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No S LUNG CANCER 1N NONSMOKERS • Kabai and WwfdCr 1219 dividual, with educational level, with different }obs, and between cases and conuols . In only 7 of the 14 cases did the coded occupation mention textile work . The remaining seven ases reported occupations not specifically associated with textiles, such as "typist," but reported exposure to textiles . Evidence from existing occupational studies of lung cancer risk in textile workers is scanL'3-" No cahon study of textile workers appears to have been a.rried out. The apparently minor role of occupational exposures in our male cases is consistent with the high peranta ;e of professionaLs (60%) among them . Altbough our data do not suggest an important role of occupation or exposure to specific substanca, it .vould be desirable in the future to obtain more detailed and objective occupational histories on cases of lung cancer occurring in nonsrnokers . Passive inAalation The plausibility of a role of passive inhalation in lung ancer can be questioned on several frounds . Although sidestrcam cigarette smoke contains higher concentrations of toxic components than mainstream smoke," it is diluted in the ambient air to varying degrees (depending on the size and shape of the room, proximity to the smoker, and ventilation) by the time it reaches the passively exposed person . As shown by Auerbach and coworkers," the changes in the bronchial epithelium characteristic of smokers are rarely observed in lifetime nonsmokers . Nevertheleis, the possibility that havy exposure to secondhand smoke over a long period of time could lead to increased cancer risk cannot be ruled out at prescnt . 8ecause questions on passive inhalation were introduced in our questaonnaire in 1978, we only have information on this factor for between 28% and 68% of our subjects depending on the specific question . We present the distributions of responses to these questions as preliminary data since the numbers are small . Cases do not differ from controls except for the greater exposure to eijaretu smoke at work reported by male cases compared to male controls. Those cases who reported passive inhalation exposure did not differ in their distribution of histolotic types from unexposed cases . The ditference between exposure to ciprette smoke at work between male cases and eontxvis could be due to information bias, althoujh there is no indication of such bias in the responses to the other questions on passive inhalation . The studies which, to date, have addresssd the issue of passive inhalation and lung cancer have differed in methodology, the population studied, the type of lung cancer studied, the degree of histologic confirmation, and in results . These studies are summarized in Table 4 . They have been commented on by a number of investiptors ." ."''• We wish to draw attention here to several poinu which are crucial in assessinj a eontribution of passive smoking to lung cancer and which need to be http://legacy.library.ucsf.edu/tid/wyk81f00/pdf considered in future studies . First, the proportion of histologically confirmed diagnoses in the studies listed in Table 4 ranged from 35% (Trichopoulos a al (2G)) to 82% (Chan and FunQ 1211) . Given the difficulty of diajnosing lung cancer, histologic confirmation is essent .ia). Second, Trichopoulos et al .i0 excluded adenocarrinoma and terminal bronchiolarcases, whereas adenocarcinom3 predominated in Hirayama's easesu (personal commuttication, 1981), in those of Chan and Futt=,2' and in our csses . In the American Cancer Society study reported by Garfinkel," histologic type was obtained for lung cancer cases during the first 6 of 12 years of the study . Seventy percent of these nses had histotofic confirmation but some of these were only identified as "arcinoma." Among the ases with confirmed histology and information on specific cell type, 46% of the male and 59% of female nonsmokers had adenocarcinoma compared to 23% among male and 46% among female smokers (personal communication) . Since tittle is known about the etiologic significance of different histologic xypes and since the distribution of types differs in different populations, it is premature to restrzct studies of passive inhalation to particular types . Third, although histologic classification of lung cancer is imperfect, it is desirable to stratify by the major histologic types in the analysis if the number of cases permits since differtnt histologic types may have different etiologies . Finally, all of the previous studies used the amount and duration of spouse's smoking as the measure of exposure to passive inhalation . Focus on the spouse's smokin; may fail to provide an adequate measure of the subject's exposure for a number of reasons : (1) a subject's actual exposure depends on how much time the smoking spouse smokes in his or her immediate presence ; the spouse could be a heavy smoker but spend very little time at home ; (2) in addition to the current spouse's smoking habits, those of former spouses may be equally important; (3) the subject may live with other relatives who smoke ; (4) exposure to tobacco smoke at work can be a substantial proportion of a person's exposure ; (5) exposure in cYSS, tommuter trains, buses, and in other situations, such as restaurants, movie theaters, etc, eould be sitnificxnt It is for these reasons that we have recently revised our questionnaire to include detailed questions which will give a more complete picture of the subject's exposure, both in respect to diffcrent environmental aettings and to duration of exposure for each specific component . If passive inhalation in nonsmokers is associated with increased lung cancer risk, by what mechanism does it exen its effect? Since adenocarcinoma is the most common histologic type of lung cancer in nonsmokers, one could hypothesize that inhaled sidesttram smoke increases
, 1220 GNCER March 1 1984 TaaLE 4 . Summary of Studia of the Rolc of Rsssslve Inhatation in Lung Canccr in NonSmoken Author/ type of siudy/ population No of asss Histology Hiryyama (t9a1 174 datlu in marncd Out of a sampk of 23 aaes_ fropecu .t/ r«oaxnoicia` .roenen 17 were adenoarrieoma lap.nesc w/)unb a amonj twnsmo k i n6 9 I .340 nonszrtokt nt ..iva atKd 40+ wrr+ed +oomen yClan Garfinkel (19{l)" 195 daths from lung a Analytis oa dlta among male from two twnsmokers: 56A pxospmtve daths from lung a txudies/ACS among female population and tsonamolcen (ACS) : Dom study of 168 lung a deaths vetersns" among nonsmokers (Dorn) http://legacy.library.ucsf.edu/tid/wyk81f00/pdf Histdots SC . Ho HC, lronthial aaar in the risk for this type. Volatile components of cigarette smoke, including volatile nitrasamines, are more likely than respirable particulate nutter to reach the periphery of the lung . Current 6ndings suggest most lesions in nonsmokers are located in the deeper portions of the lung . Nonsmokers exposed to ciprette smoke in enclosed spaca are reported to have increased levels of carbon monoxide in their blood,"2s which su=esu that other F'indinfs A dae-rssyonae esiatiooshtp .as aten herwven the iocttmoking wivts' titah aad ahe kustxnds' amokirtr Mab(t wives of tatenoktn or of 1-19 dss/day-unokers bad RR - 1 .61 : Wi .a ot unoken of a20 eies/day had RR •2.0b No aigni6cant iactsax in lun/aftskfeenin aasnmokinb wi .es of amoking husbands compared with aonsmokintt wlvss of monsmokink hustxnds RR of lung a associnted w/ Mayin= a husb.nd who nrtsokes 1 pock/day wu ) .4 . (xt for linear trend • 6 .45 : P < 0.021 Amon4 t+onsmokins women the prnponton of ases whwe >tpouae tunoked was slightl,v krwer than that o(contro(s (34 of 64 or40 .S1,n66of139or 47 .3%). Among aonsmokin ; women . there was no aqnificant diRettnce in the proponion of ases who wed kernoene fueltn Cookin; compared with tontzols Hotit Kong 1976-1977, Ir J Csnct* 1979 : I9 :1t2-t92 . Commenu Exposurc tadcx was, based oa tmok nt hab+u of husband : Exposure index wu duad on smok nt habtts of husbanG . Exposurc tnbex was brxd od unottn4 ha.biu of kusMnds and former husbands It is uncku what quesuon .as uied feprdins inhatauon since in an earlier p.peY . the quesuon it pren at'Art you exposed to the tob.eeo smoke of oehen u Mome or at wo .k?' ; whCrru here reference is madc only to -smoktnt Mabiu of spouus " No tnformauan ts yven on how many sub~etta wors tturned N volatile components could reach the lunii . It would be C important to know in this regard whether the loation o!n lesions in the lungs of nonsmoking lung cancer cascs with C4 exposure to passive inhalation differs from that amone(Z smokers. ' CA In addition to the etiologic factors discussed in this}A artick, other possible explanations of the occurrence ofCA lung cancer in nonsmokers should also be considered .0 W
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