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Critic Penelope Green reviews and critiques Caitlin Macy's The Fundamentals of Play, paying particular attention to how gender impacts the story. Green comments "what a book Macy might have made of Kate's inner life," but sadly, the book focuses on the bland Carraway-lite George Lenhart. Green wishes that the Macy would have chosen a female narrator, which would have better illuminated the confluence of gender and class in the 1990s.

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THE FUNDAMENTALS OF PLAY

By Caitlin Macy.

289 pp. New York:

Random House. $24.95.

KATE GOODENOW is the kind of girl who works at Sotheby's, summers in Maine and truly believes that her years at boarding school were the best of her life. She finds New York ''dirty and awful,'' but ''so, so, so, so fun.'' She's such a type she scarcely seems real. Nevertheless, she's the axis on which Caitlin Macy's first novel spins -- the blond, blank foil for the passions and aspirations of her many male admirers. Kate is sporty and she's a sport too, which means she's always up for white-bread shenanigans like prank calls to someone's boss or swimming in public fountains. She's also something of a bore. Still, according to George Lenhart, the book's narrator and Kate's chief apologist, ''Kate was what you wanted, somehow, in this infinitely ironic age. She was the kind of girl about whom other girls used to say, 'All right, so she's thin but,' trying vainly to suss out the appeal.''

George and Kate and their boarding-school pals find themselves in Manhattan after college (Dartmouth for George, Yale for Kate), but it's a weird, anomalous young fogy's Manhattan, a coded world of private clubs and shared antecedents and endless cocktails. The odd man out is Harry -- originally Henry -- Lombardi, a computer and math wizard who dropped out of Dartmouth to become a mini-software mogul. When we meet him, he's looking for seed money for his new company, which has something to do with providing access to -- you won't believe this -- the World Wide Web.

Harry is awkward and eager and totally N.O.C.D. (not our class, dear), but he aches, improbably, to be part of this retrograde crowd. He has absorbed the Kate myth from his college friends: George and a pompous throwback called Chat Wethers. Harry can recite the details of Kate's privileged life, from her yacht club victories to her boarding-school romance with a stoned sailor townie, like a well-learned catechism. (Harry, it must be pointed out, is also -- yikes! -- a Catholic.) Harry sets out on a quest for Kate, and the collision between his world and hers spells ''train wreck'' in capital letters. George watches from the sidelines, keeping a cool, ironic distance until a final act forces him to choose between the ''Fairisles in camphor'' and real life.

If this all seems familiar, it's because you've read it before -- or at least bits of it. I had so thoroughly confused George Lenhart with Nick Carraway that it was something of a shock when another Nick, the stoned sailor who is the book's real tragic figure, drifted across the page. I found myself riffling back to remind myself of George's name. Kate, inane and featherbrained and totally undeserving, is mostly Daisy Buchanan, yet without Daisy's innate sense of doom. Daisy knows she's dancing on the edge of the volcano; Kate is oblivious, although Macy throws in a few chiaroscuro touches, hints of a ''rest'' cure or two. ''It's just a little trouble she had last winter,'' Chat confides to George. ''She wasn't getting out enough, she wasn't having fun.'' But Kate is mostly just a bowl of milk: ''From the blank, pleasant expression on her face, you would have thought she could see no farther than the inner surface of her own eye.''

Sometimes Harry is Gatsby and sometimes he's Rex Mottram, the ''new man'' in Waugh's ''Brideshead Revisited,'' another portrait of a society's last days. Sometimes Kate is Julia Marchmain, trying to pole-vault herself beyond the irrelevancies of her class in an alliance with the new man. And then George is Charles Ryder, Waugh's emotionally hamstrung narrator. Says George-as-Charles: ''It was my problem if I lived life ironically, if indeed it was the only way I knew. It wasn't as if I even believed in it. I saw how thin it was, I saw the poverty of it -- that I couldn't make love to her because it wasn't an ironic act.''

''The Fundamentals of Play'' invites these sorts of lit-crit imaginings because it has such a period-piece feel. It's like a Whit Stillman movie; you keep thinking, ''Who are these people?'' Macy is a nice writer, and there are some wonderfully evocative passages -- about the group's anachronisms, say, or Newport, Kate's family seat, or sailing, or this one about Kate's aunt: ''Her face was tan -- the whole party was filled with parents who had better tans than their children -- and she wore pink lipstick that sat on her lips and beamed when they beamed.'' But you wish Macy would shake the shtick. It doesn't help that she's chosen a male narrator; the gender switch ruins the pitch and compounds the book's costume-drama portentousness. In any case, the mental terrain of a narrator like George has been amply Baedekered. But the Kates of this world represent truly foreign territory. What a book Macy might have made of Kate's inner life.

Much of the time, Macy's characters say and do the most improbable things. It's hard to stifle the giggles when Harry starts talking about his business: ''The computer network -- the interconnected networks. The 'World Wide Web.' And I'm going to be providing a, a, like an entrance to it. Or like, like a navigation tool. A, ah, whatchama call it -- on a boat. You know.'' Poor Harry is always sputtering. If you've read ''The New New Thing,'' it's hard not to see the dissonance between Harry and Jim Clark, with his damn-them-all flourishes. Sure, it's not fair to make comparisons between journalism and fiction, but by inserting such a specific real-time reference, Macy forces this one.

I READ that Scott Rudin has bought the rights to this novel for Paramount Pictures -- for a sum in ''the mid-six figures,'' according to The Hollywood Reporter -- because the story has so many casting opportunities for young actors. Come to think of it, ''The Fundamentals of Play'' probably would make a good movie -- at least a better movie than a novel like this, with its cardboard-cutout characters, upon whom the plot rests uneasily, just as Kate wears her clothes. While I was reading it, I amused myself by casting the different parts.

The default choice for Kate, of course, is Gwyneth Paltrow, for her long-limbed, blond blandness, her Spenceness. But really, even Paltrow is too kittenish for the wooden Kate. The newly blond but still-dark-at-heart Ed Norton can be George, with his genteel poverty and his doubts. Harry's a tough one. Ben Stiller? Too goofy. Johnny Depp? Too delicate. Keanu Reeves? Just kidding. But I'm still stumped. Unlike Gatsby, Harry isn't done in by his humanity -- which I guess makes this a new story after all.

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THE FUNDAMENTALS OF PLAY By Caitlin Macy. 289 pp. New York: Random House. $24.95. KATE GOODENOW is the kind of girl who works at Sotheby's, summers in Maine and truly believes that her years at boarding school were the best of her life.

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As The Fundamentals of Play focuses heavily on issues of class and economics in 1990s New York City, it is important that we understand the real world economic context during that time period. According to "Retrospective on American Economic Policy in the 1990s", a paper analyzing the 1990s American economy published by the Brookings Institution, "The 1990s American boom, to the contrary, was led by private-sector spending and private-sector employment. And for the first time in three decades, productivity growth rose substantially in the late 1990s." Despite this "outstanding" economic success, "Personal bankruptcies climbed, the personal saving rate plummeted (as measured in the national income statistics), the trade deficit expanded dramatically, and the stock market may well have become substantially overvalued." This economic boom coincided with the rise of the dot-com bubble in 1991, which is reflected in Harry's backstory as a pioneer of early internet services.

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Abstract
This paper is based upon the Introduction to American Economic Policy in the 1990s, which will be published in the Spring of 2002 by the MIT Press. The book is the outcome of a conference held at Harvard's Kennedy School of Government in June 2001, which brought together leading policy-makers and economists with the goal of providing a preliminary history of U.S. economic policy-making during the past decade. The book is divided into 14 chapters, each examining a different area of economic policy: Monetary policy, fiscal policy, tax policy, international finance and crises in emerging markets, trade policy, information technology, industrial organization, energy policy, environmental policy, labor and education, poverty and welfare, health care and tobacco policy, Medicare policy, and the policy-making process. This paper, which is based upon the Introduction to the volume, includes a discussion of distinguishing characteristics of "Clintonomics" in historical perspective, a cataloguing of reasons for the good economic performance enjoyed by the country during the years 1993-2000, an explanation of the difficulties of apportioning credit for such outcomes, and some thoughts on the under-appreciated perils of excessive transparency in government.

Decades take on characteristics in our minds. The 1970s make us think of oil shocks and Watergate, and the 1980s of supply-side economics and the end of the Cold War. How will historians-or economic historians, at any rate-remember the 1990s?

It is not too soon to predict. The New Economy and Greenspan. The Internet, dotcoms, and IPOs. Monica and the West Wing. The cell phone and the Palm Pilot. Policy-wonk slogans, some carefully planned and some unplanned: "The Economy, Stupid"; "The era of big government is over"; and "Save Social Security First." The Contract with America and the Gingrich revolution. NAFTA and the "giant sucking sound." The Asian crisis. Tobacco litigation and the Microsoft trial.

The two Clinton terms occupied most of the 1990s. Unquestionably, history will remember this period as a time of strong economic performance. Between 1993 and 2000, the United States exhibited the best economic performance of the past three decades. In 2000, the U.S. economic expansion surpassed in length the expansion of the 1960s, and thus became the longest on record. During Clinton's second term, real economic growth averaged 4 ½ percent per year, and unemployment fell to four percent, the level that had been specified by the Humphrey-Hawkins legislation three decades earlier to be the goal of national policy. During the early 1990s, economists would have considered these outcomes wildly unattainable.

Strong growth and low unemployment were particularly remarkable because they were accompanied by structural budget surpluses and low inflation. Long expansions have historically been fueled in large part by expansionary fiscal or monetary policies, with the result that, by their six-year mark, debt ratios and inflation rates had risen to high levels, sowing the seeds of a subsequent contraction. Furthermore, productivity growth typically slows as an expansion matures. The 1990s American boom, to the contrary, was led by private-sector spending and private-sector employment. And for the first time in three decades, productivity growth rose substantially in the late 1990s, despite the length of the expansion at that point. The cause of this acceleration in productivity is still the subject of debate. (Section II of this paper briefly catalogs the likely contributing factors to the strong performance of the U.S. economy during the 1990s.)

To be sure, some observers found cause for concern in various aspects of economic performance during the 1990s. Personal bankruptcies climbed, the personal saving rate plummeted (as measured in the national income statistics), the trade deficit expanded dramatically, and the stock market may well have become substantially overvalued. Overall, however, U.S. economic performance during the 1990s was outstanding.

The reader may wonder if the subject of American Economic Policy in the 1990s is the years 1991-2000, or the Clinton Administration per se (1993-2000). The answer is that it examines both. The period 1990-2000 approximates a complete business cycle. The economy was close to potential in early 1990, before Iraq invaded Kuwait. The recession of 1990-91 and the continued high unemployment rates over the two years after the recession had technically ended-which initially tarred the expansion with the label "jobless recovery"-are widely thought to have cost George Bush the 1992 election. The years 1990-92 thus set the stage for the years 1993-2000. This is true in macroeconomic terms, and as well in many of the specific areas of policy. By the year 2000, the economy had returned to approximately the same point in the business cycle it had occupied in 1990.

Incidentally, the pattern of recession in the first few years of the decade, followed by steady growth in the remainder, repeated the pattern of the 1960s, 1970s, and 1980s.
I. Clintonomics
Arguably, the Clinton Administration had an overarching vision. It sought to adopt some of the pro-market orientation associated with the ascendancy of the Republicans in the 1980s, and marry it with traditional Democratic values such as concern for the environment and a more progressive income distribution. This combination made sense from an economic viewpoint. Standard textbook economics says that environmental externalities, anti-competitive practices, and other market failures or social goals require government involvement, while everything else should be left to the market.

Yet it produced tension within the Administration and with traditional Democratic constituencies. The "soft-hearted" and "hard-headed" components of the strategy were often in conflict, as evidenced by the debate over welfare reform, corporate responsibility, trade and the environment, and deficit reduction instead of aggressive public investments.

The 1993 budget package offers perhaps the most vivid example of the underlying vision of-but also the tensions inherent in-the Clintonomics approach. The 1993 budget agreement was politically difficult. Democrats feared that it might cost them their positions in Congress, a fear that eventually turned out be accurate in some cases. By the end of the 1990s, however, Democrats had largely embraced what one pundit called the "progressive fiscal conservatism" of the 1993 package. Such progressive fiscal conservatism combines modest attempts at redistribution (the progressive component) and budget discipline (the fiscal conservative component). Thus the 1993 package included significant spending reductions and tax increases. But it concentrated the tax increases on upper-income taxpayers, while substantially expanding the Earned Income Tax Credit, Head Start, and other government programs aimed at lower earners.

The experience of the 1990s eventually convinced even many liberal-leaning policy-makers that the progressive fiscal conservatism at the heart of Clintonomics offered an auspicious alternative to more traditional Democratic fiscal policies, which had emphasized government spending and public investment rather than fiscal discipline and private investment. One explanation for the shift may be that fiscal discipline had traditionally been presented as offering long-term benefits in exchange for short-term costs, a calculus that is not usually appealing in a political context. But fiscal discipline appeared to promote strong economic performance even in the short run. The short-run stimulative effect of long-run deficit reduction packages with accommodating monetary policy brought potential benefits for lower-income workers and others disproportionately affected by cyclical fluctuations in the economy. It thus relieved some of the tension inherent in progressive fiscal conservatism. Since economic benefits of fiscal discipline appeared to manifest themselves even in the short run, sound economic strategy was also a viable political strategy. (President Clinton urged supporters to "vote Democratic so that they could live like Republicans.")

Despite the conflicts in Clintonomics, or perhaps partly as a reflection of them, the combination of fiscal discipline and progressive policies made sense from a political viewpoint. If Democratic leaders in the 1970s and 1980s had often lost office by deviating too far to the "left" of the median American voter, and if Republican leaders since 1996 have often lost by deviating too far to the "right," Bill Clinton's policies were more in tune with the preferences of the median voter. This positioning undoubtedly contributed to his generally high popularity ratings and electoral success.

Indeed, critics of President Clinton often argued that he was too much in tune with the median voter-that he allowed polls and public opinion to determine policy positions. This is not to say that he never took positions that differed from what he thought the public wanted. The Mexican bailout of January 1995 provides perhaps the most vivid example. Management of this and subsequent financial crises in emerging markets may have turned out, quite unexpectedly, to be the second most important accomplishment of the Administration, after elimination of the budget deficit.

Critics of Clintonomics also argued that it was consumed with "nano"-level or small-bore policies, such as targeted tax cuts or minor changes to existing programs. The emphasis on small-bore policies reflected several fundamental forces.

First, the defining events in the Administration's first two years were the enactment of the 1993 budget agreement and the failure to enact the Administration's Health Security Act. The fiscal discipline created by the 1990 budget agreement and extended by the 1993 budget deal substantially reduced the scope for policy-makers to create or expand programs in a dramatic fashion. As a result, the natural tendency of policy-makers to "do" something, or at least to be viewed as doing something, was subsequently channeled into small-bore activities. The policies of the later years are therefore partly a reflection of the successful macro-policy of 1990 and 1993. Furthermore, the budget agreements also created pressure for emphasizing targeted tax cuts rather than spending programs within the sphere of small-bore policies. The budget agreements of 1990, 1993, and 1997 imposed tight limits on discretionary spending, but allowed tax cuts as long as they were coupled with "offsets" (reductions in entitlement spending or increases in other taxes). The budget rules, combined with the political economy favoring tax cuts rather than spending, biased policy-makers toward narrowly targeted tax cuts. Targeted tax credits were thus used in areas such as higher education (the Hope scholarship and the lifelong learning credit) and environmental research and development efforts (the proposed tax credit for high-mileage vehicles) that would have traditionally been addressed through spending programs.)

Second, the failure of the Health Security Act in 1994 convinced policy-makers in the Clinton Administration that it was wiser to attempt smaller changes than larger ones, since the larger ones were unlikely to be passed. Within health care, the upshot was a focus on providing health insurance coverage to women and children first. This approach continued a trend that preceded the Clinton Administration: Throughout the mid- and late-1980s, policy-makers had successively loosened access to the Medicaid program for poor children and mothers.

The basic continuity of policy across Administrations extends into many other areas. Often a new president, notwithstanding attacks on his predecessor during the election campaign, discovers not long after taking office that there turn out to have been good reasons for the way some things were done.

Third, the Republican takeover of Congress in 1994, the so-called Gingrich revolution, affected Administration strategy. In the face of Republican opposition to major Democratic initiatives, the Administration was forced to adopt more modest goals in many areas. The major domestic exception was welfare reform. Welfare reform was opposed by many traditional Democrats and may therefore support the general point that the political split between the executive and legislative branches precluded dramatic policy shifts toward "Democratic" policies; given Republican control of Congress, enactment of significant changes seemed possible only when the executive branch was willing to adopt a "Republican" policy. Some Republicans complained that Clinton was co-opting their issues. Moving to the political center on particular issues is, however, an option that is available to anyone.

This paper focuses primarily on the executive branch. The executive branch, however, does not exist in a vacuum. The constraints imposed by, and policies favored by, the Congress strongly condition executive-branch policy-making.

Fourth, small-bore initiatives often represented sound political strategy in the context of larger budget and programmatic reductions. For example, it was estimated that the Balanced Budget Agreement of 1997 would reduce Medicare spending by $385 billion over 10 years. Yet it also included small expansions in certain benefits-such as coverage for prostate cancer screening, annual rather than bi-annual mammograms, and annual pap smears-that helped to generate support for the overall package. The Administration's presentations tended to emphasize the expansions almost as much as the overall reductions, despite the dramatically different scales of the two policies. Whether the small-bore policies were necessary in order to make the overall package politically acceptable, and therefore whether the small-bore policies played a critical economic as well as political role, is an important question. In some cases, the complexity created by the small-bore policies was arguably the cost necessary for enacting a broader set of economically beneficial policies.

Finally, it is important to emphasize that many individual policy questions properly merit at most a small-scale government response. The cumulative effect of even small-bore policies can be significant. In information technology, for example, the Clinton Administration adopted an array of initiatives. The cumulative effect of those initiatives represented sound policy with regard to the Internet and other technological developments. In other areas, similarly, relatively small annual expansions in programs cumulated to a significant increase over the eight years of the Administration. For example, funding for Head Start more than doubled in constant dollars between 1992 and 2000, while enrollment rose by 38 percent.

Leaving aside the question of the Clinton Administration's focus on small-bore policies, some analysts argue that the Administration could not take credit for the success of the U.S. economy during the 1990s because that success was due to factors other than the Administration's own policies. We turn now to the various factors affecting U.S. performance during the 1990s.
II. Explaining U.S. Economic Performance in the 1990s
What are the reasons for the outstanding U.S. economic performance of the 1990s? A variety of short-term, medium term and long-term factors played a role. The short-term factors were luck, the medium term factors were skill, and the long-term factors are ongoing favorable structural trends in the U.S. economy.
Short-term factors: Temporary good luck on prices
In the 1990s, relative prices for computers and health care fell significantly. Until 1999, world prices for oil also remained low. And U.S. import prices were low generally, due both to the appreciation of the dollar in the second half of the 1990s, and to deflation in some partner countries, particularly in East Asia. All these factors put downward pressure on inflation, and thus prevented overheating despite rapid growth in the economy. Measured consumer price inflation was also temporarily restrained by revisions to the price index. Thoughtful observers knew these trends were unlikely to continue for long, and indeed some of the trends did come to an end at the close of the decade. But even if one adjusted the inflation rate for such short-term factors, the record of price stability at a time of high employment and growth was still impressive.
Medium-term factors: Good macroeconomic policy
The skillful exercise of macroeconomic policy, both fiscal and monetary, contributed significantly to the strong economic performance of the 1990s. Three key fiscal policy turning points included the 1990 budget agreement, the 1993 budget agreement, and the 1998-2000 preservation of the emerging unified budget surpluses for debt reduction. The 1990 budget agreement represented an important step toward fiscal discipline, and included marginal tax rate increases that imposed substantial political costs on President George Bush. In 1993, the Clinton Administration built upon and strengthened the 1990 deficit reduction effort, by further raising taxes on the highest-income taxpayers and reducing spending relative to the budget baseline. These efforts, along with strong growth in income and therefore tax revenue, replaced intractable budget deficits with substantial surpluses by the end of the decade. Indeed, in the last years of the decade, the principal fiscal accomplishment of policy-makers was what they didn't do-dissipate the accruing surpluses in the form of substantial tax cuts or program expansions-rather than what they did do.

Whatever the explanation, the Federal government's movement from deficit to surplus accounted for all of the improvement in net national saving between 1993 and 2000. This additional saving restrained long-term interest rates, thereby boosting private-sector domestic investment. As noted above, the experience of the 1990s highlights the economic stimulus that can be provided by long-run deficit reduction accompanied by monetary ease-a phenomenon that had been discounted by many macroeconomists before the 1990s.

Fiscal responsibility ultimately proved to be more politically popular than could have been expected from President Bush's experience in 1990. The surprising popularity that Ross Perot achieved in 1992 with the budget issue pointed the way. The public had apparently learned from the experience of the 1980s to be skeptical of politicians selling snake-oil tax cuts. A decade ago it looked as if the country might be doomed to a pro-cyclical fiscal policy of pursuing fiscal expansion when times were good and finding discipline only in time of recession, the point in the business cycle when raising taxes was least appropriate. The Clinton Administration's clever "Save Social Security First" strategy in 1998 underscored the political viability of fiscal discipline even in an expansion, transforming what had previously appeared to be politically unattractive-the preservation of the unified budget surplus for debt reduction-into a politically successful strategy.

True, the long-term fiscal positions of Social Security and, especially, Medicare have not yet been fully addressed. Furthermore, it should be noted that the new Bush Administration succeeded in passing a significant tax cut in 2001. But despite an active Bush Administration effort to convince the public that the tax cut was needed, polls indicated that many Americans would rather have spent the money on paying off the debt and putting Social Security and Medicare on a sound footing than on a tax cut.

We turn now from fiscal policy to monetary policy. The Clinton Administration made two contributions to monetary policy. First, the elimination of the budget deficit allowed the Fed to lower interest rates. Second, the Clinton Administration's monetary policy otherwise was simple to state: leave it to the Fed. Adhering to this policy is more difficult than it sounds. The political temptation is always strong to nudge the central bank toward an easier monetary policy: even if the monetary authorities don't respond, the complaints give the Administration someone to blame in the future if the economy slows down. In addition, officials are naturally tempted to respond to press inquiries with statements that, while not intended to be critical, or even substantive, are nevertheless inevitably interpreted as second-guessing the Fed. With remarkably few exceptions, the Administration adhered to its self-imposed rule of silence.

The lack of Administration interference worked well because the Fed was skillful. Even if, in retrospect, the tightening of 1999-2000 may have gone one step too far, Chairman Greenspan's record overall during the decade was quite impressive. The truly remarkable feature of the 1990s was not just its low inflation, but its low and steady inflation. At least some of the credit for this stability must belong to Greenspan. Like Paul Volcker before him, Greenspan followed a tight monetary policy early in his term, established a reputation for discipline, and was thereby able to take a more moderate stance during the remainder of his term. His forbearance during 1995-1998, even as growth and employment exceeded levels previously considered inflationary, was a gamble; but from many perspectives it appears to have been a wise gamble and an important component of the expansion's longevity.

Perhaps the simplest overall conclusion one can draw from the 1990s is that the U.S. economy runs relatively well given a little luck and the avoidance of major macroeconomic policy mistakes.
Long-term factors
Many of the most fundamental factors in explaining U.S. economic performance during the 1990s stretch back over two decades or more:

Deregulation. The U.S. economy has long been less regulated than most other industrialized economies. But the past 25 years have witnessed important further steps toward deregulation. The deregulation trend began during the Carter Administration, in trucking, airlines, natural gas, and banking. During the Reagan Administration, deregulation was extended to the telecommunications sector. More recently, further deregulation has occurred in the electricity market, and market-friendly environmental regulation, such as in the sulfur dioxide permit program, has been expanded. Some of these deregulation efforts have faced bumps in the road, particularly banking and electricity. Nevertheless, the overall effect of deregulation has been to make the U.S. economy more efficient in the long run. The fundamental continuity of policy across Administrations in these areas also highlights a theme mentioned above: despite the drama of changes in Administrations, policy does not shift nearly as much as one would imagine.

Globalization. With important exceptions, the U.S. has had a basic free trade orientation since World War II. The ratio of trade to GDP has more than tripled since the middle of the 20th century and now stands at 26 percent (imports plus exports, including services, which have increased especially rapidly). Economic theory tells us that trade improves economic performance. This is true both of old trade theory (classical "comparative advantage") and of new trade theory (which allows for changing technology, increasing returns to scale, and imperfect competition). Perhaps more convincingly, the statistical evidence also tells us that openness contributes to growth. Exports grew rapidly, a major selling point for free trade policy. Even the increases in imports and in the trade deficit during the 1990s, though politically unpopular, were a useful safety valve during the strongest phase of the U.S. expansion. They released pressure from rapidly growing domestic demand, pressure that would otherwise have shown up as higher inflation and interest rates.

Innovation. The third category of favorable long-run structural factors is innovation. Innovation can be further divided into three types: technology, competition and flexibility in goods and labor markets, and the public sector. Technological innovation, especially information technology, received much attention during the 1990s. Although the IT revolution was not the sole reason for strong U.S. economic performance in the 1990s, it certainly was a positive factor. The second type of innovation involves competitive markets. The United States has always had relatively competitive goods and labor markets, compared with Europe for example. But the last two decades have seen a further movement in this direction, including the initially unpopular corporate restructuring of the 1980s and the initially popular dot-com start-up firms of the 1990s. Anti-trust enforcement became more active during the Clinton Administration. The final category is innovation in the public sector. Public-sector reforms include reinventing government and defense reconversion, which have allowed previously low-productivity resources to be shifted to more productive uses, and welfare reform.

Apportioning credit
Short-term luck on the supply side, medium-term skill in macroeconomic policy management, and long-term favorable structural trends that were called by some a "New Economy"-this is a long list of factors. After compiling the list, is it possible to apportion the credit among the various factors? In particular, many observers and pundits are interested in how much credit for the strong economic performance of the 1990s should be given to the Clinton Administration's policies. Unfortunately, providing a specific answer to this question is not possible, at least not in this book.

On the one hand, we often speak as if the perceived performance of the economy during a given period shows directly the virtues of the president and his team during that period. On the other hand, observers often note that the course of the economy in fact reflects exogenous factors to a greater extent than it reflects the actual personal strengths and weaknesses of the man who was president, with the implication that the contribution of the latter should be dismissed. It should be evident that the president in fact generally deserves a share of credit for what happens on his watch that is neither zero nor 100 percent. But it is more complicated than that.

A metaphor may offer insight. Imagine the president as the captain of a large ship. Whether the passengers in the hold experience rough seas or a calm ride depends on factors such as the weather and the construction of the ship to a greater extent than the skills of the captain. Nevertheless, helmsmen can be skilled or incompetent, and the difference affects the ride.

Disentangling causality, credit, and blame for either a smooth sail or a rough one is exceedingly complex. Things can go wrong through no fault of the leadership, or can go right for the wrong reason. If an unpredictable squall arises on a particular navigational route, it does not mean that the captain erred in choosing that route over another. Conversely, smooth sailing does not mean that he picked the best route. Thus it is not meaningful to parse out fractions of the total credit for the economy's good economic performance in the 1990s to Bill Clinton, Alan Greenspan, information technology, or other forces.

An example illustrates the problems in parsing out credit for what happened (or did not happen). The White House sent Zhu Rhong Zhi away in the spring of 1999 without an agreement on Chinese accession to the World Trade Organization (WTO), even though China had made many important concessions (relative to what other developing countries have agreed to when joining the WTO, or what had been expected). Was this a mistake on the part of the White House? It seemed like a mistake over the subsequent months, as the U.S. business community reacted adversely, Zhu and other reformers were undercut politically in China, and the accidental bombing of the Chinese Embassy in Belgrade further worsened U.S.-China relations. In judging the wisdom of the spring 1999 decision, however, the key question is: Did the decision reflect a sensible balancing of the pros and cons at the time, given the information that was available? Such an evaluation would have to include the political constraints on the White House, which are often conveniently forgotten in discussions of this type. For example, the White House had to consider the reactions an agreement on Chinese accession would elicit from Senators opposed to such an agreement, and the reaction (or absence thereof) from businessmen favoring it. It would have been of little use to sign a good agreement that could not have been ratified by the Senate. Complaints from the business community about the lack of an agreement were in the end important in persuading Congress to vote for it.

Too often, we evaluate the captain's performance only by conducting polls among the passengers in the hold. It is indeed worth knowing whether the passengers feel they are experiencing a smooth ride. But journalists, academics, and other opinion leaders have the ability to go on deck and observe for themselves what sort of job the captain is doing. It is their responsibility to do so, and they owe it to the passengers to report on what they see. In undertaking such evaluations, five different levels of performance are relevant:

Personal characteristics: How do the president's abilities compare to others who have held the office or could have held the office? Relative criteria include stamina, capacity to absorb and synthesize information, ability to make decisions, speaking ability, ability to communicate warmth and inspire confidence in common people, honesty, skill at picking good staff, and so on. In the specific case of economic policy, another relevant attribute is whether the president is economically literate and numerate.

Process: How well does the president's administration function? When it is reported in the press that the president has done something, often it is in fact not he but his representatives who have done it. Of course it is appropriate to hold him, as a manager, responsible. But analytically we must realize that other random factors begin to enter at this second stage. To take but one example, if many of the president's nominees have not been confirmed by the Senate, nor even considered by the Senate, the president may not be wholly to blame if the policy process then does not run smoothly.

Quality of policies implemented: How good are the spending programs, tax policies, regulatory decisions, international negotiations, and so forth that are implemented? In the face of Congressional opposition, it may be foolish to blame the White House for a budget or a trade measure if it is clear that it did its best to argue for some other better outcome but was stopped by the Congress.

Outcomes: What are the actual outcomes in the economy? What are the rates of growth, unemployment, and inflation? How strong is the budget position? The government may function well, and the policies chosen may be good, but exogenous shocks, like the oil price increases of the 1970s or some favorable developments in the 1990s, may be beyond its control.

Perceptions: What are the public's perceptions of the president's performance? Although economists are primarily interested in actual outcomes, much of the rest of society is interested in this final level. What are the president's popularity ratings, what do polls say on aspects of his performance, what are the editorial writers and other opinion leaders saying, how well do he and his party do at the next elections, and what is the judgment of history?

to be sure, causality runs in all directions among these five levels of evaluation. For example, confidence about the direction in which the country is headed is often reflected in consumer confidence and stock market prices, which in turn can affect consumption, investment, and overall growth. But the central point is that, even though only the first level concerns the intrinsic abilities of the president, additional exogenous random factors can enter at each stage as we move down the chain to lower levels. This makes it hard to judge a president solely by perceived or actual outcomes: we can't trace our way back up the chain from the perceived or actual outcomes to the president's own characteristics.

Thus it is not the task of this paper or the forthcoming volume to evaluate the quality of presidential leadership in the 1990s. Rather the point is primarily to examine in detail the many policy decisions that were made-the third stage above. This examination will shed light on the links back to the first and second levels, as well forward to the fourth and fifth levels. But it does not answer, nor even attempt to answer, what specific share of the credit for good economic performance during this period should be given to the Clinton Administration.
III. A Note of Warning
We close this paper with a note of caution: future endeavors of the type embodied in American Economic Policy in the 1990s may be undermined by the rules governing disclosure of internal information. Advocating transparency has become akin to advocating motherhood and apple pie. For example, it is an important part of reforms urged on governments in developing countries, as well as on the International Monetary Fund itself, in the aftermath of the international currency crises of 1997-98. But there can be such a thing as too much transparency. To take an example, sunshine laws essentially forbid a group of governors of the Federal Reserve Board from informally discussing monetary policy with each other outside official meetings. What is gained by this?

Our experience in the Clinton Administration suggests that despite the general benefits of disclosure in promoting good government, the formal disclosure rules have become counter-productive. In particular, the Freedom of Information Act (FOIA) and the rules governing Congressional subpoena powers sometimes discourage executive-branch policy-makers from writing things down. Such written material is too often subject to Congressional inquiry, discovered through the FOIA process, or otherwise proven to be politically problematic.

The intent of these rules is to expose the decision-making process to scrutiny. Such scrutiny is generally beneficial. But the ultimate effect of the rules may be to expose decisions to less scrutiny, because of the response of policy-makers to the incentives posed by the rules. It is not only the policy-making process that suffers as a result; historians will also find it much more difficult to discern what actually happened and why without the benefit of an accurate paper trail. Furthermore, compliance with the current system consumes an inordinate amount of policy-makers' time.

The balance between public disclosure and internal candor has thus, in our opinion, tipped too far toward the former in the United States. For example, top Administration economists spent substantial amounts of time combing through files in response to Congressional subpoenas, looking for internal background memoranda on climate change. Such internal memoranda, which explored potential policy options and evaluated the pros and cons of different approaches, were essential to an honest internal policy process. But some were also politically sensitive. The benefits of transparency in such cases are not entirely clear: What specific public benefit (as opposed to political benefit to the Administration's opponents) arises from publicly releasing the CEA's internal analyses of potential Administration policies, including those not chosen by the Administration? How should one weigh any such benefits against the costs of the associated incentive to avoid writing things down?

In our view, it would be beneficial to provide more protection for pre-decision internal analyses. Put simply, the Administration should be expected to provide rigorous analysis of the option it finally chose, but should be able to protect-at least temporarily-materials regarding the options not chosen as well as internal views of the pros and cons regarding the chosen option. For such politically sensitive internal analyses, disclosure could be undertaken after some suitable period of time had elapsed, thereby limiting the potential political costs but still imposing discipline on policy-makers (who know that their internal analyses may eventually see the light of day).

This model would mimic the policy of the Federal Reserve Board, which releases the minutes of its confidential meetings only after some delay.

This volume benefited from the policy-making paper trail on numerous issues. The danger is that future volumes of this type may not benefit from such access, if disclosure rules discourage policy-makers from committing their thoughts and opinions to paper. The ultimate cost will then not be borne by future Administrations, but rather by those seeking lessons to be learned but finding only incomplete or inaccurate histories.

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Retrospective on American Economic Policy in the 1990s

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Abstract This paper is based upon the Introduction to American Economic Policy in the 1990s, which will be published in the Spring of 2002 by the MIT Press. The book is the outcome of a conference held at Harvard's Kennedy School of Government in June 2001, which brought together leading policy-makers and economists with the goal of providing a preliminary history of U.S.

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The book was set "the year they changed the name on the building that ruins the view down Park Avenue," referring to the MetLife building (1). This building, according to Wikipedia, changed its name from the Pan Am building to the MetLife building in 1992, meaning that the events of the book are set in or directly after 1992.

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The MetLife Building (also 200 Park Avenue and formerly the Pan Am Building) is a skyscraper at Park Avenue and 45th Street, north of Grand Central Terminal, in the Midtown Manhattan neighborhood of New York City. Designed in the International style by Richard Roth, Walter Gropius, and Pietro Belluschi and completed in 1962, the MetLife Building is 808 feet (246 m) tall with 59 stories. It was advertised as the world's largest commercial office space by square footage at its opening, with 2.4 million square feet (220,000 m ²) of usable office space. As of 2021, the MetLife Building remains one of the 100 tallest buildings in the United States.

The MetLife Building contains an elongated octagonal massing with the longer axis perpendicular to Park Avenue. The building sits atop two levels of railroad tracks leading into Grand Central Terminal. The facade is one of the first precast concrete exterior walls in a building in New York City. In the lobby is a pedestrian passage to Grand Central's Main Concourse, a lobby with artwork, and a parking garage at the building's base. The roof also contained a heliport that briefly operated during the 1960s and 1970s. The MetLife Building's design has been widely criticized since it was proposed, largely due to its location next to Grand Central Terminal.

Proposals for a skyscraper to replace Grand Central Terminal were announced in 1954 to raise money for the New York Central Railroad and New York, New Haven and Hartford Railroad, the financially struggling railroads that operated the terminal. Subsequently, plans were announced for what later became the MetLife Building, to be built behind the terminal rather than in place of it. Work on the project, initially known as Grand Central City, started in 1959 and the building was formally opened on March 7, 1963. At its opening, the building was named for Pan American World Airways, for which it served as headquarters. The Metropolitan Life Insurance Company (MetLife) bought the Pan Am Building in 1981 and used it as their headquarters before selling the building in 2005. The MetLife Building has been renovated several times in its history, including in the mid-1980s, early 2000s, and late 2010s.

The MetLife Building is at 200 Park Avenue, between the two roadways of the Park Avenue Viaduct to the west and east, in the Midtown Manhattan neighborhood of New York City. The building faces the Helmsley Building across 45th Street to the north and Grand Central Terminal to the south. Other nearby buildings include the Yale Club of New York City clubhouse to the west, across Vanderbilt Avenue; The Roosevelt Hotel to the northwest, across Vanderbilt Avenue and 45th Street; 450 Lexington Avenue to the east; and the Graybar Building to the southwest.

In 1871, the New York Central Railroad built the Grand Central Depot, a ground-level depot at the intersection of Park Avenue and 42nd Street; it was succeeded in 1900 by Grand Central Station, also at ground level. The completion of Grand Central Terminal in 1913 resulted in the rapid development of the areas around Grand Central, which became known as Terminal City. The Grand Central Terminal complex included a six-story building for baggage handling just north of the main station building, on what is now the site of the MetLife Building. The baggage handling building was converted to an office building late in its history. The surrounding stretch of Park Avenue was developed with International Style skyscrapers during the 1950s and 1960s.

Designed in the International style by Richard Roth, Walter Gropius, and Pietro Belluschi, the MetLife Building was completed in 1963 as the Pan Am Building. It is 808 feet (246 m) tall with 59 stories, containing both commercial and office space. As of March 2021, the MetLife Building is the 31st-tallest building in New York City and 74th-tallest in the United States.

The Diesel Construction Company was the general contractor for the building's construction. Numerous other engineers and contractors were involved in the building's construction, including Hideo Sasaki as site planning consultant and landscape architect; Jaros, Baum & Bolles as consulting engineers; and James Ruderman as structural engineer. From the beginning, the building was intended for large firms, with 2.4 million square feet (220,000 m ²) in office floor area. In total, it has 2,841,511 square feet (263,985.0 m ²) of gross floor area, according to The Skyscraper Center.

As designed, the massing consists of a base of nine stories, atop which is an octagonal section of fifty stories. Outside the building, both on the sidewalks and above the roof of the base, were planted areas.

The tower stories' floor plates are designed in an elongated octagonal lozenge, with the longer axis running parallel to 45th Street. The north and south facades are divided into three broad segments, while the west and east facades are one segment each. The building's form may have been influenced by the 1961 Zoning Resolution, a major change to New York City zoning code that was proposed just before construction started. The massing is similar to Le Corbusier's unbuilt tower in Algiers, proposed between 1938 and 1942, as well as the nearly contemporary Pirelli Tower in Milan. The architects intended for the octagonal shape and exterior curtain wall to reduce the building's perceived sense of scale.

The facade of the first two stories and mezzanines is clad with granite, aluminum, marble, and stainless steel with glass windows. On Depew Place, an alley running below the eastern leg of the Park Avenue Viaduct, fifteen loading docks were constructed for trucks to conduct deliveries and loading. On the Vanderbilt Avenue side, a marquee was installed over the entrance in the 1980s. The third through seventh stories are exclusively sheathed in granite, with window inserts. The eighth and ninth floors, which are slightly set back, are clad in aluminum.

The 10th through 59th stories of the MetLife Building contain one of the first precast concrete exterior walls in a building in New York City. About nine thousand light-tan precast concrete Mo-Sai panels were installed, each measuring 6 feet (1.8 m) wide by 13.67 feet (4 m) high. The panels each contain one window measuring 4 feet (1.2 m) wide by 8 feet (2.4 m) high. Each panel, weighing 3,500 pounds (1,600 kg), is coated with a quartz aggregate to give texture to the facade. Vertical concrete mullions project from the facade, separating the panels on every story. Flat concrete spandrels separate the windows between stories. The curtain wall is positioned slightly behind the columns on the 21st and 46th stories, where there is mechanical space. These recesses create the impression of deep shadows. Though Walter Gropius had considered a precast concrete facade to be more solid than a glass curtain wall, this only made the building appear bulkier. Furthermore, the appearance of concrete degraded over time; this effect could be seen in structures such as the Solomon R. Guggenheim Museum but was more pronounced on 200 Park Avenue's facade.

200 Park Avenue originally bore 15-foot-tall (4.6 m) "Pan Am" displays on its north and south facades and 25-foot-tall (7.6 m) globe logos on the east and west facades. This was swapped with neon "MetLife" displays to the north and south in 1992. These displays were changed again in 2017, being replaced with LED letters to conserve energy. The Pan Am Building was the last tall tower erected in New York City before laws were enacted preventing corporate logos and names on the tops of buildings. Modern New York City building code prohibits logos from being more than 25 feet (7.6 m) above the curb or occupying over 200 square feet (19 m ²) on a blockfront. The sign replacements had been permitted because the city government considered the new signs to be an "uninterrupted continuation of a use" that was allowed before the zoning laws were changed.

200 Park Avenue was built atop two levels of railroad tracks underground, which feed directly into Grand Central Terminal. The substructure of the building uses foundational columns that extend into the track levels, descending some 55 feet (17 m) below street level into the underlying bedrock. The substructure includes more than 300 columns, each 18.5 inches (470 mm) across and clad with 2 inches (51 mm) of concrete. Ninety-nine columns were built specifically for the Pan Am Building; these columns were installed within several inches of existing steel members such as third rails, but had to be isolated from the other steel. The new columns weighed between 22 and 44 short tons (20 and 39 long tons; 20 and 40 t). Approximately two hundred existing columns, which supported the former baggage building on the site, were reinforced. The work involved abridging the tops of many existing columns and installing horizontal beams weighing up to 36 short tons (32 long tons; 33 t). A "triple decker sandwich" made of lead, asbestos, and sheet steel was installed under each level of tracks to provide insulation.

The superstructure was constructed similarly to bridge spans. To fabricate the floor slabs, builders used a process called composite action, in which concrete was bonded with structural steel panels to create a stronger structure. Steel panels were fabricated, rather than concrete floors, because steel panels were lighter and could be constructed regardless of unfavorable weather. Over 56 acres (230,000 m ²) of steel panels are used in the floor plates, each of which contains wire and cable ducts. A standard floor slab could handle loads of 50 pounds per square foot (240 kg/m ²). The building's steel frame weighs over 45,000 short tons (40,000 long tons; 41,000 t) in total. The roof of the building contains NOAA Weather Radio Station KWO35, a National Weather Service radio station.

The initial plans for the Pan Am Building were altered in March 1961 to provide for a helipad on the east side of the roof. The heliport required approval from the Federal Aviation Administration (FAA), the city government, and the Port Authority of New York and New Jersey. After a contentious approval process, helicopter service started on December 22, 1965. The service was operated by New York Airways, which flew Vertol 107 helicopters from the rooftop helipad to Pan Am's terminal at John F. Kennedy International Airport (JFK). For a short period starting in March 1967, the company also offered service to Teterboro Airport. All helicopter service stopped on February 18, 1968, because of insufficient ridership, as well as disagreements over the helicopter contract.

Though discussions to restart helicopter service were held in 1969, approval was not given until early 1977. Service to JFK resumed that February using Sikorsky S-61s. On May 16, 1977, about one minute after an S-61L landed and its 20 passengers disembarked, the right front landing gear collapsed, causing the aircraft to topple onto its side with the rotors still turning. One of the five 20-foot (6.1 m) blades detached, killing four men who were waiting to board, then fell to the ground, where it killed a woman on the corner of Madison Avenue and 43rd Street. Two other people were seriously injured. Helicopter service was suspended that day and never resumed. During its short periods of operation, the heliport was largely perceived as a nuisance and danger, but its presence was also seen as satisfying what David W. Dunlap described as "the consummate technological fantasy of airborne travel through skyscraping pinnacles".

A central telephone office was installed on two of the upper floors, serving 30,000 telephones within the offices of tenants. The central office, operated by New York Telephone, eliminated the need for tenants to have individual telephone offices and equipment rooms. To avoid interfering with the subterranean railroad tracks, the telephone conduits were routed through the roof of the railroad tunnel. On the two floors where the telephone office was installed, the floor slabs could handle loads of 150 to 300 pounds per square foot (730 to 1,460 kg/m ²), and floor heights were increased to provide clearance of at least 13.5 feet (4.1 m).

A refrigeration plant, described at the time of construction as the world's largest such plant, was installed on the roof with three steam-powered units each weighing 3,333 short tons (2,976 long tons; 3,024 t). The plant was placed on the roof because the building has no usable basement, as all the subterranean space is part of Grand Central Terminal. The plant could melt up to 20 million pounds (9.1 kt) of ice each day and could use 200,000 pounds of steam every hour. Large fan rooms were placed on the mechanical stories at the 21st and 46th floors, dispersing air to the other floors, and two individual air supply systems were placed on each story. The ventilation systems could deliver 5,000,000 cubic feet (140,000 m ³) every minute. The pipes and ducts had to serve all the building's floors, with an electrical system and water pressure system capable of serving all the building's stories. At ground level was a room where wastepaper could be " baled" on-site to make easier to dispose of paper.

Westinghouse Electric Corporation also manufactured 65 elevators and 21 escalators for 200 Park Avenue, which at the time of construction was the largest-ever order for elevators. One bank of six elevators was able to travel 1,600 feet per minute (490 m/min), the fastest elevators in the world at the time of their installation. Five elevators were reserved for freight. The elevators rise from the second-story lobby because the elevator pits could not descend below the first story due to the presence of the tracks. According to the Skyscraper Center, as of 2021, the building has 85 elevators.

The MetLife Building's base contains a lobby across its lowest two stories. At ground level is a 76-foot-wide (23 m) pedestrian passageway, enabling traffic flow between the Helmsley Building's pedestrian arcades and Grand Central Terminal. The 45th Street entrance to the passageway is set back 65 feet (20 m) from the sidewalk. A 103-foot-wide (31 m) entrance arcade is placed on Vanderbilt Avenue, with the doorways set about 81 feet (25 m) back from the sidewalk there. The building's main office lobby is placed at the second story, at the level of the viaduct. The lobby was also designed with plantings and a 40-foot-high (12 m) enclosed plaza. Four escalators lead to the Main Concourse at the southern end of the passageway, while fourteen more lead from the passageway to the office lobby.

During a 1980s renovation by Warren Platner, some 15,000 square feet (1,400 m ²) of retail space were constructed in the lobby. Also installed was a staircase at the center of the lobby on 45th Street, which consisted of alternating travertine and gray-granite risers. The staircase ranged from 10 feet (3.0 m) wide at the ground floor to 20 feet (6.1 m) at an intermediate landing, where it split into two flights and reached a width of 30 feet (9.1 m) at the mezzanine. There were four triangular planters at the bottom of the staircase, which complemented an orange carpet with flower motifs at the mezzanine. The lobby also contained unusual semicircular discs that were either mounted atop poles or suspended from the ceiling. In an early-2000s renovation by Kohn Pedersen Fox, the lobby received tile and black travertine floors, the storefronts were moved to the side, and the central staircase was removed. The storefronts were removed in the late 2010s and the lobby was reclad in light-colored travertine. The renovated lobby has an oak-floored reception lounge overlooking the entrance.

The Pan Am Building's lobby was planned with several works of art. One such artwork is Flight, a triple-story wire sculpture by Richard Lippold. The sculpture contains a sphere, representing the earth; a seven-pointed star, representing the seven continents and seas; and gold wires representing aircraft flight patterns. The composer John Cage, a friend of Lippold's, had initially proposed a musical program to complement Flight, but Lippold canceled the idea and management instead agreed to play classical music in the lobby. At the Pan Am Building's opening, the entrance from the Main Concourse was topped by Manhattan, a 28-by-55-foot (8.5 by 16.8 m) mosaic mural of red, white, and black panels by Josef Albers. That work was removed in a 2001 renovation, though Albers had left exact specifications for reproducing the work, and a replica was installed in 2019. Suspended over the 45th Street entrance was an architectural mural by György Kepes, consisting of a set of aluminum screens with concentric squares, which was removed in the 1980s. At Vanderbilt Avenue, Robert Berks sculpted a bronze bust depicting Erwin S. Wolfson, who had developed the Pan Am Building.

The MetLife Building was designed with a six-level parking garage with room for 400 cars. The garage contains entrances and exits from both roadways of the Park Avenue Viaduct. According to owner Tishman Speyer, as of 2021, the building's garage contains 248 spots across four levels.

A variety of commercial and office spaces were included in the Pan Am Building when it opened. Pan Am, the airline for which the building was originally named, contained a ticketing office at 45th Street and Vanderbilt Avenue, similar in design to Eero Saarinen's TWA Flight Center at JFK Airport. Office stories in the octagonal slab typically have between 32,000 to 36,000 square feet (3,000 to 3,300 m ²) of usable space, with elevators and stairs at the center, as well as uneven column spacing. This arrangement allows a large amount of window-office space for tenants, as each story contains 780 feet (240 m) of outer perimeter walls. Different companies with full-floor leases designed their spaces in various manners. Some tenants placed private offices along the perimeter, with important executive offices at the far corners of the story. Other tenants placed open spaces at the west and east ends of the floor or in the center.

The Sky Club, a private luncheon club, had been on the 56th floor of the Pan Am Building. For several years the Sky Club had contained a private restaurant. Aircraft pioneer Juan Trippe, founder of Pan Am, was a member of this club. Trippe had commissioned a mural of clipper ships for the walls of the Sky Club; it was sent to Tucker's Point resort in Bermuda after the club shuttered. On the 57th and 58th stories was the Copter Club, which was used by passengers of the short-lived helicopter service.

By the 1950s, passenger volumes at Grand Central Terminal had declined dramatically from the early 20th century, and there were proposals to demolish and replace the station. The New York Central Railroad was losing money, partially on paying taxes on the building's air rights. New York Central wanted to sell the property or its air rights to allow the construction of a skyscraper above or on the terminal's site. At the same time, the New York, New Haven and Hartford Railroad retained a partial interest in the terminal's operation.

Initially, New York Central's chairman Robert R. Young had been negotiating with developer Erwin S. Wolfson and their mutual friends Herbert and Stuart Scheftel to determine how the Grand Central site could be redeveloped. After these discussions broke down, two competing plans for the replacement of Grand Central Terminal were proposed in 1954. One design, by I. M. Pei, was suggested by Young along with developer William Zeckendorf. The proposal called for an 80-story, 5-million-square-foot (460,000 m ²) tower that would have succeeded the Empire State Building as the world's tallest building. The other, by Fellheimer & Wagner, was put forth by New Haven's chairman Patrick B. McGinnis along with Wolfson. The plan envisioned a 55-story building, the largest office building in the world with 4 to 6 million square feet (370,000 to 560,000 m ²). Both proposals were poorly received, with 235 architects cosigning a letter imploring Young and McGinnis to reject the plans. Neither plan was ultimately ever carried out.

Though the New Haven and New York Central continued to struggle financially, both railroads agreed to work with Wolfson, the New Haven's developer. In February 1955, Wolfson, the Scheftels, and Alfred G. Burger proposed a 65-story tower called Grand Central City, which would replace a six-story baggage structure north of the terminal. The design was created by Richard Roth of Emery Roth and Sons, who agreed to participate only if the office building would not result in the passenger concourse's demolition. Roth and Wolfson's plan was effectively forgotten one month later when Zeckendorf was named the partner for any new development in the vicinity of Grand Central.

Roth's plan was resurrected in May 1958, with some revisions. The plan called for a 50-story aluminum and glass tower parallel to Park Avenue, with 3 million square feet (280,000 m ²) of floor area; three theaters with a total capacity of 5,000; an open-air restaurant on the seventh floor; and a 2,000-spot parking garage. The New York Central and New Haven railroads were guaranteed at least $1 million a year from the agreement. Despite the presence of tracks under the building site, Wolfson said a survey of the site had "no insurmountable problems". Wolfson, however, found Roth's revised plan to be unsatisfactorily modest for such a prominent site. He said in the New York Herald Tribune that he wanted to "avoid adding just another massive shape to an already developed midtown business community".

In July 1958, architects Walter Gropius and Pietro Belluschi were announced as co-designers for Grand Central City. Wolfson expressed his hope that Gropius and Belluschi, both prominent architects in the Modern style, would be able to help devise an "esthetic and functional design". That October, Wolfson traveled to Europe to study buildings and obtain inspiration for how Grand Central City could be redesigned. The revised final plans were announced in February 1959. While Wolfson had promised a "modest" redesign, the new plans were a radical change from Roth's 1958 plan, calling for a 55-story octagonal tower parallel to 45th Street, with 2.4 million square feet (220,000 m ²) of space. Roth said the octagonal massing could absorb "different planes of light as on a diamond", while Gropius said the new alignment was easier for air conditioning. A model of the redesigned tower was exhibited publicly in November 1959.

Five leases for a collective 600,000 square feet (56,000 m ²) in Grand Central City were announced immediately after the final design was announced in February 1959. A contract for 40,000 short tons (36,000 long tons; 36,000 t) of structural steel was awarded to U.S. Steel's American Bridge division that May; at the time, the contract was reportedly the most expensive ever awarded for an office building. The projected $100 million cost of the building was difficult for Wolfson's concern to cover, but British firm City Centre Properties invested $25 million in the project in October 1959, taking a half interest in Grand Central City's development. The New York Central Railroad granted an 80-year lease for the air rights above the building, in exchange for a portion of the building's gross revenue. This agreement added about $6 million to the construction cost. Final plans were filed with the New York City Department of Buildings on November 24, 1959. Construction on the structure officially started two days afterward. Cushman & Wakefield were named as leasing agents for Grand Central City the following month.

James Ruderman, the building's structural engineer, had devised engineering plans for five other structures above the Park Avenue railroad tracks. As the Grand Central City site was impossible to excavate, the substructure had to be erected while the baggage building served as a staging area. Furthermore, as some materials would have to be delivered by railroad, material deliveries would be coordinated closely to avoid delays on the commuter rail lines entering Grand Central. Work on the tower itself was held up by a steel strike that lasted through much of 1960; the baggage handling building was ultimately demolished starting that June. Foundations for the building were sunk in August 1960. The next month, Pan Am founder Juan Trippe signed a 25-year, $115.5 million lease in September 1960, allowing the airline to occupy 613,000 square feet (56,900 m ²) across 15 floors, plus a new main ticket office at 45th Street and Vanderbilt Avenue. Grand Central City officially became known as the Pan Am Building in December 1960, after its major lessee. Signs bearing the company's name or logo were placed atop all four major facades.

The Pan Am Building's developers secured a $70 million mortgage loan and a $65 million construction loan during January 1961. At the time, the building was more than half rented. Three derricks were installed to erect the steel for the tower, while four derricks were used for the base. Five to seven steel columns were installed every day during two shifts, with materials deliveries taking place mostly at night. The Pan Am Building's structural steel topped out during May 1962. The facade cladding was installed in two ways. The facade of the base was bolted into place, down to the individual spandrels and mullions. The Mo-Sai panels for the tower were installed via an interior hoist. Wolfson, though recovering from surgery during mid-1962, continued to observe the building's progress using a helicopter. When Wolfson died that June, James D. Landauer was selected to oversee the building's completion. The lobby, the last part of the Pan Am Building to be completed, was built with cheap materials such as restroom tiles because the builders had run out of money toward the project's completion.

The Pan Am Building was formally opened on March 7, 1963, despite not being completed, and tenants started moving into the structure the following month. Initially, the airline only had a 10 percent ownership stake in its namesake building. Besides Pan Am, other early tenants included the Westinghouse Electric Corporation, Alcoa, the Hammermill Paper Company, National Steel Corporation, Kodak, Reader's Digest magazine, Mitsui, Chrysler, and the British Iron & Steel Corporation. The shops at the Pan Am Building's base were opened in August 1963. The tenant selection process was rigorous, as Cushman and Wakefield examining the services and goods sold by potential tenants: for example, the firm's vice president got haircuts from each of the six applicants for the lobby barbershop. Furthermore, average rents in the Pan Am Building were about $6.75 per square foot ($72.7/m ²), slightly higher than the average of $5.25 to $6 per square foot ($56.5 to $64.6/m ²) in other Midtown Manhattan buildings. Nevertheless, the building's office space was 90 percent rented in three months. On the first anniversary of its opening, the Pan Am Building was 97 percent leased, with 241 tenants.

At the time of its completion, the Pan Am Building was the largest commercial office development in the world by square footage. The building was surpassed in size by the World Trade Center in 1970 as well as 55 Water Street in 1972. Although the Pan Am Building's completion averted the terminal's imminent destruction, New York Central had experienced further decline, merging with the Pennsylvania Railroad in 1968 to form the Penn Central Railroad. That year, Pan Am bought a 45 percent stake in the building from the estate of Jack Cotton, formerly chairman and co-owner of City Centre Properties. After Penn Central went bankrupt in 1970, it sought to sell its properties, including the land below the Pan Am Building. Among the building's tenants during this time was the United Brands Company (now Chiquita Brands International), whose CEO, Eli M. Black, jumped from the 44th story to his death on February 3, 1975.

Pan Am was considering moving its headquarters from the building by 1978. That year, the company bought the remaining 45 percent stake in the building from Wolfson, obtaining full ownership of the property. A Pan Am subsidiary, Grand Central Building Inc., acquired the underlying land for about $25 million the following year as part of a legal settlement with Penn Central. The airline sustained large financial losses during the early 1980s recession and placed the building for sale in February 1980. About half the leases were scheduled to expire in three or four years, and many lessees were exempt from paying the building's operating costs, which made the Pan Am Building only marginally profitable for the airline. Nine bidders submitted offers, five of which were selected for further consideration: the Metropolitan Life Insurance Company (MetLife), the Equitable Life Assurance Society; Donald Trump; Paul Milstein; and Olympia and York.

In July 1980, Pan Am sold the building to MetLife for $400 million. MetLife did not plan to move any offices to the building, and Pan Am planned to retain its headquarters there. The sale was finalized in 1981 when Pan Am transferred stock in the building to MetLife, a move that let the airline avoid paying an estate transfer tax. Cross & Brown assumed the responsibility of leasing the building's space. At the time, leases for much of the interior space were set to expire all at once during the early 1980s. Starting in 1984, MetLife renovated about half of the space as the original tenants' leases expanded. The deteriorating lobby, used by 100,000 pedestrians a day, was extensively reconfigured by Warren Platner. In addition, some mechanical systems were upgraded to comply with building codes, and retail spaces were added. Asbestos fireproofing on the office stories was removed in advance of an anti-asbestos regulation passed by the city government in 1985. The lobby renovation had been completed by 1987.

By 1991, Pan Am's presence had dwindled to four floors. MetLife preferred to refer to the building as 200 Park Avenue, its address. At the time, the Pan Am Building was 95 percent occupied, and the public variously referred to the building by the names of its large tenants, such as Mitsui, Dreyfus, and Rogers & Wells. Pan Am moved its headquarters to Miami that year and closed down shortly afterward. In September 1992, MetLife announced that it would remove Pan Am signage from 200 Park Avenue and add letters bearing its own name. According to a MetLife spokesperson, the sign change was taking place because the airline had become defunct. The signs were changed in January 1993. Though 200 Park Avenue subsequently became known as the MetLife Building, its namesake was then headquartered in the Metropolitan Life Insurance Company Tower. As a result, the Park Avenue structure was known specifically as the "MetLife Building 200 Park Avenue".

Further renovations to 200 Park Avenue's exterior and lobby were undertaken during 2001 and 2002. Low-pressure compressed air was used to clean the facade, while Kohn Pedersen Fox renovated the lobby. In 2005, MetLife moved its board room from the Metropolitan Life Tower to 200 Park Avenue. The same year, the company considered selling 200 Park Avenue to pay for its acquisition of Travelers Life & Annuity. Ultimately, MetLife sold the building that April for $1.72 billion, to a joint venture of Tishman Speyer Properties, the New York City Employees' Retirement System, and the New York City Teachers' Retirement System. At the time, the sale was the largest ever transaction involving an office building. The company still retained a boardroom and corporate suite at 200 Park Avenue.

MetLife announced in 2015 that it was consolidating its operations at 200 Park Avenue, with 500,000 square feet (46,000 m ²) of space in the building. At the time, the media reported that Donald Bren, the billionaire owner of the real estate firm Irvine Company, held a 97.3 percent ownership stake in the building. While Tishman Speyer remained the managing partner of the property, the company's stake in the MetLife Building had been reduced to less than 3 percent. Plans to renovate the lobby were devised in 2016. The next year, the neon light sources for the signs atop the building were swapped with LED light sources to conserve energy. A renovation of 200 Park Avenue's lobby started in late 2018. The work was to simplify the lobby's layout by removing storefronts and restoring direct connections to some of Grand Central's platforms.

When the octagonal design for 200 Park Avenue was first announced in 1959, it was controversial. Architectural historian Sibyl Moholy-Nagy wrote in Progressive Architecture magazine that the original tower plans "provided human scale and architectural personality", which were "lost" in the revision. Walter McQuade, writing for , found even the drawings for the building to be dissatisfying. Grand Central City was lambasted internationally by Italian critic Gillo Dorfles and Romanian architect Martin Pinchis. Architect Victor Gruen questioned the parking garage's necessity given the site's proximity to a major railroad terminal, while Progressive Architecture editor Thomas H. Creighton suggested the space would be better left as an open plaza. Critics also expressed concerns that the building would burden existing transit infrastructure. The plan also had its defenders, such as Natalie Parry, who wrote in rebuttal to Moholy-Nagy that the plans preserved Grand Central's "star-studded" Main Concourse, "together with the precious air space above it". Historian Paul Zucker defended the building's urbanism, and urban planner Charles Abrams and Architectural Record editor Emerson Goble also defended the plan as an addition to the cityscape.

Upon its completion, the Pan Am Building received largely negative feedback from critics. Much of the criticism came from the building's bulk, exacerbated by the design of the facade and its horizontal alignment. James T. Burns Jr. wrote in Progressive Architecture that the placement of the base, tower, parking garage, and Grand Central Terminal were "occasionally inexcusably jarring" and considered the lobby to be a continuation of the exterior's "monolithism". Ada Louise Huxtable called the building "a colossal collection of minimums", with the lobby artwork being a "face-saving gimmick". Many observers viewed the monolithic design as obstructing vistas down Park Avenue. Art historian Vincent Scully, speaking in 1961, expressed his belief that the Pan Am Building was a "fatal blow" to Park Avenue's continuity, while Claes Oldenburg mocked the building's positioning on Park Avenue with his 1965 artwork Proposed Colossal Monument for Park Avenue, NYC: Good Humor Bar.

The Pan Am Building was also highly criticized after its 1980s lobby renovation. Carter Wiseman compared the new decorations as being gaudy in a similar manner to performer Liberace, except that "even Liberace would have blushed at the vulgarity". Paul Goldberger of The New York Times said that even though the previous design was "stark and unwelcoming", the new decorations created "a space that is so forced in its joy, so false and so disingenuous, that they make one yearn for some good old-fashioned coldness". In 1987, magazine conducted a poll of "more than 100 prominent New Yorkers", asking which buildings they preferred to see demolished, and the Pan Am Building ranked at the top of that list. Architect Robert A. M. Stern said in 1988 that the building, a "wrong-headed dream badly realized", warranted preservation from the New York City Landmarks Preservation Commission, although he rhetorically suggested tearing down the building when the Pan Am sign was replaced several years later.

By the beginning of the 21st century, some onetime critics expressed ambivalence toward the building's presence, while preservationists advocated the protection of mid-20th century buildings such as the MetLife Building. magazine described it in 2016 as "commendable for its robust form and excellent public spaces, as well as its excellent integration into the elevated arterial roads around it". Furthermore, the building's reputation and presence made it the setting of several films or TV shows during its history.

Clausen, Meredith (2005). The Pan Am Building and the Shattering of the Modernist Dream. Cambridge, MA: MIT Press. ISBN 9780262033244. OCLC 803843211.

Schlichting, Kurt C. (2001). Grand Central Terminal: Railroads, Architecture and Engineering in New York. Baltimore: Johns Hopkins University Press. ISBN 978-0-8018-6510-7.

"Six Offices From New York's Pan Am Building" (PDF). Architectural Forum. 120: 102-109.

Stern, Robert A. M.; Fishman, David; Tilove, Jacob (2006). New York 2000: Architecture and Urbanism Between the Bicentennial and the Millennium. New York: Monacelli Press. ISBN 978-1-58093-177-9. OCLC 70267065. OL 22741487M.

Stern, Robert A. M.; Mellins, Thomas; Fishman, David (1995). New York 1960: Architecture and Urbanism Between the Second World War and the Bicentennial. New York: Monacelli Press. ISBN 1-885254-02-4. OCLC 32159240.

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The MetLife Building (also 200 Park Avenue and formerly the Pan Am Building) is a skyscraper at Park Avenue and 45th Street, north of Grand Central Terminal, in the Midtown Manhattan neighborhood of New York City.

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While The Fundamentals of Play by Caitlin Macy does appear as purely a The Great Gatsby derivative, it offers a new perspective on the thematic concepts interrogated by Fitzgerald in his seminal work. The most striking connections are how both authors use similar character archetypes to comment on similar thematic ideas. For example, Gatsby and Fundamentals examine the purposelessness generational wealth creates, which is compounded by the American Dream. Both works ask: what happens to a person once they have succeeded in fulfilling the Dream? However, Macy’s depiction of this purposelessness lacks the detail and nuance Fitzgerald’s depiction does. Tom and Daisy Buchanan are complex characters, motivated by apathy and boredom as much as hatred. As literary critic Scott Donaldson puts it, “the Buchanans destroy people. Myrtle Wilson, George Wilson, and Jay Gatsby are dead because of them, and they do not even feel remorse.” While Kate and her father do inadvertently cause Cara’s death, it is not comparable to the carnage left behind by the Buchanans, which consequently dampens the thematic power of the book. Despite tackling the same themes of apathy and absurd generational wealth, The Fundamentals of Play lacks the complexity and narrative depth to deeply interrogate the topic. Due to its tame writing and lack of drama compared to The Great Gatsby, it doesn’t show the horrors of capitalistic apathy the same way Gatsby is able to.

In both books, the purposelessness caused by ‘old money’ goes hand in hand with the wealthy using social convention and decorum to hold onto power. In Gatsby, Nick demonstrates the power of social decorum, when he repeatedly attempts to meet and thank Gatsby for inviting him to his party. Additionally, Nick’s perspective is run through the filter of social rules: he describes how Gatsby’s party goers operated “according to the rules of behavior associated with amusement parks” (34). Similarly, the protagonist of Fundamentals, George, values social decorum to a fault. As a result of coming from “a family who lost its fortune but not its good name,” George “wouldn't have traded places with [Harry] for anything,” even though "Harry had dropped out of college and made bonuses I could only imagine.” George is confused and dismayed by George’s lack of social clout and inability to navigate the high class world of New York. Through this, similar to Jay Gatsby in The Great Gatsby, Macy shows how social decorum is used to hold down people like Harry who threaten the stability of ‘old money’. Additionally, George also ideolizes Kate, who “always remembers [her lines],” which is a major driving factor of the plot and his affection towards her (175). Kate is a symbol of successful adherence to social rules, and Macy uses her character to interrogate the use of social decorum as a tool of control through the lens of gender.

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Having read The Great Gatsby with its magnificent writing and notable praise right before this, there were very high expectations for this book. The character dynamics were very interesting and each had a very rich history; their motives and stakes were evident, allowing them room to grow throughout the book. However, there were times where the book moved slower than preferable. If you are a person that enjoys a  narrator who takes their time, than this book will be a great choice for you! In addition, the book primarily takes place in New York City and as a result, the reader doesn't get exposed to other parts of the country during the time that the book takes place. This can be a positive thing, if you are someone that would like to dive deeper into the city's dynamics, or a negative, if you are looking for a more global perspective.

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Macy's use of the gender lens is specific to the character Kate, as she is characterized by her attractive, effortless charm, but is silenced by the narrator as he refuses to portray her depth. George himself disregards the details of Kate's interactions, making statements like "When it was over and she said no" (227) to establish his lack of interest in what she actually has to say. Additionally, Kate is never subject to confrontation, even though she acts carelessly and is extremely problematic. In ignoring Kate's faults and maintaining the "Don't get mad at Kate"  (184) narrative, Macy presents the men of this society as so belittling to women that they can't even hold them accountable for their actions. Presenting women as aloof and careless and men as dismissive is purposeful, as it reveals the issues in society regarding gender, that can be revealed through the use of the feminist/gender lens.

Referring to how society forces girls into attempting to achieve the beauty standard, Kate remarks, "New York does that to girls"(88). This is important to note, for the setting and  time period they were living in, had just begun to break the confining mold it placed on girls in the past, though not completely. Later, when George feels threatened by Harry and Kate's blossoming relationship, he says "[Delia] had great teeth when she smiled" (88). This is done purposefully to reveal that men are a major part of the society that implements these standards and see women as nothing more than their looks. When George feels disconnected from Kate, he looks to Delia to find the physical attraction he feels she possesses to support his own masculinity.

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The "Fundamentals of Play" written by Caitlin Macy describes dynamics within New York City in the 1990s, just as the World Wide Web began to emerge. There are many parallels between F. Scott Fitzgerald's "The Great Gatsby" relating to the shared characters, themes, and settings. It explores what role the American Dream plays in a character's past, present, and future, and delves into how a person's origins and relationships with others impact their successes and downfalls. Overall, this is a book that explores a generation faced with economic and societal change, causing each of them to always be thinking ahead, on to their next move.

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An extended metaphor used throughout the book, as well as seen in the title, depicts the dynamics of business and society on Wall Street being a game where there are both winners and losers. This is crucial for the reader to fully understand how certain characters use sometimes deceitful tactics to achieve their idea of the American Dream, as well as encountering obstacles along the way. It is these obstacles of the game that help the author to reveal how the characters and setting are shaped by their present-day society.

George describes how Harry "reminded [him] of an aging athlete recounting their big game" further reminding the reader that the characters are all parts of a larger system that is Wall Street (39). This is also a crucial excerpt because it characterizes Harry as living in his post-success world; from his place observing, George sees Harry as a reminder of what has been done, not a figure to look out for in the future. George goes on to say that he "loved to hear the stories of the players, the winners and losers, and the allowances made for the eccentricities of the former" (39). George is desperate to achieve higher social status and by using his strategy of listening to anyone who had worked on Wall Street, he finds himself in a better position to play the game than most.

George reflects on his generation's experience with Wall Street concluding that "that's how people [his] age wanted to play it: 'wild' but safe" (178). Understanding that this book takes place before the Internet explosion, George's generation was in a relatively good economic place, allowing them to experiment financially and socially. This also led the characters in the book into a competition where they had to figure out the balance between offensive and defensive tactics; the balance between a wild and safe environment.

For the duration of the book, characters were described in relation to machinery or as being controlled by something else. During one various dinner part, Kate seemed to be operating "as if a string in her back had been pulled and she was mechanized into conversation" (102). Kate is just another product of social standards, being forced into playing a part that she does not want to play. However, Kate fits into her generation for "like all surviving clans, [she's] had an instinct for self-preservation, it was often said that Kate was a 'smart girl'. Nobody doubted she would pick a winner" (225). This terminology lends itself to the extended metaphor, revealing how survival correlates with the actions of a character, for Kate was heavily influenced when making decisions in her love life. This sort of facade encourages ideas that promote the question: where is the line between true and fake personas?

Finally, it is important that we note that the last line describes how the characters "picked up our hands and began to play" (289). In this scene, they end by playing a game of cards, which promptly concludes the reader's insight into the game. The author, by ending with this, is emphasizing the importance of being dealt with a good hand in society, relating to wealth, connections, etc, as well as who you are playing with.

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Caitlin Macy employs literary techniques within interactions between characters – most commonly through dialogue – to constantly remind the reader that the text takes place in 1990's New York City without explicitly redirecting the reader to the setting. Deb groans that she left the store but "fagotaget cigarettes" (151). Macy spells Deb's declaration in a classic New York accent, subtly reminding the reader that the novel is set in NYC. This interaction, later involving Nick, reveals just as much about the time period in which the text occurs as its location. As Deb discusses the origins of her baby's name amid her cigarette crisis, Nick suggests that she "shouldn't smoke... not with the baby" (151). The '90's was an era of developing health and science research, even regarding familiar devices like cigarettes. While studies in the mid-20th century confirmed the previously hypothesized health risks affiliated with smoking, the National Library of Medicine's article titled "Cancer Among Adults from Exposure to Secondhand Smoke" cites studies from 1981 and 1986 as the first major studies to connect secondhand smoke to lung cancer. These studies demonstrated that non-smoking women contract lung cancer at a much higher rate if their spouse smokes cigarettes. With under a decade of research separating the studies and the period in which the text is set, secondhand smoke and other potential consequences of smoking were certainly relevant and controversial issues. This perfectly explains Deb's reaction to Nick's suggestion: "F*** you" (151).

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Pooled Analyses

Secondhand Smoke Exposure in the Workplace

Despite these geographic differences in exposure prevalences, the effect of secondhand smoke exposure in the workplace on the risk of lung cancer among lifetime nonsmokers is remarkably consistent. On the basis of these 25 studies, the pooled RR estimate associated with reported workplace secondhand smoke exposure was 1.22 (95 percent CI, 1.13-1.33) for all studies combined, 1.12 (95 percent CI, 0.86-1.50) for men, and 1.22 (95 percent CI, 1.10-1.35) for women. When the pooled analysis was conducted separately by geographic area, the pooled RR estimate was 1.24 (95 percent CI, 1.03-1.49) for the United States and Canada, 1.13 (95 percent CI, 0.96-1.34) for European countries, and 1.32 (95 percent CI, 1.13-1.55) for Asia.

Secondhand Smoke Exposure During Childhood

Conclusions

1. The evidence is sufficient to infer a causal relationship between secondhand smoke exposure and lung cancer among lifetime nonsmokers. This conclusion extends to all secondhand smoke exposure, regardless of location.

2. The pooled evidence indicates a 20 to 30 percent increase in the risk of lung cancer from secondhand smoke exposure associated with living with a smoker.

Implications

Eliminating or reducing secondhand smoke exposure at home, in the workplace, and in other public settings will reduce the risk of lung cancer among lifetime nonsmokers.

Breast Cancer

There is substantial evidence that active smoking is not associated with an increased risk of breast cancer in studies that compare active smokers with persons who have never smoked ( Hamajima et al. 2002). In a pooled analysis of data from 53 studies, the RR for women who were current smokers versus lifetime nonsmokers was 0.99 (95 percent CI, 0.92-1.05) for 22,255 cases and 40,832 controls who reported not drinking alcohol. The effect of smoking did not vary by menopausal status.

In spite of this overall null finding, active smoking could be involved in breast cancer risk. Active smoking may have effects on breast cancer development that tend to increase and decrease risk; tissues of smokers are exposed to carcinogens but smoking has antiestrogenic effects ( USDHHS 2004). Carcinogens in tobacco smoke, such as 3-4 benzo[ a]pyrene, and their metabolites are distributed systemically, and many known tobacco carcinogens, including heterocyclic aromatic amines, polycyclic aromatic hydrocarbons, and arylamines, are also mammary mutagens and carcinogens ( Nagao et al. 1994; Dunnick et al. 1995; El-Bayoumy et al. 1995). Convincing data document that constituents of cigarette smoke reach tissues outside of the respiratory system, including the breast. For example, mutagens from cigarette smoke have been found in nipple aspirates of nonlactating female smokers, and nicotine levels in breast fluid tend to increase with the daily amount smoked ( Petrakis et al. 1978, 1988). Aromatic DNA adducts that are characteristic of tobacco smoke exposure have been found in normal breast tissues of breast cancer patients but not in healthy women without cancer ( Li et al. 1996).

However, tobacco smoking also has antiestrogenic consequences; it is consistently associated with an earlier age at menopause and a lower risk of endometrial cancer ( USDHHS 2001, 2004). Smokers have lower urinary estrogen levels ( MacMahon et al. 1982) and increased estradiol 2-hydroxylation, resulting in less urinary excretion of estriol relative to estrone in smokers compared with nonsmokers ( Michnovicz et al. 1986). However, uncertainty remains concerning the influence of tobacco smoke on blood estrogen levels, and the evidence is not consistent ( Key et al. 1991, 1996; Terry and Rohan 2002). Nonetheless, the information on smoking and hormones has led to the hypothesis that the antiestrogenic effects of active smoking, but not of involuntary smoking, may obscure an increase in breast cancer risk that would otherwise result from the carcinognens in tobacco smoke. Thus, researchers have hypothesized that the dual carcinogenic and antiestrogenic effects of tobacco smoking may counteract and potentially balance influences on breast cancer risk ( Palmer and Rosenberg 1993).

When considering the biologic plausibility of a causal association of secondhand smoke exposure with breast cancer, the evidence on active smoking is critical. The absence of an established and consistent relationship between active smoking and breast cancer in epidemiologic studies weakens the biologic plausibility of a possible causal association of involuntary smoking with breast cancer. Other conditions caused by secondhand smoke exposure, such as lung cancer and coronary heart disease ( CHD), are strongly and causally related to active smoking. Evidence on the association between active smoking and breast cancer risk was reviewed thoroughly in the Surgeon General's reports of 2001 and 2004 ( USDHHS 2001, 2004). The reports addressed both the biologic basis for a possible association and the findings of epidemiologic studies. These reviews considered large, well-designed studies published in the 1990s that investigated risk patterns among various meaningful subgroups and carefully considered the role of potential confounders. These reports concluded that the weight of epidemiologic evidence strongly suggests that active smoking is not causally related to breast cancer risk. A similar conclusion was reached by IARC in its 2004 monograph on smoking ( IARC 2004). Possibly, the dose-response relationship for tobacco smoke and breast cancer might be complex and nonlinear, such that the doses associated with secondhand smoke cause breast cancer and the far greater doses from active smoking do not. There is neither mechanistic nor empiric evidence supporting this possibility.

The absence of a net increase in breast cancer risk among active, female smokers does not exclude the possibility that certain subgroups of women may be at an increased risk because of genetic or other factors. However, such groups have yet to be consistently identified ( USDHHS 2004). Studies continue on active smoking and breast cancer risk. There are recent reports of elevated RRs in smokers in some recent studies, notably in two large prospective cohort studies. In the Nurses Health Study II ( NHS-II) cohort of young women (aged 25 through 42 years at the time of enrollment), there was an association between 20 or more years of active smoking and a significant 21 percent increase in risk ( Al-Delaimy et al. 2004). In the California Teachers Study, current smokers showed a statistically significant increase in risk of 30 percent compared with lifetime nonsmokers ( Reynolds et al. 2004). Nonetheless, sufficient evidence has not accumulated since 2004 to suggest that the conclusions of the Surgeon General's report and the IARC monograph should be revised, and the possibility of selective reporting of positive associations for active smoking needs to be considered when interpreting these recent reports.

Several reports have evaluated the evidence on secondhand smoke exposure and breast cancer risk. The 1986 IARC monograph commented on the general issue of causation of cancer by secondhand smoke: "It is unlikely that any effects will be produced in passive smokers that are not produced to a greater extent in smokers and that types of effects that are not seen in smokers will not be seen in passive smokers" ( IARC 1986, p. 314). The IARC monograph on involuntary smoking, published in 2004, concluded that the evidence did not support a causal association between breast cancer and secondhand smoke ( IARC 2004). The 2001 Surgeon General's report also addressed the topic. The report considered cohort and case-control studies on involuntary smoking and breast cancer and found that the issue had not been "resolved" ( USDHHS 2001, p. 217). Most recently, the 2005 report of the California EPA ( Cal/EPA) found the evidence to be conclusive for secondhand smoke as a cause of premenopausal breast cancer ( Cal/EPA 2005).

The following section describes the prospective cohort and case-control studies on involuntary smoking and breast cancer. Whenever available, results on active smoking and breast cancer in the same study population are shown so the findings on involuntary and active smoking can be compared.

Quantitative Meta-Analysis

To synthesize the observational evidence, the technique of quantitative meta-analysis was used. The RR estimates for the various exposure measures from reports on cohort and case-control studies were abstracted and then combined using the statistical software package Stata. The studies used a variety of exposure measures to assess childhood or adulthood exposures, sources of exposure, and location of exposure. A documented set of decisions was made as to the selection of estimates from the studies. Additionally, some of the studies provided results by menopausal status.

Pooled estimates were calculated for three population samples: all women in a study (regardless of menopausal status), premenopausal women, and postmenopausal women. Eight exposure categories were considered: (1) any source during adulthood (adult all sources), (2) adult spousal/partner (adult spousal), (3) adult at home (includes smoking from any cohabitant), (4) adult at work, (5) child at home (usually parental), (6) both childhood and adulthood exposure (either at home or work or both), (7) ever exposure in studies that measured child and adult exposures (either at home or at work or both), and (8) the most comprehensive exposure for each study. For all categories, estimates of independent effects were selected over estimates of "ever" effects. In other words, if a study presented results for "ever exposed as a child" (regardless of adulthood exposure) as well as "exposed during childhood only" (no adulthood exposure), the latter was used in the analysis of childhood exposure because it represents a more unbiased estimate of the effect of childhood exposure independent of exposure during adulthood.

Whenever possible, the studies used adjusted estimates. The researchers performed subanalyses to investigate the influence of adjustment on the results. Studies were categorized according to whether they adjusted for reproductive factors (age at menarche, age at first birth, and parity) and for alcohol consumption. These factors were the focus of attention because they were the most important potential confounders.

Figure 7.2 Relative risks (with 95% confidence intervals) of breast cancer associated with adult exposure to secondhand smoke from spouses' smoking

Figure 7.3 Relative risks (with 95% confidence intervals) of breast cancer associated with all sources of adult exposure to secondhand smoke among premenopausal women

Sensitivity analyses were carried out that explored variations in the pooled estimates by the type of study, the extent of the exposure information available, and consideration of confounding ( Table 7.10). Findings from the cohort studies showed no association overall of breast cancer risk with secondhand smoke exposure, although the pooled estimate from the case-control studies was positive and statistically significant. The estimate was particularly high for hospital-based case-control studies. Comparing estimates for studies with and without consideration of confounding, the estimate was lower for those studies that included adjustment for potential confounding.

In Figure 7.5, the 21 studies are evaluated for potential publication bias using a funnel plot and a test developed by Begg and Mazumdar (1994). The funnel plot shows that less precise studies tended to have more strongly positive results, a pattern indicative of possible publication bias. The formal test for such bias was statistically significant (p <0.05).

Evidence Synthesis

The full body of evidence on secondhand smoke and breast cancer was evaluated with the criteria for causality, which have been used in this series of reports for a long time (Chapter 1, Introduction, Summary, and Conclusions). Consideration was also given to the extensive information on active smoking and breast cancer. Issues related to sources of secondhand smoke exposure, dose-response relationships, and differences in findings by menopausal status were also considered.

Consistency

Consistency refers to the replication of findings across studies with different designs, in different populations, and conducted by different investigators ( USDHHS 2004). To the extent that findings are comparable across a range of study characteristics, alternative explanations to causation in explaining associations become less tenable, particularly bias arising from methodologic limitations of particular designs.

There are currently 21 epidemiologic studies (7 cohort, 14 case-control) that have directly investigated the association between secondhand smoke exposure and the risk of breast cancer among lifetime nonsmokers. The overall evidence does not consistently show an increased risk of breast cancer in association with secondhand smoke, although the pooled estimate of all the evidence is above unity, the level of no effect ( Table 7.10); the evidence is not consistent by study design. Three well-established U.S. cohort studies each include a large number of breast cancer events: 669 breast cancer deaths in the ACS cohort; 1,359 incident invasive breast cancers in the NHS cohort; and 1,174 incident invasive breast cancers in the California Teachers Study cohort. These studies did not find an association between exposure to secondhand smoke and breast cancer risk; all RR estimates were around unity ( Wartenberg et al. 2000; Egan et al. 2002; Reynolds et al. 2004). Results from the four cohort studies from Asia are based on fewer breast cancer events (<200 breast cancer incident cases/deaths) and are more varied, but also do not provide consistent evidence for an association. Small RR increases of 10 to 30 percent were reported in three of the studies ( Hirayama 1984; Jee et al. 1999; Hanaoka et al. 2005), whereas a RR less than unity was reported in the fourth study, which is from Japan ( Nishino et al. 2001). The only significant finding came from a subgroup analysis in a cohort study in Japan with stratification by menopausal status ( Hanaoka et al. 2005). This finding was based on 77 breast cancers in premenopausal women. The pooled estimate for the cohort studies is 1.02 overall. This null finding from the cohort studies cannot be set aside as a result of methodologic limitations, because some of these studies have shown an increased risk for lung cancer and CHD associated with secondhand smoke.

A strength of the epidemiologic evidence on secondhand smoke and lung cancer has been the consistency across prospective cohort and case-control studies. Cohort and case-control studies are generally subject to somewhat differing sources of bias, and a comparability of findings in the two designs weighs against bias as the source of association. The findings of the two designs differ for secondhand smoke exposure and breast cancer, raising a concern that bias affected the findings of the case-control studies. The hospital-based, case-control studies show the strongest association and are particularly prone to bias from the noncomparability of cases and controls, and from the differential reporting of exposures by cases and controls.

The risk of breast cancer was not significantly related to workplace secondhand smoke exposure in two U.S. cohort studies ( Wartenberg et al. 2000; Egan et al. 2002) and in two case-control studies ( Smith et al. 1994; Bonner et al. 2005); lifetime workplace exposure was assessed in the case-control studies. In a cohort study conducted in Japan, the risk of breast cancer in premenopausal women was increased in association with workplace secondhand smoke exposure, but no increased risk was observed in postmenopausal women ( Hanaoka et al. 2005). In Shanghai, China, an intense (>300 minutes per day), daily, and recent workplace exposure was associated with an increased risk of breast cancer in both premenopausal and postmenopausal women, although the estimate was statistically significant only in premenopausal women ( Shrubsole et al. 2004). In the three studies that found a significantly increased risk associated with adulthood exposure ( Morabia et al. 1996; Johnson et al. 2000; Kropp and Chang-Claude 2002), RR estimates were not shown separately for occupational versus household exposures. However, in the study by Morabia and colleagues (1996), the risk estimates for spousal smoking were slightly stronger than for all sources of exposure during adulthood combined. Thus, some (but not all) studies offer evidence that breast cancer risk may be increased in association with workplace secondhand smoke exposure.

Strength of Association

Increasing the strength of association weighs more heavily against alternatives to causal association ( USDHHS 2004). For involuntary smoking and breast cancer risk, the overall association in the pooled estimates for premenopausal breast cancer indicate elevations of 40 to 60 percent ( Table 7.10). However, the highlighted limitations of the case-control studies of passive smoking and breast cancer, particularly selection bias and information bias, may be responsible, at least in part, for the increased risk. The inconsistent findings of the case-control and cohort studies for the association of passive smoking with premenopausal breast cancer also raise concerns about potential bias or unmeasured confounding, since consistency of risk estimates across varying study designs would weigh against such bias.

Biologic Plausibility

There is substantial literature on carcinogenesis in relation to breast cancer, but with more limited information directly relevant to tobacco smoke. One key aspect of biologic plausibility of secondhand smoke as a cause of breast cancer is the finding on active smoking and breast cancer. Additionally, the potential heterogeneity of breast cancer in relation to etiologic risk factors merits consideration. Epidemiologic research has only recently been directed at subgroups of breast cancer cases, defined by phenotype, such as estrogen and progesterone receptor status and genotype (e. g., susceptibility [ BRCA1 or BRCA2] or carcinogen metabolism [ NAT2]). To date, the evidence has not consistently shown active smoking to be associated with an increased risk in a particular subgroup ( Althuis et al. 2004; Ghadirian et al. 2004; USDHHS 2004).

Summary

The overall evidence is mixed and does not strongly or consistently support a causal relationship between secondhand smoke and breast cancer. Findings from prospective cohort studies and case-control studies differ to an extent that cannot plausibly be explained by differences in the quality of exposure measurements. The positive association is largely observed in case-control studies among women with premenopausal breast cancer. While greater susceptibility to tobacco smoke carcinogens during adolescence or at an early age has been hypothesized, there is still considerable uncertainty as to why secondhand smoke would only affect risk for premenopausal breast cancer. The overall pooled estimate is elevated, but the elevation largely comes from the increased risks estimated for premenopausal women in selected case-control studies. With regard to biologic plausibility, involuntary smoking would be expected to expose breast tissue to the carcinogens in secondhand smoke, as would active smoking. However, the evidence that active smoking causes no overall increase in breast cancer risks weighs against a causal role for involuntary smoking.

Conclusion

The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke and breast cancer.

Implications

Because breast cancer remains one of the most frequent cancers, research should be continued on its potential causes, including secondhand smoke exposure. While awaiting further evidence, women should be encouraged to avoid involuntary exposures to secondhand smoke because of the many documented adverse effects of inhaling secondhand smoke.

Nasal Sinus Cavity and Nasopharyngeal Carcinoma

Nasal Sinus Cavity

A few studies have investigated the relationship between secondhand smoke exposure and the risk of cancers in the upper respiratory tract, including nasal sinus cavity and nasopharyngeal carcinoma ( NPC), among lifetime nonsmokers. These sites are potentially at risk because both gases and particles in secondhand smoke are removed to some extent in the upper airway. In one cohort study ( Hirayama 1984) and two case-control studies ( Fukuda and Shibata 1990; Zheng et al. 1993) conducted among Caucasian men in the United States ( Zheng et al. 1993) and among women in Japan ( Fukuda and Shibata 1990; Zheng et al. 1993), secondhand smoke exposure was associated with up to a threefold increase in risk of nasal sinus cancer after adjusting for potential confounders. These studies were reviewed in detail in the Cal/EPA report ( NCI 1999), which concluded that the positive association between risk and secondhand smoke exposure was consistent and suggestive of a causal association. The positive association with secondhand smoke exposure is consistent with the relationship between active smoking and the risk of nasal sinus cancers. However, because the published studies were based on very modest sample sizes, further studies are needed to confirm the magnitude of risk associated with secondhand smoke exposure, to establish dose-response relationships, and to characterize the risk by the source (e. g., spouse, other household members, or coworkers) and by the timing of the exposure (current versus past exposure). The role of potential confounders, particularly occupational exposures, should be considered. Future studies should examine the association between secondhand smoke and nasal sinus cancer by histology type and subsite because the effects of tobacco smoke on nasal sinus cancers vary by both of those characteristics ( Rousch 1996).

Nasopharyngeal Carcinoma

A second study on active smoking, secondhand smoke exposure, and the risk of NPC was conducted in Taiwan, where the risk for NPC falls between that of low- and high-risk countries ( Cheng et al. 1999). Incident cases of histologically confirmed NPC (n = 378) among individuals who were younger than 75 years of age at diagnosis were prospectively ascertained from two teaching hospitals in Taipei between 1991 and 1994. Efforts were made to individually match controls for age, gender, and residence. A total of 375 NPC patients (260 men, 115 women) and 327 community controls (223 men, 104 women) were interviewed using a structured interview that asked about secondhand smoke exposures during childhood and adulthood, including the number of smokers in the household, duration of the exposures (person-years), and cumulative exposures (pack-years and person-years). The last two variables, duration and cumulative exposures, were derived from information obtained on smoking intensity and duration for each member reported to have smoked in the household.

The gender differences in secondhand smoke associations with NPC among lifetime nonsmokers were of borderline statistical significance. Because there were comparable risk estimates between men and women for active smoking and NPC, the investigators expected to find similar associations with secondhand smoke exposure. However, this was not the case. In addition, the researchers expected the magnitude of risks associated with secondhand smoke exposure to be no higher than the risks associated with active smoking, and this also was not the case.

Conclusions

1. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and a risk of nasal sinus cancer among nonsmokers.

2. The evidence is inadequate to infer the presence or absence of a causal relationship between secondhand smoke exposure and a risk of nasopharyngeal carcinoma among nonsmokers.

Implications

Larger studies with more complete information on secondhand smoke exposure are needed, with data on exposures at home and outside the home, timing of the exposure, other potential confounders (occupational factors), and tumor characteristics (histology, subsite) to definitively establish the relationship between secondhand smoke exposure and nasal sinus cancer. Studies that are designed to investigate the mechanism(s) of action of active smoking and secondhand smoke exposure will help to elucidate their respective roles in the development of nasal sinus cancer.

Further studies that include adequate numbers of men and women are needed to clarify whether the significant positive association between secondhand smoke exposure and a risk of NPC among women might reflect a chance finding.

Cervical Cancer

Some supportive evidence from epidemiologic and biochemical studies does exist that implicates a role for secondhand smoke exposure in the etiology of cervical cancer among nonsmokers. In a Japanese cohort study, the investigators observed a nonsignificant 15 percent increase in risk of cervical cancer among nonsmoking wives associated with the husbands' smoking ( Hirayama 1981). However, no association was found between the husbands' smoking and a risk of cervical cancer among participants in a Korean cohort study (adjusted OR = 0.9 [95 percent CI, 0.6-1.2]) ( Jee et al. 1999). Among the case-control studies, a significant positive association was observed in two studies ( Sandler et al. 1985b; Slattery et al. 1989). In the third case-control study, Coker and colleagues (1992) found that spousal secondhand smoke was associated with an increased risk of cervical cancer and intraepithelial neoplasia among nonsmokers that was of borderline statistical significance.

In the United States, Scholes and colleagues (1999) investigated the role of active smoking and secondhand smoke exposure in the etiology of lower grade cervical abnormalities at the Group Health Cooperative of Puget Sound in western Washington state. Between 1995 and 1996, a population-based automated cervical cytology database was used to identify women 18 years of age or older who had had cervical cytologic testing. Women with severe dysplastic changes (cervical intraepithelial neoplasia [ CIN] 3) or invasive cervical cancer (Class 5 and 6 Pap smear results) were excluded from the study. Women with mild or moderate dysplastic cytologic changes (Class 3 or 4 Pap smear results, also known as CIN 1 or 2) or Class 2 changes with epithelial cell abnormalities were classified as cases, and women with normal or Class 1 cytology results served as the control group.

Women aged 18 through 44 years who were not pregnant and did not have a history of hysterectomy were contacted and interviewed by telephone using a behavioral survey that included questions on active smoking and secondhand smoke exposure. Participants were specifically asked whether they had ever smoked as many as 100 cigarettes in their lifetime. Smokers who averaged one cigarette or more per day during the past 12 months were classified as current smokers. Women who had smoked at least 100 cigarettes in their lifetime but did not smoke daily now were classified as former smokers. Exposure to secondhand smoke was based on the smoking patterns of husbands or partners or other household members ( Scholes et al. 1999).

A total of 2,448 women-582 cases (i.e., 465 had Class 2 and 117 had Class 3 to 4 Pap smear results) and 1,866 controls (i.e., normal cytology)-were included in this analysis. Fifty-four percent (n = 315) of cases and 62 percent (n = 1,158) of controls were lifetime nonsmokers. Compared with lifetime nonsmokers, current smokers had an increased risk of an abnormal Pap smear (adjusted OR = 1.4 [95 percent CI, 1.1-1.8]) but former smokers did not (adjusted OR = 1.0 [95 percent CI, 0.8-1.3]). Compared with unexposed lifetime nonsmokers, nonsmokers who were exposed to secondhand smoke also showed an increased risk of abnormal Pap smear results of Class 2 to 4 (adjusted OR = 1.4 [95 percent CI, 1.0-2.0]). These results were adjusted for the lifetime number of sexual partners, age, and age at first sexual intercourse.

Conclusion

The evidence is inadequate to infer the presence or absence of a causal relationship between secondhand smoke exposure and the risk of cervical cancer among lifetime nonsmokers.

Implications

There is a need for additional studies with adequate sample sizes and more complete information on secondhand smoke exposures, including exposures at home and outside the home and the timing of the exposure, and other potential confounders to definitively establish an association between secondhand smoke exposure and the risk for cervical cancer and cervical abnormalities.

Lung Cancer

1. The evidence is sufficient to infer a causal relationship between secondhand smoke exposure and lung cancer among lifetime nonsmokers. This conclusion extends to all secondhand smoke exposure, regardless of location.

2. The pooled evidence indicates a 20 to 30 percent increase in the risk of lung cancer from secondhand smoke exposure associated with living with a smoker.

Breast Cancer

3. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke and breast cancer.

Nasal Sinus Cavity and Nasopharyngeal Carcinoma

4. The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and a risk of nasal sinus cancer among nonsmokers.

5. The evidence is inadequate to infer the presence or absence of a causal relationship between secondhand smoke exposure and a risk of nasopharyngeal carcinoma among nonsmokers.

Cervical Cancer

6. The evidence is inadequate to infer the presence or absence of a causal relationship between secondhand smoke exposure and the risk of cervical cancer among lifetime nonsmokers.

Cohort Studies on the Relationship of Exposure to Secondhand Smoke and Lung Cancer

Nishino and colleagues (2001) investigated the relationship between secondhand smoke exposure at home and the incidence of lung and other cancers in a population-based, prospective study of lifetime nonsmoking women who lived in Miyagi Prefecture, Japan. At the time of enrollment in 1984, 31,345 persons (13,992 men and 17,353 women) completed a baseline questionnaire on smoking, drinking and dietary habits, and reproductive history. To assess residential secondhand smoke exposure, the participants were asked to identify any smokers in their households (husband, wife, father, mother, children, or other household members).

Of the 10,334 lifetime nonsmoking women, 9,675 had no history of cancer and had a complete history of secondhand smoke exposure that included the smoking status of the husband and other household members. Nishino and colleagues (2001) used the population-based cancer registry of Miyagi Prefecture to identify 24 nonsmoking women who had developed lung cancer during the nine-year follow-up period. These investigators also found that the relative risk ( RR) for lung cancer was higher among women whose husbands were smokers (1.9 [95 percent confidence interval ( CI), 0.8-4.4]) than among women married to nonsmokers. This risk estimate was slightly weakened (RR = 1.8 [95 percent CI, 0.7-4.6]) after further adjustment for demographic characteristics and fruit and vegetable intake. When the smoking status of the husbands and other household members were considered jointly, the risk of lung cancer was 1.2 (95 percent CI, 0.3-4.0) among women who were exposed to secondhand smoke. The very small number of persons with lung cancer in each category of secondhand smoke exposure limits the interpretation of this study.

Jee and colleagues (1999) evaluated the relationship between smoking by the husbands and lung cancer incidence among 157,436 nonsmoking women in Korea whose husbands were enrolled in a health insurance plan. At the time of enrollment in 1992, information on the smoking patterns of the husbands (never, former, current smoker) was obtained during routine medical examinations, and was reassessed two years later. The classification of exposure to secondhand smoke was based on smoking intensity (the number of cigarettes currently smoked) and duration (the number of years of continuous smoking to date). During the three and one-half years of follow-up, Jee and colleagues (1999) identified 79 persons with lung cancer both existing and newly incident during follow-up.

de Waard and colleagues (1995) conducted a nested case-control study of lung cancer that used the urinary cotinine level as a marker of secondhand smoke exposure. In 1975, the investigators established a cohort of 14,697 women from Utrecht, Netherlands, to study breast cancer risk factors. There was a second screening one year later and baseline urine samples were collected from 12,865 women. In 1982 and 1983, the same investigators enrolled another breast screening cohort and collected urine specimens from more than 12,000 women aged 40 through 49 years. In 1989, 1991, and 1992, these cohorts were linked to the Netherlands Cancer Registry, and the researchers identified 92 women who had died of lung cancer (69 smokers, 23 nonsmokers). From the same cohorts, two to four comparably age-matched controls donated urine specimens on the same day that the cases were selected. Smoking status was assessed from self-reports at the time of urine collection. A total of 448 participants (257 smokers, 191 nonsmokers) participated in an evaluation of the risk of lung cancer in relation to urinary cotinine levels and self-reported smoking status ( de Waard et al. 1995).

This report on secondhand smoke exposure and lung cancer in the NHS is limited by the small number of lung cancers among lifetime nonsmokers-only a subset could be included in the analysis. Although information on exposure during childhood was obtained, these results were not presented. In addition, only age was considered in the analysis.

Case-Control Studies on the Relationship of Exposure to Secondhand Smoke and Lung Cancer

Canada and the United States

Of the 1 Canadian and 12 U.S. published case-control studies with data on secondhand smoke exposure and lung cancer risk in lifetime nonsmokers, 5 larger studies conducted in the 1990s were designed to address potential methodologic concerns such as misclassification of lifetime nonsmoking status, assessment of secondhand smoke exposure, and inclusion of potential confounders ( Table 7.1) ( Brownson et al. 1992; Stockwell et al. 1992; Fontham et al. 1994; Kabat et al. 1995; Schwartz et al. 1996; National Cancer Institute [NCI] 1999). One population-based, case-control study included female lung cancer patients who were identified through 8 of the 10 Canadian provincial cancer registries ( Table 7.3) ( Johnson et al. 2001). A total of 4,089 women responded to the mailed questionnaire. Of these respondents, 1,558 had histologically confirmed primary lung cancer and 2,531 did not have lung cancer. Of those who were eligible and who agreed to participate, 161 cases and 1,271 controls were identified; all were lifetime nonsmokers (i.e., they had smoked fewer than 100 cigarettes in a lifetime). Each respondent answered questions about the number of regular smokers in the household, the duration of residence, and a lifetime occupational history (for each job of at least one year) that included the number of regular smokers in the participant's immediate work area and the number of years at that job. This study investigated (1) the duration and smoker-years (the number of years of exposure weighted by the number of smokers) of residential secondhand smoke, which was defined as residential years multiplied by the number of regular smokers in the residence; and (2) occupational secondhand smoke exposure, which was defined as years worked multiplied by the number of regular smokers in the workplace.

This study was limited because assessments of secondhand smoke exposures were available only for 44 percent (71 out of 161) of the lifetime nonsmoking cases and 60 percent (761 of 1,271) of the lifetime nonsmoking controls. The positive associations between lung cancer risk and residential and occupational secondhand smoke exposures weakened substantially when the analyses included participants with less complete information on their exposures (137 cases and 1,178 controls), or when the participants were all lifetime nonsmokers (161 cases and 1,271 controls). Although the diluted secondhand smoke effect in all lifetime nonsmokers may be due to random (nondifferential) misclassification, the investigators acknowledged the modest overall response rate (70 percent) from the persons who had received the mailed questionnaire, and the relatively high proportion of respondents with incomplete exposure information. It is unclear whether all of the missing data for lifetime nonsmoking cases (56 percent) and controls (40 percent) was attributable to living outside of Canada. Comparisons of demographic characteristics (such as social class, age, and birthplace) and characteristics of persons with complete and incomplete secondhand smoke exposure histories may provide some clues regarding the nature of bias (if any) as a result of the missing information.

Other Asian Populations

Japan

In addition to the case-control studies conducted in various Chinese populations, case-control studies conducted in Japan ( Akiba et al. 1986; Inoue and Hirayama 1988; Shimizu et al. 1988; Sobue 1990) generally support the finding that exposure to secondhand smoke is associated with an increased risk of lung cancer in nonsmokers. These studies have been included and discussed in previous reviews.

India

A small hospital-based, case-control study of lifetime nonsmokers in Chandigarh, India, compared 58 nonsmoking adults (17 men and 41 women) diagnosed with lung cancer (histologically confirmed cases) and 123 nonsmoking controls (56 men and 67 women). Controls were either other adult patients admitted to the hospital or visitors in the hospital. Although the conditions of the patients who were admitted to the hospital were not described, the investigators excluded patients with diseases related to smoking, alcohol, or diet. No attempt was made to match cases and controls by gender, age, or other variables ( Table 7.3) ( Rapiti et al. 1999).

The study was small and the appropriateness of the control groups is uncertain. Information on potential confounders was also lacking. The very high estimate of risk associated with secondhand smoke exposure in childhood may be a chance finding because results from most published studies show either no risk or a much weaker effect on risk. The results observed in association with cigarettes versus bidis smoked by the spouses were also divergent. Although the investigators explained that a bidi is smaller in size and may emit less smoke than a cigarette, they found no basis for anticipating a protective effect from bidis.

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Cancer Among Adults from Exposure to Secondhand Smoke

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Active cigarette smoking causes cancer in multiple organs (U.S. Department of Health and Human Services [USDHHS] 2004). Secondhand tobacco smoke contains the same carcinogens that are inhaled by smokers and consequently, there been a concern for a long time that involuntary smoking also causes cancer.

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A commonality between many of the 'old money' characters in The Fundamentals of Play is an overwhelming sense of purposelessness. They regurgitate the ideals and culture of previous generations. George commentates that "we weren't making it new" (185). Despite following the goal of 'The Game', whether it be the pursuit of love or wealth, they all are trapped and purposeless.

Like The Great Gatsby, the characters in the Fundamentals of Play tend to value tangible items over personal relationships. When describing his past to George, Harry recounts how "A lotta [the] kids weren't cool in high school" but he "was cool in high school. [He] had a car" (181). This interaction demonstrates how the East Coast socioeconomic "elite" of the 1990's (equally to the upper class of the '20's) classified their peers, without hesitation, into caste-like social groups based solely on their wealth and belongings. This classification is problematic because it prevents the ultra-rich from venturing socially outside of their bubble of wealth, forcing them to create one-dimensional relationships with only those "worthy" as determined by their financial prestige. These relations deliver no true value to the involved parties because they are not true friendships, derived from commonalities in their personalities, but rather superficial connections to one another through possession of intriguing items, like a car in the case of Harry.

The true shallowness of these materialism-based relationships is evident in George's final chapter thoughts and dialogue, in which he ponders how he will miss his peers, explicitly mentioning Kate and Chat. When delving into the traits that he will miss most, George settles on the "silent tribute they have paid [him] all of these years – of recognizing [his] name" (280). Shows that all he values in his relationships revolve around the ideals of materialism and that these relationships do not satisfy or complete him in any form aside from recognition and affirmation of his societal power.