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1 James Hogg iCAPTURE Center, St. Paul's Hospital; 2 British Columbia Centre of Excellence for Women's Health; 3 BC Women's Hospital and Health Centre; and 4 School of Occupational and Environmental Hygiene, University of British Columbia, Vancouver, British Columbia, Canada
Correspondence and requests for reprints should be addressed to Don D. Sin, M.D., The James Hogg iCAPTURE Center for Cardiovascular and Pulmonary Research, St. Paul's Hospital, Room 368A, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6 Canada. E-mail: dsin{at}mrl.ubc.ca
The rate of chronic obstructive pulmonary disease (COPD) is rising rapidly in women and has become one of the leading causes of mortality in women worldwide (1). In fact, COPD kills more women in the world today than do breast and lung cancer combined (2). Although COPD prevalence and its attendant mortality have plateaued in men over the past few years, they continue to rise in women. The number of new cases of COPD is growing nearly three times faster in women than in men every year (3). Despite these trends, there is a marked scarcity of research that recognizes the importance of sex- and gender-related issues in the etiology, diagnosis, management, or experiences of COPD in women (3).
Smoking is by far the most important cause of COPD (4). At least 15% of sustained smokers develop serious impairment in lung function during their lifetime, resulting in COPD-related hospitalizations and death. Many more (perhaps another 20 to 30%) of smokers develop milder forms of COPD, which increase their risk for cardiac diseases and lung cancer (5). Once individuals develop COPD, the risk of cardiovascular morbidity and mortality increases, independent of the effects of cigarette smoking and other confounding factors (6). Across the world, nearly 1.3 billion people are daily smokers (7). If the prevalence of tobacco use remains constant, the number of smokers will rise to 1.7 billion by 2025 (7), and 50% of these individuals will die of tobacco-related disease (8).
The global prevalence of tobacco use in men has peaked and is in slow decline, but the female rates are still rapidly increasing nearly everywhere. It is expected that by 2025 over 500 million women will be daily smokers, representing 20% of the total female population in the world (up from the current prevalence of 12%) (9). This smoking epidemic in women has been (and will continue to be) driven in part by the tobacco industry's relentless promotion of cigarettes to young women using seductive but false images of vitality, slimness, freedom, sophistication, and sexuality, and by the development of female-specific products such as "light," "extra slim," and "low tar" tobacco brands. Other factors that are driving the epidemic are globalization and urbanization, especially among young women in developing countries (9).
Although the increasing trend in tobacco consumption is one of the important "drivers" of the female COPD epidemic, there are clearly other risk factors that are involved in this process. For instance, in China, fewer than 10% of women smoke; however, in 2000, COPD was the second leading cause of mortality among Chinese women 65 years and older (10). In developing countries such as China, environmental irritants such as biomass may play a significant role in the COPD epidemic (11). Because women do most of the cooking in these countries, women have disproportionately larger exposures to biomass, a by-product of coal, charcoal, wood, or animal dung combustion, during cooking (11). In addition, women may have certain biological factors, such as those related to female hormones, that may amplify the adverse effects of cigarette smoke or biomass in the lungs (12). Whatever the mechanism(s), there is strong epidemiologic evidence that women are at increased risk of COPD compared with men (13).
In the face of the COPD epidemic in women, several questions need to be addressed. They include the following:
To begin addressing these and other questions, a group of 60 experts representing a wide range of disciplines interested in combating the global epidemic of COPD in women held a 2-day meeting to advance the research agenda of gender, sex, and COPD. The meeting was held under the auspices of ICEBERGS (Interdisciplinary Capacity Enhancement: Bridging Excellence in Respiratory Disease and Gender Studies), which is funded by the Canadian Institutes of Health Research and the Canadian Tobacco Control Research Initiative. In this PATS symposium, a cast of qualified experts in gender and COPD summarize the relevant discussions from the workshop. The topics are eclectic and encompass the full spectrum of COPD from genomics to the population. An overriding and unanimous conclusion from the workshop was that all disciplines and sectors need to work together to generate more knowledge in this area. There is a paucity of good studies that have addressed the issue of gender, sex, and COPD. We hope that these proceedings will be a stimulus for researchers, clinicians, and public policy makers to work together to find solutions to the growing epidemic of COPD in women across the world.
ACKNOWLEDGMENTS
The authors thank all the participants who attended the "Toward a Research Agenda on Gender and Chronic Obstructive Pulmonary Disease" workshop and, in particular, Dr. Demet Eeder, Ms. Christie Hurrell, and Dr. Ann-Marie Nicol, who put the program together and made the workshop possible.
FOOTNOTES
This article was based on a workshop discussion at the "Toward a Research Agenda on Gender and Chronic Obstructive Pulmonary Disease" conference, which was supported by the Canadian Institutes of Health Research (Institute of Gender and Health), by the Canadian Tobacco Control Research Initiative, and by the Interdisciplinary Capacity Enhancement: Bridging Excellence in Respiratory Disease and Gender Studies (ICEBERGS) (http://www.icebergs.ubc.ca).
Conflict of Interest Statement: D.D.S. has received honoraria for speaking engagements from AstraZeneca in 2003 ($4,000), in 2004 ($3,000), and in 2005 ($11,000), and from GlaxoSmithKline (GSK) in 2003 ($4,000), in 2004 ($8,000), in 2005 ($6,500), and in 2006 ($10,000). He has also received unrestricted research funding as either the principal investigator or co-principal investigator from GSK in 2003 for $80,000 and in 2004 for $1.5 million. He has also received $3,500 from GSK for consultancy work in 2004 and $1,500 in 2006. L.G. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. S.K. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.
(Received in original form June 28, 2007; accepted in final form August 2, 2007)
REFERENCES
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