Hannah Kuper

Infections as a major preventable cause of human cancer

Abstract. Kuper H, Adami H‐O & Trichopoulos D (Harvard School of Public Health, Boston, MA, USA; Karolinska Institute, Stockholm, Sweden; University of Athens Medical School, Greece). Infections as a major preventable cause of human cancer (Internal Medicine in the 21st Century). J Intern Med 2000; 248: 171–183.

Job strain, job demands, decision latitude, and risk of coronary heart disease within the Whitehall II study.

Study objectives: To investigate the association between job strain and components of the job strain model and coronary heart disease (CHD) risk. Design: Prospective cohort study (Whitehall II study). At the first phase of the study (1985–1988), data on self reported psychosocial work characteristics were collected from all participants. Participants were followed up until the end of phase 5 (1997–2000), with mean length of follow up of 11 years. Setting: London based office staff in 20 civil service departments. Participants: 6895 male and 3413 female civil servants aged 35–55. Outcome measures: Incident validated CHD. Main results: People with concurrent low decision latitude and high demands (job strain) were at the highest risk for CHD. High job demands, and, less consistently, low decision latitude, predicted CHD incidence. The effect of job strain on CHD incidence was strongest among younger workers, but there was no effect modification by social support at work, or employment grade. Conclusions: Job strain, high job demands, and, to some extent, low decision latitude, are associated with an increased risk of CHD among British civil servants.

When reciprocity fails: effort–reward imbalance in relation to coronary heart disease and health functioning within the Whitehall II study

Background: A deleterious psychosocial work environment, as defined by high efforts expended in relation to few rewards reaped, is hypothesised to increase the risk of future poor health outcomes. Aims: To test this hypothesis within a cohort of London based civil servants. Methods: Effort–reward imbalance (ERI) was measured among 6895 male and 3413 female civil servants aged 35–55 during the first phase of the Whitehall II study (1985–88). Participants were followed until the end of phase 5 (1997–2000), with a mean length of follow up of 11 years. Baseline ERI was used to predict incident validated coronary heart disease (CHD) events during follow up and poor mental and physical functioning at phase 5. Results: A high ratio of efforts in relation to rewards was related to an increased incidence of all CHD (hazard ratio (HR) = 1.36, 95% CI 1.12 to 1.65) and fatal CHD/non-fatal myocardial infarction (HR = 1.28, 95% CI 0.89 to 1.84) during follow up, as well as poor physical (odds ratio (OR) = 1.47, 95% CI 1.24 to 1.74) and mental (OR = 2.24, 95% CI 1.89 to 2.65) functioning at phase 5, net of employment grade. A one item measure of high intrinsic effort also significantly increased the risk of these health outcomes, net of grade. ERI may be particularly deleterious with respect to CHD risk among those with low social support at work or in the lowest employment grades. Discussion: Within the Whitehall II study, a ratio of high efforts to rewards predicted higher risk of CHD and poor physical and mental health functioning during follow up. Although the increased risk associated with ERI was relatively small, as ERI is common it could be of considerable public health importance.

Tobacco smoking, alcohol consumption and their interaction in the causation of hepatocellular carcinoma

During a 4‐year period from January 1995 to December 1998, blood samples and questionnaire data were obtained from 333 incident cases of hepatocellular carcinoma (HCC), as well as from 360 controls who were hospitalized for eye, ear, nose, throat or orthopedic conditions in Athens, Greece. Coded sera were tested for hepatitis B surface antigen (HBsAg) and antibodies to hepatitis C virus (anti‐HCV) by third‐generation enzyme immunoassays, and information on smoking habits and beverage consumption was obtained. We found a significant dose‐response, positive association between smoking and HCC risk [≥ 2 packs per day, odds ratio (OR)=2.5].This association was stronger in individuals without chronic infection with either HBV or HCV (≥ 2 packs per day, OR=2.8). Consumption of alcoholic beverages above a threshold of 40 glasses per week increased the risk of HCC (OR=1.9). We also found evidence of a strong, statistically significant and apparently super‐multiplicative effect of heavy smoking and heavy drinking in the development of HCC (OR for both exposures=9.6). This interaction was particularly evident among individuals without either HBsAg or anti‐HCV (OR for both exposures=10.9). Coffee intake was not positively associated with HCC risk, but the reverse could not be excluded for the subgroup of chronically infected individuals. In conclusion, tobacco smoking and heavy alcohol consumption are associated with increased risk of HCC, especially when these 2 exposures occur together. Int. J. Cancer 85:498–502, 2000.

Tobacco use and cancer causation: association by tumour type

Abstract.  Kuper H, Boffetta P, Adami H‐O (London School of Hygiene and Tropical Medicine, London, UK; Karolinska Institutet, Stockholm, Sweden; and International Agency for Research on Cancer, Lyon, France). Tobacco use and cancer causation: association by tumour type (Review). J Intern Med 2002; 252: 206–224.

The Socioeconomic Gradient in the Incidence of Stroke A Prospective Study in Middle-Aged Women in Sweden

Background and Purpose— A socioeconomic gradient in stroke has been demonstrated in a variety of settings, but mostly in men. Our purpose was to establish whether a socioeconomic gradient in stroke existed in a group of Swedish women and whether this gradient could be explained by established stroke risk factors or psychosocial factors. Methods— The Womens Lifestyle and Health Cohort Study includes 49 259 women from Sweden aged 30 to 50 years at baseline (1991 to 1992). The women completed an extensive questionnaire and were traced through linkages to national registries until the end of 2002. Among the 47 942 women included in these analyses, there were 200 cases of incident stroke during follow up (121 ischemic stroke, 47 hemorrhagic stroke, and 32 of unknown origin). Statistical analysis was through the Cox proportional hazards model. Results— The risk of stroke was significantly inversely related to years of education completed, our proxy for socioeconomic status (hazard ratio comparing lowest with highest education group=2.1, 95% CI: 1.4 to 2.9, P for trend <0.001). This association was reduced after adjustment for established risk factors, although remaining significant (1.5, 1.0 to 2.2, P for trend=0.04). The gradient was more pronounced for ischemic stroke (2.9, 1.8 to 4.7, P for trend <0.001) than for hemorrhagic stroke (1.4, 0.7 to 2.9, P for trend=0.35). Job strain and social support were unrelated to risk of stroke. Self-rated health was strongly related to risk of stroke mediated by established risk factors. Psychosocial factors did not contribute toward the socioeconomic gradient in stroke. Conclusions— There was a strong gradient in risk of stroke by years of education, especially for ischemic stroke. Most of the social gradient was explained by established risk factors, particularly smoking and alcohol, but not by psychosocial factors.

A critical review of the SAFE strategy for the prevention of blinding trachoma

Trachoma is an ocular disease caused by repeated infection with Chlamydia trachomatis. It is the leading cause of infectious blindness globally, responsible for 5.9 million cases of blindness. Although trachomatous blindness is untreatable, it is eminently possible to prevent and the World Health Organization promotes the use of the SAFE strategy (surgery to treat end-stage disease, antibiotics to reduce the reservoir of infection, facial cleanliness, and environmental improvement to reduce transmission of C trachomatis) for this purpose. In this review we have assessed the evidence base supporting the elements of the SAFE strategy. We find strong support for the efficacy of the surgery and antibiotics components, although the optimal antibiotic regimens have not yet been established. The evidence for an effect of health education and environmental improvement is weaker, and depends mostly on cross-sectional observational studies.

The effect of control at home on CHD events in the Whitehall II study: Gender differences in psychosocial domestic pathways to social inequalities in CHD

Although there has been considerable research on psychosocial working conditions and their effect on physical and mental health, there has been little research into the effects of psychosocial domestic conditions on health. The association between psychosocial working conditions (and control at work in particular) and coronary heart disease (CHD) is not as strong for women compared to men. Other research suggests that household and domestic factors may have an important effect on womens health. Some studies have shown that low control at home affects psychological well being. However, there has been little research into its effects on physical health. Furthermore, similar to results analysing low control at work, low control at home may form part of the pathways underlying social inequalities in health. The study investigates the meaning of control at home, the effect of control at home on incident CHD events and whether this explains some of the social inequalities in CHD events in men and women. Data from phases 3-5 of the Whitehall II study, London, UK, were analysed (N = 7470). The results indicate that low control at home predicts CHD among women but not among men. Furthermore, low control at home may explain part of the association between household social position and CHD among women. There is some evidence suggesting that low control at home among women results from a lack of material and psychological resources to cope with excessive household and family demands. Psychosocial domestic conditions may have a greater effect on the health of women compared with men.

Population based study of coffee, alcohol and tobacco use and risk of ovarian cancer

Coffee, alcohol and tobacco use have been examined in many epidemiologic studies of ovarian cancer but findings have generally been inconclusive. To explain prior inconsistent findings, we sought to determine whether associations with these exposures might vary by histologic subtype of ovarian cancer or menopausal status at diagnosis. We conducted a population‐based case‐control study in eastern Massachusetts and New Hampshire involving 549 women with newly‐diagnosed epithelial ovarian cancer and 516 control women selected either by random digit dialing or through lists of residents. Coffee and alcohol consumption was assessed through a semi‐quantitative food‐frequency questionnaire, and information on tobacco smoking was collected through personal interview. Consumption of coffee and caffeine was associated with increased risk for ovarian cancer but only among premenopausal women. There was no increase in risk for ovarian cancer overall associated with tobacco or alcohol use in either pre‐ or post‐menopausal women. Association of borderline significance for tobacco and invasive serous cancers and alcohol and mucinous cancers were observed but reduced after adjustment for coffee consumption. We conclude that coffee and caffeine consumption may increase risk for ovarian cancer among premenopausal women and are findings that have some epidemiologic and biologic support. Int. J. Cancer 88:313–318, 2000.

Tobacco use, cancer causation and public health impact

Abstract. Kuper H, Adami H‐O, Boffetta P (University College London, Torrington Place, London, UK; Karolinska Institutet, Stockholm, Sweden; and International Agency for Research on Cancer, Lyon, France). Tobacco use, cancer causation and public health impact. J Intern Med 2002; 251: 455–466.