Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Risk factors for COPD in people who have never smoked

  Chronic obstructive pulmonary disease (COPD) is often associated with cigarettes, but tobacco exposure is not a requirement for developing the condition. A meaningful number of people with airflow limitation have never been regular smokers. Their illness may be linked to workplace exposures, household smoke, air pollution, childhood lung problems, genetics or long-term inflammation.

  This matters in Australia because breathlessness and a persistent cough are sometimes attributed to ageing, asthma, poor fitness or repeated chest infections. People living in regional and remote areas may also face longer travel times to spirometry, respiratory specialists and pulmonary rehabilitation. Recognising risk factors early can lead to better testing and treatment.

  The disease can develop gradually. Symptoms may include exertional shortness of breath, wheeze, phlegm, reduced exercise tolerance and frequent flare-ups. Some people adapt their routines for years before seeking help, especially if they believe COPD only affects smokers.

  A careful history should include home, workplace and community exposures, as well as previous diagnoses and family history. Respiratory medicine research discussed through the APSR congress site reflects the importance of considering COPD as a diverse condition rather than a single smoking-related disease.

  Occupational dust and chemical exposure

  Workplace exposure is an important cause of chronic airway injury in never-smokers. Dust from coal, silica, cement, grain, wood and textiles can irritate the bronchi and contribute to persistent airflow obstruction. Welding fumes, diesel exhaust, solvents and other industrial chemicals may also damage lung tissue after repeated or prolonged exposure.

  Australian examples include mining and quarry work in Western Australia and Queensland, construction around major cities, farming in regional New South Wales and grain handling in South Australia. A person may have used respiratory protection inconsistently, worked in poorly ventilated areas or carried dust home on clothing. These details are clinically relevant even when the person has never smoked.

  Indoor smoke and outdoor air pollution

  Second-hand tobacco smoke can affect lung development and accelerate chronic respiratory symptoms. Exposure may occur during childhood, through a partner or in workplaces and social settings where smoke was once common. Historical exposure can still matter because lung damage and reduced respiratory reserve may become more apparent decades later.

  Smoke from wood heaters, hazard-reduction burns and bushfires is another Australian concern. During severe fire seasons, communities in New South Wales, Victoria and South Australia can experience prolonged periods of fine-particle pollution. Urban traffic, industrial emissions and dust storms add to the burden, particularly for people with asthma or other pre-existing airway disease.

  Early-life and existing lung conditions

  Lung growth during pregnancy, infancy and childhood influences respiratory health in adulthood. Premature birth, low birth weight, recurrent lower respiratory infections and prolonged exposure to household smoke may leave a person with a smaller respiratory reserve. Severe childhood asthma can also result in fixed airflow limitation that resembles COPD later in life.

  A history of tuberculosis, bronchiectasis or repeated pneumonia should be explored when a never-smoker has chronic breathlessness. In some Aboriginal and Torres Strait Islander communities, preventable infections, overcrowded housing and barriers to consistent primary care can contribute to long-term respiratory disease. Care should be culturally safe and adapted to local access, transport and language needs.

  Genetics, ageing and immune factors

  Alpha-1 antitrypsin deficiency is the best-known inherited risk for COPD in someone who has never smoked. This uncommon condition can cause emphysema at a younger age, particularly when there is a family history of early COPD or unexplained liver disease. Genetic testing is not necessary for everyone, but clinicians may consider it when the presentation is unusual.

  Ageing can reveal the effects of earlier exposures, even when current living conditions are healthy. Autoimmune conditions, chronic inflammation and some immune deficiencies may also increase susceptibility to lung damage. These factors do not prove that COPD is present, but they can help determine whether spirometry and specialist assessment are appropriate.

  Asthma, symptoms and accurate diagnosis

  Asthma and COPD can overlap, and a never-smoker with wheeze may be diagnosed with asthma without further evaluation. Asthma typically has variable symptoms and airflow limitation, while COPD usually involves persistent obstruction, although real patients may show features of both. A clinical history alone cannot reliably distinguish them.

  Spirometry after appropriate clinical assessment is central to identifying persistent airflow obstruction. Chest imaging, blood tests, gas measurements or specialist review may be added when symptoms are severe, the diagnosis is uncertain or another condition is suspected. Breathlessness may also arise from heart disease, anaemia, obesity, deconditioning or anxiety, so a broad assessment is important.

  Prevention and care across Australia

  Reducing exposure remains useful at any stage. Employers should control dust and fumes at the source, maintain ventilation and provide properly fitted respiratory protection. At home, improving ventilation, avoiding indoor smoke and following public health advice during bushfire events can reduce inhaled pollutants. People exposed to workplace hazards can discuss monitoring and controls with an occupational health service.

  Treatment depends on the individual and may include inhaled medicines, vaccinations, pulmonary rehabilitation, physical activity and an action plan for flare-ups. In Australia, access can vary between metropolitan services and rural or remote communities, making general practice, Aboriginal Community Controlled Health Services, telehealth and outreach programs important parts of care. Smoking cessation remains valuable for anyone who smokes, but it should not be treated as the only explanation or intervention for a never-smoker’s respiratory symptoms.

  A persistent cough, regular phlegm or breathlessness that limits ordinary activity deserves assessment rather than assumption. The practical next step is to book a GP appointment and provide a clear record of occupational exposures, bushfire or household smoke exposure, childhood lung illness, family history and current symptoms.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)