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yoi;u47, pastiiv'e smc)kinb and lrist©l~o~;icai t~...pcs in l~~xa ; cancer i'c~ ~ I:~~nb Chinese tih'c)nic~a ~ Fi'6n , d T.Hi. Latrnt. I.T.Nt. Kun4,'. CA-l. Won~,'. W.~:. La(trt''. Jl~~%.L. KIca:~~eli1t. D. Sa~a'. C. Hsu=. S. Scncviratnc''. S.Y. Lattn=, K.K. Lo` & W.C. C.lnall1 Oi'puf2rqi'rtds n/'tCutwnrutir,l' Sliu/it'fnr•,. =PirrNrd,~,t,. `atit•etltrint'. Citittr+vrr I lle+n~ f.'„n;. `'[<)it.~rt LYi_ ri,u•:h If+„ptr,rt ernd ' h;usrlnrtn fln.r/eitrrl: llnrrii: Kung;. TK4 (~1 G,tACr1 C Summury In,:t caii iuntretll studv in t(a.ni 6;om_, 4-t> Wscs' e+{ Chinrsu (omrk lung,.cuutir p:dient.; .ttl rt,nlimted t'stlhuL+Licallit wurC ct+m/+:rnd w'ith b.l'j Chrnesc Iemalr liu:tlth,n n iyhhrunh.toJl i,+ntr,+li' mawhcdd fur ctge. The prt.-Jominant hi;tutt+picrl n',tw +•as uJcnrK:rrrinuma (11.:'a: The r~a:ut,c ri.k iR'R1 in uter- SrnPkurS!wsls :.$t tP '<'0!ut)1,..95 :'. Cl •• Z.s'6_ 5:Ay1:.The', R~Ri. wcrti itutisucallp' iignifi[:tndvraiiceJ for alll major aclt ty;tfes i0h siynih.:rnt trcnds Mwruni RR' anJ amuunt ut" trah:rrcu cmuLrJ d:citk . :\'mnn_ nctcr smuking wamen. RR for prssi.rsntaking Jue to a imu,t:inL,htt:h.mJ was 1L65 (iP'<llcil!.9^",CI=1'.(fi. ':!S) w,ith a sisnilicaatt trend Nxween RR anJ!lmaunt smuk-.J J;ril; b% the hushanJ. When hre~on J.+++,n by itll tv~~:,% the, numt><rs were substantial onlir I'tir iJwntwurciitwmu IiR'R'= 2.1!, Pc(3!(lt,. 9>". CI = t.3^_; 3:3'l) -ith, a siinilieant' trend Ri+recn RR anJ amount imokeJ duil) b% the hu.h:tnel. The rc:uiii' that pa:sisc smoking is :e risk I;iet.+r' I'ur' lung cuncor, particul:trly uJenrn:treinonr.t in Hr.nv: Kt+ng t hinc:c w,+mcn whu never smukcJ. I (vng; Kong; lung cunc,r is the major cause of death in bottt ntalcs und fcmadei. In I'M, there were _:?23 deaths uttributcd' to maliena!nt neoplasms of the trachra. bronchus and lung (I'CD 9th Revision Cmse' 116_) which accounted for of deaths due to ttll' forms of cancer: T.137 in malei. (3i1i.1•i:;)land, 766' (?6'.0°k0) infc;twles ( Directo;ro:t Medical ,h Hle:ehh Services of Hin:n¢~ lC~on'e. t9e6). Onj a world' icrle: male lung cancer death r_,tey :Ire not pzrtii?ularly, hhigh in Hong Kong. Ho%vever. the tcmale rates are amon_ the higi:est in, thr world with, an s;e-it.tntfardizrd inciitcnctt e'atr of 33,4 per I00a)0A in, 1971i-I'97; tW;tterhouse rr ttl:, 198_): resultinS in an untuuall~ low msle to fen::tle r:ttio: The mvst common cell type in m:les is squamous cell' carcinoma (>3.3°.±) ' and' in femalis, adlmucircint*ma ( 1+7:6'0a) (h;:ung .rrul_-, 193-7); A case c.on2rolitudk in l'y7Y~-1V77- rontirmt:d the relationship betwccn lur.e c.unccr and :m,.`,kin_:, in mali:;. but in females about hait"the lung cancer patients t,crti found tk) be non-smoktirs: of tthti*m ta+o thirds; ++xrc sutfcrini from actentDcurcinoma (Chan lr r:t:. Id-V9. Further stttdies on pussix-e smoking and other riik- factors hlre beerr carried out in' Hong kl'.br•.~_, but they fwiled to thrott much ht on (he c;tus,~; ut' lunti cancer in ne.er >mtoi:inz famlles _han ~'L': Fune., I'dS2`. Lam rr ul.. 19;`?: K") ,, u4. 1934: Koo rt ul:. 19S5). The present suuJy ;timed to q'ucstioni: :ins+ccr Lthc following; I. Ii ;mu.l'in,' a mu1or rii;; l;tctar l'or lun. tanc.r in Hon,_ K.+nL Ch'ittcic tcottten andl il'io. ++h::t ii thc rcL;tisn;lap tN+tatM1Un ;rno{:aa: and th%: histiulutiic.eN t_tpci of !lr_ cunrer:' .. (, (?a'isis'e smtnwinl dite ta' a 5mu+lin_ htt6h:rnJ a rie'N tactor fur ItrnL' .,tnccr in, Hon_ K.tn_ Chinr:.c tcur,.e1 wh0 h:ttic ni;ter ime7kttl tlium;clai :tnJ ii >o., t%hut is the rcN_tiv'nihip Hctttccn paiiine >moi:int hii.[ltlA.nri.;11 I'tspe"." J)!ttcriulx tind methoJ: :A~ a:tntlantizrtl~~ i'tructtrrna qucstiunn.tirc t+;u tlcsi-rtaJ Iti-tr intti:r•.ie.WllJv :' hetth: ia.~>~ :tt1t)d conlr0iit Th:.~ yu:.,tion~~ on S1e i.:n~. C:eurA•sp.nndlntx: Ltt. L.tm. 1):pnr,tntcat ,ri t'e'nvnuntt% t:ninursit% e+i' Fli.+ng K.+nti. Ln Shtt ran liiui!.'_t^_: i S1>a++etni tloatl. Illonr F;,~ny- 1 nt.tVx' Rttici..>s I- \;.ir.h 1^/\'. .u:J ,n re.i•cJ';:.rn. I imokinS habiw, %.crc' mouilii;d from those of the. Questit+nnairc: on Rcspicatury, Stimptunti of (he : N'Itittieal Rcseurch,Co,untiil (It)66); The subject was askZtd tshcthcr she imoketl. or had aser smoked as much as one:ci_;trcttc al day tor one ciuur l, +teel: or one ounce of tobucco a montih), for onc : V:cur. If the rLp:lv %%uinv_atltvc., vechOc{!ed aguin, by us'l:inz a further question on tthether ?ht huti erar ir,;t,*ked" any :rntounr.nf unv t%po of tobacco at all in hur wh,.tlc life t:'p to the trntC' Of the interview. Becluse Jf <<n' ft.t' positit-C rciao:li,:Ss tt,~t]tisltit}ii.ional: q~uestiun. we were iati5tie.! that unt!cr-reporting oli the imu:<inh, habit wus nuo a major pribl,mt As <lieuhcr,: an e•:cr-;m:.*~er t~;u dcrancdi as one uho h;rJ car imo.l'ed u; m:uch, us onc: cigsrctte a day or equi%;tlcnt I'Nr as lun__, as a%elr. 11' a iunict:c had cvcr smta'.'ert. questions on the type of tob:tcco- : nd, amount usuul!~ imu"'zd per Ja%, :tr_e «hcn smo'~.:ina' started rc_~ul_rlc and for es-smokers o:nik. :tcc when ~mt,nling tt: s giacn uF termunentlv; ttcre uakeJ. A , ne.er-smoker tta dl'rinet3 a:;' one to hu had never smoked as much ai unc ~t + cctt: a day ur eqvi% aicnt ior the Jhr,rtiun of one• tc1r. The >mukdr,_ hiitory of thti su.ject's husband t+si, in sim;l:tr tvuv if th: suCi,::t tc;ti murrieJ. The s_,me Jelinitions of c,-c;r- r.t?.netcr-srit:::r tterc usctl fbr thc husband. -k -.tamen tt:ti cuniiJercd ~tru cd,to hcr husbunJii tobacco smokc ii she h::J lit-cJ to'_stthcr ttirh I;er imokim; huib ant< in the same household fi+r: at Itait one .;,.er :ontinuuuslc. llf the htub:tnJ ttas an ct'tir-srno' ' -ct. :raurnuttan un ttir t.pv of tob.:c. +.tnt1 .tmot!nt u,tr: tl. :i.: JL[% :T~. thc ' hu,:+'Altll : aJ! ttt~. e!urattlUff Jf ;'cpr.>>ur;' uas obtuinrJ. The qucztiinnniir: :t(iu .ontaine, s~.uans c•n,._'l;tnu;rapht~: un: Jth:r It t+,t>' tv>: J_ and tin:1lf5iJi t*e;orc titie tr.' the ituJr. Eitihr :ohcrnm.cnt' ,+r, _o+tirnmer,e- .tsntitid hJ,p+t.tdi in tchtih mo5t of (IIJ:lhn_!'cnnCi:r patlcnti %+,:r,' Vr~:etad in Fl0n_ }:a',n_': ,rar,:_:! ua rurmkcio'n, t„r i ncervieu in _,tf patienti:. Durun~., bhc tnttini~+.in: ph::it;of the >tnt,!l .c,; int:n.l_-J t,+ . tacluJi: adl lun_'.:tncc,r' paticnt'i .tt the ci•_hc ho.pitaL• e+ho>c Jil_nw.ii t+ai huc,>t: on ;tnon_ 411ni;u ra.!te+l~e_iaa criteria and, uith h'i.taloLri:tl and or cNti,nL+_iw:at cunlirui.ai+in. PauCrtiS: ul}mlttcJ! bu thciC hu.'piPalK t+•h., a,rre ;u+tetitcJ h)' thu Iw*,(+isal t:liniat;t'n; tu ha.':' litns .anc.r ur ..•h.t, h:tti .tlrtiatl> t*ctn _itun a ut+ntirntud diu_Lms,,i>: t+f Ikint cancer ttctc inttirtie;uctl' as iotttn ai C!o;Nihlti :tft:r tltoir' ati'1nT:<a+.n: btitorc their ;ih\<ical, t:unduit7ni e!etcrioralee!'. Oiti.• p:rticnt< +c th' thcir Jl t.itu,:i: coniirtt:,tl h. a ratttuL,ent, rclxtrttit

~.•~:c tniJUJcJ as suc. a.7~ c~+n;ciJcrt:J unll• :usu..prcteJ casc.ants they were .. ::dh)ucJ up alter ceint; intcr.tc\.cd. Only those who .uh.xyuetttly had a, {t;t'thr+li+gy ' report cnn0irnting the dt.tgnu)his of Iunu' c:tnccr were includcd. Th.+.e without such ;onliirmauiun were not included in, thr p'rusrnl studi•. The pithollt`y report was required to .tatw: unanthignouily, thati t`e patient was sulTvring fraln lung cancer lxlu:re it was aaeptedl Inforrrtatian uu cell (vpe il' availahh, was nottid., C.rses \tithuut inllormatiun un cdll type or u'nclass'ilieJ hcx•rust., of untlilTcrentiatcd tumours \.crc zruupcJ, under '.tthers and unclnr;'silicd': The fww patirnts with' rure tvmours it::h as carcinoiJ wcre excluded. Because these hospitals were %isitcd frequcntly by the intenviwars so that all eligible patients would be interviewed other than the fiw patients wh'o declined to co-opcrate or were too ill. ,.c believcd' that we'hsd missed only vt7y IC.v eligible patients. For each case; a healthy ft:m•ale control matched' for' age t_S y~cars) livin + im the same nei'•hbourhovd of the case .as imersicweJ, Tc procedure of control'scli:ctio-n was that when a patient' was interviewed and included as a pathologically .onfrirtteJ case, the age and address of the case was noted.. The interviewer then went to the address of the case andd started' to visit the nearest ncighbourhood addresses until she found a' woman who appeared healthy and was within 5 years of'age of the case. A few questions on, present state of health were aslCed' ta check that the subjeco was indeed healthy and if so, the same qwestionnairc was completed. Thus the controls were matched for se.x, age' anii place of residGrll e.. Interviewing took place between 19331 and 19Ri6„ and involved experienced fcmale interviewers. The langµa_se used '•tss mainly Cantonese. Each intcrvicw took about 30min to compl:te. COoperation of' interviewees was gPod and non- r:,ipons'e was' rare (',^. I %)l, The present, paper presents the tindi'n_gs on (ht :nto'king history of the svbjccts themselves and for the nc\en-smo'lcrs, . t`e history of passive smoking due to a smoking hu,band. Four hundred and fortv-li.•e cases and 443 controls \cerz intJud.id. R'elaoivc nisks ('RR)1anJl 9>".;, coatliid'cncc inter.;il~ nCl) I1V'oolf's luvit fimits): were calculL'ted' for each I:\cl of' nik factor. Fisher's exact test (t\vo-sidcd') .o;, usedi t,t cheul: \\hether the RR' was sianiticantVv ditTercnt fro'm, unitv Z= test for linear trend was pertiormcd to test \i,hcthcr uhcrc \ca; a trend brtween, RR andl the levels of exposure (iBrv<Iow Da)•• l'93t)1: Subjects with missing, da'ta \\cre escludcd Ilrom the anal.'iii. We csrrie,i' out s'eparate an:tlg-sis on cig;rrette, on!, or cn:ni all forms of tobacco, by incluJing ii'n•_le: (me\er-tn.urri€d)', :\omen or by excluding them, by amount smoked bv du'ration' of eaposc:re or by total amount of' cv f.oiurc' t_:nount smoked dailti multip:lietd bn duration). B,~c:ur>c of t:`.c, similar results andi space limit.ttion. onl% the rc<ult;: on all forms of to'baucu. \\ith sin_It \vomcni tncluJud .:,n.l h. :i•T.ount,inlVkCtl daily ci0e rCp1^ntet) in the present pill^~,", . I'aticnts ..tth :I pr"+%i>um:tl diagn.\,;ia :.vt'p LOur I><nicnl ,+Il Ihr caNre \ctrc uonl4med printarrlyh, mthr.d ur lunc' t.i,+p,I hl• lun_, rakctiinn, %"W h\ .`ph u.r.k `)".. hy' pleural hiu+p!:.y: I7;°. by anuturn I'_",, by t\Iv;ur:rl' Iluid c\•. (i";, h±,• hrn+ncltiirl prratc. hrn,hint: etc.. U.'_".•, by auttopsy anJl _•. h\ utVucr "' : tI1oJ>: The di±ori'k;uliirn of the c.ascs by ccll tvpr and' bv_• smukin__ .tr)rs i~ ain+cn iio Tahic l. Tht Ji:<trihuui,+n uf ccll types difftriJ sumc\\'hat': accurdin_ the t+a,is \tf' diaenusis: Resection and pleurai hiupsn ; :IdcJ aJrnucarcinonta while other methods resulted % 30-c^`%4 adcnucarci!numa.: Bronchial and, lung hiursy :'ultedl in - 30% while other methods resulted in ahout, squ:tmous cell crrw inorna: A comparistxn of cases and controls by age and place oll ":::Idence conlirmcJ' that they wcre similar in the two ':::rtchin_ variables. The mean aec of the cases was 65.6 ;:ars (s.d. 11.2 years) and that of the controls was 6'5.3, years r'..dl Itl^f years): Comparison by other Jumugraphic :zrriables showed that the caxs and crJntruls were '-mpara!hIU, in place of birth, duration of stay in Hun_ K`mg„ lcvul of cducati\on, maritul status, and husbandr: -:cupatiun. Thus; by matching the controls with the cases by' ;+:x and residcnce• a hitih' dcgrce of comparability was :u:hir.xd'with regard tomany other dcmuaraphic variablcs„ 'fable' II shows the Relative Risks (RR') by history of cvcr- :rn,+king and cell types: Among the cases for all cclll ty.prs. `:`nnbinedl 5-1.5°.o wcrc e\cr-imokcrs anti 45.5% ,vere nc\cr- .rur,keri \vhcreas amon; the controls. the correspundins', Ia:rccntuY~s +vtrz' '_3and 76.1"ro, Thr o\erull'~ RR' for •:vcr-s'mukim! «'as :.311. The R'R's t\cre si`!niliCan'tlti' raised in c:+ch oil the 1 cell typcs, bein;, highest for small' cell `.:rrrinOnta 1RR =11'.0U4. follo:\.ed bv.' squ.amouis cell ucinoms (R'R='3,IU): 16r:.^ cell carcinoma,('R'R=6:9:t)iand -Il.+nacarcinunt.t (RR = 1.37), f.tblt I'II s;iti+\vs the P.'R b% amount of totiacco smvktid L r1, bv the suNjc,as_ Si,_niticaat trends \\erz found', for all 1 r11 t\ pfs combined a'ndi tt+'r rach ot the 4 ccll f\ „^eS: f.lhle IV itton\i' the RR' fur puisi'\c snt..~ki'n_ e!lic to .r .n++'kin_g husb.ind and cclll types. Singic (r.c:cr m::rri;c!) +`-rr•cn \\urc trzute+l :ts nun.e.cpusad to husband": slnokrn_j. I hc R'R, \\ai 1.65I for all c.ll tapes cumbincd., For intJi%iJu:tl it~tis:i:_rll\ II tvpvs. the numbers \\cre too imall tio be +1.uiiticanl-cxi.pt for :tdcnocarcinoma., +.it)i a R'R ur 2.1= I_rNe V sho\.i the RR fur pasai\C ir:okin_ b\ ::ntount •'11-:ed doil% by uht' husband. Sienilica'nt trtr.di \+,crc Cuund It„ .11( cull types combined and for aclcn\\narcinom:t a+nl._ N\+ ~r+rnli :ntr RR or trend \\,as found for othcr cell 1\pci :rn.d tt,,• .:,tails ttrc not rcportcdlhcrc. BcX.tuSc'sintil:ur rrsttits \+crz aaetl' \\hcn iin••IC \•Orl:irt \.CrC'Cxcl'uacde the,sc ar! ,L,• +wr '.pcwt:\l. Ilt >h.tulJ! hU n01:dl iFa. tlte prc+,pinrU,^rt> c`I .m.: _ Inr«r-ina,rric41: .•,m::n in IhC an%-! :ontruL< u.r. r. ~.:.. .Ind 5:,_„.. fi~pdQC{\~.I\'. Tablr I Di.wihutiim .dlcril',t., e nc _^J rompari<,en +\;Ih kur._ .v :a', r lvn.l •.riv: S./u.:ru. .rr. , rr!l rruairmrnd . .:ncu:..npf L:.rrci .,,'ll .'.rr,.r•:.u.,rr, Orhi•r+rur.l urxl.i.,rliol' ..Nd rr rr n~ .,. .r~ .. Pr.,rnt Scriri Na~r .mwkcr : i .11) iJ 9' 1`t, 13~ h_ 1 ~ I) Eier,rnuk.r n! nx.~' a:L S_.41 74 . ;-'r, I II \a L:aai . y_ t,in1 r) I1Mr,O' ae IfMOrr Il~i / -. 1i~rru I - JI.-:..iJ c:r>ct)I 1'I'1.i) ;'Iba , 1-10r Sarncs,nf K;ttng r.rl. ('J`)'t4q 77 r"- uI ?-4 Ilr I~. ,(.:, ,:,.9dir

t --.;-- /able 11 Ilista+ra ,~1: v::r •r+•lrn~' (»dl f.•rms .~f lotca~xul m Jad i;ues cinJ 1aN"rntr.+Tc, hi icll'typ<•t •SrI bhcn"n^ n/sruhjrr•tr C:.,nL,7,p ('.tu,- %'.r N.:a C'rMrrrul' lfn HC.c R:•larirr rack (.Q vB". (/): P Sywcmuut acl), cartI 'Y, 6:1 73 't1 x:10 E(C(x)l (4. Ub'. 15.77) Sinall ctill carrinorna 9, 4 = 36 (1 1C.tK) (J!h?: ?ll.9X) <0.(N)I r\dcnlxariin.+ma 131 7'1 158 )1! I.87 ' If.'_3. '_:S5) <0:0a LarqC scll r.trcinuma 9 1( 17, 3 6.93 <:0.05 t1.53: 31:33h' Othcrs and urtcfas.<i(icd 25 V, 54 IN i:6•1! ('2.71; 11:.614 L <0a1011 rA'll'vroll types V)- 242 };17~ 106~ 3,.11 <0.U01 (_.86. >.0'l) ,vuro.r. Far vach .nil t,%F.. the srairt aavrc oumparcdwith their, mawheJ rrrntrrnls. One rtscand 2 controlz Nat'i Trtuin;;dati on snl.tkin8 were ccaludetl. . Table IR[ Amuunt srnok:ti: d•ailn•,(alLfurms u0tobauco) in caws ind,contruils by nell,tn•pes i(rstM»1r tpnrr(.yl .{P1'crll npt;r Rkhirir¢• ri.rk rfuHi• Ay1suhjecr.r C:m'. G.{c 9 q"•. Cf 1 M(il 10: 1' 1-W 10( 90 t'U-20 1 21 + :9 Tutal Tcri for trcnJ i? . S9!>! P'<'0.001U Snr.f!l i rll ra.rc•ixru»<t ,4lrrvanr.aunC•t1d 1ts-l.rrin• risk duila; b.r_ur/•jrv7s Cu.ri C»,. r! Ict 9J"-. Cl) ?c l N il 9 1-lp 116 lP 6'.a! (?:13. t3:77) l1-20 14 - 1-.0 1L'.70• 52V_1 II rr - Tatal, Nu ; r Tx.-.t for trcnJ i= =a;.6' 1. P<11.901 <0,001 <p;o0i, <v:0U U 6m, '_3 :7 ?3 UU P' Cua.• I;~I~ :6 c0'fX) 1, <0:U01 Sqrufnwua ool(, oitrr•inund . Cnrnrrrd Relurii•r risk ( f' 9: Y: Cl4 P 72 t I l 3.; 3 ('-:3": l'.ao) <0:0)+l1 6 t_.(10 (4.49. 3'.lu), <o.(N,I 1 '_K:74 (:.1<, ,_IU;:U) <0;0N18 90: 7' ,.11.a6, P'<0:UQ1 .,I ~Ir»ui urc'i~rur»,t Gnntr.)l Rrl.rrrrr ci;k (af 9S". C1) P ti+si I 29 1.50. (Uli7„ ':j71 >U:U?, (;L1Ti •(.6-') <0:0? 9 . :.17 <)1.n~9:1. tr) I!. 6.ti1 >Dlto5 =U^ _tln ~= a <.0;. P <U.U'1, prtrri»n.rra, .4rui.ruq +rn..krii .Arih~ At~ cuhj~•ar. C.rm: Re+llnir.• r."n.( I.fCl.li C'r... R:-h:;n': risw C•.nt;..f t.( 'r'". C17 p htil v I'_ I 1-d0 6 .. ...:Xtq.?6' I<.'4J >I l: q ~' (1.'%. It):~.1 <I(:n'I I1-.0 17 J ~.IS <))Jp: j(1.1111 <a)toll.l, :1 •F I to " ?%I JI _ (I <illl¢ >t11/ . ._ . Ti)taI :p =u ' i) -) . Tcst oirr trrnJ l =s t?. l'<tt1U1 ,P<U.tA)li 1'wr,! $'uh)". aanitmt-in~ J.rl.r rni.un.••.:nt .nn•L;s! J.ulv ..rr :.:iuJc J.

smwt.ing ..aNcs:and.});cungt\~tng'.iantrrntc~hv icll u.-,txs JrnnkGr,e lu.6Nn .,% hu.P;h'urrdt. Ridunn t• C^.rse Cunernl rin! C6dLttNe No Yex \'n, Yes 1S'r 4!t"/.,('(9, P Syuamuus cell carcinoma IS 12 37 35 ' 0.35 >a).tti (0.35. 2.06') Sm:dLcdl carcinuml 2 6 I'S 19I 30) >t/.U5 (0.53, I6.Nt)) r\Wcnoc.trcinoma, ~5 3 7.4 ' a'_' t" ' Z.I',2 <U:U1 ~ (1,.32., 3.39), Lariercoll,catrcinoma 2 7 8 9 3.11 >0,05 IG zs.- s ~ s3 ' (0.50L19.54)', Others andlunclassiti.d 1^_ 12 _3 '_6' I'AS >0!OS (0.41. 2.82) '. All cell types 31 115 I'$3 152 ' l.&5 Lt6; 2 35 c0:0i1 1I Cp' ,0 s . ) ( 31 3? Nutes. For each cell type. the ases were cumpared! with their matched controls on passive smoking for ever smokers': and never-smukers: Results on ever-smokers were not' included here. One',uate and _"controls w'tth missing d7tu on smoking and 3 c:rscs',and 2 controls,wit!h missinZ data on husband's smoking were excluded. f) G-i Table V Passivasmokint due,to a smoking husband (all forms of'tobacco) in never smoking cases (all cell types and adenocarcinomm) and never smoking controls by amount of tobacco smoked daily by husband, All cell ty,pe.t' Adrnncnrcinontc .lmnuaUstrrrA-ed' Joili• br'/iwrbonJ Ci+sc Cuntrol Re(arive ruk ' (da 9J' : Cl) P Crue Contrnl' Rb(atire risk (dr 9P: Cl) P Nil s4 I'3'3 ( 531 92 I 1-110 22 22 '.113 17 12 =.i6 , ' (Il.,la1 4.15) <0.05 /II109. 5!51p <0.05 lt-?0' 36 03 66 l 1.85 37 ?3 =--9 (II.,19~, 1~:8i7) <0.01 1.)61 <0.011 ? 1 + ?0 ~ '_ 1' ?.:07 ( 5' 9 '_.39 (II.07; 4.03) <,O.US (dLIIS, 7:071 <0.05 Total 182 292 1?'_' 1.111 Tcst for trer.d ;C= - 1'0.1'7, P <0 :01 i'=11.07. P<O.Or) I Norer. Subjecu with miisinc,dlta oniamount imoked daily by husband were eccludcd. Discus.-inn T'-' prti:cnt :tudy was a case control study o'n lung canccr, in F, .g b:..nq! Chinese women' withi a larger number of' subjcCis inOuJed tha'n ini the ttvo previous local case control studies Whutt rr ul.', 1979; Koo cr ul:., 1934). Adl, our cases were Laohndi%1!icallM1• co:nlitrntcd. unlike thesc two prcviwus ituJir. tcloivh includL•d cases uu'nlarme& unl% : bu vlinical r:tdiolurt..al critcritt. Tho, priinar}, ad~:utt:tgw ol' iu: rclatihcly, lartie-sirc tilie largest such SCrics )et repurtcd) and the int(+rnttrutrttt over prctiuui Hong Ktnn,,, mudics by includin_s unl)• In:ItOtol,tgicall~ ciunlitrm.al rai:s cn:thlcd caleulatiuni ul" hii;uolis, ie-atirilitc risk eaomutcs. -rllr v-n1II- u;cd wtire he:tlthy women front tihc iamc nciihl>.~uyh.~ohl' matched fcnr aL4: Comparability hatwren c:t:r. .nnJ contrul's with rciarul to basiu dumu:_r:,Rhic .-:eriahli. %i:ts good. 5ug_c>tin,t tha!t, tltCio dcmo_r:rphic vcrricrK(c: m:rc nott' ha.o a ntajur cuniuundiit_,cl)tiet on the rcmult: nr(w.ritutl. .\. aiown in Tcrhlo' I. the di,t'ribution ul' call tvpo in the uasas in Ilte ' prescnD :ttuli:• wus comip;uruhk to: thc I:rr__ti P:tths(udk of F:ung vr rrl.' %.hi%:h inchtJl•d :urgii.rl' nt.ru•riitl ..ueli :s hrunchi:tl hiap-q. truns-hrunchial hioq,a. n.7C,llc liiinl?;t :rntJ rc.citiAnn .Occiiotcn:. Rinpny' oI'' Ivnrl,h rr,..lr: .tl~ nv \carii m+l inJutluL Ca>~; «inhout Itr•t0- Iltgical ecaminaitiun of the primain tumaur ul the, lungs. or which, wcre, t(i;tKnosed, bv cvtu')o alune were excltCetl. Despite the difference in the basis _N~ ,r,f diagnosis betueit'n the present i'tu1!y and uhait of Kun_, et uf. (l'`)as): the similario% inn the results iu_!_t5tS that the cell etpc distribution obicrted tnn the prtsent,ituay iho:uld be elose'tu the true distribution. For srI b% the ;uhjaet hcr:c:f: the prescnt; stutl\ ionl11rn1C11! . thC. Inc,reaitd, rlli.< , of lu'n_'. Ca ncCrIoun, in previous itudics im Hunet ):, ng. hut indica'tcd .1 s'IiKhulp hishcr rclutit-c risk O:S'I) than in the itu.:% of Chan rr al: ( II979) (3.18) or of Koo ir Jl: (]!91^) 1=.7;a: The ,•i_sr•.ilil.:urt trend observed iUL;_citi that the :ti>ucl:ttlO,n iil ll:elc to be cauiul. -~ With rcvartl to cell types. statiitiw:a{lir: si:nilicunit RRs wer; I'Juind fur :tlll cell tvpc;. inclwdiin_ :tdcat~*c:trcinants. Iin prvsiou:' ;tudiei in Fbon_! );on_., the RRi' tor' aden.*- cairunnomal were _reatar than unit. but Jid not rcach~ a <tati,orcalbv ;r_ni)itcon't Ic.'cl. perhap:' Jue to thc imalil.•,r nuntbcr uf subjcct, suudicJi IChan cr af:. I'•)'`D: Lam .cn ad:. IINS:1: fCoo rt al., I9aS). This led to the h'v(tuthc.i; th:u' ,tuukinL t•us not a risk factor for a.lcnucarcin.nr..:t in Hiany, Ku,n,, Chinese womcn. The results uf the prcscnt auda iu:_c.t that :rnoking is iiun'ificantlk :tiiociuttt)I tlith, 1t!iat.?• c:nrcinunta. nlthuu_h ttit a le;sar dc._rrw: thani •.cith :yu:unuu, oe .nt:rlLrcllii:triirnunta, Thc RR o( I.S' .om;aircsd uill wtla

;UiA'o risk's lir,r a,Iun,>l:rrcinonu c:,unJ in othcr I(r,l 'rtg xlu;Ii~`, I.5'91 (Cltaut rt all 1979). I.Na)' (L.tm rt n(., 9R:1'j; I.~g (krx- rr -rl.. I0;t50 and _'.I (L.arn. I9Y5). The iSnititrtnt tirtna ,thorucJ for, aden,x:arciit,,ma (mu+isdcs ,trther cviil,LnCt tlhat snt,rkin, is cJsu' a' rixk I;tut,u libr this JR type. The as.Kikiatirsn tkt+,ccn' hiietwU,ciral vv(x: and smtuking as (l recently by in (.-\R'C Witrkin, Group 01y\5) hich concltndcd dtat' all the thr« principal u)pcs of lung tll ri;;. syuamoui cClli sntall cell and au)cnwK:trcinunta: crc probably c;tu.e+l! by smc,king; although ohe relative risk as least catr2mr for aidcn+,c;nrcinttnt:t. The results ul' uhc -aenV study h:na tihcrcforv supported the IARC )nutusion. It should' be noted. huwcser„ that the proportion uf' naver- •tokers was 62:4", in :tJenoc:trcinoma; as compared with I'•r: in squamous and small cell ~.treinorna: and that some the 2denacarcin+mtas :nmung smokers may well! nt,t havc en caused by smr)king: The c.uuses of the high rates of tg cancer. purticulurly, ;tdonocurcinornal in never smoking tntcn in Hong, Kong remaincdl unc*crtain. and prompted : present study. Fvrthermore, this problem had become rrc urgent since Kung rr at. (1984) ihuwcd that therc ocsred to have been an in;lre:tsc in the relative frequency ;tdenocirrinomu in both sexes in the comparison of their ieroflung canccrca>;es in 1973-19S2 with an earlier series 1960=1972: ` ;inr he publication of the'results'on passive smoking,by ay4..,a ('1931) and TrivhopouLos er at. (11931). passive 3king was postulated as a risk factor for lung', cancer in er smoking womcn in Hong Kong and elsewhere. In n¢ Kong. Chan and Funy ((95"_)' reanl the case trol stud!v data +11' Chan rr ul: (1979) and found that )ng non-smoS:inY women there were more passive rkers in controls p66; l39) than cases (34;34): The Sl' czscs uded 34 adbn'ocarcinornas and othercell types. In a case :ro'I stud-v by K+Dort crl: (1934) on'0l) fw:male lung cancer ents' and' 2(lU healthv district controls. 69 ad~enu~- inom:.ts and 119 r-ases not' co'ntirrned' paithologically were ided. The RR in never smoked wives with smoking tands was 1.43 (;P.O.l6) and is close to that in the _nc study (1.65). The RRs Ior passive smoking in nescr <ing females by cell' types were: squambun crll' 1.75. II cell (.1i0, atiencx:ancinom:r 11.11 and large' ccill 1.-W )'rr at.. (935). However, in a'' study by Lam (1935) on female lung cancer cases and 13'_s orthopaet9ic controls. tuutiho'r focussed the alnal9sis for passive smukinz on 60 ocarcinoma <aset and 14-4 eonorols, both cases and •oIs being non-smu:.rs. For peripheral tumuur, he jl increased RR of 2.6-4' (P<0.05) for passivz ing due to a smoking husband. For central tumours: ZR was 1.61. but uas not signitircant. The RR for zcarcinoma. centrll and pkripherlli tuml combinud, '_.011 (95"~ CU_ I Jl :."_: P<t).q:,: our caliul :tiun): .c smui:in,3 in other cell c+pcs was not rcpurt:J. the present itlud+ the Jncrall RR ior pa~si%c snw;in_ u;t smoking husband' Nas 1'.65' fPc0.01) in all cell combined. When broken Jok+n by cell t+pe;, a iculi}• sienibicant RR was f+ound unlv in a,!cnu- onta but not in the other ccll t}pcs. alohuu_'h tliis l et]ected rhittl+ the ;m-sllitesn of the numbcrc innullcd. ^lut tVl RR-i1 2.12 a;ts very close tiD that ot ".OIed bk L:rm The 95".Cl for the prti:ant studM1 ::39- was narro-er than that in L:rm's itvJ+. ( I.U1. ha-c+er: bticausc the number of subjects as imullcr latter stull All b> itintr:tl or periphcral ns of uhetu'mour ++us nwtpusaible in ohu prcsr:nt'stuuly c uf lack uf inlormatiun. It is probable that the trui risk is nearer to the lut+er cnJ' ( 1.3t))' than to tltc end (3.36) of the <unludcncw: intcrtial: bLwauue it is to believc that pa:'<ir,c c.t!pu:uro is more huza'rdou: =tun~ ecpusull and IL,r aJ:nwcancinuml the l :ump;til all tnuktir: with all nev;r-,rnt,l,tir.. inc)iw6nL (n:tssivcly et'(oscd ncvcr-srntnkvr<)' lr+r al .ntr)king', was unly I.37. The :i-nitiriant trrn,l< oh.crcatl h,twcrtt RJt all unnsunt cntwkcd daily by Iiush.tnJ (i)n :rll t:clli qytis c,ornhined anul for adunwcarCint,riitu tnro>+iil,, suOpuru the view that the ncl;tliiurt<hip is likeln tra be C:tusaP. Recently. Illiot', anJ Fraumeni (I')ah) r~cvnruud ohe epiJcntiulugicail and unhcr l on passi+c smt,kin- and lung cancer and cuncluJ d that the tsi>tim; evidence is hichly sucgcsti'+e tltut lun,-tcrm cxpu,urc it, cn+irunmcntal tuhatco smoke intireairs the risk uf Iun_ cancer. Strmrrasrising the available data. they e:t'im:ttuJ th:et ohc ercess risk was ~ 30'l'•r. Tln excess risk rose with inirrtt.,il exposure. reaching -70°,o among heavily cxpu.uJ nun• smokcrs: Wald etut: ('11916) alsu calculated a relative risk of 1.35 for lung cancer amonl non-smokers li+inti with smokers by pooling the results o(' 10 case control studies and three prospective studies and concluded lihut breathing other pcopl;:'s tobacco smoke is a cause of 7ung cancer. Co'mparcd to the 13 studies includbd by VVuVd er at. (1956) the prosent study included the largest series of never smokin; Iune c:rncer cases (II99 c;ucs): Results of the present study would add more evidence on passive smoking as a risk Lirtor and they would contribute to++ards part of the explan:ution, for the high incidence of lung cancer in never smoking ++omen in Hong Kong. With regard tn the possibility of bias throu_hi the muclass, ilication of current and ex-smoL'ors as lifelone non-smokers. Wald rt at, (1936) stated that the czrtcnt of miscla:sitrcatiun bias was influencetl by the proportions ofmen and women in the population' who had smoked at some time and the greater the proportians'(uf women in purticular), the crcater, the bias. By choosing the high proportions of SU% or smol:ersln women all 70% in men anJcl lo++'C)bier+Jdl rl risk of1.351 they concluded that the nti5classiticat6l bias was unlikely to account for all the association between lung cancer and paisi+e smoking, In Harc,2 Kon_. the proportion of, smokers in men was 3'.S',o and in +vumen 4.I%.('Hung Kong Census and Statistics Departmcntt 1935). These fiRurail particularly in women; were much Icr"er than the fiQures usedl by Wald er ul: (1936): Also. the ubsan'cdi R',R was higher in the present study. Thus the extent oi influence by misclussi(ilcctiun bias would be muuh lesd and could not account for the relatuvcllp hi~h RR in the prescnt study. Fvrthermore, a compnrison for adcnocarcinuma on the RR duc to active smokin; ('O.S7) and that due to p:rssiae smokin; (2.12) suemed'tb su_'_~st that the risk for pLssi%a smoking ,cas quite iimilar to'that for ctctivc sntuJ;il for this particular cell type. This was not the case fur all other cell t)pcs im+v'hich acticc smoking posed much higher riihs than passive smoking. The apparently ercater rii;k of atli:nu• carcinoma than oI' other cell t'epes I'norn cmukin,' cu'nllicta with lirnr;im_s in othcr itucJlaN an f' this l he t fe:tturr of imall nul Hlu,+e+er: Rotu and (J,,I!' (li'l<!,) in their recent cdituriur on raiii+t :m+,k:rl a:tlt•.t t!tut t'i)c Qbbcr'lcU: risk nCal ItJtl ncCtiN<a'rrl\IDi the ~:Inw in aii c,UuntneiaiDc,PC Of tti)hac::U.p:,StiCh.r,tg,::rn ins,.l,ine hauNitti. :rnJl the eztunt' of f+:u>ite c.vpu<urc huth :tt homc and clntulterc mav Al Ji(l'tr <uh1t.rn1ia(1+ hctt,«n Jitl.r+rot cuuntric>. [n plairs If(.e Hont! Koni.: +.hcr+• rc,),li: li,r,! in tnur:, +cr-crO++.l~c1 c.^rtJilii+a., ttivh rtuur, ,Cnla.tli r r.. P.t>•t.t tvpusurc m:t+ he hcuni:r rewaltin_ nti .1 hwh,rr RR. %(i+'ntu+'rr: \WcnJar anJ Gi'»thnuin l notcd that 15, prct)ununant cell type ol' lun_ c:un.cr in n,+n-.n•.a±ktr, is :wknwcurcin;nma ul ~:*au!:lr~Jl ult.rt (,:ts*'l imh.rl.nion, rn.tt' priiuanl, il tlie risk (or aJ;nrrraruir. m r tia.::u,~ .r&- ;triJtn srnr,hti. ++hiUh irtl nt.rn+_'aliam:(,ronCnti. ian rc;tch' Ihe l llard> oflt Ihc Il .r.orc r;:ultlc ;n.:n ._:n m:an>tc+'ant .mr~ti %+rtla morc (,artictil,tlc. I'lntlin,s by L:nnt', (1').0t On I~nphur.t! :rJin;'~.:;:rr ,r:tu, ,'ur rr,ult> Jr i+)lif++r ,urnc >uhp,rrt' for 1A+n~:cr ::ntl oi. ~ ... .,., ),a,,tulatc th:r1 p:r"inc <nttolkrn_ nt:r, tti .: r:.d, p:utliul.udt IOr :ndcrnn::ttcrnwtn,:. 1t' l ,,•r.., I.

'. ;,. ,. L(*t,*ivir~ftuokin, '.unJ lun_ uaro.~r i:m ncn linnzcr :u__ra tat lilt: re:ultc irr`I (.rn_ Kuni Inil Itn :a(+pttrl the oxi;ittincc a rral re(:Ui.?nship: In Coatclut;ii)n, huwtit•er. tro' nrtte that '_5'.2",. 1)'3i'?14)1 of .tr (>:ui nt: tviu(t aJCnunrarrin,ttna wcrt nuither :nwlcrs n:m:C(.tS nor (111~.*ivc ;neol;tirS Juc t,): XiuukinL hu;hanldi: , (tht)uQh smtt,kine and p t-s%fve smtoking may airuu'nt, partly tr the high inoJon:e af ac(cnuattrcinvnta. exposurc to othcr, t,:turs ;huuld! hu I"urther e.r.tntineJ to eluu:iJatit the acliultr~% ~ I' II)ng cant:'er, particularly tha, hi-gh inviu(cnuc' uf aJUno trcinunta in this (+up'ul:rdiw,n, 'e rre must, `r.caelull lu the Int.rncuionul D.~elopment Rescarw;h entre and, Uni%ersitn ol" F(ong', Kung, for thoir, cary gcneruru !fcrsnoes .OT., W:L Sc FRA'tJME\I, J'F: (14S6). Passin•e' smoking and lung cancer. J. r@w1l Cancer lirsr., 77; Y!J3'. tESLOW, N.E. it DAl'. NJE. (t'9Sq1. Thi• cnrulnuir q!' ottvt cunrruf aarJics: Inlcrntaliorul Agency for Rcse•arch on Cancer: Lyon. iAM:, W.C.. CDLBOL'R'NE. SIJ:. FUMG. S.C. & HO. H.C. ((V79) Bronchial cattcwc in HunY Kong 1'97(+-77. Br. J. Cmtncr. 39, 13_. IAN. W.C. A FUMG:,S.C: (1'983). Lunq:¢anecr in non-imol:ero in Hong Kang- In Canrrr cunqrui,rn, Vol- 6. Canccr epiilemiulu,c, • G* imann. E. (c)1 p. 199: Fitchcr Vcrlitg: Stuttgart tcndl New Yc. .. RiECTOR, OF MEDICAL AMD HIE.CLTH SERVICES OF HONG KONG (195.6)j 195:t-lV.yrS Dnpurrturrurrf Rrpnrt: Government Printer HunS , Kong. Ri3':\MLC. T: ('19R1). \on-smuking wivc-s oti heavy smukers hane a higher risk of lung caneer. A study Rum Japan. Br. thd. f_.,28"_. 16'3: >NJG KONG CENSUS S STATISTICS DEf'AR'TSIIEitiTYil`i8'S9. Sprc'iul, Tnpics RAqx»r 111. Social Data Collcutedl by the Generali Household Survey. Guvern'm:nt Printer Hung Kong. RC IWOR'lil\GI GROUP (d!9,1'"). LJfiC .llnrtrrrrirplic ner, dthe E'rrrluurinrt ttl the Curcrnn.;c•nic Ri.t•;'s n/ C7tuntir,ult nr Hwnutra•' Tirhucru SJrnnklirr•c. Vuli 33{. (internationallA__rncl•, I'or Rrscarahion Cancer L)+on~ ,O. L.C:. HO. J'H.C: SS?.NV: D! (INi19. I> psssine,;mokin_ an ud,c:.' risk laanr fur lung :anier in Chice;r %cuman? 1 , Exp. Ciur. Crmcer !(c's:. 3. 1. )O. L.C.. HO. J:H.C & LEE. N. (t'9,55)i An anutyiis ul s+.?rr.e rir.k I'itctors for Iun,reantcrin,HonS,Kon;. Jnr. J. Crc.ncrr: 35. 1',19. .ultlxrrd nt Pru.t.I1nE' th. rc,cartih _r.tnt, tn Ihi, Itrr'Itr:t an.l trr I)r 1),.\W. It:ut Gu hiK eootinur.us vulq.crrl :md :tcln•ic.. t\'e wWi,urr th.ntt. lltc m.Jical' .ul.crintcnacnt< nl' Uranthant Ilu,pual, K.rc.I.r..n 1(usprtal; ki.ung \1'.rh Illucpit.tl. N:un Lung: Ilcr.ptt:di Ruttaul": San:rturium :rnJ' UniliAi C'hrinatara Iltunpil:cl lirr thctr Nrmr,r•n r,w ntCrviVw Ihc I:tliwnt:. :utJ the, ;t:dl' rn.rduvJ. p.trti:ulLrll clic pathnluLi,ts ilrr uheir cu-oticr:ttirnc: to Slr, Jl Chc:rr._. \1rs Ji \(iesSC \Vnnc:.. Jlis, Ci>nntc \4'u,. \li-('•:'.\W.. Yilt1.incl. \ti,n Rit.i Ln frir mtrr.icurn_s :tnJ nthrr rc•.,,:trtih a.+ixl:utc : lu \Il,e \_nc. Chuw :rnJ `Fet -r. Lain Icar Oheir saireLtrial :rnsi,tunir :tuu( nn .tllith tnlervir.•eoa lnr uhcir cct-uperauwnr,rnJ p:trliciparticon. Fin:rltp. t%c:.irc indebted t.• Dr .10 J Cnlhrourinc tior hiN cc+rnrnonts r>n the tuihtu;_,f report .uhm:ctud to LD R.C. \We an•, p:rrt+cul:trlp er:rtcful trt \ir Richard I'a,t aml Sir Richard Doll Ibr rc:rJtng anJ comrnenun_ r.n the report aml lor their ent:uurartnicnt.. KUNG, 1:T.M.. SO. K.F. & LA'NI: T'.H. ('If1R11; Lung cancer in (itun. Kong Chinese: Vlortality and histolugiial'types. I"L3-I93_. IJ:: J. Cwrccr, Sq, 3'311. LiJ't.,W.K. (1955)'. .d c•liirirul und'cpidrvuinlr+gical xru.h.'n!'curcimuu.t u[7unX in Hurr,r, h:mr,y:, M.D. Thesis. Uniw'crsity of Hong I:unt: Hong, Kony. LANt, W.K.. SO. S:Y. & YU: Da°.C. (1983). Clinical fr.tlures ul' bronchuticniit carcinoma in HunL Kong: Rkviow• uf 4BR patticnln, Cancer. 57~ ?6y. MEDICAL RESE.aRCH! COt;t*tCIL'S Cr'1%1.MITTEE ON RESEr~RK'Ya INTO CHRONtC, BRONCHITIS ('19ti6'). Questionnaire on Respiratory S+mptums, UK. PETO. JI da,DOLL. R! (11936). Pass'ise smoking. Br. 1. Ccmeer, 54. :11. (rdunriul ) TRIICHO'POL:LOS. D!. KALAS:DIDI• .a'.. SP:aRROS: L. SM-\CNUHON. B. (Dy3(I). Lung cancer and passine smco'kin;: rnr. J. Cma•,cr: ?7; 1: R'.-kLD: N.1.. NANCHAH.-~L. F:.. THO>yPSON., S.G. & CUCKLE. FI.S ('(986). Does brcithing other peopii's tubuew imut;,r: cause lur._ c:tn:_r'.' Br. tlrcL J:. 293, 1?I17'. 1S'kTE'RHOLS'E. J.. thLIR. C.. SH:-\N\IIt:G:aR.-\T\:-%Nt. K & POtV[LL. 1;'ledil I19fi:); Cunc,t•r' Mc'ulcvft'c irr firr Cunvur,'ul.a. Vol. I\'. Il-1RC Saientitie Pubiicaliun5 No. 1^_', lntern:ttiunal As.::-. Iur Rssearch un Canc.r: Lyon. • tcY\DERI [IL- S' GOODSh>~; lt.T: Smnting, ar~ lun_ eunc,:: S.)ma unresvlvtd iisuti. Enrdc'ncrnl' Rc°, I