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Table 7s. Mortality rates for major cancen other than lung in women by age group and' by smoking habit of husband (patient herself a nonsmoker): prospective study, 1966- 1981,Japan• . ' Hn.baad"s smoking labit (cigvvita a day) 1 Husband s or croup RX-Insolsw - ~ Neas~oka 1-19 ~' Taa1' ~ No. Pop. No. Pop. Ne. Pop. No. Pop. ~ 40-49 44 6.229 117 15.034 71 10,764 232 32,027 50-59 97 7,791 191 15.642 119 9,t20 407 33,253 60-69 160 7,120 274 12,443 106 4,651 540 24,21'.4 70-79 14 755 20 1,065 • 226 42 2,046 • Total 315 21.895 602 44,164 304 25,461 1,221 91,540 . 1.11:. 1_OS 1.00 1.00 1.00 0.f0 0.93 Kaeed a,ma- Z' 0.115 ~ -0.0015 0.009 .aruB 0.4994 0.41621 p.d~ 0.4542 s Table 7 b. Mortality rates for major eancets other than lung in women by a3e, otcupa- , tion, and'smoking habit of the husband (patient herself a nonstrtoker)' Husbaade age Noaamoker ls•.esoker ar 1-191dty :20/da7 (7-) Oaupatinab No. Pop. No. Pop. No. Pop. 40-49 Total 45 6,229 120 15,034 74 10,764 1 2 324 1 653 3 566 2 90 l 231 2 293 3 9 906 /7 2,247 12 1,667 4 3 476 1 993 8 1,044, 5 17 2.502 S4 5,941 35 3,636 6 46 165 108 7 1 177 6 486 426 t 10 1,112 21 3,431 13 2.241 9 1 162 4 345 1 243 10 2 432 3 542 340 10 50-39 Total 9! 7„791 195 15,642 122 9,t20 1 13 345 2 393 3 446 2 2 175 1 2S3 1 319 3 14 '17 16 1,764 10 1,324 4 1 653 18 1,133 9 1,092 5 49 3.497 $1 6,812 36 3,514 6 35 ~9 5o 7 2 120 4 273 2 234 ! 12 1.375 49 3,478 31 2,155 9 164 7 379 4 251 10 3 610 17 869 6 43S 60-69 Total 161 7,120 227 12,443 306 4,651 1 S 227 S 327 2 179 2 5 91 3 143 3 124 3 7 305 11 594 S 327 4 5 508 28 822 12 S00 5 102 4.084 1511 6,345 58 2,152

156 ?*esti Hiroramo Tabie 7 b. (omt.) H..baedr Lz -.moker sr Nos.moker w 1-19/day t 201dsy (}tan) Occupationb No. Pop. No. Pop. No. Pop. 6 9 1 31 ' D4 7 1 ' 43 3 82 2 ~ 55 tl 10 !03 40 1,784 37 i. 736 t 9 2 121 3 208 92 10 24 925 25 1.607 7 472 70 + ToRal 14 755 21 1.065 ! 226 1 32 30 3 2 1 21 14 4 • 3 1 1s 36 R 4 48 1 73 2 20 5 7 323 13 446 4 29 6 1 1 0 7 1 - S 1 tl 1 •7 2 119 1 36 9 11 19 2 10 4 213 3 322 1 61 •Sundard.ed Ruk Amc. 1.000 0.969 1.034 l/aiud.ma~.on.¢: -0.129. enruil p vdoc: 0.4i66B. 60ceypr en: 1:'rokmon.1 .nd neAnicat, .~arlers: 2. aeanrgnm and elrriib.: 7. deric.t and rdaued .oAen..4. rlm rer4,en: S. tammrn. lu,nbrrmen. and fiJicrmen. 6. .orken in minint .nd Quv.yin6 arevpu,om: 7: ,.wYen '.n, van+pon..ndmmn.unicaon oreupuiasv. f. e.tiuvra, peoduction ymcesw aohen...nd I1En.en. 9.,we.'.iee .ohen: 10t fm d..ufi.b~k aed.m reponed Comparison of the Effects of Ac#ive Smokir>0 and Passive Smoking When the risk of lung cancer in nonsmokers with nonsmoking apout+es was taken as a unit, a definite dose-reponse relationship was observed, the highest risk being -iin heavy active smokers, lollowed by mild active smokers, then heavy passive smokers, and then mild passive aaohers (Figure 7). The risk gradient was similar both in men and in women (Figure 8). A signifa`altdy ekvued risk of lung cancer also was noted for nonsmoking husbands with smoking wives. Because the size of population exposed to passive smoking is quite large in the -tase of women, the effect of passive smoking because of the husband's smoking was estimated as 65 9b of that of active smoking. Our recent survey showed that 47.5 S and 32.696 of,]apanese adult women were being exposed to passive smoking at bome and at the workplace, respectively (Figure 9), 'Fherefore it must be a sound estimate that the total effect of passive smoking is approximately equivalent to that of active smoking in women: However, as a majority of adult men are stiR smokers„the total eJkst of passive smoking relative to active smoking must be on I

Ltnp ConCet In Jt;porc NuMMOn ond Possiva 4rntoldnp 187 . (a) m.0 n.o 14.0 DE U (b) t.O 7.9 u.o 6.0 10.0 s.e ..o' i.o O.o 3.a n..a..neas n.r.aa. .•~.41n lorrln ~al. ..n. ~.0 2.0 t.o ~ I 1.0 --{ !}- - 1.0 T .. i . i . . . . .. .. .. . n f ~ I w. r.~ /.. i r. ~/O.It WIT ~ i/r. r/ w - s. •.... I.rr- 00 rT. 14 lT 71 .h t1•.4 t~•1 ~••e• MMr.<MiMI WII' V'~ ~, M IN 11~ V w.n /Iu vM Y A M wr rr~ w v w r• z~ n.N .r W . . . .. .n` Mln MM nrr~. ..la rYr ral 1a INN~. rNl w.a~. Ir I7r . tiet ~ / M NII~ aNN Mf IA1 /N. ~t CMOIrKI 1/ 1 .1 I~~N i ~~~ ~ , . I,N / .M ./ . C~Iptl~. • •.• r . 1~1/wa 1! LN Lt7 7.n I~V~ w t.N a .., . . . s , ~ ~ •~rl.y.....,.a .~... r.~..... Figu:4 7. (a) Active and passive smoking and lung cancer tnortalir+y: telative risks (RR) with 90% confidence intervals; ma)es.(Ptvspective study, 196tr 1981, Japan.) (~),Active and pauive smolung and'lung cancer mortality: relative risks (RR) with 90% confidence iater• va1s;',femalts. (Prospective study, 1966-1981. Japan.) the order of a few percent. 3he effect on lung cancer risk of passive smoking as bome in relation to active smoking for men was alcul'ated as 0.4% in our seriea. Effect of Nutrifion on Passive Smokers ' A signifit:antly lower risk of lung cancer was observed' when nonsmoking wives with smoking husbands consumed green-yellow vegetables daily (Tables 8 and 9. Figures 10 and 11) suggesting that the promoter-inhibitor interaction model also applied to passive smoking just as in active smoking (Figure 9). Such risk reduction caused by daily intake of green-yellow vegetables was not observed for ischemic heart disease (Table 10, Figure 1'2): s

188 ?droaw'Nwyiarro r so sOl1i waT . 0.. / ~ 0 wuu't ...{~ ..... t""' r01t. ~...~.... Ikla. r~~l a,..0 B11TM. 71. fl. Nl. 7 /N {tl N~t. OYULFtIOn. ONf1'. OWS'. N.N UO{ /017f Nlu Ow7n fMf.M t eOaIOLKy h..•t:N .M ..01 .:Y 0.7. L1f /tR(F.L . •.t. I:f{ f.>S !-{1 l.A f.1 ...1 l~.l! /.N ..M YY~•dlylt Fignre 1. Actiive and psoive mwking and h{ng cancer mortality: relative riaks (RR).rith 905'a corTxencT intcrvals. (Prospective study, 1966-1981. Japul.) 1: - "i. (a) .. r.ra0. Ir/. OI0N.tit A.N. Ift 47.5% hE N•06 u. 10 . » M f0 10 30 1 !0 10 a. v,..q. 4,10 „.a ~~- rrl« Ift 53.6% ~ . . • w ,~. .u L L L • s. .. N ~o (b) a• .0 w•0 n { . . » y. snr. a.. s.wr Figure 9. (a) Pertrntage of nonarwken erposed to sidesucam cnoke at home. Japan, 1983. (b) Perorntage of aonuaokers esposed to ridesclearo vaoke at the workplace„Japan, 1983.

Table S. Lung cancer monality rate in nonsmoking wives by smoking habit of the husband: comparison be- tween daily and non daily intake of green-yellow vegetables I Et+nwker wnokinR habiu Nonrmoker on 1-19 diy 20/day Husbend'r Wife'r eating babiu Greearyellow ve6etabler Dei1y Nondaily Daily Nondaily Deiiy Nonddly Lung Lung Lung Lung Lung Lung Husband'e Pop. Ca. Pop. Co. Pop. Ca. Pop. Ca. Pop. Ca. Pop. Ca. OccupatloN Age Agriculture 40-49 1,956 1 344 0 5,030 5 991 1 7,037 7 399 2 50-59 2.805 4 692 0 5,196 11 1,616 3 2,386 9 926 0 r 60-69 3,739 7 725 6 5.106 22 1,739 II 1,588 6 S64 4 70-79 256 3 63 0 287 1 159 0 45 0 44 0 Uthen 40-49 2,492 3 1,103 0 7,286 / 1,803 1 3,377 S 1,731 2 50-59 3,181 S 1,113 1 6,732 12 2.098 3 4,637 S 1,673 10 60-69 2,266 4 770 I 4,086 9 1,510 6 1.906 10 399 3 70-79 216 2 216 0 371 1 248 3 Si 1 56 0 Total 16,463 29 5,430 8 74,118 69 10,066 30 19,253 49 6,206 21 Grwd totd Populatiost 91340 Lra6 caaeers 200 E3reea-yeliow vegelaWee Manmel<etenrion xl P-value (two sailed) Daily 2.072 003827 Nondtily 2.487 0.01288 Total 3.090 0.00200 I 16 s44TTsf:zoz

190 Greo-yeDow .e`etables Table 9. Effect of daily intake of grren-yellow vegetables on lung canar esu+rPJiis in nonsmoking wives with smoking htubands• Husband's Ea-+mokrr ®okiog labit .r 1-19/day 2 !D/day Wile's eati6g Yabit YWr ` NoYYiYr LsYr N.oedLly. Laag Lt+.g Lung Lung Husbaed's top. Ca. rop. G. top. G. lop, Ca. Occupatioa Age /tgriculturc 40-49 5,050~ 5 !91 1 3,037, 7 559 2 • 50-59 5,196 11 1.616 5 2,588 9 926 0 60-69 5.106 22 1,739 11 1,588 6 564 4 70-79 287 1 159 0 45 0 44 0 Ot6en 40-49 7,288 9 1,905 1 5,377 5 1,751~ 2 50-59 6,732 12 2,098 3 4,633 5 1.673 10 60-69 4,088 9 1,510 6 1,906 10 593 3 70-79 371 1 248 3 !1 1 56 0 Toul 34,118 69 10,066 30 19,255 43 6,206 21 IMamd•Hrnod,/.. -1,9/6.P(LOL&ilM0:017).Odd.ratio:.KavLily:tsrOee-7ctlo..efetabk.r.ie:..l.000- dsjry gRT^-7elim. •egen6b.dw.ke, 0.707(w.nduduedere erin); f0% ean6dener i®./. ,0:53l-0:4i3. m i..MN'. truq wI r {n...rHOw 0"OW1.6 falaeepr'Fi:hartn Y. tru. t..t..... 1.1. rn/ N N ~r. s+lt/ WM1.(.Iw./M O1 ~ MIN rns 11.811, ..nsrt elftn t.M7 •.i1lN Figure 10. Lung rsrtcer, mortality ratio in nonsrraking wives by smoking habiis of their hushands. Comparison between daily and nondaily, untake of green-yellow vegeta5les. i f I

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J Table 10. Iarhernk hean dieea.e mortality rate In nomnrokin0 wive>I by emokin6 habit of the husband: eom- periann between Orten-yellow ve6elables intake daily and nondaily I I 1 Hu.b.nd's enwklng habit L.-e_eker Nonenakee .e 1-19/da2 :20lday Wite's edl.s babie Onen-Yellnw .eVuWes M.mde-mension x' P vdue (Iwo teiled) Deily 2.307 0.02103 Nondallr 0.02t1 0.41222 Total 2.406 0.01613 Creea-yellow .eteublee Daily Nondelly DdIF Nosddl2 D.ily Nendell2 Heeband'. Lchemk letheslc hps. Heert D. Pop. Heart D. /echesie Tsp. Heed D. leehea.k Isp. Heart D. Lcheslc lechtsk Tb'. Heart D. rep. He.rl D, Oeedpolw Age At;rkuhure 40-49 1,956 6 344 2 3,050 /S 091 7 7,037 14 399 t 30-39 2,603 11 692 4 5,196 23 1,616 2 2.5" 21 926 5 60-69 7,339 30 723 6 3,106 35 , 1,7]9 24 1,366 21 !61 6 70-79 23e 2 63 3 287 10 139 1 45 2 44 0 ahen 40-49 2.422 1 1.303 2 7,20e 10 1.603 s 3.377 12 1,7s1 s 30-39 3,181 6 1,113 3 6,732 le 2,06 11 4.633 17 1,677 6 60-69 2,266 21 770 e 4,066 » 1.510 1] 1,906 11 597 9 70-79 216 7 216 2 371 6 448 2 61 3 56 2 Total 16.463 6S 3,1)0 90 71.11e f73 10,066 63 19,233 101 6.206 35 C.rrd 1.td ieprlati.e: 91360 teche.k beat dlaaeet 494

l'tnp Corlosr in Jbport Ntfinton ond Plzs" S'nddnp 193 •a...~'. irtfq u~ll. in...talw Mqa.a.. allt •~.... p. W.e. L..s..a.r 1 ~ N Mt/~ io .. r.. a+iy Ma.l•C.4..t4.. thl ~.«lr. (tiw•fN I~~} r.7~~ •.eZICs ..~5~ •.ati: Figure 12. Ischemic heart dixase morta]ity tatio in nonutwking wives by smoking habits of their husbands. Comparison between daily and nondaily intake of green-yellow vegetabler . Discusston The age-adjusted mortality rates for lung cancer have been sharply mcrezstttg both for men and' for women in Japan. As only a fraction of Japanese women with lung cancer smoke cigarettes, the reasons for the trend of their mortality from lung cancer have been unclear. The present study appears to explain at least a part of this long-standing riddle. This observation also questions the validity of the conventional method of assess- ing the relative risk of developing lung cancer in smokers by comparing them with nonsmokers. This study shows that nonsmokers are not a homogeneous group and should be subdivided according to the extent of previous exposure to indirect or passive smoking. Although the relative risk of indirect smoking was smaller than tltat of direct smoking, the absolute excess deaths from lung cancer resulting f:om passive smoking must be important because of the large size of the exposed group. Therefore, these results of our current study must be of public health importance, trtrengthenibg already existing evidence (r a health harard from passive smoking ~11-13) (Table 1i). As shown in Figure 9, 47.5% and 32.6% of 158 nonsmoking adult women surveye+d'recently are noted to be exposed to sidestrearn smoke at home and at the workplace, tespextively. One survey conducted in Aichi prefecture in Japan showed that nonsmoking wives are exposed to their husband's smoking 6.7 times a day on the average. Because sidestream smoke contains varieties of cancer promoters ar higher eott- centration than does mainstream smoke, it must be reasonable to eonsider the a