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N 0 T I C E This materal may be prot!cted 5y~ cepyright 14ri (L'd~ 17 U.S. Cod4 Marriage to a Smoker and Lung Cancer Risk CHARLES G. HUMBLE, MS. JONATHAN M. SAMET. MD. MS. AND DOROTHY R. PATHAK. PHD. MS Abstract: As part of a population-based case-control study of lung cancer in New Mexico: we have collected data on spouses" tobacco smoking habits and on-the job, exposure to asbestos. The present, analyses include 609 cases and 781 controls with known passive and' personali smoking status, of whom 28 were hfelbng nonsmokers with lung cancer. While no effect of spouse cigarctte smoking was found'among current or former smokers, never smokers marned to smokers had about a two-fold increased nsk of lung cancer. Lung cancer nsk in never smokers also increased with duntion of exposure to a smoking spouse. but not with increasing number of cigarettes smoked'per day by the spouse. Our findings are consistent with previous reports of elevated nsk for lung cancer among never smokers living with a spouse who smokes cigarettes. (Am J Public Health 1987: 77:598=602.): Introduction rllte causal association, of activesigarette smoking witli' -1ung cancer has been accepted for many yean.ls Recent epidemiologic evidence indicates that involuntary exposure pf nonsmokers to tobacco smoke is also associated with lung cancer.}S Nonsmokers, as well as active cigarette smokers, inhale environmental tobacco smoke„ which consists of a combination of sidestream smoke and exhaled mainstream smoke. The putative association of environmental tobacco smoke with lung cancer derives biological plausibility from the lack of a demonstrated threshold for lung cancer in active amokers, from the qualitative similarities of mainstream and sidestr+eam smoke, and from the presence of mutagens in the urine of passive smokers.s•6 The association of involuntary, exposure to tobacco smoke with lung cancer has now been examined in studies condueted in Japan. Greece„Hong Kong. Scotland. Germa- ny, and the United States.s' These studies generally indicate an increased risk in nonsmokers. Studies from Japan. Greece, and the United States have shown elevated risk estimates associated with the exposure of nonsmokers to their spouses' smoking.~^ 71D Increased risks have not been found in all investigations, although estimates of effect from those reports with negative findings are generally consistent with those from repotts showing elevated risks.' 1'16 In 1980 we began collecting data in a population-based case-control study designed to explain differing lung cancer occurrence in Hispanic and non-Hispanic Whites in New Mexico.!'' The originalI study questionnaire included ques- tions on tobacco smoke exposure from spouse smoking and on indirect exposure to asbestos through a spouse's job. This report describes the risks associated with these exposures in smokers and nonsmokers in New Mexico. Methods Care Sdectloa The cases were Hispanic and non-Hispanic residents of New Mexico, less than 85 years of age at diagnosis of primary lung cancer. Cases were ascertained by the New Mexico Tumor Registry, a member of the Surveillanee. Epidemiol- ogy, and End Results (SEER) Program of the National From the New Mexico Tumor Repstry, the Departments of Medjcine and of Funily Community and Emeraency Medicine. and the Interdepartmental Proprun: ie Epdemtoto8y: University of New Mexico Medical Center. Albuquerque. Address reprint requests to,Jonathan M. Samet.,MD. New Mexico Tumor Registry. Universtty of New Mexico Medical Cemer. 90Q Caminode.Salud NE. Altwquerqpe. NM 97131. . Ttnspaper..submitted to the Journal July 18. 1986. was revised and accepted for put+bcauon November 17, 1966. C 1997 AAmerican Journal of Public Health 009a0036+67s1.S0 Cancer Institute.ls An initial ease series was selected from patients with cancer incident between January 1. 1980 and December 31, 1982. For this initial series all cases less than 30 years of age and all Hispanics were included: non- Hispanics age 50 or older were sampled randomly to select 40 per cent of the males and 50 per cent of the females. To increase the size of the female non-Hispanic subgroup and Hispanics of both sexes, we selected additional' cases: all patients in these groups with cancer incident between De- cember I, 1983 and November 30, 1984. Of the 724 eligible cases selected for the study, interviews were completed with 641, or 88.5 per cent. Of the interviews with cases, 305 were completed with the cases themselves and 336 were with surrogates, generally either the surviving spouse or a child. For the cases in nonsmokers, the histopathological type of lung cancer was classified by panel review ofi histopatho- logical matenal' (N = 17) or by information in the New Mexico Tumor Registry case abstract (N = 28). The panel, which included two pathologists, determined the histopath- ological type on the basis of conventional Gght,nucroscopy and used a modification of the World Health Organization classification." =0' Control Seiectbo Potential controls were ascertained' by two methods. Residences, identified from lists of randomly generated telephone numbers. were called and'a household census was taken from the person who answered. Telephone sampling identified 2.038 potentially eligible households. of which 287. (14.2 per cent) refused4o cooperate with the eensus. As thiss technique was not efficient for selecting older controls, an additional 252 persons were chosen from a list of randomly selected New Mexico residents, 65 years and older, who were on the Health Care Financing Administration's roster of Medicare panicipants. The controll group was frequency= matched to the cases for sex, ethnicity, and 10-year age category at a ratio of approximately 1.2 controls per case. Of the 944 controls selected for this study, 784 (83.1 per cent) were interviewed. Ialenirw D.u Colkctbo The interviews were conducted by bilingual interview• ers. Respondents were asked to describe the smoking habits of all spouses of the index subject. For each smoking spouse, duration of use and' average amount smoked daily were recorded for cigarettes, cigars, and pipes. Respondents were not asked'ao describe exposures to tobacco smoke at work or in other situations outside of the home. All jobs held by a spouse for one year or more also were recorded, as were reports of spouses' on-the-job exposures to arsenic, asbes- tos, lead, pesticides, and radiation. We hypothesized a priori that asbestos exposure nught increase lung cancer risk and 598 AJPW May 1987, vVol. 77. No. 5

PASSIVE SMOKING AND LUNG CANCER RISK added the other agents to reduce the emphasis on asbestos and to test for information bias. A detailed history of personal cigarette use was coUected' from subjects who had smoked for six months or more.. C,kui.tioo of Paaire F.>posare Indikes Measures of passive exposure to tobacco smoke and to asbestos were created by summarizing the information pro- vided for each spouse. For tobacco smoke, categorical an& continuous measures of exposure were calculated. We des- ignated as"exposed" subjects ever married to a spouse who smoked cigarettes, regardless of the spouse's use of pipes or cigars. To examine the effects of cigarette smoke alone, subjects whose spouses had smoked other tobacco products were excluded from some analyses. We created two indicator variables for these exposures: one for all forms of tobacco smoke, and the other for cigarette smoke alone. We also calculated the duration of exposure to a cigarette-smoking spouse and the average number of cigarettes smoked daily by the spouse(s). If complete data were unavailable for all marriage partners, these variables were set to unknown. Two categorical variables were created to describe potential indirect exposure to asbestos through a spouse3 job. Spouse's job histories were reviewed against a list of jobs judged a priori as possibly involving exposure to asbestos: asbestos mining, textile manufacturing, auto brake repair~, cement or construction work, pipe fitting or covering, insu- lation work, and shipyard work. If one or more jobs held by the spouse appeared on the list, the index subject was classified as exposed. Similarly, if a spouse was described as exposed at work to asbestos the index subject was considered to be exposed. Dw Aa.l,ri4 For these analyses, cigarette smokers were those indi- viduals who had smoked at least six months. Current smok• ers were those still smoking at interview or who had stopped within the previous 18 months; ex-smokers had ceased smoking at least 18 months before interview. The status of cases elassified' by questionnaire as never smokers was verified' against hospital chart summaries on file at the New Mexico Tumor Registry: Of the 28 reported nonsmokers, the summaries showed that three cases had smoked cigarettes and that one case had smoked pipes and cigars regularly. Analyses of the data for never smokers were performed with and without these four subjects. Because the study included only eight males who had never smoked cigarettes, all analyses were performed for females alone and for all subjecu combined. We used the Mantel-Haenszel technique to control for ethnicity, and age in estimating odds ratios for passive exposure to cigarette smoke, within strata of personal ciga- rette smoking. ' In these analyses, age was categorized as below 65 years or 65 years and greater. Among never smokers, the exposure-response relation of lung cancer risk with average cigarettes smoked daily by the spouse and with duration of passive cigarette exposure was tested using Mantel extension methods for stratified data.' For these vuiables, strata ofexposure were defined by the median level among all exposed never smokers. Those never exposed~ were the reference group for all analyses. To examine further the effects of the passive exposures, logistic regression models were fitted for smokers and never smokers. All models included adjustment for ethnicity and four categories of age, variables for which the controls had been frequency matched to the cases. In the model for smokers, TAiLE 1--Mz, ltlwftlty, wfE Aq. tlbtllbution of SubMota Dy ta.r.onall Ciprttb 6r/ro" Status Nf 4 CM4-ComnW ShWy kt IMw Mexbo, 1N0-i4 c.4par.nft smokwtp SurGus CtstrrrE Fpmwr NevK bi.cts (yw Su bi.c t s t+)' Ca.. Contrd C... Conad Gaw Cm*a Mi.o.nic YVNC. <65 34 22 10, te 0 10 z6b 47 30 27 29 1 21 Nw"HIMP-4c W?rb <65 77 57 19 56 1 36 r65 62 60 62 103 6 63 F.rnalhe meo- WM~ <65 11 9 3 7 2 27 a69 27 6 5 5 7 34 Non.1/dp.rrc Wwt. <65 74 34 a 17 3 47 s6S 64 t5 31 10 6 54 potential confounding by personal'cigarette use was controlled by entering the average daily cigarette consumption, the dura- tion of smoking, years since stopping for ex-smokers, and an interaction term calculated as the product of smoking duration and an indicator variable for age less than 65 years or 65 years and older. This model was selected on the basis of analyses described in more detai@ elsewhere.Z` The all-subjects modelss included control for sex. The two categorical indicators of passive exposure were tested individually in each model.. Trends in risk with number of cigarettes of exposure daily and' with duration were examined by fitting models with indicator variables to define categories of unexposed, exposed at or below the median, and above the median. Risk estimation for the effect of indirect exposure to asbestos was limited to females as no males were indirectly exposed. Logistic regression models were employed~ that controlled for active smoking as described above, for current and ex-smokers, and for marriage to a smoker for never smokers. Because surrogate interviews were necessary for 52 per cent of the cases, we assessed the effect of information source by performing the analyses separately for self-reported and surrogate-reported cases, using self-reported controls. We excluded from these analyses the 13 controls for whom surrogate interviews had been necessary. All cross tabulations and logistic models were performed with standard programs of the Statistical Analysis System, zi Odds ratios (OR) and 90 per cent two-sided Cornfield eonfl. dence intervals (CI) were calculated using prograrn 23 from the Rothman and Boice text for programmable calcula- tors.u'M Result.r The analyses were restricted to those 1,390 subjects with known passive an&personat smoking status (Table 1). The 355 exclitded subjects were older than those included (mean age 68.4 vs 65.6 years, respectively). More cases were excluded than controls (5.0 per cent vs 0.4 per cent, respectively), due in part to the greater proportion of surrogate interviews forr cases than for controls. The percentage of subjects excluded did not differ by ethnicity or sex. Based on data in the New Mexico Tumor Registry files. the cases described by interview data as "never smokers'- AIPH May 1987, Va. 77. No: s 599

HUMBLE. ET AL. TASLE 2-Odds Rsdo' Estlmat.e toa PusN. Clpanebr Esporure M+ s Ca..ConaW Stuey of Lunp Canoar In 1Nw Mtesleo. 1N0-" TABLE i-0o0s Rat1o Esdmatae hom IIAWtlpre LoqlsW Anatyaq of Paaatw Clparette Expo.urs and Lung Canoer Rlsk IA a Caae-Corttrol SIuQy In I/iw. Mexico, /aa0•-a4. F O P.rsonal Snwmny AII Sutitecta rny .rrW+s Au Suoqscts F.mate Ony Paaarve t' R R P P . Exposure StaWS OR 90% C O 90% C aaNve arponalSrnplunp Exposure Status OR 90% CI OR 90% CI Cgarett.s only Current 12 0:9. 1.6 0.9 0.4.2.2 Forrner 1.1 0,6, 1.5 0.7 0.2.2.2 Cqarrina ony Evrr? 1.0 0.8.1.4 1.0 0.5. 1.9 Never 2.9 1.3.6.7 1.6 0.6. 5.4 Nwer 2.2 1.0: 4.9 17 06. 4 3 Cqanettes antlror Current 1.2 04. 1.6 0.9 0.5. 1:6 Cqar.aas antl/or Ever° 1.0 0.6. 1.3 0 9 0.5. 1 5 pqpe or a9ar Fomwr 1.1 0.6. 1.S 0.6 0:2, 1 J ppeaapar IM+.r 2.6 12:56 2.2 0.9.5.5 PMvwr 3.2 1.5, 7.2 2.3 0.9, 6.6 mFromauon aon taaeaav; aqu.brrrx /v aq or ta w.Kly Ed rs wr.r.wrta.. R.o.ew 90 v. C.nc Comiro w*ewn..rva.. -MmoO~M KldeE nn*dw bWntrp b M hepuNnCY mWCf" . M a" YW ehic0y: Yo W& Mo n appoprw" tiAawr lar rrows mnaowo b p.r+dri aqv.a. u." a e..o,eea wwr merloft who were ever married to a smoking spouse included eight adenocarcinomas. two epidermoid carcinomas, two small cell1 carcinomas, and four large cell carcinomas. The eiQhr nonexposed cases reported to be never smokers comprised six adenocarcinomas and two epidermoid carcinomas. A specific histological type had not been assigned to four of the cases. Of the four cases in reported never smokers but who were identified by Tumor Registry information as smokers, one was small cell carcinoma, two were adenocarcinoma, and one was not classified. Because material was only retrieved for J 7 cases for panel'review, we did not compare the exposed and nonexposed based'on the pathologists' classification. Of the 17 cases, the celli type based on the panel's review eoncurred with that in the Registry for only eight cases. In the never smoking controls, marriage to a smoker of any type of tobacco was reported'for 28 per cent of males and for 56 per cent of females. The corresponding percentages for marriage to a smoker of cigarettes alone were simifar. 28per cent for males and 57 per cent forr females. Using stratified and unstratified approacties„ no effect of marriage to a smoker was found' among current or former cigarette smokers (Table 2). By eOntrast, antottg neve>i`" amokers, cigarette smoking by a spod3C: tepr,dless o(pipe or ci>iar use, was associated with a't-fotd increased risk or lung cancer. Adjustment for ethnicity (OR-= 3.2, 90 per cerit Cl (Confidence I'ntervalJ - 1.5, 7.2) or for age (OR -!+,3-2.,90 per cent CI - 1.5, 7.3) did not change tlx estimated risks. A similar close agreement of crude ;(TabW2ad~usted ' estimates was observed for expos ta~ only:: ethnicity-adjusted OR = 3.0 (CI ~~)~~6 8) ~teQ, OR.,T 2.9 (CI - 1.3, 6.7). There were ittsufftcient subjects td':" adjiist simultaneously ior ethnicity and ase:-Although the odds ratios were reduced, resuiction o[the sample tofeutales did not change the putetm qf effect from that found in tfie : analyses with all subjects.'hlyhen the analyses were per- formed separately for self- and surrogate-reported cases, the odds ratios were comparably elevated for both groups (data not shown). Because the control series did not include sufficient numbers of controls with surrogate interviews, the controls could not be similarlystratifltd by type of interview: Odds ratios from the logistic models (Table 3) tended to be lower than from the unstratified and stratified analyses (Table 2). Risk estimates for the current and former smokers from the logistic models also showed no effect of passive cigarette exposure beyond that of active smoking. However, among the never smokers all point estimates were above unity. Assessment of exposure-response relation for the dura- tion of exposure and',fon the average cigarettes smoked daily 600 TAaI.E F-Odda Ratld EaYna.a by tkrarion of Spousa Clqreela inrokinq an0 by Arwapa Clprin,ha Sm0/tatl Daily by the •pouae(s) arnorq Never anroMus ln a C..aConaol Stuey In w.. wsloa 1M0-44 t><.aoonn s26 Y.ars >26 Years 8uoi.a Cr tor Group OR 110% Cr OR 90% Ct Ard AN Suej.cv 2:2 01. 5.9 2.7 1'.0.,7.1 2.01. F.mN.. orwy 1.6 0.5.5.8 2.1 0.7, 6.9 1.29 1,1aan C+O.r.era. t» r oay. s20 >20 OR 00% CI OR 90'% CI ! AN SuD~cts 2.6 1'.2. 6.6 2.2 06.73 1.82 F.rtulee only 1.6 0.6.5.8 1.2 0.3. 5.2 0.46 80eb noe; na pirb0.br..p. a w..ery. A6u•sn.N b wtrw oc rrr t~etora dd na d,v,pr er r.«.h. The i.a/x. n.-qory..a- nr new .~o..a- by the spouse was limited to never smokers. For &I all-subjects and females-only cross tabular analyses, a pat- tern of increased risk. with ,jreater duration of cigarette I qxposure was found (Table 4). In contnst, the logistic models d'id ttot show an increase with duration of exposure in either group: (for all subjects, short duration OR - 1.9, CIi - 0.7, 4.7; long duration OR - 1.8, CI - 0.7, 4.5). The exposure- response pattern for cigarettes smoked daily showed'~ higher odds ratios for subjects whose spouses smoked a pack or less per day than for those whose spouses smoked greater amounts (Table 4). Control of stratification factors by mul- tiple lopstic modeling did not change the pattern of higher relative risk estimates for nonsmokers exposed to 20 or fewer cigarettes per day (OR - 2.0, CI - 0.9. 4.6) compared with those exposed at higher levels (OR - 1.6, CI - 0:5, 4.9). The respective logistic estimates for females were lower. OR for daily exposure of 20 cigarettes or less was 1.6 (Cl - 0.6, 4.3) .. while for exposure to more than 20ciaarettes the OR was 1.2 (Cl - 0.3, 4.4). Potential indirect exposure to asbestos was only report- ed for females. In the controls, 14.5 per cent of women were designated as exposed based' on their husband's work history and 8.2 per cent were considered as exposed based on a report of their husband's occupational exposure to asbestos. The effects of the asbestos exposure variables were assessed AJPM May 1987, Vol. 77. No. 5 2Q23382331

PASSIVE SMOKING AND LUNG CANCER RISK TABLE 6-E.tYmat." of' Lunp Canar Ruli trom 8pou..'i Oocup.RbnN Expowre to A.b..toa, by MOoettrq souro., ro. r.m.w Irt . t:aMCamol tittsdy In PMw tMxlop, 100414 Employm.rri in A.b..bs Aaw.d Job PMSOnai, Smolonp tseattts MN 8ttrt.ca Sa/- wo«wd &rroqn.' t.vottw EroeP ofl 0.6 0.7 1.1 90% Cr 0.4, 1.6 0.3, 1.5 0.s. 2.8 Nev.r OR 2.5 1.2 3.3 90% Cl 1.0.6.4 0.2: 6.2 1.1, 9.5 Rpat.d a. E M Wor< AII, S.+I. &xroqw° Sue).ets woawa noaled Ewr' OR 1.4 1.3 2.0 9pX Cli 0.6. 3.2 0.5., 34 0.7, 5.5 tl.v.r OR 2.2 2 6 2.0 9ox Cr 0.5.,9:2 0.4„20.7 01,119 41iotn amax ana b.nw m,ok.n mauo.a, aB.n.e.varo conavu ..n nr wmp.nrra+ p/ouo brW trr u.'op..•.oor»d'u.sm with multiple logistic models and found to vary with cigarette smoking habits (Table 5). The odds ratios were higher for the never smoking females: and in these never smokers the two exposure variables gave comparable risk estimates. Discussion In the context of'a population-based case-control study in New Mexico, we have examined the risk of lung cancer associated with marriage to a cigarette smoker. The results indicated increased risk from this exposure in never, smokers, but not in active smokers. Methodologic limitations of the case-control approach for studying the relation between involuntary exposure to tobacco smoke and'lung cancer must be considered. Misclas- si6eation of both active and passive exposure to cigarette smoke is of particular concern. With regard to active smok- ing, we assigned exposure on the basis of a comprehensive interview with either the index case or a surrogate respon- dent. For four of the 28 cues among never smokers, information in the hospital~ record conflicted with the inter- view. Because a similar, additional source of data was not available for controls, we did not exclude the four cases from this report. The findings were unchanged, bowever, when they were removed from the analyses. We assessed passive exposure to tobacco smoke only from marriage to a smoking spouse; exposures from other smokers at home and in the workplace were not assessed. Thus, subjects may have been misclassified on total passive smoke exposure. Wald and Ritchie' have shown that non- smoking men married to smoking women repott greater exposure to the smoke of others outside of the home than nonsmoking men married to nonsmoking women. Wald and Richie suggest that information on smoking by the spouse conveys some information on other sources of exposure. Surrogate interviews were necessary for 19 of the 28 never smokers. While the validity of surro~ate information has been questioned for some exposures, the surrogate respondents were primarily surviving spouses. who provided information on their own smoking habits and those of previous spouses, if any. Extensive misclassificatiom intro- duced by the surrogate interviews thus appears unlikely, although spouses aware of the putative association of~passive smoking with lung cancer may have minimized their own smoking. Spouse surrogates may have supplied more accu- rate information concerning their own smoking than. would have been available from the index subject. The much higher proportion of surrogate interviews forcases than for controlseould have introduced differential misclt<ssification and bi- ased effect measures upwards. The results of the present case-control study comple- ment those from other case-control studies'•'`10 and from cohort studies,3•tl'which showed increased lung cancer risks in never smokers married to smokers. The magnitude of the effect of marriage to a smoker in the present study, about a two-fold increase in risk (Tables 2 and 3): is comparable to findings by Hirayamas and by Akiba, tr al9 in JaP an. by Trichopoulos, er al,' in Greece, and by Correa, et al: and by Dalager, et a1,10' in the United States. A weak exposure- response relation was present with duration of passive exposure, but not with average number of cigarettes smoked daily by the spouse (Table 4): In contrast, in a larger case-control study. Garfinkle. et al:l found a trend of increas- ing risk for nonsmoking women with the number of cigarettes smoked daily at home by their husbands. In active smokers, we found'& that residence with a smoker did not elevate lung cancer risk (Table 2). The lack of association in active smokers is consistent with the quanti- utive differences in the exposures of active and passive smoking.° Futthermore, active smokers must receive more passive exposure to tobacco smoke from their own smoking, than from the smoking of others. The odds ratios for passive smoking in active smokers. all at or near unity; provide evidence againstconsistent under- or overreporting of expo- sure (Tables 2 and 3). We also assessed the effects of marriage to: a spouse employed in jobs possibly involving contact with asbestos. We hypothesized that asbestos brought into the home by the spouse might increase lung cancer risk in smokers and nonsmokers. Domestic exposure has been previously asso- ciated with mesothelioma, pleural abnormalities, and changes in the lung parenchyma." We used both a lifetime occupational history for the spouse of the index case and reported contact with asbestos to assess possible indirect exposure of the cases to asbestos. With both approaches for determining exposure, we found associated elevations of risk for lung cancer (Table 5). The effect was more evident in never smokers, although comparable relative risks would be anticipated if cigarette smoking and asbestos exposure interact multiplicatively in this setting:29•w The magnitude of effect was surprisingly large in view of the range of'excess risk found in asbestos- exposed workers and of the results of risk estimation.29.10 ACKNOWLEDfiMENTS Sutqorted by a pant.rrom the Nattonal Cancer Instnute. CA :71l7. and' by a cootract from tbe Biotaetry Branch. Nuional Cancer Institute NOl-CN- SSt26. Dr. Samet is rscipient ofa Research Cateer Development Av.rd. SK04 H1:00951- rrom the Divisao of Lung Direases. NatwtW Heart. Lung. and Blood lnsutute.. REFERENCES I. USDepvtmentofHeahh. Educatton.and Wetfarc: Stnokin`and Healtfi, Repon~oftAe Advisory Comnu..ttee to the Surseon Gencral of the Public Heahh. Servtce. PH5 Pub, No. 1103. Washtntiton. DC. 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SAS Institute SAS User's Gttdb: Statistics. 1962 Ed. Cary. NC: SAS tnsutute. 1962. 25, Cornfield J: Ast>,tistital problem arising ftom retrospective studies. l'n: Neyman J' (ed): Proceedings of the 3rd Berkeley Sympostum.,Berkeky: Univenity of Califortsia Press. 1956: 4:133-14t. 26. Rothman KJ, Boiee JD Jr. Epidetnblopc Analysis with a Propanmibk Caltulaor. Boston: Epidemiology Resources. 1992. 27. Wa18 N. RAchic C: Validstion,o( studies of lung cancer in non-smokers tturied to smokers 1lettcr). Lancet 19116,11; 10067. 23. Gordis L: Should dead cases be matched to dead controls' Am J Epweatiol 1992: 115:1-5., 29. National Research Cottncd. Commtnee on Nonoecupubna! Hea1tE Risks of Astxstiform Fibers: Asbestiftsrm Fiben: NonoccupatiorW Health Risks. Washinpon. f>C::Naiwml Academy Press. 1964: 30. US Departtnent,of Health tud Human Services, Public Health Service: The Health Consequences of Smokmli: Caacer and Chronic Lung Disease in the Workplace: a report of thc Suryeon Getseral: Rockrille. MD: Office on Smoking and Health. 1965. I The National!Center for Health Statistics (NCHS),has recently distributed to the 50 states the 1989 revisians of ttie US Standard Certificates and Repons of Live Birth, Death, Fetal Death. Induced Termination of Pregnancy, Marriage, and Divorce. These documents serve as models for the various states to use in developing their own forms. NCHS recommends that revised certificates and reports incorporating the 1989 changes be implemented in all states by January' l, 1989., The US Standard Certificates and Reports were developed jointly by the NCHS and' state vital registration and statistics executives. Advice was obtained from persons and organizations throughout the U'nited States who represented users of vital statistics data and those who complete the documents. The content reflects a consensus of what needs to be collected about each vital event to serve both the legal and statistical uses of these records in the 1900s. Among the more significant modifications made in these new revisions are: • the addition of an Hispanic identifier to the live birth and death certificates and the fetal death and' induced terminatiott of pregnancy reports;. • changes in the birth eertificate and fetal death report to obtain more detailed information about the pregnancy and its outcome; and • some of the factors that may have improved quality and completeness of the cause of death. Information about the trevision process and copies of the standard certi6cates and reports can be obtained by writing or calling: - George A. Gay Chief, Registration Methods Branch Division of Vital Statistics, NCHS 3700 East-West Highway, Room I-44 Hyattsville, Maryland 20782 Tel: (3o1) 4368815 W2 A.1PH' May 1987, Vol. 77, No.'S