Lung cancer and passive smoking. Turning over the wrong stone.
Year: 2000
Type: letter
Abstract: Editor—In their reanalysis of the epidemiological evidence on lung cancer and smoking Copas and Shi1 assert that after allowing for publication bias the apparent average excess risk of lung cancer from passive smoking2 would drop from 24% to 15%. Despite the lack of supporting data,3 we are asked to believe solely on the basis of statistical inference that such data must be hiding under a stone. They are, however, turning over the wrong stone.
More important than publication bias is the underestimation of risk that occurs when these studies assess exposure solely on the basis of whether non-smokers either lived or did not live with a smoker,2 when other exposure exists.
Where other exposure is common—for example, in childhood, in social situations, or in the workplace—the risk of lung cancer may be seriously underestimated. Spouses of non-smokers exposed in other circumstances will be misclassified as non-exposed, contaminating the referent group, and attenuating the risk estimate. For example, Hackshaw et al estimate that the odds ratio would have been 1.42 (95% confidence interval 1.21 to 1.66) if those with spousal exposure alone were compared with those who were truly unexposed.2 By comparison, in a recent meta-analysis of risk associated with workplace exposure, Wells found an estimated relative risk of 1.39 (1.15 to 1.68) for the five studies meeting basic study quality standards.4 Repace and Lowrey found that when both workplace exposure and an unexposed referent group were taken into account in the American Cancer Society study of passive smoking and lung cancer, a population relative risk of 1.2 increased to 1.7.5
Repace and Lowrey modelled the risk of workplace exposure, estimating the average relative risk at 2.0 for office workers in the United States in the 1980s. This result is consistent with a value reported by Reynolds et al for women with 30 or more years of workplace exposure—namely, at ages at which lung cancer mortality begins to become significant.5
Moreover, all of these analyses focus on average risk. Repace et al estimated that individuals at the 95th centile—for example, those experiencing high smoker density and low air exchange—have an exposure, and a risk, as much as four times as high as those at the median. This result is commensurate with observations of dose5 and risk.2
Turning over stones may indeed alter the estimated risk, but turning over the right stone indicates that in the original meta-analysis, the actual passive smoking-lung cancer risk is underestimated, not overestimated.
Source: PubMed
Authors: K C Johnson, J Repace
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W136731479