# Bronchodilator response and lung function decline: Associations with exhaled nitric oxide with regard to sex and smoking status

Elisabet Nerpin, Diogenes Seraphim Ferreira, Joost Weyler, Vivi Schlunnsen, Rain Jogi, Chantal Raherison-Semjen, Thorainn Gislasson, Pascal Demoly, Joachim Heinrich, Dennis Nowak, et al.

► To cite this version:

Elisabet Nerpin, Diogenes Seraphim Ferreira, Joost Weyler, Vivi Schlunnsen, Rain Jogi, et al. Bronchodilator response and lung function decline: Associations with exhaled nitric oxide with regard to sex and smoking status. World Allergy Organization Journal, 2021, 14 (5), pp.100544. 10.1016/j.waojou.2021.100544. hal-03337837

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# Bronchodilator response and lung function decline: Associations with exhaled nitric oxide with regard to sex and smoking status

Elisabet Nerpin<sup>a,b,c*</sup>, Diogenes Seraphim Ferreira<sup>d,e</sup>, Joost Weyler<sup>f</sup>, Vivi Schlunnsen<sup>g</sup>, Rain Jogi<sup>h</sup>, Chantal Raherison Semjen<sup>i</sup>, Thorainn Gislasson<sup>j,k</sup>, Pascal Demoly<sup>l,m</sup>, Joachim Heinrich<sup>n,o,p</sup>, Dennis Nowak<sup>q,r</sup>, Angelo Corsico<sup>s,t</sup>, Simone Accordini<sup>u</sup>, Alessandro Marcon<sup>u</sup>, Giulia Squillacioti<sup>v</sup>, Mario Olivieri<sup>w</sup>, Rune Nielsen<sup>x,y</sup>, Ane Johannessen<sup>z,aa</sup>, Francisco Gómez Real<sup>y,ab</sup>, Judith Garcia-Aymerich<sup>ac</sup>, Isabel Urrutia<sup>ad</sup>, Antonio Pereira-Vega<sup>ae</sup>, Jose Antonio Gullón<sup>af</sup>, Anna-Carin Olin<sup>ag</sup>, Bertil Forsberg<sup>ah</sup>, Össur Ingi Emilsson<sup>a</sup>, Isabelle Pin<sup>ai</sup>, Deborah Jarvis<sup>aj</sup>, Christer Janson<sup>a</sup> and Andrei Malinovschi<sup>b</sup>

## ABSTRACT

**Background:** Fractional exhaled nitric oxide (FeNO) is a marker of type-2 inflammation used both to support diagnosis of asthma and follow up asthma patients. The associations of FeNO with lung function decline and bronchodilator (BD) response have been studied only scarcely in large populations.

**Objectives:** To study the association between FeNO and a) retrospective lung function decline over 20 years, and b) lung function response to BD among asthmatic subjects compared with non-asthmatic subjects and with regards to current smoking and sex.

**Methods:** Longitudinal analyses of previous lung function decline and FeNO level at follow-up and cross-sectional analyses of BD response and FeNO levels in 4257 participants (651 asthmatics) from the European Community Respiratory Health Survey.

**Results:** Among asthmatic subjects, higher percentage declines of FEV₁ and FEV₁/FVC were associated with higher FeNO levels (p = 0.001 for both) at follow-up. These correlations were found mainly among non-smoking individuals (p = 0.001) and females (p = 0.001) in stratified analyses. Percentage increase in FEV₁ after BD was positively associated with FeNO levels in non-asthmatic subjects. Further, after stratified for sex and smoking separately, a positive association was seen between FEV₁ and FeNO levels in non-smokers and women, regardless of asthma status.

**Conclusions:** We found a relationship between elevated FeNO and larger FEV₁ decline over 20 years among subjects with asthma who were non-smokers or women. The association between elevated FeNO levels and larger BD response was found in both non-asthmatic and asthmatic subjects, mainly in women and non-smoking subjects.

**Keywords:** Bronchodilatation, Epidemiology, FeNO, Lung function

<footnote><sup>a</sup>Department of Medical Sciences, Respiratory Medicine, Allergy and Sleep, Uppsala University, Uppsala, Sweden
*Corresponding author. Uppsala University, Dept. of Medical Sciences: Respiratory Medicine, Allergy and Sleep Research, Akademiska sjukhuset, SE-75185, Uppsala, Sweden. E-mail: ene@du.se
Full list of author information is available at the end of the article</footnote>
INTRODUCTION

Fractional exhaled nitric oxide (FeNO) is based
on a non-invasive method to measure nitric oxide
(NO) in exhaled air and is a biomarker of type-2
inflammation,¹ reflecting activation of IL-4/-13-
driven mechanisms.² Increased FeNO is related
to response to inhaled corticosteroids in both
subjects with asthma³ and subjects with
nonspecific respiratory airway symptoms.⁴ FeNO
has a clinical role in the diagnostic workup of
asthma and the monitoring of patients with
asthma.⁵

Lung function is often assessed by measuring
forced expiratory volume in 1 sec (FEV₁) and
forced vital capacity (FVC). Early identification of
subjects at risk of accelerated decline in lung
function is important, as irreversible airflow
obstruction is known to be associated with
increased morbidity and mortality.⁶ Lung function
decline is faster in asthmatics than in healthy
subjects.⁷,⁸ Factors contributing to accelerated
lung function decline in patients with asthma are
smoking,⁷ recurrent exacerbations,⁹ and low
baseline FEV₁.¹⁰ Evidence suggests that airway
inflammation may play an important role in the
progression of lung function impairment in
asthma.¹¹,¹² Eosinophil inflammation appears to
relate to accelerated lung function decline¹³ in
both asthmatic and non-asthmatic individuals.
However, FeNO has been studied only scarcely in
relation to lung function decline. Evidence from
small, selected populations of asthmatics suggests
that higher FeNO levels predict larger lung func-
tion decline.¹⁴⁻¹⁶ To our knowledge, no studies
have investigated the relation between FeNO
levels and lung function decline in population-
based surveys.

The relation between FeNO and bronchial
hyperresponsiveness to indirect stimuli, such as
exercise or mannitol, is moderate.¹⁷,¹⁸ In lung
function testing, asthma patients show a larger
significant bronchodilator (BD) response in
lung function to a greater extent than those
without asthma,¹⁹ and the BD test is used in
the diagnostic workup of asthma (Global
Initiative for Asthma, https://ginasthma.org). An
association between increased FeNO and BD

response in subjects with asthma has been
found in two population-based studies.¹⁹

FeNO values are influenced by a number of
factors, for example age,²⁰ sex,²⁰,²¹ height,²⁰
atopy,²⁰,²¹ smoking,²⁰,²² respiratory infections,²⁰
and environmental factors.²³ One of the most
important factors in terms of magnitude is
cigarette smoking, with a mean reduction of
FeNO by up to 50%, depending on the extent of
cigarette consumption.²⁴ Sex is another
important factor, with females consistently
reporting about 25% lower FeNO levels than
men.²⁰,²¹ However, sex differences are seldom
accounted for in studies on FeNO, and smoking
status is usually only adjusted for.

Our primary aim was to study if previous lung
function decline was related to FeNO in a long-
term follow-up of a population-based adult
cohort and whether it differed between asth-
matic and non-asthmatic subjects. Our second-
ary aim was to study the association between
lung function response to BD and FeNO with
regard to presence of asthma. Lastly, we aimed
to study all these associations in relation to
current smoking status and sex.

METHODS

Study sample

This is a prospective study based on the first
and third surveys in the European Community
Respiratory Health Survey (ECRHS I and III),
performed during the periods 1990-1994 and
2010-2013, respectively, using data from 23
centres across 10 European countries and
Australia.

Briefly, ECRHS is an international multicentre
population-based study with the aim to determine
the prevalence of and risk factors for the devel-
opment of asthma, allergic disease, atopy, and
rapid loss of lung function in middle-aged adults
living in Europe and Australia. ECRHS I was first
performed in the early 1990s, in subjects aged 20-
44 years. The subjects were randomly selected to
complete a short postal questionnaire about
asthma symptoms and attacks in the preceding 12
months, current use of asthma medication, and
presence of nasal allergies, including hay fever.
Both a random sample and a symptomatic sample of responders were then invited to attend further examinations at their study centre.

In ECRHS III, subjects who participated in the clinical part of ECRHS I were sent a short postal questionnaire. Those who responded were invited to participate in lung function and blood tests and to fill out additional questionnaires. Further details about ECRHS have been published elsewhere²⁵,²⁶ and can also be found on its website: www.ecrhs.org.

The current analyses were restricted to 5295 adults from the full cohort (random and symptomatic sample) who participated in both surveys (ECRHS I and ECRHS III) and had valid information on FeNO from ECRHS III. We excluded 956 subjects with missing values (asthma and FEV₁) and 82

subjects with a diagnosis of chronic obstructive pulmonary disease (COPD) or emphysema, resulting in 4257 subjects. Of these, 651 had self-reported asthma. For analysis of bronchodilation, we had a total of 4073 subjects with both pre- and post-FEV₁ data, Fig. 1.

## Questionnaires

The participants were asked in an interviewer-led questionnaire whether they had respiratory symptoms, asthma, or COPD, and about their smoking habits and use of inhaled corticosteroids in the preceding 12 months. They were also asked whether they had any nasal allergies, including hay fever.

The asthma group consisted of participants with current asthma. Current asthma was defined as

<figure><img src="image_2.png" /><figcaption>**Fig. 1** Flowchart showing the selection process and numbers of subjects available for analyses. Definitions of asthma and bronchodilator (BD) are specified in the methods section. ECRHS, European Community Respiratory Health Survey. FeNO, fractional exhaled nitric oxide</figcaption></figure>
self-reported asthma and reported having at least
1 asthma-related symptom (wheeze, nocturnal
chest tightness or attacks of breathlessness
following activity, at rest or at night) and/or re-
ported current use of inhaled corticosteroids dur-
ing the last 12 months. Asthma duration was
defined as age at the clinical visit minus the self-
reported age of asthma diagnosis. Chronic sinus-
itis with nasal polyposis were defined as self-
reported doctor's diagnosis of the respective
conditions.

The non-asthma group consisted of subjects that did not fulfil the criteria for current asthma.

COPD and emphysema were defined as a self-reported physician's diagnosis. Use of inhaled corticosteroids was defined in 2 ways: "ever used inhaled medicine to help breathing at any time in the last 12 months" and "used inhaled steroids (only) in the last 12 months" or "used inhaled medicine to help breathing at any time in the last 12 months" and "frequent inhaled steroid use in the last 3 months". Oral steroid intake was defined as "used oral medicine to help breathing at any time in the last 12 months and used oral steroid tablets in the last 3 months".

Measurements of FeNO

FeNO measurements (only available from ECHRS III) were performed in accordance with the recommendations of the American Thoracic Society,²⁷ with the exception that they were performed as single measurements²⁸ by using hand-held portable sampling devices (NIOX MINO Aerocrine AB, Solna, Sweden). Patients were instructed to avoid smoking, eating, drinking, and strenuous exercise for at least 1 h before the test.

Values below 5 ppb (the lower limit of detection of the device) were recorded in 20 subjects and these individuals were given an arbitrary value of 3.5 ppb (5 divided by √2).

Lung function

Spirometry was performed at both baseline and
follow-up, but bronchodilation test was only per-
formed in ECRHS III. Spirometry was performed
using an EasyOne spirometer (ndd Medical Tech-
nologies Inc., Andover, MA, USA) in ECRHS III, but
a Biomedin spirometer was used (Biomedin srl,

Padua, Italy) in ECRHS I. Some centres had other
equipment, but these differences are not believed
to have affected the homogeneity of the results.²⁹
The type of spirometer used at each centre has
been presented by Accordini et al.³⁰

Spirometry measurements were performed with
the study person in a sitting position, wearing a
nose clip, and in accordance with the instructions
of the American Thoracic Society (ATS)/European
Respiratory Society (ERS).³¹ All spirometry tests
fulfilled the ATS data collection standards
regarding validity of measurements, ie, 5 or more
acceptable spirometry performances.

Variables obtained from spirometry and used in
this study included FEV₁, FVC, and FEV₁/FVC ratio.
Lung function changes (% change/year [Δ]) have
been calculated with regards to ΔFEV₁, ΔFVC, and
ΔFEV₁/FVC ratio. The calculation was performed as
100*(value at ECRHS I - value at ECRHS III)/value at
ECRHS I divided by the actual time between the
baseline and follow-up, ie, a positive value repre-
sented decline.

In ECRHS III, spirometry was performed before
and after 15 min after bronchodilation with 200
mcg salbutamol via a metred dose inhaler with a
Volumatic spacer.

Reversibility in FEV₁ was expressed as % change
and calculated as follows: (the difference between
pre- and post-bronchodilator FEV₁ divided by pre-
bronchodilator FEV₁) *100.

Anthropometry

Participants' height and weight were measured
by trained health technicians and used to calculate
body mass index (BMI) (weight [kg]/height [m²]).

Immunoglobulin E measurements

Allergen-specific immunoglobulin E (IgE) was
measured against house dust mite, cat, and
timothy grass. Analysis was performed in a single
central laboratory (AMC Amsterdam) using the
ImmunoCAP system (Thermo Fisher Scientific,
Uppsala, Sweden). The assay was calibrated
against the WHO standard for IgE with a range of
0.35-100 kU/l. A positive IgE was defined as ≥ 0.35
kU/l for one or more of house dust mite, cat, and
timothy grass. In this study, data on IgE sensitisa-
tion were available only from 3542 subjects.
Smoking

A current smoker was defined as someone who had smoked at least 20 packets of cigarettes or 360 g of tobacco in his/her life time (which equals at least 1 cigarette a day or 1 cigar a week for at least a year) and was still smoking during the month preceding the study. Non-smokers were subjects who answered questions on smoking habits and were not fulfilling the criteria for current smoker.

Statistical methods

All analyses were performed using StataSE 15.1 (StataCorp, College Station, TX, USA). The results were summarised as arithmetic and geometric means and β coefficients with 95% confidence intervals (95% CI). Logarithmic transformation was performed for variables with right-skewed distribution (FeNO). FeNO level is described using geometric means and lung function response to BD is described using arithmetic means. Differences between groups were compared using Student's t-test.

We modelled the longitudinal impact of
changes in lung function between ECRHS I to III on
FeNO level (outcome) at ECRHS III. The cohort was
divided into 2 groups: subjects free from asthma
and subjects with asthma. Multiple linear regres-
sion analyses were stratified by sex and smoking
status (2 strata: non and current smokers), adjusted
for sex, age, height, atopy, inhaled steroids,
smoking status, and study centre at follow-up
(ECRHS III).

The interactions between sex and lung function (% change/year) between ECRHS I and ECRHS III with regards to FEV₁, FVC, and FEV₁/FVC ratio and, in ECHRS III, FEV₁, FVC, and FEV₁/FVC ratio, with BD) on FeNO were evaluated, adjusted for sex, age, height, atopy, inhaled steroids, smoking status, and study centre.

Multiple linear regression analyses were used to
assess cross-sectional associations between lung
function response to BD (expressed as % change)
and FeNO level (outcome) in non-asthma/asthma
subjects. Both groups were also stratified sepa-
rately by smoking status (two strata: non and

current smokers) and sex. All analyses were
adjusted for sex, age, height, smoking, atopy,
inhaled steroids, oral steroids, and study centre.

A p value of <0.05 was considered statistically
significant.

Ethics

Informed consent was obtained from all partic-
ipants prior to inclusion in ECRHS I and III. Each
study centre obtained approval for the study from
their regional committee of medical research
ethics in accordance with national legislation.

RESULTS

In ECRHS III, 2031 (47.7%) of the 4257 par-
ticipants were men and 651 subjects had self-
reported asthma. The mean age was 54.1
(±7.1) years. Exhaled NO levels were higher in
asthmatic than non-asthmatic subjects: (geo-
metric mean) 21.1 vs. 16.5 ppb, p < 0.001.
When stratified by asthma and smoking status,
non-smokers were seen to have higher FeNO
levels than smokers: 23.4 vs 11.9 ppb. When
stratified by sex, men were seen to have higher
FeNO levels than women, regardless of asthma
status, see Table 1.

Change in lung function over time and in relation
to asthma status

Non-asthmatic subjects had lower % change
per year [Δ] of FEV₁ compared with asthmatic
subjects. The same pattern was seen between
non-smokers/smokers regardless of whether or
not they had asthma. Men and women with
asthma had higher ΔFEV₁ than non-asthmatic
subjects.

Women with non-asthma seemed to have
higher ΔFEV₁ and ΔFEV₁/FVC ratio than men. In
asthmatic subjects, women had higher % change
in ΔFEV₁/FVC ratio compared with men, see
Table 2.

Change in lung function over time and in relation
to FeNO levels

In subjects with asthma, a greater decline in
ΔFEV₁ and ΔFEV₁/FVC ratio were associated
with higher FeNO levels after adjusting for sex, age, height, weight, atopy, inhaled steroids, smoking status, and study centre, p < 0.001 for

both. After stratification by smoking status, non-smoking subjects with asthma were seen to have a positive association between ΔFEV₁,

<table><caption>**Table 1.** Baseline characteristics. All results presented as mean ± standard deviation (SD) if nothing else is stated</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">ECRHS III (n = 4257)</th></tr><tr><th>Non-asthma n = 3606</th><th>Asthma n = 651</th></tr></thead><tbody><tr><td>Sex (men), n (%)</td><td>1775 (49.2)</td><td>256 (39.3)</td></tr><tr><td>Age (years)</td><td>54.2 (±7.1)</td><td>53.7 (±7.1)</td></tr><tr><td>FeNO (ppb)* (geometric mean) 95% CI</td><td>16.5 (16.2, 16.8)</td><td>21.1 (20.0, 22.3)</td></tr><tr><td>Men</td><td>18.4 (17.9, 18.6)</td><td>23.9 (21.9, 26.1)</td></tr><tr><td>Women</td><td>15.0 (14.6, 15.3)</td><td>19.6 (18.2, 21.0)</td></tr><tr><td>Non-Smoking</td><td>17.9 (17.6, 18.3)</td><td>23.4 (22.1, 24.8)</td></tr><tr><td>Smoking</td><td>11.5 (11.0, 12.0)</td><td>11.9 (10.5, 13.4)</td></tr><tr><td>FEV<sub>1</sub> (litre)</td><td>3.1 (±0.73)</td><td>2.7 (±0.74)</td></tr><tr><td>FEV<sub>1</sub> (% predicted)</td><td>96.2 (±13.6)</td><td>87.3 (±16.4)</td></tr><tr><td>ECHRS I → ECHRS III % decline/year</td><td>0.93 (±0.45)</td><td>1.00 (±0.67)</td></tr><tr><td>FVC (litre)</td><td>4.0 (±0.94)</td><td>3.8 (±0.93)</td></tr><tr><td>FVC (% predicted)</td><td>99.7 (±13.0)</td><td>95.2 (±13.7)</td></tr><tr><td>ECHRS I → ECHRS III % decline/year</td><td>0.57 (±0.4)</td><td>0.62 (±0.5)</td></tr><tr><td>FEV<sub>1</sub>/FVC</td><td>0.76 (±0.06)</td><td>0.73 (±0.08)</td></tr><tr><td>ECHRS I → ECHRS III % decline/year</td><td>0.36 (±0.27)</td><td>0.35 (±0.35)</td></tr><tr><td>FEV<sub>1</sub> post BD (litre), n = 3440/633</td><td>3.2 (±0.73)</td><td>2.8 (±0.73)</td></tr><tr><td>FVC post BD (litre), n = 3406/621</td><td>4.0 (±0.94)</td><td>3.8 (±0.93)</td></tr><tr><td>FEV<sub>1</sub>/FVC-post BD %, n = 3387/621</td><td>0.79 (±0.06)</td><td>0.75 (±0.08)</td></tr><tr><td>Height (m)</td><td>1.70 (±0.10)</td><td>1.69 (±0.10)</td></tr><tr><td>Weight (kg)</td><td>78.6 (±16.4)</td><td>78.9 (±16.5)</td></tr><tr><td>ECHRS I → ECHRS III, kg, % decrease/year</td><td>0.43 (±0.46)</td><td>0.48 (±0.47)</td></tr><tr><td>BMI (kg/m<sup>2</sup>)</td><td>27.0 (±4.7)</td><td>27.7 (±5.5)</td></tr><tr><td>Smoking, n (%)</td><td></td><td></td></tr><tr><td>Non-smoker</td><td>2955 (82.0)</td><td>554 (85.1)</td></tr><tr><td>Smoker</td><td>651 (18.0)</td><td>97 (14.9)</td></tr><tr><td>Inhaled corticosteroids, n (%)</td><td>24 (0.7)</td><td>128 (23.2)</td></tr><tr><td>Oral corticosteroids, n (%)</td><td>7 (0.2)</td><td>5 (0.9)</td></tr><tr><td>Atopy, n (%)</td><td>675 (21.3)</td><td>168 (44.9)</td></tr><tr><td>Chronic sinusitis with polyps, n (%)</td><td>34 (1.0)</td><td>18 (2.8)</td></tr><tr><td>Asthma duration (years)</td><td></td><td>28.4 (±15.2)</td></tr></tbody></table>
<table><caption>Table 2. Arithmetic means of lung function response (ECHRS I → ECHRS III, % change per year). Abbreviations: ECRHS I = first survey of European Community Respiratory Health Survey, ECRHS III = third survey of European Community Respiratory Health Survey, Δ = % change per year, FEV<sub>1</sub> = forced expiratory volume in 1 s, FVC = forced vital capacity, CI = confidence interval</caption><thead><tr><th rowspan="2"></th><th colspan="2">ΔFEV<sub>1</sub></th><th colspan="2">ΔFVC</th><th colspan="2">ΔFEV<sub>1</sub>/FVC</th></tr><tr><th>mean (95% CI)</th><th>p value</th><th>mean (95% CI)</th><th>p value</th><th>mean (95% CI)</th><th>p value</th></tr></thead><tbody><tr><td><strong>Non-asthma</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>ECHRS I → ECHRS III, % change per year</strong></td><td>0.93 (0.92, 0.95)</td><td></td><td>0.57 (0.56, 0.59)</td><td></td><td>0.34 (0.33, 0.34)</td><td></td></tr><tr><td><strong>Smoking status</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Non-smokers (n = 2.943)</td><td>0.91 (0.89, 0.92)</td><td></td><td>0.57 (0.55, 0.59)</td><td></td><td>0.32 (0.31, 0.33)</td><td></td></tr><tr><td>Smokers (n = 647)</td><td>1.05 (1.01, 1.08)</td><td>&lt;0.001</td><td>0.59 (0.56, 0.63)</td><td>0.22</td><td>0.42 (0.40, 0.44)</td><td>&lt;0.001</td></tr><tr><td><strong>Sex</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Men (n = 1772)</td><td>0.89 (0.87, 0.91)</td><td></td><td>0.56 (0.54, 0.58)</td><td></td><td>0.30 (0.28, 0.31)</td><td></td></tr><tr><td>Women (n = 1830)</td><td>0.98 (0.96, 1.00)</td><td>&lt;0.001</td><td>0.58 (0.56, 0.60)</td><td>0.19</td><td>0.37 (0.36, 0.39)</td><td>&lt;0.001</td></tr><tr><td><strong>Asthma</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>ECHRS I → ECHRS III, % change per year</strong></td><td>1.00 (0.95, 1.05)</td><td></td><td>0.62 (0.58, 0.67)</td><td></td><td>0.35 (0.33, 0.38)</td><td></td></tr><tr><td><strong>Smoking status</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Non-smokers (n = 553)</td><td>0.96 (0.67, 1.01)</td><td></td><td>0.60 (0.56, 0.65)</td><td></td><td>0.33 (0.30, 0.36)</td><td></td></tr><tr><td>Smokers (n = 97)</td><td>1.26 (1.14, 1.38)</td><td>&lt;0.001</td><td>0.76 (0.64, 0.87)</td><td>0.009</td><td>0.47 (0.40, 0.55)</td><td>&lt;0.001</td></tr><tr><td><strong>Sex</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Men (n = 256)</td><td>0.96 (0.88, 1.04)</td><td></td><td>0.61 (0.54, 0.68)</td><td></td><td>0.30 (0.26, 0.34)</td><td></td></tr><tr><td>Women (n = 394)</td><td>1.03 (0.96, 1.09)</td><td>0.21</td><td>0.63 (0.58, 0.69)</td><td>0.61</td><td>0.39 (0.35, 0.42)</td><td>0.005</td></tr></tbody></table>
<table><caption>**Table 3.** Multiple linear regression, lung function decline (% changes per year) and the association with FeNO in non-asthma/asthma subjects stratified by smoking status and sex, respectively. Abbreviations: FeNO = fractional exhaled NO nitric oxide, FEV<sub>1</sub> = forced expiratory volume in 1 s, FVC = forced vital capacity, CI = confidence interval, ECRHS I = first survey of European Community Respiratory Health Survey, ECRHS III = third survey of European Community Respiratory Health Survey. Adjusted for sex, age, height, atopy, chronic sinusitis with polyps, asthma duration, inhaled corticosteroids, smoking status, and study centre</caption><thead><tr><th>logFeNO</th><th colspan="2">ΔFEV<sub>1</sub></th><th colspan="2">ΔFVC</th><th colspan="2">ΔFEV<sub>1</sub>/FVC</th></tr><tr><th>ECRHS I → ECRHS III,<br>% change per year</th><th>β-coefficient (95% CI)</th><th>p value</th><th>β-coefficient (95% CI)</th><th>p value</th><th>β-coefficient (95% CI)</th><th>p value</th></tr></thead><tbody><tr><td><strong>Non-asthma</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>ECRHS I → ECRHS III,<br>% change per year<br>(All, n = 3127)</td><td>0.003 (-0.02, 0.02)</td><td>0.76</td><td>0.0009 (-0.02, 0.02)</td><td>0.93</td><td>0.0009 (-0.03, 0.03)</td><td>0.96</td></tr><tr><td><strong>Smoking status</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Non-smokers (n = 2571)</td><td>0.01 (-0.007, 0.03)</td><td>0.18</td><td>0.001 (-0.02, 0.02)</td><td>0.91</td><td>0.02 (-0.01, 0.05)</td><td>0.27</td></tr><tr><td>Smokers (n = 556)</td><td>-0.05 (-0.09, 0.004)</td><td>0.07</td><td>-0.02 (-0.07, 0.04)</td><td>0.57</td><td>-0.05 (-0.12, 0.02)</td><td>0.18</td></tr><tr><td><strong>Sex</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Men (n = 1555)</td><td>-0.0001 (-0.03, 0.03)</td><td>0.99</td><td>0.002 (-0.03, 0.03)</td><td>0.88</td><td>-0.006 (-0.05, 0.05)</td><td>0.98</td></tr><tr><td>Women (n = 1572)</td><td>0.005 (-0.02, 0.03)</td><td>0.73</td><td>-0.005 (-0.03, 0.02)</td><td>0.74</td><td>-0.0001 (-0.04, 0.04)</td><td>0.99</td></tr><tr><td><strong>Asthma</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>ECRHS I-ECRHS III,<br>% change per year<br>(All, n = 315)</td><td>0.13 (0.07, 0.18)</td><td>&lt;0.001</td><td>0.07 (-0.004, 0.14)</td><td>0.06</td><td>0.23 (0.12, 0.35)</td><td>&lt;0.001</td></tr><tr><td><strong>Smoking status</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Non-smokers (n = 263)</td><td>0.16 (0.10, 0.23)</td><td>&lt;0.001</td><td>0.10 (0.01, 0.19)</td><td>0.02</td><td>0.26 (0.13, 0.38)</td><td>&lt;0.001</td></tr><tr><td>Smokers (n = 52)</td><td>-0.0007 (-0.18, 0.18)</td><td>0.99</td><td>-0.02 (-0.21, 0.17)</td><td>0.80</td><td>0.07 (-0.29, 0.44)</td><td>0.68</td></tr><tr><td><strong>Sex</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Men (n = 113)</td><td>0.13 (-0.004, 0.27)</td><td>0.06</td><td>0.07 (-0.08, 0.21)</td><td>0.37</td><td>0.22 (0.01, 0.45)</td><td>0.06</td></tr><tr><td>Women (n = 202)</td><td>0.15 (0.08, 0.22)</td><td>&lt;0.001</td><td>0.10 (0.008, 0.20)</td><td>0.03</td><td>0.24 (0.10, 0.38)</td><td>0.001</td></tr></tbody></table>
ΔFVC, and ΔFEV₁/FVC ratio and higher FeNO levels, p < 0.001, p = 0.02, p < 0.001. Further, after stratification by sex, asthmatic women showed a positive association between ΔFEV₁, ΔFVC and ΔFEV₁/FVC ratio and FeNO levels, p < 0.001, p = 0.03, p = 0.001. No association was seen in non-asthmatics, see Table 3. Results were consistent after further adjustment of BMI change over 20 years of time. When oral steroids were added to the list of covariates, the results showed similar β coefficients and p values (data not shown). No interaction was seen between sex and yearly changes in lung function (FEV₁, FVC, and FEV₁/FVC) after adjustment for age, height, atopy, inhaled steroids, and study centre (data not shown).

## FeNO and bronchodilator response

Asthmatic subjects had higher BD response with regards to FEV₁ and FVC compared with non-asthmatic subjects, see Table 4.

In non-asthmatic subjects, a positive association was seen between higher % changes in FEV₁ and FeNO levels after BD use, after adjusting for sex, age, height, weight, atopy, inhaled steroids, smoking status, and study centre, p = 0.02. No association was seen between lung function response to BD and FeNO levels in asthmatic subjects, see Table 5.

After stratification by smoking status, non-smoking subjects showed a positive association between higher % change in FEV₁ and FeNO levels after BD use, whether they were non-asthmatic, p = 0.007, or asthmatic, p = 0.03. Further, when stratified by sex, women showed a positive association between higher % changes in FEV₁ and FeNO levels after BD use, whether they were non-asthmatic, p = 0.007, or asthmatic, p = 0.04, Table 5. We also added oral steroids to our covariates; the results showed the same pattern (data not shown), except in asthmatic women where the β coefficient (95% CI) was 0.007 (−0.003, 0.02), p = 0.16. No interactions

<table><caption>**Table 4.** Arithmetic means of lung function response to BD (expressed as pre/post change) in non-asthma/asthma subjects stratified by smoking status and sex, respectively. Abbreviations: BD = bronchodilator, FEV₁ = forced expiratory volume in 1 s, FVC = forced vital capacity</caption><thead><tr><th>Lung function response to BD % change</th><th>FEV<sub>1</sub>, mean (95% CI)</th><th>p value</th><th>FVC, mean (95% CI)</th><th>p value</th><th>FEV<sub>1</sub>/FVC, mean (95% CI)</th><th>p value</th></tr></thead><tbody><tr><td>Non-Asthma n = 3440</td><td>2.4 (2.2, 2.5)</td><td></td><td>-0.9 (-1.0, -0.7)</td><td></td><td>3.3 (3.2, 3.4)</td><td></td></tr><tr><td>Smoking status</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Non-smokers n = 2818</td><td>2.3 (2.2, 2.5)</td><td></td><td>-1.0 (-1.1, -0.8)</td><td></td><td>3.4 (3.2, 3.5)</td><td></td></tr><tr><td>Smokers n = 622</td><td>2.6 (2.2, 2.9)</td><td>0.27</td><td>-0.4 (-0.7, 0.3)</td><td>0.002</td><td>3.1 (2.8, 3.4)</td><td>0.06</td></tr><tr><td>Sex</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Men (n = 1688)</td><td>2.3 (2.1, 2.5)</td><td></td><td>-0.6 (-0.8, -0.4)</td><td></td><td>2.9 (2.7, 3.1)</td><td></td></tr><tr><td>Women (n = 1752)</td><td>2.5 (2.3, 2.7)</td><td>0.14</td><td>-1.2 (-1.4, -0.9)</td><td>&lt;0.001</td><td>3.7 (3.5, 3.9)</td><td>&lt;0.001</td></tr><tr><td>Asthma n = 633</td><td>5.0 (4.4, 5.5)</td><td></td><td>1.2 (0.8, 1.7)</td><td></td><td>3.7 (3.3, 4.1)</td><td></td></tr><tr><td>Smoking status</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Non-smokers n = 540</td><td>4.9 (4.3, 5.5)</td><td></td><td>1.0 (0.6, 1.5)</td><td></td><td>3.8 (3.4, 4.2)</td><td></td></tr><tr><td>Smokers n = 93</td><td>5.5 (4.0, 7.0)</td><td>0.42</td><td>2.4 (1.2, 3.6)</td><td>0.03</td><td>3.0 (2.1, 4.0)</td><td>0.15</td></tr><tr><td>Sex</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Men n = 249</td><td>4.9 (4.1, 5.8)</td><td></td><td>-1.8 (-1.1, -1.4)</td><td></td><td>3.0 (2.5, 3.6)</td><td></td></tr><tr><td>Women n = 384</td><td>5.0 (4.2, 5.7)</td><td>0.97</td><td>0.9 (0.3, 1.5)</td><td>0.08</td><td>4.1 (3.6, 4.6)</td><td>0.009</td></tr></tbody></table>
<table><caption>**Table 5.** Multiple linear regression analyses, lung function response to BD (expressed as % change) to FeNO in non-asthma/asthma subjects (adjusted) stratified by smoking status and sex, respectively. Abbreviations: FeNO = fractional exhaled NO nitric oxide, BD = bronchodilator, FEV<sub>1</sub> = forced expiratory volume in 1 s, FVC = forced vital capacity, CI = confidence interval. Adjusted for sex, age, height, atopy, inhaled corticosteroids, smoking status, and study centre</caption><thead><tr><th rowspan="2">logFeNO</th><th colspan="2">Lung function response to BD % change FEV<sub>1</sub></th><th colspan="2">Lung function response to BD % change FVC</th><th colspan="2">Lung function response to BD % change FEV<sub>1</sub>/FVC</th></tr><tr><th>β-coefficient (95% CI)</th><th>p value</th><th>β-coefficient (95% CI)</th><th>p value</th><th>β-coefficient (95% CI)</th><th>p value</th></tr></thead><tbody><tr><td>Non-asthma (n = 2993)</td><td>0.002 (0.0003, 0.004)</td><td>0.02</td><td>0.001 (-0.0005, 0.003)</td><td>0.16</td><td>0.0007 (-0.001, 0.003)</td><td>0.49</td></tr><tr><td>Smoking status</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Non-smokers (n = 2460)</td><td>0.003 (0.0007, 0.004)</td><td>0.007</td><td>0.001 (-0.0008, 0.003)</td><td>0.26</td><td>0.001 (-0.0008, 0.004)</td><td>0.20</td></tr><tr><td>Smokers (n = 533)</td><td>-0.00008 (-0.004, 0.004)</td><td>0.97</td><td>0.003 (-0.002, 0.007)</td><td>0.25</td><td>-0.003 (-0.008, 0.002)</td><td>0.29</td></tr><tr><td>Sex</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Men (n = 1486)</td><td>0.0008 (-0.002, 0.003)</td><td>0.54</td><td>0.001 (-0.001, 0.004)</td><td>0.30</td><td>-0.0009 (-0.004, 0.002)</td><td>0.57</td></tr><tr><td>Women (n = 1507)</td><td>0.003 (0.0009, 0.006)</td><td>0.007</td><td>0.001 (-0.001, 0.003)</td><td>0.38</td><td>0.002 (-0.0003, 0.005)</td><td>0.08</td></tr><tr><td>Asthma (n = 305)</td><td>0.005 (-0.001, 0.011)</td><td>0.11</td><td>0.005 (-0.001, 0.012)</td><td>0.11</td><td>0.002 (-0.007, 0.010)</td><td>0.69</td></tr><tr><td>Smoking status</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Non-smokers (n = 250)</td><td>0.008 (0.001, 0.015)</td><td>0.03</td><td>0.009 (0.001, 0.016)</td><td>0.02</td><td>0.002 (-0.008, 0.011)</td><td>0.73</td></tr><tr><td>Smokers (n = 50)</td><td>0.004 (-0.007 0.016)</td><td>0.46</td><td>-0.0006 (-0.015, 0.014)</td><td>0.93</td><td>0.032 (0.003, 0.06)</td><td>0.03</td></tr><tr><td>Sex</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Men (n = 110)</td><td>-0.002 (-0.012, 0.008)</td><td>0.67</td><td>0.006 (-0.006, 0.018)</td><td>0.35</td><td>-0.014 (-0.030, 0.003)</td><td>0.10</td></tr><tr><td>Women (n = 195)</td><td>0.008 (0.0006, 0.015)</td><td>0.04</td><td>0.006 (-0.002, 0.014)</td><td>0.14</td><td>0.007 (-0.003, 0.017)</td><td>0.20</td></tr></tbody></table>
were seen between sex and BD response (FEV₁, FVC, and FEV₁/FVC) after adjustment for age, height, atopy, inhaled steroids, and study centre (data not shown).

## DISCUSSION

The main finding of the present study was that a larger previous lung function decline over 20 years was associated with higher FeNO levels in asthmatics in ECRHS III. We also found that a higher BD response was associated with higher FeNO levels in non-asthmatic subjects. After subjects were stratified by sex and smoking status, the association appeared to be stronger for women and non-smokers, respectively, regardless of asthma status.

### FeNO and lung function decline over time

Eosinophil inflammation, assessed through blood cell counts, has been associated with faster decline of FEV₁/FVC ratios and FEV₁ in a population-based cohort of young adults.¹³ Also, Backman et al, using a similar design to that in our study, reported an association between accelerated previous decline in FEV₁ and blood eosinophils among adults with asthma.³² This is in line with our study, where we found that a faster decline in lung function was associated with higher FeNO levels in asthmatics.

Asthma is frequently characterised by eosinophil inflammation, mainly due to type-2 inflammation, and FeNO levels are associated with degree of eosinophil airway inflammation.³³ The association between FeNO and change in lung function has only been studied in selected asthma populations.¹⁴⁻¹⁶ In a prospective study by Matsunaga et al¹⁶ on non-smoking patients with controlled asthma (n = 140), subjects who had persistently high levels of FeNO had an accelerated decline in FEV₁ and reduction in bronchodilator response over time. Similar results were shown by Van Veen et al,¹⁴ who demonstrated that FeNO level was associated with an excessive loss of lung function in non-smoking, difficult-to-treat asthmatics.

After stratification by smoking and sex, a positive association was seen only in non-smokers and women, respectively. The rationale for the first

stratification was that current smokers have significantly lower FeNO levels,³⁴,³⁵ but faster lung function decline⁷ than non-smokers. Current smoking is a known determinant of FeNO levels in both healthy subjects³⁴,³⁵ and asthmatics.³⁶ Similarly, current smoking is related to faster lung function decline both in non-asthmatic and asthmatic individuals.³⁷ Therefore, current smoking is expected to relate both to lower FeNO and higher lung function decline. Moreover, as higher degree of smoking relates to further decreased FeNO³⁸ and larger lung function decrease,³⁷ this might explain the fact that the type-2-inflammatory signal reflected by FeNO might be impaired especially when looking at associations with lung function decline in current smokers.

With regards to sex stratification, a rationale is offered by a study by James et al demonstrating that smoking subjects with asthma had a more accelerated decline in lung function compared with non-smokers, and this decline in lung function was even greater in males with asthma.³⁷ The mechanisms behind these sex differences are not fully understood, but appear to be related to differences in genetics and hormones, as well as sociocultural and environmental differences.³⁹

### Bronchodilator response

Larger BD response was associated with higher FeNO levels in non-asthmatic subjects. This has not previously been studied in large populations of healthy individuals. In previous analyses, which included the populations studied herein and two other populations, we found that FeNO levels were related to the response to BD testing in asthmatics as well.¹⁹ In the present analysis, this was found only in non-smoking asthmatics. This may be related to power, as the previous analysis was based on a larger number of asthmatics. Other studies have also found an association between FeNO and the BD response in asthmatics.⁴⁰ The fact that we found an association only in non-smoking asthmatics is probably related to the fact that smoking reduces FeNO levels;³⁵ thus, the relation to BD response is impaired. The clinical role of FeNO in smokers with asthma is still debated.⁴¹

Somewhat surprisingly, we found a sex difference between FeNO and BD response, where
women appeared to have a stronger response. Sex hormones has been shown to play an important role in the development and progression of asthma. In adults, experimental evidence from human cells and animal studies have shown that Th2-mediated airway inflammation is increased by oestrogen and that testosterone has anti-inflammatory effects.⁴²

Previous studies have also indicated that middle-aged women are at greater risk of asthma than men.⁴³,⁴⁴ Possible mechanisms include smaller airways,⁴⁵ faster lung function decline around menopause,⁴⁶ sex differences in smoke metabolism,⁴⁷ and immunological⁴⁸ or hormonal differences.⁴⁹

## Strengths and limitations

The main strength of the current study is that ECRHS is a large, multicentre, population-based cohort, which enabled us to conduct stratified analyses. It has a standardised protocol with validated questionnaires and careful attention has been paid to the quality and standardisation of lung function and exhaled NO measurements. Further, the study subjects came from different geographical areas, indicating that these findings could be valid in the general population.

Some limitations are worth mentioning. FeNO was measured only in ECRHS III, we do not have FeNO measurements at baseline or during the study period, which means that we cannot express a causal relationship. The present population was recruited from both a random sample and a symptomatic sample of responders in ECRHS. The long follow-up time and the fact that ECRHS III was the second follow-up should be taken into account. A response rate of just above 50% was found for ECRHS participants in all three surveys.⁵⁰ Therefore, selection bias cannot be ruled out, although it is unlikely to have affected the associations found in this study.

## CONCLUSIONS

Our study shows that participants with asthma and faster lung function decline are characterised by higher levels of FeNO at follow-up. It could be speculated that achieving control of type-2 inflammation might result in slower lung function

decline, but this must be tested in prospective studies. Higher FeNO levels are associated with a larger degree of response to bronchodilators. Further studies are needed to evaluate the clinical implications of our findings and to understand the sex differences observed.

## Authors' consent for publication

All authors have read, and approved submission of the manuscript and the manuscript has not been published nor is it being considered for publication elsewhere, in whole or in part in any language.

## Author contributions

E. Nerpin, PhD and A Malinovschi PhD designed the present study analyses; analysed and interpreted the data; drafted the article and are accountable for ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. C Janson PhD designed ECRHS study, collected data, assisted in data interpretation, critically revised the article draft and provided intellectual content of importance to the work described. DS. Ferreira, PhD, J.Weyler PhD, V. Schlunnsen, PhD, R.Jögi PhD, C. Raherison Semjen, PhD, T. Gislason, PhD, P.Demoly, PhD, J. Heinric, PhD, D.Novac, PhD, A. Corsico, PhD, S. Accordini, PhD, A. Marcon, PhD, G. Squillacioti, PhD, M. Olivieri, PhD, R. Nielsen, PhD, A. Johannessen, PhD, F. G. Real, PhD, J. Garcia-Aymerich, PhD, I. Urrutia, PhD, A. Pereira-Veja, PhD, J. A. Gullón, PhD, A-C. Olin, PhD, B. Forsberg, PhD, Ö. I. Emilsson, PhD, I. Pin, PhD and D. Jarvis, PhD designed ECRHS study and/or collected data, contributed to data interpretation, critically revised the article draft and provided intellectual content of importance to the work described. All authors approved the manuscript.

## Availability of data and material

Due to ethical and legal restrictions in respective participating country, the data underlying this study are available upon reasonable request to qualified researchers. Requests for data access should be direct to the corresponding author and will be handled by the ECRHS Steering Committee.

## Ethics approval

Informed consent was obtained from all participants prior to inclusion in ECRHS I and III. Each study centre obtained approval for the study from their regional committee of medical research ethics in accordance with national legislation.

## Declaration of competing interest

DF reports grants from Asthma Foundation of Victoria, grants from Allen and Hanbury's, grants from National Health & Medical Research Council, during the conduct of the study. VS reports grants from The Wood Dust
Foundation (Project No. 444508795), during the conduct of the study. RJ reports grants from Estonian Research Council Personal Research Grant no 562, during the conduct of the study; personal fees from Consultancy, grants from Grants/grants pending, personal fees from Payment for lectures, personal fees from Travel/accommodations/meeting expenses, outside the submitted work. PD reports grants from ALK, Stallergenes Greer, grants from AstraZeneca, ThermoFisherScientific, Ménarini, grants from Bausch & Lomb, personal fees from Sanofi, Regeneron, outside the submitted work. RN reports grants and personal fees from AstraZeneca, grants from Novartis, grants from Boehringer Ingelheim, grants and personal fees from GlaxoSmithKline, outside the submitted work. IP reports other from NOVARTIS, other from ASTRA ZENECA, personal fees from AGIRadom, outside the submitted work. All other authors declare no conflicts of interests.

**The following grants contributed to funding ECRHS I.**

**Australia:** Asthma Foundation of Victoria, Allen and Hanbury's. **Belgium:** Belgian Science Policy Office, National Fund for Scientific Research. **Denmark:** The Danish Lung Association. **Estonia:** Estonian Science Foundation, grant no 1088. **France:** Ministère de la Santé, Glaxo France, Institut Pneumologique d'Aquitaine, Contrat de Plan Etat-Région Languedoc-Rousillon, CNMATS, CNMRT (90MR/10, 91AF/6), Ministre delegué de la santé, RNSP, France; GSF. **Germany:** Bundesminister für Forschung und Technologie.

**Greece:** The Greek Secretary General of Research and Technology, Fisons, Astra and Boehringer-Ingelheim. **India:** Bombay Hospital Trust. **Italy:** Ministero dell'Università e della Ricerca Scientifica e Tecnologica, CNR, Regione Veneto grant RSF n. 381/05.93. **New Zealand:** Asthma Foundation of New Zealand, Lotteries Grant Board, Health Research Council of New Zealand. **Norway:** Norwegian Research Council project no. 101422/310. **Portugal:** Glaxo Farmacêutica Lda, Sandoz Portugesa. **Spain:** Fondo de Investigación Sanitaria (#91/0016-060-05/E, 92/0319 and #93/0393), Hospital General de Albacete, Hospital General Juan Ramón Jiménez, Dirección Regional de Salud Pública (Consejería de Sanidad del Principado de Asturias), CIRIT (1997 SGR 00079), and Servicio Andaluz de Salud. **Sweden:** The Swedish Medical Research Council, the Swedish Heart Lung Foundation, and the Swedish Association against Asthma and Allergy. **Switzerland:** Swiss National Science Foundation grant 4026-28099. **UK:** National Asthma Campaign, British Lung Foundation, Department of Health, South Thames Regional Health Authority. **USA:** United States Department of Health, Education and Welfare Public Health Service (grant #2 S07 RR05521-28). The coordination of this work was supported by the European Commission.

**The following grants contributed to funding ECRHS III.**

**Australia:** National Health & Medical Research Council. **Belgium:** Antwerp South, Antwerp City - Research Foundation Flanders (FWO), grant code G.0.410.08.N.10 (both sites). **Estonia:** Tartu - SF0180060s09 from the Estonian Ministry of Education. **France:** (All) Ministère de la Santé, Programme Hospitalier de Recherche Clinique (PHRC) national 2010. **Bordeaux:** INSERM U897 Université Bordeaux Segalen. **Grenoble:** Comité Scientifique AGIRadom 2011. **Paris:** Agence Nationale de la Santé,

Région Ile de France, domaine d'intérêt majeur (DIM). **Germany:** Erfurt: German Research Foundation HE 3294/10-1. Hamburg: German Research Foundation MA 711/6-1, NO 262/7-1. **Iceland:** Reykjavik, The Landspítali University Hospital Research Fund, University of Iceland Research Fund, ResMed Foundation, California, USA, Orkuveita Reykjavíkur (Geothermal plant), Végagerðin (The Icelandic Road Administration (ICERA). **Italy:** All Italian centres were funded by the Italian Ministry of Health, Chiesi Farmaceutici SpA. Verona received additional funding from the Cariverona foundation, Education Ministry (MIUR).

**Norway:** Norwegian Research Council grant no 214123, Western Norway Regional Health Authorities grant no 911631, Bergen Medical Research Foundation. **Spain:** Fondo de Investigación Sanitaria (PS09/02457, PS09/00716 09/01511) PS09/02185 PS09/03190), Servicio Andaluz de Salud, Sociedad Española de Neumología y Cirugía Torácica (SEPAR 1001/2010), Fondo de Investigación Sanitaria (PS09/02457). Barcelona: Fondo de Investigación Sanitaria (FIS PS09/00716). Galdakao: Fondo de Investigación Sanitaria (FIS 09/01511). Huelva: Fondo de Investigación Sanitaria (FIS PS09/02185) and Servicio Andaluz de Salud. Oviedo: Fondo de Investigación Sanitaria (FIS PS09/03190). **Sweden:** All centres were funded by the Swedish Heart and Lung Foundation, the Swedish Asthma and Allergy Association, the Swedish Association against Lung and Heart Disease, and the Swedish Research Council for Health, Working Life and Welfare (FORTE). Göteborg also received further funding from the Swedish Council for Working Life and Social Research. Umeå also received funding from a Västerbotten County Council ALF grant. **Switzerland:** The Swiss National Science Foundation (grants no 33CSCO-134276/1, 33CSCO-108796, 3247BO-104283, 3247BO-104288, 3247BO-104284, 3247-065896, 3100-059302, 3200-052720, 3200-042532, 4026-028099), The Federal office for Forest, Environment and Landscape, The Federal Office of Public Health, The Federal Office of Roads and Transport, the canton's government of Aargan, Basel-Stadt, Basel-Land, Geneva, Luzern, Ticino, Valais, and Zürich, the Swiss Lung League, the canton's Lung League of Basel Stadt/ Basel, Landschaft, Geneva, Ticino, Valais, and Zurich, SUVA, Freiwillige Akademische Gesellschaft, UBS Wealth Foundation, Talecris Biotherapeutics GmbH, Abbott Diagnostics, European Commission 018996 (GABRIEL), Wellcome Trust WT 084703MA, **UK:** Medical Research Council (Grant Number 92091). Support was also provided by the National Institute for Health Research through the Primary Care Research Network.

**Acknowledgements**

Grants and/or financial support

The coordination of ECRHS III was supported by the Medical Research Council (Grant Number 92091). We acknowledge support from the Spanish Ministry of Science and Innovation through the "Centro de Excelencia Severo Ochoa 2019-2023" Program (CEX2018-000806-S), and support from the Generalitat de Catalunya through the CERCA Program
Author details

ªDepartment of Medical Sciences, Respiratory Medicine, Allergy and Sleep, Uppsala University, Uppsala, Sweden.

ᵇDepartment of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden. ᶜDepartment of Medicine, Health and Social Studies, Dalarna University, Falun, Sweden. ᵈDepartment of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Melbourne, Australia. ᶜAlergia e Imunologia, Complexo Hospital de Clinicas, Universidade Federal do Paraná, Curitiba, Brazil. ᶠEpidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium.

ᵃDepartment of Environment Occupation & Health, Danish Ramazzini Centre, Aarhus University, Aarhus, Denmark.

ᵇLung Clinic, Tartu University Hospital, Tartu, Estonia.

¹U1219, Bordeaux Population Health Research Center, Bordeaux, France. ²Department of Sleep, Landspitali University Hospital, Reykjavik, Iceland. ³Faculty of Medicine, University of Iceland, Reykjavik, Iceland.

⁴Département de Pneumologie et Addictologie, Centre Hospitalier Universitaire de Montpellier, Hopital Arnaud de Villeneuve, Univ Montpellier, Montpellier, France. ⁵Institut Pierre-Louis D'épidémiologie et de Santé Publique, Équipe EPAR, Sorbonne Université, INSERM, Paris, France.

⁶Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital Munich, Ludwig Maximilians University Munich, Munich, Germany.

⁷Institute of Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany. ⁸Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.

⁹Hospital of the Ludwig-Maximilian University Munich, LMU Munich, Munich, Germany. ¹Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany. ²Division of Respiratory Diseases, Medical Sciences and Infectious Diseases Department, IRCCS Policlinico San Matteo Foundation. ³Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy. ⁴Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy. ⁵Department of Public Health and Pediatrics - University of Turin, Turin, Italy. ⁶Unit of Occupational Medicine, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.

⁷Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway. ⁸Department of Clinical Science, University of Bergen, Bergen, Norway. ⁹Department of Global Public Health and Primary Care, Centre for International Health, University of Bergen, Bergen, Norway.

aaDepartment of Occupational Medicine, Haukeland University Hospital, Bergen, Norway. abDepartment of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway. acISGlobAL, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain.

adPneumology Service of Galdakao Hospital in Bizkaia, Spain. aePneumology and Allergy Service of the Juan Ramón Jiménez Hospital in Huelva, Spain. afPneumology. San Agustín University Hospital, Avilés, Spain. agSection of Occupational and Environmental Medicine, Sahlgrenska

Academy, University of Gothenburg, Gothenburg, Sweden.

ahSustainable Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden. aiCHU Grenoble Alpes, Inserm, Institut for Advanced Biosciences, Grenoble Alpes University, Grenoble, France. aijNational Heart and Lung Institute, Imperial College London, London, UK.

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