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More than 11,000 women under 40 are diagnosed with breast cancer in the U.S. each year. Breast cancer can be scary enough without wondering if it will also prevent you from having children. More and more American women are diagnosed with breast cancer in their childbearing years, and many want to know how the disease will affect their fertility. While there's no one-size-fits-all answer to this complex question, this article attempts to answer some tough questions including: What are the risks posed by cancer treatment, methods of preserving fertility, and ways cancer might affect future offspring.

How breast cancer treatment affects fertility depends largely on three factors: the type of treatment used, type and stage of the cancer at diagnosis, and the age of the patient.

"If a patient needs only surgery and radiation and no chemotherapy, the treatment will have no impact on future fertility," Robert Barbierri, MD, chief of obstetrics and gynecology at Brigham and Women's Hospital in Boston, tells WebMD. The same, however, cannot be said for chemotherapy. Breast cancer patients treated with chemotherapy run the risk of developing premature ovarian failure or very early menopause. Almost four out of five women treated with cyclophosphamide -- an often-prescribed chemotherapy drug for treating breast cancer -- develop ovarian failure, according to Kutluk Oktay, MD, assistant professor of reproductive medicine and obstetrics and gynecology at Cornell's Center for Reproductive Medicine and Infertility. FertileHope, a nonprofit organization dedicated to disseminating education on infertility associated with breast cancer treatment, places the risk at 40% to 80%.

How advanced a cancer is upon detection, as well as what type it is, dictate whether chemotherapy will be required, thereby affecting the risk of side effects to the ovaries.

The more advanced the cancer upon detection, the greater likelihood that chemotherapy, which affects the whole body, will be used to treat it. For instance, invasive breast cancer typically requires systemic chemotherapy, whereas a small tumor with small nodes that is localized and contains a minimal threat of spreading may not. The type of tumor also impacts a patient's treatment options. Some breast cancers can be treated with the use of hormone-containing drugs. But a small percentage of breast cancer tumors are "hormonally insensitive," explains Susan Domcheck, MD, assistant professor of medicine at the University of Pennsylvania. What does this mean? "You can't use hormones to treat them. You're left with chemotherapy as your only option."

Age plays a big role in patients' future fertility. "The age of the woman at the start of systemic chemotherapy is the biggest predictor of infertility," Barbierri tells WebMD. But why? "If you're 30, your fertility is already declining. Add to that chemotherapy, and you tack on a few more years. We know that chemotherapy induces menopause, particularly with women over 40," Domcheck says.

Despite the fertility risks associated with breast cancer treatment (chemotherapy in particular), methods to preserve fertility prior to treatment offer hope to many patients.

To date, freezing embryos (fertilized eggs) created by in vitro fertilization (IVF) is the most widely used and effective method of preserving fertility. But there are potential downsides. IVF takes three to four weeks, a delay in cancer treatment that, depending on the stage and type of cancer, patients may or may not be able to afford. Sperm -- either from a partner or donor -- must be made available immediately to fertilize the eggs. And IVF is expensive -- anywhere from $10,000 to $14,000 per cycle.

Other methods of fertility preservation, albeit experimental, show promise. Egg freezing, which applies the same concept as embryo freezing, has proven less effective -- most likely because eggs are smaller, and less hardy, than embryos. There's also ovarian suppression during treatment, which "protects ovaries to some degree from chemical onslaught of chemotherapy," Barbierri tells WebMD. Freezing entire strips of ovarian tissue is a third technique under investigation; it involves surgically removing, storing, and later replacing the tissue in another part of the body.

Tamoxifen, a drug traditionally used to prevent breast cancer reoccurrence, was recently found to stimulate ovaries in breast cancer survivors during an IVF cycle, enhancing both egg and embryo production. This extra boost can combat infertility barriers such as age and the diminishing ovarian reserves, which occurs naturally with aging, notes Oktay.

Although males rarely develop breast cancer, it does happen. For male breast cancer patients who must undergo chemotherapy and want to preserve their fertility, freezing sperm is an effective option. "Since there are millions of sperm, even if you kill half in the freezing process, you still have a lot left," Barbierri explains.

Researchers' focus on fine-tuning methods of fertility preservation fuel optimism about its increasing viability. "A decade ago, there was practically no emphasis on fertility preservation. Today, there are several methods and thus a much greater potential," said Oktay.

For survivors who remain fertile, questions about conception remain. Relapse is one of them.

"A common clinical recommendation is that a survivor wait two years before attempting to become pregnant, since most serious relapses will occur within the first two years after treatment," said Barbierri. "If you wait two years, there's no strong evidence that pregnancy will influence the course of disease."

Survivors also worry that their offspring will be at risk for cancer. According to experts, that risk is small. "Only 5% of breast cancers are truly inherited via a specific genetic mutation. If you have an inherited genetic mutation, you have a 50-50 chance of passing it on to your children." To date, researchers have identified a few genetic mutations that contribute to breast cancer; these include BCRA-1 and BCRA-2.

What is the prognosis for offspring who do inherit one of these genetic mutations? "There does not appear to be an increased risk of childhood cancers. However, these children are at a slightly higher risk for developing ovarian and breast cancers," Domcheck says.

"It's likely that an interplay between a collection of genes, when added to certain environmental factors, results in breast cancer," Domcheck says. Known environmental risk factors include moderate or heavy drinking (for women, two or more drinks per day), having children later in life, and obesity.

Survivors also question the impact of cancer treatment on future offspring. The news on this front is very encouraging. "There does not seem to be any increased risk of birth defects if the woman who's gone through breast cancer treatment gets pregnant. Even if the woman gets chemotherapy during pregnancy, fetuses do surprisingly well," said Domcheck.

Absorbing news of a breast cancer diagnosis as well as focusing on how it might affect future fertility can be overwhelming. But because oncologists are trained to provide the best cancer treatment available -- not necessarily in light of fertility options -- patients interested in seeking information on fertility need to be proactive. "A patient needs to say to herself, 'What do I want in the future' and ask the doctor, 'What's this [treatment] going to do with my future plans for fertility?'" says Ann Partridge, MD, MPH, breast oncologist and instructor at Harvard School of Medicine in Boston.

Others agree. "You need to have as much information as possible," says Karen Dow, PhD, RN, professor at University of Central Florida's School of Nursing. She suggests getting a third or even fourth opinion, ideally from doctors in different specialties -- oncology, reproductive endocrinology, gynecology -- since each will bring a unique perspective unique to the table.

"It would be wonderful if, in the future, doctors would all come together to say, 'Hey, here's what's out there, here's what it means to you,'" Dow says. But for now, it's up to the patient to seek information on her options, as early as possible.

The Breast Cancer Gene: What Should You Do?

Shortly after her mother died of ovarian cancer in 1999, Karen (who asked that her full name not be used) got a call from her first cousin, Joanne. Joanne, a cancer survivor, was in the process of researching their family's cancer history and had discovered that numerous female relatives had died from breast or ovarian cancer. She suggested that Karen consider getting tested for one of the inherited mutations -- called BRCA1 and BRCA2 --, which greatly increases the risk of breast cancer and can also increase the risk of ovarian cancer. If Karen had this genetic mutation, it would mean that she was also at high risk of developing breast cancer.

Karen, now 48, was tested at Memorial Sloan-Kettering Cancer Center in New York City and learned that in fact she did have a mutation on the BRCA1 gene, which means that her lifetime risk of ever developing breast cancer is as high as 80%. Depending on the age of a woman, the risk in the general female population is about 7%-8%. Because the lifetime risk of ovarian cancer is also high (15%-60%) in these women, this, too, was a concern. "Even with my family history, I was shocked to learn that I had the gene mutation, but at the same time I felt lucky because I was the first person in my family who had the chance to do something about it," says Karen. These inherited mutations are responsible for only about 5%-10% of breast cancers.

While detection methods have come a long way, breast MRIs have been shown in studies to be better at detecting early-stage cancer in high-risk women. Screening tests, such as mammograms, when done regularly, can find cancers at an early stage and lower the risk of dying from breast cancer. But detection of a cancer is not the same as prevention of a cancer.

Bilateral prophylactic mastectomy is preventive surgery and is the only way to dramatically reduce the risk of developing breast cancer. Studies have shown that the procedure cuts the risk by nearly 90%.

In women with the BRCA mutation, preventive surgery to remove the ovaries (prophylactic oophorectomy) is most often done to reduce the risk of ovarian cancer, but it also cuts the risk of breast cancer. By removing the ovaries there are reduced amounts of hormones, such as estrogen, which stimulate breast cancer cells to grow.

Instead, they should approach their options in a very practical and rational manner, says Mark E. Robson, MD, director of the Clinical Genetics Service at Memorial Sloan-Kettering. "They weigh the physical and psychological costs of having surgery against the cost of choosing screening and having it fail." A diagnosis of breast cancer is not the only thing women hope to escape; they also want to avoid potentially grueling cancer treatments.

Assuming they're done having children, women generally have an easier time accepting the idea of losing their ovaries than they do their breasts. "Unlike breasts, the ovaries are internal organs, so the psychological impact is less and there is less stigma involved," says Carolyn Kaelin, MD, MPH. Since menopause is inevitable anyway, many women can handle the prospect of it occurring a little sooner. Kaelin is a breast surgeon at the Dana-Farber Cancer Institute and director of The Comprehensive Breast Center at Brigham and Women's Hospital in Boston.

But oophorectomy only reduces the risk of breast cancer by 50%, which isn't all that meaningful if your risk was 80% to begin with -- making prophylactic bilateral mastectomy the surest route to real peace of mind (having both surgical procedures done cuts breast cancer risk by 95% or more).

Robson says he's seen a wide variety of motivations among women who opt for this radical approach. Some have watched their mothers or other relatives die from breast cancer and will do anything to escape that experience. Others, particularly younger women, are primarily thinking of their children and wanting to be around for them. For women well past menopause, losing their breasts feels less traumatic than it might have at a younger age.

For Karen, it was a divorce and a new job that forced her hand. In January 2001, shortly after learning her genetic status, she had her ovaries removed, but wasn't able to face also losing her breasts at that time. She was living near Sloan-Kettering Cancer Center, going there every three months for screening, and felt in control of her situation. But when her husband asked for a divorce, it required her to find a new job; she ended up landing one in North Carolina, where getting top-notch cancer care would require a several-hour drive.

"I started seriously considering having the procedure at Sloan-Kettering before I left," said Karen. "I read all kinds of books and studies, talked to doctors and plastic surgeons and other women." In December, she will have both breasts removed, followed by breast reconstruction. "I feel very good about my decision," says Karen, noting that her friends and family have been supportive of her choice -- something that is not always the case.

"A lot of women who consider prophylactic mastectomy are doing so in a very measured, rational way and yet, at least in the U.S., they seem to be swimming upstream against people who are saying, 'What, are you crazy?'" explains Robson. "Those people don't understand the journeys, which have led these women to their decisions." What's most important, say Robson and Kaelin, is for a patient to be given all the information she needs to make a decision on her own, without any pressure from doctors. She should consult with a breast surgeon, a reconstructive surgeon, and most importantly, other women who have gone through it already. "One patient told me that the most helpful thing she was told was that it was perfectly reasonable to have the surgery and it was perfectly reasonable not to have it," recalls Robson. "It's just a personal choice and a woman should be supported no matter which way she goes."

Like Karen, the vast majority of women who choose prophylactic mastectomy opt for reconstructive surgery immediately afterward. During a bilateral mastectomy, a surgeon removes all breast tissue that is visible to the naked eye, including the nipple. The risk of cancer can never be 100% eliminated, says Kaelin, because there might be a wisp of a breast tissue cell that has dived down into the chest wall or beyond the normal boundaries.

Options for breast reconstruction depend largely on a woman's individual physique. The most common procedure for women who've had both breasts removed involves saline or silicone breast implants. In alternative procedures, breasts are recreated using muscle and fat from other areas of the body. These tissues are used to create a sling-like structure on the chest wall; afterwards implants are placed in the position of the breast. With a TRAM flap (transverse rectus abdominal muscle), abdominal muscle and fat are used. A similar procedure, called a DIEP flap (deep inferior epigastric perforator), leaves the abdominal muscle in place and uses only fat and skin from that area. A different procedure uses back muscle.

Because two breasts must be recreated, a woman needs to have a large amount of appropriate tissue to spare for these procedures. Also, removing major muscles can cause weakness and pain in specific body regions. Nipple reconstruction usually involves a skin graft that's formed into a nipple shape and then tattooed to resemble a natural nipple in color. While reconstructed breasts have scars and no nipple sensation, Kaelin says that some women are genuinely "delighted" with their reconstruction.

But the real delight comes from the immense relief in no longer feeling like a ticking time bomb --something that Karen looks forward to. "My risk will be below that of the normal population; I won't need the surveillance anymore and getting health insurance won't be an issue," she says, pausing and then admitting that she is also pleased about a more superficial benefit of the surgery: "My new breasts will be perky for life!"

Breast Cancer Survivors: Life After the Treatments End

The breast cancer treatments are over. Now what? Here's how to return to your "new normal."

The song says "It ain't over 'til it's over," but when you've had breast cancer, you discover that it's not even over when it's over. After a marathon of breast cancer diagnosis and treatment that may last six months to a year, you can hardly wait to get back to a normal life again. But the day of your last radiation treatment or chemotherapy infusion doesn't mark the end of your journey with breast cancer. Instead, you're about to embark on another leg of the trip. This one is all about adjusting to life as a breast cancer survivor. In many ways, it will be a lot like the life you had before, but in other ways, it will be very different. Call it your "new normal."

From your relationships with your family and your spouse to eating habits and exercise, breast cancer will change your life in ways that last well after treatment ends. How do you fight lingering fatigue? What should you eat to help prevent a breast cancer recurrence? Will you ever have a regular sex life again? These are just a few of the questions that may nag at you as you make the transition from breast cancer treatment to breast cancer survival.

You watched the last dose of chemotherapy drip from the IV into your veins six months ago. Your hair has really started to grow back. Maybe it's curly where it once was straight, or a lot grayer than before, but it's hair. You have eyebrows again. So why are you still so tired? When are you going to feel like you again? "Your body has just been through an enormous assault, and recovery is a huge thing. You're not going to just bounce back right away," says oncologist Marisa Weiss, MD, founder of Breastcancer.org and the author of Living Beyond Breast Cancer. "You've been hit while you're down so many times: with surgery and anesthesia, perhaps with multiple cycles of chemotherapy, perhaps with radiation."

Two of the biggest hurdles women with breast cancer face post-treatment are fatigue resulting from chemotherapy and/or the accumulated effects of other treatments, and a phenomenon some women have dubbed "chemobrain" -- mental changes such as memory deficits and the inability to focus. If you tried, you probably couldn't pick two more frustrating and troubling side effects for women handling busy lives, managing careers, and caring for families. "You expect them to go away as soon as treatment ends, and they don't," says Mary McCabe, RN, director of the Cancer Survivorship program at Memorial Sloan-Kettering Cancer Center in New York.

That such a program as McCabe's exists is a testament to the changing nature of what it means to have cancer. Women with breast cancer, like other people with a cancer diagnosis, are now surviving for so much longer, and in such large numbers, that some hospitals are opening entire departments devoted to survivorship. The National Cancer Institute has also launched a special research area dedicated to studying what it means to survive cancer.

How long after breast cancer treatment ends can you expect fatigue, "chemobrain," and other post-treatment side effects to persist? Everyone's different, of course, but as a general rule of thumb, Weiss tells her patients to expect a recovery period about the same time from your first "cancer scare" moment to the date of your last treatment. So if you found a lump or had a suspicious mammogram in April, and had your last radiation treatment in December, it may be August or September of the following year before you reach your "new normal."

"Even then, that doesn't mean that you're fully back to yourself again, but by then you should have a sense of where you're going to be, what your energy level will be, and so on," says Weiss. Ongoing treatments, like tamoxifen or other hormonal therapies such as arimidex, aromasin or femara, or reconstructive surgery, can affect the process. "I have a lot of patients who are in their second year of dealing with this. Yes, their main anti-cancer treatment may be over, but they're still figuring out how to manage the side effects of hormonal therapies and so on. It can feel like an endless process."

Breast cancer survivorship, Weiss observes, is a marathon, not a sprint. That means learning to handle the symptoms that stick around after treatment ends, says Sloan-Kettering's McCabe, by using those adaptive strategies you learned while on chemotherapy or recovering from surgery. "You need to continue to have planned periods of rest, and think about what times in the day and after what activities you tend to find yourself most tired," she says. "If chemobrain is still bothering you, continue using tricks like writing things down, posting reminders to yourself, and asking people to repeat information." Some women find it helps to keep a daily diary, noting down the times when fatigue or mental fogginess hit hardest, to help them plan around it.

Make sure your family and your officemates understand that just because treatment is over, that doesn't mean that you're going to be able to jump right back into running the carpool, coaching soccer, and traveling to conferences a week out of every month. "Everyone's ready for treatment to be over, not just you, and although they've been supportive, your friends and family may be expecting you to spring back right away," says McCabe. "It's an education process. They need to understand that when the therapy stops, that doesn't mean that the effects of the therapy stop immediately." Manage your expectations, urges Weiss. "Decrease the stress and the pressure on you in whatever ways you can. There are a lot of decisions you can make to take charge of how your life goes while you're in this recovery process."

For example, you may have certain ideas about how your house should look, how much income you're going to have, and what your commitments to your community need to be. Decide which of those things are really important to you and which ones don't matter quite as much. Let the less-important ones slide or find someone else to do them.

Gina Shaw is a medical writer who was treated for breast cancer in 2004, and now calls herself a "joyful breast cancer survivor."

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Social Disparities in Tobacco Use in Mumbai, India: The Roles of Occupation, Education, and Gender-(Glorian Sorensen, Prakash C. Gupta and Mangesh S. Pednekar, 09/07/2005)

Objectives. We assessed social disparities in the prevalence of overall tobacco use, smoking, and smokeless tobacco use in Mumbai, India, by examining occupation-, education-, and gender-specific patterns.

Methods. Data were derived from a cross-sectional survey conducted between 1992 and 1994 as the baseline for the Mumbai Cohort Study (n=81 837).

Results. Odds ratios (ORs) for overall tobacco use according to education level (after adjustment for age and occupation) showed a strong gradient; risks were higher among illiterate participants (male OR=7.38, female OR=20.95) than among college educated participants. After age and education had been controlled, odds of tobacco use were also significant according to occupation; unskilled male workers (OR=1.66), male service workers (OR=1.32), and unemployed individuals (male OR=1.84, female OR=1.95) were more at risk than professionals. The steepest education- and occupation- specific gradients were observed among male bidi smokers and female smokeless tobacco users.

Conclusions. The results of this study indicate that education and occupation have important simultaneous and independent relationships with tobacco use that require attention from policymakers and researchers alike. (Am J Public Health. 2005;95:1003-1008. doi:10.2105/AJPH.2004.045039)

Tobacco use in low-income and middle-income countries is predicted to contribute to an increasing share of the global burden of disease in future decades.1 Eighty-two percent of the world's 1.1 billion smokers now reside in low- and middle-income countries, where, in contrast to declining consumption in high-income countries, tobacco consumption is on the rise.1 Indeed, the World Health Organization's Framework Convention on Tobacco Control underscores the importance of tobacco control efforts within developing countries as part of a worldwide strategy to reduce the health, economic, and social consequences of tobacco use.2 Addressing this growing public health problem requires attention to increasing social disparities in patterns of tobacco use. Across high-, middle-, and low-income countries, smoking rates are highest among individuals of low socioeconomic position.3

Indicators of socioeconomic position vary across studies; often education, occupation, and income level are used interchangeably to measure socioeconomic position.4 It is important, however, to examine multiple indicators of socioeconomic position simultaneously if one is to understand their combined impact and thereby provide more complete descriptions of social inequalities in tobacco use. In particular, insufficient attention has been focused on occupational disparities in tobacco use, given the role of occupation in linking education and income as well as its role as a determinant of health in its own right, through hazardous workplace exposures. Indeed, recent analyses of US data indicate that education does not represent a "stand-in" surrogate for occupation, or vice versa; rather, they reflect distinct social constructs making overlapping as well as independent contributions to patterns of tobacco use.5

In this study, we examined social disparities in tobacco use in India, where multiple forms of tobacco consumption complicate attempts to reduce its overall impact on public health. It has been estimated that 65% of men use some form of tobacco, including 35% who smoke, 22% who use smokeless tobacco, and 8% who engage in both forms of tobacco use.6,7 About one third of women use at least one form of tobacco, although rates among women vary considerably by region (from approximately 15% to approximately 65%).6,7 In general, cigarettes account for an estimated 20% of tobacco consumption; about 50% of tobacco is consumed in the form of bidis, that is, traditional, leaf-wrapped unfiltered cigarettes.8,9

In previous studies, different patterns have been observed in the educational gradient in tobacco use depending on the type of tobacco used. Whereas overall tobacco use has been shown to be highest among those with the least education, cigarette smoking rates have been shown to increase with increasing education.10 In India, because of their low cost, bidis are more commonly smoked than cigarettes by individuals of lower socioeconomic position; in turn, cigarettes are more commonly consumed among those with greater financial resources.10,11 (Bidi smoking has been shown to pose significant health hazards.12-14) A similar socioeconomic gradient has been observed for the use of smokeless tobacco, including chewing tobacco, snuff, burnt tobacco, powder, and paste.7,15

In general, men in India smoke as well as chew or apply tobacco, whereas women generally chew or apply tobacco, with the exception of the few areas where prevalence rates of smoking among women are high.7,16 It is estimated that more than 150 million men and 44 million women in India use tobacco in various forms,14 and approximately 635000 deaths in India are attributed to tobacco each year. Tobacco-related cancers constitute about half of the total cancer incidence among men and about 20% among women.8

The purpose of this study was to assess educational and occupational differences in the prevalence of tobacco use, including total tobacco use, bidi and cigarette smoking, and smokeless tobacco use, in a large sample of residents of Mumbai, India. In addition, we sought to assess the joint effects of occupation and education level on tobacco use after controlling for other key determinants of use (i.e., gender and age).

METHODS

Baseline data for the Mumbai Cohort Study were collected between 1992 and 1994 in Mumbai (Bombay), India.17 The overall purpose of this prospective cohort study was to assess mortality associated with tobacco use in Mumbai.

Study Population

Mumbai is a large, densely populated city whose population was approximately 12 million people in 2001.18 The city is divided into 3 sectors: the main city, the suburbs, and the extended suburbs. This study exclusively focused on the main city. The sampling frame comprised the city's electoral rolls, which are updated via house- to-house visits before each major election. From these rolls, assumed to be relatively complete given that almost all adult residents are entitled to vote, data were derived on the name, age, gender, and address of all individuals older than 18 years. The electoral rolls were organized by geographical areas; sampling was based on the smallest unit, the "polling station," which included 1000 to 1500 eligible voters. Selection of polling stations excluded those involving a large proportion of apartment complexes with high levels of security; results of the pilot data collection indicated the need for this exclusion owing to the difficulty of gaining access to such buildings.

At the selected polling stations, all individuals 35 years or older who were listed on the electoral rolls were eligible to be interviewed. The age cutoff of 35 years was selected as a result of the study's overall goal of studying tobacco-attributed mortality. In selected geographical areas, lists were supplemented to include individuals who were not listed on the electoral rolls but whose residence status was confirmed by a "ration card." These cards, issued by the Bombay Municipal Corporation, serve as a proxy for residence cards and permit access to all city and state governmental services; individuals identified in this manner represented approximately 5% of the overall sample.

Of the individuals approached and invited to participate in the study, the nonresponse rate was less than 1%. It was not possible to contact approximately 50% of the individuals included on the lists as a result of incomplete addresses, houses being demolished, changes of residence, and inaccessibility of residences (often owing to security considerations). A total of 99 598 adults (40 071 men and 59 527 women) were recruited and surveyed. In the analyses presented here, we excluded respondents who reported that they were retired (n=15 223) or had missing data for occupation (n=2538). The final sample comprised 81 837 respondents.

Data Collection

The survey was conducted by trained interviewers within participants' households. Hand-held computers were used to record data at the time of the interview. Interviews were conducted in the local languages, including Hindi and Marathi. No surrogate responses were permitted.

Measures

The primary outcome in the present analyses was tobacco use, categorized as follows: (1) having no habit in either the past or present ("never user"), (2) former user (including smoking and use of smokeless tobacco), (3) current smokeless tobacco user (including betel quid, mishri, and creamy snuff), (4) current cigarette smoker, and (5) current bidi smoker (including other forms of smoked tobacco as well, e.g., chilum and hooka). Smokers who also used smokeless tobacco were classified as smokers in these analyses.

Occupation was assessed according to respondents' self-reports. Following the standard Indian classification system, occupations were coded as follows: skilled workers, unskilled workers, traders, service workers, and professionals.19 Additional categories \included unemployed and housewife. Women were considered as housewives unless they were currently employed or looking for employment. Retirees were excluded from the analyses. Education level was classified as illiterate, primary school (up to 5 years of education), middle school (6-8 years of education), secondary school (9-12 years of education), and college (including both some college and attainment of college degree). Gender and age data were also collected.

Data Analysis

Descriptive statistics were calculated for the overall population as well as for men and women separately. Logistic regression was used in conducting multivariate analyses. The response variable, tobacco use, was converted into a dichotomous variable in which current tobacco users (including users of any form of tobacco) were compared with current nonusers. Multivariate analyses of cigarette and bidi smoking were conducted only among men because of the extremely low prevalence (less than 0.5%) of smoking among women. SPSS statistical software (SPSS Inc, Chicago, Ill) was used in analyzing the data.

RESULTS

Sample Characteristics

Men represented about one third of the sample (Table 1). More than 40% of men were employed in service positions, and one third were unskilled workers, whereas a large majority (88%) of women were classified as housewives. Women were generally less educated than men; 45% of women were illiterate, as compared with 11% of men. In addition, only 5% of women had completed secondary school or college, whereas 16% of men had done so. Overall, about a quarter of the participants were between the ages of 35 and 39 years; more than a third were between 40 and 49 years of age.

Tobacco Use Prevalence: Bivariate Analyses

Patterns of tobacco use differed dramatically according to gender (Table 1). While women were less likely than men to have ever used tobacco (26% vs 41%), they were more likely to currently use smokeless tobacco (57% vs 44%). Smoking prevalence rates were 27% among men and, as mentioned, less than 0.5% among women (thus, data on female smokers are not shown separately in Table 1 or described in subsequent analyses). Among male smokers, 12% were cigarette smokers and 15% were bidi smokers. Overall, 2% of the sample members were former tobacco users, an indicator of cessation rates.

TABLE 1-Tobacco Use, by Gender, Occupation, Education, and Age: Mumbai Cohort Study

Among men as well as women, professionals were least likely to have ever used tobacco, whereas unskilled workers and unemployed individuals were most likely to have done so. Use of smokeless tobacco was more common than smoking across all occupational categories. Rates of smokeless tobacco use among women were highest among unskilled workers, those who were unemployed, and housewives. Among men, smokeless tobacco use was especially prevalent among service and unskilled workers and unemployed individuals. Bidi smoking among men followed a similar pattern, with high prevalence rates among unemployed individuals and unskilled workers. In contrast, cigarette smoking was most common among professionals and traders. Self-reported rates of former tobacco use ranged from less than 2% to 6%.

There was a strong gradient in tobacco use according to education level. Among both men and women, the rate of smokeless tobacco was highest among the illiterate and lowest among those with a college education. Among men, the prevalence of bidi smoking was highest among those at low levels of education, but the prevalence of cigarette smoking was highest among those at the highest education levels.

Multivariate Analyses

Table 2 presents gender-specific tobacco use odds ratios comparing current tobacco users, current cigarette smokers, current bidi smokers, and current smokeless tobacco users with individuals reporting no current use of any type of tobacco. Odds ratios according to occupation and education were adjusted for age and the other relevant model variable (i.e., either occupation or education). The reference category for occupation was professional, and the reference category for education was college.

Tobacco use was inversely related to education level across all types of tobacco use. The magnitudes of the odds ratios were especially large among those with no more than a primary school education; in addition, in this subgroup, odds ratios were particularly pronounced among women who used smokeless tobacco and men who were bidi smokers. Relative to participants in the reference educational category (college), odds ratios for all forms of tobacco use were significantly higher among those in the other educational categories. After adjusting for age and education, we also observed an inverse relationship between cigarette smoking and education (see Table 2).

TABLE 2-Adjusted Odds Ratios (and 95% Confidence Intervals) for Various Forms of Tobacco Use (vs No Current Habit), by Education, Occupation, and Gender: Mumbai Cohort Study

Although the magnitudes of the relationships were not as large, occupation continued to play an important role in patterns of tobacco use when education and age were controlled. In the case of men, odds ratios for smokeless tobacco use remained statistically significant among unskilled workers, service workers, and unemployed individuals, and the odds ratios for bidi smoking remained significant among unemployed individuals and both skilled and unskilled workers. None of the odds ratios for cigarette smoking were significant. After education level had been controlled, male traders were actually less likely to use smokeless tobacco than were professionals, suggesting an interesting interaction between education and occupation. Among women, after control for education level and age, only the odds ratios for those who were unemployed remained statistically significant.

DISCUSSION

The present results demonstrate the important roles of education and occupation in tobacco use patterns in India. Research in the West has consistently documented a strong socioeconomic gradient in tobacco use, with higher rates of use among those of greater social disadvantage.4,5,20-22 Indeed, Jarvis and Wardle23 concluded that, in Western countries, "any marker of disadvantage that can be envisaged and measured, whether personal, material or cultural, is likely to have an independent association with cigarette smoking." Recent evidence documents the same socioeconomic tobacco use gradient in India; tobacco use has been found to be higher among individuals at lower levels of education,10,11,15,24-27 of lower castes,15,27 and with lower standards of living.27,28 (Other research, however, has failed to reveal an association between tobacco use and socioeconomic position.29)

Education is a powerful correlate of tobacco use patterns.10 In this study, after adjustment for occupation and age, all forms of tobacco use followed an inverse linear pattern in terms of educational level; similar results have been reported by others.11,15,27 Odds ratios were alarmingly high among individuals with no more than a primary school education, particularly, as described earlier, women using smokeless tobacco and men smoking bidis. Of note, when we adjusted only for age (data not shown), the direction of the relationship between education and cigarette smoking among men was reversed relative to the bivariate relationships presented in Table 1. Unlike the use of other forms of tobacco, cigarette smoking was most prevalent among the younger groups within this sample; among male participants, age contributed significantly to both education- and occupationspecific odds of cigarette smoking. These findings underscore the importance of adjusting for age in analyses such as those described here.

Our analyses also offer evidence of the independent effects of occupation and education on tobacco use among men; even after control for education, odds ratios for occupation were statistically significant among the most disadvantaged workers in regard to bidi smoking and use of smokeless tobacco. One interesting exception in these occupationspecific results involved the odds of using smokeless tobacco among male traders; although the overall prevalence of smokeless tobacco use was somewhat higher among traders than among professionals, a lower proportion of traders than professionals in each of the various educational groups used smokeless tobacco (data not shown).

Occupation appeared to carry more weight in regard to men's tobacco use than that of women. Because a large proportion of the women in this sample were housewives and 45% were illiterate, it is not surprising that education was a more important indicator of socioeconomic position than current occupation. The "housewife" category provided insufficient information to adequately describe socioeconomic position because it included women living in a range of social and economic circumstances. In addition, education appeared to swamp any influence of occupation among women; for example, the odds of smokeless tobacco use were more than 20 times greater among women who were illiterate than among women with a college education.

Unemployment was a particularly powerful predictor of tobacco use. In the case of all comparisons, even those taking education into account, unemployed individuals were at the highest risk of using tobacco, a relationship that has been reported in other populations as well.30-34 In addition, unemployment was most strongly associated with bidi use among men (OR=3.5). Unemployment is an indicator of increased economic disadvantage and associated stressors such as poor housing conditions, unmet needs for food, and potential lack of social connectedness.23,35 Expenditures on tobacco products have been found to represent a significant portion of the daily incomes of Indian residents in low income categories, including unemployed individuals.36

The present findings demonstrate the need, instudies assessing social disparities in tobacco use, to examine occupation and education separately as well as simultaneously. This will allow researchers to gain a more complete understanding of such disparities than might be the case when considering either indicator alone.5 Others have noted the importance of considering multiple indicators of socioeconomic position in understanding patterns of tobacco use.5,23,37 Education and occupation are likely to operate through differing pathways. Education is one of the most widely used indicators of socioeconomic position, given that it is easy to measure, applicable to individuals both inside and outside the labor force, and stable across the life course. It has consistently been shown to be a strong correlate of tobacco use, both in India and elsewhere.5,10,11,15,22,24-26 Nonetheless, it may fail to capture some of the elements of socioeconomic position expressed by occupation; occupation may further indicate one's standing in the community, reveal aspects of the normative environment prevalent within one's occupational "culture," and serve as a marker for the general conditions present at one's workplace.5,37

Several caveats must be noted in interpreting our results. For example, our education and occupation data were based on self- reports. In addition, the complexities of obtaining, recording, and coding occupational data can lead to misclassification.37-40 Furthermore, our occupational categories were combined into broad groupings, which could have contributed to biased estimates in terms of the gradients observed. Nonetheless, these groupings provided greater precision than those used in earlier tobacco use research in India; in these studies, occupation was grouped into even more general categories.41 We collected data at the individual level, not the household level, and thus our data on socioeconomic position may have been incomplete, particularly in the case of women.37 Future studies could include other indicators of socioeconomic position, such as caste or different standard of living measures.

In addition, as described earlier, the present data were collected as part of the initial data collection effort in a prospective cohort study; they were not part of a surveillance study designed to assess population prevalence rates of tobacco use. The sample was not a random or representative sample of the population. In particular, we excluded individuals who resided in upper-middle- class and upper-class housing complexes that were not accessible as a result of security issues. Thus, the proportions of individuals in different occupational categories might not have been comparable to the proportions in other cities or in India as a whole. Nonetheless, our findings provide important insight into the interrelationships between education, occupation, and tobacco use. Moreover, although the proportions of different occupation types and the prevalence rates of tobacco use may not have been representative of the general population, it is highly unlikely that the interrelationships observed would have been seriously affected by our sampling methods.

Identifying occupation- and educationspecific disparities in tobacco use can provide a useful "signpost" indicating inequities that need to be addressed by policymakers and the broader community through allocation of resources.42 Our results indicate that tobacco use in India follows a social gradient mirroring that reported for Western countries. If one is to shed light on patterns of disparities, it is important to consider multiple indicators of socioeconomic position, including both education and occupation, as well as gender. Additional research elucidating the differing pathways by which occupation and education may influence tobacco use can inform future policies and other interventions.

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Social Disparities in Tobacco Use in Mumbai, India: The Roles of Occupation, Education, and Gender-(Glorian Sorensen, Prakash C. Gupta and Mangesh S. Pednekar, 09/07/2005)