Chapter Objectives:

• Identify risk factors for COPD
• Identify prevalence rates for COPD by state
• Identify prevention and management efforts for COPD
• Analyze the clean air grading system for selected states
• Recognize the unique stigma surroundings COPD

INtroduction

This chapter covers chronic obstructive pulmonary disease (COPD) from a public health standpoint. COPD is an umbrella term used to describe several progressive lung diseases including emphysema, chronic bronchitis, non-reversible asthma. The disease is characterized by increasing breathlessness that will continue to get worse over time COPD is incurable and non-reversible, but with proper treatment and management the symptoms can be managed and progression can be stalled. Click here to read characteristics and signs/symptoms of COPD. Click here to read about how COPD is diagnosed and current screenings for COPD. Watch this video to learn how COPD affects the respiratory system.

COPD Prevalence

The most recent data show there are approximately 16.4 million people living with a COPD diagnosis in the US. According to the CDC’s Behavior Risk Surveillance data, West Virginia has the highest prevalence of 15.3 percent and Hawaii has the lowest prevalence of 4 percent. Maryland has a prevalence of 5.7 percent. Currently, there are 229,485 Marylanders living with COPD.

Risk Factors

COPD is more prevalent in current and former smokers, those with lower incomes, and those who reported psychological distress (e.g. depression, anxiety). People reporting psychological distress were almost twice as likely to have COPD compared to people not reporting psychological distress. This statistic may imply that tobacco use (the leading risk factor for COPD) is used as a coping mechanism for individuals suffering from mental illness. Whitehead (1991) outlined modifiable and non-modifiable determinants for COPD. Click here to read them.

COPD Disparities

Research has shown that COPD disproportionality affect individuals of lower socio-economic (SES) status due to their increase exposure to environmental toxins. A scientific review of research by Pleasants et al. (2016) showed that “in the US, although low SES people constitute the minority of the overall population (<20%), they account for nearly two-thirds of all patients with COPD” (p. 2478).

Not only are there disparities related to risk factors, there are disparities that exist between people diagnosed with COPD and people with other diagnoses (heart disease for example). Both COPD and heart disease can be caused by smoking, but research has shown that COPD patients experience more bias from healthcare providers and may receive less quality care than people with other chronic diseases. Reducing stigma is important when it comes to getting COPD patients quality healthcare without bias. Although tobacco use is prevalent, there is a societal norm that views using tobacco, and more so succumbing to health problems as a result of tobacco use, negatively. Click here to read the full editorial.

Public Health Efforts

According to a recent Lancet publication, COPD is considered a “public health problem that requires urgent attention” (Stolz et al, 2022, p. 923). Multi-level interventions are being implemented to reduce the risk for COPD. Here are a few examples of public health efforts aiming to prevent COPD at various levels:

• Individual level: Local health departments and worksite wellness programs offer smoking cessation courses and educate their populations on the dangers of secondhand smoke. Public health measures looking at controlling environmental pollutants is critical to reduce COPD prevalence. For over 20 years, the American Lung Association has collected and reported data on the cleanliness of air in the United States. Criteria for scoring states and counties include the number of high ozone days and overall particle pollution. In Maryland, most counties scored an F for high ozone days, and there is a high number of counties that currently do not collect data on air quality. This implies the need for more state and county initiatives to improve air quality in Maryland. Click here to read the list of the cleanest US cities and here for the list of the most polluted US cities.
• Individual and relationship levels: Schools and communities provide health education to school-age children and youth to prevent them from smoking. The majority of adults who smoke started smoking before the age of 18. Therefore, prevention efforts should target children and youth before they start using tobacco. How prevalent is tobacco use in youth? According to the most recent data from the National Youth Tobacco Survey, about one in four middle or high school student has used tobacco at some point. Tobacco use is higher among lesbian, gay, bisexual, transgender (LGBT+) youth. The most common form of tobacco use is flavored e-cigarettes, with almost 80% of current tobacco users reporting the use of flavored tobacco products. Despite this prevalence of flavored tobacco products, most states do not currently regulate or restrict flavored tobacco products.
• Policy level: Public policy is implemented to create smoke-free air laws banning smoking in public places. Research has shown that “smoking and secondhand smoke exposure during childhood and teenage years can slow lung growth and development. This can increase the risk of developing COPD in adulthood” (CDC, 2022, para. 7). Asthma management programs in which community health educators visit residential housing units to ensure that parents of small children are not smoking in the home. Some states have implemented policy that makes it illegal to smoke if you have a minor (anyone under 18) in the car. Click here to read more in-depth about the initiatives being taken to promote smoke-free environments.
• The American Lung Association (ALA) collects and publishes data on state tobacco policy including access to smoking cessation services, smoke-free air laws, and tobacco prevention and cessation funding (click on each link to review the map and compare/contrast state rankings). Just like a student in school, each state receives a letter grade from A, B, C, D, and F. A is the highest score and F is the lowest score. Click here to read the scoring criteria. The darker blue states receive low scores and lighter states receive high scores. For all three rankings, southern states scored the worst on average, which makes sense because tobacco is still a major cash crop in states like North Carolina and Virginia.

recall quiz

discussion questions

1. According to Whitehead’s table of causes of COPD, which ones are modifiable?
2. Based on the Lancet editorial stigma article, how can the public health and medical community work to eliminate stigma surrounding COPD?
3. Refer to the multi-causation model in Chapter 2, and link COPD to as many of the causes noted on the model as possible. Justify your answers.

chapter activitIes

1. Using the American Lung Association state rankings data, compare Maryland and Virginia. How do these states compare and differ?
2. Click on this link and analyze air quality among the counties in Maryland. How does your home county compare?
3. Summarize at least two specific initiatives the ALA is spearheading to promote smoke-free environments.

references

American Lung Association. (n.d.). State of tobacco control. https://www.lung.org/research/sotc

American Lung Association. (n.d.-a). American Lung Association State of the Air 2021. https://www.lung.org/research/sota

American Lung Association. (n.d.-b). Cleanest cities: State of the air. Www.lung.org. https://www.lung.org/research/sota/city-rankings/cleanest-cities

American Lung Association. (n.d.-c). COPD prevalence. Www.lung.org. https://www.lung.org/research/trends-in-lung-disease/copd-trends-brief/copd-prevalence

American Lung Association. (n.d.-d). COPD risk factors and patient characteristics. https://www.lung.org/research/trends-in-lung-disease/copd-trends-brief/copd-risk-factors

American Lung Association. (n.d.-e). Maryland Air Quality Report Card. Www.lung.org. https://www.lung.org/research/sota/city-rankings/states/maryland

American Lung Association. (n.d.-f). Smokefree environments. https://www.lung.org/policy-advocacy/tobacco/smokefree-environments

Brusselle, G. G., & Humbert, M. (2022). Classification of COPD: Fostering prevention and precision medicine in the Lancet Commission on COPD. The Lancet, 400(10356). https://doi.org/10.1016/s0140-6736(22)01660-9

Centers for Disease Control and Prevention. (2022, May 19). Smoking and COPD. https://www.cdc.gov/tobacco/campaign/tips/diseases/copd.html#:~:text=Smoking%20and%20secondhand%20smoke%20exposure

COPD Foundation. (n.d.). COPD risk screener. Retrieved November 15, 2022, from https://www.copdfoundation.org/Screener.aspx

COPD Foundation. (2019a). How is COPD diagnosed? https://www.copdfoundation.org/What-is-COPD/Understanding-COPD/How-is-COPD-Diagnosed.aspx

COPD Foundation. (2019b). What is COPD? https://www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-COPD.aspx

Gentzke, A. S. (2022). Tobacco product use and associated factors among middle and high school students: National Youth Tobacco Survey, United States, 2021. MMWR. Surveillance Summaries, 71(5). https://doi.org/10.15585/mmwr.ss7105a1

Pleasants, R., Riley, I., & Mannino, D. (2016). Defining and targeting health disparities in chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease, Volume 11(11), 2475–2496. https://doi.org/10.2147/copd.s79077

Satchell, T., Diaz, M. C., Stephens, D., Bertrand, A., Schillo, B. A., & Whitsel, L. P. (2022). The impact of two state-level approaches to restricting the sale of flavored tobacco products. BMC Public Health, 22(1). https://doi.org/10.1186/s12889-022-14172-y

Stolz, D., Mkorombindo, T., Schumann, D. M., Agusti, A., Ash, S. Y., Bafadhel, M., Bai, C., Chalmers, J. D., Criner, G. J., Dharmage, S. C., Franssen, F. M. E., Frey, U., Han, M., Hansel, N. N., Hawkins, N. M., Kalhan, R., Konigshoff, M., Ko, F. W., Parekh, T. M., … Dransfield, M. T. (2022). Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission. The Lancet, 400(10356), 921–972. https://doi.org/10.1016/s0140-6736(22)01273-9