Document 2Jj4vqGQ78O7Y7ZRKYBpNVZ1N

FILE NAME: Kent (KNT) DATE: 1954 Feb DOC#: KNT136 DOCUMENT DESCRIPTION: Journal Article - Occupations and Cigarette Smoking Factors in Lung Cancer - American Journal of Public Health ' o f H e a lth 5 em 'nr|^; tH C ic c e u t a w u u z t AC* & VEATCH orm/tieg Enjin-- rt > 4 -- Electricity -- Indotiy P U B L 11C H E A L T H t r y rrd t iw s f C em h iM iU , i n d ] tm4 l e t t i . Cecdi WonAly Publication of the American Public Health Association, Inc. tdwty, Kent City 2, M* ABOUND IODINE TESTS MllBf if tt tf 'l 1 HMfiUU, rf***!. A*k ff aniHf M m e 44 ito February, 1954 Number 2. % AMSON LA808AT0RIC5 ojj r**t PhiUdvlpMt V1 * t b 1174 V.sbJ* How to Us e Financial Data as a Basic IXSON YENAILE, P. L mid %*4 Ckvmtcal Ea^ia* !"S. 'Program Planning Tool AfwpWti FWUli, A Program Director's Guide TF*iifthHnAM**M FUftCbuktgnHictl XPu*.im ,,K ._-KH, AkYEY L SHAPIRO )NAL EXAMINATION SEI Admifiistflio<% $#pmc U tk* FJ4 of Public rt#*lth $ttt leei HJth Dtp Mrif Syiftmt Rtld . _ in P u b lic Ancci<*fton. lac Irotdvtr, Nf* York 11, N. V. T**, JV * * .T 9*90 are eight im portant tear hy wki tk hutigels and periotlic ft nunHi Mafemeiili m o r benefit the a U itin m ln r anti the program he A w ls. They are not dorter* in plague prn/ettinnal p erto w trl httl ear, intieail, valued allien to p ro jraan im provem ent, atierIn the writer. ITfini to lo o k fo r and hm e I are that inform ation effectirely, It tide paper't them e. l'rop'Tly undorsl'Mxl and used. thre rcpurt can he an efTeclive *ervant. lending a slrmi" limili in dumping program dreams itilo ojieraling reaiilie. Wlieti given lleeting ntleiilion. misiiniler-lood. or gnomi. lite lm:mr'mg nf program c!cnii'iil nmv liei-piinr tln- "iii.i-br of th hoii*e." dirtating ilio ii.iloro inni exleni of professional -ori toc- un ;m iiplnnwd lav-to-day basi'. tlnis leuding to mnkc , ** long-term coii'lrui liti iil.mning pro feijj l*rcfrm budgets and related periodic gram difiicult. if noi nijin--olile. ill?lawirial re|mrts can be an indispensable The director showld recognize iti- jiX k*c part of realistic continuous itially that budget:- and periodi': n-porU ' t planning and direction if of program finiincial condilion are bui Q.:] emd eflrctively by the director and his two of lite many basir Voois usatile in & **. planning for professi,mal sen ire> in TVtr ap|iears to be little information any calegorical Itcalth program. Sudi The benefit * of brewer' jttti in the literature to guide the financial reports as llirse assume mran- ..bject to dispute. Its use k l union and animal nutrition a l f record. It is generally rtro u M j ,, y wfcionally trained administrator, W m k k* a director of a bureau of ma- ing mtly lo lite eMent ihal tbey rati Jso, itilerprelrd rasile and n laiid dircctly tie richest natural source of lb tiarmo B complex, of nut ompiele protein and tuUurtdf ing minerals. But before you prescribe; bear it hat all yeasts are not brewen' ior do all brrwcrs' yeasts m anil child health or crippled jM jW iirm , in his development of valid estimates for his special health nS'^fungn. Neither are there clear guides _ai l.i.a.b.le to ,he,lp ,hi.nt i.nterpret .Mr. .s lia|iro is a prailnno- -Uuli ui and con- sultani, T iikT 'iIv i>( l'illlniri;li tlraduatr SeluMit of Public Itrallli. l'Ut-tuli all, 1*3. Formerly lie sero-il a- r- uemal ailiiMiiolratio Nmer,lviioyilos rkco_n^s u l tya.n t , Ttll.l. >|.M|tMl.iri l tKlr.ai',H ' , , I ^ t . ure .,, ,, a ^ u. 1 <> the higher quality gad -atencr of VITA-FOOD. It mly in its superior culture _ ilso in the skill and know how ' L: tatem ents of fin an cial CO- he receives in term s of th eir real related to Ins program , M*(trr Uir M...rrn;I 3u*l < lli-ailli >rrtiim ifC Ame.i.a.. P..i,li. ll.al.l. \ss, ta,i,,n ,, the iMji(ity-(ir~t Annual 't u linj* in !> ) ork, n . V.. November 11. P/Vi. in ita production. ' - 149 ' J* ' Om. ' * CUU WW k * DeveUpweet 4 Ttthiaii^ S"*`T **mry Occupations and Cigarette Smoking as Factors in Lung Cancer r- ru '. T h * ir C W `'h X V IIJ: Naimm :a. I HvJt^ hoalwu44 pgn,l,w ' < j ,f C n rk l Fakf XIJIlM If, ^ C rrrk n l r,!*, .N*nr. CWM i , 's Nr*, EssiasA ' J r n 14:1 0 - ^'cnUtt* C ^ibrl PtW it n .M(M p ,, M uarnpl. -lo* 'Diimm i iy ^telili U--k-- * > Spre4 1 ). 1KI. i* M (EJhartaQ, D m l d r. u -I uf a CoM rmi 1C4-U1S (0d.|, | Vj 15.000 post-n this field, n honor of rthritis and a ic, or in one' must apply: for mailing I] iin Found- USTER BREiSLOW, M.D., F.A.P.H.A., LeMAR HOAGL1N, GLADYS lASMUSSEN, and HERBERT K. A8RAMS, M.D., F.A.P.H.A. studies have implicated cigarette smok 7Vi# four-year stu d y o ffers addi tional evidence tending to connect Leary cigarette sm o kin g will can ti*. la addition, it Usti several trapalloris that teem to hare nome etiological relationship to th e dis rate. They need fu r th e r stu d y , as a It suggested. ing : 5 and certain occupations 4-- es pecially those involving exposure to radioactive7 and chromate ores8 and asbestos'J--in the' causation of lung cancer. However, the numl>er of per sons known to have such occupational exposures in the United States is rela tively small. + The iltarp increase in lung cancer arialitr constitutes one of the most ^rtarulnr disease phenomena of the pt two decades. In the United States tW ape-adjusted mortality rate for lung taarrr climbed from 2.7 per 100.000 ^elation in 1930 to 11.0 in 1948, a 'The present investigation was under taken four years ago: (1) to determine whether any additional occupations might he involved in lung cancer and thus deserve intensive investigation, and (2) to obtain data on the role of tobacco usage in lung cancer. rr titan fourfold increase. In at least aae late, California, pulmonary cancer Methodological Considerations hi accounts for more deaths than does pulmonary tuberculosis, and among aulcs aged 45-64 it causes 4 jtcr cent of tS deaths. Attempts to explain this rising mor tality as spurious, e.g., as due to imyrovrd diagnosis of the disease, do not ttiml up. The lung cancer death rate-- *V-h unfortunately is still our best Definitive study of whether an occu-. pation or cigarette smoking is a causa tive factor in lung cancer requires that the incidence rate for theexposed group he determined. This rate is then com pared with that of a control population, the most acceptable control being all the rest of the population from which the a^ifnximalwn of incidence rate -- has nrrrjsctl two and a half times more rapidly among men than among women. tV* ran hardly presume that physicians Litr applied diagnostic improvements m much more completely to men than 1 omen. Likewise, the increasing profatl ion of lung cancer found as a cause aj death among autopsies supports the Dr. llrrslow is ch ieh Bureau of Chronic Disease*. C alifornia Slate Departm ent of Pub lic lleallli, Berkeley, Calif.; and Mr. Hoaglin ami Mrs. Uasmnssen are also associated with this departm ent. Dr. Abratns, who was formerly chief. Bureau of Adult Health, California Stale Department of Public Health, is now medical director, Health and W elfare Kund, Chicago Office, T heater and Amusement Building Jan ito rs1 Union, I-ocal 23, Chicago, conclusion that we arc dealing with a w*l increase in the disease.1 Environmental changes ap[>car to III. This paper is based on a study supported by a research grant (CS 9047) lrom the Na tional C ancer Institute, PH S. and was prew illed In-fore the Industrial Hygiene Section irr the best explanation for the oth(ethKeigAhlmy-efriircslanAPnnuubalilc MHeeeatlinthg AinssNoceiwatioYnorakt, piwnomcnon. Previously published N. Y., November 10. 193.1. 171 \ FEIJ.. 1951 AMERICAN JO U R N A L OF i ----------------- exposed group came. Assuming the satin* diagnostic oiul reporting standards fur both groups, one may lluis deteroiioi' liou llie chance that a member of an e\|*sed group will develop lung earner compares with the chance that such a person would develop the dis ease if he were not a member of the exposed group. If the likelihood of de veloping lung cancer is substantially in creased by being in the exposed group (e.g., a ecrlain occupation) one may conclude that the exposure is a causative factor in the disease. The key to this analysis lies in determining comparative incidence rates for a suspect group and a control population. But first it is necessary to identify sus|ect exposed groups. Thai was the aim of the present study. The im portance of pin pointing these groups arises from the fact that incidence studies require assembling sizable popu lations ami observing the occurrence of the disease in them--a large and ex pensive task. If, for example, data were obtained implicating oceupalions beyond those already known to be causative factors in lung cancer, one would be justified in assembling popu lations of the occupational groups and observing them for lung cancer inci dence rates--a study which would de velop more definite proof of the presence or absence of an etiological relationship. Several methods of investigation have advanced our knowledge in this sphere. First, is clinical observation of associa tion between a case or a few cases of lung cancer and some exposure, e.g., asbestos. One defect of this method is that such clinical observation dejiends largely on chance and often involves such small numlicrs of cases that the validity is questioned. Where made, of course, such observations are helpful. Another common method of identi fying suspect occupations in a highly fatal disease, such as lung cancer, is to note the frequency of the various patirms on death certificates disease ap|M-ars as the cause of The frequencies of the occupation such death certificates may then pared with those on all death certii for the general population. If occupations appear with much frequency on death certificates fot cancer than on certificates where is due to other causes, one may that the occupation may be and should he intensively inv Important achievements may be to the use of this method. Ho' on major difficulties with this use of dagjp?tiwfi*Jk certificate data arise from the foUoiL+fSmtm m m i circumstances: only one occupation !>c recorded; while this is supposed be the `'usual occupation," it is oft correctly recorded and duration it occupation is not recorded. AH circumstances tend to blur the id tail ion of susjicct occupations from certificates. The method selected in the study was to determine the lift occupational and tobacco-usage of lung cancer patients (and a group t by actual ' interview with patients. The work history included number of years engaged, name of puny, industry, a description of d and listing of products and haza materials known to the patient. Data Collection J1*- I' Patients observed during 1949-19 in 11 California hospitals (three coo general hospitals, five veteran or tary, two university, and one pr hospital) comprised the study An interviewer especially qualified1 occupational analysis obtained the from each patient in the coop hospitals whose condition permitted I interview. The session with each tient often lasted two hours or since many details al>out smoking \rZ>l J- ! T*U km Tul LUNC CANCER VOL. 44 173 4$ f the various occ*J tificatcs where tk lie cause of deatk' lie occupations o - may then be cot ill death certificate ilation. If cexUis with much greats ertificates for lunr ficales where deaA . one ntay conclude may he involved *ivclv investigatei at. may be credited method. However, It this use of deatk from the followmr nc occupation may this is supposed U ion," it is often net nd duration in tk corded. All that o blur the identic ipaliims from deatk 1 i f led in tlte preset 'mine the lifelong 'iacc**uuge history uts I and a contra interview with tk history included tk aged, name of coo* scriptiem of dutii ids and lutzardoa he patient. ioinnl and the information about sm occupation was highly detailed. A lata) of 518 patients who finally had i^oywtliologically proved diagnoses of hn( ranerr were ultimately included in A* analysis. For every patient in the case series Mthrr patient admitted to the hospital Uusrt the same time--of the same age Ukfcin five years), sex, and race--for a edition other than cancer or a chest wa* chosen in a random manner to a matched "control." Two inter- s*-rr> one working in Northern CaliFwaia and one in Southern California Irwpitak obtained the data from the cancer patient and control patients tooif the same schedule in identical Moaner That interviewer bias did not *wtrr into the determination of tobacco* tooge history seems likely, among other rraaon, because the results closely parallel those obtained in other investi gation* where such bias apparently was _eulnded/'* and because the results for Aw two interviewers were very similar. k W iliilicult to conceive how inter* aanrrr bias might have affected the acnpational data, since both lung ranerr patients and control patients rationed hundreds of occupations and . Soar of these was suspected by the intrrnewrn. Preliminary findings were krf* from the interviewers until the ad of the data collection. Method of Analysis Each record was reviewed by a physician, particularly with respect to the pathologic diagnosis. An industrial hvgietie chemist completed the listing of materials usually involved in the occupations mentioned by the patients but not necessarily known to them. Thereafter, the data were coded and tabulations prepared. Attempts to analyze the data concern* ing type of industry and exposure to materials already identified as toxic or carcinogenic did not prove fruitful. Hence tlte major analytical effort with rcsjHH't to work history went into the lata on occupation itself. This had Item coded according to the Dictionary of Occupational Titles (2nd ed., 1949), prepared by the Division of Occupa tional Analysis, U. S. Employment Service, a code with 367 three-digit titles. Particular attention was devoted to the question of years of exposure be cause present knowledge of carcino genesis due to environmental agents in dicates that duration of exposure and a long latent period are critical factors. Data on tobacco usage were analyzed so as to reveal the type and degree of smoking, as well as the fact of smoking itself. Finally, an attempt was made to sepa rate the effects of tobacco usage and occupations which appeared implicated. during 1919-1952 pitals t three county. \c veteran or mi [ , and one private the study gTOuy. * rially qualified a obtained the in the coopcraths ^ lilion permitted tit 'on with each vo liours or mor ihout smoking T ab le 1-- Age D is trib u tio n o f L u n g C a n c e r P a tie n ts a n d C o n tro ls Age Total Under 40 40-49 50-59 60-69 ?0 and over Adeno carcinoma 46 3 6 19 14 4 Cases Other Types o( Carcinoma 472 22 5ft 194 154 46 Total 518 2S 62 213 168 50 Controls Total 518 26 59 213 169 51 174 F E B , 1954 A M ERICA N JO U R N A L O F PU BLIC HEALTH T alile 2-- Sex and R ace D istribution of Lung Cancer l'alien U and Control Sex *nd Race Adeno carcinoma Cases Other Types of Carcinoma Total Controls gg Total Total 46 472 S18 518 Sj Total male 42 4SI W hite 41 420 Negro Other 1 20 11 493 493 . 461 461 S 20 2D I t 12 12 f 5 Total Female 4 21 25 25 I W hite 3 IS 18 18 Negro 1 3 4 4 2 O ther 3 3 3 f u v i (or the rrie*. TVi* uggesti Findings on Sm oking ***** o n ly U ( tories of having smoked cigaret:*]-^ validations in t Tabic? 1 and 2 reveal the distribution o{ the lung cancer patients according to their biological characteristics -- age, sex, race, and the essential similarity of the matched control series in respect to these characteristics. Tobacco usage by lung cancer pa tient and the control group is shown in Table 3. Here one may note that 4fIJ- f93 per cent) of the cases gave his- whereas only 394 (76 per cent) of tkKT 1 hypot he controls gave a similar history. ^ tS rrX t the c greater frequency of tobacco usage ftrla ^ - | 0( y other forms Ipipe, cigar, chew, snuff) occurs among the lung cai patients when compared with the ^ - l rTirr|,nfirT1iT trol group. In fact, o3 of the cot**, 55 MOM wherea group used tobacco in a form other tW t* prf cit) of cigarettes exclusively; whereas only li! ( earcino of the lung cancer patients did -I W - m wyuamuus, fel did not t ITt- - Om rnmmon' of expo T able 3-- T obnceo U sage D u n n e 20 Year P rio r to Study R eported by L ung C anrer Patients and C ontrols TiU S--Axe Co Cases Coatrdi | Manner of Using Tobacco Adeno carcinoma Other Types of Carcinoma Total Total | Total Total not smoking cigarrties 16 472 518 Sit : fV m tti Smoki t ksrscteristics ' 6 28 34 1 . No use of tobacco 4 15 19 Si Tobacco other th*n 3p i L * d ti is r e its me cigarettes, only 2 13 15 <8 -i i f >bp IISSy-2t1s n of Total smoking cigarettes 40 444 484 39 " ? ' ** 25 year* of Cigarettes, only 31 298 329 2 1 -* before bre Cigarettes and other 9 146 155 IS |* t H ie rough" LU.NC CANCER V O L 44 17S Tali] A m ount o f C ig a re tte S m o k in g D u rin g 2 0 Y f a n P rio r to Staiiv Rt'|HK1ril by l.n n g C a n rc r P atien t nm l C ontrol* Packages of Ggarettes Snaked per Day Number Caes Per ernt Controls Number Per cent Tsui 518 100 518 100 None 34 7 124 24 <* 19 4 so 10 H - 71 14 105 20 1 - 304 59 199 38 ni 2 at more 80 15 22 4 M Not recorded 10 2 18 3 tim l for the nonusers of tobacco in 6r two series. This suggestion of an effect by cigm ittrt only is consistent with other in* wiigitions in the field. Some support hr the hypothesis that cigarette smokWf affects the development of epithelial tarrumma of the lung more than adecarcinoma may be noted. Six out W 46 (13 per cent) of the cases of admocarcinoma did not smoke cig- arrttes; whereas only 28 out of 472 (6 per cent) of the patients with other type* of carcinoma., described variously m squamous, epithelial, utidiflcrcnbrfed, did not smoke cigarettes. One commonly used measure of the aanunt of exposure to cigarette smok- ing, the average number of packs smoked per day, appears in Table 4. Seventy-four per cent of all lung cancer patients reported smoking one or more packs of cigarettes on the average per day"over the preceding 20 years, com pared with a frequency of only 42 per cent among the controls. " Excessive cigarette smoking" (two or more packs per day) occurred almost four times as commonly among the case series as among the control group. Other items which may indicate the amount of cigarette smoking include the age at which the individual began smoking, whether or not he smokes be fore breakfast, and whether or not he " inhales." Table 5 reveals that, by all it rob Mal 9* 'IS 24 56 , 68 94 >0 54 Table 5-- Aee o f B e g in n in g C ignreM e S m o k in g , S m o k in g H a b it , a n d " C ig a re tte Cough" R eported by Lung Cancer Patients and C ontrols Ggtrttte Smoking Ouraeteristics Number Taul 518 Taui cigarette smokers 481 Began 15 yean of age J66 Began 15-24 2H6 Begin 25 years of age .12 Liu lr" 419 "SmAe before breakfast'' 373 Ggirette cough" 201 fia-es Per cent Ba-cd on Cigarette Smokrrs Only 100 34 59 7 93 77 12 Per cent Based on Tutal 100 93 32 51 6 87 72 39 Number Controls Per cent Based on C ig arette Smokers Only 518 394 100 116 29 213 62 33 9 327 83 229 38 112 28 Per cent Based on Total 100 76 22 47 7 63 44 22 i Si!ft! is! Z "I. r H -v. As. F E B , 1954 AMERICAN JO U RN A L O F PUBLIC HEALTH T a b ic 6 -- E stim a te d P re v a le n c e R ale* * o f L ung C an cer p e r 1 0 0 ,0 0 0 Mala o f S elected Ab nm l V a rio u s C ig arette S m o k in g Ila b tl af Ion _____ _ _ &t liV Estimated Prevalenre Rates Relatin fejeTtmiia? Ta an Number Quantity Smoked Daily t Prevtlenctt & fee* ly rt Lung Cancer Control All Quan Heavy ** tities None Heavy . ^V t Booking la the l Theee Patients aged 50-59 years I. Doll ami Hill 276 275 94 42 2. W ynder and C ralu m 258 210 117 47 5. Sadowsky, Gilliam, |W e i la categ Is aotoking, 7 13 4 27 n jz otoken, -|W W tWy would and Cornfield 4. Present 198 208 87 44 12 7 < 1 ak*tra4 Wagtli of t 213 213 102 46 6 17 4 U | rancct Patients aged 60-69 years 1. Doll and Hilt 197 199 137 63 2. W ynJer and Cruliam 187 lot) 138 70 3. Sadowsky, Gilliam, and Cornfield 76 71 44 71 ?5 JWayKV* af cigtrv 0 , # a OMOMkrC, (Sue 5 29 t t f *ka *y.) 5 9 t f f o etW. UtUiic 4. Present 168 169 433 78 17 25 'n %Eniird tctniia| ta tko M<tM 4 Cor*6el).u Dato tor Mutici i Dall 4 itili ; Wyviaf u S*4**k*k7, GilUaJ*. Mil Carai)J Iraw lit latter paper.** f </uaiJiy d aily , e t t t p t lor p f t m t M uJy, i< a ll forma mt m o k i a | e t pram 4 i t c i |m U a , wkk e if ara c a a r m r i ta ib a ir i ^ a i u l e a i i i* e ifa tv tte e aa l a iia v ti 1. Doll i t i H ilV--! oc, ! ta b a c c a a weak S 4 a d ay ; 2. W yadar ad Crakam--1 clear s r 5 eifarettea, 1 pipeful ss 2% tifarci!**; aad 3. Sadowaky, C o m cM -- 1 c ifa r -- 14 e ifa re tte a , I oc. p ip a ta b a c c a =s 24 eifarettea. 4. F ar p reaeat atad y , q u an tity -- for tfata torrUigatio ta make c ghbl aat aiuwer to does ci ta rlu d ea anly cifa ra ttc amok*. I Relatta peccale*# la tha ratio: lleavp^raia aataof beaey makera/r** ama* seeamakat; all Mddm amuiif maker/rat* ameof naaamokaia. llaaey m e ii | ta defined aa th e fa lla te m i a a m k e r of c ifa ra tta a oe r ai* a) tt o f eifc re ttc par dayy t aad IliJI-- 50 o r m a re ; 2. W yiider aad C ta h cm --3S o r m a re ; 3. Sadowaky, G illiam , a*d C o rab e id --41 m H | 4. p r e te s t atudy*--4d *r m ore. of these criteria, the lung cancer pa tients smoked cigarettes to a greater ex tent than did the control group. Also, approximately two-fifths of the lung cancer patients stated that they had had a "cigarette cough" usually antedating the onset of their illness by many years; 120 said that they had had a cough for five years or more. The frequency of such "cigarette cough" was only about one-half as great among the control group and only 39 of the control pa tients indicated that their cough had lasted five years or more. Significance of Findings on Cigarette Smoking The data clearly show cigarette smok ing to be more frequent and intense among lung cancer patients than among W <* the control group. Our data that of other recent, well contj studies; all indicate a positive tion between cigarette smoking and! cancer, a correlation which inco steadily with the amount of cijs; smoking. One can hardly escape! m i conclusion of Doll and Hill4 "smoking is a factor and an imp factor in the production of cards of the lung," and the more recent i elusion of Doll,10 "The results amoa believe, to proof that smoking ill cause of bronchial carcinoma." The cigarette smoker or pros cigarette smoker may wish to knovl much his chances of developing cancer are increased by such srad Acknowledging that a correlation i one may still inquire how many does cigarette smoking increase Anthon, edb .Ship captain C krka, gem ' Cb b iiu " ' Salom en to %in nil ra lirrm c n Animal amJ Farm hantir. Cenerai wix.. rlwwherr i Painters, esci Jb k k and << C aa.iru c lio n |j*eomoli*e fi, Attendant, li H i Mechanic* mi SUMI || ll ruth. 4 b aa*M m **u m* * t> \ *mm laa*4a4 Mr4u P . C i V. <*.** S3 LUNG CANCER V O L 44 177 BUfihood of lung cancer? Further, errase the likelihood of lung cancer? m *$ 1 *44 ij that likelihood in absolute Application of Cornfield's formula M> ls tn a ! To answer these questions to the data from four studies, including *3 ; Wautely would require that records of the present one (Table 6 ), indicates that dptette smoking for large numbers of for men aged 50-59 the prevalence of poena in the lung cancer age be lung cancer is from four to 11 times as allied. These persons would then great among smokers as among non- ! placed in categories with respect to smokers, and from seven to 27 times as fjprrtte smoking, e.g., nonstnokers, great among heavy smokers as among i m in tit smokers, and heavy smokers. fWUy they would be olrserved for a Aricnt length of time to determine the to of lung cancer among the various nonsmokers. Similar ratios were found for the 60-09 age group. This formula involves the assumption that in so far as smoking history is concerned, the pa wyorifs of cigarette smokers and the tients are a representative sample of all wankers. (Such studies are now lung cancer cases and the controls are a W way.) a representative sample of ail other per However, statistical devices have been sons in the general population. Jtmloped for data such as those in the Crvk**; ad ***ent investigation which, if one is Findings on Occupaiions oar to make certain assumptions, JW an answer to the question, how As noted earlier, the records for lung Marts times does cigarette smoking in* cancer patient and controls showed all tamikUa m Table 7-- Tw enty l 'r r cent S am ple from C om plete List o f O ccupational C roup 1 in W hich T here W ere at Least 5 Cases or 5 C ontrols E m ployed for 5 Years or M ore s parallel controlled e correl* ; and lun$ increase cigarette .scape the fill * that import* carcinoma .ecent co*.-j amount, I J king is i n j prospectin' know ho* oping lung 1 smoking, lion exUa, nany tinsel crease the Occupation Persons Employed in Occupation at Least 5 Years Cases Controls 006 Authors, editors, and reporters 7 9 088 Ship captains, males, pilots, and engineers 8 8 105 Clerks, general office 2 8 iSS Canvassers anti solicitors 3 11 ISO Salesmen to consumer-. 7 4 777 Waiters and waitresses, except private family 14 10 766 Policemen and detectives, public service 6 3 707 Animal and livestock farm ers 6 5 i J17 Farm hands, animal and livestock 10 10 473 General woodworking ocrtipuliun-, not elsewhere classified 8 7 j 16 Painters, except construction and m aintenance 3 6 j I Brick and stonemasons and tile setters S 1 | 132 Construction occupaiions, not elsewhere classified 45 25 j 1C Locomotive firemen 3 6 1 - 60 Attendants, filling stations and parking lots 10 9 , 13 Mechanics and repairm en, not eUewliere classified 15 Ih TU to: Staffi rm adoaywW ttdfromtH #9 ) ucru|t4iiMirmp*vbicli ait tin(tedfrcqr*vy> A hiim * {<Ira* 5 mi a t 5 M itrolvilli J y t a n a t m a ta em ploy**). Octop- ttwi cUowiW tv3'digit itr|M U1 Oi-'tiM try of Orpoiio*o) Title |!nd !.). ioim0 . C.; U . S*ptvycvt ber*K, Iflf. 17a 1 KI-. V i\ A M KKH. VN JO U C N A l. * M H i U C I I K U . T T iilflr U-- <n>np* ' in W h irl* i h r E m p i r n r * n f i M 'ir E m p lo y m e n t A m m is ( .im* W :n nt l e j n l T*ir* a* ample, one occ , _ ( m il u A m o n s (io u iro U ' 530 (plumlicrs . fitters) showed Kin|U*\*i in 'with a fivc-yc Occupation O iru ju t ii ut ijM 'l 5 ^ I'itfv ' Examination c records rcvcalc Ca-r- Controls jthe difference 1 ;series was due 016 Enpineers, civil 138 Slock clerk.266 Policemen and deleclives. pulilie servirt430 l.um lierm en, raftsm en, ami wood rh opper473 M achine hop and related occupai ions, not . l 7 3 i. 3 ii .1 had a heavy e was also noted involving asbci qucntly in the elsewhere classified R ,3 eases than amo 485 W elders and flame ru llrr520 O ccupations in production id petroleum 523 Construction machinery o|x-ralors, not elsewhere class! fieri 524 Brick and stonemasons and tile setters 1.0> n1 f ~;.tionrcyluodfincgonstteroamls. i 3 r . and boilermake .> 1 re to asbestos- 538 Brakemen, railroad 10 5 lunes among tl 570 Firem en, other than proce- firemen 11 2 573 Cranem en, derriekmon, hoist men. and -hm clm en 15 (, 575 Drillers, extraction of minerals and construction 2 time among the ; Table 9 prese lions grouped * O c r v p ttio a t claai*<) r to r d i n r to tli* D ictionary of Ocr up.stioaal T.l* Crv-1 c d .) . significant gxpo ta h i n f t o n , D . C . : U . S . F .m p lo y n irn t S * r* ic c . 1*M9. Inclut!* o n ly o c c u p a i o n t s tu t !C S co*a i i h S year o r m o re ! r m p lm m * n t. F - Vers in each of the differences i troU appear to u occupations /oliowed and their dura tions in years. A listing was prepared of the occupations pursued by at least five patients or controls for live years or more. This listing revealed 81 occu pations in this arbitrary frequency-andduration category. the numbers pertaining to any one ocrupation would be lc** impressive this in the rase of cigarette milking. How ever. the freqtienev with which the lllfl| cancer patients had pursued certain oc cupations wu< substantially greater thtt the frequency with which control &ted. It is o several of those differences invol particles and ft elallic corabusi fends to corrobc lfynder and Gra Table 7 presents a random sample of tienls had pursued these same octmpi- these occupations and the number of lions. _ patients and controls who at some time The occupations for which the fre T ab le during their work history had been en quency among cases was at least twice gaged in them for five years or more. as great as among controls, using tJr It will be noted that among the 518 same frequency-duration category * lung cancer patients seven had worked before, appear in Table 8. Such a tab as authors, editors, or reporters (occu lation. of course, shows the occupation pation) for five years or more, and classified according to'on arbitrary code among the 518 controls, nine had been which was riot devised to reflect a Welder a similarly engaged. Relative frequencies mon occupational exposures that might Steam fill i of occupation would appear to have the he responsible for lung cancer. Furths Electric h Occupatio. 4 same logical significance, as such fre analysis therefore included the i- and cop quencies of cigarette smoking. The lat tailed examination of records of i* Marine en ter is, of course, much more common dividual cases and controls and t> among both case and control groups grouping of occupations according ti Construct! Cook, cot than is any single occupation. Hence, possible common exposures. For ts * O re*patio* 4#tail**4 fu*ii*t l.U N r. <c .:\.N\n(,ur .:ikt vV<(u,,,, -iiii t:n to any one W> <s impressive tb* le smoking. J ith which the leaf.! ursued certain * itially greater ihtt which control hese same occmw iV lor which the lm ' ' was at least \mim controls, using tW-. ition category 1* >ie 8. Such a UW 'ws the occupati | <>an arbitrary cafa-|, *ed to reflect posures that ral$J(v jig cancer. Further, included the Jm'A of records of controls and lions according to*!#, \ posures. For " Itoffc, one occupational group, number X* Iplombcrs, gas filters, and steam Stoni showed 16 cases and 10 controls a five-year employment history, taaaieation of these 26 individual j w revealed that substantially all fc focace between case and control fcfce was due to the steam fitters who a heavy exposure to asbestos. It he noted that other types of work iag asbestos occurred more ire- in the employment history of dun among the employment his- controls. Thus, a new category^ steam fitters, aslieslos workers, d boilermakers--all involving expo- la asbestos--was found to occur 10 among the cases and only one t ong the controls. -- 9 presents the data for occupa- pouped according to possibly ^ fra n t exposures. Although num- V la each of the categories are small, iti trences between cases and con- Ubifpear to implicate the occupations }toi Jt is of interest to note that i of those with the- most striking roces involve exposure to metallic and fumes and products of ttJEe, combustion. This observation t h to corroborate the suggestion of and Graham 13 that "hot metal" ix-cui'otions may be involved in lung cancer. In recent data of Doll 10 the only occupation with an important cxccs in the cancer group was that directly con cerned with the production of gas. l.iltle or no support was found indicating that other occupations suffer sjxxial risks. However, Doll's study was based upon experience in England where the em ployment pattern differs from that in the United Slates, especially California. Also, Doll used an occupation code of only 76 categories which may have l>cen too coarse to reveal the. di(Terences found in the present investigation where a code of 367 categories was used and analysis carried to subgroupings of these. It may be noted that 77 persons with lung cancer had an exposure of more than five years to suspect occupations (unduplicatrd count in seven occupa tion groups) according to the data in Table 9. This number represents a not insignificant proportion of the total (518) lung cancer patients in tin: entire study. A further question upon which the presen! data might he expected to throw some light is the extent to which ciga rette smoking and occupations operate Table 9-- C ases nnd C o n tro ls E m ployed fo r ut Least 5 ) f a r s in Selected O ccupation C roups * Occupation li l tt'eldcrs and sheet metal workers doing welding :J~ L Stesm fitters, boilerm akers. and asbestos workers l Electric bridge crane operators-- metal industry i Occupations in the extraction of lead, zinc, tnd copper ore l Marine engineers, firemen, oiler*, and wiper :"h t Construction and m aintenance painters X Cooks, commercial (excluding cannery cook*) Persons Employed in Occupt ion at Lea*t 5 Years C.ontfols u . 2 1ft 1 5 1 9 3 12 h 22 12 3 21 'O rtiftti jrrmp ti nM i i i n w i l i M 'o f r r u r d in f l* rn n m u ii o rr p iit* i | ` ipnsuf* j h n m i bh *dSrI., e s hi L ' MfiV-J - ; 1; ! f!rl 3: 7 `id :y ] ; *\Y yd IS t t.!l> V I 180 FEIL, 1954 AM ERICAN J O U K N \ L OK IMJUL1C HEALTH T a b ic 10-- E x ru u i'I r o f A<lju**imcnl f o r S m o k in e A p p lie d I o F e h l e r ail S h e e t M ctni W o rk c m D o in p W e ld in g Packages oi CigarcHc Sm nknl |-cr Day how L* group lung a smokin None U. -- 1 - 2 or more Noi re* Total Conclu All c u e s and controls, male * 1. Cases 2. Controls 3. Total 4. Proportion of cases among total cases and controls W elders and sheet metal workers doing welding, male 5. Cases 6. Controls 7. Total 3. peeled number of welder cases t 22 no 132 0.167 0 1 1 0.167 16 69 296 0 45 105 193 22 61 174 489 102 0.263 0.396 0.605 0.783 0 2 11 1 0 0 1 0 0 2 12 1 0.0 0.792 7.260 o ;t83 10 493 18 493 28 986 0.357 0 14 0 2 0 16 0.0 9.002 9.003 E lp M lv d p ro p n l i cM B if w f ld f ti = ---- 1 s 0.S6J H 14 Ob*nr*4 proportion ( r iM i i o w ( r U m s -- = M ? S 1 14 N iaiy*6* p o r e r o l coo d * o Jiotif { lo r tb p ro p o rtio n -- = (0.617, 0.<*6D --'ftt'O ieally *<cn6raai I IS fm I level. 16 Female e tria d e tf iro n total iroup* oro **ly mole or {eluded io roup to which irt w o appi'ird. t O btained by applying tk o p ro p o rtio n o( {w* t o | to tal r*e and cn n trn la in each m oting cniryory ta U nnaabor of welder in that aoioktof e*te*efy (Une No. 4 X Una No. 7]. ! Haid A. S u tia t'c a i Table and F orm ulai. New Y o rk : John W iley. 19*3. N o te ; T bia teat aiao waa app lied to ail other o rtn p a tio n group* a/towo in TaM a 9. T he iro u p " teats fitter b o fia rm a k a n . tabeato w orker" waa on th a b o rd erlin e of atatiftiea) a ifa iftra o e r at th e 95 p er re n t level. Nona af tfci n lb e r group m et th e 9% p e r r e n t level of ftati tieal icm heanee. The c another connect! smoking land Joi "so stro within t word." * with he; ethics of and mec Further exact cor Ur, araen tibie., The d i occupatioi those prey etiological in the d These occ tensively s extent per: a special ; her, if a dearly esta as separate factors in lung cancer. For example, both cigarette smoking and welding appear to be related to the disease, but do welders get lung cancer more frequently merely because as a group they are heavy cigarette smokers? Although data from the present study involve small numbers for many of the occupations, analysis does indicate that welding as an occupation operates as a factor distinct from cigarette smoking in relation to lung cancer (Table 10). The group of steam fitters, boilermakers, and asbestos workers lies on the border line of statistical significance when the effect of cigarette smoking is controlled. In the other occupational groups tie numbers are such that the diflcreaca might arise from chance variation more than five times in a hundred. However, all the occupations listed in Table 9 deserve intensive study ti determine their precise relationship to lung cancer. One important step is te assemble populations of individuals en> ployed in these occupations, and with varied smoking histories, in order ta observe their lung cancer incident* rales. These rales may then be com pared with flic rate for the correspond ing age-sex group in the geneni population. One may thus determine Journal 2! A ddendi on ilio comi an cight-pag Journal, Ray o( Health ed January issi; educai ion, L; heen th aul yrars, jt havi r i l.U N C C.ANCEK V O L -U ]H! bow being in a particular occupational jump alTccta the chances of developing luRfc cancer and likewise how cigarette unoking modifies these chances. `and mechanism responsible should lie identified in order that protective meas ures may be introduced. IU 1 t.Kt.M.t.S 3t a l Conclusion 1. M. f.., I*" U, n . , n<l * * > . E. L. L**** I the Lang in U rlali 1 T ebcr. B ra. J . C a a ttr 5:1 i I . The data in this study constitute still 2 . S rfcrrk. f u B ak er. U A .. B a ila r . C. TV. ) Dolcoff. S. T obar re* S m nktftf a t aa f.t *1 FV another link in the chain of evidence connecting lung cancer with cigarette la r i D iaraar. C a n re r R****b 10 49-5A. 1950. 3. W y n d rr, F.. L., am i G ra b a n , E- A. T r b a r r n Smk- in f aa I'oewMe L liu ln fit Fartnr m Mnvking, evidence which the New Eng land Journal of Medicine notes to be C a rrm m ta . A Sfudy o i 6 4 l I'm**! Cava. J.A .M .A . 1 .329-J16. 1950. 4. D oit. R .. anH H ill, A. R. A S tud* t b r A rtm lrjy "*n strong as to be considered proof within the everyday meaning of the word." 14 It is time for those concerned o( Carcinoma oi th* L v n f. B n t. M. J. r i l 'I - U M . 1932. 3. L rvtn. X , L., (foM airtfi, H ., and C * rh rd t, T- R. C anear and T n b a ero Sm ohin*. A Ptelim iDery Re* pert. J.A.M .A. 143:336-331, t W . with health education and with the ethics of advertising, at least in health 6. K eeper, T . C. (V anpatm nal Tomor and Oioraaea. S y tincbtlU , U K; THmaa. 19\2. 7. Reatnak), O ., Sp. E-, and S<hmrl. C. Allied Oi and medical journals, to lake note. Further investigation should seek the D erfk ro k h f a d o r E rib e te J e te i* S c k o r r b r r f La Sacbaen <*4S hnebercer L u n f e n b rr b a " ) . Z taehr. (. K rebaforarh 23-JbO -M t, 1936. exact component of cigarette smoke-- Ur, arsenic, or other--which is respon sible. The data also suggest that several occupations (Table 9 ), in addition to those previously identified as having an etiological relationship, may be involved I- M ark!*. V ., d G refrioa, F. Cancar ai ib Reaptmlory Syrtcm in tbe United State. Pub. H ealth R ep. 41:1116-1127. 1949. 9 . GWywe, S. R. P n n m o co n io il; lliatn ln fte al Survey ol Neeropey M aterial 1 1705 Caaea. l-enret 1 :810, 1931. 10. D all, R. O ronebial C arcin o m a: lactd en ea and A rti, elo fy . P art t and P a ri IK B rtt. M. J. 531*137, $ > 3 9 0 . 1953. 11. C a m b rld . 1. A M ethod ol E rtiro atiag C om parative Ratea rt> C linical D ata. A pplicati* ta C aaecr af la the development of lung cancer. These occupations should now be in the 1-unt, Breast, and C eraia. J- Nat. Cancer Inat. )l:)2 f* 1 2 7 S . 193!. 12. Sadnwaky. D., C illiam , A., and Cornfield, J. T h t tensively studied to determine to what extent persons engaged in them suffer a special risk of lung cancer. There after, if an etiological relationship is dearly established, the precise exposure $ttaticaJ A raoeiati fle iv e c fran k in g and Car* r in am a a i the Lung. Ib id . 1 3 :1237-125fi. 1933. 13. V y n d e r. * L .. and G rah am . E. A. E lio)o(ie Faclara t* Bfrmchiocentc Carcinoma with Special Refute*# ta ln d e ia! E apnvuree; R eport oi 8*7 Froved Caae. A rch, lad u et. ]( f. A ( V t u f . M ed. 41721, 1931. 14. E ditorial. C anrer of |h e L n n f. N e E nfland J. M ed. 249:463-466, 1933. Journal 25 Y e a r s A g o Addendum to the January, 1954 "25 Years Ago." In addition to the articles on the common cold mentioned last month, the 1929 Journal tp. 4191 describes in eight-page booklet "That Mean Cold." by present-day associate editor of the Journal, Raymond S. Patterson. It was reportedly his first production as director of health education for the John Hancock Mutual Life insurance Company, the Jinuarv issue (p. 94) having reported his appointment ns director of health iducation, Life Conservation Service of that company. Dr. Patterson had already Wen the author of A.J.P.H.'s "Annotated Public Health Bibliography" for several jnrs, it having first appeared under his by-linc in March, 1926. ame J 'V 3 /Ii. J- ! r*. 3. (v! v :;- r \ ') 1 ,;{ i f p i':w mm li& ill ...... .1 '! * v V /,` 1 i l : ** zr-i-r+ K ,