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F I lb I 10 HealthBrief s Passive Smoking, and 20-Year Cardiovascular Disease Mortality among Nonsmoking Wives, Evans County, Georgia, CHARLES HUMBLE, MS, JANET CROFT, MPH, ANN GERBER, MSPH, MICHELE CASPER, MSPH, CURTIS G. HAMES, MD, AND HERMAN A. TYROLER,, MD Abstract: The association of passive smokingand cardiovascular disease (CVD) mortality was assessed in a cohon of 513 rural, matried Black and White women who were disease-free and self- described as never-smokers at baseline in 1960. Over a 20-year period, 76 of 147 total deaths were attrSbuted to CVD. Relative risk estimates adjusted' for age, eholesterot, blood pressure, and body mass from proportional ihazards models were 1.59 for CVD (95% C1 - 0.99. 2-57) and 1.39 (Cl - 0.99, t.94 ) for all cause motulity atrwng women with husbands who smoked cigarettes. (Am J Public Health 1990; 80:599-601_) Introduction. Cardiovascular diseases account for about one-half of all1 deaths in the United States annually,t Althoughiactive smok- ing is well-established as a CVD risk factor,2 the risk for all'. CVD mortality associated with passive smoking among non- smokers has not been previously investigated. Recent studies of risks for coronary heart disease,?-a stroke!-$ or all cause mortality'•9•10 associated with passive smoking generally have reported weak andlor statistically, nonsignificant results. The 20-year mortality experience of nonsmoking women in Evans County, Georgia was used to assess the association of passive smokingwith CVD and all cause mortality: This is the first report that includes data on both Blacks and Whites and' on the consistency of self-reporte& smoking behaviors over time. Methods In 1960-61, 92 percent ofialliresidents ages 40-74 years and a 50 percent sample of individuals ages 15-39'years in Evans County, Georgia participated in a cardiovascular disease study that included risk factor measurements, com- plete physical examinations, and a demographic and medical history interview." Detailed descriptions of the Evans County study design and the 20-year mortality follow-up of the cohort have been reported elsewhere. 11,13 Ati baseline, 554 (82 percent) White and 389 (83 percent) Black women, Address questions or reprim reqyests to H.A. Tyroler, Department of Epidemiology. Rosenau Hall CB r7A00, UniversityofNbrthCarolina. Chapel Hill. NC 27599. Mr, Humble, Ms. Croft, Ms. Gerber and Ms. Casper are cardiovascular disease trainees in that Department. Dr. Hames is principal invesugator with the Evans County, Heart Study. Hames's Clinic, Claston, GA. This paper, submitted to the Journal June t2: 14g9, was revised and accepted for publication October 30, 1989, C 1990 American Journal of Public Health 009t}003690SILXI among a total of the 1,127 women ages 40-74, reponed that they had' never smoked. The present study was restricted to the 328 White women and 185 Black older women,who ha& never smoked' and were married to male examinees who reported they either had never smoked or were current smokers at baseline. Women married to ex-smokers' were excluded from the analyses as the probability for misclassi- fication of these subjects' own smoking habits and those of their husbands was judged to be higher than for spouses of never smokers.t' A second survey of studyy subjects in, 1967 provides data on the stability of reported~ smoking status. Vital status was determined as of May 1. 1980. Under- lying cause of death was abstracted'from d'eath certificates with codes 390456 (ICD 8th Revision) defining' CVD! A]II CVD mortality was chosenias an endpoint given the limita- tions of death certificate data and the small number, of deaths attributed to eachispecific CVD entity.t` Three subjects who did not have follow-up information were excluded. Analyses for White women were stratified by sociall status because of its inverse relationship v.-ith smoking status and CVD mortality in this cohort.t' White women were divided' into high social status and low social status groups based on the median of the McGuire-White index of' sociall status for, alll Evans County Whites. This index, based oni occupation, level of education, and source of income of the head of household, was developed for use imrural settings." Since only 5 percentlof the Black women in the Evans County' population had a social status score above the median for Whites, Blacks were not stratified by social status. Exposure to passive smoking was defined by husband's smoking status (current, never) at the time of'the baseline interview. Mean baseline characteristics by passive smoke expo- sure were compared using t-tests. Cox proportional hazards modelst" were used to estimate the association; of passive smoking with time to all CVD, smoking-related CVD:and all cause mortality in this population while adjusting for age alone and forage, systolic blood prescure. serum cholesterol, body mass index (BMI), an4 a quadratic term for BMI. Relative risks (RR) and 95% confidence intervals (Cl)iwere calculated using the SAS proportional hazards (PHGLM), modeling procedures,~'-t"' and'the statistical significance of trends was tested using a method proposed by Rothman.'v Constancy of the relative risks over time was verified before the proportional hazards were mi Results Among nonsmoking married womeni there were 179'(55 percent) of 328 White women and 117 (63 percent) ofi 185 Black women whose husbands reported current cigarette 599 AJPH May 1990„Vb1J 80, No, 5

® PUBLIDr HEALTH BRIEFS 1 TABLE 1-NNan and Stsndard Er-or of Baseline Charsetnistics by Passive Snwklnp Ststus of Monsmoklnp Wlves„Aqes 16-74 Yesn, Evans County, Georgia, 1960-81 WMte Women Mgti Social Status' Low Social Status' Btadc Wornen Exposed lhrxposed Ex(wead llnexposed EAposad lh»xaaed N (78) (83) (101) (66) (117) (68) Age 51.9s1.0 54:920.9 52.1s0.0 53.920.9 50.3 0.7 55.5s 1.0 Systolic Pressure 145.5 s 3.1 150.6 = 2.9 151.6 s 2.9 157:6s4.3 170.6 3.4 176:5s5.0 Diastolic Pressure 88.4 s 1.6 90.6 s 1.4 922 - 1.3 93.121.7 103.1z1.9 103.922.5 Serum Cholbsterol l 231.9 x 4.9 237:5 s 4.5 227:0 s 4.4 235.7s7,3 216.5c3.9 216:2t4.6 Body Mass Index 26.3 t 04 26.4 s 0.6 27.0 s 0.5 28.6s0.9 29.2 0.6 30:0s0.9 B.w on Si. nww, of MeGw.Whe. smree la at WWr ae)eeta smoking behavior. Among both Black and White women there were no statistically significanti(p <0.05) differences by passive smoking status for systolic or diastolic blood pres- sure, serum cholesterol or body ~ mass (Table 1). However, passively exposed Black women and high social status White women were younger on average than nonexposed wives by 5:2 years (95% Cl = 3.0, 7.6) and 3.0 years (95% Cl = 0.3, 5:5), respectively. For all Whites combined, nonexposed women were also more likely to be above the median SES (socioeconomic status) level than passively exposed women (55.7 percent vs 43.6 percent). Comparison of self-reported~smoking status in 1960 and 1967 showed 98 percent of wives again reported themselves as never having smoked' in 1967. Similarly, 98 percent of never smoking husbands maintained their reported status in 1967 while 25 percent of husbands who smoked in 1960 described themselves as non.smokers in 19%7. Age-adjusted RRs for all :CVD, smoking-related CVD,and all cause mortality among passively exposed wives were ele- vated in Blacks and high social'status Whites and for all subjects oont5ined (Table 2). The opposite relationship of mortality with passive smoking status was found for low social status White women: Adjustment for other established CVD risk factors (lood pressure, cholesterol, and BMI):generally caused mod- est elevations of the risk estimates (Table 3) but as with the age-adjusted estimates„the confidence intervals for all subject groups included unity. A trend in, risk over level of husband's smoking as reported~ in 1960 was only seen among high social status Whites; RRs for both total and smoking-related CVD mortality among wives whose husbands smoked <10; 10-20, TABLE 2-Ay.•adlustad Relattva Risks and 95%Confldenoe Intarwls for Total ICVD, Smokinp•rabted' CYD, and All-Cause Mortality for ,yriv" Exposed to Paasive Smoke in Evans County, Georryla, 1960-80 Y,a._s d Cestti An SubjeW Blfacfcs Whites MSS_ LSS.. CYD Total RR 1.34 1.69 1.66 0.60 ~ 95%Cf 0.864.2.21 0.83; 3.46 0.64„4.32 0.27, 1.34. smokie+g• re6ated RR 1.29 1.57 1.67 0.61 95% Cl 0.79, 2.10 0.73: 3.37 0.64„4.36 0.25. 1.47 All cause RR 1.31 1.34 1.60 0.72 95% Cl: 0:95. 1.82 0.79: 2.28 0.94,3.47 0.41, 1.27 ••ICDe 410-456 Mo xOCW qftle •uo. .oon wa,. TABLE 3-Retative Risks• and 95% Confidence Intervals for Total CYD; BmoklnQtatited' CVD, and All Cause Mortality for wlvea Exposed to Passive Smoke In Evans County, Ceorpia,1960-W Whites Causa of Death AN Subqsas Bladcs HSS" LSS- CVD Total RR 1.59 1.78 1.97 0.79 95% Cl 0.99, 2.57 016, 3.71 0:72, 5.34 0 32. 1.96 Smoking- related RR 1.54 1.68 1.97 0.82 95% Cl 0.93, 2.55 0.76, 3.71 012, 5.34 0:31, 2.15 AII cause RR 1.39 1,33 1.97 0.87 95% Cl 0.99, 1.9. 0.7E, 2.28 1.00, 3.90 0:48, 1.59 •MiiLOs raLmatllutt W 1or op. OuftolM[ MooO PWKf We. tafal MrUmdloNabt body mats n0ea (BMi ~. kyrtNte2): W BMI=•1CDeaoM~ 410.456 • Mpn aooW sutua to. eoasl wa. and >20 cigarettes per day as compared to wives of nonsmokers were 1.02, 2.11, and 2.55, respectively (p for trend <0.06): A marginally significant (p <0.09)i trend in risk for all CVD and smoking-related CVD overctude levels of duration of.exposure was also apparent only among high social status White women. Discussion These data suggest an, elevation of risk for death from CVD and all causes among non-smoking married women whose husbands described themselves as current smokers at the beginning of a 20-year follow-up period. Our findings for Blacks are the first report associating CVD with passive smoking in this racial group. Our observations that social status may modify the effect of passive smoke exposure may be due to chance, but a similar pattern of results for coronary heart disease (CHD) has been reported in other studies of passive smoking, Nonsignificant(p >0.05) two-fold RRs for CHD among passive smokers were reported from studies of middle-class and'upper-middle-class womenb and men' while CHD risk was significantly but more modestly increased (RR = 1.2) among a much larger sample of predominantly blue collar Washington County, Maryl9ndwomen.eNo increased risk for CHD was reported among public hospital patients whose husbands smoked in four Bntish hospital!regions.s It is unlikely that these results can be explained by a change in smoking habits since the minimum age of these women in 1960 was 40. We lack data to examine whether exposure status changedduring follow-up due to remarriage. The absence of elevated risk among exposeddbw socialistatus A,1PH May 199Q Vol. 80i,hlo. 5

PUBLIC HEALTH BRIEFS R'hite women may reflect a failure of our passive exposure index to measure exposure within the lower social stratum. Power to test for small differences in effect of passive smoking by'race or social standing was lacking as were data to evaluate the role of other variables such as alcohol use or physical activity: Taken together With the results of previous studies"-a•w and laboratory results suggesting that passive smoke exposure causes decreases in energy production in the mitochondria of heart muscle2O and increased' piatelet aggrc- gability in nonsmokers,=t' our results support the health taazzrds of exposure to passive smoke.m ACKNOWLEDGM'ENTS This work was supponed by NIH grants S-T32-HL07055-13 and 2- R01-ML03341 (Mcrit Award). The authors thank )udson Wellsior his helpful eomments. The results described here were originally presented at the annual tneeting of the Cardiovascular Behavioral Medicine,:Epidemiology and Bio- atatisucs Training Session in San Fmncisco~,Califomia, on March 29, 191119. REFERENCES 1. Fraser GE: Preventive Cardiology. New York: Oxfortl University Press. 1'986;,3. _ 2. US Depanmenuof Health and Human Services: The Health Consequences, of Sttsoking for Women: A Report of, the Surgeon General. Washington, , DC: Govt Printing Office. 1990. 3. H irayama T: Passive smoking-A new target of epidemiology. Tokai J E><p Clin Med 1985: 10:287-293. 4. Gillis CR. Hole DJ. Hawthorne VM. Boyle P: The etkct of environmental tobacco smoke in two urban communities in the west of Scotland. EurJ Respir Dis 1994: 65 (suppl 133):121-126: S. Lee PN. Chamberlain J, Alderson MR: Relationship of passive smoking to risk of,lung cancer and other smoking associated'disuses. Bt 1 Cancer 1986; 34:97=105. 6. Garland C. Batren-Contsor E, Suarcz L,,Criqui;MH. Wingard DL: Effects af pusive smoking on ischemic heart disease mortality of'rtonsmokers: a prospective study. Am 1 Epidcmiol11965; 121:645-650. 7. Svendsen KH. Kulkr LH„Manin MI. tkkenc JK: Effects of passive smoking in the Multiple Risk Factor Interventton TnaC Am J Eptdemiol 1987: 126:783-795. E. Helting K1, Sandler DP. Comstock GW; Chet E: Aean disease mortality in nonsmokers living with smokers. Am I Epidemiol11988, 127:915-922. 9. Vandenbroucke JP, Verliersen JHH. DeBruin A, Mauritz B1. Van Der Heide-Wessel C. Van Der Heide RM: Active and passive smoking in married couples: Results of 25 year folbw-up, Br Med 1 1984; 288:Ig01- 1602. 10. Sandkr DP. Comstock GW, Helsing KJ. Short DL: Deathsfirom all causes in nonsmokers who lived with smokers. Am J Publie Health 1999; '19:163-167. 11. Cornoni, JC, Wdler LE, Cassel JC. et at: The incidence study--study design and methods. Arch Intem Med 1971; 128:896-900'. 12. Johnson JL. Heineman EF. Heiss G. Hames CG. Tyroler HA: Cardio- vascular disease risk factors and'monahty among Black women and White women aged 40 b4 years in Evans Count y; Georgia. Am J Epidemtol 1986: 123:209-20, 13. Tyroler HA. Knowles MG„Wing SM. rt of: Ischemic heart disease risk factors and twenty-year monality in middk-agc Evans County Black men. Am Hean J 19&: 108;73fi-746. 14. National Research Council:,Environmental Tobacco Smoke-Musuring Exposurts and Assessing Health Effects., Washington, DC: National Academy Press, 1986: 234-240:. 15. McGuire C, White GD. The measurement of social status. Research paper in human development No. 3(revised). Department ofi Educational ftychoiogy:,University of,Texas. Austin. 1955. 16. Cox DR:,Regression modeli and life tables. 1 R Stat Soc, senes B 1972; 3r:198-220: , 17. Harrell FE: PHGLM procedure. Depanment of Clinical Biostatistics. Duke University„Durham. NC. I8: SAS Institute Inc: SAS, Reluse 5.18. Cary, NC: SAS Instnute Inc. 1988. 19. Rothman K: Modem Epidemiology. Boston: Little, Brown and Co. 1986: 346-349. 20. Gvozd)akova A, Bada V. Sany L. er aA Smoke cardiomyopathy: distur- bance of oxidative processes in myocardiai mitochondna. Cardiovas Res 1984: 18:229-232: 21. Burghuber OC, Punzengruber CH,,Sinzinger H,,u ali Platelet sensitivity to prostacyci+n in smokers and non-smokers. Chest 1986r90:34-38. 22: We11s Ali An estimate of aduPo mortality in the United States from passive smoking: Environ Int 1988: 1<:249=265. Community Impact of a Localized Smoking Cessation Contest HARRY A., LANDO, PHD, BARBARA LOKEN, PHD, BETH HOWARD-PITNEY, PHD, AND TERRY PECHACEK, PHD lU ~ CO) ~ ~ ~ IJPH May 1990, Vol. B0; No. 5 601 AbitrtaeY: The present study assessed the effectiveness of a local+ iud eommunity contest timed to coincide with a statewide smoking cessation eontest; Follow-up interviews were conducted with 218 local contest participants and 198 participants from the statewidc contest. Ovetall cessation impact (participation i nte x abstinence) was 0.39 percent for the local contest and 0:09 percent for the statewide contest. t,ocalized community contests offcred'in conjunction with statewide or natiorul'carrtpaigns may represent cost-effective methods of reaching laege numbers of'smokers. (Am! Publie Health 1990;80:60)-W3.) Introduction Contests to promote smoking cessation appear to rep- resent cost-effective means of producing quit attempts in From the Division of Epidemiology, School of Public Health. University of Minnesota for the Minnesota Hean Health Program Researeh Group. Address reprint requests to Harry,A. Lando, PhD. Division of Epidemiology: School of Public Health. University of Minnesota„ 1-2 10 Moos Tower. 515 Delaware St.. Minneapolis, MN 55455. This paper, submitted to the Journal fNay 30, 1989. was revised and accepted for publication September Ii 1989. C 1990 Atnerican Journal of Public Health 0090.0036I90S1,50 community settings.- Quit smoking contests have beem offered on,a number of occasions as part of the smokingg intervention in the Minnesota Heart Health Program (MHHP), a 10-year research and demonstration project intended to reduce the prevalence off heart disease.4•` Several smoking cessation contests have been timed too coincide with the Great American Smokeout conducted annually by the American, Cancer Society (referred to as"D-Day" in Minnesota). The present study examined contest participation and outcome for samples of Twin Cities area residents in the 1984 Minnesota D-Day contest. Participants fromone of the intervention communities (Bloomington)' were compared with ia random sample of those from othcr .. Minneapolis suburbs (not within the immediate Bloomington, area). It, was hypothesized that the overalll impact of a contest, measured by participation and abstinence outcome, offered in conjunction with specific localized community recruitment and prizes would be greater than, that of the statewide contest alone. Method Subjects were recruited for a statewide D-Day contest during the Fall of 1984:. Recruitment began August 25, 1984