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N':OTIZ E This materat may be prot~cted 5y ccGpgnt law ;Tl:;e 17 U.a CooeL Marriage to a Smoker and Lung Cancer Risk CHARLES G. HUMBLE. MS. JONATHAN M. SAMET. MD. MS. AND DOROTHY R. PATHAK. PHD, MS Atntrsct: As part of a populauon-based case-control study of lung cancer in New Mexteo, 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 withiknown passive and personal smoking status. of whom 28 were lifelong nonsmokers with, lung cancer. While no eEect of spouse cigarette smoking was found among current or former smokers. never smokers lntroduction The causal' association of active.cigarette sthoking with lung cance4`~l~- bee a pt~"1?'0~ ~natty~ } egrs: t~ Recent epidemiolo'~.'''evidence indicates that involuntary ezposure of nonsmokers to tobacco smoke is also associated with lung cai'lcert}s Nonsmokers, as well as active cigarette smokers, inhale environmental tobacco smoke, which consists of a combination of sidestream smoke and exhaled mainstream smoke. Thefputative association: of environmental tobacco 'smoke with lung cancer denves biological plausibility from lt~e lack,of a demons ted threshold for lung eaneerin acuve_ ~Q~ers~frotri~"[li"uaLiattve'similarities ort3taitistream and sidestream striokt; andcfrom the presence ot mutagens iain the &riinr of passt4imoiters;'M The association of involuntary exposure to tobacco smoke with lung cancer has now been examined in studies conducted 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. an& the United States have shown elevated risk estimates associated with, the exposure of nonsmokers to their spouses' smoking.3.''-/0 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 reports showing elevated risks.11'1° 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 original study questionnaire included ques- tions on tobacco smoke exposure from spouse smoking andI on indirect exposure to asbestos through a spouse's job. This report describes the risks associated with these exposures in smokers and' nonsmokets in New Mexico. Methods Cau Seiectioe The casee were Hispanic and non-Hispanic residents of New Mexico, less than 85 years of age at diagnosis of primary lung cancer. Cases were ascertaitsed by the New Mexico Tumor Registry, a member of the Surveillance. Epidemiol- ogy; and' End Results (SEER)~ Program of the National From the New Mexico Tumor Repstry, Stie Departments of Medicine and of Family Cottvnunity and~ Etnersency Medxine. and the lnterdeparimentali Program in EpiderruoloQy. University of New Mextco Medical Center.. AlbuquerpNe. Address reprint requests to JonathaniM. Samet. MD!, New Mexico Tumor Registry. t'•;niventry of New Mexico MedrealICenter. 900: Camino de Salud NE. Albuquerque. NM 87131. TTus paper. submttted'to the Journal'July 18. 1986. was revised utd accepted for pubhcauon November 17. 1986. C 1987 Amenean Journal of Public Health 009ao036B7s1.50 married to smokers had about a two-fold increased nsk of lung cancer. Lung cancer nsk in never smokers also increased with duration of exposure to a smoking spouse. but not with increasing number of'Icigarettes smokedIper day by the spouse Our findmgs are consistent with previous reports of elevated nsk for: lung cancer atnong never smokers living with a spouse who smokes cigarettes. (Am J Public Health 1987: 77:59&b02.). Cancer lnstitute.1e An initial'case series was selected1rom patients withIcancer incident between January 1. 1980 and December 31, 1982. For this initial series all cases less than 50 years of age and all, Hispanics were includedt non- Hispanics age 50 or older were sampled randomly to select 40 per cent of the malos and, 50 per cenn 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 1, 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 of histopatho- logical material (N = 17) or by information itn 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 light microscopy and used a modification, of the World Health Organization classification.'9•=° Coatrot Sekction Potential controls were ascertained by two methods. Residences, identified from lists of' randomly generated telephone numbers, were called an&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) refused to cooperate with the census. As this 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 Adtninistration's roster of Medicare participants. The control' group was frequency- matched to the cases for sex, ethnicity, an& 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. tater.>}e.r D.t. CoBeetbo The interviews were conducted by bilinguali 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 nocasked to describe exposures to tobacco smoke at work or in other situations outside of the home. All's 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 might increase lung cancer risk and 598 AJRH May 1987. Vol. 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 collected from subjects who had smoked for stx months or more. Cdcul.tloa o( Psesivt Fspoeure Indkts 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 and 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 alli marriage partnerrs, these variables were set to unknown. Two categorical variables were created to describe potentiali indirect exposure to asbestos through a spouse's job. Spouse's job histories were reviewed against a list of jobs judge& 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 Gst, the index subject was classified as exposedL Similarly. if a spouse was described ass exposed arwork to asbestos the index subject was considered to be exposed. D.ta Aaatysts For these analyses, cigarette smokers were those indi- viduals who had smoked at least six months. Current smok- ers were those sti.ll stnokmg ar ttuterview or who had stopped within the previous 18 monthst ex-smokers had ceased smoking at least 18 months before interview: The status of cases classified by questionnaire as never smokers was verified against hospital chart summaries on file at the New Mexico Tumor Registry. Of the 28 reported nonsmoken, 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 subjects combined. We used the Mantel-Haenszel technique to control for ethnicity and age in estimating odds ratios for passive exposure to ci~arette smoke, within strata of personal ciga- rette smoking. ' In these analyses, age was categorized as below 65 years or 65 yean 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.u For these variables, strata of exposure 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 categones of age. variables for which the controls had been frequency matche& to the cases. In the model for smokers, TADLE t--bz. Ethn/cky, .nd Ap. n1ltrfbuHen of Sub)OctL by P.nonal Clp.nrtt. S+r+oklnp Surtua in a C.e.-Gontrol Study in N.w wxioc. 1990-414 Gp.ron. Srtiokinp Status Gurr»rrt Fo*msr (dlrsr &+bwxs ^90 (nws) C... Connd Cs« Conea c.s. Corma w* hMpanic VN1rts <65 34 22 10 t E 0 1 10 x45 47 30 27 29 1 21 rwn+i.a.Mc Wlrt. <65 77 57 19 59 1 36 :(;5 02 b0 62 103 e 63 P.rrw. Mnvanrc NMib <65 11 a 3 7 2 27 za.5 27 a 5 5 7 34 fdond+yv«rc YVlrle <65 74 y4 a 17 3 47 s(35 64 15 31 19 9 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-smokcrs, 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 detailielsewhere.v The all-subjects models included control for sex. The two categorical indicators of passive exposure were tested irtdividually 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 indirecUy 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 ziturogate-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 Analysi's System.2` Odds ratios (OR) and 90 per cent two-sided Cornfield confi, dence intervals (CI) werc calculated using program 23 from the Rothman and Boice text for programmable calcula• tors.u16 Results The analyses were restricted'to those 1,390 subjects with known passive and personal smoking status (Table 1). The 35 excluded 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 for cases than for controls. The percentage of subjects excluded did not differ by ethnicity or sex Base&on data in the New Mexico Tumor Registry files. the cases described by interview data as "never smokers" AJPH May 1987, Vol: 77, No. 5 599

HUMBLE. ET AL. TABLE 2-Oddrr Ratio' EstimMs to. Passhr. Clqar.ete Expaure In a Caa.-Contrd Study ot lynp Cancw In New AMx/co, t 84 TADLE 3--Odds RaUO EstJrnatretrom. Alun/pN Loqistic'Anayses of P.saMe Clqarats Expo.ura and LunQ Cancer Rlttk- In a Caae-Corttra : su,dy in rwr. wxico. 1 De0-44 Peraexsai Smoking Au Suq.cxs Femwe Onty AlliSuqem Femaie Only Pgsswe ° ° P P Exposure Statua OR 90% CI OR 90% CI assive ersonal Snw+ung Exposure Suuus OR 90% CI OR~ 90% CI Cgarenes only Current, 1.2 0.9. 1 6 0.9 0.4. 2.2 Former 1.1 0.8.1.5 0.7 0.2.2.2 C+qar.oe onty Ever° 1.0 0.8. 114 1 0 1 0.5. 119 Wever 2.9 1.3.6.7 1 8 0.6: 5.4 Never 2.2 1.0. 4.9 1 7 0 6. 4 3 Cgarettes andan Current 1.2 0.9. 1.6 0.9 0.5. 1.8 Ciyarett.s and/or Ever° 1.0 0.8. 113 0!9' 0.5. 115 pipe or cgar Former 1.1 0.8. 1-5 0.6 0.2. 1.7 ppe or oqar Never 2.8 1,2. 5 6 2:2' 0.9. 5.5 Wever 3.2 1.5, 7.2 2.3 0.9. 6.6 'From auos cws raouumoru: aquserwre ta aps a br .1lf.aty Odd na Mw rNues. °rwo-sow 90 vK wnt Ccrnfr.aoonhor+w ntw.r. bu: moa.b rr~,o.a v.naw« 10 cnrmd ror. eA r..ouu,cy muarnnq on aqe ana wrwtY. ane a.i, wn.n a0orwrwe. 1ot rnarrf oortR7lMO Ibr pw7aul cpW.n. u.a r a..aYJ.a uro.r,Mw0we.. who were ever married to a smoking spouse included eight adenocarcinomas. two epidermoid carcinomas, two small cell carcinomas, and four large cell carcinomas. The eightt 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 17 cases for panel review„we did not compare the exposed and nonexposed based on the pathologists' classification. Of the 17 cases, the cell type based on the panel's review concurred 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 centof males and' for 56 per cent of females. The corresponding percentages for marriage to a smoker of cigarettes alone were similar, 28 per cent for males and 57 per cent for females. Using stratified and unstratified approaches, no effect of marriage to a smoker was found among current or former cigarette smokers (Table 2): By contrast, gvndvei'~ sn~~igacett~~F$ptoking by a spouse r,~ ssof ptpe~r„~ ct ,use -~y~assc~ciYatedre~ ~qsk of ~ Itln fi2trer. Adgusent ~or etlyntuty~(QR~ peYtcent ~ (~ onfitfence IntervalJ~~~~~~fotage (QIEt° ~ 3 2 90 .~ p~r ent - ehange the estirnated risks~ surt o;e crude ~? ~S adjusced3':`>~ e;ttrtat¢s-was0 sme4kJoir ~exposulfQca~G~es only~ eXhti:ic~ty=adjusted OR ~ 3.0 (Cl _ I:~~ l. 81F,and`a~e=adjusted . ~ (~Ra'~2.9 (Ch= 1.3. 6.7). There •wet>r insufficie~ subjects to `'. adjtlsC'siQiuitaneoiislycfor ethnicity and age:' Although the odds ratios were reduced, restrictiorrof the sample to females did not change the pattern,of effect fro,nm that found in the'- abalyswwith`-W-subjectst When the analyses were per- formed separately for seif- and'~ sutrogate-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 similarly stratified 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 estimales were above unity. Assessment of exposure-response relation for the dura- tion of exposure and for the average cigarettes smoked daily TADIE 4--Oddtt Ratlo' Eahn.Yn by Durttla+ of, Spouw Clpantte Eatokktq and by Av.rpr ClqarrrtLe smokad Dally by the 5qoua.((!),ananq wver stnokars In a Ca..-Canaa study In w.w rluloo. 1lt1~84 pur.bon s26 Years >26 Years Subi.ct G+oup, OR 90% C1 OR 90+i: CI Ctr for t»+W Ap Subiecti 2.2 0.8:,5.9 2.7 1.0; 7.1 2.01 F.maNa only 1.6 0.5.5.8 2.1 0.7. 8.9 1.23 Mean Ciq.rett« p.r Day OR AN' Subiects 2.8 Femalae only 1.8 s20 > 20 90% Ci OR, 90% Cl 1 2. 6.8 2.2 0.6. 7 3 1.82 0.6, 5.6 1.2 0.3.,5.2 046 'Odtls rapos noe adlusrw lw ap" or .onrfry: Aqu,onwx br .mw.or ar.s hefon ao nCt cl r+qe th r.aWb. The r.1usM .cmaqory..rar t}ie rw.r sporG. , by the spouse was limite& to never smokers. es-only, cross tabWar,2ta1 taiii "" sr'with greater duration • of •cigarette exPlOff was~fotlhld (Table 4). contrast, the logistic models did not show an increase with duration of exposure in either group: (for all subjects, short duration OR' = 1.9. CI = 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 spouaes smoked greater amounts (Table 4). Control' of stratification factors by mul- tiple logistic 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 20 cigarettes the OR was 1.2 (CI - 0.3, 4.4). Potenttal 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 historyy 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 vanables were assessed AJPH May 1987, va. 77., No. 5

PASSIVE SMOKING AND LUNG CANCER RISK TAHLE S-Estlmat.s o1 t-unp Cano.r Rlsk Aom $pou..'t Oooupatlion.l Esposuro to Aab..toa. by, R.portlnq Souro., for Fpna« Ift:s CasaControl Stuep In /!ow Wxbo, 1990414 Emdoy?n.rrt m A.b.sms-Raat.d Joo Peraona I Smo°nq Snnu All SuDfcta SMf. r.pat.d Sutopata° r.paew Ever' OR 0.8 0.7 1.1 90% CI 0.41. 1.6 0.3, 1'.5 0.5. 2.8 MMvx OR 2.5 1.2 3.3 90'K. CI 1.ot 6,4 0.2. e.2 11. 9.5 Rpart+d a. E~o..d at W°rh An, S.d- S-ropat.a SLOj.Cta r.oaf.a noon.tl Evur' OR 1.4 1.3 2.0 90X Ci 0.6.3.2 0.5. 3 4 0.7; 5.5 NNw OR 2.2 2.8 2.0 90% C1 0.5.9.2 04.,20;7 0.3. 13.9 aBom wrt.m aro amW vroK.n xr+uc»e bS.n...von.c oennou w.r. tn" mmp.UUOn youo tor e+. .urroq.nrm0on.a u.s, 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 examine& 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. Miscias- sification 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 cases among never smokers, iztfortnation~in the hospital record conflicted with the inter- view. Because a similar, additional source of data was nott available for controls, we did not exclude the four cases from this report. The findings were unchanged, however, 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 notassessed. Thus, subjects may have been misclassifiedon total passive smoke exposure. Wald and Ritchie' have shown that non- smoking men married to smoking women report 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~ato 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 misclassification intro- duced by the surrogate interviews thus appears unlikety: although spouses aware of the putative associationiof 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.for cases than for controls could have introduced differential misclassification 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," 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 Hirayamal' and by Akiba, er a1:9 in Ja~an, by Trichopoulos, et al,' in Greece, and by Correa, er al, and by Dalager, rr 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. ec aLB 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- tative differences in the exposures of active and passive smoking.° Furthermore, 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 im active smokers. all' at or near unity,, provide evidence against consistent 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.29 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 setung.21•30' 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 estimauon.29''0 ACKMOWLEDOAIEAITS Supported by a pant from the NauotuJ Cancer Ihstnute. CA 27187. and bya eontractfrom tbe Btomerry Branch. Natiotal Cancer Institute NOI-Cw= SS426.1k. Sametis recapteot af a Research Career Development Award. S K04 HIA0951. from the Divtsan of: Lung Diseases. Nawnal Heart. Luna: and Blood Institute. REFERENCES . 1. US Department of Health. Education. andwelfarc- Smoking and Health Repon of the Advtsory. Committee to the Surteon.Genenl of the. Public Health Service. PHS Pub No. 1103 Wuhtnston, DC Govt Printing OSfice.,1964 2. US Deparneent,of Hedth~and Human Servtces. Public Health Serti cc The Heahh Consequences of Smoking Cancer a repon of the Surgeon General. Rockvdic. MD Clfficc of Smoking and Health. 198_ AJPH May 1987, va. n. No: 5 601

HUMBLE. ET AL 3- Hiravama T, Nonsmoking wtves of heavy smokers have a htghen nsk of lung cancer a studyfrom Japan Br Med 1 1951: 28'_:f83-~ 185 4 Tncttopoulbs D. Kclktrdtdt A. Spanos L Lung cancer and passrvc smoktng tnt 1 Cancer 1981.:7.1-4. ' W elss ST Passive smoking and lung cancer. Am Rev Respir Drs 1986. 1?3 1-3 6 World Health Organtzahon. Intertuttonal Agency for Rcsearch on Cancer IARC Monognphs on the Evaluapon:of the Carctnogentc Risk of Chem- icaJs to Humans- Tobacco Smoking. Vol 38. Lyon. France IARC. 1986 18, Key CR Cancer uscrdcnce and mortality in New Mexico. 19'3-- Jn US Ckpanment of Health and Human Servtces Sur.etllYncee eptdemiolop, and.end resulcss incidence and'monahty data..l97.3-7'tmonograph~'-tNIH Pub J.o: 81-2330 Bethesda. MD National Cancer Institute 198,1 19.. ButlerC.SametJM~ HumbleCG..Sweene}ES T',hetnstopathology.oP.lungeancer in Ntw Mexcco. 1970-197, and 1980.1981 1NCI 20. 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SC Chan Colbourne MJ Fun Ho HC: Bronchial cancer in Hon 14 WC 28. Gordis L: Should dead caaes be matched to dead controls' Am J Epidemiol' . . g g . , . 1976-197' Br 1 Cancer 1979: 39:182-192 Kon 1982: 116:f-S. . g 15. Koo LC. Hb 1H-C. Lee N. An anaJysts of:some nsk f.cton for lung cancer in Hong Kong. Int J Cancer 1985: 35:149-155. 29., National iReseareh Council. Comnunee on Nonoccuputonas Health Risks of Asbcstiform Fibers: Asbestifotas Fibers: Nonoccupauonal Heal[b 16. Wu AH. Henderson BE. Pike MC. Yu MC: Smoking and other risk factors for lung cancer in women, JNCI 1985: 7a.717-751. 17. Samet 1M'. Key CR. Kutvin DM. WiWns CL: Resprratory disease tnortalrty, in New Mextco's Amencatt Indians and Hispantcs. Am 7 Public Health, 1980: 70:e92-497:. Risks. Washington. DC: National Academy Press. 1984. 30. US Department of Health and Human Services. Public Health Setvice: Thc Health Consequences of Smoktng: Cancer and Chronic Lung Disease in tAe Workpuce: a report of the Surgwn Genenl I Rockvilk. MD: Offiec on Smokutg aod' Health. 1995. I 1989 Revisions of the US Standard Certificates and Reports The National Center for Health Statistics (NCHS) has recently distributed to the 50 states the 1989 revisitxts of the US Standard Certificates and Reports of Live Birth. Death, Fetal Death, Induced Termination of Pregnartcy, 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 I'. 1989. The US Standard Certificates and Reports were developed jointly by the NCHS and state vital registration and statistics executives. Advice was obtained1rom persons and organizations throughout the United 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 termination of pregnancy repons; • changes in the birth certificate and fetal death report to obtain more detailed information aboutt the pregnancy and its outcome; and • soJme of the factors that may have improved' quality and completeness of the cause of death. Information about the revision process and copies of the standard certificates and reports can be obtaincd by writing or calling: - George A. Gay Chief, Registration Methods Branch Division of Vital Statistics, NCHS 3700 East-VVest' Highway, Room 1-44 Hyattsville, Maryland 20782 Tel: (301) 436-8815 602 A.1PH Vay 1987. Vo1: 77. No. 5