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Energy, Air Pollution and Health Research


Evaluating Interventions

Randomized Exposure Study of Pollution Indoors and Respiratory Effects (RESPIRE)

A typical open fire in a highland Guatemalan homeThe first randomised controlled clinical trial to test the impact of an improved cookstove intervention on child pneumonia was conducted in the highlands of Guatemala among a population who used traditional three stone wood fires for cooking prior to the intervention.

Households (n=534) with a pregnant woman or young infant were randomised to receive an improved woodstove with chimney (n=269) or to remain as controls using a traditional three stone fire (n=265). The impact of the intervention on concentrations and exposure (women and infants) to HAP was assessed over an 18 month period through measurements of carbon monoxide levels.

the plancha chimney stoves of the type used in the RESPIRE trial

In addition to the primary outcome of child pneumonia, the effect of the stove and measured reductions in exposure on a number of other adult and child health outcomes have been studied, including birth weight and respiratory symptoms and lung function in mothers.


The trial was carried out jointly with the University of California, Berkeley (Professor Kirk R. Smith) and the University del Valle, Guatemala (Dr Byron Arana). Study team members from the University of Liverpool were Professor Nigel Bruce (Co-principal investigator), Dr Mukesh Dherani (data preparation and analysis for child pneumonia), Dr Daniel Pope (senior analyst for maternal respiratory health).


Primary funding was provided by the US National Institute of Environmental Health Sciences (NIEHS) and the World Health Organization.
Additional funding for the maternal respiratory health component was provided by The Norwegian Research Council.

Publications/ dissemination

Pope D, Diaz E, Smith-Sivertsen T, Lie RT, Bakke P, Balmes JR, Smith KR, Bruce NG. Associations of Respiratory Symptoms and Lung Function with Measured Carbon Monoxide Concentrations among Nonsmoking Women Exposed to Household Air Pollution: The RESPIRE Trial, Guatemala. Environ Health Perspect 2014 (in press).

Guarnieri MJ, Diaz JV, Chandreyi B, Diaz A, Pope D, Smith KR, Smith-Sivertsen T, Bruce NG, Solomon C, McCracken JP, Balmes J. Effects of Woodsmoke Exposure on Airway Inflammation in Rural Guatemalan Women. PLoS ONE 2014; 9(3) e0088455.

McCracken JP, Schwartz J, Diaz A, Bruce NG, Smith KR. Longitudinal Relationship between Personal CO and Personal PM2.5 among Women Cooking with Woodfired Cookstoves in GuatemalaPLoS ONE 2013; 8(2): e55670. doi:10.1371/journal.pone.0055670.

Smith KR, McCracken JP, Weber MW, Hubbard A, Jenny A, Thompson L, Balmes J, Diaz A, Arana B, Bruce NG. Effect of reduction in household air pollution on childhood pneumonia in Guatemala (RESPIRE): a randomised controlled trialLancet 2011; 378 (9804): 1717-26.

Thompson LM, Bruce NG, Eskenazi B, Diaz A, Pope D, Smith KR. Impact of Reduced Maternal Exposures to Woodsmoke from an Introduced Chimney Stove on Newborn Birth Weight in Rural Guatemala. Environ Health Perspect 2011; 119: 1489-1494.

Smith KR, McCracken JP, Thompson L, Edwards R, Shields KN, Canuz E, Bruce NG. Personal child and mother carbon monoxide exposures and kitchen levels: Methods and results from a randomized trial of woodfired chimney cookstoves in Guatemala (RESPIRE)J Expo Sci Environ Epidemiol 2010; 20: 406-416.

McCracken JP, Schwartz J, Bruce NG, Mittleman M, Ryan LM, Smith KR. Combining Individual- and Group-Level Exposure Information Child Carbon Monoxide in the Guatemala Woodstove Randomized Control Trial. Epidemiology 2009; 20 (1): 127-136.

Smith-Sivertsen T, Díaz E, Pope D, Lie RT, Díaz A3, McCracken J, Bakke P, Arana B, Smith KR, Bruce NG. Effect of reducing indoor air pollution on women’s respiratory symptoms and lung function: RESPIRE Guatemala randomized trialAm J Epidemiol 2009: 170; 203-210.

Díaz E, Bruce NG, Pope D, Díaz A, Smith KR, Smith-Sivertsen T. Self-rated health among Mayan women participating in a randomised intervention trial reducing indoor air pollution in Guatemala. BMC International Health and Human Rights 2008, 8:1-8.

Díaz E, Bruce NG, Pope D, Lie RT, Díaz A, Arana B, Smith KR, Smith-Sivertsen T. (2007) Lung function and symptoms among indigenous Mayan women exposed to high levels of indoor air pollution. Int J Tuberculosis Lung Dis 2007; 11: 1372-1379.

Diaz E, Smith-Sivertsen T, Pope D, Lie RT, Diaz A, McCracken J, Arana B, Smith KR, Bruce NG. (2007) Eye discomfort, headache, and back pain among Mayan Guatemalan women taking part in a randomised stove intervention trial.  J Epidemiol Comm Health 2007; 61: 74-79.

Bruce NG, Diaz A, Arana B, Jenny A, Thompson L, Weber M, et al. Pneumonia case- finding in the Guatemala indoor air pollution trial (RESPIRE): standardising methods for resource poor settings. Bull WHO 2007; 85: 535-44.