# Asthma is associated with increased severity and duration of rhinitis: A study with the Allergic Rhinitis and its Impact on Asthma classes in the Constances cohort

Marine Savouré, Jean Bousquet, Bénédicte Leynaert, Céline Ribet, Marcel Goldberg, Marie Zins, Bénédicte Jacquemin, Nadif Rachel

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## To cite this version:

Marine Savouré, Jean Bousquet, Bénédicte Leynaert, Céline Ribet, Marcel Goldberg, et al.. Asthma is associated with increased severity and duration of rhinitis: A study with the Allergic Rhinitis and its Impact on Asthma classes in the Constances cohort. Clinical and Translational Allergy, 2023, Clinical and Translational Allergy, 13 (11), pp.e12316. 10.1002/clt2.12316. hal-04313616

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ORIGINAL ARTICLE

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# Asthma is associated with increased severity and duration of rhinitis: A study with the Allergic Rhinitis and its Impact on Asthma classes in the Constances cohort

Marine Savouré<fnref n="1" />,<fnref n="2" /> ID

Jean Bousquet<fnref n="1" />,<fnref n="3" />,<fnref n="4" />,<fnref n="5" />,<fnref n="6" /> ID

Bénédicte Leynaert<fnref n="1" /> ID

Céline Ribet<fnref n="7" /> ID

Marcel Goldberg<fnref n="7" /> ID

Marie Zins<fnref n="7" /> ID

Bénédicte Jacquemin<fnref n="8" /> ID

Rachel Nadif<fnref n="1" /> ID

Correspondence

Marine Savouré, CESP, Equipe d'Epidémiologie Respiratoire Intégrative, Hôpital Paul Brousse, 16 avenue Paul Vaillant Couturier, Villejuif 94807, France.
Email: marine.savoure@inserm.fr

Funding information

L'Oréal; Agence de l'Environnement et de la Maîtrise de l'Energie; Merck Sharp and Dohme; Caisse nationale d'assurance maladie; Agence Nationale de la Recherche; Université Paris-Saclay

Abstract

**Background:** Few population-based studies have described allergic rhinitis (AR) according to the Allergic Rhinitis and its Impact on Asthma (ARIA) classification, and none have assessed the impact of asthma on this classification. Our aims were to 1) describe AR according to four ARIA classes and 2) within each of the four ARIA classes, compare participants with AR alone versus those with AR and asthma.

**Methods:** Cross-sectional analyses were performed using data from the 2014 annual follow-up questionnaire of the French adult population-based cohort Constances. Current AR was defined by the report of sneezing, runny, or blocked nose in the last 12 months and the report of nasal allergies. Following ARIA recommendations, rhinitis was classified according to its severity (mild or moderate-severe) and duration (intermittent or persistent). Ever asthma was also defined by a questionnaire.

**Results:** Among the 4675 participants with AR (57% women, mean age $50.2 \pm 12.7$ years), 44% were classified as mild/intermittent, 16% mild/persistent, 25% moderate-severe/intermittent, and 15% moderate-severe/persistent. Within each of the four ARIA classes, compared to participants with rhinitis alone, participants with rhinitis and asthma had significantly more severe symptoms, more conjunctivitis, a higher mean eosinophil count and more treatments with intra-nasal corticosteroids and oral antihistamines co-medication.

**Conclusions:** This is a paradigm shift study as for the first time this large population-based study in adults showed that asthma status has a profound effect on the ARIA classification. Rhinitis alone and rhinitis with asthma represent two distinct phenotypes. These results reinforce the need to include asthma status in the ARIA classification and guidelines.

<footnote n="1">¹Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, Villejuif, France</footnote>

<footnote n="2">²French Environment and Energy Management Agency, Angers, France</footnote>

<footnote n="3">³Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany</footnote>

<footnote n="4">⁴Department of Dermatology and Allergy, Comprehensive Allergy Center, Berlin Institute of Health, Berlin, Germany</footnote>

<footnote n="5">⁵Centre Hospitalier Universitaire, Montpellier, France</footnote>

<footnote n="6">⁶MASK-air, Montpellier, France</footnote>

<footnote n="7">⁷Université Paris-Cité, Université Paris-Saclay, UVSQ, Inserm, UMS 11 Cohortes Epidémiologiques en population, Villejuif, France</footnote>

<footnote n="8">⁸Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en Santé, environnement et travail) - UMR_S 1085, Rennes, France</footnote>

<footnote>Bénédicte Jacquemin and Rachel Nadif are co-last authors.</footnote>

<footnote>This is an open access article under the terms of the [Creative Commons Attribution License](https://creativecommons.org/licenses/by/4.0/), which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

© 2023 The Authors. Clinical and Translational Allergy published by John Wiley & Sons Ltd on behalf of European Academy of Allergy and Clinical Immunology.</footnote>
## KEYWORDS

ARIA, asthma, duration, rhinitis, severity

# 1 | INTRODUCTION

Allergic rhinitis (AR) is one of the most prevalent diseases in the world.¹ All countries, ethnicities, and age groups are affected by AR, leading to a global health problem.² In this context, during a World Health Organization workshop in 1999, the Allergic Rhinitis and Its Impact on Asthma (ARIA) initiative was initiated. The first ARIA report published in 2001³ as a major document for the classification and management of rhinitis was updated or revised in 2008,² 2010,⁴ 2016⁵ and 2022. The ARIA report included a classification of rhinitis according to its severity ("mild" or "moderate-severe") and duration ("intermittent" or "persistent") which allows classification of rhinitis into four classes: mild/intermittent, mild/persistent, moderate-severe/intermittent and moderate-severe/persistent.²

The ARIA classification has been validated in clinical practice.²,⁶⁻⁸ Several population-based studies have described AR according to its duration⁹⁻¹² or severity¹²⁻¹⁵ but none have investigated the duration and severity together. In a previous study based on data from the Constances population-based cohort, we observed a much higher prevalence of mild AR than in clinical practice,¹⁶ suggesting the existence of rhinitis profiles with different characteristics in the general population, in particular regarding rhinitis severity. Another gap in the literature concerns whether the co-occurrence of asthma may impact the characteristics of the different AR classes: even if it is known that asthma and AR often coexist, no study has investigated the impact of asthma in the ARIA classification. Furthermore, a recent hypothesis proposed that rhinitis alone is a disease distinct from rhinitis with asthma.¹⁷ Overall, no population-based study has been conducted in adults to describe AR according to its severity and duration or to assess if within each of the four ARIA class participants with AR alone are different from those with AR and asthma.

Our aim was to describe AR according to its severity and duration defined by the ARIA classification among adults from the general population. Our specific objectives were to 1) describe AR according to four ARIA classes and 2) within each of the four ARIA classes, compare participants with AR alone versus those with AR and asthma.

# 2 | METHODS

## 2.1 | Study design

A cross-sectional study was carried out with the data from the 2014 annual follow-up questionnaire of the Constances cohort among participants reporting current AR. We first describe AR according to

the two major criteria of ARIA that is, severity and duration and then we studied the impact of asthma on these ARIA classes concerning clinical features, eosinophils and medication needs.

## 2.2 | Settings and participants

Constances is a population-based cohort of 220,000 adults aged 18–69 at inclusion, randomly selected from social security affiliates in France (https://www.constances.fr/index_EN.php). The participants were enrolled from 2012 to 2020 in 20 administrative districts. At inclusion, participants completed several standardized questionnaires and had a complete medical examination.¹⁸⁻²⁰ An annual follow-up was done through a postal or online self-questionnaire. The annual follow-up questionnaires present different questions each year, according to specific research themes. One of the themes of the 2014 annual follow-up questionnaire was rhinitis. All participants who were included until the end of 2013 received the 2014 annual follow-up questionnaire, which included two pages of detailed, validated, and standardized questions on rhinitis (online supplement).

All confidentiality, safety and security procedures were approved by the French legal authorities. Approvals were obtained from the National Data Protection Authority on March 3, 2011 (Commission Nationale de l'Informatique et des Libertés—CNIL, French National Data Protection Authority (authorisation no. 910486)), the National Council for Statistical Information (Conseil National de l'Information Statistique—CNIS), the National Medical Council (Conseil National de l'Ordre des Médecins—CNOM), and the Institutional Review Board of the National Institute for Medical Research-INSERM (authorisation no. 01-011). All participants signed a written informed consent.

## 2.3 | AR and asthma

As specific Immunoglobulin E (IgE) and Skin Prick Tests (SPTs) are not available in Constances, we used a definition of AR based on a questionnaire, as published previously.¹⁶,²¹ Participants were considered as having current AR if they answered "yes" to all the three following questions: "During your lifetime, have you ever had a problem with sneezing, or a runny, or a blocked nose when you did not have a cold or the flu?", to "Have you had these problems in the last 12 months?", and to "Have you ever had nasal allergies in your lifetime, including hay fever?".

Following the ARIA recommendations,² AR was defined as moderate-severe if at least one of the symptoms of rhinitis: rhinorrhea, nasal congestion, nasal pruritus, or sneezing has been reported
as a disturbing problem affecting daily activities and sleep. Otherwise, rhinitis was defined as mild if none of the symptoms have been reported as a disturbing problem affecting daily activities and sleep.

Allergic rhinitis was defined as persistent if symptoms occurred more than 4 days per week and more than four consecutive weeks. Otherwise, AR was defined as intermittent.

Participants were considered as having ever-asthma if they answered yes to "Have you ever had asthma?" at inclusion or answered "asthma" to: "Here is a list of health problems. Indicate here the ones you have suffered from in the last 12 months (whether or not there was a work interruption, whether or not there is a treatment)" at the 2014 follow-up questionnaire.

Other variables of interest are described in the supplement.

## 2.4 | Statistical analyses

Analysis in complete-cases, that is, by excluding participants with missing data, was carried out, and no imputation was performed.

We described AR according to the ARIA classification of severity (mild versus moderate-severe) and duration (intermittent versus persistent) separately. The severity and duration of rhinitis were then combined into four classes according to the ARIA classification: mild/ intermittent, mild/persistent, moderate-severe/intermittent, and moderate-severe/persistent. Then, we compared participants with AR and never asthma versus those with AR and ever asthma within each of the four ARIA classes.

Pearson Chi-2 tests for categorical variables and Student t test/ analysis of variance comparison of variances for continuous variables were used. We computed effect size measures.²² For categorical variables (Cramer's V coefficient), values of 0.1-0.3 were considered to represent small effect sizes, 0.3-0.5 medium effect and ≥0.5 large effect sizes.²³ For continuous variables (Cohen's D coefficient), values of 0.2-0.5 were considered to represent small effect sizes, 0.5-0.8 medium effect and ≥0.8 large effect sizes.²⁴ We performed additional analyses with multivariate logistic regressions comparing participants with ever asthma to those with never asthma among the different strata of ARIA classification, adjusting for age, gender, smoking, diploma, conjunctivitis and eczema.

All analyses were performed using SAS 9.4 software (SAS Institute).

# 3 | RESULTS

## 3.1 | Demographic characteristics of the participants

Among the 26,737 participants included in the cohort by 2013, 21,507 (80%) of them completed the 2014 follow-up questionnaire. Participants with missing data regarding the definition of AR (n = 735) were excluded from the analyses. Among participants with current AR, participants with missing data regarding severity

(n = 1031), duration (n = 100), or ever asthma (n = 91) were also excluded. Finally, 4584 participants with AR were included (Figure 1).

Compared to participants with missing data for severity and duration, participants included in the analyses were younger and had a higher level of education (Table S1).

## 3.2 | Descriptive data

Table 1 shows the demographic characteristics of the study population: the mean age was 50.1 years, 57.2% of the participants were women and 25.3% reported ever asthma. Based on the ARIA severity classification, 60.0% of the participants were classified as having mild and 40.0% as having moderate-severe rhinitis. The mean Total Nasal Symptom Score (TNSS4) was 5.8. Based on the ARIA duration classification, 68.7% of the participants were classified as having intermittent and 31.3% as having persistent rhinitis. By combining the two classifications, 2019 (44.0%) participants were classified as having mild/intermittent, 731 (15.9%) as having mild/persistent, 1131 (24.7%) as having moderate-severe/intermittent, and 703 (15.3%) as having moderate-severe/persistent rhinitis.

## 3.3 | AR severity

The characteristics of participants with AR according to its severity are presented in Table 2. There were more women with moderate-severe AR than with mild AR (62.1% vs. 53.9%, *p* < 0.001). Participants with moderate-severe AR had a higher mean eosinophil count (218.5 vs. 203.2, *p* = 0.004) and a higher TNSS4 score (7.8 vs. 4.5, *p* < 0.001) as well as an earlier age of onset of rhinitis symptoms (21.4 vs. 24.6, *p* < 0.001) than those with mild AR. Compared to participants with mild AR, those with moderate-severe AR reported more multi-morbidities: ever asthma (30.8% vs. 21.6%, <0.0001), ever conjunctivitis (59.7% vs. 51.3%, *p* < 0.0001), and/or ever eczema (44.9% vs. 37.6%, *p* < 0.0001). They also reported more nasal symptoms: rhinorrhea (82.2% vs. 68.6%, *p* < 0.0001), nasal congestion/obstruction (92.2% vs. 63.6%, *p* < 0.0001), nasal itching (71.3% vs. 61.1%, *p* < 0.0001), sneezing (81.1% vs. 69.2%, *p* < 0.0001) and associated-eye symptoms (73.9% vs. 62.1, *p* < 0.0001). Participants with moderate-severe AR reported more triggers of rhinitis symptoms: dust mites or house dust (39.3% vs. 32.7%, *p* < 0.0001), animals (15.9% vs. 10.8%, *p* < 0.0001), air pollution (31.1% vs. 24.3%, *p* < 0.0001), change in weather (33.8% vs. 25.2%, *p* < 0.0001), tobacco (8.3% vs. 5.3%, *p* < 0.0001), pollens (56.3% vs. 52.8%, *p* = 0.02), cold air (26.6% vs. 22.9%, *p* = 0.005) or other triggers (14.9% vs. 11.2%, *p* = 0.0002), and more persistent rhinitis (38.3% vs. 26.6%, *p* < 0.0001) than those with mild AR. Regarding treatments, participants with moderate-severe AR reported more co-medication (Oral Antihistamines (OA) + Intranasal Corticosteroids (INCS)) than those with mild AR (42.4% vs. 25.7%, *p* < 0.0001). Large effect sizes were observed for TNSS4 as expected, medium effect sizes for the congestion/obstruction symptom and the number of reported
<figure><img src="image_4.png" /></figure>

<figure><img src="image_5.png" /><figcaption>FIGURE 1 Flow chart. Among the 26,737 participants included in the cohort by 2013, 21,507 (80%) of them completed the 2014 follow-up questionnaire. Participants with missing data regarding the definition of allergic rhinitis (AR) (n = 735) were excluded from the analyses. Among participants with current AR, participants with missing data regarding severity (n = 1031), duration (n = 100), or ever asthma (n = 91) were also excluded. Finally, 4584 participants with AR were included in the present analysis.</figcaption></figure>

symptoms and small effect sizes for asthma, duration, rhinorrhea, nasal itching, sneezing, associated-eye symptoms, the number of reported triggers and co-medication.

## 3.4 | AR duration

The characteristics of participants with AR according to its duration are presented in Table 3. No significant differences were observed for gender, age, smoking status, education level and body mass index between groups. Participants with persistent AR had a higher mean eosinophil count (222.1 vs. 203.4, *p* = 0.001), a higher TNSS4 (6.4 vs. 5.6, *p* < 0.0001) and reported more moderate-severe rhinitis (49.0% vs. 35.9%, *p* < 0.0001) than those with intermittent AR. Participants with persistent AR also reported more ever asthma (28.3% vs. 23.9%, *p* = 0.002) and ever conjunctivitis (58.2% vs. 53.0%, *p* = 0.002). Regarding treatment, participants with persistent AR reported more co-medication (OA + INCS) than those with intermittent AR (42.6% vs. 27.8%, *p* < 0.0001). Small effect sizes were observed for TNSS4, severity, and co-medication.

## 3.5 | AR according to the four classes ARIA classification

The characteristics of participants with AR according to the four ARIA classes are presented in Table 4. The four classes had different characteristics: participants with mild AR, whether it was intermittent or persistent, had the lowest prevalences for ever asthma (21.2%), ever conjunctivitis (50.6%), and ever eczema (37.4%), the highest proportion of participants with neither OA nor INCS (43.7%), and the lowest mean eosinophil count (201 ± 138). In contrast, participants with moderate-severe/persistent AR had the highest prevalences for ever asthma (34.1%), ever conjunctivitis (63.4%), and ever eczema (46.3%), the highest proportion of participants with co-medication (OA + INCS) (52.3%), and the highest mean eosinophil count (235 ± 188). Participants with mild/persistent rhinitis had the latest age of onset of symptoms and a higher percentage of participants reported not knowing what triggered their symptoms. In contrast, participants with moderate-severe/persistent rhinitis had the earliest age of onset of symptoms and a lower percentage of participants reporting not knowing what triggered their symptoms.
<table><caption>TABLE 1 Demographic characteristics, and allergic rhinitis and its impact on asthma (ARIA) classification of participants with allergic rhinitis (AR).</caption><thead><tr><th></th><th>Analysis population<br>(n = 4584)</th></tr></thead><tbody><tr><td>Sex, n (%)</td><td></td></tr><tr><td>Men</td><td>1964 (42.8)</td></tr><tr><td>Women</td><td>2620 (57.2)</td></tr><tr><td>Age, years, mean (SD)</td><td>50.1 (12.7)</td></tr><tr><td>Tobacco status, n (%)</td><td></td></tr><tr><td>Never smoker</td><td>2053 (46.6)</td></tr><tr><td>Ex-smoker</td><td>1791 (40.7)</td></tr><tr><td>Current smoker</td><td>559 (12.7)</td></tr><tr><td>Educational level, n (%)</td><td></td></tr><tr><td>Less than high school</td><td>319 (7.0)</td></tr><tr><td>High school</td><td>1274 (28.0)</td></tr><tr><td>University</td><td>2957 (65.0)</td></tr><tr><td>Asthma, n (%)</td><td></td></tr><tr><td>Never asthma</td><td>3424 (74.7)</td></tr><tr><td>Ever asthma</td><td>1160 (25.3)</td></tr><tr><td>Rhinitis severity, n (%)</td><td></td></tr><tr><td>Mild</td><td>2750 (60.0)</td></tr><tr><td>Moderate to severe</td><td>1834 (40.0)</td></tr><tr><td>TNSS4, mean (SD)</td><td>5.8 (2.8)</td></tr><tr><td>TNSS4, n (%)</td><td></td></tr><tr><td>[0-2]</td><td>604 (13.2)</td></tr><tr><td>[3-4]</td><td>1030 (22.5)</td></tr><tr><td>[5-6]</td><td>1183 (25.8)</td></tr><tr><td>≥7</td><td>1767 (38.5)</td></tr><tr><td>Rhinitis duration, n (%)</td><td></td></tr><tr><td>Intermittent</td><td>3150 (68.7)</td></tr><tr><td>Persistent</td><td>1434 (31.3)</td></tr><tr><td>ARIA classification, n (%)</td><td></td></tr><tr><td>Mild/Intermittent</td><td>2019 (44.0)</td></tr><tr><td>Mild/Persistent</td><td>731 (15.9)</td></tr><tr><td>Moderate-severe/Intermittent</td><td>1131 (24.7)</td></tr><tr><td>Moderate-severe/Persistent</td><td>703 (15.3)</td></tr></tbody></table>

Note: Data are mean (SD) or n (%).

Abbreviation: TNSS4, Total Nasal Symptom Score 4.

## 3.6 | Influence of asthma on the ARIA classification

Eight sub-classes were defined according to the ARIA classification and the ever asthma status in each subclass (Table 5), with the number of participants per subclass ranging from 166 (mild/

persistent AR with ever asthma) to 1590 (mild/intermittent AR without ever asthma).

Whatever the ARIA subclass considered, within each ARIA subclass, asthma multimorbidity further separated participants, showing significant differences for most outcomes. In particular, ever conjunctivitis was higher by 10%-20% in AR and ever asthma in comparison to AR alone for all 4 ARIA classes (small effect size). In each category, the largest effect size between participants without ever asthma and with ever asthma was for the age of onset of rhinitis. The age of onset of rhinitis ranged from 16.1 years (moderate-severe/intermittent AR + ever asthma) to 26.0 years (mild/intermittent AR alone). Importantly, co-medication (OA + INCS) was reported from 18.8% (mild intermittent AR alone) to 64.1% (moderate-severe AR + ever asthma). The prevalence of reported symptoms was always higher in the AR + ever asthma group regardless of the ARIA class. Reported triggers of rhinitis symptoms were far higher in AR + ever asthma than AR alone for mites or house dust and animals. Eosinophil counts were significantly higher for all ARIA classes in participants with asthma than in those with rhinitis alone (small to medium effect sizes). Of note, mean eosinophil counts varied little across the ARIA classes in participants without asthma (range from 192 to 203 cells/mm³), but more marked differences between classes were observed in participants with ever asthma (range from 231 to 291 cells/mm³). The results of the multivariate logistic regressions after adjustment for age, gender, smoking, diploma, conjunctivitis and eczema are presented in the Table S2. Overall, the strength of the effects and the significance were the same as in the unadjusted analyses.

## 4 | DISCUSSION

For the first time in a population-based study in adults, AR has been described according to the four classes of ARIA classification. More symptoms, conjunctivitis, and eczema were associated with moderate-severe AR. Asthma prevalence, treatments and reports of rhinitis triggers were higher for participants with moderate-severe and/or persistent rhinitis. Considering asthma status provided additional information to the ARIA classification. The major finding is that within each of the four ARIA classes, compared to participants with rhinitis alone, participants with rhinitis and asthma had significantly more severe nasal symptoms, more conjunctivitis, higher mean eosinophil count, and more need for INCS and OA co-medication.

## 4.1 | Strengths and limitations

Constances is the largest French population-based epidemiological study in adults, presenting in 2014 a detailed questionnaire on rhinitis which allowed us to describe in detail the characteristics of AR according to the ARIA classification. Constances is however not fully representative of the French adult population as 1) participants were randomly selected from the affiliated of the National Health
<table><caption>TABLE 2 Characteristics of participants with allergic rhinitis (AR) according to its severity.</caption><thead><tr><th></th><th>Mild (n = 2750)</th><th>Mod-severe (n = 1834)</th><th>p</th><th>Effect size</th></tr></thead><tbody><tr><td>Sex, n (%)</td><td></td><td></td><td>&lt;0.0001</td><td>0.08</td></tr><tr><td>Men</td><td>1268 (46.1)</td><td>696 (38.0)</td><td></td><td></td></tr><tr><td>Women</td><td>1482 (53.9)</td><td>1138 (62.1)</td><td></td><td></td></tr><tr><td>Age, years, mean (SD)</td><td>51.8 (12.5)</td><td>47.6 (12.5)</td><td>&lt;0.0001</td><td>0.34</td></tr><tr><td>Tobacco status, n (%)</td><td></td><td></td><td>0.08</td><td>0.03</td></tr><tr><td>Never-smoker</td><td>1220 (46.2)</td><td>833 (47.3)</td><td></td><td></td></tr><tr><td>Ex-smoker</td><td>1106 (41.9)</td><td>685 (38.9)</td><td></td><td></td></tr><tr><td>Current smoker</td><td>317 (12.0)</td><td>242 (13.8)</td><td></td><td></td></tr><tr><td>Educational level, n (%)</td><td></td><td></td><td>0.64</td><td>0.01</td></tr><tr><td>Less than high school</td><td>183 (6.7)</td><td>136 (7.5)</td><td></td><td></td></tr><tr><td>High school</td><td>765 (28.1)</td><td>509 (27.9)</td><td></td><td></td></tr><tr><td>University</td><td>1776 (65.2)</td><td>1181 (64.7)</td><td></td><td></td></tr><tr><td>Body-mass index, kg/m², n (%)</td><td></td><td></td><td>0.61</td><td>0.02</td></tr><tr><td>&lt;18.5</td><td>55 (2.0)</td><td>45 (2.5)</td><td></td><td></td></tr><tr><td>[18.5-25]</td><td>1602 (59.1)</td><td>1037 (57.9)</td><td></td><td></td></tr><tr><td>[25-30]</td><td>780 (28.8)</td><td>519 (29.0)</td><td></td><td></td></tr><tr><td>≥30</td><td>272 (10.0)</td><td>191 (10.7)</td><td></td><td></td></tr><tr><td>Asthma, n (%)</td><td>0 (0.0)</td><td></td><td>&lt;0.0001</td><td>0.10</td></tr><tr><td>Never asthma</td><td>2155 (78.4)</td><td>1269 (69.2)</td><td></td><td></td></tr><tr><td>Ever asthma</td><td>595 (21.6)</td><td>565 (30.8)</td><td></td><td></td></tr><tr><td>Conjunctivitis, n (%)</td><td></td><td></td><td>&lt;0.0001</td><td>0.08</td></tr><tr><td>Never conjunctivitis</td><td>1228 (48.7)</td><td>686 (40.3)</td><td></td><td></td></tr><tr><td>Ever conjunctivitis</td><td>1292 (51.3)</td><td>1017 (59.7)</td><td></td><td></td></tr><tr><td>Eczema, n (%)</td><td></td><td></td><td>&lt;0.0001</td><td>0.07</td></tr><tr><td>Never eczema</td><td>1557 (62.4)</td><td>922 (55.1)</td><td></td><td></td></tr><tr><td>Ever eczema</td><td>938 (37.6)</td><td>751 (44.9)</td><td></td><td></td></tr><tr><td>Eosinophils count, cell/mm³, mean (SD)</td><td>203.2 (139.0)</td><td>218.5 (162.3)</td><td>0.004</td><td>0.10</td></tr><tr><td>TNSS4, mean (SD)</td><td>4.5 (2.1)</td><td>7.8 (2.3)</td><td>&lt;0.0001</td><td>1.52</td></tr><tr><td>Rhinitis duration, n (%)</td><td></td><td></td><td>&lt;0.0001</td><td>0.12</td></tr><tr><td>Intermittent</td><td>2019 (73.4)</td><td>1131 (61.7)</td><td></td><td></td></tr><tr><td>Persistent</td><td>731 (26.6)</td><td>703 (38.3)</td><td></td><td></td></tr><tr><td>Reported symptoms<sup>a</sup>, n (%)</td><td>0 (0.0)</td><td></td><td></td><td></td></tr><tr><td>Rhinorrhoea</td><td>1885 (68.6)</td><td>1508 (82.2)</td><td>&lt;0.0001</td><td>0.15</td></tr><tr><td>Nasal congestion/obstruction</td><td>1750 (63.6)</td><td>1691 (92.2)</td><td>&lt;0.0001</td><td>0.32</td></tr><tr><td>Nasal itching</td><td>1680 (61.1)</td><td>1307 (71.3)</td><td>&lt;0.0001</td><td>0.10</td></tr><tr><td>Sneezing</td><td>1902 (69.2)</td><td>1487 (81.1)</td><td>&lt;0.0001</td><td>0.13</td></tr><tr><td>Associated-eye symptoms</td><td>1693 (62.1)</td><td>1348 (73.9)</td><td>&lt;0.0001</td><td>0.12</td></tr><tr><td>Number of reported symptoms, mean (SD)</td><td>3.2 (1.3)</td><td>4.0 (1.1)</td><td>&lt;0.0001</td><td>0.63</td></tr><tr><td>Age of onset of rhinitis, year, mean (SD)</td><td>24.6 (15.5)</td><td>21.4 (13.6)</td><td>&lt;0.0001</td><td>0.21</td></tr></tbody></table>
<table><caption>TABLE 2 (Continued)</caption><thead><tr><th></th><th>Mild (n = 2750)</th><th>Mod-severe (n = 1834)</th><th>p</th><th>Effect size</th></tr></thead><tbody><tr><td>Reported triggers of symptoms<sup>a</sup>, n (%)</td><td></td><td></td><td></td><td></td></tr><tr><td>Dust mites or house dust</td><td>900 (32.7)</td><td>720 (39.3)</td><td>&lt;0.0001</td><td>0.07</td></tr><tr><td>Animals</td><td>296 (10.8)</td><td>291 (15.9)</td><td>&lt;0.0001</td><td>0.07</td></tr><tr><td>Air pollution</td><td>667 (24.3)</td><td>571 (31.1)</td><td>&lt;0.0001</td><td>0.08</td></tr><tr><td>Change in weather</td><td>692 (25.2)</td><td>620 (33.8)</td><td>&lt;0.0001</td><td>0.09</td></tr><tr><td>Tobacco</td><td>146 (5.3)</td><td>153 (8.3)</td><td>&lt;0.0001</td><td>0.06</td></tr><tr><td>Pollens</td><td>1451 (52.8)</td><td>1033 (56.3)</td><td>0.02</td><td>0.04</td></tr><tr><td>Cold air</td><td>630 (22.9)</td><td>487 (26.6)</td><td>0.005</td><td>0.04</td></tr><tr><td>Other</td><td>307 (11.2)</td><td>274 (14.9)</td><td>0.0002</td><td>0.06</td></tr><tr><td>Unknown</td><td>735 (26.7)</td><td>459 (25.0)</td><td>0.20</td><td>0.02</td></tr><tr><td>Number of reported triggers, mean (SD)</td><td>2.1 (1.2)</td><td>2.5 (1.4)</td><td>&lt;0.0001</td><td>0.31</td></tr><tr><td>Rhinitis treatment, n (%)</td><td></td><td></td><td>&lt;0.0001</td><td>0.21</td></tr><tr><td>Neither OA nor INCS</td><td>1100 (40.5)</td><td>405 (22.4)</td><td></td><td>0.19</td></tr><tr><td>OA only</td><td>617 (22.7)</td><td>398 (22.0)</td><td></td><td>0.01</td></tr><tr><td>INCS only</td><td>303 (11.2)</td><td>239 (13.2)</td><td></td><td>0.04</td></tr><tr><td>OA and INCS</td><td>698 (25.7)</td><td>770 (42.5)</td><td></td><td>0.18</td></tr></tbody></table>

Note: Data are mean (SD) or *n* (%). Orange: Small effect size (Cramer's V from [0.1-0.3] or Cohen's D from [0.2-0.5]); Yellow: medium effect size (Cramer's V from [0.3-0.5] or Cohen's D from [0.5-0.8]); Green: large effect size (Cramer's V ≥ 0.5 or Cohen's D ≥ 0.8).

Abbreviations: BMI, Body Mass Index; INCS, Intranasal Corticosteroids; OA, Oral Antihistamines; TNSS4, Total Nasal Symptom Score 4.

ªSeveral possible answers.

<table><caption>TABLE 3 Characteristics of participants with allergic rhinitis (AR) according to its duration.</caption><thead><tr><th></th><th>Intermittent (n = 3150)</th><th>Persistent (n = 1434)</th><th>p</th><th>Effect size</th></tr></thead><tbody><tr><td>Sex, n (%)</td><td></td><td></td><td>0.10</td><td>0.02</td></tr><tr><td>Men</td><td>1375 (43.7)</td><td>589 (41.1)</td><td></td><td></td></tr><tr><td>Women</td><td>1775 (56.4)</td><td>845 (58.9)</td><td></td><td></td></tr><tr><td>Age, years, mean (SD)</td><td>50.3 (12.5)</td><td>49.8 (13.0)</td><td>0.28</td><td>0.03</td></tr><tr><td>Tobacco status, n (%)</td><td></td><td></td><td>0.35</td><td>0.02</td></tr><tr><td>Never-smoker</td><td>1415 (46.6)</td><td>638 (46.8)</td><td></td><td></td></tr><tr><td>Ex-smoker</td><td>1224 (40.3)</td><td>567 (41.6)</td><td></td><td></td></tr><tr><td>Current smoker</td><td>400 (13.2)</td><td>159 (11.7)</td><td></td><td></td></tr><tr><td>Educational level, n (%)</td><td></td><td></td><td>0.46</td><td>0.02</td></tr><tr><td>Less than high school</td><td>217 (7.0)</td><td>102 (7.2)</td><td></td><td></td></tr><tr><td>High school</td><td>892 (28.6)</td><td>382 (26.8)</td><td></td><td></td></tr><tr><td>University</td><td>2014 (64.5)</td><td>943 (66.1)</td><td></td><td></td></tr><tr><td>Body-mass index, kg/m<sup>2</sup>, n (%)</td><td></td><td></td><td>0.07</td><td>0.04</td></tr><tr><td>&lt;18.5</td><td>58 (1.9)</td><td>42 (3.0)</td><td></td><td></td></tr><tr><td>[18.5-25]</td><td>1805 (58.3)</td><td>834 (59.4)</td><td></td><td></td></tr><tr><td>[25-30]</td><td>905 (29.2)</td><td>394 (28.0)</td><td></td><td></td></tr><tr><td>≥30</td><td>328 (10.6)</td><td>135 (9.6)</td><td></td><td></td></tr></tbody></table>

(Continues)
<figure><img src="image_6.png" /></figure>

<table><caption>TABLE 3 (Continued)</caption><thead><tr><th></th><th>Intermittent (n = 3150)</th><th>Persistent (n = 1434)</th><th>p</th><th>Effect size</th></tr></thead><tbody><tr><td>Asthma, n (%)</td><td></td><td></td><td>0.002</td><td>0.05</td></tr><tr><td>Never asthma</td><td>2396 (76.1)</td><td>1028 (71.7)</td><td></td><td></td></tr><tr><td>Ever asthma</td><td>754 (23.9)</td><td>406 (28.3)</td><td></td><td></td></tr><tr><td>Conjunctivitis, n (%)</td><td></td><td></td><td>0.002</td><td>0.05</td></tr><tr><td>Never conjunctivitis</td><td>1359 (47.0)</td><td>555 (41.8)</td><td></td><td></td></tr><tr><td>Ever conjunctivitis</td><td>1535 (53.0)</td><td>774 (58.2)</td><td></td><td></td></tr><tr><td>Eczema, n (%)</td><td></td><td></td><td>0.15</td><td>0.02</td></tr><tr><td>Never eczema</td><td>1721 (60.2)</td><td>758 (57.9)</td><td></td><td></td></tr><tr><td>Ever eczema</td><td>1137 (39.8)</td><td>552 (42.1)</td><td></td><td></td></tr><tr><td>Eosinophils count, cell/mm³, mean (SD)</td><td>203.4 (139.7)</td><td>222.1 (166.3)</td><td>0.001</td><td>0.13</td></tr><tr><td>TNSS4, mean (SD)</td><td>5.6 (2.7)</td><td>6.4 (2.8)</td><td>&lt;0.0001</td><td>0.29</td></tr><tr><td>Severity, n (%)</td><td></td><td></td><td>&lt;0.0001</td><td>0.12</td></tr><tr><td>Mild</td><td>2019 (64.1)</td><td>731 (51.0)</td><td></td><td></td></tr><tr><td>Moderate-severe</td><td>1131 (35.9)</td><td>703 (49.0)</td><td></td><td></td></tr><tr><td>Reported symptoms<sup>a</sup>, n (%)</td><td></td><td></td><td></td><td></td></tr><tr><td>Rhinorrhoea</td><td>2289 (72.7)</td><td>1104 (77.0)</td><td>0.002</td><td>0.05</td></tr><tr><td>Nasal congestion/obstruction</td><td>2299 (73.0)</td><td>1142 (79.6)</td><td>&lt;0.0001</td><td>0.07</td></tr><tr><td>Nasal itching</td><td>2030 (64.4)</td><td>957 (66.7)</td><td>0.13</td><td>0.02</td></tr><tr><td>Sneezing</td><td>2301 (73.1)</td><td>1088 (75.9)</td><td>0.04</td><td>0.03</td></tr><tr><td>Associated-eye symptoms</td><td>2066 (66.1)</td><td>975 (68.7)</td><td>0.08</td><td>0.03</td></tr><tr><td>Number of reported symptoms, mean (SD)</td><td>3.5 (1.3)</td><td>3.7 (1.3)</td><td>&lt;0.0001</td><td>0.15</td></tr><tr><td>Age of onset of rhinitis, year, mean (SD)</td><td>23.0 (14.6)</td><td>23.7 (15.2)</td><td>0.20</td><td>0.05</td></tr><tr><td>Reported triggers of symptoms<sup>a</sup>, n (%)</td><td></td><td></td><td></td><td></td></tr><tr><td>Dust mites or house dust</td><td>1095 (34.8)</td><td>525 (36.6)</td><td>0.22</td><td>0.02</td></tr><tr><td>Animals</td><td>401 (12.7)</td><td>186 (13.0)</td><td>0.82</td><td>0.003</td></tr><tr><td>Air pollution</td><td>790 (25.1)</td><td>448 (31.2)</td><td>&lt;0.0001</td><td>0.06</td></tr><tr><td>Change in weather</td><td>937 (29.8)</td><td>375 (26.2)</td><td>0.01</td><td>0.04</td></tr><tr><td>Tobacco</td><td>180 (5.7)</td><td>119 (8.3)</td><td>0.001</td><td>0.05</td></tr><tr><td>Pollens</td><td>1691 (53.7)</td><td>793 (55.3)</td><td>0.31</td><td>0.02</td></tr><tr><td>Cold air</td><td>774 (24.6)</td><td>343 (23.9)</td><td>0.63</td><td>0.01</td></tr><tr><td>Other</td><td>378 (12.0)</td><td>203 (14.2)</td><td>0.04</td><td>0.03</td></tr><tr><td>Unknown</td><td>757 (24.0)</td><td>437 (30.5)</td><td>&lt;0.0001</td><td>0.07</td></tr><tr><td>Number of reported triggers, mean (SD)</td><td>2.2 (1.2)</td><td>2.4 (1.5)</td><td>0.0001</td><td>0.13</td></tr><tr><td>Rhinitis treatment, n (%)</td><td></td><td></td><td>&lt;0.0001</td><td>0.17</td></tr><tr><td>Neither OA nor INCS</td><td>1179 (37.8)</td><td>326 (23.1)</td><td></td><td>0.15</td></tr><tr><td>OA only</td><td>722 (23.2)</td><td>293 (20.7)</td><td></td><td>0.03</td></tr><tr><td>INCS only</td><td>350 (11.2)</td><td>192 (13.6)</td><td></td><td>0.03</td></tr><tr><td>OA and INCS</td><td>865 (27.8)</td><td>603 (42.6)</td><td></td><td>0.15</td></tr></tbody></table>

Note: Data are mean (SD) or n (%). Orange: small effect size (Cramer's V from [0.1–0.3] or Cohen's D from [0.2–0.5]); Yellow: medium effect size (Cramer's V from [0.3–0.5] or Cohen's D from [0.5–0.8]); Green: large effect size (Cramer's V ≥ 0.5 or Cohen's D ≥ 0.8).

Abbreviations: BMI, Body Mass Index; INCS, Intranasal Corticosteroids; OA, Oral Antihistamines; TNSS4, Total Nasal Symptom Score 4.

ªSeveral possible answers.
<table><caption>TABLE 4 Characteristics of allergic rhinitis (AR) according to the allergic rhinitis and its impact on asthma (ARIA) classification.</caption><thead><tr><th></th><th>Mild<br>Intermittent<br>(n = 2019)</th><th>Mild<br>Persistent<br>(n = 731)</th><th>Mod-severe<br>Intermittent<br>(n = 1131)</th><th>Mod-severe<br>Persistent<br>(n = 703)</th><th>p</th></tr></thead><tbody><tr><td>Sex, n (%)</td><td></td><td></td><td></td><td></td><td>&lt;0.0001</td></tr><tr><td>Men</td><td>937 (46.4)</td><td>331 (45.3)</td><td>438 (38.7)</td><td>258 (36.7)</td><td></td></tr><tr><td>Women</td><td>1082 (53.6)</td><td>400 (54.7)</td><td>693 (61.3)</td><td>445 (63.3)</td><td></td></tr><tr><td>Age, years, mean (SD)</td><td>51.9 (12.3)</td><td>51.8 (13.2)</td><td>47.4 (12.4)</td><td>47.8 (12.6)</td><td>&lt;0.0001</td></tr><tr><td>Tobacco status, n (%)</td><td></td><td></td><td></td><td></td><td>0.06</td></tr><tr><td>Never smoker</td><td>889 (45.7)</td><td>331 (47.6)</td><td>526 (48.2)</td><td>307 (46.0)</td><td></td></tr><tr><td>Ex-smoker</td><td>821 (42.2)</td><td>285 (40.9)</td><td>403 (36.9)</td><td>282 (42.2)</td><td></td></tr><tr><td>Current smoker</td><td>237 (12.2)</td><td>80 (11.5)</td><td>163 (14.9)</td><td>79 (11.8)</td><td></td></tr><tr><td>Educational level, n (%)</td><td></td><td></td><td></td><td></td><td>0.76</td></tr><tr><td>Less than high school</td><td>134 (6.7)</td><td>49 (6.7)</td><td>83 (7.4)</td><td>53 (7.6)</td><td></td></tr><tr><td>High school</td><td>564 (28.2)</td><td>201 (27.7)</td><td>328 (29.2)</td><td>181 (25.8)</td><td></td></tr><tr><td>University</td><td>1300 (65.1)</td><td>476 (65.6)</td><td>714 (63.5)</td><td>467 (66.6)</td><td></td></tr><tr><td>BMI, kg/m<sup>2</sup>, n (%)</td><td></td><td></td><td></td><td></td><td>0.36</td></tr><tr><td>&lt;18.5</td><td>34 (1.7)</td><td>21 (2.9)</td><td>24 (2.2)</td><td>21 (3.1)</td><td></td></tr><tr><td>[18.5-25]</td><td>1175 (59.1)</td><td>427 (59.3)</td><td>630 (56.9)</td><td>407 (59.4)</td><td></td></tr><tr><td>[25-30]</td><td>572 (28.8)</td><td>208 (28.9)</td><td>333 (30.1)</td><td>186 (27.2)</td><td></td></tr><tr><td>≥30</td><td>208 (10.5)</td><td>64 (8.9)</td><td>120 (10.8)</td><td>71 (10.4)</td><td></td></tr><tr><td>Asthma, n (%)</td><td></td><td></td><td></td><td></td><td>&lt;0.0001</td></tr><tr><td>Never asthma</td><td>1590 (78.8)</td><td>565 (77.3)</td><td>806 (71.3)</td><td>463 (65.9)</td><td></td></tr><tr><td>Ever asthma</td><td>429 (21.2)</td><td>166 (22.7)</td><td>325 (28.7)</td><td>240 (34.1)</td><td></td></tr><tr><td>Conjunctivitis, n (%)</td><td></td><td></td><td></td><td></td><td>&lt;0.0001</td></tr><tr><td>Never conjunctivitis</td><td>913 (49.4)</td><td>315 (46.8)</td><td>446 (42.6)</td><td>240 (36.6)</td><td></td></tr><tr><td>Ever conjunctivitis</td><td>934 (50.6)</td><td>358 (53.2)</td><td>601 (57.4)</td><td>416 (63.4)</td><td></td></tr><tr><td>Eczema, n (%)</td><td></td><td></td><td></td><td></td><td>&lt;0.0001</td></tr><tr><td>Never eczema</td><td>1144 (62.6)</td><td>413 (61.9)</td><td>577 (56.0)</td><td>345 (53.7)</td><td></td></tr><tr><td>Ever eczema</td><td>684 (37.4)</td><td>254 (38.1)</td><td>453 (44.0)</td><td>298 (46.3)</td><td></td></tr><tr><td>Eosinophil count, cells/mm<sup>3</sup>, mean (SD)</td><td>200.7 (138.0)</td><td>209.9 (141.3)</td><td>208.1 (142.7)</td><td>234.7 (188.0)</td><td>&lt;0.0001</td></tr><tr><td>TNSS4, mean (SD)</td><td>4.3 (2.1)</td><td>4.8 (2.2)</td><td>7.7 (2.3)</td><td>8.0 (2.5)</td><td>&lt;0.0001</td></tr><tr><td>Reported symptoms<sup>a</sup>, n (%)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Rhinorrhoea</td><td>1346 (66.7)</td><td>539 (73.7)</td><td>943 (83.4)</td><td>565 (80.4)</td><td>&lt;0.0001</td></tr><tr><td>Nasal congestion/obstruction</td><td>1263 (62.6)</td><td>487 (66.6)</td><td>1036 (91.6)</td><td>655 (93.2)</td><td>&lt;0.0001</td></tr><tr><td>Nasal itching</td><td>1240 (61.4)</td><td>440 (60.2)</td><td>790 (69.8)</td><td>517 (73.5)</td><td>&lt;0.0001</td></tr><tr><td>Sneezing</td><td>1387 (68.7)</td><td>515 (70.5)</td><td>914 (80.8)</td><td>573 (81.5)</td><td>&lt;0.0001</td></tr><tr><td>Associated-eye symptoms</td><td>1241 (61.9)</td><td>452 (62.7)</td><td>825 (73.4)</td><td>523 (74.8)</td><td>&lt;0.0001</td></tr><tr><td>Number of reported symptoms, mean (SD)</td><td>3.2 (1.3)</td><td>3.3 (1.3)</td><td>4.0 (1.0)</td><td>4.0 (1.1)</td><td>&lt;0.0001</td></tr><tr><td>Age of onset of rhinitis, year, mean (SD)</td><td>24.2 (15.3)</td><td>25.4 (16.0)</td><td>21.1 (13.3)</td><td>22.0 (14.2)</td><td>&lt;0.0001</td></tr><tr><td>Reported triggers of rhinitis symptoms<sup>a</sup>, n (%)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Dust mites or house dust</td><td>654 (32.4)</td><td>246 (33.7)</td><td>441 (39.0)</td><td>279 (39.7)</td><td>0.0001</td></tr><tr><td>Animals</td><td>222 (11.0)</td><td>74 (10.1)</td><td>179 (15.8)</td><td>112 (15.9)</td><td>&lt;0.0001</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 4 (Continued)</caption><thead><tr><th></th><th>Mild<br>Intermittent<br>(n = 2019)</th><th>Mild<br>Persistent<br>(n = 731)</th><th>Mod-severe<br>Intermittent<br>(n = 1131)</th><th>Mod-severe<br>Persistent<br>(n = 703)</th><th>p</th></tr></thead><tbody><tr><td>Air pollution</td><td>464 (23.0)</td><td>203 (27.8)</td><td>326 (28.8)</td><td>245 (34.9)</td><td>&lt;0.0001</td></tr><tr><td>Change in weather</td><td>541 (26.8)</td><td>151 (20.7)</td><td>396 (35.0)</td><td>224 (31.9)</td><td>&lt;0.0001</td></tr><tr><td>Tobacco</td><td>94 (4.7)</td><td>52 (7.1)</td><td>86 (7.6)</td><td>67 (9.5)</td><td>&lt;0.0001</td></tr><tr><td>Pollens</td><td>1077 (53.3)</td><td>374 (51.2)</td><td>614 (54.3)</td><td>419 (59.6)</td><td>0.009</td></tr><tr><td>Cold air</td><td>468 (23.2)</td><td>162 (22.2)</td><td>306 (27.1)</td><td>181 (25.7)</td><td>0.03</td></tr><tr><td>Other</td><td>213 (10.5)</td><td>94 (12.9)</td><td>165 (14.6)</td><td>109 (15.5)</td><td>0.0007</td></tr><tr><td>Unknown</td><td>497 (24.6)</td><td>238 (32.6)</td><td>260 (23.0)</td><td>199 (28.3)</td><td>&lt;0.0001</td></tr><tr><td>Number of reported triggers, mean (SD)</td><td>2.1 (1.1)</td><td>2.2 (1.3)</td><td>2.5 (1.3)</td><td>2.6 (1.5)</td><td>&lt;0.0001</td></tr><tr><td>Rhinitis treatment, n (%)</td><td></td><td></td><td></td><td></td><td>&lt;0.0001</td></tr><tr><td>Neither OA nor INCS</td><td>873 (43.7)</td><td>227 (31.5)</td><td>306 (27.4)</td><td>99 (14.3)</td><td></td></tr><tr><td>OA only</td><td>456 (22.8)</td><td>161 (22.4)</td><td>266 (23.8)</td><td>132 (19.0)</td><td></td></tr><tr><td>INCS only</td><td>211 (10.6)</td><td>92 (12.8)</td><td>139 (12.4)</td><td>100 (14.4)</td><td></td></tr><tr><td>OA and INCS</td><td>458 (22.9)</td><td>240 (33.3)</td><td>407 (36.4)</td><td>363 (52.3)</td><td></td></tr></tbody></table>

Note: Data are mean (SD) or n (%).

Abbreviations: BMI, Body Mass Index; INCS, Intranasal Corticosteroids; OA, Oral Antihistamines; TNSS4, Total Nasal Symptom Score 4.

ªSeveral possible answers.

Insurance Fund ("Caisse nationale d'assurance maladie", CNAM). In France, the General Health Insurance Fund administered by CNAM is compulsory for salaried workers, even during unemployed periods and their families; it covers about 85% of the population living in France. Individuals not covered by this scheme are those belonging to the agricultural scheme, which provides social protection for farmers and agricultural workers, the schemes for the liberal professions, and special schemes (such as those for the French National Railway Company). As a result, some of the workers associated with these professions could not be included in Constances. 2) some geographical areas of France were not included. In addition, about 20% of participants had missing data for rhinitis severity. Compared to the participants included in the analysis population, the participants with missing data had a lower level of education and a higher average age, and we cannot exclude that they may have a particular rhinitis profile.

As specific IgE and SPTs are not available in Constances, we used a definition of AR based on a questionnaire. We acknowledge that defining AR by questionnaire may be considered a limitation, even if we have used validated and standardized questions.²⁵ We recently showed that the definition we have used is a suitable proxy for AR,²¹ and we found the known characteristics of AR using this definition in Constances.¹⁶ These questions have the advantage of being based on the main symptoms of AR and are understandable to all participants, which allows all rhinitis to be considered, even those that have not been diagnosed by a doctor. This is especially important as many patients with mild symptoms do not consult a doctor for their rhinitis. Although the questionnaire-based definition of asthma could be perceived as a limitation, it is important to note that many previous

epidemiological studies have already used and validated our definitions based on the European community respiratory health survey questionnaire.²⁵,²⁶

## 4.2 | Interpretation

1. The percentage of patients with moderate-severe rhinitis was lower in Constances than in the patient cohorts both in primary²⁷ and specialist care.⁷,²⁸⁻³⁰ This is not surprising as it is known that patients who consult a health professional are mainly those with severe symptoms. Few population-based studies have estimated the prevalence of rhinitis according to its severity. Participants with moderate-severe AR reported a higher TNSS4 score as compared to those with mild AR, as previously reported in the literature.⁸,³¹ Similar to Antonicelli et al.,³² in our study, the participants with mild rhinitis reported less treatment than those with moderate-severe rhinitis. In four previous studies,¹²⁻¹⁵ the prevalence of moderate to severe rhinitis ranged from 56% to 87%, which is higher than the prevalence observed in our study; however, the differences in AR definitions across studies make comparisons difficult.

2. Severity impacts more the characteristics of AR than duration, as shown by the higher effect sizes observed for severity than for duration. This was already observed in patients consulting for rhinitis in primary care.²⁷ Thus, (i) the treatment strategy should be based on severity. This is reflected by real-world data obtained from an app showing that European patients treat themselves according to symptoms³³ (ii) Duration is important for its
<table><caption>TABLE 5 Characteristics of allergic rhinitis (AR) according to the allergic rhinitis and its impact on asthma (ARIA) classification and asthma status.</caption><thead><tr><th rowspan="2"></th><th colspan="3">Mild intermittent</th><th colspan="3">Mild persistent</th><th colspan="3">Moderate-severe intermittent</th><th colspan="3">Moderate-severe persistent</th></tr><tr><th>Never asthma (n = 1590)</th><th>Ever asthma (n = 429)</th><th>ES</th><th>Never asthma (n = 565)</th><th>Ever asthma (n = 166)</th><th>ES</th><th>Never asthma (n = 496)</th><th>Ever asthma (n = 197)</th><th>ES</th><th>Never asthma (n = 463)</th><th>Ever asthma (n = 240)</th><th>ES</th></tr></thead><tbody><tr><td>Sex, n (%)</td><td></td><td></td><td>0.005</td><td></td><td></td><td>0.04</td><td></td><td></td><td>0.01</td><td></td><td></td><td>0.06</td></tr><tr><td>Men</td><td>736 (46.3)</td><td>201 (46.9)</td><td></td><td>262 (46.4)</td><td>69 (41.6)</td><td></td><td>310 (38.5)</td><td>128 (39.4)</td><td></td><td>179 (38.7)</td><td>79 (32.9)</td><td></td></tr><tr><td>Women</td><td>854 (53.7)</td><td>228 (53.2)</td><td></td><td>303 (53.6)</td><td>97 (58.4)</td><td></td><td>496 (61.5)</td><td>197 (60.6)</td><td></td><td>284 (61.3)</td><td>161 (67.1)</td><td></td></tr><tr><td>Age, years, mean (SD)</td><td>52.6 (12.1)</td><td>49.3 (12.7)</td><td>0.27**</td><td>52.5 (13.2)</td><td>49.2 (12.9)</td><td>0.26*</td><td>48.1 (12.5)</td><td>45.7 (12.2)</td><td>0.20*</td><td>49.0 (12.9)</td><td>45.5 (11.7)</td><td>0.28*</td></tr><tr><td>Tobacco status, n (%)</td><td></td><td></td><td>0.03</td><td></td><td></td><td>0.09</td><td></td><td></td><td>0.03</td><td></td><td></td><td>0.03</td></tr><tr><td>Never-smoker</td><td>692 (45.1)</td><td>197 (47.9)</td><td></td><td>268 (50.0)</td><td>63 (39.4)</td><td></td><td>375 (48.2)</td><td>151 (48.1)</td><td></td><td>205 (46.8)</td><td>102 (44.4)</td><td></td></tr><tr><td>Ex-smoker</td><td>657 (42.8)</td><td>164 (39.9)</td><td></td><td>211 (39.4)</td><td>74 (46.3)</td><td></td><td>291 (37.4)</td><td>112 (35.7)</td><td></td><td>183 (41.8)</td><td>99 (43.0)</td><td></td></tr><tr><td>Current smoker</td><td>187 (12.2)</td><td>50 (12.2)</td><td></td><td>57 (10.6)</td><td>23 (14.4)</td><td></td><td>112 (14.4)</td><td>51 (16.2)</td><td></td><td>50 (11.4)</td><td>29 (12.6)</td><td></td></tr><tr><td>Educational level, n (%)</td><td></td><td></td><td>0.05</td><td></td><td></td><td>0.03</td><td></td><td></td><td>0.02</td><td></td><td></td><td>0.04</td></tr><tr><td>Less than high school</td><td>115 (7.3)</td><td>19 (4.5)</td><td></td><td>40 (7.1)</td><td>9 (5.5)</td><td></td><td>62 (7.7)</td><td>21 (6.5)</td><td></td><td>36 (7.8)</td><td>17 (7.1)</td><td></td></tr><tr><td>High school</td><td>446 (28.3)</td><td>118 (27.9)</td><td></td><td>156 (27.8)</td><td>45 (27.4)</td><td></td><td>231 (28.8)</td><td>97 (29.9)</td><td></td><td>124 (26.9)</td><td>57 (23.8)</td><td></td></tr><tr><td>University</td><td>1014 (64.4)</td><td>286 (67.6)</td><td></td><td>366 (65.1)</td><td>110 (67.1)</td><td></td><td>508 (63.4)</td><td>206 (63.6)</td><td></td><td>301 (65.3)</td><td>166 (69.2)</td><td></td></tr><tr><td>Body-mass index, kg/m², n (%)</td><td></td><td></td><td>0.03</td><td></td><td></td><td>0.04</td><td></td><td></td><td>0.06</td><td></td><td></td><td>0.05</td></tr><tr><td>&lt;18.5</td><td>25 (1.6)</td><td>9 (2.1)</td><td></td><td>18 (3.2)</td><td>3 (1.8)</td><td></td><td>20 (2.6)</td><td>4 (1.2)</td><td></td><td>14 (3.1)</td><td>7 (3.0)</td><td></td></tr><tr><td>[18.5-25]</td><td>926 (59.1)</td><td>249 (58.9)</td><td></td><td>329 (59.3)</td><td>98 (59.4)</td><td></td><td>456 (58.1)</td><td>174 (54.0)</td><td></td><td>276 (60.9)</td><td>131 (56.5)</td><td></td></tr><tr><td>[25-30]</td><td>457 (29.2)</td><td>115 (27.2)</td><td></td><td>160 (28.8)</td><td>48 (29.1)</td><td></td><td>230 (29.3)</td><td>103 (32.0)</td><td></td><td>117 (25.8)</td><td>69 (29.7)</td><td></td></tr><tr><td>≥30</td><td>158 (10.1)</td><td>50 (11.8)</td><td></td><td>48 (8.7)</td><td>16 (9.7)</td><td></td><td>79 (10.1)</td><td>41 (12.7)</td><td></td><td>46 (10.2)</td><td>25 (10.8)</td><td></td></tr><tr><td>Conjunctivitis, n (%)</td><td></td><td></td><td>0.15**</td><td></td><td></td><td>0.16**</td><td></td><td></td><td>0.10*</td><td></td><td></td><td>0.17**</td></tr><tr><td>Never conjunctivitis</td><td>771 (53.5)</td><td>142 (35.0)</td><td></td><td>264 (51.1)</td><td>51 (32.7)</td><td></td><td>340 (45.9)</td><td>106 (34.6)</td><td></td><td>184 (42.6)</td><td>56 (25.0)</td><td></td></tr><tr><td>Ever conjunctivitis</td><td>670 (46.5)</td><td>264 (65.0)</td><td></td><td>253 (48.9)</td><td>105 (67.3)</td><td></td><td>401 (54.1)</td><td>200 (65.4)</td><td></td><td>248 (57.4)</td><td>168 (75.0)</td><td></td></tr><tr><td>Eczema, n (%)</td><td></td><td></td><td>0.09**</td><td></td><td></td><td>0.09*</td><td></td><td></td><td>0.04</td><td></td><td></td><td>0.10*</td></tr><tr><td>Never eczema</td><td>931 (64.9)</td><td>213 (54.1)</td><td></td><td>328 (64.3)</td><td>85 (54.1)</td><td></td><td>419 (57.4)</td><td>158 (52.7)</td><td></td><td>246 (57.3)</td><td>99 (46.3)</td><td></td></tr><tr><td>Ever eczema</td><td>503 (35.1)</td><td>181 (45.9)</td><td></td><td>182 (35.7)</td><td>72 (45.9)</td><td></td><td>311 (42.6)</td><td>142 (47.3)</td><td></td><td>183 (42.7)</td><td>115 (53.7)</td><td></td></tr><tr><td>Eosinophils count, cell/mm³, mean (SD)</td><td>192.4 (133.1)</td><td>231.0 (151.1)</td><td>0.28**</td><td>192.4 (121.4)</td><td>268.5 (182.5)</td><td>0.55**</td><td>192.7 (133.3)</td><td>247.1 (157.8)</td><td>0.39**</td><td>203.0 (155.2)</td><td>291.1 (225.0)</td><td>0.48*</td></tr><tr><td>TNSS4, mean (SD)</td><td>4.2 (2.1)</td><td>4.8 (2.1)</td><td>0.27**</td><td>4.6 (2.2)</td><td>5.3 (2.1)</td><td>0.29*</td><td>7.6 (2.2)</td><td>7.9 (2.3)</td><td>0.14*</td><td>7.7 (2.5)</td><td>8.5 (2.3)</td><td>0.30*</td></tr></tbody></table>
<table><caption>TABLE 5 (Continued)</caption><thead><tr><th rowspan="2"></th><th colspan="2">Mild intermittent</th><th colspan="3">Mild persistent</th><th colspan="3">Moderate-severe intermittent</th><th colspan="3">Moderate-severe persistent</th></tr><tr><th>Never asthma (n = 1590)</th><th>Ever asthma (n = 429)</th><th>Never asthma (n = 565)</th><th>Ever asthma (n = 166)</th><th>ES</th><th>Never asthma (n = 496)</th><th>Ever asthma (n = 197)</th><th>ES</th><th>Never asthma (n = 463)</th><th>Ever asthma (n = 240)</th><th>ES</th></tr></thead><tbody><tr><td colspan="12">Reported symptoms<sup>a</sup>, n (%)</td></tr><tr><td>Rhinorrhoea</td><td>1045 (65.7)</td><td>301 (70.2)</td><td>0.04</td><td>411 (72.7)</td><td>128 (77.1)</td><td>0.04</td><td>667 (82.8)</td><td>276 (84.9)</td><td>0.03</td><td>362 (78.2)</td><td>203 (84.6)</td><td>0.08</td></tr><tr><td>Nasal congestion/obstruction</td><td>968 (60.9)</td><td>295 (68.8)</td><td>0.07*</td><td>358 (63.4)</td><td>129 (77.7)</td><td>0.13*</td><td>739 (91.7)</td><td>297 (91.4)</td><td>0.005</td><td>428 (92.4)</td><td>227 (94.6)</td><td>0.04</td></tr><tr><td>Nasal itching</td><td>945 (59.4)</td><td>295 (68.8)</td><td>0.08*</td><td>332 (58.8)</td><td>108 (65.1)</td><td>0.05</td><td>555 (68.9)</td><td>235 (72.3)</td><td>0.03</td><td>324 (70.0)</td><td>193 (80.4)</td><td>0.11**</td></tr><tr><td>Sneezing</td><td>1086 (68.3)</td><td>301 (70.2)</td><td>0.02</td><td>392 (69.4)</td><td>123 (74.1)</td><td>0.04</td><td>638 (79.2)</td><td>276 (84.9)</td><td>0.07*</td><td>359 (77.5)</td><td>214 (89.2)</td><td>0.14**</td></tr><tr><td>Associated-eye symptoms</td><td>932 (59.1)</td><td>309 (72.5)</td><td>0.11**</td><td>346 (62.1)</td><td>106 (64.6)</td><td>0.02</td><td>570 (71.0)</td><td>255 (79.4)</td><td>0.09*</td><td>325 (70.7)</td><td>198 (82.9)</td><td>0.13**</td></tr><tr><td>Number of reported symptoms, mean (SD)</td><td>3.1 (1.3)</td><td>3.5 (1.3)</td><td>0.28**</td><td>3.3 (1.3)</td><td>3.6 (1.2)</td><td>0.24*</td><td>3.9 (1.1)</td><td>4.1 (1.0)</td><td>0.18*</td><td>3.9 (1.2)</td><td>4.3 (1.0)</td><td>0.39**</td></tr><tr><td>Age of onset of rhinitis, year, mean (SD)</td><td>26.0 (15.4)</td><td>18.6 (13.5)</td><td>0.49**</td><td>27.5 (16.0)</td><td>18.7 (14.3)</td><td>0.57**</td><td>23.2 (13.4)</td><td>16.1 (11.6)</td><td>0.56**</td><td>24.4 (14.0)</td><td>17.8 (13.4)</td><td>0.48**</td></tr><tr><td colspan="12">Reported triggers of symptoms<sup>a</sup>, n (%)</td></tr><tr><td>Dust mites or house dust</td><td>412 (25.9)</td><td>242 (56.4)</td><td>0.27**</td><td>165 (29.2)</td><td>81 (48.8)</td><td>0.17**</td><td>275 (34.1)</td><td>166 (51.1)</td><td>0.16**</td><td>137 (29.6)</td><td>142 (59.2)</td><td>0.29**</td></tr><tr><td>Animals</td><td>120 (7.6)</td><td>102 (23.8)</td><td>0.21**</td><td>38 (6.7)</td><td>36 (21.7)</td><td>0.21**</td><td>86 (10.7)</td><td>93 (28.6)</td><td>0.22**</td><td>49 (10.6)</td><td>63 (26.3)</td><td>0.20**</td></tr><tr><td>Air pollution</td><td>339 (21.3)</td><td>125 (29.1)</td><td>0.08*</td><td>153 (27.1)</td><td>50 (30.1)</td><td>0.03</td><td>223 (27.7)</td><td>103 (31.7)</td><td>0.04</td><td>153 (33.1)</td><td>92 (38.3)</td><td>0.05</td></tr><tr><td>Change in weather</td><td>412 (25.9)</td><td>129 (30.1)</td><td>0.04</td><td>115 (20.4)</td><td>36 (21.7)</td><td>0.01</td><td>273 (33.9)</td><td>123 (37.9)</td><td>0.04</td><td>144 (31.1)</td><td>80 (33.3)</td><td>0.02</td></tr><tr><td>Tobacco</td><td>65 (4.1)</td><td>29 (6.8)</td><td>0.05*</td><td>29 (5.1)</td><td>23 (13.9)</td><td>0.14*</td><td>46 (5.7)</td><td>40 (12.3)</td><td>0.11*</td><td>37 (8.0)</td><td>30 (12.5)</td><td>0.07*</td></tr><tr><td>Pollens</td><td>816 (51.3)</td><td>261 (60.8)</td><td>0.08*</td><td>267 (47.3)</td><td>107 (64.5)</td><td>0.14**</td><td>409 (50.7)</td><td>205 (63.1)</td><td>0.11*</td><td>249 (53.8)</td><td>170 (70.8)</td><td>0.16**</td></tr><tr><td>Cold air</td><td>358 (22.5)</td><td>110 (25.6)</td><td>0.03</td><td>130 (23.0)</td><td>32 (19.3)</td><td>0.04</td><td>212 (26.3)</td><td>94 (28.9)</td><td>0.03</td><td>111 (24.0)</td><td>70 (29.2)</td><td>0.06</td></tr><tr><td>Other</td><td>180 (11.3)</td><td>33 (7.7)</td><td>0.05*</td><td>62 (11.0)</td><td>32 (19.3)</td><td>0.10*</td><td>117 (14.5)</td><td>48 (14.8)</td><td>0.003</td><td>66 (14.3)</td><td>43 (17.9)</td><td>0.05</td></tr><tr><td>Unknown</td><td>432 (27.2)</td><td>65 (15.2)</td><td>0.11**</td><td>204 (36.1)</td><td>34 (20.5)</td><td>0.14*</td><td>205 (25.4)</td><td>55 (16.9)</td><td>0.09*</td><td>162 (35.0)</td><td>37 (15.4)</td><td>0.21**</td></tr><tr><td>Number of reported triggers, mean (SD)</td><td>2.0 (1.1)</td><td>2.6 (1.3)</td><td>0.52**</td><td>2.1 (1.2)</td><td>2.6 (1.6)</td><td>0.41**</td><td>2.3 (1.2)</td><td>2.9 (1.5)</td><td>0.43**</td><td>2.4 (1.5)</td><td>3.0 (1.6)</td><td>0.42**</td></tr><tr><td>Rhinitis treatment, n (%)</td><td></td><td></td><td>0.22**</td><td></td><td></td><td>0.21**</td><td></td><td></td><td>0.20**</td><td></td><td></td><td>0.20**</td></tr><tr><td>Neither OA nor INCS</td><td>758 (48.1)</td><td>115 (27.3)</td><td>0.17</td><td>198 (35.6)</td><td>29 (17.7)</td><td>0.16</td><td>251 (31.5)</td><td>55 (17.1)</td><td>0.15</td><td>84 (18.4)</td><td>15 (6.3)</td><td>0.16</td></tr><tr><td>OA only</td><td>340 (21.6)</td><td>116 (27.5)</td><td>0.06</td><td>123 (22.1)</td><td>38 (23.2)</td><td>0.01</td><td>188 (23.6)</td><td>78 (24.3)</td><td>0.01</td><td>91 (19.9)</td><td>41 (17.3)</td><td>0.03</td></tr><tr><td>INCS only</td><td>181 (11.5)</td><td>30 (7.1)</td><td>0.06</td><td>77 (13.9)</td><td>15 (9.2)</td><td>0.06</td><td>112 (14.1)</td><td>27 (8.4)</td><td>0.08</td><td>71 (15.5)</td><td>29 (12.2)</td><td>0.04</td></tr><tr><td>OA and INCS</td><td>297 (18.9)</td><td>161 (38.2)</td><td>0.19</td><td>158 (28.4)</td><td>82 (50.0)</td><td>0.19</td><td>246 (30.9)</td><td>161 (50.2)</td><td>0.18</td><td>211 (46.2)</td><td>152 (64.1)</td><td>0.17</td></tr></tbody></table>

Note: Data are mean (SD) or n (%). Orange: Small effect size (Cramer's V from [0.1–0.3] or Cohen's D from [0.2–0.5]); Yellow: Medium effect size (Cramer's V from [0.3–0.5] or Cohen's D from [0.5–0.8]); Green: Large effect size (Cramer's V ≥ 0.5 or Cohen's D ≥ 0.8).

Abbreviations: BMI, Body Mass Index; INCS, Intranasal Corticosteroids; OA, Oral Antihistamines; TNSS4, Total Nasal Symptom Score 4.

ªSeveral possible answers.

*p* < 0.05; **p* < 0.0001.
association with asthma and to give an indication to the physician for the duration of the treatment.

3. The ARIA classification has been criticized for only considering the severity of rhinitis in a dichotomous way: indeed, the large prevalence of moderate-severe rhinitis found in patient cohorts suggests an important heterogeneity in this disease severity group.³¹ Noteworthy, in Constances, we observed that participants with mild AR constituted more than half of the participants with AR. As an alternative to the classification into two classes, a three-class classification has been proposed (mild, moderate and severe).³⁴ However, we were unable to carry out analyses using this classification, given the way the questions were asked in the Constances.

4. The major novel finding is the impact of asthma on rhinitis in all four ARIA classes. For most important outcomes, asthma has a significant impact (conjunctivitis, eczema, eosinophil counts or combined treatment). The effect size was often moderate, except for treatment (INCS + OA) and the age of onset where it was stronger, and the results persisted after adjusting for age, gender, smoking, diploma, conjunctivitis and eczema. An extremely important data is the treatments reported. For oral antihistamines, asthma does not make any difference. More patients without asthma reported intra-nasal corticosteroids. On the other hand, there was a major impact on asthma by increasing the use of combined intra-nasal corticosteroid and oral antihistamine by around 20% for the four ARIA classes. It has been found in real-world data of over 10,000 patients that patients with rhinitis using this combination are less well controlled than those using intra-nasal corticosteroids. These findings were observed in both cross-sectional and longitudinal studies.³⁵,³⁶ In the present study, around 65% of patients with moderate-severe rhinitis and asthma reported this treatment. On the other hand, it was expected from the ARIA-MeDALL hypothesis that the age of onset of rhinitis and asthma was earlier than for rhinitis alone and was confirmed in the present study. The present study shows for the first time that the ARIA classification needs to be revised taking into account asthma multimorbidity.

In conclusion, for the first time in a large population-based study in adults, the characteristics of AR according to the four ARIA classes were described. This result confirms what has been observed in clinical practice and highlights the interest of using the ARIA classification to define AR in the general population. Furthermore, asthma status added important information to the ARIA classification. These findings indicate that ARIA or other rhinitis guidelines should make a distinction between rhinitis alone and rhinitis with asthma for AR management. This critical information is already considered in the development of ARIA 2024.

## AUTHOR CONTRIBUTIONS

**Marine Savouré:** Conceptualization, methodology, formal analysis, writing – original draft, visualization. **Jean Bousquet:** Conceptualization, methodology, writing – review & editing. **Bénédicte Leynaert:** Review & editing. **Céline Ribet:** Resources, review & editing. **Marcel

**Goldberg:** Resources, review & editing. **Marie Zins:** Resources, review & editing. **Bénédicte Jacquemin:** Conceptualization, methodology, writing – review & editing, supervision. **Rachel Nadif:** Conceptualization, methodology, writing – review & editing, supervision.

## ACKNOWLEDGMENTS

The authors thank L Orsi for his support on the statistical methodology. They also acknowledge the Constances Respiratory Group: MC Delmas, O Dumas, V Giraud, Y Itwasubo, B Leynaert, N Le Moual, R Nadif, T Perez, N Roche, R Varraso. The authors thank the team of the "Population-based Cohorts Unit" (Cohortes en population) that designed and manages the Constances Cohort Study. They also thank the French National Health Insurance Fund ("Caisse nationale d'assurance maladie", CNAM) and its Health Screening Centres ("Centres d'examen de santé"), which are collecting a large part of the data, as well as the French National Old-Age Insurance Fund ("Caisse nationale d'assurance vieillesse", Cnav) for its contribution to the constitution of the cohort, and ClinSearch, Asqualab and Eurocell, which are conducting the data quality control. This work is part of a thesis prepared in the framework of the Doctoral Network in Public Health coordinated by the EHESP. This work was supported by the French Environment and Energy Management Agency (ADEME) and the Université Paris-Saclay. The Constances Cohort Study is an "Infrastructure nationale en Biologie et Santé" and benefits from a grant from the French National Agency for Research (ANR-11-INBS-0002). Constances is also partly funded by Merck Sharp & Dohme (MSD) and L'Oréal. None of these funding sources played any role in the design of the study, collection and analysis of data, or decision to publish.

## CONFLICT OF INTEREST STATEMENT

Dr. Bousquet reports personal fees from Cipla, Menarini, Mylan, Novartis, Purina, Sanofi-Aventis, Teva, Uriach, other from KYomed-Innov, and other from Mask-air-SAS, outside the submitted work. The other authors have nothing to disclose.

## DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from CONSTANCES. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from https://www.constances.fr with the permission of CONSTANCES.

## CLINICAL IMPLICATIONS

Our findings strongly indicate for the first time that rhinitis guidelines should make a distinction between AR alone and AR with asthma for AR management.

## CAPSULE SUMMARY

For the first time in a large population-based study in adults, AR according to the four AR and Its Impact on Asthma classes was described. Asthma status added important information to the classification.
ORCID

Marine Savouré https://orcid.org/0000-0003-3220-8175

Jean Bousquet https://orcid.org/0000-0002-4061-4766

Bénédicte Leynaert https://orcid.org/0000-0001-5045-2492

Céline Ribet https://orcid.org/0000-0003-2174-1126

Marcel Goldberg https://orcid.org/0000-0002-6161-5880

Marie Zins https://orcid.org/0000-0002-4540-4282

Bénédicte Jacquemin https://orcid.org/0000-0003-1273-9892

Rachel Nadif https://orcid.org/0000-0003-4938-9339

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## SUPPORTING INFORMATION

Additional supporting information can be found online in the Supporting Information section at the end of this article.

**How to cite this article:** Savouré M, Bousquet J, Leynaert B, et al. Asthma is associated with increased severity and duration of rhinitis: a study with the Allergic Rhinitis and its Impact on Asthma classes in the Constances cohort. *Clin Transl Allergy*. 2023;e12316. https://doi.org/10.1002/clt2.12316