Bladder Cancer and Water Disinfection By-product Exposures through Multiple Routes: A Population-Based Case-Control Study (New England, USA).

BACKGROUND: Ingestion of disinfection byproducts has been associated with bladder cancer in multiple studies. Although associations with other routes of exposure have been suggested, epidemiologic evidence is limited. OBJECTIVES: We evaluated the relationship between bladder cancer and total, chlorinated, and brominated trihalomethanes (THMs) through various exposure routes. METHODS: In a population-based case­control study in New England (n=(1,213) cases; n=(1,418) controls), we estimated lifetime exposure to THMs from ingestion, showering/bathing, and hours of swimming pool use. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using unconditional logistic regression adjusted for confounders. RESULTS: Adjusted ORs for bladder cancer comparing participants with exposure above the 95th percentile with those in the lowest quartile of exposure (based on the distribution in controls) were statistically significant for average daily intake mg/d of total THMs [OR=1.53 (95% CI: 1.01, 2.32), p-trend=0.16] and brominated THMs [OR=1.98 (95% CI: 1.19, 3.29), p-trend=0.03]. For cumulative intake mg, the OR at the 95th percentile of total THMs was 1.45 (95% CI: 0.95, 2.2), p-trend=0.13; the ORs at the 95th percentile for chlorinated and brominated THMs were 1.77 (95% CI: 1.05, 2,.99), p-trend=0.07 and 1.78 (95% CI: 1.05, 3.00), p-trend=0.02, respectively. The OR in the highest category of showering/bathing for brominated THMs was 1.43 (95% CI: 0.80, 2.42), p-trend=0.10. We found no evidence of an association for bladder cancer and hours of swimming pool use. CONCLUSIONS: We observed a modest association between ingestion of water with higher THMs (>95th percentile vs.<25th percentile) and bladder cancer. Brominated THMs have been a particular concern based on toxicologic evidence, and our suggestive findings for multiple metrics require further study in a population with higher levels of these exposures. Data from this population do not support an association between swimming pool use and bladder cancer. https://doi.org/10.1289/EHP89.

The role of public policies in reducing smoking prevalence: results from the Michigan SimSmoke tobacco policy simulation model.

INTRODUCTION: Michigan has implemented several of the tobacco control policies recommended by the World Health Organization MPOWER goals. We consider the effect of those policies and additional policies consistent with MPOWER goals on smoking prevalence and smoking-attributable deaths (SADs). METHODS: The SimSmoke tobacco control policy simulation model is used to examine the effect of past policies and a set of additional policies to meet the MPOWER goals. The model is adapted to Michigan using state population, smoking, and policy data starting in 1993. SADs are estimated using standard attribution methods. Upon validating the model, SimSmoke is used to distinguish the effect of policies implemented since 1993 against a counterfactual with policies kept at their 1993 levels. The model is then used to project the effect of implementing stronger policies beginning in 2014. RESULTS: SimSmoke predicts smoking prevalence accurately between 1993 and 2010. Since 1993, a relative reduction in smoking rates of 22 % by 2013 and of 30 % by 2054 can be attributed to tobacco control policies. Of the 22 % reduction, 44 % is due to taxes, 28 % to smoke-free air laws, 26 % to cessation treatment policies, and 2 % to youth access. Moreover, 234,000 SADs are projected to be averted by 2054. With additional policies consistent with MPOWER goals, the model projects that, by 2054, smoking prevalence can be further reduced by 17 % with 80,000 deaths averted relative to the absence of those policies. CONCLUSIONS: Michigan SimSmoke shows that tobacco control policies, including cigarette taxes, smoke-free air laws, and cessation treatment policies, have substantially reduced smoking and SADs. Higher taxes, strong mass media campaigns, and cessation treatment policies would further reduce smoking prevalence and SADs.

Randomized noninferiority trial of telephone versus in-person genetic counseling for hereditary breast and ovarian cancer.

PURPOSE: Although guidelines recommend in-person counseling before BRCA1/BRCA2 gene testing, genetic counseling is increasingly offered by telephone. As genomic testing becomes more common, evaluating alternative delivery approaches becomes increasingly salient. We tested whether telephone delivery of BRCA1/2 genetic counseling was noninferior to in-person delivery. PATIENTS AND METHODS: Participants (women age 21 to 85 years who did not have newly diagnosed or metastatic cancer and lived within a study site catchment area) were randomly assigned to usual care (UC; n = 334) or telephone counseling (TC; n = 335). UC participants received in-person pre- and post-test counseling; TC participants completed all counseling by telephone. Primary outcomes were knowledge, satisfaction, decision conflict, distress, and quality of life; secondary outcomes were equivalence of BRCA1/2 test uptake and costs of delivering TC versus UC. RESULTS: TC was noninferior to UC on all primary outcomes. At 2 weeks after pretest counseling, knowledge (d = 0.03; lower bound of 97.5% CI, -0.61), perceived stress (d = -0.12; upper bound of 97.5% CI, 0.21), and satisfaction (d = -0.16; lower bound of 97.5% CI, -0.70) had group differences and confidence intervals that did not cross their 1-point noninferiority limits. Decision conflict (d = 1.1; upper bound of 97.5% CI, 3.3) and cancer distress (d = -1.6; upper bound of 97.5% CI, 0.27) did not cross their 4-point noninferiority limit. Results were comparable at 3 months. TC was not equivalent to UC on BRCA1/2 test uptake (UC, 90.1%; TC, 84.2%). TC yielded cost savings of $114 per patient. CONCLUSION: Genetic counseling can be effectively and efficiently delivered via telephone to increase access and decrease costs.

The benefits from complying with the framework convention on tobacco control: a SimSmoke analysis of 15 European nations.

INTRODUCTION: This article compares the predicted impact of tobacco tax increases alone and as part of a comprehensive tobacco control strategy on smoking prevalence and smoking-attributable deaths (SADs) across 15 European countries. METHODS: Country-specific population, smoking prevalence and policy data with modified parameter values have been applied to the previously validated SimSmoke model for 10 high-income and 5 middle-income European nations. The impact of past and potential future policies is modelled. RESULTS: Models generally validated well across the 15 countries, and showed the impact of past policies. Without stronger future policies, 44 million lives would be lost due to smoking across the 15 study countries between 2011 and 2040, but effective policies could avert 7.7 million of those premature deaths. CONCLUSIONS: Results suggest that past policies have been effective in reducing smoking rates, but there is also a strong potential for future policies consistent with the Framework Convention on Tobacco Control. When specific taxes are increased to 70% of retail price, strong smoke-free air laws, youth access laws and marketing restrictions are enforced, stronger health warnings are implemented, and cessation treatment and media campaigns are supported, smoking prevalence and SADs will fall substantially in European countries.

Russia SimSmoke: the long-term effects of tobacco control policies on smoking prevalence and smoking-attributable deaths in Russia.

BACKGROUND: Russia has high smoking rates and weak tobacco control policies. A simulation model is used to examine the effect of tobacco control policies on past and future smoking prevalence and premature mortality in Russia. METHODS: The Russia model was developed using the SimSmoke tobacco control model previously developed for the USA and other nations. The model inputs population size, birth, death and smoking rates specific to Russia. It assesses, individually and in combination, the effect of seven types of policies consistent with the WHO Framework Convention on Tobacco Control (FCTC): taxes, smoke-free air, mass media campaign, advertising bans, warning labels, cessation treatment and youth access policies. Outcomes are smoking prevalence and the number of smoking-attributable deaths by age and gender from 2009 to 2055. RESULTS: Increasing cigarette taxes to 70% of retail price, stronger smoke-free air laws, a high-intensity media campaign and comprehensive treatment policies are each potent policies to reduce smoking prevalence and smoking-attributable premature deaths in Russia. With the stronger set of policies, the model estimates that, relative to the status quo trend, smoking prevalence can be reduced by as much as 30% by 2020, with a 50% reduction projected by 2055. This translates into 2 684 994 male and 1 011 985 female premature deaths averted from 2015-2055. CONCLUSIONS: SimSmoke results highlight the relative contribution of policies to reducing the tobacco health burden in Russia. Significant inroads to reducing smoking prevalence and premature mortality can be achieved through strengthening tobacco control policies in line with FCTC recommendations.

Smoking-related deaths averted due to three years of policy progress.

OBJECTIVE: To evaluate the global impact of adopting highest-level MPOWER tobacco control policies in different countries and territories from 2007 to 2010. METHODS: Policy effect sizes based on previously-validated SimSmoke models were applied to determine the reduction in the number of smokers as a result of policy adoption during this period. Based on previous research suggesting that half of all smokers die from smoking, we also derived the estimated smoking-attributable deaths (SADs) averted due to MPOWER policy implementation. The results from use of this simple yet powerful method are consistent with those predicted by using previously validated SimSmoke models. FINDINGS: In total, 41 countries adopted at least one highest-level MPOWER policy between 2007 and 2010. As a result of all policies adopted during this period, the number of smokers is estimated to have dropped by 14.8 million, with a total of 7.4 million SADs averted. The largest number of SADs was averted as a result of increased cigarette taxes (3.5 million), smoke-free air laws (2.5 million), health warnings (700,000), cessation treatments (380,000), and bans on tobacco marketing (306,000). CONCLUSION: From 2007 to 2010, 41 countries and territories took action that will collectively prevent nearly 7.5 million smoking-related deaths globally. These findings demonstrate the magnitude of the actions already taken by countries and underscore the potential for millions of additional lives to be saved with continued adoption of MPOWER policies.

Which strategies reduce breast cancer mortality most? Collaborative modeling of optimal screening, treatment, and obesity prevention.

BACKGROUND: US breast cancer mortality is declining, but thousands of women still die each year. METHODS: Two established simulation models examine 6 strategies that include increased screening and/or treatment or elimination of obesity versus continuation of current patterns. The models use common national data on incidence and obesity prevalence, competing causes of death, mammography characteristics, treatment effects, and survival/cure. Parameters are modified based on obesity (defined as BMI ≥ 30 kg/m(2) ). Outcomes are presented for the year 2025 among women aged 25+ and include numbers of cases, deaths, mammograms and false-positives; age-adjusted incidence and mortality; breast cancer mortality reduction and deaths averted; and probability of dying of breast cancer. RESULTS: If current patterns continue, the models project that there would be about 50,100-57,400 (range across models) annual breast cancer deaths in 2025. If 90% of women were screened annually from ages 40 to 54 and biennially from ages 55 to 99 (or death), then 5100-6100 fewer deaths would occur versus current patterns, but incidence, mammograms, and false-positives would increase. If all women received the indicated systemic treatment (with no screening change), then 11,400-14,500 more deaths would be averted versus current patterns, but increased toxicity could occur. If 100% received screening plus indicated therapy, there would be 18,100-20,400 fewer deaths. Eliminating obesity yields 3300-5700 fewer breast cancer deaths versus continuation of current obesity levels. CONCLUSIONS: Maximal reductions in breast cancer deaths could be achieved through optimizing treatment use, followed by increasing screening use and obesity prevention.

Estimating water supply arsenic levels in the New England Bladder Cancer Study.

BACKGROUND: Ingestion of inorganic arsenic in drinking water is recognized as a cause of bladder cancer when levels are relatively high (≥ 150 µg/L). The epidemiologic evidence is less clear at the low-to-moderate concentrations typically observed in the United States. Accurate retrospective exposure assessment over a long time period is a major challenge in conducting epidemiologic studies of environmental factors and diseases with long latency, such as cancer. OBJECTIVE: We estimated arsenic concentrations in the water supplies of 2,611 participants in a population-based case-control study in northern New England. METHODS: Estimates covered the lifetimes of most study participants and were based on a combination of arsenic measurements at the homes of the participants and statistical modeling of arsenic concentrations in the water supply of both past and current homes. We assigned a residential water supply arsenic concentration for 165,138 (95%) of the total 173,361 lifetime exposure years (EYs) and a workplace water supply arsenic level for 85,195 EYs (86% of reported occupational years). RESULTS: Three methods accounted for 93% of the residential estimates of arsenic concentration: direct measurement of water samples (27%; median, 0.3 µg/L; range, 0.1-11.5), statistical models of water utility measurement data (49%; median, 0.4 µg/L; range, 0.3-3.3), and statistical models of arsenic concentrations in wells using aquifers in New England (17%; median, 1.6 µg/L; range, 0.6-22.4). CONCLUSIONS: We used a different validation procedure for each of the three methods, and found our estimated levels to be comparable with available measured concentrations. This methodology allowed us to calculate potential drinking water exposure over long periods.

Sorption of trihalomethanes in foods.

Trihalomethanes (THMs, namely, CHCl(3), CHCl(2)Br, CHClBr(2) and CHBr(3)) are disinfection by-products that are present in drinking water. These toxic chemicals are also present in meat, dairy products, vegetables, baked goods, beverages and other foods, although information regarding their concentrations and origin is very limited. This study investigates sorption of THMs occurring during rinsing and cooking of foods and the significance of food as an exposure source. Initial estimates of THM uptake were measured in experiments representing rinsing with tap water at 25 C using nine types of food, and for cooking in tap water at 90 C for fourteen other foods. A subset of foods was then selected for further study over a range of THM concentrations (23.7-118.7 microg/l), temperatures (25 C and 90 C), food concentrations (0.2-1.4, food weight: water weight), and contact times (5-240 min). Data were analyzed using regression and exponential models, and diffusion models were used to help explain the trends of THM uptake. Among vegetables, sorbed THM concentrations at 25 C were 213 to 774 ng/g for CHCl(3), 53 to 609 ng/g for CHCl(2)Br, and 150-845 ng/g for CHClBr(2). Meats at 90 C tended to have higher concentrations, e.g., 870-2634 ng/g for CHCl(3). Sorbed concentrations increased with contact time and THM concentration, and decreased with food concentration in rinsing tests (using spinach, iceberg-head lettuce and cauliflower) and cooking tests (using tomato, potato, beef and miso-tofu soup). For most foods, THM uptake was diffusion limited and several hours were needed to approach steady-state levels. Swelling, hydrolysis and other physical and chemical changes in the food can significantly affect sorption. Screening level estimates for CHCl(3) exposures, based on experimental results and typical food consumption patterns, show that uptake via foods can dominate that due to direct tap water consumption, suggesting the importance of sorption and the need for further evaluation of THM intake due to foods.

Bladder cancer and reproductive factors among women in Spain.

Hormonal factors, possibly related to reproductive characteristics, may play a role in the risk of bladder cancer among women. To study this, we investigated the effects of reproductive factors on female bladder cancer risk. Information on reproductive and other risk factors was gathered in personal interviews from 152 female cases and 166 matched controls from 18 hospitals in five regions of Spain during 1998­2001. Logistic regression was used to estimate the association between bladder cancer and reproductive factors, including ever-parous status, age at first live birth, age at last live birth, age at menarche, age at menopause, menopausal status, and duration of menstruation. After adjustment for age, smoking, and high-risk occupation, ever-parous women were at decreased risk relative to nulliparous women (odds ratio = 0.43, 95% confidence interval = 0.21­0.87). There was no consistent pattern in risk with the age- or duration-related reproductive factors (e.g., age at first live birth, age at last live birth, age at menarche, age at menopause, menopausal status, and duration of menstruation) that we evaluated. Women have a lower risk of bladder cancer than men, and hormonal factors related to childbearing may play a role.