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California's tobacco control program contracted for tobacco use surveillance of Asian Indian Americans to address the paucity of information about tobacco use in this community, given their growing proportion of California's population. This study examined correlates of conventional (CTU) and Asian Indian traditional tobacco use (TTU) in a population-based sample of predominantly immigrant Asian Indian adults residing in California (N = 3228). The analytic sample (n = 2140) was limited to self-identified immigrants from India. Descriptive statistics, bivariate analyses, and multivariate logistic regressions were conducted to examine correlates of tobacco use among Asian Indian immigrants related to their acculturation and religious affiliation. While 65% of the sample had ever used traditional tobacco products (paan masala, gutka, bidis), only 25% had ever used conventional tobacco (cigarettes, cigar, pipe, chewing tobacco, snuff). Less than 5% reported tobacco use in the past 30 days. Rates of ever TTU and CTU were higher among men than women. Ethnic enclave residence was not associated with tobacco use. Impaired mental health was associated with CTU, and number of years spent in the U.S. was positively associated with both CTU and TTU. Individuals affiliated with Sikhism were less likely to use tobacco than individuals affiliated with Hinduism. Few population-based studies in the U.S. address both CTU and TTU use among Asian Indian immigrants. Tobacco use in Asian Indian immigrants may be seriously underestimated if surveillance is limited to conventional tobacco products. Interventions to reduce tobacco use should address mental health issues and consider religious affiliation.

STUDY OBJECTIVE To estimate the risk of incident antidepressant-treated depression in men with benign prostatic hyperplasia (BPH) who were prescribed 5α-reductase inhibitors (5-ARIs) compared with those prescribed an active comparator, α-blockers (ABs). DESIGN Retrospective cohort study with a nested case-control analysis. DATA SOURCE United Kingdom's Clinical Practice Research Datalink. PATIENTS A total of 77,732 men with a diagnosis of BPH who received a prescription for a 5-ARI only and/or AB between January 1, 1992, and December 31, 2013. Of these men, 2842 had a first-time (incident) diagnosis of depression and received a prescription for an antidepressant within 90 days of the depression diagnosis date (cases); 11,333 controls without a diagnosis of depression were matched to the cases for the case-control analysis. MEASUREMENTS AND MAIN RESULTS Exposures were classified as 5-ARI only, 5ARI + AB, or AB only. We calculated incidence rates of antidepressant-treated depression and compared rates among users of 5-ARIs only and 5-ARIs + ABs with rates among users of ABs only (i.e., incidence rate ratios [IRRs]). We also calculated odds ratios (ORs) to estimate the risk of incident depression with use of 5-ARIs only and 5-ARIs + ABs compared with ABs only. In this population of men with BPH, the risk of depression was not increased with use of 5-ARIs only (IRR 0.94, 95% confidence interval [CI] 0.85-1.04) or 5-ARIs + ABs (IRR 1.04, 95% CI 0.89-1.21) compared with use of ABs only. In the case-control analysis, exposure to 5-ARIs only (adjusted OR 0.88, 95% CI 0.78-1.01) or 5-ARIs + ABs (adjusted OR 0.90, 95% CI 0.73-1.10) was not associated with the risk of treated depression compared with exposure to ABs only, and results remained null regardless of number of prescriptions or timing of exposure. The risk of incident antidepressant-treated depression increased with longer duration of BPH, independent of study drug exposure. CONCLUSION In this population of men with treated BPH, use of 5-ARIs, alone or in combination with ABs, did not increase the risk of incident antidepressant-treated depression compared with use of ABs only. Risk of treated depression increased with longer duration of BPH.

Katrina Wilcox Hagberg,1 Hozefa A Divan,2 Shona C Fang,2 J Curtis Nickel,3 Susan S Jick1 1Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, 2New England Research Institutes, Inc., Watertown, MA, USA; 3Kingston General Hospital, Queen’s University, Kingston, ON, Canada Background: Clinical trial results suggest that 5-alpha reductase inhibitors (5ARIs) for the treatment of benign prostatic hyperplasia (BPH) may increase the risk of gynecomastia and male breast cancer, but epidemiological studies have been limited. Patients and methods: We conducted a cohort study with nested case–control analyses using the UK Clinical Practice Research Datalink. We identified men diagnosed with BPH who were free from Klinefelter syndrome, prostate, genital or urinary cancer, prostatectomy or orchiectomy, or evidence of gynecomastia or breast cancer. Patients entered the cohort at age ≥40years and at least 3years after the start of their electronic medical record. We classified exposure as 5ARIs (alone or in combination with alpha blockers [ABs]), AB only, or unexposed to 5ARIs and ABs. Cases were men who had a first-time diagnosis of gynecomastia or breast cancer. Incidence rates and incidence rate ratios (IRRs) with 95% confidence intervals (CIs) in the gynecomastia analysis and crude and adjusted odds ratios (ORs) with 95% CIs in both analyses were calculated. Results: Compared to no exposure, gynecomastia risk was elevated for users of 5ARIs (alone or in combination with ABs) in both the cohort (IRR=3.55, 95% CI 3.05–4.14) and case–control analyses (OR=3.31, 95% CI 2.66–4.10), whereas the risk was null for users of AB only. The increased risk of gynecomastia with the use of 5ARIs persisted regardless of the number of prescriptions, exposure timing, and presence or absence of concomitant prescriptions for drugs known to be associated with gynecomastia. The risk was higher for dutasteride than for finasteride. 5ARI users did not have an increased risk of breast cancer compared to unexposed men (OR=1.52, 95% CI 0.61–3.80). Conclusion: In men with BPH, 5ARIs significantly increased the risk of gynecomastia, but not breast cancer, compared to AB use and no exposure. Keywords: 5ARIs, benign prostatic hyperplasia, gynecomastia, male breast cancer

Background Thrombotic events (TEs) are rare and serious adverse events after administration of immune globulin (IG) products. Our study evaluated the occurrence of same-day TEs for different IG products and ascertained potential risk factors. Study Design and Methods This retrospective cohort study utilized HealthCore's Integrated Research Database (HIRD) to assess individuals exposed to IGs during 2008 to 2012. IG products were identified using recorded procedure codes and TEs were ascertained using ICD-9-CM diagnosis codes. The unadjusted same-day TE rates (per 1000 persons exposed) were estimated overall and by IG products, age, and sex. Multivariable logistic regression analyses were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for same-day TEs by IG products. Results Of 14,944 individuals exposed to IG products, 233 (15.6 per 1000 persons) had TE diagnosis code(s) recorded on the same-day as the IG exposure. Compared to Gammagard Liquid, Gammaplex (OR, 20.96; 95% CI, 2.45-179.33) and Vivaglobin (OR, 2.74; 95% CI, 1.19-6.32) users had a significantly increased same-day TE risk. Elevated, but nonsignificant TE risks were identified for Octagam, Gamunex, Privigen, and Lyophilized IG(s). An increased TE risk was also found with older age (≥45 years), prior TEs, and other health conditions. Conclusion Our claims-based cohort study suggests a potentially elevated TE risk with different IG products and shows importance of recipient factors such as older age, previous TE, hypercoagulable state(s), and other health conditions. The results of this study suggest the need for continuous evaluation of procoagulant activity and manufacturing processes for IG products to further assure their safety.

e19506 Background: MM is characterized by repeated relapses and refractoriness and is managed by successive lines of therapies (LT) each typically resulting in shorter response duration over prior LT. This study describes current MM treatment (tx) landscape in US clinical practice. Methods: Adult MM patients (pts) with continuous Medicare Part A, B, and D coverage initiated on 1st LT (1L), without stem cell transplant, were identified in the Medicare Research Identifiable Files (2012-2016). Claims for any MM tx within 60 days of the 1st tx constituted the tx regimen of an LT. End of LT was defined as a claim for a new MM tx > 60 days post LT initiation (tx augmentation or switch), discontinuation of all tx in a regimen for > 90 consecutive days, end of Medicare coverage/data or death. From 1L to 3L, overall survival (OS), LT duration (DoT), tx regimens and sequences were assessed. Results: 8374 MM pts with 1L (median [med] age = 76 years at 1L; 55% female) were analyzed. Over a med follow-up of 20 months (mos) from 1L (med 1L DoT = 5.6 mos), 2849 pts received a 2L (med 2L DoT = 5.6 mos) and 978 received a 3L (med 3L DoT = 4.7 mos). The most prominent tx regimens were bortezomib/corticosteroids (CS; VD) in 1L, and lenalidomide/CS (RD) in 2L and 3L. The most prevalent tx sequence was 1L VD, 2L RD and 3L VD. The 1- and 2-year OS rates were 81% [95% confidence interval: 81-82] and 68% [67-69] from 1L initiation, 80% [78-82] and 64% [61-66] from 2L, and 73% [69-76] and 55% [51-60] from 3L initiation, respectively. Conclusions: MM Medicare pts mainly cycle through bortezomib- or lenalidomide-based regimens in front LT; newer agents gain more usage in later LT. A better understanding of tx options and sequencing is warranted to prolong survival. [Table: see text]

Objective: The aim of this study was to examine the association between religiosity and overweight or obese body mass index among a multi-religious group of Asian Indian immigrants residing in California. Methods: We examined cross-sectional survey data obtained from in-language telephone interviews with 3228 mostly immigrant Asian Indians in the 2004 California Asian Indian Tobacco Survey using multivariate logistic regression. Results: High self-identified religiosity was significantly associated with higher BMI after adjusting for socio-demographic and acculturation measures. Highly religious Asian Indians had 1.53 greater odds (95% CI: 1.18, 2.00) of being overweight or obese than low religiosity immigrants, though this varied by religious affiliation. Religiosity was associated with greater odds of being overweight/obese for Hindus (OR 1.54; 95% CI: 1.08, 2.22) and Sikhs (OR 1.88; 95% CI: 1.07, 3.30), but not for Muslims (OR 0.69; 95% CI: 0.28, 1.70). Conclusions: Religiosity in Hindus and Sikhs, but not immigrant Muslims, appears to be independently associated with greater body mass index among Asian Indians. If this finding is confirmed, future research should identify potentially mutable mechanisms by which religion-specific religiosity affects overweight/obesity risk. © 2013 Elsevier Inc.

Background Potential health effects of cell phone use in children have not been adequately examined. As children are using cell phones at earlier ages, research among this group has been identified as the highest priority by both national and international organisations. The authors previously reported results from the Danish National Birth Cohort (DNBC), which looked at prenatal and postnatal exposure to cell phone use and behavioural problems at age 7 years. Exposure to cell phones prenatally, and to a lesser degree postnatally, was associated with more behavioural difficulties. The original analysis included nearly 13 000 children who reached age 7 years by November 2006. Methods To see if a larger, separate group of DNBC children would produce similar results after considering additional confounders, children of mothers who might better represent current users of cell phones were analysed. This 'new' dataset consisted of 28 745 children with completed Age-7 Questionnaires to December 2008. Results The highest OR for behavioural problems were for children who had both prenatal and postnatal exposure to cell phones compared with children not exposed during either time period. The adjusted effect estimate was 1.5 (95% CI 1.4 to 1.7). Conclusions The findings of the previous publication were replicated in this separate group of participants demonstrating that cell phone use was associated with behavioural problems at age 7 years in children, and this association was not limited to early users of the technology. Although weaker in the new dataset, even with further control for an extended set of potential confounders, the associations remained.

In this study, we demonstrate the complexities of performing a sibling analysis with a re-examination of associations between cell phone exposures and behavioral problems observed previously in the Danish National Birth Cohort. Children (52,680; including 5441 siblings) followed up to age 7 were included. We examined differences in exposures and behavioral problems between siblings and non-siblings and by birth order and birth year. We estimated associations between cell phone exposures and behavioral problems while accounting for the random family effect among siblings. The association of behavioral problems with both prenatal and postnatal exposure differed between siblings (odds ratio (OR): 1.07; 95% confidence interval (CI): 0.69-1.66) and non-siblings (OR: 1.54; 95% CI: 1.36-1.74) and within siblings by birth order; the association was strongest for first-born siblings (OR: 1.72; 95% CI: 0.86-3.42) and negative for later-born siblings (OR: 0.63; 95% CI: 0.31-1.25), which may be because of increases in cell phone use with later birth year. Sibling analysis can be a powerful tool for (partially) accounting for confounding by invariant unmeasured within-family factors, but it cannot account for uncontrolled confounding by varying family-level factors, such as those that vary with time and birth order.Journal of Exposure Science and Environmental Epidemiology advance online publication, 25 September 2013; doi:10.1038/jes.2013.56.

Thrombotic events (TEs) are rare and serious adverse events after administration of immune globulin (IG) products. Our study evaluated the occurrence of same-day TEs for different IG products and ascertained potential risk factors.This retrospective cohort study utilized HealthCore's Integrated Research Database (HIRD) to assess individuals exposed to IGs during 2008 to 2012. IG products were identified using recorded procedure codes and TEs were ascertained using ICD-9-CM diagnosis codes. The unadjusted same-day TE rates (per 1000 persons exposed) were estimated overall and by IG products, age, and sex. Multivariable logistic regression analyses were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for same-day TEs by IG products.Of 14,944 individuals exposed to IG products, 233 (15.6 per 1000 persons) had TE diagnosis code(s) recorded on the same-day as the IG exposure. Compared to Gammagard Liquid, Gammaplex (OR, 20.96; 95% CI, 2.45-179.33) and Vivaglobin (OR, 2.74; 95% CI, 1.19-6.32) users had a significantly increased same-day TE risk. Elevated, but nonsignificant TE risks were identified for Octagam, Gamunex, Privigen, and Lyophilized IG(s). An increased TE risk was also found with older age (≥45 years), prior TEs, and other health conditions.Our claims-based cohort study suggests a potentially elevated TE risk with different IG products and shows importance of recipient factors such as older age, previous TE, hypercoagulable state(s), and other health conditions. The results of this study suggest the need for continuous evaluation of procoagulant activity and manufacturing processes for IG products to further assure their safety.

Thrombotic events (TEs) are rare serious complications following administration of hyperimmune globulin (HIG) products. Our retrospective claims-based study assessed occurrence of same-day TEs following administration of HIGs during 2008-2011 and examined potential risk factors using HealthCore's Integrated Research Database (HIRD(SM) ) and laboratory testing of products' procoagulant Factor XIa activity by U.S. Food and Drug Administration. Multivariable regression was used to estimate same-day TE risk for different products. Of 101,956 individuals exposed to 23 different HIG product groups, 86 (0.84 per 1,000 persons) had a TE diagnosis code (DC) recorded on the same day as HIG administration. Unadjusted same-day TE DC rates (per 1,000 persons) ranged from 0.4 to 148.9 for different products. GamaSTAN S/D IG >10 cc had statistically significantly higher same-day TE DC risk compared to Tetanus IG (OR = 57.57; 95% CI = 19.72-168.10). Increased TE risk was also observed with older age (≥45 years), prior thrombotic events, and hypercoagulable state(s). Laboratory investigation identified elevated Factor XIa activity for GamaSTAN S/D, HepaGam B, HyperHep B S/D, WinRho SDF, HyperRHO S/D full dose, and HyperTET S/D. Our study, for the first time, identified increase in the same-day TE DC risk with GamaSTAN S/D IG >10 cc and suggests potentially elevated TE risk with other HIGs.

Objective To estimate the risk of erectile dysfunction in men who used 5-α reductase inhibitors to treat benign prostatic hyperplasia or alopecia. Design Cohort studies with nested case-control analyses. Setting UK Clinical Practice Research Datalink. Population Two populations of men free of risk factors for erectile dysfunction and other sexual dysfunction or its treatment: men aged 40 or more with benign prostatic hyperplasia who received a prescription for a 5-α reductase inhibitor (finasteride or dutasteride) or α blocker, or both, and men aged 18-59 with alopecia. Exposures In the benign prostatic hyperplasia study, exposures were classified as 5-α reductase inhibitors only, 5-α reductase inhibitors+α blockers, or α blockers only. In the alopecia study, exposures were finasteride 1 mg or no treatment. Main outcome measures Cases were men with a diagnosis of erectile dysfunction or treatment (procedure or prescription for a phosphodiesterase type 5 inhibitor) during follow-up. We calculated incidence rates and adjusted incidence rate ratios with 95% confidence intervals. We also conducted nested case-control analyses to control for major confounders, and calculated adjusted odds ratios with 95% confidence intervals. Results In the population with benign prostatic hyperplasia (n=71 849), the risk of erectile dysfunction was not increased with use of 5-α reductase inhibitors only (incidence rate ratio 0.92, 95% confidence interval 0.85 to 0.99; odds ratio 0.94, 95% confidence interval 0.85 to 1.03) or 5-α reductase inhibitors+α blocker (1.09, 0.99 to 1.21, 0.92; 0.80 to 1.06) compared with α blockers only, and remained null regardless of number of prescriptions or timing of use. The risk of erectile dysfunction increased with longer duration of benign prostatic hyperplasia, regardless of exposure. For the alopecia population (n=12 346), the risk of erectile dysfunction was not increased for users of finasteride 1 mg compared with unexposed men with alopecia (1.03, 0.73 to 1.44; 0.95, 0.64 to 1.41). Conclusion 5-α reductase inhibitors do not seem to significantly increase the risk of incident erectile dysfunction, regardless of indication for use. Risk of erectile dysfunction increased with longer duration of benign prostatic hyperplasia.

Udgivelsesdato: 2008-May-7 BACKGROUND:: The World Health Organization has emphasized the need for research into the possible effects of radiofrequency fields in children. We examined the association between prenatal and postnatal exposure to cell phones and behavioral problems in young children. METHODS:: Mothers were recruited to the Danish National Birth Cohort early in pregnancy. When the children of those pregnancies reached 7 years of age in 2005 and 2006, mothers were asked to complete a questionnaire regarding the current health and behavioral status of children, as well as past exposure to cell phone use. Mothers evaluated the child's behavior problems using the Strength and Difficulties Questionnaire. RESULTS:: Mothers of 13,159 children completed the follow-up questionnaire reporting their use of cell phones during pregnancy as well as current cell phone use by the child. Greater odds ratios for behavioral problems were observed for children who had possible prenatal or postnatal exposure to cell phone use. After adjustment for potential confounders, the odds ratio for a higher overall behavioral problems score was 1.80 (95% confidence interval = 1.45-2.23) in children with both prenatal and postnatal exposure to cell phones. CONCLUSIONS:: Exposure to cell phones prenatally-and, to a lesser degree, postnatally-was associated with behavioral difficulties such as emotional and hyperactivity problems around the age of school entry. These associations may be noncausal and may be due to unmeasured confounding. If real, they would be of public health concern given the widespread use of this technology.

Vietnamese populations in Vietnam and the United States have a high prevalence of smoking. The associations among behavioral risk factors, acculturation, and smoking among the Vietnamese population living in the United States are not well documented. The present study aimed to identify the factors associated with smoking behavior among Vietnamese men living in Santa Clara County, California. A cross-sectional random-digit-dialed telephone survey was conducted. The sampling frame consisted of 27 Vietnamese surnames from the Santa Clara County telephone directory. A total of 660 adult respondents were interviewed to collect information on general health status, alcohol and tobacco use, HIV/AIDS, sexual behavior, injury control, hypertension, cholesterol screening, and acculturation. Of the 660 adults interviewed, 364 (55.2%) were male and 296 (44.8%) were female. Among males, 31.9% were current smokers, and among females, only one woman reported smoking. Univariate analyses revealed that having less than a college education, having poor English language skills, using Vietnamese at home and with friends, being less acculturated, not having a routine physical or blood cholesterol check, and being a binge drinker were significantly associated with an increased likelihood of smoking. Multivariate analysis revealed two independently associated factors: Respondents who were more acculturated were less likely to smoke (OR = 0.38, 95% CI = 0.18-0.83), and those not having cholesterol checked were more likely to smoke (OR = 2.48, 95% CI = 1.30-4.71). Acculturation level was inversely associated with smoking among Vietnamese adult men in Santa Clara County. Other health risk behaviors coexisted with smoking behavior and should be considered in prevention programs.

The purpose of this paper is to provide a framework for future research and awareness activities in the United States.The current literature in the English language on cancer incidence and mortality among Asian Indians was reviewed.Asian Indians comprise 89% of the U.S. South Asian population. There are few studies in the United States or Canada on cancer incidence or mortality. In India, oral and cervical cancers have high incidence and mortality rates, but the rates of cancers common in the West are rising. In Great Britain, cancer rates in the South Asian community are similar to those of their non-Asian counterparts.Cancer incidence and mortality rates in India and Great Britain provide a foundation for scientific inquiry among this population in the United States, but more data is needed to assess the cancer burden and implement cancer prevention activities in this country.

Introduction: Occupational exposure to arylamine compounds is a well-established risk factor for bladder cancer. With greater regulation, industrial arylamine exposure in the United States has reduced, thus making tobacco smoke the predominant source of arylamine exposure. Though exposure is greater in China than in the US, bladder cancer rates are higher in the US. These circumstances, together with evidence of familial aggregation of bladder cancer, have long suggested a role of inherited genetic factors in disease etiology. Previous studies indicate that slow variants of polymorphic N-acetyltranseferase, an arylamine-metabolizing enzyme encoded by the NAT2 locus, is a risk factor. Differences in distribution of slow acetylation may underlie demonstrated ethnic differences in bladder cancer risk. Thus cases of transitional cell carcinoma of the urinary bladder were studied to understand the role of the NAT2 gene and arylamine exposure differences between Caucasians and Chinese. Methods: A population-based case-control study of bladder cancer conducted in Los Angeles County (LA), California and Shanghai, China. Cases were diagnosed with urothelial carcinoma from 1987 to 1996 and from 1995 to 1998 in Shanghai. Controls were matched on gender, age in both populations, with further matching on neighborhood in Los Angeles. Participants completed in-person interviews providing information on several risk factors including smoking. All Shanghai participants and those LA participants interviewed from 1992 onward provided peripheral blood samples. Participants also provided samples of urine following timed ingestion of caffeine from which urinary metabolite ratios were assessed as a phenotypic measure of NAT2 activity. Genotypic analysis of 30 Tag SNPs within the NAT2 locus was conducted, and inferred phenotype assigned by haplotype analysis (SAS/Genetics, Proc Haplotype) followed by assignment of “slow” and “rapid” alleles according to consensus NAT2 gene nomenclature (http://louisville.edu/medschool/pharmacology/consensus-human-arylamine-n-acetyltransferase-gene-nomenclature/nat_pdf_files/Human_NAT2_alleles.pdf) was done. Gene-disease associations were estimated in subsequent statistical analysis employing logistic regression using N:M matching and an additive model for genetic effect. Results: 786 (LA) and 1026 (Shanghai) participants contributed to the analysis. As previously reported (Carcinogenesis 29:1386, 2008), bladder cancer risk was associated with “slow” measured phenotype among the LA participants who reported smoking 30 or more pack-years. Among LA participants, we further observed that rs1495741A (OR=1.47, 95% CI: 1.08–1.99) to be associated with risk, as reported for a separate study population of European origin (Pharmacogenetics and Genomics 21:231,2011). Among Shanghai participants, “slow” measured phenotype was also associated with risk (OR=1.44, 95% CI: 1.08–1.92). Unexpectedly, among Shanghai participants, both the “slow” inferred phenotype and rs1495741A allele were associated with risk in the direction opposite to that observed among LA participants (OR=0.65, 95% CI: 0.44–0.94; OR=0.70, 95% CI: 0.50–0.97). Based upon consensus NAT2 gene nomenclature, nearly 29% of Shanghai participants had at least one haplotype defined as a “slow substrate dependent” allele, whereas such alleles were observed in fewer than 3% of LA participants. Conclusions: Lower bladder cancer occurrence among Chinese compared with non-Hispanic whites may be related in part to differences in genetic susceptibility. Additional studies are ongoing to clarify whether ethnic differences in associations to inferred phenotype and to rs1495741A arise from differences in organization of the NAT2 locus between populations of European and Chinese descent as well as differential exposure of these populations to mono-versus diarylamines (Int J Cancer 118:161, 2006), or perhaps to both of these factors. Citation Information: Cancer Prev Res 2011;4(10 Suppl):A62.

We feel that Baluja and her coauthors1 missed an opportunity to address a paradox. Rates of smoking among male Chinese American youths are remarkably low,2 yet smoking rates among Chinese males living in China are said to exceed 60%.3 Baluja and associates reported the smoking prevalence rate for Chinese American immigrant males to be around 13%, which was well below the corresponding US male smoking prevalence rate of 24%.1 From these results, we infer that selection pressures involved in the immigration of Chinese to the United States favor Chinese who do not smoke. Indeed, immigrants generally exhibit healthier lifestyle practices and experience lower mortality rates than demographically similar US natives.4 We also feel that the authors could have been more proactive in warning readers about 2 additional limitations of their data. First, no questions were asked about tobacco products rarely used by Americans but commonly used overseas, such as bidis or paan. The low rates of smoking reported for US immigrants from India compared with US immigrants from other Asian countries might lead the naive reader to assume that overall tobacco use among immigrant Indians was low. Such an inference may be incorrect. Recent worldwide comparisons suggested that Indian women had the highest world incidence of oral cancer, attributable to their habit of chewing betel nut mixed with tobacco.5 Babu estimated that 90% of oral cancers in India were tobacco-related.6 In fact, estimates for 20007 suggested that oral cancers were the most important cause of cancer death in Indian males and the no. 2 cause of non–reproductive organ cancer death in Indian females. Comparisons between countries in use of just 1 tobacco product may hence suggest misleadingly low rates of overall tobacco use for some countries and their emigrants. A second additional limitation of the data was the implicit assumption that “country of origin” was a highly sensitive way to capture US immigrants of Asian national origin. In fact, US immigration quotas compelled many would-be immigrants to sojourn in Canada, Mexico, or Europe before migrating to the United States. Historic diasporas, such as the emigration of Indian nationals to British commonwealth countries, have also contributed to 2-step migrations to the United States. It is likely, then, that some US immigrants of Indian national origin were not counted in the results reported by Baluja and her associates because they listed a country other than India as their most recent country of origin.