The baby-friendly hospital initiative in Switzerland: trends over a 9-year period.

BACKGROUND: This article reports the trends over a 9-year period for 4 steps of the Baby-Friendly Hospital Initiative (BFHI) (exclusive breastfeeding, uninterrupted rooming-in, no use of pacifiers, and initiation of breastfeeding within the first 2 hours after birth) during hospital stays in Switzerland. METHODS: Data were collected annually over a period of 9 years from a monitoring survey of all BFHI-accredited hospitals in Switzerland (between 41 and 65 hospitals). The number of participants included in the study per year ranged between 15 627 and 31 141 healthy mother-newborn pairs. RESULTS: Significant improvements were found for 3 of the 4 steps of the BFHI between 2000 and 2008: rates of exclusive breastfeeding during postpartum stay (35.9%-57.6%, P < .001), uninterrupted rooming-in (48.2%-73.1%, P < .001), and no use of pacifiers (33.6%-48.1%, P < .001). Initiation of breastfeeding within the first 2 hours after birth was always > 90% and did not change significantly over the 9 years. Exclusive breastfeeding during hospital stay was significantly related to no use of pacifiers (P < .001) and to uninterrupted rooming-in (P < .001) in the years when exclusive breastfeeding particularly increased (2003, 2004, and 2008). CONCLUSION: Rates of exclusive breastfeeding during hospital stay and uninterrupted rooming-in increased significantly over the 9 years. Continued promotion of the BFHI may be needed to maintain or further improve the breastfeeding rates and to find ways to deal with difficulties that hospitals face when applying the 10 steps of the BFHI.

Decreased PM10 exposure attenuates age-related lung function decline: genetic variants in p53, p21, and CCND1 modify this effect.

BACKGROUND: Decreasing exposure to airborne particulates was previously associated with reduced age-related decline in lung function. However, whether the benefit from improved air quality depends on genetic background is not known. Recent evidence points to the involvement of the genes p53 and p21 and of the cell cycle control gene cyclin D1 (CCND1) in the response of bronchial cells to air pollution. OBJECTIVE: We determined in 4,326 participants of the Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults (SAPALDIA) whether four single-nucleotide polymorphisms in three genes [CCND1 (rs9344 [P242P], rs667515), p53 (rs1042522 [R72P]), and p21 (rs1801270 [S31R])] modified the previously observed attenuation of the decline in the forced expiratory flow between 25% and 75% of the forced vital capacity (FEF(25-75)) associated with improved air quality. METHODS: Subjects of the prospective population-based SAPALDIA cohort were assessed in 1991 and 2002 by spirometry, questionnaires, and biological sample collection for genotyping. We assigned spatially resolved concentrations of particulate matter with aerodynamic diameter < or = 10 microm (PM(10)) to each participant's residential history 12 months before the baseline and follow-up assessments. RESULTS: The effect of diminishing PM(10) exposure on FEF(25-75) decline appeared to be modified by p53 R72P, CCND1 P242P, and CCND1 rs667515. For example, a 10-microg/m(3) decline in average PM(10) exposure over an 11-year period attenuated the average annual decline in FEF(25-75) by 21.33 mL/year (95% confidence interval, 10.57-32.08) among participants homozygous for the CCND1 (P242P) GG genotype, by 13.72 mL/year (5.38-22.06) among GA genotypes, and by 6.00 mL/year (-4.54 to 16.54) among AA genotypes. CONCLUSIONS: Our results suggest that cell cycle control genes may modify the degree to which improved air quality may benefit respiratory function in adults.

Improvements in PM10 exposure and reduced rates of respiratory symptoms in a cohort of Swiss adults (SAPALDIA).

RATIONALE: Reductions in mortality following improvements in air quality were documented by several studies, and our group found, in an earlier analysis, that decreasing particulate levels attenuate lung function decline in adults. OBJECTIVES: We investigated whether decreases in particulates with an aerodynamic diameter of less than 10 microm (PM10) were associated with lower rates of reporting respiratory symptoms (i.e., decreased morbidity) on follow-up. METHODS: The present analysis includes 7,019 subjects who underwent detailed baseline examinations in 1991 and a follow-up interview in 2002. Each subject was assigned model-based estimates of average PM10 during the 12 months preceding each health assessment and the difference was used as the exposure variable of interest (DeltaPM10). Analyses were stratified by symptom status at baseline and associations between DeltaPM10 and change in symptom status during follow-up were adjusted for important baseline characteristics, smoking status at follow-up, and season. We then estimated adjusted odds ratios for symptoms at follow-up and numbers of symptomatic cases prevented due to the observed reductions in PM10. MEASUREMENTS AND MAIN RESULTS: Residential exposure to PM10 was lower in 2002 than in 1991 (mean decline 6.2 microg/m3; SD = 3.9 microg/m3). Estimated benefits (per 10,000 persons) attributable to the observed changes in PM10-levels were: 259 (95% confidence interval [CI]: 102-416) fewer subjects with regular cough, 179 (95% CI, 30-328) fewer subjects with chronic cough or phlegm and 137 (95% CI, 9-266) fewer subjects with wheezing and breathlessness. CONCLUSIONS: Reductions in particle levels in Switzerland over the 11-year follow-up period had a beneficial effect on respiratory symptoms among adults.

Is age at menopause increasing across Europe? Results on age at menopause and determinants from two population-based studies.

OBJECTIVE: To investigate the variability and determinants of menopause age in two European cohort studies, the European Respiratory Health Survey and the Swiss Air Pollution and Lung Disease in Adults Cohort. METHODS: Age at menopause was estimated in 5,288 women, aged 30 to 60 years, randomly selected in nine European countries between 1998 and 2002. Determinants of natural and surgically induced menopause were investigated by Cox regression and heterogeneity by meta-analysis. Follicle-stimulating hormone and luteinizing hormone levels were assessed in a subsample. RESULTS: A quarter of the women were postmenopausal by age 50.8 years. Median age of natural menopause was 54 years. Hormone levels were within expected ranges for premenopausal and postmenopausal women. Surgically induced menopause was highly prevalent (22%-47%), associated with earlier timing of menopause. Determinants of earlier menopause were current smoking (hazard ratio [HR], 1.59; 95% CI, 1.27-1.98), body mass index greater than 30 kg/m (HR, 1.32; 95%, CI, 1.02-1.70), and low physical activity (HR, 1.37; 95%, CI, 1.12-1.67). The determinant for later menopause was multiparity (HR, 0.74; 95% CI, 0.62-0.89). Predictors were similar for naturally and surgically induced menopause. Oral contraceptive use yielded heterogeneous effects on timing of menopause. Later birth was associated with later menopause (HR, 0.934; 95% CI, 0.91-0.96). This evidence of a secular trend is heterogeneous across countries. CONCLUSIONS: Age at menopause varies across Europe, shifting toward higher ages. This secular trend seems paradoxical because several adult determinants, that is, overweight, smoking, sedentarity, and nulliparity, associated with early menopause are on the rise in Europe. The heterogeneity of the secular trend suggests additional country-specific factors not included in the study, such as improved childhood nutrition and health, that have an influence on reproductive aging.

Glutathione S-transferase polymorphisms, passive smoking, obesity, and heart rate variability in nonsmokers.

BACKGROUND: Disturbances of heart rate variability (HRV) may represent one pathway by which second-hand smoke (SHS) and air pollutants affect cardiovascular morbidity and mortality. The mechanisms are poorly understood. OBJECTIVES: We investigated the hypothesis that oxidative stress alters cardiac autonomic control. We studied the association of polymorphisms in oxidant-scavenging glutathione S-transferase (GST) genes and their interactions with SHS and obesity with HRV. METHODS: A total of 1,133 nonsmokers > 50 years of age from a population-based Swiss cohort underwent ambulatory 24-hr electrocardiogram monitoring and reported on lifestyle and medical history. We genotyped GSTM1 and GSTT1 gene deletions and a GSTP1 (Ile105Val) single nucleotide polymorphism and analyzed genotype-HRV associations by multiple linear regressions. RESULTS: Homozygous GSTT1 null genotypes exhibited an average 10% decrease in total power (TP) and low-frequency-domain HRV parameters. All three polymorphisms modified the cross-sectional associations of HRV with SHS and obesity. Homozygous GSTM1 null genotypes with > 2 hr/day of SHS exposure exhibited a 26% lower TP [95% confidence interval (CI), 11 to 39%], versus a reduction of -5% (95% CI, -22 to 17%) in subjects with the gene and the same SHS exposure compared with GSTM1 carriers without SHS exposure. Similarly, obese GSTM1 null genotypes had, on average, a 22% (95% CI, 12 to 31%) lower TP, whereas with the gene present obesity was associated with only a 3% decline (95% CI, -15% to 10%) compared with nonobese GSTM1 carriers. CONCLUSIONS: GST deficiency is associated with significant HRV alterations in the general population. Its interaction with SHS and obesity in reducing HRV is consistent with an impact of oxidative stress on the autonomous nervous system.

Differences in heart rate variability associated with long-term exposure to NO2.

BACKGROUND: Heart rate variability (HRV), a measure of cardiac autonomic tone, has been associated with cardiovascular morbidity and mortality. Short-term studies have shown that subjects exposed to higher traffic-associated air pollutant levels have lower HRV. OBJECTIVE: Our objective was to investigate the effect of long-term exposure to nitrogen dioxide on HRV in the Swiss cohort Study on Air Pollution and Lung Diseases in Adults (SAPALDIA). METHODS: We recorded 24-hr electrocardiograms in randomly selected SAPALDIA participants >or= 50 years of age. Other examinations included an interview investigating health status and measurements of blood pressure, body height, and weight. Annual exposure to NO2 at the address of residence was predicted by hybrid models (i.e., a combination of dispersion predictions, land-use, and meteorologic parameters). We estimated the association between NO2 and HRV in multivariable linear regression models. Complete data for analyses were available for 1,408 subjects. RESULTS: For women, but not for men, each 10-microg/m3 increment in 1-year averaged NO2 level was associated with a decrement of 3% (95% CI, -4 to -1) for the standard deviation of all normal-to-normal RR intervals (SDNN), -6% (95% CI, -11 to -1) for nighttime low frequency (LF), and -5% (95% CI, -9 to 0) for nighttime LF/high-frequency (HF) ratio. We saw no significant effect for 24-hr total power (TP), HF, LF, or LF/HF or for nighttime SDNN, TP, or HF. In subjects with self-reported cardiovascular problems, SDNN decreased by 4% (95% CI, -8 to -1) per 10-microg/m3 increase in NO2. CONCLUSIONS: There is some evidence that long-term exposure to NO2 is associated with cardiac autonomic dysfunction in elderly women and in subjects with cardiovascular disease.

Effect of physical activity on heart rate variability in normal weight, overweight and obese subjects: results from the SAPALDIA study.

Many studies have demonstrated an association of both a sedentary lifestyle and a high body mass index (BMI) with greater risk for cardiovascular disease. Within the prospective SAPALDIA cohort (Swiss cohort Study on Air Pollution and Lung Diseases in Adults), we investigated whether regular exercise was protective against reduced heart rate variability (HRV), a clinically relevant predictor of cardiovascular morbidity and mortality, and whether adverse effects of obesity and weight gain on HRV were modified by regular exercise. Twenty-four-hour electrocardiograms were recorded in 1,712 randomly selected SAPALDIA participants aged >or=50, for whom BMI was assessed in the years 1991 and 2001-2003. Other examinations included an interview investigating health status (especially respiratory and cardiovascular health and health relevant behaviours including physical activity) and measurements of blood pressure, body height and weight. The association between regular physical activity and HRV and interactions with BMI and BMI change was assessed in multivariable linear regression analyses. Compared to sedentary obese subjects, SDNN (standard deviation of all RR intervals) was 14% (95% CI: 8-20%) higher in sedentary normal weight subjects; 19% (CI: 12-27%) higher in normal weight subjects exercising regularly >or=2 h/week; and 19% (CI: 11-28%) higher in obese subjects exercising regularly >or=2 h/week. Compared with sedentary subjects who gained weight, those who gained weight but did exercise regularly had a 13% higher SDNN (CI: 7-20%). Regular physical exercise has strong beneficial effects on cardiac autonomic nervous function and thus appears to offset the negative effect of obesity on HRV.

Circulating alpha1-antitrypsin in the general population: determinants and association with lung function.

BACKGROUND: Severe alpha1-antitrypsin (AAT) deficiency associated with low AAT blood concentrations is an established genetic COPD risk factor. Less is known about the respiratory health impact of variation in AAT serum concentrations in the general population. We cross-sectionally investigated correlates of circulating AAT concentrations and its association with FEV1. METHODS: In 5187 adults (2669 females) with high-sensitive c-reactive protein (CRP) levels < or = 10 mg/l from the population-based Swiss SAPALDIA cohort, blood was collected at the time of follow-up examination for measuring serum AAT and CRP. RESULTS: Female gender, hormone intake, systolic blood pressure, age in men and in postmenopausal women, as well as active and passive smoking were positively, whereas alcohol intake and BMI inversely correlated with serum AAT levels, independent of CRP adjustment. We observed an inverse association of AAT with FEV1 in the total study population (p < 0.001), that disappeared after adjustment for CRP (p = 0.28). In addition, the AAT and FEV1 association was modified by gender, menopausal status in women, and smoking. CONCLUSION: The results of this population-based study reflect a complex interrelationship between tobacco exposure, gender related factors, circulating AAT, systemic inflammatory status and lung function.

Comparing a disease-specific and a generic health-related quality of life instrument in subjects with asthma from the general population.

BACKGROUND: Few epidemiologic studies have assessed health-related quality of life (HRQL) of asthma patients from a general population and it is unclear which instrument is best suitable for this purpose. We investigated the validity of the Asthma Quality of Life Questionnaire (AQLQ) and the SF-36 completed by individuals with asthma from the population-based SAPALDIA (Swiss study on air pollution and lung diseases in adults) cohort. METHODS: The study included 258 participants with a physician-diagnosed asthma who had completed the AQLQ and SF-36. We assessed floor and ceiling effects, internal consistency reliability and cross-sectional validity with a priori hypotheses that correlations between the specific HRQL domains (e.g. "symptoms" or "physical functioning") and the corresponding external validation measures (respiratory symptoms, need for doctor visits, limitation in activities due to asthma and lung function) would capture similar aspects and be correlated moderately (> or = 0.3) to strongly (> or = 0.5), whereas non-corresponding domains be correlated weakly with each other (<0.3). RESULTS: The AQLQ showed pronounced ceiling effects with all median domain scores above 6 (scores varied from 1-7). For the SF-36, ceiling effects were present in 5 out of 8 domains. Cronbach's alpha was >0.7 for all AQLQ and SF-36 domains. Correlations between the AQLQ domains "respiratory symptoms", "activity limitation" and "environmental exposure", and the validation measures ranged from 0.29-0.57. Correlations between the "emotional function" domain and the validation measures were also in this range (0.31-0.55) and not as low as we hypothesized. For the SF-36, correlations between "physical functioning" and "role physical", and the validation measures ranged from 0.25-0.56, whereas "role emotional" and "mental health" correlated with these measures from 0.01-0.23. CONCLUSION: The AQLQ and the SF-36 showed fairly good internal consistency. Both instruments are limited by ceiling effects, but they appear less pronounced in the SF-36, which also shows a better discrimination between different aspects of HRQL. The SF-36 may therefore be a more valid measure of HRQL than the AQLQ when applied to individuals with asthma from the general population.

Secondhand smoke and health-related quality of life in never smokers: results from the SAPALDIA cohort study 2.

BACKGROUND: Although secondhand smoke (SHS) has been linked with various respiratory conditions and symptoms, its association with health-related quality of life (HRQOL) is unknown. METHODS: A cross-sectional study was performed of 2500 never smokers in Switzerland who participated in the Swiss Cohort Study on Air Pollution and Lung Diseases in Adults and completed a 36-Item Short Form Health Survey (SF-36) in 2002. Using linear regression models adjusting for confounders, we measured the association between HRQOL and moderate or high SHS exposure (< or =3 h/d or >3 h/d) compared with no SHS exposure. Data from men and women were analyzed separately and further stratified by source of SHS (home, workplace, and public spaces). RESULTS: After adjustments, SHS was associated with reduced scores in all SF-36 domains. High SHS exposure predicted a greater reduction in HRQOL. Compared with nonexposed women, those with high SHS exposure at home had significantly lower scores on the physical functioning (-7.8, P < .001), role physical (-10.5, P = .02), bodily pain (-9.2, P = .01), and social functioning (-8.1, P = .007) domains. Exposed men had lower scores for the role physical domain (-20.0, P < .001) and a trend toward lower scores in other domains. In women, exposure to SHS at home was associated with a stronger negative effect on HRQOL than at work and in public spaces. CONCLUSIONS: Secondhand smoke is associated with reduced HRQOL, more significantly so in women. Exposure to SHS at home and high levels of exposure are associated with lower SF-36 scores, suggesting a dose-response relationship.

Reduced exposure to PM10 and attenuated age-related decline in lung function.

BACKGROUND: Air pollution has been associated with impaired health, including reduced lung function in adults. Moving to cleaner areas has been shown to attenuate adverse effects of air pollution on lung function in children but not in adults. METHODS: We conducted a prospective study of 9651 adults (18 to 60 years of age) randomly selected from population registries in 1990 and assessed in 1991, with 8047 participants reassessed in 2002. There was complete information on lung volumes and flows (e.g., forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1], FEV1 as a percentage of FVC, and forced expiratory flow between 25 and 75% of the FVC [FEF25-75]), smoking habits, and spatially resolved concentrations of particulate matter that was less than 10 microm in aerodynamic diameter (PM10) from a validated dispersion model assigned to residential addresses for 4742 participants at both the 1991 and the 2002 assessments and in the intervening years. RESULTS: Overall exposure to individual home outdoor PM10 declined over the 11-year follow-up period (median, -5.3 mug per cubic meter; interquartile range, -7.5 to -4.2). In mixed-model regression analyses, with adjustment for confounders, PM10 concentrations at baseline, and clustering within areas, there were significant negative associations between the decrease in PM10 and the rate of decline in FEV1 (P=0.045), FEV1 as a percentage of FVC (P=0.02), and FEF25-75 (P=0.001). The net effect of a decline of 10 microg of PM10 per cubic meter over an 11-year period was to reduce the annual rate of decline in FEV1 by 9% and of FEF25-75 by 16%. Cumulative exposure in the interval between the two examinations showed similar associations. CONCLUSIONS: Decreasing exposure to airborne particulates appears to attenuate the decline in lung function related to exposure to PM10. The effects are greater in tests reflecting small-airway function.

Characterization of source-specific air pollution exposure for a large population-based Swiss cohort (SAPALDIA).

BACKGROUND: Although the dispersion model approach has been used in some epidemiologic studies to examine health effects of traffic-specific air pollution, no study has evaluated the model predictions vigorously. METHODS: We evaluated total and traffic-specific particulate matter < 10 and < 2.5 microm in aero-dynamic diameter (PM(10), PM(2.5)), nitrogren dioxide, and nitrogen oxide concentrations predicted by Gaussian dispersion models against fixed-site measurements at different locations, including traffic-impacted, urban-background, and alpine settings between and across cities. The model predictions were then used to estimate individual subjects' historical and cumulative exposures with a temporal trend model. RESULTS: Modeled PM(10) and NO(2) predicted at least 55% and 72% of the variability of the measured PM(10) and NO(2), respectively. Traffic-specific pollution estimates correlated with the NO(x) measurements (R(2) >or=0.77) for background sites but not for traffic sites. Regional background PM(10) accounted for most PM(10) mass in all cities. Whereas traffic PM(10) accounted for < 20% of the total PM(10), it varied significantly within cities. The modeling error for PM(10) was similar within and between cities. Traffic NO(x) accounted for the majority of NO(x) mass in urban areas, whereas background NO(x) accounted for the majority of NO(x) in rural areas. The within-city NO(2) modeling error was larger than that between cities. CONCLUSIONS: The dispersion model predicted well the total PM(10), NO(x), and NO(2) and traffic-specific pollution at background sites. However, the model underpredicted traffic NO(x) and NO(2) at traffic sites and needs refinement to reflect local conditions. The dispersion model predictions for PM(10) are suitable for examining individual exposures and health effects within and between cities.

Caesarean sections and breastfeeding initiation among migrants in Switzerland.

OBJECTIVES: Twenty-six percent of all women giving birth in Switzerland are of non-Swiss nationality. Differences in reproductive health outcomes such as preterm deliveries, Caesarean sections, and breastfeeding initiation for mother-child pairs of various nationalities are investigated, and the influence of the educational level was assessed. In order to identify trans-national differences, national breastfeeding rates from 22 countries and Caesarean section rates from 24 countries were compared to the rates in Swiss hospitals. STUDY SAMPLE: Drawing on routinely collected monitoring data, 37332 mother-child pairs from various nationalities, who delivered in Swiss Baby-Friendly hospitals between 2000 and 2002, were included in the study. All nationalities with at least 150 deliveries were coded individually, while the remaining were summarised in regional groups. RESULTS: Sub-Saharan African, Latin American and Asian mothers had higher rates of Caesarean sections compared to Swiss mothers (OR = 1.77, 95% CI 1.49-2.22; OR = 1.80, 1.51-2.17; OR = 1.37, 1.18-1.59). African and Asian children were at an increased risk of being transferred to neonatal care units (OR = 1.48, 95 %CI 1.19-1.83; OR = 1.45, 1.21-1.73;). In addition, infants from Balkan countries, who showed lowest Caesarean section rates, were also more likely to be transferred to an ICU (OR = 1.30, 95% CI 1.12-1.52). Apart from the country or region of origin, the maternal educational level was an important influence and modified the effect of the mother's nationality. Mothers from all regions, apart from Western Europe, were significantly more likely to breastfeed their children after being discharged. Established determinants for breastfeeding duration, including feeding exclusively with breast milk in maternity wards, early initiation of breastfeeding, rooming-in and pacifier use, varied according to nationality. The comparison of Caesarean section and breastfeeding rates with the rates in the mother's country of origin additionally investigates the relation between reproductive health outcomes of migrant women in Switzerland compared to their country of origin. In both cases, a significant rank correlation (Spearman) could be established between the rate in Swiss hospitals and the rate in the mother's country of origin (P < 0.001, P = 0.04). CONCLUSIONS: Our data confirms inequalities in reproductive health outcomes and responses to health promotion programmes among migrant women in Switzerland. These differences are dependent on educational level and on the mothers' nationality. The large variation suggests that different trans-national experiences play some role in health-related decision-making and access to health care. This should be considered when planning health promotion programs and the individual counselling of pregnant mothers in Switzerland.

Variability of reproductive history across the Swiss SAPALDIA cohort--patterns and main determinants.

BACKGROUND: Reproductive characteristics play an aetiological role for many diseases, including reproductive cancers. They have been shown to vary internationally and nationally, but have not yet been described for the whole Swiss population. AIM: The study investigated the variability of reproductive characteristics, their patterns, and main determinants across a population-based female study population in Switzerland. METHODS: Reproductive characteristics obtained from 3119 women (28-72 years) participating in the SAPALDIA cohort survey in 2001-2003 are described across birth cohorts, study areas, language regions, and levels of urbanization. Determinants of age at menopause were analysed by Cox regression. RESULTS: Reported median age at menarche was 13 years and median age at natural menopause was 52 years. The prevalence of nulliparity was 27%, and the fertility rate 1.6. Across birth cohorts there was a decline of menarcheal age and fertility rates, and an increase of nulliparity and age at last pregnancy. All characteristics varied across study areas, language regions, and levels of urbanization. Smoking, parity, and physical exercise were stronger predictors of earlier (<52 years) than older (>52 years) menopausal age. CONCLUSION: Reproductive events show secular and geographic variation within Switzerland. Smoking, parity and physical activity significantly predict age at natural menopause, particularly before age 52. The secular trend of earlier menarche and increased nulliparity may result in a higher risk of reproductive cancers in younger generations.

Annoyance due to air pollution in Europe.

BACKGROUND: Annoyance due to air pollution is a subjective score of air quality, which has been incorporated into the National Environmental monitoring of some countries. The objectives of this study are to describe the variations in annoyance due to air pollution in Europe and its individual and environmental determinants. METHODS: This study took place in the context of the European Community Respiratory Health Survey II (ECRHS II) that was conducted during 1999-2001. It included 25 centres in 12 countries and 7867 randomly selected adults from the general population. Annoyance due to air pollution was self-reported on an 11-point scale. Annual mean mass concentration of fine particles (PM(2.5)) and its sulphur (S) content were measured in 21 centres as a surrogate of urban air pollution. RESULTS: Forty-three per cent of participants reported moderate annoyance (1-5 on the scale) and 14% high annoyance (> or =6) with large differences across centres (2-40% of high annoyance). Participants in the Northern European countries reported less annoyance. Female gender, nocturnal dyspnoea, phlegm and rhinitis, self-reported car and heavy vehicle traffic in front of the home, high education, non-smoking and exposure to environmental tobacco smoke were associated with higher annoyance levels. At the centre level, adjusted means of annoyance scores were moderately associated with sulphur urban levels (slope 1.43 microg m(-3), standard error 0.40, r = 0.61). CONCLUSIONS: Annoyance due to air pollution is frequent in Europe. Individuals' annoyance may be a useful measure of perceived ambient quality and could be considered a complementary tool for health surveillance.

Effects of passive smoking on heart rate variability, heart rate and blood pressure: an observational study.

BACKGROUND: Exposure to environmental tobacco smoke (ETS) has been shown to increase the risk for cardiovascular diseases and death, and autonomic dysfunction (specifically, reduced heart rate variability (HRV)) is a predictor of increased cardiac risk. This study tests the hypothesis that ETS exposure reduces HRV in the general population and discusses possible pathways. METHODS: This cross-sectional study was conducted between 2001 and 2003 and is part of the SAPALDIA (Swiss Cohort Study on Air Pollution and Lung Diseases in Adults) study. The analysis included 1218 randomly selected non-smokers aged 50 and above who participated in 24-h electrocardiogram recordings. Other examinations included an interview, investigating health status (especially respiratory and cardiovascular health and health relevant behaviours and exposure to ETS) and measurements of blood pressure, body height and weight. RESULTS: Subjects exposed to ETS at home or at work for more than 2 h/day had a difference of -15% in total power (95%CI: -26 to -3%), low frequency power (-28 to -1%), low/high frequency ratio (-26 to -3%) and -18% (-29 to -4%) in ultralow frequency power of HRV compared with subjects not exposed to ETS at home or work. We also found a 2.7% (-0.01 to 5.34%) higher heart rate during the recording in exposed subjects. CONCLUSIONS: Exposure to ETS at home and work is associated with lower HRV and with higher heart rate in an ageing population. Our findings suggest that exposure to ETS increases cardiac risk through disturbances in the autonomic nervous system.