Summary of avoidable cancers in the Nordic countries

An overview is given of the most important known causes of cancer in the five Nordic countries and the resulting number of cancers that are potentially avoidable. The main causes include active and passive smoking, alcohol consumption, exposure to asbestos and other occupational carcinogens, solar and ionizing radiation, obesity, human papillomavirus infection in the female genital tract and infection with Helicobacter pylori. The organs most commonly affected are those of the respiratory system, the upper digestive tract and stomach, skin, the lower urinary tract and the uterine cervix. Annually, more than 18,000 cancers in men and 11,000 in women in the Nordic populations could be avoided by eliminating exposure to known carcinogens which is equivalent to 33% and 20% of all cancers arising in men and women, respectively, around the year 2000. Smoking habits account for a little more than half of these avoidable cases. Estimates of avoidable cancers are given for each Nordic country, separately.

Survival of breast cancer patients in Lithuania and Norway, 1988-1992

In Norway, the incidence of breast cancer is almost twice that in Lithuania, whereas the mortality rates of the disease are approximately the same in both countries. The aim of the present study was to compare the survival of breast cancer patients in the two countries according to stage. The material from both countries included cases diagnosed between 1988 and 1992 with complete follow-up of date of death to the end of 1995. The Norwegian data consisted of all 9403 new cases recorded by the Norwegian Cancer Registry. The Lithuanian data included in all 1649 new cases treated at the Oncology Centre in Vilnius, which represents 40% of breast cancer cases in Lithuania--these cases had the same distribution of the disease by age and stage as for the whole country. The overall 5-year relative survival was lower in Lithuania (57.3%) than in Norway (78.4%). Lower survival was observed in Lithuania compared with Norway for all stages. In stage I, the difference was 7.8% in absolute terms which could be explained by a higher proportion of small tumours among the Norwegian cancer cases (63.7% of tumours were 2 cm or less, while in Lithuania the proportion of small stage I tumours was only 27.9%). Therefore, early diagnosis within the stage I category seems relevant. The difference in survival was, however, most pronounced in stage II (20%) and III (29%). In Norway, the better overall survival is partly explained by a more favourable stage distribution. The lower survival of Lithuanian cases within stage categories could be explained by more advanced metastases to regional lymph nodes and by higher proportions of large tumours within stage.

The role of alcohol, tobacco, and dietary factors in upper aerogastric tract cancers: a prospective study of 10,900 Norwegian men

Previous knowledge on risk factors for oral, pharyngeal, laryngeal, and esophageal cancer has been based mainly on case-control studies. In the present study, the impact of alcohol consumption, tobacco smoking, and dietary factors on upper aerogastric tract cancer risk was studied in a cohort of 10,960 Norwegian men followed from 1968 through 1992, in which period a total of 71 upper aerogastric tract cancers occurred. The relative risk (RR) of cancer was 3.9 (95 percent confidence interval [CI] = 2.1-7.1) for the highest consumption group of alcohol and 4.7 (CI = 1.7-13.2) for the highest smoking level, compared with the respective reference groups. Among the dietary items, high consumption of oranges was associated with reduced cancer risk (RR = 0.5, CI = 0.3-1.0), as was high consumption of bread (RR = 0.2, CI = 0.1-0.5). Frequent consumption of beef and bacon increased relative cancer risk bordering on significance. The present results are largely in accordance with previous studies. The decreased risk associated with a high intake of bread deserves further investigation.

Intratumoral differences in methotrexate levels within human osteosarcoma xenografts studied by microdialysis

A central tenet in oncology is the assumed relationship between drug concentration and cytotoxicity. Determinations of drug levels in tumor tissues are, however, generally not undertaken. Microdialysis is a method where continuous drug monitoring may be achieved by sampling of low molecular weight substances from the extracellular space. By employing this technique it is possible to observe variable drug levels within tissues, including tumors, over time. Herein, we present results from a nude rat model where subcutaneous human osteosarcoma xenografts were established prior to the administration of the antifolate methotrexate as an intravenous infusion. Significant differences in drug exposure within single tumors were evident. Generally, peak drug concentrations were lower and drug efflux slower from the center of the tumors as compared to the periphery. The use of microdialysis could be an important tool for optimizing current strategies in anticancer chemotherapy.

Effects of 3-deazaadenosine on apoptosis-related gene transcripts in HL-60 cells

The effect of the transmethylation inhibitor 3-deazaadenosine on transcription levels of genes associated with apoptosis was investigated in HL-60 cells. After incubation of HL-60 cells with 100 microM 3-deazaadenosine for 45 min., a schedule known to perturb transmethylation metabolites and initiate apoptosis in these cells, a 50% decrease in c-myc and a 50% increase in bcl-2 RNA steady-state levels compared to control cells were observed. Transcription levels of c-myc continued to decrease after extended exposure to 3-deazaadenosine, while bcl-2 mRNA levels dropped to 25% and 30% below those in control cells after 1.5 hr and 3 hr, respectively. The expression levels of the bcl-2 related bax gene, showed a similar pattern as bcl-2; a 60% increase was initially measured, but after 1.5 and 3 hr, bax transcripts were 80% and 70% respectively, of those found in untreated cells. Another bcl-2 related gene, bcl-x, was previously reported to generate two transcripts in human cells. The long variant bcl-x1 acts as bcl-2, while the short form bcl-xs induces apoptosis. We were unable to detect bcl-xs transcripts in untreated and 3-deazaadenosine treated cells by the highly sensitive reverse transcriptase polymerase chain reaction method. This suggests that this gene product may not be involved in 3-deazaadenosine induced apoptosis in HL-60 cells. Bcl-x1 mRNA levels, however, slowly decreased with about 50% after 1.5 or 3 hr 3-deazaadenosine treatment. It is concluded that 3-deazaadenosine initiated apoptosis affects c-myc, bcl-2, bax and bcl-x1 mRNA levels.

Comparison of information on occupation and lifestyle habits obtained from European man-made vitreous fibre production workers and their relatives

BACKGROUND

Studies of the aetiology of fatal diseases often rely on data obtained from relatives, which can cause loss of precision and introduce bias. We assessed the quality of such information on demographics, occupation, smoking and alcohol habits.

METHODS

We compared contemporary interviews, based on a structured questionnaire, with male workers from the man-made vitreous fibre production industry in four European countries and their relatives. The participation rate was 63% (74 pairs of workers and relatives).

RESULTS

Only minor differences in the ability to answer the questions appeared among workers and relatives, except for specific occupational questions. There was moderate to excellent agreement for demographics, residential and work history (kappa or intraclass correlation range: 0.44-0.98). For smoking habits, beer and wine consumption the agreement was good to excellent (range: 0.59-0.99). In particular, number of different residential areas, jobs, industries, and duration of wine drinking were significantly underreported by the relatives. No general determinant for reduced agreement appeared.

CONCLUSIONS

In general, the quality of information obtained from relatives appeared good. However, information on specific occupational exposures may be improved by supplementing the information from relatives with details obtained from colleagues, occupational hygiene experts or occupation-exposure matrices.

Birth defects among offspring of Norwegian farmers, 1967-1991

We investigated birth defects (N = 4,565) reported to the Medical Birth Registry of Norway among 192,417 births between 1967 and 1991 to parents identified as farmers in five agricultural and horticultural censuses between 1969 and 1989. The prevalences at birth of all and specific birth defects deviated little from those among 61,351 births to non-farmers in agricultural municipalities. We classified exposure indicators on the basis of information provided at the agricultural censuses. The main hypotheses were that parental exposure to pesticides was associated with defects of the central nervous system, orofacial clefts, some male genital defects, and limb reduction defects. We found moderate increases in risk for spina bifida and hydrocephaly, the associations being strongest for exposure to pesticides in orchards or greenhouses [spina bifida: 5 exposed cases, odds ratio (OR) = 2.76, 95% confidence interval (CI) = 1.07-7.13; hydrocephaly: 5 exposed cases, OR = 3.49, 95% CI = 1.34-9.09]. Exposure to pesticides, in particular in grain farming, was also associated with limb reduction defects (OR = 2.50; 95% CI = 1.06-5.90). We also saw an association with pesticides for cryptorchism and hypospadias. We found less striking associations for other specific defects and pesticide indicators, animal farming, and fertilizer regimens.

Gestational age, birth weight, and perinatal death among births to Norwegian farmers, 1967-1991

Perinatal health was investigated by linkage with the Medical Birth Registry of Norway for 192,417 births that took place between 1967 and 1991 among parents identified as farm holders in Norwegian agricultural censuses in 1969-1989. In a comparison with 61,351 births to nonfarmers in agricultural municipalities, farmers' births had an advantageous distribution of gestational ages and birth weights. Perinatal mortality was similar in the two groups, but the proportion of late-term abortions (gestational weeks 16-27) was higher among farmers' birth (odds ratio (OR) = 1.9, 95% confidence interval (CI) 1.6-2.3). Exposure indicators were classified on the basis of information given in the agricultural censuses and climate data for the grain harvest seasons of 1966-1991. The main hypotheses were that perinatal death is associated with parental exposure to pesticides. Toxoplasma contracted from infected sheep or pigs, or mycotoxins found in grain farming. There was no convincing evidence that perinatal death is associated with use of pesticides, sheep farming, or pig farming. The increase in late-term abortion among the farmers could to some extent be attributed to an excess of midpregnancy (weeks 21-24) deliveries among grain farmers; grain farmers had 132 deliveries at this time in pregnancy (2.8 per 1,000 pregnancies), while the nongrain farmers had 236 deliveries in midpregnancy (1.8 per 1,000). The authors found odds ratios (95% CI) that indicated that grain farming risk was higher after the harvest (1.8, 1.1-2.8), in seasons with a poor quality harvest (2.4, 1.5-3.8), and in pregnancies with multiple births (3.8, 1.7-8.2). These results support the hypothesis that occupational exposure to mycotoxins in grain induces labor at an early stage of pregnancy.

Provocative appeals in anti-smoking mass media campaigns targeting adolescents--the accumulated effect of multiple exposures

This paper reports findings from a longitudinal study that evaluated the accumulated effect of three consecutive mass media campaigns using provocative and dissonance arousing appeals to prevent cigarette smoking by adolescents. In the spring of 1992, all eligible adolescents aged 14 and 15 in one intervention county (N = 4898) and one control county (N = 5439) in Norway were included in the study, and were followed until they were 17 and 18 years of age in 1995. Only students who completed questionnaires both in 1992 and 1995 were included in the analyses. Among the non-smokers at baseline, a significantly lower proportion of adolescents of both genders had started to smoke in the intervention county compared to the proportion in the control county. Among those who were smokers at baseline, significantly more girls in the intervention county had stopped smoking than in the control county, while no significant difference between the counties was detected among boys. Our findings suggest that provocative and dissonance arousing appeals that create affective reactions and lead to interpersonal communication should be given more attention in campaigns designed to influence adolescent smoking. However, such appeals may easily produce negative reactions and the normative context should be thoroughly considered when using such appeals in future interventions.

Cancer mortality among man-made vitreous fiber production workers

We have updated the follow-up of cancer mortality for a cohort study of man-made vitreous fiber production workers from Denmark, Finland, Norway, Sweden, United Kingdom, Germany, and Italy, from 1982 to 1990. In the mortality analysis, 22,002 production workers contributed 489,551 person-years, during which there were 4,521 deaths. Workers with less than 1 year of employment had an increased mortality [standardized mortality ratio (SMR) = 1.45; 95% confidence interval (CI) = 1.37-1.53]. Workers with 1 year or more of employment, contributing 65% of person-years, had an SMR of 1.05 (95% CI = 1.02-1.09). The SMR for lung cancer was 1.34 (95% CI = 1.08-1.63, 97 deaths) among rock/slag wool workers and 1.27 (95% CI = 1.07-1.50, 140 deaths) among glass wool workers. In the latter group, no increase was present when local mortality rates were used. Among rock/slag wool workers, the risk of lung cancer increased with time-since-first-employment and duration of employment. The trend in lung cancer mortality according to technologic phase at first employment was less marked than in the previous follow-up. We obtained similar results from a Poisson regression analysis limited to rock/slag wool workers. Five deaths from pleural mesothelioma were reported, which may not represent an excess. There was no apparent excess for other categories of neoplasm. Tobacco smoking and other factors linked to social class, as well as exposures in other industries, appear unlikely to explain the whole increase in lung cancer mortality among rock/slag wool workers. Limited data on other agents do not indicate an important role of asbestos, slag, or bitumen. These results are not sufficient to conclude that the increased lung cancer risk is the result of exposure to rock/slag wool; however, insofar as respirable fibers were an important component of the ambient pollution of the working environment, they may have contributed to the increased risk.

Risk of cancer and exposure to gasoline vapors

Until the introduction of self-service around 1970, service station workers in the Nordic countries were exposed to gasoline vapors. Based on measurements reported in the literature, the 8-hour time-weighted average benzene exposure was estimated to be in the range of 0.5-1 mg/m3. We studied the cancer incidence in a cohort of 19,000 service station workers from Denmark, Norway, Sweden, and Finland. They were identified from the 1970 censuses and followed through 20 years, where 1,300 incident cancers were observed. National incidence rates were used for comparison. The incidence was not increased for leukemia (observed = 28, standardized incidence ratio (SIR) = 0.9, 95% confidence interval (CI) 0.6-1.3) not for acute myeloid leukemia (observed = 13, SIR = 1.3, 95% CI 0.7-2.1). The incidence was slightly elevated for kidney cancer observed = 57, SIR = 1.3, 95% CI 1.0-1.7) and for pharyngeal, laryngeal, and lung cancer. A 3.5-fold risk of nasal cancer was found (observed = 12, SIR = 3.5, 95% CI 1.8-6.1). This cohort exposed to gasoline vapors with benzene levels estimated to be 0.5-1 mg/m3 showed no excess risk of leukemia or acute myeloid leukemia, a 30% elevated risk of kidney cancer, and a previously unnoticed risk of nasal cancer.

[Use of occupational disease benefits]

Persons with pleuramesothelioma were studied to find out the share receiving occupational injury benefit from the National Insurance Scheme. This disease, caused by inhaling asbestos, was chosen because it has been estimated that between 70 and 80 per cent of persons with pleuramesothelioma fulfil the criteria for compensation. During the period 1970-93, 662 men and 104 women were recorded as having this disease. Up to June 1996, the National Insurance Administration had considered the cases of only 163 men, and no women. A further 25-30 patients may have filed claims with the local national insurance office. This implies that, overall, maximum one third of those entitled to occupational injury benefit have received it. The fraction would probably be even lower in the case of diseases where the association with occupation is less certain. It is recommended that national disease registries, such as the Cancer Registry, should report possible cases of occupational disease to the National Insurance Administration.

Alterations in methotrexate pharmacokinetics by naproxen in the rat as measured by microdialysis

Reports of a potentially life-threatening interaction between the antifolate methotrexate (MTX) and drugs belonging to the NSAID class instigated a study of MTX pharmacokinetics by a microdialysis technique in the presence and absence of the NSAID naproxen in anesthetized rats. After pretreatment with naproxen, the animals received either 750 or 1,000 mg/kg MTX as a 6 h continuous intravenous infusion. During infusions, microdialysis effluents were obtained from probes situated intravenously, intrahepatically and intrarenally. In all three compartments, time-concentration AUCs for both MTX and its major extracellular metabolite, 7-hydroxymethotrexate (7-OH-MTX), increased about two-fold in the presence of naproxen. The mechanisms responsible for the MTX-NSAID interaction are briefly discussed. The study demonstrate that the microdialysis technique offers a means to investigate pharmacokinetic drug-drug interactions.

Continuous intratumoral microdialysis during high-dose methotrexate therapy in a patient with malignant fibrous histiocytoma of the femur: a case report

We used a microdialysis technique to assay intratumoral methotrexate (MTX) levels during high-dose (12 g/m2 given as a 4-h infusion) therapy in a 43-year-old man with a malignant fibrous histiocytoma in the medial femoral condyle. Additional microdialysis probes were implanted in muscle tissue contralateral to the tumor and in an antecubital vein. Microdialysis was attempted during the initial two high-dose courses, but the two latter probes were removed at the start of the second treatment cycle due to leakage. No attempt to correct for microdialysis recovery was made. The intratumorally localized probe gave reproducible data on tumor MTX exposure of 9.3-14% of unbound systemic MTX. There was a close correlation between tumor and systemic levels for both MTX and its major extracellular metabolite 7-hydroxymethotrexate. Although limited to the study of MTX pharmacokinetics in a single subject, the experiment demonstrates that intratumoral microdialysis may provide data on tumor drug exposure, although of an indirect nature and dependent on the probe characteristics, the flow rate, and, possibly, the time after probe implantation. We propose that the application of microdialysis may prove useful for elucidation of the relationship between local drug exposure and the therapeutic response in normally inaccessible compartments during cancer pharmacotherapy.

Truly late onset of eating disorders: a study of 11 cases averaging 60 years of age at presentation

OBJECTIVE

To study late-onset cases of eating disorders in order to (1) document the occurrence of these cases as truly new onset, even if postmenopausal; (2) to alert clinicians to the category of late-onset eating disorders, especially clinical features and treatment response; (3) to challenge some prevailing assumptions of etiology.

METHODS

Selection of cases of eating disorders with first onset after age 40 that met DSM-IV criteria, by review of eating disorders admissions to three university hospital programs.

RESULTS

Eleven patients, approximately 1% of all cases of eating disorders, had first onset of an eating disorder after age 40 and as late as 77, with an average onset of 56 and clinical presentation at 60 years. They met DSM-IV criteria for all subtypes of eating disorders. In general, concurrent medical and comorbid psychiatric symptoms made recognition and treatment more complex.

DISCUSSION

Truly late-onset cases do occur, challenging etiological theories requiring adolescent age of onset, premenopausal endocrine functioning, or adolescent psychodynamic conflicts. Late-occurring cases, after accurate diagnosis, require an appreciation of psychological themes pertinent to this age group, such as bereavement or unresolved body image issues. Age by itself is no barrier to onset of eating disorders, which may occur whenever self-starvation and/or binge-purge behaviors become entrenched as sustaining behaviors for amelioration of psychodynamic conflicts, mood disorders, or interpersonal distress.

Exposure to nickel compounds and smoking in relation to incidence of lung and nasal cancer among nickel refinery workers

OBJECTIVES

To investigate the relation between occupational hazards among nickel refinery workers and their exposure to different forms of nickel over time and the interaction between smoking and total exposure to nickel.

METHODS

The cohort consisted of 379 workers with first employment 1916-40 and at least three years of employment and 4385 workers with at least one year of employment 1946-83. Data on smoking (ever or never) were available for almost 95% of the cohort. Two analyses were used, indirect standardisation from observed and expected numbers and Poisson regression.

RESULTS

During the follow up 1953-93, 203 new cases of lung cancer were observed v 68 expected (standardised incidence ratio (SIR) 3.0, 95% confidence interval (95% CI) 2.6-3.4) and 32 cases of nasal cancer were observed v 1.8 expected (SIR 18.0, 95% CI 12-25). The Poisson regression analysis showed an excess risk of lung cancer in association with exposure to soluble forms of nickel, with a threefold increase in relative risk (RR) (P < 0.001) and a multiplicative effect of smoking and exposure to nickel. The RRs were 1.1 (95% CI 0.2-5.1) for exposed workers who had never smoked and 5.1 (95% CI 1.3-20.5) for exposed workers who smoked.

CONCLUSION

It is not possible to state with certainty which specific nickel compounds are carcinogenic, but a significant excess risk was found for workers exposed to soluble nickel alone or in combination with other forms of nickel. The present study suggests a multiplicative effect of smoking and nickel exposure.

Exposure to styrene and mortality from nervous system diseases and mental disorders

Chronic low-dose exposure to solvents has been associated in epidemiologic studies with chronic neurotoxicity, but the evidence is not consistent. Styrene causes acute disturbances in the central and peripheral nervous systems. To determine if exposure to styrene may contribute to chronic diseases of the central nervous system, the authors examined mortality from nervous system diseases, mental disorders, and suicide in relation to styrene exposure in an international historical cohort study. The cohort involved 35,443 workers employed during 1945-1991 in the reinforced plastics industry, where high exposures to styrene occur. Indicators of exposure were reconstructed through job histories and environmental and biologic monitoring data. Poisson regression was used for internal comparisons. Mortality from diseases of the central nervous system (27 deaths) increased with time since first exposure, duration of exposure, average level of exposure, and cumulative exposure to styrene. A quadratic model described best the dose-response shape for cumulative exposure and duration of exposure with the highest risks at around 300 ppm-years and 5 years, respectively, and a subsequent decrease in risk in the highest exposure categories. Mortality from epilepsy increased monotonically with all styrene exposure indicators, while associations for degenerative diseases of the central nervous system were generally weaker. Mortality from mental disorders and suicide decreased with increasing duration of exposure and cumulative exposure, while there was no trend with time since first exposure and average exposure to styrene. These findings suggest that, in addition to the known acute effects, exposure to styrene may contribute to chronic diseases of the central nervous system.

Smoking habits and risk of cancers other than lung cancer: 28 years' follow-up of 26,000 Norwegian men and women

The impact of tobacco smoking on lung cancer risk has been investigated thoroughly since the 1950s, but other types of cancer also have been associated with smoking. In the present study, the aim was to explore the variation in risk connected with cigarette, cigar, and pipe smoking of suspected smoking-associated cancers other than lung cancer. Data were obtained from a survey of a random sample of the Norwegian population. A self-administered mailed questionnaire, which included questions about smoking habits, was completed by 26,000 men and women in 1965 (response rate: 76 percent). The cohort was followed from 1966 through 1993, including registration of all incident cancer cases. A dose-response relationship of cigarette smoking to the risk of urinary bladder cancer and cancers of the upper digestive and respiratory tract was observed. For the latter forms of cancer, a dose-response relationship of pipe smoking also was observed. In cancer of the pancreas, a stronger association between cigarette smoking and cancer risk was observed when the analysis was confined to histologically confirmed cases only. Current cigarette smokers at baseline had a significantly higher risk of cervical cancer than those who never smoked cigarettes. In cancers of the stomach, colon, rectum, breast, corpus uteri, ovary, and prostate, and in leukemia, no association between smoking and cancer risk was observed.

Exposure to styrene and mortality from nonmalignant respiratory diseases

A cohort of 34,560 men and 6128 women employed in 660 European factories manufacturing reinforced plastic products, followed up originally to assess the risk of cancer, was used to assess the risk of non-malignant respiratory diseases associated with exposure to styrene. Mortality from pneumonia was associated with intensity of exposure to styrene, but this may have been due to chance. Mortality from bronchitis, emphysema, and asthma was not associated with styrene exposure.

Exposure to styrene and mortality from nonmalignant diseases of the genitourinary system

OBJECTIVES

A historical cohort study was carried out to investigate mortality from nonmalignant diseases of the genitourinary system among workers in the reinforced plastics industry, where high workroom concentrations of styrene are encountered.

METHODS

The external comparisons in this report were based on an average of 12.6 years of retrospective follow-up of 35 443 workers who were first employed in the reinforced plastics industry during 1945-1991 and were known to have been exposed to styrene in their work. For the internal comparisons, 2641 subjects with incomplete occupational histories were excluded, leaving 32 802 subjects. Previous individual exposure histories to styrene were reconstructed through job histories and environmental and biological monitoring data.

RESULTS

Mortality from nonmalignant diseases of the genitourinary system (N = 20) was associated with average exposure to styrene (P for trend 0.05). Weaker increasing trends in risk were seen for time since first exposure and cumulative exposure, while no increase was identified for duration of exposure. There was a significant increasing trend in mortality from nephritis and nephrosis (N = 5), associated with an increasing average level of exposure to styrene (P for trend 0.03). No clear trend was observed for time since first exposure, duration of exposure, or cumulative exposure.

CONCLUSIONS

In this large cohort study of workers exposed to styrene, mortality from nonmalignant diseases of the genitourinary system increased as the average intensity of exposure increased. This finding indicates that other data should be scrutinized.

The impact of smoking habits on lung cancer risk: 28 years' observation of 26,000 Norwegian men and women

While factory-made cigarettes dominate the market in most countries, the use of handrolled cigarettes accounts for a substantial proportion of the tobacco consumption in Norway. In the present study, we examined the impact of tobacco smoking on lung cancer in general, and the effect of handrolled cigarettes in particular. The data used was from a self-administered mailed questionnaire which included questions about smoking habits and which was completed by about 26,000 men and women in 1964-65. During the follow-up from 1966 to 1993, 333 lung cancers in men and 102 in women were registered. The analysis was performed by use of the Cox proportional hazards regression models. A clear dose-response relationship was found both for cigarette smoking, and for pipe smoking (in men). The dose-response relationship of cigarette smoking was seen in all the three histologic groups considered-squamous cell carcinoma, adenocarcinoma, and small cell carcinoma. The highest relative risks were noted in squamous cell and small cell carcinoma. A higher risk of lung cancer was found for cigarette-smoking women who started cigarette smoking before the age of 30 compared with similar groups of men. In a combined analysis of men and women, an elevated relative risk of 1.9 (95 percent confidence interval = 1.2-3.3) was found for those smoking only handrolled cigarettes compared with those smoking factory-made filter cigarettes only.