Last reviewed 25 September 2013

Caroline Raine discusses the findings identified in the European Lung White Book and the trends that emerge between air pollution, smoking, occupational health and lung disease.


The European Respiratory Society (ERS) recently published the European Lung White Book using data from the World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC). The report analyses trends in lung disease. The European Respiratory Society (ERS) was established in 1990, as a non-profit organisation that is devoted to ensuring that “every breath counts”. The first White Book, published in 2003, highlighted the problem of lung disease across Europe. This latest report re-emphasises the problems and highlights key facts and figures. Factors resulting in lung disease are considered and discussed, and recommendations are suggested.

  1. Lung diseases are responsible for 86% of deaths in Europe. There is a large financial strain associated with the disease.

  2. Smoking is a key factor in most cases of lung disease.

  3. There is limited awareness and understanding, including a severe absence of surveillance data.

  4. Air pollution is considered to be a serious respiratory health issue. Many European air quality standards are far lower than WHO recommended levels.

Economic impact

The report reflects on the associated financial burden respiratory disease costs the EU. It is estimated that more than €380 billion a year is spent directly and indirectly. Direct costs associated with medical care include hospitalisation, rehabilitation, medication, tests, doctors and medical staff costs. Indirect costs are caused by time off work and premature death. Within Europe, approximately 66,155 working days per 100,000 of the population are lost per annum due to diseases of the respiratory tract.


Smoking-related diseases are considered within the report in great detail, predicting that lung cancer and chronic obstructive pulmonary disease (COPD) will rise over the next 20 years because of past smoking rates. It also indicates that more people today than ever known in history smoke. The report spells out the hard harsh facts that “smoking does kill” — 90% of chronic obstructive pulmonary disease, and 80–85% of lung cancer are shown to be directly linked to tobacco smoking. Despite the fact that the report heavily emphasises smoking, there are, of course, many other factors that can cause lung disease: genetic influences, nutritional, environmental and poverty-related factors. The human respiratory tract is also vulnerable to infectious agents.

Air pollution

Since the early 1930s, outdoor air pollution has been known to be related to adverse respiratory effects. An increase in the concentration of particulate matter (PM), black smoke and sulphur dioxide are all known to increase the risk of death from a respiratory disease. Indoor air pollution has also been highlighted as a serious issue. In fact, one in eight deaths in the EU are due to inhalation of air pollutants caused by PM, nitrogen dioxide (NO2) and ozone (O3). Inhalation of PM causes irritation and damage to the lungs; ozone causes respiratory problems and is known to trigger asthma, while nitrogen dioxide causes reduced lung function.

Occupational health

Changes in workplace legislation have contributed towards the advance of workplace conditions to help prevent inhalation of pollutants, but it was noted that many air quality standards need to be improved. Cases of silica and asbestos exposure are still being seen, and this is due to the latency period. In addition, exposure to diisocyanates and beryllium is still increasing, hence an increase in cases of asthma and berylliosis.

Occupational agents are known to cause 15% of respiratory cancers in men and 5% in women, 17% of all adult asthma cases, 15–20% of chronic obstructive pulmonary disease (COPD) cases and 10% of interstitial lung disease cases.

The key points of the report with regards to occupational health include the following.

  • A detailed history is key when assessing a worker's occupational exposure risk and establishing a diagnosis. The latency of occupational respiratory diseases can range from a few hours to 50 years.

  • National and international bodies set maximum allowable workplace concentrations for a wide range of substances. However, these limits are not usually set at a level designed to avoid sensitisation.

  • The effects of workplace respiratory exposures can be life-changing, ranging from acute inhalation injuries to lung cancer, and running the full spectrum of pleural, interstitial and inflammatory respiratory disease.

Exposure history and assessment

Detailed history is identified as being key — so what should be included in the history of occupational exposure?

The components of a thorough occupational exposure history are detailed in the report and are stated (taken directly from the report) as follows.

  • Job type and activities: employer, products the company produces, job title, years worked, description of job tasks or activities, description of all equipment and materials the patient used, description of process changes and dates they occurred, any temporal association between symptoms and days worked.

  • Exposure estimate: visible dust or mist in the air and estimated visibility, dust on surfaces, visible dust in sputum (or nasal discharge) at end of work shift, hours worked per day and days per week, open or closed work process system, presence and description of engineering controls on work processes (for instance, wet process, local exhaust ventilation), personal protective equipment used (type, training, testing for fit and comfort and storage locations), sick co-workers.

  • Bystander exposures at work: job activities and materials used at surrounding work stations, timing of worksite cleaning (during or after shift), individual performing clean-up and process used (wet versus dry).

  • Bystander exposure at home: spouse’s job, whether spouse wears work clothes at home and who cleans them, surrounding industries.

  • Other: hobbies, pets, problems with home heating or air-conditioning, humidifier and hot tub use, water damage in the home.


It is clear from the report that while industry has taken some positive steps towards reducing exposure, there is clearly room for improvement. Employers need to start recording occupational exposure and introduce more controls to ensure that air quality standards are met.

What is interesting is that despite the fact that the information in the report is harsh and to the point, suggesting that smoking and pollutant inhalation are primary causes of death, the exposure levels recommended are significantly lower than those supplied by the HSE.

The Scientific Committee on Occupational Exposure Limit Values (SCOEL) advises the Commission on occupational exposure limits for chemicals in the workplace. Compared to the UK exposure limits, the recommended limits are much lower. For example, for respirable silica dust, the advice is that exposure should be no more than 0.05mg/m3, yet in the UK EH40 lists the 8-hour exposure limit to be 0.1mg/m3. Likewise with man-made mineral fibres (MMMFs), the advice from the SCOEL is a level of 0.03mg/m3; EH40 is listed as 5mg/m3.

The European Lung White Book highlights some alarming facts and is hard hitting. Workplace exposure limits need to be kept to a minimum and those who smoke need to stop.

Where to find the information

The European Lung White Book can be found on the ERS website and can also be purchased from the ERS Bookshop for a fee of €40 for members and €45 for non-members.

The European Lung Foundation (ELF) works closely with the European Respiratory Society (ERS) and has jointly produced a brochure which summarises the key facts and information from the European White Book. This can be downloaded from the ELF website.

Scientific Committee on Occupational Exposure Limits is available from the EC website.