COPD in the Never-Smoker

By David M. Mannino, MD, FCCP; and Kathryn Marie McGonigle

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Epidemiology of COPD

In 2000, an estimated 10 million US adults reported physician-diagnosed COPD.⁴ Data from the Third National Health and Nutrition Examination Survey (NHANES III), however, estimate that among 11 million US adults with evidence of low lung function, < 40% reported a diagnosis of COPD or asthma, suggesting that COPD is underdiagnosed.⁵ In 2000, COPD was responsible for 8 million physician-office and hospital outpatient visits, 1.5 million emergency department visits, 726,000 hospitalizations, and 119,000 deaths. The most dramatic change over the 21-year period analyzed in the Centers for Disease Control report was the increase in the COPD death rate for women, from 20.1 per 100,000 in 1980 to 56.7 per 100,000 in 2000, compared with the more modest increase in the death rate for men, from 73.0 per 100,000 in 1980 to 82.6 per 100,000 in 2000.⁴ COPD is a costly disease, with estimated direct medical costs in 1993 of $14.7 billion.⁶ The estimated indirect costs related to morbidity (loss of work time and productivity) and premature mortality represent an additional $9.2 billion, for a total of $23.9 billion. When the $12.6 billion in indirect and direct medical costs attributable to asthma are added to this, the total cost of obstructive lung disease in the United States is $36.1 billion. Another manifestation of the importance of COPD is its effect on the burden of disease in population determined using disability-adjusted life-years (DALYs).⁷ In 1996, COPD was estimated to be the eighth leading cause of DALYs among men and the seventh leading cause of DALYs among women.⁷ Worldwide, COPD is expected to move up from the 12th leading cause of DALYs in 1990 to the fifth leading cause in 2020.⁸

Smoking is the primary risk factor for the development and progression of COPD; however, < 25% of smokers develop COPD⁹ and about 15% of COPD-related mortality occurs in never-smokers, suggesting that other factors are important.¹⁰ Several pathways have been proposed for the pathogenesis of COPD: reduced lung growth during childhood to young adulthood (from birth to 15 years in women and from birth to 25 years in men); a premature decline when lung function should be stable during young adulthood (age 15 to 35 years); or accelerated decline in lung function after the age of 35 years.¹¹ Identified factors other than smoking that are important in COPD development and progression include asthma and bronchial responsiveness,¹² occupation,¹³ genetic factors,⁹ air pollution,¹⁴ sex,^15,16 socioeconomic status,¹⁷ nutrition,¹⁸ and childhood exposures.¹⁹ Understanding how these factors work together to cause diminished lung function in never-smokers may improve our understanding of and treatment options for COPD in general population. In addition, the majority of COPD in the developing world probably occurs in never-smokers.

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