0
Original Research: Asthma |

Experiences of Racism and the Incidence of Adult-Onset Asthma in the Black Women’s Health StudyRacism and Adult-Onset Asthma FREE TO VIEW

Patricia F. Coogan, ScD; Jeffrey Yu, MPH; George T. O’Connor, MD, FCCP; Timothy A. Brown, PsyD; Yvette C. Cozier, ScD; Julie R. Palmer, ScD; Lynn Rosenberg, ScD
Author and Funding Information

From the Slone Epidemiology Center at Boston University (Drs Coogan, Cozier, Palmer, and Rosenberg and Mr Yu); Boston University School of Medicine (Dr O’Connor); and the Center for Anxiety and Related Disorders (Dr Brown), Boston University, Boston, MA.

Correspondence to: Patricia F. Coogan, ScD, Slone Epidemiology Center at Boston University, 1010 Commonwealth Ave, Boston, MA 02215; e-mail: pcoogan@bu.edu


For editorial comment see page 442

Funding/Support: This work was funded by grants from the National Heart, Lung, and Blood Institute [R01 HL107314] and the National Cancer Institute [R01 CA058420].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(3):480-485. doi:10.1378/chest.13-0665
Text Size: A A A
Published online

Background:  Chronic stress resulting from experiences of racism may increase the incidence of adult-onset asthma through effects on the immune system and the airways. We conducted prospective analyses of the relation of experiences of racism with asthma incidence in the Black Women’s Health Study, a prospective cohort of black women in the United States followed since 1995 with mailed biennial questionnaires.

Methods:  Among 38,142 participants followed from 1997 to 2011, 1,068 reported incident asthma. An everyday racism score was created based on five questions asked in 1997 and 2009 about the frequency in daily life of experiences of racism (eg, poor service in stores), and a lifetime racism score was based on questions about racism on the job, in housing, and by police. We used Cox regression models to derive multivariable incidence rate ratios (IRRs) and 95% CIs for categories of each racism score in relation to incident asthma.

Results:  The IRRs were 1.45 (95% CI, 1.19-1.78) for the highest compared with the lowest quartile of the 1997 everyday racism score (P for trend <.0001) and 1.44 (95% CI, 1.18-1.75) for the highest compared with the lowest category of 1997 lifetime racism. Among women who reported the same levels of racism in 1997 and 2009, the IRRs for the highest categories of everyday and lifetime racism were 2.12 (95% CI, 1.55-2.91) and 1.66 (95% CI, 1.20-2.30), respectively.

Conclusions:  Given the high prevalence of experiences of racism and asthma in black women in the United States, a positive association between racism and asthma is of public health importance.

The burden of asthma in the United States is high, with the prevalence rising from 3.1% in 1980 to 8.2% in 2009.1 In 2009, the annual incidence rate of adult-onset asthma was 3.8 in 1,000, and 17.5 million adults were affected by the disease.1 The established risk factors for adult-onset asthma include obesity2,3 and certain occupational exposures.4 Sedentariness,5,6 smoking,5,7 female hormone supplements,8 acetaminophen,9 and short stature5,6,10 have also been implicated.

In various studies, war-related stress,11 perceived stress,12 and abuse during childhood13 have been associated with an increased risk of adult-onset asthma. Racism is a source of stress for blacks,1418 and experiences of racism have been associated with several adverse health outcomes, including hypertension,19 preterm birth,20,21 sleep disturbance,22 and obesity.23 A stress pathway has been hypothesized to explain the association between experiences of racism and adverse health outcomes.15 The physiologic response to chronic stress, particularly its effects on the immune system and the airways,2426 may be relevant to asthma.

The objective of the current analysis was to test the hypothesis that experiences of racism are positively associated with adult-onset asthma incidence. The data were derived from 14 years of follow-up of a large cohort study of black women.

Establishment of the Black Women’s Health Study

The Black Women’s Health Study (BWHS) is a prospective cohort study established in 1995, when 59,000 black women aged 21 through 69 years enrolled by completing health questionnaires.27 The baseline questionnaire elicited information on demographic and lifestyle factors, reproductive history, and medical conditions. The cohort is followed biennially by mailed questionnaires to update exposures and ascertain incident disease. Follow-up of the original cohort through seven completed questionnaire cycles is 80%. The study protocol was approved by the institutional review board of Boston University School of Medicine (H-31125). Participants indicate consent by completing and returning the questionnaires.

Diagnosis of Asthma

On all questionnaires from 1997 through 2011, participants were asked whether they had been diagnosed with asthma in the previous 2-year interval, the year in which they had first been diagnosed, and if they used “inhalers or pills” for asthma at least 3 days per week. Adult-onset asthma was defined as an initial physician diagnosis of asthma made after 1997 through 2011, with concurrent use of asthma medication. In a subset of 43 women who met the case definition and who gave permission to contact their physicians, 39 (91%) were confirmed by the physician as having asthma.

Ascertainment of Racism

The 1997 follow-up questionnaire contained eight questions on experiences of racism adapted from an instrument developed by Williams et al.16 Five questions about everyday racism asked about the frequency in daily life of the following experiences: “You receive poorer service than other people in restaurants or stores,” “People act as if they think you are not intelligent,” “People act as if they are afraid of you,” “People act as if they think you are dishonest,” and “People act as if they are better than you.” Response options were “never,” “a few times a year,” “once a month,” “once a week,” and “almost every day,” coded as 1 through 5. An everyday racism score was created by averaging subjects’ responses to the five questions. Three questions ascertained lifetime racism by asking whether the participant was ever “treated unfairly due to your race” on the job, in housing, and by the police. Response categories were “yes” and “no.” A lifetime racism score summed the positive responses (0, 1, 2, or 3). The racism questions were asked again on the 2009 questionnaire and scored in the same way.

Covariates

Data on weight, height, and education were obtained at baseline in 1995; weight was updated on each subsequent follow-up questionnaire. Data on smoking, alcohol consumption, hours/week spent in vigorous physical activity, and use of female hormone supplements were ascertained at baseline and updated at every questionnaire cycle. In 1997, respondents were asked about exposure to secondhand tobacco smoke at ages 0 to 10 years (home), 11 to 20 years (home), 21 to 30 years (home and work), 31 to 40 years (home and work), and currently (home and work), with exposure defined as being “in the same room with a smoker for at least an hour a day for 12 consecutive months or more.” Follow-up questionnaires also obtained information on asthma in the participant’s mother or father and whether the participant had health insurance and a regular doctor (ascertained in 1997), household income (ascertained in 2003), whether the participant was abused as a child (ascertained in 2005), and whether the participant’s mother smoked when pregnant with her (ascertained in 2009).

Analytic Cohort

Follow-up for the current analysis was 1997 through 2011. Of 51,070 women who completed the 1997 questionnaire and at least one follow-up questionnaire, we excluded those who did not answer all of the racism questions (n = 4,381), had prevalent lung cancer (n = 41), were missing information on smoking (n = 27), reported childhood asthma (n = 866), or reported prevalent asthma as of 1997 (n = 4,987). We also excluded 1,110 women who reported a diagnosis of asthma but no concurrent asthma medication use, 1,430 women who reported asthma medication use but no diagnosis of asthma, and 86 women who met the case criteria but who disconfirmed having asthma on a supplemental questionnaire. After exclusions, 38,142 women remained in the analytic cohort, of whom 1,068 met the case criteria.

Statistical Analysis

We used Cox proportional hazards regression models to estimate incidence rate ratios (IRRs) and 95% CIs for incident asthma. Participants contributed person-time from 1997 until diagnosis of asthma, death, loss to follow-up, or end of follow-up, whichever came first. In an initial model, we adjusted only for age and questionnaire cycle (time period). In a multivariable model, we added covariates that may be risk factors for adult-onset asthma: BMI, weight in kg/height2 in m (< 25.0, 25.0-29.9, 30.0-34.9, 35.0-39.9, ≥ 40.0); pack years of smoking (0, 1-4, 5-14, 15-24, ≥ 25); current smoking (yes, no); exposure to secondhand smoke at each of ages 0-10, 11-20, 21-30, and 31-40 years and currently (yes, no); vigorous exercise in hours/week (0, < 5, ≥ 5); female hormone use (never, < 5 years, ≥ 5 years); parental history of asthma (yes, no, unknown); mother’s smoking status (yes, no, unknown); education in years (≤ 12, 13-15, 16, ≥ 17); household income (≤ $25,000, $25,001-50,000, $50,001-100,000, > $100,000); and alcohol consumption in drinks/week (never, past any amount, current 1-3, 4-6, 7-13, ≥ 14). Alcohol consumption was a risk factor for asthma in a large Danish study28 and was associated with asthma incidence in the BWHS. The addition of indicators for having health insurance and a regular doctor, and the presence of childhood abuse (associated with asthma incidence in the BWHS),13 did not change the results. Missing values were modeled as separate categories. We tested for trend by including the everyday and lifetime racism scores in the model as ordinal variables.

Women in the analytic cohort were followed for an average of 13 years, for a total of 227,651 person-years. At baseline in 1997, compared with women in the lowest quartile of the everyday racism score, those in the highest quartile were younger, more highly educated, and heavier; had greater exposure to secondhand smoke; and were more likely to have used female hormones, to be current drinkers, and to report more pack-years of smoking (Table 1). Women who answered “yes” to all three lifetime racism questions were older than those who answered “no” to all questions; had higher levels of education, income, and exercise; and were more likely to be current drinkers and to have been exposed to secondhand smoke.

Table Graphic Jump Location
Table 1 —Baseline Characteristics According to Summary Racism Scores, BWHS

Data are presented as % or mean ± SD. Means and percentages were standardized to the age distribution of the cohort in 1997. Extreme categories of everyday and lifetime racism are shown. BWHS = Black Women’s Health Study.

a 

Characteristics are percentages ascertained in 1997 unless noted otherwise.

Table 2 shows data on the relation between everyday and lifetime racism scores and asthma incidence. In the initial model adjusted for age and time period only, relative to the first quartile of the everyday racism score, IRRs increased with increasing quartiles to 1.68 (95% CI, 1.37-2.04) for the fourth quartile (P for trend < .0001). Adjustment for confounders in the multivariable model attenuated the association; the IRR in the highest quartile of everyday racism was 1.45 (95% CI, 1.19-1.78) (P for trend < .0001).

Table Graphic Jump Location
Table 2 —Everyday and Lifetime Racism Scores in 1997 and Asthma Incidence, BWHS, 1997-2011

IRR = incidence rate ratio; Ref = reference. See Table 1 legend for expansion of other abbreviation.

a 

Adjusted for age, time period, BMI (< 25.0, 25.0-29.9, 30.0-34.9, 35.0-39.9, ≥ 40.0 kg/m2, missing), current smoker (yes, no), pack-y of smoking (0, 1-4, 5-14, 15-24, ≥ 25, missing), secondhand smoke exposure (ages 0-10 y at home, 11-20 y at home, 21-30 y at home or work, 31-40 y at home or work, and currently at home or work) (yes, no, missing), vigorous exercise in h/wk (0, < 5, ≥ 5, missing), alcohol use in drinks/wk (never, past any amount, current 1-3, 4-6, 7-13, ≥ 14, missing), female hormone use (never, < 5 y, ≥ 5 y, missing), parental history of asthma (yes, no, unknown), mother’s smoking status (yes, no, unknown), education in years (≤ 12, 13-15, 16, ≥ 17, missing), and household income (≤ $25,000, $25,001-50,000, $50,001-100,000, > $100,000, missing).

In the initial model, the IRRs for the lifetime racism categories (Table 2) increased with increasing quartiles to 1.52 (95% CI, 1.25-1.84) in the highest compared with the lowest category. In the multivariable model, the IRR in the highest category was 1.44 (95% CI, 1.18-1.75) (P for trend = .0004).

We conducted a subanalysis confined to women who answered the racism questions in 2009 as well as in 1997; the results were similar to those shown in Table 2 (data not shown). In an analysis of women who were in the same quartile of everyday racism (n = 11,256) or category of lifetime racism (n = 13,083) in both time periods (Table 3) and may have had more consistent experiences of racism over time, the IRRs were higher than in the main analysis. The multivariable IRRs for the highest categories of everyday and lifetime racism were 2.12 (95% CI, 1.55-2.91) and 1.66 (95% CI, 1.20-2.30), respectively. In a sensitivity analysis, we expanded the incident case definition to include all physician-diagnosed asthma, regardless of medication use (n = 2,102); the results were similar to the main results (data not shown).

Table Graphic Jump Location
Table 3 —Everyday and Lifetime Racism Scores in 1997 and 2009 and Asthma Incidence Among Women With Unchanged Scores in Both Years, BWHS, 1997-2011

See Table 1 and 2 legends for expansion of abbreviations.

a 

Adjusted for age, time period, BMI (< 25.0, 25.0-29.9, 30.0-34.9, 35.0-39.9, ≥ 40.0 kg/m2, missing), current smoker (yes, no), pack-y of smoking (0, 1-4, 5-14, 15-24, ≥ 25, missing), secondhand smoke exposure (ages 0-10 y at home, 11-20 y at home, 21-30 y at home or work, 31-40 y at home or work, and currently at home or work) (yes, no, missing), vigorous exercise in h/wk (0, < 5, ≥ 5, missing), alcohol use in drinks/wk (never, past any amount, current 1-3, 4-6, 7-13, ≥ 14, missing), female hormone use (never, < 5 y, ≥ 5 y, missing), parental history of asthma (yes, no, unknown), mother’s smoking status (yes, no, unknown), education in years (≤ 12, 13-15, 16, ≥ 17, missing), and household income (≤ $25,000, $25,001-50,000, $50,001-100,000, > $100,000, missing)

b 

Includes 11,256 women who stayed in the same quartile of everyday racism in 1997 and 2009.

c 

Includes 13,083 women who stayed in the same category of lifetime racism in 1997 and 2009.

In this large population of black women, experiences of everyday and lifetime racism were associated with an increased incidence of adult-onset asthma. The associations were stronger when we confined the analyses to women who reported the same level of everyday and lifetime racism in 1997 and 2009; these women may have had more consistent experiences of racism over time.

Previous studies, none reporting on racism, have found associations between a variety of types of stress and asthma incidence.1113,29,30 A prospective study that followed children from birth to age 3 years found that the presence of maternal intimate partner violence increased the odds of doctor-diagnosed asthma (OR = 1.8; 95% CI, 1.0-3.5).30 In another study in children up to age 9 years, levels of community violence were associated with asthma risk, with an OR of 1.56 (95% CI, 1.12-2.18) for a high relative to a low level of violence.29 Several prospective studies suggest a role for stress in the development of adult-onset asthma.1113 The first was a study of the effects of war-related stress on older adults (aged 50-69 years) in Kuwait following the 1990 Iraqi invasion.11 Using a war-related stress score, the authors found that subjects at the highest level were more than twice as likely to report incident asthma over 13 years of follow-up than were those reporting no stressors (OR = 2.3; 95% CI, 1.3-3.9). In a recent Danish study, participants who reported high levels of stress in 1981 had more than twice the risk of adult-onset asthma over the next decade than did those reporting low stress levels (OR = 2.32; 95% CI, 1.47-3.65).12 Finally, in previous analyses in the BWHS, childhood physical abuse, a source of stress that may persist into adulthood,31 was positively associated with adult-onset asthma: The IRR was 1.26 (95% CI, 1.07-1.49) for childhood physical abuse relative to no abuse.13 Although the biologic pathways linking stress to asthma onset have yet to be described definitively, evidence suggests that stress effects on the immune3234 and autonomic nervous systems24,35 may increase airway inflammation and hyperresponsiveness25 and thereby contribute to the development of asthma.

In the current study, experiences of racism in 1997 were reported before the diagnoses of asthma during subsequent follow-up, obviating recall bias. The large sample size produced stable estimates, and we controlled for a range of potentially confounding factors, including known and suspected risk factors for adult-onset asthma. However, it was not possible to control for environmental factors that may have been confounders, including indoor allergens and outdoor air pollution. Misclassification may have affected our measures of experiences of everyday and lifetime racism. However, the measures used were similar to those used previously in other studies of racism.16,3638 The racism questions have shown good reproducibility in other studies.16,39 Reproducibility was also good in our cohort: Among 1,172 women in the BWHS who returned duplicate questionnaires in 1997, weighted κ values for agreement between questionnaires ranged from 0.54 to 0.73.40 Finally, in the current study, the associations were stronger based on women whose racism scores in 1997 and 2009 were similar, and these may have been less affected by misclassification than the associations that relied only on the 1997 measure.

We relied on self-reported physician-diagnosed asthma. Self-report is the standard method of identifying asthma cases in large national cohort studies5,4144 because it is not feasible to examine all cases to verify asthma or to examine all noncases to identify undiagnosed asthma. In a validation study among 43 women in the BWHS who met our case definition and who gave us permission to contact their physicians, 39 (91%) were confirmed by their physicians as having asthma. In addition, the overall results were consistent when we used a less-strict case definition (physician-diagnosed asthma regardless of medication use).

Experiences of racism were positively associated with adult-onset asthma in this large cohort of black women, suggesting that the chronic stress associated with such racism contributes to the onset of asthma in adults. Given the high prevalence of this stressor in the lives of black women,45 the association is of significant public health importance. Our observations contribute to a growing body of evidence indicating that experiences of racism can have adverse health effects. School- and community-based programs to combat racism, if successful, may have benefits in terms of health. Furthermore, interventions to reduce racism-related stress may be an important component of any comprehensive strategy for primary asthma prevention, especially in communities with a high proportion of minority residents and a high prevalence of asthma. Brief stress-reduction interventions that have been developed to address stress from other sources (eg, stress related to intimate partner violence46 and military service47) may hold promise for ameliorating racism-related stress.

Author contributions: Dr Coogan takes responsibility for the content of the manuscript, including the data and analysis.

Dr Coogan: contributed to the idea for this study, study design conceptualization, analysis and interpretation of the data, and writing of the manuscript.

Mr Yu: contributed to the study design conceptualization, analysis and interpretation of the data, and critical rewriting and approval of the final version of the manuscript.

Dr O’Connor: contributed to the study design conceptualization, analysis and interpretation of the data, and critical rewriting and approval of the final version of the manuscript.

Dr Brown: contributed to the study design conceptualization, analysis and interpretation of the data, and critical rewriting and approval of the final version of the manuscript.

Dr Cozier: contributed to the study design conceptualization, analysis and interpretation of the data, and critical rewriting and approval of the final version of the manuscript.

Dr Palmer: contributed to the idea for this study, study design conceptualization, designing of the BWHS, supervision of the data collection, analysis and interpretation of the data, and critical rewriting and approval of the final version of the manuscript.

Dr Rosenberg: contributed to the idea for this study, study design conceptualization, designing of the BWHS, supervision of the data collection, analysis and interpretation of the data, and critical rewriting and approval of the final version of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The funding bodies supported the collection, maintenance, and analyses of data. They had no role in study design or in the analysis or interpretation of data, in writing the manuscript, or in the decision to submit the manuscript for publication.

BWHS

Black Women’s Health Study

IRR

incidence rate ratio

Winer RA, Qin X, Harrington T, Moorman J, Zahran H. Asthma incidence among children and adults: findings from the Behavioral Risk Factor Surveillance system asthma call-back survey—United States, 2006-2008. J Asthma. 2012;49(1):16-22. [CrossRef] [PubMed]
 
Coogan PF, Palmer JR, O’Connor GT, Rosenberg L. Body mass index and asthma incidence in the Black Women’s Health Study. J Allergy Clin Immunol. 2009;123(1):89-95. [CrossRef] [PubMed]
 
Ford ES. The epidemiology of obesity and asthma. J Allergy Clin Immunol. 2005;115(5):897-909. [CrossRef] [PubMed]
 
Lummus ZL, Wisnewski AV, Bernstein DI. Pathogenesis and disease mechanisms of occupational asthma. Immunol Allergy Clin North Am. 2011;31(4):699-716. [CrossRef] [PubMed]
 
Beckett WS, Jacobs DR Jr, Yu X, Iribarren C, Williams OD. Asthma is associated with weight gain in females but not males, independent of physical activity. Am J Respir Crit Care Med. 2001;164(11):2045-2050. [CrossRef] [PubMed]
 
Huovinen E, Kaprio J, Koskenvuo M. Factors associated to lifestyle and risk of adult onset asthma. Respir Med. 2003;97(3):273-280. [CrossRef] [PubMed]
 
Gwynn RC. Risk factors for asthma in US adults: results from the 2000 Behavioral Risk Factor Surveillance System. J Asthma. 2004;41(1):91-98. [CrossRef] [PubMed]
 
Barr RG, Wentowski CC, Grodstein F, et al. Prospective study of postmenopausal hormone use and newly diagnosed asthma and chronic obstructive pulmonary disease. Arch Intern Med. 2004;164(4):379-386. [CrossRef] [PubMed]
 
Barr RG, Wentowski CC, Curhan GC, et al. Prospective study of acetaminophen use and newly diagnosed asthma among women. Am J Respir Crit Care Med. 2004;169(7):836-841. [CrossRef] [PubMed]
 
Jones DP, Camargo CA Jr, Speizer FE, Barr RG. Prospective study of short stature and newly diagnosed asthma in women. J Asthma. 2007;44(4):291-295. [CrossRef] [PubMed]
 
Wright RJ, Fay ME, Suglia SF, et al. War-related stressors are associated with asthma risk among older Kuwaitis following the 1990 Iraqi invasion and occupation. J Epidemiol Community Health. 2010;64(7):630-635. [CrossRef] [PubMed]
 
Rod NH, Kristensen TS, Lange P, Prescott E, Diderichsen F. Perceived stress and risk of adult-onset asthma and other atopic disorders: a longitudinal cohort study. Allergy. 2012;67(11):1408-1414. [CrossRef] [PubMed]
 
Coogan PF, Wise LA, O’Connor GT, Brown TA, Palmer JR, Rosenberg L. Abuse during childhood and adolescence and risk of adult-onset asthma in African American women. J Allergy Clin Immunol. 2013;131(4):1058-1063. [CrossRef] [PubMed]
 
Harrell CJ, Burford TI, Cage BN, et al. Multiple pathways linking racism to health outcomes. Du Bois Rev. 2011;8(1):143-157. [CrossRef] [PubMed]
 
Clark R, Anderson NB, Clark VR, Williams DR. Racism as a stressor for African Americans. A biopsychosocial model. Am Psychol. 1999;54(10):805-816. [CrossRef] [PubMed]
 
Williams DR, Yan Y, Jackson JS, Anderson NB. Racial differences in physical and mental health. Socioeconomic status, stress, and discrimination. J Health Psychol. 1997;2(3):335-351. [CrossRef] [PubMed]
 
Williams DR. Race, socioeconomic status, and health. The added effects of racism and discrimination. Ann N Y Acad Sci. 1999;896:173-188. [CrossRef] [PubMed]
 
Thompson VL. Perceived experiences of racism as stressful life events. Community Ment Health J. 1996;32(3):223-233. [CrossRef] [PubMed]
 
Williams DR, Neighbors H. Racism, discrimination and hypertension: evidence and needed research. Ethn Dis. 2001;11(4):800-816. [PubMed]
 
Rosenberg L, Palmer JR, Wise LA, Horton NJ, Corwin MJ. Perceptions of racial discrimination and the risk of preterm birth. Epidemiology. 2002;13(6):646-652. [CrossRef] [PubMed]
 
Rankin KM, David RJ, Collins JW Jr. African American women’s exposure to interpersonal racial discrimination in public settings and preterm birth: the effect of coping behaviors. Ethn Dis. 2011;21(3):370-376. [PubMed]
 
Grandner MA, Hale L, Jackson N, Patel NP, Gooneratne NS, Troxel WM. Perceived racial discrimination as an independent predictor of sleep disturbance and daytime fatigue. Behav Sleep Med. 2012;10(4):235-249. [CrossRef] [PubMed]
 
Cozier YC, Wise LA, Palmer JR, Rosenberg L. Perceived racism in relation to weight change in the Black Women’s Health Study. Ann Epidemiol. 2009;19(6):379-387. [CrossRef] [PubMed]
 
Douwes J, Brooks C, Pearce N. Stress and asthma: Hippocrates revisited. J Epidemiol Community Health. 2010;64(7):561-562. [CrossRef] [PubMed]
 
Vig RS, Forsythe P, Vliagoftis H. The role of stress in asthma: insight from studies on the effect of acute and chronic stressors in models of airway inflammation. Ann N Y Acad Sci. 2006;1088:65-77. [CrossRef] [PubMed]
 
Wright RJ. Epidemiology of stress and asthma: from constricting communities and fragile families to epigenetics. Immunol Allergy Clin North Am. 2011;31(1):19-39. [CrossRef] [PubMed]
 
Rosenberg L, Adams-Campbell L, Palmer JR. The Black Women’s Health Study: a follow-up study for causes and preventions of illness. J Am Med Womens Assoc. 1995;50(2):56-58. [PubMed]
 
Lieberoth S, Backer V, Kyvik KO, et al. Intake of alcohol and risk of adult-onset asthma. Respir Med. 2012;106(2):184-188. [CrossRef] [PubMed]
 
Sternthal MJ, Jun HJ, Earls F, Wright RJ. Community violence and urban childhood asthma: a multilevel analysis. Eur Respir J. 2010;36(6):1400-1409. [CrossRef] [PubMed]
 
Suglia SF, Duarte CS, Sandel MT, Wright RJ. Social and environmental stressors in the home and childhood asthma [published correction appears inJ Epidemiol Community Health. 2010;64(12):1105]. J Epidemiol Community Health. 2010;64(7):636-642. [CrossRef] [PubMed]
 
Heim C, Newport DJ, Heit S, et al. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA. 2000;284(5):592-597. [CrossRef] [PubMed]
 
Deshmukh A, Kim BJ, Gonzales X, Caffrey J, Vishwanatha J, Jones HP. A murine model of stress controllability attenuates Th2-dominant airway inflammatory responses. J Neuroimmunol. 2010;225(1-2):13-21. [CrossRef] [PubMed]
 
Iwakabe K, Shimada M, Ohta A, et al. The restraint stress drives a shift in Th1/Th2 balance toward Th2-dominant immunity in mice. Immunol Lett. 1998;62(1):39-43. [CrossRef] [PubMed]
 
Pincus-Knackstedt MK, Joachim RA, Blois SM, et al. Prenatal stress enhances susceptibility of murine adult offspring toward airway inflammation. J Immunol. 2006;177(12):8484-8492. [PubMed]
 
Miller BD, Wood BL, Lim J, Ballow M, Hsu C. Depressed children with asthma evidence increased airway resistance: “vagal bias” as a mechanism? J Allergy Clin Immunol. 2009;124(1):66-73. [CrossRef] [PubMed]
 
Borrell LN, Diez Roux AV, Jacobs DR Jr, et al. Perceived racial/ethnic discrimination, smoking and alcohol consumption in the Multi-Ethnic Study of Atherosclerosis (MESA). Prev Med. 2010;51(3-4):307-312. [CrossRef] [PubMed]
 
Chae DH, Lincoln KD, Jackson JS. Discrimination, attribution, and racial group identification: implications for psychological distress among Black Americans in the National Survey of American Life (2001-2003). Am J Orthopsychiatry. 2011;81(4):498-506. [CrossRef] [PubMed]
 
Chae DH, Nuru-Jeter AM, Lincoln KD, Jacob Arriola KR. Racial discrimination, mood disorders, and cardiovascular disease among black americans. Ann Epidemiol. 2012;22(2):104-111. [CrossRef] [PubMed]
 
Krieger N, Smith K, Naishadham D, Hartman C, Barbeau EM. Experiences of discrimination: validity and reliability of a self-report measure for population health research on racism and health. Soc Sci Med. 2005;61(7):1576-1596. [CrossRef] [PubMed]
 
Cozier Y, Palmer JR, Horton NJ, Fredman L, Wise LA, Rosenberg L. Racial discrimination and the incidence of hypertension in US black women. Ann Epidemiol. 2006;16(9):681-687. [CrossRef] [PubMed]
 
Burr ML. Diagnosing asthma by questionnaire in epidemiological surveys. Clin Exp Allergy. 1992;22(5):509-510. [CrossRef] [PubMed]
 
Camargo CA Jr, Weiss ST, Zhang S, Willett WC, Speizer FE. Prospective study of body mass index, weight change, and risk of adult-onset asthma in women. Arch Intern Med. 1999;159(21):2582-2588. [CrossRef] [PubMed]
 
Nystad W, Meyer HE, Nafstad P, Tverdal A, Engeland A. Body mass index in relation to adult asthma among 135,000 Norwegian men and women. Am J Epidemiol. 2004;160(10):969-976. [CrossRef] [PubMed]
 
Romieu I, Avenel V, Leynaert B, Kauffmann F, Clavel-Chapelon F. Body mass index, change in body silhouette, and risk of asthma in the E3N cohort study. Am J Epidemiol. 2003;158(2):165-174. [CrossRef] [PubMed]
 
Forman T, Williams D, Jackson J. Race, Place, and Discrimination.. In:Gardner C., ed. Perspectives on Social Problems. Greenwich, CT: JAI Press; 1997:231-261.
 
Graham-Bermann SA, Miller LE. Intervention to reduce traumatic stress following intimate partner violence: an efficacy trial of the Moms’ Empowerment Program (MEP). Psychodyn Psychiatry. 2013;41(2):329-349. [CrossRef] [PubMed]
 
Carlson KJ, Silva SG, Langley J, Johnson C. Mindful-veteran: the implementation of a brief stress reduction course. Complement Ther Clin Pract. 2013;19(2):89-96. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Baseline Characteristics According to Summary Racism Scores, BWHS

Data are presented as % or mean ± SD. Means and percentages were standardized to the age distribution of the cohort in 1997. Extreme categories of everyday and lifetime racism are shown. BWHS = Black Women’s Health Study.

a 

Characteristics are percentages ascertained in 1997 unless noted otherwise.

Table Graphic Jump Location
Table 2 —Everyday and Lifetime Racism Scores in 1997 and Asthma Incidence, BWHS, 1997-2011

IRR = incidence rate ratio; Ref = reference. See Table 1 legend for expansion of other abbreviation.

a 

Adjusted for age, time period, BMI (< 25.0, 25.0-29.9, 30.0-34.9, 35.0-39.9, ≥ 40.0 kg/m2, missing), current smoker (yes, no), pack-y of smoking (0, 1-4, 5-14, 15-24, ≥ 25, missing), secondhand smoke exposure (ages 0-10 y at home, 11-20 y at home, 21-30 y at home or work, 31-40 y at home or work, and currently at home or work) (yes, no, missing), vigorous exercise in h/wk (0, < 5, ≥ 5, missing), alcohol use in drinks/wk (never, past any amount, current 1-3, 4-6, 7-13, ≥ 14, missing), female hormone use (never, < 5 y, ≥ 5 y, missing), parental history of asthma (yes, no, unknown), mother’s smoking status (yes, no, unknown), education in years (≤ 12, 13-15, 16, ≥ 17, missing), and household income (≤ $25,000, $25,001-50,000, $50,001-100,000, > $100,000, missing).

Table Graphic Jump Location
Table 3 —Everyday and Lifetime Racism Scores in 1997 and 2009 and Asthma Incidence Among Women With Unchanged Scores in Both Years, BWHS, 1997-2011

See Table 1 and 2 legends for expansion of abbreviations.

a 

Adjusted for age, time period, BMI (< 25.0, 25.0-29.9, 30.0-34.9, 35.0-39.9, ≥ 40.0 kg/m2, missing), current smoker (yes, no), pack-y of smoking (0, 1-4, 5-14, 15-24, ≥ 25, missing), secondhand smoke exposure (ages 0-10 y at home, 11-20 y at home, 21-30 y at home or work, 31-40 y at home or work, and currently at home or work) (yes, no, missing), vigorous exercise in h/wk (0, < 5, ≥ 5, missing), alcohol use in drinks/wk (never, past any amount, current 1-3, 4-6, 7-13, ≥ 14, missing), female hormone use (never, < 5 y, ≥ 5 y, missing), parental history of asthma (yes, no, unknown), mother’s smoking status (yes, no, unknown), education in years (≤ 12, 13-15, 16, ≥ 17, missing), and household income (≤ $25,000, $25,001-50,000, $50,001-100,000, > $100,000, missing)

b 

Includes 11,256 women who stayed in the same quartile of everyday racism in 1997 and 2009.

c 

Includes 13,083 women who stayed in the same category of lifetime racism in 1997 and 2009.

References

Winer RA, Qin X, Harrington T, Moorman J, Zahran H. Asthma incidence among children and adults: findings from the Behavioral Risk Factor Surveillance system asthma call-back survey—United States, 2006-2008. J Asthma. 2012;49(1):16-22. [CrossRef] [PubMed]
 
Coogan PF, Palmer JR, O’Connor GT, Rosenberg L. Body mass index and asthma incidence in the Black Women’s Health Study. J Allergy Clin Immunol. 2009;123(1):89-95. [CrossRef] [PubMed]
 
Ford ES. The epidemiology of obesity and asthma. J Allergy Clin Immunol. 2005;115(5):897-909. [CrossRef] [PubMed]
 
Lummus ZL, Wisnewski AV, Bernstein DI. Pathogenesis and disease mechanisms of occupational asthma. Immunol Allergy Clin North Am. 2011;31(4):699-716. [CrossRef] [PubMed]
 
Beckett WS, Jacobs DR Jr, Yu X, Iribarren C, Williams OD. Asthma is associated with weight gain in females but not males, independent of physical activity. Am J Respir Crit Care Med. 2001;164(11):2045-2050. [CrossRef] [PubMed]
 
Huovinen E, Kaprio J, Koskenvuo M. Factors associated to lifestyle and risk of adult onset asthma. Respir Med. 2003;97(3):273-280. [CrossRef] [PubMed]
 
Gwynn RC. Risk factors for asthma in US adults: results from the 2000 Behavioral Risk Factor Surveillance System. J Asthma. 2004;41(1):91-98. [CrossRef] [PubMed]
 
Barr RG, Wentowski CC, Grodstein F, et al. Prospective study of postmenopausal hormone use and newly diagnosed asthma and chronic obstructive pulmonary disease. Arch Intern Med. 2004;164(4):379-386. [CrossRef] [PubMed]
 
Barr RG, Wentowski CC, Curhan GC, et al. Prospective study of acetaminophen use and newly diagnosed asthma among women. Am J Respir Crit Care Med. 2004;169(7):836-841. [CrossRef] [PubMed]
 
Jones DP, Camargo CA Jr, Speizer FE, Barr RG. Prospective study of short stature and newly diagnosed asthma in women. J Asthma. 2007;44(4):291-295. [CrossRef] [PubMed]
 
Wright RJ, Fay ME, Suglia SF, et al. War-related stressors are associated with asthma risk among older Kuwaitis following the 1990 Iraqi invasion and occupation. J Epidemiol Community Health. 2010;64(7):630-635. [CrossRef] [PubMed]
 
Rod NH, Kristensen TS, Lange P, Prescott E, Diderichsen F. Perceived stress and risk of adult-onset asthma and other atopic disorders: a longitudinal cohort study. Allergy. 2012;67(11):1408-1414. [CrossRef] [PubMed]
 
Coogan PF, Wise LA, O’Connor GT, Brown TA, Palmer JR, Rosenberg L. Abuse during childhood and adolescence and risk of adult-onset asthma in African American women. J Allergy Clin Immunol. 2013;131(4):1058-1063. [CrossRef] [PubMed]
 
Harrell CJ, Burford TI, Cage BN, et al. Multiple pathways linking racism to health outcomes. Du Bois Rev. 2011;8(1):143-157. [CrossRef] [PubMed]
 
Clark R, Anderson NB, Clark VR, Williams DR. Racism as a stressor for African Americans. A biopsychosocial model. Am Psychol. 1999;54(10):805-816. [CrossRef] [PubMed]
 
Williams DR, Yan Y, Jackson JS, Anderson NB. Racial differences in physical and mental health. Socioeconomic status, stress, and discrimination. J Health Psychol. 1997;2(3):335-351. [CrossRef] [PubMed]
 
Williams DR. Race, socioeconomic status, and health. The added effects of racism and discrimination. Ann N Y Acad Sci. 1999;896:173-188. [CrossRef] [PubMed]
 
Thompson VL. Perceived experiences of racism as stressful life events. Community Ment Health J. 1996;32(3):223-233. [CrossRef] [PubMed]
 
Williams DR, Neighbors H. Racism, discrimination and hypertension: evidence and needed research. Ethn Dis. 2001;11(4):800-816. [PubMed]
 
Rosenberg L, Palmer JR, Wise LA, Horton NJ, Corwin MJ. Perceptions of racial discrimination and the risk of preterm birth. Epidemiology. 2002;13(6):646-652. [CrossRef] [PubMed]
 
Rankin KM, David RJ, Collins JW Jr. African American women’s exposure to interpersonal racial discrimination in public settings and preterm birth: the effect of coping behaviors. Ethn Dis. 2011;21(3):370-376. [PubMed]
 
Grandner MA, Hale L, Jackson N, Patel NP, Gooneratne NS, Troxel WM. Perceived racial discrimination as an independent predictor of sleep disturbance and daytime fatigue. Behav Sleep Med. 2012;10(4):235-249. [CrossRef] [PubMed]
 
Cozier YC, Wise LA, Palmer JR, Rosenberg L. Perceived racism in relation to weight change in the Black Women’s Health Study. Ann Epidemiol. 2009;19(6):379-387. [CrossRef] [PubMed]
 
Douwes J, Brooks C, Pearce N. Stress and asthma: Hippocrates revisited. J Epidemiol Community Health. 2010;64(7):561-562. [CrossRef] [PubMed]
 
Vig RS, Forsythe P, Vliagoftis H. The role of stress in asthma: insight from studies on the effect of acute and chronic stressors in models of airway inflammation. Ann N Y Acad Sci. 2006;1088:65-77. [CrossRef] [PubMed]
 
Wright RJ. Epidemiology of stress and asthma: from constricting communities and fragile families to epigenetics. Immunol Allergy Clin North Am. 2011;31(1):19-39. [CrossRef] [PubMed]
 
Rosenberg L, Adams-Campbell L, Palmer JR. The Black Women’s Health Study: a follow-up study for causes and preventions of illness. J Am Med Womens Assoc. 1995;50(2):56-58. [PubMed]
 
Lieberoth S, Backer V, Kyvik KO, et al. Intake of alcohol and risk of adult-onset asthma. Respir Med. 2012;106(2):184-188. [CrossRef] [PubMed]
 
Sternthal MJ, Jun HJ, Earls F, Wright RJ. Community violence and urban childhood asthma: a multilevel analysis. Eur Respir J. 2010;36(6):1400-1409. [CrossRef] [PubMed]
 
Suglia SF, Duarte CS, Sandel MT, Wright RJ. Social and environmental stressors in the home and childhood asthma [published correction appears inJ Epidemiol Community Health. 2010;64(12):1105]. J Epidemiol Community Health. 2010;64(7):636-642. [CrossRef] [PubMed]
 
Heim C, Newport DJ, Heit S, et al. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA. 2000;284(5):592-597. [CrossRef] [PubMed]
 
Deshmukh A, Kim BJ, Gonzales X, Caffrey J, Vishwanatha J, Jones HP. A murine model of stress controllability attenuates Th2-dominant airway inflammatory responses. J Neuroimmunol. 2010;225(1-2):13-21. [CrossRef] [PubMed]
 
Iwakabe K, Shimada M, Ohta A, et al. The restraint stress drives a shift in Th1/Th2 balance toward Th2-dominant immunity in mice. Immunol Lett. 1998;62(1):39-43. [CrossRef] [PubMed]
 
Pincus-Knackstedt MK, Joachim RA, Blois SM, et al. Prenatal stress enhances susceptibility of murine adult offspring toward airway inflammation. J Immunol. 2006;177(12):8484-8492. [PubMed]
 
Miller BD, Wood BL, Lim J, Ballow M, Hsu C. Depressed children with asthma evidence increased airway resistance: “vagal bias” as a mechanism? J Allergy Clin Immunol. 2009;124(1):66-73. [CrossRef] [PubMed]
 
Borrell LN, Diez Roux AV, Jacobs DR Jr, et al. Perceived racial/ethnic discrimination, smoking and alcohol consumption in the Multi-Ethnic Study of Atherosclerosis (MESA). Prev Med. 2010;51(3-4):307-312. [CrossRef] [PubMed]
 
Chae DH, Lincoln KD, Jackson JS. Discrimination, attribution, and racial group identification: implications for psychological distress among Black Americans in the National Survey of American Life (2001-2003). Am J Orthopsychiatry. 2011;81(4):498-506. [CrossRef] [PubMed]
 
Chae DH, Nuru-Jeter AM, Lincoln KD, Jacob Arriola KR. Racial discrimination, mood disorders, and cardiovascular disease among black americans. Ann Epidemiol. 2012;22(2):104-111. [CrossRef] [PubMed]
 
Krieger N, Smith K, Naishadham D, Hartman C, Barbeau EM. Experiences of discrimination: validity and reliability of a self-report measure for population health research on racism and health. Soc Sci Med. 2005;61(7):1576-1596. [CrossRef] [PubMed]
 
Cozier Y, Palmer JR, Horton NJ, Fredman L, Wise LA, Rosenberg L. Racial discrimination and the incidence of hypertension in US black women. Ann Epidemiol. 2006;16(9):681-687. [CrossRef] [PubMed]
 
Burr ML. Diagnosing asthma by questionnaire in epidemiological surveys. Clin Exp Allergy. 1992;22(5):509-510. [CrossRef] [PubMed]
 
Camargo CA Jr, Weiss ST, Zhang S, Willett WC, Speizer FE. Prospective study of body mass index, weight change, and risk of adult-onset asthma in women. Arch Intern Med. 1999;159(21):2582-2588. [CrossRef] [PubMed]
 
Nystad W, Meyer HE, Nafstad P, Tverdal A, Engeland A. Body mass index in relation to adult asthma among 135,000 Norwegian men and women. Am J Epidemiol. 2004;160(10):969-976. [CrossRef] [PubMed]
 
Romieu I, Avenel V, Leynaert B, Kauffmann F, Clavel-Chapelon F. Body mass index, change in body silhouette, and risk of asthma in the E3N cohort study. Am J Epidemiol. 2003;158(2):165-174. [CrossRef] [PubMed]
 
Forman T, Williams D, Jackson J. Race, Place, and Discrimination.. In:Gardner C., ed. Perspectives on Social Problems. Greenwich, CT: JAI Press; 1997:231-261.
 
Graham-Bermann SA, Miller LE. Intervention to reduce traumatic stress following intimate partner violence: an efficacy trial of the Moms’ Empowerment Program (MEP). Psychodyn Psychiatry. 2013;41(2):329-349. [CrossRef] [PubMed]
 
Carlson KJ, Silva SG, Langley J, Johnson C. Mindful-veteran: the implementation of a brief stress reduction course. Complement Ther Clin Pract. 2013;19(2):89-96. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543