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vi Preface

health-related behavior can occur at any one or several of those levels. A full under-
standing of the interactions between health and behavior requires consideration of the
separate levels and the interplay among them (i.e., the social ecology).
Asthma, Health and Society represents an effort to view asthma from a perspective
of public health. It is divided into three sections: introduction, control of asthma, and
the social ecology of asthma. The first section, the introduction, deals with basic
aspects of asthma including its epidemiology, its pathogenesis, its genetic and envi-
ronmental risk factors, its identification, and its role in society. Section II deals with
asthma management. It includes discussions of medical and behavioral management
of the disease and considerations of specific management questions concerning
administration of steroid medication, home monitoring, and computer applications.
Section III focuses on the problems of subpopulations of asthma patients, and how
the disease impacts important societal institutions: the family, schools, and the work-
place. It also includes chapters on barriers to asthma care and efforts to surmount
them. Section III closes with a discussion of public policy as it relates to asthma.
Together the three sections provide a comprehensive view of asthma as both an indi-
vidual and societal problem, one deserving of a prominent place in discussions of
public health policy.
Each contributor to this volume developed a highly original chapter with a broad
public health audience in mind. We are grateful to them; this is their book.
Asthma, Health and Society was made possible, in part, by a grant (5R01HL068706)
from the National Institutes of Health/National Heart, Lung, and Blood Institute to
the senior editor and by support from The University of North Carolina at Charlotte
and Ohio University.

Andrew Harver
Harry Kotses
Contents

I Asthma: An Introduction

1 Considerations Regarding the Epidemiology and Public

Health Burden of Asthma.......................................................................... 3
Earl S. Ford and David M. Mannino

2 Asthma: Pathophysiology and Diagnosis................................................. 19

Susie Yim Yeh and Richard Schwartzstein

3 Genetic and Environmental Factors in Asthma...................................... 43

David B. Peden

4 Screening for Asthma................................................................................. 59

Robert M. Kaplan, W. Fred, and Pamela D. Wasserman

5 Ecology and Asthma.................................................................................. 71

Barbara P. Yawn

II Managing Asthma

6 Medical Management of Asthma.............................................................. 89

Andrej Petrov and Sally E. Wenzel

7 Impact of Medication Delivery Method on Patient Adherence............. 107

Bruce G. Bender, Vasilisa Sazonov, and Karl J. Krobot

8 Asthma Self-Management......................................................................... 117

Harry Kotses and Thomas L. Creer

9 Home Monitoring of Asthma: Symptoms and Peak Flow...................... 141

Andrew Harver, Maeve O’Connor, Sam Walford, and Harry Kotses

10 Computer-Based Applications in the Management of Asthma.............. 153

Ross Shegog and Marianna M. Sockrider

vii
viii Contents

III Asthma: A Social Ecological Perspective

11 Asthma: A Lifespan Perspective............................................................... 181

Tomas Tamulis and Monroe J. King

12 Adolescents and Asthma............................................................................ 201

David R. Naimi and Andrea J. Apter

13 Asthma and the Family............................................................................. 217

Elizabeth L. McQuaid and Deborah Friedman

14 Asthma in the Schools................................................................................ 229

Joan M. Mangan, Sarah Merkle, and Lynn B. Gerald

15 Women and Asthma................................................................................... 245

Jan Warren-Findlow, Larissa R. Brunner Huber, Melanie J. Rouse,
and Andrew Harver

16 Asthma in Minority Populations.............................................................. 263

Alexander N. Ortega, Daphne Koinis-Mitchell, and Peter J. Gergen

17 Asthma: Interventions in Community Setting........................................ 277

James Krieger and Edith A. Parker

18 Asthma and the Workplace....................................................................... 303

Jean-Luc Malo, Catherine Lemière, Denyse Gautrin,
Manon Labrecque, and Kim Lavoie

19 The Cost of Asthma.................................................................................... 325

Adam Atherly

20 Asthma, Public Health, and Policy........................................................... 335

Noreen M. Clark

Index.................................................................................................................... 347
Contributors

Andrea J. Apter, MD, MSc

Division of Pulmonary, Allergy, Critical Care, Hospital of the University
of Pennsylvania, Philadelphia, PA, USA
Adam Atherly, PhD
Department of Health Systems, Management & Policy, Colorado
School of Public Health, Aurora, CO, USA
Bruce G. Bender, PhD
Pediatric Behavioral Health, National Jewish Medical
and Research Center, Denver, CO, USA
Larissa R. Brunner Huber, PhD
Department of Public Health Sciences, The University of North Carolina
at Charlotte, Charlotte, NC, USA
Noreen M. Clark, PhD
Myron E. Wegman Distinguished University Professor, Center for Managing
Chronic Disease, University of Michigan, Ann Arbor, MI, USA
Thomas L. Creer, PhD
Department of Psychology, Ohio University, Athens, OH, USA
Earl S. Ford, MD, MPH
Division of Adult and Community Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and Prevention,
Atlanta, GA, USA
Deborah Friedman, PhD
Bradley Hasbro Children’s Research Center, Brown Medical School, Providence RI,
USA
Denyse Gautrin, PhD
Center for Asthma in the Workplace, Hôpital du Sacré-Coeur de Montréal,
Montreal, QC, Canada
Lynn B. Gerald, PhD, MSPH
Canyon Ranch Endowed Chair, Mel and Enid Zuckerman
College of Public Health, University of Arizona, Tucson, AZ, USA

ix
x Contributors

Peter J. Gergen, MD
National Institute for Allergy & Infectious Disease, National Institutes of Health,
Atlanta, GA, USA
Andrew Harver, PhD
Department of Public Health Sciences, The University of
North Carolina at Charlotte, Charlotte, NC, USA
Robert M. Kaplan, PhD
Fred W. and Pamela K. Wasserman Professor, Department of Health Services,
UCLA School of Public Health, UCLA David Geffen School of Medicine,
Los Angeles, CA, USA
Monroe J. King, DO
College of Medicine, University of South Florida, Tampa, FL, USA
Daphne Koinis-Mitchell, PhD
Bradley Hasbro Children’s Research Center, Brown Medical School,
Providence, RI, USA
Harry Kotses, PhD
Department of Psychology, Ohio University, Athens, OH, USA
James Krieger, MD, MPH
Epidemiology Planning and Evaluation Unit, Public Health – Seattle
and King County, University of Washington Schools of Medicine and
Public Health, Seattle, WA, USA
Karl J. Krobot, MD, PhD, MPH
Outcomes Research, MSD Sharp & Dohme GmbH, Haar, Germany
Manon Labrecque, MD, MSc
Center for Asthma in the Workplace, Hôpital du Sacré-Coeur de Montréal,
Montreal, QC, Canada
Kim Lavoie, PhD
Center for Asthma in the Workplace, Hôpital du Sacré-Coeur de Montréal,
Montreal, QC, Canada
Catherine Lemière, MD, MSc
Center for Asthma in the Workplace, Hôpital du Sacré-Coeur de Montréal,
Montreal, QC, Canada
Jean-Luc Malo, MD
Center for Asthma in the Workplace, Hôpital du Sacré-Coeur de Montréal,
Montreal, QC, Canada
Joan M. Mangan, PhD, MST
Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
David M. Mannino, MD
Division of Pulmonary, Critical Care, and Sleep Medicine,
University of Kentucky Medical Center, Lexington, KY, USA
Elizabeth L. McQuaid, PhD
Bradley Hasbro Children’s Research Center, Brown Medical School, Providence,
RI, USA
Contributors xi

Sarah Merkle, MPH

Division of Adolescent and School Health, Centers for Disease Control
and Prevention, Atlanta, GA, USA
David R. Naimi, DO
Pediatrics, University of Washington, Seattle, WA, USA
Maeve O’Connor, MD, FAAAI
Carolina Asthma and Allergy Center, P.A., Charlotte, NC, USA
Department of Public Health Sciences, The University of North Carolina at
Charlotte, Charlotte, NC, USA
Alexander N. Ortega, PhD
School of Public Health and Institute for Social Science Research,
University of California Los Angeles, Los Angeles, CA, USA
Edith A. Parker, DrPH
Academic Affairs and Health Behavior and Health Education,
University of Michigan School of Public Health, Ann Arbor, MI, USA
David B. Peden, MD, MS
The Center for Environmental Medicine, Asthma and Lung Biology,
The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Andrej Petrov, MD
Division of Pulmonary, Allergy and Critical Care Medicine,
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Melanie J. Rouse, MS
Department of Public Health Sciences, The University of North
Carolina at Charlotte, Charlotte, NC, USA
Vasilisa Sazonov, MPharm, PhD
Global Outcomes Research, Reimbursement & Health Technology
Assessment Department, Merck & Co. Inc., Whitehouse Station, NJ, USA
Richard Schwartzstein, MD
Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess
Medical Center, Boston, MA, USA
Ross Shegog, PhD
Center for Health Promotion & Prevention Research, University of Texas
Health Science Center – School of Public Health, Houston, TX, USA
Marianna M. Sockrider, MD, DrPH
Section of Pulmonology, Baylor College of Medicine, Houston, TX, USA
Pulmonary Medicine Clinics, Texas Children’s Hospital, Houston, TX, USA
Tomas Tamulis, PhD
Office of Public Health Studies, University of Hawaii,
Honolulu, HI, USA
Sam Walford, MA
School of Nursing, College of Health and Human Services,
The University of North Carolina at Charlotte, Charlotte, NC, USA
xii Contributors

Jan Warren-Findlow, PhD

Department of Public Health Sciences, The University of North
Carolina at Charlotte, Charlotte, NC, USA
Sally E. Wenzel, MD
Division of Pulmonary, Allergy and Critical Care Medicine,
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Barbara P. Yawn, MD, MSc
Olmsted Medical Center, Rochester, MN, USA
Susie Yim Yeh, MD
Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess
Medical Center, Boston, MA, USA
 Part I
Asthma: An Introduction
Chapter 1
Considerations Regarding the Epidemiology and Public Health
Burden of Asthma

Earl S. Ford and David M. Mannino

Epidemiologic Studies: An Introduction between potential risk factors and diseases, in part
because the exposure of interest occurs prior to the
outcome. Cross-sectional studies, case-control studies,
Epidemiology has been defined as the study of the
and prospective studies are commonly referred to as
distribution and determinants of diseases and health.
observational studies. Each of these study designs is
Commonly used epidemiological study designs are
subject to various biases. Thus, the results from studies
ecological studies, cross-sectional studies, case-control
using these various study designs must be interpreted
studies, prospective studies, and randomized trials. In
in the context of potential bias. In a randomized clini-
an ecological study, levels of potential or actual risk
cal trial, participants with a condition are selected, and
factors are correlated with levels of disease across dis-
they are then randomly assigned to one or more inter-
tinct geographically defined populations either among
vention groups or a control group. In a randomized
countries or within countries. In a cross-sectional
community trial, communities are selected and ran-
study, a sample of participants is selected and subse-
domly allocated to receiving an intervention or no or
quently those with a particular condition are compared
lower-level intervention. Such trials are generally con-
with those who do not have that condition. Such studies
sidered to provide the most rigorous evidence support-
provide solid information about the prevalence of a
ing the causal relationship between a risk factor and
condition and the attendant risk factors. However,
disease or the usefulness of a specific treatment.
cross-sectional studies provide weaker evidence for
potential associations between possible risk factors
and outcomes than case-control or prospective studies.
In a case-control study, people with a condition are Public Health Burden of Asthma
selected and a separate control group is selected, and
then the two groups are compared. These studies are
usually performed to look for associations between A variety of measures can be used to assess the public
potential risk factors and disease. Furthermore, case- health burden of asthma (Sennhauser et al. 2005;
control studies are a practical method to study associa- Bousquet et al. 2005). Prevalence is the proportion of
tions for diseases that are relatively rare. In a prospective people with asthma in a population, and incidence rate
study (cohort study, panel study, longitudinal study), a is a measure of the instantaneous force of asthma
sample of participants is selected and they are followed occurrence. Prevalence may be delineated into point
forward in time. These studies provide the most com- prevalence (the proportion of people with asthma at a
pelling evidence for possible causal relationships given point in time) and period prevalence (the propor-
tion of people with asthma during a specified period of
time such as the past 12 months). Incidence rate refers
E.S. Ford (*) to the new onset of asthma during a specified period of
Division of Adult and Community Health, National Center for time (number of new cases per unit of person-time),
Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, 4770 Buford Highway, MS whereas cumulative incidence refers to the proportion
K66, Atlanta, GA, 30341, USA of people initially free of disease who subsequently
e-mail: [email protected] develop disease over a certain time span. Mortality

A. Harver and H. Kotses (eds.), Asthma, Health and Society: A Public Health Perspective, 3
DOI 10.1007/978-0-387-78285-0_1, © Springer Science+Business Media, LLC 2010
4 E.S. Ford and D.M. Mannino

rates provide an idea of how deadly the condition is Table 1.1 Methods for determining asthma in epidemiological
and also an estimate of premature mortality through a studies
calculation of years of productive life lost. Examining Questionnaires
Diaries
the number of physician office visits, emergency room
Medical records
visits, and hospitalizations yields important insights Administrative data bases
into the use of and need for medical resources and Pharmacy
whether the capacity of the medical care sector is ade- Health maintenance organizations
quate to meet the need. Estimates of the direct and Outpatient visits
indirect costs of the disease provide critical insights Emergency room
into the dimensions of health care resources that are Hospitalizations
Vital statistics
needed to combat this condition. Inherently tied to
Provocation tests (bronchial hyperresponsiveness)
estimating indirect costs are the number of lost school Methacholine challenge test
days and lost workdays attributable to asthma. Histamine challenge
Measuring disability-adjusted life years and health- Adenosine 5¢-monophosphate
related quality of life of people with asthma provides Exercise challenge test
another dimension of the burden of asthma. Cold air challenge
Hypertonic saline
Lung function tests
Spirometry
Defining Asthma Peak expiratory flow rate variability
Exhaled nitric oxide
Eosinophilia
Critical to the conduct of epidemiological studies and to Blood sputum eosinophils
examining the various facets of asthma is the availability
of a case definition for asthma. In the Second Expert
ceptually attractive and is inexpensive, the validity and
Panel Report of the Guidelines for the Diagnosis and
reliability of identifying people with asthma in this way
Management of Asthma, asthma was defined as “a
need to be established. The simplicity of this approach
chronic inflammatory disorder of the airways in which
can also lead to the creation of numerous such instru-
many cells and cellular elements play a role, in particular,
ments that differ in minor or major ways, thus possibly
mast cells, eosinophils, T lymphocytes, neutrophils, and
compromising comparisons of study results.
epithelial cells. In susceptible individuals, this inflamma-
Consequently, attempts have been made to standardize
tion causes recurrent episodes of wheezing, breathless-
asthma questionnaires to facilitate comparisons of the
ness, chest tightness, and cough, particularly at night and
prevalence of asthma among populations as was done in
in the early morning. These episodes are usually associ-
the European Community Respiratory Health Survey
ated with widespread but variable airflow obstruction that
(ECRHS 2007) and International Study of Asthma and
is often reversible either spontaneously or with treatment.
Allergies in Childhood (ISAAC 1993). The develop-
The inflammation also causes an associated increase in
ment of such questionnaires requires a process of testing
the existing bronchial hyperresponsiveness to a variety of
the validity and reliability of the questions (Venables
stimuli” (National Asthma Education and Prevention
et al. 1993; Jenkins et al. 1996; Galobardes et al. 1998;
Program 1997). This definition is rooted in physiology
Sole et al. 1998; Wolf et al. 1999; Kilpelainen et al.
and clinical considerations. For epidemiological pur-
2001a; Aroni et al. 2004; Redline et al. 2004). This pro-
poses, however, a workable definition for use in often
cess may have to be repeated for special populations
large-scale studies is a sine qua non.
such as health-care workers (Delclos et al. 2006).
Several approaches to defining asthma for epidemio-
logic use or developing case definitions have been taken
(Table 1.1). The use of questionnaires is perhaps the
most common approach. A single question or a series of
questions is used to identify people with asthma. Asthma from Medical Records
Examples from several large US surveys have been
summarized elsewhere (Centers for Disease Control Using medical records to identify people with
and Prevention 2009). Although this approach is con- asthma is another method of case ascertainment
1 Considerations Regarding the Epidemiology and Public Health Burden of Asthma 5

(Wamboldt et al. 2002). The use of this technique hyperreactivity, whereas approximately 15% of
depends heavily on the diagnosis made by clinicians. children who have never wheezed may have a positive
Although national or professional guidelines for bronchial hyperreactivity test (Phelan 1994).
diagnosing asthma have been developed, the degree to Nevertheless, bronchial hyperreactivity is often used
which clinicians adhere to these guidelines is not as a “hard measure” of asthma. Testing for bronchial
always clear. Thus, differences in diagnostic prac- hyperreactivity may involve the use of metacholine,
tices may occur among clinicians. In a sample of 182 histamine, adenosine, cold air, hypertonic saline solu-
children, the reliability and validity of coding asthma tion, and exercise as triggers (de Meer et al. 2004).
outcomes were good (Wamboldt et al. 2002). Furthermore, different protocols exist for various
stimulants that could yield somewhat different find-
ings in studies. The relative merit of these protocols is
still being investigated (Haby et al. 1995).
Asthma from Administrative Databases

Large administrative databases are used for a variety of Death Certificates

purposes including estimating the prevalence of dis-
ease, examining the use of medical resources (hospi- Because deaths from asthma are a relatively rare occur-
talizations, physician-office visits, emergency room rence, the use of death certificates for case-definitions
visits), performing pharmacoepidemiological studies, of asthma is usually confined to studies of mortality
examining treatment patterns, following the prognosis trends. Diagnostic practices for asthma may show geo-
of a disease, and studying compliance with guidelines graphical and temporal variation, and it is, therefore,
(Blais et al. 2006). In the United States, examples helpful to understand the validity of death certificates
include the National Hospital Discharge System, when comparing study results (Subcommittee of the
Nationwide Inpatient Sample, the National Ambulatory BTA Research Committee 1984; Sears et al. 1986;
Care Medical Survey, National Hospital Ambulatory Campbell et al. 1992; Jenkins et al. 1992; Hunt et al.
Medical Care Survey, National Disease and Therapeutic 1993; Wright et al. 1994; Guite and Burney 1996;
Index, Medicare, Medicaid, and health maintenance Sidenius et al. 2000).
organization databases. For many of these databases,
conditions are often coded using the International
Classification of Diseases. In addition, large pharmacy
databases can be used to identify people who use Exhaled Nitric Oxide
asthma medications (Allen-Ramey et al. 2006).
The recognition that inflammation of the airways is an
important component of asthma provides a rationale to
attempt to diagnose asthma by measuring the underly-
Bronchial Hyperreactivity Testing ing inflammation. One such test is the measurement of
exhaled nitric oxide (Dupont et al. 2003; Deykin et al.
2002; Smith et al. 2004; Berkman et al. 2005; Zitt
Determining the presence of asthma using question- 2005). Patients perform a slow expiratory vital capacity
naires was not considered a rigorous method; measuring maneuver with a constant flow rate. The optimal cutoff
airway hyperresponsiveness was considered a more point of exhaled nitric oxide still needs to be estab-
physiologic approach. However, several considerations lished. Thus far, measuring exhaled nitric oxide has not
limit the use of this method. It is time-consuming, been commonly used in epidemiologic studies.
resource-intensive, and carries a small risk for an
adverse event. Some proportion of people with asthma
do not have airway hyperresponsiveness as determined
by bronchial hyperreactivity testing. Thus, this approach Summary
may underestimate people with asthma, especially
those with mild asthma. For example, approximately A number of methods exist to identify asthma in
30% of children with asthma may not have bronchial patients and study participants, each of which has
6 E.S. Ford and D.M. Mannino

advantages and disadvantages. Because there is no Control and Prevention 2004a). In contrast, the prevalence
“gold standard” to assess asthma, the validity of the of ever having asthma or having an asthma attack
different methods is difficult to establish. A clinical in the past 12 months among children varied only
diagnosis of asthma derived by following professional slightly from 1997 through 2004, according to NHIS
guidelines is often used as the “gold standard.” The data (Fig. 1.2) (Centers for Disease Control and
choice of which test to incorporate in a study will be Prevention 2005; Centers for Disease Control and
based on the perceived accuracy of a test as well as on Prevention 2002a, b; Centers for Disease Control
practical considerations involving cost, invasiveness, and Prevention 2003a, b, c; Centers for Disease
complexity, and patient acceptability. Attempts have Control and Prevention 2004b; Centers for Disease
been made to assess the validity of different methods Control and Prevention 2006b). Previously, the prev-
in diagnosing asthma (Hunter et al. 2002; Yurdakul alence of having asthma during the previous 12
et al. 2005). The findings of inconsistent rates of months in children increased from 3.6% in 1980 to
asthma across four different data sources used rou- 6.2% in 1996 (Akinbami and Schoendorf 2002).
tinely for surveillance purposes in the United Kingdom
sound a note of caution about the use of such data
(Hansell et al. 2003).
Age, Sex, and Race or Ethnicity

Prevalence of Asthma In general, the prevalence of ever having asthma and

having an asthma attack in the past 12 months increases
progressively during childhood (Fig. 1.3). In addition,
Estimates of the prevalence of asthma show tremen- during childhood, the prevalence of ever having asthma
dous temporal and spatial variation (Pearce and and having an asthma attack in the past 12 months is
Douwes 2006). In the United States, several data sys- higher among males than females (Fig. 1.4), whereas
tems provide information about the prevalence of among adults the prevalence of lifetime asthma and cur-
asthma including National Health and Nutrition rent asthma is generally higher among females than
Examination Surveys, National Health Interview males (Fig. 1.5). US data from the 2004 NHIS show
Surveys (NHIS), Behavioral Risk Factor Surveillance somewhat varying patterns in the prevalence of ever
System (BRFSS), and ISAAC. Estimates from these having asthma with respect to age (Figs. 1.3 and 1.6).
surveys are all based on the results from question- The prevalence of ever having asthma is highest among
naires. Data from the NHIS show that the prevalence those aged 12–17 years. Among adults, relatively little
of asthma, based on a household member having had variation in the prevalence of ever having asthma by age
asthma during the previous 12 months, in the US pop- group is present. In contrast, the prevalence of still having
ulation rose from <4% to approximately 5.5% in 1996 asthma increases gradually with age through ages 65–74
(Mannino et al. 2002). In 2004, 9.9% of US adults rep- years. Of the three major racial or ethnic groups, the
resenting an estimated 21.3 million people had ever prevalence of ever having asthma is highest among
had asthma, and 6.4% or approximately 14.4 million African American children and lowest among Hispanic
still had asthma (Centers for Disease Control and children (Fig. 1.7) (McDaniel et al. 2006). Racial or ethnic
Prevention 2006a). In 2004, 12.2% of US children rep- differences among adults were similar to those among
resenting an estimated 8.9 million children were ever children except that the difference between whites and
diagnosed with asthma, and 5.4% or 4 million children African Americans was less pronounced (Fig. 1.8).
had experienced an attack in the past 12 months
(Centers for Disease Control and Prevention 2005).
Data from the BRFSS administered to participants
aged 18+ years showed a steady rise in the prevalence
of lifetime asthma (“Did a doctor ever tell you that you
Geographic Variability Within Countries
had asthma?”) from 10.4% in 2000 to 13.3% in 2004
and that of current asthma (“Do you still have asthma?”) BRFSS data for the United States show significant
from 7.2% to 8.1% (Fig. 1.1) (Centers for Disease variation among the fifty states and two territories
1 Considerations Regarding the Epidemiology and Public Health Burden of Asthma 7

14

12

10
2000
8 2001
% 2002
6
2003
4 2004

0
Lifetime Current

Fig. 1.1 Trend in the prevalence of asthma among US adults aged ³18 years with asthma, Behavioral Risk Factor Surveillance
System, 2000–2004

14

12 1997

10 1998
1999
8
2000
%
6 2001
2002
4
2003
2 2004

0
Ever told had asthma Attack in past 12 months

Fig. 1.2 Trend in the prevalence of asthma among US children aged <18 years with asthma, National Health Interview Survey,
1997–2004

16

14

12
10 0-4 years
8
%

5-11 years
6 12-17 years

0
Ever told had asthma Attack in past 12
months

Fig. 1.3 Age-specific percentage of US children aged <18 years with asthma, National Health Interview Survey, 2004
8 E.S. Ford and D.M. Mannino

16

14

12

10
Male
% 8
Female
6

0
Ever told had asthma Attack in past 12 months

Fig. 1.4 Age-adjusted percentage of US children aged <18 years with asthma, by gender, National Health Interview Survey, 2004

16

14

12

10
Male
% 8
Female
6

0
Lifetime Current

Fig. 1.5 Age-adjusted percentage of US adults aged ³18 years with asthma, by gender, Behavioral Risk Factor Surveillance
System, 2004

12

10

8 18-44 years
45-64 years
% 6
65-74 years
4 75+ years

0
Ever told had asthma Still has asthma

Fig. 1.6 Age-specific percentage of US adults with asthma, National Health Interview Survey, 2004