Smoking among women has drawn increasing attention because of the increase (or less pronounced decrease) in its prevalence when compared with that observed for men, as well as because of the specific effects that smoking has on women's health. For the 2010 "World No Tobacco Day", the World Health Organization chose the theme "Gender and tobacco with an emphasis on marketing to women", with the aim of encouraging policies to combat marketing strategies employed by the tobacco industry and to curb the epidemic of smoking among women. In this article, we discuss the characteristics of smoking among women, addressing factors such as smoking prevalence, nicotine dependence, the role of the tobacco industry, health risks, approaches to smoking cessation, treatment strategies, and prevention measures.

Keywords: Smoking; Women's health; Tobacco industry.

Spontaneous pneumomediastinum is an uncommon event, the clinical picture of which includes retrosternal chest pain, subcutaneous emphysema, dyspnea, and dysphonia. The pathophysiological mechanism involved is the emergence of a pressure gradient between the alveoli and surrounding structures, causing alveolar rupture with subsequent dissection of the peribronchovascular sheath and infiltration of the mediastinum and subcutaneous tissue with air. Known triggers include acute exacerbations of asthma and situations that require the Valsalva maneuver. We described and documented with HRCT scans the occurrence of pneumomediastinum after a patient with bleomycin-induced interstitial lung disease underwent pulmonary function testing. Although uncommon, the association between pulmonary function testing and air leak syndromes has been increasingly reported in the literature, and lung diseases, such as interstitial lung diseases, include structural changes that facilitate the occurrence of this complication.

Keywords: Mediastinal emphysema; Subcutaneous emphysema; Spirometry; Bleomycin.

Objective: To profile the characteristics of adult patients with bronchiectasis, drawing comparisons between cystic fibrosis (CF) patients and those with bronchiectasis from other causes in order to determine whether it is rational to extrapolate the bronchiectasis treatment given to CF patients to those with bronchiectasis from other causes. Methods: A retrospective analysis of the medical charts of 87 patients diagnosed with bronchiectasis and under follow-up treatment at our outpatient clinic. Patients who had tuberculosis (current or previous) were excluded. We evaluated the clinical, functional, and treatment data of the patients. Results: Of the 87 patients with bronchiectasis, 38 (43.7%) had been diagnosed with CF, through determination of sweat sodium and chloride concentrations or through genetic analysis, whereas the disease was due to another etiology in 49 (56.3%), of whom 34 (39.0%) had been diagnosed with idiopathic bronchiectasis. The mean age at diagnosis was lower in the patients with CF than in those without (14.2 vs. 24.2 years; p < 0.05). The prevalence of symptoms (cough, expectoration, hemoptysis, and wheezing) was similar between the groups. Colonization by Pseudomonas aeruginosa or Staphylococcus aureus was more common in the CF patients (82.4 vs. 29.7% and 64.7 vs. 5.4%, respectively). Conclusions: The causes and clinical manifestations of bronchiectasis are heterogeneous, and it is important to identify the differences. It is crucial that these differences be recognized so that new strategies for the management of patients with bronchiectasis can be developed.

Keywords: Cystic fibrosis; Bronchiectasis/diagnosis; Bronchiectasis/therapy; Respiratory function tests.

Smoking causes an intense inflammatory reaction in the airways and is associated with worse clinical outcomes in patients with asthma. The objective of this study was to determine the prevalence of active and passive smoking in a population of patients with asthma. The sample of asthma patients (n = 100) consisted of 47 nonsmokers, 33 former smokers, 17 passive smokers and 3 active smokers. Most had moderate or severe asthma. Mean exhaled CO was 9.34 ppb in smokers, 4.19 ppb in passive smokers, 3.98 ppb in nonsmokers and 3.98 ppb in former smokers. We conclude that the prevalence of exposure to tobacco smoke is high among asthma patients.

Keywords: Smoking; Asthma; Prevalence.

Objective: To evaluate the short-term impact of tiotropium in patients with severe or very severe COPD who complain of dyspnea despite being currently treated with other bronchodilators. Methods: A prospective study including patients with severe or very severe COPD and complaining of dyspnea at rest or on minimal exertion. Every 15 days, the bronchodilator treatment regimen was altered, from salmeterol to tiotropium to salmeterol+tiotropium. At the end of each regimen, pulmonary function tests and the six-minute walk test (6MWT) were performed. The degree of dyspnea and the ability to perform activities of daily living were also assessed. To evaluate patient ability to perform activities of daily living, we employed the London Chest Activity of Daily Living (LCADL), validated for use in Brazil. Results: We evaluated 52 patients, 30 of whom completed the study. The use of tiotropium in isolation resulted in significant improvement in dyspnea at baseline (mean Medical Research Council scale score reduced from 3.0 to 2.5) and at the end of 6MWT (mean Borg scale score reduced from 6.1 to 4.5), and the differences were significant (p < 0.05 for both). The use of the salmeterol+tiotropium combination resulted in a significant (81 mL) increase in FEV1 and a 5.7 point improvement in the LCADL score. Conclusions: The introduction of tiotropium into the treatment of patients with severe or very severe COPD and using long-acting β2 agonists improves pulmonary function and provides symptomatic relief, as perceived by patients in the short term. These results, obtained under real life treatment conditions, support the use of the salmeterol+tiotropium combination in specific treatment protocols for these patients.

Keywords: Pulmonary disease, chronic obstructive; Bronchodilator agents; Dyspnea; Activities of daily living.

Objective: To evaluate the ability of COPD patients to perform activities of daily living (ADL); to identify barriers that prevent these individuals from performing ADL; and to correlate those barriers with dyspnea severity, six-minute walk test (6MWT), and an ADL limitation score. Methods: In COPD patients and healthy, age-matched controls, the number of steps, the distance walked, and walking time were recorded with a triaxial accelerometer, for seven consecutive days. A questionnaire regarding perceived barriers and the London Chest Activity of Daily Living (LCADL) scale were used in order to identify the factors that prevent the performance of ADL. The severity of dyspnea was assessed with two scales, whereas submaximal exercise capacity was determined on the basis of the 6MWT. Results: We evaluated 40 COPD patients and 40 controls. In comparison with the control values, the mean walk time was significantly shorter for COPD patients (68.5  25.8 min/day vs. 105.2  49.4 min/day; p < 0.001), as was the distance walked (3.9  1.9 km/day vs. 6.4  3.2 km/day; p < 0.001). The COPD patients also walked fewer steps/day. The most common self-reported barriers to performing ADL were lack of infrastructure, social influences, and lack of willpower. The 6MWT distance correlated with the results obtained with the accelerometer but not with the LCADL scale results. Conclusions: Patients with COPD are less active than are healthy adults of a comparable age. Physical inactivity and the barriers to performing ADL have immediate implications for clinical practice, calling for early intervention measures.

Keywords: Pulmonary disease, chronic obstructive; Activities of daily living; Exercise tolerance.

Objective: Water-pipe tobacco smoking is becoming increasingly more common among young people. The objective of this study was to estimate the prevalence of the use of water pipes and other forms of tobacco use, including cigarette smoking, among medical students, as well as to examine the attitudes, beliefs, and knowledge of those students regarding this issue. Methods: We administered a questionnaire to students enrolled in the University of São Paulo School of Medicine, in São Paulo, Brazil. The respondents were evaluated in their third and sixth years of medical school, between 2008 and 2013. Comparisons were drawn between the two years. Results: We evaluated 586 completed questionnaires. Overall, the prevalence of current cigarette smokers was low, with a decline among males (9.78% vs. 5.26%) and an increase among females (1.43% vs. 2.65%) in the 3rd and 6th year, respectively. All respondents believed that health professionals should advise patients to quit smoking. However, few of the medical students who smoked received physician advice to quit. Experimentation with other forms of tobacco use was more common among males (p<0.0001). Despite their knowledge of its harmful effects, students experimented with water-pipe tobacco smoking in high proportions (47.32% and 46.75% of the third- and sixth-year students, respectively). Conclusions: The prevalence of experimentation with water-pipe tobacco smoking and other forms of tobacco use is high among aspiring physicians. Our findings highlight the need for better preventive education programs at medical schools, not only to protect the health of aspiring physicians but also to help them meet the challenge posed by this new epidemic.

Keywords: Tobacco products; Smoking/prevention & control; Education, medical, undergraduate; Health knowledge, attitudes, practice.

Objective: Smoking prevalence is frequently estimated on the basis of self-reported smoking status. That can lead to an underestimation of smoking rates. The aim of this study was to evaluate the difference between self-reported smoking status and that determined through the use of objective measures of smoking at a pulmonary outpatient clinic. Methods: This was a cross-sectional study involving 144 individuals: 51 asthma patients, 53 COPD patients, 20 current smokers, and 20 never-smokers. Smoking status was determined on the basis of self-reports obtained in interviews, as well as through tests of exhaled carbon monoxide (eCO) and urinary cotinine. Results: All of the asthma patients and COPD patients declared they were not current smokers. In the COPD and asthma patients, the median urinary cotinine concentration was 167 ng/mL (range, 2-5,348 ng/mL) and 47 ng/mL (range, 5-2,735 ng/mL), respectively (p < 0.0001), whereas the median eCO level was 8 ppm (range, 0-31 ppm) and 5 ppm (range, 2-45 ppm), respectively (p < 0.05). In 40 (38%) of the patients with asthma or COPD (n = 104), there was disagreement between the self-reported smoking status and that determined on the basis of the urinary cotinine concentration, a concentration > 200 ng/mL being considered indicative of current smoking. In 48 (46%) of those 104 patients, the self-reported non-smoking status was refuted by an eCO level > 6 ppm, which is also considered indicative of current smoking. In 30 (29%) of the patients with asthma or COPD, the urinary cotinine concentration and the eCO level both belied the patient claims of not being current smokers. Conclusions: Our findings suggest that high proportions of smoking pulmonary patients with lung disease falsely declare themselves to be nonsmokers. The accurate classification of smoking status is pivotal to the treatment of lung diseases. Objective measures of smoking could be helpful in improving clinical management and counseling.

Keywords: Asthma; Pulmonary disease, chronic obstructive; Cotinine; Carbon monoxide; Smoking.

Approximately seven million Brazilians over 40 years of age have COPD. In recent years, major advances have been made in the pharmacological treatment of this condition. We performed a systematic review including original articles on pharmacological treatments for COPD. We reviewed articles written in English, Spanish, or Portuguese; published between 2005 and 2009; and indexed in national and international databases. Articles with a sample size < 100 individuals were excluded. The outcome measures were symptoms, pulmonary function, quality of life, exacerbations, mortality, and adverse drug effects. Articles were classified in accordance with the Global Initiative for Chronic Obstructive Lung Disease criteria for the determination of the level of scientific evidence (grade of recommendation A, B, or C). Of the 84 articles selected, 40 (47.6%), 18 (21.4%), and 26 (31.0%) were classified as grades A, B, and C, respectively. Of the 420 analyses made in these articles, 236 were regarding the comparison between medications and placebos. Among these 236 analyses, the most commonly studied medications (in 66, 48, and 42 analyses, respectively) were long-acting anticholinergics; the combination of long-acting 2 agonists and inhaled corticosteroids; and inhaled corticosteroids in isolation. Pulmonary function, adverse effects, and symptoms as outcomes generated 58, 54, and 35 analyses, respectively. The majority of the studies showed that the medications evaluated provided symptom relief; improved the quality of life and pulmonary function of patients; and prevented exacerbations. Few studies analyzed mortality as an outcome, and the role that pharmacological treatment plays in this outcome has yet to be fully defined. The medications studied are safe to use in the management of COPD and have few adverse effects.

Keywords: Pulmonary disease, chronic obstructive/therapy; Pulmonary disease, chronic obstructive/mortality; Review.