Environmental tobacco smoke exposure and risk of breast cancer in nonsmoking women: a review with meta-analyses.

Recent authoritative reviews consider smoking has no effect on breast cancer risk, but some studies report an increase from environmental tobacco smoke (ETS). We reviewed the overall evidence on ETS and breast cancer in nonsmoking women. We extracted details of available studies, derived relative risk (RR) estimates with confidence intervals (CIs) for various ETS exposure indices and conducted meta-analyses. Using an index for each study most closely equivalent to "spouse ever smoked," a weak, but significant, association was seen (random-effects RR = 1.12, 95% CI = 1.02-1.24, n = 22). However, the estimates were heterogeneous: close to 1.0 for prospective, North American and larger studies, and those adjusting for many potential confounders, but significantly (p < .05) elevated in case-control, European, and smaller studies, and those accounting for fewer potential confounders. Risk was increased in premenopausal women (RR = 1.54, 95% CI = 1.16-2.05, n = 10), but not postmenopausal women. Dose-response findings were similarly heterogeneous. No significant increase was seen for ETS in childhood or the workplace or from the spouse specifically, but an increase was seen for total exposure (RR = 1.54, 95% CI = 1.17-2.04, n = 6). Increases mainly derive from case-control studies asking detailed ETS histories, where RRs depend heavily on who is classified in the totally unexposed reference group, and may be prone to recall bias. Results from prospective studies using similar histories are needed. Study weaknesses and possible publication bias also limit interpretation. Because of the inherent implausibility that ETS exposure might cause breast cancer, given the similar risks of smokers and nonsmokers, one cannot confidently conclude ETS exposure increases risk in nonsmokers.