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I I ~ I I An Alternative Explanation for the Apparent Elevated Relative Mortality and Morbidity Risks of Spouses and Other Family Members of Smokers Associated with Exposure to Environmental Tobacco Smoke T.D. Sterling, Professor W.L. Rosenbaum, Senior Research Associate J.J. Weinkam, Professor Faculty of Applied Sciences, School of Computing Science Simon Fraser University Burnaby, British Columbia, Canada, V5A 1S6 May 18, 1994

SUNIlVIAR.Y I I ~ I I I I I In its proposed air quality standard in the workplace, OSHA (1994) faces the dilemma of a lack of evidence for elevated risk associated with actual workplace exposure to ETS. OSHA briefly discusses and attempts to resolve its' dilemma in 6ection IV. (Preliminary Quantitative Risk Assessment). OSHA concludes that "risk estimates calculated from studies of the general population or of selected subgroups, such as non-smoking wives of smoking husbands, are relevant to the working non-smoking population.". OSHA then defends extrapolating from assumed or observed risks of female spouses of smokers to all persons in the workplace by concluding that "it is the exposure to environmental tobacco smoke and not the environment in which that exposure occurs that is the important factor." (OSHA, 1994:15994). This set of assumptions does not justify OSHA's extrapolation from risks associated with having a smoking spouse to risks associated with ETS exposure in the workplace because there is an alternative explanation for the apparent elevated lung cancer risk found in some spousal studies and the failure to find such elevated lung cancer risks in studies of workplace ETS exposure. In this review we show that there is a strong possibility that factors other than ETS were acting in those spousal studies that compared lung cancer and other disease risks of non-smoking female spouses of smoking males with the same diseases among non-smoking female spouses of non-smoking males. Our analysis details an alternative explanation for elevation of relative risks observed in some spousal studies: The presence of a smoking spouse or parent within the household demonstrably corresponds to a greater likelihood that the household belongs to a I

2 I I I lower socio-economic stratum and that its' members are subjected to paraoccupational exposure than if no smoking spouse or parent is present. (Paraoccupational exposure is defined as an exposure to a substance outside the ... ...... ... ... occupational setting in which workers are exposed to that substance.) Insofar as service or industrial workers are much more likely to smoke than persons in other occupations and in higher socio-economic strata, observed differences in risk of morbidity or mortality ascribed to ETS on the basis of the comparison of households with or without smokers may be partly or entirely due to differences in socio- economic strata and paraoccupational exposure. The major supporting evidence are based: 1. On the substantial confounding of occupation and economic factors wit smoking patterns; 2. On the link between paternal and spousal occupation and disease; 3. On the possible exposure to carcinogens brought home by parents and spouses from the workplace; 4. On the inverse relation between socio-economic levels and mortality; I I I 5. On the fact that elevated lung cancer risks is reported in non-smoking • females living with smoking males but not generally for non-smoking males living with smoking females; 6. On the lack of evidence for an elevated lung cancer risk associated with EfiS exposure in the workplace; and 7. On the observation of "healthier" lifestyles of wives married to non- smokers. I

3 I I I I I Important factors besides paraoccupational exposure rooted in socio-economic differences between households with or without smokers are discussed as well. Our investigation not only of possible ETS effects but also on effects socio- economicc and paraoccupational variables concludes that it is the peculiar setting of spousal studies and related socio-economic factors involved in househol stu ies that make for an apparent elevated disease risk in spousal studies. There is no justification for extrapolating from assumed or observed risk levels in spousal studies to calculate risks associated with ETS exposure in the workplace. ~

- INTRODUCTION I I I I I I I I In its proposed air quality standard, OSHA (1994) faces a dilemma which never is directly discussed. That dilemma is the lack of evidence for elevated risk + associated with actual workplace exposure to ETS. There are 10 studies which calculate 13 relative lung cancer risks associated with workplace exposure to ETS , for males, females and all workers. Of these 13 relative risks, 3 are of borderline statistical significance. These are Fontham's relative lung cancer risk for females of 1.34 (confidence interval 1.03 - 1.73); Kabat and Wynder's relative lung cancer risk for males of 3.27 (confidence interval 1.01 - 10.60); and Wu-Williams relative lung cancer risk for females of 1.20 (confidence interval 1.00 - 1.40). The findings of all available studies combined would ordinarily be dismissed as not demonstrating a relationship between workplace exposure to ETS and lung disease. Yet OSHA is pressed to set a standard for regulating tobacco smoke exposures at the workplace. OSHA resolves this dilemma by concluding that "risk estimates calculated from studies of the general population or of selected subgroups, such as non-smoking wives of smoking husbands, are relevant to the working non-smoking population". _ _ OSHA. defends that extrapolation from female spouses of smokers to all persons in the workplace by concluding that "it is the exposure to environmental tobacco smoke and not the environment in which that exposure occurs that is the important factor. " (OSHA, 1994: 15994). .. OSHA does not further refer to its dilemma but instead, deals with it by assuming that the lung cancer relative risk observed by Fontham et al, (1991) of 1.34 is representative of the risk for workplace exposures and uses a spousal study,

5 I I I I I I I I I Helsing et al, (1988) to estimate the relative heart disease risk for workplace exposure -- a risk for which no direct workplace investigations exist at this time. A conclusion by OSHA that a risk exists in the workplace based on evidence ~ that is not related to workplace exposure and, in fact, is in conflict with negative results of workplace exposure studies, would have far reaching implications for , setting standards altogether. It is therefore important to investigate whether or not an explanation exists that would link the negative results of workplace ETS exposure to the apparent observed elevation in risk of family members of smokers, especially of non-smoking spouses. The alternative to OSHA's reasoning is that the environment in which the exposure occurred in so called spousal ETS studies ig an important factor. In this review we show that there is a strong possibility that factors other than ETS were acting in those spousal studies that compared lung cancer and related disease of ~ non-smoking female spouses of smoking males with the same diseases among non- smoking female spouses of non-smoking males. We believe that there is an alternative explanation for these observed elevation in relative risk, namely: The presence of a smoking spouse or parent within a household corresponds to greater likelihood that the household belongs to a lower socio-economic stratum and that its members are subjected to paraoccupational exposurei than when a smoking spouse or parent is not present. Insofar as service and industrial workers are much more likely•to smoke than those in other occupation and in higher socio-economic IParaoccupational exposure is defined as an exposure to a substance outside the occupational setting in which workers are exposed to that substance. It usually is an exposure of workers' family materials brought home on the hair, skin, and clothing ofworkers. ~

6 strata, observed differences in risk of morbidity or mortality ascribed to ETS on the basis of a comparison of households with and without smokers may be partly or entirely due to differences in socio-economic. strata and in paraoccupational exposures. MAJOR SUPPORTING EVIDENCE2 I I I I I I I I I I There is persuasive, albeit only indirect, evidence that an elevated disease risk in homes of smokers (primarily in homes of male smokers) is due at least in part to socioeconomic and especially occupation-related factors. This evidence rests on six sets of interrelated observations: 1. On The Extent of Confounding of Occupation and Economic Factors with Smoking Patterns . Sterling (1976, 1990) and Weinkam (1987) have shown a pattern between occupation of members of the household and their smoking behavior. Two of the findings by Sterling and Weinkam are especially relevant: (a) Nonsmoking females whose husbands smoke are about 40% more likely to live in a blue collar household and about 50 % less likely to live in a professional household than are nonsmoking females whose husbands do not smoke. (b) Infants whose mothers smoke are 25 % more likely to live in blue collar households and one third less likely to live in professional households than infants whose mothers do not smoke (Sterling, 1990). 2 An alternative explanation for the apparent association with ETS exposure of non-smoking _ spouses is discussed in a lengthy paper presently uader review by the Epidemiologic an Environmental Journal. I

7 I I I I I Differences in the prevalence of smoking among various occupations are indeed striking. Table 1 shows the 20 occupations with the highest smoking prevalence and Table 2 shows the 20 occupations with the lowest smoking prevalence among white males in 1970. While these prevalences were observed in 1970, the last year the ~ National Health Interview Survey collected detailed information about smokers in the total probability'sample, they give insight into the relative levels of smoking by occupation that are relevant today - even though the absolute number of smokers has declined for all occupations. Prevalence of tobacco use among the 20 highest ranking occupations ranges from 72% to 38%. On the other hand, prevalence of smoking among the lowest ranking occupations ranges from 30% to 7%. Tables 1 and 2 also show that there are no occupations with high smoking prevalence that also might be expected to incur relatively low exposure to toxic or carcinogenic substances on the job. All of the 20 occupations with high smoking prevalence expose workers to various types of toxic products in many instances to substances that may be brought home on the worker's person. The reverse is true for the lowest levels of smoking. With the possible exception of chemical engineers and farmers, all occupations with low smoking prevalence involve work in clean environments and most individuals in these occupations belong to higher socio%conomic strata. All 20 occupations with the highest prevalence of current smokers are blue collar occupations. None of the occupations with the lowest smoking prevalence are blue collar._ Weinkam and Sterling (1987) showed that by 1980, the percent of current smokers had decreased and the percent of former or never, smokers had increased

8 I I I I I I I I I I I I I I ~ within each occupation. However, despite the decline among current smokers and increase among former and never smokers, the basic pattern of distribution of occupation within smoking categories remains substantially unchanged from 1970 to 1980. Also, changes in smoking habits for cohorts moving from younger to older ages from 1970 to 1980 are similar for all occupations. I The 1970 National Health Interview Survey also provides information which is especially relevant to comparison of households with or without male smokers. Information in the 1970 NHIS makes it possible to compare the percent of blue collar and professional occupations in households with different patterns of smoking of husbands and wives (i.e. where both the husband and wife smoke, where only the husband smokes, only the wife smokes, and neither smoke). Because spousal studies of the effect of ETS compare disease incidence of nonsmoking wives married to smoking males with nonsmoking wives married to nonsmokers, these two categories are especially important. We see from Figure 1 (based on the population of employed males of ages 20-64) that the percentage of blue collar households was 48.1% where the husband smokes and the wife doesn't, but only 35.1% where neither spouses smoke-- a ratio of 1.37. The opposite tendency is seen for professional occupations. For employed males only, 7.1% of households with nonsmoking wives and smoking husbands were of a professional background while 17.3% were of that background if neither the husband nor the wife smokes or a ratio of 0.40. It is obvious that a comparison of households with a nonsmoking wife and a smoking husband with households where neither the wife nor husband smokes compares two groups of households which differ quite significantly. These differences also affect the likelihood that either the nonsmoking wife or other

9 I I I members of the family may be paraoccupationally exposed to materials brought home from the workplace by industrially employed members of the family. That likelihood is greater if the husband is a smoker. The 1970 NHIS also made possible comparison of the blue collar and professional backgrounds of husbands of smoking and nonsmoking mothers. Figure ~ 2 summarizes that information and is based on wives of employed males ages 20-64. This figure shows that for households in which the mother of an infant was a smoker, 51.4% were of blue collar background whereas in households where the ~ mother did not smoke 41.8% were of blue collar background. Again, the relative frequencies are the reverse for professional households with respect to smoking and ' nonsmoking mothers of infants. In families of employed males ages 20 - 64, the ~ percent of professional households is 10.2 if the mother smokes versus 14.9 if the mother does not smoke. I I I I I Again, these data show that a comparison of households in which the mother of an infant smokes as opposed to households in which the mother of an infant does not smoke also compares households with a greater prevalence of blue collar backgrounds and a smaller prevalence of professional backgrounds. Since smoking is distributed unequally among different categories of individuals, any comparison of infants based on differences in mother's smoking habits must adjust for the differences in socioleconomic backgrounds of the infants who are being compared and of the possibilities of their paraoccupational exposures. ~ 2. On The Link Between Paternal and Spousal Occupation and Disease Epidemiologic studies of parental occupation and childhood cancer date back ~ to 1974 when Fabia and Thuy reported a two-fold excess risk of cancer mortality N among children less than 5 years of age whose fathers had jobs classified as 4 ~ CJI ~ ~ Q? ~ ~

10 I I I I I I I I I "hydrocarbon related". The relevant literature linking parental occupation to childhood cancer has grown considerably since then. For example, parental exposures associated with cancer of their children include solvents (Peters, 1981), paints (Hemminki, 1981 ;Peters, 1981); metals (Wilkins, 1988); printing (Johnson, 1987); construction (Wilkins, 1988) and agriculture (West, 1987). + The most convincing evidence for the link between male workers' exposure . ........ and cancer of their wives comes from epidemiologic studies that find increased levels of mesotheliomas and lung cancer and evidence of asbestosis among family members of asbestos workers (for instance, Anderson et a1,1976, 1979; Anderson, 1982; Ashcroft and Heppleston, 1970; Dodoli et al, 1992; Joubert et al, 1991; Lieben and Pistawka, 1967; Maltoni et al, 1991; Newhouse and Thompson, 1965; Roggli and Longo, 1991; Wagner et al, 1960). 3. On the Possible Exposure to Carcinogens Brought Home by Parents ~ and Spouses from the Workplace Knishkowsky and Baker (1986) have summarized the evidence that occupational exposures can be transferred to families of industrial workers who bring home toxic materials, including arsenic, asbestos, beryllium, lead, mercury, polycyclic compounds, pesticides,.. and synthetic estrogens on their persons. The extensiveness of these paraoccupational exposures is unknown but appears to be large. For instance, Rinehart and Yanagisawa (1993) cite seventeen previous studies recording paraoccupational exposures to both lead and tin carried home by electric cable splicers. They estimate that New York, Detroit, Cleveland, Dayton and Boston-have 5,000 to 7,000 underground electrical workers. Because underground water line and gas line workers in these cities also frequently use lead and may have similar exposures, the number of workers carrying home toxic lead and/or tin dusts is potentially increased to 14,000 to 15,000 for those cities alone. I

11 I I I I I I I I Also elevated lead levels are found in homes of electric cable splicers, (Rinehart, 1993) A variety of children's illnesses caused by toxic materials brought home by parents have been recently reviewed by McDiarmid and Weaver (1994). Findings of the extensiveness of paraoccupational exposures are strong enough to have motivated the U.S. Congress to pass a special bill, the 'Workers' : Family Protection Act, Public Law # 102-522 (1992) which instructs the Director of NIOSH to investigate the risk to household members from carcinogens brought home on the persons of industrial workers. Indeed, the possibility of paraoccupational exposure has been greatly underestimated. 4. On the Association Between Socioeconomic Level and Mortality A strong association between socioeconomic level and mortality has been demonstrated in Finland (Nayha, 1989; Slonen, 1982); Norway (Holme et al, 1982) ~ Scotland, England and Wales (Carstairs and Morris, 1989); Netherlands (Mackenbach et al, 1990); the United States (Weinkam et al, 1992; Sterling et al, ... ........ 1993 a,b) and Japan (Araki and Murata, 1986; Araki, 1986). 5. On the Fact that Elevated Lung Cancer Risk is Reported for Non- smoking Females Living with Smoking Males but not Generally for Non-smoking Males Living with Smoking Females. While the EPA's meta-analysis yields a significantly elevated lung cancer relative risk of 1.3 (1.18,1.43) for nonsmoking females exposed to ETS at home, that for nonsmoking males is not elevated. The fact that significantly elevated risk is limited to female nonsmoking spouses and children of smokers supports the .......... presence of factors other than or in addition to ETS.

I I I I I I I I I I I I I I 12 6. On the Fact that Elevated Lung Cancer Risk for ETS Exposure in the Workplace is Negative. Of ten studies of exposure to ETS in the workplace, only three find a significantly elevated lung cancer risk (Fontham,1991, Kabat and Wysder, 1984, Wu-Williams, 1990) all of which are borde _ rluie. r 7. On the Observation of "Healthier" LifestyIes of Wives Married to Non- Smokers Koo (1988), Koo et al (1988) and Sidney et al (1989) have shown that wives of non-smokers are more likely to have healthier lifestyles than wives of smokers -- such as higher consumption of fresh vegetables, lower consumption of fatty foods, lower consumption of alcohol, and more frequent exercising. The relationship between alcohol and cancer is well known. Recent work has also demonstrated elevated lung cancer risk among nonsmoking women related to saturated fat intake (Alavanja, 1994). DISCUSSION The apparent association between reported exposure to ETS and lung cancer (as well as other diseases) may be due to confounding of smoking with socioeconomic level of the household, and correspondingly with occupations that expose industrial workers and; through them their families, to carcinogens and other toxic agents from the workplace. Disproportionately more households with smokers are from lower socioeconomic classes, and have blue collar and service worker backgrounds _ :. than households without smokers, This pattern results in a greater level of exposure to carcinogens in such households. Some important factors besides paraoccupational exposures are: I

I I I I I I I I I I I I I I I I 13 Women in lower income strata may be exposed more frequently and more intensively to carcinogens present in household cleaners and also to other occupational employment exposures than women in higher income strata. This exposure may be further intensified if women in lower income strata are exposed to these carcinogens in homes that are smaller and less well ventilated J ... . . .. ... .. . ... .. . . ... . _ . than the homes of persons in higher income strata (Dolk,1993). • The exposure in lower income households to carcinogens that are present may be further intensified by the ry el .a..tively small frequency with which others from outside the home are employed to do household cleaning. Not only are there differences in household exposure associated with socioeconomic and occupational differences, but there are also documented differences in other factors that are related to cancers, such as overall health care and nutrition. Finally, it should not be forgotten that ETS exposures differ by social class as well. As we have pointed out, elevated risk related to social class may also be related to the distribution of ETS exposure by social class and occupation. There exists then a situation where two explanations are. advanced for the same phenomena (lung cancer and respiratory problems and other diseases of members of a household), each based on similar study populations but focused on different major variables: ETS on one hand, socioeconomic status and paraoccupational exposure on the other. An effort is called for to clarify the extent to which the increased mortality and morbidity reported for family members of smokers are due to ETS exposure to socioeconomic and paraoccupational factors, or both. Unfortunately, studies of the effects of paraoccupational exposures have I

I I I I I I I I I I I I I 14 _ ..S consistently failed to ac~just for ETS exposure and studies of the health effects of ETS exposure have almost never adjusted for socioeconomic status and paraoccupational exposure. Studies of paraoccupational exposure very often are based on death certificates and on other data that usually do not provide the data needed to permit ~ a~justing for ETS exposure. Also, their principal investigators come from a background of occupational health investigations. While active smoking is always considered to be an important variable and adjustment for smoking is included in occupational risk analyses whenever possible, ETS exposure has not been considered a possible confounder in the past. Similarly, studies of reported ETS effects have neglected socioeconomic confounders. A review of 27 recent epidemiological studies investigating the association between lung cancer risk of nonsmoking women and smoking status of _ their husbands revealed not a single instance in which published risk estimates were adjusted for paraoccupational confounding and only a few studies that attempted to adjust for socioeconomic status (The studies reviewed are Akiba et al, 1986; Brownson et al, 1987; Brownson et al, 1987, 1991; Bufler et al, 1984; Chan and Fung, 1982; Correa et a1,1983; Du et al, 1993; Garfinkel et a1,1981; Garfinkel, 1985; Geng et al, 1988; Gillis et al, 1984; Gao et al, 1988; Hirayama, 1984; Humble et a1,1987; Inoue and Hirayama, 1988; Janerich et al, 1990; Kabat and Wynder, 1984; Kalandidi et al, 1990; Koo et al, 1987; Lam et al, 1987; Lee et al, 1986; Liu et al, 1991; Pershagen et al, 1987; Shimizu et al, 1988; Sobue et al, 1990; Trichopoulous et al, 1983; Wu et al, 1985; Wu-Williams et al, 1990.) Only two studies attempted some adjustment for past direct occupational exposure of the case herself - but not for paraoccupational exposure through her spouse (Brownson et al, 1987; Fontham, 1993). Garfinkel (1985) adjusts risks by "lower", "middle" and I

15 I I I I I I I I I I I I "upper" classes. Neither the Brownson nor the Garfinkel studies reported significantly elevated relative risks. Several studies attempted controls for socioeconomic factors by matching controls to cases on the basis of some socioeconomic related variable such as education or neighborhood of residence. ...... .. However, such matching may introduce its own confounding (Rothman,1986), especially when the matching is later disregarded. CONCLUSION OSHA is sensitive to the lack of evidence for elevated risk associated with workplace exposure to ETS, especially to the lack of studies of a possible elevated heart disease risk associated with.. ETS workplace exposure. In fact, OSHA points to ........ . ........ . ......... _ the two alternative possible explanations about the apparent elevated risk of non- smoking female spouses of smokers and the apparent lack of an elevated risk for workers exposed to ETS. in the workplace. The choice among explanation is that the increased lung cancer and other disease risk of spouses and other household members of smokers are due to (1) exposure to environmental tobacco smoke or (2) to the environment in which the exposure occurs. Our investigation not only of possible ETS effects but also of effects of socio-economic and paraoccupational variables concludes that it is the peculiar setting and socio-economic factors involved in household studies that make for an apparent elevated disease risk. The general failure of studies of ETS in the workplace to result in elevated disease risks only buttresses our conclusions. OSHA cannot be expected to wait until there are a sufficient number of studies to clarify a confounding of socio-economic and paraoccupational exposures with ETS. However, in view of the considerable evidence that household studies in fact blundered because of their failure to include socio-economic and especially I

16 I I I I I I I I I I I I I occupational variables, it would be negligent, given OSHA's responsibility to occupational health problems, to willy-nilly assume that risks observed in spousal studies may be simply transferred to the workplace. This is a fortioi true for the' postuiated link between heart disease and exposure to ETS in the workplace where no direct workplace data exists and the confounding with socio-economic factors is even stronger than for lung cancer. In recognition of this situation it is difficult to see how OSHA can be guided to conclude anything about heart disease risk due to ETS. I

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26 TABLE 1 Twenty Occupations with Greatest Proportion of Current Smokers From the 1970 National Health Interview Survey I r CATEGORY Roofers and Slaters % CURRENT SMOKERS 72.22 Bartenders 68.42 Painters, Construction, Maintenance 68.29 I Cleaners 62.50 Cooks, not private households 57.52 Millwrights 56.82 I Taxidrivers, Chauffeurs 60.00 Bakers 61.54 Pressmen, Plateptntrs, Prtg 55.56 Conductors, Railroad 46.67 I Crane, Derrick, Hoistment 56.92 Tin, Coppersmths, Shtmetal 63.10 Inspectors (NEC) 55.74 Locomotive engineers 61.29 I WJGrsrs GargelLabor'rs C 58.54 . Brick, Stone Masons, Tiles 54.39 Attendants Auto Svc, Prkg 51.80 I Packrs, Wrapprs, (NEC) 52.13 Mine Operative, Laborers 57.30 Operatives, Kindred (NEC) 53.48 I I I I I A ~ ~ I I ~ ~ ~ ~

I I TABLE 2 27 I Twenty Occupations with the Lowest Proportion of Current Smokers From the 1970 National . Health Interview Survey I CATEGORY 96 CURRENT SMOHERS I Messengers, Office Boys 30.00 Draftsmen 34.16 Ins Adjstrs, Exmrs, Invstgrs 42.42 Engineers, Civil 29.81 Lawyers 30.27 Teachers, Secondary School 27.59 engineers, Mechanical 30.00 Cashiers 29.51 Farmers (owners & tenants) 28.12 Engineers, Aeronautical 26.19 Chemists 28.81 Artists and Art Teachers 26.53 Teachers, Elementary Schl 28.57 Engineers, Chemical 20.59 Pharmacists 34.48 Engineers, Sales 29.03 Physicians & Surgeons 21.28 Engineers, Electrical 20.25 Sports Instrs, Officiais 25.45 Clergymen 7.69

Figure 1: Percentage of Husbands With Blue Collar or Professional Occupations in Households with Non Smoking Wives, by Husband's Smoking Status White Persons Age 20 to 64 Estimated from 1970 NIiTS Husband Does Not Smoke 0.0 -f I - M- -- --i f ~ _~~ --~ 5.0 10.0 15.0 20.0 * 25.0 30.0 35.0 40.0 45.0 50.0 PcrccntMre orllouscholds ®Blue Collar OProfessional

.. r r= rr .r ia= rr .rr m rwi .r r.r ... = .. .. rr .r Figure 2: Percentage of Husbands With Blue Collar or Professional Occupations in Households with Infants, by Smoking Status of Mother in Household. White Persons Age 20 to 64 'r Estimated From 1970 N1XIS Mothcr Smokes 0,0 %ST4V845OZ 10.0 . - --I 30.0 40.0 50,0 60.0 Pcrccntngc ofttouscGolds Blue Collar m aFr~ ofessiona;-~