Examination of Witnesses (Questions 263-279)
Professor Anthony Newman Taylor, Mr Rob Miguel, Professor
Raymond Agius and Dr David Orton
10 JANUARY 2007
Q263Chairman: Can
I thank our witnesses for coming today. I am Lady Finlay. I am
chairing this select committee inquiry. There is an information
note with all the declared interests of members of the Committee
so we will not be going round declaring our interests during the
evidence session today, but it is available for members of the
public. We are most grateful to you for coming today. Professor
Agius, you have sent in a document which we have now circulated
to the Committee. I wonder if you could introduce yourselves briefly.
Dr Orton: Good morning.
I am Dr David Orton. I am a Consultant Dermatologist at Buckinghamshire
NHS Trust with an interest in contact dermatitis and occupational
dermatitis generally.
Professor Agius:
My Lord Chairman, I am Raymond Agius. I am Professor of Occupational
and Environmental Medicine at the University of Manchester and
I am Director of the Centre of Occupational & Environmental
Health there which, amongst other things, collects data on occupational
and work-related disease.
Mr Miguel: My Lord
Chairman, I am Rob Miguel. I am the Health & Safety Officer
at Amicus, which is a trade union with 1.2 million members representing
quite a few sectors in the UK. I deal with general practice and
I serve on a number of government committees.
Professor Newman Taylor:
I am Professor Anthony Newman Taylor. I am a Consultant Chest
Physician at Brompton Hospital. I am the Head of the National
Heart and Lung Institute and the Department of Occupational and
Environmental Medicine there, and I am also Chairman of the Industrial
Injuries Advisory Council which advises the Department of Work
and Pensions on the Industrial Injuries Disablement Benefit Scheme.
Q264 Chairman: Thank you. Perhaps
I could start with a question which I would like you all to try
and answer. We have a lot of questions that we want to get through
with you today so it is helpful if you can keep your answers concise
so that we can get through all the topics we want to cover. Which
occupations present the highest risk to workers of developing
conditions such as occupational asthma, dermatitis, rhinitis and
other allergic diseases?
Dr Orton: My Lord
Chairman, as a dermatologist I think I had best restrict myself
to dermatology but I would say that the largest groups in occupational
practice that we see with skin problems are from the healthcare
sector, healthcare workers and hairdressers. It really depends
on how you examine the data. If you look at point-prevalence cross-sectional
studies amongst certain occupations or you look at the data submitted
by medical practitioners to organisations such as EPIDERM, generally
speaking, fairly consistently across Europe and Australia and
the United States certain groups such as healthcare workers and
those in hairdressing, as well as those exposed, obviously, to
sensitisers in the plastics industry and the construction industry,
are going to be represented fairly consistently.
Professor Agius:
I would agree entirely with what my colleague has said. I think
one also has to bring the matter of denominators into account,
so while I would agree with him that one tends to see more cases
reported to us from amongst healthcare workers, of course they
constitute a large proportion of the working population and if
we took their denominator into account then the risk amongst,
say, hairdressers and beauticians is about 10 times higher than
the risk amongst healthcare workers, because of course there are
fewer hairdressers and beauticians. So we might see in the order
of three per thousand hairdressers per annum reported to us by
specialists and there is only one tenth that rate for nurses.
Of course, if one looks further down the pyramid one has to bear
in mind that the reports from specialists are only a proportion
of the cases seen by GPs, perhaps one in four, so the pyramid
then gets wider and wider at the base and it is difficult to measure
at the base.
Mr Miguel: I have
been looking at the figures produced by HSE, and hairdressers
in relation to dermatology is the highest group followed by chemical
workers, but these figures could be confusing because there are
other factors to be taken into account. For example, there is
an amount of screening which goes on which screens out workers
who may be susceptible to asthma. There are other reasons to believe
that these figures are accurate but not completely accurate. The
figures I looked at came from EPIDERM for dermatitis and from
SWORD for occupational asthma—moulders, core makers and
die casters. I do not know if you know what those occupations
are but primarily moulders and core makers are producing things
like taps and boilers and they are cast in a die. Secondly on
occupational asthma, if you take other figures into account spray
painters come out the highest figure. If you look at things like
industrial injuries' disablement benefit information from occupational
health physicians the figures come out slightly different. I will
say though that there is quite significant under-reporting in
dermatology and in occupational asthma. You only have to look
at the example of Powertrain, where they had a massive outbreak
at Longbridge. There were 101 cases reported. Eighty seven of
those were of occupational asthma, 24 of alveolitis. If you look
at the figures and I give you a figure per 100,000 workers of
96 for paint sprayers, if I do that calculation in Powertrain
alone the incident rate per 100,000 workers would be 4,000, and
you can see there is a significant difference, so there is a lot
of under-reporting that goes on. However, I have sat on a board
with HSE which looks at occupations and at anomalies, and they
roughly came out with the same sorts of figures, so for occupational
asthma it is people in engineering, paint sprayers, people in
confectionery, flour, and with dermatitis it is hairdressers.
Even when you look at all the anomalies, the highest occupations
still come out the same. Part of the under-reporting is due to
UK employment law, frustration of contract, where if a worker
is deemed not to be able to do his job then he can be laid off
by his/her company. This is going to account for quite a bit of
under-reporting. Also, the occupational health system relies upon
GPs within the system, and they do not actually feed into the
reporting. I understand from HSE that they are looking at inviting
GPs to become involved in the reporting system. I have some more
to say but I know you want the answer to be concise so I will
leave that there.
Q265 Chairman: Bring that in later.
Professor Newman Taylor:
In terms of occupational asthma, the most common group is spray
painters. There are then plastic workers, chemical process workers,
bakers and laboratory technicians that constitute the highest
incidence, as far as we are aware, of occupational asthma, and
then healthcare workers. I would add to what has been said that
that is based upon the reporting by consultant specialist chest
physicians and occupational physicians, and so therefore, in order
for us to be aware of those cases, they need to have been seen
by a specialist chest physician in the case of asthma or a dermatologist
in the case of dermatitis, and clearly a significant proportion
of cases does not get there. In terms of occupational physicians,
it is worth appreciating that it is estimated only about 12 per
cent of the workforce is covered by an occupational physician;
therefore the opportunity for them to report cases is going to
be relatively small. We did a study trying to estimate both the
numerator and the denominator for laboratory animal allergy and
came to the conclusion that in relation to the SWORD data the
numerator was higher and the denominator was lower and so the
true incidence was higher, but these are the major causes.
Q266 Chairman: Can I just ask you
how many do you estimate have got multiple allergies?
Professor Newman Taylor:
When you say "multiple allergies", multiple allergies
to both agents they meet in the general way as well as at work?
Q267 Chairman: I was thinking about
patients who would be going round different specialist services
because their allergies manifest in different ways.
Professor Newman Taylor:
I would have thought that that is a minority, because the reality
is that although there are overlaps in terms of what causes dermatitis
and what causes asthma, the two tend to be fairly separate.
Dr Orton: There is
just one point that needs to be clarified from the outset, which
is that although occupational skin disease is extremely common
and may be due to contact dermatitis, there are, of course, two
sorts of contact dermatitis—irritant contact dermatitis
and allergic contact dermatitis, and the majority of cases that
primary care physicians, or indeed consultant dermatologists,
might end up seeing will be irritant contact dermatitis, but often
cases are complex and involve both irritant and allergic factors
and that the diagnosis of allergy needs to be teased out in order
to help with the management of that specific patient.
Q268 Lord Taverne: How has the pattern
changed? In Professor Newman Taylor's letter he mentions that
there are now fewer reported cases of certain kinds of asthma,
that there is no change, as far as one can see, in the case of
bakery workers, and that the increase in latex allergy has decreased.
What is the cause of the change?
Professor Newman Taylor:
Maybe I can start with this and Professor Agius, who is particularly
familiar with the data, can follow. What has happened since the
reporting scheme started in the late 1980s is that there has been
a fairly consistent number of cases reported and the causes of
those cases have been fairly consistent. Overall there has been
a decline in the number of cases reported due to isocyanates.
It remains the most frequent cause, but the number of cases reported
has declined. There was the epidemic caused by latex in the 1990s,
particularly in healthcare workers, with a marked increase and
subsequent reduction following the introduction of non-powdered
low protein latex gloves. There has been an overall reduction
in the number of cases which seems to have occurred in one year
so that it has been about flat, come down and then been reasonably
flat again. There have been changes but overall, the incidence
of the disease and the causes which are being reported, with the
particular exception of latex and the reduction in isocyanates,
has not been that dissimilar during the period of reporting.
Professor Agius:
As Professor Newman Taylor has said, the situation is rather complex.
There are many factors which militate against getting the highest
quality data. One is that to a great extent what we get is collected
from specialist doctors reporting voluntarily. We have recently,
in response to a point made by Mr Miguel, started collecting data
from GPs as well. If one assumes a linear trend, and of course
there are lots of reasons why that trend might not be the true
one, and takes into account as far as one possibly can factors
like the fact that doctors might get tired of reporting and so
on, then if pushed I might say that we have found significant
year-on-year reductions but the extent to which the reductions
are manifest varies slightly by the reporting group. For example,
amongst dermatologists reporting occupational respiratory disease
we tend to see a year-on-year reduction of about 3 per cent, whereas
amongst occupational physicians with skin disease it might be
of the order of 10 per cent. For respiratory physicians reporting
occupational asthma and occupational physicians reporting occupational
asthma there are suggestions of a significant trend year-on-year
to the order of seven per cent. Having said that, one has to exercise
caution because even though we are using the best statistical
methods to take into account possible artefacts, such as doctors
getting tired of reporting and so on, it cannot be conclusively
said that we have got rid of all of those. Professor Newman Taylor
has said that the pattern is very patchy within the various causes,
so, sadly, for occupational asthma caused by flour, which arguably,
subject to correction by Professor Newman Taylor, is probably
the oldest known cause of occupational asthma dating back a few
hundred years, there has been no change in that. As Professor
Newman Taylor has said, insofar as latex and glutaraldehyde over
the last three or four years we do not get more than 10 specialist
reported cases per annum and yet for some of the commoner and
big causes the problem still persists.
Q269 Chairman: Are there actions
that should be being taken to decrease the incidence? You cited
the change in latex gloves. Are there other things we should be
doing to minimise or even possibly eliminate risk in some of these
groups of workers that are just not being done at the moment?
Mr Miguel: Yes, more
could be done in the way of identifying sensitisers and putting
in the appropriate controls, but as well what you have to remember
is that in the UK the structure of the workforce is changing.
I had some figures from our personal injury lawyers. We have 134
dermatitis cases and 102 occupational asthma cases and those occupations
come from engineering and manufacturing. The UK is changing to
service based industries so therefore you are going to find a
decrease in the reported incidence.
Q270 Lord Soulsby of Swaffham Prior:
With respect to these various conditions that are being discussed
in this question, is the fundamental immunological response the
same in them all, starting with sensitisation of a delayed character
and then moving to an acute response, or are there differences
with asthma, dermatitis, rhinitis and other allergic conditions?
I am wondering if there is a unity there.
Professor Newman Taylor:
If I can answer the question particularly in relation to asthma
because the underlying immunological response in relation to dermatitis
is different. In relation to asthma, what we can describe as allergic
asthma, fulfils the criteria of a hypersensitivity response: it
develops in a minority of people who are exposed; it occurs after
a latent interval, and those affected react to levels of exposure
which are much less than cause problems in other people. So it
fulfils the criteria of an allergic reaction. But it is only in
a minority of the cases we can identify a specific immunological
response in the usual way by finding IgE in the blood. We can
do that for almost all of the protein causes of occupational asthma
but for chemicals it is only in a minority of causes. We can do
it for acid anhydrides, for complex platinum salts, and for a
minority of cases of isocyanates. So for many of the causes one
cannot identify evidence of a specific immunological mechanism,
although the character of the disease is the same as in those
in which we can.
Dr Orton: Again,
with allergic responses in the skin there are two distinct processes
that can result in skin problems. There is an immediate type of
allergic response which is predominantly what we have seen very
frequently with latex proteins in gloves, and then there is the
delayed hypersensitivity reaction involving a different immunological
mechanism that results in dermatitis. It is the basis of the latter
which we use in the diagnosis of allergic contact dermatitis with
our patch testing technique.
Q271 Lord Soulsby of Swaffham Prior:
Where there is a delayed response will that always be a delayed
response or will it change to an immediate response?
Dr Orton: No. It
usually is delayed. There is a rare exception when exposure to
certain proteins can result in an immediate type of response which,
after a prolonged period of time, evolve into a dermatitis and
we see that certainly in certain food handlers such as sandwich
makers, this is described as protein contact dermatitis.
Q272 Chairman: Professor Agius, could
you confirm to me that the general practitioners' Quality Outcomes
Framework does not specify allergic occupational diseases?
Professor Agius:
to the best of my knowledge, my Lord Chairman, it does not.
Q273 Baroness Perry of Southwark: My
question is about the role of the Health & Safety Executive.
When they gave evidence to us they said that they were currently
making efforts to reduce work-related allergies by raising awareness.
They have got schemes such as National Hairdressers' Day, which
is aimed at raising awareness about dermatitis. Do you think schemes
such as this will reduce the incidence of occupational allergic
diseases and what else do you think the Government should be doing
to ensure that employers, staff and health and safety personnel
are aware of the number of agents known to cause occupational
allergic diseases?
Professor Newman Taylor:
I can try and start to answer that question. The important thing
that needs to be understood is that the best evidence which we
have, and it is now quite consistent in relation to a number of
different causes of occupational asthma, and I am focusing now
on asthma, is that the risk of developing the disease is predominantly
a consequence of the level of exposure to the agent which causes
it. The higher the exposure in general, the greater the risk of
the disease developing. If the incidence of the disease is going
to be reduced what needs to be focused on is a reduction in the
level of exposure to its cause, be it urinary proteins from laboratory
animals, flour and enzymes in bakery, et cetera. There have been
two good examples where control measures have been taken that
have made a significant difference to the incidence of the disease,
virtually eliminating it. One is enzymes in the detergent industry
and the second is latex. In the detergent industry, which caused
major problems when powdered enzymes were added to detergents
in the late 1960s, it caused problems not only in the workforce
but also in consumers. The way this was got round was to encapsulate
the enzymes in granules, which were too large to be suspended
in the air, so they fell out of it and could not be inhaled. One
has to recognise that there was a solution there which was possible,
as indeed with latex because it was the powder which the protein
from the rubber was absorbing that was getting into the air and
being inhaled. By providing gloves with low protein content in
the rubber and which were not powdered latex allergy could be
virtually eliminated. That is a much more difficult thing to do
in many other circumstances, but the principle is the same and
we need to see how we can apply it. The principle is more difficult,
for instance, with laboratory animal urine proteins because you
cannot really granulate an animal, you cannot granulate its urine.
We need to find ways in which we can prevent the urine deposited
on the dust in the cage getting into the air and being inhaled,
but it is more difficult. The second problem is that these two
examples are in large employers. The enzyme detergent industry
employs many people. Procter & Gamble, Unilever, many others,
are big companies employing occupational health physicians and
safety advisers and are able to implement on a large scale these
sorts of changes. As Rob Miguel has said, the problem we have
now is with an industry that increasingly is moving from manufacturing
to service, with smaller workforces, smaller factories and more
self-employed people. That is a much more difficult problem. Hairdressing
is, generally speaking, in relatively small outlets where there
are relatively few people who are working, so there is greater
difficulty in finding ways to ensure they work in a safe fashion
which reduces the risk of disease developing. The answer is that
the type of program the Health & Safety Executive is doing
is welcome because it is raising awareness. It is also hopefully
going to be backed up by informed discussion with employers about
what the risks are and how they can be reduced, but the difficulty
for the Health & Safety Executive in this sort of workforce
is that it is very difficult to enforce regulations. It is much
easier to enforce at ICI than it is in a local hairdresser and
to my way of thinking this is the real problem and we need to
look at means to persuade employers that it is in their interests
to ensure safe working conditions. That is, I believe, what we
need to look at now. There has been some recent research looking
at the costs of occupational asthma, which is quite considerable
in terms of people leaving the workforce, loss of productivity,
benefits paid, et cetera. The great majority of the costs falls
on the individual and on government and a relatively small proportion
on the employer, so at the moment those sorts of incentive are
not really there.
Mr Miguel: My Lord
Chairman, I agree with everything that has been said there, especially
about the fragmentation of the workforce; there are a lot of small
workforces out there. These sorts of campaigns are very effective
as long as they are run in combination with the workforce through
trade unions and employers. One of the HSE boards, the Disease
Reduction Programme Board, has been set up to get all these people
together, trade unions, employers, medical people, and look at
these deliveries. For example, in the Powertrain incident, and
that is a major company, they did not actually know what the sensitiser
was there, so consequently people were sensitised and disease
occurred, so it is not just occurring in small companies; it is
also occurring in large companies because they are unaware of
the facts. Part of the programme, regarding these initiatives
is for trade unions and others to get involved in that campaign,
and to help the HSE with that campaign because they cannot achieve
outcomes by themselves. Amicus and other trade unions have undertaken
to help the HSE. One of the things we are doing is introducing
this type of material and these initiatives into our education
programme, where we ask our safety representatives to take the
material that they have learned back into the workplace, because
they have direct access to safety committees, especially in large
companies and direct access to employers' health and safety professionals
in there. This campaign can only be effective if run together
with employers and trade unions and other work/employee organisations.
It is about awareness. It is okay sending a leaflet out to hairdressers
so that they can have a look at it, but this needs supporting.
I did make some suggestions, we ran a campaign on prostate cancer
several years ago and we approached a television company to put
a storyline on prostate cancer in a very popular television programme
which came out on a Sunday. That had a very positive effect and
I did suggest that if you are looking at hairdressers, who are
very difficult to reach, and I know it sounds silly, but maybe
to have a storyline in Coronation Street where they have
got a hairdressing shop. That would reach more people than just
sending out a couple of leaflets. This is the type of thing that
needs to be done to back up these sorts of campaigns.
Q274 Chairman: Have you approached
Coronation Street?
Mr Miguel: We have
not yet.
Chairman: It sounds like a job for tomorrow.
Q275 Lord Soulsby of Swaffham Prior:
Under the 2002 Control of Substances Hazardous to Health regulations
which have recently been revised employers are required to ensure
that exposure to substances that may cause asthma or dermatitis
is controlled. Does this in fact work effectively? Is it a problem
for employees to ensure that the workers are not exposed? Are
there always additional substances that come to light that may
be problematic?
Dr Orton: Only if
it really happens. Education and legislation can achieve only
so much. I would like to revert quickly to the last question in
the sense that if you target your audience and your trainees,
for example, in the hairdressing industry, evidence from Europe
does suggest that you can reduce the incidence of occupational
skin disease. That is mainly, I suspect, irritant contact dermatitis,
but as I keep saying, with dermatitis it is often complex and
there are both irritant and allergic factors playing a role in
the end skin-related problem. We have great problems even investigating
cases of allergic contact dermatitis, looking at the material
safety data sheets that are often provided by companies because
they are often incomplete and it takes a great deal of time and
effort to be able to identify what the sensitisers are. Legislation
is useful, obviously, and it does help, but there are changes
that need to be made to make even the investigation of such cases
easier for the clinicians.
Professor Agius:
I certainly agree with what Dr Orton and Professor Newman Taylor
have said and I would emphasise that the steps have to start at
the very top following the hierarchy in the Control of Substances
Hazardous to Health regulations, so every effort must be made
to substitute harmful agents for ones which are less harmful and
to reduce exposure. All too often we find that convenience in
using certain agents is exposing workers to greater risk, so we
find that people are using aerosol sprays to clean surfaces because
it is quicker to use an aerosol spray and just aim it in various
directions than it is to use a gloved hand holding a hand wipe.
It is those steps that have to be implemented at the highest level
insofar as what manufacturers produce and what employers expect
by way of work practices, and only after all those things have
been done is it then possible to try and achieve, a final level
through personal protection and education of the workforce. In
response to the earlier question about hairdressers, I do share
some of the doubts that have already been expressed by witnesses
as to the extent to which education alone will help things. The
proof of the pudding will be in the eating. Sadly, hairdressers
have got a very high incidence especially of dermatitis, possibly
to the order of one per hundred per year, and it should be possible
to track and prove in due course whether or not these interventions
have helped and whether the legislation has helped.
Mr Miguel: The legislation,
COSHH, as it is generally known, is procedurally fine and it can
transpose to allergies easily: identifying a sensitiser, calculating
the risk to the person and controlling this using a hierarchy,
and the hierarchy is first to eliminate the hazard in ways that
have been described or using engineering controls and so on. The
downfall with it is that it is too generic and in cases that are
complex, such as this, identifying the hazard, identifying the
sensitiser, is easier said than done. In the Powertrain incident
at Longbridge the sensitiser was not identified, and there is
evidence that the causative agent could have been bacteria. There
is also evidence that biocides used in the metal cleaning fluid
also contain endotoxins which could be a sensitiser. These are
all complex issues which a major company failed to pick up, so
the legislation was there, and the procedures were there, but
obviously you have to identify the hazard in the first place.
If there is no research, or if there is low level research or
that research is not published, then the employer is not going
to pick that up. In relation to data sheets, data sheets are very
generic themselves, so in this instance, the data sheets said
the health risk was irritation to the respiratory tract. It did
not mention possible bacterial contamination of the metal fluid
when it was in use, so we were just looking at the metal fluid
itself, not the process, and no specific respiratory disease was
mentioned. It did say that local exhaust ventilation could have
been used if the mists were excessive, but did not describe "excessive",
so the information available to employers from this legislation,
and data sheets, is inconsistent and it does not help employers.
It helps the HSE to prosecute employers if they go wrong, but
it does not on its own help employers enough. More work needs
to be done in relation to COSHH. There is some new European legislation
coming up called REACH which asks the supplier to identify the
hazards/risks and I think a push needs to be made in relation
to allergies to identify properly the sensitisers in these materials.
Q276 Lord Soulsby of Swaffham Prior:
Is it legitimate to refuse employment to someone who is known
to be allergic to items in the workplace?
Mr Miguel: I would
not say it as illegal, although the disability law has to be considered,
because if you have a pre-employment check which asks those questions
then the employer is not going to give that as a reason. They
will just refuse employment.
Q277 Earl of Selborne: Can I ask
a question with reference to REACH? This has been in the offing
for an awfully long time, it seems to me, and it never seems to
quite come to fulfilment and it only deals with chemicals and
not with other substances to which there might be an allergic
reaction. Do you have much confidence therefore that REACH is
going to help?
Mr Miguel: I think
REACH will help as long as it is combined with existing legislation
and existing guidance because that point has come out on several
committees, that REACH was going to overshadow COSHH, which includes
biological hazards. That would be unacceptable because you can
see from the example I gave you that there was a process, and
information from suppliers did not identify the sensitisers which
come from that process, it was not the original chemical, so there
are going to be faults with REACH but that has to be backed up
further by UK legislation.
Q278 Viscount Simon: What training
do health and safety inspectors receive with regard to occupational
allergic diseases and is this adequate? Do you think there are
enough health and safety factory inspectors for small businesses,
such as the car spraying operations that you have already mentioned?
Mr Miguel: I do a
lot of work with the Health & Safety Executive so I know the
answer to this. When they begin their training, they get an occupational
health tutorial, which includes allergies, this includes respiratory
diseases, skin sensitisation, asthmagens and COSHH, so they do
get training in the beginning. This is reinforced by experts that
work within the Health & Safety Executive, so inspectors can
call on colleagues. When they go to sites in the first instance,
if there is a specific thing, such as occupational asthma, they
usually have a specialist colleague with them. If they have a
specific intervention which deals with risks to skin, for example,
they take a colleague with them and they get advice from that
colleague, so they do have training from the beginning, which
is reinforced by supervision and by experts. The HSE also have
doctors and nurses and occupational hygienists. I do not have
any measure of whether that training is sufficient but I know
the training exists and is fairly comprehensive.
Professor Newman Taylor:
Could I just add to that? You asked about sufficient numbers.
I suspect that the numbers are not sufficient, nor could they
ever be sufficient. If we are thinking about asthma in hairdressers,
to be able to have individuals who are going to be able to focus
at that sort of level in such small workforces I would think is
asking a great deal, so therefore we need to look at other means
additional to HSE or ways in which HSE can be supported in terms
of bringing awareness of the problems and education as to how
to reduce their incidence over time.
Q279 Chairman: Professor Newman Taylor,
could I ask you how much you think occupational asthma is compounded
by smoking in the workplace or smoking overall?
Professor Newman Taylor:
There is evidence that for some, particularly chemical, causes
of asthma the risk of developing occupational asthma has increased.
You see that clearly with platinum salts and acid anhydrides but
they are relatively small contributors to the overall burden.
With regard to the evidence we have in terms of the extent to
which it increases the probability of getting occupational asthma,
probably it does not contribute very greatly. On the other hand,
if you are a cigarette smoker and you develop this disease then
the consequences may be worse because you are smoking as well
as having asthma due to this.
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