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Welcome to Audiko.net! It's easy to download a free Lucenzo ringtones for your iPhone or mobile. Scope out your favorite moments from your favorite hit - baila morena, Danza Kuduro (feat. Don Omar) [From Fast & Furious 5], Danza Kuduro (From the Soundtrack of Fast & Furious 5), or any other track. Then download the prepared Lucenzo ringtones to your cell phone, and enjoy Hip-Hop music by Lucenzo every time your phone rings. If you love Hip-Hop or maybe Reggae and music, then you will probably like Neg' Marrons as love Hip-Hop or maybe Reggae and music, then you will probably like Neg' Marrons, [similar_artist_2], or [similar_artist_3] as well. Here you can obtain your tune both in the MP3 and m4a formats, compatible with both mobile phones and iPhones. Just select a track, and choose free Lucenzo ringtones download option.
Download Lucenzo Ringtones
10 Jun 2011
15 Nov 2010
15 Aug 2010


text: I currently am using a Manfrotto tripod and on my last hiking trip I just put my pack on my four wheeler on the way out and scuffed off the finish/paint near the head. Was wondering if anyone had any suggestions for products to fix this. Everyone says it gives it character but it annoys me and I am giving this to my dad and I will not let him have a scuffed up piece of equipment. Thanks in advance!

subset: commoncrawl


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Interlibrary Loan REQUEST Service
What is the Request Service?
UC faculty, students and staff may use the request service to automatically place an interlibrary request for material found in the Melvyl Catalog, UCR & UC-licensed databases, or using Citation Linker.
Note: Students may not request required textbooks or course books through interlibrary loan.
Using the Melvyl Catalog
The Request button is available from the detailed search results display. Seperate requests must be made for each item.
- Select item(s) by checking the box next to each item then click on the Request button.
- Enter your department, library card number (14-digit library card barcode), your preferred UCR Library delivery location, and other relevant information.
- Click the Continue button.
- Review the item(s) you have requested.
- Read and accept the copyright statement.
- Request may show you a link to an online copy of your item or in some cases ask you to make some addtional decisions about an item.
- When the item(s) complete processing, a confirmation message is displayed. It is recommended that you send this page to your personal email account.
Note: Journal articles are usually delivered via the web.
Melvyl Catalog (All UC)
Using Request in article databases
The UC-eLinks button is available in the search results display. Seperate requests must be made for each item.
- Click on the UC-eLinks button. If the item is unavailable, choose Request from the UC-eLinks menu.
- Once you choose Request, the steps are the same as described above.
Using Request via Citation Linker
- Complete the Citation Linker form. After you click "Continue", you will see the UC-eLinks window.
- If the item is unavailable, choose Request from the UC-eLinks menu.
- Once you choose Request, the steps are the same as described above.
Note that you may receive messages during the REQUEST process that inform you about local availability of the item(s) or your authorization to use the service. Contact Interlibrary Loan Services if you have questions about the service or process.
You will be notified when the item arrives and may pick it up at the Rivera Library Circulation Desk, the Orbach Science Library Circulation Desk, the Music Library Circulation Desk, the Multimedia Library Circulation Desk, or the Palm Desert Library, Admistrative Desk in Building B.
.Photocopies will be emailed to you.
Are There Any Limits on Use?
UC faculty, staff and students may use the service to request items from the MELVYL Catalog, from the UCR & UC-licensed databases and from UC-eLinks. There is no limit to the number of items that may be requested.
REQUEST will inform you if you've requested material that is held by UCR and will suggest you look for it at the library.
Faculty, staff and students may submit a request to have available UCR Library materials paged for pick up at the Circulation desk of the Rivera, Orbach Science, Multimedia or Music Libraries. Please see the Paging Service webpage for additional information.
For more information please contact:
|Rivera Interlibrary Loans
Phone: 951-827-3234
E-mail: email@example.com
|Orbach Science Library Interlibrary Services
Phone: 951-827-2819
Email: firstname.lastname@example.com


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10 Steps to Pick the Right Doctor
Whether you need a primary care doctor or a specialist, these 10 steps will ensure you find the right doctor for you. View Slideshow
Dr. Maher's Experience
- Cardiology
- Interventional Cardiology
Board Certifications
- Cardiovascular Disease
- Internal Medicine
- Cardiac Catheterization (incl. Coronary Angiography)
- Cardiac Electrophysiology
- Cardiac Imaging
- Cardiac Myocardial Perfusion Imaging
- Cardioversion, Elective
- Cardioverter-Defibrillator or Pacemaker Insertion, Removal or Repair
- Chest CT (incl. Heart and Lungs)
- Coronary Angioplasty, Atherectomy and Stent
- Non-Coronary Angioplasty, Atherectomy, and Stenting
- Pacemaker Insertion or Replacement
- Peripheral Artery Catheterization
- Tilt Testing or Cardiac Event Monitors
- Valve Repair or Replacement (Aortic, Mitral, Tricuspid, and Pulmonary)
- Vascular Duplex Ultrasonography and Plethysmography
Conditions Dr. Maher Treats
Dr. Maher does not have any conditions listed. If you are Dr. Maher and would like to add conditions you treat, please update your free profile.
Background Check for Dr. Maher
0 Malpractice Claims
- No malpractice history found for California.
- No sanctions history found for the years that Healthgrades collects data.
0 Board Actions
- No board actions found for the years that Healthgrades collects data.
Awards & Recognitions
Education & Training
Medical School
- Keck Sch Of Med Of The Usc
- Graduated in 1978
Internship Hospital
- Huntington Meml Hosp
Residency Hospital
- Huntington Meml Hosp
Fellowship Hospital
- Huntington Meml Hosp
Languages Spoken by Dr. Maher & Staff
- English


text:
Hartford, a city of 15,000 inhabitants at the time, had no general hospital. City doctors visited the injured in their homes. The disaster underscored the city's inability to treat serious injuries.
The physicians of the Hartford Medical Society, community leaders and the editorial voice of The Hartford Courant combined to urge legislation creating a general hospital for Hartford and to raise the necessary funds from private donations
The hospital was founded out of humanitarian concern for all of the citizens of Hartford, and was envisioned as a place where the finest medicine would be made available to those in need.


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Overview available titles by artist/scenarist Braithwaite, Doug
Doug Braithwaite in the
"Doug (or Dougie) Braithwaite was encouraged by his high school teacher to become a comic artist. He went to show his work at Marvel UK, when he was only 15 years old. After a try-out, he took courses at the London Cartoon Centre from among others David Lloyd. He eventually made his debut..." [ Lees meer ]


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The Adventure Cycling blog covers bicycle-travel news, touring tips and gear, bicycle routes, organizational news, membership highlights, guided tours, and more. Follow us on Facebook or Twitter for daily updates. Interested in becoming a guest blogger for Adventure Cycling? Share your story with us.
Photo by photo contest 2014
One of my favorite parts of my job in the summer is reading the blogs and tweets of cyclists on the road. It keeps me in touch with the issues folks might be having on the routes for various reasons and it fills my coffee and lunch breaks with a bit of vicarious thrill!


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UPS reduces planned number of pilot furloughs
August 24, 2010
Citing improving financial conditions, UPS said it is reducing the number of its planned pilot furloughs from 300 down to 230, according to an Associated Press report.
This follows a February announcement from UPS that stated the company planned to furlough at least 300 of its 2,800 pilots represented by the Independent Pilots Association (IPA), which represents pilots flying for UPS, as part of a cost-cutting initiative. UPS officials said at the time it was actively working with the IPA "avert or mitigate layoffs before they take effect." In February, UPS added that if furloughs were to occur, the first 170 pilots were to be furloughed in May.
Earlier this year, the IPA said that 54 pilots would be furloughed on May 23, and the AP report indicated that a total of 109 of the 230 scheduled furloughs had already occurred.
UPS officials told LM in an e-mail earlier this year that the furloughs were needed, because they have more crewmembers than needed to operate its airline. They explained that UPS is flying 48 fewer aircraft—214 compared to 262—than it was at its peak in 2003.
What's more, UPS is flying 15 fewer block hours—the amount of time planes are in flight—than in 2007 before the recession kicked in. And UPS added that the FAA's 2007 "retirement age 65" ruling has kept 200 pilots on the payroll whom previously would have been required to retire at age 60.
"Our business model is pretty simple: packages equal jobs," spokesman Norman Black said in a statement. "Our hope is that the economy improves to the point we can return more employees to work. We will continue to examine business conditions and adjust pilot staffing levels appropriately in the future."
This news follows a June 2009 agreement between UPS and the IPA in which they reached terms on money-saving measures totaling $131 million over three years. As part of this deal, UPS and the IPA pledged to not have any pilot furloughs until April 1, 2010. And UPS officials said at the time that voluntary pilot savings generated in 2009 could potentially eliminate any proposed layoffs, adding that savings identified by the IPA have been produced through voluntary programs, including pilots taking short- and long-term leaves of absence; military leaves; job-sharing; reductions in flight-pay guarantees; early retirement; and sick bank contributions.
But according to an IPA statement, they claim UPS said in January of this year that UPS now needed $244 million in cost-savings measures through 2015, up from the $131 million over three years in June 2009, with a preference for "compulsory savings," which the IPA said indicates furloughs.
Despite an uneven economy, UPS reported second quarter earnings—with quarterly revenue at $12.2 billion—was up 12.7 percent year-over-year, and operating profit—at $1.4 billion—was up 56.6 percent. Earnings per share—at $0.84—were up 71 percent.
UPS added that average volume per day of 14.8 million packages was up 3.4 percent, and consolidated quarterly volume of 948 million packages was up 4 percent, with consolidated revenue per piece—at $10.47—up 7.1 percent. Company officials said that these increases represent higher base rates, fuel surcharge increases, and heavier average shipment weight.
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Bubble Mouse Blast
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Snow Queen
by Zygomatic
Everything is frozen by the Snow Queen, you have to save the frozen animals by collecting their image parts from the game. Swap 2 items and create 3 in a row to remove them from the game. Collect all items from the picture on the left to advance to the next level. You get help from the magic dragons. You can activate a dragon by removing a color. If you remove that color again, the bonus is activated.
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text:
Forty acres of lights will illuminate the Denver Zoo.
Featuring more than 200 Asian lanterns of various shapes, sizes and colors, visitors can waltz through the Denver Zoo's new Toyota Elephant Passage.
The Sea of Lights showcases whales, an octopus and seahorses frolicking around.
Kids can ride the Zoo Train Experience while listening to the story of extinct animals and learn why it is important to help animals.
Naughty and nice girls and boys can visit Santa from Friday until Dec. 23.
Icecarvers will show off their skills Sundays through Thursdays from 6 to 8 p.m.
On Nov. 24, Dec. 19 and Dec. 31, Bunk with the Beasts will let kids explore how wild animals adapt to winter habitats and sleep overnight at the zoo.
Zoo Lights runs from Friday until Jan. 2 from 5:30 to 9 p.m.
(KUSA-TV © 2012 Multimedia Holdings Corporation)


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ATLANTA - The Georgia Department of Natural Resources recently unveiled an interactive map that identifies DNR-managed lands and outdoor recreation opportunities.
The Rape Crisis Center of the Coastal Empire will present UnMaskerade 2014 at 6 p.m. April 26 at Andaz Hotel, formerly Avia, in Ellis Square in Savannah.
The Community Collaborative Rain, Hail and Snow network is holding its March Madness recruiting contest this month nationwide.
Are you up to date on all things television?
HINESVILLE: Liberty Stadium Cinemas 9
Feb. 19 to March 20: An offer you previously turned down might no longer be available. But if you do some checking around, you could find something else that would suit you just fine.
Fort King George State Historic Site will be invaded again by the Scots this weekend.
The Long County Public Library has expanded its schedule to offer additional operating hours.
Last week, we examined "Non-Stop," the high-flying Liam Neeson movie that opened No. 1 at the box office.
Gary Sinise and The Lt. Dan Band are coming to Fort Stewart for a free concert that is open to the public.
HINESVILLE: Liberty Stadium Cinemas 9
Feb. 19 to March 20: Instead of spending too much time floundering around wondering if you can meet your deadline, you need to spend more time actually working toward reaching it.
Did you see the Oscars last weekend? USA Today reported the telecast, hosted by Ellen DeGeneres, drew 43.7 million viewers, making it the most watched Academy Awards show in 14 years.
HINESVILLE: Liberty Stadium Cinemas 9
About 150 people from 18 states checked into the Desoto Hotel in Savannah last weekend for the Southern Garden History Society's 32nd annual meeting. The two-day event included talks by landscape-design and preservation experts, and tours of gardens that traditionally are not open to the public. On the third day, according to SGHS Immediate Past President Lucy Hitch, attendees are offered the opportunity to tour additional sites that are a bit further away from the conference.
© 2016 Hinesville Publishing - All Rights Reserved
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You are here : Home > Highlights > Nespresso in Central America
Nespresso in Central America
Accelerating AAA Progress in Central America
Environment Events
Since 2007, Nespresso has been working in partnership with the International Finance Corporation (IFC, a member of the World Bank Group) and ECOM, one of our green coffee supplier partners, to help farmers continuously improve in all three areas of the AAA Program: quality, sustainability and productivity. To date, the partnership has benefited around 6,000 farmers in four clusters in Mexico, Guatemala, Costa Rica and Nicaragua. Making a long-term commitment to farmers belonging to the AAA community, the partnership has been extended for another three years and will now run until at least 2013.
Must see


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Things to see and do - Lyons-la-Forêt
Leaving for France
Lyons-la-Forêt :
Unmissable tourist site
Where to sleep?
Lyons-la-Forêt Hotel tips
Les Lions De Beauclerc from95 €Book
Les Maisons de La Licorne from128 €Book
Hôtel La Licorne & Spa from180 €Book
Lyons-la-Forêt Travel guide
Lyons-la-Forêt : Michelin's recommendations
Lyons is one of those villages which, once seen, is never forgotten. Spruce and intact, its half-timbered cob and brick buildings situated against a woodland backdrop, this is the very essence of traditional Normandy. Place Benserade has wood-panelled residences and market. 12km to the south is Écouis, worth visiting for its Collegiate Church of Notre Dame with 14C-17C furnishings and statues (that of St Agnes, with her cascading hair, is remarkable).
Tourist attractions Lyons-la-Forêt : Things to see and do
Lyons Forest
F - Lyons-la-Forêt
Surrounding the village of Lyons-la-Forêt, this vast woodland (10 700ha) is "one of the natural wonders of France and the apogee of the beech tree". Its trees often have trunks over 20m high; the highest, the Bunodière beech, nudges 50m. Wi..
Hotels Lyons-la-Forêt
Hotel Du Grand Cerf & Spa
Place De La Halle F - 27480 Lyons-la-Forêt
Prix Prices from : 170 €
With a chalet style, Hotel Le Grand Cerf & Spa is set within a 17th-century building in the heart of Lyons-la-Forêt. Guests have unlimited access to the pool, hot tub, sauna, hammam and tea room. The spacious guest rooms feature exposed beams and la..
Les Maisons de La Licorne
38 rue de l'hôtel de ville F - 27480 Lyons-la-Forêt
Set in a half-timbered building, this hotel is situated in Lyons-la-Forêt in the Lyons Forest and features a garden. Guests have free access to the wellness centre next to the hotel. The apartments and suites offer views of the village or the garden..
Les Lions De Beauclerc
7 Rue De L'hôtel De Ville F - 27480 Lyons-la-Forêt
The Lions de Beauclerc is situated in the heart of the historic village of Lyons la ForêT. At the Lions de Beauclerc you will discover a refined and warm decor. There are six bedrooms, each decorated in a different style using antique furniture. Al..
Restaurants Lyons-la-Forêt
Les Lions de Beauclerc
7 rue de l'Hôtel-de-Ville F - 27480 Lyons-la-Forêt
La Licorne Royale
27 place Issac-Benserade F - 27480 Lyons-la-Forêt
Quality ingredients, careful technique, balanced and subtle marriages of flavours, all combined to stimulate the taste buds. You can be sure of a pleasant meal here, which you will enjoy all the more thanks to an intimate and charming interior that s..
Le Bistrot du Grand Cerf
31 32 place Isaac-Bensarade F - 27480 Lyons-la-Forêt
This new-style rustic bistro really has character! Beams, exposed brick and an attractive terrace on the paved courtyard. Bistro cuisine and monthly changing set menus.


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Lung Cancer Prevention (PDQ®): Prevention - Health Professional Information [NCI]Skip to the navigation
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Note: Separate PDQ summaries on Lung Cancer Screening; Small Cell Lung Cancer Treatment; Non-Small Cell Lung Cancer Treatment; and Cigarette Smoking: Health Risks and How to Quit are also available.
Who is at Risk?
Lung cancer risk is largely a function of older age combined with extensive cigarette smoking history. Lung cancer is more common in men than women and in those of lower socioeconomic status. Patterns of lung cancer according to demographic characteristics tend to be strongly correlated with historical patterns of cigarette smoking prevalence. An exception to this is the very high rate of lung cancer in African American men, a group whose very high lung cancer death rate is not explainable simply by historical smoking patterns.[1]
In nonsmokers, important lung cancer risk factors are exposure to secondhand smoke, exposure to ionizing radiation, and occupational exposure to lung carcinogens, such as asbestos. Radiation exposures relevant to the general population include environmental exposure to radon and radiation exposures administered in the medical care setting, particularly when administered at high doses, such as radiation therapy to the chest or breast.[2] Cigarette smoking often interacts with these other factors. There are several examples, including radon exposure and asbestos exposure, in which the combined exposure to cigarette smoke plus another risk factor results in an increase in risk that is much greater than the sum of the risks associated with each factor alone.
Factors associated with increased risk of lung cancer
Cigarette smoking
Starting with the 1964 Surgeon General's Report and followed by each subsequent Surgeon General's Report that has included a review of the evidence on smoking and lung cancer, an enormous body of scientific evidence clearly documents that cigarette smoking causes lung cancer, and that cigarette smoking is the major cause of lung cancer.
Based on solid evidence, cigarette smoking causes lung cancer. The risks of lung cancer associated with cigarette smoking are dose-dependent and increase markedly according to the number of cigarettes smoked per day and the number of years smoked. On average, current smokers have approximately 20 times the risk of lung cancer compared with nonsmokers.
Magnitude of Effect: Increased risk, very large.
|Study Design: Numerous prospective cohort and case-control studies, combined with quasi-experimental evidence showing population-level smoking prevalence predicts the population-level burden of lung cancer.
|Internal Validity: Good.
|Consistency: Good.
|External Validity: Good.
Exposure to secondhand smoke
Based on solid evidence, exposure to secondhand smoke is an established cause of lung cancer.
Magnitude of Effect: Increased risk, small magnitude. Compared with nonsmokers not exposed to secondhand smoke, nonsmokers exposed to secondhand smoke have approximately a 20% increased risk of lung cancer.
|Study Design: Prospective cohort and case-control studies.
|Internal Validity: Good.
|Consistency: Good.
|External Validity: Good.
Radon exposure
Based on solid evidence, exposure to radon increases lung cancer incidence and mortality.
Magnitude of Effect: Increased risk that follows a dose-response gradient, with small increases in risk for levels experienced in most at-risk homes to greater increases in risk for high-level exposures.
|Study Design: Cohort and case-control studies.
|Internal Validity: Fair.
|Consistency: Good.
|External Validity: Fair.
Occupational exposure to lung carcinogens
Based on solid evidence, workplace exposure to asbestos, arsenic, beryllium, cadmium, chromium, and nickel increases lung cancer incidence and mortality.
Magnitude of Effect: Increased risk, large magnitude (more than fivefold). Risks follow a dose-response gradient, with high-level exposures associated with large increases in risk. Cigarette smoking also potentiates the effect of many of these lung carcinogens so that the risks are even greater in smokers.
|Study Design: Cohort and case-control studies.
|Internal Validity: Good.
|Consistency: Good.
|External Validity: Good.
Air pollution
Based on solid evidence, exposure to outdoor air pollution, specifically small particles, increases lung cancer incidence and mortality.
Magnitude of Effect: Increased risk; compared with the lowest exposure categories, those in the highest exposure categories have approximately a 40% increased risk of lung cancer.
|Study Design: Cohort and case-control studies.
|Internal Validity: Good.
|Consistency: Good.
|External Validity: Good.
Factors of uncertain association with risk
Dietary factors
Based on equivocal evidence, the observed inverse associations between lung cancer and dietary factors, such as fruit and vegetable consumption, are difficult to disentangle from cigarette smoking.
Magnitude of Effect: Inverse association, moderate magnitude, but difficult to determine if true cause-effect association or due to confounding by cigarette smoking.
|Study Design: Numerous cohort and case-control studies, and meta-analyses.
|Internal Validity: Fair.
|Consistency: Fair.
|External Validity: Good.
Physical activity
Based on equivocal evidence, the observed inverse associations between lung cancer and higher levels of physical activity are difficult to disentangle from cigarette smoking.
Magnitude of Effect: Inverse association, moderate magnitude, but difficult to determine if true cause-effect association or due to confounding by cigarette smoking.
|Study Design: Numerous cohort and case-control studies, and meta-analyses.
|Internal Validity: Fair.
|Consistency: Fair.
|External Validity: Good.
Interventions Associated With Decreased Risk of Lung Cancer
Smoking avoidance
Based on solid evidence, cigarette smoking causes lung cancer and therefore, smoking avoidance results in decreased mortality from primary lung cancers.
Magnitude of Effect: Decreased risk, substantial magnitude.
|Study Design: Cohort and case-control studies.
|Internal Validity: Good.
|Consistency: Good.
|External Validity: Good.
Smoking cessation
Based on solid evidence, long-term sustained smoking cessation results in decreased incidence of lung cancer and of second primary lung tumors.
Magnitude of Effect: Decreased risk, moderate magnitude.
|Study Design: Cohort and case-control studies.
|Internal Validity: Good.
|Consistency: Good.
|External Validity: Good.
Eliminating secondhand smoke
Based on solid evidence, exposure to secondhand smoke causes lung cancer and therefore, preventing exposure to secondhand smoke results in decreased incidence and mortality from primary lung cancers.
Magnitude of Effect: Decreased risk, small magnitude.
|Study Design: Cohort and case-control studies.
|Internal Validity: Good.
|Consistency: Good.
|External Validity: Good.
Reducing or eliminating occupational exposure to lung carcinogens
Based on solid evidence, occupational exposures such as asbestos, arsenic, nickel, and chromium are causally associated with lung cancer. Reducing or eliminating workplace exposures to known lung carcinogens would be expected to result in a corresponding decrease in the risk of lung cancer.
Magnitude of Effect: Decreased risk, with a larger effect, the greater the reduction in exposure.
|Study Design: Cohort and case-control studies.
|Internal Validity: Good.
|Consistency: Good.
|External Validity: Good.
Reducing or eliminating exposure to radon
Based on solid evidence, indoor exposure to radon increases lung cancer incidence and mortality, particularly among cigarette smokers. In homes with high radon concentrations, taking steps to prevent radon from entering homes by sealing the basement would be expected to result in a corresponding decrease in the risk of lung cancer.
Magnitude of Effect: Increased risk that follows a dose-response gradient, with small increases in risk for levels experienced in most at-risk homes to greater increases in risk for high-level exposures.
|Study Design: Cohort and case-control studies.
|Internal Validity: Fair.
|Consistency: Good.
|External Validity: Fair.
Interventions Associated With an Increased Risk of Lung Cancer
Beta-carotene supplementation in current smokers
Based on solid evidence, high-intensity smokers who take pharmacologic doses of beta-carotene have an increased lung cancer incidence and mortality that is associated with taking the supplement.
Magnitude of Effect: Increased risk, small magnitude.
|Study Design: Two randomized controlled trials with consistent results.
|Internal Validity: Good.
|Consistency: Good.
|External Validity: Good.
Interventions That Do Not Decrease Risk of Lung Cancer
Beta-carotene in nonsmokers
Based on solid evidence, nonsmokers who take pharmacological doses of beta-carotene do not experience significantly different lung cancer incidence or mortality compared with taking a placebo.
Magnitude of Effect: No substantive effect.
|Study Design: Randomized controlled trial.
|Internal Validity: Good.
|Consistency: Good.
|External Validity: Fair.
Vitamin E (Tocopherol)
Based on solid evidence, taking vitamin E supplements does not affect the risk of lung cancer.
Magnitude of Effect: Strong evidence of no association.
|Study Design: Randomized controlled trials.
|Internal Validity: Good.
|Consistency: Fair.
|External Validity: Good.
- Pinsky PF: Racial and ethnic differences in lung cancer incidence: how much is explained by differences in smoking patterns? (United States). Cancer Causes Control 17 (8): 1017-24, 2006.
- Friedman DL, Whitton J, Leisenring W, et al.: Subsequent neoplasms in 5-year survivors of childhood cancer: the Childhood Cancer Survivor Study. J Natl Cancer Inst 102 (14): 1083-95, 2010.
Description of the Evidence
Incidence and mortality
Lung cancer has a tremendous impact on the health of the American public, with an estimated 221,200 new cases and 158,040 deaths predicted in 2015 in men and women combined.[1] Lung cancer causes more deaths per year in the United States than the next four leading causes of cancer death combined. Lung cancer incidence and mortality rates increased markedly throughout most of the last century, first in men and then in women. The trends in lung cancer incidence and mortality rates have closely mirrored historical patterns of smoking prevalence, after accounting for an appropriate latency period. Because of historical differences in smoking prevalence between men and women, lung cancer rates in men have been consistently declining since 1990. The incidence rate in men declined from a high of 102.1 cases per 100,000 men in 1984 to 78.6 cases per 100,000 men in 2011. Consistent declines in women have not been seen.[1,2] In the United States, it is estimated that lung cancer will account for about 13% of new cancer cases and about 27% of all cancer deaths in 2015. Lung cancer is the leading cause of cancer deaths in both men and women. In 2015, it is estimated that 71,660 deaths will occur among U.S. women due to lung cancer, compared with 40,290 deaths due to breast cancer.[1]
Lung cancer incidence and mortality is highest in African Americans compared with any other racial/ethnic group in the United States, primarily due to the very high rates in African American men. Between 2007 and 2011, the incidence rate in black men was higher than in white men (93 vs. 72.4 cases per 100,000 men, respectively), whereas among women no racial difference in incidence rates was present (51.1 vs. 51.2 cases per 100,000 women, respectively). Similarly, the mortality rates among black men were higher than among white men during the same time frame (87.5 vs. 68.3 deaths per 100,000 men, respectively), whereas the mortality rates among black women were lower than among white women (36.5 vs. 39.8 deaths per 100,000 women, respectively).[3]
Surgical treatment or radiation therapy is the treatment of choice for early stages of cancer.[4] The overall 5-year relative survival rate from lung cancer was 16% in 2006. Lung cancer survival is worse for men compared with women and for blacks compared with whites. For example, 5-year lung cancer survival was 18% lower in black men compared with white men (11.3% vs. 13.8%, respectively) and 23% lower in black women compared with white women (14.4% vs. 18.6%, respectively).[3]
The hypothesis has been proposed that women may be more susceptible than men to smoking-caused lung cancer. However, the results of studies that have compared the association between smoking and lung cancer in men and women using appropriate comparisons do not support this hypothesis.[5]
The results of the Multi-Ethnic Cohort Study indicated that for a given degree of cigarette smoking, African Americans had a higher risk of lung cancer compared with other racial/ethnic groups.[6] Menthol cigarettes have been hypothesized as one potential factor contributing to the observed greater susceptibility to smoking-caused lung cancer in African Americans, but menthol cigarettes have not been observed to be associated with a higher risk of lung cancer than nonmenthol cigarettes.[7,8]
Cigarette smoking is the primary risk factor
The epidemic of lung cancer in the 20th century was primarily due to increases in cigarette smoking, the predominant cause of lung cancer. The threefold variation in lung cancer mortality rates across the United States more or less parallels long-standing state-specific differences in the prevalence of cigarette smoking. For example, average annual age-adjusted lung cancer death rates for 1996 to 2000 were highest in Kentucky (78 deaths per 100,000 individuals) where 31% were current smokers in 2001; whereas the lung cancer death rates were lowest in Utah (26 deaths per 100,000 individuals), which had the lowest prevalence of cigarette smoking (13%).[9]
The biology of carcinogenesis
Understanding the biology of carcinogenesis is crucial to the development of effective prevention and treatment strategies. Two important concepts in this regard are the multistep nature of carcinogenesis and the diffuse field-wide carcinogenic process. Epithelial cancers in the lung appear to develop in a series of steps extending over years. Epithelial carcinogenesis is conceptually divided into three phases: initiation, promotion, and progression. This process has been inferred from human studies identifying clinical-histological premalignant lesions (e.g., metaplasia and dysplasia). The concept of field carcinogenesis is that multiple independent neoplastic lesions occurring within the lung can result from repeated exposure to carcinogens, primarily tobacco. Patients developing cancers of the aerodigestive tract secondary to cigarette smoke also are likely to have multiple premalignant lesions of independent origin within the carcinogen-exposed field. The concepts of multistep and field carcinogenesis provide a model for prevention studies.[10]
Risk Factors
Factors associated with increased risk of lung cancer
Cigarette smoking
The most important risk factor for lung cancer (and for many other cancers) is cigarette smoking.[11,12,13] Epidemiologic data have established that cigarette smoking is the predominant cause of lung cancer. This causative link has been widely recognized since the 1960s, when national reports in Great Britain and the United States brought the cancer risk of smoking prominently to the public's attention.[12] The percentages of lung cancers estimated to be caused by tobacco smoking in males and females are 90% and 78%, respectively. The manufactured cigarette has changed over time, but there is no evidence to suggest that changes such as "low tar" or "low nicotine" cigarettes have resulted in reduced lung cancer risks.[8] Cigarette smoking is the most important contributor to the lung cancer burden because of its high prevalence of use and because cigarette smokers tend to smoke frequently, but cigar and pipe smoking have also been associated independently in case-control and cohort studies with increased lung cancer risk.[14,15] The cigar risks are of particular concern because of the increased prevalence of cigar use in the United States.[16]
The development of lung cancer is the culmination of multistep carcinogenesis. Genetic damage caused by chronic exposure to carcinogens, such as those in cigarette smoke, is the driving force behind the multistep process. Evidence of genetic damage is the association of cigarette smoking with the formation of the DNA adducts in human lung tissue. A strong link between tobacco smoke and lung carcinogenesis has been established by molecular data.[17,18]
Secondhand tobacco smoke
Secondhand tobacco smoke is also an established cause of lung cancer.[19] Secondhand smoke has the same components as inhaled mainstream smoke, though in lower absolute concentrations, between 1% and 10% depending on the constituent. Elevated biomarkers of tobacco exposure, including urinary cotinine, urinary NNK metabolites, and carcinogen-protein adducts, are seen in those who are exposed to secondhand cigarette smoke.[20,21,22]
Family history
A positive family history of lung cancer is a risk factor for lung cancer. The results of a meta-analysis of epidemiologic studies indicated that those with a positive family history of lung cancer were at approximately twice the risk of lung cancer compared with those with no affected relatives.[23,24] Cigarette smoking behavior tends to run in families and family members are exposed to secondhand smoke, so the extent to which measured family history represents a genetic predisposition to lung cancer independent of the shared risk factor of cigarette smoking is uncertain.
Human immunodeficiency virus (HIV) infection
HIV infection has been observed to be statistically associated with an increased lung cancer risk; for example, the results of a meta-analysis of 13 studies indicated HIV-infected individuals had a 2.6-fold higher risk of lung cancer than non-HIV-infected individuals (standard incidence ratio = 2.6; 95% confidence interval [CI] 2.1–3.1).[25] The clinical significance of this association remains to be elucidated, as it raises the possibility that HIV infection increases susceptibility to lung cancer, but may merely reflect the high smoking prevalence (study estimates ranged from 59% to 96%) among those infected with HIV compared with the general population (smoking prevalence approximately 20%).
Other environmental causes of lung cancer
Occupational exposures to lung carcinogens
Several environmental exposures other than tobacco smoke are causally associated with lung cancer, but the proportion of the lung cancer burden due to these exposures is small compared with cigarette smoking. Many lung carcinogens have been identified in studies of high occupational exposures. Considered in total, occupational exposures have been estimated to account for approximately 10% of lung cancers.[26] These carcinogens include asbestos, radon, tar and soot (sources of polycyclic aromatic hydrocarbons), arsenic, chromium, nickel, beryllium, and cadmium.[27] For many of these workplace carcinogens, cigarette smoking interacts synergistically to increase the risk.[28] In developed countries, workplace exposures to these agents have largely been controlled.
Approximately 10% of all lung cancer deaths and 30% of lung cancer deaths in lifetime nonsmokers are estimated to be attributable to indoor exposure to radon, estimations that are supported by a meta-analysis and pooled-analyses of case-control studies of lung cancer and indoor radon exposure.[29,30] Due to a synergistic interaction between cigarette smoking and radon exposure, the radon-associated risk of lung cancer among smokers is considerably greater than for nonsmokers.[31] The prevention strategy for residents of homes with high radon concentrations is to have the basement sealed to prevent radon gas from leaking into the home.[32]
Air pollution
Although early evidence from case-control and cohort studies did not support an association between air pollution and lung cancer, the evidence now points to a genuine association.[33] In particular, two prospective cohort studies provide evidence to suggest that air pollution is weakly associated with the risk of lung cancer. In an extended follow-up of a study of six U.S. cities, the adjusted relative risk (RR) of lung cancer mortality for each 10 µg/m3 increase in concentration of fine-particulate was 1.27 (95% CI, 0.96–1.69).[34] Using data from the American Cancer Society's Cancer Prevention Study II, it was observed that compared with the least polluted areas, residence in areas with high sulfate concentrations was associated with an increased risk of lung cancer (adjusted RR = 1.4; 95% CI, 1.1–1.7) after adjustment for occupational exposures and the factors mentioned above.[35] In a subsequent update to this report, the risk of lung cancer was observed to increase 14% for each 10 μg/m3 increase in concentration of fine particles.[36] The evidence indicating an association between constituents of ambient air pollution and increased lung cancer mortality continues to strengthen, with reports from Asia,[37,38] New Zealand,[39] and Europe,[40] documenting increased risks with exposure to certain components of particulate matter.
Factors of uncertain association with risk
Dietary factors
The results of many case-control and prospective cohort studies show that individuals with high dietary intake of fruits or vegetables have a lower risk of lung cancer than those with low fruit or vegetable intake.[41] In a systematic review of the evidence, the World Cancer Research Fund (WCRF) rates the evidence as "limited suggestive" that nonstarchy vegetable consumption decreases lung cancer risk and "probable" that fruit consumption and foods containing carotenoids decrease lung cancer risk. However, a subsequent systematic review and meta-analysis limited to prospective studies that adjusted for cigarette smoking found the evidence for carotenoids to be equivocal.[42]
While the focus has been on fruit and vegetable consumption and micronutrients, a wide range of dietary and anthropometric factors have been investigated. Anthropometric measures have been studied, indicating a tendency for leaner persons to have increased lung cancer risk relative to those with greater body mass index.[43,44] The results of a meta-analysis showed that alcohol drinking in the highest consumption categories only (in excess of about a drink a day) was associated with an increased risk of lung cancer.
Studies of dietary factors have yielded intriguing findings, but because the diets of smokers tend to be less healthy than those of nonsmokers, it is challenging to separate the influence of dietary factors from the effects of smoking. When considering the relationships between lung cancer and dietary factors, confounding factors related to cigarette smoking cannot be dismissed as a possible explanation.
Physical activity
A meta-analysis of leisure-time physical activity and lung cancer risk revealed that higher levels of physical activity protect against lung cancer.[45] The overall evidence for physical activity has been mixed, but several studies have reported that individuals who are more physically active have a lower risk of lung cancer than those who are more sedentary,[46,47,48] even after adjustment for cigarette smoking. The WCRF evidence review rated the inverse association between physical activity and lung cancer as "limited suggestive" evidence.[49]
Studies of physical activity yield findings consistent with an inverse association, but because physical activity behaviors differ between smokers and nonsmokers, it is difficult to infer that there is a direct relationship between physical activity and lung cancer risk.
Lung cancer in never smokers
In countries where cigarette smoking is common, about 10% to 20% of lung cancer cases occur in never smokers.[50] Radon and second-hand smoke exposure are established causes of lung cancer in never smokers. An increase in lung cancer risk among never smokers also has been observed with exposure to asbestos, ionizing radiation from sources other than radon, and indoor air pollution caused by combustion of coal or other solid fuel.[51] Limited data are available about the association of lung cancer in never smokers with physical activity, diet, alcohol, and anthropometry, yet they typically suggest that the relationships do not differ markedly from those in ever smokers.[42,43,46,47,48,52] Nevertheless, the inability to fully control for confounding by smoking in epidemiologic analyses of ever smokers and the possibility of different lung cancer causal pathways from never and ever smokers warrants care when extrapolating results for ever smokers to never smokers.
Interventions Associated With Decreased Risk of Lung Cancer
Smoking avoidance and cessation
Substantial harm to public health accrues from addiction to cigarette smoking. Compared with nonsmokers, smokers experience a dose-dependent increase in the risk of developing lung cancer (and many other malignancies).[53,54]
Approximately 85% of all lung cancer deaths are estimated to be attributed to cigarette smoking. Substantial benefits accrue to the smoker by quitting smoking. (Refer to the PDQ summary on Cigarette Smoking: Health Risks and How to Quit for more information.) Avoidance of tobacco use is the most effective measure to prevent lung cancer. The preventive effect of smoking cessation depends on the duration and intensity of prior smoking and upon time since cessation. Compared with persistent smokers, a 30% to 50% reduction in lung cancer mortality risk has been noted after 10 years of cessation.[11,54,55,56]
The benefits of tobacco control at the population level provide strong quasi-experimental evidence that reducing population-level exposure to cigarettes has resulted in population-level declines in the occurrence of lung cancer. Reduced tobacco consumption, due to both decreases in smoking initiation and increases in smoking cessation, led to a decline in overall age-adjusted lung cancer mortality among men since the mid-1980s, consistent with reductions in smoking prevalence among men since the 1960s.[57] Gender differences in time trends for lung cancer are a reflection of (1) the later adoption of cigarette smoking in women compared with men and (2) the later reduction in smoking prevalence among women compared with men.
Smoking cessation guidelines
Nicotine dependence exposes smokers in a dose-dependent fashion to carcinogenic and genotoxic elements that cause lung cancer.[55] Overcoming nicotine dependence is often extremely difficult. The Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research [AHCPR]) developed a set of clinical smoking-cessation guidelines for helping nicotine-dependent patients and health care providers.[56] The six major elements of the guidelines include the following:
- Clinicians must document the tobacco-use status of every patient.
- Every patient using tobacco should be offered one or more of the effective smoking cessation treatments that are available.
- Every patient using tobacco should be provided with at least one of the effective brief cessation interventions that are available.
- More intense interventions are more effective than less intense interventions in producing long-term tobacco abstinence, reflecting the dose-response relationship between the intervention and its outcome.
- One or more of the three treatment elements identified as being particularly effective should be included in smoking-cessation treatment:
- Nicotine-replacement (e.g., nicotine patches and gum) or other evidence-based smoking cessation pharmacotherapy (e.g., varenicline or bupropion).
- Social support from clinician in the form of encouragement and assistance.
- Skills training/problem solving (cessation/abstinence techniques).
- To be effective, health care systems must make institutional changes resulting in systematic identification of tobacco users and intervention with these patients at every visit.
Pharmacotherapy for smoking cessation
Many pharmacotherapies for smoking cessation, including nicotine replacement therapies (e.g., gum, patch, spray, lozenge, and inhaler) and other smoking cessation pharmacotherapies (e.g., varenicline and bupropion), result in statistically significant increases in smoking cessation rates compared with placebo. Based on a synthesis of the results of 110 randomized trials, nicotine replacement therapy treatments, alone or in combination, improve cessation rates over placebos after 6 months (RR, 1.58; 95% CI, 1.50–1.66).[58] Since the AHCPR guidelines were published, additional evidence of the effectiveness of such pharmacotherapies for smoking cessation has been published.[59,60,61] The choice of therapy should be individualized based on a number of factors, including past experience, preference, and potential agent side effects. (Refer to the PDQ summary on Cigarette Smoking: Health Risks and How to Quit for more information on pharmacotherapy for smoking cessation.)
Population-level interventions
In addition to individually focused cessation efforts, a number of tobacco control strategies at the community, state, and national level have been credited with reducing the prevalence of smoking. Strategies include the following:[62,63]
- Reducing minors' access to tobacco products.
- Disseminating effective school-based prevention curricula together with media strategies.
- Raising the cost of tobacco products by raising taxes.
- Using tobacco excise taxes to fund community-level interventions including mass media.
- Providing proven quitting strategies through health care organizations.
- Adopting smoke-free laws and policies.
Smoke-free workplace legislation
A review of more than 50 studies found that smoke-free workplace legislation was consistently associated with reduced secondhand smoke exposure, whether measured in reduced time of exposure (71%–100% reduction) or prevalence of persons exposed to secondhand smoke (22%–85% reduction), with particularly marked reductions among hospitality workers.[64] Smoke-free workplace legislation was associated with consistent and statistically significant reductions in levels of nicotine, dust, benzene, and particulate matter. Health indicators including respiratory systems, sensory symptoms, and hospital admissions were reported as outcomes in 25 studies. With respect to health outcomes, a consistent finding was reduced hospital admissions for cardiac events. Evidence suggested that smoke-free workplace legislation may also result in reduced prevalence of active cigarette smoking; for example, one study observed a 32% decreased smoking prevalence in a county that enacted smoke-free workplace legislation compared with a 2.8% decrease in nearby counties with no smoke-free workplace legislation.
Preventing occupational exposure to lung carcinogens
After cigarette smoking and exposure to secondhand smoke, occupational exposure to lung carcinogens, such as asbestos, arsenic, nickel, and chromium, is the most important contributor to the lung cancer burden. When occupational exposure to lung carcinogens are all considered together, 9% to 15% of all lung cancer deaths can be attributed to occupational exposure to lung carcinogens.[8] Reducing or eliminating workplace exposures to known lung carcinogens would be expected to result in a corresponding decrease in the risk of lung cancer. Consequently, the proportion of the lung cancer burden attributable to occupational exposures is declining over time in countries like the United States that have taken steps to protect the workforce from exposure to known lung carcinogens.
Interventions Associated With Increased Risk of Lung Cancer
Beta-carotene supplementation in smokers
Results of the National Cancer Institute (NCI) Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) trial were first published in 1994.[65] This trial included 29,133 Finnish male chronic smokers aged 50 to 69 years in a 2 x 2 factorial design of alpha-tocopherol (50 mg/day) and beta-carotene (20 mg/day). Subjects were randomly assigned to one of the following four groups for 5 to 8 years: beta-carotene alone, alpha-tocopherol alone, beta-carotene plus alpha-tocopherol, or placebo. Subjects receiving beta-carotene (alone or with alpha-tocopherol) had a higher incidence of lung cancer (RR = 1.18; 95% CI, 1.03–1.36) and higher total mortality (RR = 1.08; 95% CI, 1.01–1.16). This effect appeared to be associated with heavier smoking (one or more packs/day) and alcohol intake (at least one drink/day).[66] Supplementation with alpha-tocopherol produced no overall effect on lung cancer (RR = 0.99; 95% CI, 0.87–1.13).
In 1996, the results of the U.S. Beta-Carotene and Retinol Efficacy Trial (CARET) were published.[67] This multicenter trial involved 18,314 smokers, former smokers, and asbestos-exposed workers who were randomly assigned to beta-carotene (at a higher dose than the ATBC trial, 30 mg/day) plus retinyl palmitate (25,000 IU/day) or placebo. The primary endpoint was lung cancer incidence. The trial was terminated early by the Data Monitoring Committee and NCI because its results confirmed the ATBC finding of a harmful effect of beta-carotene over that of placebo, which increased lung cancer incidence (RR = 1.28; 95% CI, 1.04–1.57) and total mortality (RR = 1.17; 95% CI, 1.03–1.33). In a follow-up study of CARET participants after the intervention discontinued, these effects attenuated for a period of time. After 6 years of postintervention follow-up, the postintervention RR for lung cancer incidence was 1.12 (95% CI, 0.97–1.31) and for total mortality was 1.08 (95% CI, 0.99–1.71). During the postintervention phase a larger RR among women, rather than men, emerged for both outcomes in subgroup analyses; the reason for this observation, if reliable, is not known.[68]
The overall findings from the ATBC [65,66] and CARET [67,69] studies, which include over 47,000 subjects, demonstrated that pharmacological doses of beta-carotene increase lung cancer risk in relatively high-intensity smokers. The mechanism of this adverse effect is not known. Lung cancer risks were not increased in subsets of moderate-intensity smokers (less than a pack per day) in the ATBC study, or in former smokers in the CARET study. Evidence from other studies, such as the Physicians' Health Study (PHS),[70] does not indicate that beta-carotene supplementation increases lung cancer risk in nonsmokers. Subsequent analyses of participants in these trials and cohorts suggest that the beneficial outcomes associated with high beta-carotene plasma levels may be due to increased dietary intake of fruits and vegetables. These findings show the importance of randomized controlled trials to confirm epidemiologic studies.
Interventions With Adequate Evidence That They Do Not Reduce Risk
Studies have examined whether it is possible to prevent cancer development in the lung using chemopreventive agents. Chemoprevention is defined as the use of specific natural or synthetic chemical agents to reverse, suppress, or prevent carcinogenesis before the development of invasive malignancy. So far, agents tested for efficacy in lung cancer chemoprevention have been micronutrients, such as beta-carotene and vitamin E.
Beta-carotene supplementation in nonsmokers
Two other randomized controlled trials of beta-carotene were carried out in populations that were not at excess risk of lung cancer. The PHS was designed to study the effects of beta-carotene and aspirin in cancer and cardiovascular disease. The study is a randomized, double-blind, placebo-controlled trial begun in 1982 involving 22,071 male physicians aged 40 to 84 years. After 12 years of follow-up, beta-carotene was not associated with overall risk of cancer (RR = 0.98) or lung cancer among current (11% of study population) or former (39% of study population) smokers.[70]
In the Women's Health Study (WHS) approximately 40,000 female health professionals were randomly assigned to 50 mg beta carotene on alternate days or placebo. After a median of 2.1 years of beta-carotene treatment and 2 additional years of follow-up, there was no evidence that beta-carotene protected against lung cancer, as there were more lung cancer cases observed in the beta-carotene (n = 30) than placebo (n = 21) group.[71] The strong evidence from rigorous randomized, placebo-controlled trials clearly indicate that beta-carotene supplementation does not lower the risk of lung cancer in populations that are not high-risk for lung cancer.
Vitamin E supplementation
The Heart Outcomes Prevention Evaluation (HOPE) trial began in 1993 and continued follow-up as the HOPE-The Ongoing Outcomes (HOPE-TOO) through 2003. In this randomized, placebo-controlled trial, patients aged 55 years or older with vascular disease or diabetes were assigned to 400 IU vitamin E or placebo. With a median follow-up of 7 years, the group randomly assigned to vitamin E had a significantly lower lung cancer incidence rate (1.4%) than the placebo group (2.0%) (RR = 0.72; 95% CI, 0.53–0.98).[72] However, the protective association between vitamin E supplements and lung cancer in the HOPE-TOO study needs to be interpreted in the context of evidence from other randomized trials. In the ATBC study, supplementation with alpha-tocopherol produced no overall effect on lung cancer (RR = 0.99; 95% CI, 0.87–1.13). In the WHS of 40,000 female health professionals, using 600 IU of vitamin E every other day showed no evidence of protection against lung cancer in women (RR = 1.09; 95% CI, 0.83–1.44).[73] The Medical Research Council/British Heart Foundation Heart Protection Study (HPS) is a randomized placebo-controlled trial to test antioxidant vitamin supplementation with vitamin E, vitamin C, and beta-carotene among 20,536 United Kingdom adults with coronary disease, other occlusive arterial disease, or diabetes. The trial began recruitment in 1994, and as of the 2001 follow-up the results showed a slightly higher rate of lung cancer in the vitamin group compared with the placebo group (1.6% vs. 1.4%, respectively).[74]
Looking at the vitamin E results for the ATBC, HPS, and HOPE-TOO studies combined, the summary odds ratio was 0.97 (95% CI, 0.87–1.08),[72] and adding the results from the WHS to this would bring the association even closer to the null. The combined evidence for vitamin E supplementation thus continues to be consistent with no effect on lung cancer risk.
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- Albanes D, Heinonen OP, Taylor PR, et al.: Alpha-Tocopherol and beta-carotene supplements and lung cancer incidence in the alpha-tocopherol, beta-carotene cancer prevention study: effects of base-line characteristics and study compliance. J Natl Cancer Inst 88 (21): 1560-70, 1996.
- Omenn GS, Goodman GE, Thornquist MD, et al.: Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease. N Engl J Med 334 (18): 1150-5, 1996.
- Goodman GE, Thornquist MD, Balmes J, et al.: The Beta-Carotene and Retinol Efficacy Trial: incidence of lung cancer and cardiovascular disease mortality during 6-year follow-up after stopping beta-carotene and retinol supplements. J Natl Cancer Inst 96 (23): 1743-50, 2004.
- Omenn GS, Goodman GE, Thornquist MD, et al.: Risk factors for lung cancer and for intervention effects in CARET, the Beta-Carotene and Retinol Efficacy Trial. J Natl Cancer Inst 88 (21): 1550-9, 1996.
- Hennekens CH, Buring JE, Manson JE, et al.: Lack of effect of long-term supplementation with beta carotene on the incidence of malignant neoplasms and cardiovascular disease. N Engl J Med 334 (18): 1145-9, 1996.
- Lee IM, Cook NR, Manson JE, et al.: Beta-carotene supplementation and incidence of cancer and cardiovascular disease: the Women's Health Study. J Natl Cancer Inst 91 (24): 2102-6, 1999.
- Lonn E, Bosch J, Yusuf S, et al.: Effects of long-term vitamin E supplementation on cardiovascular events and cancer: a randomized controlled trial. JAMA 293 (11): 1338-47, 2005.
- Lee IM, Cook NR, Gaziano JM, et al.: Vitamin E in the primary prevention of cardiovascular disease and cancer: the Women's Health Study: a randomized controlled trial. JAMA 294 (1): 56-65, 2005.
- Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of antioxidant vitamin supplementation in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 360 (9326): 23-33, 2002.
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The Courier of Caswell Hall, American Tapestries Series #5
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Product Description
An unlikely spy discovers freedom and love in the midst of the American Revolution.
As the British and Continental armies wage war in 1781, the daughter of a wealthy Virginia plantation owner feels conflict raging in her own heart. Lydia Caswell comes from a family of staunch Loyalists, but she wavers in her allegiance to the Crown.
On the night the British sail up the James River on a mission to destroy the new capital, Lydia discovers a wounded man on the riverbank near Caswell Hall. Fearing his identity but unwilling to leave him for dead, she secretly nurses him back to health. The man identifies himself as Nathan, a Patriot—and an enemy. But Lydia's American sympathies grow, and when British officers return to the plantation, Lydia must help Nathan escape.
Product Information
|Format: Paperback
Number of Pages: 336
Vendor: Summerside Press
Publication Date: 2013
Dimensions: 8.25 X 5.25 X 1.00 (inches)
Availability: In Stock
Series: American Tapestries
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Product Reviews
Rebecca ManeyGastonia, North CarolinaAge: 55-65Gender: female5 Stars Out Of 5An Absolutely Amazing Story!September 15, 2014Rebecca ManeyGastonia, North CarolinaAge: 55-65Gender: femaleQuality: 5Value: 5Meets Expectations: 5Amazing in so many ways! I am continually astounded, when I read historical fiction at this level of poignancy, at the bravery and courage of our forefathers (and daughters) as they blazed a trail for the many freedoms that we so casually enjoy. "The Courier of Caswell Hall" exemplifies these "patriots" who, even though it cost them dearly, stood for the right to govern themselves by the rule of democratic law.
Lydia Caswell, daughter of a wealthy Virginia tobacco plantation owner must decide; will she trade Loyalist complacency for a legacy of freedom? Her decision may have been cemented when she risked her own life to nurse a severely injured Patriot spy, found along the banks of the James River at the edge of her family's property, back to health. Her own family has been splintered; her grandfather "tarred and feathered", her brother missing, her father staunchly Loyalist, her mother avoiding conflict and her sister, an incessant flirt with any man wearing a red coat. Her thought-to-be fianc was banished from their home by her father, and her best friend has been shunned for her political views.
Nathan changes everything. When he persuades Lydia to participate in his covert activities, life as they once knew it; dangerously tilts.
Melanie Dobson has woven yet another outstanding tapestry of historical fiction; with characters so real in nature that I read her notes at the end of the book several times to convince myself that Lydia and Nathan were just figments of her imagination and a great deal of research.
debwilsonSummerfield, FLAge: 18-24Gender: female5 Stars Out Of 5December 20, 2013debwilsonSummerfield, FLAge: 18-24Gender: femaleQuality: 5Value: 5Meets Expectations: 5This review was written for The Courier of Caswell Hall - eBook.An unlikely spy discovers freedom and love in the midst of the American Revolution.
As the British and Continental armies wage war in 1781, the daughter of a wealthy Virginia plantation owner feels conflict raging in her own heart. Lydia Caswell comes from a family of staunch Loyalists, but she cares only about peace. Her friend Sarah Hammond, however, longs to join the fight. Both women's families have already been divided by a costly war that sets father against son and neighbor against neighbor; a war that makes it impossible to guess who can be trusted.
One snowy night Lydia discovers a wounded man on the riverbank near Caswell Hall, and her decision to save him will change her life. Nathan introduces her to a secret network of spies, couriers, disguises, and coded messages -- a network that may be the Patriots' only hope for winning the war. When British officers take over Caswell Hall and wreak havoc on neighboring plantations, Lydia will have to choose between loyalty and freedom; between her family's protection and her own heart's desires.
As both armies gather near Williamsburg for a pivotal battle, both Lydia and Sarah must decide how high a price they are willing to pay to help the men they love.
About the American Tapestriesâ"¢ series: Each standalone novel in this line sets a heart-stirring love story against the backdrop of an epic moment in American history. This is the fifth book in the series.
My Review:
The last thing Lydia was expecting when she snuck off to admire British ships in the moonlight was a man. But find him she did, and with her discovery, an entire network of spies, couriers, coded messages, disguises, and operatives. The secret network may be the only thing that wins the war, but Lydia's allegiance lies - by association with her family - with the crown.
Lydia's wavering allegiance to the crown made the story for me. Her uncertainty between what she was told was right and then her startling belief to the contrary got my attention and kept it throughout the entire book. Danger, action, suspense, forbidden romance, and espionage run rampant through the book, and whether or not this genre is your cup of tea - it was a very enjoyable book to read and a perfect recipe for a relaxing evening.
This book was provided by the publisher through Litfuse Nest for free in exchange for an honest review.
barbjan10Arlington, TXAge: Over 65Gender: female5 Stars Out Of 5INCREDIBLE ESPIONAGE TALE OF ESPIONAGE PLOTS....October 15, 2013barbjan10Arlington, TXAge: Over 65Gender: femaleQuality: 5Value: 5Meets Expectations: 5Melanie Dobson has eloquently written an emotive story of fictional characters immersed in accurate facts of America history. Imagining myself living in Virginia during the 1780's, was easy to comprehend how confusing one's choice of loyal political stance would be. Identifying to any party publically could mean the difference in one's life or death, and possible seizure or destruction of the home and properties that were God's blessings. Lydia Caswell's family are staunch Loyalists, but as in any war, all involved are absorbed in winning the peace; or - solely control.
Insecurity of what the future held_.and trust of others, including friends, was always in doubt. This story is of great intrigue about strong characters who believed in what they were doing. It had humor which is always an indication of skilled writing to lighten chapters full of pain and anguish. Romance was not lacking, nor the longing and prayers of hope for those loved ones who left home to fight to return alive. Not knowing where family members were or what might have happened to them was a haunt to all for years at a time. Melanie Dobson is indeed an intricate weaver of several stories intermingled like puzzle pieces that paint a vivid picture when all the pieces come together. The espionage plot is well planned and created an attention-grabbing page turner for this reader.
The women characters in this story about factual jeopardy made me proud of my gender. Each one beautiful in their unique personalities - sensitive, afraid and yet fearless, tender, smart and even little sister was likeable in her own way. Ms Dobson has given each character, male or female, a unique personality quite fitting to that time era - all believable. Most importantly, redemption, reconciliation and belief in the freedom to worship God was shown with such conviction, that only a true believer in our Lord could have written these words to so glorify Him that blesses all. Most of the characters had a relationship with the Lord, and the decision was left open to those that professed no belief.
You might note that I didn't mention actual names or situations in this review. It would be hard to tell you about one person, one situation_.without leading into another. Ms Dobson has written a supreme story with a firm foundation of history that takes you into Caswell Hall as a guest watching the action as though in a movie theatre. Even the music can be heard and the tension felt - a real experience! Yes, I felt this story emotionally and hope you will get The Courier of Caswell Hall to meet all these characters yourself. You will be giving the compliments to Melanie Dobson and the glory to God.
Pam BurkePotosi, MOAge: 55-65Gender: female5 Stars Out Of 5Unlikely Spies and RomanceOctober 5, 2013Pam BurkePotosi, MOAge: 55-65Gender: femaleQuality: 5Value: 5Meets Expectations: 5The Courier of Caswell Hall is a touching story of romance and sacrifice set against the backdrop of the American Revolution. It provides an intriguing look at the kinds of personal struggles and difficult decisions families and individuals were forced to make at that crucial time in our country's history.
Historical fiction is a genre that I am coming to enjoy more and more, and this was my first journey into this particular time period. The history lesson woven into such a compelling story filled with rich characters made for a very enjoyable read. This is the first book I've read by Melanie Dobson, but I hope it will not be my last. She hooked me from the very beginning with a touching prologue that gently invited me into the story of Lydia and Nathan. The twists and turns of so many joys and sorrows held my interest to the last page.
Thanks to Litfuse Publicity Group for providing me a copy of the book in exchange for my honest review.
Carole JarvisJonesboro, GeorgiaAge: 55-65Gender: female5 Stars Out Of 5Surprisingly deep and moving historical romanceOctober 5, 2013Carole JarvisJonesboro, GeorgiaAge: 55-65Gender: femaleQuality: 5Value: 5Meets Expectations: 5Standalone novel The Courier of Caswell Hall by Melanie Dobson is the fifth book in the American Tapestries line, a series that sets romance against the backdrop of epic moments in American history. This is an extremely well-written and moving novel, one that I highly recommend.
I've enjoyed books by Melanie before, so I was expecting this to be another great read, but I was surprised at the depth of characterization, historical detail, and emotion found within its pages. The Courier of Caswell Hall is an interesting and moving read that captured and held my attention from the first page, but it's not a light read. Yes, it's a beautiful and touching romance, but Nathan and Lydia's love story is secondary to the themes of divided loyalties, courage, deceit, sacrifice, and the realities of war.
The story opens with a prologue that sets up all that happened 45 years earlier, beginning in 1781 on the banks of the James River and the Caswell Plantation, when Lydia risks all to rescue an injured Patriot courier who will only reveal his first name, Nathan. Lydia knows that "right and wrong can be muddied during a war" . . . and Nathan sees Lydia as "a beautiful young woman with a penchant to heal what had been destroyed and to help those who had been wounded."
Melanie brings women's roles during the war to the forefront through the courageous actions of Lydia and Sarah. Though the methods associated with their spying might seem rather innocent - listening to conversations, memorizing details, retrieving notes from behind bricks and passing them through the exchange of books - the penalty if caught was unthinkable.
It was a time when, rather than people being united against a common enemy, families and neighbors were divided and no one knew who to trust. Lydia's brother, Grayson, realized that the British "had no love of freedom, no hope for the future; they just wanted to stop those who did."
And freedom certainly had different meanings, depending which side you were on. Men like Nathan, who refused to ever use slaves, were rare at this time. The Patriots fought to be free from a king's tyranny, while keeping slaves in submission - and the British granted freedom to slaves willing to fight with them, while denying Americans theirs. Nathan reflected: "It was a strange world. The Americans purported freedom for some men while the British talked only of freedom for the Negro slaves."
In The Courier of Caswell Hall, Melanie has created a superb blend of rich characterization, great storytelling, and historical detail. This is a moving story that I highly recommend to all readers.
This book was provided by Litfuse Publicity Group and Summerside Press in exchange for my honest review.
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David Boswell grew up in London, Hamilton and Dundas, Ontario. He studied film at Oakville's Sheridan College, where he graduated in 1974. After graduating, he tried to earn a living drawing cartoons, and his first full page comic, 'Heart Break Comic' was published in The Georgia Straight. He moved to Vancouver in 1977, and in 1978, he launched the comic 'Reid Fleming, World's Toughest Milkman'.
Based on a childhood bully with the same name, Reid Fleming skirts no aggressive means to sell his dairy products. The series of underground comix was a hit, and in the 1990s Hollywood bought the rights to the screenplay, which has yet to make the silver screen. Another title David Boswell created is 'Ray-Mond'. He is also a photographer and illustrator.


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