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Alcohol-induced upper airway symptoms: prevalence and co-morbidity

Open ArchivePublished:January 24, 2005DOI:https://doi.org/10.1016/j.rmed.2004.11.010

      Summary

      Little is known about effects of alcohol intake on the upper, nasal airways. The present aim was to examine the prevalence of alcohol-induced nasal symptoms (ANS) and to explore associations between ANS and other respiratory diseases. A postal questionnaire focused on respiratory diseases and symptoms was sent to 11,933 randomly selected adult individuals. Subjects with ANS, n=316 (3.4%) received a second questionnaire focusing on this condition. Nine thousand three hundred and sixteen (78%) subjects answered the first and 228 (72%) the second questionnaire. Two-thirds of the subjects with ANS were women. Red wine and white wine were the most frequent triggers of ANS, reported by 83% and 31% of the subjects, respectively. Nasal blockage was the most prominent symptom, but also sneezing, nasal discharge, as well as lower airway symptoms occurred after intake of alcoholic drinks. Self-reported physician's diagnoses of asthma, chronic bronchitis⧸emphysema, chronic obstructive pulmonary disease (COPD), as well as allergic rhinitis were more common in subjects with ANS compared with the general population (P<0.001 for all comparisons). In conclusion, ANS are common and are about twice as frequent in women than in men. ANS seem to be associated with important respiratory diseases such as asthma, chronic bronchitis, COPD, and allergic rhinitis.

      KEYWORDS

      Introduction

      Rhinitis and asthma are chronic diseases with substantial impact on the quality of life of the affected patients. Both diseases also have important economic effects on the diseased persons, their families, and the society.
      • Bousquet J.
      • Van Cauwenberge P.
      • Khaltaev N.
      Aria workshop group. World Health organization. Allergic rhinitis and its impact on asthma.
      Rhinitis and asthma can have different underlying causes, but allergic sensitisation is the most common aetiology.
      Airway symptoms are often triggered by inhaled factors that interact with the airway mucosal membrane. Some forms of rhinitis and asthma, however, may not be directly linked to this interaction. One such reaction is known as alcohol-induced asthma. Alcoholic beverages, notably red and white wines, are known to produce bronchial symptoms in certain individuals.
      • Vally H.
      • de Klerk N.
      • Thompson P.
      Alcoholic drinks. Important triggers for asthma.
      • Gershwin M.E.
      • Ough C.
      • Bock A.
      • Fletcher M.
      • Nagy S.
      • Tuft D.
      Grand rounds. Adverse reactions to wine.
      • Dahl R.
      • Henriksen J.M.
      • Harving H.
      Red wine asthma a controlled challenge study.
      Nasal symptoms can also occur after wine intake,
      • Vally H.
      • de Klerk N.
      • Thompson P.
      Alcoholic drinks. Important triggers for asthma.
      • Andersson M.
      • Persson C.G.A.
      • Svensson C.
      • Cervin-Hoberg C.
      • Greiff L.
      Effects of loratadine on red wine-induced symptoms and signs of rhinitis.
      but not much is known about the prevalence and presentation of alcohol-induced nasal symptoms (ANS). Little is also known about associations between ANS and common airway diseases such as allergic rhinitis, nasal polyposis, asthma and other chronic lower airway diseases.
      In this study, we used two different questionnaires and determined the prevalence of ANS, and its potential associations with different nasal symptoms, triggering factors, and common chronic respiratory diseases. We analysed a large-scale questionnaire exploring respiratory symptoms and diseases in a random population sample in the most southern part of Sweden.
      • Nihlen U.
      • Nyberg P.
      • Montnemery P.
      • Lofdahl C.G.
      Influence of family history and smoking habits on the incidence of self-reported physician's diagnosis of COPD.
      After that a second questionnaire specifically focused on alcohol-induced symptoms was sent to those who in the first survey reported ANS.

      Methods

      Study design

      A first questionnaire was mailed out to a random population encompassing 11,933 men and women, aged 18–77 years. They were all randomly selected from the Swedish Population Register. It was mailed to the study population during the spring of 2000. If no response was received within two weeks a first reminder was sent out, and after ten weeks, a second, final reminder including a new questionnaire was mailed. Subjects who reported ANS were identified and received a second questionnaire, the “Alcohol-Induced Rhinitis Questionnaire” (Appendix A).

      Study area and population

      The study was performed in the southern part of Sweden. The study area included the city of Malmö (257,574 inhabitants), and ten of its surrounding municipalities. In total, 540,497 individuals resided within the study area.

      Questionnaires

      The first questionnaire included two parts, entitled “Questions about the Lungs” and “Questions about the Nose”, respectively.
      • Andersson M.
      • Persson C.G.A.
      • Svensson C.
      • Cervin-Hoberg C.
      • Greiff L.
      Effects of loratadine on red wine-induced symptoms and signs of rhinitis.
      • Nihlen U.
      • Nyberg P.
      • Montnemery P.
      • Lofdahl C.G.
      Influence of family history and smoking habits on the incidence of self-reported physician's diagnosis of COPD.
      The questionnaire contained the same questions and had the same layout as the one used previously.
      • Nihlen U.
      • Nyberg P.
      • Montnemery P.
      • Lofdahl C.G.
      Influence of family history and smoking habits on the incidence of self-reported physician's diagnosis of COPD.
      • Montnemery P.
      • Popovic M.
      • Andersson M.
      • Greiff L.
      • Nyberg P.
      • Lofdahl C.G.
      • et al.
      Influence of heavy traffic, city dwelling and socio-economic status on nasal symptoms assessed in a postal population survey.
      In addition to previous versions,
      • Nihlen U.
      • Nyberg P.
      • Montnemery P.
      • Lofdahl C.G.
      Influence of family history and smoking habits on the incidence of self-reported physician's diagnosis of COPD.
      • Montnemery P.
      • Popovic M.
      • Andersson M.
      • Greiff L.
      • Nyberg P.
      • Lofdahl C.G.
      • et al.
      Influence of heavy traffic, city dwelling and socio-economic status on nasal symptoms assessed in a postal population survey.
      one question was added; “Do you develop nasal symptoms after intake of alcoholic beverages”? In total, the questionnaire included 43 questions, and with most of the answer alternatives being “Yes” or “No/do not know”.
      The second questionnaire comprised questions designed for the present study. Briefly the subjects were asked whether or not they perceived runny nose, sneezes and/or nasal obstruction after alcohol consumption. Similarly they were asked whether or not they perceived breathlessness, wheezing, cough, itching, and/or headache. Furthermore, the subjects were asked to specify the beverages (red wine, white wine, sparkling wine, beer, sherry, port wine, hard liquor, brandy, whisky) that produced nasal symptoms. Moreover, whether or not the subjects had any other nasal diseases were assessed by specific questions with Yes or No/don’t know answering alternatives. These questions included nasal allergy, nasal polyposis, and nasal hyperreactivity. Similarly the subjects were asked if they were sensitive to food containing preservatives and/or painkillers, like aspirin or non-steroidal anti-inflammatory drugs, and were both scored as yes or No/don’t know. Finally, they were asked whether or not they used nasal medication on a daily basis or as needed.

      Statistical methods

      Results are presented as percentage of positive answers to a question. Non-responders to single questions are quoted, as “no/do not know. The χ2 test was used to examine differences in prevalence rates between groups. Multiple logistic regression analysis with adjustment for the influence of age, gender and smoking habits was used for calculation of odds ratios (ORs) for potential associations between different alcoholic beverages provoking ANS and lung symptoms as well as self-reported nasal disorders. Independent T-test was used to examine age differences between groups. The computer-based analysis program SPSS (version 10.1) was used for all calculations. P-values <0.05 were considered statistically significant.

      Results

      Questionnaire I “questions about the lungs” and questions about the nose”

      Of the 9316 subjects who returned the questionnaire (response rate 78.1%), 3028 (32.5%) subjects reported that they suffered from daily permanent nasal symptoms (n=654) or recurrent (n=2374) nasal symptoms. These subjects were classified as having recurrent or chronic nasal symptoms (RCNS). Of these individuals, 316 subjects (103 men and 213 women) reported that their nasal symptoms could be provoked by consumption of alcoholic beverages (ANS). Characteristics of subjects with RCNS with regard to gender and smoking habits were similar compared with the study population as a whole (Table 1). About two-thirds of the subjects with ANS were women. Subjects with ANS were somewhat older, 47.4 years, than subjects without ANS, 45.0 years (P=0.005).
      Table 1Gender and smoking habits in the whole study population and in subjects with recurrent or chronic nasal symptoms (RCNS) divided into those with alcohol-induced rhinitis (ANS) and without ANS
      Whole study population (n=9316)Subjects with RCNS (n=3028)
      Subjects with ANS (n=316)Subjects without ANS (n=2712)
      %95% CI%95% CI%95% CI
      Women53.452.4–54.467.461.1–73.752.448.8–55.0
      Men46.645.6–47.632.627.4–37.847.645.7–49.5
      Smokers26.125.2–27.026.621.7–31.527.225.5–28.9
      Ex-smokers29.828.9–30.734.529.2–39.829.027.2–30.7
      Values shown are percentages (%) and 95% confidence intervals (CI).
      Subjects with ANS described a somewhat different symptom-profile compared with the rest of the subjects with RCNS. As seen in Table 2, subjects with ANS more often reported nasal blockage and sneezing than RCNS subjects without ANS. Nasal symptoms, commonly associated with upper respiratory tract infections such as thick yellow discharge, however, were equally common in both groups.
      Table 2Prevalence of self-reported nasal symptoms in subjects with recurrent or chronic nasal symptoms (n=3028), divided into subjects with alcohol-induced rhinitis (ANS) and without ANS
      Nasal symptomSubjects with ANS (n=316)Subjects without ANS (n=2712)P-value
      n%n%
      Nasal discharge15850.0138451.00.904
      Thick, yellow discharge4012.739114.40.605
      Blocked nose23775.0159158.7<0.001
      Sneezing18959.8142752.60.009
      Itching8225.958721.60.050
      Values shown are numbers of subjects (n) and percentage (%). P-values reflect comparisons between subjects with and without ANS (χ2 test). Subjects with ANS more frequently reported blocked nose and sneezing than subjects without ANS.

      Alcohol-induced nasal symptoms and respiratory diseases

      Among individuals with RCNS, report of physician's diagnoses of asthma, chronic bronchitis (CBE), as well as chronic obstructive pulmonary disease (COPD) were more common in subjects with ANS than subjects without ANS (Table 3). Furthermore, a physician's diagnosis of nasal allergy was more frequently accounted for in the group with ANS compared with the rest of subjects with RCNS. Report of a physican's diagnosis of common cold or sinusitis did not differ between the subjects with ANS and the rest of subjects with RCNS, however.
      Table 3Percentage (%) and 95% confidence interval (CI) of respiratory diseases in the whole study population, and in subjects with recurrent or chronic nasal symptoms (RCNS) with and without alcohol-induced rhinitis (ANS)
      DiagnosisWhole study population (n=9316)Subjects with RCNS (n=3028)P-value
      Subjects with ANS (n=316)Subjects without ANS (n=2712)
      %95% CI%95% CI%95%CI
      Asthma
      Self-reported physician's diagnosis.
      7.46.8–7.920.816.2–25.413.712.4–15.00.001
      CBE
      Self-reported physician's diagnosis.
      4.23.8–4.610.67.1–14.06.85.8–7.70.018
      COPD
      Self-reported physician's diagnosis.
      0.50.4–0.62.30.6–4.00.60.3–0.90.007
      Other lung disease
      Self-reported diagnosis, i.e. not necessarily made by a physician.
      8.07.4–8.510.67.1–14.011.610.3–12.70.703
      Nasal allergy
      Self-reported physician's diagnosis.
      11.410.8–12.043.638.0–49.233.431.6–35.20.001
      Nasal polyposis
      Self-reported physician's diagnosis.
      1.00.8–1.26.33.5–9.02.72.1–3.30.002
      Sinusitis
      Self-reported physician's diagnosis.
      4.33.9–4.714.510.5–18.512.411.2–13.70.316
      Common cold
      Self-reported physician's diagnosis.
      3.73.3–4.19.96.5–13.311.09.8–12.20.627
      P-values reflect comparisons between subjects with and without ANS (χ2 test).
      * Self-reported physician's diagnosis.
      Self-reported diagnosis, i.e. not necessarily made by a physician.

      Nasal symptoms provoked by other exposures

      Subjects with ANS, more commonly than the rest of subjects with RCNS stated that their nasal symptoms could be provoked by different exposures not related to intake of alcohol. This was most marked for “spicy food”: 24.4% vs. 8.3% (P<0.001) and “strong smelling scents”: 49.4% vs. 25.7% (P<0.001), while only minor differences were seen for allergic factors like “tree pollen”: and “grass pollen”: 37.3% vs. 30.9% (P=0.021) and 42.7% vs. 37.1% (P=0.057).

      Questionnaire II the “alcohol-induced rhinitis questionnaire”

      Basic characteristics

      Of the 316 subjects with ANS, 228 (72.2%) subjects answered and returned the “Alcohol-Induced Rhinitis Questionnaire”. Of these, 156 subjects (68.4%) were women and 72 (31.6%) were men. Mean age (in 2000) was similar for both men and women, 48 years.

      Nasal symptoms

      Of the responders with ANS, 79% described nasal blockage as the most prominent symptom associated with consumption of alcoholic beverages, followed by sneezing (reported by 33%), and nasal discharge (reported by 29%). Of the subjects, 14% experienced breathlessness, while 9% and 7% reported wheezing and cough, respectively, associated with alcoholic beverage intake. Furthermore, itching and flushing was experienced by 24% of the ANS subjects.

      Relationship with alcoholic beverages

      Red wine was clearly the most common alcoholic drink that caused nasal symptoms, followed by white wine, beer and strong liquor. However, also other alcoholic drinks were reported to cause nasal symptoms (Table 4). ANS associated with intake of red and white wine as well as sherry and report was more common among women than men, while ANS following intake of whisky was more common in men.
      Table 4Number (n) and percentage (%) of all subjects with alcohol-induced rhinitis (ANS) induced by various alcoholic beverages.
      BeverageAll (n=228)Men (n=72)Women (n=156)
      n%n%n%P-value
      Red wine184835071134880.006
      White wine6931131956360.008
      Sparkling wine4319101433210.206
      Beer5726192738250.742
      Sherry31143428180.006
      Port wine32144618280.013
      Strong liquor5726213036240.326
      Brandy3013111619120.528
      Whisky532428402516<0.001
      P-values reflect comparisons of the prevalence between men and women (χ2 test).

      Alcoholic beverages causing ANS—associations with lung symptoms

      Multiple logistic regression analysis while using age, sex, smoking habits, and all alternative beverages causing nasal symptoms as covariates showed that brandy causing ANS was associated with both wheezing in the chest: OR=6.2 (2.2–17.7) and breathlessness: OR=2.7 (1.3–10.1). No specific alcoholic drink reportedly causing ANS was associated with report of cough.

      Nasal conditions, intolerance to pain relievers and nasal medications

      When asked about other nasal diseases the subjects, in resemblance to the first postal survey, gave a high account of nasal allergy and nasal hyperreactivity. Moreover, a large proportion of subjects with ANS described intolerance to pain relievers like aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) (Table 5). In addition, almost 60% used nasal treatment when needed or on a regular basis.
      Table 5Number of subjects (n) and percentage (%) of the group with alcohol-induced rhinitis (n=228), who reported nasal diseases, intolerance to preservatives or pain relievers, and intake of nasal medication as needed or daily.
      DiseaseAll (n=228)Men (n=72)Women (n=156)
      n%n%n%
      Nasal allergy964226377046
      Nasal polyposis17881196
      Nasal hyperreactivity592615214429
      Intolerance
      Preservatives188231611
      Pain relievers (Aspirin, NSAIDs)39179133020
      Nasal medication
      As needed1044629417549
      Daily25111491116
      Abbreviation: NSAID=Non-steroid anti inflammatory drug.

      Alcoholic beverages causing ANS—associations with self-reported nasal conditions

      Associations between the different alcoholic beverages causing ANS and self-reported occurrence of nasal allergy, nasal polyposis, and nasal hyperreactivity were analysed by using multiple logistic regression. White wine as a cause of ANS was the only beverage significantly associated with nasal allergy: OR=2.3 (1.2–4.1). In addition, beer as reportedly causing ANS was associated with nasal polyposis: OR=3.9 (1.4–10.7). No specific alcoholic beverage was associated with nasal hyperreactivity.

      Discussion

      In this study, we have shown that more than 3% of an adult Swedish population report nasal symptoms after drinking alcoholic beverages. ANS were about twice as common in women than in men. Nasal blockage was the dominating symptom of ANS and red wine was the most frequently described alcoholic beverage causing these symptoms. Furthermore, subjects who reported ANS were more likely to suffer from chronic upper and lower respiratory tract diseases such as allergic rhinitis, nasal polyposis, asthma, COPD, and chronic bronchitis than subjects without ANS. Taken together the present epidemiological observations provide new information on various features of ANS.
      To the best of our knowledge this is the first study that explores the prevalence of alcohol-induced airway symptoms. Apart from clinical experience, our knowledge regarding these conditions largely has emerged from examinations on selected individuals.
      • Andersson M.
      • Persson C.G.A.
      • Svensson C.
      • Cervin-Hoberg C.
      • Greiff L.
      Effects of loratadine on red wine-induced symptoms and signs of rhinitis.
      The present prevalence figure of 3.4% is likely to reflect an accurate estimate of the regional occurrence of ANS, because the study was of a large-scale design, and the subjects were randomly selected. Furthermore, the response rate was acceptable high (78%). Further studies in this field should encompass also alcohol-induced bronchial symptoms and possible relationship with ANS.
      One feature of ANS, emerging from the present study, is that women are more likely to report this condition than men. This finding is in agreement with previous observations by Vally and co-workers, who reported that asthmatic reactions following intake of alcohol were more common amongst women than men.
      • Vally H.
      • de Klerk N.
      • Thompson P.
      Alcoholic drinks. Important triggers for asthma.
      The explanation for this preponderance of women is uncertain, but it may be speculated that women in general tend to report side effects more often than men,
      • Emery N.
      • Vollmer W.
      • Buist S.
      • Osborne M.
      Self-reported food reactions and their associations with asthma.
      and experience a more pronounced impact of rhinitis symptoms on psychosocial well being than men.
      • Rydén O.
      • Andersson B.
      • Andersson M.
      Disease perception and social behaviour in persistent rhinitis a comparison between patients with allergic and non-allergic rhinitis.
      Women are also found to be more sensitive to effects of alcohol.
      • Bergman H.
      • Källmen H.
      Alcohol use among swedes and a psychometric evaluation of the alcohol use disorders identification test.
      It would have been interesting to assess the drinking habits in the subjects with ANS. Still, this may be a sensitive issue, and perhaps fewer subjects would have responded to the questionnaires. The clinical impression, based on previous studies is, however, that ANS subjects are average consumers compared to the normal population and may even drink less due to their alcohol-induced symptoms. Furthermore, if ANS had been associated with a larger consumption of alcohol, then ANS probably would have been more common in the younger age groups who are known to be the largest consumers.
      • Boström G.
      Habits of life and Public Health.
      However, ANS was quite equally distributed over the ages. In addition, more women than men reported ANS, and it seems unlikely that this is due to larger alcohol consumption among women since they are known to drink less than men.
      • Bergman H.
      • Källmen H.
      Alcohol use among swedes and a psychometric evaluation of the alcohol use disorders identification test.
      • Boström G.
      Habits of life and Public Health.
      • Kraus L.
      • Bloomfield K.
      • Augustin R.
      • Reese A.
      Prevalence of alcohol use and the association between onset of alcohol-related problems in a general population sample in Germany.
      The symptoms associated with intake of alcoholic drinks reported by the present ANS-subjects agree with previous observations.
      • Andersson M.
      • Persson C.G.A.
      • Svensson C.
      • Cervin-Hoberg C.
      • Greiff L.
      Effects of loratadine on red wine-induced symptoms and signs of rhinitis.
      In addition, the present study provides information on how subjects with ANS perceive their overall condition. Thus, nasal blockage was clearly the most common symptom associated with the consumption of alcoholic drinks followed by other “rhinitis symptoms” and other-airway and extra-airway symptoms. Report bias may be a common problem in respiratory questionnaires. This may explain the high prevalence of other airway diseases in ANS sufferers. However, the prevalence of sinusitis, common cold and “other lung diseases” were not different from those without ANS, suggesting that the high prevalence figures for chronic airway diseases may not be due to report prejudice. Furthermore our observations are in agreement with the findings by Vally and co-workers, who also reported a wide range of symptoms after intake of alcoholic drinks.
      • Vally H.
      • de Klerk N.
      • Thompson P.
      Alcoholic drinks. Important triggers for asthma.
      Wine, particularly red wine, is generally considered as the most common trigger of alcohol-induced bronchial symptoms.
      • Vally H.
      • de Klerk N.
      • Thompson P.
      Alcoholic drinks. Important triggers for asthma.
      While confirming this characteristic with regard to ANS, the present study also indicates that a wide range of other alcoholic beverages may be of importance. Whether or not all these beverages contain the substances that hypothetically have been suggested to initiate ANS like sulphur dioxide, bisulphites, histamine, tyramine and putrescine is uncertain.
      • Gershwin M.E.
      • Ough C.
      • Bock A.
      • Fletcher M.
      • Nagy S.
      • Tuft D.
      Grand rounds. Adverse reactions to wine.
      • Subden R.
      • Brown R.
      • Noble A.
      Determination of histamines in wines and musts by reversed-phase high-performance liquid chromatography.
      • Lonvaud-Funel A.
      Biogenic amines in wines role of lactic acid bacteria.
      • Kutlan D.
      • Molnar-Perl I.
      New aspects of the simultaneous analysis of amino-acids and amines as their o-phtaldialdehyde derivatives by high-performance liquid chromatography. Analysis of wine, beer and vinegar.
      However, it is evident that ethanol itself is a common factor for all these beverages. Indeed moderate alcohol consumption have been associated with a positive skin prick test to allergens,
      • Linneberg A.
      • Petersen J.
      • Nielsen N.
      • Madsen F.
      • Frölund L.
      • Dirksen A.
      • et al.
      The relationship of alcohol consumption to total immunoglobulin E and the development of immunoglobulin E sensitization the Copenhagen Allergy study.
      and with total IgE levels in serum.
      • Gonzalez_Quintela A.
      • Gude F.
      • Bouquete O.
      • Rey J.
      • Meijide L.M.
      • Suarez F.
      • et al.
      Association of alcohol consumption with total serum immunoglobulin E levels and allergic sensitisation in an adult population-based survey.
      In a recent study it has also been shown that pure ethanol itself may cause adverse reactions in subjects with a history of hypersensitive reactions to alcoholic beverages.
      • Ehlers I.
      • Hipler U.C.
      • Zuberbier T.
      • Worm M.
      Ethanol as a cause of hypersensitivityreactions to alcoholic beverages.
      These reactions, however, were performed with a much higher dose of alcohol than in previous studies.
      • Vally H.
      • de Klerk N.
      • Thompson P.
      Alcoholic drinks. Important triggers for asthma.
      • Dahl R.
      • Henriksen J.M.
      • Harving H.
      Red wine asthma a controlled challenge study.
      • Andersson M.
      • Persson C.G.A.
      • Svensson C.
      • Cervin-Hoberg C.
      • Greiff L.
      Effects of loratadine on red wine-induced symptoms and signs of rhinitis.
      Furthermore, it has been demonstrated in Japanese patients that alcohol can increase blood levels of acetaldehyde, which then can induce mast cell degranulation,
      • Shimoda T.
      • Kohno S.
      • Takao A.
      • Fujiwara C.
      • Matsuse H.
      • Sakai H.
      • et al.
      Investigation of the mechanism of alcohol-induced bronchial asthma.
      which in turn may lead to a release of chemical mediators, such as histamine. This phenomenon, however, has not been demonstrated in caucasian subjects.
      Intriguingly, the function of the metabolising enzyme for biogenic amines in the gastrointestinal tract, diamine-oxidase, is known to be sensitive to ethanol.
      • Littlewood J.T.
      • Glover V.
      • Sandler M.
      Red wine contains a potent inhibitor of phenolsulfotransferase.
      Hence, it could be speculated that if a histamine rich wine is ingested, the histamine itself can then not be degraded and may produce the airway symptoms. Nevertheless, this assumption seems controversial, since some authors could not find any association between the histamine content in wine and intolerance reactions.
      • Kanny G.
      • Gerbaux V.
      • Olszewski A.
      • Fremont S.
      • Empereur F.
      • Nabet F.
      • et al.
      No correlation between wine intolerance and histamine content of wine.
      Focusing on the various nasal symptoms that may be produced by intake of alcoholic beverages, it is likely that subjects presenting such symptoms would be classified as having vasomotor rhinitis (persistent non-allergic rhinitis) if other known causes were excluded. The present observation that ANS sufferers also report a hypersensitivity to hot/spicy food may further add to this conclusion. However, the present study intriguingly suggests that alcoholic beverages may aggravate not just asthma, but also allergic rhinitis, nasal polyposis, asthma, chronic bronchitis and COPD.
      Brandy was associated with wheezing and breathlessness. The reason for this association is not known, but it can be speculated whether the drinking style is somewhat different with brandy, than with other alcoholic beverages. Hence, a deep nasal inhalation is often performed with the nose placed deep in the brandy glass before the drinking. Hypothetically could the strong scents from the brandy then cause breathlessness and wheezing?
      We conclude that alcohol-induced nasal symptoms exhibit a prevalence of more than 3% in the general adult population is often associated with other important chronic airway diseases like allergic rhinitis, asthma and COPD.

      Acknowledgments

      We thank Mrs. Charlotte Cervin-Hoberg for excellent assistance. This study was supported by grants from the Swedish Research Council (project no: 8308), and the ALF foundation.

      Appendix A.

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