High prevalence of COPD symptoms in the general population contrasting with low awareness of the disease.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is underdiagnosed because of limited disease awareness with trivialization of the symptoms in the general population. METHODS: A survey was conducted in a representative sample (n=2758) of individuals older than 40 years of age in the general population of France. Respiratory symptoms and knowledge about COPD were assessed in individuals with or at risk for COPD (n=860, 31% of the sample). RESULTS: In the overall sample, 40% of individuals had a Medical Research Council dyspnea grade of 1 or more but only 9% spontaneously reported shortness of breath. Of these 9%, 72% reported limitations to their daily activities but only 14% believed they had severe lung disease. In the overall sample, only 220 (8%) individuals knew the term COPD and only 66% associated the term COPD with respiratory disease. CONCLUSIONS: Despite a large proportion of individuals at risk for COPD or having COPD and a high prevalence of breathlessness, awareness of respiratory symptoms and knowledge of COPD were limited. These findings indicate a need for educating the general population about COPD.

[The gap between the high impact and low awareness of COPD in the population]. / Sujets à risque de BPCO en population générale: disproportion entre la fréquence des symptômes, leur perception et la connaissance de la maladie.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is markedly under-diagnosed, which may relate to under-reporting of symptoms and poor awareness of the disease. METHODS: A survey was conducted in a sample of the French general population aged 40-75 years (n=2758) to assess respiratory symptoms and level of knowledge of the disease in subjects with or at-risk of COPD (n=860, 31%). RESULTS: The high frequency of dyspnoea (MRC dyspnoea grade > or =1: 40%) contrasted with that of subjects spontaneously reporting respiratory problems (9%). Among these, 72% reported limitations in daily-life activities but only 14% considered that they were severely affected by their respiratory status. A very low proportion of subjects knew the term COPD (8%) and only 66% of these associated COPD with a respiratory disease. CONCLUSIONS: There is a wide gap between the high number of subjects at risk of COPD in the general population and the frequency of breathlessness in these subjects on one hand, and the poor knowledge of the disease, poor perception of symptoms, and under-diagnosis and under-use of spirometry on the other. Increasing awareness of COPD in the population is needed.

[Characteristics of the patients included in the French cohort of patients with emphysema caused by alpha-1 antitrypsin deficiency]. / Caractéristiques des patients inclus dans la cohorte française de patients emphysémateux déficitaires en alpha-1 antitrypsine.

INTRODUCTION: Alpha-1 antitrypsin deficiency is associated with the occurrence of pulmonary emphysema. The aim of this study is to describe the characteristics of patients with alpha-1 antitrypsin deficiency associated pulmonary emphysema. METHODS: We describe a prospective cohort study including adult patients with alpha-1 antitrypsin deficiency associated pulmonary emphysema confirmed by CT scan living in France. Patients' clinical and functional characteristics, quality of life measures and management were recorded every 6 months during a five-year period. RESULTS: 201 patients were included from 56 centres between 2005 and 2008. The characteristics of 110 patients have been analysed. Mean age was 50 years (SD:11.8), 62.7% were males, 90% were tobacco smokers. The main functional results (% predicted) were: FEV1: 42.8 (19.6), CPT: 128.3 (21.7), CRF: 167.0 (46.0), 6 minute walking distance (meters): 413 (130). 51 (46.4%) patients received augmentation therapy. Augmentation therapy was administered weekly (37.5%), twice a month (35.4%) or monthly (25.5%). Study centre was the only factor associated with the likelihood to received augmentation therapy. CONCLUSIONS: The clinical and functional characteristics as well as management of these patients varied markedly. There is a need for a standardization of the management of patients with alpha-1 antitrypsin deficiency associated pulmonary emphysema.

Association of lung function decline with the heme oxygenase-1 gene promoter microsatellite polymorphism in a general population sample. Results from the European Community Respiratory Health Survey (ECRHS), France.

Inducible heme oxygenase (HO-1) acts against oxidants that are thought to play a major role in the pathogenesis of chronic obstructive pulmonary disease (COPD), characterised by impaired lung function. A (GT)(n) repeat polymorphism in the HO-1 gene promoter can modulate the gene transcription in response to oxidative stress. We hypothesised that this polymorphism could be associated with the level of lung function and decline in subjects exposed to oxidative aggression (smokers). We genotyped 749 French subjects (20-44 years, 50% men, 40% never smokers) examined in both 1992 and 2000 as part of the ECRHS. Lung function was assessed by forced expiratory volume in 1 second (FEV1) and FEV1/forced ventilatory capacity (FVC) ratio. We compared long (L) allele carriers ((GT)(n) > or =33 repeats for one or two alleles) to non-carriers. Cross sectionally, in 2000, L allele carriers showed lower FEV1/FVC than non-carriers. During the 8 year period, the mean annual FEV1 and FEV1/FVC declines were -30.9 (31.1) ml/year and -1.8 (6.1) U/year, respectively. FEV1/FVC decline was steeper in L allele carriers than in non-carriers (-2.6 (5.5) v -1.5 (6.4), p = 0.07). There was a strong interaction between the L allele and smoking. In 2000, the L allele was associated with lower FEV(1) and FEV(1)/FVC in heavy smokers (> or =20 cigarettes/day) only (p for interaction = 0.07 and 0.002 respectively). Baseline heavy smokers carrying the L allele showed the steepest FEV1 decline (-62.0 (29.5 ml/year) and the steepest FEV1/FVC decline (-8.8 (5.4 U/year) (p for interaction = 0.009 and 0.0006). These results suggest that a long (L) HO-1 gene promoter in heavy smokers is associated with susceptibility to develop airway obstruction.

Serum carotenoids, vitamins A and E, and 8 year lung function decline in a general population.

BACKGROUND: Oxidative stress is thought to have a major role in the pathogenesis of airway obstruction. A study was undertaken to determine whether subjects with low levels of antioxidants (serum beta-carotene, alpha-carotene, vitamins A and E) would be at a higher risk of accelerated decline in forced expiratory volume in 1 second (FEV1) as their lungs would be less protected against oxidative stress. METHODS: 1194 French subjects aged 20-44 years were examined in 1992 as part of the European Community Respiratory Health Survey (ECRHS); 864 were followed up in 2000 and 535 (50% men, 40% lifelong non-smokers) had complete data for analysis. RESULTS: During the 8 year study period the mean annual decrease in FEV1 (adjusted for sex, centre, baseline FEV1, age, smoking, body mass index and low density lipoprotein cholesterol) was 29.8 ml/year. The rate of decrease was lower for the subjects in tertile I of beta-carotene at baseline than for those in the two other tertiles (-36.5 v -27.6 ml/year; p = 0.004). An increase in beta-carotene between the two surveys was associated with a slower decline in FEV1. No association was observed between alpha-carotene, vitamin A, or vitamin E and FEV(1) decline. However, being a heavy smoker (> or =20 cigarettes/day) in combination with a low level of beta-carotene or vitamin E was associated with the steepest decline in FEV1 (-52.5 ml/year, p = 0.0002 and -50.1 ml/year, p = 0.010, respectively). CONCLUSIONS: These results strongly suggest that beta-carotene protects against the decline in FEV1 over an 8 year period in the general population, and that beta-carotene and vitamin E are protective in heavy smokers.

Changes in active and passive smoking in the European Community Respiratory Health Survey.

The aim of the present investigation was to study changes and determinants for changes in active and passive smoking. The present study included 9,053 adults from 14 countries that participated in the European Community Respiratory Health Survey II. The mean follow-up period was 8.8 yrs. Change in the prevalence of active and passive smoking was expressed as absolute net change (95% confidence interval) standardised to a 10-yr period. Determinants of change were analysed and the results expressed as adjusted hazard risk ratio (HRR) or odds ratio (OR). The prevalence of active smoking declined by 5.9% (5.1-6.8) and exposure to passive smoking in nonsmokers declined by 18.4% (16.8-20.0). Subjects with a lower educational level (HRR: 0.73 (0.54-0.98) and subjects living with a smoker (HRR: 0.45 (0.34-0.59)) or with workplace smoking (HRR: 0.69 (0.50-0.95)) were less likely to quit. Low socio-economic groups were more likely to become exposed (OR: 2.21 (1.61-3.03)) and less likely to cease being exposed to passive smoking (OR: 0.48 (0.37-0.61)). In conclusion, the quitting rate was lower and the risk of exposure to passive smoking higher among subjects with lower socio-economic status. Exposure to other peoples smoking decreased quitting rates and increased the risk of starting to smoke.

Twenty five year mortality and air pollution: results from the French PAARC survey.

AIMS AND METHODS: Long term effects of air pollution on mortality were studied in 14,284 adults who resided in 24 areas from seven French cities when enrolled in the PAARC survey (air pollution and chronic respiratory diseases) in 1974. Daily measurements of sulphur dioxide, total suspended particles, black smoke, nitrogen dioxide, and nitric oxide were made in 24 areas for three years (1974-76). Cox proportional hazards models controlling for individual confounders (smoking, educational level, body mass index, occupational exposure) were applied, and frailty models used to take into account spatial correlation. Indicators of air pollution were the mean concentration. RESULTS: Models were run before and after exclusion of six area monitors influenced by local traffic (NO/NO2 >3 in ppb). After exclusion of these areas, analyses showed that adjusted risk ratios (95% CI) for TSP, BS, NO2, and NO for non-accidental mortality were 1.05 (1.02 to 1.08), 1.07 (1.03 to 1.10), 1.14 (1.03 to 1.25), and 1.11 (1.05 to 1.17) for 10 microg/m3 respectively. Consistent patterns for lung cancer and cardiopulmonary causes were observed. CONCLUSIONS: Urban air pollution assessed in the 1970s was associated with increased mortality over 25 years in France.

Prevalence of nasal polyposis in France: a cross-sectional, case-control study.

BACKGROUND: The prevalence of nasal polyposis (NP) has never been established in France due to the lack of diagnostic tools for population-based studies. METHODS: Using a recently validated questionnaire/algorithm (90% specificity and sensitivity) in a population-based random sample, the present cross-sectional, case-control study allowed to determine NP prevalence and describe the principal aspects of NP epidemiology. A total of 10 033 subjects (>/=18 years) were screened. After identification of subjects with NP and those without, another questionnaire was submitted to NP patients only for further data collection. Controls were individuals without NP, matched by gender and age to NP patients. RESULTS: Nasal polyposis prevalence was 2.11% (95% CI 1.83-2.39). NP patients (n = 212, 45% males) were aged 49.4 +/- 17.6 years. No gender preponderance was observed, but NP tended to increase with age. Mean duration of nasal symptoms was 22.4 +/- 15.7 years. Among the 145 patients having already seen a doctor for their symptoms, 77.2% have been referred to a specialist, and 18.6% had a diagnosis of NP. Rhinorrhoea was reported by 39.9% of NP patients, blocked nose by 30.8%, and anosmia by 28.9%. Only 6.9% reported facial discomfort while 24.6% complained about general discomfort. Most NP patients (61.3%) had a pharmacological treatment, a nasal spray for the major part (76.9%). CONCLUSION: The present study provides valuable and reliable information on NP epidemiology in France; the collected information are in accordance with most published international data.

Association of bronchial hyperresponsiveness and lung function with C-reactive protein (CRP): a population based study.

BACKGROUND: C-reactive protein (CRP), a marker of systemic inflammation, is a powerful predictor of adverse cardiovascular events. Respiratory impairment is also associated with cardiovascular risk. Although some studies have found an inverse relationship between lung function and markers of systemic inflammation, only one study has reported a relationship between lung function and CRP levels. In contrast, little is known about the relationship between bronchial hyperresponsiveness (BHR) and systemic inflammation. The association between lung function and CRP and between BHR and CRP has been investigated. METHODS: As part of the European Community Respiratory Health Survey follow up study serum CRP levels, forced expiratory volume in 1 second (FEV(1)), and BHR to methacholine (>/=20% decrease in FEV(1) to <4 mg methacholine) were measured in 259 adults aged 28-56 years free of cardiovascular disease or respiratory infection. RESULTS: Mean (SD) FEV(1) (adjusted for age, sex, height, and smoking status) was lower in subjects with a high CRP level (high tertile) (3.29 (0.44) l/s v 3.50 (0.44) l/s; p<0.001) and BHR was more frequent (41.9% v 24.9%; p = 0.005) than in subjects with lower CRP levels (low+middle tertiles). Similar results were obtained when the potential confounding factors were taken into account. Similar patterns of results were found in non-smokers and in non-asthmatic subjects. CONCLUSIONS: Increased CRP levels are strongly and independently associated with respiratory impairment and more frequent BHR. These results suggest that both respiratory impairment and BHR are associated with a systemic inflammatory process.

An international survey of chronic obstructive pulmonary disease in young adults according to GOLD stages.

BACKGROUND: The recently published GOLD guidelines provide a new system for staging chronic obstructive pulmonary disease (COPD) from mild (stage I) to very severe (stage IV) and introduce a stage 0 (chronic cough and phlegm without airflow obstruction) that includes subjects "at risk" of developing the disease. METHODS: In order to assess the prevalence of GOLD stages of COPD in high income countries and to evaluate their association with the known risk factors for airflow obstruction, data from the European Community Respiratory Health Survey on more than 18,000 young adults (20-44 years) were analysed. RESULTS: The overall prevalence was 11.8% (95% CI 11.3 to 12.3) for stage 0, 2.5% (95% CI 2.2 to 2.7) for stage I, and 1.1% (95% CI 1.0 to 1.3) for stages II-III. Moderate to heavy smoking (> or =15 pack years) was significantly associated with both stage 0 (relative risk ratio (RRR)=4.15; 95% CI 3.55 to 4.84) and stages I+ (RRR=4.09; 95% CI 3.17 to 5.26), while subjects with stages I+ COPD had a higher likelihood of giving up smoking (RRR=1.39; 95% CI 1.04 to 1.86) than those with GOLD stage 0 (RRR=1.05; 95% CI 0.86 to 1.27). Environmental tobacco smoke had the same degree of positive association in both groups. Respiratory infections in childhood and low socioeconomic class were significantly and homogeneously associated with both groups, whereas occupational exposure was significantly associated only with stage 0. All the GOLD stages showed a significantly higher percentage of healthcare resource users than healthy subjects (p<0.001), with no difference between stage 0 and COPD. CONCLUSIONS: A considerable percentage of young adults already suffered from COPD. GOLD stage 0 was characterised by the presence of the same risk factors as COPD and by the same high demand for medical assistance.

[Factors predicting the severity and the degree of symptom control of asthma in a recently diagnosed cohort of adult patients (A.S.M.A study)]. / Facteurs liés à la sévérité et au contrôle de l'asthme récemment diagnostiqué dans une cohorte de patients adultes.

INTRODUCTION: The aim of this cohort study was to describe the evolution of recently diagnosed (<12 months) asthma, and to identify outcome predictive factors. This paper describes the evolution of an adult cohort and the factors related to asthma severity and control. METHODS: In 1995, 251 chest specialists from throughout France, recruited 347 asthmatic adults (subjects with severe asthma were excluded). 220 eligible patients were examined every four months over a three year period. Data (socio-demographic characteristics, asthma history, results of atopy testing and lung function tests, treatment, drug compliance, respiratory infections, changes in lifestyle and environment, and major life events) were collected by means of detailed standardised questionnaires completed by physicians. Asthma severity, recorded one year after study inclusion, and asthma control, assessed at each follow-up visit in the second and third year, were defined according to the international guidelines. RESULTS: The clinical status of these adult patients generally improved rapidly. Asthma severity correlated closely with allergy, with a history of childhood asthma and with sensitisation to indoor allergens. After adjusting for severity, poor asthma control was associated with poor compliance, with respiratory infections, and, to a lesser extent, with animals inside the home. CONCLUSIONS: This cohort study highlights the association of asthma severity with allergy, and of poor asthma control with poor compliance and respiratory infections.

Long-term mortality among adults with or without asthma in the PAARC study.

The Pollution Atmosphérique et Affections Respiratoires Chroniques (PAARC; Air Pollution and Chronic Respiratory Diseases) study provided the opportunity to examine the 25-yr mortality of 940 asthmatic adults drawn from a large population-based sample of 14,267 adults investigated during 1974-1976 in seven French cities. Vital statistics were collected in 2001 for the whole population. Multivariate survival analysis was used to assess exact survival rates in asthmatics and nonasthmatics taking relevant confounders into account. On average, the mortality rates obtained were 10.4 and 6.9 deaths 1,000 person-yrs-in asthmatics and nonasthmatics, respectively. On univariate analysis, asthma increased the relative risk (RR) of death by 1.48 (95% confidence interval (CI) 1.29-1.69). The association between asthma and death had an RR of 1.16 (95% CI 0.99-1.37) when age, sex, educational level, smoking habits, occupational exposure and forced expiratory volume in one second (FEV1) were taken into account. FEV1 was an important contributive factor causing increased risk of death in both smokers and nonsmokers. For instance, in asthmatics, the numbers of deaths due to respiratory disease and cancer appeared excessive. The present study suggests that asthmatics exhibit a higher risk of mortality.

Treatment compliance, passive smoking, and asthma control: a three year cohort study.

AIMS: To study the role of treatment compliance and parents' smoking on asthma control in children with recently diagnosed mild or moderate persistent asthma who were prescribed inhaled anti-inflammatory treatment. METHODS: Prospective cohort study of 167 children aged 6-12 years (64% boys). Patients were examined at inclusion and followed up for three years with a visit every four months. Peak expiratory flow (PEF) was measured twice a day during the week before each visit. Two control criteria were monitored: (1) symptom control = having diurnal or nocturnal exacerbations less than once a week and no symptoms between exacerbations, at all visits; and (2) PEF control = daily PEF variability <20% on each of the seven days before each visit. RESULTS: Symptom control was achieved by 25.1% of children and PEF control by 53.3%. Symptom control was positively related to having understood the way in which the medication worked and taking the prescribed doses (odds ratios (OR) = 3.38 and 4.82 respectively). It was inversely related to smoking within the home (OR = 0.34). PEF control was positively related to taking the prescribed doses (OR = 3.58). It was less frequently achieved if the mother smoked within the home (OR = 0.34). CONCLUSIONS: Results suggest that, to maximise the benefits of available asthma medication and to improve health outcomes, further efforts should be made to convince the parents of asthmatic children not to smoke in the house, and to improve compliance by increasing the patients' understanding of the disease and its treatment.

Chronic bronchitis among French adults: high prevalence and underdiagnosis.

The aims of this survey were to determine the prevalence of symptoms indicative of chronic bronchitis (CB) in the French adult population, to identify the role of risk factors for CB, and to assess rates of CB diagnosis and pulmonary function testing (PFT) in the presence of CB. A representative sample of 14,076 individuals aged > or = 25 yrs completed a self-administered questionnaire on symptoms, comorbidities, smoking history, sociodemographical data, and diagnosis and care by physicians. The prevalence of CB was 4.1% and the prevalence of chronic cough and/or expectoration was 11.7%. In individuals with comorbidity, these figures were 10.4% and 24.4%, respectively. Smoking was associated with an increased frequency of CB. In subjects with CB, 44.6% had PFT (spirometry or peak expiratory flow measurement), 24% were diagnosed as having CB, and 7.2% received care. Rates of diagnosis, PFT, and follow-up were lower in young individuals and in those without comorbidity. PFT and follow-up were less common in current smokers. Prevalence of chronic bronchitis in French adults is high and similar in magnitude to that of other industrialised countries. Comorbidities and tobacco smoking increase the frequency of chronic bronchitis symptoms. Chronic bronchitis is too infrequently diagnosed, investigated and cared for.

[Development over 3 years of asthma recently diagnosed in a cohort of children (ASMA study). Factors related to improvement in clinical status]. / Evolution sur 3 ans de l'asthme récemment diagnostiqué dans une cohorte d'enfants (étude ASMA). Facteurs liés à l'amélioration de l'état clinique.

OBJECTIVE: The objective of the ASMA study was to describe the evolution of light to moderate asthma, newly or recently (12 Pounds months) diagnosed in private pneumology centers, and to search for the predictive factors. METHODS: In 1995, 251 private pneumologists, throughout Metropolitan France, recruited 396 asthmatic children, 6 to 12 years old (64% boys). The 334 patients eligible for the study were examined every 4 months during 3 years (a mean of 6 controls were conducted out of the expected 9). The data were collected on standardized questionnaires completed by the physicians and notebooks filled-in by the patients the week before each control. This questionnaire comprised two asthma 'control' criteria: "control" of the clinical state, defined as asthma attacks < 1 per week AND nocturnal awakening < 1 per week AND absence of asthma symptoms between attacks on every control visit; "control" of the need for b2 mimetics on request, defined as the non-use throughout the week preceding the control visit. RESULTS: The global clinical state of the cohort rapidly improved once care was initiated: the proportion of children exhibiting at least one attack of asthma per week rapidly dropped to 43% on inclusion and to 13% on the first control visit (4 months), 10% on the second control visit, and then fluctuated at around 8% up until the last control visit. A similar evolution was noted regarding nocturnal asthma attacks. The proportion of patients with prescriptions for inhaled corticosteroids and long-lasting b2-mimetics increased over the three years of follow-up. Analysis of the factors related to the individual 'control' of the clinical state showed a negative effect in family histories of asthma (father) and the presence of smokers in the home, but above all a positive effect of compliance to treatment and particularly its understanding (OR = 2.5; p = 0.03) and respect of the doses (OR = 2.7; p < 0.01). The positive effect of compliance was confirmed by analysis of the factors related to the use of b2 mimetics on request. CONCLUSION: Smoking should be avoided in the home. Compliance to treatment could be improved by making sure that the patients and their parents fully understand the disease and its treatment, and by persuading them to strictly follow the treatments prescribed.

[Epidemiological study on the Genetics and Environment of Asthma, bronchial hyperresponsiveness and atopy (EGEA) - First results of a multi-disciplinary study]. / Etude Epidémiologique sur les facteurs Génétiques et Environnementaux de l'Asthme, l'hyperréactivité bronchique et l'atopie (EGEA). Premiers résultats d'une étude multidisciplinaire.

The French co-operative epidemiological study EGEA realised in 1991/95 combines a case control study and a study of the families of asthmatic cases. A synthesis of the results already obtained is presented. Smoking was related to IgE, even in asthmatics and was clearly related to the clinical severity of asthma, an aspect insufficiently taken into account. The relationships of occupational exposures to asthma have been assessed using a job exposure matrix. Segregation analyses on IgE have shown, after correction for the mode of ascertainment, the existence of a dominant major gene and familial residual correlation. A systematic genome screen realised in families with 2 asthmatic siblings showed linkage of various regions in the genome implicated to asthma or related phenotypes (1p, 11p, 11q, 12q, 13q, 17q, 19q), coherent with genome screens realised in other studies. Regarding candidate genes, no association was evidenced between asthma and the AF508 mutation of the cystic fibrosis gene. The analysis is still in progress by studies on the heterogeneity of asthma with refined genetic studies and by searching to integrate results regarding environmental and genetic factors and studying their interactions.

[Epidemiological study of genetic and environmental factors in asthma, bronchial hyperresponsiveness and atopy. Protocol and potential selection bias]. / Etude épidémiologique des facteurs génétiques et environnementaux de l'asthme, l'hyperréactivité bronchique et l'atopie (EGEA). Protocole et biais de sélection potentiels.

BACKGROUND: The EGEA study combines a case-control study and a family study to assess genetic and environmental risk factors and their interactions for asthma, bronchial hyperresponsiveness and atopy. Information is scanty regarding potential selection biases, in particular regarding familial ressemblance in epidemiological surveys of this kind. METHODS: Asthmatic probands (adult and paediatric) were recruited in chest clinics of six clinical centres. Controls were mostly population-based (electoral rolls) for adults and recruited in surgery departments for children. RESULTS: The population examined includes 348 nuclear families ascertained by one asthmatic and 416 controls, totalling 1847 subjects (EGEA I) and an additional sample of 40 families ascertained by two asthmatic siblings (EGEA II). Potential biases for the various types of analyses have been studied. Quantification of the consequences of the greater participation of probands with a parental history of asthma shows it does not introduce a major bias in the estimates of familial resemblance. Cases and controls showed a good comparability regarding sex, age, area of residence and familial geographical origin, allowing proper associations studies for environmental and candidate genetic factors. CONCLUSIONS: The case-control component of the study will allow to perform studies on environmental factors and association studies for various genetic polymorphisms. Using the family base collected, segregation and genetic linkage/association analyses with DNA markers may be performed.

Perennial rhinitis: An independent risk factor for asthma in nonatopic subjects: results from the European Community Respiratory Health Survey.

BACKGROUND: Although clinical and experimental studies suggest that upper respiratory tract dysfunction may affect the lower airways, rhinitis is usually not studied as a potential risk factor for asthma. This is because both diseases share key elements of pathogenesis and are usually considered as different manifestations of the same underlying "atopic" state. OBJECTIVE: We sought to assess whether asthma is associated with rhinitis in the absence of immunologic disorders in a population study. METHODS: Data from 34 centers participating in the European Community Respiratory Health Survey were analyzed. Random samples of 20- to 44-year-old subjects were invited to complete a detailed questionnaire and undergo total and specific IgE measurements, skin prick tests to 9 allergens, and bronchoprovocation challenges with methacholine. RESULTS: Subjects with perennial rhinitis (n = 1412) were more likely than control subjects (n = 5198) to have current asthma. After adjustment for sex, age, smoking habit, family history of asthma, geographic area, and season at the time of examination, asthma was strongly associated with rhinitis among atopic subjects (odds ratio [OR] = 8.1; 95% confidence interval [CI] = 5.4-12.1) but also among nonatopic subjects (OR = 11.6; 95% CI = 6.2-21.9). Moreover, the association remained very strong when the analysis was restricted to nonatopic subjects with IgE levels of 80 kIU/L or less (OR = 13.3; 95% CI = 6. 7-26.5). In nonasthmatic subjects bronchial hyperresponsiveness was also more frequent in subjects with rhinitis than in those without rhinitis (OR = 1.7; 95%CI = 1.2-2.6 in nonatopic subjects with IgE levels of