Biomarkers of exposure to environmental tobacco smoke in infants

Non-invasive biomonitoring of exposure to environmental tobacco smoke (ETS) by means of hair is attractive in children, although systematic evaluation is required in infants. The objective was to compare nicotine and cotinine concentrations in hair and plasma and parentally reported exposure to ETS in a birth cohort of 411 infants. Plasma was collected from 356 six-month-old infants and hair samples were collected from 368 one-year-old infants. Concentrations of nicotine and cotinine were measured by an optimized gas chromatography-mass spectrometry (GC/MS)-based method requiring 4 mg hair or 200 µl plasma. Information was obtained on the number of days with ETS exposure during the first year of life, the smoking habits of the parents, and the number of cigarettes smoked per day in the home. All three parentally reported indices of ETS exposure were significantly associated with the biomarkers, with clear dose-response relationships. There was a significant association between days with ETS exposure and nicotine in hair at relatively low exposure levels (10-99 days per year), whereas the other biomarkers only showed significant increases at higher exposure levels. In conclusion, nicotine in hair appears to be the biomarker most strongly associated with parental reports on exposure to ETS in infants.     

Biomarkers of exposure to environmental tobacco smoke in infants

Non-invasive biomonitoring of exposure to environmental tobacco smoke (ETS) by means of hair is attractive in children, although systematic evaluation is required in infants. The objective was to compare nicotine and cotinine concentrations in hair and plasma and parentally reported exposure to ETS in a birth cohort of 411 infants. Plasma was collected from 356 six-month-old infants and hair samples were collected from 368 one-year-old infants. Concentrations of nicotine and cotinine were measured by an optimized gas chromatography-mass spectrometry (GC/MS)-based method requiring 4 mg hair or 200 µl plasma. Information was obtained on the number of days with ETS exposure during the first year of life, the smoking habits of the parents, and the number of cigarettes smoked per day in the home. All three parentally reported indices of ETS exposure were significantly associated with the biomarkers, with clear dose–response relationships. There was a significant association between days with ETS exposure and nicotine in hair at relatively low exposure levels (10–99 days per year), whereas the other biomarkers only showed significant increases at higher exposure levels. In conclusion, nicotine in hair appears to be the biomarker most strongly associated with parental reports on exposure to ETS in infants.     

Environmental tobacco smoke in the workplace: markers of exposure, polymorphic enzymes and implications for disease state

Studies focusing directly on tobacco smoke have tended to center on the differences in effect between smokers and non-smokers and many hundreds of such studies have been performed. In this review, we examine the current literature specifically concerning workplace exposure to environmental tobacco smoke (ETS) and its impact on individuals, particularly non-smokers and never smokers. The paper deals with quantifying and minimizing ETS exposures in a working environment, the effect of polymorphisms and other genetic factors that influence health outcomes after exposure to ETS and the association of occupational ETS exposure to disease-specific biomarkers.     

NAD(P)H: Quinone oxidoreductase 1, glutathione S-transferase M1, environmental tobacco smoke exposure, and childhood asthma

Environmental tobacco smoke (ETS) exposure might increase the risk for childhood asthma, and we hypothesized the effect may be modified by the phase II genes NAD(P)H: quinone oxidoreductase 1 (NQO1) and glutathione S-transferase (GST) M1. To investigate the genetic and environmental associations with asthma, GSTM1 and NQO1 functional polymorphisms and ETS were analyzed in a two-staged cross-sectional study among elementary schoolchildren in Taiwan. Multiple logistic regression analysis revealed a significant association between the Ser allele of the NQO1 Pro187Ser polymorphism and asthma (OR = 1.6, 95% CI 1.3–1.8). Although GSTM1 genotype itself was not significantly associated with asthma (OR = 1.0, 95% CI 0.8–1.1), the GSTM1 genotype modified the association between the NQO1 polymorphism and asthma in children exposed to ETS (p = 0.0002). The NQO1 gene might be involved in the development of asthma, especially in children carrying the GSTM1 null genotype who are exposed to ETS.     

Reaction of tobacco smoke aldehydes with human hemoglobin

Formaldehyde, acetaldehyde, propionaldehyde, butyraldehyde, isobutyraldehyde, and acrolein, all of which are constituents of tobacco smoke, were reacted in 5 mM concentration with the purified major fraction of normal adult human hemoglobin (hemoglobin Ao) in 1 mM concentration. A cigarette smoke condensate, diluted to contain 5 mM total aldehydes, was also reacted with 1 mM hemoglobin Ao. Cationic exchange high-performance liquid chromatography (HPLC) showed that the products formed from simple aliphatic aldehydes, with the exception of formaldehyde, were analogues of those formed from acetaldehyde, earlier shown by us to be imidazolidinone derivatives, that is, cyclic addition products of the N-terminal aminoamide function of α and β chains. Formaldehyde and acrolein produced a heterogeneous mixture of derivatives including crosslinked hemoglobin dimers. The greater proportion of modified hemoglobins produced by condensate aldehydes resembled those formed from acetaldehyde, the most abundant aldehyde in the condensate. A smaller fraction consisted of crosslinked hemoglobin dimers, presumably due to the action of formaldehyde. Mass spectrometric and HPLC analyses of the 2,4-dinitrophenylhydrazones precipitated from the condensate documented the presence of formaldehyde, acetaldehyde, propionaldehyde, butyraldehyde, furfsral, and methylfurfural. The toxicity of aldehydes is briefly discussed in the context of the findings of this study.     

Different genes interact with particulate matter and tobacco smoke exposure in affecting lung function decline in the general population

Background

Oxidative stress related genes modify the effects of ambient air pollution or tobacco smoking on lung function decline. The impact of interactions might be substantial, but previous studies mostly focused on main effects of single genes.

Objectives

We studied the interaction of both exposures with a broad set of oxidative-stress related candidate genes and pathways on lung function decline and contrasted interactions between exposures.

Methods

For 12679 single nucleotide polymorphisms (SNPs), change in forced expiratory volume in one second (FEV₁), FEV₁ over forced vital capacity (FEV₁/FVC), and mean forced expiratory flow between 25 and 75% of the FVC (FEF_25-75) was regressed on interval exposure to particulate matter <10 µm in diameter (PM10) or packyears smoked (a), additive SNP effects (b), and interaction terms between (a) and (b) in 669 adults with GWAS data. Interaction p-values for 152 genes and 14 pathways were calculated by the adaptive rank truncation product (ARTP) method, and compared between exposures. Interaction effect sizes were contrasted for the strongest SNPs of nominally significant genes (p_interaction<0.05). Replication was attempted for SNPs with MAF>10% in 3320 SAPALDIA participants without GWAS.

Results

On the SNP-level, rs2035268 in gene SNCA accelerated FEV₁/FVC decline by 3.8% (p_interaction = 2.5×10⁻⁶), and rs12190800 in PARK2 attenuated FEV1 decline by 95.1 ml p_interaction = 9.7×10⁻⁸) over 11 years, while interacting with PM10. Genes and pathways nominally interacting with PM10 and packyears exposure differed substantially. Gene CRISP2 presented a significant interaction with PM10 (p_interaction = 3.0×10⁻⁴) on FEV₁/FVC decline. Pathway interactions were weak. Replications for the strongest SNPs in PARK2 and CRISP2 were not successful.

Conclusions

Consistent with a stratified response to increasing oxidative stress, different genes and pathways potentially mediate PM10 and tobacco smoke effects on lung function decline. Ignoring environmental exposures would miss these patterns, but achieving sufficient sample size and comparability across study samples is challenging.     

Environmental tobacco smoke effects on lung surfactant film organization

Adsorption of the clinical lung surfactants (LS) Curosurf or Survanta from aqueous suspension to the air-water interface progresses from multi-bilayer aggregates through multilayer films to a coexistence between multilayer and monolayer domains. Exposure to environmental tobacco smoke (ETS) alters this progression as shown by Langmuir isotherms, fluorescence microscopy and atomic force microscopy (AFM). After 12 h of LS exposure to ETS, AFM images of Langmuir-Blodgett deposited films show that ETS reduces the amount of material near the interface and alters how surfactant is removed from the interface during compression. For Curosurf, ETS prevents refining of the film composition during cycling; this leads to higher minimum surface tensions. ETS also changes the morphology of the Curosurf film by reducing the size of condensed phase domains from 8-12 μm to ∼ 2 μm, suggesting a decrease in the line tension between the domains. The minimum surface tension and morphology of the Survanta film are less impacted by ETS exposure, although the amount of material associated with the film is reduced in a similar way to Curosurf. Fluorescence and mass spectra of Survanta dispersions containing native bovine SP-B treated with ETS indicate the oxidative degradation of protein aromatic amino acid residue side chains. Native bovine SP-C isolated from ETS exposed Survanta had changes in molecular mass consistent with deacylation of the lipoprotein. Fourier Transform Infrared Spectroscopy (FTIR) characterization of the hydrophobic proteins from ETS treated Survanta dispersions show significant changes in the conformation of SP-B and SP-C that correlate with the altered surface activity and morphology of the lipid-protein film.     

Cigarette smoke alters the secretome of lung epithelial cells

Cigarette smoke is the most relevant risk factor for the development of lung cancer and chronic obstructive pulmonary disease. Many of its more than 4500 chemicals are highly reactive, thereby altering protein structure and function. Here, we used subcellular fractionation coupled to label‐free quantitative MS to globally assess alterations in the proteome of different compartments of lung epithelial cells upon exposure to cigarette smoke extract. Proteomic profiling of the human alveolar derived cell line A549 revealed the most pronounced changes within the cellular secretome with preferential downregulation of proteins involved in wound healing and extracellular matrix organization. In particular, secretion of secreted protein acidic and rich in cysteine, a matricellular protein that functions in tissue response to injury, was consistently diminished by cigarette smoke extract in various pulmonary epithelial cell lines and primary cells of human and mouse origin as well as in mouse ex vivo lung tissue cultures. Our study reveals a previously unrecognized acute response of lung epithelial cells to cigarette smoke that includes altered secretion of proteins involved in extracellular matrix organization and wound healing. This may contribute to sustained alterations in tissue remodeling as observed in lung cancer and chronic obstructive pulmonary disease.     

Acute effects of smoking and high experimental exposure to environmental tobacco smoke (ETS) on the immune system

Controversial results have been published on the immune response to cigarette smoking while the effects of exposure to environmental tobacco smoke (ETS) have not yet been reported. In a controlled study, acute effects of smoking and of a high environmental exposure to ETS on immunological parameters have been investigated. The study consisted of four experimental days, two control and two exposure days. On control days, 1 and 3, smokers (n=5) and nonsmokers (n=5) sat in an unventilated 45 m³ room for 8 h. On the exposure days, 2 and 4, each of the smokers smoked 24 cigarettes in 8 h, while the nonsmokers were exposed to the ETS generated by the smoking volunteers. Blood was drawn before and after each exposure session on all four experimental days for dosimetry of tobacco smoke exposure and determination of the immune response. Flow cytometry using monoclonal antibodies was used to determine CD3⁺ cells (whole T cells), CD19⁺ cells (B lymphocytes), CD16⁺ and CD56⁺ cells (natural killer cells), CD4⁺ cells (T-helper cells), CD8⁺ cells (T-suppressor cells), the CD4⁺/CD8⁺ (helper/supressor ratio), and Fc receptors on granulocytes. Serum was analyzed for soluble CD14 receptors (scD14), interleukin 1, interleukin 6 and prostaglandin E₂ (PGE₂). Functional stimulation assays were performed to determine the basal and induced level of reactive oxygen intermediate (ROI) production by polymorphic neutrophils. Exposure to tobacco smoke in both groups was confirmed by dosimetry of carboxyhemoglobin, plasma nicotine, and cotinine levels. In comparison to nonsmokers, smokers had elevated granulocyte cell counts, increased CD16⁺ and CD56⁺ cell levels and decreased CD3⁺ and CD19⁺ levels. Acute smoking, but not exposure to ETS, resulted in a slight decrease in the number of CD19⁺ cells and an increase in the number of granulocytes; the latter was restricted to one subject. Acute smoking and exposure to high experimental concentrations of ETS resulted in a slight increase in CD16⁺ and CD56⁺ cells. None of the changes determined in immunological parameters after either acute smoking or exposure to ETS reached statistical significance. Serum sCD14, cytokine and PGE₂, functional stimulation of in vitro ROI production, and changes in Fc receptors were not affected by acute smoking or exposure to ETS. Although no clear guidelines exist to assess immunotoxicity in man, our data do not favor immunosuppression and the possibility of increased risk of infection in nonsmokers exposed to ETS under real-life conditions.Abbreviations AM alveolar macrophage - BALF bronchoalveolar lavage fluid - CO carbon monoxide - CO₂ carbon dioxide - COHb carboxyhemoglobin - ELISA enzyme linked immunoassay - ETS environmental tobacco smoke - FITC fluorescein isothiocyanate - IL interleukin - MHC major histocompatibility complex - NK natural killer cell - NO nitrogen oxide - NO₂ nitrogen dioxide - PBS phosphate-buffered saline - PE phycoerythrin - PGE₂ prostaglandin E₂ - PMA phorbol-12-myristate-13-acetate - PMN polymorphic neutrophils - RIA radioimmunoassay - ROI reactive oxygen intermediates - RSP respirable suspended particles - sCD14 soluble CD14 receptor     

Tobacco smoke is a likely source of lead and cadmium in settled house dust

IntroductionEnvironmental exposure to lead (Pb) and cadmium (Cd) are risk factors for adverse health outcomes in children and adults. This study examined whether thirdhand smoke residue contributes to Pb and Cd in settled house dust.MethodsParticipants were 60 multiunit housing residents in San Diego, California. All had indoor smoking bans during the study period, and 55 were nonsmokers. Wipe samples from different surfaces and vacuum floor dust samples were analyzed for nicotine, a marker of thirdhand smoke, and for Pb and Cd using liquid chromatography-triple quadrupole mass spectrometry and inductively coupled plasma-mass spectrometry, respectively.ResultsExamined in each sample type separately, Pb and Cd loadings were significantly correlated (r = 0.73, vacuum floor dust; 0.52, floor wipes; 0.72, window sill/trough wipes; all p < 0.0025). Pb and Cd loadings from different sample types were not correlated (all p > 0.30). Nicotine loading in dust was significantly correlated with Pb and Cd loading in dust (r = 0.49 for Pb; r = 0.39 for Cd, all p < 0.0025). Pb and Cd loadings on floor or window surfaces, showed no association with nicotine loading in dust, on floors, or on furniture (all p < 0.30).ConclusionsTobacco smoke is a likely source of Pb and Cd that accumulates in settled house dust in multiunit housing, suggesting that Pb and Cd are constituents of thirdhand smoke that lingers long after smoking has ended.     

The accumulated evidence on lung cancer and environmental tobacco smoke.

OBJECTIVE: To estimate the risk of lung cancer in lifelong non-smokers exposed to environmental tobacco smoke. DESIGN: Analysis of 37 published epidemiological studies of the risk of lung cancer (4626 cases) in non-smokers who did and did not live with a smoker. The risk estimate was compared with that from linear extrapolation of the risk in smokers using seven studies of biochemical markers of tobacco smoke intake. MAIN OUTCOME MEASURE: Relative risk of lung cancer in lifelong non-smokers according to whether the spouse currently smoked or had never smoked. RESULTS: The excess risk of lung cancer was 24% (95% confidence interval 13% to 36%) in non-smokers who lived with a smoker (P < 0.001). Adjustment for the effects of bias (positive and negative) and dietary confounding had little overall effect; the adjusted excess risk was 26% (7% to 47%). The dose-response relation of the risk of lung cancer with both the number of cigarettes smoked by the spouse and the duration of exposure was significant. The excess risk derived by linear extrapolation from that in smokers was 19%, similar to the direct estimate of 26%. CONCLUSION: The epidemiological and biochemical evidence on exposure to environmental tobacco smoke, with the supporting evidence of tobacco specific carcinogens in the blood and urine of non-smokers exposed to environmental tobacco smoke, provides compelling confirmation that breathing other people''s tobacco smoke is a cause of lung cancer.     

Exposure to tobacco smoke and low birth weight: from epidemiology to metabolomics

Introduction: The exposure to tobacco smoke during pregnancy is one of the leading causes of perinatal adverse outcomes such as stillbirth, intrauterine growth restriction (IUGR), and low birth weight, but the underlying biological mechanisms are still unclear. The incidence of this phenomenon maybe largely underestimated since the evaluation is made mainly by self-assessment questionnaires rather than measuring nicotine metabolites (such as cotinine) in biological fluids. In this context metabolomics may be useful to assess the actual number of pregnant women and to highlight the pathophysiological mechanisms that lead to the abovementioned adverse outcomes.

Areas covered: The aims of this review are to analyze the literature and the application of the omics sciences, such as genomics and metabolomics concerning the negative effects of smoking during pregnancy in order to give a comprehensive picture of all the study made so far and to point out the potential of metabolomics as an investigative, predictive, and diagnostic tool.

Expert commentary: Metabolomics in recent years has proved an excellent tool to try to understand the problems in perinatal medicine. With the increase in the number of studies we are convinced that it can be a useful instrument of investigation in this field.     

Population burden of lung cancer due to environmental tobacco smoke

The population burden of lung cancer due to environmental tobacco smoke is significant because a large fraction of the population is exposed. The risks are, of course, lower than those to smokers themselves; but smoking is self-inflicted, passive smoking is involuntary. Making various assumptions, the proportion of lung cancer cases among non-smokers that could reasonably be attributed to environmental tobacco smoke can be calculated to be about 20–30% in western countries. Thus, non-smokers in the society could benefit considerably from diminishing exposures to other people's smoke.     

Quantification of cotinine in dried blood spots as a biomarker of exposure to tobacco smoke

Objective: We present an ultra-sensitive, minimally-invasive method for quantifying cotinine in dried blood spot (DBS) samples as a biomarker of exposure to tobacco smoke that can be collected using a simple heel or finger prick to obtain blood samples.

Methods: Cotinine levels were measured in matched plasma and reconstituted DBS samples from smokers and nonsmokers to evaluate assay parameters. In addition, we applied this new method to finger-prick DBS samples that were collected from infants, children and young adults ages 1–21 to estimate exposure to tobacco smoke. Partitioning of cotinine across red blood cells and haematocrit effects were investigated.

Results: Cotinine levels measured in matched plasma and reconstituted DBS samples from smokers and nonsmokers were found to be highly correlated (R²=0.94), with 100% sensitivity and 94% specificity to differentiate reported smokers from nonsmokers. With this method, the LOQ is <0.25?ng/mL using a single 3.2?mm punch of a DBS, and haematocrit effects are negligible.

Conclusions: This sensitive, high-throughput and minimally-invasive method for quantifying cotinine in DBS samples provides a simple and cost effective means for estimating exposure to tobacco smoke in population based studies, and has particular advantages in studies involving infants and children.     

Environmental tobacco smoke and sudden infant death syndrome: a review

Environmental tobacco smoke (ETS), containing the developmental neurotoxicant, nicotine, is a prevalent component of indoor air pollution. Despite a strong association with active maternal smoking and sudden infant death syndrome (SIDS), information on the risk of SIDS due to prenatal and postnatal ETS exposure is relatively inconsistent. This literature review begins with a discussion and critique of existing epidemiologic data pertaining to ETS and SIDS. It then explores the biologic plausibility of this association, with comparison of the known association between active maternal smoking and SIDS, by examining metabolic and placental transfer issues associated with nicotine, and the biologic responses and mechanisms that may follow exposure to nicotine. Evidence indicates that prenatal and postnatal exposures to nicotine do occur from ETS exposure, but that the level of exposure is often substantially less than levels induced by active maternal smoking. Nicotine also has the capacity to concentrate in the fetus, regardless of exposure source. Experimental animal studies show that various doses of nicotine are capable of affecting a neonate's response to hypoxic conditions, a process thought to be related to SIDS outcomes. Mechanisms contributing to deficient hypoxia response include the ability of nicotine to act as a cholinergic stimulant through nicotinic acetylcholine receptor (nAChR) binding. The need for future research to investigate nicotine exposure and effects from non-maternal tobacco smoke sources in mid to late gestation is emphasized, along with a need to discourage smoking around both pregnant women and infants.     

Proteomic profiling of human respiratory epithelia by iTRAQ reveals biomarkers of exposure and harm by tobacco smoke components

Historically, it has been challenging to go beyond epidemiology to investigate the pathogenic changes caused by tobacco smoking. The EpiAirway-100 (MatTek Corp., Ashland, MA) was employed to investigate the effects of cigarette smoke components. Exposure at the air-liquid-interface represented particle and vapour phase components of cigarette smoke. A proteomic study utilising iTRAQ labelling compared expression profiles. The correlative histopathology revealed focal regions of hyperplasia, hypertrophy, cytolysis and necrosis. We identified 466 proteins, 250 with a parameter of two or more peptides. Four of these proteins are potential markers of lung injury and three are related to mechanistic pathways of disease.     

Management of Braula orientalis Örösi (Diptera: Braulidae) in honeybee colonies with tobacco smoke under semiarid conditions

In the present study, bee colonies were smoked with tobacco smoke in order to evaluate the monthly changes in the numbers of worker bees, the infestation rates of worker bees and queens with bee lice, and the annual average honey production per colony. In July of each year, 12 colonies were smoked with tobacco smoke; the remaining hives not smoked with tobacco smoke served as the control. The results indicated that the applications of tobacco smoke during July gave rise to an impressive reduction in the Braula infestation rate on workers (below 1.8%) and reduced the amount of bee lice on the queen to zero throughout the 2–3 months following smoke treatment. In the colonies not treated with smoke, the Braula infestation rates on worker bees started to increase in May and continued to increase constantly during the rest of year, reaching maximum infestation rates of 28.2% and 33.8% in December, with an average of 15 and 17 lice per queen in November in the first and second years, respectively. Worker bee populations peaked in April and July of each year in both treatments. The average honey production per colony was significantly higher in the colonies treated with smoke than those that were not for the first and second years. In conclusion, early summer months may be the crucial time to smoke the colonies with tobacco smoke in order to keep bee lice at low levels for the remaining seasons.     

The effect of coal stoves and environmental tobacco smoke on the level of urinary 1-hydroxypyrene

The objective of this study was to investigate a relationship between indoor air pollution from heating and cooking with coal-burning stoves and from environmental tobacco smoke (ETS), and the level of urinary 1-hydroxypyrene (1-OH-PY). 1-OH-PY was analysed in children living in three areas of Silesia, a province in Poland. Urine samples were collected in winter, (1) from children exposed to ETS and smoke resulting from indoor coal-burning and (2) from control children. Airborne particulates had been sampled by use of stationary samplers by the Regional Sanitary-Epidemiological Station, Katowice throughout 12 months prior to the urine sampling. The urinary level of 1-OH-PY tended to increase in children exposed to ETS, but the increase was not significant. The concentrations of 1-OH-PY in urine of passive smokers were significantly elevated only in Bytom where an index of smoking parents of the studied children was highest as compared to other areas. Exposure to polycyclic aromatic hydrocarbons (PAH) due to domestic heating and cooking with coal-burning stoves resulted in significantly increased levels of 1-OH-PY. The results of this study indicate that the uptake of PAH due to indoor air pollution strongly affected the level of 1-OH-PY and that the main source of PAH in indoor air was the household use of coal for heating and/or cooking. When the results associated with this kind of exposure were excluded, median 1-OH-PY levels from the three examined areas assumed a pattern more similar to that of the benzo(a)pyrene (BaP) concentrations in ambient air.     

Genetic variants associated with lung function: the long life family study

Background

Reduced forced expiratory volume in 1 second (FEV₁) and the ratio of FEV₁ to forced vital capacity (FVC) are strong predictors of mortality and lung function is higher among individuals with exceptional longevity. However, genetic factors associated with lung function in individuals with exceptional longevity have not been identified.

Method

We conducted a genome wide association study (GWAS) to identify novel genetic variants associated with lung function in the Long Life Family Study (LLFS) (n = 3,899). Replication was performed using data from the CHARGE/SpiroMeta consortia. The association between SNPs and FEV₁ and FEV₁/FVC was analyzed using a linear mixed effects model adjusted for age, age², sex, height, field center, ancestry principal components and kinship structure to adjust for family relationships separately for ever smokers and never smokers. In the linkage analysis, we used the residuals of the FEV₁ and FEV₁/FVC, adjusted for age, sex, height, ancestry principal components (PCs), smoking status, pack-years, and field center.

Results

We identified nine SNPs in strong linkage disequilibrium in the CYP2U1 gene to be associated with FEV₁ and a novel SNP (rs889574) associated with FEV₁/FVC, none of which were replicated in the CHARGE/SpiroMeta consortia. Using linkage analysis, we identified a novel linkage peak in chromosome 2 at 219 cM for FEV₁/FVC (LOD: 3.29) and confirmed a previously reported linkage peak in chromosome 6 at 28 cM (LOD: 3.33) for FEV₁.

Conclusion

Future studies need to identify the rare genetic variants underlying the linkage peak in chromosome 6 for FEV₁.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-014-0134-x) contains supplementary material, which is available to authorized users.