with ETS, and have influenced public policy regarding the regulation of smoking in public places. Further studies are planned to evaluate the risks of ETS and other environmental pollutants in the etiology of respiratory cancer.

The Community Intervention Trial For Smoking Cessation (COMMIT) is the largest smoking intervention study in the world, involving some two million people directly, and millions more indirectly. COMMIT is testing whether a community-based intervention protocol can be effectively disseminated nationwide to meet NCI's year 2000 objective to reduce smoking prevalence. The COMMIT design involves 11 pairs of communities in North America that were matched in size, demographics, and location.

The American Stop Smoking Intervention Study for Cancer Prevention (ASSIST) represents a collaborative effort between the National Cancer Institute, the American Cancer Society, State and local health departments and other voluntary organizations to develop comprehensive tobacco control programs in up to 20 states and metropolitan areas. The ASSIST intervention model is based on proven smoking prevention and control methods developed within the National Cancer Institute's intervention trials and other smoking and behavioral research. The purpose of ASSIST is to demonstrate that the wide-spread, coordinated application of the best available strategies to prevent and control tobacco use will significantly accelerate the current downward trend in smoking and tobacco use, thereby reducing the number and rate of tobacco-related cancers in the United States.

The "Tobacco Policy Interventions in Northwest Indian Tribes" project will develop and evaluate a consultative process and materials that will assist tribal councils in creating and implementing more explicit, comprehensive and stringent tobacco use policies. The primary outcome measures will be the extent and comprehensiveness of (a) tribal tobacco use policies and (b) the implementation process including amount of tribal publicity and activity regarding smoking related issues.

A project entitled "Por La Vida Model in Cancer Prevention" will evaluate the effectiveness of the Por La Vida model used by the National Heart, Lung and Blood Institute to promote behavior change to reduce cardiovascular risk factors and adapt it to a cancer risk reduction intervention. This grant-based study will expand the model to address cancer prevention and control in an area of San Diego. The general design is to promote better health among residents of a predominantly Mexican American community. Its original focus was on the reduction of cardiovascular disease risk factors among Hispanic women. This grant will stress increased use of mammography, increased use of PAP smears, breast self-exams, and changes in dietary habits appropriate for MexicanAmerican women. Some 500 Mexican American women are to be randomly recruited and randomized to one of two groups: cancer prevention intervention or community skills intervention. The intervention involves a series of group sessions stressing either cancer prevention (including the role of fat in cancer, screening, and smoking) or community living skills, such as communication, language, and time management. One of the key outcome measures will be changes in the frequency of breast and cervical cancer

screening. The grant will address such barriers as the availability of services and language.

Half of the

A three-part motivational program for Head Start mothers is under evaluation. The impact of this program on the proportion of mothers (Black American women 18-40 years old) who either quit smoking or reduced their consumption will be evaluated. Self-reporting and follow-up data will be collected. 300 participating mothers will compose an experimental group, and half will compose a control group. It is anticipated that approximately 50 women will refuse the program. consist of one Head Start program in each of 20 schools.

The program will

The workplace is an obvious channel for cancer control activities aimed both at reducing occupational exposures and modifying unhealthy lifestyle choices. Research is underway to explore the potential of the worksite to improve a broad set of cancer prevention and control behaviors. The Working Well cooperative agreement is a large, Phase III project involving four research centers, a coordinating center and 120 randomized worksites. The project is designed to determine effective worksite-based intervention methods to reduce tobacco use, achieve cancer preventive dietary modification, increase screening prevalence, and reduce occupational exposures. Smaller worksite-based projects will develop mechanisms to assist worksite wellness managers to choose appropriate cancer control materials and develop interactive computer-based nutrition self-help programs.

The Community Clinical Oncology Program (CCOP), initiated in the fall of 1983, is a major cancer control effort which links community-based physicians with clinical cooperative groups and Cancer Centers (as research bases) for participation in NCI-approved research. The objectives of the CCOP include the development of research trials for effective implementation of cancer treatment and prevention and control research in multi-institutional settings, the testing of intervention strategies such as chemoprevention in large populations, and the assessment of the impact of targeted research on community practices.

One way to develop and implement effective treatment and cancer control strategies in minority populations, and thereby reduce disparities in cancer incidence, morbidity, and survival rates between whites and minority populations, is the participation of minority populations in the conduct of clinical trials. Since the CCOP model is an effective mechanism for linking investigators and their institutions with the clinical trials network, a Minority-Based CCOP (MBCCOP) was initiated to provide minority cancer patients with access to state-of-the-art cancer treatment and control technology. Twelve programs with greater than 50 percent of new cancer patients from minority populations were funded for the next three years. Through this effort, NCI aims to meet a need of minority cancer patients and individuals at risk for cancer by establishing a system of oncology programs for participation in clinical research trials through the NCI network. An evaluation of the MBCCOP is under way using the methodology developed in the CCOP evaluation.

In addition to the numerous studies in rehabilitation and continuing care supported through the CCOP, several other research programs are underway. An ongoing program designed to improve the quality of survival among childhood cancer patients focuses on school attendance and employment/insurance issues. NCI proposes to extend this research to adult patients. A current research program is designed to determine the need for and availability of home care for cancer patients. A complementary program studies nursing interventions designed to promote the ability of patients undergoing chemotherapy or radiotherapy to take an active role in managing their own care.

The "Prevention of Cervical Cancer in Native American Women" is a health education research project focusing on cancer prevention among two populations of Native Americans, the Cherokee and the Lumbee. The major goal of the study is to increase screening and follow-up for cervical cancer prevention among women, age 18 and older, who receive Pap smears at appropriate intervals and return for follow-up care when necessary.

The "Wai'anae Coast Cancer Control Project" in Wai'anae Hawaii will test the effectiveness of an integrated, community-driven, cancer control intervention as a means of increasing breast and cervical cancer screening practices among Native Hawaiian women. Research objectives include the development of health-activated mutual support groups within existing Hawaiian social and family networks and their sense of "Kokua" (a Hawaiian social concept that encourages mutual support of community members), the presentation of information about available cancer screening services; assistance in reducing logistical barriers to receiving cancer screening services; and the discussion of personal attitudes and beliefs as a motivating factor.

During the past year, three of the six NCI breast cancer screening grants have received supplements to design, implement, and evaluate one-year interventions to increase breast cancer screening rates in women 65 and older. In addition, a fourth grant was supplemented to sponsor a "Forum on Breast Cancer Screening in Older Women" held July 30-August 2, 1990. The Forum is developing recommendations for breast cancer screening in women aged 65 and over, and future research needs in this area.

ENVIRONMENTAL CARCINOGENESIS

The U.S. cancer mortality maps provide a major means of highlighting geographic areas experiencing unusual variations in cancer trends and risks that may be associated with environmental carcinogens. Updated U.S. atlases, illustrating geographic patterns of cancer deaths by state economic area over three decades (1950-1980), were published for the white population in 1987 and for nonwhite populations in 1990. Etiologic clues from these maps can be evaluated by more analytical epidemiologic studies, leading to prevention strategies. For example, elevated rates of oral cancer among women in the southeastern United States prompted studies that identified snuff dipping as its major cause, leading to legislative action affecting the advertising and labeling of smokeless tobacco and educational initiatives about

its health hazards. Further studies are planned to identify reasons for the high- and low-risk areas.

Air: A number of investigations have been undertaken due to concerns about cancer risks associated with indoor and outdoor air pollution. Studies by NCI and other groups have shown a relationship between passive smoking and lung cancer, particularly among nonsmoking women married to smokers. These studies indicate an overall risk of about 30 percent, rising to 70 percent among those most heavily exposed to environmental tobacco smoke (ETS). These findings have increased public awareness of the hazards associated with the inhalation of ETS, and have influenced public policy regarding the regulation of smoking in public places.

Radon is a radioactive gas that decays into solid alpha-emitting short-lived daughters, which are inhaled and deposited on the bronchial tree of the lung. The radiation from these daughter products has been shown to cause lung cancer in underground miners. Because radon can concentrate in homes, especially when tightly insulated, a proportion of lung cancers may be attributable to residential exposures. Studies will continue to assess the magnitude of the risk of lung cancer from indoor radon exposure. In studies in China, the excess risk of lung cancer among nonsmoking women has been attributed to indoor pollutants from high-temperature wok cooking and home-heating devices.

In a study of outdoor air pollution in Shenyang, China, the risk of lung cancer was increased among males living within one kilometer of a large copper smelter, whose stacks emit high levels of inorganic arsenic. This finding supports earlier NCI studies in the United States which showed that both occupational and residential exposures to inorganic arsenic from metal smelters are related to lung cancer risk.

Water: In an earlier NCI study, bladder cancer risk was associated with the intake of chlorinated tap water from surface sources, with long-term consumers having the greatest risk. Data are now being analyzed from the first phase of a case-control study of six anatomical sites of other cancers that also may be at higher risk. The second phase of the study, currently in the field, is restricted to collecting information from additional bladder cancer patients and controls. A recent mortality and incidence survey in various counties across the United States revealed no cancer trends or patterns that could be attributed to the intake of fluoridated drinking water. In particular, no relation was found between osteosarcoma incidence and fluoridated water supplies, which is noteworthy in view of an animal bioassay study by the National Toxicology Program suggesting that sodium fluoride induces osteosarcoma in rats.

Workplace: Occupational studies have played an important role in identifying environmental carcinogens. Many of the chemicals that cause human cancer were first identified in the workplace. Chemicals used in industry are often found in commercial products or emitted from industrial plants through air and water, exposing the general population to them. The growing number of chemicals in the workplace and general environment

underscores the need for a strong research program to identify those that may be carcinogens.

The NCI's Epidemiology and Biostatistics Program has a broad range of studies underway to identify and clarify the role of workplace exposures in the origin of cancer. These studies span a number of industries and focus on a variety of potentially hazardous agents. To conduct these research projects, the NCI collaborates with other government agencies, companies, labor unions, professional associations, and foreign institutions. Areas of special emphasis include exposure to pesticides, focusing on applicators; studies of dry cleaners, Coast Guard marine inspectors, aircraft mechanics, and jewelry manufacturers who may be exposed to organic solvents; studies of cancer among persons exposed to dusts and fibers (e.g., asbestos, silica, and talc); and special industry-wide studies designed to evaluate cancer risks from various uses of specific chemicals (e.g., formaldehyde, acrylonitrile, methylene chloride, and benzene).

Recent findings related to pesticides include an association between non-Hodgkin's lymphoma (NHL) and use of herbicides from studies of Kansas and Nebraska farmers. The excess for this tumor rose to six-fold among Kansas farmers reporting use of herbicides 20 or more days per year. This association was primarily with the phenoxyacetic acid herbicide, 2,4-Dichlorophenoxyacetic acid (2,4-D) which is widely used in agriculture and in urban areas on lawns. In addition, farmers reporting use of insecticides on animals had elevated risks for soft-tissue sarcoma. In Nebraska, the risk of NHL rose to over three-fold among farmers using 2,4-D for 20 or more days per year. Studies to extend and clarify these findings include a case-control study of lymphatic and hematopoietic cancer in Iowa and Minnesota, and cohort studies of employees of a major lawn care company and herbicide applicators employed by county governments.

An

Leukemia was associated with farming in a study from Iowa and Minnesota. In particular, farmers using insecticides on animals had greater risks than farmers using insecticides on crops. excess of NHL was also observed among workers in the grain industry, where exposure to fumigants to control insects in stored grain may occur.

In a major effort completed a few years ago, over 26,000 workers employed in 10 different plants were studied to evaluate the risk of cancer from exposure to formaldehyde. Workers who had contact with formaldehyde containing dusts had excess mortality from nasopharyngeal cancer, which rose to nearly eight-fold among those with the heaviest exposures. The association between nasopharyngeal cancer and formaldehyde was recently observed in an NCI study of embalmers and funeral directors. Industrial workers also had a 30 percent excess of lung cancer, which did not show an exposure-response relationship with any measure of exposure to formaldehyde (including duration, intensity, peak, cumulative, or average). Such a relationship is crucial for inferring causality. Recent analyses indicate that risks of lung cancer rose with duration of exposure to melamine, phenol, urea, and wood dusts, but not with formaldehyde. In other studies, excesses from leukemia and brain cancer have been consistently noted among