Chronic bronchitis: an old man's enemy?

Abstract

All reasonably competent medical students are able to accurately deWne chronic bronchitis as the production of sputum on most days over a 3-month period on at least two consecutive years. Most of them, and indeed most doctors, would also recognise its high prevalence in middle aged and elderly people: indeed it has often been termed ‘the English disease’. In contrast many people with chronic bronchitis do not recognise the condition as abnormal at all. Chronic sputum production is almost inevitable for those with a signiWcant smoking history, so much so that in subpopulations with a high prevalence of smoking the prevalence of chronic bronchitis is so high as to be regarded as almost the norm. Furthermore the insidious onset of the condition is also likely to be a factor leading to its acceptance as normal. Indeed many smokers with chronic bronchitis, upon failing in their efforts in smoking cessation cite the fact that they ‘can’t get up the phlegm’ as a reason for restarting smoking (i.e. not realising that the absence of sputum production is a good thing not a bad thing). In the present edition of Age and Ageing, Peter Lange and colleagues [1] have, in an elegant and impressive study, taken the argument further forward. Their study, part of the Copenhagen City Heart Study, has been carried out in a large sample of elderly Copenhagen residents over a period of 25 years or more. Not only have they conWrmed the high prevalence of chronic bronchitis in the population (nearly 20% in men) and deWned risk factors for chronic bronchitis (current or previous smoking, previous dust exposure, chest infections in childhood or multiple chest infection over the previous 10-year period) but also, more importantly, they have shown a strong relationship between the presence of chronic bronchitis and lung cancer, benign respiratory disease, COPD and (most importantly) all cause mortality. This latter relationship was strong, with a 30% increase in mortality ratio in those with chronic bronchitis. Furthermore it was independent of the effects of smoking, gender and lung function. What does this tell us? Firstly and self evidently chronic bronchitis cannot be regarded as a benign ‘nuisance’. Secondly and more importantly there are potential major implications for health promotion and disease prevention in the Wndings of Lange and colleagues. It is already known, that in the elderly at least, a major predictor of smoking cessation is the patients’ knowledge that they have a disease caused by smoking and advice given to them from a health professional to stop smoking for the sake of their own health [2, 3]. The possibility that subjects with chronic bronchitis (and as yet no other signiWcant smoking-related disease) may respond in a similar way to such knowledge and advice is an attractive one and merits exploration. This may have particular value in the United Kingdom where, particularly in disadvantaged inner city populations, the prevalence of chronic bronchitis is likely to be even higher than that shown in the Copenhagen study [4]. This study comes at an opportune time particularly for those of us in this country as the NICE guidelines on COPD are currently in preparation and due for publication next year. Clinical and research interest into the effects of smoking on the lung are at an all time high. Governments have woken up (to some extent) to the urgent need to promote smoking cessation as witnessed recently by the ratiWcation of the World Health Organization initiative ‘Framework Convention for Tobacco Control’ which among other things places severe restrictions on tobacco advertising and increases the potency and physical size of health warnings on cigarette packets. The NHS in the UK, however, needs to do more. A survey conducted in 2001 by the British Thoracic Society shows that only approximately one third of NHS hospitals have smoking cessation counsellors. An update on this survey took place earlier this year but the results are not yet available in full. Whether NHS smoking cessation counselling services have any age-related elements to their policies is unknown. In terms of general medical training it is gratifying that smoking cessation training is included in the curriculum documents for senior house ofWcer and specialist registrar training and will soon be part of the foundation year curriculum. Given the evidence of beneWt of smoking cessation even in the very elderly [5] it would seem advisable that training in smoking cessation advice should be part of the curriculum for specialist registrars in geriatric medicine as well. The current paper by Lange and colleagues is a small but important advance in the battle to ‘add life to years’. Far from being a benign disease, chronic bronchitis can clearly be seen as an old man’s (and increasingly woman’s) enemy.