Alcohol, tobacco and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease.

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58,515 women with invasive breast cancer and 95,067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19-1.45, P<0.00001) for an intake of 35-44 g per day alcohol, and 1.46 (1.33-1.61, P<0.00001) for >/=45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5-8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98-1.07, and for current smokers=0.99, 0.92-1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver.

A three year outcome evaluation of a theory based drink driving education program.

This study reports on the impact of a "drink driving education program" taught to grade ten high school students. The program which involves twelve lessons uses strategies based on the Ajzen and Madden theory of planned behavior. Students were trained to use alternatives to drink driving and passenger behaviors. One thousand seven hundred and seventy-four students who had been taught the program in randomly assigned control and intervention schools were followed up three years later. There had been a major reduction in drink driving behaviors in both intervention and control students. In addition to this cohort change there was a trend toward reduced drink driving in the intervention group and a significant reduction in passenger behavior in this group. Readiness to use alternatives suggested that the major impact of the program was on students who were experimenting with the behavior at the time the program was taught. The program seems to have optimized concurrent social attitude and behavior change.

Relation between anthropometric indicators and risk of breast cancer among Australian women.

Associations between various anthropometric indicators and breast cancer were investigated in a community-based case-control study conducted among 456 premenopausal women (135 cases) and 656 women who were at least 10 years past menopause (185 cases) in Brisbane, Australia, from 1981 to 1985. Among postmenopausal women, increased risk was associated with greater weight at age 25 years (p trend = 0.002) and with a heavier maximum weight (p trend = 0.003), but not with recent weight. Results were similar for relative weight (weight (kg)/height (m)1.5). Overall, weight gain was unrelated to the occurrence of breast cancer, although risks were elevated among postmenopausal women who weighed less at age 25 (< 54 kg) and subsequently experienced a large weight gain (> 13 kg). Among premenopausal women, there was little indication that body size or change in weight was related to breast cancer. These results suggest that both heaviness in early adulthood and a large maximum weight at any time are associated with elevated risks for postmenopausal breast cancer.

Infant feeding in Queensland, Australia: long-term trends.

Infant feeding practices were retrospectively ascertained in a random cohort of parous women (mean age 54.8 years) from Brisbane, Australia. Reported proportions of infants who were ever breast-fed fell from around 90% before 1960 to around 70% in the early 1970s, with some subsequent increase. Similar but stronger trends were reported in proportions of infants breast- but not bottle-fed. Few maternal characteristics were associated with feeding practices, but women with more education appear to have led both the early retreat from and the later return to breast-feeding.

Case-control evaluation of a school-age BCG vaccination programme in subtropical Australia.

In 1956 a programme was initiated to vaccinate all children aged 12-14 years who were attending schools in Queensland, Australia. In view of the declining incidence of tuberculosis in Australia as a whole, there was a need to evaluate the effectiveness of the programme and its procedures. We therefore carried out a case-control study of Queensland's population, excluding certain known high-risk groups. Cases were Queensland residents with notified tuberculosis and of the appropriate age; two controls per case were chosen from the electoral roll. Information on vaccination status was obtained mainly from questionnaires and school records, where available. The results show that at best BCG vaccination had a modest protective effect, approximately 30% when the patients were diagnosed, which was on average 15 years after they had been vaccinated in the school programme. In the north the climate of Queensland is tropical, while in the more heavily populated south it is subtropical. A substantial proportion of the school records reported weak positive reactions to preliminary tuberculin testing, believed to be due largely to atypical mycobacteria. A similar phenomenon has been observed in other tropical regions, and may help to explain the apparent absence of a strongly protective effect for BCG vaccination.

A profile of Australian women practicing breast self-examination.

Breast self-examination (BSE) and medical breast examination practices were studied in a group of 1,103 women without diagnosed breast cancer, randomly sampled to conform in age and social status with breast cancer cases from the population of Brisbane, Australia between 1981 and 1985. Relationships between these practices and sociodemographic factors, breast cancer risk indicators, health related behaviors and source of knowledge about BSE were analyzed. Overall, 63% of women reported performing BSE. BSE was practiced frequently (monthly or more). BSE frequency was only weakly associated with breast cancer risk indicators. It was more strongly linked with age, the 20-44 year group being more likely to examine their breasts occasionally and the women 65 years and over being less likely to examine their breasts. Married women were the most likely to practice BSE frequently and widowed or single women most likely never to practice. Women who underwent cervical smear testing were more likely to perform BSE than those who did not have smear tests. Women who learned BSE from their doctors as opposed to other sources practiced BSE more frequently and were more likely to practice BSE exactly as taught.

A randomized, controlled, double-blind, cross-over, clinical trial of Q fever vaccine in selected Queensland abattoirs.

A limited, randomized, blind, placebo-controlled trial of Q fever and influenza vaccines has been conducted in three Queensland abattoirs on a sequential analysis design. Ninety-eight subjects were given Q fever vaccine and 102 influenza vaccine. Q fever cases were observed in unvaccinated workers in all three abattoirs during the period of observation. A total of seven Q fever cases in one group, one more than the number required to achieve statistical significance between the two vaccine groups, was reached after 15 months with the cases coming from two of the abattoirs. These Q fever cases were in the group which had been given influenza vaccine and none in that given Q fever vaccine. Symptomless seroconversion rates of 24% were found in the remaining influenza virus vaccinees, and those without immunity were given Q fever vaccine.

Breast cancer and breastfeeding: results from an Australian case-control study.

A case-control study of breast cancer, diet, and lactational history was carried out in Brisbane, Australia, between 1981 and 1985. Cases were recruited from both the private and the public health care sectors. The breastfeeding histories of 459 cases and 1,091 controls selected from the electoral roll were analyzed. An odds ratio of 0.85 (95% confidence interval 0.55-1.30) for any lactation versus no lactation was observed, with no suggestion of a monotonic trend with increasing duration. This estimate was only slightly altered by multiple logistic regression analysis. A statistically significant nonlinear association was noted for breastfeeding of the first liveborn child (chi 2 = 14.8, df = 6; p less than 0.05), with a slightly elevated odds ratio for lactations of less than one month, a lowered odds ratio for lactations of one month to three months, and a weakly elevated odds ratio in women breastfeeding for more than nine months. Results for premenopausal women were very similar to those for postmenopausal women. Taken together with other recent studies, these results suggest that lactation may play a modest direct or indirect part in reducing the risk of breast cancer.

Selective primary health care: strategies for control of disease in the developing world. XXII. Tetanus: a preventable problem.

Tetanus, although an eminently preventable disease, remains common and uncontrolled in many developing countries. The persistence of tetanus is attributable to health service policies that ignore the disease because of a dearth of reliable epidemiologic and economic information. In many developing countries there have, as yet, been few public or professional demands for preventive action. For the prevention of neonatal tetanus, the immediate priority is immunization timed to produce and maintain protective levels of maternal antitoxin during pregnancy. This strategy should be accompanied by the extension and improvement of scientific standards of midwifery. To protect the rest of the population from wound tetanus, the strategy of first choice consists of continuous multiple-antigen immunization in infancy and childhood. Such a program should be reinforced by the routine administration of a toxoid booster following all accidental wounds as well as before all ritual procedures known to carry risk. These strategies, which are of proven efficacy and adaptable to local conditions of the large populations still in need of protection, together provide powerful justification for the expansion of primary maternal and child health services. Careful measurement of the incidence of neonatal tetanus would provide a good indicator of the degree of effectiveness such services have attained in many rural communities.

Cohort study of internal malignancy in genetic hemochromatosis and other chronic nonalcoholic liver diseases.

The risk of hepatocellular carcinoma (HCC) and other internal malignancies was examined in patients with genetic hemochromatosis (GH) by following 208 patients from the time of diagnosis to June 1983 and by comparing the numbers of cancers they developed with expected values constructed from cancer registry incidence data by means of actuarial methods. In addition, cancers occurring in a comparison group of 148 subjects with other chronic nonalcoholic liver diseases (CLD) were determined. Among the GH group, 16 new cases of HCC occurred subsequent to the diagnosis of GH, together with 8 other malignancies. The 16 cases of HCC reflect a 200-fold excess risk, which from all indications represents the first quantitation of the risk of this tumor in GH. There appears to be no increased risk of other malignancies in this disease. Among the CLD group only 1 HCC and 1 other malignancy occurred.

The retention of calcium, iron, phosphorus, and magnesium during pregnancy: the adequacy of prenatal diets with and without supplementation.

Vitamin and mineral supplementation is often prescribed by physicians to meet the additional nutrient requirements of pregnancy. In order to partially ascertain the effectiveness of these prenatal supplements, the retention of calcium and iron was determined in pregnant women consuming supplemented or unsupplemented self-selected diets. The retention of phosphorus and magnesium, minerals not included in the prenatal supplements, was also determined. Seven-day metabolic balance experiments spaced periodically throughout the pregnancy were conducted on 10 healthy pregnant white women. The retention of calcium by the supplemented group was comparable to that of the unsupplemented group, while the retention of iron was more dependent on the magnitude of the iron intake than on its source. Although no supplement contained phosphate, the intake of phosphorus met the recommended allowances for this mineral. Significantly related to the intake of dietary calcium, the adequate phosphorus intakes reflected diets providing adequate calcium. The mean magnesium intake was only 60% of the recently established recommended dietary allowance. Although the calcium and iron salts provided by the prenatal supplements were well utilized, the intakes of phosphorus and magnesium indicate that the reliance on the effectiveness of mineral supplements should not lessen the emphasis by the physician on the importance of a good prenatal diet.

Immunization against neonatal tetanus in New Guinea.

THIS PAPER DESCRIBES: (1) a continuation of the study reported in 1965 of tetanus antitoxin titres among women after primary immunization with plain, AlPO(4)-adsorbed or oil adjuvant toxoids; (2) the effect of age and of abscess formation due to oil adjuvants on antitoxin response; and (3) a comparative study of titres in some women of the study groups who received either a plain or an AlPO(4) toxoid booster injection in pregnancy.The results support our previous recommendation to use aluminium adjuvant toxoid in the prevention of neonatal tetanus. Mean maternal protective antitoxin levels were maintained for 40 months but not for 54 months after 2 primary injections and booster response was higher in those immunized with this toxoid than in those immunized with plain toxoid. Also, the use of AlPO(4) toxoid as booster stimulated a higher antitoxin response than did the use of plain toxoid. Mean protective levels induced by oil adjuvant toxoids (1 injection) persisted for the same time as for the adsorbed toxoid (2 injections). Age did not significantly affect the level of antitoxin response, whereas abscess formation was associated with a higher level.Pregnancy appeared to favour the incidence of antitoxin responders to adsorbed toxoids. Failure to respond to primary immunization with 2 injections of adsorbed toxoid occurred in 7% of women while 100% responded to the oil adjuvant toxoids. Induction of abscess formation precludes use of the latter toxoids, however. Additional studies are needed on the influence of larger antigen doses on the primary response in different ethnic and ecological situations and on the influence of smaller antigen doses on the booster response where repeated booster injections are indicated.

Immunization against neonatal tetanus in New Guinea. 4. Comparison of tetanus antitoxin titres obtained by haemagglutination and toxin neutralization in mice.

Haemagglutination (HA) has been used frequently for the titration of tetanus antitoxin but published results have varied in relation to the "unitage" determined by the mouse toxin-neutralization test (TN). This report gives the results of the titration of a group of sera by haemagglutination and compares them with the results obtained by toxin neutralization. Although there was marked variation between HA and TN titres of individual sera, results indicated that haemagglutination is a useful procedure for the over-all evaluation of the antitoxin responses to tetanus toxoids in field studies.

Immunization against neonatal tetanus in New Guinea. 5. Laboratory assayed potency of tetanus toxoids and relationship to human antitoxin response.

Previous papers in this series have shown that plain toxoids induced early primary antitoxin levels in women in New Guinea that were not significantly different from those induced by adsorbed toxoids but that at the end of 1 year the antitoxin levels differed significantly. Protective levels (not less than 0.01 unit/ml) induced by adsorbed toxoids persisted for more than 3 years. Results of laboratory assays of the toxoids reported in this paper show that per total human immunizing dose, the plain toxoids had 72 or less international units (IU) whereas the adsorbed toxoids had approximately 200 IU. The international "unitage" of these toxoids reflected the persistence of the human protective antitoxin level but not the early primary response. The assay results were in agreement with findings of other workers that the mouse as well as the guinea-pig may be satisfactory for potency assay of adsorbed toxoids. The need for determination of the international unitage of tetanus toxoids used in human studies and the confirmation of relationship of this value to persistence of antitoxin levels is emphasized.