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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

17 REFERENCES I I I I I I I I I I I I Akiba S, Kato H, Blot WJ. Passive smoking and lung cancer among Japanese women. Cancer Res. Sept. 1986;46:4804-4807. . Alavanja MCR, Brown CC, Swanson C, Brownson, RC. Saturated Fat Intake and Lung Cancer Risk Among Nonsmoking Women in Missouri. J Natl Canc Inst, 85:1906-1916,1993. Anderson HA, Lilis R, Daum SM, Fischbein AS, Selikoff IJ. Household-contact asbestos neoplastic risk. Ann IVYAcad Sci. 1976;271:311-323. Anderson HA, Lilis R, Daum SM, Selikoff IJ. Asbestosis among household contacts of asbestos factory workers. Ann NY Acad Sci. 1979;330:397-399. Anderson HA. Family contact exposure. "Asbestos, Health and Society". World Symposium on Asbestos, Canadian Asbestos Information Centre, Montreal 1982;349 - 362. Araki S. Social life factors affecting major malignant neoplasms in Japan. Tohoku J Exp Med 1986;149:221-8. Araki S, Murata K. Social life factors affecting the mortality of total Japanese population. Soc Sci Med 1986;23:1163-9. Ashcroft T, Heppleston AG. Mesothelioma and asbestos on tyneside. Shapiro, HA (ed): "Pneumoconiosis"... Oxford University; Capetown. 1970;177-179. Blair A, Stewart PA, O'Burg M, Gaffey W, Walrath J, Ward J, Bales R, Kaplan S, Cubit D. Mortality among industrial workers exposed to formaldehyde. J Nat Cancer Inst. 1986;76:1071-1084.

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