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4 THE MEDICAL JOURNAL OF AUSTRALIA Vbl 154 June 17.,1991 ORIGINAL ARTICLES --~--- Passive smoking and the risk of heart attack or coronary death Ansu7tc 1 I3nhcnna Hi)an• M Alcsandrr. Richard F Hr11cr and Dcborah M Lln.:d Objecttvts: To estimate the prevalertce ot eumpand with those not exposed but wen pass.e sanoking in an Australian populstion, not as hiyh as eaneentrations 11t aetiw the magnitude of reak of myocvdial iMuetion strwkers, or coronary death associated witt+ passivt Conclusions: Passive smoking inerras.s smoking and the ettent,to which tibnnogenthe riskof coronary heandisease tnd oorxentrations might be affected by passive H+creased fibrinogen concentration provides amoking. a marker of Its eftOct. Design: A populetion.based ease-eontrol •(Med J Aust 1921. 154: 7i3-797) Study of myocardiau infarction or Coronary death and passive smokinq, and' meuure- onant of fibnnoqer. in s random sample from the same population. S.ftinQ and'paRrcipants: Residerns of the Lower Hunter Region of New South W.Ies aged 35-69 years in 19a8-19a9. Cue subjects were slli those who suffered rnyocardial intarctton or coronary death. Control subjects were participants in a risk factor prevalence survey. Outcome measures: Myocardial Intaretion or coronary death, defined by critena of the WNO MONICA Project, and tibnnogen Con- eentration (measured in controls on6y): Results: Prevalence ot passive smoking att home was 20% for mals case subjects. 13% for maie control subjPcts. 29% for female case subjects and 19% for temale control subjects. The t:orresponding prevalence rates for passive smoking atwork were 40%, NN, 41% and 37%. Odds ratios of myocardial Infarction or coronary death for active @nokertl compared with non-smokers were 4.70 (9SK Confidence interval (Cl1, 3.35-6-8a) Yt women and 2.71 (95% Cl, 2.07-3.53) In fnen. For women the odds ratlos of myocardial iIntarction or coronary death tor I iS well established' that cigarette smokin9 increases the risk of ischaemic heart disease.'•r There is also evidence tnat passive smoking is associated with increased ri:k.••' One of the mechanisms by which smoking acts is by increasing tibnnoqen concentrations whiCh in turn promote tnromtwqenesrs.""' This effect may aiso occur with passive smokinp," To investigate the relktionsnipbetween passive smoktng and iscnaemrc hean disease we conducted a populauon-based' case-control study and a study ot tibrino• gen in, a ranoom sample trorn the same population. Wlk wished to estimate the prevalence oU passive smoking in an Australian community: 10 estimate the magnitude of risk of' heart attack or coronary death associated with, passive smokin9 and to investigate the extent to which tibnnoflen concernrations might be aNected by passive smokinq. th6Neipoeed to passive smoking att home Methods were 2.46 (95w G1. 1.47-a.13) among non- arrwkers and 1.48 (95% Ci, 0.67-3.30) anwng The settmp tor this swdy is provwed by tne ei-amoktrs. For men the odds ratioa for World Meanh Organaatton (WHO) MONICAA passive srnoktng at home were 0.67 (!S% Ct, Pro)•Ci which is monitoring trenos and dettr- 0.50-1.66)for nornsmoken and 1.78 (6S% Cl,: mrnants o1 cardiovascular disease in weCdefuted 1.13-2.76),fores•smokers. The odos raties populations over 10 years. One of these popu- for passi've smoking at work did not suggest latibns is m the Hunter Regron of New South Mtonased nsk. Fibrinogen concentrations Wales. Australia. covering the local gOMrrMrMnt ware generally higher among people exposed areas of Newcastle. Lake Mscou.ne. Gssnock., to passive smoking at horne of work Marttan0 and Pon Stepnens. C.+ers to. Ctrniur Ewdsrmotogy and arosuustre.. pavra Waoaraon Ctrmui, Scwnces auttdrng. hoyai HNwcaafu. nosprur. Nt..c.stle. rtsw2300. ..wra J oee,a, Msc *+c P.a...a a sear.Ka wary M w..ro... s+..WVrC. .•w.e+ w.qw a,{wYe. r rMWr Me eS MZ rRAC' 0roMS1M M. GO-ftwr. WeeryptOTM M LbrO. U MYSbAN O-KM w CO-w.+. MNC~1f Ca.~ warw• . Jpae.o~ ••a..w r aeu...,e u-.w•.., a w...c..~r wsw Taos rt.ww:. Mn 0 M w..w.r cor,. v Crrcr Eae.ewa*, re Mwwrez t>w.wr.er a u.rcasur rrSW tsw Cases The Case subhcts tor this study were ali res- dlnu of the study area aged 35-69 years who durrn0 the study, period had a tatal or nCn-tata1 delinue or possible myocardAl uuarcuon or a eaonary,0tam (wnn msufficrent mformauon tor more specrtrc cttas,frcauonl: Diagnosis was made under the crtteru ot the WHO MONICA Propct.'• The prncipre uMp was to register 0oubttul,uses and suba.Quentty to e:c/ude trom artatyses tnose wnrh 04 not meet, the diagnostic crnerra. Various ouanry Control measures were use0 to Gneck tDmp/elenesf Of Cast aactnarnment. Thest included compir. aoro with ttx hospital morotdey Oats system sro offrerat eeatn records obtsmea trom the Australian Sureau ot'Statuttrs.'• The study perqd was from July 1.,1g88. to October 31. 1989 For people who hao more than one avent dunng this period onlv data for the first wem, were mauded rn the anaiyser presfinednere.d in a0drttort to the Oragn@sUC nforrnatqn. data were colyaQaO On pemoqrtaohC charanerrst,cs. medical history. cigarette srtfokrngan0 exposure to pasirve tirnokrng at, home and alwork: Currenl,smokers were rqtl asaed aDOut tnerr exposurt to passrve srttokrng. SurvMng case sublens were mten..e...o by tne stuoy nurses whde they were st,lu in nosDnai (m this population almost all ttte people wrth a suspected ~hean attacR who atHMVe long enough are somttted to hospital). Most csse sublects +.rho dted some days ahee sOmrss,on to hospital i had been srmilany intervrewed by the atudy nurses. For case subtects who ato before hospriatrsatron,, m the emerqency room. orshonly anlr a0mrfirOn 10 nN warOs. MtOrmatron was ODtarn.d frbm me{IrCat records. rl avaWaZlt. or by questionnanes marled to reutrves. mtor- meuon aDout smoking behaviour was not obtainable tor 34% pf tatal cases and 4% CN~nOn+ tatal Cases:' dala on pasarve smokrngwert missing tot about 16% of an cases. Controls 793 N vl ~ Pamnpants in the eommurntybased nsk taetor .~ prevalence study aonoucted as pan ot the WHO l~~ MONICA PrDlect were control suDlects lor th e ease-control Study an0 were also the suDlects tor the swdy o1 frbr,noqen The risk tactor stuoy ~ was conauered rn June-December 1068 ane June-Novemtxr 1989 A stranbed random

794 ssmpN of tne study t>opulatron was se/ected from the Cornmonweatth.Electoral (ioU with the tantpmg rranton being qreater tor tne older aqe strata. People cnosen foT the sample were invaed to anena sruor centres to complete s sen+ administered quKtqnnsrrt and to have physical t7Nasurements maoe and blood ssmplestaken. E',atensrve systems ot remrnders and folYow• up were used to encouraqe participation. The response rate torr full participation in the studyy for tne aqe group 35-89 years was 63%. Some people w/'W were unabk1o anend a etu0y Cerqre toF the physical maaiuremems anC blood sampMs dkt..noMVet, ronlplete a Dnet OWa• tionnaite which . C,overed demographic CharaC• ]ehfbci..smoking bertsvwurand ,msdiCallLltory.. Others were interviewed at home to obtain this 1nf'Onltatton. b1Cltrsi0nn of data tPomm all tHeet people. gives a response rate of l0% /br tns ape group. For comparisons of smoku+p behaviour among cases and ~ Controls. data tor, all the COrttrof ailb)tCts wPlo participated tul/y m the risk taClor auney or who ony.completed the brief questl0n•naire: or who pantCtpated in horne Invemews were tasetl to teouce non-response bias. tntor- mation on passive smoking. tlowever„was only ootarned from those who panrcrpated tuly in3he survey. As for cue:sub)ects. current.smokers in the Control.group were nouaske0 about their exposure to passrve smokrnp:, Fibrinogen 81ood samples ootained frorn oeot„e wno panrci- psred fully in the risk factor survey were assayed lo determine tibnnoqen C9nCtntrattoeta. Trus was not done for case suofens because this was. of CDurse, impossible tortatal Cases and for tqn• fatal cases n+e Coneentratwn of fibrrnoqen ut the blood could be aMeCteC by the myqcardial ntar9- UOn and treatment for some tlme atter the event:.. Bkboo samples were anttcoaQulated mrmeeiately stter Coblectron with disodiumm eCetate in CommeraatYy, supplied tubes.,Plasma tibnnoflen was assayed by radiormmunodiNuston using eommeneally prepared plates (Behrrnp. Germany) end Norpartigen Ptasma Standard (Bennng. Germany),as the stanoard! StatlsUul analyais Age. sex and a prior history of Ihean disease are lmponant conf0unoers 01 the relationship t>erween risk of heart anaek or eoronarydeatn and ttrnokm9, ep tne estimates 1rom tne Case•- Fpntroli Study were ao)vsteC for these factors. . Y71e stattstrcal program GLIM' was used to '~SItulate ad)ustetl Odds ratiCs and approsilrlate 6onfoenCe intervals by 1oQefttC reQreeaqn." Terms forage (five-year age groups from 35-39 10 6"9 years),and history (prevrous myocarotaw infarcuon or history Of Other uenaemrc heant disease versus no history) and interaction between these two factore ..ert included in the mooel'as weU as terms for the smoking vanablts. Any reuuonsntp t»Iween passive smokrnq THE MEDICAL JOURNAL OF AUSTRALIA, Vol 154 June 17. 1991 ano tht nsli.or heart disease may be aneCted by the person s own smoking history ano ao results tor non-srrlokers and ea-amokerswere cakurated separately The proqram Ea•trrto was used to caKulere esya bonhderlee urtervals atnd tests for trtnd for crude o0ds ratqs " Fibrinogen concerrtrattons are approstmaleNy loq-nomUlly distribute0and tney increase with age and body mass noex (kqrm'). ThMelore the IDQarithmrc.transtoRRatlOn lraa Ufed and m.an values for snloktrl9 groups ware Compared atterr adlvstment for the covarrates o1 age ano booyy mass inoex. The procedure GLM 01 tne SAS program wes usa " For presrntation 01 the results. esunated mean eoncentratrons (prL) art given forpersons sped 50 years witn a body mass r+des o1 25. Rasutts Prevalence rates tor passive smoking at home were higher among cases than Controls and among women compared with men. Prevalence rates for passive smoking at work were around 40% for alf groups (Table 1): Many of the participants in the Study. particularly the case subjects, were retired or. especially among women, did not work putslQe the tto*Te. so the ntJrntxrs available for analysts of passtve smoking at work were smallentnanthose for pissrve smoking at home Fon women the odds ratios for heart attack or coronarydeath for those exposed to passive smoking at home Comp2reo with those not exposed were 2 46 for non• smokers (95% Confidence interval (CIJ. 1.47-4.13)iand 1.48 tor ex-smokers (954e Ct, 0W-3•30) after adjwstment for age and hrstory of heart disease. For men the corresponding ad/usted odds ratios were 0:97 (95% Ci. 0.50-1.86) for non-smokers and 1.78 (95% Cl. 1.13-2.79) for ex- smokers (Table 2). The odds ratios toe passive smoking ar work were not high and the confidence intervals were wide (Table 3). To eompare the magnitude otinsk assoc: ated with passive smoking with risk alioci- aled with active smoking, adjusted odds ratios 1or t:urrent smokers and ex-smokers compared with non-smokers are shown in Tabte 4. There were consistent and statist~ Cally slgnificant dose-relateC gradients with Current, smokers having the highest odds TABLE 1: Prevalence of passive smoking at home and at work among cases and controls who did not themselves smoke At home At work Age lyearsr Cases Con:rols' Cases Contrors' Man 35-a9 30% 10ao •?CI" s.oo, 50-59 27% 1840 43an aear, 60-69 1500, 1300 290r 3040 35-69 2040 12610 400., uar, Women 35-4 ~ 36?0 22r+v 50p•o 394r 50-59 47% 25ab 50C6n 454 60-6? 23ac+ 121IL0 2240 18or 35-E9 2D0ro •9t'o a4a 37ao 'Da:a "7Tcan:rvc «nc oencAaler: 1,rir. , iT,r ra. yccx s::,o, TABLE 2: Passive smoking at home and risk of heart attack or coronary death •(odds ntios and 95% confidence intervals ICIj)! Nr,rnbers of subfects Crude Adlusted? ' Gases Corrrrols• oods rauo (Ct) oaos ratio (Ctl bten Nornamokers E=aoseo 22 34 Not e:oot+ed 167 259 1,04 /0 56 14 1) 0 97 to.So 1 .96) rs K E e s<-smo Eiraosed 8o 49 1.80 (i 20.2 74) 1 78 (1 13. 2.79) N6R ext70ied 256 2E3 Women Non.;7rwkars Er»sed A3 9o 1 61 (i 04 2 47), 2 46 (+ A7 s 13) No= eeaoseo 1 t7 433 E.•vno,ers Eiooseo 23 30: 1 63 10 82 3191 i 1 48 (0 67 3 30 No:'e=DOsed~ 5' 121 -.:a:a "¢'r• eonlrods wno aan~~?a1e_ t•n' ' •ne 'RM7s:eC rO, aqe anC n4oprtv rnvOCaroJ ~aIO V+ a OnY' 5.r%.Wnr rMa•- n YaseCn. UJDWCS .ar• wff'runo• aoo.t nsrort, ofnea,• oAea;e we nuuoen. " ma ude 2Q23~1.1715

THE MEDICAL JOURNAL OF AUSTRALIA Vol 154 June 17. 1991 TABLE 3: Passive smoking at work and risk of heart ariack or coronary death (odds ratios and 95% conlidence intervals [CI]) Nurnbers of suolOcts Cruoe Adlusted' Cases Controts' oods rauo(CI)' ooas rsrro (CI1, Men 1141101-6mo/cers Exaoseo 2" 7° No exaosed 48 t26 0 90 (0'S0:1 605: 0:45 (05t.1 78) El,,smoRers Exaoseo e• 85 0.9+ (0 56. 1.581 0.88 (0 e9 1.59) Na enooseo 55 100 . wpnen Non-sr*roliers Exoosaa 5 73 0 71 (Q ~1~e. 2:27) ~~ 0.66 (0 17.,2:62), No eaposed 12 124 E.•tvnoaers J:utoseo 5 20 115 (0 7 18) 29 221 (0 33.14 95) Na,eoosed 5 29 . . •pau NoT wwac awo oantO.+ea ru/Ir n .ne ...la.1& 4r.wV b~p.o a age No nmvv oft.ar•+or sarotinT. aeri .vwrc n.en ar.r d.v sxcrts we, non+wv anols nslo r a rwn ac.ne as +ro.m o er ude TABLE 4: Snwking behaviour and risk of weari attack or coronary death (odds ratios and 95% confidence intervals ICt)) Numbers of sublecls Crudi Adfuaudt Cases Contras" oads ratio odds ratio (Cn , Men Cunent stnokers 321 259 2.26 2 7142.07 3 53) E>•smoke^s 37a 123 1.60 1.25 (0 98. 1.60) Non-smoKers 197 356 1.00 1.00 Toui 895 1037 YMOrnm Cunem, smokers 127 168 2.95 A 7010 35 6 58). Easmo+as ' 86 t8s 1.52 1.51 (1 06 2.16) Non•smowers 174 6''9 100 1.00 Toul 387 103t ieus ra.nsr vrm - cnrx oons uen, 1r -J5: . a. •.' :.000:' .orne^ .- r'•6L r a• 1 ' P<0.001 •Dwts nOr<•GUlHroK .+awilv0w1e0 hilly n Inr /wF UOO4..tv. mfnpere0 Ine DXt4 ouHaOyMwN O.we fMR+Ylwel . n", nn"V.. Ku,aer. ur x9o la.e vea• wr• aamu nne r,•m.v M rnwrwa y'rreloon o or.r wo+sw•+c n.en aw..e Orw ppleqs wnln rlprTiYfln aDOU:: nM1lOrr'd tyanr O4MieMe +bu0en n AS talYe ratios (4.70 for women and 2.71 for men) pOputation-based with almost complete and ex-smokerS and' people exposed to ascertarnment of all cases of heart attack passive smoking at home having lower, but still elevated, odds ratios compared with nOn-smokers. Fibrinogen concentrations for partici- pants in the risk factor survey (i.e., control subjects only) are shownin Figures 1 and 2. Women had consistently higher mean values than men. Mean fibnnogen eoneen- tratipns were highest among current amokers, intermediite among ex-snsokers and: lowest, for non-smokers. People exposed to passive smoking had higher levels tnan those not exposed (axcept tor passive smoking at: home /oa women). The -jit(erences were not statistical(y signincartt (due to high variability in the measure- munts)! but were consistent with a dose- response relationship with ciganne smoke. Discussion The strength ~ of tfwis study is that d was S/AOKSVG aENAVIOUR .. Mon.n...n Ea enrrels C,.nv. sMe.ue FASSNE SMOrcNG AT~ HOME rlenynYare : 795 Or oOrOnary death in the study populit/or1." A1s0 the COntr01l gr0up was Obtalned by randbm sampling from the same popula- tton. Be(ore consldering the magnrtude of the efteas shown, however. it ts necessary to consider lactors whlchi might have affected their accuracy: A potential source of bias in the case- control compansons was that information on smoking was unobtainable for many Case subjRCts who had di.d. Among tatal Case aub)eCxs 1orwhom thif inlomtation was available. however, the patterns of smoking (Cun•ent ambker~ ex-smoker or r10n-smoker) antl psssive smoking were not different fiom those for non•fatal casc subjecta so it is p(ausible that tatal cases for whom infortrution was unobtainablb also had similar panems of exposure. Further, Mschlin et al. have suggested that smoking habits of people who have died are accurately reported by relatives and other informants." T'hus any bias caused by missing data for cases would probably be small. Another source of bias is that people who respontl to risk factori surveys are kss likety than non-respondents to be smOkers." In our study non-respondents to the main survey (which included visiimg a study antra and having physiul measurements taken) were asked to reply to a brief mailed' puestionnaire, and some people who did not complete the brief Ouestuonnaire were visited at home and interviewed. For men aged 35-69 years. smoking prevalence rates wert: 24% current Smokers. 40% ex- smokers and 354b non•smokers for the main respondent group. compared with FI Yyno9en canrtentratlonig/L) r-~ r--. ..+r Hr Ea~ln.as: r..... ~-r ne.. PASSIVE Sr'sGKNG AT WORK IYonFe/11o11eR ". .f..... ~ fIGUR[1. iD-o¢e- eo-C" /rar.iOm ImOftg rnen n e Orr^. rnw-r saMye rMean Cbn-Vn_ s,... E..nl..ers . .~r nara- 1p -1 a, oeww.peo 50 Yyrryrnn o0or inassnGess p• 25 I•D"^'1 cc"na^a' ^re"a DefeO O. ft1~0aro N1d7 MM' s..rw r- ~~ 01 CO+Iry-Ce W 41{.'IrernW-*C oara I 2023511716

796 SMOKING BEMav1OUR Man-wraers Fr-smo..n Lrriwa sono..rs PASSIVE SMOKING AT NOME Mrw~.rr..rs «~...~s a..... 6~wn.... ....r... s...... pAS$NE SMOKING AT VIrOFiK Meo-111'eMrrs. 1~w~a s...r Bwrw.n ~.......e rr.« THE MEDICAL JOURNAL OF AUSTRALIA Vbl 154 June 17. 199t Frbnnogen txncentrat/on J?1L ) 3s .! ~ a.~ 9- ..-.. t"- 28%. 42% and 30% for those who replied to the brief questionnaire and 299b. 42% and 29% for those interviewed at home. The correspondrng rates for women were 14%. 19% and : 67% tor the main group, 21 %. 13% and 66% for respondents to the brief, questionnaire and 31%, 16% and 53% for those interviewed' at home. These results illustrate how non-res- ponse among control subjects can lead to underestimation ot prevalence ofamoking. 11 is reasonable to expect that it data had been obtained from everyone selected for the sample then the smoking rates and possrbly prevalence of passive smoking among controls would have been higher and estimates of risk might have been somewhat lower. As the control group was selected from the electoral rotl. bias associated with this sampling trame should be considered. Although registration on the roll is compul- soryfor people born in Australia, about one in three of those aged 18-19 years are not enrolled and about one in 20 of thoseaged 2D-W years: beyond that age only about 1 in 50 eligible people are not enrolled." People born overseas are not necessarily required to enrol so they may be sys- tematrcally under-represented by the roll.° The distribution of countries of birth in the risk factor survey was similar to that lot the whole study population recorded at the 1986 Census: 66% of participants were Australian-born compared with 89% of the study population: 7% compared with 4% were bom in the United Kingdom or Ireland: 4% compared with 2% were born in Nbnhern Europe. 1% were born in FIGURF : . sm•cp;r- ,"-; N`Msrom arno-v • COnrrMrnll',f0mpM .4fI- :Or•- onlaaral fG•-; V* ae.Iroro +."eo 60 re.n .wr or... au -x~ or 25 (.Q•+',/ ;pnnCr-Ce nrwws osec n- stt-:rro NrCrs Monr aqn:f.p or=.8r,.. axr n- eq r;iqs•r-+et a:r l Southern Europe in both the survey and the 1986 Census and 1% were born in other countries. Differences in the methods of' data collection and truthfulness in reporting smoking habits might also have led tp bias. Control subjects completed selt•adminis- tered questionnaires whereas information for case subjects was obtained by a nurse- administered questionnaire or by mailed questionnaires completed by relatives of deceased case subjects. The most likely effect of these differences would be for t:ase subjects t0 under-report their smoking and this would reduce the magnitude of' estimates of risk.M It is also possible that case subjetts might exaggerate the extent of their exposure to passive smoking. looking for "explanations" ot'thely disease. The effects of confounding factors need to be considered. For examp/e, in this study' previous myocardial infarction or history of ischaemic heart disease was found to be a significant confounder for smoking and the risk of ~myocardial infarc- tion or coronary death: This is consistent with the observation that people with, known heart disease are urged to give up smoking and often do so. Thus differences in magnitude of estimates of risk reponed from various studies will be affected by differences in prevalence of heart disease and in the extent to which this is taken into consideration In the analysis. Another potential Confounder is soclo- economic status. Prevalence of cigarette smoking and hence the likelihood of exposure to passive smoking at home and possibly at'work are higher among people of wwer soc,oeconomre status and so is the prevalence of heart disease InAustralla.^" For example. in this study the distributions 01 socroeconomlc status as measured by education were significantly different among cases and conVOls., atter adlust• ment forr difference tn age whemn control subjects were those who partiCtpated fully in the survey or completed the brlet questionnatre (for men. x1. 44.1. dt .4. P< 0.0001: for women. zt . 60.7: dfi. 4. P<0.0001), Adjustments for thls confounder were not included in the analy- ses because of the very'smau numbers in most cross-classified categones. The effect of this factor would be to increase rtsks attributable to active and passive smoking by including effects of~other souoecartorrtre , variables. Lack of statistical power is a limttatron of this study. For many t:ompartsons the numbers of subjects were small - most notably for exposure to environmental tObaCCO smoke at work. because few of the cases, especially among women, wortted outside the home. Also: many factors increase the variation of fibrinogen measurements." Although conslstent differences were appar'ent. the results were not stalistically significant and'4ddmg other covartates such as Cholesterol levels did not reduce the variability: Far more subjects would have been needed to give unequivoCal i results. On balance, the effects of bias and confounding could have led to overestrma- tion of risks due to passive and active smoking. Nevenhelesse the magnnude of increased risks which we found 1or passive smoking at home and tor current smokers and ex-smokers are similar to those reported by others."'- In most studies ot, passive smoking and risk of hean disease. the exposure has been at home, from a smoking spouse. Dose levels from exposure at work have been reponed to be higher because of the larger number of smokers and greater density of smoke." Thus risk associated with exposure at wortc might be expected to be higher than with exposure at home.. Our results do not support this as the oods ratios for exposure at work are less than one (except for women, ex-smokers); atthough the tonfi- dence intervals are wide due tp the small numbers of subjects. Alternative explana- tions should therefore be consldered. such as: the possibility that dose levels of components ofenvironmental: tobact:osmoke which cause heart disease are higher for those exposed a1 home than at work: or inaccurate reporting in this study 2023511'71'7

, THE MED)CAL JOURNAL OF AUSTRALIA Vol 154 June 17. 1991 of exposure at work (though fibrinogen qeferences Ievels are consistent with reported exposure);' or effects of confounding vanables not considered in this study. The increased tibnnogen concentrations • Lbw•n S:aw. Dn.w-+tc r od rrartr, :Mr; Mrr,ui among current smokers and ex-smokers : are as eapec'ted.'• "°' Increased hbnnogen ~ associated-with ptssive smoking has not to our, knowleoge been reported before. This f7nding, although not statisticatly sipnificant (possibly because o! the inade- quate statistical Ipower of the study): fi1Q- pests that passive smoking increases the tisk of heart attack or coronary dsath by aa /east some of the same mechanisms as active smoking. For fibnnogen. the effea is bel:wed to be oue to'thrombogenesis rather than promot'ion of atheroselerosis.r' In summary; this study provides esti mates of' the prevalence of passive smoking in Australia in 1988-1989 and confirms previous findings of elevated risk of heart attack or coronary death associa- ted with pauive smoking at home. It'also suggesis that passive smoking is assoc-' iated with increased'' concentrations of fibrinogen and' so thati an least part of its effect is thrornbogenic. Acknowledgements Tne 7AOWICL PrtaCe.., N.+.Ca+.:~ . a.nevre.t t7,,.R• twnra.r w..r Fa..nlm v a ~. a.«: , nr.'orw.. ~.a7M,n aim M/erat~M M:x,.w-: r C~,t.r" Mrlb1A:,.. lnC7o• furrt% rt,n aa}e•S• .:: rr!•! tr.r>!u 1„. 4wa.:.a 110m Y'' NM41RC lrr. :,r- e-C C.^ .1:: 3 4 © SlrY: o: 'a!..m. Tn.r..Fl~ r o• wno,.••c :.i«tq.as:..c:r omM:r.~ a rr.uwo,.nr S.wo.,,r ('M..M7F ra~Jt....•. tVw,NwrK: ~ry llKni.r:rt+.a,. ,W5 t3tvA S.aM17t"O''hh•>y.ilrK5'rWSt~t[ ry.M:+: 6a+oo. aanw+ tsss Tne P.w++O ProM!r t'~e'MUG~ a•o.G RlMa!d+M,n a aoal o•e.rve v.•rr' eate~:NV 77ha.no mu' rets:+r..v.: aml Ew aa> lo •r.r.:et to •ncar:ce a"t.O paorwY OK+tta t.w •e:v/W a.,e Om.,~ Prowc J'CJronc t?e 1978 !• 20: 306 SvMtOlM KN Ktier LMO tiar,-•t.U OReh! JK Ea.es a a7~s.~e.ro.np ^.u wn~ac Aa. cac+a r.a.e+tpn TrW M, JEVceenw'1t16' 176.. 7u 7" 7+n.np R7. Sanoe DP. Ca,mock Gw. Cn.. E Mftan ara•iic maurrv nnprfyna.ersiner,p w~r+ 7e7w.en Am J Eper+rwr TaB' '2' 9115 222 a G+ts CF r.nK DJ hur.evnr trf,l, 9oae P Trw 797 1'.~.+rtl-r~ar.! n..v nV':.rnrhr.htyl,.• n..ww.•.. ,ybT. 25r. Ci.YC-'j- ' o.r•.l,. wV.P...,.wf.+rrn:A.o•.~.rt.+rarna.±r,aotn.D'.nr.W. +rourt+o,e.nsn,:+w.nr,... •9V.•t:., , : i' 1Y•yOM(~Mly~c qon•:+Prnr:7y rn,TS~•WMnra 7re wo•u+ r.naer, V,we~ Jaro • M JNS:.a P.oc•C' tA4... :ur.+y uanrt7e an0 ,tMHma+:,,1. +1 uro u.afGw• mvare a rr.an .ne••rnnu; s.raaa,o. J':.+• : o~oenr l Y86 0i to5 "_ u' ~..'. .U..~.A~s.rrwr wu AWRean k e: ;. ~s•........•yv.r[Mref ..: nNro•el.v nKfot n MONCCA e.e.. rar+ /ir.- Eoer+n a So.r st,o.our 7Q9C 3e 3Si7••0: The GLIM srliMrh 10101,08 3"..' 190 IptJle• 7?Oprarn) Oaaa Nr,rnercy'A1ooWwna Grwp 771s6 ,t 7a En-uro .ra•a+ 5 Ioomoura aroqrar.,l Aar.a Geo.Py Ce.rers tor De.waae Corwa Geneva won0 M.Mrn Orpa+ts2aron tf190 :t! SLS .NS•a• 6 Ioo '^o<OW doorarnJi Carr 7kpnn Caronry SA15 rm.we 7nc. 1is5 Mapwn SF Ky.r.nan JC..Naaant JN _ va+cn. a nwr.aw,,a.•wv.rF Be.eO a, rRrpunecr•.e lno.nG. IrYanMlQnI .Sfaf tNeQ 1949 . a 1797•700Q Go,, MM Ba.reo;Cana E. a.vn kt D+ee.erces QneC. R FhWOTMMIIy It71:111ct• RAO.a f11-p tRCo.n ;0 oar.+vwra r+ ew .ee a Scauro Ft.1 Aeao. _~s toe•=' 13yu+oa7 121•T26 _ 7GX""O c sarrWl'C°r'° E SJ.+rc L _"r E"NUM 7: tr t7aeu.r ,.no..wj, a. .alr+,r nean Os.afrw mawen a nonveo..ra a vara.ar+. quor Am J fDosrncr'7p115, 121 6a5•6i0' a t+c.e DJ Gre CA C••otxa C'+wrvr.rr vr.r PRa•.Pr inta.mp wt7 rmcMaes9morrnearm - a QeitnYvo(itYla, neW .m OdSCdW10 8&MlOJ 19e9, 2!i 423427 . 9 UtiKC: Su.e. Pido.r r•tarrnm Sr•rtn Tr>r nean- A tXrWe01lTll=F.a..ws.NMM 7K,O~n11i a raoor: t7•' r+o Svpron Gnr.w wa*rt<non DC L1S Goti..n :J rhF•'; Prntnp.OltCr. 1tNlb 10 6,am•,el: wB D Apoatrno AB Belwnoe^ •V Fv.ay,m tJta'.wrmc>Pnr•rtr N•+., •a.. re tartwv+K x C+aro rwaarr, •nt.l,R: Mf.n a• rrinnrpvsh Swfh a++ rWer J 1967 113 ' 100151010 1, wOYWnfws L. SY.wtliaK, h Ap•iiln Bn1,o:.P„ A ry r Fo.opCn :e. a•v. L1C.l`• tV artr,r aY: ~wn_~ma +~trr~e+ N lnc-.•a4,n19lL 37 Sfl, i505 12 taea.r:• tw Vk>trtrw•.. S ara'tw: M n w.uuorro %!A.C h.E7t1, :Wtt i:.c.wnC r.M•'. trls.t.r•' 1/epow'. rPoUt a1nr NrrWw.ri P..& «ra.• Su.h.. lwr.ynTtinG : S13 537 13 7wme1 wB waie PA . C71'oM, K'P D Aon'Y+v, R(i t7N+aYn relrlOnOeh!2 anf, h?.-relOaK1eh11 I+ a Ooo..a,o, as.a oreo.anctiae• ossair ftuor Am J'Eooc-.a 1975 106 367 3T2 Iyyrara.'. E4no.a: Ca•.nrc.on Arrt<ytl'Nepai ,fi6P-1969 Canoe•r'. AGPS +a69 Art.. Faaa he.aw,ee Stuor 6esrvpeT.n, ! Con,-ner Raa Fac,aP.evarerre Stuo,• st.rr.,rr 3198m, Cano.•rn kaiKrsy'.yan Fov+aaie,n a A.em+w" arty Msrrav.n tnewwe a r..aan ttr90' L.oePtr u*ournmtauo,~a'sro.+,p naorm aroW tmaw.r vmo.n,p a.r.v.a a Y+e e.r7e.,ce r+e.. rac Snrwe.-ve.nn 196g Doo.a- U G'nnw~m 7i1++ Lw.r SR O Cm.wrD QCLCfar[rw+.OWwnti+ot!•..w b,wnt eWrr nWAyC rntrp.+r.lwlnwlllo~a.,yprara AnrJfYO!"tr 79e5 1= 26J 2AC !F oocerA SJ S+w7r. AG Car DG e: a St7wr tasa .+.h•.% krr .. rc+annrrart net.r .. &.n. r r,e., L.•Kr,. HiF.' : 1'P'2nt :-~ L.W U brneIt wCS L u.e iSDO' Tl,v,luar POU0e ri Pte.rn wt.nwa.,larn tsratarv n., uknra art St:a,•,u, ww, w.wtn S.nr J'.s, ENefM.n''! i19C -13 9:3 YlY rrieCwrNrrOor' 7S.rt7D0. aCt:epNdYay 72. 7e9T1' Australian patterns of tobacco smoking in 19'89 (for editorial eotnment. see peye 798) David'J Hill. Viaorio M Whitr and lVigrl J' Gray Obj.cN7.e: To estimate the national preva- {or7cs of smoking. Desqn: A toW of 4920 adults aped te years end over (23aa men, 2456 women) wrre surveyed throughout Australia in 1919 eby s tsrpe market research company. SettJnp: Interviews were t:onducled in the participants• homes. Resulls: Overatl, 30.2% of tnen sed 27.0% of won7.n wen currenl sewkers:,2s.tIK' of men and 1e.06011 of women wOrs past anwkers. Tha mean daily consumption of tacuuy-rnsde cigar*nes a7nonq nsalY smo/iers was 22 a7nf among female smokers 1a.i. Taking Into accourn the published tar content of the brand sa7oked. M was estimated that the average daily exposure to tobacco tar for tnen was 204 mg and for women 157 nrp. Anri'-Conc.. t_ounck ef viltona. I rlatnee.ne snr..t. Camon..v1C 3014. D.,•rt,.!'Mi tY. 7hD DnRItM CMnM 4r Mr4.dNYMf1.rp, w r.MCF v¢.o-. rr wr,w.. a+~rrawa M..ra, Ons« C.rn,@ tr a.n..rar M..wa w tiwr wq.,. ~ Grq•. ats ss. iwACr. s7uCw t1+.na. .+.-G.wcw G.arr .r ~wrr .w.w. D. 0 j t.e Occupational and educatbnal status were invars./y related to tM prevalence eff smoking. Th. most popular packet atzo was 25 (pr.llrred py 48% Of s+nokers) ai+d thoss in tower occupational and educatlonall categories were R70te. Uketyto purchase ~ ciqarettes in large packet stns. C Concluaront: Cornparison with an eartisr Aa, asnas of studies commenced in 1974 showad r. that the national prevalence ot smoki Wnp ~amonp adults has continusdio tall, panicu- kr/Z IYny among men. ~ (Mad d Aust 1991: 164: 7l7-a.01)I-all, ~ ftj !"~ ~