Intended for healthcare professionals


Lung cancer and passive smoking

BMJ 2000; 321 doi: (Published 11 November 2000) Cite this as: BMJ 2000;321:1221

This article has a correction. Please see:

Turning over the wrong stone

  1. Kenneth C Johnson (, senior epidemiologist,
  2. James Repace (, health physicist
  1. Environmental Risk Assessment and Case Surveillance Division, Cancer Bureau, Laboratory Centre for Disease Control Health Protection Branch Health Canada, Ottawa, Ontario, Canada K1A 0L2
  2. Repace Associates, Secondhand Smoke Consultants, Bowie, MD 20720, USA
  3. Wolfson Institute of Preventive Medicine, Department of Environmental and Preventive Medicine, London EC1M 6BQ
  4. University of California, San Francisco, CA 94143-0130, USA
  5. Manor View Practice, Bushey Health Centre, Bushey WD2 2NN
  6. University of Warwick, Coventry CV4 7AL

    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 …

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