 4 4 0
Nonsmokers Past smokers Current smokers Light Moderate Heavy
43 11 29 12 12 5 83
Total Regular Regular Regular Regular Regular Regular Regular
Nf
3 28 32 14
5.9 17.5 21.8 31.8
169 58 175 68 85 22
15 9 53 11 32 10
8.9 15.5 30.3 16.2 37.6 45.5
4 12 10 3 12 4 13 3 8 2
402
77
19.2
29
TABLE 3 IN ‘THE CHEST ACCORDING Daily up to ‘951 wine
%
1 1 7 2 2 3
3.8 11.1 20.0 0 2.3 9.1 24.1 16.7 16.7 60.0
65 100 73 11 128 32 89 4400 35 10
9
10.8
249
IO
4 11.4 1 10.0 4.8
Total
R
Nf
%
2 4 6 1 3 1 9 1 6 2
50.0 33.3 60.0 33.3 25.0 25.0 69.2 33.3 75.0 loo.0
146 308 250 59
8 5.5 41 13.3 50 20.0 18 30.5
352 105 306 127 140 39
29 8.2 11 10.5 77 25.2 16 12.6 46 32.9 15 38.5
13
44.8
763
117
x2 = 28.485 x2 = 38.01 x= = 26.197 x2 = 62.299
P i 0.001 P < 0.001 P < 0.001
x2 = 50.313 x2 = 64.043 x2 = 88.264
P < 0.001
ALCOHOL
Daily more than %I wine
15.3
P < 0.001 P i 0.001 P < 0.001
CONSUMPTION
Daily more than 11 wine and spirits
Nf
1 1.5 4 4.0 5 6.8 2 18.2 5 3.9 2 6.3 5 5.6
12
Daily more than 11 wine and spirits
%
consumption combined with smoking habit consumption combined with age habit combined with age factors combined
None or occasional alcohol
CONSUMPTION
Daily more than %I wine
consumption habit
WHEELING
17
CONSUMPTION
2 TO ALCOHOL
None or occasional alcohol
Chronic bronchitis-alcohol Chronic bronchitis-smoking Chronic bronchitis-age Chronic bronchitis-alcohol Chronic bronchitis-alcohol Chronic bronchitis-smoking Chronic bronchitis-all three
REGC’LAK
BRONCHITIS
ALCOHOL
%
Total
Nf%
51 160 147 44
1 13 18 10
2.0 8.1 12.2 22.7
4 12 10 3
0 1 4 0
0 8.3 40.0 0
146 3 2.1 308 22 7.1 250 31 12.4 59 12 20.3
169 58 175 68 85 22
12 3 27 2 19 6
7.1 5.2 15.4 2.9 22.4 27.3
12 4 13 3 8 2
2 1 2 0 2 0
16.7 25.0 15.4 0 25.0 0
352 IO5 306 127 140 39
402
42
10.4
29
5
17.2
763 68
wheezing-alcohol consumption wheezing-smoking habit wheezing-age wheezing-alcohol consumption combined with smoking wheezing-alcohol consumption combined with age wheezing-smoking habit combined with age wheezing-all three factors combined
x* = 3.290 x* = 11.828 habit
x2 = 22.501 x2 = 15.016
20 5.7 7 6.7 41 13.4 4 3.1 27 19.3 10 25.6
NS P < 0.001 P
RESEARCH
Chronic
14, 14 - 21 (1977)
Nonspecific Lung Disease Consumption
M. SARIS, S. LuCIC-PALAI~, ltrsritufefor Medical U.S. Ewironmental
Research Protection
AND
and Alcohol
R. J. M. HORTON
rmd Occtrpational Health, Zagreb, Agency. Research Triangle Park.
Received March
Yugoslavia, and North Carolina
19, 1976
The relationship of the symptoms and signs of chronic nonspecific lung disease and alcohol consumption was studied in a group of 763 male workers aged 20-59. mean age 37 years. The effects of concurrent smoking habit and age were also considered. The results obtained indicate that in addition to being associated with the use of tobacco and age, respiratory symptoms and ventilatory impairment are also related to alcohol consumption. This is particularly true for the syndrome of chronic bronchitis.
INTRODUCTION
In the study of the prevalence and incidence of chronic nonspecific lung disease alcohol consumption is only occasionally mentioned as a possibly significant factor. Besides clinical experience which points out that diseases of the lung and respiratory impairment are related to alcoholism (Chomet and Gach, 1967; Banner, 1973) there are epidemiological studies which support the assumption that alcoholism plays a role in the development of chronic nonspecific lung disease (Pell and D’Alonzo, 1968; Hrubec et crl., 1973). Experiments on animals revealed that alcohol acts by reducing the resistance to infections (Stillman, 1924; Pickerel], 1938). This seems to be the result of a disturbed function of the ciliary apparatus in the bronchioli, and of alveolar macrophages which take part in the clearance of bacteria from the lung (Laurenzi and Guarneri, 1966; Rylander, 1968; Green and Green, 1968). This paper discusses the relationship between the symptoms and signs of chronic nonspecific lung disease and alcohol consumption in a group of industrial workers, with reference to smoking habit and age. SAMPLE AND METHOD
The study was carried out in a group of 763 workers, males aged 20-59 (x = 37 years; SD = 8.9 years) employed in two factories: a ferromanganese and electrode production (559) and a light metal plant (204). The subgroups did not differ in the consumption of tobacco or alcohol. Therefore they were not treated separately in this analysis. Also, as described elsewhere (Sari6 ef al., 1974), the subgroups did not differ markedly in the rate of respiratory impairment. Although all the workers examined were not engaged in the same type of work, none was exposed to distinct respiratory irritants. About 5% of the workers who were invited to be examined did not respond because of absence from work (sick leave, annual leave, etc). 14 Copyright All rights
0 1977 by Academic Press. Inc. of reproduction in any form reserved.
ISSN 0013-972,
CHRONIC
NONSPECIFIC
LUNC;
DISEASE
AND
ALCOHOL
CONSUMPTION
15
Data concerning alcohol consumption were gathered by means of a part of a (Drinking Habits) of the Division of Medical Sciences, National Research Council, U.S. National Academy of Sciences (1967). Data concerning respiratory symptoms and smoking habit were obtained in an interview based on the questionnaire of the Committee on Aetiology of Chronic Bronchitis of the British Medical Research Council (1965). Forced expiratory volumes were also measured. Among recorded respiratory symptoms the following were analysed: Phlegm part day-in the morning or during the day and/or night for longer than 3 months in the last year, Regular wheezing in the chest-independent of chest cold, Chronic bronchitis4efined as phlegm in the morning and during day and/or night for at least 3 winter months in the last 2 years or longer. FVC and FEV,,,, values are shown as percentages of the predicted values according to nomograms of Morris et al. (1971). The values of FVC and FEV,.,, which were 79% or less of the predicted were considered as reduced. “phlegm part day” does not include workers who have By definition, symptoms defined as chronic bronchitis and vice versa. However in other cases of analysed respiratory symptoms and signs an overlapping per men is possible. The intention was to analyze the relation between alcohol consumption and different types and degrees of respiratory findings. The analysis included workers who regularly or occasionally consume any kind of alcoholic drink. Those who regularly drink only wine (domestic) or wine and strong alcoholic drinks were considered separately. Wine consumption is expressed quantitatively. The categories of smokers were arranged according to Brinkman and Coates (1963). Present smokers were divided into: (a) light smokers, if the product of the average number of cigarettes smoked per day and the number of years of smoking did not exceed 200, (b) moderate smokers if the product ranged between 201 and 600, and (c) heavy smokers if the product exceeded 600. Among past smokers were grouped workers who smoked more than one cigarette a day, but stopped smoking at least 1 month prior to examination. Nonsmokers were considered workers who had never smoked or did smoke but not more than one cigarette a day. For the statistical analysis of results a method proposed by Mantel (1963) was used (chi-square tests with one degree of freedom: extensions of the Mantel-Haenszel procedure). questionnaire
RESULTS
Tables l-5 show the relationship between the prevalence of symptoms and signs of respiratory impairment and alcohol consumption considering also smoking habit and age. As seen from Table 1, the prevalence of “phlegm part day” did not differ significantly in subgroups of alcohol consumers, with the exception of those who daily drink more than 11 of wine and spirits and who had the highest rate of this symptom. At the same time the rate of “phlegm part day” appears to be higher in
16
SARI&
LUCIC-P.~LAIC$,
AND
HORTON
TABLE 1 PHLEGM PART DAY ACCORDING TO ALCOHOLCONSUMPTION Daily more than
11wine and
None or occasional alcohol
Daily up to tVz1 wine
Age and smoking habit
N
f
%
Nf%
N
f
%
Nf
20-29 30-39 M-49 50-59
26 36 20 1
I 3 3 0
3.8 8.3 15.0 0
65 2 3.1 100 11 11.0 73 7 9.6 11 3 27.3
51 160 147 44
4 23 12 6
7.8 14.4 8.2 13.6
4 12 LO 3
1 2 1 1
25.0 16.7 10.0 33.3
146 8 5.5 308 39 12.7 250 23 9.2 59 10 16.9
Nonsmokers Past smokers Current smokers Light Moderate Heavy
43 11 29 12 12 5
1 1 5 2 2 1
2.3 9.1 17.2 16.7 16.7 20.0
128 5 3.9 32 1 3.1 89 17 19.1 44 8 18.2 35 8 22.9 10 1 10.0
169 58 175 68 85 22
22 5 18 3 12 3
13.0 8.6 10.3 4.4 14.1 13.6
12 4 13 3 8 2
1 1 3 1 2 0
8.3 25.0 23.1 33.3 25.0 0
352 105 306 127 140 39
29 8.2 8 7.6 43 14.1 14 11.0 24 17.1 5 12.8
Total
83
7
8.4
249 23
402
45
11.2
29
5
17.2
763
80
part part part part part part part
day-alcohol day-smoking day-age day-alcohol day-alcohol day-smoking day-all three
Phlegm Phlegm Phlegm Phlegm Phlegm Phlegm Phlegm
9.2
Daily more than t/21 wine
consumption habit consumption combined with smoking consumption combined with age habit combined with age factors combined
habit
x2 x2 x2 x2 x2 x2 x2
spirits
= = = = = = =
2.185 6.548 2.511 8.635 4.362 8.823 10.776
Total %
Nf’%
10.5
NS P c 0.02 NS P < 0.01 P < 0.05 P < 0.01 P < 0.01
smokers than in nonsmokers or past smokers. In the workers examined there were no smokers of pipes or cigars, but only cigarette smokers. Workers in the age group 50-59 had a higher rate of the same symptom than the others. The statistical analysis also shows a significant association of “phlegm part day” with smoking. Alcohol consumption combined with smoking was associated with the rate of this symptom in the same way as smoking habit combined with age factor. The syndrome of chronic bronchitis (Table 2) was most frequent in those who daily drink more than 11 of wine and spirits but its prevalence also shows an increase in workers who daily drink more than l/21 of wine compared with those who do not drink alcohol (or drink alcohol occasionally) or those who daily drink less than 1/l of wine. As shown in the same table, chronic bronchitis was also dependent on smoking habit and age. Statistical evaluation demonstrates that all three factors (alcohol, smoking, age) combined are closely associated with chronic bronchitis. When each of these factors is considered separately. smoking seems to show the closest association with chronic bronchitis (x2 is the highest), then with alcohol consumption and age. Smoking combined with age, alcohol consumption combined with smoking, and alcohol consumption combined with age are also highly associated with chronic bronchitis. Table 3 shows that the prevalence of the symptom of regular wheezing in the chest was also highest in those who daily drink more than 11of wine and spirits,
CHRONIC
NONSPECIFIC
LUNG
DISEASE
AND
TABLE CHRONIC
Age and smoking habit 20-29 30-39 40-49 50-59 Nonsmokers Past smokers Current smokers Light Moderate Heavy Total
ACCORDING
Daily up to 1b51wine
Nf
Nf%
Nf
65 2 3.1 100 7 7.0 73 10 13.7 11 2 18.2
51 160 147 44
128 9 7.0 32 1 3.1 89 I1 12.4 44 4 9.1 35 5 14.3 10 2 20.0 249 21
%
26 36 20 1 43 11 29 12 12 5
I 2 2 1 2 0 4 0 3 1
3.8 5.6 10.0 100.0 4.7 0 13.8 0 25.0 20.0
83
6
7.2
8.4
Age and smoking habit
Nf
Nf%Nf%
20-29 30-39 40-49 50-59
26 36 20 1
1 4 4 0
Nonsmokers Past smokers Current smokers Light Moderate Heavy
43 11 29 12 12 5 83
Total Regular Regular Regular Regular Regular Regular Regular
Nf
3 28 32 14
5.9 17.5 21.8 31.8
169 58 175 68 85 22
15 9 53 11 32 10
8.9 15.5 30.3 16.2 37.6 45.5
4 12 10 3 12 4 13 3 8 2
402
77
19.2
29
TABLE 3 IN ‘THE CHEST ACCORDING Daily up to ‘951 wine
%
1 1 7 2 2 3
3.8 11.1 20.0 0 2.3 9.1 24.1 16.7 16.7 60.0
65 100 73 11 128 32 89 4400 35 10
9
10.8
249
IO
4 11.4 1 10.0 4.8
Total
R
Nf
%
2 4 6 1 3 1 9 1 6 2
50.0 33.3 60.0 33.3 25.0 25.0 69.2 33.3 75.0 loo.0
146 308 250 59
8 5.5 41 13.3 50 20.0 18 30.5
352 105 306 127 140 39
29 8.2 11 10.5 77 25.2 16 12.6 46 32.9 15 38.5
13
44.8
763
117
x2 = 28.485 x2 = 38.01 x= = 26.197 x2 = 62.299
P i 0.001 P < 0.001 P < 0.001
x2 = 50.313 x2 = 64.043 x2 = 88.264
P < 0.001
ALCOHOL
Daily more than %I wine
15.3
P < 0.001 P i 0.001 P < 0.001
CONSUMPTION
Daily more than 11 wine and spirits
Nf
1 1.5 4 4.0 5 6.8 2 18.2 5 3.9 2 6.3 5 5.6
12
Daily more than 11 wine and spirits
%
consumption combined with smoking habit consumption combined with age habit combined with age factors combined
None or occasional alcohol
CONSUMPTION
Daily more than %I wine
consumption habit
WHEELING
17
CONSUMPTION
2 TO ALCOHOL
None or occasional alcohol
Chronic bronchitis-alcohol Chronic bronchitis-smoking Chronic bronchitis-age Chronic bronchitis-alcohol Chronic bronchitis-alcohol Chronic bronchitis-smoking Chronic bronchitis-all three
REGC’LAK
BRONCHITIS
ALCOHOL
%
Total
Nf%
51 160 147 44
1 13 18 10
2.0 8.1 12.2 22.7
4 12 10 3
0 1 4 0
0 8.3 40.0 0
146 3 2.1 308 22 7.1 250 31 12.4 59 12 20.3
169 58 175 68 85 22
12 3 27 2 19 6
7.1 5.2 15.4 2.9 22.4 27.3
12 4 13 3 8 2
2 1 2 0 2 0
16.7 25.0 15.4 0 25.0 0
352 IO5 306 127 140 39
402
42
10.4
29
5
17.2
763 68
wheezing-alcohol consumption wheezing-smoking habit wheezing-age wheezing-alcohol consumption combined with smoking wheezing-alcohol consumption combined with age wheezing-smoking habit combined with age wheezing-all three factors combined
x* = 3.290 x* = 11.828 habit
x2 = 22.501 x2 = 15.016
20 5.7 7 6.7 41 13.4 4 3.1 27 19.3 10 25.6
NS P < 0.001 P
