Differences in pragmatic communication skills of adults with intellectual disabilities and dual diagnoses.

Introduction: Pragmatics includes a set of skills related to language structure and meaning that allow the speaker to use the language appropriately and in accordance with different communication situations. The aim of this research was to determine the differences in pragmatic communication skills of adults with intellectual disabilities, dual diagnoses, and typical development, and to determine the effects of gender, age, the level of intellectual functioning and speech comprehension on their achievements on two assessment instruments. Methods: The sample included 180 adults (60 typically developing participants, 60 with intellectual disabilities, and 60 participants with dual diagnoses). We used two instruments to assess pragmatic communication skills - Communication Checklist - Adult, CC-A, and the Assessment Battery for Communication, ABaCo. In order to test the differences between the three groups of participants, we used canonical discriminant analysis. Results: Discriminant analysis revealed two significant canonical functions. Function one (speech comprehension and the level of intellectual disability, social engagement, and paralinguistic scale) differentiates between typically developing participants and participants with dual diagnoses the most. The second canonical function (language structure, linguistic scale, paralinguistic scale, extralinguistic scale, and context scale) differentiates between participants with intellectual disabilities and participants with dual diagnoses the most. According to the results, age did not affect pragmatic achievements. Discussion: Pragmatic skills are very complex, and different instruments measure different dimensions of these abilities. The results of this research lead to the conclusion that we can differentiate between the pragmatic abilities of typically developing people, people with intellectual disabilities, and those with dual diagnoses with the help of the ABaCo battery and the CC-A questionnaire.

Exercise-Based Interventions Aimed at Improving Balance in Children with Autism Spectrum Disorder: A Meta-Analysis.

Children with Autism Spectrum Disorder (ASD) often have deficits in motor skills, especially balance. This article presents a meta-analytic review of 15 intervention studies that aimed to improve balance in children and adolescents with ASD. Across these studies, there were 195 participants with ASD for whom pre-intervention and post-intervention balance scores were available. We measured the standardized mean difference (Hedges' g) between their pre-intervention and post-intervention balance scores and found a large, positive effect from these balance interventions (standardized mean difference-1.82 (95% CI [1.34, 2.29]). Various balance intervention procedures were shown to be very efficacious for children and adolescents with ASD. Clearly, balance is a motor skill that is very susceptible to intervention efforts. We also provided recommendations to researchers regarding what information to include when conducting intervention studies.

Visual-Motor Integration in Children With Mild Intellectual Disability: A Meta-Analysis.

Visual-motor integration (VMI) skills, defined as the coordination of fine motor and visual perceptual abilities, are a very good indicator of a child's overall level of functioning. Research has clearly established that children with intellectual disability (ID) have deficits in VMI skills. This article presents a meta-analytic review of 10 research studies involving 652 children with mild ID for which a VMI skills assessment was also available. We measured the standardized mean difference (Hedges' g) between scores on VMI tests of these children with mild ID and either typically developing children's VMI test scores in these studies or normative mean values on VMI tests used by the studies. While mild ID is defined in part by intelligence scores that are two to three standard deviations below those of typically developing children, the standardized mean difference of VMI differences between typically developing children and children with mild ID in this meta-analysis was 1.75 (95% CI [1.11, 2.38]). Thus, the intellectual and adaptive skill deficits of children with mild ID may be greater (perhaps especially due to their abstract and conceptual reasoning deficits) than their relative VMI deficits. We discuss the possible meaning of this relative VMI strength among children with mild ID and suggest that their stronger VMI skills may be a target for intensive academic interventions as a means of attenuating problems in adaptive functioning.

Chemical and toxicological characteristics of conventional and low-TSNA moist snuff tobacco products.

Use of smokeless tobacco products (STPs) is associated with oral cavity cancer and other health risks. Comprehensive analysis for chemical composition and toxicity is needed to compare conventional and newer STPs with lower tobacco-specific nitrosamines (TSNAs) yields. Seven conventional and 12 low-TSNA moist snuff products purchased in the U.S., Sweden, and South Africa were analyzed for 18 chemical constituents (International Agency for Research on Cancer classified carcinogens), pH, nicotine, and free nicotine. Chemicals were compared in each product using Wilcoxon rank-sum test and principle component analysis (PCA). Conventional compared to low-TSNA moist snuff products had higher ammonia, benzo[a]pyrene, cadmium, nickel, nicotine, nitrate, and TSNAs and had lower arsenic in dry weight content and per mg nicotine. Lead and chromium were significantly higher in low-TSNA moist snuff products. PCA showed a clear difference for constituents between conventional and low-TSNA moist snuff products. Differences among products were reduced when considered on a per mg nicotine basis. As one way to contextualize differences in constituent levels, probabilistic lifetime cancer risk was estimated for chemicals included in The University of California's carcinogenic potency database (CPDB). Estimated probabilistic cancer risks were 3.77-fold or 3-fold higher in conventional compared to low-TSNA moist snuff products under dry weight or under per mg nicotine content, respectively. In vitro testing for the STPs indicated low level toxicity and no substantial differences. The comprehensive chemical characterization of both conventional and low-TSNA moist snuff products from this study provides a broader assessment of understanding differences in carcinogenic potential of the products. In addition, the high levels and probabilistic cancer risk estimates for certain chemical constituents of smokeless tobacco products will further inform regulatory decision makers and aid them in their efforts to reduce carcinogen exposure in smokeless tobacco products.

Providing a Science Base for the Evaluation of Tobacco Products.

OBJECTIVE: Evidence-based tobacco regulation requires a comprehensive scientific framework to guide the evaluation of new tobacco products and health-related claims made by product manufacturers. METHODS: The Tobacco Product Assessment Consortium (TobPRAC) employed an iterative process involving consortia investigators, consultants, a workshop of independent scientists and public health experts, and written reviews in order to develop a conceptual framework for evaluating tobacco products. RESULTS: The consortium developed a four-phased framework for the scientific evaluation of tobacco products. The four phases addressed by the framework are: (1) pre-market evaluation, (2) pre-claims evaluation, (3) post-market activities, and (4) monitoring and re-evaluation. For each phase, the framework proposes the use of validated testing procedures that will evaluate potential harms at both the individual and population level. CONCLUSIONS: While the validation of methods for evaluating tobacco products is an ongoing and necessary process, the proposed framework need not wait for fully validated methods to be used in guiding tobacco product regulation today.

NIH electronic cigarette workshop: developing a research agenda.

BACKGROUND: Electronic cigarettes (e-cigarettes) represent an emerging public health issue. These devices deliver nicotine along with other constituents, including flavorants, via an inhalable aerosol. Their uptake is rapidly increasing in both adults and youths, primarily among current smokers. Public debate is increasing on how these devices should be regulated and used, yet only limited peer-reviewed research exists. To develop a informed policy for e-cigarettes, their effects on human behavior, physiology, and health need to be understood. PURPOSE: This paper describes proceedings from a National Institutes of Health-sponsored workshop, which was held in November 2013, to identify research needs related to the effects of e-cigarettes. Discussion topics included e-cigarette risks and abuse potential; the potential role for e-cigarettes in harm reduction and smoking cessation; unintended consequences of e-cigarette use, such as becoming a gateway to conventional cigarettes; and dual use of both e-cigarettes and conventional cigarettes. RESULTS AND CONCLUSIONS: The research needs identified by the workshop participants included the following: standards to measure the contents and emissions of e-cigarettes; biomarkers of exposure; physiological effects of e-cigarettes on tissues and organ systems, including pulmonary and cardiovascular; information on e-cigarette users, how the devices are used, and identification of the best tools to assess these measures; factors that drive use and influence patterns of use; and appropriate methods for evaluating a potential role for e-cigarettes in smoking or nicotine cessation. To understand fully the challenges and the opportunities that e-cigarettes represent, expertise will be needed in basic, behavioral, translational, and clinical sciences.

Non-cigarette tobacco use among women and adverse pregnancy outcomes.

Although cigarette smoking remains the most prevalent form of tobacco use in girls and in women of reproductive age globally, use of non-cigarette forms of tobacco is prevalent or gaining in popularity in many parts of the world, especially in low- and middle-income countries. Sparse but growing evidence suggests that the use of some non-cigarette tobacco products during pregnancy increases the risk of adverse pregnancy outcomes. In this paper we review the literature on the prevalence of non-cigarette tobacco product use in pregnant women and in women of reproductive age in high-, middle-, and low-income countries and the evidence that maternal use of these products during pregnancy has adverse health effects. In addition, we communicate findings from an international group of perinatal and tobacco experts that was convened to establish research priorities concerning the use of non-cigarette tobacco products during pregnancy. The working group concluded that attempts to develop a public health response to non-cigarette tobacco use in women are hindered by a lack of data on the epidemiology of use in many parts of the world and by our limited understanding of the type and magnitude of the health effects of these products. We highlight research gaps and provide recommendations for a global research agenda.

Reconciling human smoking behavior and machine smoking patterns: implications for understanding smoking behavior and the impact on laboratory studies.

BACKGROUND: Recent Food and Drug Administration legislation enables the mandating of product performance standards for cigarette smoke and the evaluation of manufacturers' health claims for modified tobacco products. Laboratory studies used for these evaluations and also for understanding tobacco smoke toxicology use machines to generate smoke. The goal of this review is to critically evaluate methods to assess human smoking behavior and replicate this in the laboratory. METHODS: Smoking behavior and smoking machine studies were identified using PubMed and publicly available databases for internal tobacco company documents. RESULTS: The smoking machine was developed to generate smoke to allow for comparing cigarette tar and nicotine yields. The intent was to infer relative human disease risk, but this concept was flawed because humans tailor their smoking to the product, and chemical yields and toxicologic effects change with different smoking profiles. Although smoking machines also allow for mechanistic assessments of smoking-related diseases, the interpretations also are limited. However, available methods to assess how humans puff could be used to provide better laboratory assessments, but these need to be validated. Separately, the contribution of smoke mouth-holding and inhalation to dose need to be assessed, because these parts of smoking are not captured by the smoking machine. Better comparisons of cigarettes might be done by tailoring human puff profiles to the product based on human studies and comparing results across regimens. CONCLUSIONS: There are major research gaps that limit the use of smoking machine studies for informing tobacco control regulation and mechanistic studies.

Cigarette filter-based assays as proxies for toxicant exposure and smoking behavior--a literature review.

BACKGROUND: Cigarettes are being marketed with filters that differ in composition and design. The filters have different toxicant trapping efficiencies, and smoking stains reflect variations in smoking behavior. Presented herein are the results of a structured literature review that was done to identify cigarette filter-based assays that may serve as proxies for mouth-level exposure and assessing smoking methods. METHODS: A search of the published scientific literature and internal tobacco company documents from 1954 to 2009 was carried out. RESULTS: The literature search identified diverse schemes for assessing cigarette filters, including visual inspection and digital imaging of smoked-stained spent filters, and quantitative determinations for total particulate matter (TPM), nicotine, and solanesol. The results also showed that: (a) there are sufficient data to link filter-based chemical measures to standardized smoking machine-measured yields of tar and nicotine; (b) TPM eluted from filters or in chemical digest of filters can be used to estimate the efficiency of the filter for trapping smoke solids; (c) visual and digital inspection of spent filters is useful in finding indicators of variations in smoking behaviors; and (d) there is a correlation between solanesol and nicotine measured in filters and exposure biomarkers in smokers. CONCLUSIONS: The cigarette filter may prove useful in estimating smoking behaviors such as filter vent blocking and puffing intensity, and may have utility as proxy measures of mouth-level smoke exposure in clinical trials. Additional investigations are needed to compare the different proposed assay schemes and the assay results with measurements of human biomarker assays of smoke exposure.

Evaluation of in vitro assays for assessing the toxicity of cigarette smoke and smokeless tobacco.

BACKGROUND: In vitro toxicology studies of tobacco and tobacco smoke have been used to understand why tobacco use causes cancer and to assess the toxicologic impact of tobacco product design changes. The need for toxicology studies has been heightened given the Food and Drug Administration's newly granted authority over tobacco products for mandating tobacco product performance standards and evaluate manufacturers' health claims about modified tobacco products. The goal of this review is to critically evaluate in vitro toxicology methods related to cancer for assessing tobacco products and to identify related research gaps. METHODS: PubMed database searches were used to identify tobacco-related in vitro toxicology studies published since 1980. Articles published before 1980 with high relevance also were identified. The data were compiled to examine (a) the goals of the study, (b) the methods for collecting test substances, (c) experimental designs, (d) toxicologic end points, and (e) relevance to cancer risk. RESULTS: A variety of in vitro assays are available to assess tobacco smoke that address different modes of action, mostly using non-human cell models. However, smokeless tobacco products perform poorly in these assays. Although reliable as a screening tool for qualitative assessments, the available in vitro assays have been poorly validated for quantitative comparisons of different tobacco products. Assay batteries have not been developed, although they exist for nontobacco assessments. Extrapolating data from in vitro studies to human risks remains hypothetical. CONCLUSIONS: In vitro toxicology methods are useful for screening toxicity, but better methods are needed for today's context of regulation and evaluation of health claims.

Incremental lifetime cancer risks computed for benzo[a]pyrene and two tobacco-specific N-nitrosamines in mainstream cigarette smoke compared with lung cancer risks derived from epidemiologic data.

The manner in which humans smoke cigarettes is an important determinant of smoking risks. Of the few investigators that have predicted cancer risks from smoking on a chemical-specific basis, most used mainstream cigarette smoke (MCS) carcinogen emissions obtained via machine smoking protocols that only approximate human smoking conditions. Here we use data of Djordjevic et al. [Djordjevic, M.V., Stellman, S.D., Zang, E., 2000. Doses of nicotine and lung carcinogens delivered to cigarette smokers. J. Natl. Cancer Inst. 92, 106-111] for MCS emissions of three carcinogens measured under human smoking conditions to compute probability distributions of incremental lifetime cancer risk (ILCR) values using Monte Carlo simulations. The three carcinogens considered are benzo[a]pyrene, N'-nitrosonornicotine (NNN), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). Computed NNK ILCR values were compared with lifetime risks of lung cancer (ILCR(CMD)(obsSigma-lung)) derived from American Cancer Society Cancer Prevention Studies (CPS) I and II. Within the Monte Carlo simulation results, NNK was responsible for the greatest ILCR values for all cancer endpoints: median ILCR values for NNK were approximately 18-fold and 120-fold higher than medians for NNN and benzo[a]pyrene, respectively. For "regular" cigarettes, the NNK median ILCR for lung cancer was lower than ILCR(CMD)(obsSigma-lung) from CPS-I and II by >90-fold for men and >4-fold for women. Given what is known about chemical carcinogens in MCS, this study shows that there is a higher incidence of lung cancer from exposure to MCS than can be predicted with current risk assessment methods using available toxicity and emission data.

Nicotine content and delivery across tobacco products.

Nicotine is the principal alkaloid in both commercial and homemade products (e.g., cigarettes, smokeless tobacco, bidis, waterpipes) followed by nornicotine, anabasine, anatabine, and many other basic substances that contain a cyclic nitrogenous nucleus. Tobacco types, leaf position on the plant, agricultural practices, fertilizer treatment, and degree of ripening are among some prominent factors that determine the levels of alkaloids in tobacco leaf. From a random examination of 152 cultivated varieties of Nicotiana tabacum, a range of alkaloid variation between 0.17 and 4.93% was determined. In fact, every step in tobacco production that affects plant metabolism will influence the level of alkaloid content to a certain degree. Depending on blending recipe, type and amount of additives, and product design, all types of tobacco products contain a very wide range of nicotine concentration. However, the ultimate emission of nicotine to the user, exposure, and psychophar-macological effects depend not only on the content and emission, but also on the relationship between the product and the user.

Monitoring the tobacco use epidemic II: The agent: Current and emerging tobacco products.

OBJECTIVE: This Agent paper (II of V on monitoring the tobacco use epidemic) summarizes the findings and recommendations of the Agent (product) Working Group of the November, 2002, National Tobacco Monitoring, Research and Evaluation Workshop. METHODS: The Agent Working Group evaluated the need to develop new surveillance systems for quantifying ingredients and emissions of tobacco and tobacco smoke and to improve methods to assess uptake and metabolism of these constituents taking into account variability in human smoking behavior. RESULTS: The toxic properties of numerous tobacco and tobacco smoke constituents are well known, yet systematic monitoring of tobacco products has historically been limited to tar, nicotine, and CO in mainstream cigarette smoke using a machine-smoking protocol that does not reflect human smoking behavior. Toxicity of smokeless tobacco products has not been regularly monitored. Tobacco products are constantly changing and untested products are introduced into the marketplace with great frequency, including potential reduced-exposure products (PREPs). The public health impact of new or modified tobacco products is unknown. CONCLUSIONS: Systematic surveillance is recommended for mainstream smoke constituents such as polycyclic aromatic hydrocarbons (PAH), tobacco-specific nitrosamines (TSNA), total and free-base nicotine, volatile organic compounds, aromatic amines, and metals; and design attributes including tobacco blend, additives, and filter ventilation. Research on smoking topography is recommended to help define machine-smoking protocols for monitoring emissions reflective of human smoking behavior. Recommendations are made for marketplace product sampling and for population monitoring of smoking topography, emissions of toxic constituents, biomarkers of exposure and, eventually, risk of tobacco-related diseases.

Effect of delivered dosage of cigarette smoke toxins on the levels of urinary biomarkers of exposure.

Urinary metabolites of tobacco smoke toxins are often used as biomarkers for the evaluation of active and passive exposure to cigarette smoke toxins. In a study of healthy smokers, we investigated concentrations of urinary biomarkers in relation to concentrations of selected toxins in mainstream cigarette smoke as determined by machine smoking of cigarettes in a manner that mimics an individual's smoking behavior (topography). Concentrations of nicotine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone, and benzo(a)pyrene, in mainstream smoke determined under human smoking conditions, and their urinary metabolites cotinine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol, and 1-hydroxypyrene were established for 257 individuals who smoked low-yield (0.1-0.8 mg Federal Trade Commission nicotine/cigarette; mean, 0.66; n = 87), medium-yield (0.9-1.2 mg nicotine/cigarette; mean, 1.1; n = 109), and high-yield cigarettes (nicotine, >1.3 mg nicotine/cigarette; mean, 1.41; n = 61). Levels of urinary metabolites expressed per unit of delivered parent compounds decreased with increased smoke emissions. In smokers of low-, medium-, and high-yield cigarettes, the respective cotinine (ng/mg creatinine)-to-nicotine (mg/d) ratios were 89.4, 77.8, and 57.1 (low versus high; P = 0.06); the 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (pmol/mg creatinine)-to-4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (ng/d) ratios were 0.81, 0.55, and 0.57 (low versus high; P = 0.05); and the 1-hydroxypyrene (pg/mg creatinine)-to-benzo(a)pyrene (ng/d) ratios were 1.55, 1.13, and 0.97 (low versus high; P = 0.008). Similarly, means of cotinine per unit of delivered nicotine in smokers who consumed <20 cigarettes per day was 3.5-fold higher than in those who smoked >20 cigarettes per day. Likewise, a negative correlation was observed between cotinine-to-nicotine ratios and delivered doses of nicotine in subgroups of smokers who used the identical brand of cigarette, namely a filter tip-vented Marlboro (r = -0.59), which is a popular brand among Euro-Americans, and Newport (r = -0.37), a menthol-flavored cigarette without filter tip vents that is preferred by African-Americans. Thus, the intensity of the exposures significantly affects the levels of urinary biomarkers of exposure and should be taken into account in the evaluation of human exposure to cigarette smoke toxins.

Gender differences relative to smoking behavior and emissions of toxins from mainstream cigarette smoke.

This study examined whether gender differences exist in the exposure to select mainstream cigarette smoke toxins as a result of differences in smoking behavior or type of cigarettes smoked among 129 female and 128 male smokers. Smoking topography data indicated that, compared with men, women took smaller puffs (37.6 ml/puff vs. 45.8 ml/puff; p = .0001) of shorter duration (1.33 s/puff vs. 1.48 s/puff; p = .002) but drew more puffs per cigarette (13.5 vs. 12.0; p = .001) and left longer butts (36.3 mm or 40.2% of cigarette length vs. 34.3 mm or 39.2% of cigarette length; p = .01). These trends were similar in both African Americans and European Americans. The emissions of select toxins per cigarette, as determined by mimicking human smoking behaviors were greater among the male smokers than the female smokers and correlated significantly with delivered smoke volume per cigarette. The geometric means of emissions of nicotine from cigarettes were 1.92 mg/cigarette (95% CI = 1.80-2.05) for women versus 2.20 (95% CI = 2.04-2.37) for men (p = .005). Cigarettes smoked by women yielded 139.5 ng/cigarette of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK; 95% CI = 128.8-151.0), compared with 170.3 ng/cigarette (95% CI = 156.3-185.6) for men (p = .0007); benzo(a)pyrene (BaP) emissions were 18.0 ng/cigarette (95% CI = 17.0-19.0) for women and 20.5 ng/cigarette (95% CI = 18.8-22.3) for men (p = .01). The gender differences with regard to cigarette smoke yields of toxins were more profound in European Americans than in African Americans. On average, African American men's smoking habits produced the highest emissions of select toxins from cigarettes, and European American female smokers had the lowest exposure to carcinogens and toxins. Several studies have suggested that women may be more susceptible than men to the ill effects of carcinogens in tobacco and tobacco smoke, whereas other studies have not found differences in lung cancer risk between men and women. The present study suggests that gender differences in exposure to tobacco smoke cannot account for a higher rate of lung cancer in female smokers compared with male smokers.

Racial differences in exposure and glucuronidation of the tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK).

BACKGROUND: In the United States, Blacks who smoke cigarettes have a higher mean blood concentration of the nicotine metabolite cotinine than White smokers. It has not been determined whether there are racial differences in the exposure to the cigarette smoke carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and in the detoxification of NNK metabolites. METHODS: A community-based cross-sectional survey of 69 Black and 93 White smokers was conducted in lower Westchester County, New York. Information on smoking and lifestyle habits was collected and urinary concentrations of several tobacco smoke biomarkers were compared, including the NNK metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and its glucuronide (NNAL-Gluc). A frequency histogram and probit plot of NNAL-Gluc:NNAL ratios were constructed to determine slow and rapid glucuronidation phenotypes. RESULTS: The mean concentrations of total NNAL, urinary cotinine, plasma cotinine, and thiocyanate were significantly higher in Black men than in White men for each cigarette smoked. In women, the only biomarker that was significantly elevated in Blacks was plasma cotinine. A higher proportion of White versus Black women was categorized as "rapid" glucuronidators (two-tailed exact test, P = 0.03). In men, there were no significant differences in NNAL-Gluc:NNAL phenotypes. CONCLUSIONS: The higher rates of lung carcinoma in black men may be due in part to a higher level of exposure to tobacco smoke carcinogens.

Adipose concentrations of organochlorine compounds and breast cancer recurrence in Long Island, New York.

Several studies have measured the association between blood or adipose concentrations of organochlorinated compounds (OCs), such as pesticides and polychlorinated biphenyls (PCBs), and breast cancer. The estrogenic effects of OCs might adversely affect breast cancer recurrence. The participants were 224 women with nonmetastatic breast cancer enrolled in a New York-based case-control study. Supercritical fluid extraction followed by gas chromatography was conducted on adipose surgical specimens to determine OC concentrations. The mean follow-up time from surgery was 3.6 years. Thirty women (13.4%) were diagnosed with a recurrence. The concentration of pesticides and PCBs was correlated with baseline age and body mass index, but not with cancer stage. The highest tertile of total PCB concentration was associated with an increased risk of recurrence [relative risk (RR), 2.9; 95% confidence interval (CI), 1.02-8.2 versus the lowest tertile]. The risk for the highest tertile of the PCB congener Ballschmiter and Zell 118 was 4.0 (95% CI, 1.3-4.9). There was an increased risk for the middle level of the most abundant pesticide, 1,1-dichloro-2,2-di(4-chlorophenyl)ethylene (RR, 2.3; 95% CI, 0.9-5.7), and for beta-hexachlorocyclohexane, but not for their highest levels. Self-reported home termiticide exposure, alcohol consumption (> or = 1 drink/day), and race were not associated with prognosis. The RR for current cigarette smoking at diagnosis was 2.1 (95% CI, 0.9-5.1). In contrast to previous data showing no relationship between OC exposure and risk of breast cancer in these women, adipose PCB concentrations were associated with tumor recurrence. Pesticide levels were not related to recurrence.