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12 Exposure to Environmental Tobacco Smoke and Lung Cancer
Pages 223-249

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From page 223...
... Among smokers, an increase in exposure leads to an increase in risk, as long as the additional tobacco smoke, whether through active or passive smoking, reaches the bronchial epithelium. Passive smoking would, therefore, be expected to cause some increase In risk of lung cancer in active smokers, as well as in any other persons in whom the appropriate tissues are exposed.
From page 224...
... . USING BIOLOGICAL MARKERS TO ESTIMATE RISK Cotinine, a metabolite of nicotine, while of itself not considered a carcinogen, is a useful marker of exposure to tobacco smoke, whether through active or passive smoking.
From page 225...
... These results corroborate the use of a spouse's smoking history as a method of classifying nonsmokers into groups that have different exposure levels to tobacco smoke. Using data from the , , TABLE 12-2 Urinary Cotinine Concentration and Number of Reported Hours of Exposure to Other People's Tobacco Smoke Within the Past 7 Days in Nonsmoking Married Men According to Smoking Habits of Their Wives Exposure to Other People's Smoke in Urinary Cotinine Preceding Week, h Concentration, Smoking No.
From page 226...
... Urinary cotinine is at present the best marker of tobacco smoke intake for passive smoking dosimetry because it is highly sensitive and specific for tobacco smoke. Because it can be measured directly in nonsmokers as well as active smokers, it makes it possible to estimate the relative exposures of the two groups (see Chad ter 8~.
From page 227...
... This is equivalent to a relative risk of 1.14 in males, given that the relative risk in average male active smokers is 10 to 15 times greater than ~ nonsmokers (Hammond, 1966; Doll and Peto, 1978~. For ETS-exposed women, the average relative risk may be less.
From page 228...
... 228 ._ o o o ~5 · ~ no o Cal C)
From page 230...
... 230 cat E E o a is .~ ~: c, 0 so ~ - a., ;> ~ o x ._ 0 ~ Z ~ u, ~s 0 ° _ 3 0, c, ~ - _ ~3 c' c, ,E' 3 ~:, e E _ 2 _ Ed it, ~ ;, 3 0 <, 3 ~ O a :e Vat ~ ~ ~ 3 c ~ :~ c 3 3 ~ ~ c ~-~ E 3 : _ v ~ 0 ~ ~_ To ° ~E ~ ~ ~ ~ 5 C)
From page 231...
... The finding may represent a direct and causal effect of ETS exposure on Jung cancer In nonsmokers; or it could be due in whole or In part to bias, either in the form of systematic errors in the reporting of information or a confounding factor that is associated both with lung cancer and the fact of living with a spouse who smokes. An important question to answer is "What true risk, modified by a reasonable set of bias-producing factors, could lead to the average risk indicated by the epidemiologic studies?
From page 233...
... 233 o ~ _ ~ _ U ~U~ ~ ~o _ oo ~U~ _ _ ~ r~ r~ ~- ~ oo ~ o_ ~o o o ~ ~o oo ~ cr~r ~0~ ~ ~ ~ O ~_ o o oo o_o o o _ ___ oo ~ ~ o ~oo o ~ ~ U)
From page 234...
... "lr~, 1984. ~sclass~ed Exs~kers aud tbe ~ndency-kr Spouses to B~e S~Har Smo~g nablts One source ~ potential b1~s tbat ~uld inRuence tbe estim~es of relative risk is tb~ some people ~bo occaslonsBy smoke or ~bo b~e smoked ln tbe p~t m~ report tbat tbey b~e never smoked.
From page 235...
... From the table it is apparent that for this misclassification to fully account for the observed excess risk, it would be necessary that To or more of smokers and exsmokers report themselves as nonsmokers and that their smoking habits and history be identical with those of the self-reported smokers. The proportion of people who say that they are nonsmokers, but who in fact do smoke, can be estimated using biochemical markers of tobacco smoke absorption.
From page 236...
... 23.08 (f+h) 7.47 5.74 1.30 CONCLUSION: Misclassification error would increase the true relative risk of 1.0 to 1.30.
From page 237...
... . The overall effect on an assumed true association between passive smoking and Jung cancer, i.e., the ~true" relative risk, is shown ~ Table 12-6 for relative risks ranging from I.0 (i.e., no association)
From page 238...
... 238 TABLE 12-6 Estimates of the Observed Relative Risk of Lung Cancer from Studies of Married Nonsmokers; Assuming 35~o of Women and 50~0 of Men in the General Population Are Current Smokers True Relative Risk Marriage Proportion of Misclassified Smokers Passive Misclassified Aggregation Smokers Smokers" Factor b to to 6% 8% 10% 1.00 2.0 2.5 1.01 1.02 1.03 1.04 1.04 3.5 1.01 1.03 1.04 1.05 1.06 4.5 1.02 1.03 1.04 1.06 1.07 4.0 2.5 1.03 1.05 1.08 1.10 1.12 3.5 1.04 1.08 1.11 1.14 1.17 4.5 1.05 1.09 1.13 1.17 1.20 8.0 2.5 1.06 1.12 1.17 1.21 1.25 3.5 1.09 1.17 1.24 1.30 1.36 4.5 1.11 1.20 1.29 1.37 1.43 1.05 2.0 2.5 1.06 1.07 1.08 1.08 1.09 3.5 1.06 1.08 1.09 1.10 1.11 4.5 1.07 1.08 1.09 1.11 1.12 4.0 2.5 1.08 1.10 1.13 1.15 1.17 3.5 1.09 1.12 1.16 1.19 1.21 4.5 1.10 1.14 1.18 1.22 1.25 8.0 2.5 1.11 1.17 1.21 1.26 1.29 3.5 1.14 1.21 1.28 1.34 1.40 4.5 1.16 1.25 1.33 1.41 1.48 1.10 2.0 2.5 1.11 1.12 1.13 1.13 1.14 3.5 1.11 1.12 1.14 1.15 1.16 4.5 1.12 1.13 1.14 1.16 1.17 4.0 2.5 1.13 1.15 1.17 1.19 1.21 3.5 1.14 1.17 1.20 1.23 1.26 4.5 1.15 1.19 1.23 1.26 1.30 8.0 2.5 1.16 1.21 1.26 1.30 1.33 3.5 1.19 1.26 1.33 1.39 1.44 4.5 1.20 1.30 1.38 1.45 1.52 1.15 2.0 2.5 1.16 1.17 1.17 1.18 1.19 3.5 1.16 1.17 1.18 1.20 1.20 4.5 1.17 1.18 1.19 1.21 1.22 4.0 2.5 1.18 1.20 1.22 1.24 1.26 3.5 1.19 1.22 1.25 1.28 1.31 4.5 1.19 1.24 1.27 - 1.31 8.0 2.5 1.21 1.26 1.30 1.34 1.38 3.5 1.23 1.31 1.37 1.43 1.48 4.5 1.25 1.34 1.43 1.50 1.56 1.20 2.0 2.5 1.21 1.22 1.22 1.23 1.24 3.5 1.21 1.22 1.23 1.24 1.25 4.5 1.21 1.23 1.24 1.25 1.27 4.0 2.5 1.22 1.25 1.27 1.29 1.30 3.5 1.24 1.27 1.30 11.33 1.35 4.5 1.24 1.28 1.32 L1.361 1.39
From page 239...
... NOTE: The values inside the boxes indicate those situations that are most plausible, based on other sources of data for parameters, and yield observed relative risks of about 1.34. TABLE 12-7 Number of Smokers and Nonsmokers According to the Smoking Habits of Their Spouses and the Odds Ratio Indicating the Extent of Such Marriage Aggregationa Females Males Spouse Smoker Nonsmoker Total Smoker Nonsmoker Total Smoker S3 17 70 20 1 1 31 Nonsmoker 47 83 130 53 80 133 All 100 100 200 73 91 164 Odds ratio 3.1 2.3 "Based on interviewing 200 women and 164 men attending a health screening center in London or working in the Civil Service in Newcastle in 1985.
From page 240...
... In the studies, which do ask about exposure to ETS in all environments, there stall tends to be misclassification of some nonsmokers as "unexposed," because there may be a tendency to overlook episodes of exposure. The data from urinary cotinine studies and the observed relative risks can be used to estimate this effect.
From page 241...
... Using these values, CON will be 0.14 "rangy 0.08 to 0.213. Therefore, the relative risk of self-identified "unexposed nonsmokers compared with truly unexposed nonsmokers m: 1+fdN i ' (12-2)
From page 242...
... It is possible that a person misclassified as a nonsmoker married to a smoker wiD have a cigarette consumption that is correlated with that of his or her spouse. A misclassified nonsmoker married to a heavy smoker would, therefore, have a higher risk of lung cancer independent of spouse is smoking than a misclassified nonsmoker married to a light smoker, thus giving the appearance of a dose-response relationship between ETS exposure and lung cancer.
From page 243...
... If there were a high relative risk of adenocarcinoma associated with ETS exposure of nonsmokers, it would suggest a real effect, but the published data are insufficient or not presented in a way to allow assessing this issue at this time. Two studies have exaniined the risk of Jung cancer associated with passive smoking using parental smoking as a measure of exposure instead of spouse smoking (Correct et al., 1983; Sandier et al., 1985b)
From page 244...
... : 1-99 I.3 100-299 2.5 300+ 3.0 Correa et al., 1983 Total pack-years: Males Females 1-40 - 1.18 41+ - 3.52 All 2.0 2.07 Koo et al., 1984 Total hours: 1-3,499 1.28 3,500+ 1.02 Any 1.24 Garfinkel et al., 1985 No. of in/day: Last Syr Last25yr 1-2 1.59 0.77 3-6 1.39 1.34 > 6 0.94 1.14 Pershagen et al., in press KreyburgI KreyburgII Less than 15 cig./day or 50 g tobacco/wk for less than 30yr 1.8 0.8 More than 15 cig./day or SO g tobacco/wk for more than 30 yr , 6.0 2.4 Akiba et al., in press Pack-days within last 10 yr: < 5,000 1.0 5,000-9,999 2.8 10,000+ 1.8 NOTE: Relative risk for self-reported unexposed is assumed to be 1.0.
From page 245...
... Computations taking into account the possible effects of misclassified exsmokers and the tendency for spouses to have similar smoking habits placed the best estimate of increased risk of lung cancer at about 25%0 in persons exposed to ETS at a level typical of that experienced by nonsmokers married to smokers compared with those married to nonsmokers. Another computation using information from cotinine levels observed in nonsmokers and taking into account the effect of making comparisons with a reference population that is truly unexposed leads to an estimated increased risk of about onethird when exposed spouses were compared with a truly unexposed population.
From page 246...
... When one allows for exposure to nonsmokers who report themselves as unexposed, the adjusted increased risk is at least Who. The adjusted increased risk to a group of nonsmokers married to nonsmokers is at least 8$to (i.e., RR-1.08)
From page 247...
... Saloojee. Biochemical markers of smoke absorption and self reported exposure to passive smoking.
From page 248...
... Cumulative effects of lifetime passive smoking and cancer risk. Lancet 1:312-315, 1985b.
From page 249...
... Urinary cotinine as marker of breathing other people's tobacco smoke. Lancet 1:230-231, 1984.


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