Residential Radon Exposure in the United States: a Scoping Review

Residential Radon Exposure in the United States: a Scoping Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Residential Radon Exposure in the United States: a Scoping Review Kawther Al Ksir, Stacy Stanifer, Hadii M. Mamudu, Megan Quinn, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5656667/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Radon, a naturally occurring gas, is the second leading cause of lung cancer in the United States (U.S.), contributing to 21000 deaths and $2 billion in economic costs. Despite decades of research, epidemiological studies on residential radon exposure and lung cancer outcomes have yielded inconsistent results, which provides justification for this study. Methods: This scoping review systematically examined the national literature on residential radon exposure and radon-induced lung cancer in the U.S. A comprehensive search strategy was employed across four databases, including 13 relevant studies. These studies, conducted across various states, employed diverse methodologies and radon detection techniques. Results: The dominant factors in radon exposure and its correlation with lung cancer risk included variations in radon levels in homes and their correlation with water supply radon levels. Elevated radon concentrations near certain geological formations, like Reading Prong granites, are linked to increased lung cancer mortality. Despite some paradoxical associations, there's a general trend of increased lung cancer mortality with higher radon exposure, especially above values recommended by the U.S. Environmental Protection Agency (EPA). Discussion: Challenges such as methodological variability and potential biases were identified, highlighting the need for further research to elucidate the underlying mechanisms and guide targeted interventions. Conclusion: The broad variation in radon exposure levels between states and the observed association in specific regions highlights the importance of continued targeted research by state and public health initiatives to minimize radon exposure. Radon disparities and potential confounding factors by state highlight the need for more focused research to include the state radon profile and other geographical variations. Radon lung cancer residential exposure Figures Figure 1 Introduction Radon is a high-impact environmental pollutant and is the second leading cause of lung cancer in the United States (U.S.) (1). Radon is a naturally occurring gas that can easily enter indoor environments such as homes, schools, and workplaces (2). Radon particles produced from the decay of uranium in the ground travel in the air and get trapped in lung tissues as we breathe (1). Roughly one out of every 15 households has radon levels classified as elevated by the EPA, reaching 4 pCi/L or more (3). The typical radon concentration in the air within single-family homes across the U.S. averages 1.3 pCi/L (3). Given that individuals typically allocate around 90% of their time indoors, the issue of elevated radon exposure within residential spaces becomes a significant area of concern (3). The risk of developing lung cancer from radon exposure is dose-dependent, meaning that the higher the level of radon exposure, the greater the risk of developing lung cancer, and prolonged exposure, even at low levels, further elevates this risk (4). Early radon studies focused on radon's properties and potential therapeutic applications, while the mid-twentieth century highlighted the health risks, as evidenced by higher lung cancer rates among uranium miners (5). The 1980s focused on indoor radon levels and effective mitigation methods, shifting the focus to residential exposure (6). Epidemiological studies on residential radon exposure and lung cancer rates have yielded inconsistent results (7). Some studies have reported significant links between residential radon exposure and increased lung cancer risk, while others have found no significant correlation (8). These inconsistent results may be attributed to various factors, including differences in study design, sample sizes, geographic variations in radon levels, and variations in other potential lung cancer risk factors among study populations. This scoping review encompasses national literature on residential radon exposure and radon-induced lung cancer. It involved a systematic search and analysis of relevant peer-reviewed research studies to identify the breadth and depth of available knowledge on this topic. By synthesizing the existing literature, this paper aimed to provide a comprehensive overview of the current state of knowledge regarding residential radon exposure in the U.S., its health effects, and the prevalence and impact of radon-induced lung cancer at the national level. Methods Protocol and Registration The conduct and reporting of this scoping review were based on the Preferred Reporting Items for Systematic Reviews extension for Scoping Review (PRISMA-ScR) checklist. This protocol was registered in the Open Science Framework registry (accessible through this DOI: 10.17605/OSF.IO/4UTZN) Search Strategy Table 2.1 presents keywords used by database. PubMed, CINAHL, Web of Science and Cochrane were initially searched for eligible articles from 1980 to 2022. Radon, lung cancer, and the U.S. were used as preliminary search keywords. Publication date was restricted to 1980 because research conducted in the 1980s and 1990s, such as the landmark studies by the National Academy of Sciences (9) and the Environmental Protection Agency (EPA) (10), provided strong evidence of the association between residential radon exposure and lung cancer. Table 2.1. Keywords by Database Database Keywords used PubMed (Radon [mesh] OR radon [tiab]) AND (United States [mesh] OR “United States” [tiab]) AND (“lung cancer” [tiab] OR lung neoplasms [mesh] OR lung neoplasms [tiab] OR “Pulmonary Neoplasms” [tiab] OR “Pulmonary Cancer” [tiab] OR “Lung carcinoma” [tiab] OR ((lung[tiab] OR lungs[tiab] OR pulmonary[tiab] OR bronchus[tiab] OR brochogenic[tiab] OR bronchial[tiab] OR bronchoalveolar[tiab] OR alveolar[tiab]) AND(cancer*[tiab] OR carcinoma*[tiab] OR “malignan*[tiab] OR tumor*[tiab] OR tumour*[tiab] OR neoplasm*[tiab])) Limits: 1980 CINAHL (TX “United States” OR MH “United States”) AND (TX “lung neoplasms” OR TX “lung cancer” OR MH “lung neoplasms” OR TX “Pulmonary Neoplasms” OR TX “Pulmonary Cancer” OR TX “Lung carcinoma”) AND TX Radon Limits: Exclude PubMed Cochrane CENTRAL (TX “United States” OR MH “United States”) AND (TX “lung neoplasms” OR TX “lung cancer” OR TX “Pulmonary Neoplasms” OR TX “Pulmonary Cancer” OR TX “Lung carcinoma”) AND TX Radon Limits: Exclude PubMed Web of Science TS= United States AND TS=Radon AND (TS=” lung neoplasms” OR TS=” lung cancer” OR TS= “Pulmonary Neoplasms” OR TS= “Pulmonary Cancer” OR TS= “Lung carcinoma”) Exclude PubMed Study Eligibility Criteria The Population, Concept, and Context (PCC) framework was used to guide this research strategy. The “population” was chosen as all persons residing in the U.S. The study population included both smokers and non-smokers. The “concept” was defined as radon-related lung cancer. The “context” was the indoor or residential radon exposure with the exclusion of mining radon exposure. Predefined inclusion and exclusion criteria using contextualization and rationalization are summarized in Table 2.2. Table 2.2. Inclusion and Exclusion Criteria for Screening Articles Domain Inclusion Criteria Exclusion Criteria Study type/design Case reports, Clinical studies, Clinical Trials, Comparative studies, Meta-Analysis, Observational Studies, Randomized Controlled Trials, Systematic reviews Reports, editorials, commentaries, grey literature, abstracts, posters, conference proceedings, narrative reviews Study population Adults 18+ residing in the U.S. (both smokers and never smokers) U.S. Individuals < 18 years old Concept Radon related lung cancer Other cancers Context Indoor or residential radon exposure Mining radon exposure Time of publication From 1980 to 2023 Before 1980 Type of publication Free full text published article Reports, editorials, commentaries, grey literature, abstracts, posters, conference proceedings, narrative reviews Language English Language other than English Study Selection Process The author [KA] examined the text words in the title and abstract of the retrieved papers, as well as the MeSH terms used to describe the articles. Articles written prior to 2000, those reporting on mining radon exposure, reports, editorials, commentaries, grey literature, abstracts, posters, conference proceedings, narrative reviews, and finally, articles written in a language other than English were excluded. The author [KA] located and evaluated full-text articles that are potentially relevant for inclusion. In case of uncertainties, a second reviewer [DS] was consulted. Once the studies were selected, a data extraction form guided by the scoping review aim and the PCC framework was employed to detail each item to be extracted. With the assistance of a third reviewer [SS] and utilizing this extraction form, the extraction themes were refined to include: first author, publication date, study design, radon detection technique, population source, age, sex, lung cancer histologic type, smoking status, and key points. All excluded articles, as well as the reasons for exclusion, are reported in Figure 2.1. The PRISMA-ScR adapted chart was used to present the search process graphically. Results A description of the search process is presented in Figure 2.1. The preliminary literature search yielded 834 articles. Out of the total articles initially identified, 102 were duplicates, while 634 were excluded as they did not fulfill the inclusion criteria, either due to focusing on exposures or outcomes unrelated to radon or being centered on studies involving miners. After reading the full-text articles, only 13 records were included in this scoping review, and their characteristics are summarized in Table 2.3. Figure 2 .1. Flowchart of the Search Process and Results for Studies looking at Radon and Lung Cancer Table 2.3. Summary of the Studies Included in The Scoping Review First author Study design Radon detection technique Population source Age Sex Lung cancer Histologic Type Smoking Status Key points Hess et al. (1983) Cross sectional 2000 Wells: liquid scintillation method, 70 Houses: grab samples General: 16 counties in Maine Not reported Both Not reported (lung cancer mortality rate reported instead) Not reported Radon levels in homes varied widely, from 0.05 to 210 pCi/l. Even though only a small portion of radon came from the water supply in some homes, results showed that there was a significant correlation between these water supply radon levels and cancer rates. Specifically, rates for all cancers combined and lung and reproductive cancers showed a positive correlation with average radon levels in water supplies. Counties with higher levels of radon in water supplies tended to have higher lung cancer mortality rates. Archer (1987) Case control Not reported General, 16 counties in New York, Pennsylvania and new Jersey lung cancer cases + 17 nearby control counties All ages Both Not reported (lung cancer mortality rate reported instead) Not reported Elevated radon concentrations have been found in homes near the Reading Prong granites. Positive correlation between lung cancer mortality and counties with Reading Prong granites. Klotz et al. (1989) Historic cohort mortality Alpha scintillation detectors General: 752 person who lived for at least one year in any of 45 contaminated houses Not reported Both Standardized mortality ratio reported instead. Not reported No statistically significant increase in lung cancer was observed among the entire cohort or its subsets. A higher mortality rate for lung cancer was noted among white males. Lung cancer mortality rates were compared between the U.S. and New Jersey. There was no observed increase in lung cancer mortality among females or nonwhites. Alavanja et al. (1994) Case control Alpha track detectors General Nonsmoking (538 lung cancer cases + 1183 population-based, age matched controls) 30-84 Female Adenocarcinoma (262), Other cell types (147), Not reviewed by panel (129) Smoking History active Case (Never: 377, Former: 161, ), Control (Never: 983, Former: 200) 6.5% of case subjects and 6.8% of control subjects experienced radon levels exceeding 4 pCi/L. When analyzing all data together, there was minimal evidence of a relationship between increasing radon concentrations and lung cancer risk. Alavanja et al. (1995) Case control Dosimeters General Nonsmoking (618 lung cancer cases + 1402 population-based, age matched controls) 30-84 Female Adenocarcinoma (292), Squamous cell carcinoma (27), Small cell carcinoma (12), Bronchoalveolar (19), Other cell types (118), No pathologic confirmation (150) Smoking history: Never (Case: 432, Control: 1168) Former (Case:186, Control:234) Among lifetime nonsmokers, dietary intake of saturated fat and nonmalignant lung disease were the top identified risk factors for lung cancer. A minor, non-significant risk was detected for individuals exposed to a median domestic radon concentration of 4 pCi/L over a 25-year time-weighted average. Alavanja et al. (1999) Case control Dosimeters + Surface monitors General (512 lung cancer cases + 553 population based, age matched controls) 30-84 Female Adenocarcinoma (158), Small cell (117), Squamous (110), Other (127) Smoking status: Never (Case: 41, Control: 73) Stopped >3 years ago (Case:143, Control:170) Light to moderate (Case: 235, Control: 258) Heavy (case: 93, Control: 52) Significant lung cancer risk was detected for radon concentrations at and above the U.S. action level for house mitigation (4 pCi/L). This risk was evident when surface monitors were employed but not when standard radon dosimetry was utilized. Field et al. (2001) Case control Dosimeters General (413 lung cancer cases + 614 population based, age matched controls) 40-84 Female Not reported Not reported Individuals exposed to approximately 11 working level months (WLM), equivalent to a 15-year exposure at an average radon level of 4 pCi/L, faced a heightened risk of approximately 40-50%. This risk estimate surpasses those noted in prior residential radon studies. Bogen and Cullen (2001) Ecological study Radon climatical and geological survey data 2821 U.S. counties Two age groups: 40+ and 60+ Female Not reported ( lung cancer mortality rate reported instead) Not reported Significant negative trends between lung cancer mortality (LCM) and radon (Rn) were discovered in both age groups. These trends remained significant even after adjusting for age and various county-level factors. These findings were adjusted for climate and education related factors, which likely influenced exposure to indoor air contaminants like radon and cigarette smoke. Sandler et al. (2007) Case control 12-mo alpha-track etch detectors General (1474 lung cancer cases + 1811 population based, age matched controls) 40-79 Both Small cell= 252, Squamous cell=376, Adenocarcinoma= 543, Other non-small cell=245, Uncertain= 58 Percent of smoking 10 years ago: Never (Total population= Cases: 8.7, Controls: 14.1, Connecticut= Cases: 5.7, Controls: 7.5, Utah/Southern Idaho= Cases: 11, Controls: 23.3) Ex-smoker (Total population= Cases: 25.1, Controls: 24.8, Connecticut= Cases: 24.3, Controls: 29.5, Utah/Southern Idaho= Cases: 16.8, Controls: 24.3) Light smoker (Total population= Cases: 9.4, Controls: 15.8, Connecticut= Cases: 18.1, Controls: 9.6, Utah/Southern Idaho= Cases:9 , Controls: 13.2) Heavy smoker (Total population= Cases: 55.5, Controls: 43.5, Connecticut= Cases: 49.7, Controls: 52.1, Utah/Southern Idaho= Cases: 62, Controls: 36.7) Unknown (Total population= Cases: 1.3, Controls: 1.8, Connecticut= Cases: 1.2, Controls: 1.3, Utah/Southern Idaho= Cases: 1.2, Controls: 2.5) Median radon exposures in Connecticut and Utah/southern Idaho were lower than expected, and there was limited correlation between past radon exposures and lung cancer risk, with no statistically significant linear increase in risk observed. Wilcox et al. (2007) Case control Alpha track detectors General ( 561 cases and 740 controls) All ages Both Squamous cell= 166, Small/oat cell= 105, Adenocarcinoma= 271, Large cells = 34, Other =75 % Smoking: Never smoked: Controls: 16, Cases: 6.1 Smoked cigarette only: Controls: 69, Cases: 80 Smoked pipe/cigar: Controls: 0, Cases: 0.2 Mixed smoking habits: Controls: 15, Cases: 13.7 Radon effects did not vary significantly based on demographic factors such as age at disease occurrence, education level, or type of respondent. Analyzing different categories of smoking status, frequency, or duration did not alter the risk estimates of radon on lung cancer. Thompson et al. (2008) Case control Etch-track detectors General (200 lung cancer cases, 397 controls matched based on age and sex) Mean age reported (66.6 cases, 67.6 controls) Both Not reported % Smoking: Never smoker: Controls: 40.8, Cases: 7.5 Former smoker: Controls: 49.4, Cases: 40 Current smoker: Controls: 9.8, Cases: 52.5 Higher radon exposure was associated with decreased odds ratios for lung cancer. Ou et al. (2018) Cohort study Short term radon test kits General (Metropolitan vs Nonmetropolitan areas) All ages Both Not reported Smoking prevalence: 1991-1995: Metropolitan: 14.3, Nonmetropolitan: 17.9 1996-2000: Metropolitan: 13.8, Nonmetropolitan: 17.2 2001-2005: Metropolitan: 13.8, Nonmetropolitan: 16.5 2006-2010: Metropolitan: 12.8, 1Nonmetropolitan: 5.9 Radon levels were moderate in both metropolitan and nonmetropolitan counties, but nonmetropolitan counties had higher lung cancer incidence rates, particularly for distant stage lung cancers, and this trend was more pronounced in nonmetropolitan counties with high radon levels. Obenchain et al. (2019) Ecological study Not reported General (2881 U.S. County) 65+ Both Not reported (lung cancer mortality rate reported instead) Not reported Higher background radon exposure was associated with a decrease in lung cancer mortality, and the effect sizes were predicted based on local characteristics such as age, smoking, and obesity rates. Overview of the Included Studies A total of 13 studies were included in this scoping review. The studies were carried out in a number of states across the U.S., including Maine (11), New York (12), Pennsylvania (12), New Jersey (12,13), Missouri (14–16), Iowa (17), Utah (18), Connecticut (19), Southern Idaho (19), and Massachusetts (20). The studies encompassed diverse research designs, such as cross-sectional (21), case-control (12,14,15,17,19,20,22–24), cohort (25,26), and ecological studies (28,29). The population sources were equally varied, ranging from general populations in specific states (21,25–27,29,30) to cancer cases and control groups from different sources (14,15,17,19,20,23,24,31). The age ranges varied across the studies, with some including all ages (12,18,32,33) and others focusing on specific age groups (14–17,19,20,28). The sex distribution was generally both male and female (11–13,18,19,32–34), except for 6 studies that focused specifically on females (14–17,28). Radon Detection Techniques Different studies employed various radon detection techniques. These included the liquid scintillation method (11), grab samples (11), alpha scintillation detectors (13), alpha track detectors (15,32), dosimeters (14,16,17), surface monitors (16), etch-track detectors (19,20), and unspecified techniques (12,18,22,33–36). Each technique had its own advantages and limitations regarding accuracy, sensitivity, and ease of use. Association with Health Outcomes Radon levels in homes varied widely, with some exceeding recommended safe levels. Elevated radon levels in domestic water supplies were found to be significantly associated with increased rates of lung and reproductive cancers in certain counties (11). Studies examining the risk of lung cancer associated with radon exposure found conflicting results, with some indicating a significant risk associated with higher radon concentrations (13) and others indicating little evidence of a linear relationship (14). Furthermore, the effect of radon on lung cancer differed depending on the histologic type (35). Some studies reported lung cancer mortality rates (11,25,29–31,36,37). These rates differed across populations and regions. Some studies found correlations between radon exposure and lung cancer incidence or mortality, indicating the relationship between radon levels and lung cancer outcomes (18,22,23,25,31,36). The reported lung cancer types varied among the studies. Adenocarcinoma, squamous cell carcinoma, small cell carcinoma, bronchoalveolar carcinoma, and other cell types were identified (14–16,19,22,35). Some studies did not provide specific information on the histologic types of lung cancer (11–13,17,18,20,28,33,34,36). The potential interaction between radon exposure and smoking status in terms of lung cancer risk was investigated. While the results were not uniform, lung cancer rates were associated with high radon levels (14,19,20,22–24,32,36,38). The studies sought to determine whether the combination of these factors had an additive or interactive effect on the risk of lung cancer. Geographical Patterns Radon geographical patterns were revealed in this study, indicating that radon exposure and lung cancer incidence may be linked to specific counties and regions of the U.S. Radon concentrations were found to be elevated in areas near the Reading Prong granites (31). Significant associations between radon exposure levels and lung cancer incidence or mortality rates in specific counties were highlighted, supporting that radon contributes to lung cancer risk in specific geographical areas (39). Discussion This scoping review aimed to better understand the association between residential radon exposure and lung cancer in the U.S. by examining a diverse range of studies spanning different states and methodologies. The wide range of radon exposure levels reported emphasizes the importance of testing homes for this environmental risk factor. Concentrations varied greatly, with some homes exceeding the recommended EPA limits of 4pCi/L, highlighting the importance of increased awareness and effective mitigation strategies. This finding is consistent with the literature highlighting the link between ecological indicators of residential radon and lung cancer incidence ( 39 ). Examining the interaction between radon exposure and smoking status is critical to understanding lung cancer risk. Both radon exposure and smoking are established risk factors for lung cancer. The findings indicate that the interaction of radon exposure and smoking may result in a greater-than-additive increase in lung cancer risk. In areas where both factors are prevalent, a multifaceted approach needs to be implemented to address both radon exposure and smoking to call for a more significant reduction in lung cancer incidence. One of the most significant challenges concerning radon pertains to the extent of public knowledge and awareness regarding residential radon exposure. Notably, none of the articles examined in this review delved into the population's awareness level regarding their radon exposure. The reviewed studies have several imitations. The variability in radon detection techniques, data sources, and study designs introduces potential biases. This complexity is consistent with challenges faced in other environmental exposure studies ( 9 ). The reliance on historical data might introduce recall bias or misclassification of exposure. Furthermore, uncontrolled confounders must be considered, including radon occupational exposures, smoking and second-hand smoking. Conclusion Collaborative interdisciplinary efforts, as recommended by some authors, could further deepen our understanding of the radon induced lung cancer relationship ( 20 ). 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Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol. 2011 Mar;20(3):438–48. Subramanian J, Govindan R. Lung cancer in never smokers: A review. J Clin Oncol. 2007 Feb 10;25(5):561–70. Alavanja MCR, Brownson RC, Lubin JH, Berger E, Chang J, Boice JD Jr. Residential Radon Exposure and Lung Cancer Among Nonsmoking Women. JNCI J Natl Cancer Inst [Internet]. 1994 Dec 21 [cited 2023 Aug 22];86(24):1829–37. Available from: https://doi.org/10.1093/jnci/86.24.1829 Turner MC, Krewski D, Chen Y, Pope CA, Gapstur S, Thun MJ. Radon and lung cancer in the American Cancer Society cohort. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol. 2011 Mar;20(3):438–48. Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5656667","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":391071120,"identity":"3ac40be1-e04c-4184-a435-ce71f3119e23","order_by":0,"name":"Kawther Al Ksir","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYBACgwMMDMwgGkQe+ABksbET0GLYwMDYDNXCeHAGSAszAS3GDDAtQNsO84CECGkxYz9j/rig4p6xfDvvg8M2v7bJ8wGt+/AxB7cWG54cw+YZZ4rNDA6zGxzO7btt2MbMwCw5cxseLQy5G5t52xJsDJjZGA7n9txmBGphY+bFo8WM/y1Qy78EG/lmoBbLntv2BLUYS4BsaUgwYzgM1MLw43YiQS2GM95/nM1zLMHYAKjlYG/D7eQ2ZsZmvH4xOJ+W8JmnJsFwfv8x5g8//ty2nd/efPDDRzxaUAFjG5hsIFY9CPwhRfEoGAWjYBSMFAAA3UxPkpsJqH0AAAAASUVORK5CYII=","orcid":"","institution":"East Tennessee State University, College of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Kawther","middleName":"Al","lastName":"Ksir","suffix":""},{"id":391070941,"identity":"a758de4b-7dbe-454c-a06b-36eb1bccf1ec","order_by":1,"name":"Stacy Stanifer","email":"","orcid":"","institution":"University of Kentucky, College of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Stacy","middleName":"","lastName":"Stanifer","suffix":""},{"id":391070942,"identity":"38c3b295-45ee-4f4a-a0bb-dd7de90306c6","order_by":2,"name":"Hadii M. Mamudu","email":"","orcid":"","institution":"East Tennessee State University, College of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Hadii","middleName":"M.","lastName":"Mamudu","suffix":""},{"id":391070943,"identity":"21e17006-e937-497b-9edb-a66d401c05fe","order_by":3,"name":"Megan Quinn","email":"","orcid":"","institution":"East Tennessee State University, College of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Megan","middleName":"","lastName":"Quinn","suffix":""},{"id":391070944,"identity":"b6741872-06e2-46cd-911e-d4289bd34274","order_by":4,"name":"Deborah Slawson","email":"","orcid":"","institution":"East Tennessee State University, College of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Deborah","middleName":"","lastName":"Slawson","suffix":""}],"badges":[],"createdAt":"2024-12-16 21:11:27","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5656667/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5656667/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71709912,"identity":"27570c45-0a20-4a97-9033-e4188cdca775","added_by":"auto","created_at":"2024-12-18 02:05:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":67139,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2.1. \u003c/strong\u003eFlowchart of the Search Process and Results for Studies looking at Radon and Lung Cancer\u003c/p\u003e","description":"","filename":"2.1.png","url":"https://assets-eu.researchsquare.com/files/rs-5656667/v1/2d7b2493a470dc8958727aa3.png"},{"id":72405534,"identity":"6656eb76-a9c9-4ce4-84b2-23c25a4e7249","added_by":"auto","created_at":"2024-12-26 15:23:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":434722,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5656667/v1/714d3b77-b46c-4418-b474-40c955f7c28e.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eResidential Radon Exposure in the United States: a Scoping Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRadon is a high-impact environmental pollutant and is the second leading cause of lung cancer in the United States (U.S.) (1). Radon is a naturally occurring gas that can easily enter indoor environments such as homes, schools, and workplaces (2). Radon particles produced from the decay of uranium in the ground travel in the air and get trapped in lung tissues as we breathe (1). Roughly one out of every 15 households has radon levels classified as elevated by the EPA, reaching 4 pCi/L or more (3). The typical radon concentration in the air within single-family homes across the U.S. averages 1.3 pCi/L (3). Given that individuals typically allocate around 90% of their time indoors, the issue of elevated radon exposure within residential spaces becomes a significant area of concern (3).\u003c/p\u003e\n\u003cp\u003eThe risk of developing lung cancer from radon exposure is dose-dependent, meaning that the higher the level of radon exposure, the greater the risk of developing lung cancer, and prolonged exposure, even at low levels, further elevates this risk (4). Early radon studies focused on radon\u0026apos;s properties and potential therapeutic applications, while the mid-twentieth century highlighted the health risks, as evidenced by higher lung cancer rates among uranium miners (5). The 1980s focused on indoor radon levels and effective mitigation methods, shifting the focus to residential exposure (6). Epidemiological studies on residential radon exposure and lung cancer rates have yielded inconsistent results (7). Some studies have reported significant links between residential radon exposure and increased lung cancer risk, while others have found no significant correlation (8). These inconsistent results may be attributed to various factors, including differences in study design, sample sizes, geographic variations in radon levels, and variations in other potential lung cancer risk factors among study populations.\u003c/p\u003e\n\u003cp\u003eThis scoping review encompasses national literature on residential radon exposure and radon-induced lung cancer. It involved a systematic search and analysis of relevant peer-reviewed research studies to identify the breadth and depth of available knowledge on this topic. By synthesizing the existing literature, this paper aimed to provide a comprehensive overview of the current state of knowledge regarding residential radon exposure in the U.S., its health effects, and the prevalence and impact of radon-induced lung cancer at the national level.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eProtocol\u0026nbsp;and Registration\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe conduct and reporting of this scoping review were based on the Preferred Reporting Items for Systematic Reviews extension for Scoping Review (PRISMA-ScR) checklist. This protocol was registered in the Open Science Framework registry (accessible through this DOI: 10.17605/OSF.IO/4UTZN)\u003c/p\u003e\n\u003cp\u003eSearch Strategy\u003c/p\u003e\n\u003cp\u003eTable 2.1 presents keywords used by database. PubMed, CINAHL, Web of Science and Cochrane were initially searched for eligible articles from 1980 to 2022. Radon, lung cancer, and the U.S. were used as preliminary search keywords. Publication date was restricted to 1980 because research conducted in the 1980s and 1990s, such as the landmark studies by the National Academy of Sciences (9) and the Environmental Protection Agency (EPA) (10), provided strong evidence of the association between residential radon exposure and lung cancer.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.1.\u0026nbsp;\u003c/strong\u003eKeywords by Database\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eDatabase\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 304px;\"\u003e\n \u003cp\u003eKeywords used\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003ePubMed\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 304px;\"\u003e\n \u003cp\u003e(Radon [mesh] OR radon [tiab])\u003c/p\u003e\n \u003cp\u003eAND (United States [mesh] OR “United States” [tiab])\u003c/p\u003e\n \u003cp\u003eAND (“lung cancer” [tiab] OR lung neoplasms [mesh] OR lung neoplasms [tiab] OR “Pulmonary Neoplasms” [tiab] OR “Pulmonary Cancer” [tiab] \u0026nbsp;OR \u0026nbsp; \u0026nbsp; “Lung carcinoma” [tiab] OR\u003c/p\u003e\n \u003cp\u003e((lung[tiab] OR lungs[tiab] OR pulmonary[tiab] OR bronchus[tiab] OR brochogenic[tiab] OR bronchial[tiab] OR bronchoalveolar[tiab] OR alveolar[tiab])\u003c/p\u003e\n \u003cp\u003eAND(cancer*[tiab] OR carcinoma*[tiab] OR “malignan*[tiab] OR tumor*[tiab] OR tumour*[tiab] OR neoplasm*[tiab]))\u003c/p\u003e\n \u003cp\u003eLimits: 1980\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eCINAHL\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 304px;\"\u003e\n \u003cp\u003e(TX “United States” OR MH “United States”)\u003c/p\u003e\n \u003cp\u003eAND (TX “lung neoplasms” OR TX “lung cancer” OR MH “lung neoplasms” OR TX “Pulmonary Neoplasms” OR TX “Pulmonary Cancer” OR TX “Lung carcinoma”)\u003c/p\u003e\n \u003cp\u003eAND TX Radon\u003c/p\u003e\n \u003cp\u003eLimits: Exclude PubMed\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eCochrane CENTRAL\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 304px;\"\u003e\n \u003cp\u003e(TX “United States” OR MH “United States”)\u003c/p\u003e\n \u003cp\u003eAND (TX “lung neoplasms” OR TX “lung cancer” OR TX “Pulmonary Neoplasms” OR TX “Pulmonary Cancer” OR TX “Lung carcinoma”)\u003c/p\u003e\n \u003cp\u003eAND TX Radon\u003c/p\u003e\n \u003cp\u003eLimits: Exclude PubMed\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eWeb of Science\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 304px;\"\u003e\n \u003cp\u003eTS= United States\u003c/p\u003e\n \u003cp\u003eAND TS=Radon\u003c/p\u003e\n \u003cp\u003eAND (TS=” lung neoplasms” OR TS=” lung cancer” OR TS= “Pulmonary Neoplasms” OR TS= “Pulmonary Cancer” OR TS= “Lung carcinoma”)\u003c/p\u003e\n \u003cp\u003eExclude PubMed\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\n\u003cp\u003eStudy Eligibility Criteria \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Population, Concept, and Context (PCC) framework was used to guide this research strategy. The “population” was chosen as all persons residing in the U.S. The study population included both smokers and non-smokers. The “concept” was defined as radon-related lung cancer. The “context” was the indoor or residential radon exposure with the exclusion of mining radon exposure. Predefined inclusion and exclusion criteria using contextualization and rationalization are summarized in Table 2.2. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.2.\u0026nbsp;\u003c/strong\u003eInclusion and Exclusion Criteria for Screening Articles\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eDomain\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eInclusion Criteria\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003eExclusion Criteria\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eStudy type/design\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eCase reports, Clinical studies, Clinical Trials, Comparative studies, Meta-Analysis, Observational Studies, Randomized Controlled Trials, Systematic reviews\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003eReports, editorials, commentaries, grey literature, abstracts, posters, conference proceedings, narrative reviews\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eStudy population\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eAdults 18+ residing in the U.S. (both smokers and never smokers)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003eU.S. Individuals \u0026lt; 18 years old\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eConcept\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eRadon related lung cancer\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003eOther cancers\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eContext\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eIndoor or residential radon exposure\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003eMining radon exposure\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eTime of publication\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eFrom 1980 to 2023\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003eBefore 1980\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eType of publication\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eFree full text published article\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003eReports, editorials, commentaries, grey literature, abstracts, posters, conference proceedings, narrative reviews\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eLanguage\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003eLanguage other than English\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\n\u003cp\u003eStudy Selection Process \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe author [KA] examined the text words in the title and abstract of the retrieved papers, as well as the MeSH terms used to describe the articles. Articles written prior to 2000, those reporting on mining radon exposure, reports, editorials, commentaries, grey literature, abstracts, posters, conference proceedings, narrative reviews, and finally, articles written in a language other than English were excluded. The author [KA] located and evaluated full-text articles that are potentially relevant for inclusion. In case of uncertainties, a second reviewer [DS] was consulted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOnce the studies were selected, a data extraction form guided by the scoping review aim and the PCC framework was employed to detail each item to be extracted. With the assistance of a third reviewer [SS] and utilizing this extraction form, the extraction themes were refined to include: first author, publication date, study design, radon detection technique, population source, age, sex, lung cancer histologic type, smoking status, and key points.\u003c/p\u003e\n\u003cp\u003eAll excluded articles, as well as the reasons for exclusion, are reported in Figure 2.1. The PRISMA-ScR adapted chart was used to present the search process graphically.\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n\n\n\n"},{"header":"Results","content":"\u003cp\u003eA description of the search process is presented in Figure 2.1. The preliminary literature search yielded 834 articles. Out of the total articles initially identified, 102 were duplicates, while 634 were excluded as they did not fulfill the inclusion criteria, either due to focusing on exposures or outcomes unrelated to radon or being centered on studies involving miners. After reading the full-text articles, only 13 records were included in this scoping review, and their characteristics are summarized in Table 2.3.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFigure\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.1.\u0026nbsp;\u003c/strong\u003eFlowchart of the Search Process and Results for Studies looking at Radon and Lung Cancer\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 2.3.\u0026nbsp;\u003c/strong\u003eSummary of the Studies Included in The Scoping Review\u003c/p\u003e\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFirst author\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadon detection technique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopulation source\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLung cancer\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHistologic Type\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking Status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey points\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eHess et al. (1983)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eCross sectional\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e2000 Wells: liquid scintillation method, 70 Houses: grab samples\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral: 16 counties in Maine\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eNot reported\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(lung cancer mortality rate reported instead)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eRadon levels in homes varied widely, from 0.05 to 210 pCi/l.\u003cbr\u003e\u0026nbsp; Even though only a small portion of radon came from the water supply in some homes, results showed that there was a significant correlation between these water supply radon levels and cancer rates.\u003cbr\u003e\u0026nbsp;Specifically, rates for all cancers combined and lung and reproductive cancers showed a positive correlation with average radon levels in water supplies.\u003cbr\u003e\u0026nbsp;Counties with higher levels of radon in water supplies tended to have higher lung cancer mortality rates.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eArcher (1987)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral, 16 counties in New York, Pennsylvania and new Jersey lung cancer cases + 17 nearby control counties\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eAll ages\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eNot reported (lung cancer mortality rate reported instead)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eElevated radon concentrations have been found in homes near the Reading Prong granites. Positive correlation between lung cancer mortality and counties with Reading Prong granites.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eKlotz et al. (1989)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eHistoric cohort mortality\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eAlpha scintillation detectors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral: 752 person who lived for at least one year in any of 45 contaminated houses\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eStandardized mortality ratio reported instead.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eNo statistically significant increase in lung cancer was observed among the entire cohort or its subsets.\u003cbr\u003e\u0026nbsp;A higher mortality rate for lung cancer was noted among white males.\u003cbr\u003e\u0026nbsp;Lung cancer mortality rates were compared between the U.S. and New Jersey. There was no observed increase in lung cancer mortality among females or nonwhites.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eAlavanja et al. (1994)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eAlpha track detectors\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral Nonsmoking (538 lung cancer cases + 1183 population-based, age matched controls)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e30-84\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eAdenocarcinoma (262), Other cell types (147), Not reviewed by panel (129)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eSmoking History active\u003cbr\u003e\u0026nbsp;Case (Never: 377, Former: 161, ), Control (Never: 983, Former: 200)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;6.5% of case subjects and 6.8% of control subjects experienced radon levels exceeding 4 pCi/L.\u0026nbsp;\u003cbr\u003e\u0026nbsp;When analyzing all data together, there was minimal evidence of a relationship between increasing radon concentrations and lung cancer risk.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eAlavanja et al. (1995)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eDosimeters\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral Nonsmoking (618 lung cancer cases + 1402 population-based, age matched controls)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e30-84\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eAdenocarcinoma (292), Squamous cell carcinoma (27), Small cell carcinoma (12), Bronchoalveolar (19), Other cell types (118), No pathologic confirmation (150)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eSmoking history:\u003cbr\u003e\u0026nbsp;Never (Case: 432, Control: 1168)\u003cbr\u003e\u0026nbsp;Former (Case:186, Control:234)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eAmong lifetime nonsmokers, dietary intake of saturated fat and nonmalignant lung disease were the top identified risk factors for lung cancer.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;A minor, non-significant risk was detected for individuals exposed to a median domestic radon concentration of 4 pCi/L over a 25-year time-weighted average.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eAlavanja et al. (1999)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eDosimeters + Surface monitors\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral (512 lung cancer cases + 553 population based, age matched controls)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e30-84\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eAdenocarcinoma (158), Small cell (117), Squamous (110), Other (127)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eSmoking status:\u003cbr\u003e\u0026nbsp;Never (Case: 41, Control: 73)\u003cbr\u003e\u0026nbsp;Stopped \u0026gt;3 years ago (Case:143, Control:170)\u003cbr\u003e\u0026nbsp;Light to moderate (Case: 235, Control: 258)\u003cbr\u003e\u0026nbsp;Heavy (case: 93, Control: 52)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eSignificant lung cancer risk was detected for radon concentrations at and above the U.S. action level for house mitigation (4 pCi/L).\u003cbr\u003e\u0026nbsp;This risk was evident when surface monitors were employed but not when standard radon dosimetry was utilized.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eField et al. (2001)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eDosimeters\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral (413 lung cancer cases + 614 population based, age matched controls)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e40-84\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eIndividuals exposed to approximately 11 working level months (WLM), equivalent to a 15-year exposure at an average radon level of 4 pCi/L, faced a heightened risk of approximately 40-50%.\u003cbr\u003e\u0026nbsp;This risk estimate surpasses those noted in prior residential radon studies.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eBogen and Cullen (2001)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eEcological study\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eRadon climatical and geological survey data\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e2821 U.S. counties\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eTwo age groups: 40+ and 60+\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eNot reported ( lung cancer mortality rate reported instead)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eSignificant negative trends between lung cancer mortality (LCM) and radon (Rn) were discovered in both age groups.\u003cbr\u003e\u0026nbsp;These trends remained significant even after adjusting for age and various county-level factors.\u003cbr\u003e\u0026nbsp;These findings were adjusted for climate and education related factors, which likely influenced exposure to indoor air contaminants like radon and cigarette smoke.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eSandler et al. (2007)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e12-mo alpha-track etch detectors\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral (1474 lung cancer cases + 1811 population based, age matched controls)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e40-79\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eSmall cell= 252, Squamous cell=376, Adenocarcinoma= 543, Other non-small cell=245, Uncertain= 58\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003ePercent of smoking 10 years ago:\u003cbr\u003e\u0026nbsp;Never (Total population= Cases: 8.7, Controls: 14.1, Connecticut= Cases: 5.7, Controls: 7.5, Utah/Southern Idaho= Cases: 11, Controls: 23.3)\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Ex-smoker (Total population= Cases: 25.1, Controls: 24.8, Connecticut= Cases: 24.3, Controls: 29.5, Utah/Southern Idaho= Cases: 16.8, Controls: 24.3)\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Light smoker (Total population= Cases: 9.4, Controls: 15.8, Connecticut= Cases: 18.1, Controls: 9.6, Utah/Southern Idaho= Cases:9 , Controls: 13.2)\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Heavy smoker (Total population= Cases: 55.5, Controls: 43.5, Connecticut= Cases: 49.7, Controls: 52.1, Utah/Southern Idaho= Cases: 62, Controls: 36.7)\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Unknown (Total population= Cases: 1.3, Controls: 1.8, Connecticut= Cases: 1.2, Controls: 1.3, Utah/Southern Idaho= Cases: 1.2, Controls: 2.5)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eMedian radon exposures in Connecticut and Utah/southern Idaho were lower than expected, and there was limited correlation between past radon exposures and lung cancer risk, with no statistically significant linear increase in risk observed.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eWilcox et al. (2007)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eAlpha track detectors\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral ( 561 cases and 740 controls)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eAll ages\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eSquamous cell= 166, Small/oat cell= 105, Adenocarcinoma= 271, Large cells = 34, Other =75\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e% Smoking:\u003cbr\u003e\u0026nbsp;Never smoked: Controls: 16, Cases: 6.1\u003cbr\u003e\u0026nbsp;Smoked cigarette only: Controls: 69, Cases: 80\u003cbr\u003e\u0026nbsp;Smoked pipe/cigar: Controls: 0, Cases: 0.2\u003cbr\u003e\u0026nbsp;Mixed smoking habits: Controls: 15, Cases: 13.7\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eRadon effects did not vary significantly based on demographic factors such as age at disease occurrence, education level, or type of respondent.\u003cbr\u003e\u0026nbsp;Analyzing different categories of smoking status, frequency, or duration did not alter the risk estimates of radon on lung cancer.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eThompson et al. (2008)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eEtch-track detectors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral (200 lung cancer cases, 397 controls matched based on age and sex)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eMean age reported (66.6 cases, 67.6 controls)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e% Smoking:\u003cbr\u003e\u0026nbsp;Never smoker: Controls: 40.8, Cases: 7.5\u003cbr\u003e\u0026nbsp;Former smoker: Controls: 49.4, Cases: 40\u003cbr\u003e\u0026nbsp;Current smoker: Controls: 9.8, Cases: 52.5\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eHigher radon exposure was associated with decreased odds ratios for lung cancer.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eOu et al. (2018)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eCohort study\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eShort term radon test kits\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral (Metropolitan vs Nonmetropolitan areas)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eAll ages\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eSmoking prevalence:\u003cbr\u003e\u0026nbsp;1991-1995: Metropolitan: 14.3, Nonmetropolitan: 17.9\u003cbr\u003e\u0026nbsp;1996-2000: Metropolitan: 13.8, Nonmetropolitan: 17.2\u003cbr\u003e\u0026nbsp;2001-2005: Metropolitan: 13.8, Nonmetropolitan: 16.5\u003cbr\u003e\u0026nbsp;2006-2010: Metropolitan: 12.8, 1Nonmetropolitan: 5.9\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eRadon levels were moderate in both metropolitan and nonmetropolitan counties, but nonmetropolitan counties had higher lung cancer incidence rates, particularly for distant stage lung cancers, and this trend was more pronounced in nonmetropolitan counties with high radon levels.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eObenchain et al. (2019)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eEcological study\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eGeneral (2881 U.S. County)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e65+\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eNot reported (lung cancer mortality rate reported instead)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eHigher background radon exposure was associated with a decrease in lung cancer mortality, and the effect sizes were predicted based on local characteristics such as age, smoking, and obesity rates.\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003cp\u003eOverview of the Included Studies\u0026nbsp;\u003c/p\u003e\u003cp\u003eA total of 13 studies were included in this scoping review. The studies were carried out in a number of states across the U.S., including Maine (11), New York (12), Pennsylvania (12), New Jersey (12,13), Missouri (14–16), Iowa (17), Utah (18), Connecticut (19), Southern Idaho (19), and Massachusetts (20). The studies encompassed diverse research designs, such as cross-sectional (21), case-control (12,14,15,17,19,20,22–24), cohort (25,26), and ecological studies (28,29). The population sources were equally varied, ranging from general populations in specific states (21,25–27,29,30) to cancer cases and control groups from different sources (14,15,17,19,20,23,24,31). The age ranges varied across the studies, with some including all ages (12,18,32,33) and others focusing on specific age groups (14–17,19,20,28). The sex distribution was generally both male and female (11–13,18,19,32–34), except for 6 studies that focused specifically on females (14–17,28).\u003c/p\u003e\u003cp\u003eRadon Detection Techniques\u003c/p\u003e\u003cp\u003eDifferent studies employed various radon detection techniques. These included the liquid scintillation method (11), grab samples (11), alpha scintillation detectors (13), alpha track detectors (15,32), dosimeters (14,16,17), surface monitors (16), etch-track detectors (19,20), and unspecified techniques (12,18,22,33–36). Each technique had its own advantages and limitations regarding accuracy, sensitivity, and ease of use.\u003c/p\u003e\u003cp\u003eAssociation with Health Outcomes\u003c/p\u003e\u003cp\u003eRadon levels in homes varied widely, with some exceeding recommended safe levels. Elevated radon levels in domestic water supplies were found to be significantly associated with increased rates of lung and reproductive cancers in certain counties (11). Studies examining the risk of lung cancer associated with radon exposure found conflicting results, with some indicating a significant risk associated with higher radon concentrations (13) and others indicating little evidence of a linear relationship (14). Furthermore, the effect of radon on lung cancer differed depending on the histologic type (35). Some studies reported lung cancer mortality rates (11,25,29–31,36,37). These rates differed across populations and regions. Some studies found correlations between radon exposure and lung cancer incidence or mortality, indicating the relationship between radon levels and lung cancer outcomes\u0026nbsp;(18,22,23,25,31,36).\u0026nbsp;The reported lung cancer types varied among the studies. Adenocarcinoma, squamous cell carcinoma, small cell carcinoma, bronchoalveolar carcinoma, and other cell types were identified\u0026nbsp;(14–16,19,22,35). Some studies did not provide specific information on the histologic types of lung cancer\u0026nbsp;(11–13,17,18,20,28,33,34,36). The potential interaction between radon exposure and smoking status in terms of lung cancer risk was investigated. While the results were not uniform, lung cancer rates were associated with high radon levels (14,19,20,22–24,32,36,38). The studies sought to determine whether the combination of these factors had an additive or interactive effect on the risk of lung cancer.\u003c/p\u003e\u003cp\u003eGeographical Patterns\u003c/p\u003e\u003cp\u003eRadon geographical patterns were revealed in this study, indicating that radon exposure and lung cancer incidence may be linked to specific counties and regions of the U.S. Radon concentrations were found to be elevated in areas near the Reading Prong granites (31). Significant associations between radon exposure levels and lung cancer incidence or mortality rates in specific counties were highlighted, supporting that radon contributes to lung cancer risk in specific geographical areas (39).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis scoping review aimed to better understand the association between residential radon exposure and lung cancer in the U.S. by examining a diverse range of studies spanning different states and methodologies.\u003c/p\u003e \u003cp\u003eThe wide range of radon exposure levels reported emphasizes the importance of testing homes for this environmental risk factor. Concentrations varied greatly, with some homes exceeding the recommended EPA limits of 4pCi/L, highlighting the importance of increased awareness and effective mitigation strategies. This finding is consistent with the literature highlighting the link between ecological indicators of residential radon and lung cancer incidence (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Examining the interaction between radon exposure and smoking status is critical to understanding lung cancer risk. Both radon exposure and smoking are established risk factors for lung cancer. The findings indicate that the interaction of radon exposure and smoking may result in a greater-than-additive increase in lung cancer risk. In areas where both factors are prevalent, a multifaceted approach needs to be implemented to address both radon exposure and smoking to call for a more significant reduction in lung cancer incidence.\u003c/p\u003e \u003cp\u003eOne of the most significant challenges concerning radon pertains to the extent of public knowledge and awareness regarding residential radon exposure. Notably, none of the articles examined in this review delved into the population's awareness level regarding their radon exposure. The reviewed studies have several imitations. The variability in radon detection techniques, data sources, and study designs introduces potential biases. This complexity is consistent with challenges faced in other environmental exposure studies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The reliance on historical data might introduce recall bias or misclassification of exposure. Furthermore, uncontrolled confounders must be considered, including radon occupational exposures, smoking and second-hand smoking.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCollaborative interdisciplinary efforts, as recommended by some authors, could further deepen our understanding of the radon induced lung cancer relationship (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Future research can build on these findings to investigate the mechanisms underlying the observed association between residential radon exposure and lung cancer. Furthermore, technological advancements such as geographic information system (GIS) data integration could aid in the identification of radon exposure hotspots and guide targeted interventions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRadon | NCEH | CDC [Internet]. 2023 [cited 2024 Feb 12]. Available from: https://www.cdc.gov/radon/index.html\u003c/li\u003e\n \u003cli\u003eCDC. Centers for Disease Control and Prevention. 2022 [cited 2023 Jan 4]. Radon in the Home. Available from: https://www.cdc.gov/radon/radon-facts.html\u003c/li\u003e\n \u003cli\u003eRadon Entry | National Radon Program Services [Internet]. [cited 2023 Aug 20]. Available from: https://sosradon.org/Radon%20Entry\u003c/li\u003e\n \u003cli\u003eUS EPA. What is Radon and How are We Exposed to It? [Internet]. IAEA; 2022 [cited 2023 Jun 21]. Available from: https://www.iaea.org/newscenter/news/what-is-radon-and-how-are-we-exposed-to-it\u003c/li\u003e\n \u003cli\u003eRichardson DB, Rage E, Demers PA, Do MT, Fenske N, Deffner V, et al. Lung Cancer and Radon: Pooled Analysis of Uranium Miners Hired in 1960 or Later. Environ Health Perspect [Internet]. 2022 May;130(5):057010\u0026ndash;1. Available from: https://search.ebscohost.com/login.aspx?direct=true\u0026amp;AuthType=ip,shib\u0026amp;db=ccm\u0026amp;AN=157276661\u0026amp;site=ehost-live\u0026amp;scope=site\u0026amp;authtype=shib\u0026amp;custid=etsu\u003c/li\u003e\n \u003cli\u003eNgoc LTN, Park D, Lee YC. Human Health Impacts of Residential Radon Exposure: Updated Systematic Review and Meta-Analysis of Case-Control Studies. Int J Environ Res Public Health. 2022 Dec 21;20(1):97.\u003c/li\u003e\n \u003cli\u003eAgency for Toxic Substances and Diseases. 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Environmental radon and cancer correlations in Maine. Health Phys. 1983 Aug;45(2):339\u0026ndash;48.\u003c/li\u003e\n \u003cli\u003eArcher VE. Association of Lung Cancer Mortality with Precambrian Granite. Arch Environ Health Int J [Internet]. 1987 Apr 1 [cited 2023 Jul 4];42(2):87\u0026ndash;91. Available from: https://doi.org/10.1080/00039896.1987.9935801\u003c/li\u003e\n \u003cli\u003eKlotz JB, Petix JR, Zagraniski RT. Mortality of a residential cohort exposed to radon from industrially contaminated soil. Am J Epidemiol. 1989 Jun;129(6):1179\u0026ndash;86.\u003c/li\u003e\n \u003cli\u003eAlavanja MC, Brownson RC, Benichou J, Swanson C, Boice JD. Attributable risk of lung cancer in lifetime nonsmokers and long-term ex-smokers (Missouri, United States). Cancer Causes Control CCC. 1995 May;6(3):209\u0026ndash;16.\u003c/li\u003e\n \u003cli\u003eAlavanja MCR, Brownson RC, Lubin JH, Berger E, Chang J, Boice JD Jr. Residential Radon Exposure and Lung Cancer Among Nonsmoking Women. JNCI J Natl Cancer Inst [Internet]. 1994 Dec 21 [cited 2023 Jul 4];86(24):1829\u0026ndash;37. Available from: https://doi.org/10.1093/jnci/86.24.1829\u003c/li\u003e\n \u003cli\u003eAlavanja MC, Lubin JH, Mahaffey JA, Brownson RC. Residential radon exposure and risk of lung cancer in Missouri. Am J Public Health. 1999 Jul;89(7):1042\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eField RW, Steck DJ, Smith BJ, Brus CP, Fisher EF, Neuberger JS, et al. The Iowa radon lung cancer study--phase I: Residential radon gas exposure and lung cancer. Sci Total Environ. 2001 May 14;272(1\u0026ndash;3):67\u0026ndash;72.\u003c/li\u003e\n \u003cli\u003eOu JY, Fowler B, Ding Q, Kirchhoff AC, Pappas L, Boucher K, et al. A statewide investigation of geographic lung cancer incidence patterns and radon exposure in a low-smoking population. BMC Cancer [Internet]. 2018 Jan 31 [cited 2023 Jul 4];18(1):115. Available from: https://doi.org/10.1186/s12885-018-4002-9\u003c/li\u003e\n \u003cli\u003eSandler DP, Weinberg CR, Shore DL, Archer VE, Bishop Stone M, Lyon JL, et al. Indoor Radon and Lung Cancer Risk in Connecticut and Utah. J Toxicol Environ Health A [Internet]. 2006 May 1 [cited 2023 Jul 4];69(7\u0026ndash;8):633\u0026ndash;54. Available from: https://doi.org/10.1080/15287390500261117\u003c/li\u003e\n \u003cli\u003eThompson RE, Nelson DF, Popkin JH, Popkin Z. Case-control study of lung cancer risk from residential radon exposure in Worcester county, Massachusetts. Health Phys. 2008 Mar;94(3):228\u0026ndash;41.\u003c/li\u003e\n \u003cli\u003eHess CT, Weiffenbach CV, Norton SA. Environmental Radon and Cancer Correlations in Maine: Health Phys [Internet]. 1983 Aug [cited 2023 Aug 20];45(2):339\u0026ndash;48. Available from: http://journals.lww.com/00004032-198308000-00006\u003c/li\u003e\n \u003cli\u003eTaga M, Mechanic LE, Hagiwara N, V\u0026auml;h\u0026auml;kangas KH, Bennett WP, Alavanja MCR, et al. EGFR somatic mutations in lung tumors: radon exposure and passive smoking in former- and never-smoking U.S. women. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol. 2012 Jun;21(6):988\u0026ndash;92.\u003c/li\u003e\n \u003cli\u003eAlavanja MC, Lubin JH, Mahaffey JA, Brownson RC. Residential radon exposure and risk of lung cancer in Missouri. Am J Public Health. 1999 Jul;89(7):1042\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eWilcox HB, Al-Zoughool M, Garner MJ, Jiang H, Klotz JB, Krewski D, et al. Case-control study of radon and lung cancer in New Jersey. Radiat Prot Dosimetry. 2008;128(2):169\u0026ndash;79.\u003c/li\u003e\n \u003cli\u003eA Am J Epidemiol [Internet]. 1989 Jun 1 [cited 2023 Aug 22];129(6):1179\u0026ndash;86. Available from: https://doi.org/10.1093/oxfordjournals.aje.a115239\u003c/li\u003e\n \u003cli\u003eOu J, Fowler B, Ding Q, Kirchhoff A, Pappas L, Boucher K, et al. A statewide investigation of geographic lung cancer incidence patterns and radon exposure in a low-smoking population. BMC CANCER. 2018 Jan 31;18.\u003c/li\u003e\n \u003cli\u003eSamet J, Avila-Tang E, Boffetta P, Hannan L, Olivo-Marston S, Thun M, et al. Lung Cancer in Never Smokers: Clinical Epidemiology and Environmental Risk Factors. Clin CANCER Res. 2009 Sep 15;15(18):5626\u0026ndash;45.\u003c/li\u003e\n \u003cli\u003eBogen KT, Cullen J. Residential Radon in U.S. Counties V Lung Cancer in Women Who Predominantly Never Smoked. Environ Geochem Health [Internet]. 2002 Sep 1 [cited 2023 Jul 4];24(3):229\u0026ndash;47. Available from: https://doi.org/10.1023/A:1016051322603\u003c/li\u003e\n \u003cli\u003eObenchain R, Young SS, Krstic G. Low-level radon exposure and lung cancer mortality. Regul Toxicol Pharmacol RTP. 2019 Oct;107:104418.\u003c/li\u003e\n \u003cli\u003eBogen K, Cullen J. Residential radon in US counties v lung cancer in women who predominantly never smoked. Environ Geochem Health. 2002 Sep;24(3):229\u0026ndash;47.\u003c/li\u003e\n \u003cli\u003eArcher VE. Association of Lung Cancer Mortality with Precambrian Granite. Arch Environ Health Int J [Internet]. 1987 Apr 1 [cited 2023 Aug 22];42(2):87\u0026ndash;91. Available from: https://doi.org/10.1080/00039896.1987.9935801\u003c/li\u003e\n \u003cli\u003eWilcox HB, Al-Zoughool M, Garner MJ, Jiang H, Klotz JB, Krewski D, et al. Case-control study of radon and lung cancer in New Jersey. Radiat Prot Dosimetry. 2008;128(2):169\u0026ndash;79.\u003c/li\u003e\n \u003cli\u003eSamet JM, Avila-Tang E, Boffetta P, Hannan LM, Olivo-Marston S, Thun MJ, et al. Lung cancer in never smokers: clinical epidemiology and environmental risk factors. Clin Cancer Res Off J Am Assoc Cancer Res. 2009 Sep 15;15(18):5626\u0026ndash;45.\u003c/li\u003e\n \u003cli\u003eObenchain R, Young SS, Krstic G. Low-level radon exposure and lung cancer mortality. Regul Toxicol Pharmacol RTP. 2019 Oct;107:104418.\u003c/li\u003e\n \u003cli\u003eSubramanian J, Govindan R. Lung cancer in never smokers: a review. J Clin Oncol Off J Am Soc Clin Oncol. 2007 Feb 10;25(5):561\u0026ndash;70.\u003c/li\u003e\n \u003cli\u003eTurner MC, Krewski D, Chen Y, Pope CA, Gapstur S, Thun MJ. Radon and lung cancer in the American Cancer Society cohort. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol. 2011 Mar;20(3):438\u0026ndash;48.\u003c/li\u003e\n \u003cli\u003eSubramanian J, Govindan R. Lung cancer in never smokers: A review. J Clin Oncol. 2007 Feb 10;25(5):561\u0026ndash;70.\u003c/li\u003e\n \u003cli\u003eAlavanja MCR, Brownson RC, Lubin JH, Berger E, Chang J, Boice JD Jr. Residential Radon Exposure and Lung Cancer Among Nonsmoking Women. JNCI J Natl Cancer Inst [Internet]. 1994 Dec 21 [cited 2023 Aug 22];86(24):1829\u0026ndash;37. Available from: https://doi.org/10.1093/jnci/86.24.1829\u003c/li\u003e\n \u003cli\u003eTurner MC, Krewski D, Chen Y, Pope CA, Gapstur S, Thun MJ. Radon and lung cancer in the American Cancer Society cohort. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol. 2011 Mar;20(3):438\u0026ndash;48.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"East Tennessee State University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Radon, lung cancer, residential exposure","lastPublishedDoi":"10.21203/rs.3.rs-5656667/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5656667/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRadon, a naturally occurring gas, is the second leading cause of lung cancer in the United States (U.S.), contributing to 21000 deaths and $2 billion in economic costs. Despite decades of research, epidemiological studies on residential radon exposure and lung cancer outcomes have yielded inconsistent results, which provides justification for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis scoping review systematically examined the national literature on residential radon exposure and radon-induced lung cancer in the U.S. A comprehensive search strategy was employed across four databases, including 13 relevant studies. These studies, conducted across various states, employed diverse methodologies and radon detection techniques.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dominant factors in radon exposure and its correlation with lung cancer risk included variations in radon levels in homes and their correlation with water supply radon levels. Elevated radon concentrations near certain geological formations, like Reading Prong granites, are linked to increased lung cancer mortality. Despite some paradoxical associations, there's a general trend of increased lung cancer mortality with higher radon exposure, especially above values recommended by the U.S. Environmental Protection Agency (EPA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChallenges such as methodological variability and potential biases were identified, highlighting the need for further research to elucidate the underlying mechanisms and guide targeted interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe broad variation in radon exposure levels between states and the observed association in specific regions highlights the importance of continued targeted research by state and public health initiatives to minimize radon exposure. Radon disparities and potential confounding factors by state highlight the need for more focused research to include the state radon profile and other geographical variations.\u003c/p\u003e","manuscriptTitle":"Residential Radon Exposure in the United States: a Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-18 02:05:29","doi":"10.21203/rs.3.rs-5656667/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bb1c9120-93da-4c48-ada9-1c6b169d8c16","owner":[],"postedDate":"December 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-18T02:05:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-18 02:05:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5656667","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5656667","identity":"rs-5656667","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}